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Effects of disaster nursing education on nursing students’ knowledge and preparedness for disasters
Author’s Accepted Manuscript Effects of Disaster Nursing Education on Nursing Students’ Knowledge and Preparedness for Disasters Bilge Kalanlar www.elsevier.com/locate/ijdr
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S2212-4209(17)30383-7 https://doi.org/10.1016/j.ijdrr.2017.12.008 IJDRR734
To appear in: International Journal of Disaster Risk Reduction Received date: 12 September 2017 Revised date: 20 December 2017 Accepted date: 21 December 2017 Cite this article as: Bilge Kalanlar, Effects of Disaster Nursing Education on Nursing Students’ Knowledge and Preparedness for Disasters, International Journal of Disaster Risk Reduction, https://doi.org/10.1016/j.ijdrr.2017.12.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Effects of Disaster Nursing Education on Nursing Students’ Knowledge and Preparedness for Disasters Bilge Kalanlar PhD, Asisstant Proffessor* Hacettepe University, Nursing Faculty, Department of Public Health Nursing
*Corresponding author. Mailing address: Hacettepe University, Nursing Faculty, Department of Public Health Nursing 06100 Sıhıye Ankara TURKEY, Telephone: +9005068017022. [email protected]
Abstract This research has been prepared to determine the effects of disaster nursing education on nursing students’ knowledge and preparedness for disasters which was conducted within the undergraduate programme of study of a nursing faculty, and put forward proposals in this respect. In this research, “quasi-experimental design pretest-posttest with control group” methods were used. Final year undergraduate nursing students who selected to study option module on disaster nursing and management constituted the treatment group. All of the students in the treatment group took scores with a success rate of 90% in the final examination of the module. Data analysis showed that there was significant increase in the knowledge and preparedness of the treatment group students for disasters, disaster nursing and management, which was relatively higher than those of control group students. It has shown that this module can be benefited from to equip undergraduate students to be effective in the processes of disaster preparedness, response, recovery and rehabilitation once they graduate. The result recommended that the module on disaster nursing and management should be included in all of the undergraduate programme of study of nursing faculties.
Keywords: Disaster nursing, Nursing education, Disaster preparedness,
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1. Introduction Disasters have direct impact on community. They can make individuals, families and populations in desperate need of healthcare. In addition, they are unfortunately far more devastating in today’s world than ever before. In this contex, all health disciplines accept that disaster preparedness is no longer an option but a critical phenomenon (Jungvon, 2017; Marion, 2016; Savage and Kub, 2009; Coyle et al., 2007). This phenomenon has emphasized the importance of and the need for disaster nursing services (Heagele, 2017; Giarratano, 2014; Veneema, 2003). Disaster nursing can be defined as systematic usage of nursing knowledge and skills in disasters, and development of practices designed to reduce disaster demages to health and eliminate its life-threathening hazards (Venema, 2016; Ohara et al., 2013). It is obvious that various nursing issues should be addressed in this field, especially related to nurses’ roles, responsibilities, education, area of practice and nursing researches to ensure that nurses serve with these competencies in the course of a disaster. (Stanley, 2005; WADEM, 2013). Conferences, seminars, meetings and trainings on distaster nursing are crucial strategies for preventing uncertainities and insufficiencies, and enhancing proficiency of nurses in disaster response (Alim et al., 2015; Chan et al., 2010; O'Boyle et al., 2006; Polivka et al., 2008). For this reason, necessary educational programmes, technological applications and resources should be developed rapidly so that study of nursing could prepare nursing students to adequately responde to disasters (Yamamoto, 2006; Caudill, 2011; Schmıdt et al., 2011; Cusack et al., 2010). Among the health professionals in the world, nurses are the largest occupational group. Furthermore, nursing students are the largest group among students of healthcare. Nurses are considered to be the biggest potentials to take active role during disasters in the future (Gebbie and Qureshi, 2002; INCMCE, 2003; ICN, 2006). In the literature, it is stressed that disaster nursing and management education for nurses will lead to positive outcomes such as reduced mortality, improved health services and reduced costs associated with disasters (Sanders, Frisch and Wing, 2005). Education on disaster nursing and management and revealing its effectiveness are pointed out as a research priority. It can be seen in developed countries that disaster nurse plays an important role in disaster management system, there are successful practices acquired in this field, and disaster nurses have vested rights in both organizational and legal areas and
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they have continuously developing roles and functions (Polivka et al.,2008; Veenema,2003). It is possible to say that current education on this area in Turkey is far from comprehensive disaster nursing and management education and international samples of its kind. For this reason, integrating disaster nursing and management education into the nursing curriculum is considered to be a requirement. This requirement is recognized as a necessity to make disaster nursing visible in Turkey, revise nursing task definition in accordance with contemporary roles and functions of disaster nurses, find them area of practice and set up education infrastructure related to disaster nursing. There is a need to enhance nursing students’ knowledge and skills in this field and standardize training courses. The aim of this research is to determine the effects of implementing a senerio-based training module on ‘Disaster Nursing and Management’ on students’ awareness, knowledge and preparedness for disasters. This study is of high importance in terms of the contribution it will do to disaster nursing education, research and practice in Turkey that it explores effetcts of a training module which was designed, developed and implemented for the first time in Turkey.
Disaster Nursing and the Steps of Training Module Content Development An option module on “Disaster Nursing and Management” was prepared according to the National Core Nursing Curriculum (HUCEP) educational standarts of Turkey and the Framework of Disaster Nursing Competencies and Global Standards for the Initial Education of Professional Nurses and Midwives that was created by International Council of Nurses (ICN) and World Health Organization (WHO). Developed according to the recent literature (Persiridis and Apostolara, 2010; World Health Organization [WHO], 2009), the training module was implemented both theortically and practically towards final year undergraduate students (Figure 1).
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Week 1-Introduction of education to students and voluntary enrollment for the module edilmesi
Week 2-Treatment Pretest, Questionnaire
Week 3
Week 4
Week : 5 Implement ation: Video clips on disaster types and discussion about roles and responsibili ties of nurses before, during and after disaster
Week 6-7
Week 2-Control Group Pretest, Questionnaire
Week 8 Implementation: Week 11
Triage-role play.
