The Knowledge of Disaster Preparedness Management by Nurses in Emergency Department in Saudi Arabia

This study assesses the knowledge, awareness, and skills of emergency nurses in Saudi Arabia in response to disaster during Hajj mass gathering in Mecca. It highlights the deficit in knowledge and awareness about disaster management among nursing staff and the need for improvement in involvement in disaster situations.

The Knowledge of Disaster Preparedness
Management by Nurses in Emergency Department
in Saudi Arabia.
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Abstract:
Objectives: To assess the knowledge, awareness and skills of emergency nurses in response
to disaster during Hajj mass gathering in Mecca.
Design: Cross-sectional survey with non-probable purposive sampling and primary data
collection.
Setting: Emergency Department of Security Forces Hospital Makkah.
Participants: 96 registered emergency nurses in the hospital.
Outcome measures: Knowledge, awareness, perceptions and skills of emergency nurses in
Mecca with regard to mass gathering disaster preparedness.
Results: Majority of the participants were between 20 to 40 years. Participants between age
20-30 years were 62.5 % and participants between 31-40 years were 26.3 %. Knowledge and
awareness of the participants about disaster management is variable for different aspects.
There is significant deficit in the knowledge and awareness about disaster management
among nursing staff of Emergency Department of Security Forces Hospital Makkah. It is also
evident that emergency nurses wish to perform acute clinical tasks rather than proactive
clinical tasks like surveillance and prevention. data indicate that emergency nurses put less
emphasis on the leadership and psychological care. Emergency nurse exhibited good
understanding about their role in the management of mass gathering.
Conclusions: This study provides outline of the understanding of the role of emergency
nurses during Hajj mass gathering. Hospital management and Ministry of Heath need to
encourage and provide support for emergency nurses to improve involvement in disaster
situations.
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Table of Contents
Chapter 1 Introduction 4
1.1 Background of the study 4
1.2 Statement of the problem 8
1.3 Objectives 8
1.4 Research questions 8
1.5 Significance of the study 9
1.6 Scope and limitations 10
1.7 Definition of terms 10
Chapter 2 Literature Review 11
2.1 Introduction to literature review 11
2.2 Extent of disaster preparedness in the nurses 11
2.3 History of disaster response experience 12
2.4 Usefulness of disaster training and courses 13
2.5 Awareness and execution of organisational disaster plans and
approaches to improve disaster preparedness 13
2.6 Strategies to enhance disaster preparedness 14
Chapter 3 Methodology 15
3.1 Research design 15
3.2 Setting of the study 16
3.3 Study population 16
3.4 Study sampling 16
3.5 Sampling criteria 16
3.6 Sample and its size 17
3.7 Variables 17
3.8 Study instrument 17
3.9 Validity and reliability 19
3.10 Pilot study 19
3.11 Data collection procedure 19
3.12 Data analysis 20
3.13 Ethical consideration 21
Chapter 4 Findings 22
4.1 Participants demographic characteristics 22
4.2 Emergency nurses disaster knowledge and awareness 23
4.3 Emergency nurses role during mass gathering 24
4.4 Level of understanding of their role by emergency nurses in mass gathering disasters 25
Chapter 5 Discussion 28
Chapter 6 Conclusion 30
Appendix 32
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CHAPTER 1
1.Introduction:
1.1 Background of the study:
According to World Health Organisation (WHO) (2002), disaster is a condition in which
there is disruption of normal conditions and there is increase in the suffering which outdo
capability of tolerance of affected community. Disaster affects all the aspects like human,
other living species, economical, material, natural and environmental. Reason behind
occurrence of disaster can be man-made or natural and disaster can affect local area or it can
extend to larger geographical region which call for the health emergencies (UNISDR, 2017).
In the recent past, there has been the tremendous augmentation in the frequency and
magnitude of the disaster which affect public health. Hence, there is steady increase in the
public health emergencies. According to international disaster data base, between 1995 to
2015, globally there were approximately 6457 disaster incidences occurred. These disaster
incidences included earthquakes, floods, cyclones and landslides which affects approximately
606000 lives and affected health of approximately 4 billion people. Centre for Research on
the Epidemiology of Disasters (CRED) report stated that there were 346 whether related
disaster incidences occurred after 2015 and affected more than 205 million people.
Augmentation of the disaster incidences in year 2017 were more fearful because 93 % higher
disaster incidences occurred in 2017 as compared to the year between 2000 – 2016 average.
Moreover, statistical report stated that these causalities for disaster are other than non-natural,
human-made disasters such as war, stampedes, terrorism, transport accidents and even
infectious outbreaks (IFRC, 2014).
Saudi Arabia in the recent past experienced both natural and human-error disastrous
incidences. Saudi Arabia is associated with natural disastrous events like earthquakes, land
sliding, volcanic activity and flooding. Disastrous events occur mainly because of
inhabitation of zones potential of natural hazards. Overcrowded population is mainly
responsible for the human error emergency situations. In recent past, large number of
casualties occur in Jezan hospital in the south region of Saudi Arabia. Death of 25 patients
and injury to the 175 people occurred as a result of fire due to human error in Jezan hospital.
Other human error emergency situations in Saudi Arabia include terror attacks, motor vehicle
accidents and deleterious health effects due to ample migration of pilgrims during “Hajj”.
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These types of incidences indicate lack of manpower and preparedness of nurses to manage
such emergency situations (Ahmed, Arabi, and Memish, 2006; Alamri, 2011). WHO stated
that none of the healthcare system should be considered prepared for the emergency situation;
unless, its nursing staff is prepared for managing disaster and emergency situations.
However, emergency nurses in the Saudi Arabia remarked themselves as not-prepared for the
emergency situations. Hence, disaster preparedness is necessary for the nursing professionals.
It is essential to provide disaster preparedness training to the nursing professionals
considering the complex situations arising out of the emergency incidences. Preparedness is
the proactive strategy to address the disaster incidence prior to its occurrence (Hammad et al.,
2011). Preparedness include analysis of the potential risks, forecasting the effect and
monitoring the incidence in the effective manner. Core preparedness activities include :
preparation of theoretical foundation for disaster planning, making assumptions for the
effective disaster planning, thinking beyond routine activities, performing community needs
assessments, identifying leadership qualities and commanding post prior to occurrence of
incidence, designing expected local response for initial period, identifying and
accommodating vulnerable population, knowing about Government assistance, identifying
educational requirements, training, resources and personal protective equipment (PPE) and
planning for the initial period damage evaluation and monitoring (Magnaye et al., 2011).
Nurses are the first professionals to respond to the emergency and critical situations like
disasters. Hence, it is essential for them to apply their professional skills to take necessary
actions to provide appropriate service and to prevent further exaggeration of the problem and
its complications. Nurses should assess themselves for their knowledge, nursing skills,
capabilities and self-efficiency for disaster management and prepare themselves fulfilling all
the deficiencies. Assessment of all these aspects proved helpful for the nurse to identify the
risks at the earliest and provide prompt response (Conlon and Wiechula, 2011; Martin et al.,
2010).
In many countries including Saudi Arabia nurses are the integral part of the healthcare
system. Hence, nurse should be the integral part of the disaster preparedness plan. Nurses
should have basis knowledge of the disaster science and significant aspects of the disaster
preparedness. Nurse need to be aware of the following aspects like : 1) definition and
classification of disaster depending on the exclusive characteristics of disaster like onset,
duration, effect and recovery period, 2) Epidemiological aspects and determination of health
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effects of disaster, 3)areas of emergency which need attention like preparedness, mitigation,
response, recovery and evaluation, 4) procedures useful in planning management of disaster
like risk assessment, identification of hazard and weakness analysis, 5 ) preparedness
comprise of six domains like community resilience, incident managing, knowledge
managing, countermeasures and mitigation, flow managing and biosurvveillance, 6 )
cognizance of roles and responsibilities of nurses in the emergency incidences (Chapman &
Arbon, 2008; Hassmiller and Cozine, 2006).
Health effects of disasters:
Disasters produce deleterious effects on the communities and its population. Physical damage
of disaster includes damaging and collapsing of buildings, roads and bridges destruction,
demolition of tunnels and rails, blockade of telephone and cable lines. All these physical
damage affects humans. The north-western region of Saudi Arabia is at risk of earthquake
and volcanic hazards. Moreover, floods due to heavy rainfall are evident in central and
western regions of Saudi Arabia. Inhabited mountainous regions of the southwest are mainly
associated with the landslides. Cities in the central and eastern Saudi Arabia experience
shifting sand dunes and dust storms. Interruption in public utilities like water, gas, electricity
and sewage disposal produce disturbance in normal living and affect health of the affected
