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Original Articles

Nurse Leaders' Knowledge and Confidence Managing Disasters in the Acute Care Setting

Cariaso-Sugay, John DNP, RN, NEA-BC; Hultgren, Marianne DNP, RN, CNE; Browder, Beth A. MHSA, BSN, NE-BC; Chen, Jyu-Lin PhD, RN, CNS, FAAN

Author Information
Nursing Administration Quarterly: April/June 2021 - Volume 45 - Issue 2 - p 142-151
doi: 10.1097/NAQ.0000000000000468
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Abstract

WHETHER NATURAL or human-induced, disasters are a global issue that impact health care systems' operations, especially in the acute care setting. The current COVID-19 pandemic is a recent illustration of how health care systems and providers, especially nurses, respond to a rapidly evolving crisis. Disaster types that affect acute care settings include natural (flood, tornado, earthquake, fires), human-made (explosion, cyberattack, mass casualty event), and infectious diseases (influenza, Ebola virus disease, Zika virus disease, COVID-19). Disasters create an unexpected demand for health care services that annihilates the hospital's ability to function under normal circumstances due to surge capacity.1 According to the American College of Emergency Physicians,2 surge capacity is the health care system's ability to manage situations such as a sudden increase in the number of patients admitted to the hospital using available resources. As of October 25, 2020, COVID-19 is a global pandemic affecting almost every country, with 42 million confirmed cases and 1.15 million deaths worldwide.3 Nurses are at the forefront, innovating care to meet the needs of their communities.

It is well documented in the literature that nursing leadership has been shown to positively affect change due to the profound influence on the organization's culture.4,5 Nurse leaders are responsible for integrating research findings into practice and creating supportive environments with sufficient resources for nursing research, scholarly inquiry, and the generation of knowledge. Nurse leaders in the acute care setting are pivotal in responding to the multifactorial challenges caused by a disaster and should anticipate an expanded role, including caring for the sick, managing infection control, and participating in surge planning.6 Foundational competencies in disaster management and preparedness are critical in order for nurse leaders to confidently lead and promptly make decisions. Moreover, essential nursing leadership behaviors, including remaining composed, unflappable, open-minded, and confident, are expected in disaster situations.7

In the current pandemic, nurse leaders play a critical role in developing evidence-based guidelines and protocols in the treatment and management of COVID-19. The role of a leader is to empower individual autonomy and promote innovative and evidence-based approaches to improving patient care processes and outcomes. During a disaster, such as the COVID-19 pandemic, utilizing evidence-based practice (EBP) principles can build the nurse leader's confidence in managing the rapidly evolving circumstances. Therefore, it is essential to develop a quality improvement (QI) program to increase nurse leaders' knowledge and confidence regarding disaster management.

LOCAL PROBLEM

After an introductory meeting with the project site's chief nurse executive and associate chief nursing officer, the creation of this QI project was based on an internal gap of disaster management competencies of nurse leaders. However, there was a need to formally evaluate the level of disaster management knowledge and confidence of existing nurse leaders and any deficiencies could be potentially addressed through an EBP project. The project site's nursing strategic plan includes advancing high-reliability behaviors, supporting nursing professional development, and improving the quality of care. There is alignment between this QI project and the nursing strategic plan, as the project facilitated the development of nursing leadership skills supported by evidence-based research and practice. The health system has a robust interprofessional emergency management committee. However, an immediate opportunity identified was the lack of standardized nurse leader competencies in disaster management. This QI project's overall goal was to improve the nurse leader's knowledge and confidence in managing disasters that impact the acute care setting.

METHODS

This QI project utilized the Plan, Do, Study, Act (PDSA) cycle design with pre- and postintervention surveys. The PDSA cycle proposed by the Institute of Health Quality Improvement (IHI) allows for continuous improvement opportunities as generated ideas are tested and adjusted through cycles, increasing the likelihood of goal achievement and sustainability.8 The QI project occurred within John Muir Health's 2 acute care hospitals, both Magnet-designated facilities.

