Culturally Competent Disaster Nursing

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


A Race for Life

As a rookie emergency medical technician, Jeffrey Brown went to work his first day on the job both excited and nervous. He was starting work for a private service in Oklahoma. However, it was not a typical first day on the job. It was September 11, 2001, and fire departments, ambulance services and hospitals across the country were being warned by authorities that there had been threats of terrorists loading up ambulances with explosives and blowing them up at hospital doors. In the next days and weeks that followed, Brown and his fellow EMTs and paramedics received frantic calls from paranoid citizens who saw anthrax in every letter and small pox in every child coming down with a common case of chicken pox.

Most EMTs have easier starts to their job. EMTs and paramedics say they’ve had so much textbook and clinical training by the time they begin their careers, that they feel ready to treat patients in any number of unpredictable conditions. Still the first year is a crucial, steep learning curve for those embarking on such a tough job.

“The hardest part is realizing that you can’t help everyone,” says Brown, who now lives in New Orleans. He recalls patients such as an elderly man who refused help despite his children’s worried pleas. Beyond the patients who cannot be helped medically, there are also those whom EMTs cannot help for legal reasons, such as a man who insisted he was fine even though EMS and his own children could see that he was not.

Trial by Fire

Fortunately for students who might not be cut out for dealing with patients in often-difficult circumstances, EMT and paramedic programs require clinical training. The education of EMTs and paramedics (who are also EMTs but have additional classroom and clinical training beyond the EMT-basic or -intermediate level) includes clinical experience, such as following and assisting real EMTs on the job. Usually a percentage of students drop out at this stage, realizing the work isn’t right for them.

Susan Schmele, director of the Oregon Health and Science University (OHSU) Paramedic Program in Portland, Ore., says paramedics-in-training have a lot to learn in that one crucial year of studying and internships. “Students have to learn how to step out onto a scene and take control,” says Schmele. “It’s not like you’re in a controlled environment like a hospital or doctor’s office. You could be anywhere from in the middle of a cow field to a million-dollar home.”
Despite the rigors of unpredictable work in the field, many students are hooked early on and stick with the hours of studying and internships with hospitals, fire departments or ambulance services because they love the work.

Take Peter Lehmann a paramedic and firefighter for Tualatin Valley Fire and Rescue in Portland, Ore., who completed the paramedic program at OHSU. He left an unfulfilling job in corporate sales with an eye toward a career change.

Lehmann, who had a bachelor of arts in business from the University of Vermont, used his new freedom to have some fun and became a rafting guide in Montana. He had to learn first aid for the job, which he found intriguing. Later, he did some ride-alongs in ambulances and knew that he had found his calling.
“It involves teamwork and serving your community,” he says now. “You feel a sense of comfort working with your crews. You have people looking out for you and you’re looking out for them.”

Because Lehmann already had a bachelor’s degree, he was able to skip a lot of the required courses in the associate’s degree program at OHSU and focus almost entirely on emergency medicine. After he received his EMT basic training at another college, he spent four months in classroom instruction at OHSU, another four months doing clinical rotations in the emergency room, operating room and in the obstetrics ward of a local hospital, and the final four months at an internship working on an ambulance with experienced paramedics.

Lehmann, who was one of 1,600 firefighter applicants for 24 openings at Tualatin Valley, is one of the fortunate paramedic grads who found a job that not only pays fairly well, but also offers continuing training. His first days on the job were spent in a three-month fire and paramedic training program in which participants are faced with scenarios-including live fires-to practice what they’ve learned.

Still, even for those with extensive training and the support of fellow paramedics and firefighters, the first year of actually working on an ambulance can be rough.

“Some calls are really hard in your first year,” says Lehmann. “Like bad car wrecks. Those are difficult calls because the patients are so critical. But you’re working with people who are experienced and who can offer another opinion or advice.”

Lehmann adds, “After a call I’ll ask, ‘How could that call have been done better? What could I have done differently?'”

Salaries Out of Step

Not only does Lehmann appreciate the training opportunities and enjoy the camaraderie that comes with being in a fire station, he also enjoys the better pay that is part of his position. In fact, on average firefighters earn higher wages than paramedics.

Training and coursework standards depend on state standards and vary by program, but requirements for paramedics are extensive compared to their EMT-basic counterparts. However their pay is typically lower than that of other allied health professionals with similar levels of medical training. Basic EMTs are versed in first aid techniques, such as CPR, but intermediate EMTs and paramedics can perform more invasive procedures and administer certain drugs.
Low pay has been a frequent topic of discussion and complaint among EMT circles for years. Now a shortage of EMTs is bringing greater attention to the issue.

According to an April 2004 article in the Journal of EMS, most states have seen a decrease in the number of newly certified EMTs and licensed paramedics. Some speculate that declining numbers are due to new curriculum guidelines that are adding hours to many training programs. Pay and attrition are also potential culprits, and many believe that a combination of all three is to blame.

