This chapter from Designing and Integrating a Disaster Preparedness Curriculum: Readying Nurses for the Worst examines how to apply specific leadership skills to disaster training.
This chapter discusses the importance of promoting leadership skills in disaster training when it is integrated with and applied to nursing curriculum. Disaster preparedness is of global importance in healthcare. It is critical that educators expose students to disaster preparedness as part of their curriculum and use activities to reflect and reinforce learning outcomes. This effort can directly address the challenges faced by nurse educators in addressing the need for nursing students to demonstrate competency in leadership roles (Foli, Braswell, Kirkpatrick, & Lim, 2014).
Many entities support the use of nurse leadership in healthcare and disaster operations. Both the Commission on Collegiate Nursing Education (CCNE, 2013) and the American Association of Colleges of Nursing (AACN, 2008) have specified leadership competencies as graduation requirements for professional nursing programs. In addition, the Institute of Medicine (IOM, 2010) looks to nurses’ competence and innovation to lead in the healthcare industry. Lastly, the Education Committee of the Association of Community Health Nurse Educators (ACHNE) recognizes emergency preparedness, response, and recovery as core elements in their Essentials of Baccalaureate Nursing Education for Entry-Level Community/Public Health Nursing (Education Committee of the Association of Community Health Nurse Educators [ACHNE], 2010; Kuntz, Frable, Qureshi, & Strong, 2008).
Leadership in nursing is not optional. It is required to effect change (Curtis, deVries, & Sheerin, 2011). Leadership concepts are a key part of any nursing curriculum. To achieve success in leadership, though, a leader must understand how to apply leadership skills. Nursing faculty are in a prime position to educate new leaders in nursing (Kalb, O’Conner-Von, Schipper, Watkins, & Yetter, 2012). This descriptive study by Kalb et al. noted multiple methods that current faculty use to facilitate leadership skills in nursing students, providing students opportunities to lead in a safe environment. In addition, the authors note that the use of interprofessional learning experiences in classroom, clinical, and community settings provides students opportunities to learn and practice collaboration, thereby improving patient outcomes (Kalb et al., 2012). Halstead (2007) stresses that when conceptualizing new curriculum models, nursing faculty can direct nursing education by forming interprofessional partnerships. When disaster training and leadership experience are combined, health professionals can combine knowledge and attitude for integrated outcomes.
This chapter describes the experiences of students who participate in disaster preparedness as part of a nursing leadership course. In addition to classroom theory, students are actively engaged in leadership positions during a community disaster simulation exercise in the hospital and in community agencies. Students can then apply the knowledge gained from theory presented prior to the disaster exercise. This sequencing enables students to meet overall learning outcomes by reinforcing concepts through experiential application and providing realistic and valuable learning about their roles as future professional nurses. This method also focuses on the leadership roles in a team environment, building success in disaster-management decision making in times of crisis.
Disasters come in many forms and sizes. Disasters are natural, human made, or some combination of natural and human made. In addition, there are local emergencies as well as regional, state, and national disasters or catastrophes.
Recorded natural disasters have increased exponentially since the 1950s, from fewer than 50 per year to a peak of approximately 550 in the year 2000 (Centre for Research on the Epidemiology of Disasters, 2014). Factors affecting this increase include civil unrest, global climate change, emerging infectious diseases with pandemic possibilities, and increased population growth (Baack & Alfred, 2013). These increases in turn demand increases in healthcare resources, including healthcare providers.
Historically, nurses have prepared for and responded to disasters. Although these individuals might not have been professionally trained, their nursing role was consistent with today’s nursing role. They cared for the injured and the ill and provided essentials such as food, water, and shelter; relief from pain; and a reassuring touch (Gebbie & Qureshi, 2006). By the mid-20th century, emergency medicine had evolved into a full specialty area of care. Emergency nurses also developed skill sets that set them apart. The Emergency Nurses Association (ENA), formed in 1970, has emerged as an influential national organization that supports education and certification for nurses in emergency and disaster care (ENA, 2014).
Today, nurses remain the largest discipline in the healthcare workforce. As such, they are very much involved in the preparedness, response, and recovery aspects of disaster management in various clinical capacities. The participation of nurses in disaster drills potentially results in both experience and leadership development (Baack & Alfred, 2013). As Gebbie and Qureshi noted in 2002 and again in 2006, nurses are expected not just to anticipate and perform in a disaster to address triage and caring for the sick and injured, but to think ahead regarding infection control and immunization and mass evacuations. Critical thinking and planning are key to preventing further damage as well as to prioritizing all of these interventions. As the needs become greater, nurses remain key players in local and national emergency response efforts (Gebbie & Qureshi, 2006). Because of these combined factors, nursing leadership is pivotal to both positive patient outcomes and healthy work environments (Curtis et al., 2011).
It is ironic, then, that many nurses are not confident in their abilities to respond to disasters. They report a lack of understanding in their perception of their role and how to provide safe, effective care in the event of a disaster. Those with previous experiences in actual disasters and simulation exercises feel more confident in their response efforts than those without that experience, however. Those nurses who lack experience state that they would feel better prepared with improved training (Baack & Alfred, 2013). DeJong et al. (2010) found similar results in a study of military nurses serving in active combat in Iraq and Afghanistan. Scenario-based, focused, and repetitive training exercises successfully prepared nurses for their roles in response to mass casualties in field hospitals. The nurses, in turn, reported that they felt more competent and in control when later faced with a mass casualty incident. They also noted that these types of exercises were more realistic than tabletop exercises, which offered no direct, hands-on practice and only discussed problem solving theoretically.
