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Feature

Are emergency care staff


prepared for disaster?
Jennifer Worrall discusses findings from a review
of emergency preparedness among nurses and
healthcare assistants at two minor injuries units
Correspondence
Disasters are often unpredictable, and their
jennifer.worrall@wiltshire.nhs.uk Abstract
frequency and magnitude are escalating (Hoyois et al
Jennifer Worrall is an When disasters occur, nurses of all specialties 2007). The multidimensional nature of disasters are
emergency nurse practitioner
at Trowbridge minor injury unit,
require the appropriate knowledge and skills such that nurses in all specialties must be prepared
Trowbridge Hospital, Wiltshire to respond effectively and efficiently. To assess to respond and assist in various capacities (Cole
the extent to which nurses in the US are prepared 2005, Douglas 2007, Reilly and Markenson 2009).
Date of acceptance
December 12 2011
for emergencies, researchers have developed the Dealing with emergencies requires
Emergency Preparedness Information Questionnaire ‘comprehensive knowledge, skills, abilities and
Peer review (EPIQ), in which participants are invited to actions’ (Slepski 2005), and there are concerns
This article has been subject
to double-blind review and
assess their familiarity with aspects of emergency that some nurses are unprepared to meet
has been checked using preparedness. This article discusses a pilot study of these requirements (Veenema 2006). Although
antiplagiarism software the use of the EPIQ among minor injury unit nurses preparedness for all eventualities is impossible
Author guidelines
and healthcare assistants in the UK. The results to achieve (Rebman 2006), nurses should have a
www.emergencynurse.co.uk suggest that the principle of the EPIQ is sound basic understanding of the logistics of managing
but that it should be adapted to cater for different disasters, when clinical facilities can soon become
disaster situations and the needs of individual overwhelmed by events (Pelaccia et al 2008).
nurses. Terms that describe disasters and large-scale During disaster situations, Powers (2009) suggests,
emergency situations are often used interchangeably between 66 and 93 per cent of patients self‑present
so, to avoid confusion, this article uses ‘disaster’ to healthcare facilities, typically within 30 minutes
to refer to all such events. of a disaster having occurred and without facility
staff having received prior notification. It may be
Keywords assumed, therefore, that minor injury unit (MIU)
Minor injury unit nurses, emergency preparedness nurses are more prepared than other nurses to cope
with the effects of disasters because they see and
After the terrorist attacks on the World Trade treat patients with a wide range of undifferentiated
Center in 2001, the extent to which nurses in the conditions, most of whom self-present. However,
US were prepared for emergency situations was to assume that all MIU nurses are fully prepared to
reviewed (Slepski 2005). Similarly, events following participate in any disaster situation could undermine
the London bombings in July 2005 indicate a need disaster response plans (Considine and Mitchell 2009).
for a review of emergency preparedness among In the US, competencies for nurses’ emergency
nurses in the UK (Lockey et al 2005, Taylor 2005). preparedness have been devised by Gebbie and
Meanwhile, outbreaks of severe acute respiratory Qureshi (2002) and the Nursing Emergency
syndrome, avian flu and swine flu (Krau and Preparedness Education Coalition (2003).
Parsons 2007, Robinson et al 2009), as well as To achieve these competencies, nurses must
a host of natural global disasters, have shown be able to identify the areas of practice they must
that nurses must be ready to deal with a wide improve to become effective in disaster situations
range of disasters. (Subbarao et al 2008).

