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Nursing and Health Sciences (2015), 17, 434–443

Research Article

Cross-sectional survey of the disaster preparedness of

nurses across the Asia–Pacific region
Kim Usher, RN, RPN, A/DipNEd, BA, BHSc, MNSt, PhD, FACN, FACMHN,1
Jane Mills, RN, BNurs, MNurs, GradCertEd, MEd, PhD,1,2 Caryn West, RN, GDip Res Methods, PhD,1,2
Evan Casella, Nursing Student,1 Passang Dorji, RN,3 Aimin Guo, RN,4 Virya Koy, RN,5 George Pego, RN,6
Souksavanh Phanpaseuth, RN,7 Olaphim Phouthavong, RN,8 Jamuna Sayami, RN,9 Muy Seang Lak, RN,10
Alison Sio, RN,11 Mohammad Mofiz Ullah, RN,12 Yu Sheng, RN,4 Yuli Zang, RN,13
Petra Buettner, BSc, MSc, PhD14 and Cindy Woods, BEd, PhD2,15
1
College of Nursing, Midwifery and Nutrition, 2Centre for Nursing and Midwifery Research (CNMR), 15College of
Medicine and Dentistry, James Cook University, Cairns, Australia, 14School of Public Health, Tropical Medicine &
Rehabilitation Sciences, James Cook University, Townsville, Queensland, Australia, 3Jigme Dorji Wangchuk National
Referral Hospital, Thimphu, Bhutan, 4Peking Union Medical College School of Nursing, Shijingshan District, Beijing,
13
School of Nursing, Shandong University Jinan, China, Departments of 5Hospital Services and 10Preventative Medicine
Department, Ministry of Health, Phnom Penh, Cambodia, 6Ministry of Health and Medical Services, Horiara, Solomon
Islands, 7School of Nursing, University of Health Sciences, Lahore, 8Department of Health Care, Ministry of Health, Laos,
LAO PDR, 9National Center for Health Professional Education, Tribhuvan University, Maharajgunj, Nepal, 11National
Referral Hospital, Ministry of Health & Medical Services, Honiara, Solomon Islands and 12College of Nursing, Dhaka
University, Dhake, Bangladesh

Abstract Healthcare workers who have received disaster preparedness education are more likely to report a greater
understanding of disaster preparedness. However, research indicates that current nursing curricula do not
adequately prepare nurses to respond to disasters. This is the first study to assess Asia–Pacific nurses’
perceptions about their level of disaster knowledge, skills, and preparedness. A cross-sectional survey was
conducted with 757 hospital and community nurses in seven Asia–Pacific countries. Data were collected using
the modified Disaster Preparedness Evaluation Tool. Participants were found to have overall low-to-
moderate levels of disaster knowledge, skills and preparedness, wherein important gaps were identified. A
majority of the variance in disaster preparedness scores was located at the level of the individual respondent,
not linked to countries or institutions. Multilevel random effects modelling identified disaster experience and
education as significant factors of positive perceptions of disaster knowledge, skills, and management. The first
step toward disaster preparedness is to ensure frontline health workers are able to respond effectively to
disaster events. The outcomes of this study have important policy and education implications.

Key words Asia–Pacific, Asia–Pacific Emergency Disaster Nursing Network, disaster education, disaster nursing, disaster
preparedness, survey.

INTRODUCTION adequate to respond to such events (Collander et al., 2008;

Usher, 2010; Rokkas et al., 2014). Unfortunately, there have
An increase in disasters in the Asia–Pacific region (Fritsch &
been a number of recent claims that nurses do not possess the
Zang, 2009; Herbosa et al., 2009; Lake, 2009; Rodriguez et al.,
required competencies for this task (Slepski, 2007; Chapman
2009) highlights the need to upscale healthcare workers’ pre-
& Arbon, 2008; Collander et al., 2008; Duong, 2009; Usher,
paredness to respond when required. Nurses make up the
2010; Usher & Mayner, 2011; Khalaileh et al., 2012; Jiang
majority of frontline responders in disasters, so it is particu-
et al., 2015). While the same claim can be levelled at other
larly important to ensure that their knowledge and skills are
healthcare workers, including doctors (Corrigan &
Samrasinghe, 2012), the need to improve the preparedness of
Correspondence address: Kim Usher, College of Nursing, Midwifery and Nutrition,
James Cook University, 14-88 McGregor Road, Smithfield, QLD 4878, Australia.
nurses for disaster response is evident, given that prepared-
Email: Kim.usher@une.edu.au ness is linked to performance in disaster situations (Putra
Present address: Kim Usher, Head of School, School of Health, University of New et al., 2011).
England, Meredith Road Armidale, NSW 2351, Australia. Email: Kim.usher@
The Asia–Pacific Emergency Disaster Nursing Network
une.edu.au
Received 26 October 2014; revision received 21 January 2015; accepted 23 January (APEDNN) was formed in 2007 in order to better prepare
2015 nurses to respond effectively to disasters (Fritsch & Zang,

