For the past 100 years, and particularly in the last decade, the damage inflicted by natural hazards and disasters due to climate change and global warming has been growing steadily.1 Natural hazards are defined as naturally occurring phenomena, including earthquakes, volcanic eruptions, hurricanes, landslides, tsunamis, floods, drought and epidemics.2 Natural disasters are defined as the consequences or effects of natural hazards that harm humans.3 It is estimated that between 2000 and 2018, natural hazards and disasters killed approximately 1.3 million people worldwide and left 4.4 billion people requiring assistance due to injuries, loss of their homes and so on.4 The leading cause of death by hazard or disaster was earthquake (56%), followed by storm (17%), extreme temperature (13%) and flood (11%).5 In percentage terms, the proportion of people whose lives were disrupted by disaster type were flood (45%), drought (33%), storm (16%) and earthquake (3%).5 In total, more than 130 million people lost their homes due to natural hazards and disasters between 1900 and 2015.6
Many people who lose their homes have to live in evacuation shelters for prolonged periods. According to the Sphere Association,7 protecting people who live in shelters from falling ill is a major priority in these disaster response situations. Shelter is defined as the household living space with necessary items for daily activities, and essentially it is used for people who are displaced from their own homes.7 Living in a shelter can be an extremely challenging and traumatic experience for disaster victims. In many cases, school gymnasiums and other public buildings serve as shelters, although they are not designed for this purpose or generally accepted as long-term living arrangements.7
When evacuation life is prolonged, living conditions gradually deteriorate and become more stressful, undermining and affecting people's physical, mental and social health. Previously published reviews revealed that many survivors are at risk of post-traumatic stress disorder (PTSD)8-10 or depression.11 One systematic review identified groups particularly vulnerable to PTSD and adjustment disorders; for example, older adults are 2.11 times more likely to develop PTSD than younger people following a natural hazard and/or disaster.12 Furthermore, one systematic review of perinatal outcomes13 revealed that disaster can impact upon maternal mental health and perinatal wellbeing. Moreover, the loss of medical infrastructure in disaster-stricken areas can result in evacuees’ compromised health and the spread of disease and/or infection.14,15
In order to protect the health of survivors, disaster relief nurses play a critical role in supporting people who are forced to live in shelters.16 They are usually sent by local, regional or national government authorities, disaster rescue organizations or health care services to provide prompt nursing care for evacuees in these shelters. According to the International Council of Nurses (ICN),16 nurses are often the first responders who provide direct care on site after a disaster strikes. Therefore, it is crucial to develop a strong evidence base for supporting disaster relief for professional nursing practice.
However, there is a paucity of research papers on this topic in the nursing literature. The authors identified only two existing literature reviews published post-2000 in international nursing journals that addressed nursing at a shelter. Veenema14 examined the quality of health care provided at shelters in disaster situations. None of its included studies examined the quality of health care that care providers, including nurses, provide in shelters at times of disaster. Additionally, the author noted that the majority of articles were US-based and did not reflect what was happening elsewhere in the world. The other review by Kako et al.17 examined the literature on competencies published in the Japanese disaster nursing journals. They found that definitions of competency varied and arriving at a common definition was difficult, leading them to conclude that disaster nursing demands various skills and a wide range of knowledge.
Disaster relief nursing is a relatively new area, and sharing knowledge obtained through the provision of care for evacuees in the shelters should be facilitated to assist care providers in being fully prepared when natural hazards and disasters occur. Several qualitative studies have reported on nursing practice in disaster shelters. For example, a study by Deal15 on nurses who worked in shelters in Texas, reported on the challenges that these nurses encountered, including protecting privacy and providing continuity of medical treatment for people with unique individual needs. Lack of standard operating procedures was reported to be another barrier, as was the difficulty in locating patients in large shelters. To overcome this time-consuming problem, a photo board map with digital pictures of patients was devised so that nurses could easily find the patient they were looking for.15 Furthermore, another qualitative study on shelter nursing18 was conducted in Japan following the 2016 Kumamoto earthquake. The study explored the role of nurses in connecting various workers and individual victims in order to provide a safe and healthy environment for daily living at shelters. Nurses were challenged to make flexible judgments to distribute the limited resources. Nurses were also required to identify and intervene if other professionals put too much stress on evacuees when seeking their personal information.
These findings may have been previously addressed in activity/project reports of disaster nursing but they were largely non-research-based.19,20 Synthesizing such qualitative accounts should provide a useful evidence base for understanding the complex nature of nursing care in shelters following disasters. This should also be useful for national, regional and local governments and disaster rescue organizations when preparing their disaster relief nursing and healthcare teams. Since conducting well-planned rigorous quantitative studies appears to be difficult in the disaster nursing field, exploring qualitative evidence on nurses’ experiences should be the first priority.
