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ORIGINAL ARTICLE
Abstract
Aim: As healthcare professionals, nursing educators need to be prepared to manage and deliver care in what
are often dangerous conditions. This research aims to determine and compare nursing educators’ perceptions
of disaster preparedness and response (DP&R) in Istanbul and Miyazaki.
Methods: An 18 question descriptive questionnaire was used.
Results: One hundred and forty-four nursing educators representing two state university nursing schools in
Istanbul, Turkey, and one state and two private universities in Miyazaki, Japan were enrolled. Educators had
an average age of 40 years and had been educators for 1–15 years. Just over half of the participants had basic
knowledge regarding DP&R with most of them considering taking special courses in the future. The
majority considered “caregiver” as a role they could undertake in a disaster situation. The existence of major
concerns and conflicts in disaster responses were low. The top ranked item was in the area of conflict
between family and job responsibilities. Age and academic levels showed significant differences in basic
knowledge on DP&R. Regardless of knowledge in this subject area, no statistical significance on personal
preparedness or being a volunteer to disaster events was found.
Conclusion: Nursing educators were not thinking about what kinds of disasters occur in the areas where
they currently teach and were underprepared to deal with disaster situations. To improve the perceptions of
the nursing educators on DP&R, mass casualty care and disaster management skills need to be incorporated
into formal education and training on disaster preparedness and workplace preparedness.
Key words: disasters, emergency preparedness, nursing faculty, perception, response.
purpose of this preliminary joint research is to clarify students to use appropriate assessment, clinical judg-
current perceptions of nursing educators’ knowledge ment, and decision-making skills during disasters, MCI,
about disaster preparedness and their willingness to and other emergency situations (Culley, 2010). Perhaps
respond to possible disasters. the greatest reason why nursing educators find it diffi-
cult to provide learning experiences for their students is
Disaster situation internationally their own lack of information in this area.
Natural disasters and its victims are increasing world- Nursing educators are accountable for their students,
wide. With many of those affected living in Asia, coun- communities, and society at large to prepare graduates
tries like Japan and Turkey need to increase their who can work in an environment where the potential for
exchange of information about disaster education and disasters is no longer a probable event (Whitty &
research (Ohara et al., 2012). Burnett, 2009). However, many nurses lack the confi-
dence in preparedness to respond to emergency manage-
Disaster education internationally ment situations (Mosca, Sweeney, Hazy, & Brenner,
In most countries, disaster-nursing education is rarely 2005; WHO & ICN, 2009).
provided at basic nursing education levels (Yamamoto, Review of previous disaster response efforts reveals
2008). The World Health Organization (WHO) and that patients are frequently transferred without
International Council for Nurses (ICN) (2009) indicated adequate triage and patient distribution to existing
that the lack of knowledge in disaster response and healthcare facilities is often grossly unequal and not
management creates confusion among the responders coordinated (Auf der Heide, 2002; Auf der Heide, 2006;
and delays effective humanitarian responses. Nursing Romig, 2013; Veenema & Woolsey, 2013). Thus, all
students are not the only ones lacking in the mastery of nurses should have sufficient knowledge and skills to
emergency preparedness content. Nursing faculties were recognize trauma, injury, or illnesses that are disaster-
found to be inadequately prepared in the field of disaster related, intervene appropriately, and conduct basic
preparedness as well (Chapman & Arbon, 2008; assessment and triage in emergency situations (Rains,
Weiner, Irwin, Trangenstein, & Gordon, 2005; WHO & 2013; Romig, 2013).
