Final_Evolve_Q&As – Flashcards

Combined public sources. By the end of the previous century, health care financing had evolved from a system in which the consumer paid the costs to a system financed primarily by third-party payers, which included private health insurers and local, state, and federal governments. However, recent trends indicate that combined local, state, and federal spending exceeds private health insurance spending in third-party health care financing.

All of them The factors that are frequently cited as having caused increases in total and per capita health care spending in the United States are cost inflation in the production of goods and services; changes in population demography (aging of the population, immigration); increased adoption of medical technology (new procedures, equipment, or pharmaceuticals); increases in the intensity of services, especially when government controlled (legislated programs or mandates); and increases in the incidence of chronic illnesses (ischemic heart disease and obesity). These factors alter the supply of and demand for services to meet identified needs

Rationing of health care. Health care reform approaches under consideration to control the use of services and technologies is considered rationing of health care. Rationing of health care in any form implies reduced access to care and potential decreases in acceptable quality of services offered. A provider's refusal to accept Medicare or Medicaid clients is a form of rationing. Like access to care, rationing of health care is a public health issue. Where care is not provided, the public health system and nurses have an ethical obligation to ensure that essential services are available. This is currently being observed in the Katrina Hurricane recovery efforts, in which the health care infrastructure is being severely compromised by the refusal of previous practitioners to reopen their practices in New Orleans because of the impoverished economy. Nursing and public health agencies are stepping into the void left by these practitioners to provide essential services to the population.

Preserving and maximizing human capital. Behavior and lifestyle have been shown to have the greatest effect on health, and together with environment and biology accounting for 70% of all illnesses. Yet 97% of health care dollars are spent on secondary and tertiary care. A more proactive investment in disease prevention and health promotion targeted at improving behaviors, lifestyle, and the environment has the potential to improve health status and thus improve the quality of life while reducing health care costs. The U.S. Department of Health and Human Services has argued that a higher value should be placed on primary prevention with the goal of preserving and maximizing human capital by encouraging health promotion and social practices that result in less disease. Preserving and maximizing human capital will have a profound positive impact on economics in this country.

Reimbursing for treatment by pediatric and family nurse practitioners. Any state participating in the Medicaid program is required to provide inpatient and outpatient hospital care; laboratory and radiology services; physician services; skilled nursing care at home or in a nursing home for people older than age 21 years; and early periodic screening, diagnosis, and treatment for those younger than age 21 years; and, subsequently, family planning. The 1989 amendments required states to provide care for children younger than 6 years of age and to pregnant women with incomes less than 133% of the poverty level. These changes also provided for reimbursement for treatment by pediatric nurse practitioners and family nurse practitioners and thereby increased access to qualified providers.

Medical savings account (MSA). MSAs are touted as a way of turning health care decision-making control over to the individual receiving care. MSAs are tax-exempt accounts available to individuals who work for small companies, usually established through a bank or insurance company, that enable individuals to deposit money into an MSA on a pretax basis. Interest earned is tax free, and unused MSA money can be held in the account from year to year until it is needed to purchase health care services. This transfers to the individual the responsibility for knowledge and decision making regarding health care cost/quality tradeoffs.

Increase in demand because of increased life expectancy. By the year 2050, individuals age 65 years and older will make up 20% of the population, or one in five Americans. The life expectancy for these individuals is higher, with the number of people age 85 years and older expected to double between 1990 and 2050. Although many older adults are independent and active, because they will live longer they are likely to experience multiple chronic conditions that may become disabling. Older adults are admitted to hospitals three times more often than the general population, and their average length of stay is three days longer than the overall average. They visit physicians more often and make up the larger percentage of nursing home residents. Older adults consume a larger proportion of health care resources, including long-term care, hospital care, pharmaceutical products, and chronic disease management services.

Cost-effectiveness analysis. Cost-effectiveness analysis compares net direct and indirect costs, and cost savings with respect to a defined health outcome. Cost-effectiveness analysis is best used to compare two or more strategies or interventions that have the same health outcome in the community. This comparison can be between two program models or one intervention model and the absence of that intervention.