The social cognitive theory (SCT) and the concept of self-efficacy developed by Albert Bandura provided a framework to support this QI project's intervention constructs to improve the participants' perceived knowledge and confidence through an educational intervention. According to Bandura,9 self-efficacy is “the belief in one's capabilities to organize and execute the courses of action required to manage prospective situations.”(p2) Bandura10 described the SCT as a central role of cognitive self-regulatory and self-reflective processes that determine what information will be conveyed and organized for future use. Individuals with a high sense of efficacy can visualize success that supports positive performance, whereas those who doubt their effectiveness may visualize failure scenarios, leading to poor performance.10 It was anticipated that this project would improve participants' perceived knowledge and confidence after the online educational intervention, leading to improved leadership performance and response in a disaster situation.

Nurse leaders at all levels (charge nurses, supervisors, managers, directors) with formal direct reports who work in the acute care setting were allowed to participate in this project. Outcome measures included change in perceived disaster management knowledge and confidence in fulfilling the nurse leader's role during a disaster. Along with qualitative feedback from the participants, the evaluation offered insights to enhance the education course for future sustainment and achievability.

QI intervention

Following a thorough literature review and support from the health system's emergency management expert, an education module was created and made available on demand within the organization's online learning management platform. The education module included an overview of Federal Emergency Management Agency (FEMA) standards of care,11 the health system's emergency and department operations plans, and the American Organization of Nurse Leaders (AONL) guiding principles for nurse leaders in crisis management.7 Moreover, a list of references and links related to this topic were provided to project participants. Eligible participants were invited to take part in the project via e-mail and at various leadership meetings.

Before assessing the intervention information, participants were required to complete an anonymous survey that captured demographic characteristics and questions measuring their perceived knowledge and confidence while leading during the COVID-19 pandemic. This was administered via e-mail using an online survey system. After completing the preintervention survey, participants had 30 days to access the education material online and complete the suggested posteducation activities. Participants were encouraged to utilize their learnings from the educational module and apply them within their practice setting during the active pandemic. Examples of the posteducation activities included reviewing the health system's emergency operations plans, fulfilling a role in the hospital incident command center, updating their respective department operations plans, and attending an emergency management committee meeting.

After 30 days from the educational module launch, the same knowledge and confidence survey was administered to individuals who completed the preintervention survey. The postintervention survey included an attestation to confirm the participant completed the educational intervention. If the participant did not complete the intervention, he or she was not eligible to move forward to the postintervention survey. This project was exempt from the institutional review board review due to the nature of the QI project.

Demographic survey

The demographic questionnaire elicited data on a variety of characteristics of the project participants. Each participant was asked to provide information on gender, age, highest level of education, years in nursing, years in a nurse leader role, years in current position, department, and current nurse leader title. In addition, participants were asked to indicate their experience with disaster management in an acute care setting as well as their experience fulfilling a role in a hospital incident command center.

Disaster preparedness knowledge survey

After receiving approval from the Wisconsin Nurses Association, disaster preparedness perceived knowledge was measured using subscales from the Emergency Preparedness Information Questionnaire (EPIQ). The EPIQ instrument is a knowledge-based survey consisting of 45 questions within 8 subscales that examine the different aspects of emergency preparedness in nurses to develop educational programs to enhance knowledge in this field.12 In various research studies, the EPIQ instrument offered a systemized evaluation to measure nurses' knowledge of emergency preparedness and response.13–15 The EPIQ tool has a reliability coefficient α value between .827 and .94.12

For this QI project, 3 subsections of the EPIQ instrument were included to measure perceived knowledge: (1) the incident command system; (2) communication and connectivity; and (3) isolation, decontamination, and quarantine. The intent behind choosing these specific subsections was to concentrate on domains applicable to the acute care nurse leader's expected functions in a disaster. The 20 items on the survey measured perceived knowledge using a Likert scale (1 = no knowledge; 2 = beginner knowledge; 3 = intermediate knowledge; 4 = expert knowledge). A higher score indicated higher perceived knowledge.

