Digital Repository Doctoral Projects Spring 2021 Preparing Nurses in Communities to Respond to Local Disasters: A Quality Improvement Project Shane A. Archibald, MSN TNCC Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Archibald, S. A. (2021). Preparing Nurses in Communities to Respond to Local Disasters: A Quality Improvement Project. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Preparing Nurses in Communities to Respond to Local Disasters: A Quality Improvement Project by Shane A. Archibald A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 25, 2021 Mary Anne Hales Reynolds PhD, RN, ACNS-BC_ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Running head: PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL Preparing Nurses in Communities to Respond to Local Disasters: A Quality Improvement Project Shane A. Archibald, MSN, TNCC Annie Taylor Dee School of Nursing, Weber State University PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 2 Abstract History and present-day circumstances worldwide show that natural and human-made disasters are events that can, and will continue to happen. Disaster Preparedness Organizations, at all levels, recognize the challenges and limitations to local and immediate responses. Nurses living within a community are a valuable, and overlooked, resource for disasters. However, many nurses do not have the required disaster education, experience, or resources. The purpose of this DNP led project is to prepare and educate nurses living in Davis County, and working at Lakeview Hospital, about disaster skills and to respond to any future community disaster. This project used the World Health Organizations Disaster Management Cycle to develop a modified virtual program during the COVID-19 pandemic to help educate and prepare Lakeview nurses on early or immediate disaster recognition, assessment, interventions and skills, and build confidence. The impact of the program was evaluated using Likert scale surveys of pre- and post-teaching evaluations which were collected and evaluated for improvements and changes. Eight nurses from Lakeview Hospital volunteered for the course, all of whom have previous Emergency Room experience, with three of the eight nurses now working in management positions elsewhere within the hospital. Education amongst the nurses who were involved in the project was noted and helped encourage self-reliance and self-sustainment for the participants. All nurses showed an increase in knowledge about early disasters and learned skills, along with an increase in overall confidence. This program demonstrated that there is a need in the nursing community for further education and preparedness related to disasters and immediate community response. It is critical the community neighborhood is prepared to respond immediately to any disaster. Nurses living in a community can be prepared to meet that need by using programs to PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 3 educate and prepare them. Continued work with both hospital and community preparedness programs is needed to further develop partnerships, establish coalitions, develop measurable objectives, and help solve preparedness problems. This program can be used in both a university or community setting to teach or re-teach nurses on basics of disaster response and preparedness. Keywords: disaster, preparedness, community preparedness, nursing education, community education, planning, community planning, disaster impact, disaster response. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 4 Dedication For my awesome family and all future DNP’s. Before I started this program, I used to wonder what I could accomplish; now, I only know that with family and preparedness everything is possible. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 5 Acknowledgment This project would not have been possible without the love, support, and encouragement I received from my family. I am only now beginning to realize how much they each sacrificed so that I could attend Weber State University, through many programs and classes to achieve my dreams. I do not have words to adequately describe my deep gratitude for all they have sacrificed for me, though I hope to show them in the years to come. I have benefited greatly from the mentoring of many of the faculty from the Annie Taylor Dee School of Nursing, from beginning of nursing school to completion of the Doctoral Program, and faculty across the campus of Weber State University. I am especially grateful to Dr. Mary Anne Reynolds whose comments and mentoring helped me grow educationally and personally. Also, a special thanks to Tamera Timothy of Lakeview Hospital for her mentoring and guidance in seeing that the project came to fruition. Finally, to each of my peers both professionally and throughout the School of Nursing program a very special thank you for your knowledge, encouragement, and support. By Example my friends! PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 6 Preparing Community Nurses to Respond to Local Disasters: A Quality Improvement Project "In the last decade, natural and man-made disasters around the world have increased in both frequency and severity" (Alfred et al., 2014, p. 82). The 2018 Review of Disaster Events reported 315 climate-related and geophysical events with 11,804 deaths. Over 68 million people worldwide were affected by these disasters, which left more than $138 billion in property and economic losses (Centre for Research on the Epidemiology of Disasters [CRED], 2018). These disasters do not take into account human-made calamities such as terrorism, civil war, or other disasters. After September 11, 2001, a greater focus began in the United States of America on preparedness and response to mass disasters of all types. A greater focus has been made on the responsibilities of the Federal Emergency Management Agency (FEMA) and the training it provides to federal, state, and local government groups and public citizenry/voluntary organizations. Governments pass laws and policies from which agencies make procedures and regulations that help local cities and community organizations to prepare for disasters. Passed down to the community level, education and preparation should inform citizens how to individually prepare themselves to mitigate damages and respond to disasters prone to their areas (U.S. Department of Homeland Security, 2019). However, despite all of these governmental efforts to increase preparedness, preparedness levels in communities nationwide are lacking (Kohn et al., 2012). In the sense of healthcare with disasters and preparedness, two significant challenges in the face of any disaster will be first, the established typical hospital and clinical standards of care may be impossible to maintain, and second, “despite efforts to advance nurse PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 7 readiness, many nurses lack the necessary skills to demonstrate clinical competence in a disaster” (Veenema, Andrews, & Hilmi, 2016, p. 51). The purpose for this project is to highlight education and skills that will help prepare and re-educate nurses to care for members of the community in all aspects of pre-, during, and post-disaster care in a way to help with community preparedness. Nurses make up one of the largest groups in the healthcare force (Al-Maaitah et al., 2019). Nurses are an invaluable resource, under non-emergent and emergent conditions, based on their training and experience in both acute and chronic medical situations. Nurses are educated in the evaluation and management of patients across the life-span in various environments. Nurses will be pivotal in the coordination of response in a disaster (Johnstone & Turale, 2014). However, many nurses are unprepared to respond to disasters due to a lack of knowledge or skills directly related to emergency management, treatment, and triage (Barclay, 2010; De Jong et al., 2010; Littleton-Kearney & Slepski, 2008; "Mass Casualty Management Systems", 2007; "Ready or Not?", 2009; Strangeland, 2010). The U.S. Government has learned from past experiences and now recognizes its limitations to respond immediately to disasters and knows that it cannot do everything in preparedness and response alone. The government also realizes that as a nation, we cannot afford the continual economic impact of disasters. Engagement in all areas of societal capacity, especially in large-scale and catastrophic events, at the community level is the only way to approach all of the needs that now exist in preparing for and preventing loss of life and property (Rademacher & Crabill, n.d.). How then can we prepare our greatest asset, namely nurses, of all skill sets (e.g., medical-surgical, OB, OR, ER, home-health) who may find themselves at home, in the community, or at their workplace to best respond? PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 8 Disasters The World Health Organization (WHO) defines a disaster as "an occurrence disrupting the normal conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of the affected community" (Ababa, 2002, p. 3). The International Federation of Red Cross further defines it as: …a