Consider the children:
Pediatric disaster planning By Catherine J. Goodhue, MN, CPNP; Ann C. Lin, BS; Rita V. Burke, PhD, MPH; Bridget M. Berg, MPH; and Jeffrey S. Upperman, MD
44
November 2013 • Nursing Management
www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
R
e ecent large-scale disasters, both natural and manb made, have profoundly m impacted the pediatric i population, resulting in p significant injuries and s death. Examples include d the t Russian Beslan school hostage crisis in 2004 and h the Haiti earthquake in t 2010, both of which resulted in a disproportionately large number of pediatric deaths.1,2 Although it’s impossible to fully anticipate the needs of pediatric victims during mass casualty events, it is possible to identify the needs of special patient populations ahead of time and implement plans to reduce their risk of harm during a crisis. Children have unique anatomical, physiological, developmental, and psychological characteristics that make them especially vulnerable.3-5 Healthcare providers must be aware of these considerations to appropriately treat pediatric victims in disaster situations. Nurses make up the single largest group of healthcare workers in the United States and are the primary providers of patient care in hospitals.6 Currently, the United States faces a substantial nursing shortage, despite employing over 3 million RNs.7 This translates into an even more limited number of healthcare providers with pediatric expertise. Combined with a lack of sufficient pediatric equipment and supplies in nonspecialty facilities (such as a general hospital), this shortage forecasts that an influx of pediatric victims could rapidly overwhelm both healthcare workers and their organizations.8 What are the implications of the current nursing shortage on hospital pediatric surge capacity and outcomes? We provide recommendations to address the nursing shortage in terms of pediatric disaster preparedness.
www.nursingmanagement.com
U.S. nursing shortage The United States has been experiencing a shortage of RNs since the late 1990s, with the growing healthcare demands of an aging population outstripping the supply of new nurse graduates.9 In 2008, approximately 62% of employed nurses worked in a hospital setting.10 This is an increase from 57% in 2004 (the first increase since 1984).10 Despite this growth in employment, forecasts predict the nursing shortage will only continue to worsen over the next two decades, especially in the southern and western United States.9 Models of the nursing shortage have identified age and age-related issues as the main triggers for the shortage.9,11 Particularly concerning is the simultaneous increase in demand and decrease in supply caused by aging.9 Baby boomers comprise a majority of the RN workforce, and their impending retirement, as well as their own increasing medical needs, aren’t being counterbalanced by adequate numbers of young and newly trained nurses.10,12 Other contributing factors to this prolonged shortage include an everchanging work environment, negative perceptions of nursing, and high hospital turnover rates.13,14 More nursing shortage issues arise in nursing education. The ever-expanding opportunities available to young adults have resulted in decreased enrollment in nursing programs.12 Additionally, the American Association of Colleges of Nursing reports that 75,587 qualified applicants were turned away from U.S. nursing schools in 2011 due to insufficient faculty, clinical sites, and funding.7 The limited availability of faculty members is primarily due to retirement and lack of qualified replacements—fewer nurses are pursuing graduate degrees to fill these open teaching
Nursing Management • November 2013 45
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Consider the children: Pediatric disaster planning
positions.13,14 This has been attributed to low salaries, high educational costs, and general lack of interest in nursing education careers.15,16 Currently, specific estimates of the pediatric nursing shortage aren’t available.17 One study merged data from an American Hospital Association survey and the U.S. Census Bureau, finding significant variability between states in terms of available pediatric hospital beds and pediatric RN full-time equivalents.18 A survey of U.S. schools of nursing indicates a widespread belief that a pediatric nursing faculty shortage exists, and that such a shortage will adversely affect the availability and quality of pediatric nursing education, as well as the recruitment of new graduates into pediatric nursing.19 This paucity of relevant literature demonstrates the need for further investigation into the supply-anddemand dynamics of pediatric care, and also raises concerns about the available supply of pediatric nurses.
Pediatric surge capacity Surge capacity is a healthcare facility’s ability to handle an influx of victims in the event of a disaster.20 Current guidelines suggest that surge preparations should accommodate 500 new patients per million people in a disaster, or a 300% increase in capacity.21 Besides the usual concerns about quality of care and provisions, a pediatric mass casualty event elicits additional considerations. The availability of pediatric specialty equipment and staffing needs to be considered. A 2003 national survey of EDs indicates that only 6% had all the recommended pediatric equipment.8 A quantitative simulation study simulated a typical region’s ability to accommodate pediatric critical 46
care surge during a widespread emergency (such as an influenza pandemic) when considering manpower, equipment, and protocol.22 The study found that using mass critical care approaches, such as postponing less-urgent routine procedures and conserving and reusing resources, allows existing resources to accommodate a moderate pandemic surge, but would be inadequate during a severe surge, leaving some patients without necessary intensive care.15 This quantitative model projected pandemic conditions based on federal surge guidelines, with the typical region facing a total of 211 and 2,431 children requiring PICU care during moderate and severe pandemics, respectively.15 The nursing shortage has several key implications on pediatric surge capacity during large-scale disasters. Simplistically, the low number of nurses available for response, especially those trained in pediatrics, means fewer responders well versed in the specialized nature of pediatric care. Additionally, studies report that the number of pediatric healthcare workers who actually respond during a disaster is complicated by their own safety and welfare, concern for family, and dependent care responsibilities.23-26 Due to fundamental physical and mental differences, injured children often require alternate and more intense care plans than adults.3-5 Common challenges encountered during disaster scenarios include inability to communicate or follow directions, varying normal vital sign ranges, propensity for respiratory infections, and unstable temperature control.4,5 For healthcare providers accustomed to adult patients, these pediatric distinctions could compromise the timely devel-
November 2013 • Nursing Management
opment of appropriate treatment plans. In a survey of healthcare providers who cared for victims of Hurricanes Katrina and Rita, many reported unfamiliarity with the standards of appropriate care required by their pediatric victims.27 In terms of disaster training and education, the effect is twofold. Understaffed hospitals are unable to spare RNs for disaster education, continuing education (CE), or disaster drills, creating clinicians who are unprepared for a disaster situation. Training has been directly related to willingness to respond during a disaster.24,26 A survey of pediatric NPs identified several factors that would increase willingness to respond: having family disaster plans in place, disaster training, and preassigned roles in disaster plans.26 Lastly, understaffed hospitals (caused by the nursing shortage) promote a high-stress work environment due to increases in workload, patient ratios, strain, work hours, and number of shifts. Poor work environment has been shown to be a main cause of nursing burnout and lower retention rates, which further exacerbates the nursing shortage.13,14 However, such an environment could prepare healthcare providers for disaster response by acclimating them to the pace and surge of patients they’d treat during a disaster. A model of the nursing shortage’s impact on pediatric surge capacity during potential disasters is presented in Figure 1.