© 2015 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12211

Disaster preparedness of Asia–Pacific nurses
2009; Usher, 2010). Part of the remit of the APEDNN is to
conduct nursing research to appropriately inform future dis-
aster responses (Fritsch & Zang, 2009). To achieve this goal,
APEDNN has worked with partner organizations to increase
the research capacity of their members. James Cook Univer-
sity’s World Health Organization (WHO) Collaborating
Center (Cairns, Queensland, Australia), with funding from
AusAID, hosted a three week research capacity-building
course in Cairns, Australia in 2012 (Usher et al., 2015). One
outcome of the course was a jointly-developed research pro-
posal that members conducted upon return to their home
country. This paper provides an overview of the combined
results from seven countries.
Literature review
Successful response to disasters has been linked to prepared-
ness (Khalaileh et al., 2012), with nurses and other healthcare
workers who have received disaster preparedness education
more likely to report a higher perception of disaster prepar-
edness (Brennan et al., 1994; Alexander & Wynia, 2003;
Bartley et al., 2006; 2007; Hsu et al., 2006; Katz et al., 2006;
Lenaghan et al., 2006; Chapman & Arbon, 2008; Duong,
2009), while a lack of knowledge and preparedness can result
in poor performance when delivering care in disasters (Putra
et al., 2011).
Recently, the WHO and the International Council of
Nurses collaborated to develop a set of competencies that are
proposed as the minimum requirements for nurses to be
prepared to respond to disasters (WHO & ICN, 2009). The
development of the new disaster competencies could encour-
age coordinators of undergraduate nursing curricula to incor-
porate the new competencies, as suggested recently (Pang
et al., 2009). However, research indicates that current nursing
curricula do not adequately prepare nurses to respond to
disasters (Weiner, 2005a,b; Zhang, 2009; Usher & Mayner,
2011).
While there is a call for more disaster preparedness train-
ing at both undergraduate and postgraduate levels, there are
few evidence-based education programs available (Fung
et al., 2008). Interestingly, it appears that most of the skills
needed to respond effectively to disaster situations are the
skills used by emergency department nurses on a daily basis
(Duong, 2009; Yin et al., 2011). If that is in fact the case, then
perhaps the best place for future disaster preparedness train-
ing is in the workplace, where nurses rotate through areas,
such as accident and emergency departments, on a regular
basis.
In relation to the Asia–Pacific region, there is a gap in the
literature about the actual level of disaster knowledge, skills,
and post-disaster-management preparedness of nurses; this
study seeks to address this void. Without understanding
nurses’ current levels of perceived preparedness for disasters,
it is difficult to plan for an appropriate educational strategy to
increase preparedness. Determining the actual level of regis-
tered nurses’ (RN) preparedness can be used to evaluate the
need for incorporating disaster management in undergradu-
ate nursing programs, and will help in planning for continuing
education courses to meet nurses’ needs.
435
Aim
The aim of this study was to assess the perceptions of Asia–
Pacific RNs regarding their knowledge, skills, and prepared-
ness for disaster management. A cross-sectional survey was
conducted. The study sought to answer the following
research questions: (i) What knowledge do Asia–Pacific
RNs have about disaster management?; (ii) What skills do
Asia–Pacific RNs have for disaster management?; and (iii)
How do Asia–Pacific RNs perceive their preparedness for
disaster management?
METHODS
Setting and participants
Participants were selected from a sample of hospitals and
community settings across seven countries (Bangladesh,
Bhutan, Cambodia, China, Laos, Nepal, and the Solomon
Islands). The included countries are all members of the
APEDNN, and members from each country were supported
by an Australian aid grant to attend a research workshop in
Australia. An outcome of that workshop was a research grant
conducted in each participant’s home country after returning
from the workshop. Hospital and community nurses in each
country were selected using a convenience approach. The
number of hospitals involved ranged from one (Bhutan,
China, and the Solomon Islands), two (Bangladesh, Laos, and
Nepal), or three (Cambodia).
Inclusion criteria included: (i) a three year diploma in
nursing; (ii) currently working at a hospital or community
setting; (iii) at least one year of experience; and (iv) agree-
ment to participate.
All nurses who met the inclusion criteria in the selected
hospitals were invited to participate. The survey was distrib-
uted to the hospital and community nursing staff at selected
hospitals and/or community health facilities through the
head nurse or similar in each Asia–Pacific country. The
surveys were collected at a central location at each facility,
and later sent to a member of the research team located in
each country.
Data-collection instrument
Data were collected through a self-administered question-
naire that included the Disaster Preparedness Evaluation
Tool (DPET) (Tichy et al., 2009) and a number of demo-
graphic questions (e.g. years of experience, qualification).The
DPET tool, originally designed to measure nurse practition-
ers’ disaster preparedness, and later revised and tested to
assess perceptions of the disaster preparedness of registered
nurses in Jordan, contains 68 items ranked using a six point
Likert scale (1–6; strongly disagree to strongly agree). The
survey was delivered in English. Members of the research
team from the countries involved gave an assurance that the
English literacy of RNs in each country was sufficient to
enable completion of the survey questionnaire. Cronbach’s
alpha internal consistency reliability for the original tool was
0.91 (Tichy et al., 2009), and 0.90 in the study by Khalaileh
© 2015 Wiley Publishing Asia Pty Ltd.
436 K. Usher et al.

