R E S E A R C H

B R I E F S

The Importance of Instruction on Mass Casualty Incidents in

Baccalaureate Nursing Programs: Perceptions of Nursing Faculty
Kristin K. Whitty, PhD, RN; and Michael F. Burnett, PhD

ABSTRACT
This study examined whether a
relationship exists between mass
casualty incident knowledge and
perceived importance of incorporating competencies regarding mass
casualty incidents into baccalaureate nursing programs by faculty in
Louisiana. A total of 285 educators in
baccalaureate nursing programs in
Louisiana were asked to complete the
survey instrument; usable surveys
was collected from 166 participants
(58%). Results indicated participants
had limited training and life experiences regarding mass casualty incidents, as well as limited knowledge
of mass casualty incidents. However,
participants perceived mass casualty
incident instruction as important for
inclusion in nursing curricula. There
was a positive relationship between
self-perceived knowledge of mass casualty incidents and perceived importance of including these competencies
Received: July 3, 2007
Accepted: March 2, 2008
Posted: March 27, 2009
Dr, Whitty is Assistant Professor, School
of Nursing, College of Nursing and Health
Sciences, Southeastern Louisiana University, Hammond, and Dr. Burnett is Professor
and Director, School of Human Resource
Education and Workforce Development,
Louisiana State University, Baton Rouge,
Louisiana.
Address correspondence to Kristin K.
Whitty, PhD, RN, Assistant Professor, School
of Nursing. College of Nursing and Health
Sciences, Southeastern Louisiana University, Box 10781, Hammond, LA 70402; e-mail;
kwhitty@selu.edu.

doi:10.9999/01484834-20090416-10
May 2009, Vol. 48, No. 5

into the nursing curriculum. These

findings suggest schools of nursing
take steps to identify or train a pool
of educators who can teach mass casualty incident preparation.

ow would today's medical

community react to historical
disasters such as the eruption of Vesuvius in 79 AD that buried
the towns of Herculaneum and Pompeii ("79 AD Eruption of Vesuvius,"
n.d.), the black plague of 1348 AD
that took as much as 50% of Europe's
population ("Black Death," 2001), or
the great fire of London in 1666 AD
("Great Fire," 2004) that destroyed
more than 13,000 houses and buildings? Disasters, either natural or man
made, have occurred since the beginning of civilization and may strike
at any time or place. An average of
one disaster per week occurs globally
requiring international assistance,
and since 1976, the number of federally declared disasters in the United
States has averaged 34 per year
(Veenema, 2003). Whether occurring
naturally from environmental forces
or generated by humans, disasters
have placed extraordinary stresses on
society's ability to deal with the catastrophic effects of such events.
In the event of a bioterrorist attack, health care professionals will
be first responders for victims who
will require prophylaxis and treatment. Niirses, with a licensed pool of
2.9 million in the United States, comprise the largest group of health care
professionals. The roles of professional nurses in a disaster setting vary
because nurses practice in assorted

settings and have diverse educational

backgrounds and varied experiences.
When disaster happens, all nurses
may be called to participate; however,
there are few or no requirements to
educate RNs on coping with largescale trauma in a community affected
by a disaster.

Literature Review
Disaster nursing involves preparedness for and response to natural or man-made events that affect
an entire community or communities
usually involving massive numbers
of casualties and extensive property
damage (Beaton, 2002). During disaster situations, nursing interventions
often have occurred without clear
instruction. Nurses who volunteered
during the 1985 Puerto Rico flooding
reported a lack of direction of nursing
roles (Rivera, 1986). Following this
experience, nurses recommended inclusion of basic guidelines for disaster
nursing services in nursing curricula.
Mitani, Kuboyama, and Shirakawa (2003) explored the issues and
concerns that nurses faced when
asked to respond to the 1995 Great
Hansbin-Awaji Earthquake event in
Japan. Most nursing personnel reported they needed direction because
they were accustomed to working in
an environment with clearly defined,
expected duties.
Suserud and Haljamae (1997) compared the performance and psychological experiences of two groups of
Swedish nurses involved in disaster
nursing. Nurses who were educated
for specific disaster situations coped
better mentally and consistently pro291

