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International Journal of Nursing Practice 2015; 21: 60–69
RESEARCH PAPER
Knowledge, attitudes and competence in nursing practice of typhoon disaster relief work among Chinese nurses: A questionnaire survey Lin Jiang BSc RN Master’s Student, No.174 Hospital of People’s Liberation Army Clinical School, The Affiliated Chenggong Hospital of Xiamen University, Xiamen, China Staff Nurse, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China*
Hong-Gu He PhD MD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Wen-Guang Zhou MM Senior Technician, Material Department, No.174 Hospital of People’s Liberation Army, Xiamen, China Professor, Xiamen University, Xiamen, China
Su-Hua Shi MSc (Med.) RN Associate Chief Nurse, Department of Nephrology, No.174 Hospital of People’s Liberation Army, Xiamen, China Associate Professor, Anhui Medical University, Hefei, China
Ting-Ting Yin MSc (Nurs.) RN Nurse-in-Charge, Division of Nursing, No.174 Hospital of People’s Liberation Army, Xiamen, China Teaching Assistant, Xiamen University, Xiamen, China
Yue Kong MSc (Med.) RN Associate Chief Nurse, Associate Professor, Division of Nursing, No.174 Hospital of People’s Liberation Army, The Affiliated Chenggong Hospital of Xiamen University, Xiamen, China
Accepted for publication May 2013 Jiang L, He H-G, Zhou W-G, Shi S-H, Yin T-T, Kong Y. International Journal of Nursing Practice 2015; 21: 60–69 Knowledge, attitudes and competence in nursing practice of typhoon disaster relief work among Chinese nurses: A questionnaire survey The aim of this paper is to examine the relationships among nurses’ knowledge of, attitudes towards and level of competence in nursing practice, as well as factors influencing nurses’ competence in nursing practice, in typhoon disaster relief work. A cross-sectional descriptive study was conducted using a self-developed questionnaire to obtain data from 607 nurses working in four tertiary hospitals and two secondary hospitals in Fujian, China, in November 2011. Our Correspondence: Yue Kong, Division of Nursing, No.174 Hospital of PLA, 92-96 Wen Yuan Road, Xiamen 361003, Fujian Province, China. Email: [email protected] *[Correction added on 09 January 2015, after first online publication: Second affiliation of the author has been updated.]. © 2013 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12214
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findings show that the nurses’ average percentage scores on their responses to questions in the domains of knowledge, attitudes and practice were 66.33%, 68.87% and 67.60%, respectively. The findings demonstrated a significant positive relationship between nurses’ attitudes and their practice. Nurses’ working unit, prior training in typhoon disaster relief, current position of employment and attitudes were significant predictors of nurses’ competence in practice. The results indicate that strategies need to be developed for nurses to improve their knowledge, attitudes and practice. Key words: China, disaster, nurse, practices, relief, typhoon.
INTRODUCTION Typhoons are common disasters worldwide. The number of people who died as a result of typhoons from 1947 to 1998 was approximately 499 000, accounting for 41% of total death from the 10 main types of natural disaster, including earthquake and tsunami, worldwide.1 Typhoons have struck the areas along the South China Sea 254 times in the past 50 years; approximately 35% of typhoon strikes were on the northeast coast of Taiwan, and 22% of them were in Fujian and Zhejiang Provinces in China.2 Nurses need adequate skills and training in disaster management and relief work, as they are key members of health-care teams responding to national disaster situations.3 To prepare adequate health-care manpower to cope with sudden and unexpected challenges, health-care professionals, including nurses, should be equipped with the relevant knowledge and skills in disaster relief work, with training conducted during periods when there is no disaster.4 The literature has shown that drilling—that is, holding mock disasters—is one of the best and most preferred methods of training for improving the quality of nursing care and equipping nurses to fulfil their obligations in disaster relief.5 However, currently, there is no training programme for nurses in disaster relief work that is evidence-based and widely accepted.6 Thus, to develop a typhoon disaster relief training programme for nurses, it is necessary to understand nurses’ knowledge, attitudes and practices and the relationships among these, as well as the factors that influence nursing practice with regard to typhoon disaster relief work.
BACKGROUND An Australian study exploring 194 South Australian emergency nurses’ knowledge and preparedness for disaster response in an emergency setting reported that most nurses (85%) failed the knowledge test.7 The study also found that although a large number of nurses had completed what they perceived to be disaster education and training, the appropriateness, relevance and availability of such education was questionable. The other study conducted in South Australia reported that although 95% of
nurses agreed that disaster education for emergency nurses was important, limited education opportunities and little previous disaster response experience might be responsible for diminished confidence and disaster awareness among emergency nurses in South Australia.8 Little experience and knowledge of typhoon disaster relief work might be the main reasons causing panic among nurses.9 Nurses preferred to be with their families during typhoon disasters, and they experienced higher anxiety when they were separated from family members.10 Fortunately, the anxiety that these nurses experienced was not associated with impaired functioning or job abandonment.10 Conflict between nurses’ responsibilities at home and their obligations towards disaster response work was a common concern.11 A Hong Kong study4 reported that almost all respondents (97.6%) believed that the Hospital Authority was the main organization involved in responding to disaster situations. As the majority of Hong Kong nurses work in hospitals under the Hospital Authority, they have a sense of responsibility during disasters. Nurses felt obliged to respond to disasters; however, their intention to respond to disasters depended on the type of disaster.12 It is a challenge for nurses to work in clinical settings located in districts where disasters occur frequently. Nurses need to have adequate knowledge and skills to be competent in managing clinical situations related to disasters. Lack of knowledge and preparedness can lead to inadequate performance by health-care providers in caring for disaster victims.13 Experiences with responses to previous disasters have indicated the importance of emergency education and disaster preparedness.14,15 Nurses who are prepared and trained for disaster management can play an important role; one study4 also found that nurses cope better than those without preparation and training when disasters occur. To identify nurses’ training and education needs for typhoon disaster relief work, the first step would be to identify their existing knowledge, attitudes and competence in nursing practice with regard to disaster relief work. However, a review of © 2013 Wiley Publishing Asia Pty Ltd
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the literature shows that very few studies have been conducted to examine the relationships among nurses’ knowledge, attitudes and competence in nursing practice with regard to typhoon disaster relief work. There have been very few studies regarding typhoon disaster relief conducted in China. The aim of this study was to examine the relationships among nurses’ knowledge, attitudes and competency in nursing practice with regard to typhoon disaster relief work, as well as factors influencing nursing practice in typhoon disaster relief work.
METHODS Study design A cross-sectional, descriptive correlational design was adopted.
Participants Convenience sampling was used to recruit participants in the province of Fujian, China, in November 2011. A total of 648 nurses in medical, surgery, emergency and other working units were recruited from four tertiary hospitals and two secondary hospitals in the province of Fujian, China. The inclusion criteria for the participants were that they should be registered nurses who (i) were working at the participating wards and (ii) had more than 1 year of clinical experience. Registered nurses who (i) were parttime employees and/or (ii) were working at allied health departments (e.g. medical examination center, blood bank, rehabilitation department) were excluded. The sample size was determined by the number of participants required to maintain the statistical power for a correlational study. We adopted a medium effect size in the relationship between knowledge and practice. In order to achieve a power of 0.80 at the 0.05 significance level (two-sided), a minimum of 85 participants was required.16 We recruited as many participants as possible in our study.