Prepping for the inevitable Currently, the disaster preparedness infrastructure of the United States lacks pediatric elements, and most organizations are ill prepared for a large influx of pediatric disaster victims.8,28,29 At the time of the 9/11 tragedy, there were no pediatricspecific evacuation plans or pediatwww.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ric practitioner mobilization plans in place.30 A national survey found that only 13% of emergency medical services agencies have pediatric mass casualty protocols.28 In light of recent disasters, where children make up a majority of the victim pool, considerations for primary pediatric events, as well as general pediatric disasters, need to be integrated into regional systems of care. At the most fundamental level, current disaster preparedness plans need to be assessed and altered accordingly for the inclusion of pediatric victims. Effective hospital- and communitybased pediatric disaster management systems focus on comprehensive training in pediatric care for staff, use of pediatric disaster management tools, and extensive disaster planning and practicing in the community.21,31-33 In light of the nursing shortage, the pediatric critical care community will need to consider strategies to increase the number of nurses trained in pediatrics, as well as modify pediatric disaster preparedness plans to adapt to the shortage. (See supplemental content on the Nursing Management iPad app.) One of the first issues that must be addressed is the nursing shortage. There needs to be a twopronged approach to correcting this problem: develop effective retention plans at hospitals and encourage students to pursue a career in nursing. To retain qualified nurses, employers need to address the key factors identified in hospital RN turnover. Nurses’ increasing dissatisfaction with their work climate can be reversed by improving personnel policies and benefits, designing more flexible schedules, and mandating nurse-patient ratios to relieve stress and strain.12,13 More opportunities for career advancement will also promote nursing as a lifelong career with room for growth.13 Recruitment efforts need to be aimed primarily www.nursingmanagement.com
Figure 1: Impact of the nursing shortage on disaster pediatric surge capacity
NURSING SHORTAGE
KEY = Promotes = Inhibits
Less training
Low number of nurses
Stressful work environment
INCREASED DISASTER PEDIATRIC SURGE CAPACITY
at young adults, especially men and minority ethnic groups, and need to start earlier—at high school or even grade school levels.13 Hospitals and schools of nursing must employ competent faculty. As mentioned previously, qualified nursing school applicants are being turned away because of limited numbers of faculty.11 Practicing RNs should be encouraged to pursue advanced degrees in preparation for careers as professors through the use of financial aid support and wage incentives. The time lag between receiving a bachelor’s of science in nursing degree and returning to graduate school should be minimized by exploring graduate opportunities during undergraduate studies.13 Mentorship programs aimed at facilitating recruitment and retention of faculty can provide a source of guidance for interested applicants and prevent workload burnout by creating a support system for new faculty struggling to balance teaching, clinical practice, and research.16
Thinking outside of the box The unique instruction needed for disaster response calls for the
inclusion of more comprehensive disaster care training in nursing programs. When faced with a largescale disaster, healthcare workers may need to think outside the box. Disasters have been classified as routine (earthquakes, fires, hurricanes) versus crisis/nonroutine (mega-disaster flood events, such as Hurricane Katrina).34 Although routine scenarios prompt autonomic responses, crisis emergencies lack an executable script and require adaptability, creativity, and teamwork. Increased training will equip healthcare workers with more tactics when confronted with a megadisaster. The current emergency and disaster core competencies for both public health and hospital nurses don’t address all skill sets, and they haven’t been validated.27,35 A recent survey of faculty in baccalaureate nursing programs in Louisiana indicated that although faculty felt mass casualty incident education was important, most lacked the training and experience to teach such a subject.36 In addition, it’s imperative that healthcare workers be aware of the differences between pediatric critical care and adult critical care.