et al. (2012). The tool amended by Khalaileh et al. (2012) was conduct the study in all participating countries was sought
further amended for suitability for use with participants and obtained prior to the commencement of the study.
across Asia and the Pacific by a group of local, culturally-
aware experts who are members of the APEDNN; a group of
RNs who are specialists in disaster nursing. Only minor RESULTS
wording changes were suggested prior to dissemination of
the questionnaire. Demographics
The DPET tool was pilot tested in each participating A total of 757 survey responses were received from the seven
country with a group of RNs (n = 10–15), respectively, prior participating countries. The distribution of participants from
to dissemination. Pilot data were carefully analyzed prior to each country is shown in Table 1. Of the respondents, 625
distribution of the survey. No further changes were made to (83%) were female and 132 (17%) were male. The overall
the questionnaire prior to distribution. mean age was 37 years (SD = 8.8). The mean age of males
(mean = 37, SD = 9.2) and females (mean = 38, SD = 8.7) did
Data analysis not differ significantly (P = 0.257). All participants were RNs
or the equivalent in their country.
Raw data were entered into SPSS version 22 (IBM SPSS, Overall, 9% of participants reported their highest nursing
Chicago, IL, USA). Descriptive statistics were used to deter- qualification was a certificate (n = 69), 61% a diploma
mine the sample characteristics and distribution of responses. (n = 461), 25% a bachelor degree (n = 190), 5% a masters
Categorical characteristics were described using absolute and (n = 35), and 0.3% reported a doctorate (n = 2).
relative frequencies. Numerical variables were described The majority of the participants worked in a hospital
using mean and standard deviation (SD). In order to measure (98%), with only 2% working in a health clinic. Participants
RNs perception of their preparedness toward disasters in worked in a variety of wards and departments (> 82), with the
general, and toward knowledge, skills, and management, largest proportion (15%) working in obstetrics, followed by
means and SD of the collected data were categorized as 11% working in surgical, and 8% in a medical ward. The
weak, moderate, and strong based on the respective values: majority of participants (78%) worked as a nurse in some
1–2.99 = weak; 3–4.99 = moderate; and 5–6 = strong percep- capacity, from assistant nurse to senior staff nurse and sister
tions of preparation. in charge, and 10% worked as a midwife.
The items of the questionnaire tool concerning knowledge, Participants worked an average of 46 h per week
skills, and management were summed. Cronbach’s alpha (SD = 10.5), ranging from 4 hours to 96 h per week. Female
coefficients were calculated for the subscales. participants (mean = 46.8 h/week, SD = 10.4) worked signifi-
Multilevel mixed-effects modelling using generalized mul- cantly longer hours than male participants (mean = 43.8 h/
tiple linear regression analysis was performed to identify week, SD = 10.7, t[754] = 2.99, P = 0.003). The distribution of
whether variations in DPET scores were located at the
country level, hospital level, or at the individual level. Taking
into account the nested structure of the data, three level
models of individuals nested within hospitals nested within Table 1. Distribution of survey respondents
countries were constructed. The dependent variables for the
three models were the summed score for disaster knowledge, Country N Percentage
disaster skills, and disaster management, respectively. Fixed
effects included age, sex, previous disaster education, and Bangladesh 200 26.4
previous disaster response experience; the latter three being Bhutan 110 14.5
Cambodia 61 8.1
binary variables. Multilevel modelling was conducted using
China 86 11.4
STATA release 12 (StataCorp LP, College Station, TX, USA) Laos 177 23.4
xtmixed command. Nepal 63 8.3
Solomon Islands 60 7.9
Ethical issues
The study was considered low risk. Participants were not
expected to become distressed as a result of completing the Table 2. Distribution of hours worked per week by country
survey, and no identifying information was gathered. A par-
ticipant information sheet was attached to the front of the Country Mean hours/week Standard deviation
survey to explain the purpose of the study; the requirements
of the participants; and all other necessary information per- Bangladesh 48.0 0.0
taining to the study, including researcher contact details. Par- Bhutan 40.7 7.0
ticipants were informed that completion of the survey Cambodia 49.2 14.5
China 41.9 4.2
implied consent to participate in the study, thus a separate
Laos 51.9 15.9
consent form was not required. Ethics approval to conduct
Nepal 43.7 6.5
the study was granted by the James Cook University Human Solomon Islands 40.3 5.6
Research Ethics Committee. Ethical and access clearances to

© 2015 Wiley Publishing Asia Pty Ltd.

