Factors affecting nurses' ability to provide effective care in a disaster response: a review.

Disasters cause death, trauma, and psychological distress. Comprising the largest number of healthcare workers, nurses play a crucial role in reducing the impact of a disaster. The objective of this review is to identify the factors that influence nurses' ability during a disaster emergency response to provide adequate care. This research was conducted by doing a literature search from the Pro-Quest and Science-Direct databases using the PRISMA-ScR to screen the articles. The final results included 13 articles. An analysis was performed to identify themes in line with the purpose of the review. All factors affecting nurses' ability to respond to a disaster situation were classified into three themes: 1) factors increasing nurses' ability, 2) barriers to delivering effective nursing care, and 3) support needed to maintain the nurses' ability. During an emergency situation due to a disaster, adequate knowledge and skill to save lives, treat injuries, manage stress and coordinate between teams are the basic competencies needed for optimal care. Nurses' clinical experience or previous disaster experience and training could increase nurses' adaptability in disaster conditions. Support from nurses' workplace and proper implementation of disaster management policy enhance nurses' services and prevent barrier under disaster condition. The results emphasize that future training should aim for improving nurses' knowledge and skills, including the knowledge of nurses' family to protect themselves and deal with disasters. Such knowledge increased family preparedness, which is an important factor to enhance nurses' willingness to work following a disaster.

Introduction

In addition to causing death, trauma, and damage, disasters can lead to psychological, social, and spiritual distress, which can have long-term effects, potentially leading to post-traumatic stress disorder (PTSD).[1,2] Nurses need to be prepared to overcome the complexity of health problems caused by a disaster. They are required to possess the proper competences to reduce trauma due to the physical, psychological, and social distress suffered by the disasters’ survivor; however, it was found that nurses’ preparedness level in dealing with disasters is still low.[3-7] Research on emergency nurses in hospitals in New York,[3] and in Mecca Saudi Arabia[4] are indicating that nurses not fully prepared to handle disaster. It was also found that Indonesian nurses’ preparedness level is still low.[5,6] This low level of preparedness causes a lack of ability and confidence when nurses must act during disasters.[7] It is necessary to identify the factors that influence nurses’ services during a disaster emergency response in relation to providing adequate services so that a program to improve the ability of nurses can be developed by considering the factors identified. Therefore, a literature review was conducted to find studies related to the factors affecting nurses’ performance in responding to a disaster emergency.

The aim of this study was to review information through a literature review to identify the factors that influence nurses’ ability during a disaster emergency response to provide adequate care after a disaster occurs.

Design and Methods

A literature review was conducted to analyze previous research publications. The search was carried out using the ProQuest and Science-Direct databases with the following keywords: nurse OR nurses AND preparedness AND disaster response AND emergency response. This search process was conducted by the first author, and then the third author re-checked the information found during the screening process.

The inclusion criteria were full-text, peer-reviewed studies in the English language, including studies with various designs, such as quantitative, qualitative, and mixed-method studies. The articles were published from January 2010 to March 2020. Full access to the file was provided, and the keywords are mentioned in the titles or abstracts. The exclusion criteria were articles that do not discuss nurses and articles that are not accessible. To enhance the quality of this literature review manuscript, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist was used as the reporting guideline.[8] The search using the keywords produced 132 articles. All articles were then checked for duplication, which resulted in 34 articles. The search continued by checking the abstracts, and 68 articles were excluded. All articles found (n=18) were then checked by the relevancy of the content, and the final result of the search produced 13 articles (Figure 1).

Figure 1.

PRISMA flow diagram for included articles.

The data from the articles were charted manually using Excel, including their general characteristics: author/year/country, aims, research design, sample/type/size, major findings, and the implications of the relevant studies, such as factors supporting a disaster response and potential barriers. The extraction was carried out using the Mixed Methods Appraisal Tool (MMAT).[9] The aim of the screening using the MMAT was to determine whether the literature obtained in the previous stage was adequate to be included in the literature that may be analyzed. The final articles were analyzed to identify the major findings from each article, which were the factors affecting nurses’ ability to respond to a disaster. All findings then were classified into themes in accordance with the factors increasing nurses’ ability, the barriers, and the support needed to deliver optimal services during the response to a disaster.

Results

This study includes four articles using quantitative methods, five articles using qualitative methods, one article using mixedmethods, and three articles using a literature review. The respondents were from several countries, including China, Taiwan, Australia, Indonesia, Israel, Iran, Kapan, Kenya, Palestine, Saudi Arabia, and the US. The quantitative and mixed-methods studies had 2,171 respondents, while the qualitative studies had 73 participants. From these articles, three articles used a literature review, including a total of 84 articles. In the quantitative and qualitative articles, all samples met the criteria: 1) nurses involved in a disaster emergency response or disaster response from an earthquake, storm and flood, forest fire, or mass riots, and 2) nurses working in a hospital or in community services. There were only two articles that involved other healthcare professionals (doctor and midwife) as their respondents. Table 1 presents the characteristics of the included articles.

Table 1.

Characteristics of the included articles.