This lack of ability to provide a confident response has been reported consistently for more than 10 years (Adams & Canclini, 2008; Broz et al., 2009; International Nursing Coalition for Mass Casualty Education, 2003; Seaton, Seaton, & Yarwood, 2013; Weeks, 2007). Although not all nurses need to be trained for first response in disasters, they should be aware of how to identify a disaster, how to protect themselves and others while providing immediate care for those who need it, what their role and limitations are, and where to locate resources.
In a disaster, nurses are faced not only with professional responsibilities, but also with personal imperatives. Finding a balance between these consuming priorities can be difficult at best. Key themes for successful response and recovery focus on leadership skills, including good communication, making decisions, and taking action (Grossman & Valiga, 2013; Seaton et al., 2013). In addition, nursing programs and their students can be instrumental in educating the community to enhance public self-care capability following a disaster. The question remains, what can we do as nurse educators to empower our students?
An overview of nursing leadership
As a part of a multidisciplinary health team, nurses participate in the decisions that affect the delivery of care in any care setting. They are equally important in the decision-making processes and leadership in a disaster, no matter the type of incident (Hynes, 2006). Fostering a sense of collegiality without hierarchy will facilitate communication and collaboration, yet the response phase of most incidents involves a chain of reporting within the National Incident Management System (NIMS) (FEMA, 2012). In addition, nurse educators function as change agents and leaders, expected to demonstrate sound leadership skills as role models for students (Adelman-Mullally et al., 2013).
As noted, nurses cannot view leadership as an optional role. They must demonstrate leadership on a daily basis to achieve high standards of care and produce positive change. According to Curtis, DeVries, and Sheerin, “A leader must be knowledgeable about leadership and be able to apply leadership skills in all aspects of work” (2011, p. 306). The American Association of Colleges of Nursing (AACN, 2008) also notes that leadership is not a standalone concept. Rather, it should be present in multiple aspects of curriculum. This again reinforces the notion that leadership should be presented as a part of nursing practice with multiple opportunities to observe and model behaviors.
Leadership and management are not interchangeable terms. Leadership skills are much more complex, with leadership occurring in facilitation and innovation through vision rather than through direction and the task-oriented goals of managing (Grossman & Valiga, 2013).
Instructional methods to instill and strengthen leadership skills for baccalaureate students have been covered significantly in the literature. Watts and Gordon (2012) note that leadership skills, values, and attitudes in practice are key elements to learning. Peer leadership has been shown to benefit senior as well as junior peers (Bensfield, Solari-Twadell, & Sommer, 2008; Daley, Menke, Kirkpatrick, & Sheets, 2008; Kling, 2010). Students can also build leadership skills by participating in community partnerships, projects to promote healthy lifestyle changes such as health fairs, and service learning (Foli et al., 2014; Harrison, 2010; Mansfield & Meyer, 2007). Group projects integrated throughout a course provide opportunities for multiple students to lead portions of the project and allow practice exploration and implementation of personal leadership styles.
Teaching methods to promote leadership skills in nursing students
The National Student Nurses’ Association (NSNA) has implemented a virtual program called The Leadership University. It was designed to promote and assist with leadership development in nursing students (NSNA, 2012). Four key areas of leadership attributes and competencies are incorporated into this shared governance program, with related activities for participants to develop, practice, and perfect these areas. These areas are as follows:
- Working skills: These develop the nurse’s intellectual and analytical capability to not only use critical thinking, but to also make decisions based on evidence as well as from a systems perspective.
- Role identity: This focuses on interdisciplinary models to enhance collaboration and communication, and to empower decision making from a team approach.
- Personal improvement: This encourages a balance of personal life and professional responsibilities through introspection and reflection that will enhance acceptance of responsibility and accountability for decisions made.
- Communication skills: This fosters the ability to communicate effectively both verbally and in writing to enhance interpersonal skills from a professional standpoint, aiding in communication and conflict resolution.
These leadership attributes and competencies support the guidelines for leadership needed for clinical practice and may also be realized through the use of disaster education in a nursing curriculum. This may be accomplished through the incorporation of transformational leadership models, active learning, and critical thinking in leadership decision making, which are described in the following sections in more detail.
The use of transformational leadership models has been supported in multiple studies in the literature over the past two decades (Bowles & Bowles, 2000; Carney, 2006; Curtis et al., 2011; Sofarelli & Brown, 1998; Sullivan & Garland, 2010; Trofino, 1995). As students learn through experience and engage in self- reflection, they reach a new level of knowledge and expertise from which to draw in future decision making. Leadership models are able to promote vision along with the ability to empower and inspire the trust of followers while sharing a bond. Leadership in nursing may be developed through modeling and practice of relationship skills as well as educational or classroom activities. Opportunities to practice, observe, and model leadership can lead to greater realization of leadership qualities in students, producing long-term changes as well as short-term effects and resulting in a sustainable skill set for future practice (Cummings, Lee, & MacGregor, 2008; Kalb et al., 2012).