RESEARCH BRIEFS

vided better care in emergency situations than did nurses who lacked disaster education. In addition, the
nurses who lacked disaster education
often doubted their own competence
and indicated a lack of confidence
in their ability to perform adequate
treatment to victims.
On September 11, 2001, nurses
in the New York area immediately
reported to work, and the New York
State Nurses Association reported
nurses from across the country volunteered to help (North Dakota
Nurses' Association, 2001). Nurses
reported there were no policies or
procedures, no routines or schedules, and no instruction or direction
{Gatto, 2002). Following the September 11th terrorist attacks, Orr (2002)
reported that although many nurses
receive training in first aid and infectious disease outbreaks, as well as
training related to fires, multiple vehicle accidents, and plane and train
crashes, most health care professionals lack formal preparation to respond to mass casualty disasters and
that few educational institutions or
health care facilities provide courses
on mass casualty incidents or disasters of this scale.
Although others expect a knowledgeable nursing response, research
shows most nurses are not prepared
for mass casualty incidents or disasters, and their ill preparation is not
their fault (Chaffee, Conway-Welch,
& Sabatier, 2001). Many nurses currently licensed to practice nursing,
which includes the current pool of
nurse educators, have not received
this needed education. Regarding
mass casualty preparation, there are
no educational competencies mandated for existing nursing curricula,
and there are no mandatory continuing educational courses that exist for
the current nursing pool (Gebbie &
Qureshi, 2002).
Rose and Larrimore (2002) surveyed 291 health care staff on knowledge and awareness of chemical and
biological terrorism. Findings demonstrated 53% of the participants
claimed a willingness to work during
a terrorist event; however, only 23%
answered knowledge questions cor292

rectly and indicated feeling confident

to render such care.
A 3-year national study by Weiner, Irwin, Trangenstein, and Gordon
(n.d.) found that 79% of nurse educators selected curriculum plans as
the best place to increase emphasis
on disaster preparedness; however,
nationally, nursing programs provided limited curriculum content in
disaster preparedness. In additional,
this study found that approximately
75% of the nursing faculty felt inadequately prepared in the area of disaster preparedness. Hilton and Allison (2004) noted nurse educators
who are ill informed in education and
training hesitate in incorporating disaster preparedness into the nursing
curriculum.
The purpose of nursing programs
is to graduate nurses equipped with
the basic knowledge and skill to contribute to the health and quality of
life of the individuis and communities in which they serve. Nurse
educators are challenged to develop
relevant curricula to equip novice
nurses for new roles and responsibilities needed for entry-level preparation. In a study of disaster nursing
curriculum development. Bond and
Beaton (2005) found botb practicing
nurses and nursing students indicated a strong need for disaster nursing
content. This indicates formal educational practices regarding mass casualty preparation needs to be included
as part of tbe undergraduate nursing
training.

Purpose
The primary purpose of this study
was to examine the relationship between faculty knowledge of educational competencies regarding mass
casualty incidents and the importance
they place on including these competencies in baccalaureate programs in
Louisiana. The research objectives
were to:
Evaluate the perceived knowledge of educational competencies
regarding mass casualty incidents
among nurse educators currently
teaching in accredited baccalaiireate
programs.

Examine the importance of incorporating educationed competencies

regarding mass casualty incidents
into the current curricula of accredited baccalaureate programs by nurse
educators.
Determine whether a relationship exists between the level of
knowledge and the overall level of importance of incorporating educational
competencies regarding mass casualty incidents into the current curricula
of accredited baccalaureate programs
as perceived by nurse educators.

Method
Participants
The target population for this study
was the faculty of accredited baccalaureate nursing programs currently
teaching theory or clinical courses or
both. The accessible population consisted of nurse educators employed
full-time by January 1, 2006, in all
accredited baccalaureate nursing programs in Louisiana.
First, a list of each baccalaureate
nursing program currently accredited
by the state board of nursing was obtained. A list of nurse educators holding current teaching positions along
with current e-mail addresses of the
list of educators was obtained from
each institution's faculty directory
and verified by correspondence with
a representative of the dean's office
of each program. After the population
frame of 285 educators of baccalaureate nursing programs was established, a census sampling technique
was used for the design of this study.
The study was approved by the university's institutional review board
prior to data collection.
Instrument
The instrument used to collect
data was a questionnaire designed by
the researcher (K.K.W.). The first part
of the instrument identified 51 core
knowledge and competencies regarding mass casualty incidents related to
those identified by the International
Nursing Goalition for Mass Casualty
Education Competency Committee
(2003). For perceived level of knowledge scale, pEirticipants were asked
Journal of Nursing Education

