Call for national dialogue: Adapting standards of care in extreme events. We are not ready.

Clinical practices are based on a common understanding of nursing's professional standards in all aspects of patient care, no matter what the circumstances are. Circumstances can however, change dramatically due to emergencies, disasters, or pandemics and may make it difficult to meet the standard of care in the way nurses are accustomed. The Australian nursing profession has not yet facilitated a broad discussion and debate at the professional and institutional level about adapting standards of care under extreme conditions, a dialogue which goes beyond the content of basic emergency and disaster preparedness. The purpose of this paper is to encourage discussion within the nursing profession on this important ethical and legal issue. A comprehensive review of the literature was undertaken to determine the state of the evidence in relation to adapting standards of care under extreme conditions. Content analysis of the literature identified categories related to adapting standards of care that have been considered by individuals or groups that should be considered in Australia, should a dialogue be undertaken. The categories include ethical expectations of professional practice; legal interpretation of care requirements, resource priority between hospital and public health and informing communities. Literature reviews and commentary may provide the background for a national dialogue on the nursing response in an extreme event. However, it is only with the engagement of a broadly representative segment of the professional nursing community that appropriate guidance on adapting standards of care under extreme conditions can be developed and then integrated into the professional worldview of nursing in Australia.

Tailoring curricula to fit health professionals needs in a disaster: a proposal for Brazilian nurses. / Adaptando o currículo para atender a necessidades de profissionais de saúde em um desastre: uma proposta para enfermeiras brasileiras.

Introduction Education and training are the cornerstones of disaster preparedness and best curricula and training programs are competency-based. Objective This paper presents a proposal to be applied in nursing curricula in Brazil, based on the National Curriculum Guidelines and the recommendations for integrating skills and competencies into undergraduate curricula proposed by the World Health Organization. Results Comparison of competencies sets was conducted to indicate the specific competencies to be included as essential for Brazilian nurses. Levels of proficiency were indicated for the establishment of learning objectives and learning experiences and evaluation tools recommended from the literature. Conclusions The competencies provided are the beginning of the discussion that will have to take place in every nursing school, if all Brazilian nurses are to graduate ready to participate should a disaster occur.

Core competency model for the family planning public health nurse.

OBJECTIVES: A core competency model for family planning public health nurses has been developed, using a three stage Delphi Method with an expert panel of 40 family planning senior administrators, community/public health nursing faculty and seasoned family planning public health nurses. DESIGN AND SAMPLE: The initial survey was developed from the 2011 Title X Family Planning program priorities. The 32-item survey was distributed electronically via SurveyMonkey(®). RESULTS: Panelist attrition was low, and participation robust resulting in the final 28-item model, suggesting that the Delphi Method was a successful technique through which to achieve consensus. CONCLUSIONS: Competencies with at least 75% consensus were included in the model and those competencies were primarily related to education/counseling and administration of medications and contraceptives. The competencies identified have implications for education/training, certification and workplace performance.

Implications of preparedness and response core competencies for public health.

Public health care practitioners and organizations are a part of community readiness for, response to, and recovery from emergencies and disasters of all kinds. Although response to health threats, particularly communicable disease outbreaks, have long been a part of public health practice, 2 advancements in preparedness, including the integration of public health into the broader community emergency response system and the clarification of exactly what knowledge, skills, and attitudes a public health professional brings to the response, have been made since 2001. This article presents the newly affirmed core competencies to be attained and maintained by the majority of the public health workforce and discusses some of the many ways in which these competencies influence practice, research, and education.

Update on competencies and education.

The beginning of the 21st century has been marked by an increase in attention to the quality of emergency and disaster response, particularly the preparedness of health workers of all kinds. The increase in natural disasters, civil unrest, and dislocation of populations has seen health workers mobilized. These workers are moving, both within countries and across borders, as members of long- organized teams such as the National Disaster Medical System (NDMS), volunteers joining through a nongovernmental organization (NGO) such as a Red Cross/Red Crescent unit, or individuals self-deploying to the scene of the emergency. Postevent evaluations have consistently identified the need for those responding to be able to join in an organized response that includes taking on assigned roles, communication through established channels and minimization of the number of "SUVs" or "spontaneous unrequested volunteers." Although bystanders and self-deployed helpers (some with professional qualifications) are the first at any disastrous event, the subsequent response efforts are expected to be organized, efficient, and effective. This requires advance training of the responders.

Lived-Experience of Women's Well-Being in the Cyclone Shelters of Coastal Bangladesh.