Disaster preparedness of Asia–Pacific nurses 437

average hours worked per week by country is shown in Participants from all countries indicated moderate-to-
Table 2. Bangladesh, Cambodia, and Laos RNs worked sig- high interest in educational classes on disaster prepared-
nificantly longer hours than RNs in Bhutan, China, Nepal, ness, but RNs from Bhutan and the Solomon Islands had a
and the Solomon Islands (χ2[6, n = 756] = 185.90, P < 0.001). low awareness of classes offered in their workplace, univer-
sity, or community. RNs from Bangladesh, Bhutan, China,
and the Solomon Islands reported low participation in con-
Disaster experience tinuing education about disaster preparedness. Research lit-
Nineteen percent (n = 144) of participants reported partici- erature on disaster preparedness and management is not
pation in a disaster training course. Most commonly, the easily accessible to RNs from Bangladesh, Laos, and the
course was of one week duration (32%), or less than one day Solomon Islands, and the RNs from Bangladesh and the
(13%). Respondents from China, Nepal, and Cambodia were Solomon Islands were unaware of where to find relevant
more likely to have completed disaster training compared research or information related to disaster preparedness.
with participants from the other countries (χ2[6, Participation in regular disaster drills or exercises was
n = 755] = 129.20, P < 0.001). found to be weak for RNs from Bangladesh, Bhutan, and
Nineteen percent (n = 142) of participants reported previ- the Solomon Islands. Participants from Bangladesh and
ous experience responding to a disaster. The majority of RNs Cambodia considered themselves weakly prepared for
who had responded to a disaster were from Nepal (23%), having a list of contacts in the medical or health communi-
Bangladesh (20%), and Bhutan (20%). Of the 142 partici- ties in which they practice, and participants from all coun-
pants, 137 described the types of disasters to which they tries, except China, considered themselves weakly prepared
had responded (see Table 3). Some participants reported for participating in emergency planning for disaster situa-
responding to more than one type of disaster. The most tions. For all other areas of knowledge, the RNs considered
common types of disasters participants responded to were themselves moderately prepared (see Table 4).
flooding (28%), road traffic accidents (26%), earthquakes Multilevel modelling showed that age (P = 0.091) and sex
(23%), tsunamis (11%), tornados or cyclones (11%), and (P = 0.171) had no statistically-significant effects on the
bomb blasts (4%). Some participants had different roles in knowledge score. The knowledge score was significantly
different disasters or had more than one role in a disaster. Of higher for participants with prior disaster experience
the 126 respondents, the most frequently-reported roles were (mean: 3.8) compared to participants with no prior experi-
providing patient care (41%), first aid (13%), emergency ence (mean: 3.4, P < 0.001), and for participants with disas-
medical help (10%), and assistance with evacuations (10%). ter education (mean: 3.8) compared to those without
(mean: 3.3, P = 0.003). Within this model, the country level
variance to the overall mean was 0.023, the hospital level
Knowledge variance to the respective country means was 0.080, and the
The first research question was: “What knowledge do Asia– individual level variance to the respective hospital level
Pacific RNs have about disaster management?” Thirteen means was 0.632.
items on the DPET were related to knowledge, with answers
ranging from 1–6 (strongly disagree to strongly agree). Skills
Cronbach’s alpha for the knowledge scale items was 0.81,
indicating good reliability. The second research question was: “What skills do Asia–
Pacific RNs have about disaster management?” There were
10 DPET items related to skills, with answers ranging from 1
to 6 (strongly disagree to strongly agree). Cronbach’s alpha
Table 3. Types of disasters in which participants have responded
was 0.84, indicating good reliability.
Type of disaster (n = 137) N Percentage
Participants from all countries, except Cambodia, consid-
ered themselves weakly prepared for participating in creat-
Bomb blast 6 4.4 ing new guidelines, emergency plans, or lobbying for
Building collapse 2 1.4 improvements on the local or national level. Less than one-
Cyclone or tornado 15 10.9 third of RNs from Bhutan had emergency family plans in
Earthquake 32 23.3 place for disasters (n = 29), and a similarly low proportion
Fire (forest, factory, town) 9 6.5 had an agreement with family members on how to execute
Flooding 39 28.4 family emergency plans (n = 31). Participants from the
Road traffic accident 36 26.2 Solomon Islands considered themselves weakly prepared in
Tsunami 15 10.9 the case of a bioterrorism/biological attack or accident, or
Poisoning 1 1.0
emerging infections, to execute decontamination procedures.
SARS 1 1.0
Landslide 1 1.0
In all other skill items, the RNs considered themselves mod-
Gas pipe blast 1 1.0 erately prepared (see Table 5).
Diarrhea epidemic 1 1.0 Multilevel modelling showed that sex (P = 0.540) had no
Unspecified 13 9.5 statistically-significant effect on the skills score. The older a
participant was, the higher the skill score (P = 0.001). The
Note: Some participants responded to more than one disaster. skill score was significantly higher for participants with prior

© 2015 Wiley Publishing Asia Pty Ltd.

438 K. Usher et al.

Table 4. RN level of knowledge for disaster management (mean ± SD)

Solomon
Bangladesh Bhutan Cambodia China Laos Nepal Islands

Finding relevant information about disaster 3.58 (1.90) 3.33 (1.35) 3.73 (1.21) 3.69 (1.68) 4.76 (0.92) 3.23 (1.75) 3.55 (1.77)
preparedness related to my community needs
is an obstacle to my level of preparedness
I would be interested in educational classes on 5.64 (0.92) 5.20 (1.26) 4.10 (1.31) 4.83 (1.24) 5.14 (0.77) 5.31 (1.17) 5.65 (0.58)
disaster preparedness that relate specifically
to my community situation
I am aware of classes about disaster 3.18 (1.94) 2.75 (1.60) 3.70 (1.22) 3.92 (1.77) 4.49 (0.97) 4.15 (1.75) 2.55 (1.75)
preparedness and management that are
offered in my workplace, university, or
community
I read journal articles related to disaster 2.93 (1.83) 3.25 (1.47) 3.43 (1.51) 3.44 (1.52) 3.03 (1.14) 3.79 (1.61) 3.03 (1.76)
preparedness
I find that the research literature on disaster 3.01 (1.83) 3.94 (1.43) 3.37 (1.13) 3.80 (1.41) 4.84 (0.75) 3.97 (1.34) 3.58 (1.89)
preparedness is understandable
In case of a disaster situation, I think there is 5.31 (1.29) 3.55 (1.49) 3.02 (1.72) 4.48 (1.42) 4.59 (0.81) 3.48 (1.64) 3.67 (1.75)
sufficient support from local officials on the
country/district/province level
I know whom to contact (chain of command) in 3.78 (2.04) 3.19 (1.67) 3.54 (1.07) 3.58 (1.86) 3.23 (1.14) 3.37 (1.71) 3.07 (1.82)
disaster situations in my community
I participate in one of the following educational 1.83 (1.45) 2.26 (1.51) 3.75 (1.26) 2.94 (1.63) 3.32 (1.26) 3.06 (1.77) 2.23 (1.57)
activities on a regular basis: continuing
education classes, seminars, or conferences
dealing with disaster preparedness
I find that the research literature on disaster 2.13 (1.55) 3.02 (1.37) 3.02 (1.09) 3.50 (1.60) 2.79 (0.99) 3.02 (1.37) 2.73 (1.61)
preparedness and management is easily
accessible
I know where to find relevant research or 2.45 (1.52) 3.33 (1.44) 3.34 (1.33) 3.49 (1.51) 3.03 (1.07) 3.82 (1.48) 2.85 (1.51)
information related to disaster preparedness
and management to fill in gaps in my
knowledge
I participate in disaster drills or exercises at my 2.26 (1.70) 2.66 (1.62) 3.30 (1.43) 3.67 (1.70) 3.50 (1.27) 3.49 (1.90) 2.52 (1.78)
workplace (clinic, hospital, etc.) on a regular
basis
I have a list of contacts in the medical or health 2.73 (1.88) 3.83 (1.61) 2.83 (1.13) 3.36 (1.52) 3.31 (1.33) 3.69 (1.43) 3.42 (1.83)
community in which I practice. I know
referral contacts in case of a disaster
situation (e.g. health department)
I have participated in emergency planning for 2.33 (1.80) 2.15 (1.59) 3.37 (1.15) 3.00 (1.83) 2.49 (1.14) 2.29 (1.72) 2.20 (1.71)
disaster situations in my community
Total disaster knowledge 3.16 (0.92) 3.28 (0.84) 3.42 (0.84) 3.67 (1.04) 3.73 (0.53) 3.59 (0.73) 3.15 (1.07)
Cronbach’s alpha coefficient 0.81

