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A new scale for disaster nursing core competencies: Development and psychometric testing
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Australasian Emergency Nursing Journal (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/aenj
RESEARCH PAPER
A new scale for disaster nursing core competencies: Development and psychometric testing Abdulellah Al Thobaity, RN, MN a,b Brett Williams, PhD c Virginia Plummer, RN, PhD a,d,∗ a
School of Nursing & Midwifery, Monash University, Australia College of Applied Medical Science, Taif University, Saudi Arabia c Department of Community Emergency Health and Paramedic Practice, Monash University, Australia d Nursing Research, Monash University and Peninsula Health, Australia b
Received 18 July 2015; received in revised form 15 November 2015; accepted 16 December 2015
KEYWORDS Disaster; Management; Competence; Saudi Arabia; Principal component analysis
Summary Background: All nurses must have core competencies in preparing for, responding to and recovering from a disaster. In the Kingdom of Saudi Arabia (KSA), as in many other countries, disaster nursing core competencies are not fully understood and lack reliable, validated tools. Thus, it is imperative to develop a scale for exploring disaster nursing core competencies, roles and barriers in the KSA. Objectives: This study’s objective is to develop a valid, reliable scale that identifies and explores core competencies of disaster nursing, nurses’ roles in disaster management and barriers to developing disaster nursing in the KSA. Methods: This study developed a new scale testing its validity and reliability. A principal component analysis (PCA) was used to develop and test psychometric properties of the new scale. The PCA used a purposive sample of nurses from emergency departments in two hospitals in the KSA. Participants rated 93 paper-based, self-report questionnaire items from 1 to 10 on a Likert scale. PCA using Varimax rotation was conducted to explore factors emerging from responses. Findings: The study’s participants were 132 nurses (66% response rate). PCA of the 93 questionnaire items revealed 49 redundant items (which were deleted) and 3 factors with eigenvalues of >1. The remaining 44 items accounted for 77.3% of the total variance. The overall Cronbach’s alpha was 0.96 for all factors: 0.98 for Factor 1, 0.92 for Factor 2 and 0.86 for Factor 3.
∗ Corresponding author at: School of Nursing & Midwifery, Monash University, McMahons Road, Frankston, Victoria 3199, Australia. Tel.: +61 3 9904 4064; fax: +61 3 9940 4655. E-mail address: [email protected] (V. Plummer).
http://dx.doi.org/10.1016/j.aenj.2015.12.001 1574-6267/Crown Copyright © 2015 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
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A. Al Thobaity et al. Conclusions: This study provided a validated, reliable scale for exploring nurses’ core competencies, nurses’ roles and barriers to developing disaster nursing in the KSA. The new scale has many implications, such as for improving education, planning and curricula. Crown Copyright © 2015 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
What is known • Core competencies in disaster nursing management have been developed but they are inconsistent and have not been empirically validated. Their structures and vocabularies differ considerably. It is difficult to build an educational framework for education and training on this platform.
What this paper adds? • A new disaster competency instrument was developed, with strong psychometric properties. Preliminary evidence has been provided of its reliability and validity to assess nurses’ roles and core competencies and identify the barriers to their development in Saudi Arabia. It is suggested that this could support an education program in disaster nursing education in Saudi Arabia.
Introduction Disaster management is an ongoing, sophisticated process. Effective disaster management does not happen automatically; rather, it is a structured, disciplined approach that aligns people, strategy, processes, technology and knowledge to evaluate and manage uncertainty in the natural world.1 Morton and Vu describe the disaster management process as comprising two aspects: minimising risk and maximising the benefits of disaster preparedness.2 Effective disaster management is not restricted to avoiding danger; it also can facilitate opportunities.3 In other words, disaster management focuses on preparation for, mitigation of and response to disasters as well as on restoring communities to pre-disaster status. Different principles govern each of these phases. Similarly, the concept of disaster nursing focuses on providing a high level of holistic care during all phases of disasters to populations affected by or at risk of disaster.4 To achieve the goals of disaster nursing, all nurses must have core competencies in terms of skills, knowledge, leadership and ability to provide holistic care to affected populations.4 Although disaster nursing is a relatively new specialty in the early stages of development globally,5,6 researchers and stakeholders in many countries recognise its importance.7—14 In particular, Western and East Asian countries have made efforts to develop core competencies and prepare nurses to translate plans into practice via education and training. Despite these efforts, many issues can affect the development of core competencies in disaster nursing. For instance,
disaster nursing is not fully incorporated into nursing curricula, and evidence-based practices lack key aspects, such as preparedness, education, training and nurses’ roles.5,9,11,15—19 Therefore, the core competencies of disaster nursing need to be developed and validated worldwide. Hundreds of core competencies have been developed for nurses in disaster management.20,21 However, they are inconsistent in structure, validity and terminology.20 There are very few frameworks for core competencies. One example is the International Council of Nurses (ICN) Framework of Disaster Nursing Competencies (2009) which has 10 domains and 130 core competencies.22 Recently, Schultz et al. developed a framework that identified 19 core competencies.17 However, previous works have not psychometrically tested the elements in either framework. Despite these measurement limitations, there has been a gradual development of core competencies for healthcare providers, particularly nurses, during disasters. The most common core competencies identified as essential include knowledge related to (1) detection of and response to an event, (2) the role of a nurse in incident command centres, (3) triage, (4) epidemiology and surveillance, (5) isolation, quarantine and decontamination, (6) communication, (7) psychological issues and care of special populations, (8) accessing critical resources and (9) reportage and (10) ethics. Each competency is a key component of disaster preparedness and response.17,22—25 The disaster nursing literature reveals few validated, reliable tools in more specific areas of core competencies. Few tools that have been psychometrically tested, and most tools previously used have not been examined rigorously. As examples, two developed tools in disaster nursing include the following. The first is the disaster preparedness evaluation tool (DPET), developed by Bond and Tichy in 2007 for nurses in the United States.26,27,16 Bond and Tichy aimed to evaluate the level of nurses’ disaster preparedness relating to 45 items on a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). In 2010, their tool was tested psychometrically in Jordan using a principal components analysis (PCA) with Varimax. Three factors were extracted from the data: knowledge, skills and preparedness.27 DPET also was used in 2012 to evaluate the knowledge of nurses in military and civilian hospitals.5 The Cronbach’s alpha of this tool in all previous studies has been excellent, with a minimum score of 0.88.5 The second established tool related to disaster nursing is the Emergency Preparedness Information Questionnaire (EPIQ), originally developed by Wisniewski et al. in 200428 in the United States. The primary purpose of this questionnaire was to evaluate nurses’ competencies in terms of disaster preparedness with 45 on a Likert scale from 1 (not familiar) to 5 (very familiar). In 2008, EPIQ was tested psychometrically by Garbutt, Peltier and Fitzpatrick,29 who conducted a PCA using Varimax. EPIQ was used again in 2012 in the United Kingdom to measure the familiarity of nurses with disaster
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
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Disaster competency using PCA nursing preparedness, helping to enhance the tool’s validity and reliability.30 The literature shows that nursing plays critical roles in preparing for and responding effectively to disasters in hospitals and communities. However, there is a paucity of well-established tools for exploring the three core constructs of disaster nursing (core competencies, nurses’ roles and barriers to disaster nursing) globally. Furthermore, disaster nursing in the KSA is not structured fundamentally, and there is a need to explore its core competencies.5 The objective of this study is to develop a valid, reliable scale that identifies and explores the core competencies of disaster nursing, nurses’ roles in disaster management and the barriers to developing disaster nursing in the KSA.
3
PCA design After developing the instrument and testing it on a small group, it was applied to a larger group be means of a non-experimental research design using a paper-based, selfreport survey. PCA using Varimax rotation was conducted to explore factors emerging from nurses’ responses.
PCA settings This study was carried out in two major hospitals operated by the Ministry of Health in the KSA. The hospitals are located in cities that have been affected by natural disasters in the past and that are at risk for disasters in the future.