A preliminary search of PROSPERO, MEDLINE via PubMed, Cochrane Database of Systematic Reviews and JBI Database of Systematic Reviews and Implementation Reports was conducted. However, no current or underway systematic reviews on this topic were identified. The objective of this review is to systematically review the existing evidence on the experiences of nurses providing care to people who are in shelters as a consequence of natural hazards and disasters.
What are the experiences of nurses in providing nursing care for disaster victims at shelters following natural hazards and disasters?
Definition of terms
Nurses: The review will define nurses as those who provide nursing care in the shelter. The ICN defines nursing as follows: “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”21(para.1)
Natural hazard and disaster: The review will define natural hazards as naturally occurring phenomena, including earthquakes, volcanic eruptions, hurricanes, landslides, tsunamis, floods, droughts and bushfires,2 and natural disasters as the consequences or outcomes of natural hazards that harm humans and the communities they live in. Such disasters are the result of the way individuals and societies relate to threats originating from natural hazards.
Shelter (evacuation center): Facilities where those who escape from a natural hazard and disaster can stay and live; for example, suitable buildings located in an elementary school or junior-high school.14,15
This systematic review will consider qualitative studies that address the experiences/views of nurses in providing nursing care at shelters following natural hazards and disasters, including registered nurses, enrolled nurses, public health nurses and other nurses with formal nursing qualifications.
Non-nurse healthcare workers/professionals, nursing assistants without formal nursing qualification and nursing students will be excluded. There will be no limitations on participant inclusion regarding gender or ethnicity.
Phenomena of interest
The review considers nurses’ experiences in providing nursing care for disaster victims at shelters. It will identify the nursing care experience, what nurses observe and how they act when they encounter the hardships and subsequent phenomena that the evacuees from natural hazards and disasters undergo.
The context will include shelters in natural hazard and disaster situations including earthquake, tsunami, hurricane, typhoon, heavy rainfall and bushfire at any geographical and social settings. The review will exclude dispute, terrorism and war since these are man-made.
Types of studies
The proposed review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research.
Studies published in English or Japanese will be included. Studies published from 1995 to the present day will be considered. This decision was made because disaster nursing has rapidly developed worldwide since the Great Hanshin–Awaji Earthquake which occurred on 17 January 1995 in the southern part of Hyōgo Prefecture, Japan. Japan has a long history of coping with natural disasters and catastrophes, and is familiar with having to create and supply survival shelters following such events.19 The number of shelters required to remain open for more than one day reached 28 after 2000.19 Utilizing findings from Japanese studies together with analyses in English should produce a rich, informative evidence base on disaster nursing practice in survival shelters.
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.22
The search strategy will aim to find both published and unpublished studies in English or Japanese. An initial limited search of PubMed and CINAHL (for English studies) and ICHUSHI (for Japanese studies) will be undertaken, followed by analysis of the text words contained in the titles and abstracts, and of the index terms used to describe relevant studies. The search strategy, including all identified key words and index terms, will be adapted for each included information source. A full search strategy is detailed in Appendix I. The reference lists of all studies selected for critical appraisal will be screened for additional studies.
The following databases will be used for a full and comprehensive search: PubMed, CINAHL and PsycINFO via EBSCO, Scopus via ScienceDirect and Embase. The search for unpublished studies and gray literature will include Web of Science, MedNar, Proquest Health and Medical Complete, and ProQuest Dissertations and Theses Global. WHO Library Database (WHOLIS) will also be searched. To find any relevant Japanese studies, ICHUSHI will be investigated.
Following the search, all identified citations will be collated and uploaded into EndNote v. X8 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).22 The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram.23
Assessment of methodological quality
Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI critical appraisal checklist for qualitative studies.22 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. The results of critical appraisals will be reported in narrative form and in a table with detailed justifications for all decisions. Studies with more than four “No” or “Unclear” results will be excluded from the review in order to only include high-quality studies. The reasons for exclusion due to the methodological quality will be addressed in detail. The possible impact of methodological quality in included studies on the review will be addressed in the discussion section.
Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool.22 The data extracted will include specific details about the populations, context, culture, geographical location, study methods and the phenomena of interest relevant to the review objective. Findings and their illustrations will be extracted and assigned a level of credibility. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required. Extracted data from included Japanese studies will be translated into English by the first reviewer and then checked by the second reviewer. This will ensure that the more subtle meaning and nuance in the original language are appropriately translated.
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.22 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.24 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest and context for the specific review. Each synthesized finding derived from the review will then be presented, along with the type of research informing it, score for dependability, credibility and the overall ConQual score.
Mr Toshiyuki Suwa, research librarian, for assisting with the database search.
