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Social Work Student Participation in a Mock Disaster: Brief Notes from the Field.

Social workers play a vital role in responding to natural and human-induced disasters locally, nationally, and internationally (Nikku, 2015). With the emergence of integrated health care teams, the inclusion of social workers in natural and human-induced disaster response is essential. The increase in disaster events in recent years makes disaster preparedness a necessity. The impact of these events on the immediate and long-term safety, health, and economic well-being of the community makes preparing for and responding to disasters an ongoing public health issue (Quinn, 2006; Toner, Schoch-Spana, Waldhorn, Shearer, & Inglesby). Health care systems are challenged with responding to a broad range of disasters, each affecting communities in different ways over time; therefore specific responses are needed to address both the immediate event and the long-range implications for community stakeholders.

The range of both natural disasters (e.g., hurricanes, wild fires, earthquakes, and floods) and human-induced disasters such as mass shootings requires hospitals and first responders to provide immediate medical triage for victims, stabilize the scene, address communication issues, and prevent or contain mass hysteria. These issues affect the ability to respond to emergency situations and deliver assistance, which can ultimately mean the difference between life and death.

Preparedness planning and the ability to respond to natural disasters and human-induced violence are imperative in large organizations. The U.S. Department of Health and Human Services (HHS; 2019) provides federal guidelines on emergency preparedness to regional hospitals through initiatives such as the Hospital Preparedness Program (HPP). The federal government mandates that hospitals demonstrate the capacity to respond to these types of emergencies, particularly those involving a surge or influx of patients. To accomplish this, the Office of the Assistant Secretary for Preparedness and Response (ASPR) and HPP support "the nation's ability to withstand adversity, strengthening health and emergency response systems, and enhancing national health security" (Office of the ASPR, 2016, p. 5). The Office of the ASPR developed guidelines for health care facilities, hospitals, and emergency medical services that describe what these entities must do to effectively prepare for and respond to emergencies that affect the public's health. Most importantly, these facilities must demonstrate the capacity to plan, share information, train, and provide training exercises.

Based on the notion that disaster response addresses immediate needs, health recovery, and management, the social work values regarding person in environment and strengths of the individual, family, and system are perfectly suited to this role (Carp, 2010; Walsh, 2007). These values are inherent in the application of crisis intervention, psychological first aid, and disaster mental health services. Disaster preparedness has evolved from a perspective of immediate readiness to a culture of inherent and adaptive resilience to assist communities in ensuring survival and well-being post-disaster (Toner et al., 2018, p. 6). This paradigm shift is apparent in the rebuilding of communities and the effort to ensure that the health care needs of the community continue to be met. This shift is aligned with the social work value of resilience and the importance of reestablishing the equilibrium of the individual, system, and community.

Involving social work students in disaster response training and mock disasters is essential to ensure that these students enter the field equipped with the knowledge and competencies to address the needs of victims, survivors, family members, first responders, and communities (Squillace, Williams, Wells, Chumley, & Berent, 2016). Students learn how to think on their feet by observing other social work employees who design and participate in mock disasters. Closer observation of student experiences with disaster response, often for the first time, is important in developing didactic and experiential approaches for classroom learning. Moreover, classroom instruction addresses the importance and need for future focus on the social work value of community participation in rebuilding marginalized communities. These are the communities that are most often harmed by disasters such as Hurricane Katrina in Louisiana in 2005 and Hurricane Maria in Puerto Rico in 2017 (Morris, Hayward, & Otero, 2018; Moyo & Moldovan, 2008) and that suffer serious social impact (Barry, 1998; Bass, 2006; Jenson, 2005; Niman, 2005). Curriculum content should include various types of disasters, responses needed, community rebuilding, and cultural sensitivity, particularly in marginalized communities. Student experiences in mock disasters can be shared during field placements to increase agency and community awareness and readiness.

The Role of Social Work

Throughout social work's history, social workers have addressed the needs of those involved in human-induced and natural disasters (Nikku, 2015). They have assumed different roles at different times (e.g., providing immediate relief such as safety, shelter, food, and clothing and participating in fund-raising). They have also provided crisis intervention, debriefing, psychoeducation, grief counseling, and disaster mental health services (Rosen, Greene, Young, & Norris, 2010). The social work profession is uniquely positioned to understand how ethnicity, culture, racism, and policy play key roles in mediating disaster impact, recovery efforts, and the rebuilding of communities (Morris et al., 2018; Rosen et al., 2010).

