Natural disasters are scary, devastating, and sometimes fatal. There are many organizations that jump in to help when disasters occur, and Hope Force International is one of them. Tina Busby, FNP, RN, works for a group of Federally Qualified Community Health Centers, called NOAH-Neighborhood Outreach Access to Healthcare, part of Honor Health, a larger medical system in the greater Phoenix area, made up of multiple medical group practices and multiple hospitals.
She and her husband also volunteer with Hope Force International, a Christian-based disaster relief organization that, as Busby says, “works nationally and internationally to provide disaster services as well as services to help communities rebuild after disaster. It uses volunteers, both professionals and nonprofessionals, from multiple nations.”
Busby answered questions about her work with the organization.
How did you become involved with Hope Force International (HFI)?
My husband and I have known the founders of HFI, Jack and Cheri Minton, since 2000 while serving with them in another faith-based ministry, Mercy Ships International. Since their conception of HFI, we have both had a desire to be involved, and we were finally able to complete our training and become HFI reservists about 6 years ago.
How does volunteering work? Are you put on alert or called in at certain times? How are you able to get time off from work?
When there is a disaster, HFI sends out a text message followed by an email to all reservists putting them on standby for possible deployment and asking them to pray and assess whether it is the right time for them to go and serve.
Because I have always been a part of a medical team, I have more notice and have not served with HFI immediately after a disaster. For the last few years, I have been a part of medical teams returning to both Haiti and Nepal. These HFI teams work with local community partnerships to show the love of Christ and advance His name. Since completing my education as an NP, I have felt a strong call from the Lord, that my skills and talents are to be used for His glory. Thus, I have tried to work in situations that allow for enough flexibility in my schedule to be able to serve others in this way.
Because we have a large family that is spread out all over the nation, finding a NP position with enough time off for both is almost impossible, and so, for the last seven years I have worked in a Per Diem or On Call position. Basically, I have an irregular schedule, and I fill in the open provider slots in multiple clinics, so that I am able to have control over my schedule and time off.
What do you do as a volunteer with HFI? How many times have you worked as a volunteer?
As a volunteer with HFI, my role has been to be a medical provider on multiple medical teams in both Haiti and Nepal, where I’ve traveled three times each with HFI. I have wanted to also help in other capacities, such as immediately after a disaster such as the recent hurricanes in Texas, Puerto Rico, and now the Bahamas. But at this point in my life, my resources (time and funds) are limited, and I also have a part-time job to keep up.
What did you enjoy most about volunteering for HRI?
I enjoy the people, all created in the image of God, both my teammates and those we are serving. I love seeing God work in so many different ways. I love meeting and making new friends and having the opportunity to serve alongside old friends. Having the luxury of going back to the same communities over the last few years, I love seeing how people’s hearts are becoming more responsive to Him and the great love He has for them.
What have been your greatest challenges?
My greatest challenge currently is that my husband, also a nurse, hasn’t been able to travel with me the last few years, due to his work schedule. Keeping my work and personal schedule flexible enough to serve, along with having the financial resources to serve, are always challenges. Some of the travel, long flights, and exciting bus rides, can be challenging for me as well.
What have been your greatest rewards?
Some of my greatest rewards have been the bonding of teammates and feeling the pleasure of God. I often personalize Eric Liddell’s quote to read, God gave me a compassionate heart and made me a healer. When I serve the least of the least, whether that’s at home or abroad, I feel His pleasure.
What would you say to someone who was considering volunteering for Hope Force International?
I would say, attend a Reservist Training and then go as God leads you! If you’re a nurse, we could really use you! We’ve just had to recently cancel an upcoming medical team to Haiti because we did not have enough nurses able to go.
Once you go, your life will never be the same and you will be “spoiled for the ordinary!”
A spate of disasters this past decade, including Hurricane Katrina and the Boston Marathon bombing, have shown us as a nation just how vulnerable our health care facilities can be. We’re not as naïve as we were in the pre-September 11th days—and we are learning from each and every disaster. Make sure your hospital, clinic, or other care facility is prepared in case of an emergency so that you can protect patients, staff, and the physical building itself.
The majority of a hospital’s staff is nurses, so hospital disaster planning necessarily involves nurses. Minority populations tend to be hardest hit by disasters—we saw that with Katrina. They were the ones less likely to be able to evacuate. Hospitals must plan for people who speak a different language or persons with different cultural backgrounds and religious beliefs. Follow these steps so you’ll be prepared for expected emergencies (e.g., power outages), the horribly unexpected (e.g., bioterrorist attacks), and everything in between. Best of all, in planning for disasters at your clinical workplace, you also take steps to safeguard yourself, your family, and your wider community.
