The Indispensable Role of Nurses in Disasters, War and Conflict: Clinical Excellence in the Most Challenging Environments

Abstract

Nurses are an integral element of the global response to healthcare emergencies, whether they are caused by natural disasters, terrorism, armed conflicts or humanitarian crises. In all of these circumstances, the fragility of many countries healthcare system is laid bare and staff are left to cope as front-line providers (Al Thobaity 2024). Nurses are major contributors at times of war and disaster as they work not only in the immediate emergency response, but they cope with the psychological and long-term aspects of recovery. When International Nursing Review put out the call for papers for this virtual special issue in 2024, the world had faced unprecedented global disaster challenges. Hurricane Helene and Typhoon Yagi had caused widespread damage, and flooding had also claimed a number of lives in Africa, Spain, Brazil, Bangladesh and India. Other countries were impacted by extreme heat with thousands of people dying in Saudi Arabia, North America and Pakistan. Overall, natural disasters killed more than 16,753 people in 2024, with extreme weather events accounting for the majority of these fatalities (Centre for Research on the Epidemiology of Disasters 2024). This figure is staggering as disasters had only claimed 65,566 lives in the previous 20-year period (Centre for Research on the Epidemiology of Disasters 2024). It was clear to me and my fellow editors that we needed to think differently about the role of nurses in disasters as many countries were now experiencing significant mass casualty events when disaster competencies were not really embedded in nursing education.

During disasters, nurses act as first responders, managing triage, stabilizing patients and delivering emergency care. At the same time, colleagues from other non-emergency care areas, such as public health, are ensuring that displaced people with no access to medication are appropriately managed. Wherever care is provided, nurses need ingenuity and resourcefulness in emergency situations in order to deliver care in unusual environments with resource limitations (Veenema 2009).

Nurses have a significant role beyond physical health and immediate emergency care. They address the longer-term impact of disasters on individuals and communities. In the aftermath, nurses deliver psychological first aid and trauma-informed interventions to people impacted by disasters and conflict. The mental health toll of such events on the population is profound, as is the impact on nurses and other healthcare workers. The COVID-19 pandemic has brought into the spotlight the impact of moral insult and injury that having to work in extreme circumstances and having to make challenging ethical decisions has on individuals (Scott et al. 2023). Working during disasters and conflict also brings such challenges and we need to ensure the workforce is both resilient and supported to deliver such care (Xue et al. 2020). The nursing role also extends in developing community resilience in the period after a disaster as people try to return to some sense of normality. This role requires a different set of skills and knowledge as it involves wider public health interventions, including monitoring for disease and working with communities to rebuild social structures and strengthening community networks (Committee on Post-Disaster Recovery, Institute of Public Health 2015).

It is clear that disasters, either natural or manmade, and other challenges such as emerging infections, bioterrorism and mass casualty events are an ever present threat for many countries around the world. As highlighted earlier, climate change is also causing more extreme weather events, which make natural disasters more frequent and more intense (Vernick 2025). It is now common to see ‘once-in-a-lifetime’ events occurring two to three times in a decade. Extreme weather events, excessive heat and drought now affect a number of continents. Weather events such as storms, torrential rain and hurricanes are now more intense than they were previously, fuelled by a rise in global temperatures (Earth Justice 2024). At the International Council of Nurses (ICN) Congress in Helsinki, in June 2025, Howard Catton, CEO of the ICN, called on nurses from all countries to pay attention to global crises like climate change and conflict no matter how far removed they seem to be from their own country. This reaffirms that countries need to think differently about disaster competencies for nurses and other health professionals. While such competencies have been embedded for many years in countries that face geological and other threats, every country on earth now faces the threat of disaster because of extreme weather.

