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Factors Affecting Hospital-based Nurses’
Willingness to Respond to a Radiation Emergency
Tener Goodwin Veenema, RN, PhD, MPH, MS, CPNP, Bonnie Walden, MS, RN,
Nancy Feinstein, PhD, RN, and Jacqueline P. Williams, PhD
ABSTRACT
Background: Despite increased government and public awareness of the threat of a radiological emergency
resulting from a terrorist attack or industrial accident, limited emphasis has been placed on preparing the
US health care workforce for such an event. The purpose of this study was to develop and apply a rapid
survey to evaluate hospital-based nurses’ baseline knowledge, self-assessed clinical competence, percep-
tion of personal safety, and willingness to respond in the event of a radiological emergency.
Methods: The study was conducted in 2 phases, the first targeting nursing units likely to respond in the
event of a radiological emergency and the second focusing more generally on members of the New
York State Emergency Nurses Association currently employed as hospital-based nurses.
Results: Among the 668 nurses surveyed, baseline knowledge was found to be inadequate. Although
baseline knowledge, clinical competence, and perception of personal safety were all positively
associated with willingness to respond, perception of safety appeared to be the primary determi-
nant. Furthermore, baseline knowledge did not appear to be strongly associated with perception
of personal safety.
Conclusions: Based on these results, the investigators recommend further clinical training to
enhance preparedness and a more detailed exploration of the determinants of perceived personal
safety. (Disaster Med Public Health Preparedness. 2008;2:224–229)
Key Words: nursing, radiation emergency, radiological terrorism, perceived safety, willingness to report
In the decades since the end of the Cold War, the
threat of a major radiation emergency, inten-
tional or otherwise, remains an unfortunate real-
ity.
1
Radiological incidents have resulted in large-
scale evacuations, hospitalizations, death due to
radiation sickness, and long-term health effects.
1,2
Such a scenario would have devastating conse-
quences on a region’s health care system and work-
force, including nurses.
2,3
Concern regarding the use
of radiological weapons within the United States is of
paramount importance to the Department of Home-
land Security and media reports document the gov-
ernment’s heightened concern regarding the poten-
tial use of radioactive dispersal devices (“dirty
bombs”) by terrorists.
4,5
Although the United States
has made preparation for natural disasters as well as
biological and chemical terrorism-related incidents a
priority for government and military agencies,
6
re-
sponse to radiological threats remains one of the least
emphasized aspects of current terrorism preparedness
efforts. Unintentional radiation exposures from in-
dustrial accidents and nuclear power plant failures
such as those that occurred at Three Mile Island
(1979) or Chernobyl (1986) also present unique chal-
lenges to health care workers.
1,7,8
It is important to recognize that there is minimal
health risk to nursing or emergency personnel from
working with patients exposed to high levels of radi-
ation. Patients contaminated, even at high levels,
pose little to no threat; radiation exposure and con-
tamination are not likely to be significant hazards to
staff.
9
Staff can protect themselves from radioactive
contamination by using universal precautions while
treating these patients. As opposed to chemical or
biological agents that arrive with contaminated pa-
tients, radioactive contamination is easy to detect.
10
Nurses comprise the largest segment of the health
care workforce and, in the event of an emergency,
would constitute the front line in patient care. De-
spite the minimal risk associated with caring for ex-
posed individuals,
9–11
many nurses have significant
anxiety related to treating patients exposed to radia-
tion.
12
This anxiety is generally exacerbated by insuf-
ficient knowledge regarding the true effects of radia-
tion, inability to recognize radiation injuries, or lack
of appropriate clinical experience with patients in-
volved in radiological incidents.
7
Inadequate knowl-
edge on the part of health care providers has histor-
ically resulted in the delay or denial of treatment to
mildly contaminated patients, underestimation of to-
RESEARCH
224 Disaster Medicine and Public Health Preparedness VOL. 2/NO. 4
tal radiation exposure, and failure to recognize acute radia-
tion injury.
