Evaluation of an Instrument to Measure Nurses' Familiarity with Emergency Preparedness

INTRODUCTION

The events of September 11, 2001, and the 2005 devastation of Hurricane Katrina in New Orleans, Louisiana, have emphasized the importance of educating nurses and other health care responders regarding emergency preparedness and bioterrorism. Traditionally, nurses on the front lines (i.e., military, emergency department, and public health) have been entrusted with the responsibility to care for victims of disasters. However, emergency preparedness is a critical competency that is needed by both experienced nurses and new graduates no matter where they are employed. Slepski'(P426) defined emergency preparedness as "the comprehensive knowledge, skills, abilities, and actions needed to prepare for and respond to threatened, actual, or suspected chemical, biological, radiological, nuclear, or explosive incidents, manmade incidents, natural disasters, or other related events."

Research is needed to assess nurses' familiarity with emergency preparedness, because it is crucial to have a nursing workforce prepared to respond. This study is a further evaluation of an instrument developed to assess nurses' familiarity with emergency preparedness. Refinement of the instrument was considered an important first step before widespread investigation of nurses' preparedness could be performed.

REVIEW OF LITERATURE

O'Boyle et al.2(p351) noted that "public health emergencies, including bioterrorism events, are viewed as realistic possibilities." The American Association of Colleges of Nursing and the International Coalition for Mass Casualty Education recognized that all nurses need the knowledge and skills to be able to respond to bioterrorism and other mass casualty events.3,4 Despite these calls for emergency preparedness education, there is currently a lack of emergency preparedness and mass casualty education in the curricula of nursing schools, and little is known about how well prepared current nurses are for handling large-scale medical events.5-7

Patillo8 emphasized that disaster nursing was once the purview of military nurses and emergency department personnel. This perspective has been expanded through the growing belief that disaster preparedness is now a requisite competency in undergraduate nursing programs and across all nursing professions.8-10

Veenema11 noted that educators responsible for staff development and continuing education in all types of health care settings must develop continuing education programs on bioterrorism. Weiner et al.12 noted that, although some nurses have had community health education on natural disasters, most have not been fully educated about bioterrorism and how to respond to other large-scale emergency events. Stanley13 recommended that every nurse possess the basic knowledge and skill to respond to a mass casualty incident. Without this competency, nurses will not be adequately prepared to function as front-line responders to a natural or man-made disaster.

To date, there is minimal empirical evidence regarding emergency preparedness knowledge among nurses. Lanzilotti et al.14 surveyed 3,386 Hawaiian doctors and nurses to determine their ability to recognize and to treat victims exposed to biological and chemical agents, their interest in training/ education, and their willingness to staff field medical facilities during a natural or man-made disaster. Results of this study indicated that they were most able to recognize influenza (54% and 49% for physicians and nurses, respectively) and least able to recognize tularemia (5% and 2%, respectively). Scores for the ability to recognize and to treat exposure to specific chemical agents were consistently low (=8%) for both the physicians and nurses surveyed. A majority of the survey respondents expressed interest in continuing education programs. Physicians and nurses indicated tiiat they were most willing to staff field medical facilities in a natural disaster (83% and 90% for physicians and nurses, respectively) and were least willing to do so in a radiological incident (52% and 49%, respectively).

Wisniewski et al.15 surveyed 877 Wisconsin registered nurses by using the Emergency Preparedness Information Questionnaire (EPIQ). The 44-item EPIQ assessed nurses' self-reported familiarity with eight dimensions of emergency preparedness (scale of 5 = very familiar to 1 = not familiar). In the original analysis, eight dimensions were identified, mat is, (a) detection, (b) incident command system, (c) triage, (d) epidemiology and surveillance, (e) isolation, decontamination, and quarantine, (f) communication, (g) psychological issues, and (h) reporting. Survey respondents indicated the most familiarity with triage (average familiarity score, 3.15) and the least familiarity with communication and connectivity (average familiarity score, 2.08).

There is support in the literature for examining emergency preparedness training needs. The Agency for Healthcare Research and Quality16 and Veenema17 addressed training needs for nurses and health care workers. Gebbie and Qureshi18 and the International Coalition for Mass Casualty Education4 developed emergency preparedness competencies for nurses. Assessing training needs is a necessary first step in implementing training programs.

There is little information available in the literature concerning nurses' emergency preparedness knowledge. Reineck et al.19 developed the Readiness Estimate and Deploy ability Index to assess the ability of Army nurses to provide care in austere environments. Stevenson et al.20 assessed 63 Air Force nurse anesthetists' readiness for deployment with a modified Readiness Estimate and Deployability Index. Reineck21 developed a version of the Readiness Estimate and Deployability Index for use by emergency center nurses in the civilian sector. No data have been reported in the literature on results with the civilian Readiness Estimate and Deployability Index.

The EPIQ was the only tool described in me literature that comprehensively assessed civilian nurses' perceived familiarity with eight competency dimensions of emergency preparedness. Despite potential broad applicability, the EPIQ has been administered only once, by the original researchers.

Using the EPIQ, the current study represents a beginning stage of development of a program of emergency preparedness research. The goal is to better understand nurses' emergency preparedness needs and ways to best convey emergency response skills and procedures. The EPIQ can be used to survey nurses in a variety of practice settings, to determine their particular training needs within various dimensions of emergency preparedness.

METHODS

In this study, we expanded on the work by Wisniewski et al.15 with scale development and refinement, reliability assessment, scale validation, and scale predictability evaluation. Research attention is especially focused on assessing a critical and untested phenomenon of interest, namely, nurses' self-reported level of familiarity with emergency preparedness.