RN, registered nurse; SD, standard deviation.

disaster experience (mean: 3.9) compared to participants
with no prior experience (mean: 3.5, P < 0.001), and was
higher for participants with disaster education (mean: 3.9)
compared to those without (mean: 3.6, P = 0.021). Within this
model, the country level variance to the overall mean was
0.032, the hospital level variance to the respective country
means was 0.066, and the individual level variance to the
respective hospital level means was 0.895.
Perception of preparation for disaster management
The third research question was: “How do Asia–Pacific RNs
perceive their preparedness for disaster management?”
There were 20 DPET items related to preparation for post-
disaster management, with answers ranging from 1 to 6
(strongly disagree to strongly agree). Cronbach’s alpha was
0.93, indicating excellent reliability.
RNs from Bangladesh and Laos considered themselves
weakly prepared to treat patients independently without the
supervision of a physician in a disaster situation; RNs from
Cambodia considered themselves weakly prepared to iden-
tify possible indicators of mass exposure; RNs from Cambo-
dia and the Solomon Islands considered themselves weakly
prepared in health assessments related to biological or
chemical agents; RNs from Bangladesh, Bhutan, and the
Solomon Islands regarded themselves as weakly prepared in

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Disaster preparedness of Asia–Pacific nurses 439

Table 5. RN level of skills for disaster management (mean ± SD)

Solomon
Bangladesh Bhutan Cambodia China Laos Nepal Islands

I am aware of what the potential risks in my 4.47 (1.70) 4.56 (1.37) 4.12 (1.12) 4.06 (1.56) 4.40 (0.94) 4.52 (1.62) 4.55 (1.50)
community are (e.g. earthquake, floods,
terror)
In case of a bioterrorism/biological attack 3.16 (1.90) 4.45 (1.65) 3.12 (1.22) 3.67 (1.64) 4.36 (1.02) 4.27 (1.65) 3.18 (1.82)
or accident, or emerging infections, I
know how to use personal protective
equipment
I am familiar with accepted triage principles 3.68 (1.97) 3.89 (1.54) 3.58 (1.19) 3.73 (1.58) 4.71 (0.93) 4.86 (1.36) 3.33 (1.79)
used in disaster situations or emerging
infections
I have personal/family emergency plans in 4.22 (1.76) 2.76 (1.37) 3.59 (1.42) 3.36 (1.70) 3.98 (1.18) 3.46 (1.51) 3.25 (1.75)
place for disaster situations
In case of a bioterrorism/biological attack 3.05 (1.89) 4.17 (1.46) 3.33 (1.38) 3.87 (1.59) 4.05 (1.14) 4.46 (1.37) 3.27 (1.81)
or accident, or emerging infections, I
know how to perform isolation
procedures so that I minimize risks for
community exposure
I am familiar with the local emergency 3.22 (1.85) 3.37 (1.65) 4.13 (1.24) 3.56 (1.58) 3.28 (1.09) 3.44 (1.53) 3.32 (1.72)
response system for disasters
In case of a bioterrorism/biological attack 3.49 (2.03) 3.83 (1.65) 3.50 (1.38) 3.67 (1.50) 4.23 (1.10) 4.33 (1.56) 2.82 (1.70)
or accident, or emerging infections, I
know how to execute decontamination
procedures
I have an agreement with loved ones and 4.57 (1.66) 2.58 (1.46) 3.98 (1.02) 3.36 (1.70) 4.21 (1.06) 3.35 (1.40) 3.02 (1.76)
family members on how to execute our
personal/family emergency plans
I consider myself prepared for the 3.78 (2.03) 3.30 (1.54) 3.43 (1.19) 3.23 (1.53) 3.85 (1.10) 4.30 (1.53) 3.02 (1.68)
management of disasters
I participate/have participated in creating 1.90 (1.53) 2.16 (1.59) 3.07 (1.01) 2.48 (1.73) 1.48 (0.86) 2.32 (1.51) 1.95 (1.41)
new guidelines, emergency plans, or
lobbying for improvements on the local
or national level
Total disaster skills 3.56 (1.17) 3.52 (0.92) 3.58 (0.87) 3.50 (1.15) 3.85 (0.65) 3.92 (0.89) 3.17 (1.26)
Cronbach’s alpha coefficient 0.84