Active learning (Dewing, 2010) has been used as an effective learning strategy to expose nursing students to leadership. By setting clear guidelines on how students are engaged and evaluated to meet specific learning outcomes, active learning enables students to use problem-solving exercises to verbally interact, read, write, and reflect (Middleton, 2012). Through sharing, critical thinking is encouraged, enhancing lifelong learning for improved retention of knowledge and skills. Simulation exercises can be used to combine leadership role modeling and practice with active learning strategies to engage students. Repeated scenarios with multiple leadership opportunities provide a safe, nonthreatening environment to train multiple types of providers. This will enhance group cohesiveness and promote leadership training and competency in crisis management in addition to other factors affecting positive patient outcomes (DeJong et al., 2010). Again, these activities are easily translated to the student learning environment for leadership promotion in the clinical setting. By building this sustainable change, students will able to do the following (McCormack et al., 2009):
- Build collaborative working relationships.
- Engage in continuous reflective learning.
- Develop a shared vision.
- Develop participatory engagement.
- Evaluate individual as well as collaborative performance toward successful learning outcomes.
- Generate new knowledge.
- Develop and engage in good communication strategies.
- Implement processes for sharing and disseminating information.
- Apply existing knowledge.
Critical thinking in leadership
Critical thinking is often described as putting it all together via assessment; analysis, synthesis, and reasoning; problem solving; decision making; planning; and applying information (Billings & Halstead, 2009; Horan, 2009; Potgeiter, 2012). More than just a cognitive process, it drives nursing practice and interventions and is often associated with being a good leader (Grossman & Valiga, 2013). Collectively, the CCNE (2013) and the AACN (2008) have identified critical thinking as essential to the baccalaureate preparation of nurses and require outcome assessments of students’ competence as part of the accreditation criteria. This begs the question of what teaching strategies can be implemented to promote the development of critical thinking as well as defined measureable outcomes. Therefore, it makes sense to focus on critical thinking in the clinical setting, where students are active participants in gathering data, processing information, and applying theory to nursing practice as is reflected in the nursing process.
Strategies commonly used to promote critical thinking may include the following (Potgeiter, 2012):
- Mind maps (concept maps)
- Case studies
- Problem solving
- Written assignments
- Clinical conferences (debriefing)
- Reflective journaling
These may be highly effective at any clinical level. Journaling rather than written care plans is also noted as a successful strategy for promoting critical thinking (Marchigiano, Eduljee, & Harvey, 2010). Students reported a higher level of confidence when using the journal format to analyze information, assess relevance, and make clinical connections to determine positive outcomes. The ultimate focus is to put principles in place that will best allow students to engage in higher-level thinking, thus improving their confidence in their decision-making and leadership skills.
Decision making under pressure: A framework for crisis management
In the early hours of a disaster incident, when resources are stretched beyond normal limits, it is important to look at the decision-making process. The doomsday scenarios of Hollywood and the unfolding disasters on television are rampant with uncertainty, a lack of or unreliable information, time pressures, and psychological pressures. Carone and Di Iorio (2013) note that decision making under these circumstances can fall apart with even the best-laid plans if the decision makers are not aware of their own emotions and capabilities. When faced with extraordinary pressures, a lack of awareness of their emotions may cause responders to unleash and amplify their own fears, impairing their decision-making capacity when it is most needed.
Carone and Di Iorio (2013) note two distinct layers in crisis management:
- The known side: This encompasses the framework or plan for crisis management.
- The shadow side: This is where uncertainty lies—in perceptions, emotions, personalities, and personal experiences.
The shadow side reflects the human domain and may be equated with Maslow’s hierarchy of needs. “Things are not viewed the same way under stress conditions. Personal insecurity increases, context- related resources and personal means are not seen and consequently not realized” (Carone & Di Iorio, 2013, p. 351).
Those involved in disaster response are expected to act quickly, improvise, and do whatever is necessary to accommodate the needs of the community. The benefits seem obvious, but at what moral cost are these decisions made? Boin and Nieuwenburg (2013) discuss the moral costs of decision making during a crisis and the excruciating effects of making decisions under extreme pressure.
Myriad emotions may pass through the decision maker’s head at a time of crisis, including the following (Carone & Di Iorio, 2013):
- Excitement or curiosity
- Depression or sadness
Professionalism is a leadership attribute but may muddy decision making when quick and intense front-line decisions are needed. Personal perspectives and values may also undermine problem solving under crisis conditions.
These feelings are reflected by the decision maker’s emotional intelligence. That is, the decision maker has some self-knowledge and an understanding of his or her emotional limitations. The bridge between these levels of emotional intelligence allows for sound decision making, where each will have equal influence.
To improve decision making in a crisis, Higgins and Freedman (2013) suggest honing decision- making skills with repeated practice under a wide range of simulated situations. They note, “Practice provides [decision makers] with the experience to more rapidly and easily make timely and effective decisions during actual crises and emergencies” (p. 75). They support this suggestion based on the principles set forth by Nobel laureate Daniel Kahneman (2011) in his work Thinking, Fast and Slow. In this work, Kahneman defines intuitive decision making as being useful only when that intuition is supported by longstanding experiences or repeated practice exercises. Practice in decision making was again supported in a controlled study of 100 nursing students by Heidari and Shahbazi (2014). In this study, students were divided into two groups, with the experimental group receiving a short problem-solving course consisting of eight 2-hour sessions. When this group was retested, their decision-making scores showed that the problem-solving course improved students’ decision-making skills. In their discussion, the authors point out that this would be most beneficial in various emergency scenarios.
