Australasian Emergency Nursing Journal (2015) 18, 156—164 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/aenj RESEARCH PAPER Perceptions of knowledge of disaster management among military and civilian nurses in Saudi Arabia Abdulellah Al Thobaity, RN, MN a,b Virginia Plummer, RN, PhD a,c,∗ Kelli Innes, RN, MN (Emergency) a,c Beverley Copnell, RN, PhD a a Monash University, Australia Taif University, Saudi Arabia c Member CENA, Australia b Received 2 October 2014; received in revised form 1 February 2015; accepted 13 March 2015 KEYWORDS Disaster; Nursing; Management; Saudi Arabia; Military; Knowledge ∗ Summary Background: It is generally accepted that nurses have insufficient knowledge about disaster preparedness due to a lack of acceptance of core competencies and the absence of disaster preparedness in nursing curricula.1 This study explored nurses’ knowledge and sources of knowledge, and skills as they relate to disaster management in Saudi Arabia, where more than 4660 people have died, 32,000 people have been affected, and US$4.65 billion in damage has been caused by disaster since 1980.2 Methods: A quantitative, non-experimental, descriptive research design. Results: Nurses in Saudi Arabia have moderate knowledge concerning disaster preparedness. However, nurses in military hospitals possess more knowledge than those who work in government hospitals. The majority of nurses gained their knowledge and skills from disaster drills. Conclusions: Nurses need more education in all areas of disaster management, most importantly in their roles during response to disasters. Nurses perceive themselves as not well-prepared but they are willing to improve their skills in disaster preparedness if educational opportunities are provided. © 2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. Corresponding author at: Monash University, PO Box 527, Frankston 3199, Australia. Tel.: +61 03 99044064; fax: +61 03 99044655. E-mail address: virginia.plummer@monash.edu (V. Plummer). http://dx.doi.org/10.1016/j.aenj.2015.03.001 1574-6267/© 2015 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved. Perceptions of knowledge of disaster management What this paper adds? • This study is the first study of the perceptions of preparedness for disaster management (as opposed to disaster clinical skills) for nurses in Saudi Arabia. The level of preparedness was found to be moderate, with a high interest by nurses in furthering their education in this area. • In cities which are vulnerable for disaster in Saudi Arabia, the perception of preparedness by nurses working in military hospitals is higher than for those working in government hospitals. • The disaster management nursing educational needs and preferences have been identified for the first time. What is known about the topic? • Nurses have insufficient knowledge about disaster preparedness. • There is an absence of disaster preparedness content in nursing curricula. • Nurses are not equipped with essential knowledge and skills for disaster management due to a lack of opportunity for education and training. • Nurses are interested in improving their disaster — preparedness knowledge. Introduction The increase in the number of disasters of all types over the last 15 years has been accompanied by an increased focus on the work of responding health workers, both within countries and in international response.3 Awareness of, and preparedness for, disasters by both communities and healthcare workers are essential for the management of associated injury, death and loss of health service infrastructure. The field of disaster nursing is in an early stage of development. There is insufficient evidence on disaster upon which to base practice, together with a lack of qualified educators and a lack of formal education and training at the level of health organisations.12 In addition, it is not fully incorporated into nursing curricula.7 Consequently, it is important to develop disaster nursing, particularly disaster nursing management, to ensure that nurses practice with a high level of competence and clearly understand their roles and the roles of others in disaster. Due to differences in experience and qualifications, nurses hold disparate knowledge and skills in terms of disaster preparedness.13,14 However, these issues can be resolved through the identification of gaps in their expertise and the subsequent provision of further education and training to mitigate those deficits. To extend effective help to communities before, during and after the occurrence of a disaster, all nurses, including students, novice practitioners and experienced nurses, must possess high-level knowledge and proficiency in disaster nursing.15 Nurses play a critical role in managing disasters, as they account for the largest 157 professional group in the healthcare sector. Slepski and Littleton-Kearney16 argued that adequately prepared nurses were critical to confidently respond to and provide effective healthcare for victims of disaster. Nurses also play important roles in the planning, strategy, evaluation and policy development of disaster management. However, several studies have found that in many countries nurses are not fully prepared for their role in disasters.4—9 There is a growing awareness by governments, communities and healthcare agencies of the need to evaluate nurses’ roles in an organised response, especially the role of nurses in response to humanitarian disasters where populations need long-term on-going health support.2 In 2005, the World Health Organization (WHO)10 called on all countries to establish a clear plan to reduce the risks associated with disasters. In the same year, WHO identified strategies for disaster preparedness, including continuous assessment and monitoring, coordination, planning, implementation and building resilience. In particular, healthcare workers in hospitals and other medical organisations were required to possess sufficient information and skills regarding disaster management so they could assist in the event of mass casualties or damage to the facility itself. Areas that required particular attention with respect to creating guidelines were communication, response processes, chain of command, resource management, patient safety, transportation, triage and contamination.11 Disaster nursing in the Middle East is not reported often in the literature. Only a small number of studies were found that aimed to evaluate disaster management information, skills and preparedness. After the Bam earthquake in Iran, which killed more than 43,000 people, researchers investigated nurses’ experiences and skills in disaster management through semi-structured interviews of 13 Registered Nurses (RN).17 The findings were a lack of practical protocols, lack of effective teamwork at disaster sites and lack of education in disaster relief. Furthermore, there was a need to develop strategies for staff to manage catastrophic events. Recently, an integrative literature review was conducted to explore the issues of disaster nursing in Iran. This review revealed that: there is a lack of coordination between organisations that participate in disaster response; nurses are not equipped with the essential knowledge and skills for disaster management due to a lack of opportunity for education and training; finally, like many other countries, the education system of disaster nursing in Iran is not fully developed.18 Among Jordanian nurses, who share the same language, culture and religion, and a border with Saudi Arabia, a sample of 471 practitioners from five hospitals participated in a study to evaluate preparedness for disaster management.4 The study was conducted using the Disaster Preparedness Evaluation Tool (DPET) created by Tichy and Bond in 2007.4,8 The authors found variations in disaster preparedness ranging from moderate to low. The nurses had low knowledge and skills in terms of disaster planning and a low understanding of preparations for bioterrorism. However, the nurses recognised their limitations and were aware of the disaster risks in their communities. The authors found that more nurses acquired their skills from disaster drills than from any other situation. Nearly all of the participants wanted to increase their skills and knowledge in this area. 158 In Saudi Arabia, more than 4660 people have died, 32,000 people have been affected, and US$4.65 billion in damage has been caused by disaster in the 35 years since 1980.2 The disasters of recent years have been more costly in both human and fiscal terms.19 For example, ‘‘Black Wednesday’’ was a tragic day for the city of Jeddah. On November 25, 2009, a heavy rainstorm struck affecting more than 25,000 people, and resulting in 125 deaths. The storm caused around US$3 billion damage. Flooding affected over 11,000 houses and damaged hospital laboratories and databases.21 Mental disorders among vulnerable populations, mainly in the elderly and children emerged20 as issue. Momani and Fadil20 concluded that due to poor emergency management and failure to identify risks and hazards prior to flooding events, the recovery period to search for missing bodies was too long. Taif is located between two major roads that connect Riyadh and the southern cities with Makah. Various disasters have occurred in this city, including major transport accidents and flooding. However, municipal officials in Taif have been criticised for their ill-preparedness and poor mitigation strategies and planning, including allowing construction of houses close to valleys that are at a high risk of flooding during heavy rains.22 In 2013 flooding resulted in property damage and the loss of over 20 lives.23 Approximately 640 people were rescued, and shelter was provided to more than 800 people.23 The regions around Tabuk, Jizan and Yemen experience the most seismic activity in Saudi Arabia. Tabuk was affected by a destructive quake in 1995. (Al-Amri, reported by Khan).24 Despite this, no precise data are available on the number of people who have died or been injured. In this type of disaster, environmental and earthquake researchers expect loss of life and property due to a predicted increase in the onset, scope and effect of earthquakes in this region.25 Nurses will have roles in disasters in a range of settings. These include in policy development, or in-hospital, prehospital, community, retrieval, transport and deployment to the scene as first responders.26,27 Nurses are on the frontline within the full breadth of health services and are critical to the health and wellbeing of the community.5,28,29 Since nurses’ are required to respond in a variety of ways to any type of disaster, a firm foundation of disaster preparedness is imperative. Such preparedness entails adequate information and awareness of the disaster plans of government, essential services and individual health organisations, as well as an understanding of international evidence-based practices. This raises the question of whether nurses in Saudi Arabia perceive themselves as being prepared to manage disasters in their region. Therefore, the aim of the study was to evaluate disaster knowledge among nurses in Saudi Arabia and to identify the sources of their knowledge and skills regarding disaster management. Method Study design A quantitative, non-experimental, descriptive research design was selected for this study. A. Al Thobaity et al. Setting The setting was six hospitals located in Jeddah, Taif and Tabuk.22—24 Three of the hospitals were operated by the military and the other three were government hospitals. Sample and population The sample were RNs from emergency departments, critical care and surgical units holding a three-year diploma/degree in nursing. Inclusion criteria were a minimum one