Bangladesh is repeatedly threatened by tropical storms and cyclones, exposing one-third of the total population of the country. As a preparedness measure, several cyclone shelters have been constructed, yet a large proportion of the coastal population, especially women, are unwilling to use them. Existing studies have demonstrated a range of concerns that discourage women from evacuating and have explored the limitations of the shelters, but the experiences of female evacuees have not been apparent in these stories. This study explores the lived-experiences of women in the cyclone shelters of Bangladesh and discusses their health and well-being as evacuees in the shelters. Nineteen women from three extremely vulnerable districts of coastal Bangladesh were interviewed. Seven research themes were identified from the participants' narratives using van Manen's thematic analysis process. The most salient theme, being understood (as a woman), portrayed the quintessential image of these women, which subsequently influenced their vulnerability as evacuees. The next themes-being a woman during crisis, being in a hostile situation, being fearful, being uncertain, being faithful, and being against the odds-focused on the incidents they lived through which affected their physical and mental health and the emotions they felt as evacuees. The paper offers a deep inquiry into women's experiences of well-being in the shelters and recognizes the significance of women's voices to improve their experiences as evacuees.

Interdisciplinary research training in a school of nursing.

Although interdisciplinarity has become a favored model of scholarly inquiry, the assumption that interdisciplinary work is intuitive and can be performed without training is short-sighted. This article describes the implementation of an interdisciplinary research training program within a school of nursing. We describe the key elements of the program and the challenges we encountered. From 2007-2010, eleven trainees from 6 disciplines have been accepted into the program and 7 have completed the program; the trainees have published 12 manuscripts and presented at 10 regional or national meetings. The major challenge has been to sustain and "push the envelope" toward interdisciplinary thinking among the trainees and their mentors, and to assure that they do not revert to their "safer" disciplinary silos. This training program, funded by National Institute of Nursing Research (NINR), has become well-established within the school of nursing and across the entire University campus, and is recognized as a high quality research training program across disciplines, as exemplified by excellent applicants from a number of disciplines.

Vicarious Trauma: Exploring the Experiences of Qualitative Researchers Who Study Traumatized Populations.

OBJECTIVE: A substantial body of research exists regarding vicarious trauma (VT) exposure among helping professionals across disciplines and settings. There is limited research, however, on exposure to VT in qualitative researchers studying traumatized populations. The objective of this study was to explore the experiences of qualitative researchers who study traumatized populations and to identify potential protective strategies for reducing the risk of VT. METHODS: The study utilized a qualitative methodological design. Focus groups and in-depth interviews were conducted using a semi-structured script. Thematic analysis was conducted to identify both risk factors and protective factors associated with VT. A sample of 58 research participants were recruited using a multimodal recruitment strategy. RESULTS: Using thematic analysis, the following key themes emerged: exposure to primary trauma, the impact of stigma, organizational context, individual context, and research context. The opportunity for posttraumatic growth was also identified. CONCLUSION: Qualitative researchers of traumatized populations need to recognize the potential for VT and implement appropriate protection strategies from the risk of VT. The development of policies and guidelines that recognize the importance of both self-care and plan for researcher safety and well-being is a potential strategy for building researcher resilience and preventing VT.

Emergency preparedness training and response among community health centers and local health departments: results from a multi-state survey.

Due to their access to medically underserved and vulnerable populations, community health centers (CHCs) can play an essential role in emergency response. CHCs often fill this role in partnership with other local health resources, such as local health departments (LHD). Little research has been done to understand the success of these partnerships as it relates to emergency planning and emergency response. This study compares CHC and LHD personnel regarding past, present, and future collaborative preparedness and response activities. Surveys were distributed electronically to 1,265 clinical and clerical staff at LHDs and CHCs in 23 states who met the study criteria. Of the 522 respondents, 287 (55%) reported having engaged in collaborative preparedness activities in general, with CHCs more likely to report partnering than LHDs. LHDs were more likely than CHCs to report taking part in specific preparedness activities, such as planning activities (91, 79%), (chi(2)(1, N = 280) = 7.395, P < 0.05), mass dispensing drill/exercises (65, 42%), (chi(2)(1, N = 279) = 14.019, P < 0.001), and communication drill/exercises (69, 47%), (chi(2)(1, N = 280) = 13.059, P < 0.001). This study suggests that collaborations between CHCs and LHDs in general are occurring, but these general collaboration are not being translated into participation in functional drills or exercises. Additional efforts to ensure a more comprehensive partnership between CHCs and LHDs in emergency preparedness are warranted.

Public health preparedness and response competency model methodology.