Nursing Management • November 2013 47
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Consider the children: Pediatric disaster planning
Few disaster readiness programs address the specific needs of pediatric victims, and previous efforts to educate pediatric care providers about disaster preparedness lacked important information.37 Programs such as the Pediatric Disaster Resource and Training Center (PDRTC) at Children’s Hospital Los Angeles and the pediatric disaster preparedness program developed in Ohio attempt to bridge the gaps in education in the care of children who succumb to injuries during a catastrophic event.37,38 The PDRTC has developed and implemented many disaster education and training sessions for both healthcare workers as well as the general community, such as a pediatric disaster training course for hospital staff and disaster education lessons conducted at faith-based organizations in South Los Angeles. Pediatric disaster preparation is a community-wide effort and should take place in hospitals, in schools, and at home. Pediatric disaster preparedness education should target hospital
employees, hospital administrators, families, teachers, and school system administrators.38 Practice-through drills have been found to boost preparedness and confidence more so than online courses, and weaknesses can be better identified and addressed through community-wide drills.38,39 For example, the PDRTC at Children’s Hospital Los Angeles organizes annual tri-hospital disaster drills to practice interagency coordination during a large pediatric disaster scenario, involving staff from neighboring hospitals, EMS personnel, the Los Angeles Department of Transportation, and local law enforcement. These drills should occur often and include a sufficient number of pediatric “victims.”31 Similarly, a wide variety of healthcare workers should be encouraged to participate in pediatric mass casualty drills at hospitals. Given the shortage of nurses, there exists a distinct possibility that nonspecialty providers or even nonclinical staff will need to fill the gaps in pediatric critical care in the event of a disaster.38
Table 1: Recommendations for improving pediatric disaster preparedness in the face of the nursing shortage Area
Recommendations
Planning
• Review current disaster preparedness plans for inclusion of pediatric victims; revise to include pediatric victims. • Develop effective nurse retention plans at hospitals.
Education
• • • •
Drills/training
• Drill with pediatric victims. • Encourage all healthcare workers to participate in pediatric disaster preparedness activities. • Discuss family disaster plans with pediatricians or primary care physicians.
Research
50
Encourage students to consider a career in nursing. Encourage and mentor colleagues to become nursing faculty. Develop disaster care into nursing program curricula. Develop disaster CE for practicing nurses.
• Study past events, such as Hurricane Katrina, for lessons learned. • Evaluate current methods of disaster training for effectiveness. • Investigate supply and demand dynamics of pediatric nursing.
November 2013 • Nursing Management
At the family level, pediatricians and primary care physicians play a crucial role in discussing preparedness and helping families develop a family emergency plan, as well as responding to questions during and after actual disasters.5,40 (See Table 1.)
Future preparations A number of factors affect the care of children in the event of a disaster. There still exists an alarming lack of awareness of pediatric considerations during disaster situations. In light of the current nursing shortage, efforts need to be made to both promote nursing as a profession and provide more focused pediatric disaster training for current nurses, as well as the general community. Future research should focus on several topics. Given the unforeseeable and heterogeneous nature of disasters, it’s imperative to analyze the responses and outcomes of a comprehensive range of past disasters, specific to the pediatric population, and to continually incorporate new knowledge into the development of disaster preparedness plans. Additionally, means of evaluating current methods of disaster training must be developed and implemented, and any necessary adjustments must be made to increase efficiency. Lastly, the supply and demand model of pediatric care needs to be better understood, and these models must be expanded to include disaster surge situations to facilitate the development of more pediatric disaster plans. NM REFERENCES 1. BBC News. Special report: Beslan school siege. http://news.bbc.co.uk/2/shared/ spl/hi/world/04/russian_s/html/1.stm. 2. BBC News. Special Report: Haiti earthquake. http://news.bbc.co.uk/2/hi/in_ depth/americas/2010/haiti_earthquake/ default.stm. 3. Hohenhaus SM. Practical considerations www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for providing pediatric care in a mass casualty incident. Nurs Clin North Am. 2005;40(3):523-533, ix. 4. Markenson D, Redlener I. Pediatric terrorism preparedness national guidelines and recommendations: findings of an evidenced-based consensus process. Biosecur Bioterr. 2004;2(4):301-319. 5. Markenson D, Reynolds S, American Academy of Pediatrics Committee on Pediatric Emergency M, Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics. 2006;117(2):e340-e362. 6. American Association of Colleges of Nursing. Nursing fact sheet. http://www.aacn. nche.edu/media-relations/fact-sheets/ nursing-fact-sheet. 7. American Association of Colleges of Nursing. Nursing shortage fact sheet. http://www.aacn.nche.edu/mediarelations/fact-sheets/nursing-shortage. 8. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237. 9. Juraschek SP, Zhang X, Ranganathan V, Lin VW. United States registered nurse workforce report card and shortage forecast. Am J Med Qual. 2012;27(3):241-249. 10. U.S. Department of Health and Human Services Health Resources and Services Registration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. 2010. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf. 11. Siela D, Twibell KR, Keller V. The shortage of nurses and nursing faculty: what critical care nurses can do. AACN Adv Crit Care. 2008;19(1):66-77. 12. Fox RL, Abrahamson K. A critical examination of the U.S. nursing shortage: contributing factors, public policy implications. Nurs Forum. 2009;44(4):235-244. 13. Janiszewski Goodin H. The nursing shortage in the United States of America: an integrative review of the literature. J Adv Nurs. 2003;43(4):335–343. 14. Duvall JJ, Andrews DR. Using a structured review of the literature to identify key factors associated with the current nursing shortage. J Prof Nurs. 2010;26(5):309-317. 15. McDermid F, Peters K, Jackson D, Daly J. Factors contributing to the shortage of nurse faculty: a review of the literature. Nurs Educ Today. 2012;32(5):565-569. 16. Gerolamo AM, Roemer GF. Workload and the nurse faculty shortage: implications for policy and research. Nurs Outlook. 2011; 59(5):259.e1-265.e1. 17. Betz C. The call for health care reform and www.nursingmanagement.com