Nurse leaders' confidence in disaster management survey

The AONL Crisis Management Taskforce and members of the American Hospital Association's Society for Healthcare Strategy & Market Development7 developed guiding principles and priorities of nurse leaders in any crisis. Priority focus areas include the following: tenets of crisis communication; basic nursing leadership behaviors; necessary nursing leadership skills; priorities of a crisis readiness plan; and the nurse leader's role.7 There were a total of 20 guiding principles within each priority focus area. Each principle was included in the survey for participants to measure their perceived confidence using a Likert scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree). A higher score suggested more perceived confidence.

Open-ended questions

Following the PDSA cycle, using data to support continuous improvement was accomplished by including open-ended questions in the postintervention survey. The 2 open-ended questions to capture participant feedback were designed to improve future educational interventions and to sustain perceived knowledge and confidence in disaster management.

Analysis plan

Descriptive analyses (mean and percentage) were used to analyze all study variables, including aggregate analysis of each knowledge and confidence survey's subscales. A paired-samples t test was used to determine the educational intervention's effect on the participants' knowledge and confidence leading in a disaster situation. An effect size calculation was used to measure the strength in difference between pre- and postintervention means. All statistical analyses were conducted in SPSS 26.0, with a P value set at .05. Descriptive content analysis was used for analyzing the open-ended responses.

RESULTS

Of the 98 eligible participants for this QI project, 50 (51%) completed the preintervention survey. Of the participants who completed the preintervention survey, 33 (66%) completed the educational intervention and the postintervention survey. Among the 50 participants in the project, 8% were 25 to 35 years old, 24% were 36 to 45 years old, 48% were 46 to 55 years old, and 20% were 56 to 65 years old (Table 1). Their average age was 38.4 years (SD = 8.15; range, 32-65 years). The majority of the participants were female (n = 45; 90%) and had more than 10 years of nursing experience (n = 49; 98%). The highest level of education completed among the respondents included BSN (n = 26; 52%), MSN (n = 23; 46%), and DNP or PhD (n = 1; 2%). Most of the participants were unit supervisors (n = 22; 44%) and worked in Acute Care (n = 21; 42%). While 68% (n = 34) had experience with disaster management in a hospital setting, only 48% (n = 24) had experience with a hospital incident command center role.

Table 1. - Demographic Informationa
Variable n % Mean SD Range
Age, y 48.4 8.15 32-65
25-35 4 8
36-45 12 24
46-55 24 48
56-65 10 20
Gender
Male 5 10
Female 45 90
Highest level of education
BSN 26 52
MSN 23 46
DNP or PhD 1 2
Years in nursing
5-9 1 2
10+ 49 98
Years in current position
0-2 10 20
3-5 24 48
6-9 12 24
10+ 4 8
Division
Acute Care 21 42
Critical Care 10 20
Women and Children 4 8
Emergency 2 4
Surgical Services 2 4
Other 11 22
Current nurse leader role
Unit supervisor 22 44
Manager 17 34
Director 8 16
Executive director or above 3 6
Experience with disaster management in a hospital setting
Yes 34 68
No 16 32
Experience with hospital incident command center role
Yes 24 48
No 26 52
aThis table demonstrates the demographic information of 50 participants who completed the preintervention survey.

The overall postintervention knowledge scores were significantly higher than the preintervention survey scores. The mean knowledge score (t = 8.62, P < .001) as well as scores in the incident command system, communication and connectivity, and isolation, decontamination, and quarantine subscales were significantly higher after the intervention (t = 5.93, P < .001; t = 7.91, P < .001; t = 9.54, P ≤ .001, respectively; see Table 2). The greatest improvement was found in the knowledge subscale “communication and connectivity,” baseline M =1.83 and postintervention M = 2.94. There was a medium effect size range of 0.57 to 0.67 noted in all sections of the knowledge survey (see Table 2).