Leadership roles in disaster-simulation exercises
Simulation in nursing education has provided students the opportunity to practice critical thinking and decision making in safe clinical situations. How can this translate to developing leadership skills in undergraduate nursing students? As discussed in Chapter 2, “Simulation in Disaster Education,” disaster preparedness simulations are a valid and useful way to provide disaster-learning experiences for nursing students.
Training for crisis and disaster management is crucial to successful outcomes and is better delivered before the incident, prior to the demand for a quick response followed by intense recovery needs. In addition, nurses need an understanding of how to best contribute to planning, implementing, and evaluating emergency preparedness plans, as their communities need them in that decision-making process. The very nature of crisis and disaster does not allow an extensive vetting of a nurse’s ability at the time of the incident. Providing leadership experiences in disaster learning at the undergraduate level will help nurses respond appropriately in a catastrophic incident, while accrediting bodies for healthcare facilities promote ongoing training for employees in disaster preparedness and response.
In one study, researchers divided undergraduate nursing students in a community health setting into various roles—responder, leader, and survivor—in simulated infectious disease outbreaks (Morrison & Catanzaro, 2010). Leadership roles included lead school nurse and “visiting” school nurses, high school principal, and school security guard. The leaders were expected to initiate and complete appropriate assessments and forms, initiate infection control, and notify the public health department. To evaluate the exercises, students were led through a verbal debriefing and completed a written reflection of the experience. Several common themes were identified:
- Students reported feeling overwhelmed, anxious, and confused as to how to respond to a chaotic situation.
- Students realized the importance of being involved in emergency-preparedness planning.
- Students recognized their ability to apply assessment, diagnosis, and prioritization skills in addition to knowledge of chronic, acute, and communicable diseases learned in current and previous coursework.
- Students thought the simulation exercise helped to prepare them to respond to a real emergency.
Morrison and Catanzaro (2010) went on to note the importance of pre simulation briefing. This gives student responders time to meet and ask questions to better understand their roles and duties. They also suggested adding an informatics component to the simulation for research, reporting, and information-sharing purposes with the mock public health agency.
In a similar study, Kaplan, Connor, Ferranti, Holmes, and Spencer (2011) used a combination of high-fidelity simulators and people in various roles in a mock disaster drill for senior nursing students. Faculty created a purposefully chaotic and noisy environment and randomly assigned students to incident team leader and second-in-command roles, as well as patients. Students again reported that the exercise led them to respond more realistically and allowed them to act as real providers in an emerging disaster situation. Again, in discussion, the importance of presimulation briefing and debriefing was noted to better prepare students for the exercise and to evaluate responses in a facilitated discussion, respectively.
In a disaster situation, nurses must work in professional and paraprofessional teams while performing tasks they may not normally do (Mbewe & Jones, 2013). It is essential, then, that core competencies for disaster response be introduced and supported as a part of education and training. These competencies cover all aspects of disaster, from preparation (collaboratively between local agencies) and teamwork within the institution to personal strengths in critical thinking, flexibility, and resilience (Walsh et al., 2012). The very factors that promote teamwork, such as collaboration, trust, equality, mutual understanding, and shared accountability, are also crucial to the development of partnerships in interprofessional relationships (Persily, 2013).
Although interprofessional training is important to communication and professional education in healthcare, its purposeful inclusion in disaster preparedness education is not readily found in the U.S. This may be because disaster education is not a consistently delivered part of the health professional curriculum, including nursing. This integration could change as disaster education is strengthened in curricula, however.
Interprofessional healthcare disaster teams must be trained to work collaboratively to achieve optimal care and outcomes (Savage et al., 2014). In disaster, no single provider or entity can handle all the priorities. Leadership is shared and is best learned with modeling in a collegial atmosphere (Graen, 2013). As part of nursing curricula, participation in disaster simulation in various leadership roles has become an important factor, and it certainly lends itself toward interprofessional emphasis in training.
One international program that provides interprofessional disaster education was founded by an international, three-university partnership: University of Glamorgan, Wales, UK; University of Ulster, Ireland, UK; and HAMK University of Applied Sciences in Finland (Evans, 2010). The 3-year, part-time online learning experience is blended with onsite summer school sessions. It enables between 10 and 25 students from a range of healthcare disciplines to prepare to lead competently and confidently in multidisciplinary and multicultural teams involved in disaster response and field management across the world. The course results in the award of a master’s degree in disaster healthcare. Its students and graduates have included nurses (general, child, public health, and mental health), midwives, surgeons, anesthetists, military mental healthcare workers, environmental health officers, and paramedics. Nursing and medical staff from around the world have also participated, including staff from Finland, Sweden, Norway, the United States, Greece, Italy, Nigeria, Zimbabwe, and Tanzania.
Interprofessional education for disaster healthcare
The following text, from “Interprofessional Education for Disaster Healthcare” by J. Evans (2010), describes the course.