sudden, calamitous event that severely disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community's or society's ability to cope using its own resources. Though often caused by nature, disasters can have human origins” ("What is a disaster?", 2020). Khan et al. (2008) explains that disasters are the result of a combination of factors that have some measure of controllability and others that do not based on "the extent to which a community, structure, services or geographic area is likely to be damaged or disrupted by the impact of a particular hazard, on account of their nature, construction and proximity to hazardous terrains or a disaster-prone area" (p.45). Disasters can be human-made incidents or naturally occurring events caused by specific scientific events under specific circumstances that cause the event to have a catastrophic result based on size, strength, location, or duration. The Centre for Research on the Epidemiology of Disasters (CRED) (2009) discuss two major types of disasters, natural and technological. Natural disasters have been divided into six disaster groups, including biological, geophysical, short- and long-term weather events (defined as meteorological and climatological), hydrological, and extra-terrestrial (Below, Wirtz, & Guha- Sapir, 2009). Examples of these events, depending on geographical location in the world may include, for example, heat-waves, fires, blizzards, hurricanes, floods or tsunamis, droughts, diseases that create pandemics or epidemic's, earthquakes and the threat of global warming PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 9 (Leaning & Guha-Sapir, 2013). In the United States, significant disaster possibilities are most likely to involve flood, earthquake, fire, tornado, or hurricane. Technological (Human-made) disasters include terrorism, mass-shootings, chemical or hazardous materials. In areas prone towards both natural and human-made disasters failing infrastructures and over-population are also factor's that people need to educate and prepare themselves for (Centre for Research on the Epidemiology of Disasters [CRED], 2018). Disasters can lead to additional issues such as economic instability, illness' and disease's secondary to injury, loss of infrastructure and support, mental and physical trauma, and civil unrest (Global disaster management: Terrorist hazards, 2019). Shaluf (2008) proposes that regardless of the kind of disaster, it will occur in a known series of four stages and can vary in length and strength based on the disaster type and location. First, the pre-disaster stage, which is seen as the incubation period where the accumulation of the unnoticed set of events, which are at odds with the accepted beliefs about hazards and the norms are in avoidance (Turner & Pidgeon, 1997). In other words, conditions raising the potential for a disaster are ignored or not seen. Second is a triggering event that occurs when an unsafe event, act, mistake, or violation happens that forces the disaster. Third, the disaster stage covers the time of the event from the beginning of the disaster to stabilization and the start of the fourth and final stage, which is post-disaster. The disaster stage and post-disaster stage have no distinct line of delineation and may overlap one another or interfere with each other. Disasters will continue to occur and appear to be happening on a larger scale, with higher intensity, and are becoming more challenging with steadily rising human and economic losses worldwide (Rademacher & Crabill, n.d.). The WHO and other international and national organizations have researched vital changes and actions that need to occur in order to help PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 10 prepare and prevent such losses. The key is the need for disaster preparedness at all levels of community organization both government, business, and private. Disaster Preparedness Disaster preparedness is "a continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action" (Federal Emergency Management Agency [FEMA], 2013, para. 1). Global organizations, like the United Nations, WHO, and national agencies in all countries have plans, policies, and procedures in place to help their citizens with disasters. In the U.S., under the direction of the Department of Homeland Security, the organization and planning are overseen by the Federal Emergency Agency (FEMA). The U.S. National Preparedness Goal states that we should work towards “a secure and resilient Nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to, and recover from the threats and hazards that pose the greatest risk” (Federal Emergency Management Agency [FEMA], 2015, p. 1). To prepare as a community, we will require an organized approach that addresses each of these goal-related capabilities in order to ensure that lives and property are saved and protected. Management of disasters going back to the mid-1900’s primarily focused on rehabilitation and recovery efforts, though many areas of social studies, science, medicine, and educators focused on all areas across the span of disasters (Coetzee & Van Niekerk, 2012). In the 1970’s more focus was created on the prevention and mitigation of disasters to avoid the cost with rehabilitation and recovery which helped with the development of the disaster management cycle (Coetzee & Van Niekerk, 2012). The WHO adopted this around the globe as a framework to help curtail vulnerabilities in the phases of disasters. The Disaster Management Cycle works in an overlapping fashion to PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 11 address Pre-disaster, Disaster, and Post-disaster events (Wisner & Adams, 2002). The model suggests that each phase of a disaster is different, and planning requires different needs and responses of each phase. Source: Malilay et al., 2014, figure 1. Pre-disaster Pre-disaster includes prevention – which are measures taken to remove root-causes and vulnerabilities for disaster possibility (Sena & W/Michae, 2006). Prevention may mean fixing roads and bridges that are in poor repair, releasing water from a full dam when storms are expected to avoid flooding, or cutting back vegetation and brush to avoid brushfires. Mitigation – is an active, ongoing process that attempts to disrupt the effects of disasters through processes like building codes, zoning, analyses and surveys, and public education. Mitigation attempts to change the disaster itself and can be used both before and during any ongoing disaster. Preparedness - in comparison to mitigation, looks at response plans and includes exercises and training and advanced warning systems. It is a passive process that is specific to each type of disaster and must be completed before the disaster occurs. It is during this time that communities PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 12 can effectively plan and prepare, evaluate strengths, identify, position, and stock-pile resources. Disaster Moments after a disaster's impact, regardless of how much planning or preparation, there may be a sense of fear, confusion, and shock. Disaster impact may take over communities and individuals who are reckoning with the occurrence and are also dealing potentially with the injury and death of others unexpectedly. At the same time, the destruction of infrastructure can add to it. Lindell (2013) defines a disaster’s impact as “physical and social disturbances that a hazard agent inflicts when it strikes a community.” Physical impact comprises injury, death, or illness along with physical loss of property like structures, vehicles, infrastructure, and the natural environment. Further impacts are social issues such as psychological, demographic, economic, and perhaps political (Lindell, 2013; Sharrieff, 2018). Disasters always occur at the local level (U.S. Department of Homeland Security, 2019). Initially, local citizens, the local government, and voluntary agencies will be first to cope with a disaster's effects. During initial response and recovery, the local government will be the first to maintain control of all assets related to dealing with the incident (Veenema et al., 2016, figure 1) (see figure 1). Voluntary organizations, such as hospitals with nurses, working under the oversight of the local government, would also help to plan, coordinate and work to educate the public in order to develop community resilience (Disaster Sequence of Events, n.d.; Warfield, n.d.). "Neighbors don't panic and run (that's a movie myth), they adapt to the situation, take the injured to hospitals and do anything they can to be helpful" (Henry, 2018). Impacts of disasters at first will be felt individually (physically, mentally, and emotionally). It can result in loss of resources, feeling of security, may result in post-traumatic stress, and leave feelings of negativity. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 13 Post-disaster Based on the type and strength of the disaster, post-disaster recovery could be very long term in nature. As discussed under the disaster phase, this could include environmental changes that interrupt supply and logistical chains. There can be public health outbreaks of disease, lack of food/water, sanitation issues, no power, and lack of communication. During this phase, there is a focus on debriefing, coordinating efforts to address psychological and public health impact (Yan, Turale, Stone, & Petrini, 2015). Recovery/Response/Rehabilitation – covers the time during and after the disaster to prevent further damage and loss of life, including emergency relief and Search and Rescue efforts (Warfield, n.d.). This phase has three interrelated meanings. First, recovery is a goal which involves trying to restore normalcy to the community affected. Second, it is a phase in the WHO cycle involving stabilization between each point of response, recovery, and rehabilitation to help with returning to a healthy routine. Third, it is a process. Recovery, response, and rehab are achieved when the community returns to regular routines (Lindell, 2013). Pre-disaster Focus: Preparedness The focus of this project is to look at the Pre-disaster area of the Disaster Management Cycle, namely the preparedness phase. Preparedness is the measures taken to ensure “the organized mobilization of personnel, funds, equipment and supplies within a safe environment for effective relief” (Ababa, 2002, p. 21). This project explores ways to educate and prepare nurses as community members with current information and supplies to care for themselves and others during the initial phases of any incident. Further, it helps nurses prepare through mental learning and physical skills testing. Nurses can use skills taught by best evidence practices put forth by literature and research, various government agencies and community/hospital policies PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 14 and plans during the Pre-disaster Phase of disasters to help with mitigating damage, injury, and loss of life; whether at home, at work, or in the community at large. Individuals should prepare now for their role with the guidance from their community, State and Federal agencies. Nurses need to gain an understanding of what will happen and what to do if a disaster exceeds the scope of one's ability to function or handle the degree of the disaster which is everyone's responsibility (Disaster Sequence of Events, n.d.) in order to protect the community health and infrastructure. The National Incident Management System (NIMS), under FEMA, developed the preparedness cycle. The preparedness cycle works within the WHO cycles pre-disaster phase. NIMS defines the preparedness cycle as a "continuous cycle of planning, training, equipping, exercising, evaluating, and taking corrective action [sic] to ensure effective coordination during incident response" (Center of Excellence Homeland Security, 2020, para. 1). Source: (Mielke, Winchell, & Murphy, 2014, figure 2.1) The preparedness cycle looks at planning and organizing groups and resources. This includes training and equipping teams with needed education about disaster preparedness while PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 15 defining roles and responsibilities, based on skills and location, and who will be at the forefront of the response when disasters happen. Finally, through evaluation from these exercises corrective actions are made to fix problems and concerns before a disaster (Center of Excellence Homeland Security, 2020). The ongoing cycle of preparedness is key for communities to prepare to respond effectively to disasters and decrease injury, loss of life, and environmental damage (Center of Excellence Homeland Security, 2020). By using the cycle of preparedness as a guide, communities can develop better plans and exercises to help respond for the effect of disasters and possible decrease of injury, loss of life, and environmental damage (Center of Excellence Homeland Security, 2020). Community Preparedness A community is a "group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings" (MacQueen et al., 2001, p. 1929). Neighborhood’s, in comparison, are a smaller group of houses and buildings, making up a smaller subdivision of the community as a whole ("Neighborhood," 2020). Community preparedness is defined as the "ability of communities to prepare for, withstand, and recover…from public health incidents" (U.S. Department of Health and Human Services Centers for Disease Control and Prevention, 2020, p.16). Community preparedness goes beyond just expecting the government (e.g., first responders/EMT’s, police officers, and firefighters) to be right at the doorstep to help. In reality, community residents, bystanders, and neighbors are usually the first ones there – and find themselves in the best position to help save lives (Henry, 2018). By understanding the value of community, FEMA has initiated a new philosophy of disaster management called “Whole Community.” Though still being developed in the policy PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 16 framework, its terminology is already found in government documents, including Foresight Initiative Toward 2030 (FEMA, January, 2012). FEMA (2011) explains: “As a concept, Whole Community is a means by which residents, emergency management practitioners, organizational and community leaders, and government officials can collectively understand and assess the needs of their respective communities and determine the best ways to organize and strengthen their assets, capacities, and interests” (p. 3). FEMA, building on the whole community idea, includes the need for communities to include planning and preparedness by looking at socio-economic vulnerabilities in the community as part of risk planning and the capacity or ability to cope during a disaster (Khan, Vasilescu, & Khan, 2008). Accomplishing these vulnerabilities are done with the use of levers, or the means of reaching the end components of preparedness such as wellness and access, education, engagement, self-sufficiency, partnership, quality, and efficiency that assist in community preparedness (Chandra et al. 2011). An example of this would be helping communities have better access to health services as a lever. In 2001 the people of Houston, Texas, faced Tropical Storm Allison, which caused billions of dollars in damage, destruction of infrastructure, and the loss of 55 lives ("Tropical Storm Allison," n.d.). Using levers from lessons learned from that storm Texas established floodgates, above-ground electrical and water-pump systems, and provided better storage and sourcing for supplies amid known shortages. They established a strong coalition of regional healthcare systems and ensured the position of emergency management and public health agencies, which helped them be better prepared for Hurricane Harvey in 2017. In contrast, Florida did little to learn from lessons and use levers, which resulted in the deaths of 12 persons PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 17 in a nursing home during Hurricane Irma (2017) due to local agencies' inability to communicate or share resources with one another (Kacik, 2019). An integrative review of personal disaster preparedness literature found that "overall, families and households are unprepared for disaster both in the United States and abroad” (Kohn et al., 2012, p. 226). Bronfman, Cisternas, Repetto, and Castañeda (2019) found that residents had significant differences in their preparedness levels at home versus workplace as well as their preparedness based on the type of disaster that they might be facing. Residents feel more prepared and are more ready at the workplace than at home. The authors postulate that this is in part due to preparedness efforts and regulations instituted on businesses in comparison to self-preparedness at home. For successful coordination at the residential and neighborhood-level using the preparedness cycle state and local government agencies with emergency management, healthcare organizations, mental/behavioral health providers, faith-based partners, and those volunteer agencies working in this area need to create interprofessional teams. The team’s goals related to planning and organizing should look at the functional needs of at-risk individuals, including socio-economic and demographic areas of the community. Preparation should include measuring for potential adverse high-risk medical outcomes that help to understand and integrate the health needs of populations. These populations may have been displaced from a disaster, whether locally, or maybe from other distant communities, that are displaced and have moved into a new community outside of the disaster zone (U.S. Department of Health and Human Services Centers for Disease Control and Prevention, 2020). Teams should exercise the plans through training and each of the necessary organizations on what roles they play and how they should respond in a disaster, and equipping them with the necessary items to complete their assignments. Conducting PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 18 evaluations of the training and exercise levers should be incorporated in order to improve upon the lessons learned (U.S. Department of Health and Human Services Centers for Disease Control and Prevention, 2020; Chandra et al., 2011). Implementing change and action can take