Disaster Planning Nursing CE Course

lm the hospital’s resources, such as available supplies, equipment, beds, and staffing (Gebbie & Qureshi, 2018).   

What is a Mass Casualty Event? 

Consider the following scenario. A nurse is one of several staff members working in an emergency room within a large urban medical center. Traditional triage in an emergency room setting prioritizes patients into emergent, urgent, or non-urgent categories. The focus is to use all available resources to care for patients in the emergent category who are acutely ill and present with life-threatening conditions. The most used tool for triage is the emergency severity index (ESI). ESI triage is based on patient acuity and the anticipated number of resources their care will require. The concept of resources within the ESI system means a complex intervention or diagnostic tool, above and beyond the physical examination, such as an X-ray, blood tests, intravenous or intramuscular medications, and sutures. The administration of oral medications or writing a prescription does not meet the criteria to be considered a resource. There are five levels of the ESI triage system, with level 1 being emergent, level 2 being urgent, and levels 3, 4, and 5 being non-urgent (Gilboy et al., 2020). See Figure 1 for a more specific description and examples of the five levels of the ESI triage system. 

Mass Casualty Example 

A nurse is notified that a large commercial jet has crash-landed at the local airport in the middle of a shift. The emergency room expects to receive an influx of patients who have been injured in that crash. As a result, the facility activates its disaster plan, and the nurse prepares to respond to a mass casualty incident. A mass casualty incident is “an event where the number of casualties exceeds the available resources” (Markinson & Losinski, 2019, p. 61). Surge capacity is a community or healthcare facility’s ability to care effectively for more patients during a disaster or mass casualty incident. In response to a mass casualty incident, the care plan is to prioritize procedures and resources to save the most lives. According to the US Department of Health and Human Services (HHS), Chemical Hazards Emergency Medical Management (CHEMM, 2021b), and Markinson and Losinski (2019), triage in a disaster or mass casualty incident uses the START adult triage algorithm. The START algorithm was initially created in 1983 and remains the most commonly used mass casualty triage algorithm in the US (see Figure 2). Note that triage categories can change based on a patient’s status.  

In addition to the START algorithm, The North Atlantic Treaty Organization (NATO) triage system involves four triage categories, each with a designated color (CHEMM, 2021b; Hinkle & Cheever, 2018): 

Green tag: Minor 

•  The victim has minor injuries, is considered “walking wounded,” and may be able to assist with their care. Their status is unlikely to deteriorate over days. Examples include upper extremity fractures, minor burns, small lacerations without significant bleeding, and sprains. 

Yellow tag: Delayed 

• The victim has serious injuries, may require surgery, and is unlikely to deteriorate significantly over several hours. Examples include stable abdominal wounds without significant hemorrhage, soft tissue injuries, vascular injuries with adequate collateral circulation, and fractures requiring open reduction.  

Red tag: Immediate 

• The victim requires medical attention within minutes up to one hour. Injuries, such as airway obstruction, accessible hemorrhage, or emergency amputation, are severe but potentially reversible. Other examples include a sucking chest wound, hemothorax, tension pneumothorax, second- or third-degree burns over 15% to 40% of the body, and unstable chest or abdominal wounds.  

Black tag: Expectant 

• The victim is unlikely to survive due to the severity of their injuries, level of available care, or both. Therefore, these patients should receive comfort care. Examples include unresponsive patients with a penetrating head wound, wounds involving multiple anatomic locations, high spinal cord injuries, profound shock, agonal respiration, second- or third-degree burns over 60% of the body, and fixed and dilated pupils.

Disaster Planning and Emergency Preparedness 

Disaster planning can be conceptualized using the disaster cycle, which consists of 5 elements: planning, preparedness, mitigation, response, and recovery. Each of these cycles will be discussed below. Disaster planning is the first element in the disaster cycle. The goal of disaster planning is best expressed by Sharon Stanley, former chief nurse of the American Red Cross, who stated, “disaster planning is not about putting something on paper. It is about bringing all stakeholders together, ensuring they understand their roles and relationships, and determining how they can keep their population safe and well” (Trossman, 2017, para. 9). 

The Agency Strategic Plan (FEMA, 2021b) is a framework for supporting the US before, during, and after disasters. The FEMA Strategic Plan 2022-2026 has three goals that address US disaster planning and preparedness: 

1. Build a culture of preparedness: everyone should be prepared when a disaster occurs. 

2. Ready the nation for catastrophic disasters: organize the best scalable and capable incident response workforce, enhance intergovernmental coordination, and posture FEMA and the whole community to provide life-saving resources. 

