Disaster Medicine and Public

Health Preparedness
Emergency Nurse Roles, Challenges, and
Preparedness in Hospitals in the Context of
www.cambridge.org/dmp Armed Conflict
Zakaria Mani PhD1,2 , Lisa Kuhn PhD2,3 and Virginia Plummer PhD2,4
Original Research 1
Jazan University, Jazan, Saudi Arabia; 2Monash University Faculty of Medicine Nursing and Health Sciences,
Clayton, Australia; 3Australian Catholic University, Faculty of Health Sciences, Fitzroy, Victoria, Australia and
Cite this article: Mani Z, Kuhn L, Plummer V. 4
Federation University Australia, Ballarat, Victoria, Australia
Emergency nurse roles, challenges, and
preparedness in hospitals in the context of
armed conflict. Disaster Med Public Health Prep. Abstract
18(e21), 1–8. doi: https://doi.org/10.1017/
dmp.2024.7. Introduction: An understanding of emergency nurses’ roles, challenges, and preparedness in
the context of armed conflict is necessary to capture in-depth insights into this specialty and
Keywords: their preparational needs when working in these unique environments. Unfortunately, the
disasters; emergency nursing; mass casualty evidence about emergency nurses’ work in the context of armed conflict is scant.
incidence; military medicine; war
Method: Semi-structured interviews were conducted with 23 participants and analyzed using
Corresponding author: qualitative content analysis. The COREQ guideline for reporting qualitative research was
Zakaria Mani; followed.
Email: [email protected] Results: The emergency nurses’ roles, challenges, and preparedness in hospitals in the context
of armed conflict were explored in detail. The main challenges that these nurses faced included
poor orientation, access block, and communication barriers. Various perspectives about
preparation, including education, training, and strategies for preparing emergency nurses were
identified. The most striking findings in these settings were the diversity of armed conflict
injuries, clinical profiles of patients, triage of mass casualties, trauma care, surge capacity,
orientation, communication, and strategies for preparing nurses.
Conclusions: This study provided an exploration of the scope of emergency nurses’ roles, and
how they were prepared and expected to function across multiple hospitals in armed conflict
areas. The resultant snapshot of their experiences, challenges, and responsibilities provides an
informative resource and outlines essential information for future emergency nursing
workforce preparedness. There is a broad range of preparational courses being undertaken by
emergency nurses to work effectively in settings of armed conflict; however, required education
and training should be carefully planned according to their actual roles and responsibilities in
these settings.

Armed conflict increases morbidity and mortality in affected populations across the world.1,2
The nature and sophistication of armed conflict has threatened thousands of people with
violence daily, influenced health-care systems, increased societal breakdown, spread contagious
disease, and has led to a shortage of necessary resources.1,2 However, despite the dire health-
related consequences of the armed conflict, little attention has been received from health
researchers.
Armed conflicts result in an influx of patients to the most immediately accessible health-care
facilities, which are usually hospitals. Hospitals are resource-limited settings and can become
rapidly overwhelmed by injuries including trauma from bombs, gunshots, burns, motor vehicle
collisions, abscesses, and maternal fatalities.2 The ability to adapt to the myriad of situations in
resource-limited settings is a challenge, and requires highly specialized personnel.2
The use of explosives in armed conflict and terrorist attacks is common.2 Blast injuries are
© The Author(s), 2024. Published by Cambridge
prevalent and have caused civilian casualties in many parts of the world, including Baghdad,
University Press on behalf of Society for Damascus, Karachi, London, Madrid, Boston, New York City, Paris, and Atlanta.3 Most victims
Disaster Medicine and Public Health, Inc. This is did not die instantly, and those who survived tended to sustain severe musculoskeletal injuries.3
an Open Access article, distributed under the Appropriate care of injuries in the immediate aftermath of armed conflict incidents is said to be
terms of the Creative Commons Attribution key to reducing mortality rates and enhancing recovery.3
licence (http://creativecommons.org/licenses/
by/4.0/), which permits unrestricted re-use, The high-energy transfer fragment, projectile, and blast injuries need effective damage
distribution and reproduction, provided the control and operative competencies that are not usual in routine standards of care.4 Therefore,
original article is properly cited. proper training and preparedness are needed to manage these complex casualties.4
Unfortunately, previous experience has shown that health-care providers were not always
well prepared for mass casualties from armed conflicts and often worked in facilities with limited
resources.5 Multiple bombings have been perpetrated in recent decades, and unfortunately,
anticipating the end of the armed conflict is difficult.5 Bombings using various materials
increases the need for complicated preparedness in hospital systems to manage the ongoing risk
of exposure to hazardous materials.5 In addition, it has been argued that inadequate planning for

