Emergency Nursing and Disaster Preparedness During Mass Gatherings

Mass Gatherings (MGs)

Definition of Mass Gatherings

The nature of mass gatherings (MGs) presents the authorities tasked with the responsibility of maintaining public health with a number of challenges. When large numbers of people come together in one locality, they exert immense pressure on available resources, including healthcare facilities. The situation makes it very hard to serve these multitudes. Consequently, authorities are required to stay alert and to be adequately prepared for any eventualities that may arise in mass gatherings.

There are various definitions of mass gatherings as a concept. One conceptualisation defines them as a group made up of more than 1000 people (Al-Tawfiq & Memish 2014; Milsten et al. 2002; Salhanick, Sheahan & Bazarian 2003). In addition, to be regarded as an MG, the people in the group should be located in one particular place. On its part, the World Health Organisation defines MGs as “[a group] consisting of more than a specified number of persons at a specific location for a specific purpose for a defined period of time” (World Health Organisation [WHO] 2008 p. 4). The number of people in the gathering can be as low as 1000.

Other definitions of this concept differ from the one given by the WHO. For instance, Wang and Choi (2011) view an MG as a congregation of more than 25000 persons. On their part, Hilmi et al. (2011) conceptualise it as a gathering made up of more than 1000 people. The individuals come together in a variably sized location for a particular reason.

It is apparent that various practitioners and scholars in healthcare have sought to define MGs. The definition by the World Health Organisation is, however, more articulate. The definition specifies the number of people who can make up a mass gathering. More specifically, the conceptualisation given by WHO specifies that the gathering should have a specific purpose. In addition, it should last for a given duration of time in a specified location.

A number of events are held in different places every year. Such occurrences bring together millions of people either in one or varying locations. An example is the 2014 World Cup event held in Brazil. Tens of thousands of individuals travelled to the country and gathered in various stadiums to watch the matches. The matches were held in different stadia. In spite of this, the event resulted in mass gatherings around the country.

Milstein et al. (2012) argue that in most cases, the 1000 individuals used in defining MGs are applied arbitrarily. The number is only used for the purposes of staffing. It is important to come up with a specific number, especially to facilitate planning for Mass Gathering Medical Care (MGMC). The comprehension and development of the various variables associated with MGs constitutes a very essential aspect of event planners. According to Milstein et al. (2012), mass gathering medicine seeks to provide emergency medical care in organised events with more than 1000 individuals. Without these actual variables, needs assessment and allocation of resources will be extremely difficult.

Types of Mass Gatherings

MGs can be broken down into two types. The two are spontaneous and planned gatherings (Al-Tawfiq & Memish 2012). The latter forms of gatherings are usually perpetuated under certain arrangements. A case in point is the collection of individuals attending World Cup events. Planned gatherings may also take place at a recurrent or differing location. Hajj pilgrimage is a classic example of planned MGs. It is an annual gathering of Muslims, which takes place in Saudi Arabia. Other examples include Olympic events. On the other hand, spontaneous gatherings occur without any form of prior planning (Al-Tawfiq & Memish 2012).

For instance, funerals of prominent persons, such as presidents, lead to spontaneous grouping of people. Other occurrences that bring people together in a spontaneous fashion include general disasters, such as earthquakes and floods. Influx of refugees in neighbouring countries in cases of wars is also an example of spontaneous gatherings.

Mass gatherings can also be classified as either recurrent or sporadic. The former types of MGs are usually held regularly either in one or different locations (Alquthami & Pines 2014). Again, Hajj is a good example of such a gathering, which takes place in one location (Mecca). Sporadic MGs, on the other hand, are held irregularly. In addition, they are unpredictable and recur in different locations (Ahmed, Barbeschi & Memish 2009). A royal ceremony is an example of such a collection of people.