the pediatric nursing shortage. J Pediatr Nurs. 2009;24(5):347-349. 18. Lacey SR, Kilgore M, Yun H, Hughes R, Allison J, Cox KS. Secondary analysis of merged American Hospital Association data and U.S. Census data: beginning to understand the supply-demand chain in pediatric inpatient care. J Pediatr Nurs. 2008;23(3):161-168. 19. Leonard BJ, Fulkerson JA, Rose D, Christy A. Pediatric nurse educator shortage: implications for the nursing care of children. J Prof Nurs. 2008;24(3):184-191. 20. Markovitz BP. Pediatric critical care surge capacity. J Trauma. 2009;67(2 suppl): S140-S142. 21. Kelly F. Keeping PEDIATRICS in pediatric disaster management: before, during, and in the aftermath of complex emergencies. Crit Care Nurs Clin North Am. 2010;22(4): 465-480. 22. Kanter RK. Pediatric mass critical care in a pandemic. Pediatr Crit Care Med. 2012; 13(1):e1-e4. 23. Burke RV, Goodhue CJ, Chokshi NK, Upperman JS. Factors associated with willingness to respond to a disaster: a study of healthcare workers in a tertiary setting. Prehosp Disaster Med. 2011;26(4):244-250. 24. French ED, Sole ML, Byers JF. A comparison of nurses’ needs/concerns and hospital disaster plans following Florida’s Hurricane Floyd. J Emerg Nurs. 2002;28(2):111-117. 25. Qureshi K, Gershon RR, Sherman MF, et al. Health care workers’ ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005;82(3):378-388. 26. Goodhue CJ, Burke RV, Ferrer RR, Chokshi NK, Dorey F, Upperman JS. Willingness to respond in a disaster: a pediatric nurse practitioner national survey. J Pediatr Health Care. 2012;26(4):e7-e20. 27. Slepski LA. Emergency preparedness and professional competency among health care providers during hurricanes Katrina and Rita: pilot study results. Disaster Manag Response. 2007;5(4):99-110. 28. Shirm S, Liggin R, Dick R, Graham J. Prehospital preparedness for pediatric mass-casualty events. Pediatrics. 2007; 120(4):e756-e761. 29. Institute of Medicine. Emergency Care for Children: Growing Pains. Washington, DC: The National Acadamies Press; 2006. 30. Stamell EF, Foltin GL, Nadler EP. Lessons learned for pediatric disaster preparedness from September 11, 2001: New York City trauma centers. J Trauma. 2009;67(2 suppl): S84-S87. 31. Burke RV, Iverson E, Goodhue CJ, Neches R, Upperman JS. Disaster and mass casualty events in the pediatric population. Seminars
in pediatric surgery. Semin Pediatr Surg. 2010;19(4):265-270. 32. Kissoon N, Task Force for Pediatric Emergency Mass Critical Care Task Force. Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary. Pediatr Crit Care Med. 2011;12(6 suppl):S103-S108. 33. Lyle K, Thompson T, Graham J. Pediatric mass casualty: triage and planning for the prehospital provider. Clin. Pediatr. Emerg. Med. 2009;10(3):173-185. 34. Leonard HB, Howitt AM. Routine or crisis— the search for excellence. Crisis Response. 2008;4(3):32-35. 35. Littleton-Kearney MT, Slepski LA. Directions for disaster nursing education in the United States. Crit Care Nurs Clin North Am. 2008;20(1):103-109, viii. 36. Whitty KK, Burnett MF. The importance of instruction on mass casualty incidents in baccalaureate nursing programs: perceptions of nursing faculty. J Nurs Educ. 2009;48(5):291-295. 37. Fox L, Timm N. Pediatric issues in disaster preparedness: meeting the educational needs of nurses—are we there yet? J Pediatr Nurs. 2008;23(2):145-152. 38. Zmora O, Burke, RV, Upperman JS. Pediatric disaster preparedness education. J Bioterr Biodef. 2012;S5:002. 39. Charney RL, Lehman-Huskamp KL, Armbrecht ES, Flood RG. Impact of disaster drills on caregiver perception and satisfaction in the pediatric emergency department. Pediatr Emerg Care. 2011;27(11):1033-1037. 40. Olympia RP, Rivera R, Heverley S, Anyanwu U, Gregorits M. Natural disasters and mass-casualty events affecting children and families: a description of emergency preparedness and the role of the primary care physician. Clin Pediatri (Phila). 2010; 49(7):686-698. At the Children’s Hospital Los Angeles (Calif.), Catherine J. Goodhue is the research program manager of Pediatric Surgery, Ann Lin is the program assistant for the Trauma Program, Rita V. Burke is the senior research associate of Pediatric Surgery, Bridget M. Berg is the administrative manager at the Pediatric Disaster Resource and Training Center, and Jeffrey S. Upperman is the director of the Trauma Program and Pediatric Disaster Resource and Training Center and an associate professor of surgery at the University of Southern California’s Keck School of Medicine, Los Angeles. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000432222.09629.df
Nursing Management • November 2013 51
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric disaster planning By Catherine J. Goodhue, MN, CPNP; Ann C. Lin, BS; Rita V. Burke, PhD, MPH; Bridget M. Berg, MPH; and Jeffrey S. Upperman, MD
44
November 2013 • Nursing Management
www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
R
e ecent large-scale disasters, both natural and manb made, have profoundly m impacted the pediatric i population, resulting in p significant injuries and s death. Examples include d the t Russian Beslan school hostage crisis in 2004 and h the Haiti earthquake in t 2010, both of which resulted in a disproportionately large number of pediatric deaths.1,2 Although it’s impossible to fully anticipate the needs of pediatric victims during mass casualty events, it is possible to identify the needs of special patient populations ahead of time and implement plans to reduce their risk of harm during a crisis. Children have unique anatomical, physiological, developmental, and psychological characteristics that make them especially vulnerable.3-5 Healthcare providers must be aware of these considerations to appropriately treat pediatric victims in disaster situations. Nurses make up the single largest group of healthcare workers in the United States and are the primary providers of patient care in hospitals.6 Currently, the United States faces a substantial nursing shortage, despite employing over 3 million RNs.7 This translates into an even more limited number of healthcare providers with pediatric expertise. Combined with a lack of sufficient pediatric equipment and supplies in nonspecialty facilities (such as a general hospital), this shortage forecasts that an influx of pediatric victims could rapidly overwhelm both healthcare workers and their organizations.8 What are the implications of the current nursing shortage on hospital pediatric surge capacity and outcomes? We provide recommendations to address the nursing shortage in terms of pediatric disaster preparedness.