7,8
In addition, anxiety related to personal and
family safety has been shown to be a strong consideration in
nurses’ willingness to report to work.
13,14
Patients exposed to radiation require decontamination, close
monitoring, and follow-up. Nurses must ensure that their
patients are hemodynamically stable before initiating defin-
itive radiation measures of decontamination and other radi-
ation-related therapies. It is essential that nurses are able to
recognize radiation injury and provide appropriate treatment
whenever possible.
9,10
This study offers insight into nurses’
knowledge of radiation and willingness to participate in the
event of a disaster, and will aid in the development of
educational programs to prepare nurses to safely and effec-
tively deal with the public health consequences of radiation
emergencies.
The aims of this study were to assess hospital-based nurses’
baseline knowledge for identifying and treating radiation
injuries and their willingness to come to work during a major
radiation event (ie, willingness to respond). The investigators
were specifically interested in evaluating associations be-
tween willingness to respond and baseline knowledge, per-
ception of personal safety during a radiological emergency,
and self-assessed clinical competence relating to radiation
emergencies.
METHODS
This study was a cross-sectional survey using a purposive
sample of hospital-based nurses in New York state. Partici-
pation was voluntary, responses were anonymous, and all of
the surveys were accompanied by an information sheet de-
tailing the purpose of the project. This study and the sup-
porting survey instrument were approved by the New York
State Emergency Nurses Association (NYSENA) and the
institutional review boards of each participating institution.
Survey Development
The Radiation Survey (RS) is a rapid, self-administered ques-
tionnaire developed to assess hospital-based nurses’ knowl-
edge, attitudes, and behavior with regard to radiation emer-
gencies. The survey’s 38 multiple-choice questions were
conceptualized to encompass 4 specific domains: baseline
knowledge for identifying and treating radiation injuries,
perception of personal safety during a radiological emergency,
self-assessed clinical competence relating to radiation emer-
gencies, and willingness to report to work in the event of a
radiological emergency (Table 1). Although no uniquely
identifiable information was collected, the survey included a
series of 10 demographic questions to describe and classify the
respondents.
Due to the novel nature of this assessment and the limited
available literature, the researchers used a standard, multi-
stage process for developing and refining the RS.
15,16
Con-
ceptual domains were identified and operationalized through
a review of the existing literature and refined in a series of
focus groups among hospital-based nurses.
Baseline knowledge questions were derived from a previously
published survey called Radiologic Incidents and Emergen-
TABLE 1
Sample Questions by Radiation Survey Conceptual Domain
Conceptual Domain Sample Question
Baseline knowledge Q.13 The most immediate concern regarding a person with radioactive-contaminated clothing is:
(16 questions) Stroke
Tissue necrosis
Internal contamination
Development of a local radiation injury
Perception of clinical Q.17 I am clinically competent to care for patients exposed to radiation:
competence Yes
(3 questions) No
Unsure
Perception of personal Q.21 My health care organization has mechanisms in place to ensure my personal safety with regard to radiation:
safety (3 questions) Yes
No
Unsure
Willingness to respond
(6 scenario questions)
Q.25 A large sporting event is taking place in your community today with an estimated crowd of 10,000 spectators.
Toward the end of the event, a large explosion of unknown origin occurs in the lower level seating section. Injury
and death count estimates are high and your hospital declares an external disaster. Extra staff is needed to care
for the arriving wounded, as well as patients already present in the Emergency Department. You have been
called and asked to come in to work. Will you come in?
Yes
No
Unsure
Demographics
(10 questions)
Age, sex, years in clinical practice, home ZIP code, etc
Willingness to Respond to a Radiation Event
Disaster Medicine and Public Health Preparedness 225
cies
17
and from an existing national examination of radiation
knowledge from the Radiation Emergency Assistance Center/
Training Site.
18
Knowledge items were selected to cover a
broad range of basic clinical knowledge relating to radiation
injuries and emergencies.