time based on the buy-in and preparedness of the community and community partners at an individual, organizational, and environmental/systemic level (Veenema et al., 2015). Some of the more essential factors related to the level of commitment by each individual at all levels to be engaged and willing to buy-in financial and responsibly to the specific needs of the community, see Table 3 for a complete list of factors. Putting disaster preparedness and community preparedness together requires taking the best resources, groups of people, and community residents to use them as part of the resources to help prepare a community for disasters and emergencies, which may most likely be an issue within the given area. Most communities and neighborhoods have nurses in them. Nurses are uniquely prepared due to their professional preparations, continual training and learning, and hands-on experiences to respond and help in disasters. These traits can also help with improving public education and the overall health and outcomes of patients. Nurses make a logical and available group to work with for community preparedness. Nursing Role in Community Preparedness Nursing in the U.S. comprises the largest healthcare profession, having more than three times the number of nurses to physicians (American Association of Colleges of Nursing [AACN], 2020). With more than 3.8 million registered nurses nationwide, there are, on average, 874 registered nurses per 100,000 citizens in the U.S. who are not evenly distributed amongst the population ("Which States have the most registered nurses?," n.d.). Utah, for example, ranks 48th in the nation and District of Columbia, with 678 nurses per 100,000 persons. The District of PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 19 Columbia ranks 1st with 1,728 nurses per 100,000 persons ("Which States have the most registered nurses?," n.d.). Nurses train and specialize in specific areas based on their desires and qualifications, with more than 100 various types of nursing specializations (Nurse Journal, 2020). Not all of these specialties focus directly on disasters, preparedness, or trauma. In the U.S., there are only approximately 90,000 emergency room nurses ("Career info: Emergency nurse," n.d.) with another 500,000 critical care nurses (BSN Education, 2019). In school, nurses receive a base foundation of education and knowledge to evaluate patients, to discern many types of family socio-economic vulnerabilities, how to help educate and provide programs or resources that may help improve health and healthy lifestyles. The American Association of Colleges of Nursing (AACN) (2008) revised its essential curriculum for the baccalaureate (BSN) and master's (MSN) programs to align more with the Institute of Medicines (IOM) report on the future of public health and health profession education. With the revision came recommendations for more focus on emergency response and disaster preparedness (Alfred et al., 2014). Essential II (Clinical Prevention and Population Health) and Essential VIII (Clinical Prevention and Population Health for Improving Health) of the AACN for the BSN and MSN competencies respectively focus, for example, on education related to emergency preparedness, disaster response, and self-protection (American Association of Colleges of Nursing [AACN], 2008; American Association of Colleges of Nursing [AACN], 2011). Alfred et al. (2014) teach that nurses should receive education in Prevention and Preparedness in areas of risk reduction, disease prevention, health promotion, policy development and planning, ethics, legal issues and accountability, and communication sharing. During the Response phase, nurses should understand how to take care of the community at large, individuals and families, understand psychological care, and how to care for vulnerable PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 20 populations. Finally, during Recovery/Rehabilitation, nurses should know about long-term community, individual, and family recovery associated with psychological and mental health, and public health. Nurses have a low to moderate level of disaster preparedness, in preparing for mitigation with knowledge and skills competencies for large-scale health emergencies, and even less attention has been paid to psychological preparedness (Wisniewski, Dennik-Champion, & Peltier, 2004; Adelman, Frost, Wood, & Zak, 2019). Nurses lack sufficient knowledge about disaster preparedness due to a lack of training in core competencies and the absence of disaster preparedness within nursing education. Nursing programs are already extended out to maximum loads and have faculty that either lack knowledge or confidence to teach on the subject (Achora & Kamanyire, 2015; Al Thobaity, Plummer, Innes, & Copnell, 2015; Nash, 2015). Additional education and preparedness are necessary for a successful response and outcome in a disaster (Kalanar, 2017; Wilkinson & Matzo, 2015; and Yan, Turale, Stone, & Petrini, 2015). Nurses must work towards becoming better educated and trained to strengthen their preparedness and confidence (Said & Chiang, 2019). Teaching nurses in a collaborative approach as individual community members about becoming self-reliant and able to take care of their personal and family needs as an essential first step towards self-sufficiency. Once achieved, they can begin working with neighbors and the community to ensure that others are ready also (Henry, 2018). Further recommendations have been made on the use of concepts, practicing, exercising, training, receiving skills, and continuing education that nurses can and should receive about disaster preparedness. Education and training are a crucial component to being prepared ("Make a plan," n.d.; Pesiridis, Sourtzi, Galanis, & Kalokairinou, 2015; Yeager, Menachemi, McCormick, & Ginter, 2010). Nurses need to be educated to accomplish this vision and help PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 21 meet FEMA’s National Preparedness Goal of “a secure and resilient Nation with the capabilities required across the whole community…” (Federal Emergency Management Agency [FEMA], 2015, p. 1) nurses should be able to develop skills and abilities to disasters in a timely and effective manner. Veenema (2015) explains for goal achievement, nurses should ideally “possess the minimum knowledge base, skills, and abilities regarding disaster response and public health emergency preparedness” (p. 190). Education is accomplished through responding directly or providing indirect support during a disaster event or public health emergency, promotes preparedness amongst patients, families, and communities, and by participating in disaster planning, drills (Unver et al., 2018). The goal of preparedness education should enhance national disaster preparedness and response at the community level (Veenema et al., 2015). First, however, nurses must possess at least a minimum knowledge base and skill set to keep themselves, their families, and their patients safe or minimize harm. With nearly 58% of the nurses in the U.S. working in medical and surgical hospitals (AACN, 2020), much of the training and education that they can receive towards community preparedness while receiving hands-on training for it will come from within hospitals and continuing education requirements. In hospital settings, nurses can enhance and learn skills through institutional awareness, understanding protocols, and helping establish federal compliance with guidelines, assessing hazards, gauging exposure, and identifying hazards, vulnerabilities, and gaps (Veenema, Losinski, & Hilmi, 2016). There is a need for better preparedness, education, collaboration, and communication with all levels of response from the federal government down to the community level. FEMA recognizes the whole community effort as a critical resource (Federal Emergency Management Agency [FEMA], 2011). Nurses are an essential asset in this effort. Emergency Preparedness and PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 22 education are especially applicable to nurses in Utah and the Davis County area as there are fewer nurses available per capita than elsewhere in the nation ("Which States have the most registered nurses?”, n.d.). Needs/Gap Utah has seen significant events such as the 2002 Winter Olympics, which after the events of September 11, 2001, prompted significant disaster preparedness responses for potential human-made events of terrorism ("Office of the Press Secretary (The White House: President George W. Bush)," 2002). Utah is more prone, however, to natural events such as the F2 tornado (1999) and another smaller one in 2016. It is also prone to wild-land fires, droughts, blizzards, earthquakes, floods, and mudslides, which all show a need to be prepared. Statistically, Utah is ranked amongst the lowest States in the nation to declare for a federal disaster with an average of one to four declarations per year and only ranks 30th amongst the 50 States in overall preparedness (O'Donoghue, 2018; Gold Eagle, 2020; Rees, 2018). In Utah, this may mean that if an earthquake were to occur in a populous area, for example, there could be a