Disaster preparedness of nurses: a systematic review of the literature

Abstract

Aim: This review explored peer reviewed publications that measure nurses’ preparedness for disaster response.
Background: The increasing frequency of disasters worldwide necessitates nurses to adequately prepare to respond to disasters to mitigate the negative consequences of the event on the affected population. Despite growing initiatives to prepare nurses for any disasters, evidence suggests they are under prepared for disaster response.
Methods: This is a systematic review of scientific articles conducted from 2006 to 2016 on nurses’ preparedness for disasters. SCOPUS, MEDLINE, PubMed, CINAHL, and PsychINFO were the primary databases utilized for search of literature. Keywords used in this review were: ‘emergency’, ‘disaster’, ‘disaster preparedness’, ‘disaster competencies’, ‘disaster nursing’, ‘disaster role’, and ‘nurse’. Seventeen (17) articles were selected for this review.
Findings: Factors that increase preparedness for disaster response include previous disaster response experience and disaster-related training. However, it is widely reported that nurses are insufficiently prepared and do not feel confident responding effectively to disasters.
Conclusion: The findings of this review contribute to a growing body of knowledge regarding disaster preparedness in nurses and have implications for academia, hospital administration and nursing educators. The findings of this review provide evidence that could be used by nurse educators and nurse administrators to better prepare nurses for disaster response.
Implications for nursing and health policy: The findings from this review place an emphasis on hospitals to implement policies to address a lack of preparedness among their employees. Furthermore, this review highlights the benefit of further research and provision of realistic disaster exercises that mimic actual events to enhance the preparedness of the nursing workforce.

Full text

Disaster preparedness among nurses: a
systematic review of literature
L.J. Labrague
1
RN, DM ,K.Hammad
2
FCENA, RN, PhD,D.S.Gloe
3
RN,
EdD, D.M. McEnroe-Petitte
4
RN, PhD,D.C.Fronda
5
RN, MAN,A.A.
Obeidat
6
RN, MSN,M.C.Leocadio
7
RN, RM, DNsgM,A.R.Cayaban
8
RN, MSN
&E.C.Mirafuentes
9
RN, MAN
1Lecturer, 5Lecturer, 6Lecturer, 7Assistant Professor, 8Lecturer, 9Lecturer, Sultan Qaboos University, Muscat, Sultanate of
Oman, 2Lecturer, Flinders University, Adelaide, SA, Australia, 3Clinical Instructor, Southwest Baptist University, Bolivar, MO,
USA, 4Associate Professor, Kent State University Tuscarawas, New Philadelphia, Ohio, USA
LABRAGUE L.J., HAMMAD K., GLOE D.S., MCENROE-PETITTE D.M., FRONDA D.C., OBEIDAT
A.A., LEOCADIO M.C., CAYABAN A.R. & MIRAFUENTES E.C. (2017) Disaster preparedness among
nurses: a systematic review of literature. International Nursing Review 00, 000–000
Aim: This review explored peer-reviewed publications that measure nurses’ preparedness for disaster
response.
Background: The increasing frequency of disasters worldwide necessitates nurses to adequately prepare to
respond to disasters to mitigate the negative consequences of the event on the affected population. Despite
growing initiatives to prepare nurses for any disasters, evidence suggests they are under prepared for disaster
response.
Methods: This is a systematic review of scientific articles conducted from 2006 to 2016 on nurses’
preparedness for disasters. SCOPUS, MEDLINE, PubMed, CINAHL and PsychINFO were the primary
databases utilized for search of literature. Keywords used in this review were as follows: ‘emergency’,
‘disaster’, ‘disaster preparedness’, ‘disaster competencies’, ‘disaster nursing’, ‘disaster role’ and ‘nurse’.
Seventeen (17) articles were selected for this review.
Findings: Factors that increase preparedness for disaster response include previous disaster response
experience and disaster-related training. However, it is widely reported that nurses are insufficiently
prepared and do not feel confident responding effectively to disasters.
Conclusion: The findings of this review contribute to a growing body of knowledge regarding disaster
preparedness in nurses and have implications for academia, hospital administration and nursing educators.
The findings of this review provide evidence that could be used by nurse educators and nurse
administrators to better prepare nurses for disaster response.
Implications for nursing and health policy: The findings from this review place an emphasis on hospitals
to implement policies to address lack of preparedness among their employees. Furthermore, this review
highlights the benefit of further research and provision of well-grounded disaster exercises that mimic actual
events to enhance the preparedness of the nursing workforce.
Correspondence address: Leodoro J. Labrague, Sultan Qaboos University, Al Khoudh, Muscat, Sultanate of Oman; Tel: +968 2414 5401; Fax: +968 2441 3535; E-mail:
leo7_ci@yahoo.com.
Funding
This study was not funded.
Conflict of interests
Authors declare no conflict of interest.
1
©2017 International Council of Nurses
Literature Review