While all disasters bring ethical challenges and psychological trauma for the public and healthcare staff, conflict and war bring extended periods of challenging or intolerable conditions. During conflict, nurses carry a triple burden of caregiving, personal risk and concern about their own families. Despite this, civilian nurses provide care without discrimination, treating the wounded from either side alongside injured civilians. Increasingly, we are seeing attacks on health facilities and healthcare workers during conflict, breaching international humanitarian law. This protection is afforded by the Geneva Convention and associated protocols, and while hospitals can lose such protection if they are used by the enemy for military operations. Despite this position, the International Committee of the Red Cross is clear that the fact that hospitals can lose protection is not a free licence to attack them (ICRC 2023). The lack of clarity around how and why facilities can lose their protections is a concern. Increasingly, health facilities are used as a shield, placing healthcare workers and patients at increased risk of attack. My view is that this notion of a hospital ‘carrying out an act harmful to the enemy’ requires urgent clarification, as it is not the facility or the staff who are carrying out the act but the military or terrorist forces who are occupying the facilities. The thought of patients and staff being caught in the crossfire through no fault of their own makes an attack on a facility even more abhorrent. The ICN has called numerous times for the protection of nurses, healthcare workers and facilities, and this was reinforced by a motion of the recent Council of National Nursing Association Representatives at their meeting in June 2025. Despite this, attacks continue in numerous conflict zones, with the notion of military operations taking place in the facilities used as a justification.

The United Nations outlines how conflict is becoming more entrenched, although the absolute number of deaths as a result of war and conflict has declined year by year since 1946. Yet there is more conflict between groups within countries, as well as notable wars in Europe and the Middle East. Global conflict is now at the highest level since the Second World War (Bowman 2025). More nurses than ever before are working in areas affected by conflict or delivering care under repressive regimes. Of course, we should not forget our military colleagues working at the front lines, providing care to injured soldiers. Many of these individuals also work in civilian healthcare services and are no more immune to the challenges that war and conflict bring than their colleagues.

Recognizing that disasters, war and conflict are becoming increasingly common, what needs to be done to ensure healthcare services are resilient and nurses are well prepared. The International Council of Nurses launched the second version of their disaster nursing core competencies in 2019 (ICN 2019). The core competencies cover eight domains from preparation and planning, communication, incident management, safety and security, assessment, intervention, recover and law and ethics. The framework considers three levels of nurses from Level 1, all registered nurses, through to Level 2, a nurse designated in their own organization to supervise and lead the response, and finally Level 3 for a nurse who is part of a deployable team. The core competencies are a useful framework to develop education programmes, and many countries have gone on to integrate Level 1 competencies into pre-registration nursing programmes (Ranse et al. 2022; Erkin and Kiyan 2025).

Level 1 preparation is not universal across the world, and the United Nations warned in 2022 that half the world was not prepared for disasters (United Nations Office for Disaster Risk Reduction 2022). Many of these countries in the Asia-Pacific region and Africa are prone to extreme weather events and other forms of natural disaster, which often lead to drought, crop failure and famine. Other countries are experiencing increasing events with wildfires and extreme heat, and report feeling less well prepared than they should be, including Portugal, Greece, Spain and Italy (Yanatma 2025). It is clear that with the increased risk of disaster and rising conflict, we need to ensure all countries are embedding disaster nursing competencies in initial nurse education as well as preparing practitioners in hospitals and public health to deal with emergencies. Without such preparation, countries will not be able to cope with emergencies arising from extreme weather, natural disasters or conflict.

This Special Issue brings together a wide collection of published papers around disaster preparedness, exploring system preparation for natural and climate-related disasters. The mass migration of people is a common feature, either within a country or to other countries during war and conflict, and two papers explore displaced populations from Ukraine and Syria. The Special Issue also includes wide-ranging experiences of war and conflict, including an enlightening paper on Voice from Hiding, exploring the work of nurses in Myanmar during the military coup.

Three papers explore the emerging threats from bioterrorism, mass casualty events caused by extreme heat and nuclear and radiological disasters. Several papers examine the immediate and long-term recovery of the devastating Türkiye–Syria earthquakes.

The Special Issue also explores disasters through the eyes of various vulnerable populations, including children, newborn infants and mothers, and those with chronic conditions.

It is abundantly clear that as we enter an era of marked climate emergencies, increasing armed conflict and displaced populations, the role of the nurse must be redefined as central to disaster and crisis response. Countries that have viewed disasters elsewhere need to prepare for climate-related catastrophes within their own borders. At the same time, clarity is needed that it is never acceptable to target health facilities and health workers. Disaster preparedness must be embedded into all nursing programmes, and staff must be adequately prepared and supported throughout their careers. Unless we prepare, we will be doomed to fail, and the people we serve simply deserve better.

None of the authors have a conflict of interest to disclose.