signature page - simmons university€¦ · web viewin preparation for response to disaster...

Running head: NURSES’ KNOWLEDGE OF CRISIS STANDARDS OF CARE

Understanding Emergency Nurses’ Knowledge of and

Preparation for Crisis Standards of Care

Daniel Nadworny, MSN, RN

Doctor of Nursing Practice Capstone

Simmons College

2018

NURSES’ KNOWLEDGE OF CRISIS STANDARDS OF CARE

Signature Page

Simmons CollegeDoctor of Nursing Practice ProgramCapstone Manuscript Approval FormName: Daniel Nadworny

Title of Project: Understanding Emergency Nurses’ Knowledge of and


Date: _________Capstone Manuscript is approved

_________Capstone Manuscript is approved with the following revisions:

________Capstone Manuscript is not approved

Committee Signatures:

_____________________________________________________________Shelley Strowman, PhD

_____________________________________________________________Patricia Folcarelli, PhD, MA, RN

_____________________________________________________________Ritu Sarin, MD


Abstract

Background: Disasters often occur with little warning and can have catastrophic

consequences for the community. Emergency nurses are positioned to have a leadership role

in the operational management of these events. At its core, a disaster is a substantial

imbalance between the resources at hand and the demands for those same resources (National

Disaster Life Support Foundation, 2012). In events that impact the health and wellness of the

community, healthcare resources can be expected to be an area of significant strain at the

same time as being in high demand.

Crisis standards of care (CSCs) are a framework that was first developed at the

request of the U.S. Department of Health and Human Services (HHS) and developed by the

Institute of Medicine (IOM) to guide clinical decision-making during events when available

resources may not meet the demands of the incident (IOM, 2007).

Objectives: The primary goal of this quantitative and qualitative survey study was to

assess the level of knowledge and preparation of emergency nurses regarding CSCs. The

study also evaluated how knowledge and preparation are related to participation in real

disasters or practice drills, nurses’ education, years of experience, and working in a

designated trauma center. Research on this topic is needed to help define the gaps in the

current knowledge of emergency nurses to help guide future educational activities and

curriculum changes.

Methods: An online survey was distributed through social media and by email to

emergency nurses within the US over a two week period in January 2018. The survey tool

has 43 items and uses a 5 point Likert scale for respondents to rate their level of knowledge

and preparation related to CSCs. In addition, a series of open-ended questions based on a


fictional scenario was completed giving further insight into barriers and best practices of

respondents.

Results: The study results showed that emergency nurses tend to be knowledgeable

about disaster care principles, including CSCs, and they feel prepared for disaster care, but

there is room for improvement. Nurses with more drill exposure and participation in real-

world events had higher total knowledge and preparation scores. Training through didactic

education, simulation, and drills were all noted to improve the readiness and self-perceived

comfort to respond to events where CSCs may be needed. Despite their awareness and

knowledge, nurses reported that disaster research is not easy to understand. They are not

given adequate exposure to annual drills to prepare them for events. Fewer than half of

participants were familiar with the term “Crisis Standards of Care.”

Conclusions and Implications for Practice: This study provides guidance to nurse

educators and emergency preparedness staff to assist in the development of education and

training for emergency nurses.


Acknowledgements

The author would like to recognize the community that supported me as I worked to

create this capstone. To the faculty of Simmons College who have been dedicated to our

success and supportive of our goals, and have demonstrated the impact of nursing educators

on the art and science of nursing. To Shelley Strowman, PhD who served as my primary

advisor and statistical expert, this paper and the results are stronger because of your

expertise. I also would like to thank Pat Folcarelli, RN, MA, PhD and Ritu Sarin, MD for the

input of their clinical expertise, regular encouragement and support through the review and

editing process.

I would like to recognize the leadership at Beth Israel Deaconess Medical Center who

have invested in me as a nurse leader, especially Marsha Maurer, Laurie Bloom and Kirsten

Boyd. To the other members of the cohort program, I have learned from each of you and will

take that knowledge as I continue my career.

Finally, I would like to thank my family, in particular my wife Sharon who has been

my consultant, editor, support and teammate through an arduous process. There is little that I

could ever accomplish without you and this project has been no different.

KNOWLEDGE AND PREPARATION 6

Table of Contents

SIGNATURE PAGE.......................................................................................................................II

ABSTRACT..................................................................................................................................III

PROBLEM STATEMENT............................................................................................................10

REVIEW OF LITERATURE........................................................................................................12

SEARCH STRATEGY....................................................................................................................12DEFINITION OF STANDARDS OF CARE........................................................................................13HISTORICAL IMPACTS OF DISASTERS.........................................................................................14ETHICAL IMPACTS OF DISASTERS..............................................................................................15KNOWLEDGE AND EDUCATION OF NURSES FOR DISASTERS AND CSCS...................................18BARRIERS TO TRAINING.............................................................................................................23PREPARATION FOR POTENTIAL CSCS........................................................................................24

SUMMARY...................................................................................................................................25

OBJECTIVES AND AIMS...........................................................................................................26

RESEARCH QUESTIONS...........................................................................................................26

METHODOLOGY........................................................................................................................26

DESIGN.......................................................................................................................................26SAMPLE......................................................................................................................................27TOOL..........................................................................................................................................28ETHICS AND HUMAN SUBJECTS PROTECTION............................................................................32PROCEDURE FOR DATA COLLECTION.........................................................................................32

ANALYSIS....................................................................................................................................33

RESULTS......................................................................................................................................36

DEMOGRAPHIC ITEMS................................................................................................................36MEANS AND PERCENTAGES OF SURVEY ITEMS.........................................................................38ALLOCATION OF RESOURCES.....................................................................................................42KNOWLEDGE AND PREPARATION: TOTAL SCORE......................................................................42KNOWLEDGE SCORE...................................................................................................................44PREPARATION SCORE.................................................................................................................46FAMILIAR WITH CRISIS STANDARDS OF CARE...........................................................................47SELF-REPORTED COMPETENCE WITH WORKING IN A DISASTER OR PANDEMIC.......................49SCENARIO RESPONSES................................................................................................................51

Challenges of the CSCs scenario...........................................................................................51Preparation for a CSC scenario..............................................................................................52Training needed to prepare for scenario................................................................................53

DISCUSSION................................................................................................................................55WHAT IS THE LEVEL OF KNOWLEDGE OF EMERGENCY NURSES REGARDING CSCS?..............55KNOWLEDGE OF PLANS AND PROTOCOLS..................................................................................55


TRAINING AND EDUCATION.......................................................................................................56YEARS OF EMERGENCY NURSING..............................................................................................57PARTICIPATION IN TRAINING EVENTS........................................................................................58PARTICIPATION IN REAL-WORLD EVENTS.................................................................................59STATE LEVEL PUBLISHED CSCS................................................................................................59LIMITATIONS..............................................................................................................................59

CONCLUSIONS...........................................................................................................................60

IMPLICATIONS FOR PRACTICE..............................................................................................61

FUTURE RESEARCH..................................................................................................................61

CONCLUSION..............................................................................................................................62

REFERENCES..............................................................................................................................63

APPENDIX A: SURVEY TOOL..................................................................................................74

APPENDIX B: APPROVAL LETTER FROM NATIONAL ACADEMIES PRESS..................84

APPENDIX C: IRB APPROVAL FROM BIDMC.......................................................................85

APPENDIX D: IRB APPROVAL FROM SIMMONS.................................................................86


Understanding Emergency Nurses’ Knowledge of and


Introduction

Background

The sequelae of disaster events continue to occur in all areas of the world despite the

best efforts of emergency planners to mitigate risks to the public and other groups. Events in

the last 20 years such as Hurricane Katrina, Superstorm Sandy, the Joplin tornado and, more

recently the 2017 hurricane season, have demonstrated the vulnerability of healthcare

facilities to catastrophic failures because of weather-related events. Global pandemics such as

the emergence of Ebola virus disease and severe acute respiratory syndrome (SARS) have

challenged standard infection control practices and training used in hospitals daily (National

Institute for Occupational and Safety Health, NIOSH, 2017; Venkat, et al., 2015). These

events along with others have had a significant impact on the communities they occurred in

and have caused considerable strain on the healthcare systems in those specific areas.

Scarce Resource Allocation

In situations where usual care delivery systems are overwhelmed or unavailable due

to natural or human made disaster events, the need for routine care will need to be augmented

by other specialized care needs as resource demands increase (U.S. Department of Health

and Human Services (HHS), 2017). Knowledge of crisis standards of care (CSCs) for

nurses and other healthcare professionals is needed during disasters. CSCs have been

defined as the “substantial change in the usual health care operations and the level of care

that is possible to deliver” (Institute of Medicine (IOM), 2009, p. 3). CSCs are designed to


give guidance and structure in situations where normal care delivery activities may not be

possible. These guidelines can aide in the delivery of resources, triage decisions, and

subsequent allocation of these resources (HHS, Office of the Assistant Secretary for

Preparedness and Response, 2012; Kluge, 2017; Michigan Department of Health & Human

Services, 2012). In any disaster, there will be ethical concerns raised such as the

management of scarce resources and prioritization of care (Hodge, Hanfling & Powell,

2013). The existence of structured and vetted guidelines will help clinical staff navigate such

challenging situations and ensure community support for the healthcare system

CSCs describe the steps needed to adjust the decision making related to allocation of

resources or treatments during a set period. An example of this would be in the setting of a

novel infectious outbreak such as the SARS case. In a situation where there is an expectation

for high numbers of patients requiring mechanical ventilation, there may not be enough

ventilators in the area (Huang et al., 2017). A retrospective review done by the Centers for

Disease Prevention and Control (CDC) modeled data from the 2009 influenza season against

prior pandemics with higher virulence such as the 1918 influenza event. The study, looking

specifically at the resources within the state of Texas, found that hospital supplies of

mechanical ventilators would fall short of needs (CDC, 2017). CSCs would help guide the

decision making and triage associated with which patients would be eligible for a ventilator

and who would be given palliative care. The specific resources may be a single resource

such as an intensive care bed or ventilator, as in the scenario surrounding the SARS outbreak

in 2003, or wide-reaching, such as seen in the generalized collapse of the healthcare

infrastructure in Haiti after the 2010 earthquake.

Disaster Triage


The usual goal of triage of care in hospitals as described by Gawande (2010) is to

identify the resources needed for each patient and then determine the process for matching

those resources and needs without concern for exhaustion of resources. In disaster care, the

paradigm changes from offering the maximum resources to one patient to doing the greatest

good for the greatest number (Baker, 2007). When a disaster occurs, it is expected that this

shift in practice may pose an ethical dilemma to nurses. Disaster triage follows a utilitarian

theory approach to care and triage of limited resources that allows for the care of the

population and not the individual (Beauchamp & Childress, 2013; Wagner & Dahnke, 2015).

Preparedness and Mitigation

The preparation for events of a magnitude such as Hurricane Katrina or the Haitian

earthquake relies on the engagement of key stakeholders in the medical community. In the

event of a large-scale pandemic, it is anticipated that over 9.9 million people will seek care in

healthcare facilities (Levin et al., 2009). Nurses will play a vital role in any such event,

therefore, understanding the knowledge and preparation of nurses will allow for the highest

success in healthcare delivery. In a 2009 report by the IOM, education and preparation of

nurses in emergency preparedness are noted as essential to ensure the healthcare workforce is

ready and prepared to respond when needed (IOM, 2009; World Health Organization and

International Council of Nurses, WHO and ICN, 2009).

Problem Statement

The ability for emergency nurses to execute CSCs leads to the need to assess their

current knowledge related to disaster planning, response, and CSCs. In the event of a

catastrophic event, the public will undoubtedly look to the healthcare system to be a reliable

source of care and comfort. The ability for these guidelines to be established as part of


mitigation and planning is essential to allow staff to understand their role in these situations.

The nurse's efficacy in these situations may be challenged by a lack of resources, insufficient

workforce, or being faced with a novel illness without existing, known treatment options.

The WHO and ICN (2009) published a set of competencies for nurses in disaster situations.

These competencies identify the role and set of skills nurses should have in preparedness and

response activities such as performing a community risk assessment as part of mitigation.

Despite published competencies, the nursing community is lacking a consensus on the type

and frequency of training that would achieve these competencies (Gebbie, Hutton, &

Plummer, 2012; Hodge, Miller & Skaggs, 2017). The lack of consensus for recommended

training was described by Slepski (2007) and Labrague et al. (2018) who reported that there

were no studies that have identified or verified that there exists an adequately trained group

of volunteer clinicians within medical facilities to care for injured patients in the event of a

mass causality incident.

The creation of hospital and governmental policies related to response and recovery

requires input from nurses as they are key stakeholders. For example, nursing input is needed

for the development of policies related to use of unlicensed personnel and inclusion of health

care providers from outside the disaster jurisdiction. Frameworks that guide medical staff in

the situations where CSCs may be used cannot be created without the full involvement of

nursing professionals. The role of the nurse in a disaster setting is to help provide

assessments of community needs and then contribute to the development of strategies for

mitigation and recovery (WHO and ICN, 2009).