Data collection The purpose and procedures of this study were explained to the ward managers and all participants. Questionnaires were distributed to nurses at their workplace. Instructions on how to complete the questionnaire were attached to each questionnaire. The completed questionnaires were placed in sealed envelopes and returned to the researcher directly or through the nurses’ ward managers. © 2013 Wiley Publishing Asia Pty Ltd
Instruments The instrument used was developed by the researchers based on the literature17–19 and opinions from seven experts. The instrument consisted of two sections. Section 1 inquired about nurses’ demographic data (8 items), which included gender, age, marital status, work experience in nursing, current position of employment, department and education level. Moreover, a question inquiring about whether participants had received any prior training in typhoon disaster relief work was asked. Section 2 included questions on nurses’ knowledge, attitudes and practice with regard to typhoon disaster relief work. This section was divided into three parts. Part 1 comprised four subcategories that assessed nurses’ knowledge on typhoon disaster relief work (12 items): (i) related concepts (three items); (ii) preventive measures (three items); (iii) types of burns (two items); and (iv) principles of rescue (four items). The responses were ‘yes’, ‘no’ and ‘don’t know’. One correct answer scored one point, with the total score ranging from 0 to 12; a higher score indicated a higher level of knowledge. Part 2 consisted of three subcategories about nurses’ attitudes (10 items): (i) personal attitudes towards typhoon disaster relief work (five items); (ii) influence of nurses’ family on their attitudes towards typhoon disaster relief work (two items); and (iii) influence of social norms on nurses’ attitudes towards typhoon disaster relief work (three items). Nurses were asked to rate each item using a five-point Likert scale, ranging from 0 (‘strongly disagree’) to 4 (‘strongly agree’). The total score ranged from 0 to 40, with a higher score indicating a more positive attitude towards typhoon disaster relief work. Part 3 also consisted of three subcategories about nursing practice (9 items): (i) individual behaviour with regard to typhoon disaster relief work (four items); (ii) influence of nurses’ family on their behaviour with regard to typhoon disaster relief work (three items); and (iii) influence of social norms on nurses’ behaviour with regard to typhoon disaster relief work (two items). The responses were ‘yes’, ‘no’ and ‘don’t know’. Each positive answer (i.e. ‘yes’) scored one point. Thus, the total score for Part 3 ranged from 0 to 9. The self-developed questionnaire was reviewed for its relevance, clarity and linguistic appropriateness by seven nursing experts (two academics, three nurse managers and two experts in surgical or medical nursing). The content validity indices of knowledge, attitudes and
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nursing practices with regard to typhoon disaster relief work were 0.87, 0.98 and 0.92, respectively, which indicated that the questionnaire had good content validity.20 The test–retest reliability of the questionnaire was calculated with 30 nurses at 14-day intervals. The intraclass correlation coefficient was 0.80 (P < 0.001). Cronbach’s alpha coefficients were 0.73–0.74, 0.70–0.72 and 0.72– 0.74 for the items in knowledge, attitudes and practice, respectively. These figures suggest that the developed questionnaire has good reliability.20
Ethical considerations Ethical approval was obtained from all participating hospitals. Written consent was obtained from each participant. Nurses were informed that their participation was voluntary and their refusal to participate would have no negative consequences. All data were kept anonymous and confidential throughout the study.
Data analysis Data were analysed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe demographic data, as well as the knowledge, attitude and nursing practice scores of nurses. The Pearson productmoment correlation coefficient was used to analyse the relationships among nurses’ knowledge, attitudes and practices. Independent t-test or anova was used to analyse the differences between and among different subgroups of nurses according to demographics and their knowledge, attitudes and nursing practice. Multiple linear regression was used to identify predictors for nurses’ behaviours related to typhoon disaster relief work from a set of independent variables, including demographics, knowledge and attitudes. The significance level was set at 0.05.
RESULTS Demographic characteristics of nurses Among 648 nurses, 607 returned the questionnaires, giving a response rate of 94%. Table 1 shows the demographic characteristics of the participants.
Knowledge, attitudes and practice with regard to typhoon disaster relief work and their relationships Table 2 shows the results for nurses’ knowledge of typhoon disaster relief work. The mean score for knowledge was 7.96 (SD = 1.59), with a range of 3–12.
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Table 3 shows the most important items that influenced nurses’ attitudes towards typhoon disaster relief work. The mean score on the attitudes scale was 27.55 (SD = 4.38), with a range of 13–40. Table 4 shows the nurses’ competence in nursing practice in typhoon disaster relief work. The mean score on the scale measuring practice was 5.55 (SD = 1.69), with a range of 0–9. For comparison, we converted the mean score into a percentage of correct responses using the mean score divided by the total score, and then multiplied the result by 100%. The scores for knowledge, attitudes and practice were categorized as good, moderate or poor, with the percentage of correct responses for the category being > 85%, 60–85% and < 60%, respectively. The average percentage scores for nurses’ knowledge, attitudes and competence in nursing practice were 66.33% (7.96/12), 68.87% (27.55/40) and 67.60% (5.55/9), respectively. A significant positive relationship was found between nurses’ attitudes and their nursing practice (r = 0.450, P = 0.000), but not between knowledge and attitudes or between knowledge and nursing practice.
Differences among subgroups according to demographics and nurses’ knowledge, attitudes and practice As shown in Table 1, significant differences in knowledge were found among nurses with different educational backgrounds (F = 4.399, P = 0.013) and current positions of employment (t = 5.944, P = 0.015). Significant differences in competence in nursing practice in typhoon disaster relief were found depending on the nurses’ working unit (t = −4.166, P = 0.000) and previous training in typhoon disaster relief work (t = −4.152, P < 0.001).
Predictors of nurses’ competence in nursing practice in typhoon disaster relief work Table 5 shows that all independent variables explained 25.5% (adjusted R2 = 0.242) of variance in nurses’ practice. Nurses’ working unit, training experience, current position and attitudes were found to be significant predictors of nurses’ competence in nursing practice.
DISCUSSION Our results showed that nurses had moderate to low levels of knowledge, positive attitudes and competence in nursing practice with regard to typhoon disaster relief work, which is consistent with previous studies.15,21–23 © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 Nurses’ demographic characteristics Demographic characteristic
Gender Male Female t P Age (years) 18–25 26–30 31–35 36 or above F P Marital status Single Married or others t P Working experience in nursing (years) 10 F P Current position Nurse Senior nurse or above t P Working unit† Medical/surgical/specialty Acute care t P Education level Diploma or below Bachelor or above t P Experience of participating in the typhoon disaster relief training Yes No t P
n (%)
Knowledge, mean (SD)
Attitudes, mean (SD)
Practices, mean (SD)
6 (1.0) 601 (99.0) — —
8.00 ± 1.79 7.96 ± 1.59 0.059 > 0.05
27.00 ± 3.29 27.55 ± 4.38 −0.308 > 0.05
5.50 ± 2.25 5.55 ± 1.69 −0.318 > 0.05
248 (40.9) 251 (41.4) 83 (13.7) 25 (4.1) — —
7.90 ± 1.61 8.04 ± 1.60 7.90 ± 1.53 7.92 ± 1.61 0.375 > 0.05
27.70 ± 4.61 27.50 ± 4.34 27.20 ± 3.81 27.64 ± 4.32 0.284 > 0.05
5.64 ± 1.65 5.45 ± 1.70 5.39 ± 1.72 6.28 ± 1.82 2.387 > 0.05
330 (54.4) 277 (45.6) — —
7.92 ± 1.66 8.01 ± 1.52 0.741 > 0.05
27.28 ± 4.52 27.87 ± 4.20 1.679 > 0.05
5.45 ± 1.70 5.67 ± 1.67 1.550 > 0.05
250 (41.2) 148 (24.4) 138 (22.7) 71 (11.7) — —
7.88 ± 1.64 8.10 ± 1.62 7.98 ± 1.47 7.92 ± 1.61 0.600 > 0.05
27.56 ± 4.72 27.20 ± 3.93 27.96 ± 4.27 27.42 ± 4.22 0.754 > 0.05
5.53 ± 1.66 5.53 ± 1.63 5.63 ± 1.73 5.52 ± 1.87 0.129 > 0.05
277 (45.6) 330 (54.4) — —
7.79 ± 1.57 8.11 ± 1.61 −2.440 0.015*
27.32 ± 4.38 27.74 ± 4.37 −1.164 > 0.05
5.63 ± 1.58 5.49 ± 1.78 1.018 > 0.05
454 (74.8) 153 (25.2) — —
7.92 ± 1.59 8.18 ± 1.64 −1.451 > 0.05
27.40 ± 4.50 28.39 ± 3.55 8.056(F) 0.005
5.43 ± 1.69 6.22 ± 1.57 −4.166 0.000**
340 (56.0) 267 (44.0) — —
7.83 ± 1.58 8.13 ± 1.60 −2.375 0.018*
27.50 ± 4.33 27.61 ± 4.45 0.290 > 0.05
5.68 ± 1.60 5.39 ± 1.79 2.026 0.043*
125 (20.6) 482 (79.4) — —
8.03 ± 1.59 7.71 ± 1.59 1.971 0.049*
27.43 ± 3.94 27.99 ± 5.77 −1.023 0.308
5.41 ± 1.65 6.10 ± 1.73 −4.152 0.000**
* Significant at P < 0.05. ** Significant at P < 0.01. † Medical/surgical includes outpatient department, infection control unit and the like. Acute
care includes emergency department, intensive care unit, high-dependency unit, operating theatre, coronary care unit and the like. Specialty includes obstetrics, gynaecology, neurology, oncology, psychiatry and the like. t Score by independent t-test. F score by one-way anova.
