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PEDIATRIC MASS-CASUALTY EDUCATION: EXPERIENTIAL LEARNING THROUGH UNIVERSITY-SPONSORED DISASTER SIMULATION Authors: Elizabeth N. Austin, PhD, MA, RN, CNE, CEN, Serap E. Bastepe-Gray, MD, H. Wayne Nelson, PhD, Judith Breitenbach, MS, RN, Kathleen T. Ogle, PhD, RN, FNP-BC, Angela Durry, MSN, RN, Sheila D. Green, PhD, RN, Lisa A. Crabtree, PhD, OTR/L, and Mindy Haluska, MS, RN, Towson and Hagerstown, MD
hildren are highly vulnerable in disaster situations and have specific and unique disaster-related health care needs. 1 Coordination and planning of disaster response that meets the needs of pediatric victims require specialized training opportunities. 2 Nurses have expressed a lack of confidence in their ability to respond to disasters. 3 Emergency nurses have reported a lack of education in emergency planning and preparedness. 4 Academic institutions are uniquely poised to assuage these problems and promote community disaster resilience by forging synergistic partnerships among schools of all age groups, emergency planners and practitioners, private citizens, and organizations. 5,6 However, experiential models for such partnerships are scarce in the literature. The purpose of this paper is to describe Operation STAT 2013, a mass-casualty drill in an
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Elizabeth N. Austin, Member, Metropolitan Baltimore Chapter, is Assistant Professor, Department of Nursing, and Director, Integrated Homeland Security Management, Towson University, Towson, MD. Serap E. Bastepe-Gray is Graduate Student, Towson University, Towson, MD. H. Wayne Nelson is Professor and Chair, Department of Interprofessional Health Studies, Towson University, Towson, MD. Judith Breitenbach is Clinical Assistant Professor and Nursing Programs Director, University System of Maryland at Hagerstown, Department of Nursing, Towson University, Hagerstown, MD. Kathleen T. Ogle is Associate Professor, Interim Chair, and Director, Graduate Nursing Program, Towson University, Towson, MD. Angela Durry is Clinical Assistant Professor, Department of Nursing, Towson University, Towson, MD. Sheila D. Green is Assistant Professor and Assistant Chair, Department of Nursing, Towson University, Towson, MD. Lisa A. Crabtree is Assistant Professor, Department of Occupational Therapy, Towson University, Towson, MD. Mindy Haluska is Clinical Assistant Professor, Department of Nursing, Towson University, Towson, MD. For correspondence, write: Elizabeth N. Austin, PhD, MA, RN, CNE, CEN, Department of Nursing, Towson University, 8000 York Rd, Towson, MD 21252; E-mail: [email protected]. J Emerg Nurs 2014;40:428-34. 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.05.015
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academic setting that incorporated local middle and high school students with health professions students. Background DISASTER SIMULATION TRENDS
Complex, large-scale medical surge and triage preparedness drills are designed to simulate a disaster context and involve civilian and military partners, including a broad spectrum of emergency experts, as well as local schools and community groups. 4,5,7–9 Annual drills provide nursing and other college students, faculty, community members, and partner organizations opportunities to experience a mass-casualty drill in a safe environment; this might help them function better in their formal or informal everyday roles should they be involved in a disaster. 5,6 University partnerships with the Medical Reserve Corps (MRC) have proven valuable in providing a range of disaster education and community outreach initiatives as evidenced by relationships between the military-based Texas State Guard’s MRC and the University of Texas Health Science Center at San Antonio 7; by a similar, albeit civilian MRC relationship at the School of Medicine at the University of Virginia 10; and by nursing programs at Lander University, Vanderbilt University, and the University of South Carolina. Academic, civilian-military grassroots partnerships provide skill groups and equipment that might not otherwise be available to the sponsoring universities. Those partner organizations could have physicians; nurses; emergency medical technicians; communications, command, and security experts; and others who prepare to act as vital surge force multipliers augmenting first responders in times of public need to boost community resiliency and tightening the fabric of the national health infrastructure. 11,12 Nursing curricula are challenged to provide meaningful educational opportunities to meet accreditation requirements that include disaster and mass-casualty education. The American Association of Colleges of Nursing recently revised The Essentials of Baccalaureate Education for Professional Nursing Practice. 13 The Essentials document provides the competency standards for baccalaureate nursing programs in
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TABLE 1
Operation STAT whole-community disaster education partners and participants Partner/participant
Exercise role
Local emergency management task force (n = 3) Local office of emergency management (n = 2) Local health department (n = 2) Interprofessional university collaborators: faculty and students from the Office of Collaborative Programs (n = 2), nursing (36 students and 11 faculty), health care management (n = 2), gerontology (n = 1), and occupational therapy (n = 25) Local seventh-grade students, faculty, and staff (n = 94) Local high school students, faculty, and staff (n = 24) from program in homeland security and emergency preparedness State department of health and mental hygiene (n = 2) State emergency medical services (n = 1) MRC (n = 15) including physicians, PAs, RNs, and EMTs Fraternity and sorority life students (n = 50) Public information personnel (university, press, military) (n = 5)
Planning committee and resource assistance Observers/evaluators Observers/evaluators Crowd control, safety support, registration, patient and equipment tracking, nursing care, and mental health care
Scripted and student victims, faculty, and parents Smart victims, shadowed professional mentors in areas of interest
Mental health team/evaluators Observer and evaluator Clinical support: physicians, PAs, EMTs, nurses, security, communications, and administration Victims, registration, and breakdown Report drill, impact on community, student education, and emergency collaborations
EMTs, Emergency medical technicians; MRC, Medical Reserve Corps; PA, physician assistant; RNs, registered nurses.
the United States. Standard VII addresses the application of “clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.” 13 OPERATION STAT: AN ANNUAL DRILL
Operation STAT is a “bottom-up” initiative to improve whole-community resiliency. A key educational goal is to introduce nursing students to patient assessment, triage, and nursing interventions in mass-casualty situations.