While there has been published information related to the education and activities that

nurses should be involved in, there has not been an assessment to determine if current


disaster training is useful in providing a level of knowledge that ensures adequate preparation

of frontline nurses (Magney, Munuz, S., Munoz, M., Munoz, R., Muro, 2011; Murray, 2012).

This lack of research to determine the type of training that is beneficial was an essential

aspect of this study and an opportunity for further research. Understanding how exposure to

real-world events and drills, years of nursing practice, level of education, and working in a

designated trauma center relate to both knowledge and preparation of emergency nurses can

aide in the development of training recommendations for all emergency nurses.

Review of Literature

Search Strategy

A database search was conducted using both the CINAHL and MEDLINE to review

the current literature on the subject of disaster preparedness using the keywords: Crisis

standards of care; disaster care; knowledge of disaster preparedness; and pandemic planning.

The online search was initially started with the direct topic of crisis standards of care and

resulted in 67 articles published between 2000 and 2017. This range of dates was chosen to

include the attacks of September 11th and subsequent response as part of the possible

literature available. The search was expanded with the addition of searches for allocation of

scarce resources; triage of resources; along with reviews of cited works. The published work

of the IOM on CSCs presented a large body of information and also an expansive list of

currently published works for review (IOM, 2009). Moreover, HHS and the Technical

Resources Assistance Center and Information Exchange (TRACIE) websites were utilized

for possible search terms and articles. The expanded search along with the review of cited

works produced an additional set of articles for review.


Included works were English language or translated from other languages. Articles

from other countries were included if peer review was completed and medical infrastructure

was similar to the United States. As much of the research and publication related to disaster

response and preparedness is based on government support, these documents were also

reviewed. Reports published by governmental agencies were included. This left 55 peer-

reviewed articles and 19 technical documents from both Federal and State agencies to be

included in the review.

Definition of Standards of Care

The definition of CSCs has been refined over time since the original 2009 American

College of Emergency Physicians (ACEP) article, which described the allocation of scarce

resources (Hick, Hanfling, & Cantrill, 2011). CSCs are defined as occurring when there is a

substantial change in the ability to deliver services and a need for alternative healthcare

decision-making strategies (Hick et al., 2011; IOM, 2010). The IOM defined CSC as a

“substantial change in the usual health care operations and the level of care it is possible to

deliver… justified by specific circumstances… and formally declared by a state government

in recognition that crisis operations will be in effect for a sustained period” (IOM, 2012,

p.18). HHS identified those disaster situations representing a risk to public health, and in

2009 the agency asked the IOM to develop a framework that could be used to guide decision-

making during crisis events (IOM, 2012). The workflows and programs that support CSCs

are described by Ciottone, et al. (2016) as the need for transparent stewardship of resources

by those involved in the response rather than adherence to a set of protocols or list of

procedures.


The management of care in disaster situations was initially called altered standards of

care, but was later renamed as crisis standards of care (IOM, 2009). This change was made

to emphasize that while there are situations in which care may be altered, it does not support

or endorse substandard care. While the literature presents a definition of CSCs and

descriptions of potential impacts, there is little published information about the associated

education or training necessary for nurses who are likely to be working in these situations.

The American Nurses Association (ANA), Emergency Nurses Association (ENA),

Association of Public Health Nurses (APHN), Association of State and Territorial Health

Officials (ASTHO) and other professional organizations all have statements that endorse the

nursing role in disaster planning and response (ANA, 2002; ASTHO, 2017; APHN, 2014;

ENA, 2014; APHN, 2014). Specifically, the ANA (2002) has recommended that nurses

develop plans for themselves and their families, understanding that responding to

emergencies can have an impact both at home and in the workplace. They also suggested

that all nurses be proactive in gaining knowledge and skills through continuing education

courses and by participating in emergency drills (Murray, 2012).

Historical Impacts of Disasters

The scope of disasters worldwide has been cataloged by the Centre for Research on

the Epidemiology of Disease (CRED). According to CRED, between 1994 and 2013, there

were 6,873 natural disasters worldwide affecting 218 million people and claiming nearly

68,000 lives (CRED, 2015). This number of events equates to the fact that 75 percent of the

world has been impacted by a disaster in that 19 year period (WHO and ICN, 2009). In

2013, CRED reported that 529 disasters occurred worldwide in that one year, ranging from

natural disasters to technologic failures such as loss of power or the collapse of a highway


bridge (Hodge, Miller, & Skaggs, 2017). The scope and occurrence of disasters have also

increased in recent time. Leaning and Guha-Sapir (2013) reviewed published data available

from 1950 through 2012 and confirmed a substantial rise in annual events worldwide from 18

in 1950 to 318 in 2012 with a peak economic impact of $370.6 billion in 2011 (CRED,2015)

Events in recent memory ranging from the September 11, 2001 attacks to the Ebola

pandemic in 2014 have brought to focus the risk that the healthcare system may become

compromised in the face of a mass casualty event (AHRQ, 2005). Because crisis care shifts

the focus from matching maximum resources to a position of ‘do the best for the greatest

number of people,' the IOM specifies that CSCs should be initiated “only when no

alternatives are possible.” (IOM, 2009) The differences in how resources are allocated in

situations from conventional care to CSCs are illustrated in Figure 1 (Hick et al., 2011).

Figure 1. Allocation of example resources across the continuum from conventional care to

crisis standards of care (Hick et al., 2011).


Devastating events, such as the Japanese earthquake and tsunami in 2011 illustrated

how susceptible the medical systems can be to unplanned events as experienced with the

subsequent failure of the Fukushima Daiichi nuclear power plant and release of radiologic

contamination to the local community (IOM, 2012; Nohara, 2011).

Ethical Impacts of Disasters

If CSCs are enacted, there will be ethical and moral concerns raised by healthcare

workers and the public. The primary concerns for healthcare workers are expected to center

around allocation of resources and triage of patients (Wagner et al., 2015). The community

will need to have confidence in the healthcare system to provide care in a just and ethical

manner (ACEP, 2013; Daugherty et al. (2014). In a review of the 2003 SARS outbreak that

challenged the medical infrastructure, the University of Toronto published the paper “Stand

on Guard for Thee: Ethical considerations in preparedness planning for pandemic influenza”

(Upshur et al., 2005). The paper discussed the ethical considerations that were seen during

the pandemic and made recommendations for future events. The authors described that, in

general, healthcare systems had not made preparations for the need for hard ethical choices

that arose during the SARS pandemic. This included the concerns of staff that were afraid

that while caring for patients, they would become ill as well as concerns for the risk and

safety of their families (University of Toronto Joint Centre for Bioethics Pandemic Influenza

Working Group, 2005).

Other descriptions of ethical concerns were published in the aftermath of the 2010

earthquake that occurred in the island country of Haiti. In the aftermath of the earthquake,

triage decisions needed to be made to match the limited resources with the substantial need

present. In a case report by Goodman & Black (2015), an example of limited oxygen is


described. Prior to the earthquake, the Haitian healthcare system was heavily funded by

outside agencies and non-governmental organizations (NGOs). The standard of care for

patients with significant injuries was often to evacuate the patients off the island to other

countries with more stable medical care (Etienne, Powell, & Amundson, 2010). In the days

and weeks that followed the earthquake, disaster medical teams from around the world

arrived to support the response. The Israeli team that was located at the international airport

published their account of the ethical issues associated with CSCs and the triage of resources

(Merin, Ash, Levy, Schwaber, & Kreiss, 2010). In addition to the imbalance of resources and

demands, the Israeli team also recounted the struggle about how to manage patients who had

been rescued.

The ethical concerns of choosing when to enact CSCs was recounted by one of the

care responders:

“We believed it would be inappropriate to deny treatment to a patient who had

survived days under the rubble before a heroic rescue, even though this policy

meant potentially diverting resources from other patients with a better chance of a

positive outcome. Indeed, one patient who was rescued a week after the quake

was brought to us in dire condition. She was admitted, was intubated, and

underwent surgery but ultimately did not survive.” (Merin, Ash, Levy, Schwaber,

& Kreiss, 2010, p. 2)

The issues that arose in Haiti were not unique to an under-resourced developing

island country. In the U.S., just five years earlier in 2005, Hurricane Katrina became a key

incident in the discussion of the effectiveness of implementing CSCs. Hurricane Katrina was

a Category 5 hurricane with devastating wind and deadly floods. In the aftermath of the


initial storm, thousands of people were stranded in various locations from makeshift shelters

to hospitals. At Memorial Medical Center, the primary electrical power supply and then the

backup generators failed to create the horrific situation of silence of all the critical medical

equipment (Schaffer, 2013). Schaffer went on to describe the dire situation in which

healthcare providers worked in darkness and without critical medical equipment, air

conditioning, or functioning toilets (Schaffer, 2013). Doctors and nurses made decisions, at

times without the informed consent of their patients. This lack of patient autonomy was

uncovered when autopsies were performed on the victims revealing that some patients had

unexpectedly high levels of Morphine or Versed. Subsequently, this finding led to homicide

charges brought against members of the healthcare team (Gebbie et. al, 2009; Schaffer,

2013). In a review of records, it was discovered that doctors ordered and administered doses

of Morphine and Versed that raised questions about whether the intention was pain relief or

euthanasia. The hospital conditions in which these decisions were made had never been

experienced in recent United States history and were a surprising illumination of the state of

our emergency preparedness systems.

Although there are similarities between the Haitian Earthquake and Hurricane

Katrina, the differences may be in the training and preparations between the Israeli team and

the United States caregivers. In Haiti, the Israeli teams that responded had experienced

structured, established training programs with well-developed plans to mitigate ethical

concerns. In New Orleans, the staff may not have had the training or education needed to

guide these difficult medical decisions and associated ethical challenges.

Knowledge and Education of Nurses for Disasters and CSCs


Disaster education has moved from the purview of military and emergency nursing to

be seen as a core competency that is part of education for both the undergraduate and

postgraduate educational groups (Fitzpatrick, 2008; Garbutt, Peltier, & Jacobson et al., 2010;

Langan, Lavin, Wolgast, & Goodwin Veenema, 2017). Education related to disaster

preparedness and the triage of resources has been included as part of the educational program

of the ENA’s Trauma Nursing Core Course (TNCC) (ENA, 2014). However, there is no

explanation of CSCs throughout the program’s text (ENA, 2014). The lack of CSCs

coverage in this program illustrates that while disaster education is improving, there are still

gaps in education and training.

Nurses have a history of responding to calls for help, and in the acute phases of an

emergency or disaster, they may feel a duty to respond. Nurses may respond across state

lines either through established programs or if they self-deploy to an area. However, without

adequate training and education related to CSCs, nurses may be placing themselves or others

at risk (WHO and ICN, 2009). This was illustrated in a report on the 2003 earthquake that

struck outside Bam, Iran which destroyed the established medical system (Nasrabadi, Naji,

Mirzabeigi, & Dadbakhs, 2007). In Bam, nurses who did respond were ill-prepared and

worked without protocols and often in the dark. According to a study done after that event,

nurses reported feelings of hopelessness and dissatisfaction (Nasrabadi et al., 2007). The

study found a need for protocols and hospital policies for the structure of disaster response

along with teamwork and education in disaster nursing (Nasrabadi et al., 2007).

The lack of standardized education has been demonstrated to have a negative impact

on the level of perceived preparation by nurses in various settings (Schmidt et al., 2011;

Slepski, 2008; Veenema et al., 2017). In a study of nursing students, Schmidt et al. (2011)


reported that the students, in particular, had developed an understanding of disaster nursing

based on media depictions and were unclear about roles and responsibilities. The authors did

note that despite a lack of knowledge, the group was willing to be involved in disaster

response. While the study was done in Australia, the outcomes can be applied to the nurses

within the US.

The IOM report in 2010 highlighted the lack of training and education as a complex

problem. In the situations in which CSCs are used, there will be a diverse group of

responders from various backgrounds and with mixed clinical experience. The diversity of

backgrounds of the responders can pose a challenge if the team’s makeup is not

complimentary. The development of a healthy team dynamic requires training. This need for

training will require the support from leadership at all levels (IOM, 2010).

The WHO and UN collaborated to build an international coalition to address

perceived risks in the aftermath of a large-scale disaster. In 2009, the group published the

ICN Framework of Disaster Nursing Competencies (ICN, 2009). The work of the ICN

focused attention on nursing disaster competencies and is included in reviews of past works,

training materials, and existing protocols. The organization of the framework moves from

pre-incident to response and then to recovery efforts. Prior to an incident occurring, nurses

should be well versed in prevention and mitigation strategies. This includes knowledge of

policies and involvement in planning in the development of response plans. In the response

window, care of the community, care of individuals, psychological care, and care of

vulnerable populations are all aspects that are described in the ICN framework. Figure 2

shows the competencies divided into four groups of prevention/ mitigation, preparedness,


response, and recovery.