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Table 2 Nurses’ knowledge of typhoon disaster relief work (n = 607) Item number 1 2 3 4 5 6 7 8 9 10
11 12
Item
Yes, n (%)
A typhoon is formed when tropical cyclones build up in tropical oceans and the maximum wind speed near the ground is no less than 17.2 km/s. Early warning signals for typhoons include codes blue, red, orange and yellow, in ascending order of severity. There are limited ways to obtain warning of a typhoon before its arrival. The main protective measures before the arrival of a typhoon are to close all doors and windows and avoid going out. A typhoon disaster is usually caused by gale, rainstorm and storm surge. The ideal objectives of a typhoon disaster relief operation are to participate in the typhoon disaster relief work and rescue simultaneously. The main types of typhoon-related injuries include blunt trauma, lacerations, puncture wounds and fall injuries (including falls from heights). Typhoon disaster relief operations and emergency field ambulance operations are the same conceptually. Typhoon disaster relief refers to out-of-hospital field ambulance operations and medical treatment, postdisaster epidemic prevention and so on. High-risk factors causing injury at typhoon disaster rescue sites include collapsed building, shattering glass from doors and windows, unexpected hard objects, and falls. Health professionals from various departments of the hospital can participate as members of the typhoon disaster rescue team without any restrictions. At the typhoon disaster relief site, all injured persons should be treated regardless of the severity of injury. Total score, mean ± SD (range)
282 (47)
44 (7)
28 (46)
216 (36)
300 (49)
91 (15)
411 (68) 559 (92)
171 (28) 39 (6)
25 (4) 9 (2)
462 (76) 184 (30)
70 (12) 399 (66)
75 (12) 24 (4)
529 (87)
56 (9)
22 (4)
37 (61)
517 (85)
53 (9)
571 (94)
26 (4)
10 (2)
578 (95)
19 (3)
10 (2)
228 (38)
355 (59)
24 (4)
441 (72)
162 (27)
4 (1)
Rassin et al. also found low levels of preparedness among physicians and nurses for disaster management,21 and a study using a stratified random cluster sample of 205 community nurses in China found that nurses were inadequate in their knowledge and ill prepared for disasters.15 According to Liu et al.,22 although most nurses (97.97%) showed positive attitudes towards disaster relief work, the level of their knowledge was, on the whole, moderate to low, and training was considered to be the best way to improve it. Al Khalaileh et al.23 reported that registered nurses considered themselves weak to moderate in terms of their level of preparedness for disaster management. They suggested that additional training through courses and facility drills would be beneficial in increasing nurses’ level of preparedness. The results from our study and previous studies indicate the need for future research to develop appropriate education and training programmes on disaster management for health-care professionals.15
No, n (%)
Don’t know, n (%)
7.96 ± 1.59 (3–12)
Our results on nurses’ knowledge of disaster relief work concur with previous studies.15,23,24 Our findings showed that nurses had a good knowledge of typhoon disaster prevention and the rescue process. One possible reason for this finding might be that typhoon strikes are frequent in Fujian province, and a lot of knowledge on disaster prevention could have been acquired from personal experiences. However, our findings also showed that the nurses were poorly prepared for typhoon disaster management. Lack of training, workload and time constraints mean that nurses have little time to undertake training on their own initiative,25 which could be the main reason why nurses are not knowledgeable about disaster relief work. In terms of the nurses’ attitudes towards typhoon disaster relief work, our findings showed that the nurses scored highest on items in skill training (items. 2 and 4, Table 3), whereas they scored lowest on items pertaining © 2013 Wiley Publishing Asia Pty Ltd
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Table 3 Nurses’ attitudes towards typhoon disaster relief work (n = 607) Attitudes towards typhoon disaster relief work
Mean ± SD
Table 4 Nurses’ competence in nursing practice in typhoon disaster relief work (n = 607)
Range 1
1
2
3 4
5
6
7
8
9
10
I will not participate in a typhoon disaster relief operation for my own safety. My willingness to participate in the rescue will increase if the hospital provides training on typhoon disaster relief work regularly. I might not participate in disaster relief operations due to fear. My confidence in participating in a rescue operation will increase if I have received training in typhoon disaster relief work. I will not participate in a typhoon disaster relief operation for fear that it might affect my normal family life. I might not participate in disaster relief operations due to my lack of ability to perform rescue. My willingness to participate in a rescue operation will increase with the support from my leaders and family. I might express my willingness to participate in typhoon disaster relief operations, with or without being assigned to such operations by my leaders. I will participate in typhoon disaster relief operations regardless of whether the hospital has a policy of providing corresponding emotional and psychological support to the rescue team. My willingness to participate in rescue operations will increase if the hospital in which I am employed appoints a capable and responsible rescue team for disaster relief operations. Total score
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2.71 ± 0.81
0–4
2.98 ± 0.61
1–4
2
3 2.76 ± 0.79
0–4
3.16 ± 0.66
0–4 4
2.57 ± 0.85
0–4
2.32 ± 0.91
0–4
5
6 2.95 ± 0.70
0–4 7
2.55 ± 7.45
1–4
8 2.67 ± 0.71
0–4 9
2.89 ± 0.69
27.55 ± 4.38
0–4
13–40
Items
Mean ± SD
Range
I have participated in one or more typhoon disaster relief operation(s) previously. I should pay close attention to the disaster no matter how severe it is. I have encountered a typhoon disaster, but did not participate in the rescue due to other reasons, but I learned the related knowledge actively afterwards. I will not participate in rescue work unless and until my supervisor assigns me to do so. I will actively prepare for the possibility of participating in a disaster rescue even though there are enough rescuers on hand at the site of the disaster. I will leave all my personal problems behind and focus my attention on the rescue work. My willingness to participate in typhoon disaster rescue operations will be affected by the attitudes of my family towards my participation as a member of the disaster relief team. I will not hesitate to join a rescue operation as typhoon disaster relief operations need a huge amount of manpower. When typhoon disaster occurs, my supervisor and I should not participate in the rescue team in order to ensure the medical safety of my department. Total score
0.08 ± 0.27
0–1
0.85 ± 0.36
0–1
0.50 ± 0.50
0–1
0.63 ± 0.48
0–1
0.74 ± 0.44
0–1
0.78 ± 0.42
0–1
0.43 ± 0.50
0–1
0.70 ± 0.46
0–1
0.85 ± 0.36
0–1
5.55 ± 1.69
0–9
to their perception of personal ability (items 1, 3 and 6, Table 3). Nurses who had received prior training in typhoon disaster relief work were more likely to hold positive attitudes about participating in typhoon disaster relief work. Even in unexpected situations such as
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Table 5 Summary of multiple regression statistics for the predictor variables of nursing practice in typhoon disaster relief work (n = 607) Predictor variables
Gender† Age‡ Marital status§ Working experience in nursing‡ Current position¶ Working unit†† Educational level‡‡ Participated in typhoon disaster relief training previously§§ Total mean knowledge score Total mean attitudes score
B
−0.01 0.04 −0.16 −0.01 −0.26 0.65 −0.56 0.12 −0.02 0.44
β
−0.17 0.09 −0.22 −0.04 −0.34 0.62 −0.20 0.59 −0.03 0.17
t
−0.28 0.69 −1.32 −0.33 −2.05 3.70 −1.54 3.98 −0.65 12.14
P
95% confidence interval for B
0.78 0.49 0.18 0.74 0.04* 0.000* 0.125 0.000* 0.51 0.000*
Lower bound
Upper bound
−1.37 −0.16 −0.55 −0.25 −0.67 0.29 −0.45 0.30 −0.10 0.14
1.03 0.34 0.11 0.18 −0.01 0.95 0.06 0.89 0.05 0.20
* P < 0.05. † 1 = male, 0 = female. ‡ Variables were treated as continuous variables. § 1 = single, 0 = married and other status. ¶ 1 = nurse, 0 = nurse practitioner and others. †† 0 = medical/surgical, 1 = acute care and specialty. ‡‡ 1 = diploma or below, 0 = bachelor’s degree and above. §§ 1 = yes, 0 = no.