www.nursingmanagement.com
U.S. nursing shortage The United States has been experiencing a shortage of RNs since the late 1990s, with the growing healthcare demands of an aging population outstripping the supply of new nurse graduates.9 In 2008, approximately 62% of employed nurses worked in a hospital setting.10 This is an increase from 57% in 2004 (the first increase since 1984).10 Despite this growth in employment, forecasts predict the nursing shortage will only continue to worsen over the next two decades, especially in the southern and western United States.9 Models of the nursing shortage have identified age and age-related issues as the main triggers for the shortage.9,11 Particularly concerning is the simultaneous increase in demand and decrease in supply caused by aging.9 Baby boomers comprise a majority of the RN workforce, and their impending retirement, as well as their own increasing medical needs, aren’t being counterbalanced by adequate numbers of young and newly trained nurses.10,12 Other contributing factors to this prolonged shortage include an everchanging work environment, negative perceptions of nursing, and high hospital turnover rates.13,14 More nursing shortage issues arise in nursing education. The ever-expanding opportunities available to young adults have resulted in decreased enrollment in nursing programs.12 Additionally, the American Association of Colleges of Nursing reports that 75,587 qualified applicants were turned away from U.S. nursing schools in 2011 due to insufficient faculty, clinical sites, and funding.7 The limited availability of faculty members is primarily due to retirement and lack of qualified replacements—fewer nurses are pursuing graduate degrees to fill these open teaching
Nursing Management • November 2013 45
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Consider the children: Pediatric disaster planning
positions.13,14 This has been attributed to low salaries, high educational costs, and general lack of interest in nursing education careers.15,16 Currently, specific estimates of the pediatric nursing shortage aren’t available.17 One study merged data from an American Hospital Association survey and the U.S. Census Bureau, finding significant variability between states in terms of available pediatric hospital beds and pediatric RN full-time equivalents.18 A survey of U.S. schools of nursing indicates a widespread belief that a pediatric nursing faculty shortage exists, and that such a shortage will adversely affect the availability and quality of pediatric nursing education, as well as the recruitment of new graduates into pediatric nursing.19 This paucity of relevant literature demonstrates the need for further investigation into the supply-anddemand dynamics of pediatric care, and also raises concerns about the available supply of pediatric nurses.
Pediatric surge capacity Surge capacity is a healthcare facility’s ability to handle an influx of victims in the event of a disaster.20 Current guidelines suggest that surge preparations should accommodate 500 new patients per million people in a disaster, or a 300% increase in capacity.21 Besides the usual concerns about quality of care and provisions, a pediatric mass casualty event elicits additional considerations. The availability of pediatric specialty equipment and staffing needs to be considered. A 2003 national survey of EDs indicates that only 6% had all the recommended pediatric equipment.8 A quantitative simulation study simulated a typical region’s ability to accommodate pediatric critical 46
care surge during a widespread emergency (such as an influenza pandemic) when considering manpower, equipment, and protocol.22 The study found that using mass critical care approaches, such as postponing less-urgent routine procedures and conserving and reusing resources, allows existing resources to accommodate a moderate pandemic surge, but would be inadequate during a severe surge, leaving some patients without necessary intensive care.15 This quantitative model projected pandemic conditions based on federal surge guidelines, with the typical region facing a total of 211 and 2,431 children requiring PICU care during moderate and severe pandemics, respectively.15 The nursing shortage has several key implications on pediatric surge capacity during large-scale disasters. Simplistically, the low number of nurses available for response, especially those trained in pediatrics, means fewer responders well versed in the specialized nature of pediatric care. Additionally, studies report that the number of pediatric healthcare workers who actually respond during a disaster is complicated by their own safety and welfare, concern for family, and dependent care responsibilities.23-26 Due to fundamental physical and mental differences, injured children often require alternate and more intense care plans than adults.3-5 Common challenges encountered during disaster scenarios include inability to communicate or follow directions, varying normal vital sign ranges, propensity for respiratory infections, and unstable temperature control.4,5 For healthcare providers accustomed to adult patients, these pediatric distinctions could compromise the timely devel-
November 2013 • Nursing Management
opment of appropriate treatment plans. In a survey of healthcare providers who cared for victims of Hurricanes Katrina and Rita, many reported unfamiliarity with the standards of appropriate care required by their pediatric victims.27 In terms of disaster training and education, the effect is twofold. Understaffed hospitals are unable to spare RNs for disaster education, continuing education (CE), or disaster drills, creating clinicians who are unprepared for a disaster situation. Training has been directly related to willingness to respond during a disaster.24,26 A survey of pediatric NPs identified several factors that would increase willingness to respond: having family disaster plans in place, disaster training, and preassigned roles in disaster plans.26 Lastly, understaffed hospitals (caused by the nursing shortage) promote a high-stress work environment due to increases in workload, patient ratios, strain, work hours, and number of shifts. Poor work environment has been shown to be a main cause of nursing burnout and lower retention rates, which further exacerbates the nursing shortage.13,14 However, such an environment could prepare healthcare providers for disaster response by acclimating them to the pace and surge of patients they’d treat during a disaster. A model of the nursing shortage’s impact on pediatric surge capacity during potential disasters is presented in Figure 1.