Figure 2. ICN Framework of Disaster Nursing Competencies

Slepski (2007) conducted a survey of 200 doctors, nurses and other health

professionals at a regional conference to assess the self-reported competency of medical

providers who participated in a hurricane response. Of the respondents, 56.5% responded to

Hurricane Katrina, 6% responded to Hurricane Rita and 37.5% to both events. The majority

of respondents (78%) reported having the ability and competence to perform key aspects of

disaster care. The high percentage of positive responses may have been due in part to the

background and training of the participants. The majority of individuals (94%) reported that

they deployed to these events as part of a structured team such as the National Disaster

Medical Service (NDMS) or US Public Health Service (USPHS). These organizations have

structured training and education-based core competencies that review expectations inclusive

of CSCs. The training these organizations provide is further demonstrated by the open-ended


responses from participants where these events were their first exposure to a disaster event.

These participants reported concerns and challenges such as the process for triage, lack of

resources or medications, and psychological care of patients and providers (Slepski, 2007).

Unique challenges to field responses were also reported such as the use of point-of-care lab

equipment and oxygen concentrators (Slepski, 2007). Because the study only surveyed a

convenience sample of respondents related to two US hurricanes, the generalizability of this

into practice is not clear. Also, the tool utilized was created by the author and validity of the

tool was not reported.

The risks associated with deployment to a disaster situation were also reported during

the response to the 2010 Haiti earthquake. In the weeks that followed a large and mostly

uncoordinated response occurred from both governmental and non-governmental

organizations (NGOs). The majority of the NGOs or individuals traveled on their own in a

medical tourism model that was described by Van Hoving, Wallis, Docrat & De Vries

(2010). These groups arrived on the island without clear structure or operating procedures to

prepare the group for the situations that they would face.

In preparation for response to disaster situations, the necessary nursing competencies

directly related to disaster planning and response need to be established. The need for

education to match competencies has been endorsed by nursing experts in the US (Langan,

Lavin, Wolgast, & Veenema, 2017;Veenema, Griffin, et al., 2016). The first examples of

competencies identified were from 2003, published by the International Nursing Coalition for

Mass Casualty Education (Gebbie et al., 2012). These competencies were critiqued by

Gebbie et al. (2012) as lacking outcome measures and a conceptual framework, yet this work

was credited for guiding improved competency development by other groups. Despite the


initial work, to date, there is a dearth of research on the specific types of training or

frequency of training that should be in place to demonstrate competency (Gebbie, Hutton, &

Plummer, 2012; Hodge, et al., 2017; Littleton-Kearney & Slepski, 2008).

Although many studies have demonstrated positive impacts of disaster training there

remains a need to obtain nurses’ opinions about the specific types of training that have been

useful and would be most useful to them (Skryabina, Reedy, Amlot, Jaye & Riley, 2017).

There is also a need for studies that examine how demographic variables, such as years of

experience, are related to disaster knowledge and preparation.

A 2008 systematic review looking at the effectiveness of disaster training for

prehospital care providers was not able to find an evidence-supported model of education

(Williams, Nocera & Casteel, 2008). The study used an electronic search of multiple

healthcare databases looking for articles demonstrating associations between emergency care

and disaster training. In total, 227 articles were found in the search, and after review by the

authors, nine final articles were selected for review. Articles were included that described

drills or training and evaluated knowledge or skills during the response. The studies largely

covered online or instructor-led sessions and not high fidelity simulation or live drill

exercises. Their findings demonstrated that various types of learning may have benefits, but

a standardized evaluation system would allow for better validation of training types

(Williams, Nocera, & Casteel, 2008).

Nurses self-assessment related to generalized disaster response has been noted by

several articles as being low to moderate, representing a need for continued training

(Baack&Alfred, 2013; Fung et al., 2008; Hodge et al. 2015; Labrague et al., 2018; Skryabina

et al., 2017). In one article, Skryabina, Reedy, Amlot, Jaye & Riley (2017) looked at self-


reported outcomes after disaster training events including confidence and knowledge of

nurses and other healthcare providers. In that study, the authors concluded that there was a

benefit and an increase in self-reported confidence and understanding when exposed to drills

or training environments (Skryabina et al., 2017). However, there remains a lack of

validation that the educational exercises had a direct impact on operational outcomes due to

challenges in tracking subjects over time and studying the influence of training on

performance in actual disaster events.

The frequency of training that should be provided is discussed by Labrague et al.

(2018) as being related to nurses’ level of perceived preparation. Another finding of this

review was that previous disaster response experience to actual disaster events and having

disaster-related training and exercises is seen as important in preparing nurses for disasters.

However, it is not clear from the reviewed research what type of disaster-related training is

effective in adequately preparing nurses (Labrague et al., 2018).

Barriers to Training

Barriers to training and education are often related to a lack of funding to accomplish

the suggested training (Schultz, Koenig, Whiteside, & Murray, 2012). But ultimately,

training and preparation can play a role in mitigation and recovery, thereby reducing

operational and financial impacts. The calculated impacts of disasters worldwide have been

in excess of 800 billion dollars between 2005 and 2012 (Leaning & Guha-Sapir, 2013; WHO

& ICN, 2009). The financial risks associated with disasters supports the need for investment

in training to build a responsive, efficient, and competent staff.

Preparation for Potential CSCs


Preparation for events that could lead to CSCs is linked to the potential risks that are

present in the regional area. Hazard vulnerability assessments have been advocated by

groups such as The Joint Commission (TJC) as part of emergency preparedness standards

(ACEP 2011; Campbell, Trockman, & Walker, 2011). The TJC has published as part of the

Environment of Care newsletter that CSCs should be included as part of hospital planning for

events that extend to 24 hours and beyond (TJC, 2015). These tools can be used to identify

the specific risks that may exist within the region that a hospital or healthcare organization

cares for. Depending on the geographic location, concerns such as hurricanes may be a

significant risk such as in the US Gulf coast. This is in contrast to higher concerns for an

earthquake along the Pacific Coast with population centers such as San Francisco, Los

Angeles or Anchorage.

Part of preparation and mitigation also includes the need to identify the possible

secondary impacts on medical staff in the occasions of CSCs implementation. O’Boyle et

al. (2006) conducted focus groups with Midwest nurses who worked at hospitals that were

designated as receiving hospitals in the event of a public health emergency. The group

interviews revealed that nurses abandoning their shift or leaving their care assignment in the

face of an emergency was a theme that emerged (O'Boyle, Robertson, & Secor-Turner,

2006). The authors discussed that the theme of abandonment arose from other concerns such

as chaos, lack of safety in the environment, loss of freedom and limited institutional

commitment. The study was limited by the small number of participants in the focus groups

and by the bias of a self-selected group. While the experiences of the nurses in the group

might represent that geographic area, the authors do explain that this same theme had been

described in other published works such as the report from the University of Toronto


(O'Boyle et al., 2006; University of Toronto Joint Centre for Bioethics Pandemic Influenza

Working Group, 2005).

Summary

Disasters that challenge health care services will continue to occur throughout the

world due to both human made and natural causes. Although nurses may be expected to

have an ability to respond to any disaster, the lack of knowledge in critical situations may

have negative impacts both on clinical outcomes and recovery. As noted by Nasrabadi et al.

(2007), nurses will undoubtedly be compelled to respond and support disaster responses

either as part of their required scope of practice or because they feel ethically obligated to

help. The ability for nurses to successfully respond to disaster situations is linked to their

individual preparation and training.

In order to develop planning and education recommendations for nurses, their current

knowledge and preparation must be first assessed. With the information that can be gained

from this study, the potential need for additional training and education can be recommended

to key stakeholders in emergency and disaster nursing education and operations.

The continued development of CSCs will require collaborative decision-making by

governmental agencies and healthcare providers. The CDC (2011) published the document

Public Health Preparedness Capabilities: National Standards for State and Local Planning.

The document contained essential capabilities that should be reviewed and developed by

each state or territory. Included in the document is a recommendation that medical care

groups should work together in a collaborative manner to define and operationalize CSCs

(CDC, 2011; HHS, Office of the Assistant Secretary for Preparedness and Response, 2012,

HHS, N.D.).


Objectives and Aims

The purpose of this study was to assess the current knowledge and preparation of

emergency nurses as related to CSCs. Published works highlight the need for competency-

based learning for nurses and other allied health professionals (Hodge et al., 2017; Slepski,

2007; WHO, 2007; Yamamoto, 2013). Understanding the current level of knowledge and

degree of preparation is important to help guide and build an ongoing nursing practice and

education related to CSCs. There is a need for describing the current state of knowledge and

preparation of nurses, associated explicitly with CSCs, who may be asked to execute these

medical decisions. This study also examined the association between both respondent and

workplace demographic factors and emergency nurses’ knowledge of and preparation for

CSCs.

Research Questions

1) What is the level of knowledge of emergency nurses regarding CSCs?

2) What is the level of preparation of emergency nurses regarding CSCs?

3) How do emergency nurses’ knowledge and preparation regarding CSCs relate to

participation in real disasters or practice drills, years of experience, level of

education, and working in a designated trauma center?

Methodology

Design

This capstone used a quantitative and qualitative survey methodology to assess the

current knowledge and preparation of emergency nurses related to CSC’s. This was a cross-

sectional study using a convenience sample of emergency nurses. The study assessed the

association between level of knowledge/preparation and participation in real disasters or


practice drills, years of nursing experience, highest degree earned and working in a trauma

center.

Sample

The sample for this study was recruited from two sources: 1) current emergency

medicine nurses at Beth Israel Deaconess Medical Center (BIDMC) in Boston,

Massachusetts and 2) emergency nurses recruited through social media. A snowballing

technique was used to recruit participants through Facebook, Twitter, and LinkedIn. The

snowballing technique was implemented by posting a link to the survey on the author’s social

media accounts. From the original post by the author, the information was shared by others

through their social connections to reach a final audience. To account for individuals who

might have received the survey, but did not have emergency nursing experience, a screening

question was built into the survey to exclude participants without emergency nursing

experience.

Inclusion criteria were being a nurse with current or past emergency nursing

experience, living in the US, and having both English and computer proficiency. Paper

surveys or translated versions were not created. Participants were excluded if they had zero

years of emergency nursing experience and received a message on the survey tool thanking

them for their time.

While the use of social media was successful in recruiting subjects, the exact response

rate could not be determined because the survey was anonymous and it was not known

whether a respondent was from BIDMC or recruited through social media. In addition, it

cannot be determined how many nurses who met inclusion criteria viewed the survey link on

the social media sites in order to compute response rate.


A total of 148 participants started the survey through the online link provided through

email or social media. Data review was completed before any data analysis. People who did

not complete the knowledge and preparation questions and/or demographics items were

removed. Participants who completed the survey, but did not complete the open-ended

questions were included. This resulted in a final sample size of 125 respondents.

Tool

A new survey tool was developed for use in this study by the author of the capstone

(see Appendix A). The survey is a modification of the survey tool developed by the IOM.

Reprinted with permission from Crisis Standards of Care: A Systems Framework for

Catastrophic Disaster Response 2012 by the National Academy of Sciences, Courtesy of the

National Academies Press, Washington, D.C. Permission for use and modification was

granted from the National Academies Press (see Appendix B).

The modified tool used in this study was reviewed by three subject matter experts for

content and relevance of items to the topic. Each of these individuals have served as a

content expert for local and national disaster plans along with CSCs planning. Suggestions

for content and layout were reviewed and edits completed. The completed tool was

pretested by distribution to a group of cardiac intensive care nurses (n=12) and emergency

preparedness project managers (n=6). These participants were asked about the layout of the

survey, ease of navigation, and wording of questions. Based on their feedback, examples of

disaster training types were added to the final survey. Two questions related to exposure to

the allocation of resources were changed from a five-point scale to yes/no responses based on

feedback. An open-ended hypothetical scenario section was included, and the original two


questions were broken into four individual questions. All responses from the pretest were

deleted before the final survey was sent out.

The survey tool consists of 14 demographic items, 23 questions rated on a 5-point

Likert scale, two yes/no items, and four open-ended questions based on a hypothetical crisis

scenario. The scenario was taken from the IOM CSC framework, with permission, and

presented a situation where an earthquake in a metropolitan area would force the use of CSCs

(IOM, 2012). The survey asked for demographic information about individual participants

(e.g., age, gender, and nursing experience), knowledge about CSCs, and an assessment of

participation in disaster training and disaster response to real events. Respondents were

asked to specify in which state they live in order to determine whether the 10 FEMA regions

in the US were represented in the sample.

The IOM (2012) survey was modified for this study in order to map each of the

knowledge and preparation questions to a competency group as identified by the ICN report

published by the WHO in 2009 (WHO and ICN, 2009) (see Table 1).

Table 1

Mapping of Knowledge and Preparation Questions to ICN CompetenciesStudy Question ICN Framework Competency

I am aware of classes about disaster preparedness and management that are offered, for example, at my workplace or community.

