Emergency Nurses' Knowledge of PDF

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EMERGENCY NU RSES’ KNOWLEDGE
OF
DISASTER PROCEDURES/MANAGEMENT
by
Starre A. Haney
A Thesis Presented in Partial Fulfillment

o f the Requirements for the Degree
M aster o f Science
ARIZONA STATE UNIVERSITY
May 1996
UMI Number: 1378801
Copyright 1996 by
Haney, Starre Ann
All rights reserved.
UMI Microform 1378801

Copyright 1996, by UMI Company. All rights reserved.
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EMERGENCY NURSES’ KNOWLEDGE
OF
DISASTER PROCEDURES/MANAGEMENT
by
Starre A. Haney
has been approved
May 1996
APPRO’
■Chairperson
Supervisory Committee
ACCEPTED:
Associate Dam Graduate Program
Dean, Graduate College
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission
ABSTRACT
Emergency nurses have a major role in any disaster and must have the knowledge,
organizational skills and leadership abilities to fulfill their responsibilities. To assess
knowledge a questionnaire was distributed to a sample o f thirteen hundred Emergency
Nursing Association members. The purpose o f the survey was to identify the knowledge
o f emergency nurses o f disaster procedures and management. In addition, the relationship
between emergency nurses’ participating in disaster planning, disaster drills or mass
casualty incident experience and disaster knowledge was explored. Five hundred and
twenty six nurses responded.
The Disaster Knowledge and Management Questionnaire was developed by the
author and consisted o f knowledge questions regarding disaster procedures and disaster
management. Three faculty members o f the College o f Nursing, Arizona State
University, reviewed the questionnaire which was subsequently pilot tested by four
Registered Nurses with varying amounts o f disaster experience, education, and emergency
nursing experience.
Significant differences were found between nurses with and without disaster
planning experience and nurses with and without disaster drill experience occurred on the
disaster management score variable. Nurses with disaster planning or disaster drill
experience scored higher on the disaster management scale. In addition, those nurses with
mass casualty incident experience and disaster planning experience scored higher on the
disaster management scale. A positive correlation between years o f experience and the
disaster management score indicated that nurses with more years o f experience tended to
iii
have higher disaster management scores. Nurses with certification in emergency nursing
scored higher on both the disaster procedure and disaster management scales than nurses
without certification.
Further study o f nurses with and without disaster planning experience is indicated
to further define the knowledge needs o f emergency nursing. Certification in emergency
nursing as an additional component enhancing the disaster knowledge o f emergency
nurses is an area for further research.
iv
DEDICATION
To my parents, Mervin and Sondra Christensen for their encouragement and
support and to my husband Bill, my children Patrick, Breann and Courtney for their love,
support and sharing o f their time and our computer while I completed this project.
ACKNOWLEDGMENTS
This author wishes to express appreciation to Dr. Pauline Komnenich for guidance,
direction, and many words o f encouragement throughout the study and to Dr. Joseph
Hepworth for support and encouragement in the data collection phase. I would also like
to thank Dr. Carolyn Feller for the positive comments and encouragement during my
thesis preparation. A thank you to Sharon Spreitzer, Betty McCarter, Rita Speranza,
Patti Root, Philomene Spadefore, Denise Kirkendall, and Mary Jo Bertsch, my emergency
nursing colleagues, who encouraged and supported my interests in disaster nursing.
A special acknowledgment and thank you is extended to the Emergency Nurses
Association Foundation for the financial support to carry out the study.
vi
TABLE OF CONTENTS
Page
LIST OF TABLES ................................................................................................................. ix
CHAPTER
1 Introduction .................................................................................................. 1
Purpose o f the Study ........................................................................ 2
Statement o f the Problem ................................................................. 3
Research Questions .......................................................................... 3
Definition o f Terms .......................................................................... 4
2 Review o f Literature ...................................................................................... 5
Theory ................................................................................................. 5
Disaster Procedure Knowledge ..................................................... 8
Disaster Management Knowledge .............................................. 12
Role o f the Emergency N u r s e ....................................................... 15
Summary .......................................................................................... 16
3 M ethods ......................................................................................................... 17
Design ............................................................................................... 17
S a m p le ............................................................................................... 17
D ata Collection Procedure ............................................................ 18
D ata Collection Instrument .......................................................... 19
4 Data Analysis and Results ........................................................................... 21
D ata Analysis Plan .......................................................................... 21
vii
CHAPTER Page
Description o f the Sample ............................................................ 22
Research Questions ....................................................................... 27
Ancillary Analyses ......................................................................... 38
5 Conclusions and Recommendations .......................................................... 39
Implications for N u r s in g ................................................................ 40
Limitations and Assumptions ....................................................... 41
Recommendations ......................................................................... 43
R E F E R E N C E S....................................................................................................................... 45
APPENDIX
A Cover L e tte r................................................................................................... 51
B Data Collection Instrum ent.......................................................................... 53
viii
LIST OF TABLES
Table Page
1 Nursing Years o f Experience and

