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Running head: ADVANCED PRACTICE NURSES AND DISASTER RESPONSE

Advanced Practice Nurses and Patient Outcomes in Disaster Response

A Scholarly Project Presented to

The Faculty of the Maryville University

Catherine McAuley School of Nursing

In Fulfillment of the Requirements

For the Degree of Doctor of Nursing Practice

MELISSA I. HULETT

SPRING 2018

2ADVANCED PRACTICE NURSES AND DISASTER RESPONSE

TABLE OF CONTENTS

Practice Support for Project

Benefit of Project to Practice

Discussion


ABSTRACT

Advanced Practice Nurses and Patient Outcomes in Disaster Response

Background: Over the last ten years, there has been a well-documented increase in the severity and frequency of disease outbreaks and both natural and man-made disasters requiring coordinated disaster management. Minimal research exists addressing the Registered Nurse (RN) an Advanced Practice Nurse (APRN) role or education needs to effectively respond to a disaster. Understanding the RN and APRN provider’s perception of their role and effect on patient outcomes in disaster response is imperative.

Objective: The purpose of this scholarly project is to determine if completion of four online disaster preparedness modules developed by the Federal Emergency Management Agency (FEMA) lead to a better understanding of the Public Health Service (PHS) RN and APRN responder of their role in disaster management and if the RN and APRN believe completion leads to more positive patient outcomes. Design: This paper explores project data from a mixed method quasi experimental designed study. Data collection was accomplished through respondent’s completion of a voluntary opt-in survey created through Qualtrics. The survey invitation link was posted on four Facebook sites dedicated to PHS officers for respondents to voluntarily access and complete. Data was collected via the electronic survey over a three-week period.

Results: Data analysis revealed over 57% of respondents felt disaster management training was extremely necessary. After completion of at least one of the FEMA courses, 40.5% of respondents felt slightly well prepared for disaster response. Over 28% of respondents were moderately satisfied with their understanding of their role in disaster response after completion of the FEMA courses. More than 23% of respondents perceived positive patient outcomes increased after their completion of the FEMA training. Additional themes were the respondents’ perception of the importance of completion of the FEMA disaster management training courses on understanding the emergency response framework and their perception of areas for improvement in the FEMA training.

Conclusions: The completion of online FEMA disaster preparedness modules leads to a better understanding of the PHS RN and APRN responder of their role in disaster management. Respondents (a) have a large variation in their perception of importance of completion of the FEMA courses, (b) do not feel course completion affects patient outcomes, and (c) most would not recommend completion to colleagues. Additional research is needed in this area.

Key words: Disaster management, Public Health Service, registered nurses, advance practice registered nurses, perception


Acknowledgments

I would like to express my deep gratitude to the Professors who I have had the pleasure to study under at Maryville University for their guidance, encouragement and useful critiques of this research work.

Secondly, I would like to thank the United States Public Health Service officers for their support during the research process and for their dedication to protect, promote, and advance the health and safety of our nation.

Finally, I would like to extend my gratitude to the staff of the Food and Drug Administration, Office of Compliance, Office of Program and Regulatory Operations, for their support and encouragement throughout my doctoral journey.

Dedication

This work is dedicated to my spouse Charles and daughters’ Emily and Elizabeth for their unwavering confidence and consistent encouragement throughout my doctoral journey.

This work is additionally dedicated to my battle buddies from the Monrovia Medical Unit Team 1. This incredible team of Public Health Service Officers reinforced in me that with selfless service, perseverance, commitment, and the right team, all things are possible.


Chapter I: Introduction

There is an inadequate definition of the Registered Nurse (RN) and Advanced Practice

Registered Nurse (APRN) roles and functions in disaster management. Registered Nurse and

APRN providers responding to disasters, to be effective, must be able to transition from their

usual nursing position when a catastrophic event occurs (Slepski, 2007). The RN and APRN role

in a disaster differs from their position in routine practice settings. A role is an overarching set of

functions completed by the RN or APRN shaped by professional practice guidelines and

legislation (Poitras, Chouinard, Fortin, & Gallagher, 2016). For better utilization of the RN and

APRN in a catastrophe, specific training on disaster interventions and roles should occur (Role,

2016).

The need for role definition and preparation for a disaster response crosses healthcare

disciplines. Education on functional roles is imperative to improve the possibility of success.

Articulated and defined roles increase efficiency and effectiveness (Bekemeier, Linderman,

Kneipp, & Zahner, 2014). Understanding the education needs of the RN and APRN in disaster

management is vital for adequate preparation of the RN and APRN for disaster response. Natural

and man-made disasters, humanitarian missions, and disease outbreak responses are disaster

management responses for the purpose of this paper. The American Nurses Credentialing Center

(ANCC) acknowledges the importance of defining the education needs of disaster management

responders. The ANCC completed development of certification in disaster management in 2017,

which provides education in disaster management response to all healthcare disciplines (ANCC

American Nurses Credentialing Center, 2017).

Purpose

The purpose of this scholarly project is to determine if completion of four online disaster

preparedness modules developed by the Federal Emergency Management Agency (FEMA) lead


to a better understanding of the RN and APRN responder of their role in disaster management.

The project will also assess whether RNs and APRNs perceive completing this training leads to

more positive patient outcomes. Evaluation of the study respondents’ understanding of the RN

and APRN role in disaster response is based on their (a) perception, (b) thoughts, (c) memories,

and (d) ability to process, and structure information. The survey questions utilized in the project

were designed to determine if RN and APRN providers perceive completion of the FEMA IS

modules provide them a better understanding of their role and lead to more positive patient

outcomes in a disaster management response. Data stratification by base education type, (a)

Bachelor of Science in Nursing, (b) Master of Science in Nursing, (c) Master of Science in

Nursing- Nurse Practitioner, (d) Master’s degree in a discipline besides nursing, (e) Doctoral

Degree in Nursing, or (f) Doctoral Degree in a discipline other than nursing assists in clarifying

study results. An understanding of the baseline education before the FEMA IS courses are

completed, provides additional clarity of the survey results and the RN and APRN perceptions.

