Australasian Emergency Nursing Journal (2011) 14, 8794

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

RESEARCH

Emergency nurses and disaster response: An

exploration of South Australian emergency nurses
knowledge and perceptions of their roles in
disaster response
Karen S. Hammad, BN(Hons), GradDipEmergNurs, RN a,,
Paul Arbon, PhD, MEd Studies, Grad Dip Health Ed, Dip Ed, BSc RN a,
Kristine M. Gebbie, DrPH, RN b

a
Flinders University, School of Nursing and Midwifery, Flinders Drive, Bedford Park, SA 5042, Australia
b
CUNY Hunter College, School of Nursing, Park Avenue, NY, USA

Received 7 July 2010; received in revised form 1 September 2010; accepted 7 October 2010

KEYWORDS Summary The word disaster for many people conjures up images of well publicized events
such as 9/11 (2001), the London bombings (2005), Hurricane Katrina (2005) and more recently
Emergency nurse;
the Haiti earthquake (2010). For Australians, the impact of disasters closer to our shores has
Disaster;
been felt through such incidents as the Bali bombings (2002 and 2005) and the Boxing Day
Disaster education;
Tsunami (2004). Signicant events that have occurred on Australian soil include Cyclone Tracey
Disaster training;
(1974), the Granville Rail disaster (1977) and Ash Wednesday bushres (1983). Natural disasters
Emergency
such as ooding, cyclones and bushres continue to impact Australian communities. However,
department;
to date Australia has avoided a large scale disaster event that has overwhelmed the health care
Previous disaster
system.
response;
A mixed method approach underpins this study. Both quantitative and qualitative data was
Disaster knowledge
collected through a self report questionnaire. Quantitative data has provided statistic evidence
nurse
to support the ndings, while the qualitative data has allowed for a richer understanding of
nurses perceptions. The population for this study is South Australian emergency nurses working
in public hospital emergency departments in metropolitan Adelaide.
Three key themes emerged from the data. Firstly, South Australian emergency nurses have
had minimal previous disaster experience (either through a real event or simulated exercises).
Second, although a large number of nurses have completed what they perceive to be disaster
education and training, questions were raised regarding the appropriateness, relevance and

Corresponding author.
E-mail address: karen.hammad@inders.edu.au (K.S. Hammad).

1574-6267/$ see front matter 2010 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.aenj.2010.10.002
88 K.S. Hammad et al.

availability of such education. Third, South Australian emergency nurses have a low level of
disaster knowledge. The ndings from this study are relevant not only for emergency nurses, but
for all health professionals involved in disaster response. In particular for those who have had
minimal disaster response experience and limited exposure to disaster education and training
opportunities. This study suggests a disaster training program for South Australian emergency
nurses would be benecial. The need for future research into appropriate disaster education and
training for health professionals is highlighted by the study.
2010 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