Emergency Years o f Experience ............................................................................ 23
2 Years o f Disaster Planning Experience ................................................................. 23
3 Current E m p lo y m en t................................................................................................. 24
4 Ethnic Group ............................................................................................................. 25
5 Year B o m .................................................................................................................... 25
6 Military Service Y e a r s ............................................................................................... 26
7 Emergency Department Patient Visits per M onth ............................................... 27
8 Disaster Procedure Frequency Scale ...................................................................... 28
9 Disaster Management Frequency Scale ................................................................. 29
10 Disaster Procedure Items ........................................................................................ 30
11 Disaster Management Items .................................................................................... 32
ix
CHAPTER 1
Introduction
Emergency nurses have a critical role whenever an external or internal disaster
occurs. They must have the knowledge, organizational skills and leadership abilities to
fulfill their responsibilities. These responsibilities include disaster preparedness, nursing
care during an actual disaster and nursing care during the recovery phase o f the disaster.
Disasters immediately affect nurses in emergency departments and prehospital settings
including flight services and critical care transport nurses. A successful disaster response
depends on how well the acute care facility and the emergency department staff are
prepared.
The Joint Commission on Accreditation o f Healthcare Organizations requires
health care facilities to hold a minimum o f tw o disaster drills per year (Joint Commission,
1993). The Commission also suggests that nurses participate in the disaster planning for
these facilities (Bushelle & Tomasik, 1994). In addition, nurses need to be part o f the
planning process (Holloway, 1990; Larsen, 1991;M aule, 1967). Nurses with experience
in disaster planning are able to assume leadership roles more effectively (Demi & Miles,
1984). Disasters frequently strike without warning; therefore, emergency nurses on all
shifts must be knowledgeable about disaster procedures and management.
Disaster nursing procedures and management knowledge are not typically
included in basic nursing curriculums and yet are considered important for the emergency
nurse to possess. Ellison (1967) discussed the difficulties o f incorporating disaster nursing
into the curriculums o f schools o f nursing. This subject continues to be one that is not
typically included in undergraduate education today. Yet the "survival o f victims may be
influenced by the staffs organization, training, and experience" (Waeckerle, 1991, p. 819).
Participation in disaster drills, planning or an actual disaster may increase the nurse's
knowledge. Demi and Miles (1984) found that during the Hyatt disaster in Kansas City,
nurses who held formal roles in the disaster planning process and had prior disaster
experience were most effective in assuming leadership roles during the disaster.
The United Nations General Assembly has declared the 90s the International
Decade o f Natural Disaster Reduction (Holloway, 1990; Waeckerle, 1991). This world
wide effort to reduce the loss o f life and property from disasters is keyed on disaster
preparedness. Are emergency nurses adequately prepared for disaster procedures and
management? Komnenich and Feller (1992) indicate there is a definite need for disaster
nursing research especially research "focused on identifying the health practices that
promote quality o f life during and after disasters as well as on developing and testing
nursing interventions that promote health" (p. 132). Disasters require a multi disciplinary
response (Becker, 1991). This study will examine the knowledge that emergency nurses
have on disaster procedures and management.
Purpose o f the Study
The purpose o f this study was to identify the knowledge level o f emergency
nurses on disaster procedures and management. In addition the relationship between
emergency nurses participation in disaster planning, disaster drills or mass casualty
incident experience and disaster knowledge will be explored.
Statement o f the Problem
Emergency nurses are part o f the disaster response team whenever there is a
disaster event. Disasters are occurring at a more frequent rate around the world.
Emergency nurses need to be prepared for the roles that they will need to fill when
disasters occur. It is not known what knowledge emergency nurses have regarding
disaster procedures and management or how that knowledge has been learned.
It has been suggested that nurses involved in disaster planning are more prepared
for assuming leadership roles when an actual event occurs. Identifying the knowledge of
emergency nurses will assist educators and administrators in preparing their staff for an
actual disaster event. If disaster planning does influence the knowledge o f emergency
nurses, then that knowledge should be examined further, so that the knowledge o f
disaster procedures and management for all emergency nurses can be enhanced.
Research Questions
1. What knowledge do emergency nurses have o f disaster procedures and
management as measured by the Disaster Procedure and Management Knowledge
Questionnaire (DPMK)?
2. Do emergency nurses who report participating in disaster planning, disaster
drills or have participated in a mass casualty incident have a higher level o f knowledge o f
disaster procedures and management than those emergency nurses who do not?
3. Does educational preparation contribute to the knowledge emergency nurses
have o f disaster management and procedures?
4. What does work experience contribute to the knowledge o f emergency nurses
on disaster management and procedures?
Definition o f Terms
D isaster refers to any incident, man-made or natural, that involves an influx o f
patients that overloads the existing personnel or existing supplies o f an acute care facility.
D isaster drill refers to a test o f the disaster plan, or component o f the plan, at an
acute care facility. The drill may be with moulaged victims or simulated victims.
D isaster procedures refers to procedures that are utilized only in disaster
situations and differ from normal day to day operations in an emergency department or
emergency services. It is subdivided into prehospital, triage, communications, common
disaster patient care situations, and psychological support for victims.
D isaster m anagem ent refers to the organization and leadership o f a disaster
response and is subdivided into disaster planning, disaster leadership, command post
activities, and critical incident stress debriefing.
CHAPTER 2
Review o f Literature
The review o f literature addresses the need for all emergency nurses to be
prepared for a disaster event. Carley's theory o f knowledge acquisition as a social
phenomenon is discussed as a method o f knowledge acquisition o f disaster procedures and
management. The knowledge needs o f emergency nurses for disaster procedures and
management are presented.
Theory
Knowledge Acquisition as a Social Phenomenon
Knowledge acquisition does not occur in a vacuum and is a by-product o f human
interaction. An individual's cognitive development is a result o f the continuous
interactions that occur as one completes various tasks with others and thus gathers
information. Carley (1986) defined social structure as the perceived regularities in the
network o f ties between individuals in the society and social knowledge as that
information which is known by everyone in that society. Social knowledge provides the
background necessary to interpret and analyze, thus affecting future interactions.
O ur social world affects the information that w e know and choose to store. There
is a relationship between the social and the individual world. Carley (1986) believes that
"social interaction is the driving force behind knowledge acquisition" (p. 383).
“Constructuralism theory” purports that the social world and the individual's cognitive
world are continuously developing in response to each other (Carley, 1986, p. 386). As
people move through the various tasks o f the day, they interact with others and as a result
they gain new knowledge. The knowledge that is acquired depends on with whom they
interact.
An individual's frame o f reference for a specific task is dependent on the
information that he/she knows about the task. As individuals perform various tasks
communication occurs. The communication is linked to the individual's current frame o f
reference for that particular task or will be closely linked to that task. This information
can also affect future task performance. M ore knowledge is acquired through
communication then by discovery (Carley, 1986). Therefore the individual's knowledge
base grows through performance o f tasks and the social structure within which the task is
performed. Knowledge shared by a social unit also develops as each individual member o f
the unit develops, due to communication between members o f the group.
Emergency nurses may be considered a social unit that works in a unique area and
shares knowledge as they work together with other members o f the health care team to
solve the health care problems o f the clients that present themselves with an emergency or
perceived emergency health care need. This task performance leads to communication
and interaction among the staff and increases the knowledge base o f the staff. Emergency
nurses participating in disaster planning, disaster drills or actual disaster situations will
have new tasks to perform, and will gain new knowledge that is acquired through this
experience.
The knowledge that is gained will depend on the degree to which the task can be
related to others in the person's past frame o f reference. A nurse familiar with emergency
triage and priority setting can acquire knowledge regarding disaster triage by experiencing
or interacting with a nurse performing that task. If nurses are unfamiliar with emergency
triage they will not have a frame o f reference from which to develop the knowledge o f
disaster triage. Limiting an individual's interaction also limits knowledge acquisition to
that knowledge that is communicated by the social environment. I f all emergency nurses
are to be prepared for disaster nursing, they need to participate in disaster planning and
drilling for disaster situations, so the disaster frame o f reference can be established within
the emergency nurses' cognitive structures.
Need for Disaster Knowledge
Disasters may occur at any time, day or night, regardless o f staffing levels, holidays
or vacation schedules. They are sudden, unexpected and “overwhelm the capabilities o f
the available emergency medical and other rescue services” (Becker, 1991, p. 383). The
impact that is made on the area's medical facilities depends on the size o f the receiving
facility or facilities and the number o f victims. It is the emergency nurses who will assist
with triage and emergency care for disaster victims at the hospital as well as at the scene,
if needed. Whereas normal emergency care procedures direct all available resources to the
care o f any individual needing that care; in a disaster, the goal is to provide emergency
care to those with the greatest chances o f survival (Butman, 1982; Waeckerle, 1991).
Precious resources, including time, supplies and equipment and personnel need to be
utilized first for those who have the greatest chance o f survival. Garcia (1985) reports
that confusion and delays must be minimized to accomplish these goals.
In 1963, a National League o f Nursing stu d y ," Disaster Nursing Preparation",
"aimed at improving preparation o f nurses for the functions they were expected to assume
during a disaster" (Neal, 1963) was published. This was one o f the first studies indicating
the need for education and further research for nurses regarding disaster nursing concepts.
Ellison (1967) discussed the difficulties o f implementing disaster nursing in the
curriculums o f schools o f nursing. Lack o f disaster experienced or interested faculty,
disagreement on essential disaster nursing functions, and resistance to accepting the need
for knowledge o f disaster situations w ere problems mentioned. Garcia's (1985) Disaster
Nursing Planning. Assessment, and Intervention text is based on a needs assessment o f
250 nurses. Garcia identifies major topics o f concern to nurses providing disaster care
including field assessment skills, management and triage at the disaster site, disaster
decision making at the hospital, the irradiated patient, psychological aspects o f disaster
situations, development and design o f educational programs, disaster planning and legal
implications o f nursing practice.
Disaster Procedure Knowledge
Disaster procedure knowledge is subdivided by the author into five areas:
prehospital, triage (scene and hospital), communication, care o f disaster victims, and
psychological support for victims. Knowledge o f local prehospital disaster management
will assist the emergency nurse to prepare for victim reception at the emergency
department as well as the meshing o f the prehospital response with the hospital disaster
plan. In addition, nurses working in the prehospital area or nurses who may need to