Week 12 Fire & National Medical Rescue Presentation
Week 9-10
Week 13- Implementation: Visit to Earthquake Simulation Center
Week 14- Treatment Posttest, Distribution of Certificate of Participation
Week 14- Control group Posttest Müdahale ve kontrol grubu Son
Figure 1: Disaster Nursing and Management Training Module Chart
This training module was integrated into undergraduate programme of study of a nursing faculty. Jennings Disaster Nursing Management Model was utilized in content design of the module (Sanders 2004). The module named as “Disaster Nursing and Management”. Trainer was a public health nursing faculty member. In defining the aim and objectives of the module, it is targeted that nursing students acquire ability and skills to deliver services as a disaster nurse and take duties in disaster management when they graduate. With this aim, training details like lesson plans, learning objectives, training materials, duration and training methods were structured and presented at the start of each unite. The module was delivered to the treatment group students for one semester. It was taken on Mondays for 2 hours during 14 weeks. Effects of the module on treatment group students’ knowledge and preparedness were compared with that of the control group through the questionnaires applied. A pretest was perfomed for both groups at the beginning of the study and a posttest at the end. Module plan includes main headings as follows: disaster risk reduction, public awareness, education, CBRN (chemical, biological, radiological, nuclear) defence, roles of disaster nurses as first phase; issues during a disaster, impact of disaster on public health and health services, role of mass media and information systems in disaster
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management as second phase; finally disaster response and recovery, vulnerable groups to be prioritized, nursing care as third and fourth phases.
2. Method 2.1. Design In the study, quasi-experimental design and pretest-posttest with nonequivalent control group were used. 2.2. Sample Research was conducted in nursing faculties of two universities located in Ankara city, Turkey. Research scope is composed of final year undergraduate students studying in nursing faculty (75 in the control and 75 in the treatment group). The main reason for choosing final year students as a study group was that they were already equiped with fundemental knowledge and skills, and completed some core training modules till their last year. In both of the universities, undergraduate nursing programmes were being conducted in theory and practice in comply with the European Union standards. Moreover, core training modules they provided were in accordance with HUCEP framework of Turkey. The treatment group studied the module on ‘Disaster Nursing and Management’, while control group continued their regular study without any intervention. 2.3. Data collection Questionnaire was used in data collection, which was prepared according to the recent literature on disaster nursing and disaster management. The questionnaire had two sections. The first section collected demographic profiles of students (age, gender, employment, participation in any training on disaster), while the second asked students disaster nursing roles in disaster phases (knowledge and preparedness for pre disaster, disaster and post disaster phases). The questionnaire was administered to 15 students in a pilot study. Feedback was obtained from these students and changes were made to ensure that the wording of the survey was comprehensible. To assess the reliability of the questionnaire results, consistency analyses were carried out using
SPSS software. As a result, it was found that there was relatively high internal
consistency with a Cronbach’s Alpha value of 0,819 which was considered acceptable. 2.4 Data analysis
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Within the study, treatment group students attended disaster nursing and management module for 2 hours in a week during a 14-week long semester. As for the control group, they continued studying their regular programme without any intervention. At the end of the module, open-ended and test-type examinations were held. The data were analysized using percentage analyisis, t-test and ANOVA tests.
To determine similarities and
differences between groups before and after the training module, ANOVA test (one way) was used. To identify the direction and nature of differences when the variations were equal, Scheffe test was used. When the variations were unequal, Tamhane test was used in analysis. 2.5. Ethical consideration Prior to commencing the study, ethical clearance was sought from University Ethics Board. Formal permissions were taken from both target univesities for implementation. Moreover, each student completed an approval form and their written and oral informed consent that contained information on the scientific purpose of the study survey and on the use of data was obtained.
3. Results There were 150 students (75 in the control and 75 in the treatment group) participating in the study with ages ranging from 20-31 years (response rate 100%). The mean age of students was 22,96±1.7 years. Of all the students, 96,8% were female and 3,2% were male. Of the students, 90,4% were not working at any job. The students with a job expressed that they worked as babysitter, nurse or sales assistant. Of the students, 94,7% indicated they had not participated yet in any training on disaster nursing and management. In the survey, when students were asked about the type of disaster nursing training they wanted, they said they wanted a training module which was a clear and understandable one, applicable in daily life including topics about what to do during and after a disaster, visual, not boring, pertaining information about disaster management and involving both theory and practice. On the question of the length of the training, while some of the students suggested limited time periods ranging from one week, ten hours, one semester, two months etc., some suggested that this module should be permenant during undergraduate programme of study.
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In the study, nursing students’ knowledge and preparedness for disasters were examined in three phases. These are before, during and after disaster periods. In this regard, the findings of the study are presented below in the contex of these three main periods.
3.1. State of Knowledge and Preparedness for Pre-Disaster The vast majority of the students do not feel themselves and their families prepared for disasters. (Table 1) Table 1: Students’ feelings of preparedness for disasters about themselves and their families. Pretest a
Posttesta
Pretestb
Posttestb
2,8 %
78%
12%
14%
97,2%
22%
88%
Yes, feel No, do not feel Postest Scheffe Test
Pretest
Pretesta
b
Posttest
a
a
b
,000 ,378
Pretest Posttest
a
Pretest
,299
Treatment Group
b
Posttest
b
Control Group
*
a
b
,000
86% Pretest
,000
Pretest
a
,378
b
,000
(Levene’s Test): 17,720 sig:0,000 F:64,171 Sig:0,000 Pretesta ,299
,000
Posttesta Posttestb
Posttestb
,989
,000
Posttesta Pretestb
,989
Not all respondents answered all questions.
According to responses in the pretest, almost all of the treatment group students (97,2%) did not feel themselves prepared for disasters, while in the post-test this rate in the same group decreased to 22%. Further analysis showed that there was a significant difference between the two results (p<0,05). Table 2.Students’ feelings of their families preparedness for disasters Pretest a
Posttesta
Pretestb
Posttestb
Test
Yes, feel
2,7 %
18%
1,3%
2%
No, do not feel
97,3%
82%
98,7%
98%
(Levene’s Test): 32,865 sig:0,000 F:7,484 Sig:0,000
Postest a
Scheff e Test
a
Pretes ta
Treatment Group
,00 2
b
,98 6
Posttes tb
,99 9
Pretest
b
Posttes ta
Control Group
*
Pretesta
,00 2
Pretestb
,00 1
Posttes tb
,00 4
Pretesta Pretes tb
Posttes ta Posttes tb
,98 6 ,00 1 ,99 9
Pretesta Posttes tb
Posttes ta Pretest b
,99 9 ,00 4 ,99 9
Not all respondents answered all questions.