that community and/or damage to property, the environ-

What is known about the topic?
There is an abundance of disaster related literature,
but very little regarding emergency nurses and disas-
ter. Particularly with regards to their knowledge and
perception their role in disaster response.
What this paper adds or contributes?
This paper adds to the body of knowledge regarding
emergency nurses and disasters. This is particularly
relevant to disaster education and training, previous
disaster response experience and disaster knowledge
amongst South Australian emergency nurses. It is
anticipated that this study will provide a founda-
tion into future studies aimed at better preparing
emergency nurses for disaster response.
Introduction
Background
To date Australia has avoided a catastrophic disaster that
has overwhelmed the health care system.13 Such an
event would have a considerable impact on the emergency
department (ED) which is considered to be at the front line
of the hospital response.4 Emergency nurses play a vital role
in executing the department disaster plan and providing
treatment for disaster victims.58 It is expected that nurses
working in the ED have the necessary skills and experience
to effectively manage every day emergencies and chaotic
situations. However, little is understood about what skills
or experience they need in order to respond effectively
when the every day work of the ED is amplied by a disaster
event. Such an event could signicantly impact a system
that is already struggling with the daily effects of stafng
shortages and overcrowding.
Denitions of the word disaster can be found in abun-
dance and vary according to who is studying the topic and
the discipline to which the persons conducting the study
belong.9 Because of the wide range of denitions, for the
purposes of this paper, the denition provided by Emergency
Management Australia (EMA), the Australian government
agency responsible for coordinating the Commonwealths
response to disaster, was utilised; A serious disruption to
community life that threatens or causes death or injury in
ment and/or economic activity that is beyond the day to day
capacity of the prescribed statutory authorities and which
requires special mobilisation and organisation of resources
other than those normally available to those authorities.10
A review of the literature demonstrated that there
are only a small amount of studies that directly relate
to emergency nurses and disasters. Existing research that
specically informs emergency nurses and disasters has
explored willingness to respond,6 needs and concerns of
emergency nurses,11 emergency department response12,13
and the experiences of emergency nurses who have been
involved in disaster response.1416 There is no current
research that explores emergency nurses knowledge and
perceptions of their roles in disaster response.
Purpose of study
This study was conducted with the aim of enhancing the
current body of knowledge regarding emergency nurses and
disaster response. It was anticipated that the study would
provide a foundation for further research into determining
what type of disaster education and training would benet
emergency nurses. The study explores South Australian (SA)
emergency nurses knowledge and preparedness for disaster
response in the acute setting.
Method
Study design
A questionnaire was chosen as the data collection tool. The
questionnaire elicited both qualitative and quantitative data
through different questioning styles. In an effort to gain a
deeper understanding of nurses opinions, open ended ques-
tions were included in the questionnaire. The use of open
ended questions allowed participants to use their own words
thus providing a deeper understanding of the population that
may not have been gained from the use of a quantitative
questionnaire alone.
Participants and setting
Public hospitals were the focus of this study and the ED
of eight public hospitals in metropolitan Adelaide provide
the setting for this research. South Australian emergency
nurses were chosen as the population for this study. There
were 4432 critical care/emergency nurses employed in SA
in 2007.17 At the time the study was conducted there were
Emergency nurses and disaster response
588 Registered Nurses (RN) employed in public hospital ED
in metropolitan Adelaide. This number includes nurses who
were on leave at the time the survey was circulated.
Ethics
Approval to conduct the proposed research was initially
sought from individual department heads, Clinical Service
Coordinators and Nurse Managers. Ethics approval was then
gained from research committees representing each of the
eight different sites.
Data collection
A self designed questionnaire was chosen as the data collec-
tion tool for this study. A thorough search did not identify
an existing survey tool that would suit the purposes of
this study. The questionnaire was piloted amongst a group
(n = 10) of senior emergency nurses. Following this, minor
grammatical changes were made to the questionnaire. The
questionnaire was circulated to RN via individual pigeon
holes. RN had a period of four weeks to complete the ques-
tionnaire and return it to a designated box in the ED.
The questionnaire incorporated ve main areas of ques-
tioning; demographics, knowledge, awareness, previous
disaster response experience and roles of nurses in disas-
ters. As data was collected it was entered verbatim onto a
Microsoft Excel database. Missing responses from the data
were also noted in the database.
Data analysis
Data was analyzed using sum, percentage, frequency distri-
butions and measures of central tendency. Thematic analysis