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Feature

According to Wisniewski et al (2004a),

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the ‘critical first step’ in the development of
appropriate responder capabilities among nurses
is self‑assessment of emergency preparedness.
to this end, Wisniewski et al (2004b) developed
the emergency Preparedness Information
Questionnaire (ePIQ). this comprises 45 statements
relating to eight emergency preparedness
competency dimensions. these are:
A. Incident command system.
B. triage.
C. Communications and connectivity.
D. Psychological issues and special populations.
e. Isolation, decontamination and quarantine.
f. epidemiology and clinical decision making.
G. reporting and accessing critical resources.
h. Biological agents.
Participants are asked to state their familiarity
with each of the statements by giving a score of
between 1 and 5, where 1 represents ‘very familiar’
and 5 represents ‘unfamiliar’. the ePIQ also includes
sections on learning and training preferences,
and demographic data.
Are nurses prepared for emergency events such as biological attack? Initially, 877 nurses in Wisconsin were asked
to complete the ePIQ through an online health
Meanwhile, Stanley (2005) and Weiner (2006) network and, in response to the initial findings,
have criticised nurse education programmes in appropriate state‑wide educational opportunities
the US because they fail to offer sufficient training were created to address emergency preparedness
in emergency preparedness. this criticism has (Wisniewski et al 2004a).
led other researchers to question whether nurses to evaluate the ePIQ further, Garbutt et al
in the US and elsewhere are fully prepared for (2008) asked 776 nurses to complete ePIQ through
emergencies (Garfield and Ward 2008, turale 2008, the same online health network. the researchers
fung et al 2009). reported similar findings, concluding that the ePIQ
Shortly after the attack on the World trade can be used to assess civilian nurses’ perceived
Center, the US government asked the National familiarity with emergency preparedness.
Defense research Institute to form an advisory
panel to assess domestic response capabilities for Study
terrorism involving weapons of mass destruction, to establish whether an assessment tool based
and to report its findings to the White house. on the ePIQ can be adapted to support emergency
In its fourth report, the commission, known preparedness training for healthcare staff in the
as the Gilmore Commission (2003), notes that UK, the author undertook a pilot study in which
healthcare organisations often implement workforce nurses and healthcare assistants at two nurse‑led
preparedness activities before completing needs MIUs in Wiltshire were asked to complete an adapted
assessments, including assessments of the baseline version of the ePIQ. Because some of the original
knowledge levels of staff (Gilmore Commission 2003). ePIQ terminology would have been unfamiliar to
Arguably, little has changed since this report was UK nurses, it was changed. In addition, the number
published. Criticism of a lack of scientific rigour of statements was reduced to 41, although
in disaster training for healthcare workers has these include three new statements on previous
continued (Williams et al 2008), and nurses continue emergency preparedness training. the adapted ePIQ
to report that they are unprepared to deal with is shown in table 1.
disaster situations (fung et al 2008, O’Sullivan et al Participants were asked to complete the adapted
2008, Duong 2009). this suggests that, before ePIQ twice, before and after completing a learning
disaster education and training programmes are intervention, in which they were expected to read
implemented, nurses’ awareness and understanding a book of information derived from healthcare
of emergency preparedness must be reviewed. emergency response plans and technical data

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Table 1 Adapted emergency preparedness information questionnaire

Dimension Score between 1 (‘very familiar’) and 5 (‘unfamiliar’) the extent to which are you familiar with: Score

Incident 1. The functional group in the incident command system (ICS) to which you are assigned during large‑scale
command emergency events.
system 2. The location to which you would report if a large-scale emergency event occurred.
3. Your agency’s preparedness for responding to large-scale emergency events.
4. The content of the emergency operations plan, or major incident plan, in the local primary care trust.
5. The strategic rationale for the ICS response and action plan.
6. Assessing site safety for yourself, co-workers and victims during large-scale emergency events.
7. Differences between the ICS’s decision-making processes for large-scale emergency and non‑emergency events.
8. Tasks that should not be delegated to volunteers during large-scale emergency events.

Triage 9. Performing a rapid physical assessment of a victim of large-scale emergency events.


10. Assisting with triage during large-scale emergency events.
11. Basic first aid, including oxygen administration and ventilation, during large-scale emergency events.
12. Performing a rapid mental health assessment of a victim of a large-scale emergency event.
13. Evaluating the effectiveness of your actions during large-scale emergency events.