National Guard; state, city, and county emergency planners; and other area MRCs, including an MRC funeral directors unit that specializes in disaster body recovery and disposition. 6 Those assuming the role of victims, which number in the hundreds, have included fraternity and sorority members and other students, faculty, a growing number of volunteers from community groups across the lifespan including Area Agency on Aging volunteers, and students at all grade levels. Operation STAT 2013 PARTICIPANTS
INTERAGENCY AND INTERPROFESSIONAL STRUCTURE OF OPERATION STAT
From its inception, Operation STAT planning and delivery were coordinated, to a significant extent, by the university-sponsored military MRC unit from the Maryland Defense Force. The MRC provided support to Operation STAT by providing health care teams, safety and security personnel, communications experts and equipment, incident command staff, and other key personnel. 5 Other Operation STAT partners have included representatives of various police and fire departments; the
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Participants in Operation STAT 2013 (Table 1) included approximately 250 people from 2 university campuses, 1 middle school (Friends School of Baltimore), 1 high school (Joppatowne High School), and the Maryland Defense Force. Other partners were the local office of emergency management and the local representative from the state emergency medical services region. Regarding the protection of human subjects, the university institutional review board granted approval (No. 13-A055) for the evaluation of Operation STAT
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FIGURE Operation STAT 2013 timeline.
2013. Participants were required to sign waivers indicating their agreement to participate and be photographed. Local television crews received instruction by the university public information officer prior to video coverage of the drill. Consent was obtained from all adult students, faculty, and staff, as well as a parent or guardian of each child. MINI CASE STUDY
To prepare the nursing students for the simulation, nursing faculty created a mini case study on the assessment of the school-aged child with closed head trauma and triage. The scenario involved an 8-year-old child who sustained a closed head injury and concussion subsequent to a fall from a tree house—an aftermath of an explosion in the neighborhood vicinity where the child lived. The objectives for this didactic experience were to prepare senior nursing student participants to 1 perform a focused pediatric assessment 2; incorporate disaster triage; and 3 prioritize, implement, and evaluate selected emergent nursing interventions. A pretest/post-test design was used to evaluate educational outcomes. SIMULATION
The simulation scenario was based on a non-terrorist explosion that resulted in hundreds of casualties and
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required the deployment of the MRC to increase medical surge capacity in the community. According to the scenario, local hospitals and resources were overwhelmed with casualties and Towson University created a masscasualty triage and treatment site. Everyone received safety briefings and education regarding specific roles before victims arrived for care (Figure). Seventh-grade student victims were organized into groups of 8 and participated in moulage application for injury simulation. Occupational therapy students were assigned to each group to ensure that the youth were engaged in activities while they waited for their turn to be evaluated and treated for their injuries. The youth had practiced their individual roles and were fully prepared for their rehearsal portrayals, including appropriate emotional responses to their simulated injuries. Seventh-grade students participated in an onsite post-treatment debriefing by their faculty and the occupational therapy students before returning to their school. High school students studied the incident command system, practiced injury scenarios, and completed projects related to emergency preparedness. Some students elected to shadow nursing faculty to increase their understanding of the nursing profession. The high school students remained onsite for the after-action reporting and debriefing with nursing faculty, nursing students, and the rest of the Operation STAT team.
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TABLE 2
Evaluation data for nursing students and faculty from Operation STAT 2013 Ranking by nursing students (n = 26) Median Mean ± SD
Incident command awareness My roles and responsibilities were clear to me. * I was aware of the chain of command for my area. * The agencies that participated in Operation STAT were well integrated into the organizational structure. Confidence in own role and within teams Members of my team worked well together. I felt comfortable working with other volunteers and staff. * I felt confident in my ability to respond to patient questions. * I felt confident in my ability to recognize patients with special needs or issues. * I felt confident in my ability to find responses and solutions for patients with special needs. * I was able to apply concepts from my coursework into the mass-casualty environment. Disaster, response, and preparedness awareness Disasters are likely to have severe public health consequences where I live or work/go to school. I was able to increase my awareness of disaster response. Perception of educational benefit Operation STAT was a positive learning experience. Operation STAT increased my knowledge about disaster response. My coursework was helpful in preparing me for Operation STAT. Operation STAT is relevant to my career development. * I would participate in another disaster response exercise/Operation STAT drill.
Ranking by nursing faculty (n = 7) Median Mean ± SD
3.0 4.0
3.1 ± 1.6 3.7 ± 1.5
4.0 5.0 5.0
4.1 ± 1.8 4.7 ± 1.8 4.9 ± 1.8
6.0 5.0 4.0 5.0 4.5
5.6 4.9 4.0 4.4 4.3
5.0 6.0
4.9 ± 1.8 5.1 ± 1.9
5.0
4.9 ± 0.8
5.0
4.4 ± 1.4
6.0
5.7 ± 0.5
5.0
5.0 ± 0.6
5.0 5.0
5.3 ± 0.5 5.0 ± 0.6
6.0
5.6 ± 0.5
4.0 5.0 4.0 5.0 4.0
4.2 4.6 3.7 4.5 3.8
± ± ± ± ±
± ± ± ± ±
0.5 0.8 1.5 1.2 1.0
1.1 1.2 1.4 1.5 1.7
* Items in the questionnaires that are indicated with an asterisk are in the public domain and were reprinted or adapted from, Savoia E, Higdon MA, Massin-Short S, Tallon L, Soto MA.14.