In the pretest, again nearly all of the treatment group students (97,3%) did not feel their families prepared for disasters. On the other hand, in the post-test this rate fell to 82%. The
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difference between two tests was significant (p<0,05). Nearly all of the students (93,3% of the treatment group and 97,3% of the control group) in pretest said that they did not find community aware of disasters. Respondents reported that they thought of unconscious actions of individuals during disasters, lack of training in disaster management, and absence of preparation as grounds for this unawereness. Only a small number of students, pointing at prior disaster experiences community faced, saw community awere of disasters. In comparing the answers given by treatment and control group students to the question: “do you think that community is awere of disasters?”, no significant differences were found between them (p>0,05). In the pretest, a vast mojority of the students, 98,7% of the treatment group and 93,3% of the control group, did not see Turkey as prepared for disasters. Students reported several reasons for this as follows: inadequate precautionary measures, absence of training of occupational groups and community on disasters, challenges in infrastructure, and insufficient knowledge of community on disaster management, unconsciousness, urban sprawl and lack of essential precautions. 3.2. State of Knowledge and Preparedness for Disaster Period According to the pre-test, 44% of the treatment group and 80% of the control group said that they did not know the duties of a disaster nurse during a disaster. Whilst in pretest students gave many incorrect answers to the open-ended question about duties of a disaster nurse during a disaster, it was discovered that treatment group students managed to describe them correctly in posttest. Table 2 compares the experimential data on students’ knowledge about how to react during a disaster between treatment and control groups. Table 3. Students’ Knowledge about duties of a disaster nurse for Disaster Period Pretest a
Posttesta
Pretestb
Posttestb
Yes, know
56 %
100%
20%
20%
No, I do not know
44%
0
80%
80%
Postest a
Scheff e Test
Pretes ta
,00 0
b
,00 0
Posttes tb
,00 0
Pretest
Pretest a
Posttes ta
Pretest
,00 0
b
,00 0
Posttes tb
,00 0
Pretest
,000
Pretest
a
Pretes tb
Posttes ta Posttes tb
(Levene’s Test): 80,423 sig:0,000 F:50,641 Sig:0,000
,000
a
,000 1,00 0
Posttes tb
Posttes ta Pretest b
,000 1,00 0
9
a
Treatment Group
b
*
Control Group
Not all respondents answered all questions
Table 4. Knowledge about what to do during a disaster as an individual Pretest a
Posttesta
Yes, know
42,7 %
100%
No, I do not know
57,3%
0
Postest a
Scheff e Test
a
Treatment Group
b
Pretes ta
,00 0
b
,54 8
Posttes tb
,59 0
Pretest
Control Group
*
Pretest a
Posttes ta
Pretest
Pretestb
Posttestb 54%
53,3%
46,7% ,00 0
b
,00 0
Posttes tb
,00 0
46%
Pretest
,548
Pretest
a
Pretes tb
Posttes ta Posttes tb
(Levene’s Test): 1439,174 sig:0,000 F:17,853 Sig:0,000
,590
a
,000 1,00 0
Posttes tb
Posttes ta Pretest b
,000 1,00 0
Not all respondents answered all questions
In the pretest, almost half of the students (57,3% of the treatment group and 46,7% of the control group) expressed that they did not know what to do during a disaster. In other words, 42,7% of the treatment group students said in pretest they knew what to do during a disaster. However, this rate increased to 100% in the posttest. In comparing the pretest and posttest results of the treatment group students with regard to this question, it was found that there was a positive and remarkable increase, and difference between two test results was statistically significant. (p<0,05). This striking increase is also an important proof of the training module’s success. As for the control group students, no significant differences were found between their pretest and postest results (p>0,05). When just posttests are taken into account, all of the treatment group students and %54 of the control group students answered positively this question. There was statistical significance between the answers of the two groups to this question in the posttests (p<0,05).
3.3. State of Knowledge and Preparedness for Post-Disaster In prestest, 44% of the treatment group students and 80% of the control group students said that they did not know the duties of a disaster nurse for post-disaster period. There was significant difference between the answers of the control and treatment groups (p<0,05). Taking into account the posttests, all of the treatment group students said they knew the duties of a disaster nurse for post-disaster, while this rate remained steady at 20% in the control group.
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Table 5. Students’ Knowledge about duties of a disaster nurse for Post-Disaster Pretest a
Posttesta
56 %
100%
44%
0
Yes, know No, I do not know Postesta Scheffe Test
Pretest
Pretesta
b
Posttest
a
b
Treatment Group
,000
b
Posttest
a
Pretest
,000
Control Group
*
20%
,000
b
Pretest
b
80% ,000 a
Posttest
,000
(Levene’s Test): 80,423 sig:0,000 F:50,641 Sig:0,000
20%
Pretesta
,000
b
Posttest
Posttestb
80%
Pretesta
,000
Pretestb
Posttest
b
,000
Posttest
1,000
Pretesta
,000
Posttesta Pretestb
,000
b
1,000
Not all respondents answered all questions
Table 6. Students’ feeling of preparedness for disasters after taking the training module Pretest a
Posttesta
Pretestb
Posttestb
No , I do not feel
42,5 %
4%
9,5%
20,8%
Not sure
34,2%
8%
73%
47,9%
23,3%
88% Pretesta ,000
Yes, I feel Postesta Scheffe Test
Pretest
Pretest
a
b
Posttest
a
Treatment Group
b
b
,000 ,089
Posttest
,109
Control Group
a
Pretest
b
Posttest
*
b
,000 ,000
17,6% Pretesta Pretest
b
Posttesta Posttestb
(Levene’s Test): 14,834 sig:0,000 F:26,313 Sig:0,000
31,3% ,000 ,000 ,998
Posttest
Pretesta
,109
Posttesta Pretestb
,000
b
,998
Not all respondents answered all questions
In the pretest 23,3% of the treatment group students said that they felt themselves prepared for disasters taking into account the education they received till that time, whereas this rate increased to 88% in the posttest. In the comparing the answers of the treatment group, 84,9% of the students in the pretest agreed with the statement of “I don’t find myself suffient as a nurse about how to react before, during and after a disaster”, while in the posttest this rate decreased to 12%.