ICN, 2009). Most faculty members felt they were poorly Nurses, in particular, are ideally positioned to assume
or not at all prepared to teach disaster preparedness “new” roles related to disaster response with nursing
content (Weiner, Irwin, Trangenstein, & Gordon, 2005). curricula as a key area where the teaching of these new
Similar findings have been presented by researchers in skills should operate. Disaster-related roles of nurses
Japan in relation to faculty learning needs (Weiner, may involve responding to emergencies, detecting
2006; Weiner et al., 2005; Yamamoto, 2004). threats, providing direct patient care, managing health-
Nurses are expected to demonstrate basic competency care teams and facilities, reducing or eliminating injuries
in responding to emergencies that also include emer- and deaths, developing health policies, conducting
gency preparedness and disaster response (Culley, research, and working in collaboration with other orga-
2010). In particular, nursing educators need to develop nizations including the military (Perron, Rudge, Blais, &
strategies to prepare their students for disasters (Ranse, Holmes, 2010).
et al., 2013; Schmidt et al., 2011). In addition, given the Ohara et al. (2012) conducted research in 205 univer-
current overall nursing shortage and to meet the increase sities from 11 countries in Asia to study how disaster
nursing workforce demand for disaster response, it will nursing is introduced at nursing schools. Results from
likely be necessary to identify and educate a supplemen- the survey show many respondents wishing to share
tal workforce, like nursing students and other healthcare lessons learned from Japan. With similar types of disas-
professionals, who can be cross-trained to provide ters in Turkey and Japan, nursing educators in Istanbul
nursing care during surge emergencies (National and Miyazaki should be aware of the high possibility of
Advisory Council on Nurse Education and Practice unforeseeable disasters and be ready to take part in
(NACNEP), 2009). disaster management situations.
All nurses should possess minimum knowledge about
disasters and emergency preparedness, and have funda-
mental skills that are refined enough to incorporate that Disaster situation in Japan and Turkey
knowledge into everyday practice when the need pres- While Japan is known for its earthquakes, it also has
ents itself (Rains, 2013). Nursing faculties find it chal- frequent flooding like Turkey (Center for Research on
lenging to provide learning experiences that enable the Epidemiology of Disasters [CRED], 2009; Nozawa,
research team, and minor amendments were made to the Nursing University’s Ethics Board in Miyazaki
questionnaire in response to comments from the pilot approved the study. Ethical and humans rights were
study. approved. Permission to use the questionnaire was
granted from the directors of the affiliated nursing
Data collection schools. The researchers asked written permission from
Questionnaires were hand delivered to the deans of all participants. They were then informed that the
the participating universities’ nursing schools. Deans researchers would store all information on the ques-
planned to distribute the questionnaires to 171 tionnaire confidentially and that it would only be used
nursing educators by using staff notice boards. One for scientific purposes. Members were then assured
hundred and forty-four questionnaires were completed that their participation was voluntary and that they
anonymously. could withdraw from the study at any time with no
Data from nursing educators were collected through a risk of penalties. Return of the completed question-
questionnaire between May and July 2012 in Istanbul naire was considered as implied consent. The research
and Miyazaki. Paper-based questionnaires are readily was conducted in accordance with the approved pro-
distributed, easy to complete, and obviate researcher tocol and there were no withdrawals or complaints
bias (Jirojwong, Johnson, & Welch, 2011). The ques- received.
tionnaire used in this research was designed to be brief,
taking less than 10 min to complete. The paper-based
questionnaire was completed by participants and RESULTS
returned to a secure locked box within the participant’s
workplace. The questionnaires in both cities were col- Nursing educators’ demographics
lected roughly a week later by the researchers due to Most participants were women (96.5%), aged 25–40
the different workloads of the participating nursing years (56.9%). They had an average age of
educators. 40.01 ± 10.04 years and had been working for up to
15 years. In Istanbul, most of the participants (n = 60;
Data analysis 61.9%) were research assistants, had Ph.D. qualifica-
The characteristics of the participants, roles of nurses, tions, and were working in either medical–surgical
conflicts, and concerns in cases of disaster events, char- nursing or obstetric and gynecologic nursing (20.6%);
acteristics of disasters, likelihood of natural or man- in Miyazaki, however, most participants were working
made disaster types occurring in the region of current in “fundamentals of nursing” (53.2%). Of the nursing
residence, and most serious impact of possible disasters educators in Miyazaki, 57.4% were lecturers and 30
for nursing educators and/or families were determined (63.8%) had licenses and bachelor degrees and had no
using descriptive statistics, including frequency of cat- basic knowledge about DP&R (63.8%), while 60.8%
egorical values, numerical values, and mean and stan- of participants in Istanbul showed knowledge in
dard deviation. Associations between the basic DP&R. In general, most nursing educators considered
knowledge status about DP&R with characteristics of taking special courses on DP&R in the future
participants (age, years worked as nurse, and academic (Miyazaki, 83%; Istanbul, 69.1%; total, 73.6%)
level), attending a special course about DP&R, knowl- (Table 1).