In spite of the differences indicated above, most MGs share some common attributes and objectives. For instance, some of them, such as Hajj and funerals, take place within a confined duration of time. In addition, they occur in specific geographical locations (WHO 2008). Some MGs are predictable, while others are not. Most of them take place due to various significant events, such as political gatherings.

Al-Tawfiq and Memish (2012) argue that the preparedness for needed resources in relation to MGs is influenced by various situations. For instance, planned MGs are easier to respond to than the unplanned ones such as those originating from natural disasters. In addition, unplanned MGs are usually allocated to public safety agencies.

History of Mass Gatherings in the World

The phenomenon has a long history in the community. It has developed over time. What this means is that MGs have evolved with time. During the evolution, they have retained some characteristics and lost others. According to Memish et al. (2012), some of the earliest recorded MGs involved religious pilgrimages. Historically, pilgrimages are regarded as some of the central aspects of numerous belief systems. Consequently, MGs were earlier associated with homoviators. The term refers to individuals who used to wander for spiritual purposes (Higgins et al. 2004).

Such figures were common in most of the ancient civilisations, for instance the Hellenic civilisation which hosted Delphi; the home of Pythia the Oracle. Other civilisations, such as Huichol tribes of Western Mexico, Shona of Southwest Africa, and Lunda from Central Africa, incorporated pilgrimages into their cultures (Memish et al. 2012).

Some of the earliest MGs are also associated with the popular world religions. For instance, the Kumbi Mela pilgrimage of Hindus makes up the largest human MG to date (Enock & Jacobs 2012). The event is held every 3 years at various points along river Ganges (Martin-Gill et al. 2007). Christians also have a similar MG in Lourdes France, whereby more than 5 million Catholics visit a shrine annually (Memish et al. 2012).

Other historical MGs have been to celebrate or mourn political and iconic figures, as well as various life events. For instance, in 1798, Paris France witnessed a gathering of more than 1 million mourners, who were attending the funeral of François-Marie Arouet de Voltaire (Memish et al. 2012). Other MGs in history were on political protests or assemblies, or celebrations, concerts and sporting events. For instance, the recent Arab Spring in 2011 attracted millions of protesters across cities in Tunisia and Egypt (Burstein 2006).

Challenges Associated with Mass Gatherings

Various challenges have been historically associated with MG. In line with earlier definitions of MGs, Soomaroo and Murray (2012) hold that the major challenges involve disasters. MGs disasters are essentially incidents considered calamitous, since they occur suddenly leading to massive deaths and destruction.

According to Khan and McLeod (2012), MGs constitute of common phenomenon exhibiting varying levels crowd types. Consequently, inherent problems are always exhibited requiring different complexity management due to potential of fatality outcomes. The need to provide practical public health and safety guides and measures thus becomes more apparent.

A major MGs challenges include public health, as well as infection control problems (Shafi et al. 2008; Ahmed, Arabi & Memish, 2006). Usually, distance between individuals in MGs is very small due to congestion. Consequently, the congestion poses great physical as well as environmental and healthcare demands (Ahmed et al. 2006). For instance, the severe congestion increases the risk of contracting infectious diseases, which can easily turn into epidemics (Soomaroo & Murray 2012).

The congestion of individuals in MGs causes temperatures to rise. The situation increases the risks of airborne diseases (Alquthami & Pines 2014). In addition, factors such as stampedes, traffic jams, and poorly prepared and stored foods enhance other health risks, such as food poisoning (Shafi et al. 2008).

Due to these and other MG challenges, preparations constitute an essential component of these events. An example of a disaster in a MG is the epidemic outbreak of Neisseria meningitides W135 in 2000–01, during the Muslim Hajj (Ahmed et al. 2006). Table 1 below highlights some of the common challenges faced in MGs:

Table 1: Challenges associated with mass gatherings.