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 2 Z Mani et al.

chemical, biological, radiological, nuclear, and high yield explosive Data Analysis
(CBRNe) incidents might result in functional failures, for instance,
Data were analyzed using the qualitative inductive content analysis
secondary contamination of facilities, teams, and patients.6
method that was outlined by Elo and Kyngäs (2008).8 It consisted
The health services of many countries have come to recognize
of 3 phases: preparation, organizing, and reporting.8 NVIVO was
the necessity to better educate and prepare the nursing workforce
used for code development and data organization.10 Finally, codes
for disaster management, to ensure they are competent and can
were grouped into subcategories, and then categories, which were
confidently respond to major incidents. The literature reveals that
then refined into main categories.8 The process of the abstraction is
nurses play a crucial role in disaster management; however, a
presented in Figures 1-3.
national study found out that health-care providers perceived
themselves to have low ratings on their knowledge about bombing
situations and mass shootings.7 Moreover, there remains a paucity Trustworthiness
of evidence for emergency nurses’ roles, challenges, and The transcription was conducted by a specialized expert in this
preparedness in the context of armed conflict. Therefore, this context11 and then reviewed several times by the research team.
study aimed to explore emergency nurses’ roles, challenges, and The process of developing codes, subcategories, categories, and
preparedness in the context of armed conflict. main categories were evaluated by all members of the research
team to consolidate the findings.

Methods Ethical Considerations

Design Ethical approval to conduct this study was obtained from both the
A qualitative descriptive design was conducted using semi- Directorate of Health Affairs of Jazan: Research Ethics Committee
structured interviews. The data were analyzed using inductive (Registry no. 119/2019 – approval no. 010/2019), and Monash
content analysis as described by Elo and Kyngäs (2008).8 University Human Research Ethics Committee (Project Number:
20330). A signed informed consent form for each participant was
obtained.
Setting of the Study
The settings for this study were Ministry of Health (MoH) operated Findings
hospitals in the Kingdom of Saudi Arabia (KSA) in Jazan, which
are near the Saudi border shared with Yemen. Seven hospitals that Recognizing Roles, Challenges, and Preparedness and
receive many casualties from armed conflict in this region were Planning
chosen.9 The interviews commenced by exploring how the participants
viewed their roles in the hospitals in areas of armed conflict, and,
Participants what they liked about the role. The views regarding the main
challenges they faced there, and finally, their views of the required
All emergency nurses working in this region, including those who preparedness and planning for nurses were explored.
were part of the Regional Backup Nurses for Disaster (RBND)
group and key informants who oversaw management within these Recognizing Roles
hospitals were eligible for inclusion in this study. The RBND group
is a select group of emergency nurses who respond immediately The responses regarding nurses’ roles in the hospitals in areas of
when notified of any armed conflict incident and attend the armed conflict resulted in 6 sub-categories and 2 categories
receiving hospital. The key informant participants were leaders or included clinical nurse and head nurse (see Figure 1).
managers of emergency nurses in these areas close to armed Within the hospitals where the participants worked, each of the
conflict, and they included nursing directors, emergency nursing emergency departments were divided into various areas including
supervisors, medical directors, and emergency physicians. triage, which was usually situated at each facility’s entrance to
classify the patients into the following categories to indicate their
level of priority: red, yellow, and green. During every shift,
Participant Recruitment emergency nurses were assigned to an area in which they would
The recruitment process was undertaken between June 20 and July work. As illustrated in the following quotes:
20, 2019, in KSA. Flyers were posted to advertise the study in the We divide the hospital area, and it should always include the triage area
ED staff tearooms and nursing administration areas throughout (Amnah, RN)
the included hospitals. We receive the patients in the triage area (Natasha, RN)
We have a plan for every shift and who will be in triage and the red area, who
Data Collection will be in the green area and yellow area (Sharifa, RN)