significant disruption to infrastructure, business, healthcare, and severe loss of life and injury. Resources would quickly be overwhelmed or depleted and would require the help of outside agencies and the government to help restore a sense of normalcy and order to the area over possibly a considerable period (U.S. Department of Homeland Security, 2019). Nurses, as community first-responders, comprise one of the largest sectors of the healthcare professions and are essential in disaster response (AACN, 2020; Nash, 2015). Their education and community preparedness are two of the primary solutions in dealing with potential disasters and learning how to mitigate the effects of them on communities, the environment, and PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 23 the economy. It is essential to ensure that nurses become knowledgeable about disaster response and preparedness. Theory The Planned Change Theory or the Three-Stage Change Model developed by Kurt Lewin (Psicopolis, n.d.), directed the planning and implementation of education for this DNP project. Lewin’s theory was developed to try and understand behavior and attitudes. Lewin proposed "that human behavior is the function of both the person and the environment," meaning that "one's behavior is related to both one's personal characteristics and to the social situation in which one finds oneself" (para. 14). People do not just act from internal impulses but are influenced dramatically by their surroundings. The Planned Change Theory is a simple model for helping plant an idea which provides thoughts and perceptions that changes are needed, then using those concepts to move toward the need, and finally the idea is solidified as the new need and the new norm (Kritsonis, n.d.). Lewin's theory works in three phases, unfreezing the existing status quo by causing an imbalance in the equilibrium. Next, changing the behavior. And finally, refreezing ("Kurt Lewin English Language Index," n.d.) (See Appendix B). For this DNP project the goal was to use the Planned Change Theory with nurses in a hospital setting and unfreeze potential poor behaviors and learned attitudes, including the notion that preparedness can wait to be learned or accomplished later. With proper education and preparation, there will be a change in these types of behaviors towards being ready for possible disasters within their communities. Finally, using the new knowledge and change in behavior, goals can be made to aid in community and self-preparedness before disasters occur. Many nurses, especially nurses working in the profession for some time, have some established knowledge, skill, experiences, and beliefs about how to care for patients in various PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 24 settings. Unfreezing took learned attitudes and behaviors that nurses developed about disaster preparedness education and by providing new knowledge and ideas for adaptation and became a catalyst for change in the perceptions and understanding of the importance of self-preparedness and self-reliance. Education and simulation training showed nurses that preparedness now can help later in emergencies or disaster situations, to focus on community needs, including stress reduction, injury prevention, and recovery. By refreezing the performance skills in high-stress situations, confidence building, and independent thinking these newly created norms showed ways to apply preparedness into the nurse's daily lives and how to help others develop similar attitudes and behavioral changes. Disasters will continue to occur all over the world with and without warning. Despite government efforts to increase personal preparedness, numerous studies and polls suggest that preparedness levels in communities are lacking in our nation and worldwide (Kohn et al., 2012). The literature shows that education is necessary and lacking in many areas related to response, mitigation, and preparedness of emergencies and disasters. With education and increased knowledge given to nurses, there will be a positive outcome that increases personal preparedness within their community neighborhood. One goal for this project was to look at ways to embed positive experiences from nurses. Building upon that knowledge, it will help motivate and use the positives to work against the equilibrium of lack of knowledge or any disbelief that a disaster could occur in their location and to help improve community response to disaster preparedness. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 25 Setting Utah, with an ever-growing population, has associated growing pains in dealing with infrastructure to State and local government readiness in preparing for any type of disaster (Alfred et al., 2014; Neely, 2018). Utah is reported to have over 3.3 million residents living in the State, approximately 80%, more than two million, of those residents live along the Wasatch Front (Weber, Davis, Salt Lake, and Utah counties). The smallest of the 29 counties in Utah is Davis County (Co.), which has the third-largest population in the State, with over 360,000 residents and growing. Davis Co. is diverse in its area with the Wasatch mountains running along the entirety of its eastern border and the dry and arid Antelope Island and the Great Salt Lake, with all of the marshes and wetlands along the western border. In between these two areas, the county is surrounded and filled with agricultural, semi-rural, and urban/metropolitan areas (Davis County: Community & Economic Development (C.E.D.), 2015). Davis Co. is susceptible to natural disasters such as fire, windstorm, earthquake, mudslide, and winter blizzards or avalanches and the potential for technological disasters such as major roads, interstates, and railways carrying chemicals and hazardous materials. Hill Air Force Base military installation houses munitions, chemicals, hazardous materials, and planes. There is a total of 5 large oil refineries with fuels, chemicals, and combustible materials, along with several large industrial areas, businesses, and a small civilian airport scattered throughout the county (Davis County Government, 2014). Lakeview Hospital, founded in 1972, is located in Bountiful Utah on the south end of Davis County. The hospital is part of the Hospital Corporation of America (HCA) system. Today the hospital has a Trauma III level acute care rating and has 128-beds in a 210,000 square foot facility, including 15 ER beds, 8 ICU beds, and 6 OR suites. There are some 600 full-time PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 26 employees, 225 physicians on staff, with 200 nurses. Located along the Wasatch fault line on the east bench, the area around Lakeview Hospital also has a large senior citizen population that will have a great need for help in the event of an emergency disaster. Within the borders of the community, there are also several refineries, industrial areas, and a small community airport, which all leave possibilities for technological disasters. Lakeview recognizes the need to be supportive of community preparedness and is providing resources to this project by allowing the use of their training facilities, and funding the training hours for each of the participants which helps the hospitals EOP and response goals. Population In 2016, the Utah Medical Council surveyed Utah's Registered Nurses. In that survey, it was reported that there were 28,948 RN's licensed to actively practice in the State of Utah, with 27,330 (94%) of those working. More than 50% of those 27,330 are working along the Wasatch Front. 61% of the nurses across the state work in a hospital setting with the remainder working in a variety of other nursing professions or areas such as school, public health, or administration, to name just a few (Nagelhout, 2016). There are approximately 1,017 registered nurses working within Davis Co. (Nagelhout, 2016), approximately 200 of whom are working at Lakeview Hospital. The demographics of the nurses at Lakeview vary across each department with a variety of educational levels, experience, and knowledge. Every nurse has basic life support (BLS)(CPR) certification, basic FEMA courses related to introduction to incident command systems, and basic incident command system for an initial response as required by their administration during the initial hiring orientation. The Emergency Room (ER), Intensive Care Unit (ICU), and Operating Room (OR) nurses are certified in Advanced Cardiac Life Support PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 27 (ACLS). The ER and ICU are certified in Trauma Nursing Core Course (TNCC). The ER nurses also have Pediatric Advanced Life Support (PALS) and Emergency Nursing Pediatric Course (ENPC) certifications. Eight nurses were selected, due to the COVID pandemic, to participate in an online/virtual experience of this project. All eight currently work or have worked within Lakeview’s ER, 5 are currently still in the ER and 3 are now in higher management positions within Lakeview to include the Stroke/Trauma/Disaster Preparedness Director, Orthopedics Director and the and Emergency Department Director. Years of nursing amongst the participants averaged 