Five hours ago, a 6.8 earthquake struck a California community. Even before the Red Cross shelter is completely ready, people start streaming in. Juan Gomez* has lacerations and burns on both arms from a broken water heater. Sarah Chan, eight months pregnant, is worried about her toddler, whose asthma medication is in the damaged apartment they abandoned. George Wiley lost his glasses and hearing aid in the confusion after the quake. The Ferraro family is just recovering from the flu, and two children have bronchitis. Frank Thomas, who has diabetes, is worried about missing a podiatrist appointment to treat his ingrown toenails. Eighteen-year-old Jenny Lee wanders in, crying uncontrollably. Welcome to the world of American Red Cross Disaster Health Services.

The Red Cross has about 30,000 volunteer nurses in chapters across the U.S., many of whom are involved in DHS. But many more are needed to respond to future local and national disasters. This module will help nurses better understand the Red Cross DHS nurses’ role during major disasters and help nurses decide whether DHS nursing may be where they can offer their time and talents.

Never in the history of the U.S. has disaster preparation and response been as vital as it is today. The massive destruction from hurricanes in 2005 imperiled community health. Future natural disasters — and possible large-scale terrorist attacks — could do the same in the future.

Major disasters may result in many deaths and injuries and can quickly overwhelm a community’s health care system and public health infrastructure.¹ Chaos and panic can result.¹ Hurricanes Katrina and Rita overwhelmed public service personnel; destroyed buildings; depleted water, food, and medical supplies; and disrupted essential communication, utility, and sanitation services.²

In a disaster, people may or may not have time to prepare logistically or emotionally. During a slow-rising flood, evacuees may have time to gather essential medications and supplies and to anticipate the stresses of dislocation. In an earthquake, people have to seek safety on the spur of the moment.² Preparing for and responding to community disasters and emergencies is the responsibility of local and state agencies.³ When the effects of a disaster exceed the capacity of local responders, they call on the federal government. The National Response Plan provides a framework for national disaster assistance. The NRP consists of 15 emergency support functions (ESFs): 1) transportation; 2) communications; 3) public works and engineering; 4) firefighting; 5) emergency management; 6) mass care, housing, and human services; 7) resource support; 8) public health and medical services; 9) urban search and rescue; 10) oil and hazardous materials response; 11) agricultural and natural resources; 12) energy; 13) public safety and security; 14) long-term community recovery and mitigation; and 15) external affairs.

Enter the Red Cross

The primary responsibility for each ESF falls to a specific agency.³ The American Red Cross, the only nongovernmental agency the NRP specifically names, is the lead agency for mass care, housing, and human services (ESF No.6). The American Red Cross also functions as a support agency for five other ESFs, including ESF No.8 (public health and medical services).^4,5,6

The American Red Cross, founded by nurse Clara Barton in 1881, is an independent organization supported by public contributions.⁷ In 1905, Congress chartered the Red Cross to operate a program of national and international relief in times of peace and to help relieve suffering caused by “pestilence, famine, fire, floods, and other great national calamities.”⁴ As part of the Red Cross disaster relief response, DHS provides emergency and preventive health services to victims of disasters and to Red Cross staff assigned to a disaster relief operation.⁸

In 2005, the American Red Cross provided relief to the victims of nearly 73,000 disasters in the U.S.⁹ The majority were house and apartment fires, to which local chapter disaster action teams respond. Team members are on call 24 hours a day to meet the immediate health and family service needs of victims. Typically, people displaced by local disasters, such as apartment fires, are housed in local motels or hotels.

When disasters affect large numbers of people who cannot remain in their own homes or find alternative housing, the Red Cross opens community shelters. Red Cross shelters may be opened in facilities, such as schools, that have large spaces for dormitory living, sanitary facilities, and kitchens for food preparation and distribution. The Red Cross and local facilities establish agreements as part of disaster preparation so that the facilities can be used quickly when a disaster strikes. Shelters must follow state and local health standards for food storage, preparation, and service; sanitary facilities; congregate dormitories; emergency aid stations; and health care areas.¹⁰

If compliance with local health regulations is not realistic given the extent of a disaster, DHS is responsible for obtaining waivers from public health officials or seeking alternative arrangements.¹⁰

The American Red Cross assigns DHS staff members to mass care shelters based on their professional education and experience, in conjunction with state practice acts. Registered nurses must have current active licenses. Vocational nurses, emergency medical technicians, paramedics, and physician assistants also must have current active licenses or certifications and work under the supervision of an RN or a physician.⁸ Health care services that DHS staff provides are based on current professional nursing standards. Preventive care and health promotion are provided following Red Cross protocols. Each DHS protocol contains directions regarding client history and assessment, points of emphasis, management, and physician referral.