population. Interruption in the public transport lead to temporary or permanent homelessness
in the population which can produce deleterious health effect on the people. Moreover, it also
led to disruption in access to primary care and preventive health services. Disaster affect
health status of affected people in different ways like 1 ) premature death, eternal illness and
injuries which usually surpass capability of local healthcare system, 2) abolished local
healthcare infrastructure; hence inability to manage disaster situation with existing resources,
3 ) long term health effects would lead to increased morbidity and mortality, 4 )
environmental imbalance lead to prevalence of communicable disease due to hazardous
effects of air, water and soil, 5 ) disaster affects social, psychological and emotional well-
being of the affected community people, 6 ) disaster can affect food availability and lead to
nutritional deficiency (Birnbaum et al., 2015; Veenema et al., 2017).
Theoretical framework:
Nurses role in the disaster response is based on the different scopes. The first scope is based
on the competency standards necessary for education and training in order to prepare nurses
for disaster and emergency management. The second scope is related to development of
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preparedness measures in order to reduce disaster impact in more effective manner. In
alignment with the aim of the study, it is necessary develop preparedness in nurses in resilient
and responsive manner. According to United Nation International Strategy for Disaster
Reduction (UNISDR) which is known as Disaster Risk Reduction Framework for Building a
Resilient Health Care System (UNISDR, 2017); Saudi Arabia need to develop resilient health
care system. United Nations (UN) and the World Health Organisation (WHO) established the
worldwide standards for the emergency and disaster management in 2005. Goal of these
standards is to minimize the risk of disaster by improving the preparedness of respective
national healthcare systems by providing quality training to the healthcare workers including
nurses. Disasters are complex and unexpected in nature; hence, education and training need
to be given to healthcare workers including nurses not only at the institutional level but also
in collaboration with the associated organisations (Bajow et al., 2015). According to United
Nation International strategies in 2015; world is targeting to minimise risks of disaster instead
of responding to events. Along with other nations, Saudi Arabia dedicated to follow UN
action plan for reducing risks associated with disaster. Hence, Saudi Arabia is preparing for
the reduction of potential risks due to disaster by providing education and training for the
healthcare workers specifically nurses to ensure efficient healthcare services (Khan and Noji,
2016). There should be effective co-ordination among healthcare systems, healthcare
organisations and Government for designing framework to improve preparedness among
nurses in Saudi Arabia. Disaster preparedness framework offer international standards for the
establishment of disaster preparedness plan and delivering efficient approach to disaster (Bin
Shalhoub, Khan, and Alaska, 2017). Hence, nurses in Saudi Arabia should understand
standards and policies for disaster preparedness. Healthcare organisation in Saudi Arabia
need to develop organisational structure and chain of command for effective implementation
of disaster preparedness. Preparedness in healthcare organisation ca be effectively
implemented through providing competency training to the nurses. Disaster competencies
should reflect in knowledge and skills necessary for performing activities for disaster
management. International council of nursing framework for disaster
competenciesestablished several nursing competencies for providing response to emergency
and disaster situations (Ahmed, Barbeschi and Memish, 2009).
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1.2 Statement of the problem:
Since, there is increased frequency of disasters; it is necessary for the healthcare workers
specifically nurses to be well aware of the basic knowledge, skills and attitudes to manage
emergency conditions. However, it has been reported that nurses are lacking necessary basic
knowledge, skills and attitudes for managing emergency situations.
Major workforce in healthcare sector are nurses; hence, they should be crucial during
disasters and emergency situations. Nurses should have capability and efficiency to manage
disaster and emergency conditions. However, it has been reported that approximately 80 % of
nurses do not have prior experience of disaster and emergency incidence management. It
indicate nurses are imperfectly ready for disaster management.
Capability of Security Forces Hospital Makkah was challenged during an emergency
situation. This emergency was stampede in Mina during Hajji on September 24th where 717
people died and 863 people left injured. There was no assessment done prior to and after this
incident to assess capability of nurses. Hence, this research aims to investigate skills,
knowledge, competency and preparedness of Emergency Department nursing staff for
disaster and emergency management in Security Forces Hospital Makkah.
1.3 Objective
The study aims to investigate the emergency department nursing staff’s level of knowledge
and preparedness in disaster management.
Specific Objective
1. To assess the level of knowledge in disaster response of the emergency nurses
working in Security Forces Hospital Makkah (SFHM).
2. Assess the current roles and skills in disaster preparedness as reported by
emergency nurses, in particular against existing standards and disaster plans of
SFHM;
3. To determine the association between socio demographic of Emergency
Department Nurses with level of knowledge and preparedness in disaster
management.
1.4 Research questions:
1. What is the level of knowledge and awareness of emergency nurses about disaster
situation management?
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2. What is the prior experience of emergency nurses about disaster situation
management?
3. Is there relationship between standard practice and actual practice in providing care to
disaster victims at SFHM ?
1.5 Significance of the study:
Saudi Arabia is high at high risk of natural and human-error disasters. Different geographical
regions of the Saudi Arabia experienced varied natural emergency and disaster situations
which were disastrous and these incidences claimed loss of lives and financial loss (Al-
Bassam et al., 2014).
It has been reported that emergency nurses in Saudi Arabia are not willing to respond
effectively to disasters. Reports demonstrated that poor healthcare system in Saudi Arabia is
unable to manage disaster condition when the victims number surpass the capability of the
healthcare staff specifically nurses. Nurses in Saudi Arabia do not have experience in
handling mass causalities. Hence, it is need of hour, to augment the disaster management
skills of nurses in Saudi Arabia. Saudi Arabia is directing emergency responses of its
healthcare staff specifically nurses towards preparedness and prevention. Nurses are being
considered as most appreciated healthcare staff for disaster because nurses are aware of the
basic healthcare services (Nofal et al., 2018; Alzahrani and Kyratsis, 2017).
Makkah, the location for conducting this study is associated with high risk for the occurrence
of disasters. Makkah is the place where people of Muslim community gather in large number
during Hajj and Umrah. Gathering of people in such a large number produce emergency
condition due to epidemic outbreak of infectious disease and risk of accidents due to
overcrowded transport.
Hence, this study will be conducted to explore the nurses awareness about knowledge, skills,
competency and preparedness to manage disaster and emergency situation in future.
Moreover, this study will also be helpful in the identifying knowledge gaps and
incompetency of nurses to address issues during disaster management. This study will also
address training necessary for management of disaster and emergency situation.
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1.6 Scope and limitation:
The study is limited to investigating the knowledge, preparedness and competence of
emergency room nurses of Security Forces Hospital Makkah (SFHM) on the occurrence of
disaster and its management. The Emergency Department of SFHM consists of 42 beds that
caters to Ministry of Interior employees and dependents.
The study will use a cross – sectional research design. Thus, it does not permit analysis of the
direction of influence between the different variables and the outcomes of interest.
1.7 Definition of terms:
Disaster: Disaster is a serious disturbance of normal activities of the community or society at
all the levels as result of disastrous events which lead to human, material, economic and
environmental losses and impacts (UNISDR, 2017).
Disaster management: Disaster management is defined as the organisational roles and
responsibilities considering all the available resources and humanitarian aspects with respect
to preparedness, response and recovery for lessening disasters impact.
Knowledge: Knowledge is defined as nurses cognition to remember, comprehend and apply
techniques.
Preparedness: Preparedness is defined as measure which is useful in ensuring organised
mobilization of individuals, finance and other resources for providing effective relief in the
safe environment.
Competency:
Competency is defined as the capability of a person to perform specific activity in a specific
provided situation. Competency is the intergraded knowledge, skills, abilities and behaviour
of an individual to perform specific activity.
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Chapter 2
2. Literature review:
2.1 Introduction to literature review:
Literature search was carried out through electronic database like SCOPUS, MEDLINE,
PubMed, CINAHL and PsychINFO. Different keywords or terms were used for the search of
articles related to the preparedness of nurses for the disaster and emergency situations. These
keywords were nurse, emergency, disaster, disaster preparedness, disaster role, disaster