Macroeconomics. There are two branches of economics: microeconomics and macroeconomics. Macroeconomics focuses on the "big picture" such as the business cycle and economic growth-the total or aggregate of all individual and organizational behaviors such as growth, expansion, or decline of an aggregate. The aggregate is usually a country or nation. Factors such as levels of income, employment, general price levels, and rate of economic growth are important. Human capital is an important element in macroeconomic theory. Improvement of a human condition like health is a focus for raising and spending money on goods and services because health is valued. This approach also enhances the income-earning ability of people and improves the economy. If the population is healthy, premature morbidity and mortality are lowered, chronic disease and disability are decreased, and economic losses to the nation are reduced. Socioeconomic status is inversely related to mortality and morbidity for almost all diseases.

Cost-effectiveness analysis. In community health it is generally believed that interventions have a net positive value such as improving access to services. Nurse-managed clinics provide access to quality care for under-served populations. Nurses can use data to demonstrate the cost-effectiveness and efficiency of their programs without a detailed cost-benefit analysis and gain support from business-oriented health system managers. Efficiency refers to producing maximum output, such as goods or services, using a given set of resources (input), defined in terms of labor, time, and money. Efficiency depends on tasks and process. Effectiveness, on the other hand, refers to the extent to which a health care service meets its intended objective. A cost-effectiveness analysis would allow expression of the net direct and indirect costs and cost savings of a defined outcome in the proposal and planning phases. Cost-benefit analysis would be used to evaluate and demonstrate the effectiveness and efficiency of the program once hard data can be obtained.

Obtain a desired health outcome for an individual, family, group, community, or society. Health policy is a set course of action to obtain a desired health outcome, either for individuals, families, groups, communities, or societies. Policies are made not only by governments but also by institutions such as a health department or other health agency, a family, or a professional organization. Politics plays a role in the development of such policies. Politics is found in families, professional and employing agencies, and governments. Therefore political activities are used to arrive at a course of action (the policy). Policy is a settled course of action to be followed by a government or institution to obtain a desired end.

Advocacy. Advocacy begins with the art of influencing others (politics) to adopt a specific course of action (policy) to solve a societal problem and is accomplished by building relationships with appropriate policy makers-the individuals or groups that determine a specific course of action to be followed by a government or institution to achieve a desired end (policy outcome). This can be done in many ways. Types of advocacy include actions on behalf of clients served by nursing, especially vulnerable populations; activities of the nursing profession itself; work to develop needed health policies or revise existing policies; and actions related to the community.

Federal, state, and local. Federal, state, and local governments are responsible for carrying out the five core government health care functions. All levels of government provide direct services, but the targeted populations may vary; for example, at the federal level the focus is on the members and dependents of the military, whereas the states focus on childhood immunizations. The federal government provides funding for health care education and research. The states provide maternal-child health care services through state-level funding for the poor or near poor. Local governments/organizations provide health care services through funding for free clinics that serve the uninsured. All branches and levels of government collect vital statistics and census data, and conduct health surveys. Governments, agencies, and organizations at all levels make health policy. Functions that protect the public, such as monitoring air and water and regulating food, drug, or animal transportation, are carried out at all levels. Affirmation of a woman's right to reproductive privacy occurred at the federal level (Supreme Court). Requiring vaccinations for school entry occurs at the state level.

Nurse practice acts promulgated by state legislatures and operationalized by the state boards of nursing. State legislatures enact laws that establish boards of nursing. The functions of the board are described by the nurse practice act of each state. The boards of nursing license nurses, oversee training programs, and interpret and enforce statutory law.

Centers for Disease Control and Prevention. The Centers for Disease Control and Prevention serve as the national focus for development and application of measures to advance disease prevention and control, environmental health, and health promotion, and for educational activities designed to improve the health of the people of the United States. The mission of the Centers for Disease Control and Prevention is to promote health and quality of life by preventing and controlling disease, injury, and disability.

Are guides for in-country initiatives and priorities. In 1948, the WHO was created through a United Nations initiative as a special autonomous organization. The WHO provides services worldwide to promote health, cooperates with member countries in promoting their health efforts, coordinates collaborative activities between countries, and disseminates information on biomedical research and vital international statistics. The World Health Assembly (WHA) is the policy-making arm of the WHO and meets annually. The WHA's health policy work provides policy options for many countries of the world in their development of in-country initiatives and priorities. Although WHA policy statements are very important everywhere, they are guides and not law.

