Educational Competencies
for Registered Nurses
Responding to Mass Casualty
Incidents
As
part of the international community’s overall plan for emergency preparedness
in mass casualty incidents (MCI), nurses world-wide must have a minimum level
of knowledge and skill to appropriately respond to a mass casualty incident, including
chemical, biologic, radiologic, nuclear, and explosive (CBRNE) events. Not all
nurses can or should be prepared as First Responders. Every nurse, however,
must have sufficient knowledge and skill to recognize the potential for a MCI,
identify when such an event may have occurred, know how to protect oneself,
know how to provide immediate care for those individuals involved, recognize
their own role and limitations, and know where to seek additional information
and resources. Nurses also must have sufficient knowledge to know when their
own health and welfare may be in jeopardy and have a duty to protect both themselves
and others. The potential roles of professional nurses in a MCI may vary
extensively due to diverse educational backgrounds, experiences, and practice settings
within the community and health care system. These roles may include
identifying when a MCI has occurred, responding to a call to go to the scene of
an incident, working at a local hospital or emergency field hospital where
victims are being treated, or relieving nurses who were initially involved in
these activities.
The
competencies identified in this document apply to all professional nurse roles
and practice settings. Practice sites encompass a wide array of settings,
including acute care facilities, clinics, schools, homes, and other community
venues. The individual competencies are
general and must be interpreted in relation to the functional role of an
individual nurse within an agency or community and the respective emergency
response plan. Therefore, competencies will be applied to practice in differing
ways depending on the specific roles and responsibilities the nurse performs
within the agency, community and national response plans.
Much of the
knowledge and experiences underpinning the competencies related to appropriate
and timely response to MCIs are basic to nursing practice. Therefore, most of
the principles and information necessary for the development of competence in
these areas are included in all basic nursing education programs. However, the
context in which these competencies may be employed could vary and the nurse’s role
would be specific to the situation. The competencies in this document have been
prepared to help nurse educators include MCI preparedness in the nursing
curriculum.
Six
essential components of professional nursing education have been identified (American
Association of Colleges of Nursing, 1998).
The MCI nursing competencies identified in this document fall within
three of the components of nursing education: core competencies, core
knowledge, and professional role development. Therefore, to facilitate the
integration of these competencies within the nursing curriculum, The Essentials of Baccalaureate Education
for Professional Nursing Practice (1998) is used as a framework to delineate
MCI competencies.
All
nurses from novice to expert should have a basic knowledge and ability to
appropriately respond to MCIs. This
document describes competencies of graduates of entry-level registered nursing programs. Nurses upon graduation
from an entry-level nursing education program should have sufficient knowledge
and skill to demonstrate these competencies. To attain this goal, all
entry-level nursing education programs should integrate the necessary knowledge
and experiences throughout the nursing curriculum. Nurses who have completed
basic education requirements and are registered to practice should receive the
needed additional education through continuing education opportunities, provided
through a various modalities.
Background
Americans
and the international community must be well prepared to respond to MCIs. The
2.7 million registered nurses in the United States, as well as the
nursing population worldwide, provide a tremendous untapped resource that can
and must be used if the nation is to adequately prepare for MCIs. In order for nurses to respond appropriately
to MCIs, guidelines and recommendations must be in place to ensure that they
can recognize and respond to potential and occurring emergency events.
Currently, nursing education guidelines do not mandate or recommend that all
nurses be educated on how to recognize or respond to MCIs.
The International Nursing
Coalition for Mass Casualty Education (INCMCE) is coordinated by the Vanderbilt
University School of Nursing. (See Appendix B for a list of organizations
participating in the INCMCE.) It was founded to assure a competent nurse
workforce to respond to mass casualty incidents. The INCMCE seeks to facilitate
the systematic development of policies related to mass casualty incidents as
they influence the public health infrastructure and impact on nursing practice,
education, research and regulation. The INCMCE currently focuses on several
areas: 1) increasing the awareness of all nurses about mass casualty incidents;
2) providing leadership to the nursing profession for the development of knowledge
and expertise related to mass casualty education; 3) identifying competencies
for nurses at academic and continuing education levels; 4) establishing a
clearinghouse of information and web links for professional development of
nurses; and 5) providing input into policy development related to nursing
practice, education and research at the governmental and institutional levels. The
INCMCE consists of organizational representatives of schools of nursing,
nursing accrediting bodies, nursing specialty organizations and governmental
agencies interested in promoting mass casualty education for nurses.