Packs of interview questions, consent forms, and accompanying I worked as a triage nurse, or work in red, yellow, or green based on the
explanatory statements, sealed post boxes for anonymously leader[s] assignment (Amnah, RN)
“posting” the consent were provided in the staff tearooms. The emergency department in a 50-bed capacity hospital can
Interviews were conducted in quiet, private, and safe areas within receive multiple patients with different levels of triage priority
the hospitals. Data saturation was believed to have been reached by concurrently. The emergency needs to decide if the incident is
the 22nd interview. A further interview was conducted, with no should be considered a “disaster” or not, which is defined as more
new data forthcoming. than 6 cases. The nurse participants explained their role in

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 Disaster Medicine and Public Health Preparedness 3

Subcategory Category Main category

Triage

Clinical profile Clinical nurse

Working in different areas

Roles
Collaborator

Distributing staff and organizing resources Head nurse

Surge capacity

Figure 1. Abstraction of the findings adapted from Elo and Kyngäs (2008)8.

determining when to declare a disaster and where to place these patients directly to other hospitals that were geographically further
patients in the following: removed from the conflict zones. The role of the emergency nurses
ED can receive up to 11 red cases, up to 9 yellow cases, and the green cases in is described in the following quotes by an RN:
the outpatient area (Thamer, RN) Well, as we are stopping the cold patients and we are triaging the armed
My first role is to determine the incident; for example, if the cases [total] more conflict patients (Natasha, RN)
than 6, we consider it as disaster (Jill, RN) So, as what we can do only emergency treatment, as early as possible we are
receiving the [cold] patient, and we are referring directly to other hospitals
Having an expert nurse for doing armed conflict triage is crucial
(Natasha, RN)
because by using the tenets of mass casualty care effectively, they can
reduce the load of patients in immediate need of emergency Participants revealed that armed conflict cases were different from
management considerably. It helps nurses to deal with higher routine cold patient cases. When responding to armed conflict
volumes of patients with fewer resources. As indicated by 1 incidents, there is a different scope of practice required of
participant. emergency nurses was often different to routine emergency
presentations. They explained that applying care expected of
We need triage for disaster; we need someone to perform good or effective
triage. If you have a good triage, it reduces a load of patients by 50%
regular nurses’ roles and only following directions of doctors was
(Rashad, RN) not enough to manage the cases that presented from armed conflict
incidents. The ratio of nurses is mostly large compared with
Following triage, emergency nurses working near armed conflict physicians, and they are an important resource. Therefore, the
zones begin managing critical cases who need immediate inter- scope of nursing practice should be advanced in areas close to
ventions to save their lives. The people with the most severe injuries, armed conflict to maximize the nurses’ critical care services, and
but who can likely be saved will be managed in the red area. Then, the this increased independence could reduce the morbidities and
yellow area is reserved for casualties who are assessed to be in stable mortalities rates. As stated in the following quotes:
conditions and whose injuries are not immediately life-threatening
and can safely remain under observation. The green area is reserved Before when I came here, we had not had these kinds of cases in our
for casualties with minor injuries who may be called “walking emergency department (Natasha, RN)
wounded” and can safely wait for treatment. The other area is black I witnessed 2 periods of armed conflicts; the cases are varied compared to
and is where casualties are placed if they are deceased or assessed to routine trauma cases (Fahad, RN)
have injuries that are incompatible with life. Managing more patients These armed conflict cases are a different kind, and it is different approach
with fewer resources is an important aspect of these nurses’ care. (Jill, RN)
Participants described their roles in the following quotes:
The normal role of the nursing, normal scope of the practice, it cannot be
In general, just in disaster, some disaster goals just to deal with a higher applicable for the armed conflict incident. Your nursing practice is not only
number with less material (Wajdy, RN) following the order, but there is also a different scope of the practice for
We are distributing them to the red, yellow, green, or black area nursing in the armed conflict incident (Rayan, RN).
(Natasha, RN) Most of the armed conflict cases were soldiers and their injuries
After triage, we start with the red case or critical case (Rashad, RN) were severe traumatic injuries. Some cases had heavy bleeding and
nurses got experience of dealing with those cases. Therefore,
Participants explained that, during armed conflicts, all cases working in the situation of armed conflict incident enhanced
involved in the incidents had to be assessed and treated. Other nurses’ competence to manage these scenarios as they arose, as
noncritical cases, whose conditions were not related to armed described in the following:
conflict and were referred to as “cold patients” were asked to go
another second-line hospital. Nurses were mainly responsible for It is mostly gunshot and mine bomb (Fahad, RN)
these cold patients, who needed carefully applied nursing care We deal with gunshot and bomb blast cases (Sara, RN and Natasha, RN)
before they could be referred away. They provided emergency
Bomb blast and gunshot injuries, so actually, most of the soldiers that we
treatment immediately as necessary and then referred these receive here, most of them have lost a lot of blood (Sara, RN)