This distinctive Masters (HEFCW Level 7) award is aimed at experienced healthcare professionals working in the humanitarian field, or those who aspire to do so. Participants study the key areas of theory and practice that are relevant to healthcare in complex humanitarian disasters, from resilience and response to mitigation and recovery. A key element of this course is its strong international and transcultural focus, which is needed to develop and maintain relationships between colleagues in the institutions and countries that underpin the programme.
Participants study on a part-time, distance learning basis, with an annual two-week residential summer school. National healthcare providers, non-governmental organisations (NGOs) and inter-government organisations usually employ healthcare professionals undertaking this award. Graduates of this award have taken up key posts with the International Federation of Red Cross (IFRC) and Red Crescent Societies, the UK Foreign and Commonwealth Office, the Department of Health, the armed forces and with NGOs in Sudan, Iraq, Angola and Afghanistan.
The programme began life over ten years ago as a collaboration of higher education institutes interested in disaster nursing…[resulting] in the development of a Level 7 programme in disaster relief nursing that was an award shared by three partner institutions, University of Glamorgan, University of Ulster and HAMK in Finland. Following critical appraisal of the award as it stood, it was obvious that there was great interest in the programme from non-nurse health care professionals. At that time there was no provision for awards specifically in disaster health care services.…it was decided to change the name of the award to Master in Disaster Healthcare. Nursing was deemphasized and a more generic approach to health care taken. This has resulted in the recruitment of an increasingly diverse student body. In addition, the scope of the teaching team has expanded to support this increased diversity.
In this country, the IOM and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have provided teamwork competencies and interprofessional education (IPE) standards to improve patient safety (Persily, 2013). This guidance also applies to interprofessional collaboration among healthcare students in their disaster education. As early as 2003, the IOM identified a set of five core competencies for all healthcare providers (HCPs) that included the ability to work as members of an interdisciplinary team (IOM, 2003). The IOM report points out that changes in the culture of educational institutions and delivery will be needed to truly achieve IPE (IOM, 2011).
Interactive learning methods can support interprofessional interactions, including seminars, patient visits, and role playing. In those interactions, two pieces of advice are provided:
1) Group dynamics work best with a balance of professions and stability so one profession does not necessarily dominate; 2) IPE value is assured in meaningful assessment of learning needs and a clear clinical focus (Persily, 2013, p. 51).
This need for IPE is supported by a recent study evaluating the attitudes of medical and nursing students (Delunas & Rouse, 2014). While medical students’ attitudes toward interprofessional communication differed from nursing students, it was interesting to note that the positive attitudes of both the medical and the nursing students toward interdisciplinary collaboration dropped over the course of the study. Part of this drop was reported by both groups of students as related to having had no formal introduction to each other’s roles. This further solidifies the need to continue to push for IPE and collaboration, as well as the need to start before students graduate from professional programs (Delunas & Rouse, 2014), as suggested by the IOM (2011).
Student involvement in interprofessional education (IPE) should begin early in their programs and include joint planning processes for care to emphasize understanding of the overall goals of the experience.
Another key aspect of developing positive leadership behaviors lies in the accompanying discussions and reflection that facilitate growth in these skills. Debriefing after a simulation exercise provides opportunities for timely exercise wrap-up. It also provides students additional learning opportunities through active engagement. This is vital for building collaborative working relationships and shared vision. It provides time for evaluation while sharing and synthesizing new knowledge and for the application of previous knowledge learned. This also encourages the demonstration of good communication strategies and the dissemination of key information (McCormack et al., 2009).
Debriefing that includes discussion of problem solving, decision making, and reasoning will enhance critical thinking as well as development of clinical judgment (Lavoie, Pepin, & Boyer, 2013; Walsh & Seldomridge, 2006). Kaplan et al. (2011) used a standard debriefing guide to provide consistency between exercises and to ensure all pertinent topics were covered. Debriefing should cover students’ assessments of the scene as part of the response team, decision making (including students’ feelings regarding those decisions), and suggestions for changes in future practice.
Inexperienced faculty may need to be coached in higher level thinking to actively encourage complex reasoning as a part of debriefing (Walsh & Seldomridge, 2006). Use of a standardized list of guided questions may help with this.
Data collected during the simulation exercise using a rapid assessment form may also be discussed to compare experiences between roles and encourage discussions about the different perspectives of each role in the exercise. Students’ evaluations and debriefing points can be turned over to the exercise coordinators. Exercise coordinators can then include these in the main debriefing following the exercise and use them in the formal incident report. Students’ perspectives will provide different insights, both positive and negative, that may have gone unnoticed by the evaluators.
In addition to the group debriefing, writing prompts can be used to encourage reflection on the communication aspects. These will enhance students’ understanding of the overall disaster simulation process (Foli et al., 2014). For some students, written assignments allow the exploration of personal feelings about the simulation exercise and reflection on how the experience will affect their future practice. Although reflective journaling has long been in use as a viable learning tool in nursing education, successful and meaningful journaling depends significantly on the facilitation of supportive faculty (Benner, Sutphen, Leonard, & Day, 2009; Kennison, 2012). By using specific writing cues or questions, students may be guided to participate in dialogue that promotes autonomy and empowerment by reflecting on what they were thinking and feeling at the time.