3. Reduce the complexity of FEMA: promote simpler, less complex processes to support  

4. individuals and communities.  

The FEMA Strategic Goals support the mission to prepare and plan for disasters in the United States and provide a national scope for disaster preparedness goals (FEMA, 2021b). 

Personal Disaster Plan 

Disasters or mass casualty incidents can occur suddenly with little to no warning, and nurses may be called upon to respond and provide care to disaster victims. To focus on caring for patients in a disaster, each nurse needs to have an up-to-date personal disaster plan that can be implemented to keep them and their families safe during a disaster. Nash (2015) completed a pilot study on nurses’ personal preparedness for disaster response, finding that “although nurses are essential caregivers in disaster response, many are not prepared personally to report to the workplace during a disaster situation” (p. 425).  

The first step in developing a personal disaster plan is to familiarize oneself with the types of disasters that can occur within one's community. Consider the following questions:  

• Do you live in an area that experiences weather-related disasters such as hurricanes or tornadoes?  

• Do industries in your community produce, store, or transport hazardous materials?   

Communication is a vital element of a personal disaster plan. Teach children how to call 911. Have a communication plan for how family members would stay in contact if they became separated in a disaster. Talk with family members about potential emergencies (natural disaster, fire) and how to respond to each, including evacuation routes. Establish emergency meeting places outside of the home and in the neighborhood if an evacuation is necessary. Choose a friend or family member who lives out of state as an emergency contact for family members to call. Texting is preferable over phone calls during an emergency, as phone lines must be clear for first responders. FEMA (2021a) has a Family Emergency Communication Plan template with wallet-sized cards available on the website. Each family member should carry a copy of the completed family emergency communication plan in their backpack or wallet (FEMA, 2021a; Veenema, 2018a). 

Personal disaster planning also includes familiarizing oneself with an employer’s and children’s school’s emergency response plans. Ensure that homeowners', flood, and health insurance policies are current and that premiums are paid on time. If the family needs to evacuate during a disaster, take important documents, such as birth certificates and insurance policies. Keep cash, loose change, and a credit card to cover expenses in an evacuation. If the disaster has caused power failures, credit card machines will not work. Caregivers should plan for any family member with special needs, such as those requiring prescription medications or vision, hearing, or mobility impairments. Prepare for the safety of pets during a disaster, as pets other than service animals are often not permitted in shelters. Maintain a disaster supply kit containing nonperishable food, water, and supplies for at least three days and store the kit in a grab-and-go location. Consider keeping an additional disaster supply kit at work. Assemble and maintain a first aid kit for the home and each vehicle. Gather additional emergency supplies, such as a portable battery-powered radio or weather radio, flashlight(s) with extra batteries, matches in a waterproof container, tools (wrench, pliers, shovel), compass, and kitchen items (manual can opener, household bleach, paper cups and plates, utensils). Kits should include at least one complete change of clothing, footwear, pillows, blankets, or sleeping bags for each family member (FEMA, 2021a; Veenema, 2018a). 

Healthcare Facility Disaster Plan 

A healthcare facility disaster plan addresses four key components: resource management (supplies and staffing), communication systems and methods, reporting structure, and patient management. Best practices for writing a healthcare facility disaster plan focus on using a multiagency, interdisciplinary collaborative process, endorsing input from all key stakeholders. The planning committee tasked with writing the disaster plan should include representatives from nursing administration, infection control, hospital epidemiology, medical staff, security, housekeeping, central supply, risk management, dietetics, respiratory therapy, occupational therapy, local emergency management services, and public health departments. The size of this group may vary depending upon the size of the healthcare institution. Resource management is a key concern and includes planning, allocating, and distributing resources. Resources consist of supplies, equipment, and staff necessary to effectively respond to a disaster or mass casualty incident. Key considerations include on-hand equipment, backup equipment, pharmaceutical supplies, backup pharmaceutical supplies, available staff, backup staff, and facility surge capacity (FEMA, 2021b; Veenema, 2018c). 