RESEARCH BRIEFS

to rate their knowledge on a 5-point

scale (1 = not at all knowledgeable,
2 = slightly knowledgeable, 3 = fairly
knowledgeable, 4 = quite knowledgeable, 5 = very knowledgeable). Cronbach's alpha internal consistency
measure for the knowledge scale was
0.985, indicating an excellent estimate of reliahility {George & Mallery,
2003).
Participants were asked to rate the
importance of each item for inclusion
in the haccalaureate nursing curriculum on a 5-point scale (1 = not at all
important, 2 - slightly important, 3 =
fairly important, 4 = quite important,
5 = very important). Cronhach's alpha
internal consistency measure for the
Importance scale was 0.989, indicating an excellent estimate of reliability
(George & Mallery, 2006).
The second part of the instrument
collected information on selected personal and professional characteristics
of the participants. Content validity
of the instrument was established by
a panel of experts consisting of six
nurse educators who were formerly
or currently employed part-time in
accredited baccalaureate nursing
programs and had expertise in research design. Afler revisions were
made to the instrument based on
the input from the panel of experts,
the instrument was field tested by a
sample of nurse educators teaching
in programs other than the baccalaureate level.
The instrument for data collection was delivered using an online
survey delivery service that provided an Internet link to the instrument. In addition, the researcher
sent a paper version of the cover
letter and questionnaire addressed
to each faculty member. The accessible population of 285 educators
in Louisiana baccalaureate nursing
programs was asked to complete the
survey.

Results
Sample
Usable data was collected from
166 participants (58%). Of the
164 participants who indicated their
age, 49 respondents (30%) were age
May 2009, Vol. 48, No. 5

44 and younger, 65 respondents (40%)

were age 45 to 54, and 50 respondents
(30%) were age 55 and older. Of the
160 participants who provided their
years of nursing employment, 111 respondents (69%) indicated they had
^21 years experience as a nurse and
49 respondents (31%) had ^20 years
experience.
For the 161 participants who provided their years of employment as a
nurse educator, 29% (ra = 47) reported
having worked as a nurse educator for
11 to 20 years. The breakdown for the
remaining participants was almost
equally divided, with 25% (n = 40)
employed less than 5 years, 23% (n =
37) employed 5 to 10 years, and 23%
(n = 37) employed 21 years or longer.
Of the 162 participants who reported their primary teaching area,
59% in = 95) indicated adult health
was their primary teaching area. The
breakdown for the remaining respondents was fairly equally dispersed,
with the primary teaching area of
other for 15% (n = 24), child health
for 10% in = 16), woman's health for
9% (n = 15), and mental health for 7%
in = 12). The majority (n = 16) of respondents who listed "other" specified
community health as their primary
teaching area.
Level of Knowledge
Respondents were asked to rate
their perceived level of knowledge of
51 items pertaining to mass casualty
incidents on a 5-point scale. The following breakdown of scores was used
to interpret the results: 1 to 1.49 = not
at all knowledgeable, 1.50 to 2.49 =
slightly knowledgeable, 2.50 to 3.50 =
fairly knowledgeable, 3.51 to 4.50 =
quite knowledgeable, and 4.51 to 5 =
very knowledgeable.
Participants responded as being
quite knowledgeable for 6 items, fairly knowledgeable for 28 items, and
slightly knowledgeable for 17 items.
The six items rated highest in perceived knowledge were: demonstrate
basic first aid skills (mean = 4.13,
SD = 0.99), demonstrate personal
protective equipment (mean = 4.01,
5 0 = 1.1), perform head-to-toe assessment (mean = 3.63, SD = 1.2),
demonstrate higher order nursing