An example of leadership training using disaster in action
By ensuring exposure to disaster-response core competencies as educators, we can provide experiences to enhance students’ leadership skills. Through the incorporation of leadership education, critical thinking, and active learning, students placed in various positions and decision-making scenarios during a disaster simulation will gain valuable experience not only in leadership and decision making, but in collaborative and interprofessional practice. By ensuring exposure to disaster-response core competencies as educators, we can provide experiences to enhance students’ leadership skills. Through the incorporation of leadership education, critical thinking, and active learning, students placed in various positions and decision-making scenarios during a disaster simulation will gain valuable experience not only in leadership and decision making, but in collaborative and interprofessional practice.
Placements with a specific eye toward leadership might include the following:
- Healthcare settings, including hospitals, alternate care center areas, field clinics, and points of dispensing (PODs), using assigned positions such as incident commander, communications lead, unit manager, and RN supervisor, as well as placement in support units including emergency triage areas, security, and facilities management to broaden interprofessional awareness
- Community agencies, including public health departments, emergency medical services (EMS), the local emergency management agency (EMA), social service agencies, the local Medical Reserve Corps, American Red Cross, and other regional disaster-response NGOs
In addition to participating in the disaster exercise, students should have specific learning objectives for the simulation. These include the following:
- Research and demonstrate an understanding of the observation role and its fit into the exercise.
- Discuss the role and its application to leadership competencies and practice.
- Analyze communication strategies for strengths and weaknesses.
- Review specific decisions and their impact on specific areas during the exercise.
- Complete exercise performance evaluation tool (used as part of the debriefing session after the exercise).
At the Arnot-Ogden School of Nursing, the last diploma program in the state of New York, senior nursing students enrolled in the Leadership and Management course are invited to participate in the hospital’s annual disaster simulation exercise. Faculty members discussed and decided on clear-cut learning objectives and responsibilities during the simulation exercise to ensure a meaningful learning experience. At the time of their participation, students had completed the Basic Disaster Life Support (BDLS) course during the preceding term. The BDLS is an 8-hour, competency-based, awareness-level course that introduces concepts and principles to prepare health professionals for the management of injuries and illnesses caused by disasters and public health emergencies.
The BDLS course is offered by the National Disaster Life Support Foundation (NDLSF), whose mission is to provide formalized, lifelong learning in disaster medicine and public health preparedness to meet the health and safety needs of people and communities affected by disasters and public health emergencies (NDLSF, 2014).
To build on this knowledge, students attend a lecture on disaster preparedness by the hospital’s director for safety and security, who coordinates the simulation. Lecture content includes basic information regarding types of disasters and how these different situations would be handled by the facility’s disaster plan. Students also participate in a lecture defining the emergency nursing role in the exercise by the facility’s emergency department (ED) nurse. In this facility, an ED nurse is in charge of disaster education and preparedness for the department’s staff. The students are then provided the opportunity to practice donning and doffing various examples of personal protection equipment (PPE) used by the staff during hazardous materials responses. Education for the facility’s disaster plan and PPE practice is completed one week prior to the scheduled simulation date. The week of the simulation, students receive the same alerts as the hospital staff in preparation for the pending incident. This includes weather reports with predictions of storm surges with potential for flooding due to the impending “flurricane.” Flooding secondary to heavy rains from hurricane conditions is not new to this community; it was flooded in 1972 by Hurricane Agnes leaving severe devastation in her wake. Neither the staff nor the students are notified as to which day the flurricane and flooding will hit the community.
On the day of the simulation exercise, the students report for their normal clinical day as part of the course and are updated about the immediate potential for flooding in the hospital’s surrounding community. The simulation creates an exciting, hands-on experience in leadership for nursing students. Half the students are pulled back to the school as mock patients, and the other half are sent to the designated site of the labor pool to service the patient surge’s immediate staffing needs. The students who portray simulation patients are given character descriptors that outline age, sex, basic past medical history, current injuries, and the severity status of those injuries. Some students are assigned “family member roles” that include accompanying a patient to the ED or in some cases looking for a family member who is missing. The students take their charge seriously and stay in character for the triage process.
The labor pool students are eventually sent to the ED to help the ED staff nurses provide care for the simulation patients in the triage and designated patient care areas. Nonurgent care is provided in the designated area in the School of Nursing building, and care for higher acuity patients is in the main ED. After student “patients” are triaged, treated, and discharged, they return to the starting point for simulation patients. There, they receive a new identity and presenting problem until the exercise is over. Debriefing is done at the end of the exercise by the course coordinator and the ED nurse who provided the preexercise lecture on the ED nurse role. After the debriefing, the students are assigned to complete a reflective journal entry regarding their experience in the simulation exercise.
The debriefing session reveals both positive and negative points of the assignment and the simulation. Common themes of students who were patients during simulation are feelings of being lost and confused on their arrival to the ED, with further comments on how it was “scary to be on that side of patient care,” not knowing what was going to happen. Once they were triaged, they were sorted to either the nonurgent designated area or to the main ED for treatment there. Those sent to the nonurgent care area were promptly treated and discharged, with quick verbal communication of what action would have been taken given their condition and sent back to the simulation starting point for a new identity.