“Paramedics are making a living now, but they often have more than one job,” says Ken Bouvier, president of the National Association of EMTs. “But the ultimate goal is to get salaries up comparable to other jobs in America where you can afford to put food on your family’s table without having to work two or three jobs.”

According to Bouvier and others, pay depends a lot on geography. An EMT in a rural area could make barely more than minimum wage-and that is for non-volunteer EMS. Those who volunteer, however, make as little as $12 a run. That means on a slow day, you might only make $12-if anything. Bouvier says paramedic pay typically ranges anywhere from $10 to $17 an hour, but again, it’s difficult to generalize typical pay because standards and funding vary dramatically from state to state and from county to county. Still, it’s clear that in a profession in which it takes years to become properly trained, and, in the case of paramedics, includes hours of additional classroom and clinical study, salaries are out of step with the level of expertise demanded by the job.

“You pay more money to the lady who would groom your pet than you would a paramedic to save your life,” says Bouvier. “She would spend about an hour grooming your dog and charge you $25; a paramedic might get paid $17 in an hour to save your life.”

The shortage could be good news for those who are considering a career in EMS. In many states, it will mean that jobs will be more plentiful and in some cases may be paying better to attract new talent. Bouvier says many ambulance services and other employers are losing paramedics to competing services that offer sign-on bonuses. As a result, job-hopping is adding to the retention problem. Other trends are less hopeful for future paramedics, like services and government departments replacing two-paramedic teams with one EMT and one paramedic.

Still, for EMTs such as Lehmann and Brown, passion for the work more than makes up for the profession’s drawbacks. Before he decided to go into EMS, Brown was diagnosed with Hodgkins Lymphoma and forced to quit his job as a professional diver, a career he loved. “I’m actually glad I’m not a diver anymore because I never would have found this job,” he says. “I love to do this so much.”

Observing the Experts

Both Brown and Lehmann advise new EMTs to spend their first few years on the job expanding their knowledge outside the classroom, especially by observing experienced colleagues. Lehmann says that working with other paramedics was one of his primary learning tools in his early months on the job. Rookie paramedics often underestimate how much they still have to learn once they are licensed or certified. Both Lehmann and Brown say that new EMTs and paramedics typically encounter cases that are not only difficult to deal with but tough to diagnose, as well.

“When I first got out of school as an EMT-basic, I thought, ‘I’m ready to go. I could be a paramedic now’,” says Brown.

Months later, after a move to New Orleans and a new job at the health department, Brown remembers going on a call to a nursing home with an “old-hand” EMT with several years of experience under his belt. The home had called EMS because one of its patients, an elderly woman, was acting strangely. Brown’s partner took one look at the woman and said to Brown, “Load and go.” Brown, used to the usual protocol of talking to the patient and asking basic questions, didn’t understand but followed his more experienced partner’s lead. As soon as the woman was loaded on to the ambulance, her heart stopped beating regularly, and the two EMTs had to use electric paddles to regain a regular rhythm. Brown’s partner recognized the symptoms, including the familiar pallor that he’d seen on a handful of patients over the many years he had worked in EMS.

Zero to Hero?

While new EMTs are often surprised by life-or-death cases that challenge what they think they already know, they are also equally surprised to find that much of an EMT’s typical day can be slow and quiet. Schmele says sometimes new paramedics are disappointed by the lack of excitement. “Especially younger people,” she says. “They’re a little disappointed that it’s not all car wrecks and gun shot wounds. They’re all geared up for this excitement and then it’s sit around and wait.”

“When I first started,” says Brown, “I thought every call was going to be life and death.” Instead he found his first job working for a private service to involve a lot of transporting patients from nursing homes to hospitals. Bouvier says that typically 90% of EMS work doesn’t involve life or death cases.

Some have used this reality to bolster the notion of “zero to hero” programs that reduce the number of classroom and clinical hours required to earn EMT certification. Looking at the profession more as one of ambulance driving than one of patient care also supports the argument that fewer paramedics are needed on ambulance crews. But EMT advocates think this view is shortsighted.

“Rarely are you going to have the opportunity to save a life,” says Bouvier, conceding that inexperienced, basic EMTs can handle the majority of these non-emergency cases. “Most of the calls are routine. The other seven or eight percent are going to be crisis, life-threatening calls without a well-trained, experienced EMT or paramedic, that patient won’t have a second chance at life.”

Bob Luftus is a retired paramedic in Carbondale, Ill., with decades of experience as a military and civilian paramedic who has worked all over the country and witnessed first hand the struggle of EMTs to be recognized as full-fledged medical professionals and not just patient transporters. “We’re still trying to grow up and be treated like other first responders,” he says of the profession’s growing movement to demand recognition and better pay. “You’re out there helping people, sometimes saving lives, and in the bigger scope of things that’s better than making money.”