Community Disaster Plan 

A community disaster or emergency management plan is implemented during or after a mass casualty incident affecting the entire community. A community disaster plan is collaborative like a healthcare facility disaster or emergency management plan. It encourages representation and input from all key stakeholders, such as first responders, law enforcement, public health, and other response agencies within the community. Since some disaster/mass casualty incidents involve infectious agents, it is critical to include infection preventionists, often nurses, on the team responding to a community disaster or mass casualty incident (Veenema 2018b, 2018c). 

Principles of Disaster Planning 

There are two distinct approaches to disaster planning: the all-hazards approach and the agent-specific approach. The agent-specific approach is geared toward disasters or threats likely to occur in specific locations, such as tornadoes in Oklahoma or hurricanes in Florida. For example, healthcare facilities near a nuclear power plant or a large chemical manufacturing facility may elect to use an agent-specific approach to write and update their disaster plan. The all-hazards approach, recommended by FEMA, is a more comprehensive disaster planning method that includes disaster planning and management components covering all types of disasters to make the best use of resources. The initial response to a disaster or mass casualty incident occurs locally. Then, additional resources from surrounding communities, state agencies, or the federal government are requested and obtained depending upon the scope and nature of the disaster or mass casualty incident. The all-hazards approach is a community-wide effort that encourages collaborative planning for and responding to disasters. The whole community concept includes local, state, and national governmental and non-governmental entities (e.g., religious groups, private businesses, nonprofits) and the public health department (FEMA, 2021b; Sledge & Thomas, 2019; Veenema, 2018c). 

The UNDRR (n.d.) facilitated the development of the Sendai Framework for Disaster Risk Reduction 2015-2030, a global policy that focuses on risk reduction to decrease the impact of a disaster using an all-hazards approach to planning (Atisi-Selmi et al., 2015). Noting that disasters vary in size and onset, the Sendai Framework addresses disaster impact using the following terms (UNDRR, n.d.): 

• A small-scale disaster affects local communities that require assistance beyond the affected community. 

• A large-scale disaster affects a society that requires national or international assistance. 

• Frequent disasters have an impact that can be cumulative or chronic on a community or a society. 

• A slow-onset disaster emerges gradually over time. 

• A sudden-onset disaster is triggered by a hazardous event that emerges quickly or unexpectedly. 

Components of a Disaster Plan 

A key component of disaster planning consists of assessment, including hazard identification, vulnerability analysis, and risk assessment (Veenema, 2018c). A thorough evaluation of hazards, vulnerabilities, and risks is essential for designing an effective disaster response. For example, according to Atisi-Selmi and colleagues (2015): 

Progress in disaster risk reduction research has shown that it is often not the hazard that determines a disaster, but the vulnerability, exposure, and ability of the population to recover from its effects . . . [thus,] the identification, assessment, and ranking of vulnerabilities and risks become critical. (p. 165) 

The first step in developing a disaster plan involves hazard identification and vulnerability assessment; these elements examine the region-specific hazards (e.g., floods, tornadoes, earthquakes, or hurricanes) and assess the likelihood of mass casualty incidents. Hazard identification and vulnerability assessment are critical to predicting a future disaster's location, timing, and magnitude (Veenema, 2018c).  

When completing a thorough disaster risk assessment, agencies and providers can mitigate the severity of a potential disaster’s impact upon a healthcare facility or a community. The overall goal of mitigation is to lessen the impact of a disaster by removing hazards and relocating vulnerable populations. For example, in a disaster likely to include high winds, mitigation strategies include placing outdoor furniture indoors, boarding up windows, or applying hurricane shutters. Additional mitigation strategies in hurricane-prone states, such as Florida, Texas, Mississippi, or Louisiana, include evacuating residents of a long-term care facility or a hospital in a low-lying, flood-prone area to a nearby facility located on higher ground. Unlike tsunamis, earthquakes, and tornadoes, which may have a short opportunity for a watch or warning, hurricanes have a longer watch and a warning period that allows those affected, including healthcare facilities, to evacuate patients and residents to other healthcare facilities situated on higher ground (FEMA, 2019, 2021bc; Veenema, 2018c).  

Researchers have emphasized the importance of disaster planning and organizational readiness in long-term care facilities, including the critical importance of allowing at least 48 hours for a facility evacuation in the event of a hurricane. Vulnerable populations include the homeless, minorities, elderly, infants, children, pregnant women, and individuals with mental illness or disabilities. The healthcare needs of vulnerable populations must be addressed in disaster planning, response, and recovery (Davis et al., 2018). 