Step 1: Your hospital has devised an emergency operations/management plan. Learn it. In order to meet hospital certification/accreditation requirements and myriad federal, state, and local regulations, management has to have emergency plans and procedures on file. In addition, they must keep evacuation equipment on hand and enough generators, portable ventilators, and food and water to last for three days without access to outside resources.
For example, natural disasters (severe weather patterns, such as a storm system) and human-made disasters (such as an accidental or deliberate airplane crash) may be deemed top risks by a certain health care facility. But that organization also has to be prepared for common and ordinary events, such as a building fire, which is the number one reason for a hospital evacuation.
Nurses need to learn all they can about their hospital’s response plan, advises Jacquelyn Nally, RN, BSN, an emergency preparedness HAZMAT program coordinator at Massachusetts General Hospital and an emergency department staff nurse at Newton Wellesley Hospital.
Most hospitals put their emergency plan on an Intranet for staff members, but you can also get more details at a new employee orientation or at a regular staff meeting. “Nurses should ask many questions about the plan, such as: ‘Who will be in charge during an incident?,’ ‘What’s my role if we have an evacuation?,’ ‘What’s my role if there’s a mass casualty?,’ ‘What equipment will be used in these various scenarios?,’ [and] ‘What other resources might be available to me then?,’” explains Nally.
Examples of logistical matters that nurses need to be aware of—and which aren’t usually covered in school—are how to protect patients during a disaster. Your hospital plan may have a designated safe location for tornado or other severe weather conditions on the lowest floor in a windowless interior space. Nurses should also know how to operate equipment in case the power goes out. (For instance, certain outlets are connected to the hospital’s emergency power supply.) Of course, you’ll need to avoid elevators during a power outage or in the event of a fire.
Once familiar with the hospital’s existing plan and procedures, you have an opportunity to influence it by participating on a hospital planning committee. Nurses are a critical part of a hospital’s emergency response team so their involvement in the process is vital.
Step 2: Pump up your knowledge and skills for handling hazards. The key for nurses in all settings and departments is to continue learning more and to take every opportunity to practice your disaster response. The Department of Homeland Security (www.dhs.gov) offers free online courses for clinicians. The Institute of Medicine (http://iom.edu) also has a helpful toolkit for hospital disaster planning.
As part of your continuing education, you can go to FEMA’s website (www.fema.gov) and take the Introduction to the Incident Command System for Healthcare/Hospitals online course (IS-100.HC). It will help you understand how your hospital uses the incident command system. Most large hospitals have coalitions of local (hospital), state, and federal agencies.
“Request unit-based training from your educator or clinical specialist or nurse manager,” says Nally. “The Joint Commission [on Accreditation of Healthcare Organizations] requires hospitals to have drills, so participate when you’re able to in drills and other exercises, like tabletop discussions with fire, police, and health care workers. Volunteer to act as a victim or clinical participant in a training exercise. Your goal is to protect your patients, yourself, other staff members, or the facility.”
One thing that may change during an emergency is the chain of command. “Know who to take direction from. Don’t just go off and do your own thing. Take direction from your nurse manager or the unit leader in charge,” says Nally. “That individual gets direction and information pushed down to the unit, and they feed information and needs back up that chain of command. So there aren’t 10 nurses from one unit calling the president of the hospital.”
Repeated drills and exercises allow nurses to perform their jobs during a disaster without missing a step. You may want to get more training and experience (while helping victims of disasters around the world) by signing up for the Nurse Volunteer Corps and volunteering through the Medical Reserve Corps Network.
Step 3: Make sure your personal and family disaster plan is in place. “When Hurricane Katrina hit, I was called in the middle of the night and had to be ready to go—but I had a nine- and an eleven-year-old at home,” remembers Mary Massey, BSN, MA, PHN, hospital preparedness coordinator at the California Hospital Association’s Hospital Preparedness Program. “My family is my life, so I wasn’t leaving until my family was taken care of.”
Thankfully, Massey had already arranged for childcare and household back-up so she could deploy to Biloxi, Mississippi, quickly. “At home, I always have my ‘go bag’ packed with two weeks of stuff, including food that I regularly replace as it expires,” she explains.
Nurses will have different plans depending on their dependents, which may go beyond family and pets, “to the lady down the street who you get medicine for,” she adds.
The American Red Cross has incredible programs for individuals and families that nurses can access (www.redcross.org/prepare). “You can register ahead of time so that your family or other loved ones (and only those people) can call them to see if you’re okay during a disaster,” says Massey. “The Centers for Disease Control and Prevention’s website [emergency.cdc.gov] also has resources for clinicians, and the general public and even one for kids.” The Ready.gov website, by the US Department of Homeland Security, is another good resource.
Step 4: Acknowledge that we’ve come a long way as a nation in our response to hazards and incidents. Probably the toughest decision hospital management has to make is when to evacuate. “Hospitals must treat patients, protect staff and visitors, and they can’t evacuate in an emergency like a school can,” says Cheri Hummel, vice president of disaster preparedness at the California Hospital Association.
