Evaluation of an Instrument to Measure Nurses Familiarity with Emergency Preparedness

MILITARY MEDICINE, 173, 11:1073, 2008 Evaluation of an Instrument to Measure Nurses Familiarity with Emergency Preparedness MAJ Susan J. Garbutt, NC USAFR*; James W. Peltier, PhD ; Joyce J. Fitzpatrick, PhD RN FAAN ABSTRACT The events of September 11, 2001, and the 2005 devastation of Hurricane Katrina have emphasized the importance of educating all nurses in emergency preparedness and bioterrorism. Methods: Further evaluation (secondary data analysis) of the Emergency Preparedness Information Questionnaire (EPIQ) was conducted, to assess nurses familiarity with emergency preparedness. Results: This study confirmed that the EPIQ, as revised, has sound psychometric characteristics (construct validity and internal reliability) as a tool to measure nurses self-reported level of familiarity with emergency preparedness. Conclusions: Additional studies using the revised EPIQ should provide data to assist civilian and military nurse educators and to facilitate the development of competency-based, relevant, emergency preparedness curricula. INTRODUCTION The events of September 11, 2001, and the 2005 devastation of Hurricane Katrina in New Orleans, Louisiana, have emphasized the importance of educating nurses and other health care responders regarding emergency preparedness and bioterrorism. Traditionally, nurses on the front lines (i.e., military, emergency department, and public health) have been entrusted with the responsibility to care for victims of disasters. However, emergency preparedness is a critical competency that is needed by both experienced nurses and new graduates no matter where they are employed. Slepski 1 (p426) defined emergency preparedness as the comprehensive knowledge, skills, abilities, and actions needed to prepare for and respond to threatened, actual, or suspected chemical, biological, radiological, nuclear, or explosive incidents, manmade incidents, natural disasters, or other related events. Research is needed to assess nurses familiarity with emergency preparedness, because it is crucial to have a nursing workforce prepared to respond. This study is a further evaluation of an instrument developed to assess nurses familiarity with emergency preparedness. Refinement of the instrument was considered an important first step before widespread investigation of nurses preparedness could be performed. REVIEW OF LITERATURE O Boyle et al. 2(p351) noted that public health emergencies, including bioterrorism events, are viewed as realistic possibilities. The American Association of Colleges of Nursing *Galen School of Nursing, St. Petersburg, FL 33702. College of Business and Economics, University of Wisconsin Whitewater, Whitewater, WI 53190-1790. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106. This manuscript was received for review in April 2008. The revised manuscript was accepted for publication in August 2008. Reprint & Copyright by Association of Military Surgeons of U.S., 2008. and the International Coalition for Mass Casualty Education recognized that all nurses need the knowledge and skills to be able to respond to bioterrorism and other mass casualty events. 3,4 Despite these calls for emergency preparedness education, there is currently a lack of emergency preparedness and mass casualty education in the curricula of nursing schools, and little is known about how well prepared current nurses are for handling large-scale medical events. 5 7 Patillo 8 emphasized that disaster nursing was once the purview of military nurses and emergency department personnel. This perspective has been expanded through the growing belief that disaster preparedness is now a requisite competency in undergraduate nursing programs and across all nursing professions. 8 10 Veenema 11 noted that educators responsible for staff development and continuing education in all types of health care settings must develop continuing education programs on bioterrorism. Weiner et al. 12 noted that, although some nurses have had community health education on natural disasters, most have not been fully educated about bioterrorism and how to respond to other large-scale s. Stanley 13 recommended that every nurse possess the basic knowledge and skill to respond to a mass casualty incident. Without this competency, nurses will not be adequately prepared to function as front-line responders to a natural or man-made disaster. To date, there is minimal empirical evidence regarding emergency preparedness knowledge among nurses. Lanzilotti et al. 14 surveyed 3,386 Hawaiian doctors and nurses to determine their ability to recognize and to treat victims exposed to biological and chemical agents, their interest in training/ education, and their willingness to staff field medical facilities during a natural or man-made disaster. Results of this study indicated that they were most able to recognize influenza (54% and 49% for physicians and nurses, respectively) and least able to recognize tularemia (5% and 2%, respectively). Scores for the ability to recognize and to treat exposure to specific chemical agents were consistently low ( 8%) for 1073