participate in the field response o f a disaster need to be knowledgeable in field disaster
response and incident command structures.
Triage is "the key to the management o f mass casualties" (Neff, 1980, p. 178).
Nursing knowledge o f disaster triage procedures is critical to the functioning o f the
disaster plan. Triage is a French word meaning to sort. Its initial use was during
Napoleon's time (A uf der Heide, 1989). During W orld W ar I military officials needed to
identify those soldiers with minimal injuries that could be quickly treated, returning the
soldier to the battlefields (Ramler, 1990). The concept o f triage has since been applied to
disaster situations and in emergency departments. Ramler (1990) describes early
emergency department triage as being instituted in the late 50s and early 60s due to
increased emergency department cases and an increase in the number o f patients seeking
nonurgent care in the emergency department.
Disaster triage occurs in two settings; at the disaster scene and again on arrival to
the emergency department. The goal and setting in disaster triage is very different from
day to day emergency procedures. Usual emergency care procedures direct all available
resources to the care o f any individual needing that care; in a disaster the goal is to
provide emergency care to those with the greatest chances o f survival (Butman, 1982;
Waeckerle, 1991). Individuals needing cardiopulmonary resuscitation (CPR) or that have
severe head injuries have little chance o f survival. Care for those victims with minimal
potential for survival would utilize precious resources that would be better used for
victims with a better chance o f survival.
During a disaster normal emergency triage is changed using predefined triage
categories so that only potentially salvageable patients utilize critical resources first (Earl,
1994). Frequently the hospital disaster triage area is located near the ambulance entrance
10
to the emergency department, whereas the regular triage station may be located near the
walk in patient entrance.
N eff (1980) reports that triage is the one important component in the care o f
disaster victims both at the site and at the hospital. Hospital disaster categories should
correspond with those definitions and guidelines used in the local emergency medical
system disaster plans. Prehospital triage will prevent any one hospital from being
overloaded with too many critical patients, an occurrence that would compromise the
emergency care o f those who are critically injured (A uf der Heide, 1989). Triage divides
the victims into separate categories. Those victims needing emergency interventions for
lifesaving or limb saving purposes and who are easily treated, can be treated first and
receive earliest transport to the hospital. By early identification o f those who may require
immediate life saving interventions from those who have minor injuries, emergency
resources are efficiently provided. On the average most major incidents produce at least
40-80 victims with serious multiple injuries (Butman, 1982).
Triage systems vary throughout the country. Butman (1982) reports a color code
priority system that is internationally recognized:
1. Red = Critical or 1st priority 3. Green = Nonurgent, minor, or 3rd priority
2. Yellow = Urgent or 2nd priority 4. Black = Dead
Other systems use one additional category for those that are alive on initial assessment but
are found with catastrophic injuries. Some refer to this category as expectant, yellow
prime or blue (A uf der Heide, 1989; Butman, 1982). Nabbe (1963) describes the
expectant category as those victims that are so severely injured that definitive care will be
complicated and there is still little hope for survival. These victims would receive
emergency care and be transported to the hospital after all critical or red priority patients
were taken care of. Disaster victims who have urgent injuries can wait up to 1 hour
before transport to the hospital for definitive care and those with minor injuries can wait
up to 12 hours before definitive treatment is received.
Disaster triage needs to be accomplished in a rapid and efficient manner as victims
arrive. The emergency nurse needs to know the location o f all the disaster treatment areas
that are designated in the facilities' disaster plan. The emergency department becomes the
center for the critically injured while other hospital areas are designated as centers for
urgent or nonurgent disaster patients. In addition, emergency nurses need to manage and
direct care in all disaster treatment areas, assisting medical-surgical or critical care nurses
who may be assigned to assist in the acute care facilities' disaster response.
Communication, "both internal and external, is crucial for disaster operations and
must be planned in advance" (Earl, 1993, p. 725). Good Emergency Medical System
(EMS) communications with the receiving emergency departments is needed so
departments can be prepared for the incoming patients and can communicate current
department status to the field triage centers so that disaster victims can be distributed
equally among facilities, as needed. Back up communication m ethods are needed both in
the acute care facility and within the Emergency Medical System. Back up telephone
lines, ham radio operators or portable radios may be necessary to assure communication
lines remain intact.
Limiting staff use o f phone lines reduces the telephone line jam that can occur
from inside the hospital. Assigning one person per department to notify other employees
o f the disaster and the need to respond will also reduce phone line difficulties. Cellular
phone communications depend on the availability o f working communication towers. If
phone lines are not working, the cellular transmissions will also be inoperable.
Accurate information from a single field source will decrease misinformation and rumors.
Prilliman, Solis, Swartz, and Conley (1993) reported many resulting difficulties when
EMS radio communications differed from one county to another. These included unequal
distribution o f disaster victims, inaccurate estimations o f actual victim numbers which lead
to one facility dispatching a hospital team to the scene to find there were no more victims,
and no reports o f incoming disaster victims from transporting ambulance services.
Psychological support for disaster victims is an important aspect o f emergency
nursing care. Emotional crisis is a "state o f disequilibrium that occurs when usual coping
strategies are inadequate and immediate interventions are required" (Jacobs & Baker,
1995, p.326). Psychological support may not be recognized as a priority by emergency
health care providers because treatment o f injuries is a priority during the immediate
disaster situation. "Simple human compassion and common sense support are the best
preventive measures for psychological casualties" (Richtsmeier & Miller, 1985, p. 191).
Disaster Management Knowledge
Disaster management knowledge is subdivided into disaster planning, disaster
leadership, command post activities, and critical incident stress debriefing for all those
involved in disaster operations. Any emergency nurse may be required to initiate the
department’s disaster response until management personnel arrive. Rayner's (1958) study
reported that nurses had problems with organization o f care during disasters. Knowledge
o f the basic concepts o f organizing the initial response as well as organizing disaster site
triage and care are important for the emergency nurse to function well in the disaster.
A disaster plan should contain prearranged agreements with local and regional
emergency management agencies including police, fire, rescue and transport services, Red
Cross, and other agencies. In addition a plan for managing the disaster victims, disaster
site team response, and an evacuation plan should be included (Committee on Trauma,
1985). The hospital plan for managing the disaster victims should address identification of
victims, managing the media, communications, crisis intervention, notification o f staff,
designated treatment areas, discharge areas, and a family waiting area (Bonet, 1990). The
emergency department must be prepared for efficient management o f disaster victims.
Demi and Miles (1984) reported that those nurses who were actively involved with
disaster planning and had prior training or experience in disasters were most effective in
leadership roles. Their leadership model also proposes that nursing leadership is important
in all phases o f a disaster and that nurses use the nursing process to impact goal setting
and achievement. All emergency nurses have a responsibility in knowing what their role
may be in a disaster and knowing their facility’s disaster plan. Disaster planning also
requires anticipation o f natural disasters such as tornados, earthquakes, floods, or
hurricanes and the types o f problems that they will present (Counts & Prowant, 1994).
The purposes o f disaster drills are to provide an opportunity for testing the disaster
plan, for all staff to practice the concepts o f disaster operations, identify problems and
14
solutions and observe the staff’s response (Aghababian, Lewis, Gans, & Curley, 1993;
Becker, 1991; Bushelle & Tomasik, 1994). Drills are an opportunity for educating the
staff as well as testing their knowledge and the disaster plan. Table top drills are not
acceptable to the Joint Commission on Accreditation o f Healthcare Organizations
(Bushelle & McLean, 1994). Paper patient drills, where the patient characteristics are
documented on a piece o f paper and then the paper is transported like a real patient to the
different hospital disaster areas, is an acceptable alternative to the costly moulaged (injury
makeup) mock victims.
The command post serves as the executive group that works to meet the needs
required by the disaster response, set priorities, approve resource allocation, approve
public information release, and coordinate with other agencies and public officials (A uf der
Heide, 1989; Schlaeppi & Rogers, 1985). The emergency department charge nurse
communicates with the command post regarding patient status, resource needs (personnel
or supplies), and as otherwise indicated by facility policies and procedures.
Day to day operations for an acute care facility change when it is necessary to
implement the disaster plan. All elective diagnostic testing and surgical procedures are
immediately canceled to prepare for emergency procedures (Klinghoffer, 1994). Security
officers must screen all those entering the hospital and ensure that media representatives
don't get in the way o f patient care or increase the emotional distress o f victims or
families. Media personnel should be contained in a designated area with telephone access,
so that public relations staff may provide equal information to them and yet maintain the
rights o f the patients. Pastoral care services will be needed for families and victims as well
as staff. They may help in next o f kin notification o f victims that have been taken to the
hospital. Maintenance and engineering staff must ensure that adequate power and other
utilities are maintained and that any structural damage to the hospital is temporarily
repaired.
Critical incident stress debriefing is needed for health care workers following a
disaster. Rayner (1958) discussed the emotional toll o f disasters on the nurse that may be
either due to the urgency o f the situation or due to problems o f organization for disaster
medical care. Stress debriefing teams "offer educational programs on the recognition and
management o f stress in order to prepare people to deal better with calamities"
(Waeckerle, 1991, p. 820). During a mass casualty incident, debriefing teams should be
available to assist emergency personnel at breaks or at any other time that is needed. All
the staff involved from clerks, transporters, techs, nurses, physicians, and chaplains need
to be included in the stress debriefing sessions. In-depth therapy sessions should also be
available to those who need them. The disaster critique session is also helpful to assist
staff in evaluating the care provided as well as how the disaster plan functioned.
Role o f the Emergency Nurse
The role o f the emergency nurse in a disaster situation is varied. The nurse
practicing in prehospital o r flight nursing roles is active with extrication, triage, field
treatment and transporting o f disaster victims. Nurses who staff emergency departments
may also be needed at the scene to assist prehospital personnel depending on the
magnitude and logistics o f the disaster site. Others man hospital triage and disaster victim
treatment areas. Emergency nurses coordinate the disaster response o f their departments
and hospitals. The roles are varied but the basic knowledge o f disaster procedures and
management is the key to coordinated, life saving disaster victim care.
Summary
Disaster nursing procedures and management knowledge are not generally
included in nursing curricula and yet are considered important for the emergency nurse to
possess. It is unknown what knowledge exists among the thousands o f emergency nurses
and if disaster drills or participating in disasters affects the knowledge o f those nurses. Yet
the "survival o f victims may be influenced by the staffs organization, training, and
experience" (Waeckerle, 1991, p. 819).
The disaster knowledge o f emergency nurses may be affected by participating in
disaster drills, disaster planning or actual disaster management. This study explores the
knowledge o f emergency nurses and their experience with disaster planning and disaster
management.
CHAPTER 3
Methods
Design
This study employed a descriptive survey to examine the knowledge emergency