was also used for the analysis of all the open ended and short
answer questions. Individual words, word combinations and
themes were manually extracted from the data and cate-
gorized. Both explicit and implicit themes were extracted
from the data.
Table 1 Participants responses to knowledge test on disaster misconceptions.
Statement
Disasters kill people without respect for social class
or economic status in a disaster.
Most people behave rationally in a disaster.
The poor and marginalized are more at risk of death
than the rich people or the middle classes in a
disaster.
Looting is a common problem following disasters.
All victims of a CBR (chemical biological radiological)
incident will be decontaminated at the scene of an
incident prior to their arrival to hospital.
Un-buried dead bodies will create a disease epidemic
following a disaster.
The majority of casualties from a disaster will arrive
to your emergency department via the SAAS (SA
Ambulance Service).
89
Results
Demographic data
A total of 588 questionnaires were circulated, 194 were
returned resulting in a response rate of 32.9%. The demo-
graphic ndings paint a prole of emergency nurses that is
not dissimilar from the state and national nursing popula-
tion. Emergency nurses in this study are aged between 21
and 59 years with an average age of 36 years. 65% (n = 112) of
nurses have been working in their current ED between 0 and
5 years and over half (52%, n = 98) have been employed in the
eld of emergency nursing for 05 years. Most nurses in this
study (77%, n = 136) work seven or more shifts a fortnight.
Although females account for the majority of the nurses
in this study, the proportion of males was double that of
national and state averages. Nearly one quarter (23%, n = 39)
of the emergency nurse participants in this study are male,
compared with a national average for nurses in all elds and
specialties combined, of 9.6%.17
Level one RN make up the bulk of participants in this
study (77%, n = 132). In SA there are six RN and Midwife
classications.18 A level one RN is the lowest classication
on the hierarchy.18 Level one RN include new graduates and
nurses who do not hold managerial positions. There were 16%
(n = 27) level two/Clinical Nurses. Nurses in this classica-
tion provide advanced nursing services and are accountable
for their own practice standards, activities delegated to oth-
ers and the guidance and development of less experienced
staff.18 There were 6% (n = 10) level three/Clinical Practice
Consultant nurses. In broad terms these nurses provide clin-
ical nursing expertise and leadership.18 There was only 1%
(n = 1) level four/Advanced nurse in this study. Nurses in this
classication may practice beyond the usual extent of nurs-
ing scope of practice and are autonomous clinical decision
makers, working independently and collaboratively in the
health care system.18 There were no level ve or level six
banded RN in this study. The nurses in this classication are
directors of health units and directors of nursing.18 The large
number of level one and two RN is an indication that most
Response rate Correct answer Agree (%) Disagree (%)
100%, n = 194 Disagree 94 6
100%, n = 194 Agree 12 88
99%, n = 193 Agree 43 57
99% n = 194 Disagree 92 8
97%, n = 191 Disagree 25 75
97% n = 191 Disagree 86 14
99%, n = 193 Disagree 27 73
90
Who nurses take orders from during a disaster
response
unclear (n=86)
nursing (n=35)
medical/nursing (n=34)
medical (n=16)
hospital executive (n=6)
emergency services (n=2)
0 10 20 30 40 50
percentage of nurses
Figure 1 Who nurses believe they will take orders from during
a disaster response.
nurses in this study are involved in direct patient care and
will play a signicant role in disaster response.
Disaster knowledge and awareness
The questionnaire started with a knowledge test adapted
from a study by Alexander.19 The purpose of this was to cap-
ture the participants attention and focus them toward the
topic at hand disaster response. Participants were asked
to agree or disagree with seven statements which were
designed to test the participants knowledge of common dis-
aster misconceptions. A percentage score was established
by determining how many nurses responded correctly. 15%
(n = 30) scored above the chosen pass mark of 50%, with only
4% (n = 8) scoring 100%. Most nurses (85%, n = 164) failed the
knowledge test with a score of less than 50% (see Table 1).
Nurses appeared to be unclear regarding command struc-
ture (see Fig. 1). Almost half (48%, n = 86) were unclear as
to who they would take orders from during a response. Many
responses to this question were ambiguous regarding the
chain of command or the ofcial title of the person they
would take orders from. The suggestion by nurses that they
would take their orders jointly from nursing and medical
staff (19%, n = 34) indicates not only confusion as to who
orders would be taken from, but also may lead to confusion
on the oor.
Nurses also displayed confusion regarding their likely role
in a disaster. Responses fell into four categories: typical
nursing roles or allocations (29%, n = 49), dependant on the
disaster and the day (14%, n = 24), general roles (49%, n = 83)
and other (8%, n = 4). Again, response were vague referring
to general nursing duties such as; treating patients, care
of injured patients and clinical care, or to general all
encompassing titles such as: senior nurse, junior nurse
and Registered Nurse.
Disaster education and training
Hospital education sessions were the most common form
of disaster related education/training that nurses had
completed (69%, n = 134). Other forms of disaster educa-