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 4 Z Mani et al.

If there are heavy bleeding cases, we know how we are treating them The views of nurses who worked in armed conflict areas for the
(Natasha, RN) first time was fear of the unknown and examples were reported in
Here, usually, we are receiving more emergency and trauma cases (Sara, RN) the following quotes:
Very good area to improve all the nurse’s skills, especially we are doing Actually, when I came to this place I was really scared because it is not like
everything there, we are learning new skills (Rayan, RN) normal things (Noor, RN).

I think after coming to this field, in the sense of the armed conflict incident, Well, the major challenges are like I’m risking my life. The war is almost
we are able to manage (Noor, RN) 4 years [long] (Sara, RN).

Due to the numerous armed conflict incidents, the MoH developed Providing a proper orientation for the external nurses from RBND
a specialized group of emergency responding nurses known as the who came to support the teams was a challenge. During the armed
Regional Backup Nurses for Disaster, or RBND, team. This conflict incidents, nurses proceeded to the areas to support, and
included many nurses from other hospitals, who together, act as a they might not get enough orientation and preparation. Therefore,
mobile team. The primary purpose of this group is to support nurses need to know about the situation, hospital plan and
nurses in borderline hospitals during armed conflict incidents, as locations of the resources, when they came from various hospitals
illustrated by participants in the following quotes. systems to support the receiving emergency department that might
also operate with different disaster policies and plans. Such
They choose so many nurses from other hospitals, and they also make a group
inconsistencies could worsen the situation for nurses and patients
in WhatsApp for a mobile team. We go to armed conflict incident place as
and a solution is, therefore, urgently needed. As stated in the
needed (Salah, RN)
following.
We are giving support as nursing care in armed conflict field, we like just to
help in emergency situations (Wajdy, RN). The external nurses do not know about hospital internal plan and locations
of the resources, and sometimes they are not aware of the armed conflict
The next role identified was that of a collaborator, who was working incidents management [procedures or plan] (Thamer, RN)
with various organizations to facilitate the management of care.
The armed conflict incident policy was lacking (Fahad, RN)
During armed conflict incidents, collaborators can request further
nurses by contacting RBND. They could also request further medical We do not have a real armed conflict incident plan (Jill, RN)
support and ambulance services as needed from the MoH’s disaster Several issues were identified about insufficient educational
and emergency administration, as described in the following: planning to manage armed conflict incidents. The frequency of
I communicate disaster and emergency administration for medical supports armed conflict incidents might influence the availability of
and transportation supports and getting RBND supports (Thamer, RN) education and training in the affected areas because most of the
nurses already had experience to manage such incidents, and the
Hospital, and also other government associations are involved in this kind of
armed conflict (Wajdy, RN)
nurses always needed to be available clinically. However, disaster
drills, training and updates were still wanted by participants, as
If I need more nurses, I request further nurses from other areas and request illustrated in the following quotes.