nurses have o f disaster procedures and management. In addition the intent was to explore
the relationship o f education, work experience and disaster planning, disaster drill or mass
casualty experience to this knowledge.
Sample
The target population for this study was Registered Nurses who are Emergency
Nursing Association members throughout the United States. A power analysis (Cohen,
1988) was completed to select the number o f subjects needed to detect a correlation o f
0.10 using a two-tailed alpha o f 0.05 with a power o f 0.80. The subjects were randomly
selected from the Emergency Nurses Association's data bank o f members, approximately
21,000 members at the time o f power analysis. One thousand three hundred and five
potential subjects based on a potential return percentage o f sixty percent was randomly
selected via computer. Seven hundred and eighty-three Emergency Nurses Association
members were expected to participate in the study. The sample is representative only o f
those nurses participating in the study.
A response o f 535 emergency nurses (41%), was obtained with 526 (40%)
questionnaires being complete. Two respondents were excluded from the data analysis
because one identified as a student nurse and one identified as an LPN. Others were
excluded because the questionnaires w ere not complete.
Data Collection Procedure
A cover letter, introducing the research study, and the questionnaire was mailed to
each nurse (see Appendix A). In the cover letter, the purpose o f the study was explained
and the nurse was requested to complete the questionnaire and return it promptly.
The letter explained that individual questionnaire results would remain confidential
and known only to this researcher. For subject confidentiality, individual nurses would not
be identified in the discussion o f results or publication o f the data obtained. The mailing
labels were coded for followup purposes only. Individuals consenting to participate
returned the questionnaire by mail, in a sealed business reply envelope provided by the
researcher. Completion o f the questionnaire took approximately 60 minutes.
To increase the response rate a modified version o f the Dillman (1978) Total
Design Method (TDM)was used. The use o f self administered questionnaires offer the
advantages o f anonymity and that a larger and more geographically diverse sample can be
obtained (Polit & Hungler, 1991). Although the questionnaire was a knowledge exam, a
high rate o f return was expected. Emergency Nursing Association members were
expected to have an interest in the subject matter. According to Dillman (1978) a
postcard follow up timed to arrive after the first mailing has had an effect "to jog
memories and rearrange priorities" (p. 183). Within 3 weeks o f mailing the initial
questionnaire, a postcard designed to thank the participants for returning the questionnaire
was sent. It also reminded those who hadn't returned the questionnaire they were an
important part o f the study. Those individuals were requested to complete the
questionnaire as soon as possible and return it.
19
Data Collection Instalment
The data collection instrument utilized in the study was a self administered
questionnaire entitled the Disaster Procedure and Management Knowledge Questionnaire
(DPMK). This questionnaire was developed by the researcher and designed to reflect the
knowledge base needed for emergency nurses in disaster procedures and management.
The questionnaire was divided into 3 parts (see appendix B) with each section addressing
a major concern.
Section I: This section addressed background information including past
disaster drill, disaster planning, care o f disaster victims and
disaster management experience.
Section II: This section involved multiple choice, matching and true-false
questions on disaster procedures (triage, prehospital,
communications, psychological support o f victims and
disaster victim care).
Section III: This section included multiple choice and true-false questions on
disaster management (leadership, disaster planning, C.I.S.D.
and command post).
Demographic information concerning the nurse's years o f nursing and years o f
emergency nursing experience, educational preparation, whether they were certified in
emergency nursing, and any military experience was requested. In addition respondents
were asked their sex, ethnicity, year o f birth, annual income, number o f emergency
department visits per month at their hospital, and marital status.
20
The instrument was developed by the researcher after studying Garcia (1985) and
examining current post disaster research and literature (Bell, 1993; Cowants & Prowant,
1994; Demi & Miles, 1984; Dulchavsky, Geller, & Iorio, 1993; Hodgetts, 1993; Kater,
Braverman, Chuwers, 1992/93; Kumar & Jagetia, 1994; Lippman, 1992; Pointer et al.,
1992; Prilliman et al., 1993; Rivera, 1986; Van Aerongen, Fine, Tunik, Young, & Foltin,
1993; Welte, 1991). Questions were formulated using Reilly's (1980) condensed Blooms'
Taxonomy (1956) utilizing behavioral objectives from the cognitive domain. The
questionnaire was revised by three faculty members and the author to include relevant
questions regarding disaster nursing.
The instrument was piloted using volunteer emergency nurses who had a variety o f
disaster and educational backgrounds, and were from a large metropolitan area. Final
revisions were completed and data were collected in the summer o f 1995.
CHAPTER 4
D ata Analysis and Results
Data Analysis Plan
Both descriptive statistics and inferential testing were utilized in this research
project. To examine research question 1, "What knowledge do emergency nurses have o f
disaster procedures and management as measured by the Disaster Procedure and
Management Knowledge Questionnaire (DPMK)?" frequency distributions and descriptive
statistics were used. Frequency distributions for the total disaster procedure scale and the
total disaster management scale are presented along with the means and standard
deviations for both o f these scales. The percent o f respondents correctly answering each
individual item in these scales is also presented.
To examine research question 2, "Do emergency nurses who report participating in
disaster planning, disaster drills or have participated in a mass casualty incident have a
higher level o f knowledge o f disaster procedures and management than those emergency
nurses who do not?" t-tests and ANOVA were used. Differences between those who
have participated in disaster planning and those who have not, those who have
participated in disaster drills and those who have not, and those who have participated in a
mass casualty incident and those who have not, were examined using t-tests and using the
total disaster procedures and total disaster management scales as dependent variables. A
2x2x2 ANOVA was also used to assess possible interaction effects o f participation in
disaster planning, disaster drills and mass casualty incidents.
22
A one factor ANOVA was used to examine research question 3, "Does
educational preparation contribute to the knowledge emergency nurses have on disaster
management procedures?" Level o f educational preparation was identified as the
independent variable and the total disaster procedures and total disaster management
scales as the dependent variables.
Correlational statistics were used to address research question 4, "What does work
experience contribute to the knowledge o f emergency nurse on disaster management and
procedures?" The number o f years o f work experience was correlated with the scores on
the total disaster procedures and total disaster management scales.
Study findings are presented in this chapter. The sample is described in detail and
the research questions are individually addressed. In addition ancillary analyses are
presented.
Description o f the Sample
Demographic and disaster experience characteristics o f the 526 respondents are
presented in Tables 1-7. The mean o f emergency nursing experience o f the respondents
was 11.01 years and the mean o f nursing experience o f the respondents was 17.02 years.
Twenty-five percent (n = 132) o f the respondents had 5 years or less o f emergency
experience and 29% (n = 153 ) had 6 to 10 years o f emergency experience. The years o f
nursing experience o f respondents, however, was greatest in the twenty one plus category
with 33 %, n = 175 and in the 16 to 20 years category with 24%, n = 126.
23
Table 1
Nursing Years o f Experience and Emergency Years o f Experience
Years 0-5 6-10 11-15 16-20 21+
Emergency 25.2% 29.3% 21.2% 15.1% 9.2%
Nursing 10.7% 13.9% 18.1% 24% 33.3%
Respondents indicated that over 67 percent (67.6) had participated in a disaster
drill in the last 12 months. Over 40 percent (43.6 %) o f respondents reported
participating in care o f disaster victims while 56.4% reported never caring for disaster
victims. However, 53% reported participating in planning disaster drills but only 30.5%
reported they were members o f disaster committees. Thirty tw o percent reported having
experience in disaster management.
Table 2
Years o f Disaster Planning Experience
Years Percent
O
80.5%
I
6-10 11.7%
11-15 5.8%
16-20 1.7%
24
The majority o f respondents were staff nurses (see table 3). Those responding in
the other category included flight nurses (7), administrators (3),consultants (2), trauma
coordinators (4), nurse practitioners (3), EMS directors (4), prehospital care nurses (2),
nursing supervisors (4), case managers (3), nursing directors (3), assistant managers (2)
and unemployed (2). Other respondent s( 19) included other occupations ranging from
EM T instructor, quality management, and disaster coordinator to the administrator o f
home care agency.
Table 3
Current Employment
Category Percent
StafFNurse 47.7 %
Charge Nurse 15.0%
Department Manager 20.5%
Educator/Clinical Specialist 5.7%
Other 11.0%
Females outnumbered the male respondents 90.3 % to 9.7% and 65.7% o f the
respondents reported being Certified in Emergency Nursing. The ethnic grouping o f
respondents is presented in Table 4 and the age o f respondents reported in the
questionnaire as year bom is reported in Table 5. The majority o f respondents were
Caucasian (93%) and in the 31-50 years o f age group.
Table 4
Ethnic Group
Ethnic Group Percent
Asian 2.3%
Black 1.2%
Caucasian 93.3%
Hispanic 1.5%
Native American 1.3%
Other 0.4%
Table 5
Year Bom
Year B om Percent Age Group
1931-1944 12.5% Age 51-64
1945-1965 79.8% Age 31-50
1966-1973 7.3% Age 22-30
Respondents with militaiy service represented 13.7% (n = 80) o f the sample. This
question was then subdivided to current active duty or current reserve duty and previous
active duty or previous reserve duty with respondents indicating the number o f years o f
service in each area. Military experience did not correlate with higher scores on disaster
procedures or disaster management. See Table 6 for military service years o f the
respondents.
Table 6
Military Service Years
Defined Duty Number o f Respondents Years o f Service
Current Active Duty 10 3-18
Current Reserves 18 1-22
Previous Active Duty 37 1-20
Previous Reserves 15 2-14
Respondents were also asked the number o f emergency department visits per month in
their respective departments. Table 7 presents this information.
27
Table 7
Emergency Department Visits Per Month
Visits per M onth Percent
Under 500 4.3%
500-2,000 40 %
2,001-4,000 34.8%
M ore than 4,000 18.1%
Research Questions
Research question 1. "What knowledge do emergency nurses have o f disaster
procedures and management as measured by the Disaster Procedure and Management
Knowledge Questionnaire (DPMK)?"
The frequency distribution for the total disaster procedures scale is presented in
Table 8. Scores could potentially range from 0 to 18. The actual scores ranged from 8 to
18 with most o f the scores being 13,14, or 15. The mean for this scale was 13.72 and the
standard deviation was 1.78.
28
Table 8
Disaster Procedure (DP') Frequency Scale
Total DP Score Frequency Percent
8 3 0.6
9 7 1.3
10 18 3.4
11 34 6.5
12 44 8.4
13 117 22.2
14 116 22.1
15 113 21.5
16 54 10.3
17 17 3.2
18 3 0.6
The frequency distribution for the total disaster management scale is presented in
Table 9. Scores could potentially range from 0 to 28. The actual scores ranged from 11-
28 with the most frequently occurring scores being 23 and 24. The mean for this scale
was 23.01 and the standard deviation was 2.01.
29
Table 9
Disaster Management (DM') Frequency Scale
Total DM Score Frequency Percent
11 1 0.2
15 1 0.2
17 2 0.4
18 6 1.1
19 17 3.2
20 27 5.1
21 57 10.8
22 73 13.9
23 112 21.3
24 114 21.7
25 68 12.9
26 41 7.8
27 5 1.0
28 2 0.4
The individual items for the disaster procedures scale are presented in Table 10
along with the percent o f respondents who answered each question correctly. The most
difficult item was item 16, "Which 3 victims should receive priority transfer to the hospital
when ambulance transport is started?", as only 16.9 % responded correctly to this item.
The easiest item w as item 5, "A disaster victim who is visibly upset because o f a missing
30
loved one should:", as 99.6% (all but two) of the respondents answered this question
correctly.
The individual items for the disaster management scale are presented in Table 11
along with the percent o f respondents who answered each question correctly. The most
difficult item was item 23, the true-false question o f "Disaster drills should always be
conducted as a training exercise.", as only 12.2% responded correctly to this item. The
easiest item was item 14, "The command post is:" as 99.8% (all but one) o f the
respondents answered this question correctly.
Table 10
Disaster Procedure Items
Score 0 = Incorrect Score 1 = Correct
Question No. Question Score Frequency Percent
1 Emergency assessment 0 76 14.4%