tion/training included; post graduate studies (33%, n = 64);
Major Incident Medical Management and Support Course
(13%, n = 25); Emergo Train (10%, n = 20); online education
(7%, n = 13); military training (5%, n = 9) and Emergency
Management Australia courses (5%, n = 9). Just under half
K.S. Hammad et al.
When participants last attended disaster training
percentage of participants
35
30
25
20
15
10
5
0
<6 months >6months >12months >2 years none (n=35)
60 (n=11) (n=56) (n=40) (n=43)
frequency of training
Figure 2 When participants last attended disaster training.
(43%, n = 83) had undertaken more than one form of disaster
education/training. Of these, 86% (n = 71) included hospi-
tal education sessions in their response. Fourteen percent
(n = 26) of nurses have not completed any form of disaster
education, the majority of these nurses (n = 22) had been
practicing for 05 years as emergency nurses.
Although the majority of nurses have completed some
disaster education/training, the frequency of this training
appears to be limited (see Fig. 2). Just under half of the
nurses (42%, n = 83) reported that they have not received
any disaster training for 12 months or more. While a further
18% (n = 35) have not received any disaster training at all.
Previous disaster experience
Two thirds (70%, n = 124) of nurses in this study have not
previously been involved in a disaster response. Of the
remaining nurses (30%, n = 53) who stated they had been
involved in a disaster response, 40% (n = 21) provided exam-
ples of events that were not declared a disaster and 17%
(n = 9) provided examples of major international events such
as the London Underground Bombings (2005), Bali Bombings
(2002 or 2004) and SARS (2003). It is unclear in what capac-
ity nurses were involved in these disasters as the survey did
not specically ask for this information. More than half of
those who stated they had been previously involved in a dis-
aster response (55%, n = 29) cited examples that were not
recognized disaster events or were not specic.
Involvement in disaster exercises is also minimal amongst
the participants. The majority (62%, n = 112) have not been
involved in a disaster exercise during their current employ-
ment. While a further 22% (n = 39) have been involved in
only one disaster exercise at their present employment (see
Fig. 3). The majority of these nurses have been working in
Percentage of nurses who have been involved in
a disaster exercise in their current employment
twice three +
5% 9%
no
once
once
twice
22% no three +
64%
Figure 3 Percentage of nurses who have been involved in a
disaster exercise during their current employment.
Emergency nurses and disaster response
their current ED for between 0 and 5 years. Of those that
have never been involved in a disaster exercise in their cur-
rent employment 12% (n = 22) have been working in their
current ED for between 6 and 20 years.
Discussion
Three key ndings emerged from the data. Firstly South Aus-
tralian emergency nurses have had limited previous disaster
response experience (real event or simulated exercise).
Secondly, although the majority of nurses appear to have
completed disaster education and training, questions have
been raised regarding the appropriateness and relevance
of this education. The third main nding from the study is
that South Australian emergency nurses have a low level of
disaster knowledge.
Previous disaster response experience
South Australian emergency nurses have had minimal expo-
sure to disaster response. This is demonstrated through the
ndings of this study as well as by existing literature.13,2022
Of the nurses in this study who stated they had been involved
in a disaster response, only a small number cited examples
of true disasters all of which had occurred internationally.
Although this would provide insight for nurses regarding
the realities of disaster response, expectations will differ
slightly with regards to policies and procedures of a disaster
response within the Australian health care system.
Where nurses responded that they had been involved in
disaster response and did not indicate a recognized disaster
event, responses were non specic and included examples
such as; bus crash, organophosphate exposure, and ED
evacuation. These responses are comparable with ndings
published by Duong and demonstrate a limited understand-
ing by nurses of the true meaning of a disaster.20
With minimal previous disaster response experience the
importance of exercises to provide nurses with insight into
the realities of disaster response is highlighted. Disaster
exercises provide nurses with a realistic expectation of how
a disaster event would progress which also provides them
with the opportunity to test systems and protocols that will
be relied on in a real life situation. Programs such as Emergo
Train24 provide health professionals with exercises run in
real time that essentially mimic the ow of a real disaster
event. It is important for hospitals to maintain frequency in
scheduling their exercises. Regular disaster drills, will keep
patterns ingrained and staff prepared.23
Although the Australian government has not published
any guidelines regarding the frequency or nature of disaster
training for hospitals, international guidelines do exist.25,26
The Joint Commission on the Accreditation of Health Organi-
zations (JCAHO) has set expectations regarding emergency
planning and minimum numbers of exercises annually. 26 The
Australian equivalent of JCAHO, the Australian Council on
Health Care Standards (ACHS) also provides an accreditation
program for health care organizations to ensure safety and
quality improvement. The ACHS has determined that hospi-