Disaster/Mass Casualty Response and Recovery 

The response plan is activated once a disaster or mass casualty incident has occurred. Depending upon the extent or impact of the incident, issues with resource management and alterations in the usual standards of care may arise. During the response phase of a disaster or mass casualty incident, available resources will quickly become depleted. During the planning phase, memoranda of understanding between the facility, other healthcare facilities, and vendors may help alleviate the depletion of resources. Even with the most thorough disaster and mass casualty response planning, the extent and scope of the disaster or mass casualty response may necessitate implementing crisis standards of care for allocating limited resources. This is where the focus of triage and management of care transitions toward doing the greatest good for the most individuals, and disaster triage is implemented instead of the traditional emergency room triage methods. The response phase of the disaster cycle concentrates efforts on emergency relief, first aid, and the restoration of damaged systems such as power, transportation, or communication. The healthcare team should focus on providing victims care and basic life necessities (food, water, shelter). (Veenema, 2018c).  

The recovery phase of the disaster cycle focuses on returning the healthcare facility and the community to normal. This phase can encompass restoring power and communication capabilities, repairing roads and damaged structures, and resuming normal healthcare operations. Disaster and mass casualty response efforts often entail situations that cause affected patients or staff members to experience some degree of mental anguish, such as moral distress, survivor guilt, or post-traumatic stress. According to the Centers for Disease Control and Prevention (CDC, 2018), responding to disasters is rewarding and challenging for nurses and other healthcare providers (HCPs). However, stressors that can affect individuals who respond to a disaster or mass casualty incident can lead to a risk of personal harm, intense workloads, life-and-death decision-making, and separation from family members.  

The Nursing Role in Disaster Planning 

As the largest occupational group of HCPs, nurses must take an active role in disaster planning, response, and recovery. Nurses with community health expertise—including public health nurses, home health nurses, and school nurses—must be involved in community risk assessments and disaster planning. In addition, community disaster plans should align with the US National Response Framework, which supports the National Preparedness Goal of “a secure and resilient nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to, and recover from threats and hazards that pose the greatest risk” (FEMA, 2019, p. 1). 

Nurses in healthcare facilities who function in leadership roles—including shift supervisors, nurse managers, staff development educators, and infection control personnel—should have a seat at the table along with other department managers when a disaster plan is written or updated. In addition, every staff nurse must know the location of the facility disaster plan and have had the opportunity to read and review the plan during their onboarding or facility orientation period. Nurses may be asked to perform duties outside their areas of expertise and may take on additional responsibilities as resources are allocated. Nursing care during a disaster is focused on essential care for the greatest number of patients possible. Therefore, nurses must prioritize patient safety and communication during disaster or mass casualty events (Hinkle & Cheever, 2018; Veenema, 2018c). 

As discussed earlier, each nurse needs to have a personal disaster plan addressing what their family members need to do in an in-home emergency or a disaster. Having a personal/family disaster plan in place will enable nurses to report to work in a disaster or mass casualty incident and know that their family members have a plan to keep them safe. Personal readiness also includes disaster and mass casualty response education and training. In addition to being familiar with their employer’s facility disaster plan, nurses need to know about the disaster response cycle, disaster triage, and nursing roles during a disaster or mass casualty incident. Disaster preparedness education can include a pre-licensure or graduate-level nursing program curriculum, continuing education courses, or experiential learning such as simulation or disaster drills (CDC, 2018; Kalanlar, 2019; Sathasivan, 2019; Veenema et al., 2017).  

Self-care and resilience are essential aspects of personal readiness that nurses can address during the disaster planning and preparedness phase. A personal/family disaster plan to promote the care and safety of family members during a disaster is one aspect of self-care. Resilience is enhanced when nurses understand they will be working longer hours with fewer breaks and caring for more patients during the disaster planning and preparedness phase. Nurses are encouraged to use the buddy system to encourage each other to take breaks to eat, sleep, or exercise. Other self-care techniques include working in teams, journaling, engaging in deep breathing and relaxation exercises, limiting working hours to no longer than 12-hour shifts when possible, and avoiding or limiting caffeine and alcohol consumption. HCPs who respond to disasters or mass casualty events can experience burnout (i.e., feelings of extreme exhaustion and being overwhelmed) and secondary traumatic stress (STS; i.e., stress reactions from the exposure to another individual's traumatic experiences). HCPs should be educated on the signs and symptoms of burnout (i.e., irritability, isolation, fatigue, anxiety, frustration) and STS (i.e., anxiety, excessive worry about something bad happening, easily startled, nightmares; CDC, 2018). 