Communications 14. The chain of custody during large-scale emergency events.


and connectivity 15. Identifying the different abilities of key partners in your emergency operation or major incident plans.
16. The procedure for documenting provision of care during large-scale emergency events.
17. Presenting information about degree of risk effectively to different audiences.
18. Appropriate debriefing activities following a large-scale emergency event.
19. Procedures for communicating critical patient information to people transporting patients.
20. The use of all types of communication devices.

Psychological 21. Signs of post-traumatic stress in patients who have been seen for routine healthcare checks following
issues and a large‑scale emergency event.
special 22. Detecting and evaluating post-traumatic stress or other mental health problems in a child or teenager.
populations 23. Appropriate psychological support for all people involved in a large-scale emergency event.
24. Providing health counselling and education to patients on the long-term impact of chemical, biological,
radiological, nuclear and explosive (CBRNE) agents.
25. The appropriate care of especially vulnerable patients during large-scale emergency events.
26. Procedures for providing care to children and younger people during large-scale emergency events
when consent cannot be obtained from their parents or legal guardians.

Isolation, 27. Selecting the appropriate personal protective equipment when caring for patients exposed to CBRNE agents.
decontamination 28. Isolation procedures for people exposed to biological or chemical agents.
and quarantine 29. Your facility’s isolation and quarantine procedures.
30. The decontamination procedures stated in your facility’s emergency operations or major incident plans.
31. The impact on the environment of large-scale emergency events.

Epidemiology 32. Assessing history and physical data when there is a high index of suspicion that a patient has been exposed
and clinical to a biological agent.
decision making 33. Identifying the exacerbation of underlying diseases due to exposure to CBRNE agents.
34. The ethical, legal, cultural and safety issues relating to the proper handling of the dead during large‑scale
emergency events.

Reporting and 35. The diseases that are immediately reportable to the Department of Health.
accessing critical 36. When unusual symptoms should be reported.
resources 37. Determining the appropriate agency to which reportable diseases are to be directed.
38. Accessing up-to-date resources quickly about specific CBRNE agents.

Biological agents 39. Modes of transmission for different types of biological agents such as anthrax and smallpox.
40. Signs and symptoms of exposure to different biological agents.
41. Assessing staff familiarity with response activities and preparedness during large-scale emergency events.

