Journal of Holistic and Midwifery. Spring2017;27(1) Pages: 35- 43

Published online 2017March Review Article

Emergency and Disaster Preparedness in Nurses: A Concept Analysis

Seyedeh Negar Pourvakhshoori1, Hamid Reza Khankeh2*, Farahnaz Mohammadi3

1Research Center in Emergency & Disaster Health, Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, 2Research Center in Emergency & Disaster Health, Professor, Department of Nursing, University of Social Welfare and Sciences, Tehran, Iran 3Social Determinants of Health Research Center (SDHRC), Assistant Professor, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

*Corresponding author: Research Center in Emergency & Disaster Health, Professor, Department of Nursing, University of Social Welfare and Sciences, Tehran, Iran E-mail: [email protected]

Received: 2014August13; Accepted: 2015December02 Abstract

Introduction: Given the growing rate of accidents and disasters in the world, preparing nurses as the main group responding to these events is crucial; however, a review of literature suggests no comprehensive and theoretical or practical definitions for this concept in nursing, which has been often misunderstood and used as an alternative to other similar concepts. Objective: The present study was conducted to analyze the concept and provide a practical definition for emergency and disaster preparedness in nurses. Materials and Methods: The eight-step Walker and Avant’s approach was used to clarify the concept of disaster preparedness in nurses. A total of 40 articles selected on the subject through an extensive review of literature up to 2013 were analyzed and the relevant definitions, applications, attributes, antecedents, consequences and empirical referents were extracted. Results: According to the analysis conducted, the concept attributes include gaining the disaster knowledge and management capability, response planning strategies, response behavior exercises and the evaluation of the knowledge level and the response program content. Improved knowledge and skills, professional accountability, more comprehensive programs and more accurate response behaviors were found to be the outcomes of disaster preparedness in nurses. Conclusion: According to the present study, disaster preparedness in nurses refers to the knowledge, skills, abilities and comprehensive functions required for responding to natural or man-made events and disasters. Nurses’ preparedness in disasters refers to a process in which nurses involve to properly prepare and effectively respond to emergencies and disasters. Given the wide range of the concept, further studies are recommended.

Keywords: Disasters, Nurses, Qualitative Research

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Introduction model cases, borderline cases, related Given the growing number of incidents cases and contrary cases as well as and disasters, health service providers play defining empirical referents [18] and a key role before, during and after these ultimately presenting a practical definition events and their preparedness is crucial [1- for the concept of disaster preparedness in 3]. The professional preparedness of nurses. In order to obtain the articles and nurses is undoubtedly crucial [4] in resources relevant to the concept, an providing health services for the injured, extensive review was first conducted on as they are often considered to be in the databases including EBSCO, front line of healthcare provision [3-6, 7]. SCIENCEDIRECT, MEDLINE, CINAHL, Given the negative impacts of disasters on IRANDOC, SID, IRANMEDEX, OVID public health and welfare, providing and PROQUEST using keywords such as proper health services is the main factor emergency and disaster preparedness in contributing to the survival, reduced nurses, emergencies and disasters, mortality and well-being in people affected preparedness, prepared and emergencies. by the events [8]. The World Health All English and Persian articles published Organization emphasizes the activities that between 1980 and 2013 were searched and are essential for achieving preparedness included in the study. A total of 34 papers [9] as part of the process of sustainable were also obtained using Google search development in communities and the most engine. The papers found to be irrelevant effective method for responding to the to nurses’ preparedness were excluded. A emerging needs [10].Research suggests no total of 40 articles selected on the subject definition for nurses’ preparedness despite finally. All these articles were thoroughly the emphasis placed mainly on their reviewed and unanimously decided on problems and the nursing position upon the their relevance to the subject by all the emergence of disasters [11-17]. three members of the research team and The services and their effectiveness cannot the relevant papers were analyzed using be investigated as long as there is no the Walker and Avant method. A pre- definition for disaster preparedness in developed checklist was used to resolve nurses. The first step in this regard is to the possible conflicts among the team conduct a concept analysis, specify the members. The concept applications were attributes and present a practical definition. thus extracted and the defining attributes The present study was therefore conducted of the concept were determined. The to practically define and analyze the antecedents and consequences were then concept of disaster preparedness in nurses identified, the model, borderline, related using the systematic approach proposed by and contrary cases were constructed and Walker and Avant. empirical referents were ultimately specified. After conducting a literature Methods and Materials review and following the steps cited, a The present study was conducted to practical definition was proposed for the specify and define the attributes of concept of emergency and disaster emergency and disaster preparedness in preparedness in nurses. nurses using the eight-step Walker-Avant’s approach to concept analysis. These eight Results steps include selecting a concept, Applications of the emergency and disaster determining the purpose of analysis, concept identifying all uses of the concept, Walker and Avant argue that illustrating an determining all the defining attributes of overall perspective of the applications of the concept, identifying antecedents, the study concept causes a more enriched identifying consequences, constructing understanding of the concept and