Background

Over the last ten years, there has been a well-documented increase in the severity and

frequency of disasters. According to the World Health Organization (WHO) (2011), 85,000

natural disasters occurred over the last 20 years. These disasters affected 2.6 billion people.

Nursing education has not focused on the need for disaster training for RN and APRN providers.

All healthcare providers, particularly nurses, articulate the need to understand disaster

management. Through collaboration between the WHO and the International Council of Nurses,

development of competencies for RN and APRN responders occurred. Use of these strategies

and guidelines to build disaster-nursing programs in Universities across the globe contributes to

nursing education on disaster management (Alfred et al., 2015). Many universities perform just-

in-time training for students to complete disaster simulations. This practice allows RN and


APRN providers’ minimal training to support community needs when disasters occur (The

University, 2010). Understanding the RN and APRN provider’s perception of their effect on

patient outcomes in disaster response is imperative.

Disaster response is a primary function of the United States Public Health Service

(USPHS). The USPHS includes a multidisciplinary team of healthcare providers, trained in

disaster management. Public Health Service (PHS) nurse officers must take certain FEMA IS

training modules to obtain a Field Medical Readiness Badge (FMRB) to prepare them for

disaster deployment (Commissioned Corps of the U.S. Public Health Service America's Health

Responders, 2014). Examination of research and data collection on the PHS RN and APRN

responder’s perception about the value of completion of the FEMA IS training modules is

valuable. Determining conclusions about the training required to improve patient outcomes

before a disaster occurs, assists in defining the RN and APRN contributions in a disaster. The

FEMA IS training modules referenced in the research question (PICOT) discussed in this

literature review are (a) IS-100 Introduction to Incident Command System (ICS), (b) IS-200 ICS

for Single Resources and Initial Action Incidents, (c) IS-700 National Incident Management

System (NIMS), An Introduction, and (d) IS-800 National Response Framework, An

Introduction (FEMA, 2016).

Significance to Nursing

There are roughly 1,300 Public Health Service (PHS) Nurse Officers available for self-

inclusion in a research study. The research impact could affect training for 6,000 plus PHS

officers and could have generalization for training needs of disaster responders outside the PHS

(Commissioned Corps of the U.S. Public Health Service America's Health Responders, 2014).

The healthcare team, including RN and APRN providers, must understand the issues unique to

disaster management response. This understanding of the RN and APRN role in disaster


management response may lead to an increase in positive patient outcomes. Through

determination of the RN and APRN’s perception of their role and the impact on patient

outcomes, awareness of training needs can be determined. Improving standards and quality of

training may improve standards for, and the quality of instruction RN and APRN providers

responding to disasters receive. Understanding the RN and APRN role and perception of patient

outcomes after completion of online training may have far-reaching ramifications for RN and

APRN nurse disaster responders and their patients. Furthermore, the findings could add value for

disaster responders across healthcare disciplines and increase positive patient outcomes through

more focused training for providers.

Practice Support for Project

Public Health Service (PHS) officers have a mission to protect public health. As a

member of one of the seven uniformed services of the United States, PHS officers complete this

task through multiple facets. The PHS supported the project through allowing posting of the

survey invitation on various Facebook pages for nurse officers to opt-in to complete the survey.

After Institutional Review Board (IRB) approval, the survey invitation was provided to the

administrators of four Facebook sites for posting. Data was collected through Qualtrics via the

opt-in, anonymous electronic survey over a three-week period.

Benefit of Project to Practice

Numerous benefits of the project to disaster management response exist. Through the

examination of the perceptions of RN and APRN responders on the value of the FEMA IS

training in influencing patient outcomes, training decisions can be made. These decisions not

only affect PHS RN and APRN responders but have potential generalizability to civilian RN and

APRN responders. An additional benefit is an increase in productivity and efficiency that could

occur through the RN and APRN responders gaining a better understanding of their role in


disaster response. Through understanding their roles, RN and APRN responders can increase

personal resiliency. Finally, the ability to improve patient outcomes in a natural or man-made

disaster, humanitarian response, or disease outbreak response is the most significant contribution

to my practice from this project.

Discussion

Substantial literature exists discussing the value of the RN and APRN response in

disaster management. However, the role and functions of the RN and APRN in disaster

management are not well defined (Slepski, 2007). A significant amount of nurse-completed

research is available. However, little research by RN and APRN providers who focus on disaster

preparedness and how it influences patient outcomes exists. Research is necessary to advance the

RN and APRN responder in disaster management. In emergency or disaster responses, nurses are

often the first responders. Determining the RN and APRN provider’s perception of how the

completion of the online FEMA IS modules affects their patient outcomes is essential.

Registered Nurse and APRN providers are in an excellent situation to evaluate this patient care

outcome. The need for provider role definition in disaster management situations crosses

healthcare disciplines. Adequate preparation for a disaster response includes education and

training on functional roles. Clearly articulated roles increase efficiency and effectiveness

Through evaluating providers’ perceptions of the effect of their training on patient outcomes,

assumptions about the value of the training are made.

Disaster management education is recognized by the American Nurses Credentialing

Center (ANCC) as a primary focus to improve patient outcome. Health care providers require an

adequate understanding of the value certification has in positive patient outcomes. Training

increases the effectiveness of RN and APRN providers responding to disasters as they transition

to the role the role of disaster management responder when a catastrophic event occurs.


