January 05 Newsletter

Bioterrorism Preparedness for Nurses: A New Training and Reference Program

Terri Rebmann RN, MSN, CIC

Biological terrorism is an old concept, which has only recently re-emerged in the literature as a current threat. In fact, according to the Centers for Disease Control and Prevention (CDC), bioterrorism has become the most imminent threat to our national security (2000). In fall, 2001, the threat of bioterrorism became reality when a terrorist sent anthrax-laden letters to members of the media and government officials.

The anthrax incident of 2001 illustrated just how truly unprepared we are as a nation to adequately respond to a bioterrorism attack of any size (Altman, & Kolata, 2002). Although the possibility of a large-scale bioterrorism attack is low, the potential consequences if we are not prepared are staggering. A large number of victims could quickly exceed healthcare's existing capacity and the financial impact could reach into the billions of dollars (Burkle, 2002; Kaufmann et al., 1997). Based on projections of the potential consequences of a bioterrorism attack and the actual reality of the immense impact of the small-scale incident utilizing anthrax in 2001, the need for bioterrorism preparedness has become a national priority and a moral imperative. This has been very well established in the literature of a variety of professions (American Academy of Pediatrics, 2000; Bernardo, 2001; Burkle, 2002; CDC, 2000; Gerberding, Hughes, & Koplan, 2002; Gwerder, Beaton, & Daniell, 2001). In response to this identified emerging threat, healthcare and public health professionals have scrambled to become better prepared by shoring up and expanding their infrastructures to respond to a potential attack.

Nursing plays a critical role in the nation's bioterrorism preparedness efforts. Composing the largest group of healthcare providers, nursing is poised to be at the forefront in bioterrorism response and management. As such, nursing must fully embrace its responsibility in bioterrorism preparedness. However, many nurses have not received bioterrorism education, do not engage in exercises and drills meant to evaluate their level of preparedness, nor do they report feeling adequate prepared to respond if an attack occurs (Rose & Larrimore, 2002). Nursing must investigate and address the profession-specific barriers to bioterrorism preparedness in order to ensure the best response to bioterrorism.

When the threat of bioterrorism first re-emerged in the 1990's, education was targeted at the traditional first responders: police, fire and emergency medical service personnel. This decision to target first responders was based on a traditional terrorism response model and was believed to be the most effective approach to preparedness. However, as emergency planners described a more realistic picture of how a bioterrorism attack would unfold, it became clear that healthcare and public health would be the "first responders" following a bioterrorism attack. Following the 1998 Presidential Decision Directive 62, federal agencies were mandated to coordinate planning efforts with healthcare and public health rather than limiting these efforts to traditional first responder groups (CDC, 2000; Malone, 1999).

This resulted in an expansion of bioterrorism education priorities from traditional first responders to include healthcare and public health. This occurred in the late-1990's and is illustrated by a sudden increase in physician and medical journal articles describing bioterrorism preparedness. However, these articles focused on either raising awareness of the potential threats and consequences of bioterrorism attacks and/or on the appropriate medical response to such an event. Nurses were still often excluded, as physicians received the highest priority for bioterrorism preparedness education.

Physicians were targeted for education first because many experts postulate that primary care providers are most likely to be the first to recognize a bioterrorism attack in the community (American Academy of Pediatrics, 2000; Gerberding et al., 2002; Meyer & Morse, 2002; Patt & Feigin, 2002). This implies, however, that nurses are not considered primary care providers and that their bioterrorism preparedness is less important than physician's. The fact that nurse practitioners function as primary care providers has not been adequately addressed in the literature; physicians are still considered "front-line" in healthcare bioterrorism preparedness by most planning agencies.

A major disadvantage to not being considered primary care providers or front-line workers in the bioterrorism preparedness battle is that nursing has been excluded from the majority of early funding opportunities. As mentioned previously, much of the early preparedness funding was aimed at traditional first responders. As the political climate evolved and healthcare and public health became the primary focus for bioterrorism education, funding shifted to public health and hospital preparedness (Fee & Brown, 2001; Sidel, Cohen, & Gould, 2001). Of the funding allotted for primary care provider education, little targeted the nursing profession.

Despite the lack of funding, nursing has slowly embraced the need for bioterrorism preparedness. Many nurses have received and continue to receive bioterrorism education. An example is the current plethora of bioterrorism preparedness articles in the nursing literature. However, these educational initiatives were developed with little regard for profession-specific needs. The majority of nursing bioterrorism preparedness efforts have utilized the medical model to describe the clinical presentation of potential bioterrorism agents.

From a logistical standpoint, this makes sense. Nursing was forced to rapidly address bioterrorism preparedness without the aid of adequate time or funding to develop nursing-specific curricula. The most time and cost-effective approach was to utilize the medical model approach to bioterrorism preparedness that was already in place across the country.

However, now is the time for change. While these trainings have increased nurses' awareness of the need for bioterrorism preparedness, it is not the best approach for future nursing educational initiatives. Although this information is important for nurses, using only the medical model approach marginalizes the unique contribution of nursing and may lead to the neglect of critical components of bioterrorism management. Most nurses will not diagnosis or prescribe treatment to victims of bioterrorism; these are medical functions. Nursing must address nursing-specific needs.