edge about personnel preparedness for a disaster event,
and being a volunteer in disaster response were assessed
using χ2-tests (Pearson’s, continuity correction, Fisher’s Roles of nurses, conflicts, and concerns in
exact test). Data obtained in the study were evaluated cases of disaster events
using IBM SPSS software for Windows 10.0 (SPSS, The majority of respondents (78.5%) perceived the
Chicago, IL, USA) and MS Excel 2003 (Microsoft, “caregiver” role as one of nursing they could undertake.
Redmond, WA, USA) and were evaluated at a 95% The possibility of the existence of major concerns
confidence interval. P < 0.05 was considered statistically about conflicts between family commitments and
significant. nursing school obligations only averaged 44.4%, but
showed significantly higher levels in Miyazaki (72.3%;
Ethical perspective Istanbul, 30.9%). The top ranked concern in this area
Istanbul University Cerrahpasa School of Medicine’s was the existence of a conflict between family and job
Ethics Board in Istanbul and Miyazaki Prefectural responsibilities (33.6%) in both cities (Table 2).
Comparison of nursing educators’ knowledge (P < 0.05, Table 3). Research assistants
considerations and characteristics with basic and young nursing educators showed higher levels of
knowledge about disaster preparedness basic DP&R knowledge. Nursing educators from
and response Miyazaki who attended special courses on DP&R
outside of university (52.9%) had more knowledge on
In general, age and academic levels were shown to DP&R rather than the others who did not attend these
be statistically significant concerning basic DP&R courses (47.1%) (P < 0.05, Table 3). Having basic
Table 3 Comparison of nursing educators’ considerations and characteristics with basic knowledge about disaster preparedness
and response
Basic knowledge about disaster preparedness and response
Istanbul Miyazaki Total
Yes No Yes No Yes No
Characteristics, basic knowledge, and considerations N % N % N % N % N % N %
Characteristics
Age (years) 25–40 43 72.9 22 57.9 7 41.2 10 33.3 50 65.8 32 47.1
≥41 16 27.1 16 42.1 10 58.8 20 66.7 26 34.2 36 52
χ2, P, d.f. 1.719,† 0.190, 1 0.049,† 0.824, 1 5.136,‡ 0.023, 1
Years worked as nurse 1–10 years 23 39.0 8 21.1 11 64.7 17 56.7 34 44.7 25 36.8
educator >10 years 36 61.0 30 78.9 6 35.3 13 43.3 42 55.3 43 63.2
χ2, P, d.f. 2.642,† 0.104, 1 0.053,† 0.818, 1 0.642,† 0.423, 1
Academic level Research assistant 40 67.8 20 52.6 4 23.5 7 23.3 44 57.9 27 39.7
Assistant professor 12 20.3 7 18.4 1 5.9 − − 13 17.1 7 10.3
Associate professor 2 3.4 7 18.4 1 5.9 1 3.3 3 3.9 8 11.8
Professor 2 3.4 3 7.9 4 23.5 2 6.7 6 7.9 5 7.4
Lecturer 3 5.1 1 2.6 7 41.2 20 66.7 10 13.2 21 30.9
χ2, P, d.f. 7.778,‡ 0.100, 4 5.575,‡ 0.233, 4 11.729,† 0.019, 4
Attended special courses at/outside of university about disaster preparedness and response
At the university Attended 14 23.7 12 31.6 8 47.1 8 26.7 22 28.9 20 29.4
Not attended 45 76.3 26 68.4 9 52.9 22 73.3 54 71.1 48 70.6
χ2, P, d.f. 0.381,† 0.537, 1 1.204,† 0.273, 1 0.000,† 1.000, 1
Outside the university Attended 6 10.2 6 15.8 9 52.9 3 10.0 15 19.7 9 13.2
Not attended 53 89.8 32 84.2 8 47.1 27 90.0 61 80.3 59 86.8
χ2, P, d.f. 0.255,† 0.614, 1 8.386,† 0.004, 1 0.674,† 0.412, 1
Having basic knowledge about personal preparedness for a possible disaster event
Knowledge Having 30 50.8 23 60.5 14 82.4 21 70.0 44 57.9 44 64.7
Not having 29 49.2 15 39.5 3 17.6 9 30.0 32 42.1 24 35.3
χ2, P, d.f. 0.527,† 0.468, 1 0.342,† 0.558, 1 0.443,† 0.506, 1
Considerations about being a volunteer fellow in community disaster response efforts in a possible disaster event