4. Discussion Among the nursing programmes in national scope, for the first time, a module on disaster nursing and management was implemented under a programme of study. From this aspect, it was unique and it has the feature of being a model at the same time. In the final written examination taken at the end of the training module, all of the students got scores of %90 success which were equivalent to grade A in the university grading system. Students earned
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two national credits and three international ECTS credits. They were also presented certificates of participation from the Faculty Deanery and Department of Public Health for the successful completion of the module. The current study found that nursing students did not see themselves and their families prepared for disasters. This result is in line with those of previous studies in literature (Fung et al., 2008). Previous researches have established that if nurses feel or know that their families are safe or their injured relatives are taken care, their concentration and skills will positively be affected (Tichy et al., 2009; Venema, 2003). Likewise, it has been indicated that nurses are more eager to serve in disasters, in condition that their families’ access effective medical treatment oppurtunites and they feel their families safe (Syrett et al., 2007). Similar to what this survey has found, the study of Suserud evaluating nursing students’ knowledge and opinions about disasters has also revealed that nursing students had limited knowledge about disasters and had different views on what to be covered in a nursing programme of study (Suserud and Haljamie, 1997). It is also worthwhile to mention it here that although there is no concensus in literature on the length and content of the training, it is determined that trainings on this topic make nurses more prepared in responding to disasters (Williams et al., 2008).
It is obvious that there is a strong need for well-trained nurses who can take missions in disasters and disaster management, taking into considiration prior disasters Turkey faced (Hekimoğlu et al., 2015; Saraçoğlu and Demirtaş, 2014), the lack of an effective and comprehensive disaster management system and the fact that Turkey is not adequately prepared for disasters depending on these reasons. Data analysis, and information given by the students demostrate that students are well aware of this need. Moreover, completing the module, they expressed that they graduated with the ability to serve as disaster nurses on site in the event of a disaster. When we look at critical approaches in this field, a variety of issues are emphasized in literature as follows: individuals or representatives who are responsible for disaster and emergency case management mostly have the experience for only post-disaster process, the fact that disaster management is a different, multi-dimensional and a disciplined study field is overlooked, legislation related to disasters lack a general framework which contains activities from all phases of disaster management and lastly disaster nursing should be included into the programmes of study of all
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undergraduate nursing faculties (Alim, Kawabata and Nakazawa, 2015; Chan et al.2010; INCMCE, 2003; ICN, 2006; Veenema, 2006; Veenema, 2003).
When we look at the legal legislation in Turkey on the role of nurses in disaster situations, it can be said that there are insufficiencies. Legislation governing nursing and disaster issues, including Nursing Implementing Regulation, Implementing Regulation on Family Physicians and Law of Civil Defense have been examined within this scope. Nursing Implementing Regulation assigns a limited task for nurses by saying ‘in emergency situations, nurses make emergency plans in cooperation with the relevant units, develop protocol and get health team prepared to response when necessary according to the disaster plan,”. Likewise, Implementing Regulation on Family Physicians charges nurses with very limited and insufficient duties in disasters, with a similar statement. Roles and responsibilities of nurses in disasters are not clearly given also under the State of Emergency Law and Law of Civil Defense. In this contex, it is still strongly argued in national platforms that the current legislation should be revised, addressed as a whole and associated with each other, and new rules and regulations should be introduced related to disaster management.
5. Conclusion
The main goal of the disaster nursing education is to prepare nurses for the challenges of unexpected events and enable them to take more active roles in disasters. As each disaster is unique and complex on its own, success in overcoming disaster to a large extent depends on preparedness of individuals for disasters. The present study was designed to determine the effects of the module on disaster nursing and management on students’ knowledge and preparedness for disasters. As a result, it has identified that there was statistically significant increase in the state of knowledge and preparedness of students on disaster nursing and management following the module they attended. The findings of this study have also a number of important implications for future practice. The findings indicate that the training module with its content design facilitated learning for students the role and duties of nurses before, during and after a disaster in a clearer way. It is recommended that this module be involved in undergraduate programmes and taken as a model for delivering disaster nursing and management issues. Disaster nursing and management education will certainly provide considerable gains
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such as reducing mortality in the event of a disaster strike. It is also strategically important for developing countries like Turkey, which often witnesses disasters. There is a definite need for well-trained personnel on disaster nursing and disaster management to proficiently manage disasters and get ready for them. Taken together, these findings suggest important roles for nursing faculties in promoting disaster nursing and management.
Acknowledgements The study was funded by the Hacettepe University Scientific Research Projects Coordination Unit in Turkey (HU012T06102006).
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http://www.jsdn.gr.jp/english/pdf/The%20Present%20Situation%20of%20Disaster%20Nursing %20Education%20at%20Nursing%20Colleges%20and%20Universities%20in%20Asian%20Re gion%20(JSDN).pdf. Persiridis, T., Apostolara, P., 2010. Critical Review Transcultural Nursing as a Theoretical Framework in Support of Disaster Nursing. Hellenic Journal of Nursing Science. 2 (1), 25-29. Retrieved from. journal-ene.gr/wp.../Tomos02_teyxos01Eng-dragged4.pdf Polivka, B. J., Stanley, S. A. R., Gordon, D., Taulbee, K., Kieffer, G., McCorkle, S. M., 2008. Public health nursing competencies for public health surge events. Public Health Nursing, 25 (2), 159-165. Regulation on Family Physicians. (2010). http://www.saglik.gov.tr/TR/belge/1-10376/ailehekimligi-uygulama-yonetmeligi.html Sanders, JA., 2004. Teaching disaster nursing by utilizing the Jennings Disaster Nursing Management
Model.
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Mar;4(1):69-76.
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5953(03)00007-6. Sanders, JA., Frisch,N., Wing, S., 2005. Nursing Students’ Perceptions About Disaster Nursing. Disaster Management Response. 3(80),5. Savage, C., Kub, J., 2009. Public health and nursing: a natural partnership. Int. J. Environ. Res. Public Health. 6 (11), 2843-2848. doi:10.3390/ijerph6112843. Schmıdt, C., Davis, J., Sanders J., Chapman, L. Cisco, M., Hady, A., 2011. Explorıng nursing students’ level of preparedness for disaster response. Nursing Education Research. 32 (6), 380383.