5.1- Maintains knowledge in areas relevant to disaster and disaster nursing.

I know whom to contact (chain of command) in disaster situations in my workplace or community.

4.1 Describes the chain of command and the nurse’s role within the system.

I know where to find relevant research or information related to disaster preparedness and management to fill in gaps in my knowledge.

5.3 Seeks to acquire new knowledge and maintain expertise in disaster nursing.


5.5 Evaluates the need for additional training and obtains required training.

I am familiar with the term Crisis Standards of Care. 2.1 Demonstrates an understanding of relevant disaster terminology.

I am familiar with the START triage protocol used in disaster situations.

7.1 Performs a rapid assessment of the disaster situation and nursing care needs.

I am familiar with principles to guide allocation of resources used in disaster situations.

7.2 Applies critical, flexible and creative thinking to create solutions in providing nursing care to meet the identified and anticipated patient care needs resulting from the disaster.

In the event of a major disaster or pandemic, I am aware of protocols in place to guide care.

1.1.6 Understands the principles and process of isolation, quarantine, containment and decontamination and assists in developing a plan for implementation in the community.

In the event of a major disaster or pandemic, I am aware of my hospital's and our department's emergency operations plans or know where to find them.

2.5 Recognizes the disaster plan in the workplace and one’s role in the workplace at the time of a disaster.

It is better to save the most lives-even if it means that some people won't receive all of the medical care they would get under normal conditions.

7.2.3 Applies accepted triage principles when establishing care based on the disaster situation and available resources.

Age of patients alone should determine decisions about who will receive care or resources.

9.1 Describes vulnerable populations at risk as a result of a disaster.

In a disaster situation, the most medical care should go to patients who probably will die unless they receive treatment.

7.2.4 Adapts standards of nursing practice, as required, based on resources available and patient care needs.


Health care providers should be allowed to perform services outside of their scope of practice if that might save more patients.

3.3.1 Accepts accountability and responsibility for one’s own actions.

Every hospital in the disaster area should be able to make their own decisions when deciding how to use limited medical resources.

1.2.10 Manages resources and supplies required to provide care in the community.

Individual health care providers should be free to make their own decisions about which patients will get treatment and which ones will not.

3.2.1 Practices in accordance with local, state, national and international applicable laws.

Patients should be given medical care or resources if they will survive, but may end up severely disabled.

7.2.1 Implements appropriate nursing interventions including emergency and trauma care in accordance with accepted scientific principles.

I read journal articles related to disaster preparedness on a regular basis.

5.3 Seeks to acquire new knowledge and maintain expertise in disaster nursing.

I find that the research literature on disaster preparedness is understandable.

5.1 Maintains knowledge in areas relevant to disaster and disaster nursing.

I participate in disaster preparedness educational activities (e.g., classes, seminars, or conferences) on a regular basis (every year or more frequently).


I participate in disaster drills or exercises at my workplace (e.g., clinic, hospital, etc.) on a regular basis (every year or more frequently).

5.2 Participates in drills in the workplace and community.

I have received training and education to prepare me for working in situations requiring allocation of scarce resources or services.


I have support in place to help me with ethical concerns that may be raised during a disaster should there be a need to triage scarce resources.

3.3.1 Collaborates with others to identify and address ethical challenges

I am competent/comfortable working in the environment of a disaster or pandemic.

5.7 Describes the nurse’s role in various disaster assignments s (e.g., shelters, emergency care sites, temporary healthcare settings, disaster coordination and management units).

In the event of a major disaster or pandemic, I understand who will make decisions about altering the

2.5 Recognizes the disaster plan in the workplace and one’s role


level of care to be provided. in the workplace at the time of a disaster.

Ethics and Human Subjects Protection

There was no expected risk to human subjects. The survey tool did not ask sensitive

questions and the scenario used was a fictional event. This study was approved by both the

BIDMC and Simmons College Institutional Review Boards (IRBs) (see Appendices C and

D). To maintain the privacy of participants, the survey was anonymous, and no individually

identifiable information was collected.

Procedure for Data Collection

The data collection for this study was done through email and social media

recruitment of emergency nurses. Email addresses for the emergency nurses at BIDMC were

used to send the online survey link to potential respondents. A snowballing technique was

used to recruit additional participants through the author’s Facebook, Twitter, and LinkedIn

accounts. The survey was open for a 16-day period in January and February 2018. A short

survey invitation (see Figure 3) was posted on the social media platforms on survey day 1

and then again on survey day 7.


Figure 3: Screenshot of the social media invitation

Study data were collected and managed using REDcap, an electronic data capture tool

hosted at BIDMC. REDcap is a secure, web-based application for research studies and

provides: 1) an intuitive interface for validated and secure data collection; 2) audit trails for

tracking data manipulation and export procedures; 3) automated export procedures for

seamless data downloads to common statistical packages, and 4) procedures for importing

data from external sources. A link to the survey was provided in the email invitation to

BIDMC emergency nurses and was included in the posting on social media.

Analysis

Quantitative data analyses were performed using IBM SPSS Version 24 software

(IBM SPSS Statistics, Armonk, NY) and qualitative analyses were conducted using

Microsoft Excel 2010. All data was checked for errors through review of frequencies, and no


errors were discovered. Survey items were analyzed using univariate statistics including

frequencies and percentages. The dependent variables used for bivariate statistical tests are

described below.

1. Total Knowledge and Preparation Score : This was calculated by summing

participants’ responses to all 23 Likert scale items which included both knowledge

and preparation questions. Each item consisted of a 5-point scale with assigned

numeric codes from 1=strongly disagree to 5=strongly agree or 1=strongly agree to

5=strongly disagree depending on whether strongly disagree or strongly agree was

associated with greater knowledge or preparation. Higher total scores were

indicative of greater knowledge and preparation. The range of possible total scores

was 23-115.

2. Total Knowledge Score : This was calculated by summing participants’ responses

to the 15 questions associated with knowledge. Each item consisted of a 5-point

scale with assigned numeric codes from 1=strongly disagree to 5=strongly agree or

1=strongly agree to 5= strongly disagree based on whether strongly disagree or

strongly agree was the correct response to the item. A higher code was always

associated with greater knowledge. The range of possible knowledge total scores

was 15-75.

3. Total Preparation Score : This was calculated by summing responses to the 8

preparation-related questions resulting in a possible range of total scores from 8 -

40. Each item consisted of a 5-point scale with assigned numeric codes from

1=strongly disagree to 5=strongly agree or 1=strongly agree to 5= strongly


disagree based on whether disagreement or agreement was associated with greater

preparation. A higher code was always associated with more preparation.

4. Question: I am familiar with the term Crisis Standards of Care : A 5-point scale

Likert scale was used for this item with assigned numeric codes from 1=strongly

disagree to 5=strongly agree.

5. Question: I am competent/comfortable working in the environment of a disaster or

pandemic: A 5-point scale Likert scale was used with assigned numeric codes

from 1=strongly disagree to 5=strongly agree.

The independent and dependent variables are listed in Table 2.

Table 2

Dependent and Independent Variables

Dependent Variables Independent Variables Total Knowledge and Preparation

Score Total Knowledge score Total Preparation score Question: I am familiar with the term

Crisis Standards of Care Question: I am competent/comfortable

working in the environment of a disaster or pandemic

Years in emergency nursing Highest degree earned Number of disaster training events in past

5 years Number of real-world disaster events in

the past 5 years Working in a Trauma Center

The means of each of the three total scores were compared across levels of the

independent variables. To allow for statistical testing, some categories within the

independent variables were collapsed if a group size had fewer than 15 people. Bivariate

analyses were performed using independent t-tests and one-way ANOVA testing with Tukey

post hoc tests.

Qualitative analyses were performed through a review of open-ended questions and a

thematic analysis was conducted. The open ended survey questions were analyzed for


thematic content. A coding scheme was developed after initial reading of a random sample of

the surveys. A Microsoft Excel spreadsheet of themes was created. This researcher then read

all survey responses to count the numbers of times that these common themes were

mentioned by respondents. Each response was numerically coded into one of the themes

with 1= mentioned in response and 0= not mentioned in response. Frequencies and

percentages of themes were calculated and reported. Coding was confirmed by a second

reader and any discrepancies were discussed and agreement reached.

Results

Demographic Items

Demographics of the respondents are displayed in Table 3. The sample consisted of

86.4% (n=108) females. A total of 50.4% (n=63) of nurses reported having a bachelor’s

degree. Years of emergency nursing was roughly equally distributed across the five

categories.

Table 3

Demographic Characteristics of Respondents

Demographic Item Frequency %Sex

MaleFemale

17108

13.6%86.4%

Age18-2526-3536-4546-5556-6566+

3303430234

2.4%24.2%27.4%24.2%18.5%3.2%

Years in Emergency Nursing1-5

6-102424

19.4%19.4%

11-1516-20

2518

20.0%14.4%


20+ 33 26.4%Highest Degree

AssociatesBachelorsMastersDoctorate

1763387

13.6%50.4%30.4%5.6%

Table 4 contains demographics related to respondents’ respective worksites. General

emergency departments represented the highest percentage of respondents (44.8%, n=56)

followed by adult only (30.4%, n=38) and then pediatric-only departments (4.0%, n=5).

There were 20% (n=26) of respondents that reported working in another department

currently. The description of other locations included flight nursing, urgent care, education

and critical care areas. The location of the departments were spread mainly between urban

(59.7%, n=74) and suburban/community (33.9%, n=42). A majority of respondents (69.4%,

n=86) work in a trauma center with Emergency Department (ED) annual volume above

50,000 visits (71.4%, n=85). Over half of the respondents were from FEMA Region I

(57.6%, n=68). The responses were received from 26 states with the majority from

Massachusetts (50.8%, n=60). This result is expected as the majority of the social media

contacts from the author and the email list from BIDMC would include nurses from this

state. States were grouped by FEMA regions with responses from all ten regions represented

to demonstrate generalization across the country.

Table 4

Demographic Characteristics of Respondent Worksites

Demographic Item Frequency %ED Volume (visits per year)


25,000 and less25,000 – 50,00050,001 - 75,00075,001 – 100,000More than 100

112352258

9.2%19.3%43.7%21.0%6.7%

Trauma CenterYesNo

8638

69.4%30.6%

FEMA RegionRegion IRegion IIRegion IIIRegion IVRegion VRegion VIRegion VIIRegion VIIIRegion IXRegion X

6844354241113

57.6%3.4%3.4%2.5%4.2%3.4%1.7%3.4%9.3%11.0%

Practice SettingGeneral EDAdult EDPediatric EDOther

5638526

44.8%30.4%4.0%20.8%

Geographic LocationUrbanSuburban/CommunityRural

74428

59.7%33.9%6.5%

Means and Percentages of Survey Items

The mean score, standard deviation, and score distribution by percent are presented

for all Likert scale items in Table 5 and Table 6 below. The number of responses varies

(n=121-125) as the respondents were not required to complete all items. Questions were

coded and assigned weights of 1-5. In Table 4, the highest score (coded as 5) is associated

with strongly agree to indicate greater knowledge and preparation. In Table 5, the highest

score is associated with strongly disagree (also coded as 5) because strongly disagree was

indicative of greater knowledge and preparation.


In Table 5, the mean for each question ranged from 2.80 – 4.31. Respondents were

most likely to agree that it is best to save the most lives (M=4.31, SD=.69) and that they

know whom to contact in a disaster situation (M=4.12, SD=.90). They also tended to agree

that they are familiar with the START triage protocol (M=4.03, SD=1.08) along with being

familiar with principles to guide the allocation of resources in a disaster situation (M=3.89,

SD=.99). Nurses were least likely to agree with the statements ‘I read journal articles related

to disaster preparedness on a regular basis’ (M=2.80, SD= 1.20) and ‘I participate in disaster

drills or exercises at my workplace (e.g., clinic, hospital, etc.) on a regular basis (every year

or more frequently) (M=2.85, SD=1.26).

Table 5

Item Means and Percentages for Items with Strongly Agree as the Highest ScoreStrongly Disagree Strongly Agree

1 2 3 4 5

Question Mean(SD) N % % % % %

I participate in disaster drills or exercises at my workplace (e.g., clinic, hospital, etc.) on a regular basis (every year or more frequently).

2.85(1.26)

123 13% 37% 14% 25% 11%

I read journal articles related to disaster preparedness on a regular basis.

2.80(1.20)

124 14% 34% 19% 25% 8%

I participate in disaster preparedness educational activities (e.g., classes, seminars, or conferences) on a regular basis. (every year or more frequently)

2.93(1.22)

124 10% 38% 13% 29% 11%

I am familiar with the term Crisis Standards of Care.

3.18(1.24)

123 10% 24% 22% 29% 16%


3.37(1.18)

124 7% 22% 16% 40% 16%


I have support in place to help me with ethical concerns that may be raised during a disaster should there be a need to triage scarce resources.