Nursing involves the diagnosis and treatment of the human response. Nursing interventions aimed at these practices, such as providing holistic care for bioterrorism victims and their families, must be addressed. The medical model does not encompass these components of bioterrorism management. This is within the science and scope of the nursing discipline, although it has been overlooked by many bioterrorism preparedness initiatives. Nursing skills are built on a foundation of assessment, critical thinking, formulation of a plan, and communication of that plan. These skills translate well into emergency management. What is missing is the bridge between emergency management principles and the science of nursing. Nursing educators who understand emergency management need to combine the two disciplines and create innovative training programs for nurses.

Even with the increase in research and nursing publications related to bioterrorism preparedness using the medical model, many nurses still have not received adequate education on bioterrorism preparedness or feel that they are not adequately prepared to respond to an attack (Rose & Larrimore, 2002). The largest gaps include a lack of nursing-specific bioterrorism information and failure to engage in exercises and drills meant to evaluate nurses' level of preparedness. These gaps in preparedness must be addressed in order to maximize nursing's capacity for bioterrorism recognition and response. The more prepared we are as a profession, the better our response to a known or suspected event will be, and this translates into lives and money saved.

It is therefore imperative that nursing-specific bioterrorism training be provided to nurses. To meet this identified need, a new training program has been developed by the Institute for Bio-Security (IBS) at Saint Louis University, School of Public Health. This program is entitled, Bioterrorism Preparedness for Nurses. It consists of three components: 1) a lecture on bioterrorism preparedness that is specific to the profession of nursing and the role nurses will play in recognizing and responding to such an attack, 2) interactive training modules that teach bioterrorism response through the use of a smallpox scenario, and 3) a reference and resource section where nurses may obtain additional training and reference materials on bioterrorism preparedness. The program is available in a CD-ROM format to allow for accessibility even during times of crisis when phone and internet lines are unavailable.

The training portion of the program lasts approximately two hours, but is divided into smaller components for user convenience. The content is provided in a train-the-trainer format so that nurse educators can utilize the training materials to educate other nurses in their facility or entity. A complete script and copy of the slides are available on the CD-ROM to facilitate teaching. Educators are encouraged to utilize the slides and scripts in their offered trainings free of charge, but IBS retains the intellectual property of the content and requests that reference be made to the Institute if the slides are modified or used in any format.

The resource section of the program consists of a list of approximately one dozen weblinks to bioterrorism websites, a reference list used to create the training program's content, five response algorithms, eight fact sheets on potential bioterrorism agents, a reference table containing isolation guidelines, and a list of other training and reference materials. Most of the resources are available for free download from either the Bioterrorism Preparedness for Nurses CD-ROM program or from the Institute website (http://bioterrorism.slu.edu/).

The newest component of the Bioterrorism Preparedness for Nurses CD-ROM program is the inclusion of an interactive training module that teaches bioterrorism response in an innovative format. A scenario was developed that walks participants through the step-by-step process of responding to a known or suspected case of smallpox. This scenario is specific to nurses' response; clinical diagnosis, confirmatory laboratory testing, and prescription of medication are not addressed, as these are not nursing functions. The scenario is presented in a question and answer format, in which the participant must answer the item correctly before advancing to the next question. Allowances for non-acute care settings were incorporated into the scenario, so that nurses in a variety of settings, such as schools and outpatient or occupational health clinics, could participate in the modules in an appropriate manner.

A pre and post-test exam are provided as a means of measuring learners' knowledge before and after the program. These exams are required for participants wishing to receive either a certificate of completion or continuing education units (CEU) for the program. Three CEU's are awarded for completion of the program, assuming that the participant passes the post-test exam. There is a $25 fee for CEU's. IBS is an approved provider of continuing nursing education by the Missouri Nurses Association (MONA), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Certificates of completion are available free of charge to all participants, but a passing score on the post-test exam is required.

The content for Bioterrorism Preparedness for Nurses program was developed by staff at the Institute for Bio-Security, and edited by national content experts from nursing, public health, infection control, and infectious diseases. The program is available for purchase from the Institute website (http://bioterrorism.slu.edu/bt/products.htm). MONA has generously offered to fund distribution of one copy of the CD to each MONA member free of charge (there is a $25 fee for those that request CEU's).

Nursing is poised to be at the forefront in bioterrorism management, and as such, we must fully embrace our responsibility in bioterrorism preparedness. In order to do so, nursing needs to examine past and current approaches to bioterrorism preparedness and evaluate whether our profession's goals are being met. Has the medical model approach, while easy and cost-efficient, been an effective means of providing education? Are nurses truly becoming better prepared to appropriately and effectively recognize and respond to a bioterrorism attack? Are all nurses engaging in bioterrorism preparedness, or only a small subset?

Differences between the science of nursing and other healthcare professions must be delineated as they relate to bioterrorism preparedness. A cookie-cutter approach to bioterrorism preparedness may not be meeting our needs as a profession. We need to unite in our preparedness efforts and engage all nurses in the process. In addition, nursing needs to mandate engagement in all components of preparedness, such as participation in exercises and drills, and not simply rely on a small group of dedicated nurses to shoulder the burden for our profession. The Institute for Bio-Security hopes that the creation of the Bioterrorism Preparedness for Nurses CD-ROM program is the first in a series of collaborations with professional nursing organizations, such as MONA, that will result in a stronger healthcare and public health infrastructure and better prepared nurses.

Have a question or comment? Email bioterr@slu.edu