Prepping for the inevitable Currently, the disaster preparedness infrastructure of the United States lacks pediatric elements, and most organizations are ill prepared for a large influx of pediatric disaster victims.8,28,29 At the time of the 9/11 tragedy, there were no pediatricspecific evacuation plans or pediatwww.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ric practitioner mobilization plans in place.30 A national survey found that only 13% of emergency medical services agencies have pediatric mass casualty protocols.28 In light of recent disasters, where children make up a majority of the victim pool, considerations for primary pediatric events, as well as general pediatric disasters, need to be integrated into regional systems of care. At the most fundamental level, current disaster preparedness plans need to be assessed and altered accordingly for the inclusion of pediatric victims. Effective hospital- and communitybased pediatric disaster management systems focus on comprehensive training in pediatric care for staff, use of pediatric disaster management tools, and extensive disaster planning and practicing in the community.21,31-33 In light of the nursing shortage, the pediatric critical care community will need to consider strategies to increase the number of nurses trained in pediatrics, as well as modify pediatric disaster preparedness plans to adapt to the shortage. (See supplemental content on the Nursing Management iPad app.) One of the first issues that must be addressed is the nursing shortage. There needs to be a twopronged approach to correcting this problem: develop effective retention plans at hospitals and encourage students to pursue a career in nursing. To retain qualified nurses, employers need to address the key factors identified in hospital RN turnover. Nurses’ increasing dissatisfaction with their work climate can be reversed by improving personnel policies and benefits, designing more flexible schedules, and mandating nurse-patient ratios to relieve stress and strain.12,13 More opportunities for career advancement will also promote nursing as a lifelong career with room for growth.13 Recruitment efforts need to be aimed primarily www.nursingmanagement.com
Figure 1: Impact of the nursing shortage on disaster pediatric surge capacity
NURSING SHORTAGE
KEY = Promotes = Inhibits
Less training
Low number of nurses
Stressful work environment
INCREASED DISASTER PEDIATRIC SURGE CAPACITY
at young adults, especially men and minority ethnic groups, and need to start earlier—at high school or even grade school levels.13 Hospitals and schools of nursing must employ competent faculty. As mentioned previously, qualified nursing school applicants are being turned away because of limited numbers of faculty.11 Practicing RNs should be encouraged to pursue advanced degrees in preparation for careers as professors through the use of financial aid support and wage incentives. The time lag between receiving a bachelor’s of science in nursing degree and returning to graduate school should be minimized by exploring graduate opportunities during undergraduate studies.13 Mentorship programs aimed at facilitating recruitment and retention of faculty can provide a source of guidance for interested applicants and prevent workload burnout by creating a support system for new faculty struggling to balance teaching, clinical practice, and research.16
Thinking outside of the box The unique instruction needed for disaster response calls for the
inclusion of more comprehensive disaster care training in nursing programs. When faced with a largescale disaster, healthcare workers may need to think outside the box. Disasters have been classified as routine (earthquakes, fires, hurricanes) versus crisis/nonroutine (mega-disaster flood events, such as Hurricane Katrina).34 Although routine scenarios prompt autonomic responses, crisis emergencies lack an executable script and require adaptability, creativity, and teamwork. Increased training will equip healthcare workers with more tactics when confronted with a megadisaster. The current emergency and disaster core competencies for both public health and hospital nurses don’t address all skill sets, and they haven’t been validated.27,35 A recent survey of faculty in baccalaureate nursing programs in Louisiana indicated that although faculty felt mass casualty incident education was important, most lacked the training and experience to teach such a subject.36 In addition, it’s imperative that healthcare workers be aware of the differences between pediatric critical care and adult critical care.