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Table 2 Familiarity scores and difference from the Health Protection Agency (Heptonstall
and Gent 2008). Participation in the pilot study
Dimension Question Mean familiarity score before Difference
number and after intervention was anonymous and the consent of participants
was assumed by their completion and return of
Before After
the questionnaires.
A Incident 1 4.12 2.72 Forty one members of staff, of whom
command system 2 3.45 2.63
3 4.37 3.09 33 are registered nurses and eight are healthcare
4 4.02 3.03 assistants, agreed to take part in the study.
5 4.45 2.96 Forty (98 per cent) participants completed the
6 3.82 2.72 questionnaires and took part in the learning
7 4.27 2.96 intervention. Of these, 33 (80 per cent) completed
8 4.00 2.54
the questionnaires again.
Mean familiarity score 3.80 2.76 1.04
B Triage 9 3.60 2.66 Results and discussion
10 3.67 2.66 After participants had provided familiarity scores
11 3.35 2.54
12 4.30 3.03 for each statement, the mean scores, as well as
13 4.10 2.93 the standard deviation and mean standard error,
Mean familiarity score 3.81 2.79 1.02 before and after the intervention were calculated.
Also calculated were the mean familiarity scores
C Communications 14 4.60 3.03
and connectivity 15 4.17 3.06 for each emergency preparedness dimension, the
16 4.25 3.09 differences between them and the mean familiarity
17 4.35 3.12 score for the questionnaire as a whole. The results
18 4.42 3.06 can be seen in Table 2.
19 4.20 2.78 The familiarity scores before and after the
20 3.45 2.81
intervention were then subject to paired t-tests to
Mean familiarity score 4.06 2.83 1.23 find out if differences between them are significant.
D Psychological 21 4.25 2.81 The results of the paired t-tests were found to be
issues and special 22 4.47 3.18 statistically significant, indicating that the adapted
populations 23 4.15 2.93
24 4.77 3.36 EPIQ is a robust instrument for assessing self-
25 4.07 3.06 reported preparedness for disasters. Intermediate
26 4.15 2.96 values used in the calculations are shown in Table 3.
Mean familiarity score 4.20 2.93 1.34 Participants’ scores before and after the
E Isolation, 27 3.85 2.87 intervention show that they are most familiar
decontamination 28 4.35 2.93 with the emergency preparedness dimensions
and quarantine 29 4.55 3.18 relating to the incident command system, triage,
30 4.32 3.24 and reporting and assessing clinical resources.
31 4.10 3.03 They recorded low familiarity scores before and
Mean familiarity score 4.23 2.99 1.21 after the intervention in two dimensions, namely
F Epidemiology and 32 4.50 3.09 epidemiology and clinical decision making, and
clinical decision 33 4.60 2.96 psychological issues and special populations.
making 34 4.35 2.96
Differences between the pre- and
Mean familiarity score 4.27 3.00 1.48 post‑intervention dimension scores indicate the
G Reporting and 35 3.45 2.57 extent to which the interventions had familiarised
accessing critical 36 3.67 2.75 participants with the relevant dimensions.
resources 37 3.97 2.78
Nine participants (23 per cent of the total
38 4.17 3.09
who took part) indicated on the pre-intervention
Mean familiarity score 4.31 3.05 1.18
questionnaires that they had received previous
H Biological agents 39 4.30 2.96 emergency preparedness training. Of these,
40 4.25 2.90
two (5 per cent) had received training in the previous
41 4.45 3.00
12 months and four (10 per cent) had received
Mean familiarity score 4.48 3.05 1.26
it in the previous three years. The remaining
Total mean familiarity score 4.1390 2.9276 1.2114 31 (78 per cent) claimed they had had no previous
Standard deviation 0.3489 0.1945 emergency preparedness training.
Mean standard error 0.0545 0.0304 The results of the study suggest that the
adapted EPIQ is a robust instrument for measuring

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self‑assessed familiarity with emergency Table 3 Paired t-test results and intermediate values used in calculations
preparedness among MIU staff. Results of the
EPIQ should be interpreted cautiously, however, Two-tailed P value and statistical significance < 0.0001
because self-assessments are by definition
subjective. Comparisons of the original and adapted Ninety five per cent confidence interval of difference 1.1395 – 1.2834
EPIQs should also be interpreted cautiously, for between mean scores
four reasons:
■■ The adapted EPIQ is accompanied by a learning t value 34.0410
intervention but the original version is not.
■■ The adapted EPIQ was delivered directly to Degrees of freedom 40
participants whereas the original version was
completed online. Standard error of difference 0.036
■■ Completing the same questionnaire in the
same format twice may have led participants and reflect on their skills. This shows that the use
to exaggerate their scores in the second of the EPIQ can highlight concerns about lack of
questionnaire needlessly. emergency preparedness but, without the inclusion
■■ In Wisniewski et al’s (2004a) and Garbutt et al’s of a learning intervention, cannot necessarily
(2008) studies, only nurses had completed the address them.
EPIQ. In the study under discussion, the adapted All participants had received instructions on
EPIQ was completed by unregistered staff too. the use of personal protective equipment (PPE)
Nevertheless, there are similarities between during influenza pandemics and all of those who
Wisniewski et al’s (2004a) and Garbutt et al’s are registered nurses had received mandatory
(2008) study results, and those of the author’s immunisation training, including the management
study. For example, the dimension with which MIU of H1N1, as part of their standard education
staff were found to be most familiar was triage, programmes. No participants referred to this
probably because this forms part of their training as ‘previous training’ in their pre-intervention
and day‑to‑day practice. Similarly, the part of the questionnaires, however, which indicates that
learning intervention that concerns triage was they, and by extension MIU staff in general, may
largely familiar to MIU staff, and so the difference not understand what constitutes emergency
in mean familiarity scores for triage before and preparedness training.
after the intervention is smaller than that for the Kerby et al (2005) suggest that many healthcare
other dimensions. workers are poor judges of their knowledge,
It should be noted, however, that the triage and that such poor judgement is not always revealed
system adopted in disaster situations can differ by single self-assessments. However, offering
significantly from that followed in conventional healthcare staff opportunities to assess themselves
emergency care settings (Castle 2006), which means can encourage them to take responsibility for
that participants in the study may have indicated their work and evaluate their decision-making
that they know more about the kinds of triage skills skills, both of which are important elements
needed in disaster situations than they do. of emergency preparedness. Pre- and post-
Participants stated that they were less familiar intervention self-assessment opportunities can also
with isolation, decontamination and quarantine, inform the development of training programmes.
and the difference in mean familiarity scores before
and after the intervention was greater than that Limitations
for triage. Again, this suggests the participants The sample size in this study is small compared with
initially considered themselves more familiar with those by Wisniewski et al (2004a) and Garbutt et al
isolation, decontamination and quarantine than (2008). Given this, and the need to preserve the
they actually were. anonymity of participants, the study includes no
The dimension with which participants were demographic data.
least familiar before undertaking the intervention, In addition, the views of the participants, all of
and in which the difference between mean pre- and whom work in nurse-led MIUs, do not necessarily
post-intervention scores was largest, concerned represent those of staff in MIUs that are affiliated
biological agents. to EDs and not led by nurses.
The differences in mean familiarity scores for Finally, it had been decided that the adapted
all the dimensions shows that, by undertaking the EPIQ’s scoring system, in which greater familiarity
intervention, participants were able to reappraise is indicated by lower scores, should be identical