Legislative branch of government. Each of the government branches at the federal level, in most states, and at the local level plays an important role in developing and implementing health law and public policy. Concerned citizens have many avenues for addressing issues related to needed laws and regulations as well as existing laws and regulations. However, each branch of government has a separate and important function. The legislative branch identifies problems and proposes, debates, passes, and modifies laws to address identified needs.

Healthy People initiatives. The Healthy People initiatives began in 1979 with subsequent updates and revisions across multiple decades. Healthy People 2020 builds on earlier versions to identify a national health agenda to attain quality, longer lives free of preventable diseases, disability, injury, and premature death; achieving health equity, eliminating health disparities and improving health for all groups; creating social environments that promote good health for all; and promoting quality of life, healthy development, and healthy behaviors across all life stages.

Nursing process. Health policy is simply the process of turning health problems into workable action solutions. Thus the policy process is very similar to the nursing process, but the focus is on the level of the larger society and the adoption of these strategies requires political action. The policy process includes statement of a health care problem, statement of the policy options to address the problem, adoption of a particular policy option, implementation of the policy product, and evaluation of the policy's intended and unintended consequences in solving the original health problem.

Documentation of client status and progress. Documentation of services. Living wills and advance directives. Resident's rights in long-term-care facilities. Right to death with dignity. State laws specify licensure and certification requirements for home health care and hospice agencies. Compliance with these laws is directly linked to the method of payment for the services. For example, a service must be provided by a licensed and state-certified agency to obtain payment from Medicare. Federal regulations implementing Medicare and Medicaid programs have an enormous effect on much of nursing practice, including documentation practices and recording of visits, client care, status, and progress. Other laws focus on issues such as the right to death with dignity, the rights of residents in long term care facilities, definitions of death and death pronouncement, and the use of living wills and advance directives.

Population base, levels of practice, and public health interventions. The components of the Intervention Wheel include population base, 3 levels of practice, and 17 public health interventions. The population-based component includes populations at risk and populations of interest. The three levels of practice include community, systems, and individual/family. The Wheel is colored coded at the intervention level, and the colors (red, blue, green, yellow, and orange) are grouped logically into wedges.

Assessment. Assessing the health status of the populations that make up a community requires ongoing collection and analysis of relevant qualitative and qualitative data. Community assessment includes a comprehensive evaluation of the determinants of health. Data analysis identifies deviations from expected or acceptable rates of disease, injury, death, or disability, as well as risk and protective factors. Community assessment generally results in a lengthy list of community problems and issues. However, communities rarely posses sufficient resources to address the entire list, and priorities must be set after assessing the community's beliefs, attitudes, and opinions, as well as the community's readiness for change.

Orange wedge at the community level of practice. The public health interventions are grouped with related interventions, and these wedges are color coordinated. The red wedge includes five interventions: surveillance, disease and health investigation, screening, outreach activities, and case finding. They typically occur in pairs or in sequence, although all can occur independently. The green wedge consists of three interventions: referral and followup, case management, and delegated functions; these are often implemented together. Similarly, the blue wedge includes three interventions-health teaching, counseling, and consultation-that are often implemented together. The orange wedge combines three interventions-collaboration, coalition building, and community organizing-which are all types of collective action that are usually carried out at the systems or community level of practice. Similarly, the three yellow wedge interventions-advocacy, social marketing, and policy development and enforcement-are often interrelated when implemented. Interventions in the orange and yellow wedges are typically used at the systems and community levels of practice, whereas those in the red, blue, and green wedges are usually carried out at the individual/family level of practice and to a lesser degree at the community and system levels of practice. Collaboration is a collective action and therefore must be in an orange wedge.

Social marketing. Social marketing utilizes commercial marketing principles and technologies in programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population of interest. Recent examples of the use of these techniques are antismoking campaigns, campaigns for refunding of the State Children's Health Insurance Program, and campaigns to address the needs of uninsured/underinsured populations.

Systems-level practice. The goal of systems-level practice is to change the laws, policies, and practices that influence immunization rates, such as promoting the creation of population-based immunization registries and improving clinic and provider practices.