RN, registered nurse; SD, standard deviation.

organizational logistics and roles; and RNs from Cambodia DISCUSSION

and China perceived they were weakly prepared in address-
ing groups A–C of biological weapons (anthrax, plague, botu-
lism, smallpox). RNs from Bhutan, China, Laos, and the
Solomon Islands deemed themselves weakly prepared to par-
ticipate in peer evaluation of skills in disaster preparedness
and response. In all other areas of post-disaster management,
the RNs felt moderately prepared (see Table 6).
Multilevel modelling showed that sex (P = 0.219) and prior
disaster education (P = 0.087) had no statistically-significant
effects on the management score. The older a participant was,
the higher the management score (P = 0.002). The manage-
ment score was significantly higher for participants with prior
disaster experience (mean: 4.1) compared to participants
with no prior experience (mean: 3.7, P < 0.001). Within this
model, the country level variance to the overall mean was
0.000, the hospital level variance to the respective country
means was 0.095, and the individual level variance to the
respective hospital level means was 0.875.
This cross-sectional study was conducted to assess the Asia–
Pacific RNs perceptions of their disaster knowledge, skills,
and post-disaster-management preparedness, and the factors
that might influence these perceptions. This study is timely,
considering that nearly half of the world’s natural disasters
occur in the Asia–Pacific region, and concern is increasing
regarding the health, social and economic consequences of
disasters.
The Asia–Pacific region is disproportionately affected by
natural disasters, such as cyclones, tsunamis, earthquakes, vol-
canic eruptions, tropical storms, landslides, and floods. Over
60% of global economic losses from disasters were sustained
by the Asia–Pacific region over the past 20 years, and 40%
of floods worldwide have occurred in this region over the
past 30 years (Jha & Stanton-Geddes, 2013). The frequency
and magnitude of natural disasters in Asia–Pacific countries
have devastating economic and health impacts, and can

© 2015 Wiley Publishing Asia Pty Ltd.

440 K. Usher et al.

Table 6. RN level of preparation for disaster management (mean ± SD)

Solomon
Bangladesh Bhutan Cambodia China Laos Nepal Islands

I would feel reasonably confident providing patient 4.63 (1.72) 4.00 (1.49) 3.62 (1.02) 3.84 (1.46) 4.16 (1.06) 4.68 (1.13) 3.93 (1.63)
education on stress and abnormal functioning
related to trauma
I am able to discern signs and symptoms of acute 4.16 (1.76) 3.68 (1.31) 3.27 (1.06) 3.28 (1.48) 3.95 (1.05) 4.16 (1.15) 3.88 (1.52)
stress disorder and post-traumatic stress disorder
I am familiar with the scope my nurse role would be 4.08 (1.87) 3.81 (1.42) 3.47 (1.30) 4.21 (1.40) 3.58 (1.06) 4.33 (1.49) 3.80 (1.69)
in a post-disaster situation
As a nurse, I would feel reasonably confident in my 4.63 (1.61) 4.21 (1.45) 4.20 (0.98) 4.24 (1.51) 4.68 (0.87) 4.40 (1.42) 4.02 (1.50)
abilities as a member of a decontamination team
I am comfortable providing education on coping skills 3.37 (1.89) 3.77 (1.46) 3.40 (1.08) 3.38 (1.43) 3.82 (0.93) 4.19 (1.46) 3.55 (1.61)
and training for patients who experience traumatic
situations
As a nurse, I would feel confident in my abilities as a 4.80 (1.72) 4.35 (1.78) 4.07 (0.89) 4.58 (1.26) 4.15 (0.89) 4.78 (1.31) 4.34 (1.58)
direct care provider and first responder in disaster
situations
I feel reasonably confident that I can treat patients 2.98 (1.92) 3.48 (1.54) 3.28 (1.13) 3.36 (1.50) 2.92 (1.15) 3.44 (1.46) 3.95 (1.59)
independently without the supervision of a
physician in a disaster situation.
I can manage common symptoms and reactions of 4.04 (1.81) 3.85 (1.40) 3.14 (0.68) 3.77 (1.48) 3.85 (0.96) 4.25 (1.27) 3.72 (1.57)
disaster survivors that are of an affective,
behavioral, cognitive, or physical nature
I would feel reasonably confident implementing 4.36 (1.87) 4.00 (1.39) 3.25 (0.96) 4.55 (1.36) 4.16 (0.91) 4.49 (1.20) 4.07 (1.46)
emergency plans, evacuation procedures, and similar
functions
I can identify possible indicators of mass exposure 3.86 (1.81) 3.50 (1.30) 2.98 (1.10) 3.41 (1.47) 3.66 (1.07) 3.63 (1.12) 3.45 (1.47)
evidenced by a clustering of patients with similar
symptoms
I am familiar with psychological interventions, 3.88 (1.92) 3.26 (1.43) 3.47 (1.08) 3.52 (1.64) 3.03 (1.15) 3.48 (1.69) 3.17 (1.84)
behavioral therapy, cognitive strategies, support
groups, and incident debriefing for patients who
experience emotional or physical trauma
As a nurse, I would feel confident as a manager or a 4.26 (1.85) 3.71 (1.60) 3.98 (1.20) 4.31 (1.41) 4.56 (0.78) 4.40 (1.36) 4.17 (1.57)
coordinator of a shelter
I am able to describe my role in the response phase of 3.99 (1.86) 3.34 (1.49) 3.20 (0.96) 3.58 (1.54) 3.18 (1.24) 4.06 (1.43) 3.02 (1.68)
a disaster in the context of my workplace, the
general public, media, and personal contacts
I participate in peer evaluation of skills in disaster 4.02 (1.83) 2.89 (1.63) 3.50 (1.42) 2.74 (1.56) 2.55 (1.09) 3.46 (1.51) 2.60 (1.67)
preparedness and response
I am comfortable managing (treating, evaluating) 4.11 (1.82) 3.64 (1.37) 3.15 (1.62) 3.30 (1.47) 3.52 (0.97) 4.11 (1.09) 3.40 (1.64)
emotional outcomes for acute stress disorder or
post-traumatic stress disorder
In a bioterrorism/biological attack or accident, I would 3.88 (1.83) 3.38 (1.57) 2.73 (1.08) 3.88 (1.79) 3.42 (1.09) 3.10 (1.54) 2.78 (1.56)
know how to perform a focused health history and
assessment specific to bioagents that are used
I am familiar with how to perform a focused health 4.26 (1.81) 3.36 (1.49) 3.20 (1.76) 3.17 (1.38) 3.29 (0.98) 3.70 (1.49) 3.18 (1.67)
assessment for post-traumatic stress disorder
I feel reasonably confident discerning deviations in 4.17 (1.82) 3.78 (1.43) 3.92 (1.06) 3.45 (1.68) 4.32 (3.08) 3.68 (1.17) 3.67 (1.51)
health assessments indicating potential exposure to
biological agents and emerging infections
I am familiar with the organizational logistics and 2.46 (1.63) 2.94 (1.44) 3.03 (1.20) 3.29 (1.57) 3.62 (1.01) 3.33 (1.52) 2.60 (1.56)
roles among local/district/province and national
agencies in disaster-response situations
I am familiar with the main groups (A, B, C) of 4.30 (1.78) 3.34 (1.56) 2.47 (1.26) 2.84 (1.55) 3.67 (1.07) 3.19 (1.54) 3.12 (1.50)
biological weapons (e.g. anthrax, plague, botulism,
smallpox), their signs and symptoms, and effective
treatment.
Total disaster-management preparedness 4.00 (1.17) 3.64 (1.04) 3.36 (0.77) 3.64 (1.16) 3.70 (0.71) 3.94 (0.84) 3.49 (1.16)
Cronbach’s alpha coefficient 0.93