includes observation of
the signs and symptoms 1 450 85.6%
of psychological trauma
2 Emergency nurse who 0 20 3.8%

anrives first at an internal
disaster site should: 1 506 96.2%
3 Caring for a patient with 0 8 1.5%

exposure to hazardous
materials the emergency 1 518 98.5%
nurse priorities of care:
4 Emergency nurse should 0 6 1.1%

know locations of
designated disaster 1 520 98.9%
patient areas.
{table contit
31
Table 10 (continued)
5 Disaster victim who is 0 2 0.4%

visibly upset because
of a missing loved one 1 524 99.6%
should:
6 Emergency nurse can’t 0 29 5.5%

call out on the telephone.
1 497 94.5%
7 Prehospital triage 0 133 25.3%

categories are
known as: 1 393 74.7%
8 Modem disaster 0 359 68.3%

communication system
should have: 1 167 31.7%
9 In house communications 0 128 24.3%

are enhanced with: 1 398 75.7%
10 Matching category with 0 189 35.9%

disaster patient description 1 337 64.1%
11 Disaster triage differs from 0 83 15.8%

the usual emergency triage. 1 443 84.2%
12 Disaster victims should 0 227 43.2%

receive hospital emergency
care based on the field 1 299 56.8%
triage tag.
13 Which disaster victim 0 52 9.9%

should have 1st priority
for treatment? 1 474 90.1%
14 Which disaster victim 0 54 10.3%

should be cared for last? 1 472 89.7%
15 Priority emergency 0 209 39.7%

interventions for victim
No. 4 are: 1 317 60.3%
{table continues)
32
Table 10 {continued)
16 Which 3 victims should 0 437 83.1%

receive priority transfer
to the hospital? 1 89 16.9%

interventions for disaster
victim No. 3 include: I 321 61.0%

interventions for
disaster victim 1 491 93.3%
No. 1 include:
Table 11
Disaster Manaaement Items
1 Emergency nurses 0 16 3.0%

should take a
leadership role 1 510 97.0%
in a disaster.
2 A disaster is 0 76 14.4%
defined as: 1 450 85.6%
3 Disaster classification 0 52 9.9%

is usually divided
into categories: 1 474 90.1%
4 Successfully managing 0 8 1.5%

a disaster situation
is dependent on: 1 518 98.5%
(table continues)
33
Table 11 (<continued)
5 When a flood disaster 0 51 9.7%

occurs the disaster
leaders should: 1 475 90.3%
6 A hospital disaster 0 34 6.5%

communication system
should facilitate 1 492 93.5%
communication with:
7 A disaster plan 0 23 4.4%

should provide: 1 503 95.6%
8 Disaster have had 0 130 24.7%

which of the 5
common problems: I 396 75.3%
9 Hospital disaster 0 410 77.9%

training programs
should include: 1 116 22.1%
10 A good disaster 0 206 39.2%

management plan
should contain: 1 320 60.81%
!1 After a disaster 0 199 37.8%

emergency personnel
may need to discuss 1 327 62.2%
concerns and emotions,
the nurse manager should:
12 The best preparation 0 3 0.6%

for the emergency
department to manage 1 523 99.4%
a disaster is to:
13 Disaster leaders 0 19 3.6%

are responsible for: 1 507 96.4%
14 The command 0 1 0.2%

post is: 1 525 99.8%
(table continues]
34
Table 11 {continued)
15 Emergency personnel 0 2 0.4%

involved in the disaster
response who experiences 1 524 99.6%
stress related problems
should:
16 A hospital’s disaster 0 17 3.2%

response is terminated
when: 1 509 96.8%
17 Initiating a hospital’s 0 78 14.8%

disaster response is
the responsibility of: 1 448 85.2%
18 The hospital command 0 369 70.2%

post is responsible lor: 1 157 29.8%
19 Information on disaster 0 26 4.9%

victims is provided
to the media via: 1 500 95.1%
20 All disaster drill must 0 70 13.3%

have moulage victims. 1 456 86.7%
21 The Joint Commission 0 112 21.3%

requires that a disaster
drill be conducted 1 414 78.7%
eveiy 4 months.
22 Disaster drills should 0 119 22.6%

always be a surprise. 1 407 77.4%

always be conducted
as a training exercise. 1 64 12.2%

be paper drills. 1 504 95.8%
{table continues)
35
Table 11 (continued)

don’t need to practice
disaster drills. 1 523 99.4%
26 Disaster supplies should 0 38 7.2%

be secui ed in a locked
area, accessible by 1 488 92.8%
the CEO.

experiencing shaking,
loss of motor function, 1 486 92.4%
should be given
a rest break with a
support person.
28 Disaster supplies should 0 39 7.4%