Description, Administration, and Scoring of the Instrument

The EPIQ is a 44-item instrument that assesses nurses' selfreported familiarity with eight dimensions of emergency preparedness and includes a self-reported measure of overall preparedness for a large-scale emergency event. Each individual item was measured on a 5-point familiarity scale, ranging from 1 = not familiar to 5 = very familiar. The EPIQ was placed online by using the Wisconsin Health Alert Network in July 2003 and is available to date. The Health Alert Network is a communication system for Wisconsin's public health departments, hospitals, clinics, emergency departments, laboratories, law enforcement agencies, fire services, emergency medical services, and otiier health agencies. A total of 776 fully completed responses were used in the current study.

Statistical Analyses

The SPSS 14.0 Graduate Pack (SPSS, Chicago, Illinois) was used for data analysis. To assess dimensionality, the data were first subjected to a principle-components analysis by using a varimax rotation. One question with a factor loading of <0.4 was removed from consideration. Based on the results of the factor analysis, die original EPIQ was revised. This revision consisted of moving items from the original dimension (factor) to the dimension where the items best fit, based on the factor analysis. The reliability of the resulting emergency preparedness dimensions was then assessed by using Cronbach's a values. The eight emergency preparedness dimensions are shown in Table ?, with me amount of variation explained by each dimension and the resulting a value. The cumulative variance explained was 73.5%.

A number of important implications can be drawn from these findings. First, the factor analysis was powerful, explaining a relatively high 73.5% of the total variance across the eight dimensions. Second, the reliability of each dimension was very high, with a values ranging from 0.83 to 0.94; the a value for the entire instrument was exceptionally high at 0.97. Third, the inclusion of a more robust factor analysis and greater detail to scale purification resulted in a different set and configuration of dimensions, compared with those reported by Wisniewski et al.15 Table II reports the average familiarity score for each of the revised emergency preparedness dimensions, as well as the average overall familiarity score. This analysis accomplishes the scale development and purification goals set forth in the study.

Nurse respondents reported an average overall emergency preparedness familiarity score of 2.3. This relatively low score indicates a positive correlation with the lack of emer- gency preparedness education in nursing programs. Although nurses felt relatively unprepared across most of the dimen- sions, the dimension scoring lowest was communication and connectivity (score, 2.1), followed by epidemiology and clin- ical decision-making (score, 2.2), psychological issues and special populations (score, 2.4), isolation, decontamination, and quarantine (score, 2.5), incident command system (score, 2.7), reporting and accessing critical resources (score, 2.8), and biological agents (score, 2.9). Nurses reported the greatest familiarity with triage (score, 3.2); mis was the only emergency preparedness dimension witii an average familiarity score above 3.0. Triage concepts have traditionally been included in nursing education programs.

RESULTS

The initial procedures for data analysis facilitated developing a testable model assessing the relative impact of each emergency preparedness dimension on nurses' perceptions of their overall preparedness in the case of large-scale emergency events such as those that occurred on September 11, 2001, and wim Hurricane Katrina. To assess the overall predictability of the instrument and the relative impact of each dimension, the factors scored for me revised EPIQ dimensions reported above were regressed against nurses' overall familiarity wim response activities/preparedness in me case of a large-scale emergency event. The findings are reported in Table UI.

As Table III shows, the revised EPIQ is very powerful for explaining respondents' self-reported preparedness in the case of large-scale emergency events (R^sup 2^ = 0.734, F = 264, p < 0.001). Of significance, each of the eight revised EPIQ dimensions had a strong significant impact in explaining overall familiarity (all significant at p < 0.001). In order of importance, communication and connectivity had the highest standardized ß value (standardized ß = 0.42), followed by incident command system (standardized ß = 0.31) and reporting and accessing critical resources (standardized ß = 0.31), epidemiology and clinical decision-making (standardized ß = 0.29) and isolation, decontamination, and quarantine (standardized ß = 0.29), psychological issues and special populations (standardized ß = 0.28) and biological agents (standardized ß = 0.28), and triage (standardized ß = 0.20). In combination, the factor analysis, reliability analysis, and regression results achieved the goal of assessing the reliability and validity of the revised EPIQ.

DISCUSSION

Studies to date have been focused on identifying training needs of public health workers, citizen volunteers, first responded, physicians, school nurses, military nurses, and nursing students. Further research is needed to determine the current level of nurses' knowledge of emergency preparedness, to design and to implement effective emergency preparedness education curricula and continuing education programs. The EPIQ was developed in 2003 and was used in only one large-scale exploratory/descriptive study. The present study extended the analysis of EPIQ data to assess the reliability and validity of this instrument to accurately measure nurses' self-reported familiarity with emergency preparedness competency dimensions.

The revised EPIQ could be used to assess the self-reported emergency preparedness knowledge of military nurses. Baker22 emphasized the importance of collaboration between military and civilian health care facilities in the event of a natural or man-made disaster. Key stakeholders in nursing might consider the use of the revised EPIQ to assess nurses' selfreported level of familiarity with emergency preparedness competency dimensions.

Although this study focused on nurses, consideration should be given to using the EPIQ to assess the emergency preparedness familiarity of other health care workers. The revised EPIQ could readily be used to assess the self-reported familiarity with emergency preparedness of physicians, first responders, and public health workers.

This study confirmed that the EPIQ as revised is a psychometrically sound instrument to measure nurses' self-reported level of familiarity with emergency preparedness. The need for emergency preparedness training is well documented in the literature. A crucial first step toward designing wellwritten, comprehensive, emergency preparedness curricula is to assess training needs. Additional studies using the revised EPIQ should provide data to assist nurse educators in the development of competency-based, relevant, emergency preparedness curricula.

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