Nurses’ willingness to respond (ie, willingness to report to
work during a radiological emergency) was assessed using a
series of questions relating to 2 hypothetical radiation events:
a nuclear power plant emergency and an explosion at a
sporting event. Each scenario comprised 3 questions of in-
creasing intensity/severity to challenge nurses’ willingness to
respond. The scenarios were created by the investigators, and
reviewed for face and content validity by 3 radiation biology
and safety experts.
To assess the influence and respondents’ awareness of their
proximity to a nuclear facility, nurses were asked to provide
their home ZIP code. These were compared with a list of ZIP
codes known to fall within the 10-mile Emergency Planning
Zone (EPZ) surrounding each of New York’s 3 operating
nuclear facilities: James A Fitzpatrick/Nine Mile Point, RE
Ginna, and Indian Point.
Once assembled, the survey instrument was again reviewed
for validity by the study’s subject matter experts. The final
version of the RS was pretested in a series of doctoral students
and pilot-tested by a group of 16 master’s degree–level nurses.
Although the final survey device was anonymous and did not
include any unique identifiers, color coding was used to
differentiate responses in the second phase of the study.
Survey Deployment/Study Design
Deployment of the RS was conducted in 2 phases, the first
targeting nursing units most likely to be involved in a radi-
ation emergency and the second focusing more broadly on
members of the NYSENA. Nursing units included in the first
phase of the study were preselected from 2 hospitals in a
midsized city in western New York state: a major tertiary
medical center and a large urban hospital. Units were se-
lected based on their likelihood of responding to a major
radiation emergency or demonstrated proficiency in caring
for burn patients. The final sample included adult and pedi-
atric emergency departments, burn and intensive care units,
a surgical intensive care unit, and a trauma intensive care
unit. The survey was distributed by nurse managers on the
selected units and returned, in the blank envelope provided,
to a locked drop box placed at each of the units. To prevent
duplication, NYSENA members were asked not to complete
the survey in the study’s first phase.
In the study’s second phase, surveys were mailed to NYSENA
members currently employed as hospital-based nurses. The
NYSENA gave a priori approval for the study and provided
mailing addresses for its membership. A letter of introduction
and endorsement from the NYSENA director was sent to
each member the week before the survey was initially mailed.
Surveys were sent via regular post and returned by prepaid
mailer. To maximize response rate, each NYSENA member
received the survey mailing up to a total of 3 times. Color
coding was used to prevent duplication across mailings.
Data Analysis
All of the data management and analyses were performed
using SPSS version 12.0 for Windows (SPSS, Chicago, IL).
Univariate descriptive statistics were used to summarize re-
spondent demographic data and survey results. Internal con-
sistency and reliability of the conceptual domain subscale
items were assessed using Cronbach
␣
and split-half correla-
tion. Relations among the survey’s conceptual domains were
evaluated using Pearson correlation. Interactions between
conceptual domains were tested using hierarchical multiple
regression and interpreted according to the mediator–mod-
erator framework described by Baron and Kenny
19
and Ben-
nett.
20
Unless otherwise specified, all of the analyses were
2-tailed and considered statistically significant at an
␣
level
of .05.
RESULTS
The response rates for phases 1 and 2 of the study were 59%
(189 nurses) and 41% (479 nurses), respectively, with an
overall response rate of 45%. Based on their comparable
demographic profiles, the 2 samples were combined to in-
crease the overall power of the study. The final combined
sample comprised a total of 668 hospital-based nurses. The
nurses in the combined sample were found to be predomi-
nantly female (82.8%) and married (63.3%), and to have
fewer than 2 dependents at home. Most respondents (67.2%)
had completed at least a bachelor’s degree and stated that
their highest level of licensure was as a registered nurse
(89.4%; Table 2).
A majority of respondents believed that they neither worked
(57.9%) nor lived (63.9%) within the 10-mi EPZ surround-
ing a nuclear facility. Nurses seemed generally less confident
when assessing the proximity of their workplace (Table 2).
These findings were validated for true proximity by compar-
ing the nurses’ home ZIP codes with a list of EPZ ZIP
codes provided by county emergency planning departments.