Being a volunteer Considering 55 93.2 34 89.5 17 100 28 93.3 72 94.7 62 91.2
Not considering 4 6.8 4 10.5 0 0.0 2 6.7 4 5.3 6 8.8
P 0.384§ 0.402§ 0.304§
†
Continuity correction. ‡Pearson χ2-test. §Fisher’s exact test. d.f.: degrees of freedom.
undergraduate and postgraduate nursing curriculum agement should come natural to nurses as they are in
content on DP&R in the future. good positions to be able to detect changes in normal
Every nurse should be considered as a disaster nurse health (Chapman & Arbon, 2008; Gebbie & Qureshi,
because the skills required in disasters are similar to 2002). However, as this research and supporting pub-
those required on regular shifts, although the settings lished work suggests, this may not be entirely true. One
are different and the resources are stretched or absent can only speculate that normal nursing managerial skills
(Gebbie, 2010). All nurses should be trained to give can be dealt with by nurses, but these same nurses feel
support to peers and team members who may be reluctant to deal with disaster management.
responding with them in MCI (Speraw & Persell, 2013).
Acute care skills are also needed to provide care specific
to the acuity level of disaster victims (Jakeway, LaRosa, Roles of nurse, conflicts, and concerns
Cary, & Schoenfisch; Association of State and In this study, the “caregiver” role one that participants
Territorial Directors of Nursing, 2008; Morrison & could undertake (Table 2). This finding was seen as
Catanzaro, 2010). Taking an active role in disaster man- normal since the majority of nursing educators were
Figure 2 Likelihood of natural or man-made disaster types occurring in the region of current residence.
working in the division fundamentals of nursing ing disaster-nursing content into nursing curricula is
(Table 1). A study by Caudill (2011) shows nursing edu- crucial in nursing education (Jennings-Sanders, 2004).
cators seem to be trusted by community members, are Therefore, research needs to aim at the content of
viewed as caregivers, and spend much of their working DP&R education and training, which also may have a
hours with patients in many different settings. If nursing positive effect on nurses’ attitudes and skills in disaster
educators were feeling competent about their roles of response (Arbon et al., 2006; Chapman & Arbon, 2008;
nursing they can perform during disasters (Ireland, Ea, Gebbie et al., 2012; Gebbie & Qureshi, 2002; Wetter,
Kontzamanis, & Michael, 2006), and if basic DP&R Daniell, & Tesser, 2001).
content was included in the nursing curriculum before Nursing educators from Miyazaki felt a deeper sense
2001 (Littleton-Kearney & Slepski, 2008), more nursing of conflict between family commitments and nursing
educators in this study may have also cited being able to school obligations than their counterparts from Istan-
carry out the roles of nursing in management and triage bul (Table 2). Similar findings by Yamamoto (2008) in
(Caudill, 2011; Gebbie et al., 2012; Ireland, Ea, other parts of Japan show faculty members struggling
Kontzamanis, & Michael, 2006; Romig, 2013; Smith, with professional versus family commitments. This
2007). conflict potentially influences nursing educators’
Knowledge required to adequately give disaster triage response to a disaster incident as reported earlier
and care for victims is generally not included in most (French, Sole, & Byers, 2002). In Miyazaki, nursing
nursing curricula (James & Duarte, 2006). Incorporat- educators may feel a deep sense of family commitment,
Figure 3 Most serious impact of possible disasters for nursing educators and/or families in Istanbul and Miyazaki.