Increasingly, social work is involved in the interprofessional training of students utilizing didactic, and experiential learning, and team building methods (Marino et al., 2017). The National Association of Social Workers calls interdisciplinary collaboration "increasingly essential" (Squillace et al., 2016, p. 30). Institutions of higher learning incorporate disaster training into classroom learning and campus events (Healy, 2009; Squillace et al., 2016). Interdisciplinary training of social work students increases their self-perceived competence and confidence and allows them to share knowledge and information about assessment and interventions with other disciplines (Squillace et al., 2016). Social work students share this type of information with their field agencies. Finally, training social work students in disaster work creates a pool of knowledgeable personnel who have the skill and confidence to respond to disasters.

As part of Dynamics and Therapeutic Interventions with Trauma, a spring elective course in a school of social welfare, second year social welfare graduate student volunteers participated in the family receiving room (FRR) during a regional hospital mock disaster. The school of social welfare is situated in the university's Health Science Center. Students' assignment included responding to family members (student actors) who had heard of the disaster and were awaiting word of their loved ones. This article addresses social welfare graduate students' initial reactions and engagement with the university student volunteer actors portraying family embers, their experience in handling the crisis, and their general assessment of and reflections on the mock disaster.

The Mock Disaster

The mock disaster is staged every April in this regional hospital. It is designed by the emergency management team, which follows federal guidelines mandated by HHS for disaster response preparedness (U.S. Department of Health & Human Services, 2019). The Stony Brook campus has twenty-five thousand students in addition to faculty and support staff. The mock disaster involves participants from the hospital, including the Emergency Department, the Social Work Department, Care Management, Psychiatry, support services, and campus police. Community participants include emergency medical services, fire and police departments, and state agencies including the Department of Health and the Department of Homeland Security. In total, the mock disaster involves more than one thousand participants. The date, time, and type of disaster are shared only with administrators and staff coordinators prior to the event. Additionally, to create a sense of surprise, mock disaster particulars such as the scenario are not shared in advance with participants. University students volunteer to play the parts of victims, perpetrators, and family members. The mock disaster focuses on communication, sequence of events, readiness, and interaction among and between agencies and the hospital command center (HCC).

The FRR is set up in a conference room within the hospital to host family members awaiting word of disaster victims and to address family reactions and requests for information regarding the disaster and the status of loved ones. A computer is set up in this room to collect information regarding victims, who may be taken to the Emergency Department or the morgue. When social welfare students meet with a family member, they ask for descriptions of the person and the clothing worn that day. The students then relay this information to the hospital social worker operating the computer, who forwards it to the Emergency Department for identification purposes. The data bank provides information on victims and survivors that can be shared with family members. Faculty and staff interact with the social welfare students throughout the mock disaster, discussing protocol, procedures, and ways to approach family members in the FRR. Students have already reviewed trauma content in their course work that addresses providing safety and comfort as an integral part of trauma-responsive work (Levenson, 2017).

After participants have spent approximately one and a half to two hours in the FRR, HCC alerts them that the disaster has concluded and that all participants will meet in a large conference area for the debriefing. During the debriefing participating entities discuss their experience of the mock disaster, problems encountered, what went smoothly, and areas for future improvement. The social welfare students sit with their instructor, debrief regarding their experiences, and discuss material from other participating entities. Further debriefing occurs in class, usually two days later. Table 1 describes the mock disasters conducted in 2016 through 2018.

Method

A broad search of peer-reviewed literature on mock disasters, social work, and social work students was conducted. Search terms included mass casualty drill, mock disaster, disaster plan, disaster program, disaster simulation, disaster mental health, and social work. Databases searched included Social Work Abstracts, Social Sciences, Academic Search, Science Direct, and Google Scholar. Additional studies garnered through bibliographic referencing were included. The search found a dearth of literature on the role of social work in mock disasters in general and the role of students in particular.

Twenty-six social welfare students volunteered for the mock disaster over a three-year period. Ages ranged from twenty-three to sixty-two, and there were three male and twenty-three female students. After each mock disaster, students wrote down and/or verbally presented the responses that they felt were most relevant to their experiences and the instructor sorted these comments into themes. In total, twenty comments were submitted. The most relevant themes were consistent over the three years: initial reactions and fears regarding how to engage the client/family member in a moment of crisis and how to handle the crisis, as well as assessments and reflections, which included positive reactions to participating in an important and worthwhile university/community endeavor for preparedness. Students also reported a sense of confidence and readiness in regard to disaster response.