Community-level practice. The goal of community-level practice is to improve the knowledge and attitude of the entire community about the importance of immunization and the consequences of not being immunized. These strategies lead to an increase in the percentage of people who obtain recommended immunizations for themselves and their children.

Individual/family + secondary. Based on this nursing diagnosis, one could assume that the level of practice is at the individual/family level (young child who is being parented by a primary parent who is experiencing mental health problems) and at the secondary level of prevention (because the family has an existing identified risk, i.e., a mental health problem).

Implementation + systems. Collaboration and advocacy are often collective actions applied at a community or systems level of practice. In this case, the identification of the community problem probably emerged out of practice, rather than from a formal community assessment. The nurse's goals were to enforce the tenant's legal rights and improve their living conditions. The nurse sought advice from a housing advocate service and connected the clients with legal counsel. The nurse also sought political support by consulting with health department officials before implementing the nursing plan.

Evaluate the effectiveness of. The evaluation phase of a community-level intervention attempts to determine the effectiveness of the intervention in meeting the desired outcome (decreased social isolation for the elder community population) and in establishing new healthier practices (increased social networking and increased involvement in other community activities) while identifying any emerging barriers (problems) that may interfere with the desired outcome. Very often this can be achieved through a repeat assessment such as a survey of the population receiving the intervention to measure change in attitudes, beliefs, and behaviors.

Education and literacy. Genetic endowment. Gender. Culture. Social status. The determinants of health identified in Healthy People 2020 influence health status throughout all stages of life and include such things as personal behavior, biology, physical environment, and social environment. Each of these broad areas encompasses multiple factors, and all of the factors listed above influence health status.

Specially trained housing inspector, pediatric specialist, lead-based paint intervention team, and laboratory specialists to test the child's home and the surrounding neighborhood. Environmental health-risk identification and risk-reduction intervention requires a multidisciplinary team. The team members needed to address an elevated lead level in a child include a specially trained housing inspector, a sanitarian familiar with lead health risks, a nurse practitioner and/or physician trained to intervene in cases of pediatric lead exposure, and housing specialists trained to reduce lead-based paint risk in the home.

Treat the client and obtain a comprehensive exposure history; if an onsite environmental exposure is suspected as the cause, screen other at-risk workers and ensure that the environmental risk is identified and eliminated. A careful history should be taken using the I PREPARE model. The client should be appropriately treated. If an onsite environmental exposure is suspected, other at-risk workers should be screened and treated as needed. The environmental cause should be resolved, either by removing the offending chemical or reducing it to safer levels. Factory safety policies should be followed, reviewed, and changed if needed. State and federal agencies should be notified as required.

Increase the use of bicycles, foot-powered scooters, rollerblades, and walking as the primary mode of transportation on campus. The burning of fossil fuels to power automobiles and buses and to generate electricity is the single greatest source of air pollution in the United States. While reducing the use of electricity on campus is helpful, the single biggest source of campus air pollution is the cars and buses used to drive to and around campus. Decreasing their use is also an application of the Precautionary Principle.

Environmental justice. Environmental health risks notably have disproportionately affected poor people and people of color in the United States. Low-income citizens and people of color are more likely to live near a hazardous waste site, and increased incidence of childhood lead poisoning and increased rates of childhood asthma are seen in these groups. Environmental justice is the principle of assuring that no group is more at risk of harmful exposure than another.

Environment and human health/disease. Understanding the relationship between the environment and human health and disease has become more important over the years. The environment is now known to play a role as a determinant of health status, an explanation of disease, an influence on health risk, and a cause of human toxicity and the ever-increasing burden of potentially toxic synthetic chemicals that our bodies carry.

Increased focus on the human health problems related to hazardous waste sites. SARA changes included an increase in the size of the trust fund; encouraged greater citizen participation in decision making on how sites should be cleaned up; increased state involvement in every phase of the Superfund program; increased focus on human health problems related to hazardous waste sites; established new enforcement authorities and settlement tools; stressed the importance of permanent remedies and innovative treatment technologies in the cleanup of hazardous waste sites; provided for Superfund actions to consider standards in other federal and state regulations; and established the federal Agency for Toxic Substances and Disease Registry. This act amended the Comprehensive Environmental Response, Compensation, and Liability Act with provisions for a broader community-level involvement and public health mission to address the effects of hazardous waste sites on people.