empowerment, and a need to respond to the event, cators not responding effectively to MCI because they
regardless of what they were doing and what com- lacked knowledge on personal preparedness for possible
plexities may arise in making preparations for their disaster and would not consider volunteering for pos-
families. One suggested area of disaster education for sible disaster response (Table 3). It is clear that nursing
faculties already includes how to deal with relatives universities need to collaborate with community agen-
following an MCI (Bergin & Khosa, 2007; Chapman cies that can demonstrate how to reach out to the com-
& Arbon, 2008; Edwards, Caldicott, Eliseo, & Pearce, munity and forge new relationships with nursing
2006; Hsu et al., 2004; Nasrabadi, Naji, Mirzabeigi, educators, individuals, and groups (Wise, 2007).
& Dadbakhs, 2007). Educational programs on DP&R must address exist-
Caudill (2011) has demonstrated the significant defi- ing knowledge deficits of nurses, including nursing edu-
cits in nursing textbooks, both in the absence of essential cators (Erickson, 2001; Fitzgerald, Aitken, Davis, &
emergency preparedness content and in the presence of Daily, 2010; James & Duarte, 2006; Urbano, 2002;
outdated information. One strategy to improve emer- Wisniewski, Dennik-Champion, & Peltier, 2004) and
gency preparedness knowledge of faculty members is to undergraduate nursing students (Gebbie et al., 2012;
ensure the content included in all nursing textbooks is Usher & Mayner, 2011). It is estimated that if half of the
accurate, evidence-based, and updated in a timely nursing population does not receive disaster content in
manner. Improved texts with standardized content an undergraduate setting, they will need to receive it in
would be a big educational step towards decreasing postgraduate settings through employer- and private-
deficits listed above. provided educational packages (Gebbie et al., 2012;
Slepski & Littleton-Kearney, 2010). Disaster-nursing
content is now being included in the curricula of a few
Associations between considerations and institutions, such as at Istanbul University, but overall
characteristics with basic knowledge about they are far too few. For example, despite being a
disaster preparedness and response country with a history of major earthquakes, 60% of
Before 2001, few nurses received any formal education the nursing programs in Japan have no disaster-nursing
in the areas of emergency preparedness or disaster courses and no intention of adding a DP&R course
response (Littleton-Kearney & Slepski, 2008). Similarly, in the future (Gebbie et al., 2012; WHO & ICN,
in this study, research assistants and participants who 2009).
were 25–40 years of age showed higher levels of basic In this study, nursing educators from Miyazaki who
knowledge about DP&R than those who were older attended special courses on DP&R outside of univer-
than 40 years (Table 3). Clearly, DP&R content was sity had more knowledge on DP&R compared to those
poor in the past. This study also showed nursing edu- who did not attend these courses. This points to the
fact that special courses taught outside of the univer- Arbon et al. (2013b) indicated in their recent findings
sities in Japan are effective in gaining knowledge for the willingness of 451 Australian emergency nurses to
nursing educators. An educational and research attend their workplace during a conventional disaster. If
program supported by the Japanese Government, these nurses worked full time, had received formal edu-
entitled “Disaster Nursing in a Ubiquitous Society in cation pertaining to disaster, had a family disaster plan,
Japan”, has been conducted throughout Japan from and had no children, they were more willing to come to
2003 to 2007. This program has facilitated the devel- work during hazardous times. Working in an environ-
opment of various networks for disaster nursing, ment in which these nurses perceived their colleagues,
disaster-nursing care strategies, and disaster-nursing managers, and organizations to be well prepared would
education (Yamamoto, 2008). Replication of these make their decision to work in conventional disasters a
activities related to disaster nursing should be orga- much easier one. The authors believe that such a number
nized globally to meet nursing educators’ educational of complex factors can change nursing educators’
needs (Yamamoto, 2008) and to identify how expected thoughts on being a volunteer in Istanbul and Miyazaki
learning outcomes can be properly assessed (Chan as well.
et al., 2010; Gebbie et al., 2012).