skills (mean = 3.61, SD = 1.33), demonstrate safe medication administration (mean = 3.55, SD = 1.28), and
assess and monitor during transport (mean = 3.53, SD = 1.15). The
six items rated lowest were: define
terms relevant to mass casualty incidents (mean = 1.86, SD = 1.12),
discuss chain of custody during a
crime scene (mean = 2.06, SO =
1.20), demonstrate use of emergency
communication (mean = 2.10, SD =
1.18), describe the incident command
system (mean = 2.13, SD = 1.27), describe standards of handling human
remains (mean = 2.15, S o = 1.22),
and describe decontamination procedures (mean = 2.17, SD = 1.21).
Mean overall knowledge score was
2.82 (So = 0.94).
Level of Importance
Respondents were asked to rate
the level of importance of 51 items
pertaining to mass casualty incidents.
The following breakdown of scores
was used to interpret the results: 1
to 1.49 = not at all important, 1.50
to 2.49 = slightly important, 2.50 to
3.50 = fairly important, 3.51 to 4.50 =
quite important, and 4.51 to 5 = very
important.
Participants perceived 50 items as
quite important, and 1 item as fairly
important. The six items rated highest were: demonstrate basic first aid
skills (mean = 4.5, SD = 0.77), demonstrate personal protective equipment
(mean = 4.46, SD = 0.83), demonstrate safe medication administration (mean = 4.37, SD - 0.90), perform head-to-toe assessment (mean =
4.29, SD = 0.89), use chnical judgment in assessment (mean = 4.26,
SD - 0.99), and assess and monitor
during transport (mean = 4.22, SD =
0.94). The items rated lowest in importance were: define terms relevant
to mass casualty incidents (mean =
3.35, SD = 1.21), identify resources
for media releases (mean = 3.52,
SD = 1.14), discuss chain of custody
during a crime scene (mean = 3.63,
SD = 1.15), describe role as nurse
epidemiologist (mean = 3.70, SD =
1.08), describe the incident command
system (mean = 3.78, SD = 1.14), and
demonstrate use of emergency com293

RESEARCH BRIEFS

munication (mean = 3.81, SD = 1.27).

Mean overall importance score was
4.02 {SD = 0.80).
Relationship Between Level of
Knowledge and Level of Importance
Findings revealed similarities in
items were rated the highest in the
level of knowledge and those rated
as the most important, as well as
the items that were rated lowest in
knowledge and of least importance.
Five of the six items rated as highest were the same in both scales, and
four of the six rated as lowest were
the same in both scales. Although
similarities existed between ratings of individual items of perceived
knowledge and level of importance,
differences were noted in their relative positions on the rating scale.
Not only were means of the individual items lower in the knowledge
scale compared with the importance
scale, but the overall mean score for
knowledge of 2.82 was lower than the
overall mean score for importance of
4.02.
The relationship between perceived
level of knowledge and level of importance was significant and measured
moderate (Davis, 1971) in a positive
direction and magnitude when correlated using the Pearson correlation,
r (162) = .33, p < 0.001. The nature
of the association was such that the
more knowledge the educators perceived that they had regarding core
competencies for mass casualty incidents, the higher the level of importance they placed on inclusion of
these competencies into the nursing
curriculum.

Conclusion and Implications

for Nursing Education
Just as emergency department
nurses are trauma trained for the inevitable, nurses who are generalists
need to receive training for the inevitable because when disaster strikes,
it often occurs in such magnitude
that an enormous pool of nurses will
be needed. In the event of chemical or
biological warfare, the response must
be rapid and coordinated with local,
state, and federal agencies to con294