Keywords: Disaster, Disaster Competencies, Disaster Nursing, Disaster Preparedness, Disaster Role,
Emergency, Nurse
Background
It has been widely reported that nurses worldwide play a sig-
nificant role in the response to disasters and have done so
since the earliest days of the profession (Turale 2014;
Veenema 2013). All communities across the world could
potentially be threatened by a disaster. In 2015 alone, 99
countries were hit by natural disasters resulting in the dis-
placement of millions of people, more than 22 000 deaths
and 70.3 billion USD (United States Dollar) worth of damage
(Guha-Sapir et al. 2015). Furthermore, these figures represent
an upward trend in disasters (Guha-Sapir et al. 2015). Given
the frequency with which disasters occur and the effect they
have, nurses’ preparedness to respond to these events is of
critical importance in reducing the negative consequences to
the health of the affected population.
A formal definition of a disaster has not been agreed upon
by all groups at this point in time (Mayner & Arbon 2015;
WHO & ICN 2009), but the World Health Organization
(WHO) draws on definitions from the International Strategy
for Disaster Risk Reduction (ISDR) and the Centre for
Research on the Epidemiology of Disaster (CRED). The defi-
nition relates to an incident or incidents which may involve a
significant number of individuals or groups of individuals,
including a community or even a country where there is a
development of an event or events that may affect the health,
economy or environment negatively. The overall effects of the
disaster may involve the need for local or even national or
international assistance to provide interventions for those
affected (CRED, 2009).
Common to these definitions is a disaster’s impact on
humanity and the ability to overwhelm existing resources. The
effect that disasters have on the health status of a community
implicates the nursing profession, who as the largest healthcare
workforce group are likely to be involved in caring of people
affected by disasters (Perron et al. 2010; WHO, 2009).
The critical role of nurses during disasters is emphasized in
health policy aimed at adequately preparing nurses for disas-
ter response locally and internationally. Most notably, a
framework of Disaster Nursing Competencies published by
the International Council of Nurses (ICN) in 2009 outlines
10 competency domains for nurses responding to disasters
(ICN 2009). In their review of literature related to disaster
competencies for healthcare providers, including nurses, Daily
et al. (2010) found that hundreds of competencies have been
developed but that terminology and structure are inconsistent
and imprecise. Furthermore, universal acceptance is lacking
and none of the competencies have been validated (Daily
et al. 2010).
There has been an increasing focus on disaster preparedness
of nurses in the literature in recent years (Chapman & Arbon
2008; Fox & Timm 2008; Labrague et al. 2016; Mayumi et al.
2009). In fact, it has been reported that disaster preparedness
has been integrated into nursing curriculum with a focus on
principles and management of patients in an event of a disas-
ter (Labrague et al. 2016; Mayumi et al. 2009). Local and
international initiatives are in place to adequately prepare
nurses and other healthcare workers to respond effectively to
disasters through extensive disaster training, disaster drills and
exercises, and the provision of disaster management courses
with the expectation that nurses should be able to deliver ade-
quate nursing care to the communities affected by disasters
(Corrigan & Samrasinghe 2012; Ibrahim 2014; Perron et al.
2010; World Health Organization (WHO) 2009). In spite of
these initiatives, available evidence has shown that nurses
remain inadequately prepared to respond to disasters and are
uncertain of their roles during these events (Duong 2009; Mel-
nikov et al. 2014; Usher et al. 2015). A comprehensive review
of the current state of disaster preparedness among nurses is
essential to enhance preparedness for disaster events.
Methods
Aim
This systematic review explored peer-reviewed publications
that measure nurses’ preparedness for disaster response.
Search strategy
A search of electronic databases was conducted to identify rel-
evant studies. The primary databases utilized for search of lit-
erature were SCOPUS, MEDLINE, PubMed, CINAHL and
PsychINFO. Keywords included the following: ‘emergency’,
‘disaster’, ‘disaster preparedness’, ‘disaster competencies’, ‘dis-
aster nursing’, ‘disaster role’ and ‘nurse’.
Inclusion and exclusion criteria
Articles were considered for review if the objective of the
research was to measure disaster preparedness in nurses. Fur-
thermore, articles were included for review if they met the
following criteria: (1) peer-reviewed, (2) published in English
language and (3) published between 2006 and 2016. Articles
©2017 International Council of Nurses
2 L. J. Labrague et al.

that did not attempt to measure preparedness of nurses were
excluded from review. Articles that included nurses as part of
a sample with other professionals were also excluded from
review, as were articles that measured preparedness for expe-
riences other than disaster response.
Search outcomes
The initial search resulted in 332 papers. This number dimin-
ished to 60 after a review of titles and abstracts found that
272 articles had no relevance to the objectives of the review.
A full text reading of the remaining articles resulted in seven-
teen (17) studies that were considered appropriate for review.
The process followed to identify relevant articles for the
review is demonstrated in Fig. 1.
Quality appraisal and data synthesis
Quality of the articles was examined using the appraisal
checklist for quantitative studies by Kmet et al. (2004). The
checklist is one of the most often used tools to appraise the
methodological quality of quantitative papers. The checklist
contains ten (10) components in which a score of 0–2is
assigned. In this review, the quality score ranged from 80% to
100% out of a possible score of 100%.
Due to variety of scales used, diversity of samples and vari-
ances in the data collection method, meta-analysis of data
was not possible. Hence, analyses of data extracted were con-
ducted following a thematic analysis technique (Center for
Reviews and Dissemination, 2008). Data extraction was per-
formed by the researchers. Data extracted from studies
included the following: authors/year, country, samples/sam-
pling technique, research design, research aim, instrumenta-
tion and findings.
Results
Findings of this review are reported based on: (1) methodol-
ogy, (2) reported level of disaster preparedness in nurses, (3)
previous disaster response experience, (4) the role of disaster
training or courses, (5) awareness and execution of workplace
disaster plans and (6) strategies to enhance disaster prepared-
ness. A summary of articles for review can be found in
Table 1.
Methodology
The majority of studies (n=5) were conducted in the United
States (US; Baack & Alfred 2013; Goodhue et al. 2012; Hodge
et al. 2015; Jacobson et al. 2010; Whetzel et al. 2013). The
CINAHL, MEDLINE, PsycINFO and
PubMed
332 titles
241 papers excluded (title not relevant to
the subject
Abstract Screening
91 papers
31 papers excluded (abstract irrelevant to
the subject)
Full Text Screening
60 papers
25 papers excluded (full text irrelevant to
the study)
35 articles
16 papers with methodological problem
(design, response rate)
17 articles included for review
Fig. 1 Flow diagram of the process used to identify references for the systematic review.
©2017 International Council of Nurses
Disaster preparedness in nurses 3