year of work experience (thus ensuring at least 12 months exposure to disaster drills and hospital based education programmes if offered), ability to read and write English and be aged at least 18 years of age. There was no upper age limit. The total population of nurses in Saudi Arabia is unknown; thus the sample size was calculated to be at least 384 participants with a 5% precision level, where the confidence level is 95%, and p = 0.05 will be at least 384 nurses.30 Data collection Data were collected from June 20, 2012 through September 1, 2012. Questionnaires (n = 600) were distributed to the nurses in English, the main language used in all Saudi Arabian hospitals. Nurses were invited to participate in this study as volunteers through announcements posted on bulletin boards throughout the hospitals. Participants were asked to return the completed anonymous questionnaires to dropboxes located near the sign-in areas in government hospitals or via the quality management departments in military hospitals. One hundred questionnaires were distributed at each of six hospitals to attain the identified sample size. Instrument Data were collected using the Disaster Preparedness Evaluation Tool (DPET) with permission from its authors. Bond and Tichy developed the DPET in 2007 to evaluate the knowledge and skills of nursing practitioners in relation to disaster management preparedness.4,8 The DPET contains 56 items that measure the perceptions of nursing practitioners regarding preparedness for disaster management and eight demographic questions. A total of 45 items were rated on a Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). Of these, 13 items relate to knowledge of disaster preparedness. An additional 11 items were closed- and open-ended questions relating to disaster preparedness and the sources of participants’ disaster management knowledge (e.g., undergraduate courses, in-service training and master’s degree courses). No modifications were made to the DPET for this investigation other than to add in an option for participants to check their hospital type. The language and terminology of the survey used by the original authors referred to a regular ‘RN’ or Registered Nurse and was not specifically framed for a Nurse Practitioner and therefore this instrument was easily transferrable for use in the settings in Saudi Arabia in its original form. In terms of reliability, the Cronbach’s alpha coefficient of knowledge items in the original tool in 2007 was 0.90. Additionally, the validity and Perceptions of knowledge of disaster management reliability of this tool was tested again in the Middle East by using a psychometric test; the result of Cronbach’s was 0.90.4 Data analysis Data were analysed using SPSS version 20. The mean and the standard deviation (SD) were calculated for each of the Likert scale questions. Perceived weak knowledge was defined as a mean between 1.00 and 2.99, perceived moderate knowledge was defined as a mean between 3.00 and 4.99, and perceived strong knowledge was defined as a mean between 5.00 and 6.00. This was applied for both individual items and overall score. Frequencies were calculated for demographic variables. Ethical considerations Prior to collecting the survey data, a Human Ethics Certificate of Approval was obtained from Monash University’s Human Research Ethics Committee (Approval CF12/09442012000431). Before the study began, approval was also obtained from the all participating military (12532/24/9) and government hospitals (01-1-183507-77-2) in Saudi Arabia. Results Demographics The sample in this study included 429 nurses from six Saudi hospitals (71.5% response rate). After a review 33 incomplete questionnaires were excluded, resulting in 396 (66%) completed questionnaires considered suitable for the study. Hospital group, gender, age, level of education and experiences of participants are presented in Table 1 by frequencies and percentages. 159 Table 1 Demographic data. Group Military Government Total Gender Female Male Total Age 20—25 years 26—30 years 31—36 years More than 36 years Total Level of education Diploma Bachelor’s Master’s Total Experience 1—3 years 4—6 years 7—10 years 11—13 years More than 13 years Total n % of total n 180 216 396 45.45 54.55 100.0 364 32 396 91.92 8.08 100.0 91 144 57 104 396 22.8 36.4 14.5 26.3 100.0 126 261 9 396 31.8 65.9 2.3 100.0 118 99 54 50 75 396 29.8 25.0 13.6 12.6 18.9 100.0 relevant research and reading journal articles related to disaster preparedness (Table 2). Disaster knowledge of participants Differences in the knowledge of nurses in military and government hospitals The frequency distributions and descriptive statistics for the responses to 13 items concerning the participants’ knowledge of disaster preparedness are presented in Table 2. The mean scores for each item were sorted in order of high to low. The overall mean score based on the 13 items was 4.16 as shown in Table 3, which tends towards the high end (i.e., towards ‘‘agree’’) of the six-point scale and implies that the level of knowledge is, on average, moderate, indicating that nurses need more preparation. Despite the fact that nurses in Saudi Arabia are moderately prepared for disasters, it is clear that they are willing to actively engage in educational activities such as drills, classes and seminars (Table 2). The findings of this study show that nurses in Saudi Arabia are willing to learn and to obtain more education in disaster preparedness. Items relating to disaster preparedness, planning and research, and finding resources for gaining disaster knowledge had the lowest ratings by participants. The highest levels of disagreement, implying the lowest levels of knowledge were for participating in disaster planning, finding The military nurses clearly perceived themselves as more disaster-prepared than the government nurses (Table 3). On average, knowledge of military nurses appeared to be better. The results of an independent-sample t-test conducted to compare the knowledge scores for military nurses and government nurses are shown in Table 4. The magnitude of the differences in the means (mean difference = 0.50, 95% CI: 0.31—0.71) was moderate (Eta-squared = 0.06). The scores obtained by nurses at military hospitals for the 13 items were consistently greater than those nurses at government hospitals, which indicated positive mean differences. The highest differences, which were greater than 0.7, were for the five items shown in Table 6. These items include participating in an emergency plan, finding relevant research about disaster preparedness, having a contact list in their health community and knowing referral contacts in case of a disaster situation, reading journal articles related to disaster preparedness and participating in disaster drills. The statistical significance of these differences was examined by independent t-test as shown in Table 5. 160 Table 2 A. Al Thobaity et al. Level of knowledge of disaster management. 13 items related to disaster knowledge n Mean SD I would be interested in educational classes on disaster preparedness that relate specifically to my community situation. I participate in disaster drills or exercises at my workplace (clinic, hospital, etc.) on a regular basis. I participate in one of the following educational activities on a regular basis: continuing education classes, seminars, or conferences dealing with disaster preparedness. In case of a disaster situation, I think that there is sufficient support from local officials at the county, region, or governance level. I know whom to contact (chain of command) in disaster situations in my community. I am aware of classes about disaster preparedness and management that are offered (for example, at my workplace, the university, or the community). I find that the research literature on disaster preparedness is understandable. Finding relevant information about disaster preparedness related to my community needs is an obstacle to my level of preparedness. I have a list of contacts in the medical or health community in which I practice. I know referral contacts in case of a disaster situation. I find that the research literature on disaster preparedness and management is easily accessible. I read journal articles related to disaster preparedness. I know where to find relevant research or information related to disaster preparedness and management to fill in gaps in my knowledge. I have participated in emergency plan drafting and emergency planning for disaster situations in my community. 395 5.10 1.091 395 4.41 1.635 394 4.40 1.530 396 4.38 1.440 388 395 4.37 4.27 1.549 1.451 390 391 4.14 4.00 1.595 1.445 395 3.92 1.566 392 3.87 1.556 395 394 3.86 3.84 1.487 1.436 393 3.60 1.695 Sources of knowledge and skills slight increase in knowledge was clear in those who acquired their knowledge and skills from continuing education. Table 6 presents the most common sources through which participants acquired their knowledge and skills for disaster preparedness. The majority of participants (n = 280; 71%) perceived that they had acquired their knowledge and skills for disasters in drill situations. The second most important source for disaster management knowledge and skills acquisition (n = 148; 37.47%) was participation in continuing education courses. Nurses reported slightly more knowledge and skills in disaster management gained from their graduate courses than from their undergraduate courses. Of the participants, 115 (29%) indicated that they acquired their knowledge and skills from graduate courses, whereas only 108 (27%) indicated receiving their knowledge and skills in undergraduate courses. Finally, 113 participants (26%) indicated that their source of disaster knowledge and skills came from being involved in actual disasters. It is noteworthy that although most of the participants reported that their knowledge and skills were acquired through disaster drills, in comparing the mean of knowledge according to the identified sources, a Table 3 Differences in level of disaster knowledge. Group Mean n SD Minimum Maximum Military Government 4.44 3.94 163 205 0.96887 0.94574 1.00 1.00 6.00 6.00 Total 4.16 368 0.98723 1.00 6.00 Discussion The level of disaster preparedness among nurses in Saudi Arabia was revealed to be moderate. This finding indicated that Saudi Arabia nurses are inadequately prepared for disaster management. This is reflected in the literature, where multiple studies have found that nurses internationally are underprepared for dealing with disasters.4—9 This study clearly demonstrated that nurses in Saudi Arabia are interested in improving their knowledge regarding disaster preparedness. Their lack of preparedness may be a consequence of their low knowledge in this area and the lack of formal and/or informal education in curricula and hospitals. This finding is similar to those of other studies, in that the participants in other studies were also interested in improving their disaster-preparedness knowledge.31—33 Moreover, studies in Jordan4 and Indonesia34 have found similar results. These knowledge deficits may be due to limitations in education for disaster preparedness. Hammad et al.31 maintained that nurses in southern Australia are unprepared due to a lack of education, training and experience in disaster preparedness. This study also indicates that providing ongoing education helps strengthen nursing practitioners’ preparedness. Therefore, it is recommended that disaster management be included in formal educational programmes and continuing education programmes for nurses, including undergraduate and post-graduate tertiary courses. Disaster education Comparing disaster knowledge between military nurses and government nurses. Group I participate in disaster drills or exercises at my workplace (clinic, hospital, etc.) on a regular basis. I have participated in emergency plan drafting and emergency planning for disaster situations in my community. I know who to contact (chain of command) in disaster situations in my community. I participate in one of the following educational activities on a regular basis: continuing education classes, seminars, or conferences dealing with disaster preparedness. I read journal articles related to disaster preparedness. I am aware of classes about disaster preparedness and management that are offered for example at either my workplace, the university, or community. I would be interested in educational classes on disaster preparedness that relate specifically to my community situation. I would be interested in educational classes on disaster preparedness that relate specifically to my community situation. I find that the research literature on disaster preparedness and management is easily accessible. I find that the research literature on disaster preparedness is understandable. I know where to find relevant research or information related to disaster preparedness and management to fill in gaps in my knowledge. I have a list of contacts in the medical or health community in which I practice. I know referral contacts in case of a disaster situation (health department, e.g.). In case of a disaster situation I think that there is sufficient support from local officials on the county, region or governance level. Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government Military Government n Mean SD 180 215 177 215 172 216 178 216 179 216 180 215 179 216 178 214 178 212 176 215 179 215 180 215 180 216 4.79 4.08 4.30 3.04 4.72 4.09 4.75 4.11 4.26 3.52 4.51 4.07 5.06 5.13 4.15 3.64 4.29 4.01 4.00 4.00 4.29 3.47 4.33 3.58 4.52 4.26 1.254 1.836 1.456 1.668 1.216 1.723 1.234 1.686 1.246 1.588 1.198 1.608 1.090 1.094 1.485 1.580 1.541 1.632 1.406 1.479 1.187 1.519 1.328 1.669 1.271 1.561 Mean differences .715 1.262 .623 .636 Perceptions of knowledge of disaster management Table 4 .734 .440 −.078 .511 .277 .000 .825 .746 .253 161 162 Table 5 Independent samples test for the highest differences. Levene’s test for equality of variances Equal Equal Equal Equal Equal Equal Equal Equal Equal Equal Q1 Q2 Q3 Q4 Q5 Q1: Q2: Q3: Q4: Q5: I I I I I variances variances variances variances variances variances variances variances variances variances assumed not assumed assumed not assumed assumed not assumed assumed not assumed assumed not assumed F Sig. 15.76 .000 26.94 .000 30.22 .000 30.89 .000 67.90 .000 t 7.89 7.99 5.92 6.05 4.85 4.95 5.03 5.15 4.43 4.58 df 390 388.66 39 390.51 393 392.014 393 391.87 393 378.41 Sig. (two-tailed) .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 Mean difference 1.262 1.262 .825 .825 .746 .746 .734 .734 .715 .715 Std. error difference .160 .158 .139 .136 .154 .151 .146 .143 .161 .156 95% confidence interval of confidence Lower Upper .95 .95 .55 .56 .44 .45 .43 .45 .40 .41 1.58 1.57 1.10 1.09 1.05 1.04 1.02 1.09 1.03 1.02 have participated in emergency plan drafting and emergency planning for disaster situations in my community. know where to find relevant research or information related to disaster preparedness and management to fill in gaps in my knowledge. have a list of contacts in the medical or health community in which I practice. I know referral contacts in case of a disaster situation (health department, e.g.). read journal articles related to disaster preparedness. participate in disaster drills or exercises at my workplace (clinic, hospital, etc.) on a regular basis. Table 6 Sources of knowledge and skills acquisition. Undergraduate Sum % of total sum Undergraduate course Graduate course Drills Continuing education Real disaster experience 396 108 396 115 396 280 396 148 396 103 27.27% 29.04% 70.71% 37.37% 26.01% A. Al Thobaity et al. Perceptions of knowledge of disaster management improves self-confidence, ability to plan for disasters, coordination of patient flow, cost-effectiveness and risk identification.1 Accessing appropriate resources, such as relevant research, is essential to improving the knowledge gap in disaster preparedness. Overall, nurses in Saudi Arabia reported difficulty finding relevant research articles and information. Whitehead and Arbon35 viewed this issue as an international concern. Additionally, protocols and guidelines are frequently not available, the information in journals varies extensively, and new articles and textbooks about disaster nursing are often outdated.35 Furthermore, Al Khalaileh et al.4 suggested that the gap in information and knowledge is related to the decrease in the number of international journals available in many developing countries. An interesting finding from this research is that military nurses read more articles, have more access to research studies and have greater access to information than nurses in government hospitals. This may be related to advancements in technology, the availability of databases, and access to qualified researchers and educators in military hospitals. However, it can be recommended that nurses in government hospitals must have the same opportunities to access the research literature to enhance their preparation. Successful disaster response commonly depends on plans that are well-established, organised, updated and understandable by response-team members. Understanding the plans, however, requires continuous evaluation, education, training and drills.36 Similar to nurses in other Middle Eastern countries, government nurses in Saudi Arabia had the lowest scores in disaster planning. For example, Jordanian nurses4 and Iranian nurses17 perceived their knowledge about participating in disaster planning as very low. The nurses in these studies perceived a lack of preparedness in guidelines and protocols, which made the situation more complex. Participants need planning and coordination before a disaster.4,28,37—39 Nurses in many countries are not permitted to be involved in developing plans and guidelines for several reasons, including gender issues.14,17 However, the nurses in Saudi Arabian military hospitals showed that they participate in drafting disaster plans, and that nurses can plan and prepare for disaster. It is recommended that nurses are involved in planning for disasters to better understand preparedness, where culturally appropriate. Achieving a solid understanding of the nurse’s role in disaster preparations may be resolved through education and training in disaster response; such measures include conducting regular drills.28,31 Fung et al.32 found that nurses in Hong Kong felt that disaster drills were very important and useful tools for building disaster competencies. Hammad et al.31 concluded that regular disaster drills allow nurses to understand their roles in real disasters. Thus, regular disaster drills are useful in training nurses to respond confidently and competently when disasters strike. While it might be reasonable to assume that nurses in military hospitals participate in disaster drills more frequently than nurses in government hospitals, international studies have found that nearly half the participants had no experience either in handling actual disasters or in mock drills.5 It is recommended that participation by nurses in real or mock drill experience is a useful adjunct for understanding their role and building disaster nursing management competencies. 163 Limitations This study has a number of limitations that should be considered when interpreting the results. The first limitation is self-reporting. Perception of knowledge does not necessarily translate into the participants’ actual level of knowledge. Secondly, the results are not generalisable, as they are specific to the hospitals participating in the study. Finally, the perceptions of employers, nursing educators and the public were not explored in this study and their perceptions of the level of knowledge of the participants may differ. There may be a heightened level of preparedness among military nurses compared to civilians by the nature of their employment in the military and the characteristics of those who are recruited to military operations, for example higher levels of confidence, though this is outside the scope of the study. Conclusion Despite acknowledging knowledge gaps, overall the participants in this study had a perceived moderate level of knowledge in disaster management. Findings indicated that participants were interested in learning and were willing to do so, but a lack of resources affected their ability to address their knowledge gaps. There are several key implications arising from this study. The first is the importance of disaster management being incorporated into educational programmes, including both formal and ongoing education. The second implication is that nurses need to better understand the role they play in response to disasters in order to effectively contribute to the team response. Nurses’ perceptions of preparedness correlate with self-recognition of their own level of competence and ability to provide highquality care in disaster situations. The concern for nurses is that every drill is virtually the same but every disaster is different, and in the latter, their competence will be tested very differently. Future research is required in this important area of nursing, particularly as disasters are increasing in frequency and impact, around the globe. Authors’ contributions AA was responsible for conceiving the study, literature review, study design, acquiring the data, data analysis and drafting the manuscript. VP, KI and BC were responsible for supervision of the study, the ethical aspects of the project, input into instrument design, data analysis, and critical review of the manuscript. Provenance and conflict of interest There were no financial or personal matters of conflict. This paper was not commissioned. Funding The project was unfunded. 164 Acknowledgements We would like to extend our appreciation, gratitude and thanks to Monash University and Taif University for their help and support. We also thank Dr. Kais Hamza for his statistical advice. References 1. Chapman K, Arbon P. Are nurses ready? Disaster preparedness in the acute setting. Australas Emerg Nurs J 2008;11(3):135—44. 2. EM-DAT. The OFDA/CRED International Disaster Database. Brussels, Belgium: Université Catholique de Louvain; 2013 www.emdat.be 3. Gebbie KM, Hutton A, Plummer V. Update on competencies and education. Annu Rev Nurs Res 2012;30(1):169—92. 4. Al Khalaileh MA, Bond E, Alasad JA. 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Australas Emerg Nurs J 2011;14(2):75—80, http://dx.doi.org/10.1016/ jaenj201102005. 14. Powers R, Daily E. Chapter One, introduction to disaster and disaster nursing. In: International Disaster Nursing. Cambridge University Press; 2010. p. 1—11. 15. Stanley JM. Disaster competency development and integration in nursing education. Nurs Clin North Am 2005;40(3):453—67. 16. Slepski LA, Littleton-Kearney MT. Disaster nursing educational competencies. In: Powers R, Daily E, editors. International Disaster Nursing. New York: Cambridge University Press; 2010. 17. Nasrabadi A, Naji H, Mirzabeigi G, Dadbakhs M. Earthquake relief: Iranian nurses’ responses in Bam, 2003, and lessons learned. Int Nurs Rev 2007;54(1):13—8. 18. Zarea K, Beiranvand S, Sheini-Jaberi P, Nikbakht-Nasrabadi A. Disaster nursing in Iran: challenges and opportunities. Australas Emerg Nurs J 2014;17(4):190—6. A. Al Thobaity et al. 19. Chakraborty A, Mujumdar M, Behera S, Ohba R, Yamagata T. A cyclone over Saudi Arabia on 5 January 2002: a case study. Meteorol Atmos Phys 2006;93(1/2):115—22. 