nursing and disaster competencies. Articles published in peer reviewed journals and
published in the English language were considered for the literature review. Articles which
didn’t determined preparedness of nurses for emergency or disaster and articles
encompassing other professionals with nurses were also excluded from the literature review.
In the initial search, 362 articles were obtained. Among these, 292 articles were excluded due
to non-relevance to the objective of the research. After full text reading 10 articles were
considered appropriate for inclusion in the literature review.
Literature review was conducted under different themes like: extent of disaster preparedness
in the nurses, history of disaster response experience, usefulness of disaster training and
courses, awareness and execution of organisational disaster plans and approaches to improve
disaster preparedness.
2.2 Extent of disaster preparedness in the nurses :
In different articles, diverse scales were used for the determination of disaster preparedness of
nurses. However, most of the articles reported that nurses are insufficiently prepared for the
disaster preparedness. Almost all the articles reported inadequate level of preparedness of
nurses for disaster management (Al Khalaileh et al. 2012; Al Thobaity et al. 2015; Baack &
Alfred 2013; Goodhue et al. 2012; Hodge et al. 2017; Ibrahim 2014; Labrague et al. 2016;
Nilsson et al. 2016; Oztekin et al. 2016; Putra et al. 2011; Tzeng et al. 2016; Usher et al.
2015; Whetzel et al. 2013). Labrague et al. (2016) demonstrated disaster preparedness of
nurses in Philippines. In this study, it was reported that approximately 80 % of the nurses
were not ready to manage disaster and emergency situations. Remaining 20 % of the nurses
demonstrated that they are aware disaster preparedness; however, they are not fully confident
of handling the disaster situation. Nilsson et al. (2016) reported that nurses are moderately
aware of the disaster preparedness. Oztekin et al. (2016) demonstrated that nurses in Japan
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are not satisfactorily aware of the disaster readiness, disaster response and disaster evaluation
which indicate that they are not well versed with the disaster preparedness. Tzeng et al.
(2016) reported that nurses exhibited low level of self-preparedness in terms of personal
preparedness, self-protection, emergency response and clinical management of disasters.
These nurses reported higher level of preparedness for clinical management and low level of
preparedness for self-protection domain. Al Thobaity et al. (2015) and Ibrahim (2014)
conducted studies in Saudi Arabia. In these studies, it was demonstrated that nurses exhibited
moderate level of preparedness for disaster management. Usher et al. (2015) conducted
studies in Asian-Pacific countries to explore knowledge and skills of nurses in disaster
preparedness. Bangladesh nurses reported that they can not provide treatment to disaster
management victims in the absence of physician. Nurses in Cambodia and Solomon Islands
reported that these nurses are not prepared for biological and chemical agents. Hodge et al.
(2015) reported that 40 % of the nurses are not ready to manage the disaster situations. Baack
& Alfred (2013) evaluated disaster preparedness on Emergency Preparedness Information
Questionnaire (EPIQ) and reported that nurses exhibited suboptimal preparedness for disaster
management. Whetzel et al. (2013) assessed emergency and disaster preparedness in
emergency nurses using self-designed survey questionnaire. In this study, approximately less
than 50 % nurses reported that they are well aware of disaster preparedness and they can
provide effective care to patients during disaster conditions. Al Khalaileh et al. (2012)
reported that less than 60 % nurses exhibited poor preparedness for disaster management.
2.3 History of disaster response experience:
Baack & Alfred (2013) demonstrated that nurses with the previous experience of disaster
management exhibited more disaster preparedness as compared to the nurses without prior
exposure to the disaster management. O’Sullivan et al. (2008) also demonstrated nurses prior
experience in infectious outbreaks including Severe Acute Respiratory Syndrome (SARS)
exhibited more preparedness for emergency situations. Al Thobaity et al. (2015)
demonstrated that 25 % of the nurses with prior experience of nurses in disaster management
knowledge and skills perceived more disaster preparedness. Tzeng et al. (2016) established
that prior disaster response experiences, disaster-management training and military training
demonstrate augmented disaster preparedness. Usher et al. (2015) also reported that
progressive age, education related to disaster and prior involvement in disaster management
demonstrated increase disaster competency and disaster preparedness. Nilsson et al. (2016)
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revealed that nurses with prior experience in disaster management displayed more
willingness to participate in disaster management. All these studies demonstrate that nurses
with prior experience in the disaster management proved more effective in managing disaster
situations. Hence, it would be beneficial to provide training to the nurses by creating disaster
like situations.
2.4 Usefulness of disaster training and courses:
Tzeng et al. (2016) reported that nurses with prior training in the disaster exhibited more
preparedness for disaster management. Al Thobaity et al. (2015) established that knowledge
and skills obtained in the actual drills and disaster trainings proved more useful in disaster
management. Oztekin et al. (2016) also reported that training in regular disaster or emergency
drills proved helpful in preparedness for disaster and emergency situations. Labrague et al.
(2016) and Fung et al. (2008) training in first aid training, infection control, advanced basic
life support and field triage helped in improving performance of nurses in disaster situations.
Duong (2009) and Labrague et al. (2016) reported that real-time exercises, practice drills and
scenarios, pre-hospital life support and desk top exercises are helpful in adequately
improving performance of nurses in the disaster situations. Jacobson et al. (2010) reported
that instructor led online disaster training programme would be helpful in improving
preparedness of nurses for disaster management.
2.5 Awareness and execution of organisational disaster plans and approaches to improve
disaster preparedness :
In most of the studies, participants reported that they were aware of the disaster management
protocol at their workplace. However, Whetzel et al. (2013) demonstrated that despite
awareness of disaster management protocol, participants did not read these protocols and
thwy were not aware of the location of the disaster plan. Labrague et al. (2016) reported that
40 % of the nurses aware of the existence of the plans; however, they were not aware how to
execute these plans. O’Sullivan et al. (2008) demonstrated that less than 50 % of the nurses
were aware of the existence of the disaster management plan; however, they were not aware
of policies and procedures for the executing disaster management plans. Ibrahim, (2014)
reported that in Saudi Arabia, nurses were not aware of the fact that whether disaster plans
were periodically updated or not. Duong (2009) reported that approximately 45 % of the
nurses read the hospital disaster management plan.
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2.6 Strategies to enhance disaster preparedness:
Labrague et al. (2016) and Baack & Alfred (2013) recommend that provision of nurses with
the disaster training and actual drills helped in improving confidence and awareness of nurses
in managing disaster. Extensive training and drills with in house nursing training for disaster
management proved helpful in improving preparedness for multiple disaster situations
(Duong 2009; O’Sullivan et al. 2008; Oztekin et al. 2016). Goodhue et al. (2012) suggested
that involvement of nurses in the preparation of organisational disaster plan helped in
improving preparedness and competency of nurses in the management of disaster. Nilsson et
al. (2016) and Ibrahim (2014) endorsed disaster experience in the realistic situations and
simulations for improving competency and preparedness for management of disaster
situations. Hodge et al. (2015) recommended development of disaster preparedness course
based on the self-study module proved helpful in improving competency of nurses in disaster
management.
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Chapter 3
3.Methodology:
3.1 Research design:
A descriptive cross-sectional study design will be implemented for this study. Online survey
will be most appropriate research design for this study. Cross-sectional study design will be
most appropriated study design in this study design because this is a type of observational
study which collects and analyse the data from the specific population during specific time
duration. In the current study data will be collected from the specific population like nurses
and data will be collected during specific duration like 16 September to 1 October. Cross-
sectional study can be conducted with little or less expenses and more evidence or data can be
collected during short duration of time from the cross-sectional study. Eligible participants
will be provided with questionnaire which will comprise of both structured and open-ended
questions. Questions will be prepared by experienced researchers through experienced
researchers. Hence, validity of these questions will be more conducting survey. Online
method will be followed for the survey because nurses are the busy professionals and they
need to carry out multiple tasks at the same time. Online survey will be more appropriate
because it will save time of nurses and they will compete the survey within the stipulated
time duration. Though on online survey, researcher will be not be having control; participants
will be able to give truthful answer due to their anonymity. In cross-sectional studies
individual level data can be collected. Cross-sectional study is applicable in diverse group of