both the physicians and nurses surveyed. A majority of the survey respondents expressed interest in continuing education programs. Physicians and nurses indicated that they were most willing to staff field medical facilities in a natural disaster (83% and 90% for physicians and nurses, respectively) and were least willing to do so in a radiological incident (52% and 49%, respectively). Wisniewski et al. 15 surveyed 877 Wisconsin registered nurses by using the Emergency Preparedness Information Questionnaire (EPIQ). The 44-item EPIQ assessed nurses self-reported familiarity with eight dimensions of emergency preparedness (scale of 5 very familiar to 1 not familiar). In the original analysis, eight dimensions were identified, that is, (a) detection, (b) incident command system, (c) triage, (d) epidemiology and surveillance, (e) isolation, decontamination, and quarantine, (f) communication, (g) psychological issues, and (h) reporting. Survey respondents indicated the most familiarity with triage (average familiarity score, 3.15) and the least familiarity with communication and connectivity (average familiarity score, 2.08). There is support in the literature for examining emergency preparedness training needs. The Agency for Healthcare Research and Quality 16 and Veenema 17 addressed training needs for nurses and health care workers. Gebbie and Qureshi 18 and the International Coalition for Mass Casualty Education 4 developed emergency preparedness competencies for nurses. Assessing training needs is a necessary first step in implementing training programs. There is little information available in the literature concerning nurses emergency preparedness knowledge. Reineck et al. 19 developed the Readiness Estimate and Deployability Index to assess the ability of Army nurses to provide care in austere environments. Stevenson et al. 20 assessed 63 Air Force nurse anesthetists readiness for deployment with a modified Readiness Estimate and Deployability Index. Reineck 21 developed a version of the Readiness Estimate and Deployability Index for use by emergency center nurses in the civilian sector. No data have been reported in the literature on results with the civilian Readiness Estimate and Deployability Index. The EPIQ was the only tool described in the literature that comprehensively assessed civilian nurses perceived familiarity with eight competency dimensions of emergency preparedness. Despite potential broad applicability, the EPIQ has been administered only once, by the original researchers. Using the EPIQ, the current study represents a beginning stage of development of a program of emergency preparedness research. The goal is to better understand nurses emergency preparedness needs and ways to best convey emergency response skills and procedures. The EPIQ can be used to survey nurses in a variety of practice settings, to determine their particular training needs within various dimensions of emergency preparedness. METHODS In this study, we expanded on the work by Wisniewski et al. 15 with scale development and refinement, reliability assessment, scale validation, and scale predictability evaluation. Research attention is especially focused on assessing a critical and untested phenomenon of interest, namely, nurses self-reported level of familiarity with emergency preparedness. Description, Administration, and Scoring of the Instrument The EPIQ is a 44-item instrument that assesses nurses selfreported familiarity with eight dimensions of emergency preparedness and includes a self-reported measure of overall preparedness for a large-scale. Each individual item was measured on a 5-point familiarity scale, ranging from 1 not familiar to 5 very familiar. The EPIQ was placed online by using the Wisconsin Health Alert Network in July 2003 and is available to date. The Health Alert Network is a communication system for Wisconsin s public health departments, hospitals, clinics, emergency departments, laboratories, law enforcement agencies, fire services, emergency medical services, and other health agencies. A total of 776 fully completed responses were used in the current study. Statistical Analyses The SPSS 14.0 Graduate Pack (SPSS, Chicago, Illinois) was used for data analysis. To assess dimensionality, the data were first subjected to a principle-components analysis by using a varimax rotation. One question with a factor loading of 0.4 was removed from consideration. Based on the results of the factor analysis, the original EPIQ was revised. This revision consisted of moving items from the original dimension (factor) to the dimension where the items best fit, based on the factor analysis. The reliability of the resulting emergency preparedness dimensions was then assessed by using Cronbach s values. The eight emergency preparedness dimensions are shown in Table II, with the amount of variation explained by each dimension and the resulting value. The cumulative variance explained was 73.5%. A number of important implications can be drawn from these findings. First, the factor analysis was powerful, explaining a relatively high 73.5% of the total variance across the eight dimensions. Second, the reliability of each dimension was very high, with values ranging from 0.83 to 0.94; the value for the entire instrument was exceptionally high at 0.97. Third, the inclusion of a more robust factor analysis and greater detail to scale purification resulted in a different set and configuration of dimensions, compared with those reported by Wisniewski et al. 15 Table II reports the average familiarity score for each of the revised emergency preparedness dimensions, as well as the average overall familiarity score. This analysis accomplishes the scale development and purification goals set forth in the study. 1074