20. Momani NM, Fadil AS. Changing public policy due to Saudi City of Jeddah flood disaster. J Soc Sci 2010;6:424—8. 21. Alamri YA. Rains and floods in Saudi Arabia Crying of the sky or of the people? Saudi Med J 2011;32(3):311—3. 22. Arab News. Taif flood plans under fire. Arab News 2013. Retrieved from http://www.arabnews.com/news/451074 23. Arab News. Body count hits 20 as rains continue. Arab News 2013. Published—–Friday 3 May 2013. Retrieved from http:// www.arabnews.com/news/450257 24. Al-Amri A.Director of the Seismic Studies Centre in Jeddah and President of the Saudi Society for Geosciences, reported by Khan, F (Saudi Gazette 12 January 2014), Conference to present the English-language ‘Arabian Journal of Geosciences’ published by King Saud University and King Abdul Aziz City for Science and Technology along with the Saudi Society for Geosciences. 2013. 25. Mater F. Hazards of disaster in Saudi Arabia. Saudi Med J 2011;11:1—3. 26. Littleton-Kearney MT, Slepski LA. Directions for disaster nursing education in the United States. Crit Care Nurs Clin North Am 2008;20(1):103—9. 27. Conlon L, Wiechula R. Preparing nurses for future disasters—–the Sichuan experience. Australas Emerg Nurs J 2011;14(4):246—50. 28. Arbon P, Ranse J, Cusack L, Considine J, Shaban RZ, Woodman RJ, et al. Australasian emergency nurses’ willingness to attend work in a disaster: a survey. Australas Emerg Nurs J 2013;16(2):52—7. 29. Arbon P, Cusack L, Ranse J, Shaban R, Considine J, Mitchell B, et al. To work or not to work: an analysis of the willingness of Australian emergency nurses to respond to a disaster. Australas Emerg Nurs J 2011;14:S31. 30. O’Leary Z. The essential guide to doing your research project. Los Angeles, CA: SAGE; 2014. 31. 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. Australas Emerg Nurs J 2011;14(2):87—94. 32. Fung WMO, Lai KYC, Loke AY. Nurses’ perception of disaster: implications for disaster nursing curriculum. J Clin Nurs 2009;18(22):3165—71. 33. Goodhue CJ, Burke RV, Ferrer RR, Chokshi NK, Dorey F, Upperman JS. Willingness to respond in a disaster: a pediatric nurse practitioner national survey. J Pediatr Healthc 2012;26(4):e7—20. 34. Husna C, Hatthakit U, Chaowalit A. Do knowledge and clinical experience have specific roles in perceived clinical skills for tsunami care among nurses in Banda Aceh, Indonesia? Australas Emerg Nurs J 2011;14(2):95—102. 35. Whitehead D, Arbon P. Disaster nursing research. In: Powers R, Daily E, editors. International disaster nursing. New York: Cambridge University Press; 2010. p. 561—82 [chapter 32]. 36. Barton CC. Chapter 22 — Disaster preparedness and management. In: Philip W, editor. Information resources in toxicology. 4th ed. San Diego: Academic Press; 2009. p. 195—201. 37. Jose MM, Dufrene C. Educational competencies and technologies for disaster preparedness in undergraduate nursing education: an integrative review. Nurse Educ Today 2014;34(4):543—51. 38. Claver M, Dobalian A, Fickel JJ, Ricci KA, Mallers MH. Comprehensive care for vulnerable elderly veterans during disasters. Arch Gerontol Geriatr 2013;56(1):205—13. 39. Fox L, Timm N. Pediatric issues in disaster preparedness: meeting the educational needs of nurses—–are we there yet? J Pediatr Nurs 2008;23(2):145—52. ORIGINAL RESEARCH Course in Prehospital Major Incidents Management for Health Care Providers in Saudi Arabia Nidaa A. Bajow, MBBS, PhD, DM;1 Wajdan I. AlAssaf, MBBS, MScEMDM, SBEM;2 Ameera A. Cluntun, MBBS, SBEM2 Conflicts of interest: none Abstract Introduction: Unacceptable practices of health care providers during disasters have been observed because they work outside the scope of their daily practices and have inadequate training. A greater need for the involvement of health professionals in disaster management has been noted in Saudi Arabia. This study evaluates the efficacy of a training course in prehospital major incident management for health care providers in Saudi Arabia. Methods: An interactive course for general principles in prehospital major incident management was developed with domains and core competencies. The course was designed according to the local context and was based on international standards. It was piloted over four days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia) and was sponsored by Mohammed Bin Naif Medical Center, King Fahd Security College in Riyadh, Saudi Arabia. The participants (n = 29) were from different disciplines from main government health facilities in Riyadh. They completed a pre-test and a posttest. Results: The overall score was 55.1% on the pre-test and 68.4% on the post-test (Wilcoxon test for paired samples, P < .05). Three out of the four domains had significant difference between pre- and post-test results, as well as the overall total knowledge. Conclusion: Conducting inter-disciplinary and competency-based disaster medicine courses for health care providers can augment appropriate disaster preparedness for major incidents in Saudi Arabia. Keywords: disaster medicine; major incident; post-graduate; training Bajow NA, AlAssaf WI, Cluntun AA. Course in prehospital major incidents management for health care providers in Saudi Arabia. Prehosp Disaster Med. 2018;33(6):587–595. 1. Disaster Medicine Unit, Mohammad Bin Naïf Medical Center, King Fahd Security College, Riyadh Saudi Arabia 2. Emergency Medicine, King Abdullah Bin Abdul-Aziz University Hospital, Riyadh, Saudi Arabia Correspondence: Nidaa Bajow, MBBS, PhD, DM Disaster Medicine Unit Mohammad Bin Naïf Medical Center King Fahd Security College Riyadh, Saudi Arabia E-mail: dr.nidaa@hotmail.com Abbreviations: EMS: Emergency Medical Services ICS: incident command system MACSIM: Major Accident Card Simulation PPE: personal protective equipment WADEM: World Association for Disaster and Emergency Medicine Received: February 11, 2018 Revised: May 6, 2018 Accepted: May 17, 2018 Online publication: September 28, 2018 doi:10.1017/S1049023X18000791 December 2018 Introduction Disasters are critical events for health workers, and responses to disasters have not always been successful. Poor communication, confused management, and inadequate patient flow usually characterize health medical services, and when resources are limited, medical care is inadequate.1 In Asia, gaps and challenges still exist in national health surge capacity, including preparedness, staff education, and training.2 The Kingdom of Saudi Arabia is the largest Arab state in Western Asia. It is divided into 13 provinces and has a population of 28 million (including expatriates).3 It is a high-income country with a gross domestic product of US$ 746.2 billion in 2014. Floods have been by far the most important natural disasters in Saudi Arabia, but the mass gatherings during Ramadan and for Hajj are important vulnerable events that create strains on public emergency and transportation services, infectious disease control, and food security.4 Saudi Arabia also faces the threats of unique pathogens, such as the Middle East respiratory syndrome (MERS).5 Moreover, political unrest in the Middle East heightens the possibility of catastrophe due to violent conflicts and terrorist attacks. Case studies of disaster responses in Saudi Arabia have noted a reactive approach and a greater need for the involvement of health professionals, including nurses and physicians, in disaster management.4,6 Analysis of case studies of different disasters shows that the learning process plays a significant role in the efficacy of crisis management. Many negative effects on health care systems are the result of inadequate or ineffective learning.7 Current education and training Prehospital and Disaster Medicine Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 588 of health workers do not adequately address the unique and complex situations that occur in disasters. Most health workers are not familiar with topics such as disaster triage, the incident command system (ICS), and the special needs of patients exposed to catastrophic events.8 Educational efforts are being invested in emergency medicine and family medicine to further develop capacities in disaster medicine,9 but knowledge of disaster medicine among health professionals remains insufficient.10,11 No published reports on the evaluation and assessments of post-graduate training programs in disaster medicine in Saudi Arabia were found. This course was proposed mainly by the disaster medicine unit at Mohammed Bin Naif Medical Center, Riyadh, Saudi Arabia, with the collaboration of three experts from the medical services of the Ministry of Interior (Riyadh, Saudi Arabia), and the Simulation and Skills Development Center of King Abdullah Bin Abdulaziz University Hospital (Riyadh, Saudi Arabia). The main objectives were to introduce an interactive practical training course for health care providers covering knowledge and skills on how to respond appropriately to prehospital major incidents and disasters according to professionspecific roles, and to support and train the health care community in disaster risk reduction approaches in collaboration with other sectors, such as civil defense, safety, and security. Methods Overview of the Course This interactive course consists of 32 hours over four days and focuses on general principles in prehospital major incident management. It was prepared by the disaster medicine unit of Mohammed Bin Naif Medical Center in collaboration with 10 external instructors. It was piloted at the Officers Club of the Minister of Interior and sponsored by Mohammed Bin Naif Medical Center, King Fahd Security College in Riyadh, Saudi Arabia. The course was started on March 13, 2017. During the first three days, morning lectures covered the main core of disaster management. In the afternoon, simulation sessions and workshops were held. The last day was a full-scale simulation using the masscausality simulation system (Major Accident Card Simulation; MACSIM).12 The course included classroom lectures, disaster exercises, skills sessions, and a tabletop session. Evaluation of Post-Graduate Course in PHMIM the instructors used two videos after the lectures to present case studies (a Hajj stampede and the 2009 Jeddah flood) for group discussion. Others used PowerPoint (Microsoft Corp.; Redmond, Washington USA) presentations. In the exercise on the Jeddah flood, the participants were divided in three groups, each of which was assigned to Emergency Medical Services (EMS), public health, or the hospital sector. The exercise was divided into three phases. In the pre-flood phase, each group had to identify activities designed to reduce or eliminate the risks to persons or property or lessen the potential consequences. In the second phase, each group had to identify the immediate response activities needed to save lives during the flood, protect the environment, and meet basic human needs. For the post-impact phase, participants had to identify activities and programs needed to return to acceptable conditions. For each phase, interactive discussions were held with the participants to compare their strategies with the actual activities that took place. The exercise ended with recommendations for future disasters. For the tabletop exercise, two instructors developed a scenario about a student housing collapse with 40 victims. The main objectives of the exercise were to practice and apply the concept of medical ICS and its functional components, and to explain how ICS elements can be modified to promote flexible adaptation of the response to the scale and type of incident. The exercise covered two phases: the first two hours of the disaster, and the following ten hours. The participants were divided in two groups, given a worksheet to organize resources (ie, personnel and ambulances), and asked to assign roles for each activated