NURSING TEAMWORK
Senior student nurses worked in teams of 5 to 6 students. One student nurse was designated to serve as the team leader. The drill included 1 triage team and 6 treatment zones (2 each for red, yellow, and green). Two nursing faculty members were assigned to each group to provide mentoring for students with respect to team leadership and patient assessment and care. One nursing faculty member assumed the role of the chief nurse. The chief nurse provided direction to faculty and student team leaders, oversaw the inflow and outflow of casualties, and maintained communication with the command center. This brief, “just-in-time” period of instruction provided guidance for the student nurse regarding expectations of the team leader role during a disaster. Team leaders were required to report the status of casualties in their assigned treatment zone to incident command by tracking the number
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of victims coming to their area, degree of injury, and patient disposition. Team leader responsibilities included providing safety to the team (rest and hydration), maintaining patient flow through the treatment areas, and collaborating with other health care team members. As casualties started arriving, the anticipatory anxiety heightened among the student nurses. Early observation of incoming casualties required a quick readjustment to the treatment zones and role assignments. Inclement weather and other logistical problems added to the fog of confusion that plagues real disasters, and plans had to be adjusted accordingly. Despite the ensuing environment of controlled chaos, student nurses and team leaders focused attentively to the injured. Implementing staff changes led to a more time-efficient and collaborative method to successfully care for the injured. Given the surprisingly serious and effective theatrical talents of the student victims, the student nurses were
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exposed to the high-level emotional trauma that may be associated with disasters. The ability of the student nurses to focus beyond their pre-disaster anxiety and control their own individual psychological state allowed them to provide calm and appropriate physical and psychological support to the victims. Faculty and the chief nurse kept a careful watch as the number of casualties presenting with more traumatic injuries increased. A planning priority was to ensure that the potentially alarming display of human suffering did not negatively affect or overwhelm anyone. Nevertheless, the number of casualties and degree of injuries coming through the treatment zones proved exhausting for both student nurses and faculty. The 2-hour time limit for the disaster seemed to extend beyond the stamina of many participants. Drill Evaluation
Written evaluations were collected from participants through self-response questionnaires. Each questionnaire consisted of items that explored the level of agreement with written statements about Operation STAT and the self-perceptions of the participants. Questionnaire items were selected from prior Operation STAT exit surveys, as well as the Volunteer SelfAssessment Questionnaire. 14 The level of agreement for each statement was rated on a 6-point Likert scale where 1 indicates strongly disagree; 2, disagree; 3, somewhat disagree; 4, somewhat agree; 5, agree; and 6, strongly agree. Data were analyzed with SPSS software, version 21.0 (IBM Corp, Armonk, NY). 15 Each questionnaire included open-ended questions to collect brief qualitative impressions of participants. EVALUATION RESULTS
Nursing Evaluation Student nurses (n = 26) indicated that Operation STAT was a positive experience that increased their knowledge about disaster response (Table 2). Student nurses were able to incorporate concepts from coursework into the masscasualty environment and were generally confident in their ability to respond to patient questions and recognize patients with special needs. Student nurses believed that their teams worked well together. Student nurses agreed that they worked well with other volunteers. Nursing faculty (n = 7) evaluations were very positive and indicated a good level of role clarity and teamwork, as well as an understanding of the consequences of disaster in the community. Faculty would be willing to participate in the drill again. A pretest/post-test design was used to evaluate the predrill mini case study. The level of knowledge related to the
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assessment of a child with a closed head injury was evaluated in nursing students (n = 26) with 10 multiple-choice questions before and after the drill with parallel forms. The results of a paired-samples t test indicated a significant difference between the mean scores on the pretest and post-test (t = − 6.753, df = 25, P b .01), suggesting an improved understanding of the nurse’s role in disaster care management of children. Seventh-Grade and High School Evaluations Seventh-grade and high school participants (n = 91) indicated 96.7% agreement that Operation STAT was a positive learning experience. The participants agreed that their role in Operation STAT helped nursing students to prepare for disasters (mean, 5.3; SD, 1.0). Operation STAT helped these participants increase their knowledge about disaster response (mean, 5.1; SD, 1.1) and disaster preparation (mean, 5.0; SD, 1.1).
Discussion
The simulation scenario approximated both the chaos and the quick pace of a real mass-casualty incident, as well as the psychological and affective responses caregivers may experience in real emergencies. Debriefing provided the forum for the student nurses and faculty and other participants to process these aspects of the simulation and was one of the strong points of this educational experience. Nursing students, under the supervision of pediatric nursing faculty, were afforded the opportunity to examine their roles as nurses caring for children, practice pediatric triage techniques and field-based nursing care, and reflect on the meaning of rapid response and emergent nursing intervention with children. The case study was an important asset to nursing student preparation for the disaster drill experience. Such competencies are essential for the care of children in emergency departments. 16 Collaboration with other health care professionals is an important aspect of disaster preparation and response. The focus of occupational therapy is to support people’s health and participation across the lifespan through engagement in occupations. 17 In disaster situations, this often involves a mental health focus to help people regain a sense of safety and control and the provision of psychological first aid to victims and surge responders who may become overwhelmed with the stress of providing disaster care. 18,19 The role of occupational therapy in Operation STAT 2013 concentrated on providing pediatric and family preparedness to the seventh
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graders, resulting in improved victim simulation as well as compliance throughout the drill.