Environmental epidemiology. Epidemiologic studies enable us to understand the strength of the association between exposures and health effects, such as the relation between air pollution and asthma exacerbation.

Include outcome measures that involve mitigation and elimination of the contributing factors. If the nurse suspects that the client's health problem is being influenced by environmental factors, the nurse should follow the nursing process and note the environmental aspects of the problem in every step of the nursing process. For instance, in goal setting, the nurse should include outcome measures that relate to mitigation and elimination of the environmental factors.

Advocating for ethical choices. Nurses, using sound risk communication skills as trusted communicators, advocate for environmental justice. Ethical issues likely to arise in environmental health decisions are: · Who has access to information and when? · How complete and accurate is the information? · Who is included in the decision making and when? · What and whose values and priorities are given weight in decisions? · How are short-term and long-term consequences considered?

All of them Nurses can have a vital role in reducing environmental risk, educating workers and/or the community, and helping to eliminate risks in the local community. As nurses learn more about the environment, opportunities for integration of such work into their practices, educational programs, research, advocacy, and policy work will become evident and will evolve.

Carrier guilt. Genomics has influenced the availability of genetic tests which has implications for families. Individuals, families and communities need to understand the purpose, limitations, potential benefits and risks of a test before submitting samples for analysis. Genetic testing is now used to predict the development of genetic disorders, screening populations, confirming diagnoses, prenatal testing, and DNA testing to develop and apply individualized medical treatment. Individuals seeking information that might affect decisions and health may also think that testing results would decrease their quality of their life and make them anxious about the future. Family members who have had cancer may refuse genetic testing because their insurance carrier does not reimburse for such testing or their deductibles may be too high for such testing. Additionally people feel that a positive result may lead to feeling of guilt about passing along a disease to children and grandchildren. Genetic testing decisions are personal and complex and can be controversial, leading to dissonance in families.

Multifactorial disease. Multifactorial diseases or those caused by gene and environment interaction influence disease risk, health conditions, and the therapies used to treat disease. Multifactorial disorders tend to occur in families and include such common inherited congenital malformations as cleft lip and palate, neural tube defects, and congenital heart disease.

Changes in deoxyribonucleic acid. Changes in ribonucleic acid. Changes in chromosomal structure Sequences of bases. Alterations in the usual sequence of bases [adenine (A), guanine (G), cytosine (C), and thymine (T)] that form a gene, changes in DNA or chromosomal structures are called mutations. A large number of agents are known to cause mutations. Despite three billion DNA base pairs that must be replicated in each cell division and the large number of mutagens we are exposed to, DNA replication is quite accurate because of the mechanism known as DNA repair that corrects 99.9% of initial errors.

Genetics. The term genetics is used to mean the study of the function and effect of single genes that are inherited by children from their parents; the cause of certain diseases, the genetic link. Genomics refers to the study of individual genes in order to understand the structure of the genome, including mapping of genes and sequencing of DNA. Genomics examines the molecular mechanisms and the interplay of genetic and environmental, cultural, and psychological factors of disease. Genomics deals with the functions and interactions of all genes in an organism and is the study of the total DNA structure.

Adoption. Family size. Current methods of testing do not detect all of the mutations that can occur in some diseases including hereditary cancer syndrome-related genes. If a mutation is detected, it does not confirm an absolute risk of cancer but a need for high-risk management. Additionally, an inherited syndrome may not be evident for someone from a small family; someone who is adopted; or someone who is not informed about their family's history of disease or cause of death. Most hereditary cancer syndromes are inherited in an autosomal dominant pattern with variable expression and incomplete penetrance (mutation in one member of the gene pair). Both men and women carry, pass on to children, and inherit these mutations. For mutation carriers, the hereditary cancer syndrome can be mild or more severe. Whether cancer ever develops, the site at which it develops, or the seriousness of the cancer can vary among different people with the same mutation, even within the same family

Genetic Information Nondiscrimination Act (GINA). The GINA of 2009 protects the public from genetic discrimination by employers or insurers. The act prevents group health plans and health insurers from denying coverage to a healthy individual or charging higher premiums based solely on genetic predisposition to disease. The legislation also prohibits employers from using individual's genetic information when hiring, firing, or making job placement or promotion decisions.