position. The instructors directed the discussion with specific questions for each group and gave them a timeline to answer the questions using the worksheet. Each group had to answer the questions, distribute the resources provided, and write the assigned role for each function position for the two above-mentioned phases. During the debriefing, the standard operation procedures and strategies for coordination with other involved agencies, such as fire brigades, search and rescue teams (under civil defense), and police, were discussed with the participants. Post-incident analysis was done at the end of the exercise. Development of the Course The course was designed according to the local context and was based on international standards proposed by the World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA).13 With focus on prehospital aspects, it includes three cores of primary disciplines, clinical and psychosocial aspects, emergency and risk management, and public health. The level of education was set at the second level of WADEM’s multi-levels scale for education and training.13 A comprehensive literature review was conducted to identify competence-based disaster medicine programs.8,14,15 Four domains were determined and six levels of proficiency (Bloom’s education taxonomy)16 were used to established core competences (Table 1). A blended learning approach was used by introducing the domains in lectures and using group discussions, experiential learning, and simulation exercises (MACSIM). Domain 2: Safety and Protection—This domain, which had four competences, was covered by three activities. The lecture covered strategies to prevent and mitigate risks to self and others. An active shooter incident was presented as an example to illustrate the standard operation procedures required from health care providers in such situations. The basic principles of selection and use of appropriate personal protective equipment (PPE) during major incidents (mainly chemical) were introduced as a three-part workshop. The first part was a lecture about the disaster-scene exclusion zone, indications for using PPE, and the levels required for PPE in chemical, biological, and radiological threats. This session was followed by a video provided by safety departments of the Ministry of Health. The video shows the steps for donning and doffing of Level C PPE and the process of decontaminating people and equipment. In the second part, the participants were trained in donning and doffing PPE Level C. In the third part, the participants practiced the decontamination process on mock victims in a large decontamination vehicle. Domain 1: General Concepts in Disaster Medicine—This domain had 11 competences and was covered by eight lectures. Some of Domain 3: Major Incidents Management in the Scene—This domain had six competences. Two lectures introducing major Prehospital and Disaster Medicine Vol. 33, No. 6 Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 Bajow, AlAssaf, Cluntun Domains General Concepts in Disaster Medicine Protection and Safety Major Incidents Management in the Scene Communication 589 Competencies Teaching and Learning Activity 1. Describe the different terminologies used in disaster medicine (ie, major incidents, disaster medicine, triage, incident command system (ICS), mass gathering, incident command system, etc). 2. Classify major incidents and disasters. 3. Distinguish between daily emergencies and major incidents. 4. Identify the characteristics of the disaster management cycle. 4. Describe the epidemiology of disasters in KSA. 5. Describe the medical aspects of specific types of disasters in KSA (eg, mass gatherings, floods, terrorist bombs, and blast injuries). 6. Describe the roles of the national and local emergency systems during major incidents and disasters (Red Crescent, civil defense, public health, and hospitals). 7. Understand the concept of ICS and it is functional components. 8. Explain and demonstrate how ICS elements can be modified to promote flexible adaption of the response (based on type and complexity of incident). 9. Describe the common stress reaction induced by disasters in the early phase. 10. Explain how to handle psychological reactions caused by exposure to disasters (psychiatric first aid). 11. Explain the ethical issues relevant to management of individuals and communities affected by disasters (triage and treatment with scarce resources, age, culture, sex). Lectures 1. Introduction to disaster medicine and principles. 2. Command-control-coordination in major incidents. 3. Emergency management in Saudi Arabia (the roles of civilian defense, Red Crescent and Ministry of Health during disasters). 4. Medical aspects of specific disasters in KSA (floods, blast injuries and terrorist bombs). 5. Overview of medico-ethical aspects during major incidents and disasters. 6. Psychiatric first aid (lectures with video for group discussion). 7. Overviews of the Hajj stampede disaster, 2015. 8. Overview of medico-ethical aspects during masscasualty events and disasters resources, triage, cultures. 12. Explain the principles for scene safety for self and others (bystanders, patients, medical personal) by recognizing specific areas that represent additional hazards after disasters. 13. Describe techniques used to mitigate these hazards for response personnel. 14. Distinguish and demonstrate the use of different levels (mainly levels C & D) of personal protective equipment (PPE). 15. List the indications for use of PPE. Lectures 1. Strategies for preventing and mitigating risks to self and others. 2. Role and responsibilities of health care providers during active shooter incidents. 16. Explain the different approaches for responses to major incidents. 16. Explain how to recognize the major incidents in the scene. 17. Explain the concept and the function of advance medical post and regional command center. 18. Distinguish between the 3 phases of the medical response in mass casualties and emergencies (providing lifesaving and triage, treatment, and transportation). 19. List the common challenges associated with transportation during mass casualties. 20. Explain and demonstrate the common types of triage during mass casualties and disasters. Lectures 1. Prehospital major incident response. 2. Mass casualties’ triage. 23. Describe the communication issues during major incidents and disasters. 24. List the communication steps that boost operational success. 25. Describe the important information that should be provided to the media (what the community needs to know and using media effectively). 24. Explain the methods and demonstrate the devices used for communication between the agencies involved during major incidents. Lecture Communication crisis during a response (runners, walkytalkies, radio). Case Study Jeddah flood, 2009. Tabletop Exercise: building collapse prehospital ICS. Workshop Seminars and lectures with video and experiential activities in basic principles of selection and use of appropriate PPE during major incidents (mainly chemical incidents). Simulation Exercise for Sieve Triage Bajow © 2018 Prehospital and Disaster Medicine Table 1. Domains, Competencies, and Educational Activities in the Course on Major Incident Management Piloted in Saudi Arabia, 2017 Abbreviations: ICS, incident command system; PPE, personal protective equipment. December 2018 Prehospital and Disaster Medicine Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 590 incidents and common triage were followed by a simulation exercise about a road traffic accident between two school buses with 25 injured victims. The participants were divided into five groups, and each group was provided with a white board. Each board had 25 magnetic cards for victims. The front of each card provided information about age and sex, position of the victim on the scene, visible injuries if present, and the mental state of the victim. On the back of the card was information about the primary assessment findings. The participants were given time to categorize the victims with triage color tags and stickers representing primary life-saving procedures and interventions. The algorithm for primary sieve triage with revised trauma score for secondary triage (used in training for the first time in Saudi Arabia) was displayed on a board for everyone to review during the exercise. The exercise ended with a debriefing in which each group discussed the categorization and triage of the victims with their instructors. The session ended with a self-assessment of the sieve triage. Domain 4: Communication—The domain of communication during major incidents and disasters was introduced as lectures followed by experiential activities on devices used for communication among rescue teams, fire brigades, EMS, hospitals, and the regional command center. Major Accident Card Simulation Model (MACSIM) The MACSIM system was used in this study for first time in Saudi Arabia and the Gulf Region. The MACSIM is used for education and training on responses to major incidents, mainly for different health care disciplines (ie, paramedics, nurses, and physicians), but it can also be used by other agencies such as rescue service, fire brigade, and police. It can test the plans, preparedness, and performance of responders (ie, prehospital, regional command center, and hospital). Training on all components of the response chain were given simultaneously, including communication and coordination between different response agencies. The system was validated for evaluation of the effect of training on knowledge and skills in medical disciplines.17 The exercise scenario was about a suicidal bomb explosion at a convention center during an international disaster day when people were having lunch, with more than 80 victims. On the first day of the course, meetings were held with a rescue team leader and police officers to explain the organization and coordination procedures during the exercise to be conducted on the last day. On the third day, the instructors delivered lectures on the MACSIM system components, including patient cards, treatment symbols, priority markers, staff symbols, and transport symbols. The participants were divided into groups for explanation of the patient card symbols. The information sheets that were distributed included signs for communication/inspection, palpation/auscultation (found on patient cards), and treatment symbols. As the virtual city in the simulation was originally in a European context, it was adapted by introducing minimal modifications in its demography, geography, health facilities resources, and layout of the area where the exercise was provided. A video was used to explain how the MACSIM exercise was performed. On the last day, the participants arrived two hours before the exercise for briefing about the MACSIM system. The participants were taken to see the stations for scene, triage, treatment, transportation, ambulance dispatch, and hospital. Each white Prehospital and Disaster Medicine Evaluation of Post-Graduate Course in PHMIM board represented one of these stations. In the patients’ cards, there were vital signs that were changed by the instructor (to show deterioration) if the participant did not provide the proper treatment. After the exercise (three hours), the participants were debriefed about performance and decision making. The discussion was mostly on how to avoid certain patient deaths on the scene and after arrival of the medical staff. The participants received a certificate of completion at the end of the exercise. Instructors Three of the instructors were from the Medical Services of the Ministry of Interior. The others were from the Ministry of Health hospitals (n = 2), King Abdullah Bin Abdulaziz University