disasters, nurses should be aware of their limitations, including skills, knowledge, ability, authority, expected role in a mass casualty incident and the equipment they might require to provide care.26–28 Our findings also showed that the degree of support from nurses’ supervisors and their families (items 5, 7 and 8, Table 3) played an important role in nurses’ attitudes towards participating in typhoon disaster relief work. Mitani et al. also reported that many registered nurses did not participate in relief work after a recent earthquake disaster in Japan because they would not have been able to provide alternative care for their families.11 Family safety, pet safety and personal safety at work when disasters struck were crucial to nurses.10 The results of the study revealed significantly positive correlations between attitudes and practice. The first step in modifying behaviours (i.e. practice) is to increase one’s awareness for change; another way is to persuade a person to change his/her behaviour directly through education. Education in disaster relief work is absolutely necessary to instil this sense of awareness and readiness for action.29 Husna et al.30 found that nurses in hospitals who maintained and improved their knowledge and skills by regularly attending training and education in emergency medicine were able to respond to disasters more effectively. Our study also found significant differences in nurses’ knowledge depending on their education level, current
position of employment and the medical unit under which they were employed. Few nurses had received training in typhoon disaster relief work (20.69%), and most of them had acquired the training on their own. Nurses who have had a higher level of education might be more knowledgeable, more adept in their skills and more competent.31 Moreover, our study found significant differences among nurses employed in different working units in their level of competence in nursing practice in typhoon disaster relief work. There were no disaster specialist nurses in China.32 Nurses from intensive care units, haemodialysis units, emergency medicine and operating theatres were often called upon to participate in disaster rescue and relief operations. Nurses with more experience in public health emergency activities, being more familiar with the emergency rescue process, were more likely to participate in disaster relief missions. Hsu et al.33 thought that effective disaster response demanded that selected health-care workers be equipped with specific technical skills and decision-making abilities and knowledge, a view with which our study concurs. In our study, we found that the higher the nurses’ education, the higher their level of competence in nursing practice in disaster relief work. This result is consistent with another study conducted in China,31 which reported that nurses who had prior training in typhoon disaster relief work scored higher on knowledge and practice. This finding suggests that providing training in disaster relief work to nurses is very important. © 2013 Wiley Publishing Asia Pty Ltd
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Limitations of the study This study only recruited nurses from Fujian Province, where typhoon attacks are not as frequent as other parts of China such as Zhejiang Province, due to limited time and manpower. Therefore, findings from this study are not generalizable for the nursing population in China. Future studies should recruit larger and more representative samples.
CONCLUSIONS This study identifies the need to encourage nurses to acquire more knowledge, enhance their attitudes and improve their competence in nursing practice with regard to typhoon disaster relief work. Strategies should be developed to provide opportunities for nurses to receive training in typhoon disaster relief work to promote the quality of their work in this field, as it has a direct impact on minimizing and containing the number of casualties and fatalities in disasters.
ACKNOWLEDGEMENTS This study was funded by Nanjing Military Region, China. The authors would like to express their appreciation to the 607 nurses who participated in this study, as well as to Dr Zhu Lixia for her valuable comments on improving this manuscript.
CONFLICT OF INTEREST None to declare.
AUTHOR CONTRIBUTIONS Study design: KY, JL; data collection and analysis: JL, HHG, ZWG; manuscript preparation: KY, HHG, SSH, JL; instrument development: JL, KY, ZWG, SSH, YTT.
REFERENCES 1 Ren ZQ. [The typhoon disaster and defense of the new situation.] Disaster Reduction in China 2000; 10: 43–45 (article in Chinese). 2 Zheng JH, Feng XB, Yan YX. [Development of typhoon driven wave nowcasting model in Southeast China Sea.] Engineering Science 2011; 9: 2–6 (article in Chinese). 3 Yin H, He H, Arbon P, Zhu J. A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sites: implications for disaster training. Journal of Advanced Nursing 2011; 67: 2231–2238.
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4 Fung OW, Loke AY, Lai CK. Disaster preparedness among Hong Kong nurses. Journal of Advanced Nursing 2008; 62: 698–703. 5 Chaput CJ, Deluhery MR, Stake CE, Martens KA, Cichon ME. Disaster training for prehospital providers. Prehospital Emergency Care 2007; 11: 458–465. 6 Slepski LA. Emergency preparedness and professional competency among health care providers during Hurricanes Katrina and Rita: pilot study results. Disaster Management and Response 2007; 5: 99–110. 7 Hammad KS, Arbon P, Gebbie KM. Emergency nurses and disaster response: An exploration of South Australian emergency nurses’ knowledge and perceptions of their roles in disaster response. Australasian Emergency Nursing Journal 2011; 14: 87–94. 8 Duong K. Disaster education and training of emergency nurses in South Australia. Australasian Emergency Nursing Journal 2009; 12: 86–92. 9 Jin LJ, Fu XQ. [Fighting with ‘cloud nuo typhoon’ and rescuing the wounded.] Tianjin Journal of Nursing 2004; 12: 249–250 (article in Chinese). 10 French ED, Sole ML, Byers JF. A comparison of nurses’ needs/concerns and hospital disaster planning following Florida’s Hurricane Floyd. Journal of Emergency Nursing 2002; 28: 111–117. 11 Mitani S, Kuboyama K, Shirakawa T. Nursing in sudden-onset disasters: factors and information that affect participation. Prehospital and Disaster Medicine 2003; 18: 359–365. 12 Stangeland PAS. Nurses’ experiences of responding to calls for emergency service and working during Hurricane Ike (Doctoral dissertation). Galveston, TX, USA: University of Texas Medical Branch, 2010. 13 Putra A, Petpichetchian W, Maneewat K. Perceived ability to practice in disaster management among public health nurses in Aceh, Indonesia. Nursing Media Journal of Nursing 2011; 1: 169–186. 14 Balicer RD, Omer SB, Barnett DJ, Everly GS Jr. Local public health workers’ perceptions toward responding to an influenza pandemic. BMC Public Health 2006; 6: 99. 15 Yang YN, Luo Y, Liu XN, Zhou J, Chen P. [Research of disaster response capabilities and its influencing factors of community nurses in Chongqing municipality.] Journal of Nursing Administration 2010; 10: 698–699 (article in Chinese). 16 Cohen J. A power primer. Psychological Bulletin 1992; 112: 155–159. 17 Ma X. [Health Education.] Beijing, China: People’s Health Publishing House, 2004; 59–61 (book in Chinese). 18 Waltz CF, Strickland OL, Lenz ER. Measurement in Nursing and Health Research, 3rd edn. New York: Springer Publishing Company, 2005; 393–396.
