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E X P L O R I N G Nursing Students

Level of Preparedness for Disaster Response

C H E RY L K . S C H M I D T, J E N N I F E R M . D AV I S , J E N N A L . S A N D E R S , L A U R A A . C H A P M A N ,

M A RY C AT H E R I N E C I S C O ,

AND

A R L E N E R . H A DY

INCE SEPTEMBER 11, 2001, ORGANIZATIONS, AS WELL AS INDIVIDUALS, HAVE PLACED GREATER EMPHASIS ON

DISASTER PREPAREDNESS.

The National Student Nurses Association (NSNA) is no exception. Nursing students must prepare for possible disasters at the individual, family, and nursing program levels. Lack of preparedness at any level can adversely affect other aspects of the students life. For instance, the student who is worried about the well-being and survival of family members during a disaster will not be effective when volunteering for disaster response in the clinical setting. No data are available on how well prepared nursing students are to respond to disasters that may affect them personally or affect their nursing programs. This descriptive study was sponsored by the NSNA to explore the level of preparedness of nursing students, their families, and their nursing programs to respond to natural and man-made disasters. NSNA, an organization of pre-licensure nursing students, has more than 55,000 members throughout the United States and its territories. Its mission is to prepare future nursing leaders, advocate for nursing students and nursing education, and contribute to the advancement of the nursing profession.

Background If faculty are not well prepared for disasters, it may be assumed that their students will also not be well prepared. In March 2001, prior to the September 11 attacks, the International Nursing Coalition for Mass Casualty Education (INCMCE), a coalition of nursing programs, nursing accrediting bodies, nursing specialty organizations, and governmental agencies interested in promoting mass casualty education for nurses, met to develop policies and standards to prepare nurses to respond to mass casualty events. Working with the National League for Nursing, INCMCE surveyed faculty in all types of nursing programs (LPN to doctoral); 348 programs responded (17.3 percent) (Weiner, Irwin, Trangenstein, & Gordon, 2005). Only 53 percent of these programs reported offering disaster preparedness content, with a mean of 4.5 to 5 hours of

content; 75 percent indicated that faculty were inadequately prepared in disaster response planning. In 2006, the American Association of Colleges of Nursing (AACN), recognizing that nursing programs need guidance to prepare for future disasters, including liability issues and partnering with local, state, and federal disaster response agencies, surveyed faculty in baccalaureate nursing programs about how they prepared students to respond to disasters (n = 338, response rate 57 percent). AACN (2008) includes a requirement for disaster preparedness content in BSN programs accredited by the Commission on Collegiate Nursing Education. In April 2003, the NSNA House of Delegates passed a resolution in support of American Red Cross (ARC) disaster training to be included in planned nursing curricula (NSNA, 2003, p. 16). As a result of that resolution, the ARC provided disaster training during the NSNA Midyear Conference in 2003 and during annual conventions in 2004, 2010, and 2011 (NSNA, 2004, 2010, 2011). Members were encouraged to ask faculty to consider adding these courses to their curricula. Another resolution was passed during the 2003 NSNA House of Delegates meeting. It supported the development and implementation of educational programs to inform nursing students and nurses about the smallpox virus and the potential complications of the smallpox vaccine (NSNA, 2003, p. 22). The 2004 House of Delegates passed another resolution, in support of raising awareness of Post Traumatic Stress Disorder in the aftermath of a crisis (NSNA, 2004, p. 14). Acting on these resolutions, the NSNA increased efforts to provide educational programs on these topics during meetings twice annually, a strategy that benefited the nursing students who were present. To reach the broad NSNA membership, an article about disaster nursing and preparedness was published in IMPRINT, the NSNA member publication (Schmidt, 2006). Following the 2005 hurricanes, Katrina and Rita, the NSNA House of Delegates passed a resolution asking NSNA to support the

RESEARCH A B S T R AC T

This descriptive study explores students perceptions of personal and program preparedness for disasters. Participants in this online survey included 1,348 nursing students from every state plus Guam, Puerto Rico, and the Virgin Islands. The study explored three questions: a) the level of preparedness, including learning about different types of disasters, preparing disaster plans, creating disaster kits, and participating in community disaster response efforts; b) the impact of disasters on nursing students; and c) strategies to assist nursing students during disasters. Results indicated that nursing students throughout the country are generally not well prepared for disasters. Nurse educators need to develop strategies to prepare their students for disasters. The American Red Cross provides templates for organizations, including colleges and universities, to prepare their campuses for emergencies. Faculty need to collaborate with staff and students to develop and implement plans appropriate for their programs.