Evaluating PHS RN and APRN providers’ perceptions regarding how completion of FEMA IS

training modules affects patient outcomes in a disaster situation could provide necessary

information to shape training needs of disaster responders across healthcare disciplines.

Chapter II: Review of Related Literature

Introduction



to a better understanding of the Registered Nurse (RN) and Advanced Practice Nurse (APRN)

responder of their role in disaster management. Additionally, the project will determine if the RN

and APRN perceive completion leads to more positive patient outcomes. The healthcare team

must understand the issues unique to disaster management response. This understanding of the

RN and APRN role in disaster management response may lead to an increase in positive patient

outcomes. Through determination of the RN and APRN’s perception of their position and the

impact on patient outcomes, awareness of training needs and improvement in training may be

possible, which could lead to far-reaching ramifications for disaster responders across healthcare

disciplines and increase positive patient outcomes through more focused training for providers.

Qualitative research provides insight into reasons, opinions, or motivations affecting

behavior or outcomes. Completion of a qualitative questionnaire evaluating the role development

and education needs of the RN and APRN in disaster management will provide clarification and

insight into the practice problem. The survey invitation will be available to U.S. Public Health

Service (PHS) officers via four Facebook pages. Respondents will have the opportunity to

complete the questionnaire at any time over a three-week period. Data will be evaluated to

determine respondent’s understanding of their role in disaster response and their perception of

the effect of completion of the FEMA IS training modules on patient outcomes. Results could


have ramifications on education guidelines for RN and APRN responders and increase positive

outcomes for patients.

Search History

A review of the literature was undertaken through CINAHL Plus and PubMed for

previously completed research for the dates January 2007 to March 2017. The literature review

was completed to identify qualitative and quantitative studies on the role and training needs of

the RN and the APRN in disaster management (see Table 1). The results from the literature

review outlined in Table 1 were narrowed to exclude textbooks, articles without abstracts, those

for which full texts were not available, and those not written in English. Abstracts of identified

articles were retrieved to select primary research and reviews.

Initial focus on the topics of relevance for this study, the role and education of the RN

and APRN provider in disaster management and relevant nursing and education theories,

occurred. Numerous articles discussing disaster management in the PubMed search were

identified. The CINAHL Plus search found multiple articles identifying theories in education and

nursing. Minimal articles addressing the RN and APRN role and education needs or relevant

theories in disaster management were located. No journal articles were found that included all

the requested search terms in either CINAHL Plus or PubMed. This research gap supports the

need for evaluation of the PICOT question outlined in this paper.

Table 1

Term Search Results

Terms Searched CINAHL Plus results PubMed results

Disaster Management 376 11,681

Disaster Management & Registered Nurse

6 561


Disaster Management & Advanced Practice Nurse

1 12

Disaster Management & Training 70 2,721

Disaster Management & Public Health Service

2 548

Disaster Management & theories 15 24

Disaster Management & education 10 2,197

Theories & education 9,849 2,455

Theories & nursing 9,479 1,023

Disaster Management & Registered Nurse & Advanced Practice Nurse & theories & education

0 0

Review of the Literature

The initial theme established in the literature review addresses the role of the RN and

APRN provider in disaster response. Substantial literature exists on the value of the RN and

APRN response in disaster management; however, the role and functions of the RN and APRN

in disaster management are not well defined. Nurse providers should be able to transition to RN

and APRN roles needed in disaster response (Slepski, 2007). The need for role definition occurs

across healthcare. Productivity and efficiency increase when positions are clear. These are

necessary quality improvement areas in disaster management (Bekemeier, Linderman, Kneipp,

& Zahner, 2014). A multidisciplinary certification in disaster management is available through

American Nurses Credentialing Center (ANCC). Development of a framework for training and

continued competency occurs when roles are defined (ANCC American Nurses Credentialing

Center, 2016).


Evaluations of RN and APRN roles in disaster management response can provide insight

into improvements in disaster management nursing. A group of international contributors

developed a robust, evidence-based framework to evaluate APRN role development (Bryant-

Lukosius et al., 2016). Knowing and understanding the nursing role leads to better-informed

education options and professional practice (Mendes, Alm da Cruz, & Angelo, 2014). Duffy

(2014) elaborates on how emerging roles and revision of current roles in healthcare will change

practice. The RN and APRN provider should be able to transition from their daily practice role

into the role of a disaster management responder. This transition is essential to increase positive

patient outcomes (Slepski, 2007).

The second theme established in the literature review addressed articles regarding the

education of RN and APRN in disaster management. According to the World Health

Organization (WHO) (2011), 85,000 natural disasters occurred over the last 20 years affecting

2.6 billion people. The severity and frequency of disasters have increased in the previous ten

years. Nursing education had all but ignored the need for disaster training for RN and APRN

providers. All healthcare providers, particularly nurses have articulated the need to understand

the disaster-nursing practice. The WHO and the International Council of Nurses collaborated to

determine competencies for RN and APRN responders across the world. These strategies and

guidelines are used to build disaster-nursing programs in Universities across the globe (Alfred et

al., 2015). Many universities utilize just-in-time training for students to complete disaster

simulations to be ready to support the need of the community when disasters occur such as the

need for medical shelters (The University, 2010).