3.56(.97)

124 7% 20% 21% 40% 11%

I am aware of classes about disaster preparedness and management that are offered, for example, at my workplace or community.

3.6(1.17)

124 4% 20% 11% 41% 23%

In the event of a major disaster or pandemic, I am aware of my hospital's and/or department's emergency operations plans or know where to find them.

3.76(1.05)

124 2% 15% 16% 42% 26%

I am competent/comfortable working in the environment of a disaster or pandemic.

3.56(.97)

124 14% 27% 27% 42% 15%

In the event of a major disaster or pandemic, I am aware of protocols in place to guide care.

3.63(.98)

124 2% 13% 19% 50% 15%

In the event of a major disaster or pandemic, I understand who will make decisions about altering the level of care to be provided.

3.67(.92)

123 1% 14% 18% 53% 15%

Patients should be given medical care or resources if they will survive, but may end up severely disabled.

3.47(.86)

122 3% 11% 30% 51% 6%

I am familiar with the START triage protocol used in disaster situations.

4.03(1.08)

122 3% 11% 9% 37% 41%

I know where to find relevant research or information related to disasterpreparedness and management to fill in gaps in my knowledge.

3.81(.99)

124 2% 9% 19% 45% 25%

I am familiar with principles to guide allocation of resources used in disaster situations.

3.89(.99)

123 2% 9% 14% 47% 28%

I find that the research literature on disaster preparedness is understandable.

3.33(.82)

121 4% 6% 47% 39% 4%

I know whom to contact (chain of 4.12 124 1% 7% 11% 44% 38%


command) in disaster situations in my workplace or community.

(.90)

It is better to save the most lives-evenif it means that some people won't receive all of the medical care they would get under normal conditions.

4.31(.69)

123 0% 2% 8% 48% 42%

Note. Strongly agree was the highest score1- Strongly Disagree, 2- Disagree, 3- Neutral, 4- Agree, 5- Strongly Agree

In Table 6, each item consisted of a 5-point scale with assigned numeric codes from

1= strongly agree to 5= strongly disagree. The calculated mean for each question ranged

from 2.88– 4.11. Respondents were most likely to disagree that age of patient should be the

primary factor in the allocation of resources in a disaster situation which is the correct

response (M=4.11, SD=.77). They also tended to disagree that healthcare providers should

be allowed to make decisions about allocation of resource alone which is also the correct

response (M=3.80, SD=.92). Nurses were more likely to agree that healthcare providers

should be allowed to work outside their scope of practices (M=2.88, SD=1.17) even though

this is not supported or endorsed.

Table 6

Item Means and Percentages for Items With Strongly Disagree as the Highest Score

Strongly Agree Strongly Disagree

1 2 3 4 5

Question Mean(SD) N % % % % %

Health care providers should be allowed to perform services outside their scope of practice if that might save more patients

2.88(1.17) 123 11% 32% 24% 24% 9%

Every hospital in the disaster area should be able to make their own

3.31(1.15) 124 4% 28% 15% 38% 15%


decisions when deciding how to use limited medical resources.

In a disaster situation, the most medical care should go to patients who probably will die unless they receive treatment.

3.59(1.20) 123 3% 23% 13% 34% 27%

Individual health care providers should be free to make their own decisions about which patients will get treatment and which ones will not.

3.80(.92) 122 3% 7% 20% 51% 21%

Age of patients alone should determine decisions about who will receive care or resources

4.11(.77) 124 1% 2% 12% 54% 31%

Note. Strongly disagree as highest score1- Strongly Agree, 2- Agree, 3- Neutral, 4- Disagree, 5- Strongly Disagree

Allocation of Resources

Two questions were included in the survey about lived experience surrounding

allocation of resources and are displayed in Table 7. Of the 124 respondents, 74% reported

that in the past six months they experienced medication and supply shortages. In addition to

being exposed to supply shortages, 26% of the nurses reported that they had to make

allocation decisions about resources that could impact patient safety. The timing of the

survey was within six months of a devastating hurricane season that had substantial impacts

on the supply chain of several medical supply companies.

Table 7

Frequency Table For The Experience Of Allocation of ResourcesQuestion n Yes (%) No (%)

In the last 6 months, I have had to make allocation decisions about inpatient beds or other resources that could result in adverse outcomes for patients.

124 26% 74%

In the last 6 months, I have experienced medication and supply shortages that I think affected patient care.

124 74% 26%


Knowledge and Preparation: Total Score

The overall mean of the total knowledge and preparation score was 81.5 (SD=12.1)

with a possible range of 23-115. Cronbach’s alpha reliability was computed for the 23 Likert

scale items in this total score and was high at α = .866. The total score means were compared

across the independent variables listed previously. The following variables were all

statistically significant at p<0.005: Number of Training Events in Past 5 Years, Number of

Real World Events, and Highest Degree Achieved (see Table 8). The mean for the number of

training events was 72.3 (SD=9.6) for participating in no events compared to 88.6 (SD=11.2)

for those with 3 or more training events. This rise indicates that increased training,

especially above three events in the past five years, gives nurses higher knowledge and

preparation. The combined knowledge and preparation score for nurses with exposure to

real-world events was statistically higher (M=85.1, SD=10.9) compared to those who did not

have real world experience (M=77.9, SD=12.2) (p=.001) Working in a Trauma Center was

not significantly significant (p=0.175), however, the mean was higher for Yes (M= 82.4,

SD=11.8) compared to No (M= 79.0, SD=12.4). Years of nursing experience was significant

at the p=0.010 level. Review of the individual groups shows a trend of increasing means

from the group 1-5 years (M=74.9, SD=12.5) to those with 16-20 years (M=88.5, SD=8.5).

There is a slight decline in those with 20 years of experience or more (M=82.5, SD=13.4).

The higher standard deviation for the 20+ years group compared to the 16-20 years group is

notable. Highest Degree earned was also significant at p<0.005 with Bachelor's prepared

nurses (M= 77.9, SD=12.2) scoring lower compared to Associates (M=84.7, SD=12.9) and

Master’s or Doctorate (M=85.7, SD=12.8). An analysis was performed examining the

association between Years of Nursing and Highest Degree. This showed that those with a


Bachelor’s degree had the fewest years of experience which could explain why respondents

with a Bachelor’s degree scored lowest.

Table 8

Knowledge and Preparation Total Score Means by Independent Variables

N Mean SD SignificanceTrauma Center

YesNo

7634

82.479.0

11.812.4

p=.175

Number of Training Events in Past 5 years

None1-23 or more

165936

72.379.688.6

9.610.811.2

p=.000***

Number of Real World Events in Past 5 years

None1 or more

5655

77.985.1

12.210.9

p=.001**

Year in Emergency Nursing1-56-1011-1516-20More than 20

2222221727

74.980.482.688.582.5

12.511.710.18.513.4

p=0.010*

Highest DegreeAssociatesBachelor’sMasters or Doctorate

155838

84.777.985.7

12.910.312.8

p=0.004**

Note. Possible score range is 23-115. Significance noted at the *p<.05 level, **p<.01, and ***p<.001

Knowledge Score

The overall mean of the knowledge score was 55.5 (SD=8.19). Cronbach's alpha

reliability was computed for the 15 Likert scale items in this total score and was α =.836. The

variables Number of Training Events in Past 5 Years, Number of Real World Events, Highest

Degree Achieved, and Years of Experience were all statistically significant with p<0.005 (see


Table 9). Working in a Trauma Center had a minimal difference with a reported mean from

55.6 (SD=8.0) for those working in a trauma center to 54.9 (SD=8.6) for those who did not.

This difference was not significant at p=0.646. The variable Highest Degree was significant

at p<0.005 with nurses with an Associate’s degree having the highest score. This was

followed by those with a Master’s and Doctoral preparation, with Bachelor’s prepared nurses

with the lowest score. As with total score, the variation in highest degree may be attributed

to those with Bachelor’s degrees having fewer years of nursing experience. While the results

are statistically significant, the differences in the means are not large.

For the variable Number of Real World Events the calculated means were statistically

significant with p<0.005. Exposure to one or more real world events in the last five years

was associated with a higher mean knowledge score (M=57.9, SD=7.0) compared with those

with no exposure in the last five years (M=53.2, SD=8.6).

Table 9

Knowledge Total Score Means by Independent Variables

N Mean SD SigTrauma Center

YesNo

7736

55.654.9

8.08.6

p=.646


None1-23 or more

166038

49.654.259.9

7.67.77.1

p=.000***


None1 or more

5856

53.257.9

8.67.0

p=0.002**

Years in Emergency Nursing1-5 22 49.8 8.1 p=0.001**


6-1011-1516-20More than 20

23221729

54.856.860.256.4

7.76.85.78.8

Highest DegreeAssociatesBachelor’sMaster’s or Doctorate

165939

59.352.857.9

7.87.38.4

p=0.001**

Note. Possible score range is 15-75. Significance noted at the *p<.05 level, **p<.01, and ***p<.001

Preparation Score

The overall mean of the total preparation score was 25.8 (SD=4.93) with a possible

range of 8-40. Cronbach's alpha reliability was computed for the 15 Likert scale items in this

total score and was α =.670. Total preparation score means were compared across several

independent variables (see Table 10). The variables Number of Training Events in Past 5

Years and Number of Real World Events were statistically significant with p<0.005 in each

test. Those who participated in more training events and more real-world events scored

higher on preparation. Highest Degree, Years of Experience, and Trauma Center were not

statistically significant.

Table 10

Preparation Total Score Means by Independent Variables

N Mean SD SigTrauma Center

YesNo

8336

26.224.8

4.94.9

p=0.161

Number of Training Events in Past 5 yearsNone1-23 or more

186438

22.724.928.8

3.44.35.0

p=.000***


Number of Real World Events in Past 5 yearsNone1 or more

5961

24.527.1

4.65.0

p=0.004**


2323251830

24.725.425.128.326.5

5.44.24.44.15.4

p=.121


156243

25.825.126.9

5.94.35.3

p=.196

Note. Possible range 8-40 Significance noted at the *p<.05 level, **p<.01, and ***p<.001

Familiar with Crisis Standards of Care

The overall mean of the question “I am Familiar With the Term Crisis Standards of

Care” was 3.18 (SD=1.24) with a possible range of 1-5. Means of Familiarity with CSCs

were calculated and compared across several independent variables (see Table 11). None of

the variables were statistically significant. The number of Training Events in Past 5 Years

and Experience in Real World Events both showed higher means associated with more

events, though neither was significant.

Table 11

Familiar with the Term Crisis Standards of Care

N Mean S D SigTrauma Center

YesNo

8438

3.23.0

1.21.3

p=.386



None1-23 or more

186441

2.73.03.6

1.01.31.1

p=0.10


None1 or more

6261

3.03.4

1.31.2

p=0.057


2424241832

2.83.33.23.93.0

1.01.21.30.91.4

p=.080


166344

3.43.03.5

1.51.11.3

p=.082

Note. Possible range 1-5 with higher means indicating more familiarity with CSCs. Significance noted at the *p<.05 level, **p<.01, and ***p<.001

Further analysis was done by collapsing the scores of Disagree or Strongly Disagree

and Agree and Strongly Agree together and the results are displayed in Table 12. Less than

half of participants (44.8%) reported either agree or strongly agree to the question "I am

familiar with the term crisis standards of care." This relatively low level of awareness may

be due to a lack of knowledge of the exact term rather than an understanding of the concepts.

This is validated when reviewing the results of selected questions related to concepts of

CSCs in which a greater percentage of nurses demonstrated their knowledge and preparation.

Six items from the survey that included concepts of CSCs were chosen to validate that

knowledge of concepts existed even if nurses did not recognize the term “Crisis Standards of

Care.” An example of knowledge of the underlying concepts is that 74.8% of nurses


reported either agreed or strongly agreed with the question "I am familiar with principles to

guide the allocation of resources used in disaster situations.” However only 55.6% of nurses

reported that they had received training or education to prepare them in situations where they

may be required to make decisions about allocation of resources.

Table 12.

Percent Agree and Disagree on Selected Items

QuestionDisagree or

Strongly Disagree

(%)

Agree or Strongly

Agree(%)

I am familiar with the term crisis standards of care 33.4 44.8

It is better to save the most lives-even if it means that some people won't receive all of the medical care they would get under normal conditions. 1.6 90.3

I know whom to contact (chain of command) in disaster situations in my workplace or community 7.3 82.3

I am familiar with the START triage protocol used in disaster situations. 13.0 78.0

I am familiar with principles to guide allocation of resources used in disaster situations 11.2 74.8

In the event of a major disaster or pandemic, I am aware of my hospital's and/or department's emergency operations plans or know where to find them

16.1 67.7

In the event of a major disaster or pandemic, I am aware of protocols in place to guide care. 15.3 65.3


28.3 55.6

Self-Reported Competence with Working in a Disaster or Pandemic


Mean scores of "I am competent/comfortable working in the environment of a

disaster or pandemic” were compared across several independent variables (see Table 13).