The level of care that DHS nurses provide cannot exceed current first-aid practices; however, all DHS staff members are expected to use professional assessment and management skills when assisting with the health problems of disaster victims.⁸ These national protocols apply to all health care professionals serving in the DHS function even though their professional licensure or certification may give them additional authority. For example, DHS nurses are prohibited from administering prescription medications. They can, however, observe and reinforce clients’ competency in self-administering medications and dispense OTC medications authorized by DHS protocols. Protocols are reviewed annually to ensure that they meet current medical/nursing, public health, and first-aid standards of practice in the state.⁸ Red Cross general liability insurance covers professional medical personnel while they volunteer under the supervision of authorized Red Cross staff and if they do not exceed the level of care described in DHS protocols.⁸

To protect clients’ health, shelter nurses must be pro-active, making regular rounds to continually assess clients’ physical and emotional needs. Establishing and monitoring minimum standards for food and water safety, sanitation, and person hygiene are vital.¹¹ Adequate and frequent handwashing provides important protection from the illnesses transmitted when people congregate.¹¹  Staff uses standard precautions in shelters to prevent transmission of bloodborne infections, such as HIV and hepatitis B.⁸ DHS works closely with the Centers for Disease Control and Prevention and other organizations to prevent or minimize hazards and injuries caused by disasters.¹⁰

What to expect

After training, DHS staff may be deployed for up to three weeks for national disasters. To gain the most satisfaction from a disaster relief assignment, nurses should have realistic expectations about how they will care for people in a shelter. Twenty-four hour nursing coverage and medical supervision are essential for maintaining health standards and preventing further illness or injury.¹⁰ Nurses work 10- to 12-hour shifts, and depending on resources, may have one day off a week. Physical hardships can be overwhelming, even for those in excellent condition.¹⁰ Nursing staff may sleep in the shelter along with residents. Food is nutritious, but food choices may be limited. Air conditioning and heating may not work. To provide nursing care in a shelter, nurses must be able to work effectively with many volunteers and with limited technology.⁴ Assessment skills, adaptability, creativity, and the ability to work as a part of a team are essential competencies. Red Cross DHS nurses spend more time using their assessment, problem-solving, case management, and advocacy skills and less time treating clients through traditional “hands-on” nursing.¹⁰ Effective shelter nurses combine the ingenuity of community nurses, the focus of public health nurses, and the practicality of occupational health nurses to meet the needs of people in crisis.

 Although nearly everyone in a major disaster experiences stress, some people are more vulnerable than others. Those at greater risk of adverse reactions include people who live alone, who lack coping skills or are mentally ill, who have limited financial and social support resources, who don’t speak the local language, or who abuse drugs or alcohol.^2,12 In the aftermath of a disaster, mental health professionals provide invaluable services to disaster victims and volunteer workers alike by supporting expressions of normal coping, treating those with coping problems, and identifying people who may be at risk for psychiatric disorders.¹² DHS nurses work closely with Disaster Mental Health Services to ensure that clients’ and volunteers’ emotional needs are met. Nurses can refer clients to DMHS when they have problems coping with the emotional aspects of the disaster or have preexisting mental health conditions that have been exacerbated by the disaster.¹⁰

People with chronic conditions, such as hypertension, cardiac and respiratory problems, and diabetes mellitus, are also vulnerable to adverse health outcomes due to the stress of the disaster itself and interruptions in their health maintenance practices. 

Maslow’s Hierarchy of Needs is a model that can help DHS nurses work with disaster survivors to regain physical and emotional equilibrium.¹³ The most basic level in the hierarchy involves physiological and safety needs. Physiological needs can be met by providing disaster survivors with water, food, and shelter from the elements. Safety needs can met by ensuring that the shelter is a safe haven from additional threats to health and survival.¹² Personal safety and the physical safety of loved ones are major concerns for disaster survivors. Some people may need to repeatedly talk about events and feelings associated with the disaster.¹² Many feel a need to be part of the recovery efforts; DHS workers can help meet this need by enlisting appropriate shelter residents to help with daily tasks.