Methods PCA population and sample Developing the instrument The first step in this study involved conducting a scoping review of existing disaster nursing literature to identify existing theories, methods and knowledge regarding core competencies for disaster nursing. Based on the review, the ICN disaster-nursing framework was used as a guideline to generate the first draft of this study’s instrument together with the work of Schultz et al. (2012) and Subbarao (2008).17,22,24 To generate the items, researchers selected all 10 domains of core competencies specified in the ICN framework. Furthermore, 18 items for nurses’ roles, 13 items for barriers to developing core competencies and 6 items for enablers to developing core competencies in the KSA were generated.4,20,31 This was followed by an iterative process of excluding items not related to emergency nursing in hospital settings or items that could be combined and replaced by items from the Schultz et al. (2012) study.
Refining and validating the instrument Before constructing the instrument, the researchers used a validated theoretical framework to design the questionnaire17,22,24 to ensure that relevant items measured the identified topic. These studies helped the researchers to construct a theoretically validated survey instrument. During this process, face validity and content validity were checked three times to ensure clarity and generate new items essential to exploring core competencies, roles, barriers and enablers in the KSA context. This process resulted in a new version of the questionnaire with the following five parts: 12 items for demographic data; 11 items for nurses’ roles in disaster management; 64 items about core competencies; 13items about barriers to disaster nursing in the KSA; and 6 items about enablers to developing disaster nursing in the KSA. All parts except the one gathering demographic data used a Likert scale from 1 to 10. After this validation process, the questionnaire was tested on a small group of expert emergency nurses in the KSA (n = 30) using a test and retest approach. The main statistics used in the test and retest were descriptive statistics for demographic data and Pearson’s product-moment correlation coefficient to measure test—retest reliability. Then, the instrument was tested on a larger sample using PCA.
The population for this study was emergency nurses working in two public hospitals in the KSA. A non-random, purposive sample was used. Inclusion criteria included participants currently working in the emergency department who had qualifications in nursing, including at least a twoyear diploma in nursing, and who were able to read and write proficiently in English, the primary language of all hospitals in the KSA. Questionnaires were not distributed in Arabic to nurses who were unable to read and write English, because the data obtained might affect validity of the results. Because the number of nurses in each emergency department is about 100, and to meet the requirement for an adequate sample size for PCA, which is a minimum of 100,32 200 questionnaires were distributed, 100 to each hospital.
PCA data collection The researchers visited both hospitals and discussed the objectives of the study with nursing supervisors. Data was collected from both hospitals between 6 June 2014 and 10 July 2014. An explanatory statement was attached to each questionnaire. No explicit consent was sought from participants, but completion and submission of a questionnaire was considered to imply consent.
PCA data analysis Data were entered into Excel and then exported into SPSS version 22 for analysis.33 Data were screened for missing data and outliers and were tested for normality by calculating skewness and kurtosis of each item, which is required for PCA.34 To evaluate the suitability of data for PCA Kaiser—Mayer—Olkin (KMO) and Bartlett’s tests were used.32 Then, the number of factors that needed to be extracted using PCA was identified. After a decision regarding this, orthogonal Varimax rotation was calculated, because it provides results that are easily interpreted and, thus, is suitable for pilot studies.34,35 Criteria for deleting redundant items were based on cross-loading of items with differences between primary and secondary loadings of >0.30.35 The final step in PCA was interpreting the identifying factors.
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
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The Cronbach’s alpha coefficient was calculated to test the scale’s internal consistency.
Ethical considerations The following approvals were obtained from the appropriate Human Research Ethics Committees and hospitals: MUHREC project number: CF14/1190 — 2014000531; KASH volume no. 37/183607 date 03/12/2013; and KFHT and KAASHJ volume no. H-02-K-001 date 29/01/2014.
Results Test—retest results The testing reliability survey involved 29 (out of 33, 87.87%) participants. The sample was dominated by Filipino nurses (80%), followed by Indian nurses (10%), Saudi nurses (approximately 7%) and Pakistani nurses (3%). Of the participants, the majority held bachelor’s degrees (79%), while smaller numbers had higher national diplomas, master’s degrees or doctorates (10%, 7% and 3%, respectively). The majority of participants (slightly more than one-third) had more than 15 years of experience, while a small minority (less than 7%) had less than five years of experience. Six cases had missing data, with less than 0.7% of the total values of the data which is considered as Missing Completely at Random (MCAR), as approved by Little’s MCAR test: Chi-Square = .000, DF = 1080, Sig. = 1.000. Thus, all 29 participants were involved in the test and retest statistical analysis. Test—retest reliability of the Disaster Nursing Core Competencies Scale was satisfactory for the correlation between Time 1 and Time 2 of the total scale (r = .76, p < .001) and moderate to excellent for the subscales (Nurses’ roles: r = .78, p < .001; Risk reduction: r = .85, p < .001; Planning: r = .82, p < .001; Ethical practice: r = .81, p < .001; Communication: r = .82, p < .001; Education: r = .89, p < .001; Care for communities: r = .93, p < .001; Care for individuals: r = .81, p < .001; Psychological care: r = .0.76, p < .001; Care of vulnerable populations: r = .82, p < .001; Recovery:
Table 1
Participants’ characteristics/PCA The total response rate was n = 139 (69.5%). Of the total questionnaires returned, 7 (3.5%) were incomplete and so were safely discarded, leaving a final response rate of n = 132 (66%). In the pilot study, the sample was dominated by female nurses, (n = 117), with only 15 male participants. The majority of participants were Filipino (50.6%), with the nationalities of the remaining participants being: Saudi (23.5%), Indian (22%), Pakistani (1.5%) and Bangladeshi, Chinese and Tunisian (.80% for each). More than 80% of participants had more than 10 years of experience as registered nurses in emergency departments, which helped enhance validity of the findings. Furthermore, 78% had received education about disaster management in the KSA.
PCA results The KMO measure was 0.88, which means there was sufficient data to conduct a factor analysis, while Bartlett’s Test of Sphericity (p = .001) indicated that there was an adequate correlation among variables. Therefore, the PCA was sufficient for this sample. Based on the results of initial eigenvalues, 12 factors had eigenvalues >1 that explained 84.34% of variance (Table 1); however, results of parallel analysis showed that only five factors could be extracted because only these factors had initial eigenvalues of more than the random values in the parallel analysis. Therefore, five factors were extracted that explained 72.28% of the total variance with loadings greater than ±40 with factors used to identify factor solutions. All items were loaded on the five factors; however, this resulted in a complex structure (redundant), which meant many items were loaded on two or more factors (cross-loading). Therefore, these redundant items were deleted in three iterations: 34 in the first iteration because they were cross-loaded; 13
Initial eigenvalues and parallel analysis.
Component
1 2 3 4 5 6 7 8 9 10 11 12
r = .92, p < .001; Barriers to developing core competencies: r = .55, p < .001; and Solutions for developing disaster core competencies: r = .61, p < .001). The findings indicate that the subscales are stable over time.
Initial eigenvalues
Parallel analysis
Total
% of variance
Cumulative %
Random
Decision
47.82 7.79 4.75 3.78 3.09 2.40 1.87 1.66 1.59 1.38 1.19 1.13
51.42 8.37 5.10 4.06 3.33 2.58 2.01 1.78 1.71 1.49 1.28 1.21
51.42 59.79 64.89 68.95 72.28 74.86 76.87 78.65 80.36 81.85 83.13 84.34
3.23 3.06 2.91 2.80 2.69 2.60 2.52 2.44 2.37 2.30 2.23 2.16
Accept Accept Accept Accept Accept Reject Reject Reject Reject Reject Reject Reject
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
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Disaster competency using PCA in the second iteration for the same reason; and 2 items because they were cross-loaded with two factors in the third iteration. After three iterations, only 44 items remained that had no cross-loading. PCA was conducted again on these remaining items, resulting in an increase in KMO value (0.89), and a commonalities value of about 0.60. However, this PCA selected only three factors, while a fourth factor had no loading of items ±0.40. One item, ‘A nurse should be able to identify other human behaviours that put individuals at risk during a disaster’, was loaded on Factor 5; however, this factor was removed, as the minimum items per factor must be at least three35 Table 2 shows the three resultant factors. All items related to recovery stages and enablers for developing disaster nursing in the KSA were deleted. Factor 1 was labelled core competencies of disaster nursing. There were 29 items loaded in this factor, with loads ranging from 0.93 to 0.72 (explained variance 51.42%). The highest two items, with a load of 0.93, were ‘A nurse should be able to participate in drills in the workplace and community’ and ‘A nurse should be able to facilitate and perform patient transport effectively and safely during a disaster’. Factor 1 included mitigation and planning and preparedness and response core competencies of disaster nursing; all items related to disaster nursing recovery were removed because of their complex structure (cross-loading). The reliability test indicated that Factor 1 was excellent (Cronbach’s alpha = 0.98). Factor 2 was labelled barriers to developing disaster nursing. There were eight items loaded on this factor, ranging from 0.89 to 0.61 (explained variance 8.37%). The highest item was ‘Lack of formal educational resources’. The reliability test indicated that Factor 2 was excellent (Cronbach’s alpha = 0.92). Factor 3 was labelled nurses’ roles in disaster management. Five items were loaded on this factor, ranging from 0.44 to 0.66 (5.10%). The highest item was ‘I participate in creating new guidelines for disaster management’. The reliability test indicated that Factor 3 was excellent (Cronbach’s alpha = 0.86). However, the overall scale reliability was very excellent, as the Cronbach’s alpha was 0.97 for all 44 items.