ambulances as well (Faisal, ND)
Actually, I attended only one disaster drill as far as I remember, and I guess
Another nursing role was identified as crucial to organizing care that we should also need some disaster training (Sara, RN)
for cases who presented from armed conflict was head nurses.
Participants explained that, every morning, the head nurse would I attend so many courses regarding the disaster, but all of it, it was around
6 years back (Rayan, RN)
identify how many nurses were working in the whole hospital and
would assign staff to roles for each area. They would then ensure Well, I think that for working in a disaster area we need some more of an
that nurses had checked and prepared the departments’ supplies update or disaster drills (Sara, RN)
appropriately, as explained by the following quotes: Actually, we should attend trauma or disaster management classes disaster
So, in the morning shift, we see how many staff in the hospital, everywhere management because we are dealing armed conflict incidents (Noor, RN)
they are mentioning who is the team leader, who is the supervisor Due to armed conflict incidents, hospitals could encounter a
(Natasha, RN) real challenge of access block or emergency department over-
So, our head nurse will inform us, will prepare our area. So, we need crowding due to limited resources and the inability to move
everything to be there, equipment, the machine should be checked like patients through to disposition so that others could be treated. As
suction. Our cardiac monitor, ventilator, portable BP (Jill, RN) indicated in the following comments:
The other role of the head nurse was to manage issues that arose Main challenge here is a shortage of nurses (Fahad, RN, and Natasha, RN)
during triage performed by either nurses or physicians as described
The challenge is a bed capacity (Sami, RN)
in the following quote:
The challenge is overloading patients (Thamer, RN)
Sometimes there was an issue in the triage, either by nurse or doctor, and
therefore for me as a leader, I always do re-triage for myself (Rashad, RN) There was also another issue that could worsen the situation of the
access block, which was the matter in the transportation systems that
sometimes delay the transfer out. As mentioned in the following
Challenges quotes:
Several views expressed by the participants provided insights into Transportation is a challenge (Sami, RN and Thamer, RN)
the various challenges that hospital nurses could face. Those Process of referring the cases takes longer times (Fahad, RN)
challenges appeared in 7 sub-categories and 3 categories including
poor orientation, access block, and communication barriers (see Possessing various effective communication systems (eg, pager,
Figure 2). intercom, special phones, or radios) inside the hospital is critical.

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 Disaster Medicine and Public Health Preparedness 5

Subcategory Category Main category

Fear of the unknown

Poor orientation for external nurses Poor orientation
Insufficient disaster plan and policy

Shortage of the staff

Challenges
Bed capacity issue Access block

Ambulance service

Interprofessional communication needs improvement

Figure 2. Abstraction of the findings adapted from Elo and Kyngäs (2008)8.

Subcategory Category Main category

Disaster management and trauma courses

On-going educational plan
Education and training
Policies and protocols education
Advancing scope of practice in emergency care Preparedness and
planning
Orientation about the policies and protocols education

Hiring experienced nurses

Orientation about the situation including ED and resourses

Figure 3. Abstraction of the findings adapted from Elo and Kyngäs (2008)8.