4. Whetzel E, Walker-Cillo G, Garrett KC, Trivett J. Emergency nurse perceptions of individual and facility emergency preparedness. J Emerg Nurs. 2013;39(1):46-52. 5. Austin EN, Nelson HW, Agley D. Emergency preparedness education using full scale exercises. State Def Force Monogr Ser. 2012;5:63-75.
Implications for Research
6. Austin EN, Hannafin N, Nelson HW. Pediatric simulation in graduate and undergraduate nursing education. J Pediatr Nurs. 2013;28:393-9. http://dx.doi.org/10.1016/j.pedn.2012.12.004.
Collaborations between health professional students and community schools provide a unique opportunity to address whole-community emergency preparedness and the use of human simulation in a wide variety of situations. Collaboration with local emergency nurses and other health care professionals would increase our partnership abilities with institutions where our students may be working. Many of our students work in patient support capacities in local hospitals and are interested in opportunities to engage nurses and other professionals in educational activities. Exploration of models for hospital and academic synergy through collaborative simulation activities would lead to realistic educational and evaluative contexts. The use of online formats for education should be studied as a means to enhance the presentation of information to nursing students prior to the drill. Because our drill included students from a variety of courses and 2 campuses, there was no opportunity to engage the students together prior to the drill. Further evaluation could include multiple points to evaluate student learning. Evaluating specific information related to nursing care and nursing performance in the mass-casualty setting would help to more clearly define educational areas that worked well and those needing improvement. Continued educational enrichment will focus on assessment of student learning upon completion of the emergency preparedness drill. Such assessment will provide insight into the impact of hands-on learning facilitated through the drill experience and means of incorporating lessons learned into classroom learning and future Operation STAT initiatives. REFERENCES 1. Davis EA, Hansen R. Vulnerable populations and public health disaster preparedness. In: Reilly MJ, Markenson DS, (eds.), Health Care Emergency Management. Sudbury, MA: Jones & Bartlett Learning; 2011:371-400. 2. Balasuriya D, Iverson E, Burke RV, Upperman JS. Community engagement and pediatric disaster readiness in a large urban disaster resource hospital network: the case of “The Great California Shakeout”. Disaster Med Public Health Prep. 2012;6(2):182-6. 3. Baack S, Alfred D. Nurses’ preparedness and perceived competence in managing disasters. J Nurs Scholarsh. 2013;45:281-7. http://dx.doi.org/ 10.1111/jnu.12029.
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7. Nelson HW, Barish R, Smalkin F, Doyle J, Hershkowitz M. Developing vibrant state defense forces: a successful medical and health service model. Jt Cent Oper Anal J. 2007;9(2):11-27. 8. Bernardo LM, Beach M, Mitchell AM, Zoldos K. Disaster preparedness at the University of Pittsburgh School of Nursing: four years of progress. Disaster Manag Response. 2006;4:77-9. http://dx.doi.org/10.1016/j.dmr. 2006.05.002. 9. Nelson HW, Austin EN. Maryland Defense Force participates in Operation STAT disaster drill. MDDF Defender, June 21, 2014. http:// mddfdefender.blogspot.com/2012/06/maryland-defense-forceparticipates-in.html. Accessed June 21, 2012. 10. University of Virginia School of Medicine. UVA Medical Reserve Corps Web site. http://www.medicine.virginia.edu/community-service/more/ uvamrc/background.html. Accessed September 30, 2013. 11. Culley JM. The role of the Medical Reserve Corps in nursing education. J Nurs Educ. 2010;49:708-11. http://dx.doi.org/10.3928/0148483420100930-04. 12. Hall HL. School of nursing awarded federal funds to build local Medical Reserve Corps. Reporter [Vanderbilt University Medical Center’s weekly newspaper]. January 23, 2004. 13. American Association of Colleges of Nursin. The essentials of baccalaureate education for professional nursing practice. http://www.aacn.nche.edu/ education-resources/BaccEssentials08.pdf. Accessed September 28, 2013. 14. Savoia E, Higdon MA, Massin-Short S, Tallon L, Soto MA. Evaluation toolkit for the deployment of MRC units during flu clinics and other public health activities. http://lamps.sph.harvard.edu/images/stories/ MRC/Volunteer%20Self%20Assessment%20Questionnaire.pdf. Accessed March 7, 2012. 15. IBM. Statistical Package for the Social Sciences: SPSS Statistics [computer program]. Version 21.0. Chicago, IL: IBM Corp; 2012. 16. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. J Emerg Nurs. 2013;39(2):116-27. 17. Roley SS, Delany JV, Barrows CJ. Occupational therapy practice framework: domain & process, 2nd edition. Am J Occup Ther. 2008;62:625-83. 18. Scaffa ME, Gerardi S, Herzberg G, McColl MA. The role of occupational therapy in disaster preparedness, response, and recovery. Am J Occup Ther. 2006;60:642-9. 19. Scaffa ME, Reitz SM, Smith TM. The role of occupational therapy in disaster preparedness, response, and recovery: a concept paper. Am J Occup Ther. 2011;65(6):511-25.
