Role of nurses in a nuclear disaster: experiencein the Fukushima Dai-ichi nuclear powerplant accident

Y. Noto1 RN, PhD, C. Kitamiya2 RN, PHN, PhD, C. Itaki1 RN, PhD, M.Urushizaka3 RN, MS, R. Kidachi RN, PhD1 & H. Yamabe MD1

1 Professor, 2 Associate Professor, 3 Lecturer, Graduate School of Health Sciences, Hirosaki University, Aomori, Japan

NOTO Y., KITAMIYA C., ITAKI C., URUSHIZAKA M., KIDACHI R. & YAMABE H. (2013) Role ofnurses in a nuclear disaster: experience in the Fukushima Dai-ichi nuclear power plant accident.International Nursing Review 60, 196–200

Background: A severe earthquake occurred in Japan on 11 March 2011. The giant tsunami devastated many

coastal communities in eastern Japan and caused the Fukushima Dai-ichi nuclear power plant incident. The

Japanese government conducted a large-scale survey of residents affected by the nuclear and natural disasters

in Fukushima prefecture and in response to the government’s request, H University dispatched a Radiation

Exposure Research Team to Fukushima.

Purpose: This article explains the activities of the Radiation Exposure Research Team and the role of nurses in

a nuclear disaster.

Conclusion: As a nurse in the field of radiation medicine, our role is to protect the health of those affected

and to reduce their anxiety. In addition, as the persons responsible for implementing these projects, it is also

necessary that we educate and foster the development of medical care personnel with the appropriate

knowledge and skills to carry out the measures required.

Keywords: Fukushima Dai-ichi Nuclear Power Plant, Nuclear Disaster, Nurses’ Professional Roles, Radiation

Emergency Medicine, Radiation Survey

IntroductionA severe earthquake occurred in Japan on 11 March 2011. Thegiant tsunami unleashed by the magnitude 9.0 earthquake dev-astated many coastal communities across a wide area of easternJapan. As a result, about 16 000 people died, and 3000 peoplewere missing (National Police Agency of Japan 2012). In addi-

tion to loss of life and vast destruction of infrastructure, thetsunami caused the Fukushima Dai-ichi nuclear power plantincident.

Many electrical generators were taken down, and at leastthree nuclear reactors suffered from explosions due to hydrogengas that had built up within their outer containment buildingsafter a cooling system failure. Fortunately, nobody died or wasinjured in the direct plant accident. However, residents within a20-km radius of the Fukushima Dai-ichi nuclear power plantwere evacuated.

The Japanese government decided to conduct a large-scalesurvey of residents affected by the nuclear and natural disastersin Fukushima prefecture. In response to the government’s

Correspondence address: Yuka Noto, Graduate School of Health Sciences, HirosakiUniversity, 66-1 Hon-cho, Hirosaki, Aomori 036-8564, Japan; Tel:+81-172-39-5923; Fax: +81-172-39-5923; E-mail: noto@cc.hirosaki-u.ac.jp.

The source of funding statement: This research received no specific grantfrom any funding agency in the public, commercial or not-for-profit sectors.Conflict of interest: No conflict of interest has been declared by the authors.

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Experience from the Field

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request, H University decided to dispatch a Radiation ExposureResearch Team to Fukushima prefecture. A total of 365 staff,including nursing staff, were dispatched from 15 March to July.

Although generally careful attention is paid to the safe use ofradiation, and appropriate radiation protection measures aretaken, the probability of a radiation exposure accident is notzero. When an accident occurs, either a nuclear disaster or aradiation accident, it has a great influence on peripheral peopleand the community as well as on the workers of the institution.Especially, health damage to a human body is the most seriousproblem (Christodouleas et al. 2011). Therefore, as a precautionagainst unlikely accident occurrence, it is necessary to maintaina system for radiation emergency medicine. But in 2011, therewere few institutions that were able to be ready for it in Japan.With the release of radiation continuing, the evacuees fromaround the facility continued living in shelters, unable to getstarted on restoring their own community (McCurry 2011).This article explains the activities of the Radiation ExposureResearch Team and the role of nurses in a nuclear disaster basedon our actual participation in the project.