Discussion The Disaster Nursing Core Competencies Scale was built on a rigorous, solid framework. Therefore, it is very useful in exploring disaster nurses’ core competencies not only in the KSA, but also in an international context. Upon data analysis of both testing and retesting, the PCA showed the validity and reliability of this scale. Various validity types, such as face validity and content validity, showed that this scale can be used with high confidence to explore the three core constructs of disaster nursing (core competencies, barriers and roles). Construct validity was examined with particularly rigorous criteria, such as cross-loading, showing a cut-off point of 0.4 regarding loading.35 PCA findings showed a three-factor structure corresponding most closely to the core constructs. Not all items generated for this scale passed the PCA fit test. The scale indicated that only 44 items were not redundant and were representative of the three core constructs of disaster nursing, whereas many items were loaded on two or more factors. The other items threatened
5 construct validity, as they measured multiple constructs, so they were eliminated to ensure that the remaining items were relevant and measured specific constructs. This scale clearly identifies three core factors as essential to nurse competency in disaster nursing management in the KSA. The first factor regards core competencies. Data revealed many core competencies in disaster nursing, such as planning, resources, triaging, communication, ethical issues, managing resources, psychological preparedness, workplace and community drills and patient transportations. These findings agree with many previous studies emphasising adequate knowledge and skills required of disaster nurses in all aspects and phases of disaster management.5,7,11,16,19,20,26,37,38 In the future, these aspects should be investigated using this scale. Of all factors, participating in drills had the highest loading, indicating a very strong positive correlation. Given that drills are the main source of developing nurses’ knowledge and skills in many countries,5,16 including the KSA, the correlation must be elaborated upon and investigated in more detail using various approaches and datasets. This scale has many implications regarding core competencies and can serve as the basis for a curricula blueprint for nursing schools in the KSA, while also providing opportunity for international benchmarking. The findings are expected to inform clinical leadership in the advanced practice area. If effective education and training programs facilitated core competencies, they would increase the ability of emergency nurses to function effectively during disasters. This scale determined the most important competencies for disaster nursing in the KSA, as listed in Table 2. These data will be very useful to decision-makers and nursing educators, enabling them to formulate and implement appropriate plans and strategies for disaster risk reduction in the future. The second factor deals with the barriers faced by disaster nurses in the KSA. This scale elaborated many items relevant to this factor, such as the restricted roles of nurses and the lack of education, training, expertise, support and research and evaluation tools. This scale confirmed that eight items in this factor have strong construct validity with strong loading. This is consistent with other findings that confirm that disaster nursing has unclear roles in early stages, lacking proper education, training, expertise and research.5,14,16,19,20,36 To improve the adequacy of disaster nursing, all aspects validated by this scale must be quantified and qualified for synthesis through evidence-based practice. In addition, this scale is recommended for use internationally to illustrate global barriers to developing disaster nursing capabilities. The scale is useful to assist development of future education and research plans. The third factor, the roles of nurses in disaster management, involved six items with a strong construct validity. The roles involve various aspects, such as planning, education, training, drills and creating guidelines. Clearly, creating new guidelines is very important for disaster nursing. Without clear procedures and guidelines for before, during and after disasters, it is difficult for nurses to provide high-quality care to affected individuals, families and communities.4 Construct validity of the items in this factor is evidently strong. Therefore, this scale is useful for exploring essential roles of nurses in disaster management, as it contributes to a critical
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
Items
2
3
4
5
h2
M
SD
.14 .13
−.01 .01
−.02 −.03
.03 −.07
0.89 0.89
8.55 8.57
1.97 1.92
0.92
.07
.05
−.01
.20
0.90
8.33
2.17
0.92
.11
.02
.01
−.01
0.86
8.39
2.04
0.91 0.90 0.90
.15 .10 .15
.06 .04 .05
−.06 .02 −.01
−.10 .11 .06
0.88 0.85 0.84
8.43 8.60 8.22
2.21 2.03 2.11
0.90
.12
.08
−.08
.01
0.84
8.40
1.95
0.89
.12
.02
.01
−.01
0.82
8.39
1.94
0.88
.10
.11
−.01
.04
0.813
8.19
2.09
0.88
.14
.01
−.03
.014
0.80
8.47
2.55
0.88 0.86
.06 .10
.08 .05
.01 −.04
.13 .19
0.81 0.80
8.23 8.16
2.00 2.27
0.86
.04
.14
−.04
.06
0.77
8.04
2.33
0.85
.17
.05
.30
−.07
0.85
8.20
2.22
0.85
.04
.05
.05
.01
0.73
8.13
2.05
0.84
−.02
.20
−.05
−.04
0.76
8.10
2.24
0.84
.14
.10
.30
−.11
0.85
8.19
2.19
0.84
.09
.08
.37
−.01
0.86
8.22
2.08
0.84
.09
.05
.33
−.08
0.83
8.18
2.08
0.83
.12
.10
.31
−.14
0.84
8.29
2.17
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0.93 0.93
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A nurse should be able to participate in drills in the workplace and community. A nurse should be able to facilitate and perform patient transport effectively and safely during a disaster. A nurse should be able to maintain knowledge in areas relevant to disaster and disaster nursing. A nurse should be able to identify and communicate important information immediately to appropriate authorities. A nurse should be able to understand the component of disaster plan. A nurse should be able to understand the purpose of disaster plan. A nurse should be able to demonstrate an ability to follow and work within an incident management system. A nurse should be able to understand how to prioritise care and manage multiple situations. A nurse should be able to list and apply principles for managing patients with the most common victims presentations, e.g., environmental illnesses; burns; blast and crush injuries; nuclear, biologic and chemical exposures A nurse should be able to participate in processes of securing adequate personal, supplies, equipment, and space for patient care (surge capacity). A nurse should be able to recognise the disaster plan in the workplace and ones role in the workplace at the time of a disaster. A nurse should be able to manage and supervise volunteers. A nurse should be able to provide up-to-date information to the disaster response team regarding health care issues and resource needs. A nurse should be able to participate in planning to meet health care needs in a disaster. A nurse should be able to describing the principles of crisis communication in crisis intervention and risk management. A nurse should be able to list the appropriate steps for requesting psychological first aid for responders, patients, and other victims. A nurse should be able to identify vulnerable populations and coordinating activities to reduce risk. A nurse should be able to describe the phases of the disaster management continuum: prevention/mitigation, preparedness, response and recovery/rehabilitation. A nurse should be able to manage the resources and supplies required to provide care in the community. A nurse should be able to identify potential threats with medical implications in response areas. A nurse should be able to describe nurses roles in various disaster assignments (e.g. shelters, emergency care sites).