Secondary prevention. When a nurse reviews the health history, the nurse observes for any disease that may have a genetic basis and if found, immediately refers the person or family to the appropriate health care provider. The goal of screening is to detect or define risk in low-risk groups and identify those people who should have diagnostic testing.

Close biologic relationship between parents. Condition occurs in the gender that is least expected. Ethnic predisposition to certain genetic disorders. Multiple affected family members. The genetic red flags developed by the NCHPEG provide an excellent tool to determine if an individual or family might be at risk. The primary red flag for the most common diseases is a large number of affected relatives who are closely related. Some of the red flags are: family history of multiple affected family members with the same or related disorders, which may or may not follow an identifiable pattern in the family; onset at an early age; condition occurs in the gender that is least expected to have it; disease occurs in the absence of known risk factors; ethnic predisposition to certain genetic disorders; and a close biological relationship between parents.

Collection and use of health histories. The profession of nursing will be impacted by new discoveries in molecular genetics in the areas of education, practice, and public health debates. The practice arena impacts are collection and use of health histories, learning and applying innovative biotechnologies, prevention and health education roles, and administration of new therapies. The collection and use of health history information has the greatest impact on the most nurses. Human disease comes from the collision between genetic variations and environmental factors (i.e., social determinants of health) that are often uncovered in individual health histories. Taking a family history is a useful place to begin when considering a genetic connection and prior to the onset of testing.

Biology, health, and society. The stated goals of the Human Genome Project were determining the sequence of the three billion chemical pairs that make up human DNA; storing this information in databases; improving tools for data analysis; transferring related technologies to the private sector; and addressing the ethical, legal, and social issues (ELSI) that may arise from the genome mapping project completed in 2003 that identified 25,000 genes in human DNA. The conceptual vision of the team addressed three overarching themes. The first, "genomes to biology," looks at how the study of genomics would affect the future understanding of biology. The second, "genomes to health," helps to explain the underlying mechanisms for human health and disease including gene-gene, gene to environment, and their interactions. The third, "genomes to society," provides the foundation for research to improve the use and interpretation of genetic information and technologies.

Support of the family in preparing a personal disaster response plan. The approach of relief activities needs to shift from short-term aid to long-term support. Promoting individual, family, and community preparedness increases safety in the event of disaster and can help children and adults feel empowered. This builds on the resilience of the individual, family, and/or community. Individuals and families still need to be assessed for indications of mental distress (case finding) and referred to a mental health professional if the need exists. Open discussions of the family's response to the slow process of recovery or long-term results of living under adverse conditions can uncover lingering mental distress or exacerbations of chronic conditions that require attention. During the initial stages of recovery environmental safety issues should have been addressed.

Immediately developing plans for effective triage and client management. The first priority when responding to a disaster is to immediately plan for, coordinate, and carry out effective triage. Disaster response includes community assessment, surveillance, health education, and coordination of shelter arrangements. However, the first task is to provide care for life-threatening injuries and conditions.

Written approach, protocol, and common language for responders from federal agencies and other voluntary organizations. The first level of disaster response is carried out by the locality (office of emergency management). Through mutual aid agreements, localities can arrange for additional support from surrounding communities (emergency operations center). When the response needs exceed the capability of the localities and state-level resources or capabilities, then the governor may request assistance under a presidential declaration of disaster or emergency. The way the federal government offers assistance is through the NRF. The NRF was written to approach a domestic incident in a unified, well-coordinated manner that enables all responding entities to work together more effectively and efficiently. All member organizations of the responding teams, including all relevant branches of the federal government, are assigned functions that are listed in the plan as emergency support functions. When large disasters require the services of a variety of emergency responding units with personnel coming from different parts of the country, the challenge of working together in unison may require the use of the NIMS, which provides all responders with a protocol and common language for working together. The importance of interoperable communication equipment is stressed by the NIMS.