The activities of the Radiation ExposureResearch TeamOn the night of 11 March 2011, the Japanese governmentdeclared a state of emergency at the Fukushima Dai-ichiNuclear Power Plant. The Fukushima prefectural governmentdecided to screen individuals for radioactive contamination, butlacked sufficient manpower to screen all who needed it. It there-fore called on the national government, local governments, uni-versities and the Federation of Electric Power Companies fortheir cooperation in conducting screening services at evacuationfacilities. H University was included in this group.

H University is located in H city in A prefecture, where manynuclear power facilities are located. Since 2008, H University hasbeen working on human resource development for radiationemergency medicine at the Graduate School of Health Sciences.Since 2 years ago, it has been educating students as well as pro-fessional nurses and radiological technologists. Faculty staff atthe university received training in radiation emergency medi-cine before teaching in this program.

H University decided on a basic policy to cooperate at a‘radiation safety mechanism’. The implementation of the policywas entrusted to each department (Institute of Radiation Emer-gency Medicine, Graduate School of Health Sciences, GraduateSchool of Medicine, and Secretariat of the H University Schoolof Medicine and Hospital). The Graduate School of Health Sci-ences selected trained medical persons from those who wereavailable for the task. The team comprised radiologists, radio-logic researchers, lecturers from the School of Health Sciences

who were also qualified nurses or radiological technologists,and clerical officers. Our participation in the screening programlasted from 17 to 19 March, 7–9 days after the initial incident. Asite for screening was set up outside the evacuation zone andlocal residents were examined for any signs of contamination.

Some team members (e.g. radiological technologists of thehospital, office workers) had never received specialized trainingin radiation emergency medicine, but otherwise staff receivedample training, including training in providing treatment toindividuals with physical disabilities who had been exposed toradiation, and the handling of many refugees with the contami-nation in the radiation hazard. When it was decided to dispatchthe support team to Fukushima, the team did not have accurateinformation on the current state of the incident and recognizedthat their exposure to radiation was a possibility. However, theywere not too anxious because they were trained and had per-sonal protective equipment and radiological monitors. The uni-versity confirmed that the best method for protecting the teamis conducting a contamination screening and decontaminationoperation for minimizing the quantity of radiation to whichthey would potentially be exposed. Furthermore, having discus-sions about safety certainly helped reduce the level of anxietyfelt by the team. I don’t know whether other team memberstalked with their families, but my family did not object to mygoing after I had explained that I would be safe.

The siteWe received our instructions from the Radiation EmergencyMedicine Coordination Headquarters, which by that time haddetermined where to conduct the contamination screening. Weconfirmed the location, the route and service stations where ouremergency vehicle could fill up with gas, and set out. Afterhaving arrived at the appointed screening location, we con-tacted the person concerned of the meeting place and set up ourequipment.

A hotel located approximately 1 h outside of FukushimaCity became our headquarters. Fortunately, we were able tosecure electricity and water for bathing and stay indoors. Weate the portable rations we had brought at a rest stop on theexpressway.

The screening programmeWe used Geiger–Müller counter-type instruments and scannedthe entire body of each person over their clothes. At first, thescreening level for residents (a criterion of comprehensive outerbody clean-up) was set at 40 Bq/cm2 (13 000 cpm). A radiologicexpert urgently visited Fukushima as a member of a radiationexposure medical care dispatch team. According to their advice,the screening level was raised in 100 000 cpm. More than a total

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of 200 000 monitoring subjects were monitored, representingover 10% of the prefectural population who received screeningservices. The Geiger count rate of those monitoring subjects wasbetween 13 000 and 100 000 cpm. The number of subjects whoneeded partial external cleansing was 901, and the number ofsubjects whose measured count rates were higher than100 000 cpm and needed whole body cleansing was 102.However, the count rates of those monitoring subjects whosemeasured exposure was higher than 100 000 cpm were belowthe designated level when they removed their clothing(Investigation Committee on the Accident at the FukushimaNuclear Power Stations of Tokyo Electric Power Company2012).