Possibly no city knows that better than New Orleans, which suffered the devastation of Hurricane Katrina, necessitating the evacuation of hospitals in addition to the area’s populace.
Knox Andress, RN, BA, ADN, FAEN, designated regional coordinator for Louisiana’s Region 7 Hospital Preparedness Coalition, served as Incident Commander during both Hurricanes Katrina and Rita.
“We’ve made plans for evacuating the coast of Louisiana,” says Andress. “To exercise those plans, we enact simulated patient evacuation—putting mannequins in planes, then tracking them, and triaging those ‘patients,’ moving them from hospitals in New Orleans and at-risk locations to safer areas.”
All that planning and drilling paid off in 2008 when Hurricanes Gustav and Ike hit the Louisiana Gulf, only three weeks apart. “They came at us just like Hurricanes Katrina and Rita did three years before, but our response was as different as night and day,” says Andress. “In Katrina, 13 hospitals evacuated pre-storm landfall and 26 evacuated post-storm. During Gustav, a full 63 hospitals evacuated pre-storm landfall and only 10 evacuated post-storm.”
With each and every disaster, we become better prepared to evacuate patients safely. In 2012, when Superstorm Sandy hit the coast of New York and New Jersey, medical personnel performed heroically as hospitals activated their emergency preparedness plans. “We commend NYU Langone,” says Hummel about the medical center’s successful evacuation of some 300 patients from its 700-bed facility. “They didn’t lose any patients or have any significant injuries. They were able to get critical patients distributed to other hospitals. We’ve made leaps and bounds over the past few years. It’s been thrilling in my position to see that, but we can’t say we’re there yet—we don’t know where there is.”
Jebra Turner is a freelance health and business writer based in Portland, Oregon. She frequently contributes to the Minority Nurse magazine and website. Visit her online at www.jebra.com.
The city looked like it had been bombed. But in fact, it was an act of nature that had caused such devastation–more specifically, the force of Hurricane Katrina. Never before had I seen such destruction and total wreckage of what had once been a treasured city. Never had I evidenced people so distraught over missing family members, not knowing whether their loved ones were alive or dead. As we drove through the streets of the famed city of New Orleans, I wondered how long it would take to rebuild, how long it would take before the city would be bubbling with life and excitement once again.
I had visited New Orleans about 10 years ago and I remembered its lively downtown, busy with people and vehicles crisscrossing. Judging from the destruction I now saw before me, it would be very costly and time-consuming to rebuild all these ruined homes, businesses and lives. Questions and thoughts ran through my mind as I looked at the damage everywhere, too stunned at first to photograph it, eventually taking a few pictures when I had returned to my senses. Would New Orleans ever be normal again?
Relief workers assist the effort.
On August 29, the day Katrina first struck the Central Gulf Coast, I received notification that I was to be deployed to the South. Hurricane Katrina was increasing in strength and power. Initially it was feared to be a Category 5 hurricane, but as it hit landfall it had lessened to a Category 4. According to the Federal Emergency Management Agency (FEMA), a Category 1 is a hurricane with winds between 74 and 95 miles per hour while a Category 5 has winds greater than 155 mph. As it slammed into the Gulf Coast, the deadly Katrina had destroyed everything in its path. I saw roofs, building structures, cars and boats positioned as if tossed around aimlessly. In the wake of the hurricane, a powerful storm surge and broken levees had caused major flooding in New Orleans, wreaking further havoc.
On September 4, after waiting for the call, I received an email instead. I was off on a mission. As a U.S. Public Health Service (USPHS) Commissioned Officer and a nurse, I was finally on the roster and on standby to deploy, having just completed my graduate studies in nursing. I had my deployment bag still packed from my military days; I had served in the Air Force as a flight nurse and clinical nurse from 1995 to 2001. I went through the bag quickly and repacked it with fresh items.
The email stated that the conditions at the deployment destination would be austere and to be prepared. We would be using porta-potties, consuming Meals Ready-to-Eat (MREs) and sleeping on cots–if we were lucky. To me, this sounded all too familiar: I was born and raised on the Navajo Reservation. I had also experienced similar conditions at the Prince Sultan Air Base in Saudi Arabia, where I flew many times to evacuate or return soldiers.
Missions, Medicine and Mosquitoes
I arrived in Alexandria, La., on a hot, humid afternoon. First stop: England Air Park, where an old Air Force hangar would be home for the next two days. We worked in the hot sun, dripping with sweat, unloading supplies, setting up and getting ready for the swarms of evacuees who were expected the next day. Then came the task of dismantling the medical equipment, cots, etc. and packing them up only to move down further south.