be checked every 5 years. 1 487 92.6%
Research question 2 . "Do emergency nurses who report participating in disaster
planning, disaster drills or have participated in a mass casualty incident have a higher level
o f knowledge o f disaster procedures and management then those emergency nurses who
do not?"
For the total disaster procedures variable there were no significant differences
between nurses with and without planning (t[523] = 1.67, p= .10), between nurses with
and without disaster drills (t[523] = .55, p=. 59) and between nurses who have participated
in a mass casualty incident and those who haven’t participated in a mass casualty incident
(t[521] = .72, p= 47). For the total disaster management variable there was no significant
difference between nurses who participated in a mass casualty incident and those who
haven't participated in a mass casualty incident (t[441.4] = .62, p=.54).
However, there were significant differences between nurses with and without
disaster planning (t[523] = 2.66, p=.0082) and nurses with and without disaster drills
(t[523] = 2.57, p=.0104) on the total disaster management variable. Nurses who
participated in disaster planning scored higher on total disaster management (M=23.2)
than nurses who did not participate in disaster planning (M=22.8). Also, nurses who
participated in disaster drills scored higher on total disaster management (M=23.2) than
nurses who did not participate in disaster drills (M=22.7).
When examining the effects o f disaster planning, disaster drills and participation in
mass casualty incidents on the total disaster procedures score using 2x2x2 ANOVA, no
significant main effects or interactions were found. However, when assessing the same
three-factor ANOVA using the total disaster management score as the dependent variable
significant main effects for disaster planning (F[l,515]=4.99, p=.0259) and disaster drills
(F[l,515]=6.26, p=.0126) were found and a significant disaster planning by participation
in a mass casualty incident interaction (F[l,515]=4.50, p=.0345) was found. The disaster
planning and disaster drills main effect would be interpreted as the t-tests were interpreted;
nurses who participated in disaster planning scored higher on the total disaster
management score and also nurses who participated in disaster drills scored higher on the
total disaster management score.
The interaction o f disaster planning by participation in a mass casualty incident on
the total disaster management score indicated that the differences on total disaster
37
management between those nurses who participated in disaster planning and those who
did not participate in disaster planning differed for nurses who participated in a mass
casualty incident and those who did not participate in a mass casualty incident. This
interaction effect was probed by doing t-tests between the disaster planning and no
disaster planning groups within each level o f participation in a mass casualty incident.
For nurses who participated in a mass casualty incident, there was a significant
difference between those who participated in disaster planning and those who did not
participate in disaster planning (t[l 66] =2.99, p=.0032). Those who participated in
disaster planning scored significantly higher on total disaster management (M=23.4) than
those who did not participate in disaster planning (M=22.5). For nurses who did not
participate in a mass casualty incident, there was no significant difference between those
who participated in disaster planning and those who did not participate in disaster
planning on the total disaster management variable (t[293]=.64, p=.52).
Research question 3. "Does educational preparation contribute to the knowledge
emergency nurses have on disaster management and procedures?" There were no
significant differences due to educational preparation on either total disaster procedures
(F[2,517]=1.44, p=2388) or total disaster management (F[2,517]=1.49, p=.2252).
Research question 4. "What does work experience contribute to the knowledge o f
emergency nurses on disaster procedures and management?" Work experience was not
related to the total disaster procedures score (r=.08, p=.0600). However, there was a
significant positive correlation between work experience and the total disaster
management score (r=.15, p=.0008) indicating that nurses with more work experience
tended to have high total disaster management scores. Military experience did not
correlate with either disaster procedures or the disaster management scales.
Ancillary Analyses
There were significant differences between nurses with certification in emergency
nursing and those without certification on both total disaster procedures (t[313]=4.32,
p=.0001) and total disaster management (t[523]=3.95, p=.0001). Nurses with
certification in emergency nursing scored higher on both disaster procedures (M= 13.97)
and total disaster management (M=23.26) than nurses without certification (M=13.24 and
M=22.53, respectively).
CHAPTER 5
Conclusions and Recommendations
This study is the beginning o f research needed to understand and strengthen the
knowledge o f emergency nurses o f disaster procedures and management. For 526
Emergency Nurses Association members (40% response rate), the knowledge o f disaster
procedures and management, has been presented. Comparable with the Demi and Miles
(1984) position (nurses with disaster planning experience are able to assume leadership
roles more effectively), nurses with disaster planning and disaster drill experience scored
higher on the disaster management scale. Knowledge gained during disaster planning
experiences was applied by nurses. Nurses with m ore years o f experience scored higher
on the disaster management scale, yet military experience did not correlate with increased
scores.
Nurses with certification in emergency nursing had significantly higher scores on
both disaster procedures and disaster management. The certification exam included
questions on disaster management and certification review manuals address knowledge
needed for disaster procedures and management. Nurses may communicate knowledge
gained by studying for the exam with their colleagues thereby increasing the knowledge o f
the work group.
Knowledge o f disaster procedures and management is needed by all emergency
nurses. It may not be possible for all emergency nurses to be involved in disaster planning,
but the knowledge gained by those who are should be shared with all emergency nursing
colleagues. It is also the responsibility o f each emergency nurse to understand their
disaster plan, how it interacts with the local emergency medical system and how it differs
40
from normal day to day operations. Nurse managers have the responsibility to include all
staff members when planning disaster drills. Disaster drill participation by participants in
this study did score significantly higher on the disaster management scale. The
respondents indicated that over 67% o f them had reported participating in a disaster drill
in the last 12 months. However, that also indicated that over 32% had not participated in
a disaster drill. Several respondents wrote side comments on the questionnaire that drills
were held only on the 7 a.m. to 3 p.m. shift at their hospital. They indicated their concern
if a disaster occurred on the 3 p.m. to 11 p.m. or 11 p.m. to 7 a.m. shift.
Implications for Nursing
Disasters appear to be occurring at an increasing rate throughout the world. This
study is a baseline for defining the knowledge base o f emergency nurses o f disaster nursing
procedures and management. Results may be used for determining the need for further
education for emergency nurses in the area o f disaster procedures and management.
Knowledge o f prehospital disaster terminology and management is needed to understand
the community disaster response and the emergency nurses’ roles.
Priority setting with multiple victims is a difficult task. Only 16.9% responded
correctly to identifying which o f the disaster victims should receive priority for transport
to the hospital (disaster procedure question number 16). Only 74.7% correctly identified
common prehospital triage categorization terminology. Placement o f disaster victims in
the appropriate disaster category was also difficult for the respondents; only 64% correctly
matched the victims with the disaster category (disaster procedure question number 10).
Disaster procedure question number 12 regarding hospital emergency care based on the
41
field triage was also difficult, with 56.8% answering the question correctly. Continuing
education programs or inservices would assist emergency nurses in reviewing and
differentiating disaster triage and priority setting.
Respondents had difficulty with disaster management question number 10 in which
they needed to select what a good disaster management plan should contain. Only 60.8%
answered that question correctly. Several respondents were not familiar with the
terminology o f C.I.S.D. (Critical Incident Stress Debriefing) that was used in disaster
management question number 11. In addition only 62.2% answered the question
correctly. Respondents from rural areas also indicated that those resources are not
available to them. Critical incident stress debriefing is an additional subject area that
continuing education would address. Knowledge o f what the command post is was
common, but identifying the command post responsibilities was not, only 29.8% answered
that question correctly.
Disaster nursing is not included in most basic nursing college curriculums and may
need to be included for the education o f all nurses or further define emergency nurses’
orientation programs. Program development should focus on prehospital disaster
terminology and management, disaster triage and priority setting, components o f a disaster
plan, critical incident stress debriefing, and command post responsibilities. Further
research will be needed to continue to define the practice o f nursing in disasters.
Limitations and Assumptions
The study utilized a data collection instrument developed by the researcher and
utilized after revisions from the small pilot group. Further examination and revision o f the
instrument may be necessary for continued utilization. On the disaster management
section, 11 questions were scored correctly by over 95% o f the respondents compared to
4 questions on the disaster procedures section. These were disaster management
questions number 1,4, 7 ,1 2 , 13,14, 15, 16, 19, 24, and 25 (see Table 11 and Appendix
B). Question number one would be better asked in a non true-false manner. Question
number four may be oversimplified and could be restated addressing the specifics o f
planning, organization and training. Changing question number seven so it would have
only one correct answer instead o f two would improve that question. Question number 15
could be written to address more specifics o f what needs to be done for staff experiencing
stress related problems during the actual disaster event.
The disaster management section had four questions which were answered
correctly by fewer than 75% o f the respondents, whereas on the disaster procedures
section there were seven questions answered correctly by fewer than 75% o f the
respondents. The disaster management questions were questions number 9, 10,11, and
18 (see Table 11 and Appendix B). These questions may indicate areas o f continuing
education needs for emergency nurses. The disaster procedure questions that were
answered correctly by fewer than 75% were questions number 7, 8 ,1 0 ,1 2 ,1 5 , 16, and 17
(see Table 10 and Appendix B). Question number eight regarding components o f a
modem disaster communication could be written in a multiple choice method with
combinations o f the possible components listed. This could be done with question number
ten as well to eliminate unnecessary distractors. Questions number 15 and 17 involve
interventions that may be regional specific versus universals in emergency care. The other
43
disaster procedure questions (numbers 7,1 2 , and 16) have been addressed as continuing
education needs for emergency nurses. These questions may need further review for
instrument clarity and response sampling. A test construction expert would also provide
valuable assistance in that review.
A larger study would also increase the data base for statistical analyses.
Respondents with military service represented'only 13.7% o f the sample. A larger
representation o f active duty military emergency nurses may show different results on the
disaster procedure and management scales. Additional demographic questions that need
to be included are the Trauma Core Course provider/instructor status o f the participants
and if the participants have received disaster nursing education from inservices, seminars,
or undergraduate curriculum.
Recommendations
Further study o f emergency nurses’ knowledge o f disaster procedures and
management is recommended. Disaster planning or participation in disaster drills was not
significantly related to the disaster procedure scores. Other factors may exist that may
influence the disaster procedure score. Instructor o r provider level status in the Trauma
Nursing Core Course (the suggested basic educational need for nurses providing trauma
care) (Emergency Nurses Association Position Statement, 1993) or actual emergency
position staff, flight, educator, charge, manager, or administrator may be statistically
significant on the disaster procedure score.
Additional evaluation o f the disaster procedure section o f the questionnaire is
suggested. The number o f military nurses participating in the study was small (n = 80). A
study exclusive to military nurses’ knowledge o f disaster procedures and management may
yield different results than the largely civilian population o f emergency nurses that were
respondents to this study. Repeating the study with the suggested revisions to the
questionnaire is also recommended. A study examining the knowledge o f paramedics and
emergency medical technicians would also be interesting. Many o f the respondents wrote
side notes on the questionnaire indicating their enthusiasm for participating in a study on
disaster procedures and voiced their concerns for additional information. Disaster
preparedness is an ongoing process o f improvement in knowledge, planning, organization,
drills, and care o f disaster victims. Continued research will enhance this process as the
International Decade o f Natural Disaster Reduction (Holloway, 1990; Waeckerle, 1991)
continues.
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APPENDIX A
Cover Letter
College of N ursing
Arizona State University

Box 872602
Tempe, A Z 85287-2602
602/965-5244 FAX: 602/965-0212
51
Dear Colleague:
Emergency department nurses have a critical role whenever an external or internal disaster
occurs. Are emergency nurses adequately prepared for disaster procedures and
management? Disaster nursing concepts are not typically included in basic nursing
education programs. I am an emergency nurse, studying emergency disaster nursing with
Dr. Pauline Komenich, Associate Professor o f Nursing, Arizona State University.
You have been selected to participate in a study that will assist us in understanding the
existing knowledge base o f emergency nurses regarding disaster procedures and
management. This study is supported by a grant from the Emergency Nurses Association
that we feel honored and grateful for. We need you to complete the enclosed
questionnaire and return it in the enclosed, stamped envelope within one week. To assure
confidentiality, participants will not be identified by name nor will individual results be
published.
Thank you for your voluntary participation in this research study. W e appreciate your time
and efforts to contribute to the emergency nursing knowledge base. If you have any
questions regarding this research study please write or contact Starre Haney (602) 641-
1723 or Dr. Pauline Komenich, Arizona State University (602) 965-3928.
Sincerely,
Starre Haney RN, BSN
Pauline Komnenich PHD, RN
APPENDIX B
Disaster Procedure and Management Questionnaire
53
Disaster Procedure and Management Questionnaire
Emergency Nursing Colleague: Thank you for participating in this research study. Your
participation will assist in defining the knowledge base o f emergency nurses regarding
disaster procedures and management. Please answer all questions to the best o f your
ability. Your answers will remain confidential. The questionnaire should be returned in the
enclosed, stamped envelope within one week. Do it today!
Section I: General Background
1. How many years have you worked in emergency nursing?
2. How many years have you worked in nursing?
3. During the last 12 months have you participated in a disaster drill?
Yes No___
4. In the last 5 years have you participated in care o f disaster victims that have
arrived at the emergency department from a mass casualty incident?
Yes No___
5. Have you participated in planning disaster drills in the last 5 years ?
Yes No___
6. Are you a current or past member o f your hospitals disaster planning committee?
Yes No___
7. How many years o f disaster planning do you have?
8. Do you have experience in disaster management?
Yes No___
9. Are you currently certified in emergency nursing?
Yes No___
10. I am currently employed as:

□ a. staff nurse
□ b. shift charge nurse
□ c. department charge nurse/manger
□ d. educator/clinical specialist
□ e. other, if so please specify____________
11. My current level o f educational preparation is:

□ a. A.D.
□ b. B.A. or B.S.N.
□ c. M.A., M .S., or M.S.N.
□ d. PHD or DSN
12. I am:
□ a. female
□ b. male
13. My ethnic background is:

□ a. Asian
□ b. Black
□ c. Caucasian
□ d. Hispanic
□ e. Native American
□ f. Other, please specify
14. I was bom in the year 19
15. I am currently:
□ a. Never married
□ b. Married
□ c. Separated
□ d. Widowed
□ e. Divorced
55
16. Have you or are you now associated with the military?
□ a. No
□ b. Yes
If yes,
□ c. Current active duty - how many years______
□ d. Current reserves - how many years_______
□ e. Previous active duty - how many y ears______
□ f. Previous reserves- how many y ears________
17. My approximate income from 18. Number o f ED visits per month

employment is: at my hospital:
□ a. Less than $ 5,000 □ a. Under 500
□ b. $5,000-315,000 □ b. 500-2,000
□ c. $15,001-525,000 □ c. 2,001-4,000
□ d. $25,001-$35,000 □ d. M ore than 4,000
□ e. $35,001-$45,000 □ e. N ot applicable
□ f. $ 45,001-$55,000
□ g. $55,0001-$65,000
□ h. $65,001-575,000
□ I. M ore than $ 75,000
Section II: Disaster Procedures
Please check the one box that you feel most correctly answers the question.
1. When caring for disaster victims, the emergency nursing assessment includes
observation o f the signs and symptoms o f psychological trauma.
□ a. true
□ b. false, psychological trauma always develops 3-5 days post
disaster event.
□ c. false, the emergency nursing assessment focus is on the physical needs o f
the disaster victim.
□ d. false, social service will assess for psychological trauma.
The emergency nurse who arrives first at an internal disaster site should
immediately:
□ a. photograph the scene for later analysis.
□ b. announce that he/she will care for the victims and everyone else should
clear out.
□ c. evacuate anyone in the area and determine the safety needs o f the site.
□ d. fax the National Disaster Management Services
56
3. In caring for a patient that has received exposure to hazardous materials the
emergency nurse knows that the priorities o f care are:
□ a. to prevent contamination o f all staff and to notify the patient's family
stat.
□ b. to provide injury treatment immediately and notify the state department
o f environmental quality.
□ c. to notify the patient's family.
□ d. to prevent further contamination and provide treatment immediately.
4. The emergency nurse should know the locations o f the designated disaster patient
reception areas in the hospital:
□ a. true
□ b. false, the transport personnel are the only staff that need this
information.
□ c. false, the emergency nurse only needs to know about the patients in the
emergency department.
□ d. false, administration will determine who needs this information.
5. A disaster victim who is visibly upset because o f a missing loved one should:
□ a. be reassured that all will be ok in the end.
□ b. be informed that all missing persons should be presumed dead until
known otherwise.
□ c. be told to tough it out because everyone is upset right now.
□ d. be reassured that everything possible is being done to locate and identify
everyone involved in the disaster.
6. When the emergency nurse notices that after repeated efforts she/he can't call out
on the telephone she should:
□ a. try a pay phone.
□ b. ask the unit secretary to make the call.
□ c. send word to the command post that the phone system is not working.
□ d. send a fax to the telephone company for notification.
7. Prehospital triage categories are frequently known as:

□ a. I, II, III, IV, V.
□ b. red, yellow, green, black
□ c. A, B, C, D
□ d. Gold, Silver, Bronze, and Platinum
57
8. A m odem disaster communication system should have the following components

(check the three correct answers):
□ a. telephone
□ b. cell phones
□ c. portable radios
□ d. fax machine
□ e. EMS system communications
□ f. satellite dish
□ g. television studio
□ h. carrier pigeons
9. In house communications during a disaster are enhanced with (check the four
correct answers):
□ a. a helpful unit secretary
□ b. an efficiently functioning command post
□ c. an open media line
□ d. a media person with camera in house
□ e. disaster victim tracking methods
□ f. a command post in the heart o f the emergency department
□ g. a well rehearsed disaster plan
□ h. back up communication method
10. Match the patient with the appropriate hospital disaster patient area by writing the
correct category number to the left o f the patient description:
Categories:
1. Emergent
2. Urgent
3. N onU rgent
4. Expectant
5. DOA
_______ a. a 15 year old female with a possible closed fracture o f the

forearm.
_______ b. a 55 year old male with right chest pain and obvious deformity to
the chest wall who is complaining o f shortness o f breath.
_______ c. a 45 year old male with an open fracture o f the low er leg,
multiple lacerations, and BP 130/70, P 92, R 16.
_______ d. a 10 year old female with penetrating abdominal injuries who is
pulse less and breathless.
11. Disaster triage differs from the usual emergency triage procedures.
□ a. true
□ b. false
58
12. Disaster victims who are triaged at the site by EMS personnel should receive
hospital emergency care based on the field triage tag.
□ a. true
□ b. false
The next 5 questions pertain to this scenario.
There has been a building collapse and explosion at a high rise office building. Employees,
persons passing by in cars and people walking on the sidewalk have ben injured. The total
number o f victims is unknown but estimated in the hundreds. You arrive at the scene to
assist with prehospital triage and on arrival find the following victims:
No. 1 27 year old female who is having a great difficulty breathing and is
cyanotic and diaphoretic. Vital signs are: BP 70/40, P 140,
R 40 and labored. There is bruising and tenderness on the
right side o f the chest.
No. 2 54 year old male who has no pulse or respirations. Pupils are fixed
and dilated. There are no physical signs o f trauma.
Bystanders started CPR.
No. 3 24 year old female who is 33 weeks pregnant, gravida 3, para 2,
who is having strong contractions every 5 minutes. She is
crying. Lacerations are noted on her right cheek and
forearm. Bleeding is easily controlled with mild pressure.
No. 4 32 year old male with multiple lacerations to his head, face, and leg.
Bleeding is slowed with pressure. He is oriented to person,
but not place or date and mumbles incoherently. Vital signs
are: BP 96/60 P 118, R 24.
No. 5 44 year old female with a right parietal head laceration and is
unresponsive to verbal or painful stimuli. Vital signs are: BP
100/46, P 48, R 10.
13. Which disaster victim should have the 1st priority for treatment ?
No._____________
14. Which disaster victim should be cared for last?
No.
59
15. The priority emergency interventions for victim No. 4 are:

□ a. airway maintenance, 0 2 per nonrebreather mask at 15 L,
dressings for lacerations, Normal Saline IV at a rapid rate,
early transport to the hospital.
□ b. airway maintenance, 0 2 at 2 L per nasal cannula, dressings for
lacerations, delayed transport to the hospital.
□ c. airway maintenance, 0 2 at 2 L per nasal cannula, Normal Saline
IV at a rapid rate, early transport to the hospital.
□ d. airway maintenance, 0 2 per nonrebreather mask at 15 L,
dressings for lacerations, Normal Saline IV at a keep open
rate, delayed transport to the hospital.
16. Which 3 victims should receive priority for transfer to the hospital when
ambulance transport is started ?
No._____________ N o._____________ N o.___________
17. Priority emergency interventions for disaster victim No. 3 include:

□ a. 0 2 per simple mask at 4 L, IV 5% Dextrose in Water,
semifowlers position, dressings to lacerations.
□ b. 0 2 per nasal cannula at 4L, IV Normal Saline at 150 cc per hour,
left lateral recumbent position, dressings to lacerations.
□ c. 0 2 per simple mask at 6 L, IV Normal Saline at keep open rate,
supine position, dressings to lacerations.
□ d. 0 2 per nasal cannula at 4 L, IV 5% Dextrose in Water, left
lateral recumbent position, dressings to lacerations.
18. Priority emergency interventions for disaster victim No. 1 include:

□ a. 0 2 per simple mask, IV normal saline wide open, chest tape,
rapid transport
□ b. 0 2 per nasal cannula at 6 L, IV normal saline at 50 cc/hr,
pericardial tap, rapid transport
□ c. 0 2 per cannula at 6 L, IV normal saline wide open, rapid
transport
□ d. 0 2 per nonrebreather mask at 15 L ,IV normal saline wide open,
rapid transport
60
Section III: Disaster Management
1. Emergency nurses should be expected to take a leadership role in a disaster

situation.
□ a. False, physicians assume the only leadership role.
□ b. False, the emergency nurse will be to busy in the emergency
department.
□ c. False, the emergency nurse has no disaster role.
□ d. True
2. A disaster is defined as an event:

□ a. in which a large amount o f violence occurs.
□ b. in which the community and its' medical facilities are overwhelmed.
□ c. when a "disaster" is proclaimed by the state authorities.
□ d. when the National Disaster Management Service is activated.
3. Disaster classification is usually divided into the following categories:

□ a. acts o f God versus plaques
□ b. regional versus man-made
□ c. man-made versus natural
□ d. rural versus city
4. Successfully managing a disaster situation is dependent on:

□ a. planning, organizational skills and training.
□ b. money, radio communications and storage o f supplies.
□ c. the National Guard, U.S. Armed Forces and the Red Cross.
□ d. none o f the above.
5. W hen a flood disaster occurs the disaster leaders should:

□ a. provide typhoid and diphtheria tetanus immunizations for all children.
□ b. call for volunteers to build rafts from all available inner tubes.
□ c. instruct everyone to buy bottled w ater or boil their water.
□ d. provide swimming and lifesaving lessons.
6. A hospital disaster communication system should facilitate communication with:

□ a. disaster shelters and personnel from the Red Cross.
□ b. the Emergency Management Agency.
□ c. the Press.
□ d. all o f the above.
61
7. A disaster plan should provide:

□ a. a plan to obtain supplies or services from outside the hospital.
□ b. a method o f identification o f disaster patient areas.
□ c. whatever the safety director wishes since there are no general
requirements.
□ d. a and b
8. Disasters have had which o f the following common problems:

(Check the five correct answers)
□ a. insufficient blood product availability.
□ b. to many volunteers.
□ c. traffic congestion.
□ d. small hospitals overwhelmed by victims.
□ e. increased illness post disaster.
□ f. to many healthcare workers and not enough victims.
□ g. long term emotional effects on victims and workers.
Hospital disaster training programs should focus on:

(Check the three correct answers)
□ a. Community lawyers and business leaders
□ b. all support staff and administrators
□ c. nurses and physicians
□ d. all students in teaching hospitals
□ e. all neighborhood school children
□ f. making sure everyone knows CPR
□ g. police
10. A good disaster management plan should contain:

(Check the three correct answers)
□ a. a telephone
□ b. approved triage guidelines including victim placement
□ c. method o f communication in case o f telephone failure
□ d. a method o f tracking all disaster victims
□ e. a detailed plan o f action including phone numbers o f personnel to be
notified, which is kept securely in the nursing administration offices
□ f. a list o f all fast food restaurants
□ g. a current first aid book
62
11. After any disaster the emergency personnel may have a need to discuss and
ventilate their concerns and emotions. The nurse manager should:
□ a. notify the hospital chaplain to schedule a meeting with the staff on an
individual basis.
□ b. schedule a staff meeting with discussion o f the disaster as the only
agenda item.
□ c. notify the CISD team.
□ d. request an emergency physician to prescribe tranquilizers for all disaster
personnel.
12. The best preparation for the emergency department to manage a disaster is to
have:
□ a. a disaster plan that is clear, concise and practiced
□ b. a medical director who has been in disasters
□ c. a nurse with Red Cross experience
□ d. a communication plan with direct connections to the press
13. Disaster nursing leaders are responsible:

□ a. for communicating with family members o f the deceased.
□ b. for communicating with the media both at the disaster site and at the
hospital.
□ c. for education and disaster drills at hospitals only.
□ d. for education, planning, organization and managemento f disasters.
14. The command post is:

□ a. a section o f a military base.
□ b. the location o f disaster supplies.
□ c. where a hospital's disaster response is coordinated.
□ d. where CEO's may park in a disaster incident.
15. Any emergency personnel involved in the disaster response who experiences stress
related problems should:
□ a. be admitted to the nearest mental hospital.
□ b. be given coffee and doughnuts.
□ c. told to toughen up because we all have to pull together until the job is
done.
□ d. receive counseling through trained stress teams.
63
16. A hospital's disaster response is terminated when:

□ a. the prehospital personnel clear the scene.
□ b. the emergency charge nurse determines the hospital has received enough
victims.
□ c. the hospital command post announces the "all clear".
□ d. the media report there are no additional victims at the scene.
17. Initiating a hospital's disaster response is the responsibility of:

□ a. the CEO.
□ b. the emergency physician.
□ c. the emergency charge nurse.
□ d. whomever the disaster plan designates.
18. The hospital command post is responsible for:

□ a. triage o f disaster victims and coordination o f personnel.
□ b. triage o f disaster victims and coordination o f supply delivery.
□ c. disaster operations internally and externally.
□ d. coordination o f needed community resources and final decisions o f
disaster operations.
19. Information on disaster victims is provided to the media representatives via:

□ a. the command post.
□ b. the triage nurse.
□ c. the chaplaincy department.
□ d. the emergency department.
The following are true-false questions. Check the correct answer.
20. All disaster drills must have moulage victims.

□ True □ False
21. The Joint Commission on Accreditation o f Healthcare Organizations requires that

a disaster drill be conducted every 4 months.
□ True □ False
22. Disaster drills should always be surprise.

□ True □ False
23. Disaster drills should always be conducted as a training exercise.

□ True □ False
24. Disaster drills should be paper drills.

□ True □ False
25. Emergency nurses don't need to practice disaster drills.
□ True □ False
26. Disaster supplies should be secured in a locked area, accessible by the CEO.
□ True □ False
27. Emergency nurses experiencing shaking, loss o f m otor function, confusion, or

blurry vision should be given an immediate rest break with a support
person.
□ True □ False
28. Disaster supplies should be checked every 5 years.

□ True □ False
Thank you for completing this questionnaire and contributing to the knowledge o f
emergency nursing practice. Please mail the questionnaire in the enclosed, stamped
envelope as soon as possible.
65
Biographical Sketch
The author, Starre Haney, was bom Starre Ann Christensen and spent her
childhood in the Midwest. She received her Diploma in Nursing from Methodist School
o f Nursing, Omaha, Nebraska in June o f 1975. Starre received undergraduate college
credits from the University o f Nebraska at Omaha, Omaha, Nebraska, Johnson County
Community College, Overland Park Kansas and graduated cum laude from Briar Cliff
College, Sioux City, Iowa with a Bachelor’s o f Science in Nursing in 1986.
Starre has been a member o f the Emergency Nurses Association since 1975
serving as chapter and state council president in both Iowa and Arizona. Starre is also a
member o f Sigma Theta Tau International Honor Society o f Nursing. She has been
interested in disaster nursing throughout her career as an emergency nurse and educator
and has participated in caring for disaster victims from several different disaster events.

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INFORMATION TO USERS

The quality o f this reproduction is dependent upon the quality o f the

Oversize materials (e.g., maps, drawings, charts) are reproduced by

Photographs included in the original manuscript have been reproduced

A Thesis Presented in Partial Fulfillment

ARIZONA STATE UNIVERSITY

All rights reserved.

UMI Microform 1378801

This microform edition is protected against unauthorized

has been approved

Associate Dam Graduate Program

Dean, Graduate College

organizational skills and leadership abilities to fulfill their responsibilities. To assess

knowledge a questionnaire was distributed to a sample o f thirteen hundred Emergency

o f emergency nurses o f disaster procedures and management. In addition, the relationship

between emergency nurses’ participating in disaster planning, disaster drills or mass

twenty six nurses responded.

The Disaster Knowledge and Management Questionnaire was developed by the

management. Three faculty members o f the College o f Nursing, Arizona State

to further define the knowledge needs o f emergency nursing. Certification in emergency

nursing as an additional component enhancing the disaster knowledge o f emergency

nurses is an area for further research.

To my parents, Mervin and Sondra Christensen for their encouragement and

nursing colleagues, who encouraged and supported my interests in disaster nursing.

A special acknowledgment and thank you is extended to the Emergency Nurses

LIST OF TABLES ................................................................................................................. ix

Purpose o f the Study ........................................................................ 2

Statement o f the Problem ................................................................. 3

Research Questions .......................................................................... 3

Definition o f Terms .......................................................................... 4

2 Review o f Literature ...................................................................................... 5

Disaster Procedure Knowledge ..................................................... 8

Disaster Management Knowledge .............................................. 12

Role o f the Emergency N u r s e ....................................................... 15

D ata Collection Procedure ............................................................ 18

D ata Collection Instrument .......................................................... 19

4 Data Analysis and Results ........................................................................... 21

D ata Analysis Plan .......................................................................... 21

Description o f the Sample ............................................................ 22

Research Questions ....................................................................... 27

Ancillary Analyses ......................................................................... 38

5 Conclusions and Recommendations .......................................................... 39

Implications for N u r s in g ................................................................ 40

Limitations and Assumptions ....................................................... 41

A Cover L e tte r................................................................................................... 51

B Data Collection Instrum ent.......................................................................... 53

1 Nursing Years o f Experience and

2 Years o f Disaster Planning Experience ................................................................. 23

4 Ethnic Group ............................................................................................................. 25

6 Military Service Y e a r s ............................................................................................... 26

7 Emergency Department Patient Visits per M onth ............................................... 27

8 Disaster Procedure Frequency Scale ...................................................................... 28

9 Disaster Management Frequency Scale ................................................................. 29

10 Disaster Procedure Items ........................................................................................ 30

11 Disaster Management Items .................................................................................... 32

Emergency nurses have a critical role whenever an external or internal disaster

fulfill their responsibilities. These responsibilities include disaster preparedness, nursing

Disasters immediately affect nurses in emergency departments and prehospital settings

The Joint Commission on Accreditation o f Healthcare Organizations requires

shifts must be knowledgeable about disaster procedures and management.

Disaster nursing procedures and management knowledge are not typically

have on disaster procedures and management.

Purpose o f the Study