Hospital (n = 2), Safety and Security Departments of the Ministry of Health (n = 1), civil defense (n = 1), and King Khalid University Hospital (n = 1). The eight medical instructors were specialized in disaster medicine and management, emergency and disaster medicine, emergency medicine, and simulation. Non-medical instructors (n = 2) were a safety engineer and a crisis consultant. Participants Twenty-nine health care providers (four females, 25 males) were recruited from main government health facilities in Riyadh (ie, hospitals and polyclinics). Invitation letters were sent to the facilities, and the participants were nominated by the chairperson of the emergency medicine department or the disaster committee at these facilities. Recruitment targeted health care providers, but one health care facility sent a safety engineer. Eleven participants were students in Master’s programs of Public Health in Disaster Management and Epidemiology, two held Master’s degrees in Disaster Management and Crisis, and one had a European Master’s degree in Disaster Medicine. All the participants consented to participation before the course, and the study was approved by the institutional review board (No. H-01-R-012). Evaluation of the Course On the first day, a pre-test of knowledge was conducted, as well as a pre-self-assessment survey specific for the MACSIM simulation exercise. The same test and survey were also given on the last day (post). Assessment Tools Pre- and Post-Test—Each instructor was asked to prepare questions relevant to their material. The test, consisting of 25 multiple-choice questions with only one correct answer, was to be completed within 30 minutes. Self-Assessment Survey—The course had two different selfassessment surveys, one for sieve triage knowledge given after the triage tabletop exercise. Sieve triage is not widely used in Saudi Arabia, and none of the attendees had prior knowledge or experience in it. This survey was prepared by three experts and was approved by the MACSIM course director in Sweden (Prof. Sten Lennquist). The second survey was done for the MACSIM simulation exercise for prehospital components. Vol. 33, No. 6 Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 Bajow, AlAssaf, Cluntun 591 Test n Mean (SD) n Median (IQR) Pre-Test 21 13.7 (SD = 2.8) 17 14 (4) Post-Test 17 17.1 (SD = 2.8) 17 18 (4) P Value .003 Bajow © 2018 Prehospital and Disaster Medicine Table 2. Pre-Test and Post-Test Scores of the Course on Major Incident Management Piloted in Saudi Arabia, 2017 Health Care Providers (n = 21) Knowledge about Disaster Medicine General Concepts of Disaster Medicine Safety and Protection Major Incidents Management in the Scene Communication Total Knowledge Pre-Test Mean (SD) Median (IQR) Post-Test Mean (SD) Median (IQR) 6.0 (SD = 1.6) 7.5 (SD = 1.8) 6 (2) 8 (2) 3.0 (SD = 1.0) 4.1 (SD = 0.9) 3 (1.5) 4 (2) 3.9 (SD = 0.8) 4.5 (SD = 1.0) 4 (1.5) 4.5 (1) 0.8 (SD = 0.4) 1.0 (SD = 0.0) 1 (0) 1 (0) 13.8 (SD = 2.7) 17.1 (SD = 2.8) 14 (4) 18 (4.5) Wilcoxon Signed Ranks Test (Z) P Value -2.428 .015a -2.835 .005a -1.676 .094 -2.000 .046a -2.972 .003a Bajow © 2018 Prehospital and Disaster Medicine Table 3. Pre- and Post-Test Knowledge About Disaster Health Management Course for health Care Providers a Statistically significant (P ≤ .05). Feedback After completion of the course, a Likert scale-based survey was used to obtain feedback from the participants on their overall evaluation of the course. The survey took about eight minutes to complete. Eight months after the course, a follow-up survey was sent to the participants. The questions included the following: (1) Was this the first course you attended in this topic? (2) Was this course beneficial to you? (3) Did you obtain the knowledge and skills needed from this course? and (4) Have you applied any principles learned from this course since taking it? Statistical Analysis The data were analyzed using Statistical Package for Social Science (IBM-SPSS; Armonk, New York USA) version 22 for Windows (Microsoft Corp.; Redmond, Washington USA). The reliability for the knowledge and practice items was analyzed by calculating the test-retest reliability coefficient. The data are presented as means and standard deviations (SD) and as medians and interquartile ranges (IQR). Descriptive analysis was used to present an overview of the findings. The non-parametric Wilcoxon signed rank test was used to compare pre-test and post-test scores, and Kruskal Wallis test was used to compare the scores by type of profession. The level of statistical significance was set at P ≤ .05. December 2018 Results Assessment of test-retest reliability for the knowledge and practice items gave a coefficient of stability of 0.8-0.7, indicating acceptable reliability. The study recruited 29 participants (25 males; four females) but eight did not do the pre-test. Of the 21 who took the pre-test (19 males; two females), there were nine paramedics (42.9%), seven physicians (33.3%), two nurses (9.5%), two technicians (9.5%), and one pharmacist (4.8%). Of these 21 individuals, 17 (80.9%) did the post-test. Descriptive statistical analysis (mean [standard deviation]) was done for all available pre-test and post-test data. The overall score on the pre-test was 55.1% and it increased on the post-test to 68.4%. To assess the gain in knowledge from the course, pre-test and post-test scores were compared by Wilcoxon signed ranks test for the 17 participants who took both tests (Table 2). The overall post-test scores (Mean 17.1 [SD = 2.8]) were significantly higher (P = .003) than the pre-test scores (Mean 13.7 [SD = 2.8]). Three out of the four domains had significant difference between pre- and post-test results (Table 3). Given that the participants were from different health care specialties (ie, physicians, paramedics, nurses, technicians, and pharmacists), there was no significant difference between them in the pre- and post-tests (P > .05). Prehospital and Disaster Medicine Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 592 Evaluation of Post-Graduate Course in PHMIM Question Test n Mean (SD) n Median (IQR) 1. How well do you know the principles for organization of the scene in a major incident? Pre 21 5.7 (SD = 2.1) 21 6 (3) Post 17 8.7 (SD = 1.2) 17 9 (2) Pre 21 5.3 (SD = 2.6) 21 6 (5) Post 17 8.7 (SD = 1.0) 17 9 (2) Pre 21 7.4 (SD = 2.0) 21 8 (3) Post 17 8.8 (SD = 1.3) 17 9 (2) Pre 21 6.5 (SD = 2.2) 21 7 (5) Post 17 8.8 (SD = 1.1) 17 9 (2) Pre 21 5.2 (SD = 2.8) 21 5 (4) Post 17 8.6 (SD = 1.3) 17 9 (2) Pre 21 5.4 (SD = 2.2) 21 6 (4) Post 17 8.4 (SD = 1.5) 17 9 (2) Pre 21 5.2 (SD = 2.7) 21 5 (4) Post 17 8.8 (SD = 1.0) 17 9 (2) Pre 21 13.7 (SD = 2.8) 21 14 (4) Post 17 17.1 (SD = 2.8) 17 18 (4) 2. How well do you know the command-structure on the scene in a major incident? 3. How capable would you be to perform primary (first) triage of injured causalities on scene in a major incident today? 4. How capable would you be to perform secondary (before transport) triage of injured causalities on scene in a major incident today? 5. How capable would you be to serve as a Medical Incident Commander (MIC) on scene in a major incident today? (if you do know what a MIC is, indicate “1”) 6. How capable would you be to serve as Triage Officer (TRO) on scene today? (if you do not know what a TRO is, indicate “1”) 7. How capable would you be to serve as an Ambulance Loading officer (ALO) on scene today? (If you do not know what an ALO is, indicate “1”) Overall P Value .001 .002 .037 .008 .002 .003 .001 .003 Bajow © 2018 Prehospital and Disaster Medicine Table 4. Pre- and Post- MACSIM Simulation Exercise Self-Assessment for Prehospital Components in the Course on Major Incident Management Piloted in Saudi Arabia, 2017 Note: Wilcoxon signed rank test; P < .05 is considered significant. Abbreviation: MACSIM, Major Accident Card Simulation. The total average improvement in the self-assessment survey of knowledge of prehospital components (MACSIM) was 80.0% (P < .05), and the post-test scores were significantly higher than the pre-test scores for each question (P = .037-.001; Table 4). The participants (n = 23) were also asked to evaluate their confidence in using sieve triage on a Likert scale. The mean score for the overall questions was (8.6 [SD = 1.2]; Table 5). Only eight participants (27.6% of all course attendees) answered the overall post-course survey (Table 6). Defining agreement or strong agreement with the given statement as a positive evaluation, 87.5% of the respondents found that the Prehospital and Disaster Medicine course was appropriate and informative, 75.0% that it was scheduled at a suitable time of year, 87.5% that the facilities and location were appropriate and satisfactory, and 75.0% that the course material was clear and organized. Moreover, 87.5% found that the instructors were effective and responded to questions in an informative, appropriate, and satisfactory manner, and 75.0% that the handouts for discussion groups and case studies were clear and useful. Finally, 75.0% of the participants found that the workshop was valuable, 87.5% that the workshop lived up to their expectations, and 87.5% that the content was relevant to their job. Vol. 33, No. 6 Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 Bajow, AlAssaf, Cluntun 593 Mean Score (SD) Question Eight months after the course, a follow-up survey was sent to the participants to assess their satisfaction with the course and with retention of the knowledge and skills they gained. Fifteen of the 29 course participants (51.7%) responded, of whom six (40.0%) indicated that it was the first time they attended such a course; all of them agreed that it was beneficial and that they still retained the knowledge and skills eight months after the course. Almost all of the respondents indicated that they applied the principles learned from the course since taking it, especially in drills and daily emergencies, but none of them dealt with real major incidents. Median Score (IQR) 1. How well do you know sieve triage system? 8.8 (SD = 1.4) 9 (2) 2. How well do you know when to use sieve triage system? 8.6 (SD = 1.5) 9 (2) 3. How capable would you be to perform primary (first) triage of injured causalities on scene in a major incident today using sieve triage system? 8.9 (SD = 1.2) 9 (2) 4. How capable would you be to perform secondary (sort) triage of injured causalities on scene in a major incident today? 8.5 (SD = 1.5) 9 (3) 5. How comfortable do you feel in using sieve as a triage system? 8.6 (SD = 1.1) 9 (1) 6. How comfortable would you be in replacing your current triage system with sieve triage system? 8.5 (SD = 1.6) 9 (2) Overall 8.6 (SD = 1.2) 9(4) Bajow © 2018 Prehospital and Disaster Medicine Table 5. Post-Sieve Triage Intervention Survey of Participants in the Course on Major Incident Management Piloted in Saudi Arabia, 2017 Note: n = 23. Discussion Disaster preparedness and training have become basic requirements for The Central Board of Accreditation for Healthcare Institutions in Saudi Arabia (Riyadh, Saudi Arabia).18 The quality of disaster training programs has an impact on self-perceived disaster readiness of first responders.19 For that reason, this pilot course is a competences-based, inter-professional course using blended learning teaching methods and involved not only medical and paramedical instructors, but also those in civil defense, safety, and security, all of whom are involved during the response phase. Competences-based programs have been shown to improve the knowledge and skills of health care professionals during major incidents responses. Several authors have recommended such programs for education and training in the disaster field8,15 because they deliver educational results that can be measured and used as quality improvement guides.8 In medical education, the effectiveness of training courses in enhancing knowledge and skills can be evaluated by comparing the clinical work before and after the training; for example, in trauma management training Positive Answers Strongly Agree Agree Neutral Disagree Strongly Disagree Overall, the workshop course was appropriate and informative. 