people with similar characteristics. In this study, nursing profession will the similar
characteristics among the participants. Cross-sectional studies are often considered as the
observational in nature and these studies are also termed as descriptive research. These
studies do not provide causal or relational data; hence, these studies are not useful in
determining the cause of something. Researchers can collect the information from the
population; however, they cannot manipulate collected variables. Cross-sectional studies are
useful in determining specific characteristics in specific population and multiple
characteristics like age, gender and education can be collected at specific duration of time.
Cross-sectional studies often focus on the principal characteristic of specific population. In
cross-sectional studies, large number of participants are required. Hence, it is difficult to get
large number of specific participants with similar characteristics except one variable.
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Moreover, different groups in the cross-sectional studies can be affected by the cohort
differences (Lavrakas, 2008; Dillman, 2011).
3.2 Setting of the study:
The setting of the study will be the Emergency Department of Security Forces Hospital
Makkah. This was chosen for the study since emergency nurses are front – liners of the
hospital whenever6 there is disaster. Moreover, Makkah has increased potential risk for a
disaster to occur due to its exceptional condition.
3.3 Study population:
Nursing technician, nursing specialists and nursing aids will be recruited in this study.
3.4 Study sampling:
Non-probability sampling method will be implemented in this study. This method of
sampling will be implemented for the participants those can be easily accessible. Nurses can
be easily accessible for recruitment in the study; hence, non-probability sampling will be
implemented in this study. Written consent will be obtained from all the participants prior to
recruitment in the study.
3.5 Sampling criteria:
Registered Emergency Nurses (EN) in Saudi Arabia will be recruited in this study. EN can be
of different educational level an experience like 1) nursing technician with high diploma in
nursing, 2) nursing specialists with bachelor’s degree in nursing and 3) nurses aides with one
year nursing course. More focus will be given to the recruitment of nursing technicians and
specialists. Opportunity will be given to the participants to withdraw from the study at any
given time point.
All these nurses will be recruited from the Emergency Department of Security Forces
Hospital Makkah. This hospital will be selected because it is responsible for responding to
the disaster in Makkah, according to the Directorate of Health Affairs for disaster
management Makkah. Most of the nurses working in the Saudi Arabia belongs to different
countries; hence, inclusion criteria will be applied for the selection of participants. Required
criteria for the inclusion of criteria will be minimum one-year experience in the Saudi Arabia
and minimum one exposure to disaster response procedure.
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3.6 Sample and its size:
Total emergency nurses in the study site is 96. At least 95% of the total population will be
considered with 95% confidence level and 5% confidence interval. The researcher will select
80 respondents by nonprobability convenience sampling technique.
3.7 Variables:
Independent variables: Independent variables in a study are usually not affected by other
variables. Independent variables can be deduced as cause. Independent variables which will
be incorporated in this study will include age, gender, educational level, job position, work
experience in emergency. Dependent variables are usually dependent on other factors which
are going to be determined. Dependent variables change with reference to the changes in the
independent variables. Dependent variables can be deduced as effect. Dependent variables
which will be incorporated in this will include awareness of practices associated with disaster
management and knowledge level associated with disaster management.
3.8 Study instrument:
Study instrument for this qualitative study will be pre-tested for the reliability and validity of
the data collection. Instrument tool will be pre-tested in small group of participants, prior to
its application to the main study. After completion of pre-test, research tool will be approved
by the experienced researcher. Pre-testing of the instrument will be aimed at assessing
whether clear questions are used, context specific and enough time has been allocated for the
completion of questionnaire. Pre-test will be carried out in EN with similar characteristics
and in the similar environment.
Study instrument will be prepared through different steps which will be corresponding to
different themes. Steps which will be included in the tool development will be 1) theoretical
and contextual basis for the development of themes, 2) design of individual themes, 3)
eliminating irrelevant items through conducting item analysis, 4) determining instrument
reliability through internal consistency, stability and equivalence and 5 ) establishing
construct validity of the instrument (Patten and Newhart, 2017).
Specific questions of the online questionnaire will be prepared according to the relevant
themes and its specificity to the scale of the instrument.
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Research instrument will be implemented for the collection of data from online questionnaire.
Questionnaire will comprise of both the types of questions like structured and open-ended
questions for collecting standardised and spontaneous responses, respectively. Collection of
both standardised and spontaneous responses will be useful in gathering in-depth information
related to preparedness of nurses during emergency. Questionnaire will be designed and
hosted on the website. In this study, 21 questions will be included and these questions will be
categorised into five sections.
These five categories include:
1) Knowledge and awareness of EN related to disaster preparedness: Questions in this
category will be appropriate to the disaster response in the Emergency Department of
Security Forces Hospital Makkah. Responses of the participants to the questions in this
section will be collected in five-point Likert scale (1 - Strongly disagree, 2 – Disagree, 3 -
Neither agree nor disagree, 4 - Agree and 5 -Strongly agree). Likert scale is the psychometric
scale is usually useful in the research which involves questionnaires. Participants usually
respond to their level of agreement or disagreement on relevant question which helps in
demonstrating their opinion or feelings about particular issue.
2) Roles of nurse in disasters: In this section 12 items will be included and these also will be
measured in 5-point Likert scale. Questions in this section will be focused on the roles and
responsibilities of nurses to provide care and provision of psychological assistance according
to the outlined plans in the hospital emergency department and disaster preparedness plan.
3) Education and training: Four items will be included in the education and training section.
Questions in this section will be useful in exploring type of education and training available
for the EN. Moreover, questions in this section also will be helpful in understanding
relevance of these questions to the EN.
4) Prior involvement in disaster response: In this section 9 items will be included and in this
section past experiences of the EN in the disaster management will be assessed.
5) In this section demographic information of the participants will be explored (Alzahrani
and Kyratsis, 2017).
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3.9 Validity and reliability:
Validity of the research instrument is defined as the precision and relevance of interpretation
made based on the study outcomes. Validity of the research instrument can be improved
through asking relevant question in the most comprehensible manner. Content validity will be
used.
3.10 Pilot study:
Pilot phase will commence and shall be conducted on 15 nurses which will include both staff
and nurse managers. Researcher will use Cronbach’s alpha to measure internal consistency.
3.11 Data collection procedure:
Questionnaire will be circulated to all the nurse managers of the emergency department.
Managers will be asked to send to the link of questionnaire survey to the individual mails of
the nurses. Nurse managers will be asked to get the feedback of the online survey within two-
week time. Each individual will be given fixed timing for the completion of survey. Each
nurse will be allowed to complete the questionnaire within one hour. Each nurse will be
informed to fix date and timings for the completion of survey and inform the same to the
manager. It will be helpful for the nurse managers to monitor survey completion by the EN.
Nurse managers will not be part of the study; hence, there will not be any sort of biasness
during the data collection. Nurse managers will also play role of ensuring participants
understand the questions mentioned in the survey. Hence, it would be feasible to conduct the
realistic, feasible and workable survey for understanding knowledge of EN in emergency
preparedness. Questionnaires will be made available in the English language. Survey
questions will be prepared in the English language most of the Saudi nurses are English
speaking and non-Saudi nationals. Potential bias in the data collection will addressed through
following several steps like : 1) validated survey structure will be implemented in this study
which will be based on the literature review of the peer-reviewed research, 2) questions
categorisation will be done to reduce participants dropout rate and to ensure truthfulness of
the participants in answering the questions. Questions will be thematically categorised in five
section, 3) data analysis plan will be enlisting with the survey; hence, questions will be linked
to the study objective, 4 ) questions will be sent to all the eligible EN and 5 ) questions will
be appropriated the research question and to meet study aims and objectives because pilot
study will be conducted prior to the main study (Mellinger and Hanson, 2016).
19