There is a need for a focus on disaster management education for nurses (Veenema et al.,

2016). Recommendations provided by the subject matter experts convened to take part in the

research outline a vision for the future of RN and APRN training, practice, and research


(Veenema et al., 2016). Nursing schools must include education for students that imparts a focus

on the concepts of disaster management and public health (Adams, Canclini, & Frable, 2014),

An additional aspect of nursing education discussed in the research is the RN and APRN’s

preparedness for disaster response. The need for readiness of RN and APRN providers includes

not only clinical skills but personal preparedness plans to ensure family obligations can be met

while deployed during a disaster. Education on how to personally prepare for disaster response is

vital to the success of RN and APRN providers. Reduction of personal concerns allows the RN

and APRN provider to focus on their role in disaster management (Nash, 2015).

The third theme established in the literature review addresses the advancement of

research completed RN and APRN providers. A significant amount of research is available,

though little research by RNs and APRNs focusing on disaster management and preparedness is

accessible. Research is necessary to advance the role of the RN and APRN responder in disaster

management. In emergency or disaster responses, nurses are often the first responders, placing

RN and APRN responders in an excellent situation to perform research. The Asia Pacific

Emergency and Disaster Nursing Network (APEDNN) held a three-week course, educating

respondents from 19 countries on the value of evaluating and conducting research in a disaster

setting. After the course, collaborative studies were launched to investigate nurses’ disaster

preparedness. An additional outcome of the course included funding to maintain research

capacity building courses in the future (Usher et al., 2015).

Substantial literature exists discussing the value of the RN and APRN response in

disaster management. However, the role and functions of the RN and APRN in disaster

management are not well defined (Slepski, 2007). A significant amount of nurse-completed

research is available. However, little research by RN and APRN providers who focus on disaster

preparedness and how it influences patient outcomes exists. Research is necessary to advance the


role of the RN and APRN responder in disaster management. In emergency or disaster responses,

nurses are often the first responders. Determining the RN and APRN provider’s perception of

how the completion of the online FEMA IS courses affects their patient outcomes is essential.

Registered Nurse and APRN providers are in an excellent situation to evaluation this patient care

outcome (Usher et al., 2015).

The Asia Pacific Emergency and Disaster Nursing Network (APEDNN) held a three-

week course to educate respondents from 19 countries on the value of analyzing and conducting

research is a disaster setting. After the course, collaborative studies were launched to investigate

nurses’ disaster preparedness. An additional outcome of the course included funding to maintain

research capacity building future courses (Usher et al., 2015). The literature review revealed a

gap between nursing research and nursing practice. Necessary transformation of the health care

system requires clinicians to apply research and participate in evidence-based practice (EBP).

Translational research can narrow the gap that exists between researchers and practitioners

(Vincent, Johnson, Velasquez, & Rigney, 2010).

Research Critique

Polit & Tatano Beck (2017), provide a guideline for performing a useful research article

critique. Through evaluating available research for specific criteria such as (1) strengths, (2)

weaknesses, (3) gaps, and (4) limitations, it can be determined if the research is reliable and

unbiased. An in-depth examination of each stage of the research process using a balanced and

objective approach to analyze strengths and weaknesses is a crucial part of the scholarly project.

Evidence-based practice requires that patient care decisions be based on scientific evidence. It is

the responsibility of RN and APRN providers to critically evaluate research to prepare

themselves to provide the highest quality of care to patients (Coughian, M., Cronin, P., & Ryan,

F., 2007).


Articles located by the literature review were critiqued for strengths. Strengths included

the use of various designs such as simulations, surveys, and scoping reviews. Additional

strengths involved the use of appropriate sample size, study population, and clear purpose

statements (Alfred et al., 2015; Bekemeier, Linderman, Kneipp, & Zahner, 2014; Poitras,

Chouinard, Fortin, & Gallagher, 2016). Many of the articles reviewed were not specific on the

details regarding the sample size or study population. Sufficient information was not provided to

determine the appropriateness of the size of the samples used. The needed sample size is

calculated based on the estimated number of people in the population. The margin of error, the

confidence level, and the estimate of the response rate desired is determined by the researcher.

These figures are utilized to determine the needed sample size to have statistical significance.

Most articles include an introduction, conclusion, and reference list. Examples include Alfred et

al. (2015), Smith & Farra (2016), Spain et al., (2012), Usher et al., (2014), and Veenma et al.,

(2016). Specifically, Spain et al. (2012) do not utilize sampling or recruitment. The article

discusses disaster preparedness and the APRN role. Smith and Farra (2016) outline the future of

disaster education and the competencies necessary to respond to disasters. Veenma et al., (2016)

utilized a sample of 14 subject matter experts to develop concepts in nursing disaster

preparedness. Eighteen experts were invited to take part in the study. The study produced

recommendations for the future of disaster nursing practice, education, policy, and research.

Weaknesses are present in the articles located in the literature review. A recurrent gap is

the lack of a designated literature review section in many of the articles (Alfred et al. 2015;

Smith & Farra, 2016; Spain et al., 2012; Usher et al., 2014; and Veenma et al., 2016). Use of

surveys or assessment tools that have not been evaluated for validity and reliability occurred in

many of the studies. Respondents used in multiple studies were specific to a geographic location


and therefore were not representative of the United States population (Alfred et al. 2015; Smith

& Farra, 2016; Spain et al., 2012; Usher et al., 2014; and Veenma et al., 2016).

Additional weaknesses apparent in some of the literature review articles located is the

lack of designation of a theoretical framework (Alfred et al. 2015; Usher et al., 2014; and

Veenma et al., 2016). Theoretical frameworks assist in explaining, predicting, and increasing the

understanding of knowledge on a topic. When research guiding conceptual frameworks are not

present, the reader may have difficulty following the thought process of the researcher (Polit &

Beck, 2017). Although this gap is current in some of the articles located in the literature review,

others specify the theoretical framework on which they were based. Some examples include

Spain et al.’s (2012) use of a holistic framework and Smith & Parra’s (2016) use of the

hierarchical learning framework.