Table 1 Quantitative studies on disaster preparedness in nurses
Author Settings Samples Sampling
Method
Research Purpose Research
Design
Instrument Major Findings
Baack &
Alfred
(2013)
USA 620
nurses
Convenience
sampling
Sampling size
determined
To describe current
status of nurses
preparedness to
manage disasters
Descriptive
correlational
Emergency Preparedness
Information Questionnaire
(EPIQ) (Garbutt et al., 2008)
•Perceived competence
with regards to
disasters was
considered low.
•Nurses were not fully
prepared to respond
effectively with
disasters
Cronbach’s alpha 0.97
Nurses Assessment Readiness
(NAR) (Baack & Alfred (2013)
Cronbach’s alpha 0.90
Job Satisfaction Questionnaire
(Wieck et al., 2009)
Cronbach’s alpha 0.85
Duong
(2009)
Australia 152
nurses
Convenience
Sampling
To explore emergency
nurses’ perceptions
of their
disaster knowledge
and experience
Descriptive
Study
Research-made questionnaire.
Questions were based
on literature review
•Nearly half (45%)
of nurses perceived
themselves to have
low level of disaster
preparedness.
•Less than a quarter
(19%) of nurses felt
confident with their
own level of disaster
preparedness
Hodge
et al.
(2015)
USA 307
nurses
Convenience
Sampling
To evaluate nurses’
self-perception
of emergency
preparedness
at a rural hospital
in southeast Ohio
Descriptive
Study
Emergency Preparedness
Information Questionnaire
(EPIQ) (Garbutt et al., 2008)
•Nearly half (44.6%)
of the respondents
rated themselves as
less prepared for
disasters.
•Nurses’ age and
experience increased
preparedness for
disasters in nurses.
•Emergency nurses
had higher level of
preparedness than
nurses in other units.
Cronbach’s alpha 0.972
Nurses Assessment
Readiness (NAR)
(Baack & Alfred (2013)
Cronbach’s alpha 0.92
Jacobson
et al.
(2010)
USA 941 Convenience
Sampling
To assess self-emergency
readiness and training
needs of nurses in rural
Texas
Descriptive
Study
Research-made questionnaire.
Questions were based
on literature review
•More than half
(58%, n = 546) of
nurses were not
confident in their
ability to care for
disaster patients
©2017 International Council of Nurses
4 L. J. Labrague et al.

Nilsson
et al.
(2016)
Sweden 227
nurses
569
student
nurse
Convenience
Sampling
Sampling size
determined
To describe and
compare self-reported
disaster nursing
competence in nursing
students and
registered nurses with
professional experience
Descriptive
Study
Nurse Professional
Competence (NPC)
Scale (Nilsson et al. 2016)
•Nurses reported
moderate readiness
to manage violence,
serious events, and
disasters.
•Nurses working in
emergency units had
higher disaster
competence than
nurses in other units
Cronbach’s alpha 0.70
Ibrahim
(2014)
Saudi
Arabia
252
nurses
Convenience
Sampling
To examine nurses’
knowledge, attitudes,
practices and
familiarity regarding
disaster and emergency
preparedness
Cross-sectional
design
Emergency Preparedness
Information Questionnaire
(EPIQ) (Garbutt et al., 2008)
•Nurses obtained
EPIQ mean score of
below the accepted
level
Cronbach’s alpha
not mentioned
Usher
et al.
(2015)
Bangladesh,
Bhutan,
Cambodia,
China, Laos,
Nepal,
Solomon
Island
757
nurses
Convenience
sampling
Sampling size
not determined
To assess Asia–Pacific
nurses’ perceptions
about their level of
disaster knowledge,
skills and preparedness
Cross-sectional
design
Modified Disaster
Preparedness Evaluation
Tool (Tichy et al. 2009)
•Nurses reported low
to moderate level of
disaster preparedness.
•Disaster knowledge
and skills were rated
below acceptable score
Cronbach’s alpha 0.90
Fung et al.
(2008)
Hong Kong 164
nurses
Convenience
sampling
Sampling size
not determined
To explore Hong
Kong nurses’
disaster preparedness
Questionnaire
survey
Research-made
questionnaire.
Questions were based
on literature review
•Majority of nurses
(97.5%) were not
adequately prepared
to respond to disaster
situations
Content validity was 0.94
O’ O’Sullivan
et al.
(2008)
Canada 1543
nurses
Convenience
sampling
Sampling size
not determined
To assess perceptions
of preparedness
for disasters and access to
support mechanisms
Web-based
survey
Canadian Community
Health Survey (CCHS)
•Nurses reported to
be inadequately
prepared to respond
to different disaster
events.
•Higher ratings of
preparedness were
noted in responding
to outbreak of disease
and natural hazards.
•Low rating of
preparedness was
noted for CBRN
events (radiological,
nuclear attacks and
accidents)
©2017 International Council of Nurses
Disaster preparedness in nurses 5