3.12 Data analysis:
Data analysis will be conducted using statistics analysis software SPSS (Statistical Package
for Social Scientists) V.22. Collected data will be downloaded from the website. Cross-
checking will be performed for the missing data. Usually, participants will not skip the
questions in the online survey. Collected data will be prepared for the data analysis.
Descriptive statistics will be generated through mean, median, mode, SD, frequency counts
and percentages, and crosstabs with the χ2 statistic. Descriptive statistics designate the basic
characteristics of the collected data. Descriptive data is useful in summarising samples and
measurements in the study. Quantitative studies usually comprise of large number of samples
and large number of measurements. Hence, descriptive statistics are applicable in simplifying
large number of data in the practical manner. Descriptive statistics is useful in presenting
large number of data in the simpler summary (Mellinger and Hanson, 2016).
In this study, a simple number will be useful in summarising the knowledge and experience
of EN in emergency preparedness.
Online survey is the appropriate method for data collection in this study because it is the
faster method of data collection as compared to the paper-pencil survey and interview-based
data collection. Advantages of online data collection method include ease of data gathering,
minimal cost, automation in data input and handling, increase in response rates and flexibility
of design. All these advantages of data collection in the current research will be helpful in
collecting necessary information related to the knowledge of EN about preparedness of
nurses for the emergency situations. Disadvantages of the online surveys include absence of
interviewer, inability to reach challenging population and survey fraud (Lavrakas, 2008).
However, in this study these disadvantages will be eliminated by allowing nurse manager to
remain present during the completion of survey. Since, there will not be challenging
population in this study; inability to reach challenging population will not be issue in this
study. Since, this survey will be conducted under the controlled and monitored setting; there
will not be any sort of fraud in this online survey. Mean and standard deviation of the
numerical values in the Likert scale will be useful in rating the participants according to their
knowledge and experience. Likert scale with value 5 will be helpful in designating the
participant as strongly agree about the services. Strong agreement of the participants about
the information would indicate ownership of knowledge and experience. Disadvantage
associated with the descriptive analysis is there would be possibility of distortion of the
20