tals need to maintain safe practice and a safe environment
for employees, consumers/patients and visitors with regards
to emergency and disaster management.27 However there
91
does not appear to be any guidelines as to what hospitals
should do to ensure this.
Previous exposure to disaster events creates a better
prepared and more condent workforce.15,2834 Due to min-
imal exposure to disasters South Australian nurses may have
unrealistic expectations of disaster response. A more serious
implication is that involvement in future disaster response
may contribute to a high rate of stress reactions and mental
health issues for emergency nurses. Previous studies have
reported that nurses who have been previously involved
in disaster response had the advantage of experience and
knowledge, which resulted in diminished feelings of inade-
quacy and fear.15 On a background of minimal involvement
in disaster response, regular disaster exercises will provide
nurses with knowledge of what to expect, realistic expecta-
tions and a feeling that they are prepared to handle a similar
situation in the future.
Disaster education and training
The primary source of disaster related education is from hos-
pital education sessions (74%, n = 143). Hospital education
sessions are site based, providing a low cost option of edu-
cation delivery to the workforce. These sessions meet a need
for the staff that require education, and almost certainly for
the individual hospitals that need to fulll certain accredita-
tion requirements, by providing low cost, on site education.
Hospital education sessions are not centrally administered
and therefore vary from hospital to hospital; making dis-
aster education inconsistent amongst the emergency nurse
population. It remains unclear as to what exactly hospital
education sessions entail, who runs them, what qualica-
tions they have, how frequently the sessions are run, what
the content is or how evidence based it is as this information
was not captured by the questionnaire.
The fact that the majority of nurses have completed
some sort of disaster education does paint the provi-
sion of disaster education/training for nurses in South
Australia in a positive light. What remains unclear is the
frequency of disaster training. Disaster plans need to be
updated regularly to allow for system changes and staff
turnover. Disaster education and training should reect
this and be provided regularly so that health profession-
als are kept abreast of latest changes. Despite this, 42%
(n = 83) of nurses reported that they have not received
any disaster training for 12 months or more. While a fur-
ther 18% (n = 35) have not received any disaster training
at all. This number has decreased somewhat since Duong
conducted her study in 2006 where 39% (n = 60) of the
population had never attended disaster training or educa-
tion and therefore suggests either an improvement in the
provision of disaster education with time or the percep-
tion by nurses that the education they have received is
adequate.20
Where nurses were provided with room at the end of
the questionnaire to comment further on emergency nursing
and disaster more than half of the responses (55%, n = 23)
made mention of disaster education and training. These
statements revolved around limited availability of training,
the need for appropriate training, the need for a larger
proportion of staff to attend training and a lack of commit-
92
ment from state government and hospital administrators.
Similar comments were also scattered throughout the ques-
tionnaires. This is an indication that nurses feel they are not
receiving enough disaster education/training, a feeling that
is supported by the ndings of the study.
On a background of minimal previous disaster response
experience (real or simulated) health professionals need
to be provided with appropriate education and training,
so as to better prepare them. This would be informed by
future research aimed at identifying what current training
programs provide as well as barriers for nurses seeking edu-
cation and training. It appears however, that provision of
disaster education and training is at best haphazard across
the board. There is no distinct structure in the provision of
standard education for all nurses. Although a large number
of nurses have completed education, it remains uncertain
as to the appropriateness, frequency or content of current
education/training models.
Disaster knowledge
A low level of global knowledge was demonstrated by the
poor performance in the knowledge test at the beginning
of the questionnaire. Common belief in disaster miscon-
ceptions is an effective barrier to the teaching of disaster
education.19 This needs to be considered when determining
appropriate and effective disaster education and training for
health professionals in the future. An overwhelming major-
ity of participants failed the knowledge test with a score of
less than 50%. This suggests a low level of general disaster
knowledge and may act as a potential barrier to effective
training.
Perhaps one of the most obvious indicators of the lack
of disaster knowledge exhibited by the nurses is the confu-
sion that exists surrounding roles and command structure.
This demonstrates a lack of understanding around local prac-
tices. Widespread confusion regarding local policies and
practices during disaster response raises questions regard-
ing the content of current education and training. The
failure to educate on local practices could have interest-
ing implications on the oor during a disaster response if
there is not a correctly delineated command structure or