The number of Training Events in Past 5 Years and Number of Real World Events were both

statistically significant with p<0.005 in each test. Nurses who participated in 1-2 training

events had a higher mean (M=3.4, SD=0.9) than those with no exposure (M=3.2, SD=1.00).

Nurses with three or more training events had the highest mean (M=4.0, SD=0.9) which was

a difference of .80 from those with no exposure. The number of Real World Events had a

higher mean for those nurses who had been involved in at least one event (M=3.8, SD=0.8)

compared to those who had been involved in no events (M=3.30, SD=1.0) and was

statistically significant p=0.004. The variables of Highest Degree Achieved, Working in a

Trauma Center, and Years in Emergency Nursing were not significant.

Table 13

Competent/Comfortable Working in the Environment of a Disaster or Pandemic

N Mean St deviation SigTrauma Center

YesNo

8538

3.63.4

0.91.0

p=.248


None1-23 or more

186541

3.23.44.0

1.00.90.9

p=.001***


None1 or more

6262

3.33.8

1.00.8

p=0.004**

Year in Emergency Nursing1-56-1011-15

242425

3.53.63.2

1.00.81.1

p=.212


16-20More than 20

1832

3.93.7

0.81.0


166345

3.93.43.7

1.01.00.9

p=.075

Note. Possible range 1-5. Significance noted at the *p<.05 level, **p<.01, and ***p<.001

Scenario Responses

A fictitious scenario was used to give the participants an example of a situation where

CSCs would be needed and is included in Figure 4.

Figure 4. Screenshot of scenario from the survey tool.

After reading the scenario, the participants answered questions about anticipated

barriers or challenges they may face in this situation and their ideas for training and

education that would prepare them for the situation.

Challenges of the CSCs scenario.


The identified themes associated with challenges are listed in Table 14 with

frequencies and percentages reported. The most frequent responses were associated with the

lack of resources, both human (n=47) and non-human types such as supplies (n=64).

Specific examples of responses are “Lack of resources like water, meds, space to look after

these patients” and “Supplies become limited due to infrastructure impairment." This was

followed by psychological concerns about both caregivers and patients after a traumatic

event (n=33). The need for staff support was noted by one person as “who to go to when I

become emotionally vulnerable” and another as the concern related to “the desire/need to

care for and treat as many patients as possible.” The reported themes around allocation of

resource and ethical concerns were also noted in the paper by Daugherty et al. (2014) based

on focus groups held in the Maryland looking at the state response to CSC events. In that

article the focus groups consisted of public participants from two different counties in the

state.

Table 14.

Themes: If You Were Placed Into a Situation Like the Scenario Above, What Type of Challenges and Barriers Do You Think May Exist?

Theme n %Resources- supplies or equipmentResources – staff or peoplePsychological supportsTriage decisionsSecurity / safetyCommunicationEthical issuesRoutine care requirements (daily meds)Access to medical recordsFatality managementAnimal/pet careLegal issue

6447332624212283211

70%52%36%29%26%23%24%9%3%2%1%1%

Preparation for a CSC scenario.


The next question asked for feedback on what types of training or education would be

helpful in preparing for a situation like this scenario (see Table 15). The theme of allocation

of resources was again noted in these responses (n=15). Education and training on rationing

along with education on where to obtain resources and supplies were noted in comments such

as: "Know what resources are available and where to find them. To totally understand that

you can't save them all.” A common theme was that general drills (n=27) would be

beneficial to preparedness with comments about the frequency of the drills being noted. One

response noted that drills should be designed for long duration events in addition to shorter

duration events such as mass causality drills. The quote is “Drilling for scenarios like the

one mentioned and not the typical train-plane crash.” Extending drills beyond the frontline

staff was also mentioned. “Hospital leaders must make a financial commitment and must be

able to think it could happen to us” is a quote that demonstrated the need for involvement of

leadership in planning as well as training and drills.

Table 15

Themes: What Additional Training, Education or Preparation Would be Helpful in Being Prepared to Work in a Situation Like This?Theme n %General drills and training 27 33%Resource allocation 15 19%Live drills 14 17%Policy / Process Review 14 17%Community training 9 11%Didactic Training 9 11%Tabletop exercises 6 7%Focused training for leadership 4 5%Use of simulation 4 5%FEMA Integrated Command system (ICS) 3 4%Basic Disaster Life Support (BDLS) 2 2%Trauma Nurses Core Curriculum (TNCC) 2 2%Hazmat 1 1%


Self-defense 1 1%Real world event exposure 1 1%

Training needed to prepare for scenario.

The next question asked the participants to report on past training or educational

activities they have already taken that they feel would have prepared them for this type of

scenario. The types of classes are reported in Table 16. While there were some specific

training examples such as the FEMA Integrated Command System (ICS) training (n=19) and

Trauma Nurse Core Curriculum (TNCC) (n=13), general exposure to any training was

reported with the highest frequency (n=56).

Table 16

Themes: What Types of Instructional Courses Have You Taken That You Think Have Made You Prepared for Scenarios Like This That Could be Suggested For Others?Theme n %General Drills 33 45%Unspecified training 23 32%FEMA ICS 19 26%Hazmat 16 22%TNCC 13 18%Drill at ENA conference 12 16%EMS/Fire 8 11%Center for Domestic Preparedness 7 10%Real world events 4 5%ENA online 4 5%Other online 3 4%Basic Disaster Life Support (BDLS) 2 3%Red Cross 1 1%Community Emergency Response Team (CERT) 1 1%

The overall mean of nurses’ knowledge and preparation related to CSCs was 81.5

(with a possible range of 23-115). This result shows that emergency nurses have a general


awareness of and knowledge about the concepts associated with advanced disaster situations

such as CSCs. With a midpoint of 69 on this total score, the mean of 81.5 demonstrates the

need for further training and education for emergency nurses.

Discussion

What is the Level of Knowledge of Emergency Nurses Regarding CSCs?

Much of the work of CSCs is about the allocation of resources and, in particular,

scarce resources. A key factor of CSCs is that the resources available to care for the number

or acuity of patients may be limited. With high percentages of nurses agreeing or strongly

agreeing with the questions “I am familiar with principles to guide allocation of resources

used in disaster situations” and “It is better to save the most lives, even if it means that some

people won't receive all of the medical care they would get under normal conditions”, there is

evidence of current knowledge existing. This ethical theory to do the greatest good for the

greatest number of people is a pillar of disaster care and essential for successful outcomes

(Baker, 2007).

Nurses today are faced with challenges around allocation of resources. This may be a

critical care bed, a transfer ambulance or, in the past year, the effects of the IV fluid shortage.

With about three-quarters of the nurses reporting that they had been impacted by resource

shortages and about a quarter noting possible safety impacts, nurses are already working in

situations of contingency care. The pressure of this situation would be expanded during a

real-world event, and this was noted in the open-ended questions where nurses reported that

resource allocation would be a barrier in a disaster or pandemic event. The systems and

processes that hospitals have recently developed for the IV shortage have given nurses


exposure to this real-world event and, based on this study, nurses should have increased

preparation in the future because of this event.

Knowledge of Plans and Protocols

No matter the efforts or advances we make, there will be disaster events that continue

to occur. Petra Nemcova, a victim of the 2004 Tsunami in Indonesia, said that "We cannot

stop natural disasters, but we can arm ourselves with knowledge: so many lives wouldn't

have to be lost if there was enough disaster preparedness" (Hoby, 2011). The ability for

knowledge to impact human life is a key part of the training of nurses and others in the

medical community.

In 2017, The Joint Commission updated their emergency preparedness plans with a

focus on continuity of operations, annual updates of plans, and emphasis on escalation (TJC,

2017). In this study, more than 65% of nurses agreed or strongly agreed when asked about

their knowledge of their hospital’s emergency operations plans or general plans to be used in

a major disaster or pandemic, This demonstrated that emergency nurses tend to be aware of

the structures and resources that are in place to assist them with decision making, although

about 35% of nurses were not familiar with these resources. Hodge et al. (2017) noted that

emergency nurses had a higher rate of disaster preparedness knowledge than nurses from

other areas of the hospital. However, both this study and Hodge et al. (2017) demonstrate

that there continues to be a need for further education around knowledge of emergency plans

and the incident command system.

With many nurses in agreement with the question “I know where to find relevant

research or information related to disaster preparedness and management to fill in gaps in my

knowledge” (70% agreed or strongly agreed), there is baseline knowledge in place.


However, 47% of nurses were neutral when asked about their ability to understand disaster

research in the literature suggesting that there is a need for improvement in the accessibility

of published studies. These findings demonstrate that nurses know how to find information,

but have a relatively low level of comfort accessing this information on a regular basis.

Training and Education

Exposure to training had a direct relationship with higher scores in both knowledge

and preparation related to disasters and CSCs. The number of training events nurses had

participated in showed a consistent association with knowledge and preparation. The need for

training to prepare nurses has been noted as necessary to ensure effective response to disaster

situations (Gebbie & Qureshi, 2002; Kolleck, 2010; Langan, Lavin, Wolgast, & Goodwin

Veenema, 2017; McKibbin et al., 2011). Nevertheless, the level and type of training

required remain as areas without a general consensus. McKibbin et al. (2011) reported that

10 hours of continuing education can help increase knowledge and preparation for disasters,

but other studies have not defined the ideal time for competency. (Hsu, Thomas, Bass,

Whyne, Kelen & Green, 2006; Williams et al., 2008)

There is a vast realm of training that can be offered to nurses, both at the institutional

level and with governmental support. As noted by Labrague (2018), there remains a dearth

of published information about what type of training should be utilized to raise the awareness

of nurses. This study adds to the body of knowledge by giving training examples that nurses

who took this survey noted have helped with their own perceived knowledge and preparation.

One purpose of this study was to provide specific examples of types of training and to offer

suggestions for nurses and nurse leaders when determining educational content for their staff.

In the open-ended items, participants said that training such as the TNCC or FEMA Center


for Domestic Preparedness would have been helpful in the scenario described. No matter the

type of training used, this study along with others, supports the notion that any training will

give exposure and improve outcomes (Hodge et al., 2017; Magnaye et al., 2011; Williams et

al., 2008).

Years of Emergency Nursing

Years of experience in emergency nursing and the overall total knowledge and

preparation score showed variation between those with 1-5 years of experience through those

with more than 20 years of experience. However, there was a slight decline from the group

with 16-20 years of experience to those with beyond 20 years of experience. This may be due

to individuals with more than 20 years of emergency nursing experience no longer being in

practice in the ED on a regular basis. While more than 20 years of experience was not the

highest score, it was still significantly higher than those with little experience. This increase

matches with Benner's Theory of Novice to Expert in nursing (Benner, 1982). With exposure

to clinical situations, a nurse advances to a clinical expert with an increase in awareness of

the rationale and reason for clinical outcomes. Magnaye et al. (2011) noted that years of

service not only improved readiness and preparedness for disaster events, but also that more

experienced nurses could respond more efficiently than novice nurses.

Participation in Training Events

The number of training events was associated with increased scores on all knowledge

and preparation variables. The concept of training improving the outcomes of any situation

was expected. Knowledge and preparation increased in a linear fashion with the number of

training events in the past five years. This result supports regular training in the hospital

setting and is consistent with past research (Baack & Alfred, 2013; Fung, Lai & Locke, 2009;


Gebbie & Qureshi, 2002). The survey did not specify the type of training or drill and the

interpretations of this were left to the participants. Within the open-ended questions, training

events such as online classes and FEMA ICS to full-scale drills were mentioned as examples

of training that would be beneficial to respondents. Bruley (2008) noted that continuous and

coordinated training across the community is key to the reduction of injury and death during

disaster events and that nurses play a critical role in providing for both physical and

emotional states of patients. The type of training nurses need does not have to be a large

scale drill. Many of the participants in this study mentioned classes that have helped prepare

them for disasters.

Participation in Real-World Events

Individuals who reported having experienced a real-world event in the past five years

felt more confident/comfortable working in a disaster or pandemic and had higher Total

Knowledge and Preparation scores when compared to those who had not. While not

statistically significant, the exposure to real-world events was also related to higher scores

regarding familiarity with the term CSC. The exposure to real-world events was noted by

Baack & Alfred (2013) who surveyed nurses from various settings and found that nurses who

had previous disaster response experience had higher scores on feeling confident with

responding to disasters than did those without that experience. Experience with an actual

disaster event gives a nurse a level of exposure and ability to recall successful measures.

State Level Published CSCs

Although this study was initially designed to assess the relationship between states

with published CSCs and the dependent measures, this was not possible. A review of the

frequencies of respondents' home states showed that almost all the responses came from


states that had published CSCs. This may have resulted in the findings showing greater

knowledge and preparation than actually exists across all US states. However, it is not

possible to determine this.