Gaps in the Evidence

A gap in research when the search terms (a) disaster management, (b) RN, (c) APRN, and

(d) theories and education are searched in CINAHL Plus and PubMed is apparent. No results

were located encompassing all the terms. Additional gaps occur when providers do not have the

knowledge to perform in a role. Without the skill set to function in a role, a gap in knowledge

and the ability to complete valid research exists (Bekemeier, Linderman, Kneipp, & Zahner,

2014; Slepski 2007).

Limitations exist in virtually all research. Understanding the potential ramifications of the

research outcomes is imperative. Research limitations include geographical bias, convenience

sample bias, and validity and reliability of a survey instrument (Nash, 2015). Selection and

review of articles by only the primary researcher is an additional example of research limitations

(Poitras et al., 2016). Further restrictions include the use of a limited study population such as

only nurses working in hospitals and not including those working in other locations (Yan, Turale,


Stone, & Petrini, 2015). Limitations such as these can lead to results that are not generalizable to

the population and add limited value to practice (Polit & Beck, 2017). The 12 research articles

located in PubMed all exhibit some level of the bias elements noted above. Many of the articles

include a section discussing the limitations of the research study, allowing the reader the ability

to understand the limitations as the research is reviewed for applicability to practice.

Concepts and Definitions

In theory construction, concepts act as components that support the framework of a

theory. Defining concepts serve to illustrate the phenomena the theory describes and increases

the understanding individuals have of the construct (Walker & Avant, 2011). The inclusion of

education, training, and certification under the measurement of the structure solidified structure

as the best measurement related concept applicable to this project (Joshi, Nash, Ransom, &

Ransom (2014). Structural measures of quality include the determination of required skill sets

and the evaluation of the competency of the provider in those skills. These functions relate

directly to my project goal of determining the needed skills and development of evaluation to

measure competency in those skills for RN and APRN disaster management responders. Relying

on already established organic devices such as licensure and board certification is not enough to

determine competency in disaster management responses. Registered nurse and APRN staff, in

their routine jobs, do not routinely practice many of the tasks necessary in disaster management

response.

Individual U.S. states define the scope of practice of the RN and the APRN through their

nurse practice acts (Russell, 2012). The role and functions of the RN and APRN in disaster

management are not well defined. When catastrophic events occur, RN and APRN providers

should be able to transition from their regular role to those necessary in disaster response

(Slepski, 2007). A precise definition and understanding of the role increases the effectiveness of


the transition. Poitras, Chouinard, Fortin, and Gallagher (2016), define a role as an overarching

set of functions completed by the RN or APRN shaped by legislation and the customs of

professional practice.

Disaster management responses include natural disasters, humanitarian missions, and

disease outbreak responses. One of the primary functions of the United States Public Health

Service (USPHS) is disaster response. As part of the Department of Health and Human Services

(DHHS), they are healthcare providers trained in disaster management (Commissioned Corps of

the U.S. Public Health Service America's Health Responders, 2014). Through examining the role

RN and APRN providers in the USPHS function in, correlations to the necessary training for

civilian nurses to be ready to respond can be obtained. By defining the role, development of a

framework for training and continued competency is possible. The American Nurses

Credentialing Center (ANCC) offers a certification in disaster management developed in 2017

(ANCC American Nurses Credentialing Center). Concepts defined here may support those the

ANCC determine necessary for certification in disaster management.

The definition of a role as a function or part of a defined process was developed in 1857

(Role, 2016). A role is defined as an overarching set of functions described by legislation and

practice customs (Poitras, Chouinard, Fortin, and Gallagher, 2016). The concept and need for

role definition occur across disciplines and specialty areas in healthcare. Industries other than

healthcare also strive to define roles to increase productiveness. When roles are articulated and

defined for personnel, efficiency and effectiveness increases (Bekemeier, Linderman, Kneipp, &

Zahner, 2014).

Duffy, Blair, Colthart, and Whyte (2014) state roles occur within or across professional

groups. The introduction of a new role is crucial to promote widespread acceptance. Barriers

may arise from the lack of role definition are mitigated through delineating the purpose and


function of the role. Often a lack of understanding of boundaries exists. Lack of role clarity and

the sharing of responsibilities routinely handled by other disciplines may lead to role blurring

(Duffy, Blair, Colthart, & Whyte, 2014).

Numerous examples of role definition and its importance exist across nursing

specializations. In 1996, The Definition and Role of Public Health Nursing (Public Health

Nursing Definition) were outlined. Since its inception, the role definition has shaped public

health nursing practice. After 16 years in existence, it was determined in 2012 that to meet the

advances in the healthcare, the Public Health Nursing Definition needed revision.

Completion of revision and sanctioning of the Public Health Nursing Definition occurred

in 2013, under the auspices of the American Public Health Association. The process for revision

of the Public Health Nurse role included a diverse task force of public health nurses. These

nurses provided support, input, and planning assistance for the change and dissemination of the

revised guidelines. The decision to revise the roles and functions added strength, credibility, and

effectiveness of the public health nursing workforce (Bekemeier, Linderman, Kneipp, & Zahner,

2014). The result of clearly defining the role of the RN and APRN in a disaster could serve to do

the same for the disaster response team to whom the RN and APRN belong.