trol widespread panic and minimize

death.
Nurse educators employed fulltime in baccalaureate-level programs
in Louisiana demonstrated limited
knowledge regarding mass casualty
incidents. Nursing education is being faced with a workforce that did
not receive adequate instruction for
mass casualty preparation. This is
verified by the findings of tbis study;
tbe overall mean score for knowledge
regarding mass casualty incidents
was 2.82, with nurse educators' ratings being fairly knowledgeable or
lower on 45 of the 51 items on the
questionnaire. Findings from this
study are similar to those reported by
Rose and Larrimore (2002) in which
23% of health care respondents answered knowledge questions correctly regarding chemical and biological
terrorism.
Nurse educators employed fulltime in baccalaureate-level programs
in Louisiana perceived mass casualty
incident instruction as quite important for inclusion in nursing curricula. This is verified by the findings
that the overall mean score for importance was 4.02, with participants
rating 50 of the 51 items as quite important or higher. These findings are
similar to a previous study by Bond
and Beaton (2005), who reported
both student and practicing nurses
indicated a strong need for disaster
nursing content.
Nurse educators are accountable
to their students, communities, and
society at large to prepare graduates
to work in an environment where the
potential for mass casualty disaster
is no longer a low probability event.
The current environment dictates an
adjustment of the curricula to include
content regarding disaster preparation to provide nursing students with
the knowledge and skills required to
participate in a national emergency
response. If the curriculum is l, it is
time to prioritize content and remove
less essential elements. Inclusion of
mass casualty incident training and
core competencies into nursing curricula is long overdue. Further research
is needed to determine the best placement in the curriculum.

The findings of this study verified

there is a positive relationship between perceived knowledge of mass
casualty incidents and importance of
inclusion of these competencies into
the nursing curriculum. The more
knowledge nurse educators perceived
they had regarding core competencies for mass casualty incidents, the
higher the level of importance they
placed on inclusion of these competencies into tbe nursing curriculum.
A perception that their knowledge
is low will have an impact on their
willingness and ability to effectively
incorporate this content into the curriculum. Similarly, Hilton and Allison (2004) reported nurse educators
who are ill informed in education
and training hesitate in incorporating disaster preparedness into the
nursing curriculum.
Deans of nursing schools should
take immediate steps to identify a
pool of educators who can teach, or
with instruction are willing to teach,
mass casualty incident preparation.
This selected cadre must be trained
immediately by professionals identified as knowledgeable and highly
experienced in mass casualty incidents such as those currently serving in the armed forces, U.S. Department of Homeland Security, National
Nurses Response Team RNs, and National Guard, as well as volunteers
from agencies such as the American
Red Cross and emergency medical
response teams. In a large-scale disaster, the cooperation of the civilian
and military sectors will be vital in
creating an environment of coordinated responses with delineation of
roles, responsibilities, and leadership.
Until a cadre of nurse educators acquire and disseminate this
information, the profession will not
be equipped with a group of selfconfident, competent nurses who
can prepare the future generation of
nurses for disasters of all types.

References
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2005, from http://www.son.Washington.
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U N I V E R S I T Y

Assistant Dean of
Doctoral StudiesSchool of Nursing
George Mason University, College of
Health and Human Services. School
of Nursing is seeking an Assistant
Dean for Doctoral Studies. This
tenured position is available for the
fall of 2009.
George Mason University is a dynamic and growing university, recently
named by U.S. News & World
Report as the #1 national university
to watch on its list of Up-and-Coming
Schools. Mason was cited as a
school that has recently made the
most promising and innovative changes in academics, faculty, students,
campus or facilities.
This is an exciting nursing leadership
opportunity. The Assistant Dean will
help set the direction for the future of
doctoral studies in the school. A new
D.N.P. (Doctor of Nursing Practice)
program is planned to complement
the Ph.D. program that currently
boasts over 50 students, with 13
graduates in the spring of 2009.
Applicants are expected to have a
defined research focus and potential
for securing extramural funding. Research agendas that link with current
initiatives and research teams in palliative care, disability and chronic illness, obesity/nutrition, emergency
preparedness, forensic nursing, vulnerable populations, and gerontology
are particularty desirable. While prior
experience in higher education is not
required, the successful candidate
will have a record of scholarship and
evidence of teaching ability consistent with the rank of tenured Full
Professor at a research university.
Required: Applicant must be a registered nurse with a doctorate in
nursing (Ph.D., D.N.S. or D.N.P.).
and have a record of publications
and history of extramural funding
consistent with tenure at the rank of
Full Professor.
George Mason University is an equal
opportunity/affirmative
action
employer dedicated to the goal of
building a culturally diverse faculty
and staff. Women and minority candidates are particularly encouraged
to apply. Questions may be directed
to Mimi Mahon, Ph.D.. A.P.R.N.,
F.A.A.N. and Chair of the Search
Committee at: mmahon@gmu.edu or
703-993-1932.

May 2009, Vol. 48. No. 5

Piease apply for position F8652z

at http://jobs.gmu.edu/.