Table 1 Continued
Author Settings Samples Sampling
Method
Research Purpose Research
Design
Instrument Major Findings
Labrague
et al.
(2016)
Philippines 170
nurses
Convenience
sampling
Sampling size
not computed
To examine the
perceived level of
preparedness in
Philippine nurses
Descriptive,
cross-sectional
Modified Disaster
Preparedness
Questionnaire
(Fung et al. 2008)
•Three fourths of
nurses (80%)
reported that they
are not fully prepared
for disasters
Goodhue
et al.
(2012)
USA 2627
paediatric
nurses
Convenience
sampling
Sampling size
not computed
To examine factors
associated with
paediatric nurse
reporting to work
in the event of a disaster
Survey approach Personal Preparation
Survey (PNP)
(Chokshi et al., 2008)
•Majority of nurses
(93.2%) reported
not fully prepared
for disaster situations
in general: natural
disasters (92%),
biological attack
(98.9%), and
terrorist attack
(98.5%)
Whetzel
et al.
(2013)
USA 177
nurses
Convenience
sampling
Sample size not
computed
To assess nurse’s
perception of their
role in a disaster and their
perceived susceptibility
to a disaster
Descriptive
survey
Researcher-made survey
questionnaire consisting
of 56 questions. Questions
were developed based on
an extensive
literature review
•Less than 40% of
nurses reported that
they are not personally
prepared to care for
patients during
disaster events
Al Khalaileh
et al.
(2012)
Jordan 474
nurses
Convenience
sampling
Sample size
not computed
To assess Jordanian
RNs’ perceptions
regarding their
knowledge, skills,
and preparedness
for disaster
management
Cross-sectional
study
Disaster Preparedness
Evaluation Tool (DPET)
(Tichy et al. 2009)
•Majority of nurses
considers themselves
having low to
moderately prepare
for disasters.
•Low levels of
preparedness were
seen in relation to
response to biological
and chemical attacks
Cronbach’s alpha is 0.91
Putra et al.
(2011)
Indonesia 252
public
health
nurses
Stratified
proportionate
random sampling
To determine the
level of perceived
ability to practice of nurses in
Aceh to deal with
disaster-related
nursing situations
Cross-sectional
design
Public Health Nurse’s
Perceived Ability to
Practice regarding
Disaster Management
Questionnaire
(PHNPP-DMQ)
•Nurses’ level of
preparedness and
readiness to practice
regarding disaster
management was
moderate
Cronbach’s alpha
ranged is 0.92
©2017 International Council of Nurses
6 L. J. Labrague et al.

Al Thobaity
et al.
(2015)
Saudi
Arabia
429
nurses
Six
hospitals
Convenience
sampling
Sampling
size computed
To evaluated disaster
knowledge among
nurses and to identify
the sources of
their knowledge and
skills regarding
disaster management
Descriptive
research
design
Disaster preparedness
Evaluation Tool (DPET)
(Tichy et al. 2009)
•In general, nurses
perceived themselves
as moderately
prepared for
disasters with mean
score of 4.16 out of
possible mean
score of 5
Cronbach’s alpha is 0.90
€
Oztekin
et al.
(2016)
Japan 902
nurses
Convenience
sampling
Sampling
size not done
The objective of
this study was to
explore nurses’ perceptions
regarding their
knowledge, skills
and preparedness
for disasters and
how they acquired
their knowledge
about disaster
preparation using
a quantitative approach
Cross-sectional
survey
Disaster preparedness
Evaluation
Tool (DPET)
(Tichy et al. 2009)
•Mean scores for
preparedness, response
abilities, and
evaluation all scored
below normal on
6-point Likert
suggesting poor
disaster preparedness
Cronbach’s alpha is 0.90
Tzeng
et al.
(2016)
Taiwan 311
nurses
Convenience
sampling
Sampling size
not determined
The aim of this study was to
explore the
perceived readiness
of hospital
nurses for a disaster
response outside
he hospital
environment
and to identify the
factors influencing their
report for work
Cross-sectional
study
Researcher-made
instrument
consisting of 42 items
•Mean item scores
for personal
preparation,
self-protection,
emergency response,
and clinical
management indicate
low level of
self-reported
readiness for
disaster responses
Cronbach’s alpha is 0.96
©2017 International Council of Nurses
Disaster preparedness in nurses 7