Nurses should assess shelter residents to determine which residents should be relocated to protect their own health or the health of other residents. Such people may include those with severe asthma, people who are immunocompromised, those with a communicable disease that requires isolation, people whose physical or emotional problems prevent them from being able to be safely sheltered, and those who are active substance abusers.⁸

Nurses make and document health histories and clinical assessments for all people seen for treatment in a shelter. The history includes information such as the time of an injury or onset of symptoms, subjective complaints, the way an injury occurred, and self-treatment and results. A medical history documents the person’s general state of health, previous health problems, prescription and OTC medications, allergies, the name and telephone number of the personal physician, and the date and reason for the person’s most recent hospitalization. Clinical assessment includes the person’s general appearance, age, sex, weight, vital signs, and objective signs such as level of consciousness, pupil status, and skin temperature and color.⁸

After assessment, clients are assigned to one of four classifications, ranging from life-threatening conditions that require immediate transport (Classification 1) to minor conditions that can be managed using DHS protocols (Classification 4).^8,10

Starting to recover

DHS nurses provide a variety of services to meet client emergency health needs, including —¹⁰

• Immediate care for disaster-caused or aggravated illnesses or injuries
• Referrals for emergency medical care
• Help in obtaining medical supplies for health maintenance
• Purchase of OTC medications for disaster-related health conditions or losses
• Purchase of disaster-related urgent medications and approval of payment by the Red Cross or other agencies.
• Purchase of eyeglasses, contact lenses, dentures, prosthetic devices, hearing aids, and other health-related equipment required because of disaster-related health problems or losses

Red Cross DHS nurses working in a shelter are part of a team that must collaborate to meet clients’ needs. DHS volunteers come from all parts of the country, bringing with them a variety of backgrounds and experiences. No matter what their background or role, DHS volunteers have common values, among them using resources wisely, respecting clients’ confidentiality, and honoring the International Red Cross principles of respect for all humanity, impartiality, and neutrality.¹⁰

In addition to frequent collaboration with their mental health colleagues, nurses work closely with client casework to help clients who need food, clothing, household furnishings, work supplies and equipment, transportation, or help with home repairs or rent payments.⁸

A shelter manager — or in a large disaster relief operation, a client services administrator — has administrative responsibility for all shelter operations. In addition to DHS functions, key shelter functions include client registration, feeding, mental health services, communications, dormitory management, material support services, and recruitment and placement of shelter staff.² The nurse reports directly to the shelter manager or client services administrator. A DHS medical consultant is always available for consultation on unusual health issues.

Ready to volunteer?

Throughout our country’s history, nurses have provided health services in response to epidemics and disasters. There are nearly 3 million registered nurses with current active licenses in the U.S.¹⁴ Nurses have excellent assessment skills, are critical thinkers and problem solvers, and come from a variety of specialty practice areas.¹⁵ The International Coalition for Mass Casualty Education believes that all nurses must have some basic level of knowledge and skill about how to respond to disasters with mass casualities.¹⁵ To be most effective in responding to a local or national disaster, nursing leaders recommend that RNs become involved with disaster relief organizations before disaster strikes.³ Nurses interested in helping the Red Cross as members of a local disaster action team or as mass care shelter nurses should contact their local Red Cross chapter.

Other relief programs involving nurses include the National Nurses Response Team, developed by the American Nurses Association with the U.S. Department of Health and Human Services to prepare teams of nurses to help with mass vaccinations or chemoprophylaxis. The Medical Reserve Corps Program coordinates nurses, physicians, and other health professionals to help during large-scale emergencies.

Whether the next major disaster is a hurricane, pandemic influenza, an earthquake, or a terrorist attack, nurses will be called upon to contribute their expertise and energy to protect the health of the American people. Individual nurses need to assess how they can best contribute during a disaster. Some nurses may find that volunteering for specific disaster relief efforts is the best use of their knowledge and skills. Others may best contribute by keeping their organizations running during a disaster by working extra shifts and cheerfully taking on additional duties. All of America’s nurses should learn more about their own organizations’ and communities’ disaster response plans and decide where they fit in. Make disaster preparation the focus of your continuing efforts this year.