RN, registered nurse; SD, standard deviation.

© 2015 Wiley Publishing Asia Pty Ltd.

Disaster preparedness of Asia–Pacific nurses
overwhelm the capacity of governments and health workers
to respond (Simpson et al., 2008). Manmade disasters, such as
road traffic accidents and bomb blasts, also require a disaster
response from frontline health workers, including RNs. In
order to respond to disaster events effectively, health workers
need to be prepared with adequate knowledge, skills, and
disaster-management training (Putra et al., 2011). Against the
backdrop of population growth, urbanization, and climate
change, health workers, such as RNs, in Asia–Pacific countries
are challenged to better respond to and manage future dis-
aster events.
Overall, the participants in the current study reported low-
to-moderate levels of disaster preparedness, with many gaps
in the knowledge and skills necessary for RNs to operate
effectively in a disaster response.This finding is consistent with
the findings of Rassin et al. (2007), Yang et al. (2010), and
Khalaileh et al. (2012), who also found low-to-moderate levels
of disaster preparedness among RNs. Participants of a recent
study of Chinese nurses’ knowledge of typhoon disaster pre-
paredness indicated a good knowledge level, which was
argued to be related to the frequency of occurrence of
typhoons in that country (Jiang et al., 2015). Unfortunately, in
this study, we were unable to determine the different types of
disaster events and their links to disaster knowledge. Within
the group, however, participants from China, Laos, and Nepal
were the most positive about their level of disaster-response
knowledge, which could have been impacted by the frequency
of disaster events in these countries.
The first part of the questionnaire focused on disaster
knowledge. Previous disaster experience and participation in
disaster training was significantly positively associated with
higher levels of disaster knowledge; however, participation in
continuing disaster education activities, disaster drills, and
exercises was relatively low. RNs from all countries indicated
a moderate-to-strong level of interest in attending disaster
education and training opportunities in the future, but there
was a low level of awareness of training opportunities in their
country.
The positive association of participation in a disaster train-
ing course and higher perceptions of disaster knowledge is
supported by previous research, which indicates that nurses
who receive disaster preparedness education are more likely
to report a higher perception of disaster preparedness
(Brennan et al., 1994; Alexander & Wynia, 2003; Bartley
et al., 2006; 2007; Hsu et al., 2006; Katz et al., 2006; Lenaghan
et al., 2006; Chapman & Arbon, 2008; Duong, 2009), and are
able to respond effectively to disasters when needed (Husna
et al., 2011). Thus, it is important that disaster education and
training are available to all nurses. As current evidence indi-
cates low levels of inclusion of disaster knowledge and skills
in preregistration nursing programs (Weiner, 2005a,b; Zhang,
2009; Usher & Mayner, 2011), these courses might need to be
available as post-registration, professional development
opportunities.
RNs from Bhutan, Laos, and the Solomon Islands reported
difficulty accessing research literature on disaster prepared-
ness and management, and RNs from Bhutan and the
Solomon Islands were unsure of where to find relevant
research information about disaster management and pre-
441
paredness. Khalaileh et al. (2012) also identified this difficulty
and suggested that it might be a common problem in devel-
oping countries, in which hospitals do not subscribe to or
have access to disaster journals.
The reported lack of participation in emergency planning
for disaster situations indicates that RNs are not included in
community disaster planning processes. Nurses play a crucial
role in any disaster response (Cox, 2008); however, a lack of
access to disaster-management research might impact on the
ability of RNs to contribute meaningfully to disaster planning
forums (Rogers & Lawhorn, 2007) when included.
The second part of the questionnaire focused on disaster
skills. Participants rated their disaster skills higher than their
knowledge, but scores were still relatively low. RNs from
Laos and Nepal were most positive about their disaster-
management skills, and RNs from the Solomon Islands were
least positive. In response to the statement:“I consider myself
prepared for the management of disasters”, RNs from Bang-
ladesh, Laos, and Nepal responded most positively. Participa-
tion in disaster training, previous experience responding to a
disaster, and age were significantly positively associated with
higher perceptions of disaster preparedness. Age is likely to
relate to more opportunities to attend disaster education and
training courses, or to have participated in a disaster
response. Previous research has found experience is the basis
of preparedness, and experienced nurses are better able to
provide care in emergency situations than less experienced
nurses (Suserud & Haljamae, 1997; Stanley, 2005). Nurses
play a critical role in emergency response teams, and it is
therefore essential to ensure that RNs have the skills and