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PEDIATRIC MASS-CASUALTY EDUCATION: EXPERIENTIAL LEARNING THROUGH UNIVERSITY-SPONSORED DISASTER SIMULATION Authors: Elizabeth N. Austin, PhD, MA, RN, CNE, CEN, Serap E. Bastepe-Gray, MD, H. Wayne Nelson, PhD, Judith Breitenbach, MS, RN, Kathleen T. Ogle, PhD, RN, FNP-BC, Angela Durry, MSN, RN, Sheila D. Green, PhD, RN, Lisa A. Crabtree, PhD, OTR/L, and Mindy Haluska, MS, RN, Towson and Hagerstown, MD
hildren are highly vulnerable in disaster situations and have specific and unique disaster-related health care needs. 1 Coordination and planning of disaster response that meets the needs of pediatric victims require specialized training opportunities. 2 Nurses have expressed a lack of confidence in their ability to respond to disasters. 3 Emergency nurses have reported a lack of education in emergency planning and preparedness. 4 Academic institutions are uniquely poised to assuage these problems and promote community disaster resilience by forging synergistic partnerships among schools of all age groups, emergency planners and practitioners, private citizens, and organizations. 5,6 However, experiential models for such partnerships are scarce in the literature. The purpose of this paper is to describe Operation STAT 2013, a mass-casualty drill in an
C
Elizabeth N. Austin, Member, Metropolitan Baltimore Chapter, is Assistant Professor, Department of Nursing, and Director, Integrated Homeland Security Management, Towson University, Towson, MD. Serap E. Bastepe-Gray is Graduate Student, Towson University, Towson, MD. H. Wayne Nelson is Professor and Chair, Department of Interprofessional Health Studies, Towson University, Towson, MD. Judith Breitenbach is Clinical Assistant Professor and Nursing Programs Director, University System of Maryland at Hagerstown, Department of Nursing, Towson University, Hagerstown, MD. Kathleen T. Ogle is Associate Professor, Interim Chair, and Director, Graduate Nursing Program, Towson University, Towson, MD. Angela Durry is Clinical Assistant Professor, Department of Nursing, Towson University, Towson, MD. Sheila D. Green is Assistant Professor and Assistant Chair, Department of Nursing, Towson University, Towson, MD. Lisa A. Crabtree is Assistant Professor, Department of Occupational Therapy, Towson University, Towson, MD. Mindy Haluska is Clinical Assistant Professor, Department of Nursing, Towson University, Towson, MD. For correspondence, write: Elizabeth N. Austin, PhD, MA, RN, CNE, CEN, Department of Nursing, Towson University, 8000 York Rd, Towson, MD 21252; E-mail: [email protected]. J Emerg Nurs 2014;40:428-34. 0099-1767 Copyright © 2014 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2014.05.015
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academic setting that incorporated local middle and high school students with health professions students. Background DISASTER SIMULATION TRENDS
Complex, large-scale medical surge and triage preparedness drills are designed to simulate a disaster context and involve civilian and military partners, including a broad spectrum of emergency experts, as well as local schools and community groups. 4,5,7–9 Annual drills provide nursing and other college students, faculty, community members, and partner organizations opportunities to experience a mass-casualty drill in a safe environment; this might help them function better in their formal or informal everyday roles should they be involved in a disaster. 5,6 University partnerships with the Medical Reserve Corps (MRC) have proven valuable in providing a range of disaster education and community outreach initiatives as evidenced by relationships between the military-based Texas State Guard’s MRC and the University of Texas Health Science Center at San Antonio 7; by a similar, albeit civilian MRC relationship at the School of Medicine at the University of Virginia 10; and by nursing programs at Lander University, Vanderbilt University, and the University of South Carolina. Academic, civilian-military grassroots partnerships provide skill groups and equipment that might not otherwise be available to the sponsoring universities. Those partner organizations could have physicians; nurses; emergency medical technicians; communications, command, and security experts; and others who prepare to act as vital surge force multipliers augmenting first responders in times of public need to boost community resiliency and tightening the fabric of the national health infrastructure. 11,12 Nursing curricula are challenged to provide meaningful educational opportunities to meet accreditation requirements that include disaster and mass-casualty education. The American Association of Colleges of Nursing recently revised The Essentials of Baccalaureate Education for Professional Nursing Practice. 13 The Essentials document provides the competency standards for baccalaureate nursing programs in
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TABLE 1
Operation STAT whole-community disaster education partners and participants Partner/participant
Exercise role
Local emergency management task force (n = 3) Local office of emergency management (n = 2) Local health department (n = 2) Interprofessional university collaborators: faculty and students from the Office of Collaborative Programs (n = 2), nursing (36 students and 11 faculty), health care management (n = 2), gerontology (n = 1), and occupational therapy (n = 25) Local seventh-grade students, faculty, and staff (n = 94) Local high school students, faculty, and staff (n = 24) from program in homeland security and emergency preparedness State department of health and mental hygiene (n = 2) State emergency medical services (n = 1) MRC (n = 15) including physicians, PAs, RNs, and EMTs Fraternity and sorority life students (n = 50) Public information personnel (university, press, military) (n = 5)
Planning committee and resource assistance Observers/evaluators Observers/evaluators Crowd control, safety support, registration, patient and equipment tracking, nursing care, and mental health care
Scripted and student victims, faculty, and parents Smart victims, shadowed professional mentors in areas of interest
Mental health team/evaluators Observer and evaluator Clinical support: physicians, PAs, EMTs, nurses, security, communications, and administration Victims, registration, and breakdown Report drill, impact on community, student education, and emergency collaborations
EMTs, Emergency medical technicians; MRC, Medical Reserve Corps; PA, physician assistant; RNs, registered nurses.
the United States. Standard VII addresses the application of “clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations.” 13 OPERATION STAT: AN ANNUAL DRILL
Operation STAT is a “bottom-up” initiative to improve whole-community resiliency. A key educational goal is to introduce nursing students to patient assessment, triage, and nursing interventions in mass-casualty situations.