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19 Shen WQ, Hu Y. [Validation of the Chinese version of the Self-Directed Learning Questionnaire.] Chinese Journal of Nursing 2011; 46: 1211–1213 (article in Chinese). 20 Polit D, Hungler B. Nursing Research: Principles and Methods, 6th edn. Philadelphia, PA, USA: Lippincott, 1999. 21 Rassin M, Avraham M, Nasi-Bashari A et al. Emergency department staff preparedness for mass casualty events involving children. Disaster Management and Response 2007; 5: 36–44. 22 Liu QQ, Li RQ, Geng XW, Zhang XJ. [Survey of status quo of nurses’ cognition level and attitudes to disaster nursing.] Chinese Nursing Research 2011; 25: 3028–3030 (article in Chinese). 23 Al Khalaileh MA, Bond E, Alasad JA. Jordanian nurses’ perceptions of their preparedness for disaster management. International Emergency Nursing 2012; 20: 14–23. 24 Fung WM, Lai KY, Loke AY. Nurses’ perception of disaster: implications for disaster nursing curriculum. Journal of Clinical Nursing 2009; 18: 3165–3171. 25 Qiao RH, Jin J, Sun JH. [Investigation and analysis of the status quo and demands of on the job training of nursing staff.] Chinese Nursing Research 2010; 24: 1623–1624 (article in Chinese). 26 Jennings-Sanders A. Teaching disaster nursing by utilizing the Jennings Disaster Nursing Management Model. Nurse Education in Practice 2004; 4: 69–76.
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27 Ireland M, Ea E, Kontzamanis E, Michel C. Integrating disaster preparedness into a community health nursing course: one school’s experience. Disaster Management and Response 2006; 4: 72–76. 28 Gebbie KM, Qureshi K. Emergency and disaster preparedness: core competencies for nurses. The American Journal of Nursing 2002; 102: 46–51. 29 Nozawa M, Watanabe T, Katada N, Minami H, Yamamoto A. Residents’ awareness and behaviour regarding typhoon evacuation advice in Hyogo Prefecture, Japan. International Nursing Review 2008; 55: 20–26. 30 Husna C, Hattakit U, Chaowalit A. Emergency training, education, and perceived clinical skills for tsunami care among nurses in Banda Aceh, Indonesia. Nurse Media Journal of Nursing 2011; 1: 75–86. 31 Yang YN, Luo Y, Liu XN. Investigation on disaster response capacity of community nurses and the influencing factors. Journal of Nursing Science 2011; 26: 10– 12. 32 Zhang LY, Guan XP, Gao YH, Gao G. [Role of disaster nursing in emergency medical rescue.] China Journal of Emergency Resuscitation and Disaster Medicine 2006; 1: 338– 340 (article in Chinese). 33 Hsu EB, Thomas TL, Bass EB, Whyne D, Kelen GD, Green GB. Healthcare worker competencies for disaster training. BMC Medical Education 2006; 6: 19.
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International Journal of Nursing Practice 2015; 21: 60–69
RESEARCH PAPER
Knowledge, attitudes and competence in nursing practice of typhoon disaster relief work among Chinese nurses: A questionnaire survey Lin Jiang BSc RN Master’s Student, No.174 Hospital of People’s Liberation Army Clinical School, The Affiliated Chenggong Hospital of Xiamen University, Xiamen, China Staff Nurse, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China*
Hong-Gu He PhD MD RN Assistant Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Wen-Guang Zhou MM Senior Technician, Material Department, No.174 Hospital of People’s Liberation Army, Xiamen, China Professor, Xiamen University, Xiamen, China
Su-Hua Shi MSc (Med.) RN Associate Chief Nurse, Department of Nephrology, No.174 Hospital of People’s Liberation Army, Xiamen, China Associate Professor, Anhui Medical University, Hefei, China
Ting-Ting Yin MSc (Nurs.) RN Nurse-in-Charge, Division of Nursing, No.174 Hospital of People’s Liberation Army, Xiamen, China Teaching Assistant, Xiamen University, Xiamen, China
Yue Kong MSc (Med.) RN Associate Chief Nurse, Associate Professor, Division of Nursing, No.174 Hospital of People’s Liberation Army, The Affiliated Chenggong Hospital of Xiamen University, Xiamen, China
Accepted for publication May 2013 Jiang L, He H-G, Zhou W-G, Shi S-H, Yin T-T, Kong Y. International Journal of Nursing Practice 2015; 21: 60–69 Knowledge, attitudes and competence in nursing practice of typhoon disaster relief work among Chinese nurses: A questionnaire survey The aim of this paper is to examine the relationships among nurses’ knowledge of, attitudes towards and level of competence in nursing practice, as well as factors influencing nurses’ competence in nursing practice, in typhoon disaster relief work. A cross-sectional descriptive study was conducted using a self-developed questionnaire to obtain data from 607 nurses working in four tertiary hospitals and two secondary hospitals in Fujian, China, in November 2011. Our Correspondence: Yue Kong, Division of Nursing, No.174 Hospital of PLA, 92-96 Wen Yuan Road, Xiamen 361003, Fujian Province, China. Email: [email protected] *[Correction added on 09 January 2015, after first online publication: Second affiliation of the author has been updated.]. © 2013 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12214
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findings show that the nurses’ average percentage scores on their responses to questions in the domains of knowledge, attitudes and practice were 66.33%, 68.87% and 67.60%, respectively. The findings demonstrated a significant positive relationship between nurses’ attitudes and their practice. Nurses’ working unit, prior training in typhoon disaster relief, current position of employment and attitudes were significant predictors of nurses’ competence in practice. The results indicate that strategies need to be developed for nurses to improve their knowledge, attitudes and practice. Key words: China, disaster, nurse, practices, relief, typhoon.
INTRODUCTION Typhoons are common disasters worldwide. The number of people who died as a result of typhoons from 1947 to 1998 was approximately 499 000, accounting for 41% of total death from the 10 main types of natural disaster, including earthquake and tsunami, worldwide.1 Typhoons have struck the areas along the South China Sea 254 times in the past 50 years; approximately 35% of typhoon strikes were on the northeast coast of Taiwan, and 22% of them were in Fujian and Zhejiang Provinces in China.2 Nurses need adequate skills and training in disaster management and relief work, as they are key members of health-care teams responding to national disaster situations.3 To prepare adequate health-care manpower to cope with sudden and unexpected challenges, health-care professionals, including nurses, should be equipped with the relevant knowledge and skills in disaster relief work, with training conducted during periods when there is no disaster.4 The literature has shown that drilling—that is, holding mock disasters—is one of the best and most preferred methods of training for improving the quality of nursing care and equipping nurses to fulfil their obligations in disaster relief.5 However, currently, there is no training programme for nurses in disaster relief work that is evidence-based and widely accepted.6 Thus, to develop a typhoon disaster relief training programme for nurses, it is necessary to understand nurses’ knowledge, attitudes and practices and the relationships among these, as well as the factors that influence nursing practice with regard to typhoon disaster relief work.