TABLE I. TABLE I. (Continued) Incident command system factor a To which functional group in the incident 0.78 command system you would be assigned during a large-scale Physical location where you would report if a 0.76 large-scale occurred Your agency s preparedness level for responding 0.75 to a large-scale Content of the emergency operations plan in 0.74 your agency/organization Strategic rationale used to develop the incident 0.71 command system response/action plan Assess and respond to site safety issues for self, 0.68 co-workers, and victims during a large-scale Differences between decision-making processes 0.67 in the incident command system for a largescale and nonemergency situations Tasks that should not be delegated to volunteers 0.48 in a large-scale Triage factor b How to perform rapid physical assessment of a 0.79 victim in a large-scale How to assist with triage in a large-scale 0.76 Basic first aid in a large-scale 0.72 How to perform rapid mental health assessment 0.65 of a victim in a large-scale How to evaluate the effectiveness of your own 0.65 actions during a large-scale Communication and connectivity factor c Chain of custody during a large-scale emergency 0.78 event Identify the different abilities of key partners in 0.76 your emergency operations plan Procedures used to document provision of care 0.75 in a large-scale Process for gaining access to the Strategic 0.74 National Stockpile Effectively present information about degree of 0.71 risk to various audiences Appropriate debriefing activities after a largescale 0.68 Psychological issues and special populations factor d Signs of post-traumatic stress in patients 0.83 How to evaluate a teenager to detect posttraumatic mental health problems 0.82 Appropriate psychological support for all parties 0.66 involved in a large-scale Provide health counseling/education to patients 0.54 regarding the long-term impact of biological, nuclear, incendiary, chemical, or explosive event Appropriate care of sensitive/vulnerable patient 0.50 groups during a large-scale Procedures for providing care to children/youths 0.48 during a large-scale (Continued) Isolation, decontamination, and quarantine factor e Selection of appropriate personal protective 0.70 equipment when caring for patients exposed to a biological, chemical, or radiological agent Isolation procedures for persons exposed to 0.69 biological or chemical agents Your facility s/community s quarantine process 0.68 Decontamination procedures stated in your 0.62 facility s emergency operations plan Impact on the environment from a large-scale 0.58 Epidemiology and clinical decision-making factor f Match antidote and prophylactic medications to 0.70 specific biological/chemical agents History and physical assessment surveillance 0.64 data for creating a high index of suspicion that a patient has been exposed to a category A, B, or C biological agent Ability to identify exacerbation of underlying 0.55 diseases from exposure to a chemical or biological agent or to radiation General issues (ethical, legal, cultural, and 0.48 safety) related to proper handling of the dead during a large-scale Reporting and accessing critical resources factor g Diseases that are immediately reportable to local 0.80 and state health departments When to report an unusual set of symptoms to 0.74 local and state health departments Determine the appropriate agency to which 0.65 reportable diseases are to be directed Where to quickly access up-to-date resources 0.48 about specific biological, nuclear, incendiary, chemical, or explosive agents during an event Biological agents factor h Signs and symptoms of anthrax inhalation 0.75 Modes of transmission for different types of 0.74 biological agents (e.g., anthrax and smallpox) Possible adverse reactions to smallpox 0.71 vaccination Signs and symptoms attributable to exposure to 0.67 different biological agents a Variance explained 11.4%; coefficient 0.94. b Variance explained 9.6%; coefficient 0.88. c Variance explained 9.5%; coefficient 0.93. d Variance explained 9.3%; coefficient 0.90. e Variance explained 9.3%; coefficient 0.90. f Variance explained 8.3%; coefficient 0.83. g Variance explained 8.3%; coefficient 0.87. h Variance explained 8.1%; coefficient 0.84. Nurse respondents reported an average overall emergency preparedness familiarity score of 2.3. This relatively low score indicates a positive correlation with the lack of emergency preparedness education in nursing programs. Although nurses felt relatively unprepared across most of the dimensions, the dimension scoring lowest was communication and connectivity (score, 2.1), followed by epidemiology and clinical decision-making (score, 2.2), psychological issues and 1075