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to the original version and as the EPIQ appears emergency preparedness needs of MIU nurses
online. Participants are more familiar with a is more important.
scoring system in which greater familiarity is
indicated by higher scores, and may have become Disaster trends Garbutt et al (2008) suggest that
confused. This may have the influenced results. the EPIQ can be used to survey the opinions of
It should be noted that, in Wisniewski et al’s nurses in any practice settings. In its current
(2004a) and Garbutt et al’s (2008) studies, the EPIQ format, it concerns mainly biological and chemical
was completed anonymously online and it is possible events, which may be considered a limitation, but
that some nurses took part in both studies. If so, there is scope for adapting it to reflect disaster
such nurses may have completed the second of trends and demands. In addition, the EPIQ’s
the studies inaccurately. This problem may have eight emergency preparedness dimensions can
been avoided if the studies had included learning be the framework for a modular-type training
interventions, and this should be borne in mind programme. The questions, which concern mainly
in future studies of emergency preparedness that terrorism events, can be changed to encompass
involve the EPIQ. all types of disaster, or new questions or dimensions
can be added.
Further research
Comparison The EPIQ appears to be the only Different grades The author’s study is the first
emergency preparedness self-assessment tool in which healthcare assistants have completed a
to be evaluated, so there is no similar tool with version of the EPIQ, although they are not identified
which it can be compared. The readiness estimate as such in the data analysis. Because of the study’s
and deployability index (Reineck et al 2001), small sample size, the familiarity with emergency
a self‑assessment instrument for military nurses preparedness of nurses of specific grades could not
working in austere environments, has been adapted be assessed, but should be considered as a subject
for civilian nurses (Reineck 2004) but there are of further studies.
no reports on its use. While a comparison of the The structure and content of the EPIQ should be
EPIQ with other self-assessment tools is desirable, relevant to all bands of registered and non‑registered
development of the EPIQ to reflect the diverse nurses, and should allow participants to provide

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as focus groups, may allow different perspectives to of gender on emergency preparedness.
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to reflect on their specific training needs. This could has produced useful data on familiarity with
result in a complete revision of the EPIQ to consider emergency preparedness among MIU nurses, such
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For related information, visit
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and professor of health research
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