13.5 years overall. Three nurses have a Bachelor’s of Science in Nursing (BSN) education level, one is working on a BSN, and three have an Associate’s Degree in Nursing (ADN). Project Implementation Plan Goal The goal for this project was to increase community disaster preparedness in order to improve overall disaster outcomes. By approaching nurses working in hospitals, namely Lakeview Hospital at first, and organizing them at a level based on their education and current training, this project will enable nurses to help mitigate additional damage, injury, or death during disasters and emergency situations, no matter the scope or size. Aims The accomplishment of this project happened in three parts—first, the recruitment of registered nurses who desired further knowledge and education. Second, the organization of resources for the didactic teaching and simulation training that met the community needs and PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 28 knowledge of the nurses involved. Third, to help nurses who participated become more confident about their possible roles in initial emergency responses. Plan The project started by partnering with a local community hospital (Lakeview). Then, working with the disaster preparedness nurse and education coordinator for Lakeview, nurses from several departments were recruited who desired to learn how to prepare for community disasters. Recruitment involved notification on in the continuing education departments application and word-of-mouth advertising by the disaster preparedness coordinator in department meetings with department managers and administrators. The program was advertised as education and skills-based scenario training with completion of a voluntary pre- and post-survey of employed nurses within the hospital related to emergency preparedness. The anticipated class size was 8-12 students participating in each class to ensure a proper student-to-instructor ratio. As the DNP project leader, the results of the pre-survey were used to establish an organized didactic presentation on topics of greatest weakness and incorporated into the programs already identified as being essential for the training. The pre- and post-survey used a tool defined as "the only reliable and valid tool in the literature utilized to evaluate nurses' perceived familiarity of emergency preparedness and disaster response core competencies…the Emergency Preparedness Information Questionnaire (EPIQ)" (Georgino, Kress, Alexander, & Breach, 2015, p. 241) (see Table 1). Using the results of the survey, curriculum-based didactic modules were organized into creation of eight modules related to community response in disasters and planning. Each module used goal concepts from the established International Council of Nurses (ICN) 2019 domains PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 29 and guidelines for disaster preparedness and the Centers for Disease Control (CDC) guidelines on Core Competencies for Nurses (2002) (Gebbie & Qureshi, 2002; Al-Maaitah et al., 2019) (See Appendix B). The modules incorporated training and education of nurses through lecture, open discussion, skills practice, and a culminating scenario exercise to test the concepts and lessons taught and to help participants to develop muscle-memory skills, develop communication and critical-thinking skills, and triage capabilities (Digregorio, Graber, Saylor, & Ness, 2019). Originally the course was to be 2 days with 12-hour class (8 hours on day one and 4 hours on day two). Day one and half of day two was to cover the educational portion of training with didactic, table-top, and break-out sessions of discussion. The second half of day two was to consist of a 4-hour simulation training exercise. This was to be completed at Lakeview Hospital in their educational conference and training room and outside of the hospital. Planned with the assistance of Lakeview Hospital and an outside volunteer organization, the Davis County Sheriff’s Search and Rescue Team (DCSAR). DCSAR will supply the needed training assets for the outdoor portion of the skills scenarios. Due to the COVID-19 pandemic causing social distancing, closure of many educational centers, non-essential programs, and increased work demand of Lakeview’s nurses the project was adapted. The change resulted in the creation of eight didactic teaching modules all being presented via PowerPoint with added audio discussion to each module. The Education Department from Lakeview assigned the modules out to the eight volunteer participant nurses after each had taken the pre-survey. Instead of being able to evaluate the results of the training with an in-person scenario exercise an online case study exercise was developed to discuss questions, quiz knowledge learned, and see what improvements to the modules are needed for further improvements in the future. The case study was conducted in two separate on-line WebEx teleconferences with four PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 30 participants in each event. The case study was related to a notional earthquake occurring along the southern area of Davis county involving and involved using concepts from the modules allowing the participants to discuss things learned and how to apply the skills. Modules included an introduction focus on the overall purpose of the project, theory, and basic concepts related to lessons learned from history, management of disasters, legal/ethical principles of disaster response, safety, communication, preparedness, basic disaster facts, disaster care across the life-span, vulnerable populations, and Incident Command Systems (ICS) basics (Veenema, 2019). Also, Lakeview is beginning a new triage system within the hospital as part of its Emergency Operations Plan (EOP) called the SALT Triage system (Sort, Assess, Life-saving interventions, Treat, and Transport). This was added as part of the triage and treatment section of training and testing. The major topics covered also incorporated subtopics focusing on leadership, confidence, and preparedness (Joint Commission on Accreditation of Healthcare Organizations, 2005). Further, the project used training on data and research related to potential disasters in Utah and concepts in use of the National Framework and Incident Command Systems (NIMS). It included behavior building solutions and changes to help increase confidence through information and skills based on the best evidence-based practice of the current research, partner hospital EOP’s, and the needs of the community to create improvement and knowledge. After completing the modules each nurse completed a post-survey questionnaire which was turned into the Emergency Preparedness Coordinator with Lakeview who shared them with me as the Project Team Leader. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 31 Timeframe The timeframe for the project included during Summer 2020 completing the oral project proposal and IRB approval and then the development of the educational modules. During the Fall of 2020 participants were recruited from the community partner hospital and the classes and case study were implemented. Spring 2021 included evaluation and analysis of the findings with adjustment to any improvement measures to the course. Ethical and Legal Considerations In the scope of this project, there were few conflicts or ethical considerations that needed to be addressed. The project and education were voluntary and opened to all who wanted to receive education and training. This project focused on working under and with all of the rules and regulations provided by the School of Nursing and Lakeview Hospital and did not require new or any kind of individual permissions. Emergency preparedness does not require a specific licensure per-se in order for anyone to be ready and able to help in a disaster. However, the more training that one receives, the more legal culpability that they may have as far as needing to respond and react to the situation; this includes professional responders as well, based upon their scope of practice (Finkelman, 2018). Issues The major issue related to implementation of this project was due to the COVID-19 pandemic that caused a shut-down of many social, educational, and training events throughout the majority of the project, especially at the time of implementation, evaluation, and analysis. This resulted in a shift from in-person centered education and training to online platforms. Organizational issues related to the project included getting buy-in by the nurses on the frontline to participate in the training, costs associated with the training, and locking in the PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 32 funding for the time to get the training completed. Recruitment, with help of the community hospital providing this support, was done by finding participants through educational opportunity announcements and word-of-mouth through the partner hospital's educational department and the emergency services coordinator for the hospital. Evaluation and Data Analysis The quality indicators and measurable outcomes for this project centered on increasing the knowledge, confidence, and skills in participants relative level of preparedness to positively contribute to disaster preparedness within the community. Evaluation Eight nurses from Lakeview Hospitals Emergency Department and Administration participated in the project. The tools used to gather data and information included the use of the Emergency Preparedness Information Questionnaire (EPIQ) (see Table 2), as part of the pre- and post-survey. The EPIQ is an 18-question survey divided into 8 knowledge-based sections related to participant's knowledge and confidence in several disaster areas of response management, assessment, treatment and communication (Georgino, Kress, Alexander, & Breach, 2015). The questions for the test covered eight areas referencing: questions 1-3 Triage and Basic first-aid concepts, questions 4-8 Biological agent detection, question 9, Assessing critical resources & reporting, questions 10-13, The Incident Command System (ICS), question 14, Isolation, quarantine, & decontamination, questions 15-16 Phycological issues, question 17 Epidemiology & Clinical decision making, and lastly question 18 Communication & Connectivity, respectively. The post-survey included one question on whether the participants felt the program increased their knowledge personally, and a section to provide feedback for any improvements or suggestions regarding the education modules themselves. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 33 The case-study also allowed for open-ended questions and dialogue to obtain feedback and discussion about class content. The skills taught could not be evaluated due to the web-conference format. Participants did discuss how they felt about tourniquet use and SALT Triage. The case study also provided the opportunity to discuss how the project had produced any individual views or attitudes to ideas on preparedness and how the participants will plan for disasters. The last question asked of the participants during the case-study was about their overall confidence level looking at all aspects of the project and its potential application. With permission from Lakeview Hospital, a return follow-up with participants will be conducted at 6- to-8 months post-education to evaluate how education retention has worked using the same survey tool. The case-study via an online platform proved to be successful and a way to discuss the project, modules, and skills in a simulated earthquake scenario to test the knowledge and comfort of the participants. Analysis The pre-survey scores, with the exception of the first 3 questions on Triage and Basic First Aid, were below a 4.0 in knowledge base. With questions 4-8, on Biological Agent Detection, receiving the lowest pre-survey scores overall. The pre-survey overall average of the group in confidence of knowledge and skills was 3.54. The post-survey confidence score showed an increase in all areas of overall knowledge and skill understanding. The final post-survey score was 4.2, an average increase greater than >.6 point using the Likert scale on all questions, showing further that continued education and skills training with nurses is a strength to the preparedness of the community. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 34 The following graph shows the overall mean score results of the pre-test (purple column) to the results of the post-test (gray column) based on the eight individual participants. These results were: Data gathered from each pre-survey and post-survey were entered into the Typeform.com application and then evaluated for comparison. Also using Microsoft Excel version 2019 data 4.37 4.25 4.12 3.60 3.37 3.25 3.12 2.87 3.12 3.87 3.50 3.37 3.50 3.50 3.62 3.50 3.25 3.62 4.8 4.4 4.5 4.1 4.1 4.1 4.1 3.9 4.0 4.2 4.1 4.1 4.0 4.1 4.4 4.4 4.2 4.2 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 SCORE BY SURVEY QUESTION Series1 Series2 3.2 3.4 3.6 3.8 4 4.2 4.4 Post-Test Pre-Test Average Level of Confidence by All Participants PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 35 were evaluated for the mean looking at the participants as a whole and by evaluating each question as whole using all participants input. Findings Case-study feedback resulted in several positive results as well as suggestions. 100% of the participants strongly agree or agree that the project was a benefit to their learning. They further agreed that a standardized process is needed and planning now will prevent panic later in the event of a disaster. One participant in the program explained during the case study that empowering nurses with education on disaster preparedness can alleviate the helplessness with an unpredictable and chaotic event. Suggestions for improvement, during the case study, asked for more information to be added into the modules related to treatment and antidotes for chemical, biological, radiological, and nuclear (CBRN) events, a glossary for acronyms, and to add more photos and videos to break up some of the PowerPoint modules. Implications Nurses are a very educated but underutilized resource in the community that show a willingness to learn new skills, and when done, there is a positive increase in learning, confidence, and skills. With better preparedness, education, collaboration, and communication on all levels of response from the federal government down to the community level programs, like the one completed with this DNP project, communities can create a stronger preparedness plan for disasters. Simplified skills and plans can increase confidence and treatments for saving lives. The project participants were introduced to the SALT Triage model, from the START program currently being used at Lakeview Hospital, and all agreed that it was an easier program that PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 36 should be implemented as a change of practice not just in the Emergency Department but throughout the Hospital. Further, emergency preparedness and education are especially applicable to nurses in Utah and the Davis County area as there are fewer nurses available per capita than elsewhere in the nation ("Which States have the most registered nurses?”, n.d.). Discussion, Recommendations, and Sustainability Expected outcomes and results from this project were to improve disaster response and preparedness for nurses in the community. The project focused on increasing knowledge by helping the participants in receiving an improving their skill, confidence, and approach to preparedness. By meeting these outcome’s, the nurses in this DNP project are more prepared to help and be critical assets to their communities if and when a disaster occurs. Discussion Community hospitals and their staff, nurses especially, will play a key role in disasters. In spite of the COVID-19 pandemic and the obstacles it presented during the implementation phase this DNP project showed that it is adaptable and can be taught via an online platform and is easily changed to meet various communities, population sizes, and disaster types. The project benefited the hospital and the community by, first, helping the hospital with evaluation of policies and procedures, education, and needed improvement. Second, the community benefited by having nurses living in and around their community who are ready and able to help in disasters due to this education opportunity. The goal for this project was to educate Lakeview Hospital nurses and other nurse’s community-wide, eventually taking the same educational course, who will then be prepared to provide basic to critical care during a disaster in their communities if necessary. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 37 Projects like the eight-modules and case-study created for this DNP project are one way to provide important information about disaster awareness to nurses in the community. The modules provided knowledge and new skills, such as SALT triage and tourniquet use during triage in mass casualty and disasters to help save lives, which the participants believed caused a change in mind-set and practice for them and were glad to see that it will be the new policy for use in the Emergency Department at Lakeview Hospital. Simplified skills and plans can increase confidence in disaster preparedness. The case study also reinforced these concepts through a scenario and direct open-ended questions which helped increased confidence for the participants. Future classes will be able to use in-person didactic discussion, skills stations, and a simulation scenario, which by incorporating each of these together to further increase knowledge, skill, and confidence. Also, during the case-study question-and-answer section a participant pointed out that this project and the education from it helped bring more understanding into everyday practice for their job. One participant explained that even as Emergency Department nurses they are minimally trained in disaster scenarios and the power point modules given out provided a resource to refer back to. Sharing these resources by the initial participants with other nurses throughout the hospital will help give a greater sense of knowledge, skill, and confidence to others, if accepted, also and help with sustainability of the