Disaster preparedness is a critical competency for nurses, as they play a major role in responding to disasters (Jose & Dufrene, 2014; Stanley, 2005). As the largest body of health care providers in the United States (2.7 million) and around the world, nurses are strategically positioned to lead at all levels of intervention. From first responders in the most acute phases of disaster to the long-term aftermath addressing loss, grief and posttraumatic stress disorders (Stanley, 2005; Veenema et al., 2017), nurses are the most likely health professional to keep “themselves, patients, and families safe” (Veenema et al., 2015, p. 191).
Disaster management has become integral to baccalaureate nursing education (American Association of Colleges of Nursing, 2008). Providing didactic disaster education and experiential learning opportunities is essential to preparing the nursing workforce (Jennings-Sanders, 2004; Veenema et al., 2017). In Bachelor of Science (BSN) programs, the didactic component includes disaster preparedness theory and frameworks for intervention. Clinical education often includes simulation experiences that range from mass casualty to active shooter; however, becoming part of an active disaster management team is less common as a clinical opportunity for students (Jose & Dufrene, 2014). A learning opportunity for disaster management interventions evolved for University of Texas Health Science Center, San Antonio School of Nursing (UT Health San Antonio SON) students after Hurricane Harvey occurred in south Texas on August 25, 2017.
Natural and man-made disasters are becoming increasingly common in the United States and around the world (Hay & Mimura, 2010). There has been a 60% increase in disasters worldwide since the fall of the World Trade Center in 2001 (Anchora & Kamanvire, 2016), 90% of those being meteorological in nature (U.S. Agency for International Development, 2018). Additionally, it is predicted that natural disasters may increase in number and severity (Veenema et al., 2017). Therefore, there is a critical need to prepare communities, citizens, and health care providers, including nurses, for disasters.
The 2017 hurricane season in the Western Hemisphere was catastrophic, with three devastating hurricanes causing loss of life and nearly $365 billion dollars of property damage on the U.S. mainland and Puerto Rico (Thevenot, 2017). Hurricane Harvey was the most devastating storm to hit Texas in more than 25 years and was the second most costly storm to hit the mainland United States since 1900, causing $125 billion dollars in damage (World Vision, 2017).
Harvey struck the Texas coast as a Category 4 hurricane, with wind speeds of over 130 miles per hour and a storm surge of 12 feet (National Weather Service, 2017). The powerful eye wall struck San Jose Island, just east of the county seat in the city of Rockport, Texas, wreaking havoc on the coastal communities. The storm moved northeast toward Houston, where it dumped 52 inches of rain, the largest recorded rainfall from a single storm in the continental United States (National Weather Service, 2017). This deluge shifted attention from the devastated coastline to Houston, one of the country's largest cities. Resources were quickly deployed, with a great deal of attention to Houston, but with far less attention to small coastal communities such as Rockport.
Columbia University's Center for National Disaster Preparedness team and the lead author of this article (C.S.) conducted an initial disaster assessment following Hurricane Harvey. The hours and days immediately following catastrophic events are the most challenging as it is a tense and unsettling time for communities as they wait for post-disaster support. The lead author, having had post-disaster experiences following 9/11 and Hurricane Sandy in New Jersey, understood the importance of first responders as they clear the way to create safe passage for the second wave of responders. Within days of Harvey's devastation, Dr. Irwin Redlener, Director of the National Center for Disaster Preparedness, contacted the lead author. Redlener, an expert in disaster management, had worked with the lead author in the aftermath of Hurricane Sandy in 2012. After contacting Texas state officials and members of the early response team, Dr. Redlener traveled to South Texas to assess the damage and ascertain where proposed funding could best be used. Redlener's connections with local and state officials allowed for safe passage into communities still under evacuation order. It took nearly 1 week for flood waters to recede and for live electrical wires, trees, and poles to be moved to allow outsiders access to the people who had not evacuated. The coastal area was badly battered, with severe damage to land and property. Rockport had fishing boats in the streets and no running water or electricity, many homes were destroyed, and people were living in tents. Signs were posted, stating “We will shoot if you loot.” During the initial windshield survey, the National Disaster Team identified a valuable community asset titled Rockport Strong on the edge of town. Rockport Strong was filled with tents, where food, water, and clothing were distributed on the property of a local chef who had opened her doors to displaced residents. A medical tent clinic was established by the residents to offer basic first aid. However, none of these residents had any health care training. Faced with these challenges, the SON team, along with Redlener's team, developed this innovative disaster relief program.
Following the initial assessment, the UT Health San Antonio SON was awarded $200,000 dollars from singers Paul Simon and Edie Brickell to provide community-based disaster relief nursing care to the coastal community of Rockport, Texas. Within days of the storm, two SON faculty members with disaster relief experience assessed resources and created partnerships that allowed for integrated and population-focused health care to the citizens of Rockport. For 2 days, SON faculty interviewed stakeholders and key informants from local, state, and federal offices, residents, and leaders of faith-based organizations in order to create a strategic plan. It was important to identify (a) organizations providing services, (b) state and local officials needed to serve as contact persons, (c) health care providers in the area, and (d) community gatekeepers. They also needed to explore (a) how to work with the Federal Emergency Management Agency and the American Red Cross, (b) how to coordinate care with local organizations, (c) how to communicate with the community, and (d) locations that could safely host faculty and students.