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establishment of protocols for disaster relief guiding the scope of practice for student nurses and the collection and distribution of donations (NSNA, 2006, pp. 10-11). During the debate, delegates described their frustration with the lack of standardized protocols for nursing student participation in disaster response. Most undergraduate nursing students are not licensed as RNs or licensed practical/vocational nurses and can work with patients or clients only under the direct supervision of nursing faculty. Delegates also described the problems they had in delivering relief supplies and donations (uniforms, textbooks, stethoscopes, personal supplies) to affected disaster zones. Therefore, the second purpose of the resolution was to develop a system to collect and disseminate donated items through appropriate channels, and to match donations to specific needs. One outcome of the 2006 resolution was the establishment of the NSNA Disaster Relief Task Force. Several task force members traveled to the Gulf Coast in August 2006, visiting nursing programs in New Orleans, Louisiana, and Hattiesburg, Mississippi. At a nursing program in New Orleans, they conducting a workshop on strategies to prepare nursing students to respond to disasters. At this time, task force members developed a survey to assess the level of preparedness of nursing students to respond to disasters. The survey was refined by the first author and disseminated to active and associate members of the NSNA. This article reports the results of the survey, which was designed to: a) assess the level of preparedness of nursing students throughout the United States to respond to disasters; b) explore the impact of disasters on nursing students who were either victims or responders; and c) determine potential strategies to help nursing students and programs who are affected by disasters. The study was approved by the first authors university Institutional Review Board. The potential sample included 39,000 active and associate NSNA members who provided email addresses. Active members were students enrolled in state-approved programs preparing for registered nurse licensure or registered nurses enrolled in programs leading to a baccalaureate in nursing (NSNA, 2007, p. 1); associate members were taking prerequisite courses designed as preparation for entrance into a prelicensure nursing program. Sustaining and honorary members were not included in the survey; these are typically RNs who have been in practice, education, administration and/or research positions for significant periods of time, with multiple opportunities to learn about disaster preparedness. Subjects were recruited by email invitation; an additional source of respondents came through a link to SurveyMonkey.com placed on the NSNA webpage. Respondents used a log-in identifier to enter the survey and were prevented from answering the survey more than once. A total of 1,351 respondents answered the survey within two months after it was opened; the survey was then closed to allow data analysis.
Methods
POPULATION AND S AMPLE

Face and content validity for the survey were initially established by task force members, who determined that the instrument adequately represented the content of interest; further validity was established by input from members of the NSNA Board of Directors and the Nominations and Elections Committees, as well as selected nursing student leaders in the first authors nursing program. These students responded to the survey prior to its release to the general membership to determine whether the questions were understandable and the survey was easily navigated. Further feedback was obtained in November 2006 from representatives of a variety of disaster response organizations and credentialing bodies. The survey instrument opened with an introduction to the purpose and voluntary, confidential nature of the study and with instructions for completing it. When formatted into the survey software, it was divided into three parts: a) demographic information, such as NSNA membership status, state of residence, type of nursing program (associate, diploma, baccalaureate, or generic graduate), year in nursing program, state where program was located, and previous nursing or other post-secondary education; b) questions about personal disaster preparation (see Table 1), including certification in the National Incident Management System and other courses and knowledge that might allow nursing students to participate in disaster relief; and c) questions for members who had been personally affected by a disaster, as either a victim or a responder. This section asked for the type of disaster experienced; how the respondent was affected; the role the respondent played if applicable; types of resources needed after the disaster; and the assistance the respondent would appreciate from NSNA. Some respondents who were not personally affected answered the open-ended questions about how NSNA can assist nursing students during future disasters. Parts I and II of the online survey took approximately 20 minutes complete. Part III, which included the open-ended questions, took an additional 15 to 25 minutes to complete. The data were collected in a password-protected Microsoft Excel spreadsheet. Aside from geographic location of their homes and nursing programs, participants provided no identifying data. DATA ANALYSIS SurveyMonkey provides descriptive aggregate data in the form of an Excel spreadsheet. Missing data were minimized because the survey was programmed to require an answer to each closed-ended question. Open-ended questions were optional. Frequency tables were used to summarize the frequency of each score, the cumulative frequency, and the percentage and cumulative percentage of each variable. Descriptive statistics were used to summarize responses to each question. Responses to the open-ended survey questions were analyzed by calculating frequencies of items identified, such as which specific disaster relief agencies students had contacted to explore volunteer opportunities.
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Table 1. Nursing Students Preparedness for Disasters at Individual, Family, and Nursing Program Levels
QUESTION YES % (n) NO % (n) DONT KNOW % (n)