In one recent simulation event, a real-time learning experience occurred. The ED physicians chose not to participate in the simulation that day, so all patients triaged for higher levels of care were returned immediately to the starting location for the patient surge without further assessment or treatment of any kind. Students who were assigned to the ED for workforce reported they felt they were not used effectively during the simulation because the “patients” were not evaluated for treatment in the ED. The students also questioned this lack of participation of a vital part of the interprofessional team, trying to understand how a lack of practice would translate into preparation for a real disaster. Students then discussed how the higher acuity patients could have been addressed and what interventions the ED staff nurses might have done had the patient surge been a reality. Students addressed moving admitted patients to waiting units and discharging all patients who no longer needed immediate care. They also identified potential problems in discharging patients whose homes may have been affected by the weather and flooding. Discussions ensued regarding sheltering those who could not go home and listing resources that would be needed to house them.
The reflective journals for that same simulation event revealed a multitude of feelings. Most students were glad for the opportunity to participate in the drill so they would have an idea of what to expect in the event of a true disaster incident in their communities. Several students commented that they had not thought about the rest of the facility and how the additional surge of patients could have been accommodated. Students noted that they could not understand why some staff did not take the exercise seriously, pointing out the need to be better prepared in the event of a real disaster. Students also suggested that future classes might benefit from observing other departments’ roles during the simulation exercise to gain a better understanding of how everyone’s roles “fit together.” This started the flow of ideas for how to improve the assignment the next time students were invited to participate in a simulation exercise.
The following year, senior nursing students in the Leadership and Management in Nursing course were again asked to participate in the simulation exercise. Based on the prior simulation experience, the course coordinator and the director of safety and security expanded student roles to leadership roles during the exercise to better align with course objectives as well as provide the students with a more global perspective of interprofessional collaboration. Students received the same preexercise training as the previous year, including the BDLS course. The week of the scheduled drill, students again received the same alerts as the staff in preparation for the pending flurricane. This time, however, students were assigned a leadership role in the hospital’s disaster-management team and affected departments. This gave students practice in the critical thinking and decision making that would guide the course of the simulation exercise at the healthcare facility in not just the provider roles, but also in ancillary roles. The students were eager to be placed in leadership roles not only to gain experience in disaster response, but also to use their assessment and decision-making skills.
On the day of the simulation, students were introduced to the people in the leadership roles they were assigned to observe prior to the patient surge. This was so students would have time to discuss the responsibilities of the role and to orient themselves to the decision-making processes that would take place as the simulation exercise began. In each role, students were included in the evaluation of staffing needs, assignments, and patient-care management decisions to accommodate the surge. Students were also included in communications between departments and staff members as the simulation exercise began.
Table 4.1 lists the positions that students learned about, including basic positions that fit within the National Incident Management System (NIMS) doctrine as operationalized in the acute care setting.
Table 4.1. Disaster Simulation Exercise Leadership Role Observations for Nursing Students
|Role Description |
|Incident commander ||Overall coordination of facility departments |
|Communications coordinator ||Continuation of communication when the switchboard is shut down due to technology difficulties |
|Senior nursing officer ||Overall coordination of nursing units and staffing decisions |
|Labor pool coordinator ||Redistribution of staff to areas of need based on skill sets |
|ED triage RN ||Maintenance of flow of incoming ED patients, in addition to surge patients who circumvented the surge triage RN |
|ED staff RN ||Provision of care for nonpatients in addition to assessment of surge patients |
|ED physician ||Incorporation of surge patients in addition to current department patients |
|Surge triage RN ||Triage of patients arriving to ED related to the simulation |
|Inpatient unit directors ||Triage of inpatients to evaluate for possible discharges to make room for ED patients who could be admitted; calling in of additional staff to assist in management of surge |
|Long-term care unit director ||Evaluation for possible inpatients who are stable and pending discharge |
|Safety and security manager ||Overall coordination of safety and security concerns during the simulation exercise |
|Security officer ||Securing the facility’s perimeter and screening entry |
|Nonurgent care coordinator ||APRN role to provide care for and management of nonurgent patient flow |
|Case manager (RN) ||Screening of surge patients for needs related to the incident (for example, housing, medications, and other sheltering needs) |
Once again, after completing the drill, students met for debriefing with the course coordinator and the ED disaster management nurse. After this exercise, students reported that they felt very engaged in the process throughout the facility. They actively engaged in comparing experiences and noted positive and negative leadership styles, communication, and the overall interdisciplinary teamwork that was necessary for positive outcomes. Students reported that they were included in unit evaluations and decision-making processes such as staffing assignments and the movement of patients who were less acute. They were able to identify areas where communication between units as well as the management of patient flow could be improved.
When discussing specific leadership roles during the drill, students commented on the importance of communication and collaboration between the different inpatient departments and the nonpatient care roles. One student noted that the cellular telephone system that the facility planned to use to facilitate communication between the incident commander, communications coordinator, and labor pool coordinator was shut down due to a malfunction related to the simulation. A student had to serve as a “runner” between the coordinators as part of a decision to enhance and maintain communication between areas. Another student noted how different the security officer’s role was from what was expected. The student noted that he had not considered the need for the perimeter of the hospital to be secured to control traffic going in and out of the facility during the drill. Students assigned to inpatient unit director roles noted that not only did they have to meet the needs of current patients and staff, but they also had to find time to call in additional staff to help manage the surge. Several of the unit managers noted that if it were a true incident, many of the staff would not have been able to come in due to the flooding impact in their own communities. This led to further discussion on staffing needs in an emergency and how it would be handled from a leadership perspective.