Challenging Definition Impact
Crowd/ Overcrowding management Entails implementing measures for ensuring that overcrowding is minimised or avoided. In addition, measures are taken to ensure panic is avoided. Overcrowding can lead to stampedes which can cause massive loss of lives and injuries.
Security Taking necessary measures to ensure individual attending MGs are secure from activities such as terrorist attacks, or fire outbreaks Reduction of insecurity cases for instance through preventions
Emergency preparedness Implementing necessary emergency response measures such availability of ambulances, fire-fighters, and emergency exits Ensures that emergencies are responded to effectively and efficiently, hence reducing casualties and/ or fatalities
Medical preparedness Ability of healthcare providers to respond to medical emergencies Significant reduction of patients requiring transportation to hospitals
Surveillance and monitoring Close observations regarding health risks Development of evidence-based measures and policies to guide health protection, infection control and immunisations

Emergency Nursing and Mass Gathering

Why Emergency Nurses are Important

Some nurses, such as those who work in emergency departments, have specialised duties. The professionals are referred to as emergency nurses. The departments are considered as the frontline of the hospital and emergency nurses. The nurses here play the critical role of providing first line treatment. It is important to ensure that emergency departments are ready at all times. The readiness would help emergency nurses to provide effective services in case disasters strike.

According to Hammad et al. (2012), the importance of emergency nurses has been addressed in a number of studies. The practitioners are important given that they make the emergency department an effective workplace. To this end, they enhance nurse-to-patient ratios (Hammad et al. 2012). Consequently, they make sure that the boarding of patients admitted under ED is avoided.

Emergency nurses promote mutually supportive relationships between them and the physicians (Cusack, Arbon & Ranse 2010; Adini et al. 2012). They provide solutions to problems related to shift work and staff scheduling. Consequently, the professionals improve the productivity of their colleagues and physicians by providing support services when handling clients in the ED. In addition, they provide care to ED patients and their families (Schriver et al. 2003). Consequently, patients and their significant others are assured of their wellbeing.

The Roles Played by Emergency Nurses during Mass Gatherings

Emergency nurses are tasked with various roles, especially during MGs. Among the initial roles of emergency nurses is that of triage (Turris & Lund 2012; Salhanick, Sheahan & Bazarian 2003). Triage entails determining the patients who need priority in relation to accessing the limited resources in a MG. Patients in MG are usually brought in such that they overcrowd the available resources, prompting emergency nurses to determine those in acute need of care.

According to Turris and Lund (2012), MGs are usually dangerous events, with higher likelihood of bringing in more casualties than is normal. Consequently, the need for emergency nurses to work with various agencies becomes necessary. In addition, a common acuity scoring or determining program is needed. The program facilitates effective response and care in relation to the emergency nurses.

Emergency nurses also have the role of general assessment and caring for patients during MGs. According to Soomaroo and Murray (2012), MGs on-site provision of care has been shown to substantially reduce proportion of patients requiring transportation to hospitals. Consequently, the impact on ambulances and local health facilities is reduced. It is the duty of emergency nurses to provide this care, hence easing the congestion that might unnecessarily be imparted on available resources.

The need for prompt psychological care for the patients in MGs is to some extent the role of emergency nurses (WHO 2008). They are the ones required to handle these clients before and immediately they get to a healthcare facility. When dealing with patients, emergency nurses are required to inform them of the risks associated with the care they are receiving. As a result of such interactions, the fears of the patients are allayed. It is important to engage the clients from this perspective given that they come from different backgrounds. As such, the nursing professionals should take into consideration the cultural and linguistic attributes of their clients.

Emergency nurses area also required to offer team leadership and guidance for the non-ED nurses during MG cases. According to Behney et al. (2006), ED clinical directors usually assume the roles of incident commanders. ED clinical directors assistants who are ED nurse managers are tasked with the role of resource leaders. Ultimately, emergency nurses are assigned the roles of offering care to incoming patients, as well as assigning them ambulances for transfer and resuscitation (Behney et al. 2006).