Social Work Student Participation in the Mock Disaster

As mentioned earlier, the advanced elective Dynamics and Therapeutic Interventions with Trauma includes information and readings regarding disasters and traumatic events that affect individuals, families, communities, and policy initiatives as well as current evidence-based practice interventions (Hagman, 2017; Levenson, 2017; Williams, Zinner, & Ellis, 1999). Class discussion revolves around crisis intervention and disaster response for victims and family members. Due to space limitations and scheduling of the mock disaster outside of class time, only ten social work students can volunteer for each event; however, the whole class is trained in disaster readiness, response, and immediate and long-term recovery.

On the day of the mock disaster and before students proceed to the FRR within the hospital, the instructor meets with them to discuss what to anticipate. Students report being anxious about what type of disaster will occur. They feel somewhat helpless and they worry about not knowing what to say or do, about how participants will act, and finally about what they'll be asked. Students are reassured by knowing that social work students have participated in past mock disasters and have been viewed as an asset by the FRR staff and faculty participants. During the trauma class following the mock disaster, participating students inform the class about the event, their feelings and reactions when dealing with family members, and what they learned to do and not do. They also discuss meeting first responders from the hospital, university, and community; the enormity of the drill; and their thoughts about working in an interprofessional capacity in the FRR.

Students' Initial Reactions and Engagement

Students have been pleasantly surprised with their learning process and their ability to handle crisis states. Year 2016 involved an active shooter, year 2017 involved a box truck slamming into a crowd of people, and year 2018 involved a mass casualty disaster with a student (actor) coming onto campus and setting off a bomb in a group of students. Students' initial reactions during debriefing included the following comments:
I was scared about what I would be asked. Like "Is my daughter still
alive?" But the family member was just crying and saying she was
worried and asked if I could hold her hand. I felt I could handle that.

I was nervous because there were so many people in the family room and
I wasn't sure who was who. People in the white coats were identifiable
but not everyone else. Some people had name tags so that made it easy.

I was nervous with the girl who was crying because she was really
crying and I thought for one moment that maybe this wasn't a drill.


Students reported seeing the staged reactions of the family members as daunting. They said that learning how to handle their own reactions and process affect during a crisis was difficult. Class discussions revealed that the inherent chaos of a trauma scene was scary, even though students did not see the actual disaster scene. All of the students reported that debriefing was helpful in understanding the universality of reactions and affect.

Handling the Crisis

Once students were introduced to the FRR staff, their hesitancy decreased and they became acclimated to the procedures of the room (computer reporting of victim descriptions) and greeting family members. They reported positive initial engagement with family members, but soon learned that nuances might exist in the crisis-laden encounter. One student said,
A young woman was crying but not talking. When I tried talking to her,
she just stared back, crying. I wanted to do something but I wasn't
sure what was going on. I thought maybe she spoke another language and
I approached the instructor about using the FRR translator phone. The
instructor came back with me and wrote on a piece of paper that she
handed to the woman, "Are you ok?" The young woman wrote back, "Yes.
I'm deaf." I asked her if she wanted me to get someone who could sign
and she wrote, "No. It's ok. You make me feel calm." That made me feel
good.


This experience prompted a lively and informative discussion both in the social work debriefing and the class discussion following the mock disaster. Students were reminded of the needs of those with disabilities, both family members and others who were involved in the disaster, and most importantly, to avoid making assumptions about the individuals they encounter in disaster situations (Morris et al., 2018).

In the most recent mock disaster (2018), a volunteer who is Asian was able to talk with a young female Asian woman who was awaiting word of her sister, a university student at the site of the mass casualty disaster. Luckily, this volunteer spoke the same dialect as the family member. The family member reported that she felt relieved that she could talk with someone who could speak her language. The student volunteer commented, "I felt happy and proud that I could connect with her by speaking her language. I felt that because I could speak with her, I could do my job as a social worker. While it was nerve-wracking to wait for word of her sister, it felt good to be able to help."

Student Assessment and Reflection

Each year a different type of mock disaster has been staged at the site of the state veteran's home. Social welfare students do not witness these events because they occur on the opposite side of the campus and students are not placed in the Emergency Department. In the FRR they may be told how many people were "killed" (if any), the kinds of wounds inflicted, and where people may be transported (if appropriate).