Understanding the definition of role across the spectrum can assist us with defining the

role of the RN and APRN in disaster management. Individual states utilize their scope of practice

to establish RN and APRN roles (Russell, 2012). Solely using a state’s scope of practice in

disaster management, on a humanitarian mission, or in a disease outbreak response to define RN

and APRN roles is not sufficient. The World Health Organization (WHO) defines a disaster as

when a disruption occurs to normal conditions of existence and suffering exceeds the capacity of

the involved community to respond to it. Disaster situations alter standards of care due to limited


resources and safety issues. One tool that most RN and APRN providers do not routinely use is

disaster and mass casualty triage (Lee, 2010).

Theoretical Framework

Cognitive learning theory is used widely in educational research. One of the oldest

cognitive learning theories is the gestalt perspective. This perspective emphasizes the learner’s

perspective. The gestalt perspective states the learner’s key to learning is perception, thoughts,

memories, and the ability to process and structure information. The theory further says that

knowledge does not require positive reinforcement as per behavioral theories (Schunk, 2012).

The gestalt perspective is significant as a theoretical framework because the FEMA IS

online training modules studied within the DNP project are online educational interventions.

Evaluation of the study respondents’ understanding of the RN and APRN role in disaster

response is based on their (a) perception, (b) thoughts, (c) memories, and (d) ability to process,

and structure information. The survey questions utilized in the project were designed to

determine if RN and APRN providers perceive completion of the FEMA IS modules provide

them a better understanding of their role and lead to more positive patient outcomes in a disaster

management response. Data stratification by base education type, (a) Bachelor of Science in

Nursing, (b) Master of Science in Nursing, (c) Master of Science in Nursing- Nurse Practitioner,

(d) Master’s degree in a discipline besides nursing, (e) Doctoral Degree in Nursing, or (f)

Doctoral Degree in a discipline other than nursing assists in clarifying study results. An

understanding of the RN and APRN baseline education provides additional clarity of the survey

results and the RN and APRN education needs. The gestalt perspective will be incorporated in

the DNP project through the evaluation of the RN and APRN’s perception of patient outcomes

about provider completion of the FEMA IS training modules.


Chapter III: Methods

Introduction



to a better understanding of the Registered Nurse (RN) and Advanced Practice Registered Nurse

(APRN) responder of their role in disaster management and if the RN and APRN believe

completion leads to more positive patient outcomes. Understanding the RN and APRN role in

disaster management response may lead to an increase in positive patient outcomes.

Methodology

Data collection for the scholarly project was accomplished through respondent’s

completion of a voluntary opt-in survey created through Qualtrics. The survey invitation link was

posted on four Facebook sites dedicated to Public Health Service (PHS) officers for respondents

to voluntarily access and complete. Data was collected via the electronic survey over a three-

week period. Anonymous real-time responses to the opt-in survey were recorded through

Qualtrics. The ability to monitor the completion rate and utilize the Qualtrics software to gather

project data allowed the student researcher to better evaluate the project throughout the data

collection period. The data collected was assessed using the Qualtrics statistical analysis

program. Using Qualtrics to evaluate responses, and present the data through charts, graphs, and

datasets, allows the story of the data to be accurately displayed.

Needs Assessment

Over the last ten years, an increase in the severity and frequency of disasters is well

documented. According to the World Health Organization (WHO) (2011), 85,000 natural

disasters occurred over the last 20 years. These disasters affected 2.6 billion people. Nursing

education has not focused on the need for disaster training for RN and APRN providers. All


healthcare providers, particularly nurses, articulate the need to understand disaster management.

Through collaboration between the WHO and the International Council of Nurses, development

of competencies for RN and APRN responders occurred. Use of these strategies and guidelines

to build disaster-nursing programs in Universities across the globe contributes to nursing

education on disaster management (Alfred et al., 2015). Although useful, practices such just-in-

time training provides RN and APRN providers’ minimal skills to utilize when disasters occur

(The University, 2010). Understanding the RN and APRN provider’s perception of their effect

on patient outcomes in disaster response is imperative.

The healthcare team, including RN and APRN providers, must understand the issues

unique to disaster management response. This understanding of the RN and APRN role in

disaster management response may lead to an increase in positive patient outcomes. Through

determination of the RN and APRN’s perception of their role and the impact on patient

outcomes, awareness of training needs can be determined.

Improving standards and quality of training may improve standards for, and the quality of

training RN and APRN providers responding to disasters receive. Understanding the role of the

RN and APRN and their perceptions of patient outcomes with and without online training may

have far-reaching ramifications for RN and APRN nurse disaster responders and their patients.

The findings could add value for disaster responders across healthcare disciplines and increase

positive patient outcomes through more focused training for providers.

Data Collection Plan

The setting for the project was online. Data collection was accomplished through

completion of a voluntary survey created through Qualtrics. The survey link was posted on

multiple Facebook pages dedicated to Public Health Service (PHS) officers including (a) PHS-2

RDF (S2N), (b) All-MMU Alumni, (c) USPHS MMU Team 1, and (d) Commissioned Corps


Officers USPHS Facebook pages for respondents to voluntarily access and complete. The survey

link was open for completion for three weeks. Estimated survey completion time was

approximately seven minutes to complete. Completion of the survey was voluntary. The choice

of the respondent to complete the survey documented consent for responses to be utilized in the

project. Responses are not traceable to individual participants.

The estimated population size the group sample represents is 1,300. A power of 0.80 is

obtained with a sample size of 138, creating a medium effect size. The project will utilize a

margin of error of 5% and a confidence interval of 95%. If there is a medium effect size, power

of 0.80 or higher can occur with a sample size of 138. The response rate is estimated at 10%. It is

anticipated that 10% of respondents will be male and 90% female due to the distribution of

gender in the United States RN nurse population. The population surveyed are active duty PHS

officers. Due to this, the anticipated age of respondents will be between 24 and 60 years of age.