37.5% 50.0% 0.0% 0.0% 37.5% 87.5% The workshop was scheduled at a suitable time of year. 37.5% 37.5% 0.0% 0.0% 37.5% 75.0% Overall, the workshop facilities and location were appropriate and satisfactory. 37.5% 50.0% 0.0% 0.0% 37.5% 87.5% Overall, the workshop material was presented in a clear and organized manner. 12.5% 62.50% 12.50% 0.0% 12.5% 75.0% 0.0% 87.5% 0.0% 0.0% Overall, the handouts for discussion groups and case studies were clear and useful. 25.0% 50.0% 12.50% 0.0% 25.0% 75.0% Overall, the workshop was valuable. 37.5% 37.5% 12.5% 0.0% 37.5% 75.0% This workshop lived up to my expectations. 25.0% 62.5% 0.0% 0.0% 25.0% 87.5% The content is relevant to my job. 25.0% 62.5% 0.0% 0.0% 25.0% 87.5% Statement Overall, the instructors were effective and responded to questions in an informative, appropriate and satisfactory manner. 0.00% a 87.5 % Bajow © 2018 Prehospital and Disaster Medicine Table 6. Overall Participant Evaluation of the Course on Major Incident Management Piloted in Saudi Arabia, 2017 Note: n = 8. a Sum of agree and strongly agree. December 2018 Prehospital and Disaster Medicine Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 594 programs.20 However, in disaster medicine education and training, the situation is different due to the wide variation in the patterns of disasters and the factors that affect the response outcome.17 Consequently, no single method can assess the value of training programs, and more than one method is used for the assessment of disaster medicine training programs.17,21 The course was evaluated by different tools for multiple components: pre- and post-tests of knowledge and skills, a post-test on intervention for sieve triage, and pre- and post-self-assessment of perceived knowledge and skills related to performance objectives of prehospital components of a MACSIM simulation exercise. Assessment of the gain in knowledge from the course by comparing pre- and post-test results showed a statistically significant enhancement in knowledge (P = .003). Assessment of perceived knowledge and skills related to performance objectives of prehospital components in MACSIM showed an overall average increase of 80.0% (P < .05). In the triage education session, lectures on all types of triage were presented, with more focus on sieve triage, followed by a simulation exercise of sieve triage on a road traffic accident scenario. The participants were divided into five groups, and each group was asked to triage 25 cases. After the subsequent debriefing session, the participants filled out a self-assessment survey of their perceived competence. The highest score was obtained on the question: “How capable would you be to perform primary (first) triage of injured causalities on-scene in a major incident today using sieve triage system?” The mean score was (8.9 [SD = 1.3]). The next highest score (Mean 8.8 [SD = 1.4]) was for “How well do you know sieve triage system?” The results of this survey showed that the participants gained considerable knowledge and skill in performances of sieve triage through their first exposure to this procedure (Table 5). In this course, the instructors from civil defense, safety and security, and police were involved to make the participants aware of the roles of other agencies, and to show them how to coordinate and communicate with them by unifying the approach and language among all responders. This setting and the group discussions also gave the participants the opportunity to network and start using a unified language and understanding the standard approach, which is essential for communication, organization, and selection of the resources required during major incident responses.8 Understanding the roles of the different responding professionals and learning how to work together are key aspects of a successful disaster response.22 The pre-test results did not differ between the different professions, and neither did the post-test results (P > .05). This is likely due to basing the course on the level-two education described by WADEM (basic knowledge for all health care providers in different professions). Inter-professional learning with colleagues improves the quality of care and assistance provided during a disaster.23 For example, involvement of medical students with other health care students (ie, nurses and technicians) can help them to understand the roles and responsibilities of other health care providers, and at the same time, integrate their understanding of teamwork and communication skills in complex situations of patient care.24-26 The same thing can be applied to post-graduate References 1. Collander B, Green B, Millo Y, Shamloo C, Donnellan J, DeAtley C. Development of an “all-hazards” hospital disaster preparedness training course utilizing multi-modality teaching. Prehosp Disaster Med. 2008;23(1):63-67; discussion 68-69. Prehospital and Disaster Medicine Evaluation of Post-Graduate Course in PHMIM practicing personnel, as in this course. A blended learning approach by combining lectures, group discussions, experiential learning, and simulation exercises was used in order to increase the knowledge and satisfaction of the participants.1,27,28 The benefit was observed in the results of the assessments. Simulation-based learning is becoming widely recognized in medical education because it offers clear, recognizable benefits for new trainees to learn invasive procedural skills, especially in environments outside hospitals and clinics, such as disaster scenes.27,29 Only the prehospital components were included in the simulation exercise because this is the first experience with MACSIM in Saudi Arabia, and because the course capacity and logistics were limited to prehospital components. The performance objectives for the prehospital components included organization on the scene, communication, coordination, principles of management of victims, and incident command structures. The overall improvement in self-assessment score was 80.0%, which was significant at P < .05. This improvement is comparable to a reported improvement of 74.0% (P < .001).17 When the participants were debriefed after the MACSIM exercise, one major deficiency was found in over-triage and overuse of resources. At the same time, there was under-triage, with green area victims being left for a long time without re-triage, which can affect the prognosis of the victims and lead to development of complications. It is important that participants retain the knowledge and skills they gain in a course for a period of time. Participants in courses using blended learning maintain enhanced confidence in their knowledge for at least six months.30,31 In agreement, a survey of the participants eight months after the course showed that they were satisfied with their retention. Importantly, they had the opportunity to apply what they learned in the course to drills and daily emergencies. Limitations This study has two limitations. First, the targeted health care providers were those without any training or experience in disaster preparedness, but some of the invited hospitals sent health care providers with previous disaster experience, which may have affected the expected improvement percentage. Second, the MACSIM instructors faced difficulty in testing the complete chain of disaster management, such as hospital components, because there are many. To maximize the benefit from MACSIM, in the future, the full chain of management will be tested, including hospital departments, providing the trainers with only related lectures of MACSIM, and allowing for two simulation exercises on two separate days. Conclusion These results show that inter-disciplinary education programs in disaster medicine for health care providers may improve their response to major incidence. Such programs can help them to respond appropriately according to their roles. Conducting competences-based, disaster medicine programs can augment disaster preparedness in Saudi Arabia. 2. Algaali KY, Djalali A, Della Corte F, Ismail MA, Ingrassia PL. Postgraduate education in disaster health and medicine. Front Public Health. 2015;3:185. 3. United Nations. Department of Economic and Social Affairs. World population prospects the 2010 revision. New York USA: United Nations; 2011. Vol. 33, No. 6 Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 Bajow, AlAssaf, Cluntun 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. http://www.un.org/en/development/desa/population/publications/pdf/trends/WPP2010/ WPP2010_Volume-I_Comprehensive-Tables.pdf. Accessed February 1, 2018. Alamri YA. Rains and floods in Saudi Arabia. Crying of the sky or of the people? Saudi Med J. 2011;32(3):311-313. Epstein JH, Olival KJ. Animal Reservoirs of Middle East Respiratory Syndrome Coronavirus. Washington, DC USA: National Academies Press; 2015. Aldamegh SA. Are we prepared? Int J Health Sci (Qassim). 2011;5(1):5-6. Raich M, Adler C, Stuhlinger V, Lorenzoni N, Duscheck S. Impacts of disasters on health system performance, security and health protection. Proceedings of the 4th International Conference on Disaster Management and Human Health; Istanbul: 2015. Schultz CH, Koenig KL, Whiteside M, Murray R. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59(3):196-208. Franc-Law JM, Ingrassia PL, Ragazzoni L, Della Corte F. The effectiveness of training with an emergency department simulator on medical student performance in a simulated disaster. CJEM. 2010;12(1):27-32. Ingrassia PL, Foletti M, Djalali A, et al. Education and training initiatives for crisis management in the European Union: a web-based analysis of available programs. Prehosp Disaster Med. 2014;29(2):115-126. Usuzawa M, E OT, Kawano R, et al. Awareness of disaster reduction frameworks and risk perception of natural disaster: a questionnaire survey among Philippine and Indonesian health care personnel and public health students. Tohoku J Exp Med. 2014;233(1):43-48. MACSIM. 2016. http://www.macsim.se/. Accessed February 1, 2018. Murray V, Clifford J, Seynaeve G, Fisher JM. Disaster health education and training: a pilot questionnaire to understand current status. Prehosp Disaster Med. 2006;21 (3):156-167. Smith J, Levy MJ, Hsu EB, Lee Levy J. Disaster curricula in medical education: pilot survey. Prehosp Disaster Med. 2012;27(5):492-494. Walsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster Med Public Health Prep. 2012;6(1):44-52. Adams NE. Bloom’s taxonomy of cognitive learning objectives. J Med Libr Assoc. 2015;103(3):152-153. Montan KL, Ortenwall P, Lennquist S. Assessment of the accuracy of the Medical Response to Major Incidents (MRMI) course for interactive training of the response to major incidents and disasters. Am J Disaster Med. 2015;10(2):93-107. December 2018 595 18. Saudi Central Board for Accreditation of Healthcare Institutions. CBAHI standards. National Hospital Standards 2016. http://portal.cbahi.gov.sa/english/cbahi-standards. Accessed February 1, 2018. 19. Stevens G, Jones A, Smith G, et al. Determinants of paramedic response readiness for CBRNE threats. Biosecur Bioterror. 2010;8(2):193-202. 20. American College of Surgeons. Advanced Trauma Life Support Program for Physicians. 9th edition. Trauma Co, editor. Chicago, Illinois USA: American College of Surgeons; 2012. 21. Amrein-Beardsley A, Narnett JH. Working with error and uncertainty to increase measurement validity. Educ Asse Eval Acc. 2012;24:369-379. 