LCDR Ruth Kawano, MSN, RN
Those first few days, the humidity seemed unbearable. For me and 75 other relief workers, our nights were spent on cots, with mosquitoes biting every exposed area. The hangar was full of dust and small creatures unknown to me. Our next journey would take us to Camp Port Allen–or Camp Mosquito as it soon became known–in Baton Rouge.
Upon our arrival in Baton Rouge, the humidity became extremely unpleasant. But by then, I had gotten used to it. We rolled up our sleeves. The first order of that afternoon was to haul luggage and medical supplies from a truck to our tent, then find our cots and get an orientation on our next missions. In addition to USPHS nurses and physicians, there were many firefighters, Disaster Management Assistance Teams (DMATs) and other volunteers who had traveled from many parts of the country to help out in this emergency.
Many people who had been displaced by the hurricane and flooding were now in shelters throughout Louisiana. Some people who needed medical care were placed in the Special Needs Shelters, a type of makeshift hospital. Others were staying in churches, Red Cross shelters or in private homes. Still others were trapped in New Orleans, unable to get out of the flooded areas, or had perished.
For the next few days, our missions ended and new ones evolved. For three days, we traveled all over Louisiana preparing Shelter Needs Assessments. These assessments were crucial in evaluating the needs of the evacuee shelters. We augmented the American Red Cross, the Centers for Disease Control and Prevention, and the Louisiana Department of Health & Hospitals to complete the assessments. We worked in teams of three or four people, consisting of a medical provider, a nurse and an environmental health officer. We assessed the environmental needs and in some areas evaluated the care of the evacuees. We made recommendations to all the shelter staff depending on their needs. Each day, we went to different parishes in the state. (A parish in Louisiana is equivalent to a county in other states.)
I also had a chance to use my nursing skills in Lafayette, La., where a Special Needs Shelter had over 65 patients. I got to meet, talk with and care for many displaced, depressed and frustrated evacuees. There I relearned how to set up a temporary hospital, much like I had done in the military.
Then, for the next few days, I was part of a group who worked with the FEMA-sponsored Find Family National Call Center, answering telephone calls from people who were trying to locate lost relatives. Over the course of several days, we worked to track down more than 3,500 people who were missing or may have perished in the disaster. By September 15, about 230 people had been located! It was amazing to have been a part of that mission and to be able to help those in need.
Other volunteers got a chance to work with the Louisiana State University evacuee Special Needs Shelters and the animal shelters in Baton Rouge, the Cajun Dome shelter in Lafayette and the shelters in Alexandria.
Into the Flood Zone
Two days before the end of my deployment, I had the chance to go into the flood-ravaged areas only a few could enter. There, in the heart of New Orleans, accompanied by LCDR Michael Truesdell–a fellow USPHS Commissioned Officer who is a physician at the Tuba City Regional Health Care Corporation in Tuba City, Ariz.–I met people who had returned to their devastated communities now that the floodwaters had receded. Some had a look of sadness; others were excited and ready to rebuild. Some people with health problems had run out of their medications and had not seen any health care providers for a while. We were able to assess some of their immediate needs; even just taking their blood pressure made them happy.
Destruction was everywhere around me. I saw buildings streaked with darkened lines of demarcation from the floodwaters and smelled the stench of garbage and decay. Cars and boats were overturned; some buildings were completely destroyed, reduced to piles of debris on the ground. The hurricane’s fierce winds had caused many trees and vehicles to plunge through houses, and debris was everywhere. The once-populated hospitals and medical centers were empty and the streets were void of the living. The famed Interstate 10 was strewn with garbage, making it unsafe to drive through. It was as if I was in a bombed-out war zone, like the images I had seen of Iraq and other foreign countries on television.
This deployment has definitely opened my eyes to what a city and its populace can experience from a powerful, ruinous force of nature. Overall, it seemed to me that there is much room for improvement in the way the federal and local government–including the mayor of New Orleans, state officials, FEMA and the President of the United States–responded to the hurricane and its aftermath. It seemed that the nation was completely unprepared because we had never had to deal with a disaster this monstrous before Katrina. Now that we have had this experience, I think the government will be able to learn from what happened and do a better job of responding in the future.
Based on my personal experience, it also seemed that some better planning may have been needed in the way the Division of Commissioned Personnel (DCP) reacted in the initial stage of our USPHS deployment. For our first few days after arriving in Louisiana, we found ourselves sitting there with equipment and supplies but not much to do until days later. I also feel that the DCP needs to provide disaster training for its Commissioned Corps officers. Not all of us are disaster-trained like the DMATs. In the Air Force I had Survival Training, Basic Field Nurse Training and yearly Survival reviews. In the civil service, however, we don’t get that type of training.
Although it was sometimes a physically and emotionally challenging experience, answering Katrina’s call has truly given me the opportunity to carry out the USPHS mission of promoting the “health of the nation [and] deliver[ing] health expertise in time of war or other national or international emergencies.” I hope and pray for the thousands of homeless, dispossessed and lost people whose lives continue to be affected by the devastation of Katrina.