Among those providing ZIP code information (n ⫽617), a
majority correctly classified their home’s proximity to a nu-
clear facility (72.4%). False positives were considerably more
common than false negatives, suggesting that individuals are
inclined to overestimate their risk for living within an EPZ.
Internal consistency and reliability of the conceptual domain
subscales was found to be generally good for willingness to
respond (.93), sense of competence (.82), and personal safety
(.69) during a radiological emergency. Despite significant
spilt-half correlations for its constituent questions, subscale
concordance for baseline knowledge was found to be low
(Table 3).
Out of a possible 16 points in the RS assessment of baseline
knowledge identifying and treating radiation injuries, the
Willingness to Respond to a Radiation Event
226 Disaster Medicine and Public Health Preparedness VOL. 2/NO. 4
respondents scored an average of 5.69 points (SD 2.13) with
none of the nurses receiving a score higher than 13 (Table 4).
The most commonly missed questions related to the correct
course of treatment for patients who were in a nuclear power
plant during a leak (90.3%), whether it is safe for a pregnant
nurse to care for patients exposed to high levels of radia-
tion (90.3%), appropriate contamination control procedures
(88.9%), and the initial treatment focus for patients with
injuries from a dirty bomb (83.5%). A majority of the re-
spondents were able to correctly define external contamina-
tion (82.0%) and thermal injury (72.9%).
To determine the nurses’ willingness to respond to work in
the event of a major radiological event, their responses to 6
scenarios in 2 major radiation events were evaluated. The
mean score was 4.18 (SD 2.36) out of a possible total 6 points
(Table 4). Although the majority of the nurses said that they
were willing to respond at least some of the time, 15.3%
(n ⫽102) were unwilling to respond to work in any of the
more severe radiation emergency event scenarios. Willing-
ness to respond decreased as the intensity of the scenario
increased.
Willingness to respond in the event of a radiological emer-
gency was found to be weakly but positively correlated with
level of baseline knowledge (r⫽.16), perception of personal
safety (r⫽.32), and perception of clinical competence (r⫽
.20). The association between level of baseline knowledge
and perception of personal safety also was found to be weak
(Table 5).
Hierarchical regression was used to determine whether the
relation between baseline knowledge and willingness to re-
spond is moderated by perception of personal safety. When
willingness to respond was regressed onto baseline knowl-
edge, the model was statistically significant and accounted for
only 3% of the variance (adjusted r
2
) in willingness to re-
spond. When personal safety was added hierarchically to the
model, the change in r
2
was found to be statistically signifi-
cant, with the model now accounting for 12% of the variance
in willingness to respond. No interaction was detected be-
tween baseline knowledge and perception of personal safety.
19,20
Therefore, although baseline knowledge and perception of
personal safety each independently predict willingness to
respond, the relation between baseline knowledge and will-
ingness to respond is not moderated by perception of personal
safety.
When perception of clinical competence was added into the
model, the change in r
2
was statistically significant, with the
second model accounting for 5% of the variance in willing-
ness to respond. No significant interaction between predic-
TABLE 2
Characteristics of Emergency Nurses Responding to the
Radiation Survey (N ⴝ668)
Characteristic Mean (SD)
Age, y 44.1 (9.7)
No. of dependents at home 1.43 (1.41)
Years in active clinical practice 18.4 (10.2)
n (%)
*
Sex
Male 102 (15.3)
Female 553 (82.8)
Marital status
Single 130 (19.5)
Married 423 (63.3)
Living with partner, not married 31 (4.6)
Divorced 67 (10.0)
Widowed 7 (1.0)
Licensure
Licensed practical nurse 12 (1.8)
RN 597 (89.4)
Nurse practitioner 45 (6.7)
RN/physicians’ assistant 1 (.1)
Highest level of education
Diploma 51 (7.6)
Associate 159 (23.8)
Bachelor’s 305 (45.7)
Master’s 139 (20.8)
MD, doctorate 5 (.7)
Live within 10 mi of a nuclear facility
Yes 116 (17.4)
No 427 (63.9)
Don’t know 117 (17.5)
Work within 10 mi of a nuclear facility
Yes 117 (17.5)
No 387 (57.9)
Don’t know 156 (23.4)
RN, registered nurse.