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Stanley, J.M., 2005. Disaster Competency Development and integration in nursing education. The Nursing Clinics of North American,40 (3), 453–467. Saraçoğlu, C., Demirtaş-Milz, N. 2014. Disasters as an ideological strategy for governing neoliberal urban transformation in Turkey: insights from Izmir/Kadifekale. Disasters. 38(1),178201. doi: 10.1111/disa.12038. Suserud, B. O., Haljamie, H., 1997. Role of nurses in pre-hospital emergency care. Accidental and Emergency Nursing, 5, 145-151. Syrett, J., Benitez, J., Livingston, W., Davis, E., 2007. Will emergency health care providers respond to mass casualty incidents? Prehospital Emergency Care. 11 (1), 49–54. Tichy, M., Bond, A.E., Beckstrand, R.L., Heise, B., 2009. Nurse practitioners’ perception of disaster preparedness education. American Journal of Nurse Practitioners. 13 (1), 10–22. Venema, T. (2007). Disaster Nursing and Emergency Preparedness. Second Edition, Springer, NY Veenema, T.G., Griffin, A., Gable, A.R., MacIntyre, L., Simons, R.N., Couig, M.P., Walsh, J.J., Lavin, R.P., Dobalian, A., Larson, E. 2016. Nurses as leaders in disaster preparedness and response--a call to action .J Nurs Scholarsh. 48(2),187-200. doi: 10.1111/jnu.12198. Williams, J., Nocera, M., Casteel, C., 2008. The effectiveness of disaster training for health care workers: A systematic review. Annals of Emergency Medicine, 52 (3), 211-222. World Health Organization and International Council of Nurses. (2009). ICN Framework of Disaster
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PII: DOI: Reference:
S2212-4209(17)30383-7 https://doi.org/10.1016/j.ijdrr.2017.12.008 IJDRR734
To appear in: International Journal of Disaster Risk Reduction Received date: 12 September 2017 Revised date: 20 December 2017 Accepted date: 21 December 2017 Cite this article as: Bilge Kalanlar, Effects of Disaster Nursing Education on Nursing Students’ Knowledge and Preparedness for Disasters, International Journal of Disaster Risk Reduction, https://doi.org/10.1016/j.ijdrr.2017.12.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Effects of Disaster Nursing Education on Nursing Students’ Knowledge and Preparedness for Disasters Bilge Kalanlar PhD, Asisstant Proffessor* Hacettepe University, Nursing Faculty, Department of Public Health Nursing
*Corresponding author. Mailing address: Hacettepe University, Nursing Faculty, Department of Public Health Nursing 06100 Sıhıye Ankara TURKEY, Telephone: +9005068017022. [email protected]
Abstract This research has been prepared to determine the effects of disaster nursing education on nursing students’ knowledge and preparedness for disasters which was conducted within the undergraduate programme of study of a nursing faculty, and put forward proposals in this respect. In this research, “quasi-experimental design pretest-posttest with control group” methods were used. Final year undergraduate nursing students who selected to study option module on disaster nursing and management constituted the treatment group. All of the students in the treatment group took scores with a success rate of 90% in the final examination of the module. Data analysis showed that there was significant increase in the knowledge and preparedness of the treatment group students for disasters, disaster nursing and management, which was relatively higher than those of control group students. It has shown that this module can be benefited from to equip undergraduate students to be effective in the processes of disaster preparedness, response, recovery and rehabilitation once they graduate. The result recommended that the module on disaster nursing and management should be included in all of the undergraduate programme of study of nursing faculties.
Keywords: Disaster nursing, Nursing education, Disaster preparedness,
2
1. Introduction Disasters have direct impact on community. They can make individuals, families and populations in desperate need of healthcare. In addition, they are unfortunately far more devastating in today’s world than ever before. In this contex, all health disciplines accept that disaster preparedness is no longer an option but a critical phenomenon (Jungvon, 2017; Marion, 2016; Savage and Kub, 2009; Coyle et al., 2007). This phenomenon has emphasized the importance of and the need for disaster nursing services (Heagele, 2017; Giarratano, 2014; Veneema, 2003). Disaster nursing can be defined as systematic usage of nursing knowledge and skills in disasters, and development of practices designed to reduce disaster demages to health and eliminate its life-threathening hazards (Venema, 2016; Ohara et al., 2013). It is obvious that various nursing issues should be addressed in this field, especially related to nurses’ roles, responsibilities, education, area of practice and nursing researches to ensure that nurses serve with these competencies in the course of a disaster. (Stanley, 2005; WADEM, 2013). Conferences, seminars, meetings and trainings on distaster nursing are crucial strategies for preventing uncertainities and insufficiencies, and enhancing proficiency of nurses in disaster response (Alim et al., 2015; Chan et al., 2010; O'Boyle et al., 2006; Polivka et al., 2008). For this reason, necessary educational programmes, technological applications and resources should be developed rapidly so that study of nursing could prepare nursing students to adequately responde to disasters (Yamamoto, 2006; Caudill, 2011; Schmıdt et al., 2011; Cusack et al., 2010). Among the health professionals in the world, nurses are the largest occupational group. Furthermore, nursing students are the largest group among students of healthcare. Nurses are considered to be the biggest potentials to take active role during disasters in the future (Gebbie and Qureshi, 2002; INCMCE, 2003; ICN, 2006). In the literature, it is stressed that disaster nursing and management education for nurses will lead to positive outcomes such as reduced mortality, improved health services and reduced costs associated with disasters (Sanders, Frisch and Wing, 2005). Education on disaster nursing and management and revealing its effectiveness are pointed out as a research priority. It can be seen in developed countries that disaster nurse plays an important role in disaster management system, there are successful practices acquired in this field, and disaster nurses have vested rights in both organizational and legal areas and
3
they have continuously developing roles and functions (Polivka et al.,2008; Veenema,2003). It is possible to say that current education on this area in Turkey is far from comprehensive disaster nursing and management education and international samples of its kind. For this reason, integrating disaster nursing and management education into the nursing curriculum is considered to be a requirement. This requirement is recognized as a necessity to make disaster nursing visible in Turkey, revise nursing task definition in accordance with contemporary roles and functions of disaster nurses, find them area of practice and set up education infrastructure related to disaster nursing. There is a need to enhance nursing students’ knowledge and skills in this field and standardize training courses. The aim of this research is to determine the effects of implementing a senerio-based training module on ‘Disaster Nursing and Management’ on students’ awareness, knowledge and preparedness for disasters. This study is of high importance in terms of the contribution it will do to disaster nursing education, research and practice in Turkey that it explores effetcts of a training module which was designed, developed and implemented for the first time in Turkey.