Role of nurses in a nuclear disasterThe following points are those that we consider the mostimportant with regard to the role of nurses, based on our actualparticipation in the project.

Flexible support, depending on individualcircumstancesWhen conducting the contamination survey, it was found thatonly a limited number of residents actually required decontami-nation such as removing their outer clothes. In this survey, thesubjects were the residents who were evacuated to evacuationareas. For these people, supplies were limited, and the thingsthat they were able to take with them from their homes werealso limited. In those cases, where residents were evacuated withonly the clothes on their backs and were not allowed to returnhome to get their belongings, they may not have been able tochange their clothes. In addition, if their hands and hair werecontaminated, washing could not be carried out satisfactorily ifthe water system had not yet been restored. Therefore, it wasessential not only to conduct contamination survey and decon-tamination procedures, but also to provide support by checkingconditions in the area and the circumstances of the individualsaffected.

Setting up a site for the contamination surveyand supporting activitiesIn any disaster, it is very important to provide thoughtful con-sideration towards the most vulnerable people in the affectedarea. Some people will need special consideration, such as theelderly who may have difficulty walking and those people with avision and hearing disability or dementia. In general, the siteused for a contamination survey should basically be set up sothat the flow lines for the people before and after the survey donot cross. However, if set up in this way, the flow line from theentrance to the exit can become extended and, even within the

site, this distance may pose a problem for some of the peopleparticipating. Even people who have difficulty walking and use awalking stick outside the site may be forced to walk and have toleave their walking sticks at the entrance. By having nursespresent at the survey site, the nurses can identify people withdisabilities early, approach them individually, and provideappropriate support. We supported their walking, or alterna-tively, we requested a checker for movement so that they weresurveyed at the entrance without their having to walk.

When setting up the site, consideration must be given notonly to the facilities and human and material resourcesrequired, but also to the following issues: the number of peopleto be surveyed, whether they will arrive in groups, how manyare likely to have a high dose of radiation and require decon-tamination, and the number of elderly or people with disabili-ties present. Depending on the particular circumstancesencountered, it is therefore necessary to take the location,resources and the local situation into account when setting upthe site. We found that there were not enough disaster resourcescreening areas. There were not enough poles and materials tocreate a secure flow of people in and out of the screening area.We made full use of a desk and a chair, a poster, as it is necessaryto clear the area construction in order to avoid confusion. Weinduced the flow of persons by using a desk and a chair in sub-stitution for a pole, and we posted the poster indicating the line.

Conducting a contamination surveyinvolving childrenSpecial consideration is necessary when carrying out a surveyinvolving children. The sight of many adults wearing masks andprotective clothes in a strange place will be something they havenever experienced before (Fig. 1). Strange monitoring machinesthat they have also never seen before will be held over theirbodies and their parents will be watching with tense expressionson their faces. In order to reduce the children’s feelings ofanxiety and fear as much as possible and prevent bad memories,it was considered important to provide as much care and con-sideration as possible. When children were with their parents,we asked them, ‘would you like to take the survey with yourmother?’, and we asked their parents to stay nearby. When thechildren underwent the survey alone, nurses stayed nearby andsaid things like, ‘it won’t hurt’, ‘it will be over soon’, and ‘you didwell’, and when the survey was complete we gave the childrencandies as a present, saying, ‘you did a great job’. By the time thesurvey was completed, many children were looking rather glumbut they smiled when they received candies. Therefore, the‘candy strategy’ was considered to be an effective means ofeasing anxiety in children.

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Providing an opportunity to answer questionsand express anxiety in wordsAs part of the survey team, each surveyor and each clericalofficer who explained the contamination survey certificateworked together in pairs. Clerical officers were also put incharge of guiding the residents through the survey process.Thus, the nurses and health professionals were able to concen-trate on providing care. We were able to identify the people whoneeded to be supported and we were able to respond promptly.Furthermore, at the completion of the survey, saying ‘you mustbe tired’ as people moved towards the exit prompted many resi-dents to ask the questions that they had wanted to ask but wereunable to do so earlier. In the case of those people in tearstelling us that ‘our home has been washed away by the tsunamiand nothing is left’, we listened to them as long as time allowed.When explaining the contamination survey certificate, manypeople asked questions and we listened and observed carefully.If it seemed that they wanted to talk longer we provided a moredetailed explanation and discussed it further (Figs 2,3).