However, the roles of emergency nursing professionals may differ from one country to the other. The variation depends on a number of factors. One of them includes the varying codes of conduct used to regulate the activities of nurses in different countries. Other issues include the different cultural values associated with communities in given nations. According to Suserud and Haljamae (1997), in Sweden, emergency nurses play the central role in case of a disaster pertaining to MGs. Swedish emergency nurses are expected to take leadership roles in MGs. For instance, they are supposed to survey the situation, undertake triage and initiate basic life support activities (Suserud & Haljamae 1997). In addition, the emergency nurses of Sweden are supposed to maintain communication with the disaster officer.

In Iran, however, registered nurses lack any distinction in relation to their role in MGs, especially when responding to disasters. Most Iranian nurses are not trained in emergency responses. As a result, general practitioner nurses are responsible for the work of emergency nurses (Nasrabadi et al. 2007).

In Southern Australia, the roles of emergency nurses are also limited due to low levels of disaster knowledge (Hammad et al. 2011; Duong 2009; Arbon et al. 2013). Despite of the presence of emergency nurses in South Australia, minimal disaster experience in their past hinders their performance. Disaster education is however taught in South Australian nursing schools, although the relevance and applicability remains questionable (Hammad et al. 2011; Taylor, O’Connor & Halpern 2003).

Factors affecting emergency Nurse’s response in Mass Gathering

The ability of nurses to respond in MGs is influenced by various factors, some acting as hindrances while others facilitating their abilities. Apparently, nurses are very essential in facilitating day to day operations in the emergency department. Consequently, their role in promoting response to disasters is equally significant. Thus, it is essential to determine what influences the response of emergency nurses while undertaking their roles.

The main factors affecting the response of emergency nurses in relation to mass gatherings include the following:

Disaster Education and Training

Disaster education and training is one of the main factors influencing emergency nurses’ response to disasters. According to Veenema (2006), trainings about disasters form one of the elements of education sessions in hospitals. In addition, drills and exercises, as well as military training and post graduate studies focusing on disaster response, constitute an important aspect of education and training in healthcare settings.

There is no specific method deemed as the best in the training of emergency nurses. However, it is a fact that the existing approaches have various shortcomings (Veenema 2006). The inadequacies are apparent in the content of the disaster education programs and mode of delivery. In addition, the relevance of these programs to nursing professionals in emergency department may not be clear (Enock & Jacobs 2012). Without proper training, emergency nurses may not be able to effectively respond to disasters.

Disaster Awareness

The other factor influencing the effectiveness of emergency nurses when responding to mass gatherings entails their awareness of disasters (Veenema 2006; Conlon & Wiechula 2011). Most of these professionals have limited exposure to catastrophes, especially those resulting from MGs (Conlon & Wiechula 2011). In addition, knowledge relating to MGs and the likelihood of disasters is limited in most settings. Consequently, some emergency nurses are not prepared enough to deal with such emergencies. As such, their response under such circumstances is limited and more likely to be ineffective (Veenema 2006).

Welzel et al. (2010) are of the view that it is essential that MGs and disasters likely to occur are communicated to emergency nurses early enough. Failure on the part of the relevant authorities to communicate this information to emergency nurses reduces their response capacity. Apparently, by preparing earlier, emergency nurses can even have opportunity to simulate response to MGs, hence increasing their response capacity.

Lack of Experience

Most emergency nurses have no prior disaster experience in their line of duty. According to Rassin et al. (2007), previous experience constitutes a key factor in relation to preparedness by the emergency nurses. Essentially, prior disaster management experience enhances understanding of emergency nurses on what to expect in case of disasters in MGs. Nurses who lack prior experience however rarely have an idea of what to expect, except in cases where disaster education and training is adequate (Worrall 2012).