Educate the rescuer about necessary stress-management techniques and offer to pair up with the individual so that each can monitor the other's stress level. The nurse needs to be aware that rescue workers are repeatedly exposed to stress and, despite their training in managing such situations, have a higher than normal risk of developing post-traumatic stress syndromes. The nurse can assist the new team member by educating the rescuer about the importance of stress-management and self-management techniques. The nurse could pair up with the new team member so that they could monitor each other's stress responses and could provide guidance in adhering to stress management techniques.

Urbanization. Florida's geographic location has always placed it in the hurricane belt. We now understand that certain weather patterns can increase the intensity of storms in any hurricane season. Hurricanes have always impacted Florida to varying degrees from hurricane season to hurricane season. The vulnerability of Florida to hurricanes has risen despite improved understanding of storm prediction and preparedness because of the increased urbanization in areas of high risk such as coastlines, which increases the population in harm's way.

Community preparedness. Preparedness takes place at three levels: personal, professional, and community. The nurse who is professionally prepared is aware of and understands the disaster plans at the workplace and in the community. Preparedness also involves the development of the knowledge one needs to respond to specific types of incidents (chemical, biological, radiological, nuclear, and explosive events, and those involving weapons of mass destruction): how to treat those injured by each, how to use personal protective equipment, and how to work safely near dangerous materials. Nurses who seek greater participation or desire more in-depth understanding of disaster management can become involved with any number of community organizations that are part of the official response team. After receiving formal disaster training nurses can register with national and state registries to provide disaster response when needed. The importance of being adequately trained and properly associated with an official response organization to ensure an orderly, effective, and efficient response cannot be overstated.

Writing after-action reports, updating implementation plans, and implementing changes. Federal agencies and professional organizations have outlined competencies for public health professionals at all points of the disaster management cycle. One competency speaks to the ability to evaluate drills, exercises, or actual events. As valuable components of preparedness, mass casualty drills and exercises can help rescuers develop the necessary coordination, skills, and confidence to operate effectively and efficiently across disciplines and agencies. Special emphasis is placed on the after-action reporting once the exercise is over, which ultimately allows improvement of the overall all-hazards disaster response plan. Such sessions may be referred to as debriefings, hot washes, or postings. Participation in these sessions develops the critical skill of evaluation that allows for process improvement.

Mutual aid agreement. The first level of disaster response occurs at the locality, with mobilization of entities such as the fire department, law enforcement, public health agencies, and voluntary organizations like the Red Cross. If the disaster warrants significant local attention and overwhelms the capacity of the local responders, then the county or city office of emergency management will coordinate activities through the emergency operation center. Generally localities within a county are signatories to a regional or statewide mutual aid agreement. This agreement provides that the signatories will assist one another with needed personnel, equipment, services, and supplies. Mutual aid agreements are established between facilities and other emergency responding entities within localities, jurisdiction(s), and states; between states; and across borders to ensure seamless service in responding to disaster events, whether caused by people or by nature. When state resources and capabilities are overwhelmed, the governor may request federal assistance under a presidential declaration of disaster or emergency.

Red Cross shelter manager. Creation and operation of shelters are generally the responsibility of the local Red Cross chapter, although the military may be charged with setting up "tent cities" or mobile home parks for large groups of people needing temporary shelter. Because nurses are comfortable performing tasks such as aggregate health promotion, disease prevention, and provision of emotional support, they make ideal shelter managers and team members. The Red Cross provides training in shelter support and use of appropriate protocols.

Completion of the American Red Cross disaster management course and registration as a disaster responder. Clinical management of blast lung injury. Monitoring of the environment to contain infectious disease. Planning and organization of mass prophylaxis and vaccine campaigns. Nurses have skills in assessment, planning, implementation, evaluation, education, priority setting, collaboration, and provision of health care services to address both preventive and acute care needs. These skills sets are important in the four stages of disaster-related work: prevention (planning/drill participation), preparedness, (course work/registration), response (clinical expertise), and recovery (monitoring). BioWatch is a system of sensors that test the air in several major metropolitan areas for biological agents that terrorists might use. This technology-based early warning system is distinctly different from BioSense, which is a public health surveillance initiative that is intended to serve as a biosurveillance program for early detection and quantification of a bioterrorism event or disease outbreak. Nursing skill sets lend themselves to participation in BioSense.