Process
To
address the critical need for MCI preparedness, the International Coalition for
Mass Casualty Education (INCMCE), in March 2001, appointed a committee to
develop competencies for professional nurses in relation to MCIs. Members of
the Committee represented graduate and undergraduate schools of nursing in the United States
and abroad, professional nursing organizations, and practicing nurses. The Committee
formed to develop a set of national consensus-based, validated competencies for
all entry-level nurses not dependent upon role or setting.
The
process used to develop the competencies consisted of three distinct phases:
Phase One: The first phase of the process was to review previously
developed sets of competencies related to MCIs. The recommendations set forth
in this document are based heavily on those competencies delineated by the
American College of Emergency Physicians (April 2001); Center for Health
Policy, Columbia School of Nursing (April 2001); University of Ulster,
University of Glamorgan School of Health Sciences School of Nursing (September
1999); Uniformed Services University of the Health Sciences Graduate School of
Nursing (November 2001); United States Air Force (2001); and the World Health
Organization (1999).
Phase Two: During phase two, the Committee and the INCMCE responded to several
drafts of nursing competencies, developed based on the literature outlined
above. This process produced a set of consensus-based competencies for
entry-level professional nurses.
Phase Three: Phase three involved the review and evaluation of the
competencies by a Validation Panel. Each school and organization participating
in the INCMCE was asked to nominate up to three individuals to serve on the
Validation Panel. The Validation Panel consisted of 46 representatives of nursing education,
regulation, accreditation, and practice from diverse practice settings and
roles. See Appendix A for organizations
and institutions represented on the Validation Panel. The Committee used
feedback from the Validation Panel to finalize and reach consensus on the
competencies.
COMPETENCIES FOR ENTRY-LEVEL REGISTERED NURSES
RELATED TO MASS CASUALTY INCIDENTS
CORE COMPETENCIES
I.
Critical Thinking
1. Use an ethical and nationally approved
framework to support decision-making and prioritizing needed in disaster
situations.
2. Use clinical judgment and decision-making
skills in assessing the potential for appropriate, timely individual care
during a mass casualty incident.
3. Use clinical judgment and decision-making
skills in assessing the potential for appropriate, individual ongoing-care
after a mass casualty incident.
4. Describe at
the pre-disaster, emergency and post-disaster phases the essential nursing care
for:
• individuals,
• families,
• special
groups, e.g. children, elderly, pregnant women; and
• communities.
- Describe accepted
triage principles specific to mass casualty incidents, e.g. the START or
Simple Triage and Rapid Treatment System.
II.
Assessment
A. General
1. Assess the safety issues for self, the
response team, and victims in any given response situation in collaboration
with the incident response team.
2. Identify possible indicators of a mass
exposure (i.e, clustering of individuals with the same symptoms.
3. Describe general signs and symptoms of
exposure to selected chemical, biological, radiological, nuclear, and explosive
agents (CBRNE).
4. Demonstrate the ability to access up-to-date
information regarding selected nuclear, biological, chemical, explosive, and
incendiary agents
5. Describe the essential elements included in a
mass casualty incident (MCI) scene assessment
6. Identify special groups of patients that are
uniquely vulnerable during a MCI, e.g. the very young, aged, immunosuppressed.
B. Specific
1. Conduct a focused health history to assess
potential exposure to CBRNE agents.
2. Perform an age-appropriate health assessment,
including:
·
airway and
respiratory assessment,
·
cardiovascular
assessment, including vital signs and monitoring for signs of shock,
·
integumentary
assessment, particularly a wound, burn, and rash assessment,
·
pain assessment,
·
injury assessment
from head to toe,
·
gastrointestinal
assessment, including stool specimen collection,
·
basic
neurological assessment,
·
musculoskeletal
assessment, and
·
mental status,
spiritual, and emotional assessment.
3. Assess the immediate psychological response
of the individual, family, or community following a MCI.
4. Assess the long-term psychological response
of the individual, family, or community following a MCI
5. Identify resources available to address the
psychological impact, e.g. Critical Incident Stress Debriefing (CISD) teams,
counselors, Psychiatric/Mental Health Nurse Practitioners (P/MHNPs).
6. Describe the psychological impact on
responders and health care providers.
III. Technical Skills
1. Demonstrate safe administration of
medications, particularly vasoactive and analgesic agents, via oral (PO), subcutaneous (SQ), intramuscular (IM), and
intravenous (IV) administration routes.
2. Demonstrate the safe administration of
immunizations, including smallpox vaccination.
3. Demonstrate knowledge of appropriate nursing
interventions for adverse effects from medications administered.
4. Demonstrate basic therapeutic interventions,
including:
·
basic first aid
skills,
·
oxygen
administration and ventilation techniques,
·
urinary catheter
insertion,
·
naso-gastric tube
insertion,
·
lavage technique,
i.e. eye and wound, and;
·
initial wound
care.