remainder originated from Australia (Duong 2009), Canada
(O’Sullivan et al. 2008), Hong Kong (Fung et al. 2008),
Indonesia (Putra et al. 2011), Japan (
€
Oztekin et al. 2016),
Jordan (Al Khalaileh et al. 2012), Saudi Arabia (Al Thobaity
et al. 2015; Ibrahim 2014), Sweden (Nilsson et al. 2016), Tai-
wan (Tzeng et al. 2016) and the Philippines (Labrague et al.
2016). One study was conducted in multiple countries includ-
ing Bangladesh, Bhutan, Cambodia, Laos, Nepal and Solomon
Islands (Usher et al. 2015).
All of the studies reviewed utilized cross-sectional research
design using a survey approach with questionnaires. Sample
sizes ranged from 164 to 2627 nurses. Although all nurses,
the study participants varied widely in terms of the specialty
area they originated from. Different practice areas included
medical, surgical, paediatric, psychiatric, operating room, crit-
ical care units, and accident and emergency units.
The tools used by researchers to measure preparedness of
nurses varied greatly. Four studies used the Disaster Prepared-
ness Evaluation Tool (DPET) to determine the level of disas-
ter preparedness of nurses (Al Khalaileh et al. 2012; Al
Thobaity et al. 2015;
€
Oztekin et al. 2016; Usher et al. 2015).
This tool consists of 68 items which measures nurses’ readi-
ness for disaster response and management. Another validated
tool used by researchers is the Emergency Preparedness Infor-
mation Questionnaire (EPIQ), which was used by three
authors (Baack & Alfred 2013; Hodge et al. 2015; Ibrahim
2014). The tool was designed to capture nurses’ familiarity to
and preparedness for disasters. Other tools included the
Disaster Preparedness Questionnaire, a 26-item instrument
developed to evaluate nurses’ preparedness for disasters (Lab-
rague et al. 2016), the Personal Preparation Survey, a 27-item
questionnaire consisting of Likert scale questions related to
disaster preparedness (Goodhue et al. 2012) and the Nurse
Professional Competence scale, which is an 88-item scale that
assesses disaster nursing competence (Nilsson et al. 2016).
The majority of researchers, however, used a self-designed
questionnaire tool (Duong 2009; Fung et al. 2008; Jacobson
et al. 2010; Putra et al. 2011; Tzeng et al. 2016; Whetzel et al.
2013). These tools varied in length and measured education,
training, preparedness, knowledge and awareness.
Reported level of disaster preparedness among nurses
Despite the use of varying scales to measure disaster prepared-
ness in nurses, a common finding among the reviewed litera-
ture is that nurses are inadequately prepared for disaster
response. All studies reported that nurses had a low to moder-
ate level of preparedness (Al Khalaileh et al. 2012; Al Thobaity
et al. 2015; Baack & Alfred 2013; Duong 2009; Fung et al. 2008;
Goodhue et al. 2012; Hodge et al. 2015; Ibrahim 2014;
Jacobson et al. 2010; Labrague et al. 2016; Nilsson et al. 2016;
O’Sullivan et al. 2008;
€
Oztekin et al. 2016; Putra et al. 2011;
Tzeng et al. 2016; Usher et al. 2015; Whetzel et al. 2013).
Labrague et al. (2016) explored the perceived level of disas-
ter preparedness among staff nurses in the Philippines. The
study found that approximately 80% (n=136) of nurses rec-
ognized they were not sufficiently prepared and were not con-
fident in responding effectively to any disasters. Less than one
quarter of nurses (n=34) in the study considered themselves
to be fully prepared to respond to a disaster. Nilsson et al.
(2016) measured self-reported disaster preparedness among
registered nurses in Sweden. A mean score of 69.77 out of a
possible score of 100 was obtained suggesting that nurses
were moderately prepared to manage emergencies and disaster
events.
€
Oztekin et al. (2016) explored disaster preparedness
among staff nurses in Japan. The study reported low mean
scores for disaster readiness, disaster response and disaster
evaluation, suggesting nurses were not adequately prepared to
respond to disaster events. Tzeng et al. (2016) who explored
disaster preparedness in Taiwanese nurses also revealed low
mean scores among nurses in relation to personal prepared-
ness, self-protection, emergency response and clinical manage-
ment of disasters. These results indicate a low level of self-
reported readiness for disaster response. Interesting to note is
that higher levels of disaster readiness were reported in rela-
tion to clinical management, while lower scores were reported
in relation to the self-protection domain.
In two separate studies conducted in Saudi Arabia to assess
knowledge on disasters among nurses working there, nurses
perceived themselves to be moderately prepared for disaster
events (Al Thobaity et al. 2015; Ibrahim 2014). Usher et al.
(2015) explored disaster preparedness, knowledge and skills of
nurses in a number of Asian-Pacific countries and reported
that nurses in Bangladesh and Laos felt unprepared to treat
disaster victims without the presence of the physician, while
nurses in Cambodia and Solomon Islands felt unprepared to
perform assessments related to biological and chemical agents.
Similarly, Hodge et al. (2015) explored readiness of nurses in
the United States to respond with disastrous events. Nearly
half of nurses (44.6%) rated themselves as unprepared for any
disasters.
Baack & Alfred (2013) assessed disaster preparedness in 620
staff nurses in the United States. The study found that nurses
obtained a mean score of 90 out of possible score of 205 on
the EPIQ suggesting a suboptimal competence in responding
to disaster events. A study conducted by Whetzel et al. (2013)
examined individual emergency and disaster preparedness in
emergency nurses in the United States using a self-designed
survey questionnaire. The questionnaire was designed based
©2017 International Council of Nurses
8 L. J. Labrague et al.