National Guard; state, city, and county emergency planners; and other area MRCs, including an MRC funeral directors unit that specializes in disaster body recovery and disposition. 6 Those assuming the role of victims, which number in the hundreds, have included fraternity and sorority members and other students, faculty, a growing number of volunteers from community groups across the lifespan including Area Agency on Aging volunteers, and students at all grade levels. Operation STAT 2013 PARTICIPANTS
INTERAGENCY AND INTERPROFESSIONAL STRUCTURE OF OPERATION STAT
From its inception, Operation STAT planning and delivery were coordinated, to a significant extent, by the university-sponsored military MRC unit from the Maryland Defense Force. The MRC provided support to Operation STAT by providing health care teams, safety and security personnel, communications experts and equipment, incident command staff, and other key personnel. 5 Other Operation STAT partners have included representatives of various police and fire departments; the
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Participants in Operation STAT 2013 (Table 1) included approximately 250 people from 2 university campuses, 1 middle school (Friends School of Baltimore), 1 high school (Joppatowne High School), and the Maryland Defense Force. Other partners were the local office of emergency management and the local representative from the state emergency medical services region. Regarding the protection of human subjects, the university institutional review board granted approval (No. 13-A055) for the evaluation of Operation STAT
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FIGURE Operation STAT 2013 timeline.
2013. Participants were required to sign waivers indicating their agreement to participate and be photographed. Local television crews received instruction by the university public information officer prior to video coverage of the drill. Consent was obtained from all adult students, faculty, and staff, as well as a parent or guardian of each child. MINI CASE STUDY
To prepare the nursing students for the simulation, nursing faculty created a mini case study on the assessment of the school-aged child with closed head trauma and triage. The scenario involved an 8-year-old child who sustained a closed head injury and concussion subsequent to a fall from a tree house—an aftermath of an explosion in the neighborhood vicinity where the child lived. The objectives for this didactic experience were to prepare senior nursing student participants to 1 perform a focused pediatric assessment 2; incorporate disaster triage; and 3 prioritize, implement, and evaluate selected emergent nursing interventions. A pretest/post-test design was used to evaluate educational outcomes. SIMULATION
The simulation scenario was based on a non-terrorist explosion that resulted in hundreds of casualties and
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required the deployment of the MRC to increase medical surge capacity in the community. According to the scenario, local hospitals and resources were overwhelmed with casualties and Towson University created a masscasualty triage and treatment site. Everyone received safety briefings and education regarding specific roles before victims arrived for care (Figure). Seventh-grade student victims were organized into groups of 8 and participated in moulage application for injury simulation. Occupational therapy students were assigned to each group to ensure that the youth were engaged in activities while they waited for their turn to be evaluated and treated for their injuries. The youth had practiced their individual roles and were fully prepared for their rehearsal portrayals, including appropriate emotional responses to their simulated injuries. Seventh-grade students participated in an onsite post-treatment debriefing by their faculty and the occupational therapy students before returning to their school. High school students studied the incident command system, practiced injury scenarios, and completed projects related to emergency preparedness. Some students elected to shadow nursing faculty to increase their understanding of the nursing profession. The high school students remained onsite for the after-action reporting and debriefing with nursing faculty, nursing students, and the rest of the Operation STAT team.
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TABLE 2
Evaluation data for nursing students and faculty from Operation STAT 2013 Ranking by nursing students (n = 26) Median Mean ± SD
Incident command awareness My roles and responsibilities were clear to me. * I was aware of the chain of command for my area. * The agencies that participated in Operation STAT were well integrated into the organizational structure. Confidence in own role and within teams Members of my team worked well together. I felt comfortable working with other volunteers and staff. * I felt confident in my ability to respond to patient questions. * I felt confident in my ability to recognize patients with special needs or issues. * I felt confident in my ability to find responses and solutions for patients with special needs. * I was able to apply concepts from my coursework into the mass-casualty environment. Disaster, response, and preparedness awareness Disasters are likely to have severe public health consequences where I live or work/go to school. I was able to increase my awareness of disaster response. Perception of educational benefit Operation STAT was a positive learning experience. Operation STAT increased my knowledge about disaster response. My coursework was helpful in preparing me for Operation STAT. Operation STAT is relevant to my career development. * I would participate in another disaster response exercise/Operation STAT drill.
Ranking by nursing faculty (n = 7) Median Mean ± SD
3.0 4.0
3.1 ± 1.6 3.7 ± 1.5
4.0 5.0 5.0
4.1 ± 1.8 4.7 ± 1.8 4.9 ± 1.8
6.0 5.0 4.0 5.0 4.5
5.6 4.9 4.0 4.4 4.3
5.0 6.0
4.9 ± 1.8 5.1 ± 1.9
5.0
4.9 ± 0.8
5.0
4.4 ± 1.4
6.0
5.7 ± 0.5
5.0
5.0 ± 0.6
5.0 5.0
5.3 ± 0.5 5.0 ± 0.6
6.0
5.6 ± 0.5
4.0 5.0 4.0 5.0 4.0
4.2 4.6 3.7 4.5 3.8
± ± ± ± ±
± ± ± ± ±
0.5 0.8 1.5 1.2 1.0
1.1 1.2 1.4 1.5 1.7
* Items in the questionnaires that are indicated with an asterisk are in the public domain and were reprinted or adapted from, Savoia E, Higdon MA, Massin-Short S, Tallon L, Soto MA.14.