5. Assess the need for and initiate the
appropriate CBRNE isolation and decontamination procedures available, ensuring
that all parties understand the need.
6. Demonstrate knowledge and skill related to
personal protection and safety, including the use of Personal Protective
Equipment (PPE) for:
·
Level B
protection,
·
Level C
protection, and
·
Respiratory
protection.
7. Describe how nursing skills may have to be
adapted while wearing PPE.
8. Implement fluid/nutrition therapy, taking
into account the nature of injuries and/or agents exposed to and monitoring
hydration and fluid balance accordingly.
9. Assess and prepare the injured for transport,
if required, including provisions for care and monitoring during transport.
10. Demonstrate the ability to maintain patient
safety during transport through splinting, immobilization, monitoring, and
therapeutic interventions.
IV.
Communication
1. Describe the Incident Command System (ICS)
during a MCI.
2. Identify your role, if possible, within the
ICS.
3. Locate and describe the emergency response
plan for the place of employment and its role in community, state, and regional
plans.
4. Identify one’s own role in the emergency
response plan for the place of employment.
5. Discuss security and confidentiality during a
MCI.
6. Demonstrate appropriate emergency
documentation of assessments, interventions, nursing actions and outcomes
during and after a MCI.
7. Identify appropriate resources for referring
requests from patients, media, or others for information regarding MCIs.
8. Describe principles of risk communication to
groups and individuals affected by exposure during a MCI.
9. Identify reactions to fear, panic and stress
that victims, families, and responders may exhibit during a disaster situation.
10. Describe appropriate coping strategies to
manage self and others.
CORE KNOWLEDGE
I.
Health Promotion, Risk Reduction, and Disease Prevention
1. Identify possible threats and their potential
impact on the general public, emergency medical system (EMS),
and the health care community.
2. Describe community health issues related to
CBRNE events, specifically limiting exposure to selected agents, contamination
of water, air, and food supplies, and shelter and protection of displaced
persons.
II.
Health Care Systems and Policy
1. Define and distinguish the terms disaster and
mass casualty incident (MCI) in relation to other major incidents or emergency
situations.
2. Define relevant terminology, including:
·
CBRNE,
·
WMD,
·
Triage,
·
Incident Command
System (ICS),
·
PPE,
·
scene assessment,
and
·
comprehensive
emergency management.
3. Describe the four phases of emergency
management: preparedness, response, recovery and mitigation.
4. Describe the local emergency response system
for disasters.
5. Describe the interaction between local, state
and federal emergency response systems.
6. Describe the legal authority of public health
agencies to take action to protect the community from threats, including
isolation, quarantine, and required reporting and documentation.
7. Discuss principles related to a MCI site as a
crime scene, e.g. maintaining integrity of evidence, chain of custody.
8. Recognize the impact MCIs may have on access
to resources and identify how to access additional resources, e.g. pharmaceuticals,
medical supplies.
III.
Illness and Disease Management
1. Discuss the differences/similarities between
an intentional biological attack and that of a natural disease outbreak.
2. Assess, using an interdisciplinary approach,
the short term and long term effects of physical and psychological symptoms
related to disease and treatment secondary to MCIs.
IV.
Information and Health Care Technologies
1. Demonstrate use of emergency communication
equipment that you will be required to use in a MCI response.
2. Discuss the principles of containment and
decontamination.
3. Describe procedures for decontamination of
self, others, and equipment for selected CBRNE agents.
V.
Ethics
1. Identify and discuss ethical issues related
to CBRNE events:
·
Rights and
responsibilities of health care providers in MCIs, e.g. refusing to go to work
or report for duty, refusal of vaccines.
·
Need to protect
the public versus an individual’s right for autonomy, e.g. right to leave the
scene after contamination.
·
Right of the
individual to refuse care, informed consent.
·
Allocation of
limited resources.
·
Confidentiality
of information related to individuals and national security.
·
Use of public
health authority to restrict individual activities, require reporting from
health professionals, and collaborate with law enforcement.
2. Describe the ethical, legal, psychological,
and cultural considerations when dealing with the dying and or the handling and
storage of human remains in a mass casualty incident.
3. Identify and discuss legal and regulatory
issues related to:
·
abandonment of
patients;
·
response to a MCI
and one’s position of employment; and
·
various roles and
responsibilities assumed by volunteer efforts.
VI.
Human Diversity
1. Discuss the cultural, spiritual, and social issues
that may affect an individual’s response to a MCI.
2. Discuss the diversity of emotional,
psycho-social and socio-cultural responses to terrorism or the threat of
terrorism on one’s self and others.