on a review of literature and clinical expertise. Nurses were
asked to rate the extent to which they were prepared when
disaster occurs. Less than 50% (n=79) of the respondents
indicated they were fully prepared to provide direct patient
care during disaster situations.
Al Khalaileh et al. (2012) explored preparedness of nurses
in Jordan and found that around 65% of nurses rated their
state of disaster preparedness as low or poor. Specifically,
these nurses rated themselves as inadequately prepared in
areas of disaster response such as conducting comprehensive
health assessments relative to chemical and biological agents
as well as undertaking organizational logistics and roles.
Goodhue et al. (2012) who explored disaster preparedness
among paediatric nurses in United States revealed that more
than 90% (n=641) of the participants in their study felt
unprepared to respond either to man-made or natural disas-
ters. Jacobson et al. (2010) explored disaster preparedness
among rural nurses and found that 60% (n=546) of nurses
in their study reported that they are not adequately prepared
to participate in disaster response and are not ready to care
for disaster victims.
In Indonesia, Putra et al. (2011) explored readiness for disas-
ters in a group of public health nurses. The study found that
nurses displayed a moderate level of readiness for disaster
response specifically in areas related to identifying disaster
prone/risk areas, recognizing command structure during disas-
ter and reporting. Duong (2009) explored disaster knowledge
and awareness among emergency nurses in Australia. The study
concluded that nearly half (45%) of nurses in perceived them-
selves to be poorly prepared for disasters. Fung et al. (2008)
who explored disaster preparedness among registered nurses in
Hong Kong reported that a large proportion (n=159) of the
participants in their study stated that they are ill-prepared to
respond when a disasters strikes with only 3% (n=5) express-
ing confidence in their own personal preparedness. O’Sullivan
et al. (2008) assessed Canadian nurses’ perceptions of disaster
preparedness. Nurses Respondents were asked to indicate in a
4-point Likert scale their preparedness to natural disaster,
nuclear attack, chemical weapons attack, disease outbreak and
radiological attack. Low preparedness was observed predomi-
nately in relation to chemical, biological, radiological and
nuclear (CBRN) events with higher levels of preparedness
reported in relation to responding to infectious disease out-
break. Overall, the authors concluded that participants were
inadequately prepared to respond to disaster situations.
Previous disaster response experience
Six studies associated previous disaster response experience
with a higher perceived level of disaster preparedness (Al
Thobaity et al. 2015; Baack & Alfred 2013; Nilsson et al.
2016; O’Sullivan et al. 2008; Tzeng et al. 2016; Usher et al.
2015). For example, Baack & Alfred (2013) reported that
nurses’ previous experience with major disasters influenced
their perceived competence in disaster preparedness. This is
consistent with findings of O’Sullivan et al. (2008) who
found that nurses’ with previous exposure to infectious dis-
ease outbreaks including the 2009 Severe Acute Respiratory
Syndrome (SARS) had a higher perception of disaster pre-
paredness. Al Thobaity et al. (2015) reported that a quarter
of the nurses in their study attributed the main source of
disaster knowledge and skills to previous involvement in
actual disaster events and Tzeng et al. (2016) reported that
previous disaster response experiences, disaster-related train-
ing and military experiences predicted a higher level of per-
sonal disaster preparedness in nurses. This aligns with a
finding by Usher et al. (2015) that advanced age, disaster
education and training and previous disaster involvement
was a predictor for increased disaster competence and pre-
paredness in nurses. In one study, nurses who had experi-
ence working in emergency units reported higher readiness
for disasters (Nilsson et al. 2016). This finding was attributed
by the author to nurses’ previous experience of handling
emergency and disaster victims.
The role of disaster training or courses
Five studies highlighted the role of disaster-related training
as an effective way in which nurses can enhance their disas-
ter knowledge and skills (Al Thobaity et al. 2015; Fung et al.
2008; Labrague et al. 2016;
€
Oztekin et al. 2016; Tzeng et al.
2016). For example, Tzeng et al. (2016) found that nurses
who had previously undertaken disaster training reported
higher personal preparedness for disaster response. Similarly,
the majority of respondents in a study by Al Thobaity et al.
(2015) reported that most of their disaster management
knowledge and skills where acquired from actual drills and
disaster trainings. These findings align with
€
Oztekin et al.
(2016) who revealed that regular disaster or emergency drills
were helpful in preparing nurses to respond to disasters. In
separate studies conducted in the Philippines (Labrague
et al. 2016) and Hong Kong (Fung et al. 2008), nurses iden-
tified first aid training, field triage, advanced basic life sup-
port and infection control as training needs that are
essential in preparing nurses for disaster response. In addi-
tion, real-time exercises, desk top exercises, pre-hospital life
support and practice drills and scenarios were also cited as
necessary experiences to adequately prepare nurses to
respond to disaster situations (Duong 2009; Labrague et al.
2016). In one study, nurses expressed preference for an
©2017 International Council of Nurses
Disaster preparedness in nurses 9