Have you talked about how to respond to a disaster? Has your faculty talked about what to do during a disaster at school? Have you discussed what to do if your dean/faculty were not available? Do you have a personal disaster plan? Does your nursing program have a plan? Does your nursing program have an alternate location for classes? Do you know what the disaster plans are at your clinical sites? Do you know how much food and water to store? Do you have the recommended supplies? Do you have a three-day Go Bag available? Does everyone know how to contact each other? Do you practice disaster drills at home? Do you practice disaster drills at school? Do you have supplies to shelter at home? Do you have supplies to shelter at school?

64.7 (800) 24.4 (301) 9.3 (115) 42.5 (525) 19.3 (238) 8.4 (104) 29.5 (357) 49.9 (576) 30.2 (348) 20.3 (234) 67.5 (770) 17.4 (194) 28.6 (319) 50.6 (564) 2.5 (28)

33.1 (409) 71.0 (878) 85.5 (1,057) 56.1 (684) 23.1 (285) 20.3 (251) 60.4 (731) 46.9 (541) 60.9 (701) 79.3 (915) 26.2 (299) 82.4 (919) 66.0 (736) 40.2 (448) 25.1 (280) 1.2 (15) 57.1 (706) 70.4 (870) 8.2 (99) 3.1 (36) 8.6 (99) 0.3 (4) 4.4 (50) 0.1 (1) 4.8 (53) 9.1 (102) 71.9 (802)

Results Survey respondents were 1,348 nursing students representing all states, plus Guam, Puerto Rico, and the Virgin Islands. The majority (n = 1,107, 82 percent) were prelicensure nursing students; 214 respondents (15.9 percent) were RN-BSN students. Respondents attended diploma programs (n = 77, 5.7 percent), associate degree (n = 560, 41 percent), BSN (n = 687, 50.9 percent), and generic MSN or doctorate programs (n = 25, 1.9 percent). Table 1 summarizes the responses to selected questions regarding students preparedness for disasters at individual, family, and nursing program levels. Responses to these questions indicated a general lack of preparedness, except for talking about disasters, knowing how much food and water to store, having sufficient supplies to shelter at home, and knowing how to contact one another. Most students did not know about the disaster plans in their clinical sites or nursing programs, which may be cause for alarm. A significant number of respondents (n = 478, 42.9 percent) had experienced a personal disaster; 141 respondents (12.7 percent) had experienced a disaster in the nursing program. Students reported emotional effects (74.0 percent); physical effects (30.8 percent); financial effects (60.6 percent); and school attendance disruption (41.4 percent). More than 70 percent either had not received crisis intervention from the nursing program or were not aware that it may have been offered. Some survey respondents (n = 46, 40.4 percent) indicated that they had participated in disaster relief work; and half of these had traveled outside their immediate area to help others affected by disasters. Most of these students (57.5 percent) had collaborated with other organizations, but only a few reported being evaluated in their work. Fortunately, only five students indicated that they performed tasks they felt unprepared to do. Of those who helped during disasters, 37 (84.1 percent) believed that the experience had enriched their nursing education; 43 (95.6 percent) believed that disaster preparedness education

should be included in nursing curricula. Table 2 summarizes nursing students participation during disaster response and the type of supervision they received. The majority (37.2 percent) received no supervision. Table 3 lists the types of community organizations in which nursing students volunteered.

Table 2. Disaster Volunteer Activities and Types of Supervision (n = 40)

QUESTION: IF YOU PARTICIPATED IN DISASTER RELIEF WORK, WHAT TYPE OF ACTIVITIES DID YOU PERFORM?

Helped reach families Basic hygiene/activities of daily living Help deal with psychological trauma Take vital signs Assist other professionals Wound care Triage Other
QUESTION:

40.9% (18) 36.4% (16) 27.3% (12) 22.7% (10) 22.7% (10) 13.6% (6) 11.4% (5) 61.4% (27)

IF YOU WERE SUPERVISED DURING YOUR VOLUNTEER WORK, WHO PROVIDED THE SUPERVISION?