I
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Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
Table 2
2
3
4
5
h2
M
SD
0.83 0.82
.05 .117
.06 .08
−.15 .37
−.16 .03
0.74 0.84
8.56 8.17
1.77 2.00
0.81 0.81
.19 .09
.08 .13
.28 −.21
−.05 .02
0.79 0.73
8.14 8.24
2.37 2.07
0.81
.11
.13
−.03
.23
0.74
8.11
2.21
0.75
.04
.12
−.23
−.13
0.66
8.62
1.98
0.73
.13
.08
−.01
.21
0.61
8.03
2.16
0.72
.13
.13
.43
.05
0.73
7.82
2.33
0.07 0.14 0.18 0.08 0.10 0.22 0.03 0.27 −0.01 0.23
0.89 0.84 0.83 0.80 0.77 0.76 0.75 0.61 .08 −.12
−.03 .02 −.04 −.07 −.02 .07 −.01 −.01 0.84 0.81
.10 −.10 −.16 .10 .01 .03 .12 −.03 .030 −.277
−.12 −.04 −.05 −.10 −.01 .26 .13 −.42 .08 .05
0.83 0.74 0.76 0.67 0.60 0.71 0.60 0.63 0.72 0.81
5.96 6.10 6.32 6.01 6.20 6.38 5.76 6.44 4.10 5.80
2.96 2.77 2.68 2.91 2.81 2.83 2.91 2.73 3.05 3.13
−0.05 0.04 0.28
.08 −.04 −.17
0.76 0.75 0.70
−.01 .27 −.32
.26 −.07 −.08
0.66 0.65 0.72
4.25 5.19 5.93
2.99 3.12 2.79
0.33 0.18
−.04 −.08
0.66 .09
.26 −.014
−.14 .74
0.65 .61
5.97 8.40
3.13 2.91
22.97 52.20 8.3 0.98
4.97 11.31 6.2 0.92
3.25 7.39 5.2 0.86
1.44 3.28 — —
1.22 2.78 — v
— — — —
— — — —
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A nurse should be able to prioritise patients to maximise survivability. A nurse should be able to list the acute and long-term consequences of exposure to an overwhelming situation. A nurse should be able to understand relevant disaster terminology. A nurse should be able to describe strategies for allocating scarce resources in an ethical manner to optimise population outcomes during triage and treatment. A nurse should be able to participate in creating new guidelines for nursing practice in disaster. A nurse should be able to use recordkeeping processes to ensure continuity of patient information. A nurse should be able to develop and maintain a personal and family preparedness plan. A nurse should be able to provide defensible solutions to a series of ethical dilemmas arising in disaster. Lack of formal educational resources. Ineffective training opportunities. Lack of evaluation instruments. Lack of health organisation support. Lack of training programs in the workplace. Lack of expert staff in disaster nursing. Restriction of nurses roles in disaster management. Lack of research studies on disaster nursing. I participate in creating new guidelines for disaster management I have a role in identifying the education and training needs of nurses with regard to disaster management I am authorised to activate a local disaster plan I participate in developing disaster plans and policy in my hospital I participate in education and training activities for health care providers that relate to disaster management I participate in mock disaster drills on a regular basis A nurse should be able to identify other human behaviours that put individuals at risk during a disaster. Eigenvalues Explained variance Mean Alpha Cronbach
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Table 2
The bold values indicate the accepted loading of items on factors (above 0.40).
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first step in enhancing continuing education and training programs for disaster preparedness, which will advance corresponding competencies of disaster nursing in the KSA. This scale has very good reliability, both internal and external consistency as indicated by testing, retesting and Cronbach’s alpha. Test and retest findings indicate moderate to excellent consistency over a period of time, while the Cronbach’s alpha indicates excellent reliability of all three extracted factors. Therefore, this scale is extremely useful and reliable, able to be used with high confidence to identify core competencies, barriers to and roles of disaster nursing in the KSA.
Limitations There are some limitations to this study. Confirmatory factor analysis to test convergent and discrimination validity was not performed; however, this is planned for future research. Another limitation is self-reporting. Finally, generalisability is limited, as the questionnaires were administered at only two hospitals in the KSA.
Conclusions This study has demonstrated a newly developed scale that has strong psychometric properties, providing preliminary evidence of its reliability and validity to assess nurses’ roles and core competencies and identifying barriers to developing disaster nursing core competencies in the KSA. It is hoped that this instrument can support disaster nursing education in the KSA and can help evaluate nurses in terms of their preparedness for and competencies regarding disasters. Furthermore, the scale can serve as the basis for a curriculum designed for nursing schools in the KSA.
Provenance and conflict of interest The authors declare that they have no conflict of interest. This paper was not commissioned.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgments All authors would like to thank Monash University and Taif University sincerely for their help and support. In addition, all authors are grateful to all study participants for their contribution.
References 1. Coppola DP. The management of disasters. Introduction to international disaster management. 2nd ed. Boston: Butterworth-Heinemann; 2011. p. 1—35. 2. Morton MJ, Vu A. International emergency medicine and global health: training and career paths for emergency medicine residents. Ann Emerg Med 2011;57(5):520—5.
3. Bern AI. Role of emergency medicine in disaster management. In: Gregory RC, Facepa R, Gregory R, Ciottone MF, editors. Disaster medicine. Philadelphia: Mosby; 2006. p. 26—33 [chapter 4]. 4. Powers R, Powers R. Introduction to disasters and disaster nursing. In: International disaster nursing. Cambridge University Press; 2010. 5. Al Thobaity A, Plummer V, Innes K, Copnell B. Perceptions of knowledge of disaster management among military and civilian nurses in Saudi Arabia. Aust Emerg Nurs J 2015;18(3):156—64. 6. Arbon P, Bobrowski C, Zeitz K, Hooper C, Williams J, Thitchener J. Australian nurses volunteering for the Sumatra-Andaman earthquake and tsunami of 2004: a review of experience and analysis of data collected by the Tsunami Volunteer Hotline. Aust Emerg Nurs J 2006;9(4):171—8. 7. Arbon P, Cusack L, Ranse J, Shaban RZ, Considine J, Kako M, et al. Exploring staff willingness to attend work during a disaster: a study of nurses employed in four Australian emergency departments. Aust Emerg Nurs J 2013;16(3):103—9. 8. Arbon P, Ranse J, Cusack L, Considine J, Shaban RZ, Woodman RJ, et al. Australasian emergency nurses’ willingness to attend work in a disaster: a survey. Aust Emerg Nurs J 2013;16(2): 52—7. 9. Hammad KS, Arbon P, Gebbie K, Hutton A. Nursing in the emergency department (ED) during a disaster: a review of the current literature. Aust Emerg Nurs J 2012;15(4):235—44. 10. Pesiridis T, Sourtzi P, Galanis P, Kalokairinou A. Development, implementation and evaluation of a disaster training programme for nurses: a switching replications randomized controlled trial. Nurse Educ Pract 2015;15(1):63—7. 11. Ranse J, Shaban RZ, Considine J, Hammad K, Arbon P, Mitchell B, et al. Disaster content in Australian tertiary postgraduate emergency nursing courses: a survey. Aust Emerg Nurs J 2013;16(2):58—63. 12. Usher K, Redman-MacLaren ML, Mills J, West C, Casella E, Hapsari ED, et al. Strengthening and preparing: enhancing nursing research for disaster management. Nurse Educ Pract 2015;15(1):68—74. 13. Wenji Z, Turale S, Stone TE, Petrini MA. Chinese nurses’ relief experiences following two earthquakes: implications for disaster education and policy development. Nurse Educ Pract 2015;15(1):75—81. 14. Ranse J, Lenson S, Aimers B. Black Saturday and the Victorian bushfires of February 2009: a descriptive survey of nurses who assisted in the pre-hospital setting. Collegian 2010;17(4):153—9. 15. Usher K, Mayner L. Disaster nursing: a descriptive survey of Australian undergraduate nursing curricula. Aust Emerg Nurs J 2011;14(2):75—80. 16. Al Khalaileh MA, Bond E, Alasad JA. Jordanian nurses’ perceptions of their preparedness for disaster management. Int Emerg Nurs 2012;20(1):14—23. 17. Schultz CH, Koenig KL, Whiteside M, Murray R. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med 2012;59(3):196—208. 18. Ranse J, Hutton A, Jeeawody B, Wilson R. What are the research needs for the field of disaster nursing? An International Delphi study. Prehosp Disaster Med 2014. 19. Duong K. Disaster education and training of emergency nurses in South Australia. Aust Emerg Nurs J 2009;12(3):86—92. 20. Daily E, Padjen P, Birnbaum M. A review of competencies developed for disaster healthcare providers: limitations of current processes and applicability. Prehosp Disaster Med 2010;25(5):387—95. 21. Kako M, Mitani S, Arbon P. Literature review of disaster health research in Japan: focusing on disaster nursing education. Prehosp Disaster Med 2012;27(2):178—83.