It was decided that the overwhelming community needs were too challenging for a small SON team. A new strategy was created to include students, thereby increasing team capacity and meeting clinical objectives for the Population Focused Health course offered in the final semester of the BSN program at UT Health San Antonio SON. This experiential learning opportunity would serve dual purposes—meeting the needs of a community in real-time crisis and providing nursing students with boots-on-the-ground disaster relief experiences. Within 18 days of the initial call for help, the SON deployed teams of faculty and students who made the 374-mile round trip to provide post-disaster relief to the residents of Rockport, Texas. With a minimum of 10 students and two nursing faculty on each trip, more than 60 trips were made in the first 6 months, with more than 200 students and 12 faculty involved in the efforts.
Establishing reliable communications between the community and SON faculty was a high priority. The evacuation order had just been lifted, so people were beginning to return to their homes but lacked coordinated communication with care providers. Social media platforms served as the main communication tool for residents to become aware of when and where the teams would be working on any given day. Facebook®, Instagram, and text messaging became the preferred methods of communication. The nursing students were extremely proficient with these platforms and collaborated with faculty to deliver the information to the community so that as many people as possible could be reached and helped. The lengthy trips to Rockport served as an ideal opportunity for faculty to teach students about disaster relief and prepare them for what they would encounter. The return trips proved to be perfect for faculty to debrief, explore the depth of student experiences, and evaluate the application of disaster nursing theory to the Rockport experience.
The nursing students, along with supervising faculty, effectively provided disaster relief to hundreds of residents through primary care, primary and secondary prevention, and door-to-door canvassing. Nursing students and faculty provided physical examinations, minor urgent care, hepatitis A vaccines, tetanus and influenza vaccines, first aid, and first aid training. They distributed carbon monoxide alarms and provided education regarding the importance and use of the devices, as unsafe heating strategies became commonplace. Ongoing assessments informed the decision to purchase a mobile health unit to deliver care even when the Texas weather became inclement.
Over the next 6 months, the efforts transitioned from first-time interactions with the community and care under a makeshift tent to valuable, longer term community partnerships. As immediate needs were met, the community shifted to recovery, at which time counseling and education sessions about loss after a natural disaster, especially for parents with children, proved to be invaluable. Many students requested the opportunity to return to the coast because the work was deeply affirming. They shared their reflections during the return trips from Rockport through reflective journaling and in-class discussions.
Through this innovative educational intervention, nursing students were able to experience the first-hand role of health care providers in early disaster response. Further, many had the opportunity to witness how the needs of the distressed population changed in the weeks and months after Hurricane Harvey. The UT Health San Antonio SON response to Hurricane Harvey continues nearly 2 years after the event. Although the Rockport partnership has sustained, SON trips to the coastal community have decreased to once every 2 to 3 months. Currently, plans are in place for monthly visits in an effort to establish a primary care practice in the community that remains medically underserved and in recovery mode.
This intervention was particularly vital because Aransas County (which includes the city of Rockport) ranks 232 of 242 counties in the state of Texas for health indices and is among the bottom quartile for social and economic factors in a state that has the lowest proportion of insured people and large numbers of medically underserved; further, it ranks in the bottom 5% nationally in health outcomes for women, children, and the poor (County Health Rankings, 2018). The SON's collaborative community-engaged effort to bring relief to many who had few resources even before Hurricane Harvey further highlights the importance of efforts toward meeting the school's vision statement “We make lives better by promoting health as an act of social justice” and our mission statement “We develop diverse nurse leaders to improve health and health care, through education, research, practice, and community engagement.” It is difficult to imagine greater community involvement than providing disaster relief—or a greater opportunity to provide education for students.
This experiential learning opportunity was filled with strengths and lessons learned. The strengths of the disaster relief interventions included the rapid response and sustained effort, needs assessment and asset mapping, collaboration with flexibility, innovative communication strategies to reach a community in need, and a dedication to fostering student education on the drive to the disaster site and to debrief with them on the trip back.
Many lessons were learned, including the fact that organization is crucial throughout an effective disaster relief intervention and that initial logistics are challenging and time consuming. Throughout relief efforts, the need to identify stakeholders, secure resources, and create educational materials are continuous and ongoing. The importance of long-range preplanning, preplanned evaluation methodologies, and clerical assistance to ensure proper tracking of disaster relief execution, patient medications, nurse and staff log-ins and log-outs, and patient contact information are also key factors in the effort. As flexible as the team was, the rapidly changing environment in disaster relief was always astounding. Keeping a cool head and rolling with the punches was vital to the remarkable success of this learning experience. Additionally, students and faculty learned of the importance of language translators, as well as coordination and collaboration with indigenous health care providers and other resources, such as charities and nongovernment organizations. Lastly, it was learned that on-site relief workers, such as those providing assistance in construction, debris removal, or road repair, are also in need of care for a variety of maladies, ranging from heat exhaustion to insect bites and wound care.
One of the critical findings from this initiative was demonstrating that nursing students can effectively participate in hands-on disaster relief as an important element of their education. To make this novel educational opportunity a reality, organization, preparation, training, and follow-through are of prime importance. The recommendation in Table A (available in the online version of this article) is made so that this learning experience can be maximized in the context of providing effective disaster relief. Based on this experience and lessons learned, these recommendations include long-range preplanning, postdisaster preplanning, execution, and follow up.
This innovative, collaborative, and community-engaged effort in Rockport to provide relief following Hurricane Harvey exemplifies the depth and range of postdisaster nursing care and demonstrates the importance of educating graduate and undergraduate nursing students in disaster preparedness and relief. Other institutions of higher learning are encouraged to use these findings to prepare similar disaster relief programs, so that when disaster strikes they will be ready to respond. In addition to the enormous benefit conferred to the Rockport community, this experience was one of the highlights for students in the UT Health San Antonio SON Population Focused Health course and has prepared them to assume leadership roles in the event of other disasters. In the words of two nursing students: “I felt like a real nurse” and “This is the best experience I have had since I decided to become a nurse.”
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