Disaster Nursing and the Steps of Training Module Content Development An option module on “Disaster Nursing and Management” was prepared according to the National Core Nursing Curriculum (HUCEP) educational standarts of Turkey and the Framework of Disaster Nursing Competencies and Global Standards for the Initial Education of Professional Nurses and Midwives that was created by International Council of Nurses (ICN) and World Health Organization (WHO). Developed according to the recent literature (Persiridis and Apostolara, 2010; World Health Organization [WHO], 2009), the training module was implemented both theortically and practically towards final year undergraduate students (Figure 1).
4
Week 1-Introduction of education to students and voluntary enrollment for the module edilmesi
Week 2-Treatment Pretest, Questionnaire
Week 3
Week 4
Week : 5 Implement ation: Video clips on disaster types and discussion about roles and responsibili ties of nurses before, during and after disaster
Week 6-7
Week 2-Control Group Pretest, Questionnaire
Week 8 Implementation: Week 11
Triage-role play.
Week 12 Fire & National Medical Rescue Presentation
Week 9-10
Week 13- Implementation: Visit to Earthquake Simulation Center
Week 14- Treatment Posttest, Distribution of Certificate of Participation
Week 14- Control group Posttest Müdahale ve kontrol grubu Son
Figure 1: Disaster Nursing and Management Training Module Chart
This training module was integrated into undergraduate programme of study of a nursing faculty. Jennings Disaster Nursing Management Model was utilized in content design of the module (Sanders 2004). The module named as “Disaster Nursing and Management”. Trainer was a public health nursing faculty member. In defining the aim and objectives of the module, it is targeted that nursing students acquire ability and skills to deliver services as a disaster nurse and take duties in disaster management when they graduate. With this aim, training details like lesson plans, learning objectives, training materials, duration and training methods were structured and presented at the start of each unite. The module was delivered to the treatment group students for one semester. It was taken on Mondays for 2 hours during 14 weeks. Effects of the module on treatment group students’ knowledge and preparedness were compared with that of the control group through the questionnaires applied. A pretest was perfomed for both groups at the beginning of the study and a posttest at the end. Module plan includes main headings as follows: disaster risk reduction, public awareness, education, CBRN (chemical, biological, radiological, nuclear) defence, roles of disaster nurses as first phase; issues during a disaster, impact of disaster on public health and health services, role of mass media and information systems in disaster
5
management as second phase; finally disaster response and recovery, vulnerable groups to be prioritized, nursing care as third and fourth phases.
2. Method 2.1. Design In the study, quasi-experimental design and pretest-posttest with nonequivalent control group were used. 2.2. Sample Research was conducted in nursing faculties of two universities located in Ankara city, Turkey. Research scope is composed of final year undergraduate students studying in nursing faculty (75 in the control and 75 in the treatment group). The main reason for choosing final year students as a study group was that they were already equiped with fundemental knowledge and skills, and completed some core training modules till their last year. In both of the universities, undergraduate nursing programmes were being conducted in theory and practice in comply with the European Union standards. Moreover, core training modules they provided were in accordance with HUCEP framework of Turkey. The treatment group studied the module on ‘Disaster Nursing and Management’, while control group continued their regular study without any intervention. 2.3. Data collection Questionnaire was used in data collection, which was prepared according to the recent literature on disaster nursing and disaster management. The questionnaire had two sections. The first section collected demographic profiles of students (age, gender, employment, participation in any training on disaster), while the second asked students disaster nursing roles in disaster phases (knowledge and preparedness for pre disaster, disaster and post disaster phases). The questionnaire was administered to 15 students in a pilot study. Feedback was obtained from these students and changes were made to ensure that the wording of the survey was comprehensible. To assess the reliability of the questionnaire results, consistency analyses were carried out using
SPSS software. As a result, it was found that there was relatively high internal
consistency with a Cronbach’s Alpha value of 0,819 which was considered acceptable. 2.4 Data analysis
6
Within the study, treatment group students attended disaster nursing and management module for 2 hours in a week during a 14-week long semester. As for the control group, they continued studying their regular programme without any intervention. At the end of the module, open-ended and test-type examinations were held. The data were analysized using percentage analyisis, t-test and ANOVA tests.
To determine similarities and
differences between groups before and after the training module, ANOVA test (one way) was used. To identify the direction and nature of differences when the variations were equal, Scheffe test was used. When the variations were unequal, Tamhane test was used in analysis. 2.5. Ethical consideration Prior to commencing the study, ethical clearance was sought from University Ethics Board. Formal permissions were taken from both target univesities for implementation. Moreover, each student completed an approval form and their written and oral informed consent that contained information on the scientific purpose of the study survey and on the use of data was obtained.
3. Results There were 150 students (75 in the control and 75 in the treatment group) participating in the study with ages ranging from 20-31 years (response rate 100%). The mean age of students was 22,96±1.7 years. Of all the students, 96,8% were female and 3,2% were male. Of the students, 90,4% were not working at any job. The students with a job expressed that they worked as babysitter, nurse or sales assistant. Of the students, 94,7% indicated they had not participated yet in any training on disaster nursing and management. In the survey, when students were asked about the type of disaster nursing training they wanted, they said they wanted a training module which was a clear and understandable one, applicable in daily life including topics about what to do during and after a disaster, visual, not boring, pertaining information about disaster management and involving both theory and practice. On the question of the length of the training, while some of the students suggested limited time periods ranging from one week, ten hours, one semester, two months etc., some suggested that this module should be permenant during undergraduate programme of study.
7
In the study, nursing students’ knowledge and preparedness for disasters were examined in three phases. These are before, during and after disaster periods. In this regard, the findings of the study are presented below in the contex of these three main periods.