The Nursing Role in Disaster/Mass Casualty Response 

The American Nurses Association (ANA, 2017) issued a brief addressing nurses' key ethical and legal concerns in a disaster or mass casualty response. In the American Nurses Association Code of Ethics, Provision 2 states that “the nurse’s primary commitment is to the patient,” and Provision 5 states that “the nurse owes the same duty to self as to others.” Consequently, every nurse has an ethical obligation to care for themselves and others. There can be an ethical conflict of obligation in a disaster response situation. Nurses must decide how much high-quality care can be delivered to others without sacrificing self-care (ANA, 2017).  

Nurses must be well versed in the four stages of triage in a disaster or mass casualty incident. Experienced nurses may be called upon to assist with disaster triage during a mass casualty incident. Once triage has been accomplished, nurses need to understand the assigned triage category, the severity of the injury, and the subsequent prioritization of nursing care. In addition, infection prevention precautions and surveillance may need to be implemented in a disaster or mass casualty event involving an infective or a harmful agent. The principles of bioterrorism management, including the exposure and response to hazardous or Infective agents, are discussed in the Bioterrorism NursingCE course (Hinkle & Cheever, 2018; Veemema, 2018c). 

In the disaster recovery phase, infrastructure is restored, and the community and affected healthcare facilities begin to resume normal operations. During disaster recovery, the nursing role includes providing care, withdrawing from the disaster scene, monitoring the long-term physical health of disaster victims, debriefing staff, and revising the disaster plan based on lessons learned during this disaster response and recovery. Nurses must be willing to assume leadership roles in disaster preparedness and response policy-making on the local, state, and federal levels. Nurses who have taken an active role in planning for, responding to, and recovering from disasters can use those experiences to influence and improve disaster preparedness and responses for future events (Veenema, 2018b, 2018c).  

Additional Disaster Planning and Response Resources 

Disaster planning and emergency preparedness are essential to keep people safe and minimize damage if a disaster occurs. Various organizations have put together resources for healthcare organizations and communities to prepare for a disaster and subsequent medical surge:  

• The CDC provides electronic access to evidence-based isolation guidelines. The CDC app is free and can be downloaded to smartphones, tablets, or PCs. Appendix A of the Isolations Guidelines document, Types and Duration of Precautions Required for Selected Infections and Conditions, provides an alphabetized list of diseases or conditions, the type and duration of isolation precautions, and a comment column containing additional information relevant to the use of precautions to assist in decision-making. Table 3 of the Isolations Guidelines document, Infection Control Considerations for High Priority Diseases that May Result from Bioterrorist Attacks, contains information on the incubation period, modes of transmission, clinical features, infectivity, and recommended isolation precautions (Siegel et al., 2019).  

• The CDC has also put together a Healthcare Preparedness Toolbox that can be found on their website within the Center for Preparedness and Response. The toolbox compiles resources for community organizations in an easy-to-use guide to developing community plans for medical surges (CDC, 2020).  

• PAHO, part of the World Health Organization (WHO), provides training and resources for all countries within the organization, including a health emergency and risk management framework, a simulation exercise manual, and a strategic plan framework for emergency preparedness. These resources are on the organization’s website (PAHO, n.d.).  

• FEMA’s Emergency Management Institute hosts a National Training and Education Division website with an online course catalog of emergency preparedness and disaster response courses available at no charge (FEMA, n.d.).  

• The UNDRR provides a global perspective on evidence-based best practices for disaster risk reduction (UNDRR, n.d.). 

• The Occupational Safety and Health Administration (OSHA) provides information on emergency preparedness and response resources to help individuals prepare and train for emergencies, particularly when hazardous materials are involved. Resources on their website include evacuation and shelter-in-place protocols, personal protective equipment (PPE) for emergency response and recovery workers, and hazardous waste operations and emergency response measures (HAZWOPER; OSHA, n.d.). 