original data and missing of important information. Despite this disadvantage, descriptive
analysis will be useful in useful in providing powerful summary and comparison among the
EN of different educational levels and experiences (Lavrakas, 2008).
3.13 Ethical consideration:
Ethical consideration is an important consideration for conducting research study. Ethical
consideration is useful in maintaining integrity, reliability and validity of the research. Study
protocol for conducting study will be approved by the institutional ethics committee of the
Makkah hospital. All the information related to study will be provided to all the participants.
Ethical approval will be helpful in ensuring all the ethical practices being followed during
conduct of the study. Codes and policies of the Institutional Review Board (IRB) will be
followed for conducting this study. Participants will be encouraged to participate voluntarily
and opportunity will be given for the participants to withdraw from the study. Written
informed consent will be taken from the participants. Maintaining confidentiality and
anonymity of the participants will also be helpful in maintaining ethical standards of the
study.
21

Chapter 4
4. Findings:
4.1 Participants demographic characteristics:
Majority of the participants were between 20 to 40 years. Participants between age 20-30
years were 62.5 % and participants between 31-40 years were 26.3 %. There were more male
(58.8 %) participants in comparison to the female (41.3 %) participants. Highest number of
participants were with designation nursing technician (58.8 %), followed by nursing
specialist (22.5 %), nursing aid (15 %) and other current clinical position (3.8 %). Maximum
number (60 %) of participants were having 0-5 years of experience in current emergency
department, followed by 23.8 %, 13.8 % and 2.5 % for 6-10 years, 11-15 years and 16-20
years respectively.Maximum number (62.5 %) of participants were having 0-5 years of total
experience in emergency department, followed by 26.3 %, 7.5 % and 3.8 % for 6-10 years,
11-15 years and 16-20 years respectively.
Table 1: Demographic charecteristics of the participants.
Variable Frequency
Age group (N = 80)
20-30 years
31-40 years
41-50 years
51-60years
50
21
6
3
62.5
26.3
7.5
3.8
Gender
Male
Female
47
33
58.8
41.3
Current clinical position
Nursing technician
Nursing specialist
Nursing aid
Other current clinical
position
47
18
12
3
58.8
22.5
15
3.8
Experience in current
emergency department
22