*Percentages reported as a proportion of the total number of survey
respondents.
TABLE 3
Consistency of Conceptual Domain Subscales From the
Radiation Survey (N ⴝ668)
Conceptual Domain Cronbach
␣
Baseline knowledge .40
Perception of personal safety .69
Perception of clinical competence .82
Willingness to respond .93
TABLE 4
Radiation Survey Results Summarized by Conceptual
Domain (N ⴝ668)
Conceptual Domain Scale Mean (SD)
Baseline knowledge 1–16 5.69 (2.13)
Perception of personal safety 1–3 1.04 (.86)
Perception of clinical competence 1–3 0.30 (.66)
Willingness to respond 1–6 4.17 (2.36)
Willingness to Respond to a Radiation Event
Disaster Medicine and Public Health Preparedness 227
tors was detected. Thus, although baseline knowledge and
perception of clinical competence each independently pre-
dict willingness to respond, perception of clinical compe-
tence does not moderate the relation between baseline
knowledge and willingness to respond (Fig. 1).
DISCUSSION
Our vulnerability to radiological terrorism persists, and insuf-
ficient emphasis has been placed on workforce preparedness
and protection from nuclear threats. The detonation of a
nuclear weapon would be a frightening reality that would
result in massive fatalities, injuries, and health problems
caused by the initial explosion and radiation exposure. As
health care providers, nurses must possess the knowledge to
effectively care for patients with radiation exposure and pro-
tect themselves and others from contamination.
9,10
The results of this study suggest that nurses’ knowledge re-
garding radiation emergencies is somewhat inadequate. Al-
though nurses are familiar with textbook definitions of types
of burns, they are unaware of which procedures to follow in
scenarios involving a patient with possible radiation expo-
sure. Nurses with a lower level of baseline knowledge regard-
ing radiation emergencies, lower perception of personal
safety, and lower perception of clinical competence were less
willing to respond during a radiation emergency, suggesting
that during an actual radiological incident, there will likely
be a shortage of nurses who are able to provide safe, evidence-
based nursing care. Most important, the results indicate that
perceptions of personal safety account for 3 times the vari-
ance in willingness to respond, as compared with baseline
knowledge. It would appear that improving baseline knowl-
edge, although clearly critical for ensuring appropriate clin-
ical care, may not significantly affect a nurse’s willingness to
respond. Given that perception of personal safety, taken
alone or in combination with baseline knowledge and per-
ception of clinical competence, accounted for only a limited
amount of the overall variation in willingness to respond,
further qualitative exploration of this concept is warranted.
The importance of perception of personal safety in determin-
ing willingness to respond has been reported previously in the
research literature
21
and studies have reported reductions in
health care personnel effectiveness in the presence of con-
cerns about the safety of themselves or loved ones.
13,14,22,23
Health care workers’ ability and willingness to respond to
such catastrophic events may be affected by multiple fac-
tors.
24
Given the proportion of respondents who either indi-
cated they lived near or did not know whether they lived
near a nuclear facility, concerns relating to family safety may
prove to be an important factor in the event of an actual
radiological event. The high false positive rate, however,
suggests that increasing knowledge in this area may be a
simple means of reducing stress and improving willingness to
respond during a crisis.
Sources of Concern
Due to the highly targeted sample used in this study (ie,
currently employed hospital-based nurses in New York state)
our findings may not be generalizable beyond that group. A
larger, more diverse sample is needed to articulate nurses’
knowledge and willingness to respond to a radiation emer-
gency on a national level. Given the voluntary nature of the
survey, some self-selection is likely, biasing results toward
higher levels of baseline knowledge, competence, and expe-
rience. The RS was a new survey instrument, and it is
possible that the necessarily limited array of survey questions
may not have fully measured the conceptualized domains.