TABLE II. Average Familiarity Scores by Dimension Average Familiarity Emergency Preparedness Dimension Score Incident command system 2.7 Triage 3.2 Communication and connectivity 2.1 Psychological issues and special populations 2.4 Isolation, decontamination, and quarantine 2.5 Epidemiology and clinical decision-making 2.2 Reporting and accessing critical resources 2.8 Biological agents 2.9 Overall familiarity with response activities/ 2.3 preparedness The scale ranged from 5 very familiar to 1 not familiar. TABLE III. Emergency Preparedness Dimension Regression Results Standardized Coefficient t p Incident command system 0.31 16.7 0.001 Triage 0.20 10.6 0.001 Communication and 0.42 22.5 0.001 connectivity Psychological issues and special 0.28 15.3 0.001 populations Isolation, decontamination, and 0.29 15.4 0.001 quarantine Epidemiology and clinical 0.29 15.5 0.001 decision-making Reporting and accessing critical 0.31 16.6 0.001 resources Biological agents 0.28 14.9 0.001 R 2 0.734, F 264, p 0.001. special populations (score, 2.4), isolation, decontamination, and quarantine (score, 2.5), incident command system (score, 2.7), reporting and accessing critical resources (score, 2.8), and biological agents (score, 2.9). Nurses reported the greatest familiarity with triage (score, 3.2); this was the only emergency preparedness dimension with an average familiarity score above 3.0. Triage concepts have traditionally been included in nursing education programs. RESULTS The initial procedures for data analysis facilitated developing a testable model assessing the relative impact of each emergency preparedness dimension on nurses perceptions of their overall preparedness in the case of large-scale emergency events such as those that occurred on September 11, 2001, and with Hurricane Katrina. To assess the overall predictability of the instrument and the relative impact of each dimension, the factors scored for the revised EPIQ dimensions reported above were regressed against nurses overall familiarity with response activities/preparedness in the case of a large-scale. The findings are reported in Table III. As Table III shows, the revised EPIQ is very powerful for explaining respondents self-reported preparedness in the case of large-scale s (R 2 0.734, F 264, p 0.001). Of significance, each of the eight revised EPIQ dimensions had a strong significant impact in explaining overall familiarity (all significant at p 0.001). In order of importance, communication and connectivity had the highest standardized value (standardized 0.42), followed by incident command system (standardized 0.31) and reporting and accessing critical resources (standardized 0.31), epidemiology and clinical decision-making (standardized 0.29) and isolation, decontamination, and quarantine (standardized 0.29), psychological issues and special populations (standardized 0.28) and biological agents (standardized 0.28), and triage (standardized 0.20). In combination, the factor analysis, reliability analysis, and regression results achieved the goal of assessing the reliability and validity of the revised EPIQ. DISCUSSION Studies to date have been focused on identifying training needs of public health workers, citizen volunteers, first responders, physicians, school nurses, military nurses, and nursing students. Further research is needed to determine the current level of nurses knowledge of emergency preparedness, to design and to implement effective emergency preparedness education curricula and continuing education programs. The EPIQ was developed in 2003 and was used in only one large-scale exploratory/descriptive study. The present study extended the analysis of EPIQ data to assess the reliability and validity of this instrument to accurately measure nurses self-reported familiarity with emergency preparedness competency dimensions. The revised EPIQ could be used to assess the self-reported emergency preparedness knowledge of military nurses. Baker 22 emphasized the importance of collaboration between military and civilian health care facilities in the event of a natural or man-made disaster. Key stakeholders in nursing might consider the use of the revised EPIQ to assess nurses selfreported level of familiarity with emergency preparedness competency dimensions. Although this study focused on nurses, consideration should be given to using the EPIQ to assess the emergency preparedness familiarity of other health care workers. The revised EPIQ could readily be used to assess the self-reported familiarity with emergency preparedness of physicians, first responders, and public health workers. This study confirmed that the EPIQ as revised is a psychometrically sound instrument to measure nurses self-reported level of familiarity with emergency preparedness. The need for emergency preparedness training is well documented in the literature. A crucial first step toward designing wellwritten, comprehensive, emergency preparedness curricula is to assess training needs. Additional studies using the revised EPIQ should provide data to assist nurse educators in the development of competency-based, relevant, emergency preparedness curricula. 1076

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