3.1. State of Knowledge and Preparedness for Pre-Disaster The vast majority of the students do not feel themselves and their families prepared for disasters. (Table 1) Table 1: Students’ feelings of preparedness for disasters about themselves and their families. Pretest a
Posttesta
Pretestb
Posttestb
2,8 %
78%
12%
14%
97,2%
22%
88%
Yes, feel No, do not feel Postest Scheffe Test
Pretest
Pretesta
b
Posttest
a
a
b
,000 ,378
Pretest Posttest
a
Pretest
,299
Treatment Group
b
Posttest
b
Control Group
*
a
b
,000
86% Pretest
,000
Pretest
a
,378
b
,000
(Levene’s Test): 17,720 sig:0,000 F:64,171 Sig:0,000 Pretesta ,299
,000
Posttesta Posttestb
Posttestb
,989
,000
Posttesta Pretestb
,989
Not all respondents answered all questions.
According to responses in the pretest, almost all of the treatment group students (97,2%) did not feel themselves prepared for disasters, while in the post-test this rate in the same group decreased to 22%. Further analysis showed that there was a significant difference between the two results (p<0,05). Table 2.Students’ feelings of their families preparedness for disasters Pretest a
Posttesta
Pretestb
Posttestb
Test
Yes, feel
2,7 %
18%
1,3%
2%
No, do not feel
97,3%
82%
98,7%
98%
(Levene’s Test): 32,865 sig:0,000 F:7,484 Sig:0,000
Postest a
Scheff e Test
a
Pretes ta
Treatment Group
,00 2
b
,98 6
Posttes tb
,99 9
Pretest
b
Posttes ta
Control Group
*
Pretesta
,00 2
Pretestb
,00 1
Posttes tb
,00 4
Pretesta Pretes tb
Posttes ta Posttes tb
,98 6 ,00 1 ,99 9
Pretesta Posttes tb
Posttes ta Pretest b
,99 9 ,00 4 ,99 9
Not all respondents answered all questions.
In the pretest, again nearly all of the treatment group students (97,3%) did not feel their families prepared for disasters. On the other hand, in the post-test this rate fell to 82%. The
8
difference between two tests was significant (p<0,05). Nearly all of the students (93,3% of the treatment group and 97,3% of the control group) in pretest said that they did not find community aware of disasters. Respondents reported that they thought of unconscious actions of individuals during disasters, lack of training in disaster management, and absence of preparation as grounds for this unawereness. Only a small number of students, pointing at prior disaster experiences community faced, saw community awere of disasters. In comparing the answers given by treatment and control group students to the question: “do you think that community is awere of disasters?”, no significant differences were found between them (p>0,05). In the pretest, a vast mojority of the students, 98,7% of the treatment group and 93,3% of the control group, did not see Turkey as prepared for disasters. Students reported several reasons for this as follows: inadequate precautionary measures, absence of training of occupational groups and community on disasters, challenges in infrastructure, and insufficient knowledge of community on disaster management, unconsciousness, urban sprawl and lack of essential precautions. 3.2. State of Knowledge and Preparedness for Disaster Period According to the pre-test, 44% of the treatment group and 80% of the control group said that they did not know the duties of a disaster nurse during a disaster. Whilst in pretest students gave many incorrect answers to the open-ended question about duties of a disaster nurse during a disaster, it was discovered that treatment group students managed to describe them correctly in posttest. Table 2 compares the experimential data on students’ knowledge about how to react during a disaster between treatment and control groups. Table 3. Students’ Knowledge about duties of a disaster nurse for Disaster Period Pretest a
Posttesta
Pretestb
Posttestb
Yes, know
56 %
100%
20%
20%
No, I do not know
44%
0
80%
80%
Postest a
Scheff e Test
Pretes ta
,00 0
b
,00 0
Posttes tb
,00 0
Pretest
Pretest a
Posttes ta
Pretest
,00 0
b
,00 0
Posttes tb
,00 0
Pretest
,000
Pretest
a
Pretes tb
Posttes ta Posttes tb
(Levene’s Test): 80,423 sig:0,000 F:50,641 Sig:0,000
,000
a
,000 1,00 0
Posttes tb
Posttes ta Pretest b
,000 1,00 0
9
a
Treatment Group
b
*
Control Group
Not all respondents answered all questions
Table 4. Knowledge about what to do during a disaster as an individual Pretest a
Posttesta
Yes, know
42,7 %
100%
No, I do not know
57,3%
0
Postest a
Scheff e Test
a
Treatment Group
b
Pretes ta
,00 0
b
,54 8
Posttes tb
,59 0
Pretest
Control Group
*
Pretest a
Posttes ta
Pretest
Pretestb
Posttestb 54%
53,3%
46,7% ,00 0
b
,00 0
Posttes tb
,00 0
46%
Pretest
,548
Pretest
a
Pretes tb
Posttes ta Posttes tb
(Levene’s Test): 1439,174 sig:0,000 F:17,853 Sig:0,000
,590
a
,000 1,00 0
Posttes tb
Posttes ta Pretest b
,000 1,00 0
Not all respondents answered all questions
In the pretest, almost half of the students (57,3% of the treatment group and 46,7% of the control group) expressed that they did not know what to do during a disaster. In other words, 42,7% of the treatment group students said in pretest they knew what to do during a disaster. However, this rate increased to 100% in the posttest. In comparing the pretest and posttest results of the treatment group students with regard to this question, it was found that there was a positive and remarkable increase, and difference between two test results was statistically significant. (p<0,05). This striking increase is also an important proof of the training module’s success. As for the control group students, no significant differences were found between their pretest and postest results (p>0,05). When just posttests are taken into account, all of the treatment group students and %54 of the control group students answered positively this question. There was statistical significance between the answers of the two groups to this question in the posttests (p<0,05).
3.3. State of Knowledge and Preparedness for Post-Disaster In prestest, 44% of the treatment group students and 80% of the control group students said that they did not know the duties of a disaster nurse for post-disaster period. There was significant difference between the answers of the control and treatment groups (p<0,05). Taking into account the posttests, all of the treatment group students said they knew the duties of a disaster nurse for post-disaster, while this rate remained steady at 20% in the control group.