Limitations

There are limitations to this study regarding the selection of participants and the

design of the survey tool. The self-selection of the participants may have led to a bias toward

nurses with interest in disaster response or prior knowledge of CSCs. The findings in the

present study could be validated by a further study with a random sample of nurses with

various backgrounds. The use of social media for study recruitment provided responses from

various states and all 10 FEMA regions, however, FEMA region I had the majority of

responses. However, the training of nurses for disaster response is not unique to the

Northeast and the results of this study can potentially be translated to other geographic

locations.

The design of the survey tool limited the analysis that could be provided regarding the

types of training completed. Further research may consider adding a section for the

respondents to report whether they had participated in specific educational and training

activities. The inclusion of closed-ended items asking about participation in specific types of

training may have allowed for validation of the open-ended responses such as TNCC and

FEMA courses.

Collapsing of item response options was determined by the author for some variables

due to small group sizes and this limited the analysis of participants. The collapsing of the

groups did not allow for granular level of review that may have allowed for additional

statistical analysis.


Conclusions

When an event of magnitude greater than the resources at hand occurs, normal care

delivery should be expected to be impacted. The level of impact that reaches the patient and

community can be mitigated by a skilled and trained healthcare team inclusive of nurses.

Emergency nurses are a highly skilled group of nurses with demonstrated knowledge of

CSCs concepts and operational priorities that are essential in disaster situations. While the

scores of both knowledge and preparation of emergency nurses are reassuring, this study

highlights the need to do more. Hospital leadership must support education and training for

events that will occur, often with no notice (Veenema et al., 2018). The current geopolitical

environment has seen acts of terror, mass shootings, and the risk of a ballistic missile all

occur in the first two months of 2018. Emergency nurses must be ready to respond.

Nursing experience cannot be understated concerning how successfully the healthcare

system responds to any crisis event. From exposure to real-world events, disaster training

and even daily operations, this study has shown that those nurses with lived experience have

greater knowledge and preparation than those without.

Implications for Practice

This study surveyed a sample of emergency nurses to determine their current level of

knowledge and preparation for disaster care. The findings provide guidance to nurse

educators and emergency preparedness staff in developing education and training for

emergency nurses. Emergency nurses are expected to play an active role in most disaster

events that occur. In part, because of that expectation, training and education have been

available to emergency nurses through programs such as the ENA’s TNCC program.


Continued education and training need to be expanded and become part of annual training for

all nurses, not just emergency nurses.

The types of training that were reported as helpful in preparing nurses for potential

events should be reviewed by nursing educators as well as hospital emergency preparedness

staff as they develop risk mitigation strategies for their hospitals. Programs such as the

online FEMA ICS and in person Hospital Emergency Response Training for Mass Casualty

Incidents (HERT) are both offered without cost to participants. Additionally, local training

that involves not only ED staff, but fire, EMS, and hospital departments should be done a

regular basis.

Future Research

The survey tool developed for this study was not validated regarding its correlation

with successful outcomes when a real disaster does occur. However, it had high internal

consistency reliability and could be used for additional studies on CSCs. Further research

could be done to validate the survey through pre and post testing of staff that has experienced

an actual disaster event. Since this type of research would be difficult to design considering

the unpredictable nature of disasters, it would be more feasible to conduct a study using this

tool to compare knowledge and preparation before and after disaster education or training.

To address some of the study limitations, the research should be repeated in a manner

that would allow for response rate to be calculated. Changes to the demographic sections

could help reduce the need to collapse groups. Expanding the sample beyond emergency

nurses to other specialty areas could provide a comprehensive review of the level of

knowledge and preparation across a hospital or healthcare system.


The cost associated with training is recognized as a factor and further studies should

be done to determine the amount of training time necessary to prepare nurses for disaster

events.

Conclusion

Emergency nurses will have a significant role in the response and ultimate level of

success during a disaster. To prepare nurses for these events, adequate resources should be

directed to the training and education of all nurses in crisis standards of care.


References

Agency for Healthcare Research and Quality. (2005). Altered standards of care in mass

casualty events (AHRQ Publication No. 05-0043). Washington, DC: Government

Printing Office Aitken, P., Leggat, P., Robertson, A., Harley, H., Speare, R., &

Leclercq, M. (2009-a). Pre-and post-deployment health support provided to

Australian disaster medical assistance team members: results of a national survey.

Travel Med Infect Dis. 2009; 7(5):305-311. doi:10.1016/j.tmaid.2009.03.001.

American College of Emergency Physicians. (2008). Disaster Planning and Response.

Retrieved from https://www.acep.org/Clinical---Practice-Management/Disaster-

Planning-and-Response/?

__taxonomyid=471104#sm.001qmvaxx10siepszrf1boltrc4wp

American College of Emergency Physicians. (2013). Guidelines for Crisis Standards of Care

during Disasters. ACEP Disaster Preparedness and Response Committee.

American College of Emergency Physicians. (2011). Health care system surge capacity

recognition, preparedness, and response. Retrieved from

https://www.acep.org/Clinical---Practice-Management/Health-Care-System-Surge-

Capacity-Recognition,-Preparedness,-and-Response/

American Nurses Association. (2008). Adapting Standards of Care under Extreme

Conditions: Guidance for Professionals during Disasters, Pandemics, and Other

Extreme Emergencies. Prepared for the American Nurses Association by the Center

for Health Policy, Columbia University School of Nursing.

American Nurses Association. (2015). Code of Ethics for Nurses with Interpretive

Statements. Silver Spring, MD: American Nurses Association. (2002). Work release

https://www.acep.org/Clinical---Practice-Management/Health-Care-System-Surge-Capacity-Recognition,-Preparedness,-and-Response/

https://www.acep.org/Clinical---Practice-Management/Health-Care-System-Surge-Capacity-Recognition,-Preparedness,-and-Response/


during a disaster-guidelines for employers. Retrieved from

http://nursingworld.org/workreleaseps

Association of Public Health Nurses. (2014). The role of the public health nurse in disaster

preparedness, response, and recovery. Retrieved from

http://www.achne.org/files/public/APHN_RoleOfPHNinDisasterPRR_FINALJan14.p

df

Association of State and Territorial Health Officials (ASTHO). (2017). Emergency Authority

and Immunity Toolkit: ASTHO legal preparedness series, emergency authorization

and immunity toolkit: Immunity issues in emergencies. [Fact Sheet]. Retrieved from

http://www.astho.org/Programs/Preparedness/Public-Health-Emergency-Law/

Emergency-Authority-and-Immunity-Toolkit/Immunity-Issues-in-Emergencies-Fact-

Sheet/

Altevogt, B. M., & Stroud, C. (2009). Guidance for Establishing Crisis Standards of Care

for Use in Disaster Situations: A Letter Report. Retrieved January 10, 2018, from

https://www.phe.gov/coi/Documents/Guidance for Est CSC for Use in Disaster

Situations A Letter Rpt.pdf

Baack & Alfred. (2013). Nurses’ preparedness and perceived competence in managing

disasters. Journal of Nursing Scholarship, 45(3), 281-287. Doi:10.1111/jnu.1209

Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics (7th Ed.). New

York, NY: Oxford University Press.

Benner, P. (1982). From novice to expert. American Journal of Nursing, 83(3), 402-407

http://www.astho.org/Programs/Preparedness/Public-Health-Emergency-Law/Emergency-Authority-and-Immunity-Toolkit/Immunity-Issues-in-Emergencies-Fact-Sheet/




Campbell, P., Trockman, S., & Walker, A. (2011, March-April). Strengthening hazard

vulnerability analysis: Results of recent research in Maine. Public Health Reports,

126(2), 290-293. http://dx.doi.org/ 10.1177/003335491112600222

Centre for Research on the Epidemiology of Disease (CRED). (2015). The Human Cost of

Natural Disasters 2015: A global Perspective. Retrieved from

http://reliefweb.int/sites/reliefweb.int/files/resources/PAND_report.pdf

Ciottone, G., Biddinger, P., Darling, R., Fares, S., Keim, M. E., & Malloy, M. (2016).

Ciottone’s Disaster Medicine. Philadelphia, PA: Elsevier.

Daugherty, L., Gwon, H., Schoch-Spana, M., Cavalier, R., White, D. B., Dawson, T., Toner,

E. S. (2014). The Community Speaks: Understanding Ethical Values in Allocation of

Scarce Lifesaving Resources during Disasters. Annals of the American Thoracic

Society, 11(5):777-783. doi:10.1513/AnnalsATS.201310-379OC.

Emergency nurses Association. (2014). Disaster and emergency preparedness for all

hazards. Retrieved from

https://www.ena.org/docs/default-source/resource-library/practice-resources/position-

statements/allhazardspreparedness.pdf?sfvrsn=ea0879a4_10

Emergency nurses Association. (2014). Trauma Nursing Core Course: Provider Manual (7th

Ed.). Des Plaines, IL: ENA.

Emergency nurses Association. (N.D.). About ENA. Retrieved from

https://www.ena.org/about/Pages/Default.aspx

Etienne, M., Powell, C., & Amundson, D. (2010, May/June). Healthcare ethics: The

experience after the Haitian earthquake. Disaster Medicine Journal, 5(3), 141-147.

http://dx.doi.org/10.5055/ajdm.2010.0016

http://dx.doi.org/10.5055/ajdm.2010.0016

http://reliefweb.int/sites/reliefweb.int/files/resources/PAND_report.pdf


Fung, Lai & Locke (2009). Nurses’ perception of disaster: implications for disaster nursing

curriculum. Journal of Clinical Nursing, 18(22). 3165-3171.

https://doi.org/10.1111/j.1365-2702.2008.02777.x

Garbutt, S., Peltier, J., & Fitzpatrick, J. (2008, November). Evaluation of an instrument to

measure nurses familiarity with emergency preparedness. Military Medicine, 1073-

1077.

Gawande, A. (2010, August 2nd). Letting go [Annals of Medicine]. The New Yorker, 36-49.

Gebbie, K. M., Hutton, A., & Plummer, V. (2012). Update on competencies and education.

In Annual Review of Nursing Research: Disasters and Humanitarian Assistance, pp.

169-192). []. http://dx.doi.org/10.1891/0739-6686.30.169

Gebbie, K & Qureshi, K. (2002). Emergency and disaster preparedness:

Core competencies for nurse: What every nurse should but may not know. American

Journal of Nursing, 102(1), p. 46-51. Retrieved from

http://journals.lww.com/ajnonline/Fulltext/2002/01000/Emergency_and_Disaster_Pre

paredness__Core.23.aspx

Gebbie, K.M., Peterson, C.A., Subbarao, I., White, K.M., (2009). Adapting Standards of

Care under Extreme Conditions. Disaster Medicine and Public Health Preparedness,

3, 111-116. DOI:10.1097/DMP.0b013e31819b95dc

Hanfling, D. (2013). Role of Regional Healthcare Coalitions in Managing and Coordinating

Disaster Response [white paper]. Retrieved from

http://www.nationalacademies.org/hmd/~/media/5774EA03CCF84347AC127C83302

89C45.ashx

http://www.nationalacademies.org/hmd/~/media/5774EA03CCF84347AC127C8330289C45.ashx

http://www.nationalacademies.org/hmd/~/media/5774EA03CCF84347AC127C8330289C45.ashx

http://journals.lww.com/ajnonline/Fulltext/2002/01000/Emergency_and_Disaster_Preparedness__Core.23.aspx

http://journals.lww.com/ajnonline/Fulltext/2002/01000/Emergency_and_Disaster_Preparedness__Core.23.aspx

https://doi.org/10.1111/j.1365-2702.2008.02777


Hick, J., Hanfling, D., & Cantrill, S. (2011, March). Allocating scarce resources in disasters:

Emergency department principles. Annals of Emergency Medicine, 59(3), 177-87.

http://dx.doi.org/10.1016/j.annemergmed.2011.06.012

Hoby, H. (2011, March 12). How supermodel Petra Nemcova's tragedy changed children's

lives. The Guardian, Retrieved from

http://www.thegaurdian.com/technology/2011/mar/13/petra-nemcova-tragedy-

children

Hodge, J. G., Hanfling, D., & Powell, T. P. (2013). Practical, Ethical, and Legal Challenges

Underlying Crisis Standards of Care. Journal of Law, Medicine & Ethics, 4150-55.

doi:10.1111/jlme.12039

Hodge, A., Miller, E., & Skaggs, M. (2017, January). Nursing self-perceptions of emergency

preparedness at a rural hospital. Journal of Emergency Nursing, 43(1), 10-14.

http://dx.doi.org/10.1016/j.jen.2015.07.012

Hsu, E. B., Thomas, T. L., Bass, E. B., Whyne, D., Kelen, G. B., & Green, G. B. (2006).

Healthcare worker competencies for disaster training. BMC Medical Education,

6(19). DOI: 10.1186/1472-6920-6-19. Retrieved from

https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-6-19

Huang, H., Araz, O. M., Morton, D. P., Johnson, G. P., Damien, P., Clements, B....Meyers,

L. (2017). Stockpiling Ventilators for Influenza Pandemics. Emerging Infectious

Diseases, 23(6), 914-921. https://dx.doi.org/10.3201/eid2306.161417.