Hurricane Katrina was the most devastating and costly natural disaster in American history, claiming many lives, destroying billions of dollars in property in the Gulf Coast region and leaving thousands of families homeless and grieving. At least 689,000 homes and businesses across Mississippi and Louisiana–including medical facilities and nursing homes–were without electric power. Homes were destroyed and thousands of people were evacuated. The number of individuals killed as a result of the hurricane and subsequent flooding was in the thousands.1
One of the evacuee families the author assisted as part of his relief work in Mississippi and Louisianna. The family pictured lost their home and everything they owned.
As the nation’s political leaders, churches, health care professionals and everyday citizens began to respond to this terrible disaster, I felt compelled to respond as well. As a nurse and a missionary pastor who has been working with the poor and the homeless in Cincinnati, Ohio, for 27 years, I had witnessed a few disasters in my time, but nothing of this magnitude. Despite the enormity of the devastation, I felt prepared to serve, thanks to the clinical training I had received at Mount Carmel College of Nursing in Columbus, Ohio, where I am a graduate student.
According to Dr. Joanne Langan, co-author of the book Preparing Nurses for Disaster Management, every nurse should be prepared in case of a disaster, because they will be sought out for help and information.2 Langan further asserts that nurses have an ethical obligation to be prepared. A recent article published in an Australian nursing journal estimates that for every nurse who is helpless in the face of disaster, at least 50 patients will not be helped.3
One of the evacuee families the author assisted as part of his relief work in Mississippi and L0uisianna.
Having made my decision to get involved in the Katrina relief efforts, I contacted Dr. Ronald Myers, a missionary physician who has worked in the Mississippi Delta region for over 18 years, and asked him what I could do to help. He responded by saying, “Whatever the Lord lays upon your heart.” After much prayer and silent contemplation, I shared my plans with my congregation. Some individuals tried to dissuade me from going to the Gulf Coast because of the potential health and safety dangers that lay ahead. I politely took their advice and placed it somewhere in my heart–but definitely not in the forefront. I was determined to go.
Dr. Ronald Myers of the Myers Foundation.
Next, I contacted Dr. Nancy Rowe, my clinical instructor at Mount Carmel, where I was one semester away from obtaining my master’s degree in nursing. Instead of discouraging me from making the trip, she encouraged me. Some well-meaning individuals asked me about completing my degree and graduating on time. I politely responded, “Graduation can wait, but our neighbors who are in need cannot. They need water, food, medical supplies and medical attention right now!”
Others at Mount Carmel, including Dr. Ann Schiele, the president of the college, and staff members who worked in the college library, were also very supportive of my desire to reach out to those affected by Hurricane Katrina. The school donated furniture, clothing, food, water and other needed items for me to take on my trip.
Listening to the Lost
With the blessing of my congregation and my school, I traveled to Greenville, Miss., in a truck donated by a local pharmacist, Nichelle Lawrence. When I arrived in Greenville, I was met by Dr. Myers and witnessed firsthand the devastation Katrina had caused. We traveled throughout Mississippi and parts of Louisiana where I saw houses overturned, vehicles split in half, grieving grandparents looking for their grandchildren, entire families who were homeless and living in shelters or motels. I witnessed a pregnant woman praying, “I hope my baby stays inside of me until all of this is over with.”
A local disc jockey from New Orleans who helped introduce the author to people in the community.
As I listened to the stories of loved ones lost, spoke with diabetics who had no insulin, saw homes destroyed and people displaced, I truly felt helpless and overwhelmed. It seemed as if all of this was some type of bad dream. I thought, what could I do to be of service to these people with my limited resources? These emotions I experienced were not unique. Studies have shown that initial feelings of being overwhelmed, helpless and in self-doubt are common among nurses who work at disaster sites.4
Many nurses historically have relied on their faith to help them overcome the obstacles they confront in daily practice. A 1999 literature review conducted by Nagai-Jacobson and Burkhardt concluded that spirituality is the cornerstone of nursing practice.5 I decided in my heart to give all that I had. My faith lifted me above the crisis and gave me renewed vigor. This new energy allowed me to accurately assess individual patient needs related to loss, bereavement and grief in this complex, challenging care-giving situation.
For example, at one shelter in Greenville that Dr. Myers and I visited, about 150 people were gathered outside the convention center in a picnic area. I met a gentleman named S.J. who continually spoke about returning to New Orleans in hopes of finding his granddaughter. He was sweating profusely and he continuously paced as he talked. I listened to him for about 45 minutes. By developing a therapeutic relationship and utilizing effective communication skills, I was able to get the man to talk about his love of New Orleans jazz. He was an accomplished jazz guitarist and for the next 20 or 30 minutes he spoke about his achievements in the music world. I could see he was more relaxed and now willing to listen to my advice about staying at the shelter until the authorities said it was safe to re-enter New Orleans.