22. Willems A, Waxman B, Bacon AK, Smith J, Kitto S. Interprofessional non-technical skills for surgeons in disaster response: a literature review. J Interprof Care. 2013;27 (5):380-386. 23. Atack L, Parker K, Rocchi M, Maher J, Dryden T. The impact of an online interprofessional course in disaster management competency and attitude towards interprofessional learning. J Interprof Care. 2009;23(6):586-598. 24. Kaplan BG, Connor A, Ferranti EP, Holmes L, Spencer L. Use of an emergency preparedness disaster simulation with undergraduate nursing students. Public Health Nurs. 2012;29(1):44-51. 25. Rega P. Interdisciplinary simulation education in disaster medicine. Public Health Nurs. 2013;30(1):3-4. 26. Zapko KA, Ferranto ML, Brady C, et al. Interdisciplinary disaster drill simulation: laying the groundwork for further research. Nurs Educ Perspect. 2015;36 (6):379-382. 27. Khorram-Manesh A, Ashkenazi M, Djalali A, et al. Education in disaster management and emergencies: defining a new European course. Disaster Med Public Health Prep. 2015;9(3):245-255. 28. Lateef F. Blended learning in emergency medicine: implementing the e-learning component. SEAJME. 2014;8(1):60-65. 29. Kneebone R. Evaluating clinical simulations for learning procedural skills: a theorybased approach. Acad Med. 2005;80(6):549-553. 30. Bajow N, Djalali A, Ingrassia PL, et al. Evaluation of a new community-based curriculum in disaster medicine for undergraduates. BMC Med Educ. 2016;16(1):225. 31. Golden T, Karpur A. Translating knowledge through blended learning: a comparative analysis of face-to-face and blended learning methods. Rehabilitation Research Policy and Education. 2012;26(4):305-314. Prehospital and Disaster Medicine Downloaded from https://www.cambridge.org/core. Scott Memorial Library @ Thomas Jefferson University, on 26 Jan 2019 at 07:58:31, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S1049023X18000791 Open Access Research Emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses’ perceptions in hospitals in Mecca, Saudi Arabia Fuad Alzahrani,1 Yiannis Kyratsis2 To cite: Alzahrani F, Kyratsis Y. Emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses’ perceptions in hospitals in Mecca, Saudi Arabia. BMJ Open 2017;7:e013563. doi:10.1136/bmjopen-2016013563 ▸ Prepublication history for this paper is available online. To view these files please visit the journal online (http://dx.doi.org/10.1136/ bmjopen-2016-013563). Received 20 July 2016 Revised 21 November 2016 Accepted 20 December 2016 1 Ministry of Health Saudi Arabia, King Fisal Hospital, Mecca, Saudi Arabia 2 School of Health Sciences, City, University of London, London, UK Correspondence to Fuad Alzahrani; alnbhan_fm@hotmail.com ABSTRACT Objectives: To assess hospital emergency nurses’ self-reported knowledge, role awareness and skills in disaster response with respect to the Hajj mass gathering in Mecca. Design: Cross-sectional online survey with primary data collection and non-probabilistic purposive sample conducted in late 2014. Setting: All 4 public hospitals in Mecca, Saudi Arabia. Participants: 106 registered nurses in hospital emergency departments. Main outcome measure: Awareness, knowledge, skills and perceptions of emergency nurses in Mecca with regard to mass gathering disaster preparedness. Results: Although emergency nurses’ clinical role awareness in disaster response was reported to be high, nurses reported limited knowledge and awareness of the wider emergency and disaster preparedness plans, including key elements of their hospital strategies for managing a mass gathering disaster. Over half of the emergency nurses in Mecca’s public hospitals had not thoroughly read the plan, and almost 1 in 10 were not even aware of its existence. Emergency nurses reported seeing their main role as providing timely general clinical assessment and care; however, fewer emergency nurses saw their role as providing surveillance, prevention, leadership or psychological care in a mass gathering disaster, despite all these broader roles being described in the hospitals’ emergency disaster response plans. Emergency nurses’ responses to topics where there are often misconceptions on appropriate disaster management indicated a significant knowledge deficit with only 1 in 3 nurses at best or 1 in 6 at worst giving correct answers. Respondents identified 3 key training initiatives as opportunities to further develop their professional skills in this area: (1) hospital education sessions, (2) the Emergency Management Saudi Course, (3) bespoke short courses in disaster management. Conclusions: Recommendations are suggested to help enhance clinical and educational efforts in disaster preparedness. Strengths and limitations of this study ▪ This is the first empirical study on the role of emergency nurses in mass gathering disaster preparedness in Saudi Arabia and the city of Mecca. ▪ The study provides valuable new information on the perceived preparedness of emergency nurses during the Hajj mass gathering against role standards as stated in the emergency plans of local hospitals. ▪ The study identifies specific health education and training programmes deemed appropriate and relevant by the emergency nurses. ▪ Limitations of this study include its crosssectional design, the relatively small and nonrandom sample, and the use of self-reported data. INTRODUCTION Background Despite the central role of front-line nursing staff in hospital emergency departments (EDs) in responding to disasters, little is known about the knowledge and skill required by this group of health professionals to effectively carry out this important clinical role. In particular, there is a paucity of studies that directly measure aspects of disaster preparedness for emergency nurses (ENs) in the context of mass gatherings (MGs).1–3 Furthermore, there is an absence of studies on assessing ENs’ perceived knowledge and role awareness in disaster response in Saudi Arabia, a country which hosts annually one of the world’s largest MGs. The WHO defines disaster as “an occurrence disrupting the normal conditions of existence and causing a level of suffering that exceeds the capacity of adjustment of the affected community.”4 In addition, Kaji et al5 defined disaster as “a natural or Alzahrani F, Kyratsis Y. BMJ Open 2017;7:e013563. doi:10.1136/bmjopen-2016-013563 1 Open Access man-made event that results in an imbalance between the supply and demand for resources.” MGs are variously described in the literature with no widely agreed definition. Most researchers agree that MGs are events attended by a large number of people (ie, over 1000) at a specific location, for a defined period of time.6 7 Hammad et al1 defined MGs as “events attended by a sufficient number of people to the level that strains the planning and response resources of the host where it is being held.” In addition to straining the planning and response resources of the host country, MGs also pose special risks for attendees. Common risks include injuries and accidents, stampedes, spread of infectious diseases, and terrorism among others.7 8 The risk of a catastrophic incident occurring during MGs also presents particular challenges in the prevention, harm minimisation and emergency response of healthcare facilities. The distinctive features of MGs that can affect public health and safety services include their wide geographical spread, large levels of attendance, their duration and the security concerns that they present. For healthcare services, the main objective during MGs is to prevent or minimise the risk of injuries or illnesses and maximise the safety of participants.1 8 9 In the case of an emergency arising from any of the above risks, there will be a strain in the local healthcare facilities. Therefore, the nurses at EDs in hospitals should be adequately trained and prepared for such eventualities to provide for an effective response and help in reducing the number of potential fatalities.10 In particular, nurses working in EDs must have the essential knowledge, skills and experience to efficiently manage emergencies and cope with often chaotic circumstances accompanying a disaster. A nascent body of literature informed by empirical work in emergency nursing disaster preparedness has started emerging, in particular in the context of MGs. In a mixed-methods study, Hammad et al1 reported on the knowledge and perceptions of ENs in South Australia on their role in disaster preparedness. Alexander11 explored the beliefs in common myths held by Massachusetts University students and three groups of trainee emergency workers in Italy. The research revealed that the participants held various misconceptions regarding disaster management. Magnaye et al2 sought to determine the opinions held by ENs in the Philippines with regard to their role in disaster management. The research also examined their preparedness and levels of their skills in response to disasters. Studies in this area suggest that a number of factors influence the ability of hospital nurses to respond to a disaster, particularly during MGs. Disaster education and training is a key element.12 Drills and exercises, as well as military training and postgraduate taught studies focusing on disaster response, constitute important aspects of education and training efforts. Nonetheless, there is less agreement in the literature regarding the content and the mode of delivery of such education programmes. In 2 addition, the relevance of existing programmes to nursing professionals in EDs is questioned.5 10 13 A second important factor influencing the effectiveness of ENs’ response, particularly in the context of MGs, is their level of knowledge and awareness of the appropriate course of action.1 11 14 Welzel et al15 argue for the necessity of early communication of relevant information to ENs, which provides them with the opportunity to simulate their response, thus increasing their response capability. Prior disaster management experience constitutes a third key factor in relation to ENs’ preparedness in MG disasters.16 Welzel et al15 argue that experience can be gained by nurses coming from societies where disasters are uncommon by volunteering to practise in societies more prone to disasters; ‘hands on’ education and field training in this context can support ENs gaining valuable experience in disaster preparedness.1 7 9 17 Finally, there is a reported need for collaboration and communication between the different professionals involved in the provision of care in EDs, including nurses, physicians, the management team and support staff.18 Study objectives This study aims to contribute to our understanding of emergency nursing and disaster response preparedness in MGs. This study was designed to specifically assess the self-reported knowledge and disaster preparedness in relation to the annual Hajj pilgrimage of registered nurses currently working in the EDs of all public hospitals in Mecca. Hajj refers to the Muslim pilgrimage to Mecca in Saudi Arabia, performed annually by more than two million people originating from more than 140 countries globally.10 19 20 The Hajj constitutes the largest annual MG in the world.18 The study had three key objectives: 1. To assess the level of awareness and self-reported knowledge in disaster response of the ENs working in public hospitals in Mecca. 2. To assess the current roles and skills in disaster preparedness during the Hajj MG as reported by the ENs included in our study, in particular against existing standards and plans in their hospitals. 3. To identify the type of training programmes and education deemed appropriate and relevant by the ENs studied. METHODS Study design...
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