knowledge to respond effectively during an emergency
(Hughes et al., 2007). It is not practical to wait until a disaster
occurs to effect training; education and training for disasters
need to be provided in a strategic manner.
The third part of the questionnaire related to RNs percep-
tions of their post-disaster-management preparedness. Previ-
ous disaster experience and age were significantly positively
associated with high perceptions of disaster-management
preparedness. Participants rated their disaster-management
preparedness as low to moderate, with RNs from Bangladesh
and Nepal rating their preparedness highest. RNs from Bang-
ladesh and Laos indicated that they were not confident
working independently without a physician in a disaster situ-
ation, and RNs from Bangladesh, Bhutan, and the Solomon
Islands were unfamiliar with logistics and roles in a disaster
situation. Hope (2010) reported that frontline hospital staff
might not be willing to report to work post-disaster if they
lack confidence in their skills or ability to perform their role.
Prior opportunities to perform in a disaster-response role,
such as field exercises, might assist with clearer role delinea-
tion and familiarity with the role, increasing RNs confidence
to respond to and operate independently in an actual disaster
(Hope, 2010). RNs from Cambodia, China, and the Solomon
Islands reported low levels of preparedness in relation to
response to biological and chemical attacks. This finding is
consistent with the findings of previous studies (Baldwin
et al., 2005; Hsu et al., 2006; Chaput et al., 2007; Jacobson
et al., 2010), and it has been suggested that future disaster
education should focus on natural disasters, which are
© 2015 Wiley Publishing Asia Pty Ltd.
442
relatively common compared to rare biological disasters
(Manley et al., 2006).
In summary, the results of this study indicate that the dis-
aster preparedness of RNs in the included countries is low to
moderate, with many gaps in the knowledge and skills nec-
essary for RNs to operate effectively in a disaster response.
The results relate to the respondents across the Asia–Pacific
region and are not confined to the hospital or country level.
As a result, it is important that training and development
opportunities related to disaster preparedness are offered to
RNs in the included countries and beyond. In addition, it is
important that disaster preparedness is included in all pre-
registration nursing education in the future. Finally, it is
imperative that policies are developed to ensure that this
occurs.
Limitations
This study is limited by its cross-sectional design. As is
common with similar study designs, results reflect partici-
pants’ intentions and perceptions, rather than actual disaster
responses. However, the results provide a baseline that can
guide planning for continuing disaster education programs
and training activities to meet the needs of RNs from each
Asia–Pacific country. In addition, the study had a three year
diploma qualification as a minimum requirement. However,
9% of the surveys were returned by RNs with a certificate
qualification. These results, included in the data set, might
have had an impact on the outcomes of the study, and thus,
the results must be interpreted with caution. It is question-
able if the questionnaire data were representative for the
nurse populations in the six countries; China, for instance, is
larger than all the other countries combined. This might
have affected the rigor and outcomes of the study. The size of
the sample from each country might also reduce the
generalizability of these results.
Conclusion
RNs are essential frontline staff in a disaster response. To
ensure that they can operate effectively and confidently in a
disaster situation, RNs require education and training in
knowledge, skills, and disaster-management preparedness.
This includes access to research literature about disaster
responses and experience in field exercises, so roles and logis-
tics are clearly defined and RNs have the confidence to
operate independently in a disaster situation. In areas that
are prone to intense geological and meteorological activity
resulting in natural disasters, the first step toward disaster
preparedness is to identify and fill health workers’ existing
gaps in knowledge, skills, and disaster-management prepar-
edness so that frontline health workers, including RNs, are
able to respond effectively to disaster events as they occur.
The outcomes of this study provide important information to
support future policy development to ensure that nurses are
adequately prepared to respond to disasters. In addition, the
outcomes provide evidence to support the need for the inclu-
sion of disaster nursing knowledge, skills, and preparedness
© 2015 Wiley Publishing Asia Pty Ltd.
K. Usher et al.
activities in all preregistration nursing courses. Further
research is needed to determine if these findings are consist-
ent across other countries.
CONTRIBUTIONS
Study Design: KU, JM, CWe, EC, PD, AG, VK, GP, SP, OP, JS,
ML, AS, MU, YS, YZ, PB.
Data Collection and Analysis: PD, AG, VK, GP, SP, OP, JS,
ML, AS, MU, YS, YZ, CWo.
Manuscript Writing: KU, JM, CWe, EC, CWo.
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