health professionals are unsure of their role. Regular disas-
ter drills would provide nurses with a clear understanding
of the local response, including roles, responsibilities and
command structure. An understanding of the local response
is essential to ensuring that nurses are prepared.23 This
becomes even more vital on the current background of min-
imal exposure to disaster response.
Competencies for RN responding to mass casualty events
have been published internationally.35,36 The International
Council of Nurses (ICN) in association with the World Health
Organisation (WHO) has published Disaster Nursing Compe-
tencies that provide guidance on the range and level of
knowledge, attitude and skills for nursing in disaster.37 In
the absence of a set of core competencies for Australian
nurses responding to disasters.22 The Australian Nursing and
Midwifery Council (ANMC) has set guidelines which pro-
vide information regarding legal parameters of practice,
licensure and competencies.38 According to these guide-
lines, nurses should be able to describe or be familiar with
K.S. Hammad et al.
the chain of command in emergency response, emergency
response functions and roles and demonstrate them in regu-
larly performed drills.38 If the above mentioned ndings are
anything to go by, South Australian emergency nurses do not
meet either the ANMC or the ICN standards.
Recommendations
Recommendations for future research
The paucity of literature regarding emergency nurses and
disasters demonstrates a signicant gap and need for fur-
ther research into understanding the role of emergency
nurses and disasters. The study demonstrates the association
between disaster response experience and disaster educa-
tion and training and the effect that inconsistencies and
limitations in these areas can have on overall knowledge and
condence. Future research will be informed by examining
the availability, content, cost and process of relinquishing
staff for disaster education and training, as well as further
exploring the role of emergency nurses in disasters. Doing
so may assist in helping to create a better prepared and
condent workforce.
Recommendations for clinical practice
It is time the Australian government gave more commitment
to the preparedness of frontline health care professionals.
Minimum standards for disaster preparedness of Australian
hospitals need to be determined. This will ensure an amount
of standardization in disaster preparedness, not only on a
state level but also nation wide. A set of minimum compe-
tencies for nurses needs to be determined and adhered to
also. In the absence of this it is important that individual
ED and hospitals ensure that staff are exposed to adequate
disaster education and are involved in regular disaster exer-
cises. By doing so, hospitals will be ensuring that staff have
more realistic expectations of disaster response as well as
appropriate knowledge and understanding of local practices
and policies. More importantly, staff will feel more condent
in their ability to respond effectively.
Limitations
The ndings discuss the type of disaster education and train-
ing that nurses have completed but fail to determine exactly
what the stated education or training involves. The involve-
ment of study participants in previous disaster response was
also explored, however the study fails to identify in what
context participants were involved in the response.
Conclusion
There is an expectation among the wider community that
emergency nurses will be prepared and will cope with a dis-
aster situation; dealing with emergencies is what they do
every day, it is what they have been trained to do. What
is overlooked however is that a disaster event will amplify
the everyday work of the ED and nurses will be exposed to
Emergency nurses and disaster response
large numbers of patients presenting within shorter periods
of time. Combined with this is the affect of the disaster
event on the community at large as well as the individual
nurse and their ability and willingness to respond.
South Australian emergency nurses have had minimal
exposure to disasters (through real events or simulated
exercises) to provide them with realistic expectations of
their role in disaster response. This highlights the need for
appropriate and consistent disaster education and train-
ing. However, the study demonstrates that South Australian
emergency nurses have not received appropriate or consis-
tent disaster education and training. These may be factors
contributing to an overall low level of disaster knowledge
and confusion regarding local policies and practice, amongst
South Australian emergency nurses.
The study demonstrates that South Australian emergency
nurses have not been adequately prepared for disaster
response and highlights not only the importance of future
research regarding disaster education and training, but also
the immediate need for individual hospitals, government
organizations and peak health bodies to address disaster and
emergency preparedness for frontline health professionals.
Australia has so far escaped a large scale disaster event
that has overwhelmed the health care system. When the
inevitable happens, it is essential that front line health pro-
fessionals, including emergency nurses feel condent and
are prepared to respond.
Provenance and competing interests
No competing interests declared. This paper was not com-
missioned.
Funding
No funding was used for this study.
Acknowledgements
Many thanks go to the emergency nurses who took time out
of their already busy work days to complete the question-
naire.
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