It is anticipated that (a) 10% of respondents will identify themselves as black or African

American, (b) 70% as white or Caucasian, (c) 10% as Asian, (d) 5% as Hispanic or Latino, and

(e) 5% as other based on the distribution of ethnicity in the United States RN population.

The inclusion criteria for the respondents allows the data reviewed to provide the

information searched by the PICOT question. For their responses to be included in the study

respondents must (a) be an RN provider, (b) have taken at least one of the designated FEMA IS

disaster management courses, and (c) have deployed at least one time for disaster management.

These inclusion criteria are chosen as they will provide data on the RN and APRN providers

perception of the value of the FEMA IS training on patient outcomes during deployment and the

RN and APRN understanding of their deployment role.

The exclusion criteria for respondents allows for data collection that does not provide the

information searched by the PICOT question to be removed. The exclusion criteria assist in the


elimination of respondents that do not meet the needs of the research, those that could not safely

contribute to the study, and assists in removal of information that could erroneously alter study

findings. Responses to be excluded from the study include respondents that (a) are not an RN

provider, (b) have not taken at least one of the designated FEMA IS disaster management

courses, and (c) have not deployed at least one time for disaster management.

The specific steps in the project include the survey development, approval through the

Maryville University IRB, and posting for potential respondents via the (a) PHS-2 RDF (S2N),

(b) All-MMU Alumni, (c) USPHS MMU Team 1, and (d) Commissioned Corps Officers USPHS

Facebook pages. The survey is voluntary and respondents’ opt-in to complete. Consent is

provided by the respondent choosing to complete the survey. The survey is open for three weeks

for data collection. Through the Qualtrics program, completions will be monitored throughout

the open period. The data collected will be evaluated at the end of the three-week period.

Consent is the act of evaluating information and deciding to move forward in the research

project. Consent for this project is implied when the respondent decides to complete the online

survey. This project depends on the RN and APRNs active cooperation in completing the survey.

The design of posting the survey link in various areas for respondents to opt-in builds in the

implied consent. Respondents implicitly grant consent online when they move forward to

complete the survey.

Data Collection Instrument

The data was collected using a survey tool created through the Qualtrics program.

Qualtrics is a privately held company which provides survey software to clients across the globe

(Qualtrics, 2017). The survey will be accessible to respondents through an online invitation link

distributed through several avenues. The survey invitation link was posted on multiple Facebook

pages dedicated to Public Health Service (PHS) officers including (a) PHS-2 RDF (S2N), (b)


All-MMU Alumni, (c) USPHS MMU Team 1, and (d) Commissioned Corps Officers USPHS

Facebook page for respondents to voluntarily access and complete. The survey design allows

respondents to complete one time. The survey was open to respondents for three weeks. The

software estimates average completion time for the survey to be seven minutes. The survey

requests data from respondents on (a) education level, (b) highest nursing degree, (c) sex, (d)

race, (e) age range (f) zip code practicing in, (g) completion of specific FEMA IS courses, (h)

respondents perception of patient outcomes, (i) respondents experience with disaster

deployments, (j) respondents satisfaction with understanding their role on deployment after

completing the FEMA IS courses, and (k) respondents perception of the value of completing the

FEMA IS courses to increase positive patient outcomes. The survey totals 22 questions of which

19 have multiple choice answers, and three provide the participant the opportunity to free write.

Completion of the survey is voluntary and confidential.

Analysis Plan

The survey questions are designed to determine if a difference exists between the

completion of the four FEMA IS courses and the RN and APRN perception of positive patient

outcomes. Additional questions determine the education level and specific demographic

information of the respondents. The independent variable in the study is the RN or APRN

provider’s completion of at least one of the FEMA IS training modules. The dependent variable

is the RN or APRN’s response to the survey regarding their perception of patient outcomes based

on their completion of at least one of the FEMA IS courses, which is ordinal data. Both

qualitative and quantitative data were collected in the survey. The quantitative data collected

were evaluated utilizing the Qualtrics program. As appropriate to the survey question, the (a)

standard deviation, (b) variance, (c) detractors, (d) promotors, and (e) the net promotor score


(NPS) were computed. Both quantitative results and insight obtained from the qualitative data

collected are discussed in Chapter 4 of this doctoral project.

Resources

A valuable resource is access to the Qualtrics program for survey development. Maryville

University provides this access to all graduate students. Tuition incorporates the cost of access.

An important additional resource necessary for the project is the ability to post the data

collection survey through the Facebook pages. Access to utilize these venues provides the ability

to reach a large group of both RN and APRN providers. Dr. Michael Landry serves as an

additional resource. Dr. Landry is a Maryville University Professor with an expertise in statistics.

His services provide expert guidance on statistical testing and representation of data necessary

for the project. Lastly, the time commitment of at least 500 clinical hours made by the DNP

student is a resource. The time dedication is a resource that ensures completion of the scholarly

project.

Budget

No financial obligations are necessary for access to the Qualtrics software or the ability to

discuss statistical questions and issues within the project with Dr. Landry. As noted in the

resources section, Maryville University incorporates access to the software and expert guidance

into the costs of the student’s tuition. Similarly, access to the Facebook pages to be used for data

collection does not require a financial commitment. The time commitment of the student is

difficult to budget for and is a sunk cost. The Maryville University Program incorporates the

development of the Doctor of Nursing Practice project over an estimated 500 hours of clinical

time. According to salary.com, the average yearly salary for a nurse practitioner is $101,443.00

(Salary, 2017). The average hours worked in a year are 2,080, equating the average per hour

salary for an APRN to be $48.77. Based on this figure, the cost of spending 500 hours on


research for an APRN who would be making an average salary is $24,385.00. This cost is a sunk

cost based on enrollment in the Maryville University DNP program. It is important to note the

additional time commitment and the financial ramifications made by the DNP student aside from

the cost of tuition and books.