BACKGROUND An Australian study exploring 194 South Australian emergency nurses’ knowledge and preparedness for disaster response in an emergency setting reported that most nurses (85%) failed the knowledge test.7 The study also found that although a large number of nurses had completed what they perceived to be disaster education and training, the appropriateness, relevance and availability of such education was questionable. The other study conducted in South Australia reported that although 95% of
nurses agreed that disaster education for emergency nurses was important, limited education opportunities and little previous disaster response experience might be responsible for diminished confidence and disaster awareness among emergency nurses in South Australia.8 Little experience and knowledge of typhoon disaster relief work might be the main reasons causing panic among nurses.9 Nurses preferred to be with their families during typhoon disasters, and they experienced higher anxiety when they were separated from family members.10 Fortunately, the anxiety that these nurses experienced was not associated with impaired functioning or job abandonment.10 Conflict between nurses’ responsibilities at home and their obligations towards disaster response work was a common concern.11 A Hong Kong study4 reported that almost all respondents (97.6%) believed that the Hospital Authority was the main organization involved in responding to disaster situations. As the majority of Hong Kong nurses work in hospitals under the Hospital Authority, they have a sense of responsibility during disasters. Nurses felt obliged to respond to disasters; however, their intention to respond to disasters depended on the type of disaster.12 It is a challenge for nurses to work in clinical settings located in districts where disasters occur frequently. Nurses need to have adequate knowledge and skills to be competent in managing clinical situations related to disasters. Lack of knowledge and preparedness can lead to inadequate performance by health-care providers in caring for disaster victims.13 Experiences with responses to previous disasters have indicated the importance of emergency education and disaster preparedness.14,15 Nurses who are prepared and trained for disaster management can play an important role; one study4 also found that nurses cope better than those without preparation and training when disasters occur. To identify nurses’ training and education needs for typhoon disaster relief work, the first step would be to identify their existing knowledge, attitudes and competence in nursing practice with regard to disaster relief work. However, a review of © 2013 Wiley Publishing Asia Pty Ltd
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the literature shows that very few studies have been conducted to examine the relationships among nurses’ knowledge, attitudes and competence in nursing practice with regard to typhoon disaster relief work. There have been very few studies regarding typhoon disaster relief conducted in China. The aim of this study was to examine the relationships among nurses’ knowledge, attitudes and competency in nursing practice with regard to typhoon disaster relief work, as well as factors influencing nursing practice in typhoon disaster relief work.
METHODS Study design A cross-sectional, descriptive correlational design was adopted.
Participants Convenience sampling was used to recruit participants in the province of Fujian, China, in November 2011. A total of 648 nurses in medical, surgery, emergency and other working units were recruited from four tertiary hospitals and two secondary hospitals in the province of Fujian, China. The inclusion criteria for the participants were that they should be registered nurses who (i) were working at the participating wards and (ii) had more than 1 year of clinical experience. Registered nurses who (i) were parttime employees and/or (ii) were working at allied health departments (e.g. medical examination center, blood bank, rehabilitation department) were excluded. The sample size was determined by the number of participants required to maintain the statistical power for a correlational study. We adopted a medium effect size in the relationship between knowledge and practice. In order to achieve a power of 0.80 at the 0.05 significance level (two-sided), a minimum of 85 participants was required.16 We recruited as many participants as possible in our study.
Data collection The purpose and procedures of this study were explained to the ward managers and all participants. Questionnaires were distributed to nurses at their workplace. Instructions on how to complete the questionnaire were attached to each questionnaire. The completed questionnaires were placed in sealed envelopes and returned to the researcher directly or through the nurses’ ward managers. © 2013 Wiley Publishing Asia Pty Ltd
Instruments The instrument used was developed by the researchers based on the literature17–19 and opinions from seven experts. The instrument consisted of two sections. Section 1 inquired about nurses’ demographic data (8 items), which included gender, age, marital status, work experience in nursing, current position of employment, department and education level. Moreover, a question inquiring about whether participants had received any prior training in typhoon disaster relief work was asked. Section 2 included questions on nurses’ knowledge, attitudes and practice with regard to typhoon disaster relief work. This section was divided into three parts. Part 1 comprised four subcategories that assessed nurses’ knowledge on typhoon disaster relief work (12 items): (i) related concepts (three items); (ii) preventive measures (three items); (iii) types of burns (two items); and (iv) principles of rescue (four items). The responses were ‘yes’, ‘no’ and ‘don’t know’. One correct answer scored one point, with the total score ranging from 0 to 12; a higher score indicated a higher level of knowledge. Part 2 consisted of three subcategories about nurses’ attitudes (10 items): (i) personal attitudes towards typhoon disaster relief work (five items); (ii) influence of nurses’ family on their attitudes towards typhoon disaster relief work (two items); and (iii) influence of social norms on nurses’ attitudes towards typhoon disaster relief work (three items). Nurses were asked to rate each item using a five-point Likert scale, ranging from 0 (‘strongly disagree’) to 4 (‘strongly agree’). The total score ranged from 0 to 40, with a higher score indicating a more positive attitude towards typhoon disaster relief work. Part 3 also consisted of three subcategories about nursing practice (9 items): (i) individual behaviour with regard to typhoon disaster relief work (four items); (ii) influence of nurses’ family on their behaviour with regard to typhoon disaster relief work (three items); and (iii) influence of social norms on nurses’ behaviour with regard to typhoon disaster relief work (two items). The responses were ‘yes’, ‘no’ and ‘don’t know’. Each positive answer (i.e. ‘yes’) scored one point. Thus, the total score for Part 3 ranged from 0 to 9. The self-developed questionnaire was reviewed for its relevance, clarity and linguistic appropriateness by seven nursing experts (two academics, three nurse managers and two experts in surgical or medical nursing). The content validity indices of knowledge, attitudes and
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nursing practices with regard to typhoon disaster relief work were 0.87, 0.98 and 0.92, respectively, which indicated that the questionnaire had good content validity.20 The test–retest reliability of the questionnaire was calculated with 30 nurses at 14-day intervals. The intraclass correlation coefficient was 0.80 (P < 0.001). Cronbach’s alpha coefficients were 0.73–0.74, 0.70–0.72 and 0.72– 0.74 for the items in knowledge, attitudes and practice, respectively. These figures suggest that the developed questionnaire has good reliability.20
Ethical considerations Ethical approval was obtained from all participating hospitals. Written consent was obtained from each participant. Nurses were informed that their participation was voluntary and their refusal to participate would have no negative consequences. All data were kept anonymous and confidential throughout the study.
Data analysis Data were analysed using SPSS 20.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe demographic data, as well as the knowledge, attitude and nursing practice scores of nurses. The Pearson productmoment correlation coefficient was used to analyse the relationships among nurses’ knowledge, attitudes and practices. Independent t-test or anova was used to analyse the differences between and among different subgroups of nurses according to demographics and their knowledge, attitudes and nursing practice. Multiple linear regression was used to identify predictors for nurses’ behaviours related to typhoon disaster relief work from a set of independent variables, including demographics, knowledge and attitudes. The significance level was set at 0.05.
RESULTS Demographic characteristics of nurses Among 648 nurses, 607 returned the questionnaires, giving a response rate of 94%. Table 1 shows the demographic characteristics of the participants.
Knowledge, attitudes and practice with regard to typhoon disaster relief work and their relationships Table 2 shows the results for nurses’ knowledge of typhoon disaster relief work. The mean score for knowledge was 7.96 (SD = 1.59), with a range of 3–12.
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Table 3 shows the most important items that influenced nurses’ attitudes towards typhoon disaster relief work. The mean score on the attitudes scale was 27.55 (SD = 4.38), with a range of 13–40. Table 4 shows the nurses’ competence in nursing practice in typhoon disaster relief work. The mean score on the scale measuring practice was 5.55 (SD = 1.69), with a range of 0–9. For comparison, we converted the mean score into a percentage of correct responses using the mean score divided by the total score, and then multiplied the result by 100%. The scores for knowledge, attitudes and practice were categorized as good, moderate or poor, with the percentage of correct responses for the category being > 85%, 60–85% and < 60%, respectively. The average percentage scores for nurses’ knowledge, attitudes and competence in nursing practice were 66.33% (7.96/12), 68.87% (27.55/40) and 67.60% (5.55/9), respectively. A significant positive relationship was found between nurses’ attitudes and their nursing practice (r = 0.450, P = 0.000), but not between knowledge and attitudes or between knowledge and nursing practice.