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Disaster competency using PCA 22. ICN & WHO. ICN Framework of disaster nursing competencies; 2009. Available at: http://www.icn.ch/icn-networks/disasterresponse-network/resources-and-related-publications.html [accessed 09.10.15]. 23. Gebbie KM, Hutton A, Plummer V. Update on competencies and education. Annu Rev Nurs Res 2012;30:169—92. 24. Subbarao I, Lyznicki JM, Hsu EB, Gebbie KM, Markenson D, Barzansky B, et al. A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness. Disaster Med Public Health Prep 2008;2(1):57—68. 25. Walsh L, Subbarao I, Gebbie K, Schor KW, Lyznicki J, Strauss-Riggs K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep 2012;6(1):44—52. 26. Tichy M, Bond AE, Beckstrand RL, Heise B. NPs’ perceptions of disaster preparedness education: quantitative survey research. Am J Nurse Pract 2009;13(1):10. 27. Al Khalaileh MAA, Bond AE, Beckstrand RL, Al-Talafha A. The Disaster Preparedness Evaluation Tool©: Psychometric testing of the Classical Arabic version. J Adv Nurs 2010;66(3): 664—72. 28. Wisniewski R, Dennik-Champion G, Peltier JW. Emergency preparedness competencies: assessing nurses’ educational needs. J Nurs Adm 2004;34(10):475—80.
9 29. Garbutt SJ, Peltier JW, Fitzpatrick JJ. Evaluation of an instrument to measure nurses’ familiarity with emergency preparedness. Mil Med 2008;173(11):1073—7. 30. Worrall J. Are emergency care staff prepared for disaster? Emerg Nurse 2012;19(9):31—7. 31. Veenema TG, Thornton CP. Understanding nursing’s role in health systems. Response to large-scale radiologic disasters. J Radiol Nurs 2015. 32. Williams B, Brown T, Onsman A. Exploratory factor analysis: a five-step guide for novices. Aust J Paramed 2012;8(3):1. 33. Statistics I IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.; 2013. 34. Hair J, Black W, Babin B, Anderson R. Multivariate data analysis. 7th ed Prentice Hall; 2010. 35. Pett MA, Lackey NR, Sullivan JJ. Making sense of factor analysis: the use of factor analysis for instrument development in health care research. Sage; 2003. 36. Husna C, Hatthakit U, Chaowalit A. Do knowledge and clinical experience have specific roles in perceived clinical skills for tsunami care among nurses in Banda Aceh, Indonesia? Aust Emerg Nurs J 2011;14(2):95—102. 37. Kako M, Arbon P, Mitani S. Disaster health after the 2011 Great East Japan earthquake. Prehosp Disaster Med 2014;29(1):54—9. 38. Chapman K, Arbon P. Are nurses ready? Disaster preparedness in the acute setting. Aust Emerg Nurs J 2008;11(3):135—44.
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Australasian Emergency Nursing Journal (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
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RESEARCH PAPER
A new scale for disaster nursing core competencies: Development and psychometric testing Abdulellah Al Thobaity, RN, MN a,b Brett Williams, PhD c Virginia Plummer, RN, PhD a,d,∗ a
School of Nursing & Midwifery, Monash University, Australia College of Applied Medical Science, Taif University, Saudi Arabia c Department of Community Emergency Health and Paramedic Practice, Monash University, Australia d Nursing Research, Monash University and Peninsula Health, Australia b
Received 18 July 2015; received in revised form 15 November 2015; accepted 16 December 2015
KEYWORDS Disaster; Management; Competence; Saudi Arabia; Principal component analysis
Summary Background: All nurses must have core competencies in preparing for, responding to and recovering from a disaster. In the Kingdom of Saudi Arabia (KSA), as in many other countries, disaster nursing core competencies are not fully understood and lack reliable, validated tools. Thus, it is imperative to develop a scale for exploring disaster nursing core competencies, roles and barriers in the KSA. Objectives: This study’s objective is to develop a valid, reliable scale that identifies and explores core competencies of disaster nursing, nurses’ roles in disaster management and barriers to developing disaster nursing in the KSA. Methods: This study developed a new scale testing its validity and reliability. A principal component analysis (PCA) was used to develop and test psychometric properties of the new scale. The PCA used a purposive sample of nurses from emergency departments in two hospitals in the KSA. Participants rated 93 paper-based, self-report questionnaire items from 1 to 10 on a Likert scale. PCA using Varimax rotation was conducted to explore factors emerging from responses. Findings: The study’s participants were 132 nurses (66% response rate). PCA of the 93 questionnaire items revealed 49 redundant items (which were deleted) and 3 factors with eigenvalues of >1. The remaining 44 items accounted for 77.3% of the total variance. The overall Cronbach’s alpha was 0.96 for all factors: 0.98 for Factor 1, 0.92 for Factor 2 and 0.86 for Factor 3.
∗ Corresponding author at: School of Nursing & Midwifery, Monash University, McMahons Road, Frankston, Victoria 3199, Australia. Tel.: +61 3 9904 4064; fax: +61 3 9940 4655. E-mail address: [email protected] (V. Plummer).
http://dx.doi.org/10.1016/j.aenj.2015.12.001 1574-6267/Crown Copyright © 2015 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
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A. Al Thobaity et al. Conclusions: This study provided a validated, reliable scale for exploring nurses’ core competencies, nurses’ roles and barriers to developing disaster nursing in the KSA. The new scale has many implications, such as for improving education, planning and curricula. Crown Copyright © 2015 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
What is known • Core competencies in disaster nursing management have been developed but they are inconsistent and have not been empirically validated. Their structures and vocabularies differ considerably. It is difficult to build an educational framework for education and training on this platform.
What this paper adds? • A new disaster competency instrument was developed, with strong psychometric properties. Preliminary evidence has been provided of its reliability and validity to assess nurses’ roles and core competencies and identify the barriers to their development in Saudi Arabia. It is suggested that this could support an education program in disaster nursing education in Saudi Arabia.