References 

American Nurses Association. (2017). Who will be there? Ethics, the law, and a nurse’s duty to respond in a disaster. https://www.nursingworld.org/~4af058/globalassets/docs/ana/ethics/who-will-be-there_disaster-preparedness_2017.pdf 

Atisi-Selmi, A., Egawa, S., Sasaki, H., Wannous, C., & Murray, V. (2015). The Sendai framework for disaster risk reduction: Renewing the global commitment to people’s resilience, health, and well-being. International Journal of Disaster Risk Science, 6(2), 164-176. https://doi.org/10.1007/S13753-015-0050-9 

Baldisseri, M. R., Reed, M. J., & Wax, R. S. (2019). Critical state of disaster preparedness. Critical Care Clinics, 35(4), xiii-xiv. https://doi.org/10.1016/j.ccc.2019.07.001 

Centers for Disease Control and Prevention. (2018). Emergency responders: Tips for taking care of yourself. https://emergency.cdc.gov/coping/responders.asp 

Centers for Disease Control and Prevention. (2020). Healthcare preparedness toolbox. https://www.cdc.gov/cpr/readiness/healthcare/toolbox.htm 

Chemical Hazards Emergency Medical Management. (2021a). START adult triage algorithm [Image]. US Department of Health and Human Services. https://chemm.hhs.gov/startadult.htm 

Chemical Hazards Emergency Medical Management. (2021b). START adult triage algorithm: Text version. US Department of Health and Human Services. https://chemm.hhs.gov/startalgotext.htm 

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Davis, E. A., Hansen, R., Peek, L., Phillips, B., & Tuneburg, S. (2018). Identifying and accommodating high-risk, high-vulnerability populations in disasters. In T. G. Veenema (Ed.), Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp 114-138). Springer Publishing. 

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Federal Emergency Management Agency. (2021b). Strategic plan executive summary. https://www.fema.gov/about/strategic-plan/goal-3 

Gebbie, K. M., & Qureshi, K. (2018). Disaster management. In T. G. Veenema (Ed.), Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp 399-416). Springer Publishing. 

Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2020). Implementation handbook 2020 edition emergency severity index: A triage tool for emergency department care. Emergency Nurses Association. https://www.ena.org/docs/default-source/education-document-library/triage/esi-implementation-handbook-2020.pdf 

Hinkle, J. L., & Cheever, K. H. (2018). Textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.  

Kalanlar, B. (2019). The challenges and opportunities in disaster nursing education in Turkey. Journal of Trauma Nursing, 26(3), 164–170. https://doi/org/10.1097/JTN.0000000000000417 

Markinson, D., & Losinski, S. (2019). Hospital and emergency department preparedness. In T. G. Veenema (Ed.), Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp 51-80). Springer Publishing. 

Nash, T. J. (2015). Unveiling the truth about nurses’ personal preparedness for disaster response: A pilot study. MEDSURG Nursing, 24(6), 425–431. https://www.thefreelibrary.com/Unveiling+the+truth+about+nurses%27+personal+preparedness+for+disaster...-a0439362285 

Occupational Safety and Health Administration. (n.d.). Emergency preparedness and response. United States Department of Labor. Retrieved May 12, 2022, from https://www.osha.gov/emergency-preparedness 

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Siegel, J. D., Rhinehart E., Jackson M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee. (2019). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 

Sledge, D., & Thomas, H. F. (2019). From disaster response to community recovery: Nongovernmental entities, government, and public health. American Journal of Public Health, 109(3), 437–444. https://doi.org/10.2105/AJPH.2018.304895 

Trossman, S. (2017). Nurses rise to disaster challenges. American Nurse Today, 12(11), 38–41. https://www.myamericannurse.com/nurses-rise-disaster-challenges/ 

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Veenema, T. G., Lavin, R. P., Griffin, A., Gable, A. R., Couig, M. P., & Dobalain, A. (2017). A call to action: The case for advancing disaster nursing education in the United States. Journal of Nursing Scholarship, 49(6), 1-9. https://doi.org/10.1111/jnu.12338 

Veenema, T. G. (2018a). Creating a personal disaster plan. Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp. 693-696). Springer Publishing. 

Veenema, T. G. (2018b). Creating healthy, sustainable communities after disasters. Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp 671-674). Springer Publishing. 

Veenema, T. G. (2018c). Essentials of disaster planning. Disaster nursing and emergency preparedness for chemical, biological, and other hazards (4th ed., pp. 2-22). Springer Publishing. 

Wikimedia Foundation, Inc. (2022). Emergency severity index [Image]. https://en.wikipedia.org/wiki/Emergency_Severity_Index