It promotes communication among staff, during the armed We need to improve our personal communication, rather than the technical
conflict incidents. As stated in the following quotes: skills (Rayan, RN).
Like, if we have a patient who is critically ill such as war trauma patients,
there should be various communications systems in the hospital, so the
Preparation and Planning
required staff will come at the same time as anesthetists, nurses (Adel, MD)
Some issues regarding communication between emergency nurses A variety of perspectives were expressed about the preparation and
and physicians occurred. Unfortunately, some physicians ignored planning. There were 7 sub-categories, and 2 categories were
nurses’ plans, and made participants feel as though the nurses identified included education and training, strategies for preparing
lacked inclusion in decision-making. Furthermore, it was nurses (see Figure 3).
explained that nurses might not always understand physicians’ Trauma and disaster management courses were recommended
communications adequately. The participants explained that by nurses, which it prepared them for working in the armed
nurses should not feel embarrassed about these issues, but conflict areas and improved their response.
communication was an area that did need to be improved in Those courses are listed in Table 1.
armed conflict areas, even more so than the physical nursing skills. The importance of the triage and trauma management for
These issues were elaborated upon in the following comments: armed conflict areas were mentioned by a participant in the
following quote:
Sometimes, physicians do not listen to the nursing leader suggestion
(Rashad, RN) In conclusion, the best things I learnt for armed conflict incidents was triage
and trauma management (Rashad, RN)
In some cases, if the doctors are telling you something, maybe suddenly we do
not hear those words, maybe it will be difficult to ask again, but we should not Education and training for nurses about policies and protocols of
be feeling ashamed (Noor, RN) how to deal with armed conflict incidents were described as
essential, particularly for those nurses who want to work in this
There could be an improvement in this communication like during the
armed conflict incidents (Sara, RN)
area. Participants said:

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 6 Z Mani et al.

Table 1. Participant-recommended courses for armed conflict incidents

Recommended courses Participant(s)

Advanced Trauma Care for Nurses (ATCN) Thamer, RN and Sami, RN
Advanced Cardiac Life Support (ACLS) Wajdy, RN and Thamer, RN
Cardiopulmonary Resuscitation (CPR) Wajdy, RN
Airway Management Saleh, RN
Intubation Noor, RN
Advanced Trauma Life Support (ATLS) Wajdy, RN and Sami, RN
International Trauma Life Support (ITLS) Wajdy, RN
Fundamentals of Critical Care and the Excellence of Emergency Care Fahad, RN
Excellence in Emergency Care Course Fahad, RN
Golden Course Thamer, RN
Defibrillation Noor, RN
Blood Transfusions Noor, RN
Disaster Management Saleh, RN; Thamer, RN; Jill, RN; Rashad, RN; Sami, RN and Natasha
Disaster Preparedness Fahad, RN
Response in Emergency and Disaster incidents (REDi) Fahad, RN
Disaster Triage Saleh, RN
Communication During Disaster Fahad, RN
Disaster Nursing Wajdy, RN