OBJECTIVE: The Pandemic and All-Hazards Preparedness Act calls for establishing a competency-based training program to train public health practitioners. To inform such training, the Centers for Disease Control and Prevention and the Association of Schools of Public Health managed groups of experts to produce a competency model which could function as a national standard of behaviorally based, observable skills for the public health workforce to prevent, protect against, respond to, and recover from all hazards. DESIGN: A systematic review of existing competency models generated a competency model of proposed domains and competencies. PARTICIPANTS: National stakeholders were engaged to obtain consensus through a three-stage Delphi-like process. RESULTS: The Delphi-like process achieved 84 percent, 82 percent, and 79 percent response rates in its three stages. Three hundred sixty six unique individuals responded to the three-round process, with 45 percent (n = 166) responding to all three rounds. The resulting competency model features 18 competencies within four core learning domains targeted at midlevel public health workers. CONCLUSIONS: Practitioners and academics have adopted the Public Health Preparedness and Response Core Competency Model, some of whom have formed workgroups to develop curricula based on the model. Efforts will be needed to develop evaluation materials for training and education programs to refine the model as well as for future training and education initiatives.

Public health certification.

In 2003, the Institute of Medicine (IOM) recommended voluntary certification of graduates achieving the Master of Public Health degree. The Association of Schools of Public Health (ASPH), the American Public Health Association, the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and the Association for Prevention Teaching and Research joined together to establish the National Board of Public Health Examiners (5). This new body will certify graduates of accredited schools and programs of public health who successfully pass their examination. If this certification becomes common, the debate will move to other questions such as (a) can those who lack a degree from a school of public health be certified through the same examination, or a similar one; (b) how will this general certificate relate to specialized areas of public health practice which are also learned elsewhere; and (c) how will we assess the public health competence of public health workers who do not have a professional education?

Public health workforce enumeration.

Comprehensive data on the public health workforce are fundamental to workforce development throughout the public health system. Such information is also a critical data element in public health systems research, a growing area of study that can inform the practice of public health at all levels. However, methodologic and institutional issues challenge the development of comparable indicators for the federal, state, and local public health workforce. A 2006-2007 Association of State and Territorial Health Officials workforce enumeration pilot project demonstrated the issues involved in collecting workforce data. This project illustrated key elements of an institutionalized national system of workforce enumeration, which would be needed for a robust, recurring count that provides a national picture of the public health workforce.

Transitions in state public health law: comparative analysis of state public health law reform following the Turning Point Model State Public Health Act.

Given the public health importance of law modernization, we undertook a comparative analysis of policy efforts in 4 states (Alaska, South Carolina, Wisconsin, and Nebraska) that have considered public health law reform based on the Turning Point Model State Public Health Act. Through national legislative tracking and state case studies, we investigated how the Turning Point Act's model legal language has been considered for incorporation into state law and analyzed key facilitating and inhibiting factors for public health law reform. Our findings provide the practice community with a research base to facilitate further law reform and inform future scholarship on the role of law as a determinant of the public's health.

Modernizing state public health enabling statutes to reflect the mission and essential services of public health.

It is unclear whether efforts of the past decade to modernize state public health statutes have succeeded in codifying into state law the currently understood mission and essential services of public health. Although many state health agencies may be operating in a manner consistent with these principles, their codification in state law is crucial for the sustainability of agency efforts in disease prevention and health promotion. This research examines the 50 state public health enabling statutes for their correspondence with the 6 mission statements and the 10 essential services of public health described in Public Health in America. This analysis finds that modernization efforts have not been universally effective in ensuring that the legislative basis of public health is commensurate with the accepted scope of authority necessary to support health agency performance. Given current imperatives for law modernization in public health, this analysis highlights the importance of model statutory language in facilitating the codification of the mission and essential services of public health in state law. As a result, this research provides the practice community with a research base to facilitate statutory reform and develops a framework for future scholarship on the role of law as a determinant of the public's health.

Building a system for preparedness: the NYCEPCE NEST experience.

The New York Consortium for Emergency Preparedness Continuing Education grew from clinician-oriented, Web-based continuing education developed with and primarily for clinicians associated with the New York Presbyterian Healthcare System. As the consortium expanded to reach all of New York State (and beyond, via the Web), courses originally developed at Columbia were transferred to a widely advertised Web site, and the content expanded. The National Education Strategy Team supplemental funds allowed New York Consortium for Emergency Preparedness Continuing Education to consider how to overcome one of the major challenges in emergency preparation, connectivity across all sectors, and levels of the public health community. We chose to use community health centers as paradigmatic of the challenge: the clinician needs emergency preparedness competencies, but if the site at which practice takes place has no plan, those skills will not be best used; if the practice site is not connected to the community-wide plan, capacity may be duplicated or unused. If clinician, practice and community all plan, train, and practice in a common framework, the community should be much more resilient in the face of emergencies of any dimension.