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validation of the defined attributes [19]. improves the knowledge and skills. In The so-called health preparedness for addition, there are different types of emergencies and disasters was found to be trainings and exercise programs [21]. used in literature as a foundation of A review of literature suggests the need for individual, local and national preparedness nurses to participate in disaster programs for enabling responses to mass preparedness training programs and casualties through hospital capacity practical exercises at least once a year, enhancement and for improving responses irrespective of their level of education, to terrorist attacks and other emergencies expertise and work place. These programs and disasters. This preparedness involves a should be multidisciplinary to enable the process of planning, training and skill nurses to cooperate with a variety of improvement through exercises and supply responding experts during emergencies of proper equipment [11, 20]. The only and disasters. Researchers identified that definition proposed in literature with an the lack of training programs as the most emphasis on the role of mayors was found common obstacle to gaining knowledge to be ‘A well-prepared political power for about responding to emergencies and structurally responding to potential threats disasters [22-24]. from the surroundings while minimizing Disaster and emergency preparedness is a the negative consequences of the incident continuous rather than a static process, in for people’s health and security as well as which nurses gain knowledge through for the integrity and function of physical training activities and response planning structures and systems”[20]. strategies. The response strategies and The literature review suggested no behaviors are practiced through emergency theoretical or practical definitions of the drills. The nurses’ knowledge and planning term emergency and disaster preparedness level is then evaluated and the based on developing its specific attributes. shortcomings in the process of knowledge The US Federal Emergency Management acquisition and planning are determined Agency defined preparedness as ‘being and addressed [11]. The present study aware of existing dangers and what to be emphasizes the process nature of the done in emergencies as well as pre- preparedness program and the need for emergency programs designed to save gaining knowledge and presenting better people’ life and help with the response and skills and responses. rescue operation’ [15]. Preparedness is therefore defined as readiness for The concept attributes immediate responses. With the need for involvement in the A review and investigation of the process of emergency and disaster applications of nurses’ preparedness in preparedness divided into two parts, the emergencies and disasters suggests some actual level of nurses’ involvement ranges attributes commonly found in all the from a minimum level of participating in a references, including gaining knowledge single training activity and practical on emergency and disaster management, exercise per year to a maximum level of response planning strategies, response enthusiastically participating in numerous behavior exercises and evaluation of the training programs, tabletop trainings and level of knowledge and the response different simulations every year. The program content. Emergency and disaster greater involvement in the preparedness preparedness was however found to be the process can improve nurses’ knowledge most dominant attribute. and enrich the response programs [11, 15]. All studies conducted on emergency and Research suggests that preparedness is a disaster preparedness described ‘the focus process in which more involvement on emergency and disaster management’