There is a reasonable public perception that schools of Characteristics, likelihood of disasters, and
nursing have a responsibility to adequately prepare their serious impact of possible disasters
students (Veenema, 2006; Veenema & Woolsey, 2013). Nursing educators in both cities described characteris-
In this study, having basic knowledge about disaster tics of disasters as “unpredictable/sudden/disorganized”
preparedness showed no statistical significance on per- (Fig. 1) as stated in the earlier study by Fung, Lai, and
sonal disaster preparedness about DP&R and consider- Loke (2009). Other descriptions of disaster characteris-
ations about being a volunteer for possible disasters tics in Istanbul were “injuries, deaths and loss of fami-
(Table 3). The decision to attend work or not during a lies” and “loss of properties”. The top characteristic
disaster includes a number of complex personal, work- of a disaster worldwide is “unpredictable/sudden/
related, and professional factors that can change, disorganized”. According to the responses of the nursing
depending on the type of disaster, preparedness of the educators in this study, “loss of lives/injuries” and “loss
work environment, and the emergency nurses’ personal of personal properties” were cited as the number one
responsibilities (Arbon et al., 2013a). Arbon et al. characteristic which is consistent and expected out-
(2013a) indicated three major themes that influenced a comes for both regions (CRED, 2009). A disturbing
willingness to work during a disaster. Theme one finding in this study was that approximately one-third of
reflected on the uncertainty of the situation, such as the participants did not know the characteristics of disasters
type of disaster. The second theme surrounded the pre- in their area (Fig. 1). It can be only hoped that a broader
paredness of the workplace, emergency nurse, and col- range of opinions on disaster characteristics may be
leagues. The third theme considered personal and obtained by a larger scale of nursing educators who have
professional choice based on home and work circum- attended special courses on DP&R at/outside of univer-
stances and responsibilities. In fact, positive outcomes sities in both cities.
on becoming a volunteer and thoughts on personal pre- Disaster awareness has increased among healthcare
paredness may improve nursing educators’ confidence professionals, yet the concept is relatively new to many
and their understandings of the importance of their roles nursing educators in Istanbul because encounters of
of nursing during a disaster event (Hsu et al., 2004; major disasters seldom occur there compared to
Jennings-Sanders, 2004). Miyazaki. In the past 10 years, a number of unfortunate
Similarly, it was reported that motivation for attending events in Turkey and Japan have been reported in pub-
training sessions on disaster preparedness was of a per- lished work (CRED, 2009). The top seven disastrous
sonal and professional matter where nurses felt that they events in the past 13 years in Turkey (2000–2012) were
had a responsibility to be trained and prepared for disas- earthquakes, severe flooding, extreme temperature/
ter events (Chapman & Arbon, 2008; Wetta-Hall, storm, mass movement, wildfires, volcanoes, and epi-
Fredrickson, Ablah, Cook, & Molgaard, 2006). Arbon demics, whereas the top seven events in Japan were
et al. (2006) found that 80% of the nurses who volun- typhoons, earthquakes, severe flooding, extreme tem-
teered in the Sumatra–Andaman earthquake and tsunami perature, epidemics, volcanoes, and wildfires. Although
did so for the first time and were inexperienced and there is no specific data for either city, this study showed
educationally unprepared for such a large-scale disaster. the top three unfortunate events being similar with the
published work (CRED, 2009) (Fig. 2). These results AUTHOR CONTRIBUTION
show that nursing educators in Istanbul and Miyazaki
are aware of the likelihood of certain disaster types in All authors have contributed significantly and all
their areas but, as stated before, lack an overall under- authors are in agreement with the content of the manu-
standing of what disasters are out there. script.
Results further showed nursing educators in Istanbul
indicating “deaths, injuries, disabilities, and physiologi-
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