Students assigned to nurses in the ED were able to take turns triaging surge patients, determining the level of care needed, and delegating to ancillary staff to transport patients to the correct care areas. Although local EMS did not participate in the simulation, some surge patients presented on stretchers to simulate arrival via ambulance and appropriate triage of higher acuity patients. Although a bottleneck was identified in the ED due to the large number of real patients, students assigned to the ED charge nurse role were guided through the simulation by one of the department nurses, who came in just for the simulation. Students were able to experience the decision-making process needed to manage the patient surge on top of an already busy ED and the responsibilities involved in those decisions.
Overall, the students’ debriefing conversations lasted approximately one hour. All student comments were recorded for the facility’s debriefing that afternoon and for the official report to be filed for the exercise. The consensus of the students prior to leaving the debriefing was an increased awareness of interprofessional teamwork and the fact that collaboration could make or break the exercise—and, therefore, a true disaster incident. As they shared their experiences of the day, students remarked that they had no idea that some of the situations their colleagues had witnessed had occurred at the time because they were so busy worrying about their own responsibilities. Their reflective journal assignments noted that they were glad to have participated and that they had a better idea of what would be expected of them professionally during a true disaster incident. Students also noted that they felt more confident in knowing what to expect in a surge situation and how to look at the bigger picture when making staffing and patient-management decisions.
Suggestion for next steps in nursing education
As nursing curricula incorporate the use of disaster nursing to enhance leadership skills in students, it is important to take IPE into account and consider extension beyond healthcare providers. This model may be further expanded to allow for collaboration of the nursing school and hospital campuses in addition to community agencies for a full-scale community. College and university campuses have also realized the need for having disaster plans in place but may not have the resources to thoroughly test them. Through collaboration with local healthcare facilities, EMS, and other community agencies, emergency plans may be implemented community wide. The better prepared the community is as a whole, the better the outcomes will be in the event of a disaster. As nursing curricula incorporate the use of disaster nursing to enhance leadership skills in students, it is important to take IPE into account and consider extension beyond healthcare providers. This model may be further expanded to allow for collaboration of the nursing school and hospital campuses in addition to community agencies for a full-scale community. College and university campuses have also realized the need for having disaster plans in place but may not have the resources to thoroughly test them. Through collaboration with local healthcare facilities, EMS, and other community agencies, emergency plans may be implemented community wide. The better prepared the community is as a whole, the better the outcomes will be in the event of a disaster.
This leaves the door wide open for practical experience in leadership decision-making training for all healthcare providers, beginning in their first educational experiences. By expanding roles in disaster- simulation exercises, students can experience the decision-making process firsthand. Through debriefing, they can then share those experiences from various perspectives. This increases the preparedness of our next generation of healthcare providers not only in the disaster cycle, but also in needed leadership positions throughout the healthcare workforce. Students will be more aware of their own roles in the decision-making process and how other resources will be affected. In addition, they will improve interprofessional communication skills that will lead to better patient outcomes.
The ever-changing landscape of health in disaster preparedness, response, and recovery demands that healthcare professionals be knowledgeable and ready to respond. Most healthcare providers will not work in disaster specialty positions. They will, however, bring their practice to disaster incidents, making a positive difference for their communities. Nurses represent the largest group of providers in the healthcare workforce. Over the past 2 decades, they have continued to become more actively involved in all aspects of preparedness, response, and recovery in various clinical and leadership capacities. Incorporating disaster education core competencies into a nursing curriculum not only meets accreditation standards, it can encourage strength in leadership as well as IPE and collaboration for future generations of healthcare providers.
- Nursing leadership is not an optional role. Leadership exists and must be demonstrated on a daily basis to strengthen and achieve high standards of care and positive health changes.
- There are many known instructional methods to instill and strengthen leadership skills for all levels of nursing students. These include participation in community partnerships, projects to promote healthy lifestyle changes such as health fairs, pairing as peer mentors, service- learning, and simulation exercises.
- Participation in disaster simulation provides a great resource for transformational leadership through active learning models that enhance leadership, critical-thinking, decision-making, and crisis-management skills in a safe but high-pressure setting.
- Student leadership experiences in disaster simulation should include the following:
- Exposure of students to leadership positions beyond the usual clinical facilities, to include partnership community agencies and organizations
- Simulation exercise scenarios in an interprofessional environment
- Exposure to templates to record key observations and immediate thoughts on roles and any circumstances they did or did not expect
- A debriefing session that is separate from that of the exercise’s formal debriefing to ensure learning objectives and student responses are evaluated
- A guided reflective written assignment, based on leadership principles, turned in within 24 hours of the exercise RNL
Sharon A. R. Stanley, PhD, RN, RS, FAAN, COL (ret.) has served over 35 years in public health at local, state, and national levels and is an Army veteran with Vietnam, Desert Storm, and OIF/OEF service. From 2009 to 2013, she was chief nurse of the American Red Cross. Thola A. Bennecoff Wolanski, MSN, RN, is assistant professor of nursing education at Elmira College and a Doctor of Nursing Practice candidate at Loyola University in Chicago. Wolanski developed the leadership model for disaster preparedness training that is presented in this text.
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