Table 2. - Nurse Leaders' Perceived Knowledge and Confidence Before and After Educational Interventiona
Category Preintervention, Mean (SD) Postintervention, Mean (SD) t (P) Effect Size
Knowledge—Overall 2.10 (0.46) 3.06 (0.35) 8.62 (<.001) 0.53
Knowledge—Incident command system 2.36 (0.57) 3.16 (0.35) 5.93 (<.001) 0.66
Knowledge—Communication and connectivity 1.83 (0.55) 2.94 (0.48) 7.91 (<.001) 0.67
Knowledge—Isolation, decontamination, and quarantine 2.01 (0.43) 3.03 (0.36) 9.54 (<.001) 0.51
Confidence—Overall 3.76 (0.52) 4.39 (0.42) 5.03 (<.001) 0.60
Confidence—Crisis communication 4.10 (0.59) 4.54 (0.44) 3.70 (.001) 0.57
Confidence—Nursing leadership behaviors 4.38 (0.54) 4.68 (0.42) 3.41 (.003) 0.37
Confidence—Nursing leader skills 3.60 (0.74) 4.36 (0.54) 5.00 (<.001) 0.73
Confidence—Crisis readiness plan 3.30 (0.90) 4.19 (0.55) 4.00 (<.001) 1.07
Confidence—Nurse leadership role 3.83 (0.55) 4.40 (0.51) 3.62 (.002) 0.70
aKnowledge was measured using a Likert scale (1 = no knowledge; 2 = beginner knowledge; 3 = intermediate knowledge; 4 = expert knowledge). Confidence was measured using a Likert scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree).

The overall postintervention confidence mean (t = 5.03, P < .001) and mean scores for the 5 subscales were also significantly higher than those at preintervention (see Table 2). Within the confidence survey, the most improved subscale was found in the “crisis readiness plan,” baseline M = 3.30 and postintervention M = 4.19. A small effect size of 0.37 was calculated in the “nursing leadership behaviors” subscale, medium effect size of 0.57 was noted in “crisis communication,” and a large effect size of 0.70 to 1.07 was noted in the remaining subsections “nurse leadership role,” “nursing leader skills,” and “crisis readiness plan” (see Table 2).

Open-ended questions were included in the postintervention survey to gain participant feedback on what was most useful in the education and what they would like to see improved in future education modules (see Table 3). The common themes for what participants felt were most useful were as follows: understanding hospital incident command structure (HICS), learning about the hospital emergency management program, and guiding principles for nurse leadership behaviors in disasters. One of the participants commented, “Understanding HICS can be a daunting exercise ... this training defines and explains the important aspects as well as the role of nursing leaders.” Regarding participants' feedback on possible improvements in the education, common themes included the following: more interactive exercises, simulation, use of case studies, and annual education opportunities on a regular cadence. A participant highlighted, “Not easy to remember, confidence comes through having been through it.” Overall, the education intervention through an online module was well received by the participants.

Table 3. - Qualitative Data Summary
Comments Themes
Question 1: What did you find most useful in education? “Understanding HICS can be a daunting exercise. This training defines and explains the important aspects as well as the nursing role”
“Emergency management program elements”
“What makes a great leader who leads through crisis”
“Concise and clear content with graphics to support”
“Chain of command and each role”
“During this challenging time, education was perfect for what we are going through ... a refresher”
“Outlining each set pin crisis management mitigation”
“The role of nurse leader in managing disasters”
“HICS structure and contents of hospital emergency operations plan”
  1. Understanding hospital incident command structure (HICS)

  2. Learning about the hospital emergency management program

  3. Nurse leadership behaviors in disasters

Question 2: What would you like to see different in the education? ”Add tabletop scenarios”
“More specifics on HICS roles not traditionally assigned to nurses”
“Similar training for frontline nurses”
“More scenarios, less lingo”
“Not easy to remember, confidence comes through having been through it”
“More interactive webinar module and use of case studies to illustrate points”
“Add mini exercises”
“Regular annual education opportunities”
  1. More interactive, simulation, and case studies

  2. Annual education opportunities on a regular cadence

Abbreviation: HICS, hospital incident command structure.