Life Goes On
As the days went by and my patients’ needs changed, my focus changed as well. I switched from an acute care mentality to addressing the basics of patients’ daily life, such as hygiene, sleep, nutrition and elimination. I encouraged the patients I spoke with to get plenty of rest, eat well and to wash their hands properly to prevent the spread of infections within the shelter. After assessing the situation further and finding out that medicines and medical supplies were lacking, I collaborated with Dr. Charles Dillard of Inner City Healthcare in Cincinnati to collect the needed items.
I went on television and radio and I wrote articles for the Cincinnati Herald to enlist the help of others. No longer did I feel overwhelmed or helpless. Instead I felt like a co-laborer with God and humanity, helping my fellow brothers and sisters in need.
Hurricane Katrina no longer commands the front page of the newspapers and it is not the lead story on the evening news, but it is still in the forefront of my heart and the hearts of many other nurses like me. As nurses, we care for people not because of the publicity we receive but for the satisfaction we get from helping those who need us. Nursing is a noble profession that has traditionally served courageously in the face of disasters and will continue to do so in the future.6
References
1. Chappell, K., Ballard, S. and Waldron, C. (2005). “Katrina Aftermath: Blacks Tell Their Stories of Courage and Survival.” Jet, Sept. 26, pp. 6-11. 2. Langan, J. and James, D. (2004). Preparing Nurses for Disaster Management. Prentice Hall. 3. “Nurses Should Take Lead in Disasters.” Australian Nursing Journal, Vol. 4, No. 13, p. 10. 4. Suserud, B.-O. and Haljamäe, H. (1997). “Acting at a Disaster Site: Experiences Expressed by Swedish Nurses.” Journal of Advanced Nursing, Vol. 25, No. 1, pp. 155-162. 5. Schubert, P.E. and Lionberger, H.J. (1999). “Cultural and Spiritual Perspectives.” In Hitchcock, J.E., Schubert, P.E. and Thomas, S.A. (Eds.), Community Health Nursing: Caring in Action, pp.111-135. Albany, N.Y.: Thomson Delmar Learning. 6. Clark, M.J. (1998). Nursing in the Community: Dimensions of Community Health Nursing, 3rd Edition. Stamford, Conn.: Appleton & Lange.
Natural disasters are colorblind in terms of whom and how they strike. “When a disaster hits, it doesn’t hit by race, color or creed. It hits people who are humans and bleed,” says Marilyn Pattillo, PhD, GNP, CNS, deputy team commander of the Federal Emergency Management Agency (FEMA)’s National Nurse Response Team. Yet, how disaster victims react to displacement, illness and stress is very much culture-based.
“Cultural competence is an integral part of any disaster behavioral health intervention,” says Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness at the University of South Florida College of Public Health in Tampa. “In order to be effective, [health workers responding to disasters] must be aware of cultural differences among survivors and patients.”
This issue has taken on additional urgency in the aftermath of the heavily criticized government response to the devastation wrought by Hurricane Katrina. The delayed and muddled relief efforts were perceived by many African Americans as the product of institutional racism.
Nurses responding to natural disasters have precious little control over how government resources are apportioned, but they do have control over how they treat patients. The consensus among many nurses who responded to Katrina is that cultural competence was the norm in the immediate wake of the hurricane. This was because the first wave of responders consisted of local nurses with first-hand knowledge of the affected communities’ cultural needs.
“The immediate disaster response was handled by the local people,” explains Trilby Barnes, RNC, president and CEO of Medi-Lend Nursing Services in New Orleans and a member of the board of directors of the National Black Nurses Association (NBNA). Although the availability of care at some of the city’s hospitals was severely disrupted by the hurricane and subsequent flooding, Barnes says she was “one of the nurses who was still there to provide normalcy for the patients. [We were there] providing our cultural know-how [and] I do feel like it had a positive effect on the patients.”
“I didn’t see a [great] amount of discord [between health care workers and patients],” adds Father James Deshotels, SJ, APRN, a nurse and Jesuit priest who treated evacuees at the Superdome.
What Went Wrong
However, significant shortcomings in cultural competence arose in the following weeks and months, as new waves of disaster responders from across the nation–who lacked the local health professionals’ cultural familiarity with the affected communities of color–began to arrive.
Jennifer Field Brown, PhD, APRN, is the only white professor in the Nursing Department at historically black Norfolk State University in Virginia. When asked by the federal Substance Abuse and Mental Health Services Administration to work in a Louisiana shelter some six weeks after Katrina hit, Brown admits she was excited and jumped at the opportunity. But the racial and cultural tensions she observed during the two-week assignment have left her thinking for months.
“Many of the nurses were angry with the [largely African American] population that was still at the shelter,” she says. “There were many times when evacuees [said], ‘they don’t care about us.’”