Introduction Disaster management is an ongoing, sophisticated process. Effective disaster management does not happen automatically; rather, it is a structured, disciplined approach that aligns people, strategy, processes, technology and knowledge to evaluate and manage uncertainty in the natural world.1 Morton and Vu describe the disaster management process as comprising two aspects: minimising risk and maximising the benefits of disaster preparedness.2 Effective disaster management is not restricted to avoiding danger; it also can facilitate opportunities.3 In other words, disaster management focuses on preparation for, mitigation of and response to disasters as well as on restoring communities to pre-disaster status. Different principles govern each of these phases. Similarly, the concept of disaster nursing focuses on providing a high level of holistic care during all phases of disasters to populations affected by or at risk of disaster.4 To achieve the goals of disaster nursing, all nurses must have core competencies in terms of skills, knowledge, leadership and ability to provide holistic care to affected populations.4 Although disaster nursing is a relatively new specialty in the early stages of development globally,5,6 researchers and stakeholders in many countries recognise its importance.7—14 In particular, Western and East Asian countries have made efforts to develop core competencies and prepare nurses to translate plans into practice via education and training. Despite these efforts, many issues can affect the development of core competencies in disaster nursing. For instance,
disaster nursing is not fully incorporated into nursing curricula, and evidence-based practices lack key aspects, such as preparedness, education, training and nurses’ roles.5,9,11,15—19 Therefore, the core competencies of disaster nursing need to be developed and validated worldwide. Hundreds of core competencies have been developed for nurses in disaster management.20,21 However, they are inconsistent in structure, validity and terminology.20 There are very few frameworks for core competencies. One example is the International Council of Nurses (ICN) Framework of Disaster Nursing Competencies (2009) which has 10 domains and 130 core competencies.22 Recently, Schultz et al. developed a framework that identified 19 core competencies.17 However, previous works have not psychometrically tested the elements in either framework. Despite these measurement limitations, there has been a gradual development of core competencies for healthcare providers, particularly nurses, during disasters. The most common core competencies identified as essential include knowledge related to (1) detection of and response to an event, (2) the role of a nurse in incident command centres, (3) triage, (4) epidemiology and surveillance, (5) isolation, quarantine and decontamination, (6) communication, (7) psychological issues and care of special populations, (8) accessing critical resources and (9) reportage and (10) ethics. Each competency is a key component of disaster preparedness and response.17,22—25 The disaster nursing literature reveals few validated, reliable tools in more specific areas of core competencies. Few tools that have been psychometrically tested, and most tools previously used have not been examined rigorously. As examples, two developed tools in disaster nursing include the following. The first is the disaster preparedness evaluation tool (DPET), developed by Bond and Tichy in 2007 for nurses in the United States.26,27,16 Bond and Tichy aimed to evaluate the level of nurses’ disaster preparedness relating to 45 items on a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). In 2010, their tool was tested psychometrically in Jordan using a principal components analysis (PCA) with Varimax. Three factors were extracted from the data: knowledge, skills and preparedness.27 DPET also was used in 2012 to evaluate the knowledge of nurses in military and civilian hospitals.5 The Cronbach’s alpha of this tool in all previous studies has been excellent, with a minimum score of 0.88.5 The second established tool related to disaster nursing is the Emergency Preparedness Information Questionnaire (EPIQ), originally developed by Wisniewski et al. in 200428 in the United States. The primary purpose of this questionnaire was to evaluate nurses’ competencies in terms of disaster preparedness with 45 on a Likert scale from 1 (not familiar) to 5 (very familiar). In 2008, EPIQ was tested psychometrically by Garbutt, Peltier and Fitzpatrick,29 who conducted a PCA using Varimax. EPIQ was used again in 2012 in the United Kingdom to measure the familiarity of nurses with disaster
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
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Disaster competency using PCA nursing preparedness, helping to enhance the tool’s validity and reliability.30 The literature shows that nursing plays critical roles in preparing for and responding effectively to disasters in hospitals and communities. However, there is a paucity of well-established tools for exploring the three core constructs of disaster nursing (core competencies, nurses’ roles and barriers to disaster nursing) globally. Furthermore, disaster nursing in the KSA is not structured fundamentally, and there is a need to explore its core competencies.5 The objective of this study is to develop a valid, reliable scale that identifies and explores the core competencies of disaster nursing, nurses’ roles in disaster management and the barriers to developing disaster nursing in the KSA.
3
PCA design After developing the instrument and testing it on a small group, it was applied to a larger group be means of a non-experimental research design using a paper-based, selfreport survey. PCA using Varimax rotation was conducted to explore factors emerging from nurses’ responses.
PCA settings This study was carried out in two major hospitals operated by the Ministry of Health in the KSA. The hospitals are located in cities that have been affected by natural disasters in the past and that are at risk for disasters in the future.
Methods PCA population and sample Developing the instrument The first step in this study involved conducting a scoping review of existing disaster nursing literature to identify existing theories, methods and knowledge regarding core competencies for disaster nursing. Based on the review, the ICN disaster-nursing framework was used as a guideline to generate the first draft of this study’s instrument together with the work of Schultz et al. (2012) and Subbarao (2008).17,22,24 To generate the items, researchers selected all 10 domains of core competencies specified in the ICN framework. Furthermore, 18 items for nurses’ roles, 13 items for barriers to developing core competencies and 6 items for enablers to developing core competencies in the KSA were generated.4,20,31 This was followed by an iterative process of excluding items not related to emergency nursing in hospital settings or items that could be combined and replaced by items from the Schultz et al. (2012) study.
Refining and validating the instrument Before constructing the instrument, the researchers used a validated theoretical framework to design the questionnaire17,22,24 to ensure that relevant items measured the identified topic. These studies helped the researchers to construct a theoretically validated survey instrument. During this process, face validity and content validity were checked three times to ensure clarity and generate new items essential to exploring core competencies, roles, barriers and enablers in the KSA context. This process resulted in a new version of the questionnaire with the following five parts: 12 items for demographic data; 11 items for nurses’ roles in disaster management; 64 items about core competencies; 13items about barriers to disaster nursing in the KSA; and 6 items about enablers to developing disaster nursing in the KSA. All parts except the one gathering demographic data used a Likert scale from 1 to 10. After this validation process, the questionnaire was tested on a small group of expert emergency nurses in the KSA (n = 30) using a test and retest approach. The main statistics used in the test and retest were descriptive statistics for demographic data and Pearson’s product-moment correlation coefficient to measure test—retest reliability. Then, the instrument was tested on a larger sample using PCA.
The population for this study was emergency nurses working in two public hospitals in the KSA. A non-random, purposive sample was used. Inclusion criteria included participants currently working in the emergency department who had qualifications in nursing, including at least a twoyear diploma in nursing, and who were able to read and write proficiently in English, the primary language of all hospitals in the KSA. Questionnaires were not distributed in Arabic to nurses who were unable to read and write English, because the data obtained might affect validity of the results. Because the number of nurses in each emergency department is about 100, and to meet the requirement for an adequate sample size for PCA, which is a minimum of 100,32 200 questionnaires were distributed, 100 to each hospital.
PCA data collection The researchers visited both hospitals and discussed the objectives of the study with nursing supervisors. Data was collected from both hospitals between 6 June 2014 and 10 July 2014. An explanatory statement was attached to each questionnaire. No explicit consent was sought from participants, but completion and submission of a questionnaire was considered to imply consent.
PCA data analysis Data were entered into Excel and then exported into SPSS version 22 for analysis.33 Data were screened for missing data and outliers and were tested for normality by calculating skewness and kurtosis of each item, which is required for PCA.34 To evaluate the suitability of data for PCA Kaiser—Mayer—Olkin (KMO) and Bartlett’s tests were used.32 Then, the number of factors that needed to be extracted using PCA was identified. After a decision regarding this, orthogonal Varimax rotation was calculated, because it provides results that are easily interpreted and, thus, is suitable for pilot studies.34,35 Criteria for deleting redundant items were based on cross-loading of items with differences between primary and secondary loadings of >0.30.35 The final step in PCA was interpreting the identifying factors.
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The Cronbach’s alpha coefficient was calculated to test the scale’s internal consistency.
Ethical considerations The following approvals were obtained from the appropriate Human Research Ethics Committees and hospitals: MUHREC project number: CF14/1190 — 2014000531; KASH volume no. 37/183607 date 03/12/2013; and KFHT and KAASHJ volume no. H-02-K-001 date 29/01/2014.
Results Test—retest results The testing reliability survey involved 29 (out of 33, 87.87%) participants. The sample was dominated by Filipino nurses (80%), followed by Indian nurses (10%), Saudi nurses (approximately 7%) and Pakistani nurses (3%). Of the participants, the majority held bachelor’s degrees (79%), while smaller numbers had higher national diplomas, master’s degrees or doctorates (10%, 7% and 3%, respectively). The majority of participants (slightly more than one-third) had more than 15 years of experience, while a small minority (less than 7%) had less than five years of experience. Six cases had missing data, with less than 0.7% of the total values of the data which is considered as Missing Completely at Random (MCAR), as approved by Little’s MCAR test: Chi-Square = .000, DF = 1080, Sig. = 1.000. Thus, all 29 participants were involved in the test and retest statistical analysis. Test—retest reliability of the Disaster Nursing Core Competencies Scale was satisfactory for the correlation between Time 1 and Time 2 of the total scale (r = .76, p < .001) and moderate to excellent for the subscales (Nurses’ roles: r = .78, p < .001; Risk reduction: r = .85, p < .001; Planning: r = .82, p < .001; Ethical practice: r = .81, p < .001; Communication: r = .82, p < .001; Education: r = .89, p < .001; Care for communities: r = .93, p < .001; Care for individuals: r = .81, p < .001; Psychological care: r = .0.76, p < .001; Care of vulnerable populations: r = .82, p < .001; Recovery:
Table 1
Participants’ characteristics/PCA The total response rate was n = 139 (69.5%). Of the total questionnaires returned, 7 (3.5%) were incomplete and so were safely discarded, leaving a final response rate of n = 132 (66%). In the pilot study, the sample was dominated by female nurses, (n = 117), with only 15 male participants. The majority of participants were Filipino (50.6%), with the nationalities of the remaining participants being: Saudi (23.5%), Indian (22%), Pakistani (1.5%) and Bangladeshi, Chinese and Tunisian (.80% for each). More than 80% of participants had more than 10 years of experience as registered nurses in emergency departments, which helped enhance validity of the findings. Furthermore, 78% had received education about disaster management in the KSA.