These events prompt students to consider the meaning of the disaster for the victims, survivors, and community, as well as the implications for their own lives. Ndlela (2012) referred to Seibert and Daudelin (1999) regarding meaning making and experiences: "people learn from the meaning they give to experiences, not from the experience itself, and they give meaning to experience by reflecting" (p. 190). Throughout the mock disaster, students had one-on-one interactions with the instructor as well as group debriefings (with the volunteer group, the large group on the day of the mock disaster, and their classmates, providing them with time to reflect and discuss the meaning of the disaster and peoples' reactions as well as their own reactions, learning, and views regarding systems responses.

All students who participated in the mock disasters from 2016 to 2018 reported being surprised by the tremendous amount of people and resources needed to mobilize the mock disaster, particularly for mass casualty events. They reported being a bit overwhelmed by reporting out to the larger group, which included first responders, emergency management, campus security, police and fire departments, hospital employees, and student volunteer actors. The enormity of this group (approximately one thousand people) was striking for students who had just come from the FRR where there were thirty to forty people. Additionally, student actors who were involved in the disaster were bandaged and bloody--an unsettling sight--and social welfare students were genuinely shocked by the physical consequences of disaster. One student said,
When we went to the report-out, I was struck by how many people were
there... people that were trying to help and then I realized that the
disaster involved this many people trying to help. I realized how big
the disaster really is. It was truly shocking to see people... the
actors, with bloody bandages on their heads, arms, or legs. That's when
you realize it's not just an emotional thing like in the FRR... it's a
thing where people get hurt or could die.


Students reported a new appreciation of and insight into the immediate and long-range difficulties that can emerge within the FRR as a result of an active shooter incident. Students quickly realized that they fulfilled the role of representative of the system (i.e., the hospital) and developed a heightened consciousness to the needs of family members. They were able to connect the trauma sequelae they had learned about-depression, anxiety, and posttraumatic stress disorder--with the etiology (the disaster). The Dynamics and Therapeutic Interventions with Trauma course covers trauma responses for victims and how a system can inadvertently create an iatrogenic trauma by not being responsive to the heightened anxiety state and need for information of victims, survivors, and family. Therefore, when students entered the FRR, they were aware that they would be entering a crisis situation and that their role involved attending to family members who were highly anxious; anticipating the worst; and very much in need of information, safety, and comfort.

Students discussed feeling nervous and anxious about not having information about a family member's loved one, worrying about saying the wrong thing, and feeling a general need for action (e.g., "I wish I could do something"). Class discussion not only helped the student participants process the mock disaster but also gave nonparticipating students the opportunity to ask questions, assist in processing the activity, and become more informed about how this vast system (the hospital and campus) responded and worked together. Most importantly, students got to see how the social work role operated and was appreciated within this interprofessional setting and large organization. Students addressed the opportunity to be involved in the mock disaster:
I think this was great to do the mock disaster. I wouldn't have the
opportunity to do this any other time, unless it was the real thing. It
helped me to see how many people are involved and the amount of energy
it takes to put this all together.


I think this was really great... scary, but really worthwhile.

Students were given ample time to reflect and consider the mock disaster and their reactions to it as well as other disasters that have occurred in the United States--the impact on victims, survivors, and community as well as the students themselves. Class discussions address, on a continuing basis throughout the Dynamics and Therapeutic Interventions with Trauma course, the importance of self-care, particularly for students who have a personal history of trauma. Several researchers have suggested that, depending on the type of trauma to which they were exposed, their levels of exposure, and their personal history, those who work with trauma may be at increased risk of experiencing secondary traumatic stress (Creamer & Liddle, 2005; Levenson, 2017; MacRitchie & Leibowitz, 2010; Robinson-Keilig, 2014). By teaching students about what to expect and how to manage trauma exposure (Tarshis & Baird, 2019) graduate education can provide experience, knowledge, and enhanced individual capacity to manage trauma. One student said,
It was really frightening to see all of the moving parts and then to
think about how people feel when there really is a disaster. It made me
realize that I have to always put together how I'm feeling about what's
happening to other people. It was helpful to talk about the experience
in class. I feel more confident in my ability to handle a disaster now.
I mean I would still be nervous, but I think I know a lot more than I
realized.