Institute of Medicine. (2012). Crisis standards of care: A systems framework for catastrophic

disaster response. Retrieved from:

http://www.nationalacademies.org/hmd/Reports/2012/Crisis-Standards-of-Care-A-

http://www.nationalacademies.org/hmd/Reports/2012/Crisis-Standards-of-Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx

https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-6-19

http://dx.doi.org/10.1016/j.annemergmed.2011.06.012


Systems-Framework-for-Catastrophic-Disaster-Response.aspx (Public Engagement:

Lead Facilitator Guidebook)

Institute of Medicine. (2013). Crisis Standards of Care: A Toolkit for Indicators and

Triggers.

Washington, DC; 2013. Retrieved from www.nap.edu.

Institute of Medicine of the National Academies (2014). Nationwide response issues after an

improvised nuclear device attack, medical and public health considerations for

neighboring jurisdictions: workshop summary. Retrieved from

https://www.nap.edu/download/18347#

Jacobson, H., Soto Mas, F., Turley, J., Miller, J., & Kim, M. (2010, January / February). Self-

assessed emergency readiness and training needs of nurses in rural Texas. Public

Health Nursing, 27(1), 41-48. http://dx.doi.org/10.1111/j.1525-1446.2009.00825.x

The Joint Commission. (2015). Emergency management resources-legal/ethical issues.

Retrieved from

https://www.jointcommission.org/emergency_management_resources_-

_legalethical_issues/

Kluge, E.H.W. (2017). Resource allocation in healthcare: implications of models of medicine

as a profession. Retrieved from http://www.medscape.com/viewarticle/551802_1

http://www.medscape.com/viewarticle/551802_1

https://www.jointcommission.org/emergency_management_resources_-_legalethical_issues/

https://www.jointcommission.org/emergency_management_resources_-_legalethical_issues/

http://dx.doi.org/10.1111/j.1525-1446.2009.00825.x

https://www.nap.edu/download/18347

http://www.nap.edu/

http://www.nationalacademies.org/hmd/Reports/2012/Crisis-Standards-of-Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx


Labrague, L., Hammad, K., Gloe, D., Mcenroe-Petitte, D., Fronda, D., Obeidat, A.,

Mirafuentes, E. (2017). Disaster preparedness among nurses: A systematic review of

literature. International Nursing Review, 65(1), 41-53. doi:10.1111/inr.12369

Langan, J., Lavin, R., Wolgast, K., & Goodwin Veenema, T. (2017, April-June). Education

for developing and sustaining a health care workforce for disaster readiness. Nursing

Administration Quarterly, 41(2), 118-127.

http://dx.doi.org/10.1097/NAQ.0000000000000225

Leaning, J., & Guha-Sapir, (2013, November 7). Natural disasters, armed conflict, and public

health. New England Journal of Medicine, 369, 1836-42.

http://dx.doi.org/10.1056/NEJMra1109877

Levin, D., Cadigan, R. O., Biddinger, P., Condon, S., Koh, H., & Joint Massachusetts

Department of Health – Harvard Altered Standards of Care Working Group. (2009).

Altered standards of care during an influenza pandemic: Identifying ethical, legal, and

practical principles to guide decision making. Disaster Medicine and Public Health

Preparedness, 3, S132-S140.

Littleton-Kearney, M., & Sheepskin, L. (2008, March). Direction for disaster nursing

education in the United States. Critical Care Nursing Clinics of North America,

20(1), 103-109. http://dx.doi.org/10.1016.j.ccell.2007.10.008

Magney, B., Munoz, S., Munoz, M., Munoz, R., Muro, J. (2011). The role, preparedness and

management of nurses during disasters. International Scientific Research Journal,

3(4), 269-294.

https://pdfs.semanticscholar.org/82f4/af57dc8e297274327e849431cb314fd4489d.pdf

https://pdfs.semanticscholar.org/82f4/af57dc8e297274327e849431cb314fd4489d.pdf

http://dx.doi.org/10.1016.j.ccell.2007.10.008


Merin, O., Ash, N., Levy, G., Schwaber, M., & Kreiss, Y. (2010, March 3rd). The Israeli

field hospital in Haiti — Ethical dilemmas in early disaster response. The New

England Journal of Medicine. http://dx.doi.org/10.1056/NEJMp1001693

Michigan Department of Health & Human Services (2012). Ethical guidelines during public

health emergencies. Retrieved from: http://www.michigan.gov/mdhhs/0,5885,7-339-

73970_71692_8347-281707--,00.html

Murray, J. S. (2012, October). Crisis standards of care: A framework for responding to

catastrophic disasters. American Journal of Nursing, 112(10), 61-63.

http://dx.doi.org/10.1097/01.NAJ.0000421030.94575.64

Nasrabadi, A., Naji, H., Mirzabeigi, G., & Dadbakhs, M. (2007). Earthquake relief: Iranian

nurses’ responses in Bam, 2003, and lessons learned. International Nursing Review,

57(1), 13-18. http://dx.doi.org/10.1111/j.1466-7657.2007.00495.x

The National Academies. (2004). Learning from SARS: Preparing for the Next Disease

Outbreak-Workshop Summary. Retrieved from:

https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-

disease-outbreak-workshop

National Institute for Occupational and Safety Health (NIOSH). (2017). Emerging Infectious

Diseases. Retrieved from

https://www.cdc.gov/niosh/topics/emerginfectdiseases/default.html

Nohara, M. (2011, October-December). Impact of the Great East Japan Earthquake and

tsunami on health, medical care and public health systems in Iwate Prefecture, Japan,

2011. Western Pacific Surveillance and Response Journal, 2(4), 24-30.

http://dx.doi.org/ 10.5365/wpsar.2011.2.4.002

https://www.cdc.gov/niosh/topics/emerginfectdiseases/default.html

https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease-outbreak-workshop

https://www.nap.edu/catalog/10915/learning-from-sars-preparing-for-the-next-disease-outbreak-workshop

http://www.michigan.gov/mdhhs/0,5885,7-339-73970_71692_8347-281707--,00.html

http://www.michigan.gov/mdhhs/0,5885,7-339-73970_71692_8347-281707--,00.html

http://dx.doi.org/10.1056/NEJMp1001693


O'Boyle, C., Robertson, C., & Secor-Turner, M. (2006). Nurses' beliefs about public health

emergencies: fear of abandonment. American Journal of Infection Control, 34, 351-

357. http://dx.doi.org/0.1016/j.ajic.2006.01.012

Schmidt, C. K., Davis, J. M., Sanders, J. L., Chapman, L. A., Cisco, M. C., & Hady, A. R.

(2011). Exploring nursing students’ level of preparedness for disaster response.

Nursing Education Perspectives, 32(6), 380–383.https://doi.org/10.5480/1536-5026-

32.6.380

Schaffer, A. (2013, September 12th). The moral dilemmas of doctors during disaster. The

New Yorker. Retrieved from: https://www.newyorker.com/tech/elements/the-moral-

dilemmas-of-doctors-during-disaster.

Schultz, C. H., Koenig, K. L., Whiteside, M., & Murray, R. (2012). Development of National

Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians,

Nurses, and EMS Professionals. Annals of Emergency Medicine, 59(3).

doi:10.1016/j.annemergmed.2011.09.003

Skryabina, E., Reedy, G., Amlôt, R., Jaye, P., Riley, P. (2016). What is the value of health

emergency preparedness exercises? A scoping review study. International Journal of

Disaster Risk Reduction. 21. 10.1016/j.ijdrr.2016.12.010.

Slepski, L. (2007, October-December). Emergency preparedness and professional

competency among health care providers during hurricanes Katrina and Rita: Pilot

study results. Disaster Management & Response, 5, 99-110.

http://dx.doi.org/10.1016/j.dmr.2007.08.001

State of Michigan, Department of Community Health, Office of Public Health Preparedness.

(n.d.) Ethical guidelines for allocation of scare medical resources and services

http://dx.doi.org/10.1016/j.dmr.2007.08.001


during public health emergencies in Michigan. Retrieved from

file:///C:/Users/mkolbuk/Downloads/Ethical%20Allocation%20Guidelines

%20(2).pdf

Stone, E. & Wolf, L. (2017). Triage Qualifications and Competency. Retrieved from

http://www.ena.org/docs/default-source/resource-library/practice-resources/position-

statements/triagequalificationscompetency.pdf?sfvrsn=a0bbc268_8

Stroud, C. (2010). Crisis standards of care: Summary of a workshop series. Washington,

D.C.: National Academies Press. doi: 10.17226/12787

The Joint Commission. (2015). Emergency management: Getting started with the crisis

standards of care, part 2 (18:12). Retrieved from https://www.jcrinc.com/

University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.

(2005). Stand on guard for thee: Ethical considerations in preparedness planning for

pandemic influenza. Retrieved from

http://www.jcb.utoronto.ca/people/documents/upshur_stand_guard.pdf

U.S. Department of Health and Human Services, Public Health Emergency (2012). The

healthcare coalition overview. Retrieved from

https://www.phe.gov/Preparedness/planning/mscc/healthcarecoalition/chapter2/

Pages/overview.aspx

U.S. Department of Health and Human Services Assistant Secretary for Preparedness and

Response (n. d.). From hospitals to healthcare coalitions: Transforming Health

Preparedness and Response in our Communities. Retrieved from

https://www.phe.gov/Preparedness/planning/hpp/Documents/hpp-healthcare-

coalitions.pdf

https://www.phe.gov/Preparedness/planning/hpp/Documents/hpp-healthcare-coalitions.pdf

https://www.phe.gov/Preparedness/planning/hpp/Documents/hpp-healthcare-coalitions.pdf

https://www.phe.gov/Preparedness/planning/mscc/healthcarecoalition/chapter2/Pages/overview.aspx

https://www.phe.gov/Preparedness/planning/mscc/healthcarecoalition/chapter2/Pages/overview.aspx

http://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/triagequalificationscompetency.pdf?sfvrsn=a0bbc268_8

http://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/triagequalificationscompetency.pdf?sfvrsn=a0bbc268_8


U. S. Department of Health and Human Services. (2017). Topic Collection: Crisis Standards

of Care. Retrieved from https://asprtracie.hhs.gov/technical-resources/63/crisis-

standards-of-care/60

U. S. Department of Health and Human Services, Public Health Emergency. (2017).

Allocation of scare resources during mass casualty events. Retrieved from

https://www.phe.gov/coi/Pages/asr.aspx

Van Hoving DJ, Wallis LA, Docrat F, De Vries S. Haiti disaster tourism--a medical shame.

Prehospital Disaster Medicine. 2010; 25(3):201-202.

http://www.ncbi.nlm.nih.gov/pubmed/20586008. Accessed March 27, 2015.

Veenema, T. G., Griffin, A., Gable, A. R., MacIntyre, L., Simons, R. A. D. M., Couig, M. P.,

Larson, E. (2016).Nurses as leaders in disaster preparedness and response: A call to

action. Journal of Nursing Scholarship, 48(2), 187–200.

Veenema, T. G., Lavin, R. P., Griffin, A., Gable, A. R., Couig, M. P. and Dobalian, A.

(2017), Call to Action: The Case for Advancing Disaster Nursing Education in the

United States. Journal of Nursing Scholarship, 49: 688–696. doi:10.1111/jnu.12338

Venkat, A., Wolf, L., Geiderman, J. M., Ashwer, A. L., Marco, C., McGreevy, J., Levine, A.

C. (2015). Ethical issues in the response to Ebola Virus Disease in US emergency

departments: A Position paper of the American College of Emergency Physicians, the

Emergency nurses Association and the Society for Academic Emergency Medicine.

Journal of Emergency Nursing, 41(2), e5-e16.

https://doi.org/10.1016/j.jen.2015.01.012

https://doi.org/10.1016/j.jen.2015.01.012

https://www.phe.gov/coi/Pages/asr.aspx

https://asprtracie.hhs.gov/technical-resources/63/crisis-standards-of-care/60

https://asprtracie.hhs.gov/technical-resources/63/crisis-standards-of-care/60


Williams, Nocera & Casteel. (20088). The effectiveness of disaster training for health care

workers: A systematic review. Annals of Emergency Medicine, 52(3), 211-222.

https://doi.org/10.1016/j.annemergmed.2007.09.030

World Health Organization and International Council of Nurses. (2009). ICN framework of

disaster nursing competencies. Retrieved from

http://www.wpro.who.int/hrh/documents/icn_framework.pdf?ua=1

http://www.wpro.who.int/hrh/documents/icn_framework.pdf?ua=1

https://doi.org/10.1016/j.annemergmed.2007.09.030


Appendix A: Survey Tool


Appendix B: Approval Letter From National Academies Press


Appendix C: IRB approval from BIDMC


Appendix D: IRB approval from Simmons