Brown believes this perception was fueled by the cultural gap between the predominately poor and African American evacuees and the mostly middle class and white shelter staff. “[Some of] the response workers were appalled that some of the evacuees would not cash their checks because they had no family member with a checking account, [or] that they’d cash their checks and buy a TV. [The prevailing attitude among many of the shelter staff seemed to be] if you didn’t lose anything you are not entitled to anything.”
Deshotels, whose parents grew up in New Orleans, points out that strained race relations are not a new phenomenon in the Crescent City. “Because we have such a long history of racism and oppression [here], there is an always an air of tension and mistrust,” he says.
New Orleans used to have–and perhaps still has–a majority black population. Katrina scattered tens of thousands of the city’s African Americans throughout much of the country, so it is impossible to know for sure. But much of the city’s longstanding black middle class and working class have been displaced and have not returned. Cheryl L. Nicks, RN, CNNP, CGT, CLNC, CPLC, president of the New Orleans chapter of the NBNA, has been in touch with only three out of 65 members since the hurricane struck. She says, “Our chapter has basically been demolished.”
Caught Unprepared
Another shortfall in culturally competent health care that has worsened in New Orleans post-Katrina is the result of a dramatic and largely unforeseen population shift. In the place of many African American evacuees have come many thousands of Hispanic workers hired to help clean up and rebuild the city. Their arrival, a direct consequence of the hurricane, has amplified the difficulties the city’s public health system already faced in treating Hispanic patients.
The Roman Catholic Archdiocese of New Orleans created the Latino Health Access Network (LHAN) three years ago in response to the lack of sufficient health services for the Hispanic community. Shaula Lovera, director of LHAN, cites the absence of any evacuation information in Spanish as what she considers a typical example of the neglect faced by the Hispanic population before Katrina.
Now, the huge influx of Hispanic workers has dramatically increased the need for Spanish-speaking nurses and doctors. What used to be a small community of 14,000 in 2004 has grown to become a significant minority population whose access to health care is challenged by cultural, linguistic and economic barriers.
“These workers don’t make great salaries,” Lovera explains. “They have no access to Medicaid or Medicare. They don’t get health insurance from their employers.”
But often the biggest obstacle, she says, is simply navigating the hospital admissions process, with its personnel who don’t speak Spanish and its English-language forms that must be signed.
Before the hurricane, LHAN ran a Saturday clinic staffed by Spanish-speaking volunteer physicians and nurses. In 2002, before the clinic was established, only 2% of patients using LHAN’s services were Hispanic. But the number shot up to 17% after the clinic opened in 2003. This proves that Spanish-language medical attention was urgently needed, says Lovera.
The clinic, which was run by the Daughters of Charity, was badly damaged during the hurricane. Given the difficulties faced by Latino workers in getting treatment at local hospitals, LHAN has opted to bring bilingual nurses and doctors directly to the worksites. They give workers tetanus shots to guard against infections from accidents on the job and treat a series of common medical complaints. The lack of work boots, masks and gloves means that broken bones, sinusitis and cuts are a constant problem.
While this approach has been helpful, LHAN is stretched thin and has had to rely on volunteer doctors and nurses from outside the region. In lieu of always being able to find Spanish-speaking clinicians, they provide qualified medical translators.
Closing Knowledge Gaps
Based on these lessons learned the hard way, Lovera feels strongly that the federal government must focus on enhancing the cultural competence of disaster response teams. And she’s not alone. How agencies such as FEMA will respond to these recommendations from health professionals, if at all, remains to be seen. But in the meantime, a growing number of nursing educators are beginning to look at ways to fill this crucial knowledge gap.
Laura Terriquez-Kasey, RN, MS, CEN, is a member of a New York-based Disaster Medical Assistance Team (DMAT) that was sent to Louisiana following Katrina. The Department of Homeland Security’s National Disaster Medical System relies, in part, on a number of DMATs stationed throughout the country. The DMATs consist of highly skilled medical professionals that can be quickly deployed following a natural or man-made disaster.
Terriquez-Kasey’s previous disaster experience includes 9/11 and Tropical Storm Allison. “When I went into Allison and the flooding in Texas in 2001, we were a large group of nurses and it was very helpful to have the capacity to speak Spanish,” she says. Too often, Terriquez-Kasey believes, in the rush to “get everyone treated right away” the “cultural piece” of disaster nursing is simply overlooked.
It is an oversight that she tries to correct as a clinical lecturer at SUNY-Binghamton’s Decker School of Nursing. “There is a tremendous knowledge deficit in our health care where we don’t necessarily take the time to understand where the [patient] is coming from,” Terriquez-Kasey contends. “You can’t help someone if you can’t assess them, and if the patient doesn’t open up to you then you are really not doing your job.”