10
Table 5. Students’ Knowledge about duties of a disaster nurse for Post-Disaster Pretest a
Posttesta
56 %
100%
44%
0
Yes, know No, I do not know Postesta Scheffe Test
Pretest
Pretesta
b
Posttest
a
b
Treatment Group
,000
b
Posttest
a
Pretest
,000
Control Group
*
20%
,000
b
Pretest
b
80% ,000 a
Posttest
,000
(Levene’s Test): 80,423 sig:0,000 F:50,641 Sig:0,000
20%
Pretesta
,000
b
Posttest
Posttestb
80%
Pretesta
,000
Pretestb
Posttest
b
,000
Posttest
1,000
Pretesta
,000
Posttesta Pretestb
,000
b
1,000
Not all respondents answered all questions
Table 6. Students’ feeling of preparedness for disasters after taking the training module Pretest a
Posttesta
Pretestb
Posttestb
No , I do not feel
42,5 %
4%
9,5%
20,8%
Not sure
34,2%
8%
73%
47,9%
23,3%
88% Pretesta ,000
Yes, I feel Postesta Scheffe Test
Pretest
Pretest
a
b
Posttest
a
Treatment Group
b
b
,000 ,089
Posttest
,109
Control Group
a
Pretest
b
Posttest
*
b
,000 ,000
17,6% Pretesta Pretest
b
Posttesta Posttestb
(Levene’s Test): 14,834 sig:0,000 F:26,313 Sig:0,000
31,3% ,000 ,000 ,998
Posttest
Pretesta
,109
Posttesta Pretestb
,000
b
,998
Not all respondents answered all questions
In the pretest 23,3% of the treatment group students said that they felt themselves prepared for disasters taking into account the education they received till that time, whereas this rate increased to 88% in the posttest. In the comparing the answers of the treatment group, 84,9% of the students in the pretest agreed with the statement of “I don’t find myself suffient as a nurse about how to react before, during and after a disaster”, while in the posttest this rate decreased to 12%.
4. Discussion Among the nursing programmes in national scope, for the first time, a module on disaster nursing and management was implemented under a programme of study. From this aspect, it was unique and it has the feature of being a model at the same time. In the final written examination taken at the end of the training module, all of the students got scores of %90 success which were equivalent to grade A in the university grading system. Students earned
11
two national credits and three international ECTS credits. They were also presented certificates of participation from the Faculty Deanery and Department of Public Health for the successful completion of the module. The current study found that nursing students did not see themselves and their families prepared for disasters. This result is in line with those of previous studies in literature (Fung et al., 2008). Previous researches have established that if nurses feel or know that their families are safe or their injured relatives are taken care, their concentration and skills will positively be affected (Tichy et al., 2009; Venema, 2003). Likewise, it has been indicated that nurses are more eager to serve in disasters, in condition that their families’ access effective medical treatment oppurtunites and they feel their families safe (Syrett et al., 2007). Similar to what this survey has found, the study of Suserud evaluating nursing students’ knowledge and opinions about disasters has also revealed that nursing students had limited knowledge about disasters and had different views on what to be covered in a nursing programme of study (Suserud and Haljamie, 1997). It is also worthwhile to mention it here that although there is no concensus in literature on the length and content of the training, it is determined that trainings on this topic make nurses more prepared in responding to disasters (Williams et al., 2008).
It is obvious that there is a strong need for well-trained nurses who can take missions in disasters and disaster management, taking into considiration prior disasters Turkey faced (Hekimoğlu et al., 2015; Saraçoğlu and Demirtaş, 2014), the lack of an effective and comprehensive disaster management system and the fact that Turkey is not adequately prepared for disasters depending on these reasons. Data analysis, and information given by the students demostrate that students are well aware of this need. Moreover, completing the module, they expressed that they graduated with the ability to serve as disaster nurses on site in the event of a disaster. When we look at critical approaches in this field, a variety of issues are emphasized in literature as follows: individuals or representatives who are responsible for disaster and emergency case management mostly have the experience for only post-disaster process, the fact that disaster management is a different, multi-dimensional and a disciplined study field is overlooked, legislation related to disasters lack a general framework which contains activities from all phases of disaster management and lastly disaster nursing should be included into the programmes of study of all
12
undergraduate nursing faculties (Alim, Kawabata and Nakazawa, 2015; Chan et al.2010; INCMCE, 2003; ICN, 2006; Veenema, 2006; Veenema, 2003).
When we look at the legal legislation in Turkey on the role of nurses in disaster situations, it can be said that there are insufficiencies. Legislation governing nursing and disaster issues, including Nursing Implementing Regulation, Implementing Regulation on Family Physicians and Law of Civil Defense have been examined within this scope. Nursing Implementing Regulation assigns a limited task for nurses by saying ‘in emergency situations, nurses make emergency plans in cooperation with the relevant units, develop protocol and get health team prepared to response when necessary according to the disaster plan,”. Likewise, Implementing Regulation on Family Physicians charges nurses with very limited and insufficient duties in disasters, with a similar statement. Roles and responsibilities of nurses in disasters are not clearly given also under the State of Emergency Law and Law of Civil Defense. In this contex, it is still strongly argued in national platforms that the current legislation should be revised, addressed as a whole and associated with each other, and new rules and regulations should be introduced related to disaster management.
5. Conclusion
The main goal of the disaster nursing education is to prepare nurses for the challenges of unexpected events and enable them to take more active roles in disasters. As each disaster is unique and complex on its own, success in overcoming disaster to a large extent depends on preparedness of individuals for disasters. The present study was designed to determine the effects of the module on disaster nursing and management on students’ knowledge and preparedness for disasters. As a result, it has identified that there was statistically significant increase in the state of knowledge and preparedness of students on disaster nursing and management following the module they attended. The findings of this study have also a number of important implications for future practice. The findings indicate that the training module with its content design facilitated learning for students the role and duties of nurses before, during and after a disaster in a clearer way. It is recommended that this module be involved in undergraduate programmes and taken as a model for delivering disaster nursing and management issues. Disaster nursing and management education will certainly provide considerable gains
13
such as reducing mortality in the event of a disaster strike. It is also strategically important for developing countries like Turkey, which often witnesses disasters. There is a definite need for well-trained personnel on disaster nursing and disaster management to proficiently manage disasters and get ready for them. Taken together, these findings suggest important roles for nursing faculties in promoting disaster nursing and management.
Acknowledgements The study was funded by the Hacettepe University Scientific Research Projects Coordination Unit in Turkey (HU012T06102006).
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