Other nurses Nursing faculty Other health professionals Firefighter Physician Social workers Police officers Other None

27.9% (12) 18.6% (8) 18.6% (8) 16.3% (7) 11.6% (5) 9.3% (4) 7.0% (3) 20.9% (9) 37.2% (16)

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Table 3. Community Organizations in Which Nursing Students Volunteered (n = 40)

COMMUNITY ORGANIZATION NUMBER REPORTING, % (n)

Faith-based American Red Cross First responders Habitat for Humanity Salvation Army Other

32.4 (334) 20.9 (214) 11.2 (112) 9.1 (91) 5.9 (59) 16.5 (153)

ions of nonrespondents. Another limitation of a one-time survey is that it may not reflect change over time or after exposure to disaster preparedness education. Finally, no correlations were examined among the data in this survey, so no conclusions can be drawn about the relationship between responses, such as the relationship of type of nursing program and geographic location to level of preparedness.
Conclusion This study provides important insights into the dis-

Discussion There is no certainty that nursing students will have

personal experiences with disasters or disaster response. But all students should receive disaster preparedness education in their nursing programs. In addition, to protect clients, students, and those providing supervision, strategies are needed to standardize the supervision of unlicensed nursing students during disaster response. One strategy to allow nursing students to participate safely in disaster response efforts is to link with organizations that have well-established policies and procedures. These include faithbased and other organizations that have responded consistently over the years and may even have nurses among their volunteers who can become formal preceptors for nursing students. This study shows that a third of the student respondents volunteered with faith-based organizations, while 20 percent volunteered with the American Red Cross. Most nurses have strong spirits of volunteerism and are eager to help when needed. Organizations would be well advised to develop strategies to prepare nurse preceptors within their ranks and to recruit a new generation of volunteers from among the thousands of nursing students who wish to volunteer.
Limitations This descriptive study explored the level of preparedness of nursing students, their families, and their nursing programs for disasters. The results relied on responses provided voluntarily by survey respondents and may not reflect the opin-

aster preparedness of nursing students. In particular, the study provides valuable data for designing appropriate educational resources to help nursing students prepare themselves, their families, and their nursing programs for future manmade and natural disasters. It is important to note that adding new content to nursing program curricula presents a challenge because of the volume of content already required by nursing program accreditation bodies. A more feasible approach may be to develop materials that students can access outside formal classroom or clinical experience time. It is hoped that this survey may serve as a model for health profession programs or organizations to assess the level of preparedness of their students or members.
NLN

About the Authors Cheryl K. Schmidt, PhD, RN, CNE, ANEF, is associate professor and associate dean, University of Arkansas for Medical Sciences College of Nursing, Little Rock. Jennifer M. Davis, BSN, RN, is with the Cleveland Clinic Foundation, Cleveland, Ohio. Jenna L. Sanders, BSN, RN, is with Parkview Health System, Fort Wayne, Indiana. Laura A. Chapman, MSN, RN, is faculty, Wallace State Community College, Hanceville, Alabama. Mary Catherine Cisco, BSN, RN, SANE, FNE, is associate administrator, Indiana University Health Methodist Hospital, Indianapolis. Arlene R. Hady, BSN, RN, PHN, is with the University of California, San Diego Health System, San Diego. For more information, contact Dr. Schmidt at [email protected]. Key Words Disaster Preparedness Nursing Students Preparedness for Disasters National Student Nurses Association

References
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. National Student Nurses Association. (2003). Proceedings of fifty-first annual meeting. Brooklyn, NY: Author. National Student Nurses Association. (2004). Proceedings of fifty-second annual meeting. Brooklyn, NY: Author.

National Student Nurses Association. (2006). Proceedings of fifty-fourth annual meeting. Brooklyn, NY: Author. National Student Nurses Association. (2007). Getting the pieces to fit. Brooklyn, NY: Author. National Student Nurses Association. (2010). Proceedings of fifty-eighth annual meeting. Brooklyn, NY: Author.

National Student Nurses Association. (2011). Proceedings of fifty-ninth annual meeting. Brooklyn, NY: Author. Schmidt, C. K. (2006). Disaster! Are you prepared? NSNA Imprint, 53(2), 50-52. Weiner, B., Irwin, M., Trangenstein, T., & Gordon, J. (2005). Emergency preparedness curriculum in nursing schools in the United States. Nursing Education Perspectives, 26(6), 334-339.

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