Examination of the relationship between public health statute modernization and local public health system performance.

OBJECTIVES: Wide variation in performance of public health (PH) systems, coupled with national interest in improving PH system quality, makes it a priority to identify factors associated with performance. One factor may be congruence between a state's PH enabling statutes and the obligations outlined in Public Health in America-the collaboratively developed framework that defines the mission and essential services (ESs) of PH. SUBJECTS: This research examined the relationship between (1) the degree to which language in a state's PH enabling statutes reflects PH's mission and ESs and (2) the performance of local public health systems in delivering ESs, measured by National Public Health Performance Standards scores in 207 local jurisdictions. METHODS: Binary logistic regression demonstrated that a high degree of congruence between statutory language and public health's mission increased the odds of above-average system performance for 5 of 10 ESs. RESULTS: High levels of congruence between statutory language and the ESs themselves increased odds of above-average system performance for 6 of 10 ESs. Results yielded modest odds ratios (<2.0). CONCLUSIONS: Limitations of the data make it impossible to draw firm conclusions; however, these modest results suggest that statutory language may account for little of the variation in local public health system performance.

20th-century reports on nursing and nursing education: what difference did they make?

At the beginning of the 21st century, public policy attention is being drawn to the profession of nursing by reports identifying demographic trends that are expected to lead to a significant shortage of nurses, given an aging population, a lengthening life span, and the increasing use of medical interventions to prevent or treat disease. This shortage is alleged to be more profound than the cyclic shortages experienced during the previous century, primarily for 2 reasons: (1) the nursing workforce is older, on average, than other professional groups, with more nurses entering practice at older ages with shorter expected work life, and (2) the capacity of the educational system to provide replacements for retiring nurses is inadequate due to a shortage of qualified faculty and limitations in clinical training sites.

Assessment of emergency preparedness of veterinarians in New York.

Veterinarians have unique skills and abilities that could be useful in preparing for and responding to disasters and emergencies. However, veterinarians are often absent from emergency preparedness planning and exercises, and little is known about veterinarians' perceptions of emergency preparedness. A focus group was conducted among veterinarians to explore issues such as previous emergency-preparedness education, types of training needed, barriers to participation in training, and future steps to overcome identified barriers. Focus-group participants reported that they had had little to no emergency-preparedness training and had no clear understanding of what their specific role should be in an emergency. Participants also reported several barriers to participation in training and expressed significant concerns about their ability to respond in an emergency. The concerns reported include limited knowledge of zoonotic diseases, confusion about providing care for animals displaced during natural disasters, and poor relationships with other health professions. In order to respond to disasters, veterinarians require training tailored to their concerns and needs. Furthermore, partnerships between veterinarians and health care workers need to be further developed and strengthened.

A Qualitative Study of Paramedic Duty to Treat During Disaster Response.

OBJECTIVES: Disasters place unprecedented demands on emergency medical services and can test paramedics personal commitment as health care professionals. Despite this challenge, guidelines and codes of ethics are largely silent on the issue, providing little to no guidance on what is expected of paramedics or how they ought to approach their duty to treat in the face of risk. The objective of this research is to explore how paramedics view their duty to treat during disasters. METHODS: The authors employed qualitative methods to gather Australian paramedic perspectives. RESULTS: Our findings suggest that paramedic decisions around duty to treat will largely depend on individual perception of risk and competing obligations. A code of ethics for paramedics would be useful, but ultimately each paramedic will interpret these suggested guidelines based on individual values and the situational context. CONCLUSIONS: Coming to an understanding of the legal issues involved and the ethical-social expectations in advance of a disaster may assist paramedics to respond willingly and appropriately. (Disaster Med Public Health Preparedness. 2019;13:191-196).

Education for the public health profession: a new look at the Roemer proposal.

Demands for a high level of professionalism in public health practice, and concomitant strengthening of public health education to match 21st-century community challenges provide an opportunity to reconsider the current paradigm for professional degrees in public health. In this article, we consider whether the currently typical public health education meets the requirements of a professional education, examine the current state of public health education, and provide a rationale for renewed emphasis on the doctor of public health (DrPH) degree. We also present one potential three-year DrPH curriculum to stimulate further discussion, while acknowledging the multiple challenges that face any school of public health moving to implement such an education.