In communities where MGs and disasters are limited, it is very unlikely to find emergency nurses with previous experience. The response capacity of these nurses can hence be expected to be low. However, Welzel et al. (2010) argue that previous experience can be gained through volunteer services by nurses from these societies to others where disasters are prone. In addition, disaster education and training can be enhanced to facilitate experience in emergency nurses (Hammad et al. 2012; Rebmann et al. 2012; Ranse et al. 2013). Disasters can be ‘recreated’ or simulated to enhance response capabilities of emergency nurses from communities where probability of them occurring is very low.

Inter-Professional Collaboration

There is need for collaboration and communication between different stakeholders involved in the provision of care in the emergency department. Such professionals include the nurse, the physician, the management team, and support staff (Martin, Ummenhofer, Manser & Spirig 2010). Functional relationships among these parties improve delivery of healthcare and patient outcomes in case of an emergency. The availability or absence of this collaboration has impacts on the reaction of nurses during a disaster (Martin et al. 2010).

Mass Gatherings in Saudi Arabia: A Case Study of Hajj

The Geography of Saudi Arabia

Saudi Arabia is largest of the Arab states in terms of land area, and it is located on the Western Asia. The country is located on the Arabian Peninsula, bordering the Red Sea and the Arab Gulf north of Yemen (Khan & McLeod 2012). The population of Saudi Arabia, according to the 2010 census, is approximately 27 million locals. In addition, there are close to 8.4 million foreigners residing in this Arab nation (Khan & McLeod 2012). The borders between the country and Yemen, United Arab Emirates, and Oman are not clearly defined. The size of the Saudi Kingdom is estimated to be approximately 2,217,949 square kilometres (Khan & McLeod 2012).

Only a small portion of the country is suitable for cultivation, totalling to less than 1% (Khan & McLeod 2012), the remaining part comprising of a vast desert. In addition, the population is varied in relation to distribution, with most people residing in cities, the coastline and the interior oases.

Hajj Pilgrimage in Mecca City

Hajj refers to the Muslim pilgrimage to Mecca Saudi Arabia performed annually, by more than two million people originating from more than 140 countries globally (Ahmed et al. 2006; Shafi et al. 2008; Al-Tawfiq & Manish 2014). The pilgrimage does not end in Mecca. On the contrary, it extends to other related holy sites, such as Miqat, Minna, Arafat, and Muzdalifah. The Hajj constitutes the largest MG event held annually in the world (Shafi et al., 2008).

According to Ahmed, Arabi and Manish (2006), the Hajj event is carried out on every twelve month of the Islamic calendar. On arriving in Mecca, the pilgrims circumambulate the Ka’aba seven times. Upon circling the stone seven times, the pilgrims then leave for plains of Arafat, which are located several miles east of Mecca (Al-Tawfiq & Manish 2014). In Arafat, the pilgrim reaches its climax with what the Muslims refer to as the “Day of Standing” (Al-Tawfiq & Manish 2014).

According to Shafi et al. (2008), the mass migrations constituting the Hajj every year make up one of the biggest MGs in the contemporary world. In addition, the congestion brought about by the massive number of people exposes the pilgrims to extreme health hazards. For instance, the fumes from vehicles and body odours among the attendees amplify the health risks associated with infectious diseases.

The Saudi authorities are faced with the massive task of preparing for the MG and implementing various public health interventions. For instance, the government performs three major tasks in managing the Hajj pilgrimage. First, a risk assessment is carried out in relation to any eventualities that may arise from the event (Al-Tawfiq & Memish 2014). Consequently, robust surveillance systems are put in place to identify any cases of disease outbreak.

Ultimately, policies are formulated to ensure that proper response mechanisms are activated in cases of such outbreaks (Al-Tawfiq & Memish 2014). In spite of the various measures by the Saudi authorities to manage Hajj MGs, more needs to be done. In several instances, disasters in forms of disease outbreaks have originated from the MG. Consequently, various international bodies, such as the WHO, guide the government on how to enhance the disaster management practices adopted for the purposes of the MG.

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