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as the key to preparedness, i.e. it can be process should enhance their knowledge obtained through . and develop more comprehensive ‘Emergencies and disaster management programs for responding to emergencies knowledge’ should be acquired by nurses and disasters. The nurses’ knowledge level primarily on triage, management of the and the content of the response programs injured and management of the victims’ should also be measured. Nurses update families. Although these features overlap their knowledge and the response strategy with other health practices, the nursing- upon the identification of the weaknesses, oriented view should prevail [25-27]. which completes the first cycle of the Emergency and disaster knowledge is preparedness process. Nurses’ gained through participating in preparedness in emergencies and disasters multidisciplinary educational activities as is a permanent process with no end point, well as emergency and disaster trainings as disasters are always possible to occur. and drills [28-33]. This process is ongoing until accidents The second attribute is ‘response planning occur and nurses are forced to respond. strategies’. Planning is made before and Emergency and disaster preparedness along with gaining knowledge [16, 34-37]. unlimitedly continues unless the nurses The analysis of the results obtained from withdraw from the process [11, 35]. the relevant studies stress the importance of response planning strategies and plans. Antecedents In all countries, nurses are required to develop emergency and disaster response Antecedents are events that exist or occur programs to meet their needs and be aware before the emergence of the concept [19]. of their emergency role and The antecedents associated with responsibilities [36, 38]. After developing emergency and disaster preparedness are the response program by nurses and as follows: making the plan, the program strategies 1- Acceptance: Acceptance is the first should be implemented and applied antecedent of emergency and disaster through drills [36]. The third attribute is preparedness in nurses, who should accept ‘response behavior exercises’ [33, 37-42]. emergencies and disasters as potential The multidisciplinary emergency and threats or hazards. Nurses, who deny the disaster programs comprise tabletop drills possibility of emergencies, disasters, and simulations [33]. Tabletop exercises terrorist attacks and the effects of these are drills based on discussions among the events on their life and actually fail to participants on how to respond to a accept them, will fail to implement the particular situation without resorting to process of emergency and disaster any practical behaviors or actual responses preparedness, unless they are ordered to to emergencies and disasters; however, [36]. maquettes of victims or paper-based 2- Readiness for changes: Nurses should descriptions of ’ clinical status are be ready for changes before they involve used in simulation exercises and in preparedness activities. Readiness for participants are required to perform changes associated with emergencies and definite behavioral responses [24]. The disasters is not clearly defined in literature. discussion and performance of the Not only can readiness for changes be simulated response behaviors reveals the considered a process, it can also refer to gaps in the programs and detects the parts the state of being prepared for changes. As requiring modification and development a process, it includes three steps; [36, 40, 43 – 44]. perceiving what requires changes, The involvement of nurses in the measuring the cost effectiveness and emergency and disaster preparedness planning for action [45]. Readiness for

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changes refers to variations in clients’ programs. They continue with this process willingness or unwillingness for changes. over time to solve new challenges, as well. They immediately follow the activated Consequences response program upon the actual occurrence of earthquakes (the Consequences are generally defined as consequence of preparedness: improved events following the emergence or response). occurrence of the concept [19] and particularly as the activities in which Related cases nurses involve to prepare for emergencies and disasters. Highly-knowledgeable Related cases represent the ideas that are nurses tend to involve more in the generally similar to the study concept, but preparedness process [15, 36], are different in details [21]. professionally more accountable, possess Several seemingly similar but different more comprehensive response plans and concepts associated with emergency and present more accurate response behaviors. disaster preparedness are used The higher the nurses’ level of knowledge interchangeably, including all-hazards and skills, the swifter the measures taken preparedness [48], bioterrorism [14, 36, 46, 47]. preparedness [48-50], citizen preparedness [51], national disaster preparedness [20 , Construction of the model case 52], emergency preparedness [11, 20 , 53], disaster response [54], family preparedness Model cases involve all the defining [52], hospital preparedness [55], individual attributes of the concept [19]. For example, preparedness [52], national bio defense nurses working in a clinic in an preparedness [49], nurses’ preparedness earthquake-prone city such as Bam, Iran, [56], public preparedness [49], identify emergencies and disasters as preparedness for public health events [57], potential threats to themselves, their family public health preparedness [58] and and their community, and consider terrorism preparedness [59]. All-hazards preparation as important (the antecedent of preparedness, hospital (medical facility) acceptance). These nurses identify and public health preparedness, public emergency and disaster preparedness as a preparedness and preparedness in other priority that requires action(the antecedent specialties are the most commonly used of readiness for changes as a state and a concepts. process), and tend to participate in All-hazards preparedness is a special emergency and disaster workshops and approach taken by hospitals and local emergency and disaster exercises, communities to prepare for the common gain knowledge about emergency and aspects of all types of disasters, which disaster management and develop cause great damage or large numbers of individual-group response programs deaths as accidents or natural disasters (attributes of gaining knowledge, planning including natural and human hazards [60]. and exercise). After simulating an Preparedness for specific hazards is more earthquake, these nurses evaluate their limited compared to all-hazards ability to respond to this event and preparedness because every disaster determine the areas in which they are short requires its own measures and of knowledge (the attribute of evaluation). preparedness. In addition, they schedule and plan the The preparedness of the community of future emergency and disaster exercises to hospitals and healthcare facilities are reevaluate their capabilities while concepts that are defined as organizational improving and updating their knowledge preparedness efforts including a large and designing new emergency response