DISCUSSION

Using an evidence-based method, this QI project's education intervention significantly improved participants' perceived knowledge and confidence levels in disaster management in the acute care setting. As identified in this project, there is a fundamental gap in nurse leaders' perceived knowledge and confidence in disaster management principles and essential behaviors. These findings correlate with existing literature supporting nurses' lack of preparedness for disaster response, including a lack of institutional disaster readiness plans and standardized training programs.13,16–18 Understanding basic emergency management principles that form an organization's emergency operations plan is essential for nurse leaders and can be achieved through an education program as designed in this project and in other published studies.19–22 With this knowledge, nurse leaders can utilize these concepts to perform the essential operational functions within their departments or in the hospital incident command center. During a crisis, the AONL guiding principles for leadership behaviors provided participants with an outline of distinguished skills to lead their teams confidently. In addition, the online platform allowed nurse leaders to access the content and information at their convenience and on demand. The success of the QI project may be contributed to the evidence-based content, AONL guiding principles, and ease of access to the educational information. However, because of the lack of published studies using the AONL guiding principles for leadership behaviors during a crisis, further research is recommended to formulate standardized nurse-specific competencies and assessment of nurse leader confidence.

Qualitative responses from project participants highlighted the need to offer this educational training annually to sustain knowledge and consistently review emergency management operations plans. This outcome is consistent with published literature that indicates the value of emergency preparedness training at continued intervals in professional development to sustain knowledge and skills over time.21 In addition, participants recommended simulation and interactive training versus a recorded online module to improve the educational experience. Miller et al21 reported improved participants' knowledge and skills in emergency preparedness training that included a blend of online and in-person workshops with immersive simulation exercises. Zell et al22 demonstrated that structured simulation activities improved multidisciplinary staff knowledge of the emergency evacuation plan in a neonate intensive care unit.

There were several limitations of this QI project that are notable. First, improved perceived knowledge and confidence cannot be generalized because of the small sample size involving one health system. In addition, unlike COVID-19 hotspots in other parts of the country, the project site did not experience an equivalent patient surge during this pandemic. Therefore, the participants' experience may differ from nurse leaders working in vastly affected acute care settings. The selection of participants should be considered as a majority of the participants were known to the project administrator. A selection of subsections of the EPIQ instrument was utilized for the knowledge survey of this project to concentrate on domains applicable to the acute care nurse leader's role in a disaster, reducing the tool's validity and reliability. Perceived knowledge and confidence were measured by surveys using a rating scale and thus response bias should be considered. Finally, because of the lack of research on nurse leader preparedness in disasters, there is limited literature or evidence to support standardized competencies.

IMPLICATIONS FOR NURSE LEADERS

The COVID-19 pandemic has challenged nurse leaders to sway from normal operations and respond to a crisis in novel ways. Within acute care settings, activating the incident command system to govern the operations, analytics, and decision-making functions to care for the ill and support the workforce has been critical. Existing areas were transformed into isolation units, equipment and supplies were strategically inventoried, employees were redeployed to work in other areas, engagement and education efforts were launched, and innovation continuously emerged. Using an evidence-based approach to leadership training, such as an online module with suggested postintervention activities, may improve nurse leaders' knowledge and confidence in disaster management. Moreover, senior nursing leaders should consider annual competencies and various educational opportunities that include simulation for nurse leaders to improve knowledge and confidence.

CONCLUSION

On the basis of the findings of this project, a significant increase in participants' knowledge and confidence in managing disasters in the acute care setting was observed. This project aimed to develop nurse leaders' knowledge and confidence supported by evidence and can be replicated in other settings. There is no better profession than nursing to lead through and recover from this pandemic. Undoubtedly, nurse leaders should find their inspiration, energy, and passion from nurses on the front line committed to caring for the sick, regardless of the challenges. Nurse leaders are the glue that keeps teams working collaboratively together. Sustaining a shared purpose to serve others during this pandemic will help us emerge into a positive trajectory ahead. As nurse leaders become confident and knowledgeable in leading through disasters, the organizations and employees they work with can flourish, increase their resiliency, and remain committed to the nursing profession. Most importantly, employees will feel supported to provide the highest quality of care, ensuring optimal patient outcomes during a disaster.

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Keywords:

acute care; competencies; confidence; disaster; disaster management; education; knowledge; nurse leaders; nursing; pandemic; preparedness; quality improvement

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