(years)
0-5
6-10
11-15
16-20
More than 20
48
19
11
2
0
60
23.8
13.8
2.5
0
Total Experience in
emergency department
(years)
0-5
6-10
11-15
16-20
More than 20
50
21
6
3
0
62.5
26.3
7.5
3.8
0
4.2 Emergency nurses disaster knowledge and awareness:
Knowledge and awareness of the participants about disaster management is variable for
different aspects. Data provided in the table 2 indicate that participants have misapprehension
on the disaster management. Approximately half of the participants (52 %) were know that
maximum number of causalities due to disaster will reach ED through Saudi Red Crescent.
Slightly less than half of the participants (46.3 %) were aware that disease prevalence are
unavoidable outcome of the disaster and poor health due to major disaster. Approximately
one in three participants (36.3 %) were aware that low socioeconomic class people are at
more risk of death due to disaster as compared to high socioeconomic class people. Slightly
less than one in five participants (17.5 %) were aware that all the victims of the CBR incident
would get hazardous material removed at the incidence place before arrival to the ED. These
findings indicate that there is significant deficit in the knowledge and awareness about
disaster management among nursing staff of Emergency Department of Security Forces
Hospital Makkah.
23

Table 2 : Participants knowledge test related to disaster misapprehension
Statement Participants
frequency with
correct response
%
Participants
Maximum number of causalities due to disaster will
reach ED through Saudi Red Crescent
42 52.5
Disease prevalence are unavoidable outcome of the
disaster and poor health due to major disaster
37 46.3
In comparison to the high socioeconomic class
people, low socioeconomic class people are at more
risk of death due to disaster.
29 36.3
All the victims of the CBR incident would get
hazardous material removed at the incidence place
before arrival to the ED
14 17.5
4.3 Emergency nurses role during mass gathering:
Data related to nurses perception of their role during mass gathering of Haji, is presented in
table 3. Maximum number of participants (60 %) perceived that they need to perform routine
assessment and caring of victims. However, less number of participants perceived that they
need to perform complex tasks like resuscitation (12.5 %), triage (20 %) and psychological
care (1.3 %). Very less number of participants (6.3 %) perceived that they need to perform
leadership activities.
Table 3 : Emergency nurse perception of their probable role in mass gathering disaster during
Haji pilgrimage
What is your probable role in mass gathering disaster response
during Haji ?
Frequency %
participants
Routine assessment and caring of victims 48 60
Resuscitation 10 12.5
Triage 16 20
Leadership 5 6.3
Psychological care 1 1.3
24

4.4 Level of understanding of their role by emergency nurses in mass gathering disasters:
Emergency nurse exhibited good understanding about their role in the management of mass
gathering. Agreement or disagreement of nurses was measured on the Likert scale. 47.5 and
42.5 % participants reported strongly agree and agree respectively for their confidence and
familiarity for providing effective response to mass gathering disaster. 47.5 and 41.3 %
participants reported strongly agree and agree for their importance in providing services for
emergency situations like mass gathering. 50 and 38.8 % participants strongly agree and
disagree for their key role in providing routine assessment and caring to the victims of the
mass gathering. 47.5 and 41.3 % participants reported strongly agree and agree that they feel
capable of providing timely response to emergency situations. 50 and 40 % participants
strongly agree and agree respectively that they need to perform important role to deliver
resuscitation. 47.5 and 41.25 % participants reported strongly agree and agree for their
capability to provide effective communication to patients, family members and healthcare
providers to provide effective during emergency situations. 47.5 and 42.5 % participants
reported strongly agree and agree about their responsibility for surveillance during mass
gathering disasters. 48.8 and 41.25 % participants reported strongly agree and agree about
their responsibility for prevention during mass gathering disasters. 48.8 and 40 % participants
reported strongly agree and agree for their leadership role in disaster management to facilitate
team work. 46.3 and 41.3 % participants reported strongly agree and agree for their
prominent role in the provision of psychological support to victims and their family members.
48.8 and 38.8 % participants strongly agree and agree for their role in providing clinical
response during emergency situations. 47.5 and 45 % participants reported strongly agree and
agree for their role in providing triage and initial consultation during emergency situations.
Table 4 : Understanding level of emergency nurse role in mass gathering disasters
Role variable Strongly
disagree
Disagree Neither Agree Strongly
Agree
Total
Emergency nurses are confident
and familiar for providing
effective response to mass
gathering disaster.
0 2 6 34 38 80
Emergency nurses are the crucial
and important service providers
0 6 3 33 38 80
25

in the mass gathering disaster.
Key role of emergency nurses
during mass gathering disaster is
to provide routine assessment
and caring to the victims.
1 3 5 31 40 80
Emergency nurses are capable of
providing timely response to
emergency situations.
1 4 4 33 38 80
Significant role of emergency
nurses is to deliver resuscitation.
1 2 5 32 40 80
Emergency nurses are capable of
providing effective
communication to patients,
family members and healthcare
providers to provide effective
during emergency situations.
2 3 4 33 38 80
Emergency nurses are
responsible for surveillance
during mass gathering disasters.
1 4 3 34 38 80
Emergency nurses are
responsible for prevention during
mass gathering disasters.
2 4 2 33 39 80
Leadership should be the
prominentrole for emergency
nurses to facilitate team work.
1 3 5 32 39 80
Prominent role for nurses should
be provision of psychological
support to victims and their
family members.
2 3 5 33 37
Emergency nurses are the key
players for providing clinical
response during emergency
situations.
1 4 5 31 39
26

Emergency nurses are the key
players for providing triage and
initial consultation during
emergency situations.
1 2 3 36 38 80
27

Chapter 5
5.Discussion:
Knowledge and awareness of disaster management is the critical component for the
preparedness emergency nurses. Saudi Arabian Ministry of Health announced priority for
improvement in preparedness of emergency nurses for mass gathering in Saudi Arabia. Al-
Tawfiq and Memish, (2012) reported that around 24 committees were asked to monitor to
promote awareness and communication for the preparation mass gathering disaster during
Haji. Saudi Arabian Ministry of Health and the WHO collected information related to the
disaster management in the Saudi Arabia (Khan and McLeod, 2012). In this study,
emergency nurses in Saudi Arabia were also participated. Despite, investment by the Saudi
Health Ministry for the preparedness in disaster management; it has been observed that
emergency nurses were with low level of knowledge and awareness about disaster
management.
Education and training:
Education and training among nurses about disaster management varied according to their
clinical posts. It indicates that inclusion of nurses of all grades in the emergency department
need to be standardised. Efforts need to be made to involve nurses of all grades in the
emergency department. Efforts taken by the Saudi Arabian Ministry of Health for providing
education and training emergency nurses for emergency preparedness were reflected in this
study because most of the nurses reported that they participated in education and training.
‘Hajj medicine’ is the emerging filed for the emergency nurses in Saudi Arabia because these
nurses need to manage health emergency arises due to Hajj (Memish et al., 2012). Emergency
nurses of Saudi Arabia can extend their knowledge and skills in regular practice to the
emergency situations like mass gathering (Welzel et al., 2010).
Previous disaster response experience for emergency nurses :
This study revealed that most of the emergency nurses enrolled in this study had previous
experience of working in the disaster management. Annual event like Hajj in Saudi Arabia,
had significant influence on the experience of emergency nurses on the management of
disaster situations. In 2008, WHO appreciated efforts made by the Saudi public health
authorities for the effective management of communicable diseases during Hajj. Appreciation
by the WHO was based on the experience of emergency nurses in the annual Hajj event. It
28