PCA results The KMO measure was 0.88, which means there was sufficient data to conduct a factor analysis, while Bartlett’s Test of Sphericity (p = .001) indicated that there was an adequate correlation among variables. Therefore, the PCA was sufficient for this sample. Based on the results of initial eigenvalues, 12 factors had eigenvalues >1 that explained 84.34% of variance (Table 1); however, results of parallel analysis showed that only five factors could be extracted because only these factors had initial eigenvalues of more than the random values in the parallel analysis. Therefore, five factors were extracted that explained 72.28% of the total variance with loadings greater than ±40 with factors used to identify factor solutions. All items were loaded on the five factors; however, this resulted in a complex structure (redundant), which meant many items were loaded on two or more factors (cross-loading). Therefore, these redundant items were deleted in three iterations: 34 in the first iteration because they were cross-loaded; 13
Initial eigenvalues and parallel analysis.
Component
1 2 3 4 5 6 7 8 9 10 11 12
r = .92, p < .001; Barriers to developing core competencies: r = .55, p < .001; and Solutions for developing disaster core competencies: r = .61, p < .001). The findings indicate that the subscales are stable over time.
Initial eigenvalues
Parallel analysis
Total
% of variance
Cumulative %
Random
Decision
47.82 7.79 4.75 3.78 3.09 2.40 1.87 1.66 1.59 1.38 1.19 1.13
51.42 8.37 5.10 4.06 3.33 2.58 2.01 1.78 1.71 1.49 1.28 1.21
51.42 59.79 64.89 68.95 72.28 74.86 76.87 78.65 80.36 81.85 83.13 84.34
3.23 3.06 2.91 2.80 2.69 2.60 2.52 2.44 2.37 2.30 2.23 2.16
Accept Accept Accept Accept Accept Reject Reject Reject Reject Reject Reject Reject
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Disaster competency using PCA in the second iteration for the same reason; and 2 items because they were cross-loaded with two factors in the third iteration. After three iterations, only 44 items remained that had no cross-loading. PCA was conducted again on these remaining items, resulting in an increase in KMO value (0.89), and a commonalities value of about 0.60. However, this PCA selected only three factors, while a fourth factor had no loading of items ±0.40. One item, ‘A nurse should be able to identify other human behaviours that put individuals at risk during a disaster’, was loaded on Factor 5; however, this factor was removed, as the minimum items per factor must be at least three35 Table 2 shows the three resultant factors. All items related to recovery stages and enablers for developing disaster nursing in the KSA were deleted. Factor 1 was labelled core competencies of disaster nursing. There were 29 items loaded in this factor, with loads ranging from 0.93 to 0.72 (explained variance 51.42%). The highest two items, with a load of 0.93, were ‘A nurse should be able to participate in drills in the workplace and community’ and ‘A nurse should be able to facilitate and perform patient transport effectively and safely during a disaster’. Factor 1 included mitigation and planning and preparedness and response core competencies of disaster nursing; all items related to disaster nursing recovery were removed because of their complex structure (cross-loading). The reliability test indicated that Factor 1 was excellent (Cronbach’s alpha = 0.98). Factor 2 was labelled barriers to developing disaster nursing. There were eight items loaded on this factor, ranging from 0.89 to 0.61 (explained variance 8.37%). The highest item was ‘Lack of formal educational resources’. The reliability test indicated that Factor 2 was excellent (Cronbach’s alpha = 0.92). Factor 3 was labelled nurses’ roles in disaster management. Five items were loaded on this factor, ranging from 0.44 to 0.66 (5.10%). The highest item was ‘I participate in creating new guidelines for disaster management’. The reliability test indicated that Factor 3 was excellent (Cronbach’s alpha = 0.86). However, the overall scale reliability was very excellent, as the Cronbach’s alpha was 0.97 for all 44 items.
Discussion The Disaster Nursing Core Competencies Scale was built on a rigorous, solid framework. Therefore, it is very useful in exploring disaster nurses’ core competencies not only in the KSA, but also in an international context. Upon data analysis of both testing and retesting, the PCA showed the validity and reliability of this scale. Various validity types, such as face validity and content validity, showed that this scale can be used with high confidence to explore the three core constructs of disaster nursing (core competencies, barriers and roles). Construct validity was examined with particularly rigorous criteria, such as cross-loading, showing a cut-off point of 0.4 regarding loading.35 PCA findings showed a three-factor structure corresponding most closely to the core constructs. Not all items generated for this scale passed the PCA fit test. The scale indicated that only 44 items were not redundant and were representative of the three core constructs of disaster nursing, whereas many items were loaded on two or more factors. The other items threatened
5 construct validity, as they measured multiple constructs, so they were eliminated to ensure that the remaining items were relevant and measured specific constructs. This scale clearly identifies three core factors as essential to nurse competency in disaster nursing management in the KSA. The first factor regards core competencies. Data revealed many core competencies in disaster nursing, such as planning, resources, triaging, communication, ethical issues, managing resources, psychological preparedness, workplace and community drills and patient transportations. These findings agree with many previous studies emphasising adequate knowledge and skills required of disaster nurses in all aspects and phases of disaster management.5,7,11,16,19,20,26,37,38 In the future, these aspects should be investigated using this scale. Of all factors, participating in drills had the highest loading, indicating a very strong positive correlation. Given that drills are the main source of developing nurses’ knowledge and skills in many countries,5,16 including the KSA, the correlation must be elaborated upon and investigated in more detail using various approaches and datasets. This scale has many implications regarding core competencies and can serve as the basis for a curricula blueprint for nursing schools in the KSA, while also providing opportunity for international benchmarking. The findings are expected to inform clinical leadership in the advanced practice area. If effective education and training programs facilitated core competencies, they would increase the ability of emergency nurses to function effectively during disasters. This scale determined the most important competencies for disaster nursing in the KSA, as listed in Table 2. These data will be very useful to decision-makers and nursing educators, enabling them to formulate and implement appropriate plans and strategies for disaster risk reduction in the future. The second factor deals with the barriers faced by disaster nurses in the KSA. This scale elaborated many items relevant to this factor, such as the restricted roles of nurses and the lack of education, training, expertise, support and research and evaluation tools. This scale confirmed that eight items in this factor have strong construct validity with strong loading. This is consistent with other findings that confirm that disaster nursing has unclear roles in early stages, lacking proper education, training, expertise and research.5,14,16,19,20,36 To improve the adequacy of disaster nursing, all aspects validated by this scale must be quantified and qualified for synthesis through evidence-based practice. In addition, this scale is recommended for use internationally to illustrate global barriers to developing disaster nursing capabilities. The scale is useful to assist development of future education and research plans. The third factor, the roles of nurses in disaster management, involved six items with a strong construct validity. The roles involve various aspects, such as planning, education, training, drills and creating guidelines. Clearly, creating new guidelines is very important for disaster nursing. Without clear procedures and guidelines for before, during and after disasters, it is difficult for nurses to provide high-quality care to affected individuals, families and communities.4 Construct validity of the items in this factor is evidently strong. Therefore, this scale is useful for exploring essential roles of nurses in disaster management, as it contributes to a critical