PROFESSIONAL ROLE DEVELOPMENT
1. Describe these nursing roles in MCIs:
·
Researcher,
·
Investigator/epidemiologist,
·
EMT or First
Responder,
·
Direct care
provider, generalist nurse,
·
Direct care
provider, advanced practice nurse,
·
Director/coordinator
of care in hospital/nurse administrator or emergency department nurse manager,
·
On-site
coordinator of care/incident commander,
·
On-site director
of care management,
·
Information
provider or educator, particularly the role of the generalist nurse,
·
Mental health
counselor, and
·
Member of
planning response team.
2. Identify the most appropriate or most likely
health care role for oneself during a MCI.
3. Identify the limits to one’s own
knowledge/skills/abilities/authority related to MCIs.
4. Describe essential equipment for responding
to a MCI, e.g. stethoscope, registered nurse license to deter imposters,
packaged snack, change of clothing, bottles of water.
5. Recognize the importance of maintaining one’s
expertise and knowledge in this area of practice and of participating in
regular emergency response drills.
6. Participate in regular emergency response
drills in the community or place of employment.
References
Cited in Document
American
Association of Colleges of Nursing. (1998). The
essentials of baccalaureate education for professional nursing practice. Washington, DC:
Author.
Center
for Health Policy, Columbia
University School
of Nursing. (April 2001). Core public
health worker competencies for emergency preparedness and response. Atlanta, GA:
Centers for Disease Control.
Cole,
F. & Ramirez, E. (1999). Evaluating an emergency nurse practitioner
education program for its relevance to the role. Journal of Emergency Nursing, 25 (6), 547-550.
Fraser,
M. & Fisher, V.S. (January 2001). Elements of effective bioterrorism
preparedness: A planning primer for local public health agencies. Washington,
DC: National Association of
County and City Health Officials.
Gebbie,
K. & Qureshi, K. (2002). Emergency and disaster preparedness: Core
competencies for nurses, What every nurse should but may not know. American Journal of Nursing, 102 (1),
46-51.
Task
Force of Health Care and Emergency Services Professionals on Preparedness for
Nuclear, Biological, and Chemical Incidents. (April 2001) Final Report: Developing objectives, content, and competencies for the
training of emergency medical technicians, emergency physicians, and emergency
nurses to care for casualties resulting from nuclear, biological, or chemical
(NBC) incidents (Contract No. 282-98-0037). American College
of Emergency Physicians.
Uniformed
Services University
of the Health Sciences Graduate
School of Nursing.
(November 2001). Materials and personal
communication from Faye G. Abdellah, Dean and Professor, Graduate School of
Nursing, including examples of advanced practice nursing objectives, course description,
and course offerings.
United States Air Force. (2001). RSV for
AFSC 46XX and RSV for AFSC 46N3E. Competencies for all clinical and emergency
department nurses. (Unpublished documents) Washington, DC:
Author.
University of Ulster,
School of Health Sciences, Nursing. (1998). Course document for postgraduate diploma/MSc
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World
Health Organization. (1999). Development
of a disaster preparedness tool kit for nursing and midwifery: Report on a WHO
meeting held at the University
of Ulster 20-21st
August 1999. Copenhagen,
Denmark: WHO.
Additional References
Advanced
Life Support Group. (1995). Major
incident medical management and support: The practical approach. London: British Medical
Journal Publishing Group.
Association
of State and Territorial Directors of Nursing. (April 2002). Position Paper: Public Health Nurses’ Vital Role in
Emergency Preparedness and Response. Atlanta,
GA: Author.
Cutts,
M. & Dingle, A. (1998). Safety first:
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edition). London:
Save the Children.
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the science and response capabilities. Washington, DC:
National Academies Press.
Institute of Medicine National Research Council.
(1999). Chemical and biological
terrorism: Research and development to improve civilian medical response. Washington, DC:
National Academies Press.
Medecins
Sans Frontieres. (1997). Refugee health:
An approach to emergency situations. London:
Macmillan Education Ltd.
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Cross & Red Crescent Societies. (1985) Guidelines
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Sphere Project. (2000). Humanitarian
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Appendix A: Organizations Represented on the
Validation Panel
American Academy of Nurse Practitioners
American Association of Critical Care Nurses
American Nurses Association
American Organization of Nurse Executives
American Red Cross
CIGNA Health Care
Columbia University
Commission on Collegiate Nursing Education
Department of Veterans Affairs
Duquesne University
Emory University
Georgia Southern University
Jacksonville State University
National Organization of Nurse Practitioner Faculties
Tennessee Wesleyan College
Union University
United
States
Navy Office of Homeland Security
United States Department of Public Health and Human
Services
University of Alabama
University of Kentucky
University of Maryland
University of Massachusetts
University of Texas-Austin
University of Washington