NURSING TEAMWORK
Senior student nurses worked in teams of 5 to 6 students. One student nurse was designated to serve as the team leader. The drill included 1 triage team and 6 treatment zones (2 each for red, yellow, and green). Two nursing faculty members were assigned to each group to provide mentoring for students with respect to team leadership and patient assessment and care. One nursing faculty member assumed the role of the chief nurse. The chief nurse provided direction to faculty and student team leaders, oversaw the inflow and outflow of casualties, and maintained communication with the command center. This brief, “just-in-time” period of instruction provided guidance for the student nurse regarding expectations of the team leader role during a disaster. Team leaders were required to report the status of casualties in their assigned treatment zone to incident command by tracking the number
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of victims coming to their area, degree of injury, and patient disposition. Team leader responsibilities included providing safety to the team (rest and hydration), maintaining patient flow through the treatment areas, and collaborating with other health care team members. As casualties started arriving, the anticipatory anxiety heightened among the student nurses. Early observation of incoming casualties required a quick readjustment to the treatment zones and role assignments. Inclement weather and other logistical problems added to the fog of confusion that plagues real disasters, and plans had to be adjusted accordingly. Despite the ensuing environment of controlled chaos, student nurses and team leaders focused attentively to the injured. Implementing staff changes led to a more time-efficient and collaborative method to successfully care for the injured. Given the surprisingly serious and effective theatrical talents of the student victims, the student nurses were
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exposed to the high-level emotional trauma that may be associated with disasters. The ability of the student nurses to focus beyond their pre-disaster anxiety and control their own individual psychological state allowed them to provide calm and appropriate physical and psychological support to the victims. Faculty and the chief nurse kept a careful watch as the number of casualties presenting with more traumatic injuries increased. A planning priority was to ensure that the potentially alarming display of human suffering did not negatively affect or overwhelm anyone. Nevertheless, the number of casualties and degree of injuries coming through the treatment zones proved exhausting for both student nurses and faculty. The 2-hour time limit for the disaster seemed to extend beyond the stamina of many participants. Drill Evaluation
Written evaluations were collected from participants through self-response questionnaires. Each questionnaire consisted of items that explored the level of agreement with written statements about Operation STAT and the self-perceptions of the participants. Questionnaire items were selected from prior Operation STAT exit surveys, as well as the Volunteer SelfAssessment Questionnaire. 14 The level of agreement for each statement was rated on a 6-point Likert scale where 1 indicates strongly disagree; 2, disagree; 3, somewhat disagree; 4, somewhat agree; 5, agree; and 6, strongly agree. Data were analyzed with SPSS software, version 21.0 (IBM Corp, Armonk, NY). 15 Each questionnaire included open-ended questions to collect brief qualitative impressions of participants. EVALUATION RESULTS
Nursing Evaluation Student nurses (n = 26) indicated that Operation STAT was a positive experience that increased their knowledge about disaster response (Table 2). Student nurses were able to incorporate concepts from coursework into the masscasualty environment and were generally confident in their ability to respond to patient questions and recognize patients with special needs. Student nurses believed that their teams worked well together. Student nurses agreed that they worked well with other volunteers. Nursing faculty (n = 7) evaluations were very positive and indicated a good level of role clarity and teamwork, as well as an understanding of the consequences of disaster in the community. Faculty would be willing to participate in the drill again. A pretest/post-test design was used to evaluate the predrill mini case study. The level of knowledge related to the
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assessment of a child with a closed head injury was evaluated in nursing students (n = 26) with 10 multiple-choice questions before and after the drill with parallel forms. The results of a paired-samples t test indicated a significant difference between the mean scores on the pretest and post-test (t = − 6.753, df = 25, P b .01), suggesting an improved understanding of the nurse’s role in disaster care management of children. Seventh-Grade and High School Evaluations Seventh-grade and high school participants (n = 91) indicated 96.7% agreement that Operation STAT was a positive learning experience. The participants agreed that their role in Operation STAT helped nursing students to prepare for disasters (mean, 5.3; SD, 1.0). Operation STAT helped these participants increase their knowledge about disaster response (mean, 5.1; SD, 1.1) and disaster preparation (mean, 5.0; SD, 1.1).
Discussion
The simulation scenario approximated both the chaos and the quick pace of a real mass-casualty incident, as well as the psychological and affective responses caregivers may experience in real emergencies. Debriefing provided the forum for the student nurses and faculty and other participants to process these aspects of the simulation and was one of the strong points of this educational experience. Nursing students, under the supervision of pediatric nursing faculty, were afforded the opportunity to examine their roles as nurses caring for children, practice pediatric triage techniques and field-based nursing care, and reflect on the meaning of rapid response and emergent nursing intervention with children. The case study was an important asset to nursing student preparation for the disaster drill experience. Such competencies are essential for the care of children in emergency departments. 16 Collaboration with other health care professionals is an important aspect of disaster preparation and response. The focus of occupational therapy is to support people’s health and participation across the lifespan through engagement in occupations. 17 In disaster situations, this often involves a mental health focus to help people regain a sense of safety and control and the provision of psychological first aid to victims and surge responders who may become overwhelmed with the stress of providing disaster care. 18,19 The role of occupational therapy in Operation STAT 2013 concentrated on providing pediatric and family preparedness to the seventh
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graders, resulting in improved victim simulation as well as compliance throughout the drill.