Recently, the Council on Social Work Education (CSWE) and Fordham University Graduate School of Social Service published a curriculum guide, Specialized Practice Curricular Guide for Trauma-Informed Social Work Practice (2018), that provides course instruction, assignments, and reading material on trauma, but most importantly, CSWE trauma-informed competencies for this specialized practice area. Preparing students with the experience and skill set to respond to disasters ensures improved outcomes in challenging and often unpredictable situations. These nine competencies were identified throughout the Dynamics and Therapeutic Interventions with Trauma course, and students demonstrated their ability to identify them and utilize them during the mock disaster, as indicated by the following student comment:
The day was an amazing experience and a wonderful opportunity.
Suddenly, you realize how big a disastrous event is and you're the one
there, trying to help. I learned that I knew a lot more than I thought,
and was able to connect to people right away even though it was scary.
I liked that I had an awareness of all the things that trauma could do
to people.


Conclusion

With the increase in natural disasters and violent incidents across America, it is imperative that social work students are educated in how to respond to survivors, family members, and communities with skill-based trauma-responsive knowledge before they enter the field. The mock disaster described in this article gave students an unparalleled opportunity to integrate their knowledge regarding disasters and trauma into practical application (Decker, Brown, & Tapia, 2017).

Additionally, graduate course work should focus on how to deal with issues of safety, worldview, and physical and psychological adjustment in the aftermath of such traumatic incidents for both victims and practitioners who assist them (Tarshis & Baird, 2019). Course content should address the impact of students reacting to and processing trauma and disaster practice events, a rarely considered practice theme in graduate education (Tarshis & Baird, 2019).

Participation in a regional hospital and university mock disaster helped twenty-six second year social welfare graduate students to understand critical incidents, emergency preparedness, disaster response, and disaster mental health, as well as to add to their repertoire of trauma-responsive skills and competencies. Not included in this article but nevertheless important are class discussions that addressed the importance of understanding the cultural and ecological environment in which the disaster occurs. Interventions should be culturally appropriate and tailored, mindful of economic conditions, and responsive to the needs of people with disabilities, older populations, and the population in general (Healy, 2009; Rowlands, 2013; Sim, 2009a). Social workers will work in institutions whose mandate is to respond to disasters, such as the Red Cross, and to volunteer when disasters occur. Alternatively, social workers may be affected when these institutions are beset by disasters.

Training prior to graduation increases the odds of successful interventions with populations affected by natural or human-induced disasters and is therefore crucial. Listed below are recommendations for incorporating disaster response work in courses offered by schools of social work that are not affiliated with hospitals:

1. Practice classes and/or electives in trauma should include didactic information on disaster response, debriefing, psychological first aid, and disaster mental health. Additionally, students should learn about post-disaster community responses and rebuilding, particularly for communities that have historically been marginalized.

2. Social work students and social workers in general should review some of the previous disaster responses around the country and understand the role of social work in those events. Within this context social work's duty is to identify and forge a role in immediate and long-term responses to disaster events on micro, mezzo, and macro levels.

3. Understanding the role of culture in disaster response and recovery is imperative, particularly in international settings. The Western approach of addressing mental health issues before basic necessities are restored has been consistently challenged as unhelpful. Community restoration is based on individual and community capacity with a major emphasis on self-determination (see Rowlands [2013] and Sim [2009a], [2009b] for further information)

4. Social work courses can include role play situations--mini mock disasters--that assist students in addressing survivors and/or witnesses of the disaster, first responders, and family members awaiting word of loved ones involved in the disaster. Role plays provide an opportunity to develop trauma-responsive competencies. Students' personal responses and self-reflection are an integral facet of this learning process.

5. Students can and should bring this kind of experience back to field educators and agencies to discuss planned and prepared responses to disaster and the development of policies to carry them out.

6. Graduate social work classes can work with other departments and/or other schools to learn what community resources currently exist to respond to a disaster. A classroom project that develops a compendium of community resources helps students network and assembles resources that remain long after the class has ended.

References

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Kathleen Monahan, DSW, LCSW, is associate professor in the School of Social Welfare, Stony Brook University, Stony Brook, NY.
Table 1 Year, types of mock disaster, and number of social welfare
students participating

Year   Type of mock disaster         No. of social welfare student
                                     participants

2016   Active shooter                 8
2017   Box truck driven into crowd   10
2018   Bombing, mass casualty         8
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Publication:Best Practices in Mental Health
Date:Sep 22, 2019
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