Differences among subgroups according to demographics and nurses’ knowledge, attitudes and practice As shown in Table 1, significant differences in knowledge were found among nurses with different educational backgrounds (F = 4.399, P = 0.013) and current positions of employment (t = 5.944, P = 0.015). Significant differences in competence in nursing practice in typhoon disaster relief were found depending on the nurses’ working unit (t = −4.166, P = 0.000) and previous training in typhoon disaster relief work (t = −4.152, P < 0.001).
Predictors of nurses’ competence in nursing practice in typhoon disaster relief work Table 5 shows that all independent variables explained 25.5% (adjusted R2 = 0.242) of variance in nurses’ practice. Nurses’ working unit, training experience, current position and attitudes were found to be significant predictors of nurses’ competence in nursing practice.
DISCUSSION Our results showed that nurses had moderate to low levels of knowledge, positive attitudes and competence in nursing practice with regard to typhoon disaster relief work, which is consistent with previous studies.15,21–23 © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 Nurses’ demographic characteristics Demographic characteristic
Gender Male Female t P Age (years) 18–25 26–30 31–35 36 or above F P Marital status Single Married or others t P Working experience in nursing (years) 10 F P Current position Nurse Senior nurse or above t P Working unit† Medical/surgical/specialty Acute care t P Education level Diploma or below Bachelor or above t P Experience of participating in the typhoon disaster relief training Yes No t P
n (%)
Knowledge, mean (SD)
Attitudes, mean (SD)
Practices, mean (SD)
6 (1.0) 601 (99.0) — —
8.00 ± 1.79 7.96 ± 1.59 0.059 > 0.05
27.00 ± 3.29 27.55 ± 4.38 −0.308 > 0.05
5.50 ± 2.25 5.55 ± 1.69 −0.318 > 0.05
248 (40.9) 251 (41.4) 83 (13.7) 25 (4.1) — —
7.90 ± 1.61 8.04 ± 1.60 7.90 ± 1.53 7.92 ± 1.61 0.375 > 0.05
27.70 ± 4.61 27.50 ± 4.34 27.20 ± 3.81 27.64 ± 4.32 0.284 > 0.05
5.64 ± 1.65 5.45 ± 1.70 5.39 ± 1.72 6.28 ± 1.82 2.387 > 0.05
330 (54.4) 277 (45.6) — —
7.92 ± 1.66 8.01 ± 1.52 0.741 > 0.05
27.28 ± 4.52 27.87 ± 4.20 1.679 > 0.05
5.45 ± 1.70 5.67 ± 1.67 1.550 > 0.05
250 (41.2) 148 (24.4) 138 (22.7) 71 (11.7) — —
7.88 ± 1.64 8.10 ± 1.62 7.98 ± 1.47 7.92 ± 1.61 0.600 > 0.05
27.56 ± 4.72 27.20 ± 3.93 27.96 ± 4.27 27.42 ± 4.22 0.754 > 0.05
5.53 ± 1.66 5.53 ± 1.63 5.63 ± 1.73 5.52 ± 1.87 0.129 > 0.05
277 (45.6) 330 (54.4) — —
7.79 ± 1.57 8.11 ± 1.61 −2.440 0.015*
27.32 ± 4.38 27.74 ± 4.37 −1.164 > 0.05
5.63 ± 1.58 5.49 ± 1.78 1.018 > 0.05
454 (74.8) 153 (25.2) — —
7.92 ± 1.59 8.18 ± 1.64 −1.451 > 0.05
27.40 ± 4.50 28.39 ± 3.55 8.056(F) 0.005
5.43 ± 1.69 6.22 ± 1.57 −4.166 0.000**
340 (56.0) 267 (44.0) — —
7.83 ± 1.58 8.13 ± 1.60 −2.375 0.018*
27.50 ± 4.33 27.61 ± 4.45 0.290 > 0.05
5.68 ± 1.60 5.39 ± 1.79 2.026 0.043*
125 (20.6) 482 (79.4) — —
8.03 ± 1.59 7.71 ± 1.59 1.971 0.049*
27.43 ± 3.94 27.99 ± 5.77 −1.023 0.308
5.41 ± 1.65 6.10 ± 1.73 −4.152 0.000**
* Significant at P < 0.05. ** Significant at P < 0.01. † Medical/surgical includes outpatient department, infection control unit and the like. Acute
care includes emergency department, intensive care unit, high-dependency unit, operating theatre, coronary care unit and the like. Specialty includes obstetrics, gynaecology, neurology, oncology, psychiatry and the like. t Score by independent t-test. F score by one-way anova.
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Table 2 Nurses’ knowledge of typhoon disaster relief work (n = 607) Item number 1 2 3 4 5 6 7 8 9 10
11 12
Item
Yes, n (%)
A typhoon is formed when tropical cyclones build up in tropical oceans and the maximum wind speed near the ground is no less than 17.2 km/s. Early warning signals for typhoons include codes blue, red, orange and yellow, in ascending order of severity. There are limited ways to obtain warning of a typhoon before its arrival. The main protective measures before the arrival of a typhoon are to close all doors and windows and avoid going out. A typhoon disaster is usually caused by gale, rainstorm and storm surge. The ideal objectives of a typhoon disaster relief operation are to participate in the typhoon disaster relief work and rescue simultaneously. The main types of typhoon-related injuries include blunt trauma, lacerations, puncture wounds and fall injuries (including falls from heights). Typhoon disaster relief operations and emergency field ambulance operations are the same conceptually. Typhoon disaster relief refers to out-of-hospital field ambulance operations and medical treatment, postdisaster epidemic prevention and so on. High-risk factors causing injury at typhoon disaster rescue sites include collapsed building, shattering glass from doors and windows, unexpected hard objects, and falls. Health professionals from various departments of the hospital can participate as members of the typhoon disaster rescue team without any restrictions. At the typhoon disaster relief site, all injured persons should be treated regardless of the severity of injury. Total score, mean ± SD (range)
282 (47)
44 (7)
28 (46)
216 (36)
300 (49)
91 (15)
411 (68) 559 (92)
171 (28) 39 (6)
25 (4) 9 (2)
462 (76) 184 (30)
70 (12) 399 (66)
75 (12) 24 (4)
529 (87)
56 (9)
22 (4)
37 (61)
517 (85)
53 (9)
571 (94)
26 (4)
10 (2)
578 (95)
19 (3)
10 (2)
228 (38)
355 (59)
24 (4)
441 (72)
162 (27)
4 (1)
Rassin et al. also found low levels of preparedness among physicians and nurses for disaster management,21 and a study using a stratified random cluster sample of 205 community nurses in China found that nurses were inadequate in their knowledge and ill prepared for disasters.15 According to Liu et al.,22 although most nurses (97.97%) showed positive attitudes towards disaster relief work, the level of their knowledge was, on the whole, moderate to low, and training was considered to be the best way to improve it. Al Khalaileh et al.23 reported that registered nurses considered themselves weak to moderate in terms of their level of preparedness for disaster management. They suggested that additional training through courses and facility drills would be beneficial in increasing nurses’ level of preparedness. The results from our study and previous studies indicate the need for future research to develop appropriate education and training programmes on disaster management for health-care professionals.15
No, n (%)
Don’t know, n (%)
7.96 ± 1.59 (3–12)
Our results on nurses’ knowledge of disaster relief work concur with previous studies.15,23,24 Our findings showed that nurses had a good knowledge of typhoon disaster prevention and the rescue process. One possible reason for this finding might be that typhoon strikes are frequent in Fujian province, and a lot of knowledge on disaster prevention could have been acquired from personal experiences. However, our findings also showed that the nurses were poorly prepared for typhoon disaster management. Lack of training, workload and time constraints mean that nurses have little time to undertake training on their own initiative,25 which could be the main reason why nurses are not knowledgeable about disaster relief work. In terms of the nurses’ attitudes towards typhoon disaster relief work, our findings showed that the nurses scored highest on items in skill training (items. 2 and 4, Table 3), whereas they scored lowest on items pertaining © 2013 Wiley Publishing Asia Pty Ltd
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Table 3 Nurses’ attitudes towards typhoon disaster relief work (n = 607) Attitudes towards typhoon disaster relief work
Mean ± SD
Table 4 Nurses’ competence in nursing practice in typhoon disaster relief work (n = 607)
Range 1
1
2
3 4
5
6
7
8
9
10