Specifically, the lower than expected subscale concordance
for baseline radiation knowledge (Cronbach
␣
⫽.4) and the
weak association between baseline knowledge and willing-
ness to respond may suggest a need for further psychometric
testing and refinement of the RS. In light of significant
split-half correlation findings among knowledge scale re-
sponses, however, these findings may simply indicate the
TABLE 5
Correlations Among Baseline Knowledge, Willingness to
Respond, Perception of Personal Safety, and Perception
of Clinical Competence
Correlated Items n rP
Nurses’ baseline knowledge and
willingness to respond to a
radiation emergency
668 .16 ⬍.0001
Nurses’ baseline knowledge and
perception of personal safety
668 .03 .402*
Nurses’ baseline knowledge and
perception of clinical
competence
668 .21 ⬍.0001
Nurses’ perception of personal
safety and willingness to
respond to a radiation
emergency
668 .32 ⬍.0001
Nurses’ perception of clinical
competence and willingness to
respond to a radiation
emergency
668 .20 ⬍.0001
*Correlation determined to be significant where P⬍.01.
FIGURE 1
Theoretical model showing associations between
radiation survey conceptual domains
Willingness to Respond to a Radiation Event
228 Disaster Medicine and Public Health Preparedness VOL. 2/NO. 4
breadth of the underlying concept (ie, identification and
treatment of radiation injuries).
25
Under either interpreta-
tion, it seems clear that additional factors, unaddressed by the
present model, are at play. Building on the findings of this
study, further exploration of the concepts underlying and
factors affecting nurses’ willingness to respond during radio-
logical and other crises is ongoing.
CONCLUSIONS
With the threat of a radiation disaster remaining an unfor-
tunate reality, education is but one critical factor in deter-
mining whether hospital-based nurses feel safe, competent,
and willing to participate in an emergency. Nurses’ knowl-
edge regarding the delivery of effective care in a radiological
emergency is inadequate. Nurses need further training with
regard to handling exposed patients and measures to be taken
to protect themselves and others from contamination. Health
care institutions should focus on developing initiatives that
will help define and enhance nurses’ perception of personal
safety when responding to a radiation emergency.
About the Authors
At the time of writing, Dr Veenema was program director, Disaster Nursing and
Strategic Initiatives, Center for Disaster Medicine and Emergency Preparedness,
University of Rochester; Ms Walden is with the Department of Obstetrics and
Gynecology, University of Rochester Medical Center; Dr Feinstein is assistant
professor, University of Rochester School of Nursing; Dr Williams is research
associate professor, Department of Radiation Biology, University of Rochester
Medical Center.
Address correspondence and reprint requests to Dr Tener Goodwin Veenema,
University of Rochester School of Nursing, 601 Elmwood Ave, Box SON,
Rochester, NY 14642 (e-mail: Tener_Veenema@urmc.rochester.edu).
Received for publication January 17, 2008; accepted August 12, 2008.
Authors’ Disclosures
The authors report no conflicts of interest.
Acknowledgments
This study was supported in part by The Center for Nursing Research at the
University of Rochester School of Nursing, and was endorsed by the New York
State Emergency Nurses Association. The authors wish to acknowledge Andrew
Karam, PhD (Radiation Physics, Rochester Institute of Technology), Jackie
Williams, PhD (Department of Radiation Biology, University of Rochester),
and Tom Morgan, PhD (Radiation Safety Officer, University of Rochester) for
their knowledge and expertise in reviewing the survey instrument. The authors
also wish to acknowledge Susan Knapp, MS, RN, and Kathy Tyo, MS, RN,
former graduate students at the University of Rochester School of Nursing, for
their individual contributions to this project. Special thanks to Adam Rains,
MSc, for assistance in the preparation of this manuscript.
ISSN: 1935-7893 © 2008 by the American Medical Association and Lip-
pincott Williams & Wilkins.
DOI: 10.1097/DMP.0b013e31818a2b7a
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