project. This DNP project has shown to be a sustainable training that will be used annually to train the Emergency Department staff, the Decontamination Team, Triage Team, and Evacuation Team. This DNP project is not just for Emergency prepared nurses but for nurses also in other units and settings to learn new skills and education that will also help them be better prepared for disasters in their communities. PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 38 Recommendations Lakeview Hospital administration recommended that the project be used with all hospitals in the area so that planning and preparedness was similar across the county for, not if but when, the next disaster that occurs in the area. Further, it is being recommended that the project be referred to the Local Emergency Planning Committee (LEPC), in this case, the Davis County Emergency Management Committee and Healthcare Coalition; as well as forwarding the presentation to the local hospitals and clinics for training. Conclusion There is no exact way to determine the location, time, and outcomes of all disasters. Communities and neighborhoods must prepare themselves for possible disaster. This DNP project prepared nurses as frontline leaders in their abilities to educate and care for themselves and their neighbors when experiencing a disaster. This DNP project partnered with a local community hospital and its nurses to look at the use of existing best practices and resources to educate and prepare for disasters. If nurses are knowledgeable and have confidence in responding to disasters then they can help their communities. 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PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 50 Appendix A Evaluation Tables Domain 1 Preparation and planning (actions taken apart from any specific emergency to increase readiness and confidence in actions to be taken during an event) Domain 2 Communication (approaches to conveying essential information within one’s place of work or emergency assignment and documenting decisions made) Domain 3 Incident management systems (the structure of disaster/emergency response required by countries/organisations/institutions and actions to make them effective) Domain 4 Safety and Security (assuring that nurses, their colleagues and patients do not add to the burden of response by unsafe practices) Domain 5 Assessment (gathering data about assigned patients/families/communities on which to base subsequent nursing actions) Domain 6 Intervention (clinical or other actions taken in response to assessment of patients/families/communities within the incident management of the disaster event) Domain 7 Recovery (any steps taken to facilitate resumption of pre-event individual/family/community/ organisation functioning or moving it to a higher level) Domain 8 Law and Ethics (the legal and ethical framework for disaster/emergency nursing) (Al-Maaitah et al., 2019, p. 4) PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 51 Appendix A cont. Table 3 Level Factors Individual factors for nurses 1. Level of personal disaster preparedness 2. Levels of knowledge, skills, and abilities regarding disasters and public health emergencies 3. Willingness to respond 4. Capacity to educate individuals, families, and/or communities on disaster preparedness and response Organizational factors 1.Level of institutional commitment to preparedness (e.g., planning, training, PPE, adoption of crisis standards of care, logistics, and effective communications) 2. Presence and influence of nurses in leadership positions in disaster and public health emergency management 3. Empowerment of nurses to lead and report issues/problems 4. Adoption of an interprofessional team approach to disasters Environmental or systemic factors 1.Authority and degree of coordination, communication, and collaboration among federal-state-local partners 2. Ability to produce and distribute adequate PPE, pharmaceutical supplies, and logistical support PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 52 3. Impact of regulations or guidelines requiring disaster preparedness (e.g., Centers for Medicare & Medicaid Services, accrediting bodies) 4. Influence of reimbursement and financial incentives for preparedness and response 5. Need for a national nursing workforce plan for preparedness and disaster response 6. Capacity and constraints of educational systems, employers, and volunteer agencies to prepare nurses for disasters 7. Lack of metrics for evaluation 8. State-based licensure constraints on the ability of nurses to respond to disasters across state lines or outside their practice area (RNs, APRNs) 9. Degree of coordination of multiple volunteer emergency response teams (e.g., ESAR-VHP, MRC, NDMS, American Red Cross) 10. Comprehensiveness of liability protection for nurses and other responders to disasters 11. Prioritization and funding of disaster nursing research 12. Suitability of current research approaches and infrastructure to assess need and inform nursing practice during the disaster cycle 13. Degree of community engagement in disaster planning, ethical considerations, and response (Veenema et al., 2015, table 2) PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 53 Appendix A cont. Core Competencies and Learning Objectives (Table 4) Collander © 2008 Prehospital and Disaster Medicine Core Competencies (CC) 1. Recognize a potential critical event and implement initial action 2. Apply the principles of critical event management 3. Demonstrate critical event safety principles 4. Demonstrate critical event communications 5. Understand the incident command system and your role in it 6. Demonstrate the knowledge and skills needed to fulfill your role during a critical event Learning Objectives based on Core Competencies (CC) Course Overview CC Format Unit 1: Disaster Basics and Fundamental Framework Lecture Unit 2: Disasters and Human Made Emergencies Lecture Unit 3: Disasters caused by Chem, Bio, Radiological, Nuclear Lecture Unit 4: Disaster in High Vulnerability Populations Lecture Unit 5: Disaster Response and Skills (SALT Triage) Lecture Video Hands on Unit 6: All Hazards Disaster Response (NAEMT) cert Lecture Unit 7: Simulation Skill Stations and Scenario Hands on Unit 8: Creating a plan and kit; Where do you go from here? Lecture, Hands on PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 54 Appendix A cont. Overview of Local, State, and Federal Emergency Response (Table 5) PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 55 Appendix C: Theoretical Model (Schematic) https://images.app.goo.gl/4GrvV65Uxb8xbs6b6 PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 56 Appendix D: Data Collection Tools This page left intentionally blank (see below) PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 57 Eighteen-Question Adapted Emergency Preparedness Information Questionnaire (EPIQ) Unique identifier (last 5 digits of your social security number [SSN], or 5 letters and numbers of your choosing): Please circle the number of your level of familiarity with the following topics before AND/OR after educational program and table top exercise. Key: 1. I have never heard of this topic before. 2. I have heard the terminology but have no knowledge of this information. 3. I know the terminology but have limited knowledge of this topic. 4. I am familiar with this topic but not extremely proficient in all subject matter. 5. I am very familiar with this topic; I am an expert in proficiency on this topic. Topic Level of Familiarity I. Triage and basic first aid Q1. Performance of a rapid physical and mental assessment 1 2 3 4 5 Q2. Assisting with triage (START model) 1 2 3 4 5 Q3. Basic first aid in a large-scale emergency event 1 2 3 4 5 II. Biological agent detection Q4. Recognition of relevant signs and symptoms 1 2 3 4 5 Q5. Modes of transmission 1 2 3 4 5 Q6. Appropriate antidote and prophylactic medicine 1 2 3 4 5 Q7. Possible adverse reactions/complications 1 2 3 4 5 Q8. Signs/symptoms of exposure to different biological agents 1 2 3 4 5 III. Accessing critical resources and reporting Q9. When to report an unusual set of symptoms to the local and state health departments 1 2 3 4 5 IV. The Incident Command System (ICS) Q10. Knowledge of an Emergency Operation Plan (EOP) 1 2 3 4 5 Q11. Processes of the ICS 1 2 3 4 5 Q12. Agency preparedness information 1 2 3 4 5 Q13. The content of the EOP at hospital 1 2 3 4 5 V. Isolation, quarantine, and decontamination Q14. Isolation procedures for persons exposed to biological or chemical agents 1 2 3 4 5 VI. Psychological issues Q15. Signs/symptoms of posttraumatic stress following a disaster 1 2 3 4 5 Q16. Appropriate psychosocial needs/resources for victims 1 2 3 4 5 VII. Epidemiology and clinical decision making Q17. Ability to discern and treat persons with comorbidities whom are exposed to chemical agents, biological agents and/or radiation. 1 2 3 4 5 VIII. Communication and connectivity Q18. Procedures for communicating critical patient information for transporting patients during a disaster transporting 1 2 3 4 5 PREPARING COMMUNITY NURSES TO RESPOND TO LOCAL 58 Table 2-Added to Table 1 for the Post-test survey