instructor led, small group disaster workshop online (Jacob-
son et al. 2010).
Awareness of and execution of workplace disaster plans
Seven studies discussed nurses’ awareness of their workplace
disaster protocols or plans as a factor in disaster preparedness
(Al Khalaileh et al. 2012; Duong 2009; Fung et al. 2008; Ibra-
him 2014; Labrague et al. 2016;
€
Oztekin et al. 2016; Whetzel
et al. 2013). The majority of nurses in five studies (Duong
2009; Fung et al. 2008; Ibrahim 2014;
€
Oztekin et al. 2016;
Whetzel et al. 2013) reported an awareness of the existence of
a disaster management protocol in their workplace. However,
in spite of their awareness, one quarter of nurses in the
Whetzel et al. (2013) study had not read the plan and 10%
(n=17) did not know how to locate the plan. In other stud-
ies, 42% (n=72) of participants stated they were aware a
plan existed (Labrague et al. 2016) and 80% (n=379) of
nurses in Al Khalaileh et al. (2012) study were not confident
in executing the plan or protocol. Similarly, less than 50%
(n=685) of Canadian nurses indicated their workplace has a
formal emergency plan and most of the respondents were
uncertain regarding the existence of adequate institutional
policies and programs for large-scale disasters (O’Sullivan
et al. 2008). In Saudi Arabia, 39.2% (n=99) of nurses did
not know whether their hospital disaster plan is periodically
updated (Ibrahim 2014). Nearly half (46%) of nurses in
Duong’s study stated they have not read their hospital plan.
Strategies to enhance disaster preparedness
Several recommendations aimed at enhancing preparedness in
nurses were put forward in the literature. Both Labrague et al.
(2016) and Baack & Alfred (2013) suggested offering nurses
opportunities to participate in disaster training and actual
drills to improve their confidence and familiarity in respond-
ing to disasters. Other authors recommended improving dis-
aster preparedness for multiple disaster scenarios, especially
for attack scenarios through extensive trainings and drills,
and offering in-house nursing education to meet nurses’ need
for disaster preparedness (Duong 2009; O’Sullivan et al. 2008;
€
Oztekin et al. 2016). Involvement in institutions’ disaster
planning was suggested by Goodhue et al. (2012) along with
the provision of all-hazards disaster training opportunities for
all nurses. Alternatively, Nilsson et al. (2016) and Ibrahim
(2014) suggested providing nurses with disaster exercises
based on realistic threats and simulation as a way of enhanc-
ing their disaster competence and readiness. Hodge et al.
(2015) suggested the development of an emergency prepared-
ness course for nurses that includes self-study modules built
upon essential disaster competencies.
Discussion
The most significant finding from this review is that nurses
are ill-prepared for disaster response. When this finding is
considered in relation to the fact that most of the research
originated from Asian countries (Al Khalaileh et al. 2012; Al
Thobaity et al. 2015; Fung et al. 2008; Ibrahim 2014; Labra-
gue et al. 2016;
€
Oztekin et al. 2016; Putra et al. 2011; Tzeng
et al. 2016; Usher et al. 2015), which have the highest
reported incidences of disaster events, this emphasizes the
need for further research originating from other countries
and nursing populations with less experience with disaster
response. A disaster can potentially occur anywhere at any
time in any community. Nurses therefore need to be prepared
to respond so that negative consequences on the affected pop-
ulation can be mitigated. A wider cross section of research
that explores nursing preparedness worldwide could better
inform nurses’ preparedness for disasters.
While the literature reports that there is a general lack of
disaster awareness among nurses, this is largely perception-
based and does not necessarily rely on objective data. Many
of the tools that were used to determine preparedness were
based on nurses self-reporting their perceptions of prepared-
ness. This highlights the need for more research that explores
what factors predict low preparedness for actual disaster
response.
Consideration of the methodology used throughout the
reviewed literature emphasizes the necessity for a more rigorous
approach to research that explores nursing preparedness for
disaster response. Major variability was noted in the instru-
ments used for data collection. Only four studies used a vali-
dated tool that specifically aimed to measure disaster
preparedness in nurses, the Disaster Preparedness Evaluation
Tool (DPET; Al Khalaileh et al. 2012; Al Thobaity et al. 2015;
€
Oztekin et al. 2016; Usher et al. 2015). The DPET, which was
developed by Tichy et al. (2009), is designed to capture nurses’
disaster knowledge, skills and disaster management and
response. Other instruments used were not specific to assessing
disaster preparedness in nurses. Variability was also noted in
the content and structure of the instruments. In most studies
reviewed, disaster preparedness in nurses was explored through
the use of a single item/question only. According to Slepski
(2005), disaster preparedness consists of competencies (disaster
knowledge and skills) that are required to respond effectively to
disaster events. This raises the question as to whether a single
item/question is sufficient enough to capture nurses’ prepared-
ness levels. Certainly, this raises some concern and doubts on
the preciseness of nurses’ responses.
Only four studies (Al Thobaity et al. 2015; Baack & Alfred
2013; Nilsson et al. 2016; Putra et al. 2011) conducted a
©2017 International Council of Nurses
10 L. J. Labrague et al.