Nursing Management • November 2013 47
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Consider the children: Pediatric disaster planning
Few disaster readiness programs address the specific needs of pediatric victims, and previous efforts to educate pediatric care providers about disaster preparedness lacked important information.37 Programs such as the Pediatric Disaster Resource and Training Center (PDRTC) at Children’s Hospital Los Angeles and the pediatric disaster preparedness program developed in Ohio attempt to bridge the gaps in education in the care of children who succumb to injuries during a catastrophic event.37,38 The PDRTC has developed and implemented many disaster education and training sessions for both healthcare workers as well as the general community, such as a pediatric disaster training course for hospital staff and disaster education lessons conducted at faith-based organizations in South Los Angeles. Pediatric disaster preparation is a community-wide effort and should take place in hospitals, in schools, and at home. Pediatric disaster preparedness education should target hospital
employees, hospital administrators, families, teachers, and school system administrators.38 Practice-through drills have been found to boost preparedness and confidence more so than online courses, and weaknesses can be better identified and addressed through community-wide drills.38,39 For example, the PDRTC at Children’s Hospital Los Angeles organizes annual tri-hospital disaster drills to practice interagency coordination during a large pediatric disaster scenario, involving staff from neighboring hospitals, EMS personnel, the Los Angeles Department of Transportation, and local law enforcement. These drills should occur often and include a sufficient number of pediatric “victims.”31 Similarly, a wide variety of healthcare workers should be encouraged to participate in pediatric mass casualty drills at hospitals. Given the shortage of nurses, there exists a distinct possibility that nonspecialty providers or even nonclinical staff will need to fill the gaps in pediatric critical care in the event of a disaster.38
Table 1: Recommendations for improving pediatric disaster preparedness in the face of the nursing shortage Area
Recommendations
Planning
• Review current disaster preparedness plans for inclusion of pediatric victims; revise to include pediatric victims. • Develop effective nurse retention plans at hospitals.
Education
• • • •
Drills/training
• Drill with pediatric victims. • Encourage all healthcare workers to participate in pediatric disaster preparedness activities. • Discuss family disaster plans with pediatricians or primary care physicians.
Research
50
Encourage students to consider a career in nursing. Encourage and mentor colleagues to become nursing faculty. Develop disaster care into nursing program curricula. Develop disaster CE for practicing nurses.
• Study past events, such as Hurricane Katrina, for lessons learned. • Evaluate current methods of disaster training for effectiveness. • Investigate supply and demand dynamics of pediatric nursing.
November 2013 • Nursing Management
At the family level, pediatricians and primary care physicians play a crucial role in discussing preparedness and helping families develop a family emergency plan, as well as responding to questions during and after actual disasters.5,40 (See Table 1.)
Future preparations A number of factors affect the care of children in the event of a disaster. There still exists an alarming lack of awareness of pediatric considerations during disaster situations. In light of the current nursing shortage, efforts need to be made to both promote nursing as a profession and provide more focused pediatric disaster training for current nurses, as well as the general community. Future research should focus on several topics. Given the unforeseeable and heterogeneous nature of disasters, it’s imperative to analyze the responses and outcomes of a comprehensive range of past disasters, specific to the pediatric population, and to continually incorporate new knowledge into the development of disaster preparedness plans. Additionally, means of evaluating current methods of disaster training must be developed and implemented, and any necessary adjustments must be made to increase efficiency. Lastly, the supply and demand model of pediatric care needs to be better understood, and these models must be expanded to include disaster surge situations to facilitate the development of more pediatric disaster plans. NM REFERENCES 1. BBC News. Special report: Beslan school siege. http://news.bbc.co.uk/2/shared/ spl/hi/world/04/russian_s/html/1.stm. 2. BBC News. Special Report: Haiti earthquake. http://news.bbc.co.uk/2/hi/in_ depth/americas/2010/haiti_earthquake/ default.stm. 3. Hohenhaus SM. Practical considerations www.nursingmanagement.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
for providing pediatric care in a mass casualty incident. Nurs Clin North Am. 2005;40(3):523-533, ix. 4. Markenson D, Redlener I. Pediatric terrorism preparedness national guidelines and recommendations: findings of an evidenced-based consensus process. Biosecur Bioterr. 2004;2(4):301-319. 5. Markenson D, Reynolds S, American Academy of Pediatrics Committee on Pediatric Emergency M, Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics. 2006;117(2):e340-e362. 6. American Association of Colleges of Nursing. Nursing fact sheet. http://www.aacn. nche.edu/media-relations/fact-sheets/ nursing-fact-sheet. 7. American Association of Colleges of Nursing. Nursing shortage fact sheet. http://www.aacn.nche.edu/mediarelations/fact-sheets/nursing-shortage. 8. Gausche-Hill M, Schmitz C, Lewis RJ. Pediatric preparedness of US emergency departments: a 2003 survey. Pediatrics. 2007;120(6):1229-1237. 9. Juraschek SP, Zhang X, Ranganathan V, Lin VW. United States registered nurse workforce report card and shortage forecast. Am J Med Qual. 2012;27(3):241-249. 