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range of responsibilities in is the final step in the concept analysis. In multidisciplinary teams [50, 55 , 61] and fact, there are some categories of involving nurses in planning committees phenomena that measure the concept or [28, 36]. Disaster preparedness in different confirm its existence in the real world [19]. experts is another related concept. To The empirical referents associated with the prepare for bioterrorism, for instance, concept of disaster preparedness in nurses nurses are required to involve in activities include the investigation of the attributes such as infection control, triage, health extracted from empirical evidence, the training and mental health training; evaluation of nurses’ preparedness, the physicians need to engage in epidemiology development of concepts and tools in of pathogenic agents and clinical diagnosis universities and the evaluation of nurses’ while planners should establish monitoring preparedness across the country by the systems, and coordinate local, regional and Department of Nursing in Iran’s Ministry national emergency and disaster agencies of Health and Medical Education. with incident management command systems [22]. The definition proposed for emergency and disaster preparedness Borderline cases Emergency and disaster preparedness Borderline cases possess not all but some refers to the knowledge, skills, abilities of the defining attributes of the concept and comprehensive functions required for [19]. Although some emergency nurses preparedness and response to natural or identify storm as a possible threat to man-made emergencies and disasters. In themselves and their community, they fact, preparedness is nothing but a rapid believe the risk is negligible. There is an response capability and mobilization of antecedent, i.e. acceptance, and an resources against life-threatening events. attribute, i.e. knowledge, but the other This preparedness process involves attributes, i.e. planning, exercises and gaining nursing-specific knowledge on evaluation, and the antecedent, i.e. disaster management, response planning readiness for changes, are lacking. Despite strategies, response behavior exercises as nurses’ tendency for a better preparedness, well as evaluating knowledge and the the obstacles prevent them from fully content of the response program, which involving in the nursing disaster distinguishes different levels of knowledge preparedness process. and different elements of the response program. The contrary cases Nursing-associated cases The contrary cases lack any of the defining attributes [19]. Nurses living in small According to Walker and Avant, towns with no rivers and sea borders developing a concept analysis can be quite cannot believe flood might threaten their useful particularly in defining ambiguous community. They therefore fail to terms with theoretical, clinical, education participate in disaster training programs and research applications, presenting and response behavior programs and avoid practical theory-based definitions, evaluating their own knowledge, as they understanding the inherent characteristics do not feel the priority and the need for of a concept as well as helping with performing these activities. developing and designing research tools Empirical referents and result evaluation instruments [20]. The definition of disaster preparedness in According to Walker and Avant, defining nurses proposed in the present study can empirical referents for the main attributes help determine the main components of

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