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
Items
2
3
4
5
h2
M
SD
.14 .13
−.01 .01
−.02 −.03
.03 −.07
0.89 0.89
8.55 8.57
1.97 1.92
0.92
.07
.05
−.01
.20
0.90
8.33
2.17
0.92
.11
.02
.01
−.01
0.86
8.39
2.04
0.91 0.90 0.90
.15 .10 .15
.06 .04 .05
−.06 .02 −.01
−.10 .11 .06
0.88 0.85 0.84
8.43 8.60 8.22
2.21 2.03 2.11
0.90
.12
.08
−.08
.01
0.84
8.40
1.95
0.89
.12
.02
.01
−.01
0.82
8.39
1.94
0.88
.10
.11
−.01
.04
0.813
8.19
2.09
0.88
.14
.01
−.03
.014
0.80
8.47
2.55
0.88 0.86
.06 .10
.08 .05
.01 −.04
.13 .19
0.81 0.80
8.23 8.16
2.00 2.27
0.86
.04
.14
−.04
.06
0.77
8.04
2.33
0.85
.17
.05
.30
−.07
0.85
8.20
2.22
0.85
.04
.05
.05
.01
0.73
8.13
2.05
0.84
−.02
.20
−.05
−.04
0.76
8.10
2.24
0.84
.14
.10
.30
−.11
0.85
8.19
2.19
0.84
.09
.08
.37
−.01
0.86
8.22
2.08
0.84
.09
.05
.33
−.08
0.83
8.18
2.08
0.83
.12
.10
.31
−.14
0.84
8.29
2.17
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0.93 0.93
A. Al Thobaity et al.
A nurse should be able to participate in drills in the workplace and community. A nurse should be able to facilitate and perform patient transport effectively and safely during a disaster. A nurse should be able to maintain knowledge in areas relevant to disaster and disaster nursing. A nurse should be able to identify and communicate important information immediately to appropriate authorities. A nurse should be able to understand the component of disaster plan. A nurse should be able to understand the purpose of disaster plan. A nurse should be able to demonstrate an ability to follow and work within an incident management system. A nurse should be able to understand how to prioritise care and manage multiple situations. A nurse should be able to list and apply principles for managing patients with the most common victims presentations, e.g., environmental illnesses; burns; blast and crush injuries; nuclear, biologic and chemical exposures A nurse should be able to participate in processes of securing adequate personal, supplies, equipment, and space for patient care (surge capacity). A nurse should be able to recognise the disaster plan in the workplace and ones role in the workplace at the time of a disaster. A nurse should be able to manage and supervise volunteers. A nurse should be able to provide up-to-date information to the disaster response team regarding health care issues and resource needs. A nurse should be able to participate in planning to meet health care needs in a disaster. A nurse should be able to describing the principles of crisis communication in crisis intervention and risk management. A nurse should be able to list the appropriate steps for requesting psychological first aid for responders, patients, and other victims. A nurse should be able to identify vulnerable populations and coordinating activities to reduce risk. A nurse should be able to describe the phases of the disaster management continuum: prevention/mitigation, preparedness, response and recovery/rehabilitation. A nurse should be able to manage the resources and supplies required to provide care in the community. A nurse should be able to identify potential threats with medical implications in response areas. A nurse should be able to describe nurses roles in various disaster assignments (e.g. shelters, emergency care sites).
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PCA results.
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Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
Table 2
2
3
4
5
h2
M
SD
0.83 0.82
.05 .117
.06 .08
−.15 .37
−.16 .03
0.74 0.84
8.56 8.17
1.77 2.00
0.81 0.81
.19 .09
.08 .13
.28 −.21
−.05 .02
0.79 0.73
8.14 8.24
2.37 2.07
0.81
.11
.13
−.03
.23
0.74
8.11
2.21
0.75
.04
.12
−.23
−.13
0.66
8.62
1.98
0.73
.13
.08
−.01
.21
0.61
8.03
2.16
0.72
.13
.13
.43
.05
0.73
7.82
2.33
0.07 0.14 0.18 0.08 0.10 0.22 0.03 0.27 −0.01 0.23
0.89 0.84 0.83 0.80 0.77 0.76 0.75 0.61 .08 −.12
−.03 .02 −.04 −.07 −.02 .07 −.01 −.01 0.84 0.81
.10 −.10 −.16 .10 .01 .03 .12 −.03 .030 −.277
−.12 −.04 −.05 −.10 −.01 .26 .13 −.42 .08 .05
0.83 0.74 0.76 0.67 0.60 0.71 0.60 0.63 0.72 0.81
5.96 6.10 6.32 6.01 6.20 6.38 5.76 6.44 4.10 5.80
2.96 2.77 2.68 2.91 2.81 2.83 2.91 2.73 3.05 3.13
−0.05 0.04 0.28
.08 −.04 −.17
0.76 0.75 0.70
−.01 .27 −.32
.26 −.07 −.08
0.66 0.65 0.72
4.25 5.19 5.93
2.99 3.12 2.79
0.33 0.18
−.04 −.08
0.66 .09
.26 −.014
−.14 .74
0.65 .61
5.97 8.40
3.13 2.91
22.97 52.20 8.3 0.98
4.97 11.31 6.2 0.92
3.25 7.39 5.2 0.86
1.44 3.28 — —
1.22 2.78 — v
— — — —
— — — —
— — — —
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A nurse should be able to prioritise patients to maximise survivability. A nurse should be able to list the acute and long-term consequences of exposure to an overwhelming situation. A nurse should be able to understand relevant disaster terminology. A nurse should be able to describe strategies for allocating scarce resources in an ethical manner to optimise population outcomes during triage and treatment. A nurse should be able to participate in creating new guidelines for nursing practice in disaster. A nurse should be able to use recordkeeping processes to ensure continuity of patient information. A nurse should be able to develop and maintain a personal and family preparedness plan. A nurse should be able to provide defensible solutions to a series of ethical dilemmas arising in disaster. Lack of formal educational resources. Ineffective training opportunities. Lack of evaluation instruments. Lack of health organisation support. Lack of training programs in the workplace. Lack of expert staff in disaster nursing. Restriction of nurses roles in disaster management. Lack of research studies on disaster nursing. I participate in creating new guidelines for disaster management I have a role in identifying the education and training needs of nurses with regard to disaster management I am authorised to activate a local disaster plan I participate in developing disaster plans and policy in my hospital I participate in education and training activities for health care providers that relate to disaster management I participate in mock disaster drills on a regular basis A nurse should be able to identify other human behaviours that put individuals at risk during a disaster. Eigenvalues Explained variance Mean Alpha Cronbach
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Items
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Disaster competency using PCA
Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001
Table 2
The bold values indicate the accepted loading of items on factors (above 0.40).
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A. Al Thobaity et al.
first step in enhancing continuing education and training programs for disaster preparedness, which will advance corresponding competencies of disaster nursing in the KSA. This scale has very good reliability, both internal and external consistency as indicated by testing, retesting and Cronbach’s alpha. Test and retest findings indicate moderate to excellent consistency over a period of time, while the Cronbach’s alpha indicates excellent reliability of all three extracted factors. Therefore, this scale is extremely useful and reliable, able to be used with high confidence to identify core competencies, barriers to and roles of disaster nursing in the KSA.
Limitations There are some limitations to this study. Confirmatory factor analysis to test convergent and discrimination validity was not performed; however, this is planned for future research. Another limitation is self-reporting. Finally, generalisability is limited, as the questionnaires were administered at only two hospitals in the KSA.
Conclusions This study has demonstrated a newly developed scale that has strong psychometric properties, providing preliminary evidence of its reliability and validity to assess nurses’ roles and core competencies and identifying barriers to developing disaster nursing core competencies in the KSA. It is hoped that this instrument can support disaster nursing education in the KSA and can help evaluate nurses in terms of their preparedness for and competencies regarding disasters. Furthermore, the scale can serve as the basis for a curriculum designed for nursing schools in the KSA.
Provenance and conflict of interest The authors declare that they have no conflict of interest. This paper was not commissioned.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgments All authors would like to thank Monash University and Taif University sincerely for their help and support. In addition, all authors are grateful to all study participants for their contribution.
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Please cite this article in press as: Al Thobaity A, et al. A new scale for disaster nursing core competencies: Development and psychometric testing. Australas Emerg Nurs J (2016), http://dx.doi.org/10.1016/j.aenj.2015.12.001