power analysis to determine the sample size. Moreover, only
one study utilized rigorous sampling (Putra et al. 2011), while
the remaining studies used convenience sampling
(Al Khalaileh et al. 2012; Al Thobaity et al. 2015; Baack &
Alfred 2013; Duong 2009; Goodhue et al. 2012; Ibrahim 2014;
Nilsson et al. 2016; O’Sullivan et al. 2008;
€
Oztekin et al.
2016; Putra et al. 2011; Usher et al. 2015). The utilization of
convenience sampling may have influenced the generalizability
of the findings. A rigorous sampling method may yield different
results. Future studies should be conducted utilizing a rigorous
sampling method with a large enough sample size to make the
results applicable and transferable to other settings.
It is difficult to independently generalize the findings from
the majority of the studies because eight of the studies used
samples from one location or hospital. This limits the find-
ings of each study to one homogenous culture. While the
findings may not individually be transferable across popula-
tions, considered as a whole, the findings of all the studies
generally support each other in recognition of the fact that
nurses across different cultures and regions feel generally
under-prepared for disaster response. Again, a wider cross
section of studies might further support this finding.
Despite the methodological challenges identified in this review,
it was clearly evident from these studies that nurses are feeling
generally unprepared and insecure in responding effectively to
disasters. This is reflected in findings from other studies that
explore nurses’ experiences of disaster response (Arbon et al.
2006; Corrigan & Samrasinghe 2012; Hammad et al. 2012). The
preparation of nurses for disaster response is considered an ethi-
cal and humanitarian requirement (Turale 2014). Nurses, as the
largest healthcare workforce group have a major role in disaster
response and should therefore have a basic understanding of dis-
aster science and be equipped with competencies to better sup-
port their response to disaster situations (Tichy et al. 2009;
Turale 2014). These findings therefore challenge nursing educa-
tors and hospital administrators to bridge the gap between disas-
ter knowledge and skills into preparedness.
Another finding of this review was that previous disaster
response experience to actual disaster events and having disas-
ter-related training and exercises is seen as important in
preparing nurses for disasters. However, it is not clear from
the reviewed research what type of disaster-related training is
effective in adequately preparing nurses. Nevertheless, view is
supported in other literature that highlights the relevance of
adequate education and training relative to disasters in
improving individual perceptions of preparedness (Corrigan
& Samrasinghe 2012; Hammad et al. 2012).
The present review also demonstrates a lack of awareness
in relation to institutional disaster plans. Although many
nurse respondents in this review were cognizant of the exis-
tence of a workplace disaster protocol/plan, they were unclear
of their role and most of them felt incapable regarding execu-
tion of the disaster plan. This highlights the need for nurses
to be actively involved in all stages of disaster planning, so
they can have a better perspective of their roles and responsi-
bilities during disaster events (Achora & Kamanyire 2016).
Recommendations
The findings of this review contribute to a growing body of
knowledge regarding disaster preparedness in nurses and have
implications for nursing administration, practice, and academia.
Implications for nursing policy
Identification of factors that contribute to nurses’ lack of pre-
paredness for disaster response such as a lack of awareness of
institutional plans as well as the relevance of disaster drills
and exercises for increasing preparedness among nurses is
critical. These findings place an emphasis on hospitals and
other healthcare settings to implement policies to address a
lack of preparedness among their employees. Doing so will
create a more confident and prepared workforce that will in
turn respond more effectively to a disaster.
Implication to nursing practice
This review also reported that nurses with previous disaster
response experience were better prepared for disasters than
those without prior experience. This finding highlights the
benefit of further research to harness the knowledge gained
from nurses who have responded to actual disaster events
for the benefit of the nursing profession as a whole. Fur-
thermore, provision of realistic disaster exercises that mimic
actual events would be useful to enhance the preparedness
of their nursing workforce. Considering the frequency and
unpredictability of disasters, periodic disaster-capacity build-
ing activities may be essential to adequately prepare nurses
to respond and better manage disasters. Such activities may
include actual mock drills, exposure to disaster simulations,
and participations and attendance in skills trainings such as
first aid training, life support training and disaster planning.
In agreement with previous authors, providing nurses with
simulation activities to improve their disaster competence
and readiness maybe an asset (Ibrahim 2014; Nilsson et al.
2016).
Implication to nursing education
The general lack of disaster preparedness among nurses that
emerged from this review highlights the role that nursing
educators can play in preparing nurses. Studies have
©2017 International Council of Nurses
Disaster preparedness in nurses 11

demonstrated that nursing curricula has a limited amount of
disaster-related content (Ranse et al. 2013a,b; Usher & May-
ner 2011). Inclusion of disaster topics into both undergradu-
ate and postgraduate curriculums can have the effect of
raising awareness among nurses. This awareness can be taken
into nurse’s everyday professional life and may support them
to seek out further training and preparedness activities.
Limitations of the study
Although this study was intended to provide foundational
knowledge related to our current understanding of disaster
preparedness among nurses, one limitation of the review was
identified. All of the studies included for review are published
in English language. This means that potentially relevant
research published in other languages was excluded. Despite
this, it is common to publish in English language journals, so
it is hoped that the majority of research relevant to the topic
has been included.
Conclusion
It is clear from this systematic review that nurses feel ill-pre-
pared to respond effectively to disasters. Exposure to actual
disaster events and provision of disaster-related training and
exercises was seen as an effective way to adequately prepare
nurses for disaster management and response. The findings of
this review offer valuable information for nurse educators,
hospital administrators and researchers in supporting nurses
to be sufficiently prepared for disaster response. However,
there is a need for further research to identify factors that
support disaster readiness and preparedness in nurses.
Acknowledgement
The authors would like to express their heartfelt thanks to Dr
Dolores L. Arteche for her expertise.
Author contributions
Study design: LL, KH, DM, DG, DF, AC, AO, ML, and EM
Data collection: LL, KH, DM, DG, DF, AC, AO, ML and EM
Data analysis: LL, DM, DG, DF, AC, EM and ML
Study supervision: LL, KH, DM, DG, and AO
Manuscript writing: LL, KH, DM, DG, DF, AC, AO, ML and
EM
Critical review for important intellectual content: LL, KH,
DM, DG, DF, AC, AO, ML and EM
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Disaster preparedness in nurses 13