10. U.S. Department of Health and Human Services Health Resources and Services Registration. The registered nurse population: findings from the 2008 National Sample Survey of Registered Nurses. 2010. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf. 11. Siela D, Twibell KR, Keller V. The shortage of nurses and nursing faculty: what critical care nurses can do. AACN Adv Crit Care. 2008;19(1):66-77. 12. Fox RL, Abrahamson K. A critical examination of the U.S. nursing shortage: contributing factors, public policy implications. Nurs Forum. 2009;44(4):235-244. 13. Janiszewski Goodin H. The nursing shortage in the United States of America: an integrative review of the literature. J Adv Nurs. 2003;43(4):335–343. 14. Duvall JJ, Andrews DR. Using a structured review of the literature to identify key factors associated with the current nursing shortage. J Prof Nurs. 2010;26(5):309-317. 15. McDermid F, Peters K, Jackson D, Daly J. Factors contributing to the shortage of nurse faculty: a review of the literature. Nurs Educ Today. 2012;32(5):565-569. 16. Gerolamo AM, Roemer GF. Workload and the nurse faculty shortage: implications for policy and research. Nurs Outlook. 2011; 59(5):259.e1-265.e1. 17. Betz C. The call for health care reform and www.nursingmanagement.com
the pediatric nursing shortage. J Pediatr Nurs. 2009;24(5):347-349. 18. Lacey SR, Kilgore M, Yun H, Hughes R, Allison J, Cox KS. Secondary analysis of merged American Hospital Association data and U.S. Census data: beginning to understand the supply-demand chain in pediatric inpatient care. J Pediatr Nurs. 2008;23(3):161-168. 19. Leonard BJ, Fulkerson JA, Rose D, Christy A. Pediatric nurse educator shortage: implications for the nursing care of children. J Prof Nurs. 2008;24(3):184-191. 20. Markovitz BP. Pediatric critical care surge capacity. J Trauma. 2009;67(2 suppl): S140-S142. 21. Kelly F. Keeping PEDIATRICS in pediatric disaster management: before, during, and in the aftermath of complex emergencies. Crit Care Nurs Clin North Am. 2010;22(4): 465-480. 22. Kanter RK. Pediatric mass critical care in a pandemic. Pediatr Crit Care Med. 2012; 13(1):e1-e4. 23. Burke RV, Goodhue CJ, Chokshi NK, Upperman JS. Factors associated with willingness to respond to a disaster: a study of healthcare workers in a tertiary setting. Prehosp Disaster Med. 2011;26(4):244-250. 24. French ED, Sole ML, Byers JF. A comparison of nurses’ needs/concerns and hospital disaster plans following Florida’s Hurricane Floyd. J Emerg Nurs. 2002;28(2):111-117. 25. Qureshi K, Gershon RR, Sherman MF, et al. Health care workers’ ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005;82(3):378-388. 26. Goodhue CJ, Burke RV, Ferrer RR, Chokshi NK, Dorey F, Upperman JS. Willingness to respond in a disaster: a pediatric nurse practitioner national survey. J Pediatr Health Care. 2012;26(4):e7-e20. 27. Slepski LA. Emergency preparedness and professional competency among health care providers during hurricanes Katrina and Rita: pilot study results. Disaster Manag Response. 2007;5(4):99-110. 28. Shirm S, Liggin R, Dick R, Graham J. Prehospital preparedness for pediatric mass-casualty events. Pediatrics. 2007; 120(4):e756-e761. 29. Institute of Medicine. Emergency Care for Children: Growing Pains. Washington, DC: The National Acadamies Press; 2006. 30. Stamell EF, Foltin GL, Nadler EP. Lessons learned for pediatric disaster preparedness from September 11, 2001: New York City trauma centers. J Trauma. 2009;67(2 suppl): S84-S87. 31. Burke RV, Iverson E, Goodhue CJ, Neches R, Upperman JS. Disaster and mass casualty events in the pediatric population. Seminars
in pediatric surgery. Semin Pediatr Surg. 2010;19(4):265-270. 32. Kissoon N, Task Force for Pediatric Emergency Mass Critical Care Task Force. Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: executive summary. Pediatr Crit Care Med. 2011;12(6 suppl):S103-S108. 33. Lyle K, Thompson T, Graham J. Pediatric mass casualty: triage and planning for the prehospital provider. Clin. Pediatr. Emerg. Med. 2009;10(3):173-185. 34. Leonard HB, Howitt AM. Routine or crisis— the search for excellence. Crisis Response. 2008;4(3):32-35. 35. Littleton-Kearney MT, Slepski LA. Directions for disaster nursing education in the United States. Crit Care Nurs Clin North Am. 2008;20(1):103-109, viii. 36. Whitty KK, Burnett MF. The importance of instruction on mass casualty incidents in baccalaureate nursing programs: perceptions of nursing faculty. J Nurs Educ. 2009;48(5):291-295. 37. Fox L, Timm N. Pediatric issues in disaster preparedness: meeting the educational needs of nurses—are we there yet? J Pediatr Nurs. 2008;23(2):145-152. 38. Zmora O, Burke, RV, Upperman JS. Pediatric disaster preparedness education. J Bioterr Biodef. 2012;S5:002. 39. Charney RL, Lehman-Huskamp KL, Armbrecht ES, Flood RG. Impact of disaster drills on caregiver perception and satisfaction in the pediatric emergency department. Pediatr Emerg Care. 2011;27(11):1033-1037. 40. Olympia RP, Rivera R, Heverley S, Anyanwu U, Gregorits M. Natural disasters and mass-casualty events affecting children and families: a description of emergency preparedness and the role of the primary care physician. Clin Pediatri (Phila). 2010; 49(7):686-698. At the Children’s Hospital Los Angeles (Calif.), Catherine J. Goodhue is the research program manager of Pediatric Surgery, Ann Lin is the program assistant for the Trauma Program, Rita V. Burke is the senior research associate of Pediatric Surgery, Bridget M. Berg is the administrative manager at the Pediatric Disaster Resource and Training Center, and Jeffrey S. Upperman is the director of the Trauma Program and Pediatric Disaster Resource and Training Center and an associate professor of surgery at the University of Southern California’s Keck School of Medicine, Los Angeles. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NUMA.0000432222.09629.df
Nursing Management • November 2013 51
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