Quantitative		Qualitative		Mix methods
4 articles		5 articles		1 article
Sample	Countries	Sample	Countries	Samples	Countries
132 hospital nurses	KSA	10 hospital nurses	Southeastern US	16 hospital nurses	New York
384 hospital nurses	Iran	12 hospital nurses	Chine	528 hospital nurses
852 healthcare workers	Israeli	11 hospital nurses	New Zealand
311 hospital nurses	Taiwan	11 hospital nurses and	Bantul Indonesia
		11 midwives 13 hospital nurses	Australia, Indonesian, Israel, Kapan, Kenya, Palestine, Saudi Arabia, and US

Most of the articles (n=5) identify nurses’ competencies in both knowledge and skills during a disaster response. Three articles that identify nurses’ readiness and willingness to response a disaster, four articles that discuss the effects of disasters on nurses, and one article focusing on the factors predicting nurses’ attitudes during a disaster response. The instrument used in the quantitative research articles was generally a questionnaire that had been modified by the researcher, while the qualitative studies involved indepth interviews.

All 13 articles analyze the factors affecting nurses’ abilities, the supporting factors, and the barriers involved when responding to disaster situations (Table 2).

Table 2.

Factors supporting nurses’ ability in disaster responses and potential barriers.

All articles identified the importance of knowledge and skills for nurses to provide optimal services when disasters occur. Hence, knowledge level is a strong predictor of nurses’ ability to work effectively in disaster responses.[10] The required knowledge and skills for disaster-trauma treatment consist of post-disaster trauma treatment, post-disaster psychological treatment, and disaster management and leadership (Table 3). Nurses’ knowledge should be increased by implementing continuing training in hospitals because their experience in clinical aspects would improve the effectiveness of their response to disasters. It is identified that participating in disaster’s training and drilling is a very strong positive correlation that would increase nurses’ ability.[11]

Table 3.

List of knowledge and skills of earthquake emergency response.

Nurses’ self-preparedness

Nurses’ self-preparedness includes the ability to prepare themselves and their families for self-rescue and managing limitations in disasters. Nurses’ self-preparedness is crucial because it strengthens nurses’ self-confidence and commitment. These aspects induce a willingness to respond in a disaster.[12-15] Another factor was nurses’ personal traits.[16-18] Certain traits, such as adaptability and flexibility, are important because these traits increase nurses’ adaptability in chaotic situations and when experiencing a high level of stress.

Nurses’ experience

Nurses’ experience in clinical aspects is considered a factor that can improve the effectiveness of the response to disasters.[16]One article mentioned that nursing experience of ≥10 years, emergency/intensive nursing care experience, ability to function in the clinical management domain, and disaster response experience improve nurses’ ability to respond to a disaster.[19]

Barriers in providing nursing care

Barriers make it difficult to provide effective nursing care. It was reported that concerns about their own and their family’s safety, stress and anxiety, and limited equipment and human resources are considered factors that decrease the effectiveness of the healthcare system in responding to a disaster.[14,18,20]

Supports to maintain the nurses’ ability

Support from nurses’ working institutions and governments were identified as important external influencing factors. The implementation of a disaster policy, the provision of tools, resources, and funds, and inter-collaborative practice training help nurses provide good health services during a disaster.[10,21] Other support needed includes psychological health services for nurses after working in a disaster situation to help them recover from trauma. [15-22]

Discussion

During a disaster, priority actions are emergency assessments, saving lives, and caring victims, which is comprised of disaster triage, emergency first aid, evacuation, transportation for victims, and treatment of mental and psychosocial disorders for those affected, also. Other actions needed is coordination to manage a healthcare post as the center of prehospital health crisis management. [23,24] Communication skills and the ability to make rapid decisions concerning the disaster situation is important to act as a leader in a crisis.[25] Training is a significant aspect in preparing nurses. Duration of work does not influence nurses’ preparedness levels; however, if it is combined with disaster training and drilling, it could significantly correlate with disaster preparedness. Therefore, regular training and drilling with a method similar to disaster conditions should be practiced more frequently.[13,26]

Self-preparedness is critical for nurses. Previous studies show that a better preparedness score can be obtained by nurses who have previous training and disaster response experience, have good self-confidence, and are supported by their working institutions.[27] It was also mentioned that good self and family preparedness, such as planning to manage children, families, and pets when disasters occur, increases the willingness to work in disaster.[3,12,28,29] Another study showed that more than half of respondents reported not having personal planning for dealing with disasters, and this group showed a low willingness to work during disasters.[30]

Factors affecting health services in earthquake areas include support from workplace institutions, opportunities for training, provision of logistics, infrastructure for disasters, and financial support as external factors, while nurses’ competencies and selfpreparedness are internal factors that affect nurses’ ability to manage a disaster.[31] The identification of these two factors helped to develop strategies to support nurses during a disaster. There is special emphasis on future training to enhance the employees’ sense of efficacy and professional commitment and to address the increasing concern regarding family preparation and well-being following an earthquake. Hence, organizations should also provide disaster standards of care and psychology support programs that influence nurses’ willingness to respond.

Conclusions

Although a careful approach has been used, the search only included electronic scientific databases accessible to the authors’ institution, and only articles published in English were included. The populations, contexts, and concepts of the literature are features of their methodologies rather than their quality. The review may not be fully comprehensive as it only covers studies between 2010 and 2020 and does not cover policy papers or guidelines.

The competencies of disaster response include not only the ability to care for patients during a disaster, which can induce physical and psychological trauma, but also to coordinate and manage health posts during a disaster. Concerns regarding nurses’ personal safety and the safety of their families are also factors that affect nurses’ readiness. It is emphasized that future education and training must include methods that can simulate disaster conditions and increase family self-rescue. Support from nurses’ workplaces in their clinical and disaster continuing education as well as a psychological support program would enhance the effectiveness of nursing care.