has been noted that few of the emergency nurses were lacking hand on experience in
emergency management; however, handling mass gathering was significantly higher in Saudi
Arabia nurses. It has been reported that Saudi public health officials and health workers along
with policymakers exhibited seasoned experience and expertise in the disaster preparedness
and management. This experience is based on the seasoned Hajj event and other mass
gatherings.
Some of the participants reported that they can effectively communicate with the victims and
family members of the emergency situation. However, few of the participants reported that
they need training for improving communication to role play and to mentor (Ranse et al.,
2013). Most of the nurses have opinion that hospital education programme and Emergency
Management Saudi Courses in disaster management are beneficial for improving their
preparedness in the disaster management. Hence, it is necessary to improve and expand these
training programmes for Emergency nurses.
Findings of this study indicate that emergency nurses need to perform wide range of clinical
activities according to the Major Incident Plans of the Emergency Department of Security
Forces Hospital Makkah. These clinical activities include prevention, surveillance, general
assessment and caring of patient, triage, resuscitation, leadership and psychological care.
Obtained data indicate that emergency nurses put less emphasis on the leadership and
psychological care. It is also evident thatemergency nurses wish to perform acute clinical
tasks rather than proactive clinical tasks like surveillance and prevention.
29

Chapter 6
Conclusion:
This study provides outline of the understanding of the role of emergency nurses during Hajj
mass gathering. Outcome of this study indicate that despite considerable clinical experience
in previous mass gathering; these nurses are associated with deficit in awareness and
knowledge about the planning in Emergency Department of Security Forces Hospital
Makkah during emergency mass gathering. Results of this also indicate that emergency
nurses are unwilling to take leadership role and to deliver psychological and preventive care
during emergency mass gathering. Emergency nurses are expected to carry out wide range of
activities to provide assistance to victims during emergency situations like mass gathering.
Online, hospital and university-based courses need to be included in providing education and
training to these nurses and special focus need to be given to neglected clinical practices like
psychological and preventive practices. Local and national level policymakers need to work
with WHO for improving preparedness of emergency nurses in the management of disaster
situations. Hospital management and Ministry of Heath need to encourage and provide
support for emergency nurses to improve involvement in disaster situations.
Limitations:
Cross-sectional design of the study is the limitation of the study because this design provides
snapshot of responses of emergency nurses during specific time duration. In this study,
responses of the emergency nurses were gathered. However, it is equally important to gather
responses of the physicians and paramedical healthcare staff because all these healthcare
service providers work in integration and play critical role in providing clinical services
during Hajj mass gathering. Small sample size, non-random sampling method and
participants form the single hospital are other limitations of this study. Limitations related to
participants specify that these findings can only be generalised to some region of Saudi
Arabia. However, these findings cannot generalise widely.
Recommendations:
National level survey of emergency nurses with recruitment of larger participants to gain
broad understanding about their awareness and knowledge is recommended. It would be
helpful for the Health ministry to develop nation wide policy for improving preparedness of
30

nurses in the disaster management. Hajj specific disaster management training need to be
provided to the emergency nurses.
31

Appendix A:
32

Appendix B :
Questionnaire
Please select an answer and tick a box in Section A, B and C. All answers are confidential.
Section A (Demographic Data)
1. What is your age group?
20 years – 30 years
31 years – 40 years
41 years – 50 years
51 years – 60 years
2. What is your gender?
Male
Female
3. What is current clinical position?
Nursing technician
Nursing specialist
Nursing aid
Other current clinical position
4. What is your Experience in current emergency department (years)?
0-5
6-10
11-15
16-20
More than 20
5. Total Experience in emergency department (years)?
0-5
6-10
33

11-15
16-20
More than 20
Section B (Knowledge) - Please select an answer and tick a box in Section B
6. Do you think maximum number of causalities due to disaster will reach ED through
Saudi Red Crescent ?
Yes
No
7. Do you think disease prevalence are unavoidable outcome of the disaster and poor
health due to major disaster?
Yes
No
8. Does you think low socioeconomic class people are at more risk of death due to
disaster as compared to high socioeconomic class people.?
Yes
No
9. Do you think all the victims of the CBR incident would get hazardous material
removed at the incidence place before arrival to the ED?
Yes
No
Section C (Practice) - Please select an answer and circle a number in Section C
Role variable Strongly
disagree
Disagree Neither Agree Strongly
Agree
10. Emergency nurses are confident and
familiar for providing effective response
to mass gathering disaster.
1 2 3 4 5
11. Emergency nurses are the crucial
and important service providers in the
1 2 3 4 5
34

mass gathering disaster.
12. Key role of emergency nurses
during mass gathering disaster is to
provide routine assessment and caring
to the victims.
1 2 3 4 5
13. Emergency nurses are capable of
providing timely response to emergency
situations.
1 2 3 4 5
14 Significant role of emergency nurses
is to deliver resuscitation.
1 2 3 4 5
15. Emergency nurses are capable of
providing effective communication to
patients, family members and healthcare
providers to provide effective during
emergency situations.
1 2 3 4 5
16. Emergency nurses are responsible
for surveillance during mass gathering
disasters.
1 2 3 4 5
17. Emergency nurses are responsible
for prevention during mass gathering
disasters.
1 2 3 4 5
18. Leadership should be the prominent
role for emergency nurses to facilitate
team work.
1 2 3 4 5
19. Prominent role for nurses should be
provision of psychological support to
victims and their family members.
1 2 3 4 5
20. Emergency nurses are the key
players for providing clinical response
during emergency situations.
1 2 3 4 5
21. Emergency nurses are the key
players for providing triage and initial
consultation during emergency
1 2 3 4 5
35

situations.
36

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