Pattillo, in her role with the National Nurse Response Team and as an assistant professor at the University of Texas at Austin School of Nursing, worries that too few nursing students receive proper training in this area. “Is cultural competency in disaster nursing being addressed? No. [Nursing schools] are not even addressing disaster nursing [in general] adequately.”
Still, Maria Warda, PhD, RN, dean of nursing at Georgia Southwestern State University in Americus, Ga., and vice president of the National Association of Hispanic Nurses (NAHN), believes there has been at least some progress in recent years. “[Considering that we were starting from zero], it is certainly a move in the right direction,” she argues.
Warda, who is an expert in Latino cultural competence, says she tries to instill in her students “an appreciation for and even a celebration of diversity. Then [I try to teach] basic communication skills that may not be perfectly culturally congruent but at least will convey human kindness, concern and empathy without offending. All that you can expect is that [nurses will develop] cultural competence for those patients whom they typically care for.” She insists that “it is not that complicated” to acquire cultural competence.
Norfolk State University’s Brown believes cultural competence must become part of disaster planning for every community, because in any disaster response there will always be outsiders arriving to help. Outsiders, that is, who may or may not speak the language of the community’s ethnic populations and who may or may not be familiar with local cultures and mores. Outsiders who need to be provided with information about what to expect regarding “the values and beliefs of the people [they] are going to work with,” Brown says.
She is critical of the prevailing approach to teaching cultural competence. “We talk about it in such broad, abstract terms of what we need to know about a person’s cultures, values and beliefs,” she explains. “We teach stereotypes even though we are trying to teach acceptance of differences. The only way we know is to teach those basic generalizations.” Brown points to work being done by the Florida Center for Public Health Preparedness (see sidebar) as “a great possible model. They are really getting things together.”
Beyond Cultural Competence
Local minority nurses from the Gulf Coast have other lessons from Katrina to share, including general advice about the more practical aspects of responding to natural disasters. Yevonne Means, LPN2, a medical-surgical nurse at Biloxi Regional Medical Center in Mississippi, recommends that nurses “bring your own food, your own water, your own blanket, whatever you need to camp out. [And] be prepared to stay for a while.”
Trilby Barnes stresses the importance of being mentally prepared for the long haul and having deep reserves of empathy for people whose lives have been devastated by a catastrophe.
“I would never want to remove the idea that there is a definite importance to cultural competence,” she says. “But I also believe there was something within me as a nurse, as a woman, as a mother, that allowed me to care for those patients. I couldn’t speak Spanish, but I still felt like I [conveyed the message] that ‘I am going to figure out what it is you need or die trying.’ I feel any nurse who [has] that compassion [can develop] the cultural competence.”
Take a Free Online Course in Culturally Competent Disaster Response
In 2004, the Florida Center for Public Health Preparedness at the University of South Florida (USF) in Tampa began offering a short online course called “Assuring Cultural Competence in Disaster Response.” The 1.5-hour course was developed by Jennifer Baggerly, PhD, LMHC, RPT-S, a professor at USF who responded to Hurricane Katrina as well as the 2004 tsunami in south Asia.
According to the center’s Web site, the course is designed to prepare public health professionals to offer culturally competent disaster interventions to survivors, witnesses and responders to bioterrorism and other major public health threats and community disasters. The course helps build competencies in such areas as:
• Identifying the role of cultural factors in determining and delivering disaster intervention services.
• Identifying cultural barriers to offering disaster intervention services.
• Approaches, principles and strategies for developing cultural competency in assisting disaster survivors from diverse populations.
• Using appropriate methods for interacting sensitively, effectively and professionally with persons from diverse cultural, socioeconomic, racial and ethnic backgrounds, and persons of all ages and lifestyle preferences, when assisting disaster survivors, their family members, witnesses and disaster responders.
Baggerly says the purpose of the course is threefold. “The first reason is to prevent harm to the individual you are attempting to help. There are numerous examples of well-intentioned public health workers actually hurting [patients]. If you are not careful you can end up promoting harm. The second reason is for [health professionals] to be more effective and achieve faster results in recovery. Third, it protects the public health worker from harm. Sometimes [you can make] an unintentional faux pas that may anger some [patients].”
Anyone who signs up can take the online course for free, although you have to pay in order to receive continuing education credits. According to Baggerly, the course was envisioned as a convenient and immediate training option. “Especially in disaster response where [it is] very fast-paced, [health workers] are trying to respond quickly, so there is some anxiety that builds up.”
Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness, stresses the course’s importance by citing research that indicates “those who are at greatest risk for adverse outcomes following any disaster are. . .non-English-speaking [and] economically disadvantaged [persons].” The course, she says, helps bridge the cultural gap to those very groups.
For more information about the “Assuring Cultural Competence in Disaster Response” online course, visit www.fcphp.usf.edu/courses/search/search.asp.
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