Our survey team was in operation from the seventh to theninth day after the disaster. Thus, it was found that the residentsundergoing the survey already understood the meaning ofradiation and the purpose of the survey, at least to some degree,as a result of the government’s previous explanations and pressreporting. Some residents had taken part in the survey before,or came along at their own initiative. Therefore, it was not con-sidered necessary to explain the meaning or the methodology ofthe survey to most of the residents. The results of the surveygenerally showed no significant effect on health, except forseveral people who could be decontaminated simply by takingoff their outer clothes and, by telling these people that ‘it is at

almost the same level as the natural background radiation’, itwas found that most residents understood and were relieved.Most of the people who went through the decontaminationprocess of taking their outer clothes off did not seem to be upsetand appeared to accept and understand the reason: that ‘I waswearing these clothes all through the disaster’.

However, there were a small number of people who seemedto be irritated and resentful, and we tried to communicate withthese people as politely and carefully as possible. Some peoplealso asked questions or expressed concerns such as: ‘it is alrightnow, but we don’t know about the future’, ‘I work outside and isit alright to take part in the survey again tomorrow?’, and ‘I

Fig. 1 Mother and the daughter who have a contamination survey. Fig. 2 We answered the question of residents.

Fig. 3 We answered the question of residents.

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would like my children to take potassium iodine as a precautionand I would like to know what to do’. In these cases, weexplained and helped as much as we could. It can be very diffi-cult for people in these situations, and it was considered desir-able to set up an individual consultation service staffed byspecialists to assist the residents visiting the survey sites.

Security and relief of the team membersThe team always assessed the risk to the staff. Then a decisionwas made as to what protective procedures the team wouldoperate under. In one example, because of the risk the staff worefull protection: hazmat suit, cap, mask and shoes covers at thesurvey site. In locations when the level was not so severe nursesonly wore gowns. The health and safety of staff is primarily theresponsibility of nurses. We explained radiation protection tothem and answered any questions. We were comforted byhaving radiation experts on our team to advise us. The protec-tor that we wore was level D and did not produce difficulty forexcretion.

We ate and drank in a bus. Because we did not wish to bringin contamination when we got on a bus, we took off a protector.Each staff member had a personal dosimeter to monitor exter-nal exposure. After the completion of our mission, we all had acomplete check of our internal exposure. The universitysupport system was effective and enabled us to complete ourmission safely.

ConclusionThe nuclear disaster that happened here will leave a large scaron Fukushima and throughout Japan. Two years have passedsince the disaster, but approximately 160 000 people are stillevacuated. Many dread the future effects to their health causedby their radiation exposure in the incident and are still dealingwith the anxiety of persistent exposure to low-dose radiation.We want to continue to provide them with the help they needwhile also monitoring future changes as a consideration fortraining other medical care personnel. On the other hand, the

nuclear power disaster has allowed us to reaffirm the impor-tance of improving the medical care system for radiation expo-sure and the roles of medical professionals who practice thistype of medicine.

In the medium to long term, nurses will serve a critical role intreating incident victims. However, as radiation incidents anddisasters are low-frequency events, the history of education onsystematic radiation emergency medicine is still short and littleempirical knowledge has been accumulated. Furthermore, inthis incident, it was found that the human resources needed toaddress these situations appropriately were not developed suffi-ciently. We urgently need to train people in the nursing profes-sion to take a central role alongside physicians in radiationemergency medicine and to support the delivery of care to localresidents in a comprehensive manner. We need to cultivatehuman resources in radiation emergency medicine who want tocontribute actively to the society of the future.

Author contributionsChiaki Kitamiya, Chieko Itaki, Mayumi Urushizaka and RurikoKidachi: Substantial contributions to conception and design,acquisition of data, or analysis and interpretation of data.Hideaki Yamabe: Drafting the article or revising it critically forimportant intellectual content.

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