Appendix I: Search strategy for PubMed
Date searched: 27 June 2019
Results: 212 citations
1. Centre for Research on the Epidemiology of Disasters, United Nations Office for Disaster Risk Reduction. Poverty & death: disaster mortality 1996–2015 [Internet]: Centre for Research on the Epidemiology of Disasters, United Nations Office for Disaster Risk Reduction; 2016 [cited 1 August 2019]. Available from: https://www.unisdr.org/we/inform/publications/50589
2. International Federation of Red Cross and Red Crescent Societies. Types of disasters: definition of hazard [cited 18 June 2019]. Available from: https://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/definition-of-hazard/
3. World Health Organization. Humanitarian health actions: definitions: emergencies [Internet]. [cited 8 June 2019]. Available from: https://www.who.int/hac/about/definitions/en/
4. Centre for Research on the Epidemiology of Disasters. Natural disasters 2017 [Internet]; 2018 [cited 18 June 2019]. Available from: https://cred.be/sites/default/files/adsr_2017.pdf
5. Mizutori M, Guha-Spir D. UNISDR and CRED report: New economic losses, poverty and disasters 1998–2017 [Internet]: Centre for Research on the Epidemiology of Disasters, United Nations Office for Disaster Risk Reduction; 2018 [cited 1 August 2019]. Available from: https://www.cred.be/new-unisdr-and-cred-report-economic-losses-poverty-disasters-1998-2017
6. Mukherji A. Post-disaster housing recovery: Oxford Research Encyclopedias, Natural Hazard Science; 2017:1–35.
7. Sphere Association. The Sphere handbook: humanitarian charter and minimum standards in humanitarian response, 2018 edition [Internet] [cited 8 June 2019]. Geneva, Switzerland: Sphere Association. Available from: www.spherestandards.org/handbook
8. Dai W, Chen L, Lai Z, Li Y, Wang J, Liu A. The incidence of post-traumatic stress disorder among survivors after earthquakes: a systematic review and meta-analysis. BMC Psychiatry
2016; 16 (1):188–199.
9. Lipinski K, Liu LL, Wong PW. Effectiveness of psychosocial interventions implemented after the Indian Ocean tsunami: a systematic review. Int Soc Psychiatry
2016; 62 (3):271–280.
10. Ando S, Kuwabara H, Araki T, Kanehara A, Tanaka S, Morishima R, et al. Mental health problems in a community after the Great East Japan Earthquake in 2011: a systematic review. Harv Rev Psychiatry
2017; 25 (1):15–28.
11. Bonde JP, Utzon-Frank N, Bertelsen M, Borritz M, Eller NH, Nordentoft M, et al. Risk of depressive disorder following disasters and military deployment: systematic review with meta-analysis. Br J Psychiatry
2016; 208 (4):330–336.
12. Parker GLD, Siskind DJ, Martin-Khan M, Raphael B, Crompton D, et al. Mental health implications for older adults after natural disasters — a systematic review and meta-analysis. Int Psychogeriatr
2016; 28 (1):11–20.
13. Harville E, Xiong X, Buekens P. Disasters and perinatal health: a systematic review. Obstet Gynecol Surv
2010; 65 (11):713–728.
14. Veenema TG, Rains AB, Casey-Lockyer M, Springer J, Kowal M. Quality of healthcare services provided in disaster shelters
: an integrative literature review. Int Emerg Nurs
2015; 23 (3):225–231.
15. Deal BJ, Fountain RA, Russell-Broaddus CA, Stanley-Hermanns M. Challenges and opportunities of nursing care in special needs shelters
. Disaster Manag Response
2006; 4 (4):100–105.
16. World Health Organization and International Council of Nurses. Core competencies in disaster nursing
: version 2.0 [Internet]. 2019 [cited 18 June 2019]. Geneva, Switzerland: World Health Organization and International Council of Nurses. Available from: https://www.icn.ch/sites/default/files/inline-files/ICN_Disaster-Comp-Report_WEB.pdf
17. Kako M, Mitani S. A literature review of disaster nursing
competencies in Japanese nursing journals. Collegian
2010; 17 (4):161–173.
18. Sakugawa S, Akiko S. [Research on the coordination of health care provided by nursing professionals at emergency evacuation shelters
]. [Journal of JSDN]
2018; 20 (2):3–13. Japanese.
19. Sakashita R. Development in disaster nursing
: The challenges of various research designs. HEDN
2014; 1 (1):19–24.
20. Japanese Nursing, Association,. The Great East Japan Earthquake report by nurses. Tokyo: Japanese Nursing Association; 2011.
21. International Council of Nurses. Definition of nursing [Internet]. International Council of Nurses; 2002 [cited 18 June 2019 June]. Available from: https://www.icn.ch/nursing-policy/nursing-definitions
22. Aromataris E, Munn Z, (Editors). Joanna Briggs Institute Reviewer's Manual [Internet].Adelaide: JBI; 2017 [cited 18 June 2019]. Available from: https://reviewersmanual.joannabriggs.org/
23. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ
24. Munn Z, Porritt K, Lockwood C, Aromataris E, Pearson A. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol
2014; 14 (1):108September 20.