Some education is needed regarding the policies or how we have to deal with Well, for the employer I can say that they should hire some nurses who are
armed conflict incidents (Noor, RN) well experienced in ED because it is not so easy to work in armed conflict
areas (Sara, RN)
External nurses should know more about the protocols of military injuries
(Sami, RN) I will choose the expert nurses in emergency for armed conflict incidents or
disaster, just to make everything easy for me (Wajdy, RN)
External nurses should follow the law and hospital instructions (Fahmy, RN)
Working in the Hajj with mass gathering is a great experience and helped me
Well, what I need, to know is which patient needs transfer first. I need
to work here (Thamer, RN)
some clear policy also. Because we are in armed conflict areas and the
team from different places. When this casualty happens, we go there Participants talked about the importance of finding ways for
(Saleh, RN) providing a practical orientation for nurses who consider working
Ongoing educational plan for various sessions related to armed in the armed conflict area. As stated by several participants in the
conflict incidents weekly, fortnightly, or monthly were wanted by following:
participants, who stated the following: Nurses need orientation of the ED design (Omar, RN and Sami, RN)
If they are not able to do the weekly education, at least monthly education, They need to know where the places are, and orientation for all hospitals
one topic or monthly 1 topic or weekly 1 or every 2-week one (Noor, RN) (Rayan, RN)
Increase the education, training, workshop, and conferences about armed Give some orientation for this emergency department, and equipment for
conflict incidents (Fahmy, RN) new nurses (Saleh, RN)
Important updates are needed like armed conflict management (Sara, RN) Orientation for ED equipment, devices for new nurses (Fahmy, RN)
Some staff who work in evening shift or night shift need education They should become familiar with the area first so that during the
(Amnah, RN) assessment, they will know where they will get all the equipment and the
things needed if there is armed conflict incident (Jill, RN)
Participants believed that hospital administrators should visit
nurses and provide them with moral support. Participants said: For dealing with armed conflict cases, nurses should be relaxed. Should deal
with that one by one and should be knowledgeable enough, because this is
Repeated visits from administrations and providing moral supports
armed conflict (Jill, RN)
(Feras, MD)
We should be calm, first emergency cases we have to do, and then we have to
Encourage them to avoid fear, face and try to learn regardless of the situation
go with the other patients (Noor, RN)
(Sharifa, RN)
Working with those experienced in trauma like a surgical physician or
Adequate previous experience was important to most of the
experienced trauma nurses (Rashad, RN)
participants. Furthermore, nurses needed to be knowledgeable
enough on the variety of cases that were likely to present and
prepare themselves for practice. As described in the following:
Discussion
It is so important that nurses have experience before working here. Because if
you are new or you are here for the first time, you will be shocked of what you The study findings of emergency nurses’ roles, preparedness, and
will do in times of armed conflict incidents. Whereas if you already have challenges in the specific settings of armed conflicts are presented.
experience from before, let’s say like 4 years, you already know what to do The findings provide an estimate of the scope of emergency nurses’
and how to deal with assessment (Sara, RN) roles, and how they were prepared across a range of hospitals in the

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 Disaster Medicine and Public Health Preparedness 7

armed conflict areas and, therefore, provide a window to their assist decision-makers and planners to mitigate risk and improve
experiences. A significant snapshot captured an informative future responses in similar contexts.18 Various strategies for
resource for these settings. The most striking findings in these improved disaster education have been suggested, including virtual
settings were the diversity of armed conflict injuries, clinical disaster collaboration exercises,19 collaborative exercises for
profiles, the triage of mass casualties, severe trauma care, health-care teamwork in a Saudi context,20 and incorporating
challenges of access block and surge capacity, orientation, simulation exercises using collaborative tools in the disaster and
communication, and strategies for preparing nurses for their role. emergency medicine curriculum.21
However, these experiences were more relevant to the response
phase and may be less applicable to the long-term of care. Those
findings provided important implications for preparedness and Conclusions
planning. Given the large number of preparational courses being Emergency nurses should have sufficient education and training
identified in these settings, the choice of the required education about the possible situations, hospital plan, surge capacity, triage,
and training must be planned accordingly. trauma, transportation, and their role in armed conflict.
Recruiting emergency nurses who had experience in disaster Participants highly recommended the availability of suitable
nursing or leadership were recommended for the hospitals in the courses in trauma, triage, and disaster management in armed
armed conflict areas. In addition, the basic competencies of conflict. The findings of nurses’ roles, challenges, and preparedness
emergency and trauma care nursing were assumed a fundamental are likely to inform future planning, education, and training, and
for emergency nurses,12 and if not demonstrated, it needs to be might enhance emergency care in the context of armed conflicts.
implemented to address this gap.13 The planning of the drills should clearly define emergency nurses’
Lack of orientation for external new nurses about the hospitals roles and responsibilities and ensure that emergency nurses are
resources and preparation for armed conflict situations could competent.
impact their emotional state when they are called to respond to
blast incidents and mass casualty scenarios.3 (Balazs et al., 2015).
Less experienced nurses in this study indicated their requirements References
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