4. Whetzel E, Walker-Cillo G, Garrett KC, Trivett J. Emergency nurse perceptions of individual and facility emergency preparedness. J Emerg Nurs. 2013;39(1):46-52. 5. Austin EN, Nelson HW, Agley D. Emergency preparedness education using full scale exercises. State Def Force Monogr Ser. 2012;5:63-75.
Implications for Research
6. Austin EN, Hannafin N, Nelson HW. Pediatric simulation in graduate and undergraduate nursing education. J Pediatr Nurs. 2013;28:393-9. http://dx.doi.org/10.1016/j.pedn.2012.12.004.
Collaborations between health professional students and community schools provide a unique opportunity to address whole-community emergency preparedness and the use of human simulation in a wide variety of situations. Collaboration with local emergency nurses and other health care professionals would increase our partnership abilities with institutions where our students may be working. Many of our students work in patient support capacities in local hospitals and are interested in opportunities to engage nurses and other professionals in educational activities. Exploration of models for hospital and academic synergy through collaborative simulation activities would lead to realistic educational and evaluative contexts. The use of online formats for education should be studied as a means to enhance the presentation of information to nursing students prior to the drill. Because our drill included students from a variety of courses and 2 campuses, there was no opportunity to engage the students together prior to the drill. Further evaluation could include multiple points to evaluate student learning. Evaluating specific information related to nursing care and nursing performance in the mass-casualty setting would help to more clearly define educational areas that worked well and those needing improvement. Continued educational enrichment will focus on assessment of student learning upon completion of the emergency preparedness drill. Such assessment will provide insight into the impact of hands-on learning facilitated through the drill experience and means of incorporating lessons learned into classroom learning and future Operation STAT initiatives. REFERENCES 1. Davis EA, Hansen R. Vulnerable populations and public health disaster preparedness. In: Reilly MJ, Markenson DS, (eds.), Health Care Emergency Management. Sudbury, MA: Jones & Bartlett Learning; 2011:371-400. 2. Balasuriya D, Iverson E, Burke RV, Upperman JS. Community engagement and pediatric disaster readiness in a large urban disaster resource hospital network: the case of “The Great California Shakeout”. Disaster Med Public Health Prep. 2012;6(2):182-6. 3. Baack S, Alfred D. Nurses’ preparedness and perceived competence in managing disasters. J Nurs Scholarsh. 2013;45:281-7. http://dx.doi.org/ 10.1111/jnu.12029.
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7. Nelson HW, Barish R, Smalkin F, Doyle J, Hershkowitz M. Developing vibrant state defense forces: a successful medical and health service model. Jt Cent Oper Anal J. 2007;9(2):11-27. 8. Bernardo LM, Beach M, Mitchell AM, Zoldos K. Disaster preparedness at the University of Pittsburgh School of Nursing: four years of progress. Disaster Manag Response. 2006;4:77-9. http://dx.doi.org/10.1016/j.dmr. 2006.05.002. 9. Nelson HW, Austin EN. Maryland Defense Force participates in Operation STAT disaster drill. MDDF Defender, June 21, 2014. http:// mddfdefender.blogspot.com/2012/06/maryland-defense-forceparticipates-in.html. Accessed June 21, 2012. 10. University of Virginia School of Medicine. UVA Medical Reserve Corps Web site. http://www.medicine.virginia.edu/community-service/more/ uvamrc/background.html. Accessed September 30, 2013. 11. Culley JM. The role of the Medical Reserve Corps in nursing education. J Nurs Educ. 2010;49:708-11. http://dx.doi.org/10.3928/0148483420100930-04. 12. Hall HL. School of nursing awarded federal funds to build local Medical Reserve Corps. Reporter [Vanderbilt University Medical Center’s weekly newspaper]. January 23, 2004. 13. American Association of Colleges of Nursin. The essentials of baccalaureate education for professional nursing practice. http://www.aacn.nche.edu/ education-resources/BaccEssentials08.pdf. Accessed September 28, 2013. 14. Savoia E, Higdon MA, Massin-Short S, Tallon L, Soto MA. Evaluation toolkit for the deployment of MRC units during flu clinics and other public health activities. http://lamps.sph.harvard.edu/images/stories/ MRC/Volunteer%20Self%20Assessment%20Questionnaire.pdf. Accessed March 7, 2012. 15. IBM. Statistical Package for the Social Sciences: SPSS Statistics [computer program]. Version 21.0. Chicago, IL: IBM Corp; 2012. 16. American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Committee, Emergency Nurses Association Pediatric Committee. Joint policy statement—guidelines for care of children in the emergency department. J Emerg Nurs. 2013;39(2):116-27. 17. Roley SS, Delany JV, Barrows CJ. Occupational therapy practice framework: domain & process, 2nd edition. Am J Occup Ther. 2008;62:625-83. 18. Scaffa ME, Gerardi S, Herzberg G, McColl MA. The role of occupational therapy in disaster preparedness, response, and recovery. Am J Occup Ther. 2006;60:642-9. 19. Scaffa ME, Reitz SM, Smith TM. The role of occupational therapy in disaster preparedness, response, and recovery: a concept paper. Am J Occup Ther. 2011;65(6):511-25.
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