I will not participate in a typhoon disaster relief operation for my own safety. My willingness to participate in the rescue will increase if the hospital provides training on typhoon disaster relief work regularly. I might not participate in disaster relief operations due to fear. My confidence in participating in a rescue operation will increase if I have received training in typhoon disaster relief work. I will not participate in a typhoon disaster relief operation for fear that it might affect my normal family life. I might not participate in disaster relief operations due to my lack of ability to perform rescue. My willingness to participate in a rescue operation will increase with the support from my leaders and family. I might express my willingness to participate in typhoon disaster relief operations, with or without being assigned to such operations by my leaders. I will participate in typhoon disaster relief operations regardless of whether the hospital has a policy of providing corresponding emotional and psychological support to the rescue team. My willingness to participate in rescue operations will increase if the hospital in which I am employed appoints a capable and responsible rescue team for disaster relief operations. Total score
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2.71 ± 0.81
0–4
2.98 ± 0.61
1–4
2
3 2.76 ± 0.79
0–4
3.16 ± 0.66
0–4 4
2.57 ± 0.85
0–4
2.32 ± 0.91
0–4
5
6 2.95 ± 0.70
0–4 7
2.55 ± 7.45
1–4
8 2.67 ± 0.71
0–4 9
2.89 ± 0.69
27.55 ± 4.38
0–4
13–40
Items
Mean ± SD
Range
I have participated in one or more typhoon disaster relief operation(s) previously. I should pay close attention to the disaster no matter how severe it is. I have encountered a typhoon disaster, but did not participate in the rescue due to other reasons, but I learned the related knowledge actively afterwards. I will not participate in rescue work unless and until my supervisor assigns me to do so. I will actively prepare for the possibility of participating in a disaster rescue even though there are enough rescuers on hand at the site of the disaster. I will leave all my personal problems behind and focus my attention on the rescue work. My willingness to participate in typhoon disaster rescue operations will be affected by the attitudes of my family towards my participation as a member of the disaster relief team. I will not hesitate to join a rescue operation as typhoon disaster relief operations need a huge amount of manpower. When typhoon disaster occurs, my supervisor and I should not participate in the rescue team in order to ensure the medical safety of my department. Total score
0.08 ± 0.27
0–1
0.85 ± 0.36
0–1
0.50 ± 0.50
0–1
0.63 ± 0.48
0–1
0.74 ± 0.44
0–1
0.78 ± 0.42
0–1
0.43 ± 0.50
0–1
0.70 ± 0.46
0–1
0.85 ± 0.36
0–1
5.55 ± 1.69
0–9
to their perception of personal ability (items 1, 3 and 6, Table 3). Nurses who had received prior training in typhoon disaster relief work were more likely to hold positive attitudes about participating in typhoon disaster relief work. Even in unexpected situations such as
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Table 5 Summary of multiple regression statistics for the predictor variables of nursing practice in typhoon disaster relief work (n = 607) Predictor variables
Gender† Age‡ Marital status§ Working experience in nursing‡ Current position¶ Working unit†† Educational level‡‡ Participated in typhoon disaster relief training previously§§ Total mean knowledge score Total mean attitudes score
B
−0.01 0.04 −0.16 −0.01 −0.26 0.65 −0.56 0.12 −0.02 0.44
β
−0.17 0.09 −0.22 −0.04 −0.34 0.62 −0.20 0.59 −0.03 0.17
t
−0.28 0.69 −1.32 −0.33 −2.05 3.70 −1.54 3.98 −0.65 12.14
P
95% confidence interval for B
0.78 0.49 0.18 0.74 0.04* 0.000* 0.125 0.000* 0.51 0.000*
Lower bound
Upper bound
−1.37 −0.16 −0.55 −0.25 −0.67 0.29 −0.45 0.30 −0.10 0.14
1.03 0.34 0.11 0.18 −0.01 0.95 0.06 0.89 0.05 0.20
* P < 0.05. † 1 = male, 0 = female. ‡ Variables were treated as continuous variables. § 1 = single, 0 = married and other status. ¶ 1 = nurse, 0 = nurse practitioner and others. †† 0 = medical/surgical, 1 = acute care and specialty. ‡‡ 1 = diploma or below, 0 = bachelor’s degree and above. §§ 1 = yes, 0 = no.
disasters, nurses should be aware of their limitations, including skills, knowledge, ability, authority, expected role in a mass casualty incident and the equipment they might require to provide care.26–28 Our findings also showed that the degree of support from nurses’ supervisors and their families (items 5, 7 and 8, Table 3) played an important role in nurses’ attitudes towards participating in typhoon disaster relief work. Mitani et al. also reported that many registered nurses did not participate in relief work after a recent earthquake disaster in Japan because they would not have been able to provide alternative care for their families.11 Family safety, pet safety and personal safety at work when disasters struck were crucial to nurses.10 The results of the study revealed significantly positive correlations between attitudes and practice. The first step in modifying behaviours (i.e. practice) is to increase one’s awareness for change; another way is to persuade a person to change his/her behaviour directly through education. Education in disaster relief work is absolutely necessary to instil this sense of awareness and readiness for action.29 Husna et al.30 found that nurses in hospitals who maintained and improved their knowledge and skills by regularly attending training and education in emergency medicine were able to respond to disasters more effectively. Our study also found significant differences in nurses’ knowledge depending on their education level, current
position of employment and the medical unit under which they were employed. Few nurses had received training in typhoon disaster relief work (20.69%), and most of them had acquired the training on their own. Nurses who have had a higher level of education might be more knowledgeable, more adept in their skills and more competent.31 Moreover, our study found significant differences among nurses employed in different working units in their level of competence in nursing practice in typhoon disaster relief work. There were no disaster specialist nurses in China.32 Nurses from intensive care units, haemodialysis units, emergency medicine and operating theatres were often called upon to participate in disaster rescue and relief operations. Nurses with more experience in public health emergency activities, being more familiar with the emergency rescue process, were more likely to participate in disaster relief missions. Hsu et al.33 thought that effective disaster response demanded that selected health-care workers be equipped with specific technical skills and decision-making abilities and knowledge, a view with which our study concurs. In our study, we found that the higher the nurses’ education, the higher their level of competence in nursing practice in disaster relief work. This result is consistent with another study conducted in China,31 which reported that nurses who had prior training in typhoon disaster relief work scored higher on knowledge and practice. This finding suggests that providing training in disaster relief work to nurses is very important. © 2013 Wiley Publishing Asia Pty Ltd
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Limitations of the study This study only recruited nurses from Fujian Province, where typhoon attacks are not as frequent as other parts of China such as Zhejiang Province, due to limited time and manpower. Therefore, findings from this study are not generalizable for the nursing population in China. Future studies should recruit larger and more representative samples.
CONCLUSIONS This study identifies the need to encourage nurses to acquire more knowledge, enhance their attitudes and improve their competence in nursing practice with regard to typhoon disaster relief work. Strategies should be developed to provide opportunities for nurses to receive training in typhoon disaster relief work to promote the quality of their work in this field, as it has a direct impact on minimizing and containing the number of casualties and fatalities in disasters.
ACKNOWLEDGEMENTS This study was funded by Nanjing Military Region, China. The authors would like to express their appreciation to the 607 nurses who participated in this study, as well as to Dr Zhu Lixia for her valuable comments on improving this manuscript.
CONFLICT OF INTEREST None to declare.
AUTHOR CONTRIBUTIONS Study design: KY, JL; data collection and analysis: JL, HHG, ZWG; manuscript preparation: KY, HHG, SSH, JL; instrument development: JL, KY, ZWG, SSH, YTT.
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