Timeline

The timeline for the project from submission to the Maryville University Institutional

Review Board (IRB) for review and approval to completion of the final project report was ten

months. Table 2 outlines the key tasks to move the project to completion and the month and year

they are scheduled to occur.

Table 2

Project Key Tasks

Task Month/Year of completion

IRB submission/Final Approval

Project Implementation/Data Collection

October 2017

November 2017

Data Analysis and Interpretation January/February 2018

Chapter 4 Findings completed February 2018/March 2018

Chapter 5 Discussion completed March 2018/April 2018

Final Paper completed April 2018

Protection of Human Subjects

Review and approval by the experts on the Institutional Review Board (IRB) before the

initiation of research is a primary act that protects human subjects. An additional avenue to

safeguard human subject respondents is to ensure the information collected is used only for the

intended purpose of the study. Participation in the survey was voluntary, and potential


respondents will not be harassed or repeatedly asked to respond. Participation was encouraged in

a positive, non-threatening way. The respondents received a clear, concise introduction to ensure

they are informed on the aspects and purpose of the project. Questions contained in the survey

were worded clearly and concisely to mitigate cultural and social differences of respondents

(Fowler Jr., 2013). Unfortunately, every study holds the risk of a breach of confidentiality. Data

collected are kept confidential and do not contain information to identify the individual

respondent. The electronic Qualtrics survey was designed to maintain confidentiality.

Chapter 4 Findings

Data Analysis

Fifty participants responded to the opt-in survey invitation. Of these respondents, 90%,

45 individuals, identified themselves as RN or APRN prepared providers. The 10%, five, who

did not were thanked for their willingness to participate and their electronic survey closed.

Responses were received from RN and APRN providers licensed in 18 different states and the

District of Columbia. The 19 licensing locations accounts for 37.3% of the continental United

States. In the sample, 31.7% male 68.3% female. Ages of respondents were recorded in 10-year

brackets. There were (a) 4.8% of respondents in the 20 to 30-year age bracket, (b) 26.2% of

respondents in the 31 to 40-year age bracket, (c) 45.2% of respondents in the 41 to 50-year age

bracket, (d) 21.4% of respondents in the 51 to 60-year age bracket, and (e) 2.4% of respondents

in the 61 years or older age bracket. The variance of the age of respondents was 0.77 with a

standard deviation of 0.88. Therefore, the distance from the mean value is relatively high and a

broad age range is represented in the respondents.

In the sample, 63% of respondents were white, 17.4% African American, 6.5% American

Indian or Alaska Native, 10.9% Asian or native Hawaiian or Pacific Islander, and 2.2% other

(one respondent who identified themselves as Irish American). The variance of the results for


reported race was 1.44 with a standard deviation of 1.20. These values indicate the distance from

the mean value is high and many races are represented in the respondents. Education levels were

recorded as (a) 14.3% with a Bachelor of Science (BS), (b) 71.4% with a Master of Science

(MS), (c) 11.9% with a Doctoral degree, and (d) 2.4% with a professional degree such as a Juris

Doctorate (JD). The variance of the results for the highest education level held was 0.37 with a

standard deviation of 0.60. These values indicate the distance from the mean value is small and

many respondents share the education level of Master of Science degree. Education levels were

further evaluated for the highest nursing degrees held. In the sample, (a) 45.2% hold a Bachelor

of Science in Nursing (BSN), (b) 50% hold a Master of Science in Nursing (MSN), (c) 2.4%

hold a Doctor of Nursing Practice (DNP), and (d) 2.4% hold a Doctor of Philosophy (PhD) in

Nursing. The variance of the results for the highest nursing degree held was 0.44 with a standard

deviation of 0.66. These values indicate the distance from the mean value is midrange therefore,

respondents have varying highest nursing degrees.

When asked about the number of deployment(s) in support of a disaster or humanitarian

mission, (a) 4.4% have never deployed, (b) 55.6% have deployed one to three times, (c) 24.4%

have deployed four to six times, (d) 8.9% have deployed seven to ten times, and (e) 6.7% have

deployed more than ten times. The variance of the results for the number of times deployed was

0.93 with a standard deviation of 0.97. Therefore, the distance from the mean value is high

indicating respondents have a wide range of deployment experience. Seven percent of

respondents reported completion of two of the four FEMA courses, 4.7% reported completion of

three of the four FEMA courses, 86% reported completion of all four of the FEMA courses, and

2.3% reported than none of the FEMA courses had been completed. The variance of the results

for completion of FEMA courses was 0.33 with a standard deviation of 0.57. Therefore, the


distance from the mean value is small indicating most respondents have completed the same

number of FEMA courses.

When asked how necessary disaster management training is for providers to understand

the disaster management system, (a) 57.1% felt training was extremely necessary, (b) 23.8% felt

training was very necessary, (c) 11.9% felt training was moderately necessary, and (d) 4.8% felt

training was slightly necessary. After completion of at least one of the FEMA courses, (a) 7.1%

of respondents felt extremely well prepared for disaster response, (b) 16.7% of respondents felt

very well prepared for disaster response, (c) 28.6% of respondents felt moderately well prepared

for disaster response, (d) 40.5% of respondents felt slightly well prepared for disaster response,

and (e) 7.1% of respondents did not feel well prepared to respond to a disaster. The variance of

the results for the respondents’ perception of preparedness after completing the FEMA training

courses was 1.11 with a standard deviation of 1.05. These values indicate the distance from the

mean value is large and respondents have a large variation in their perception of importance of

completion of the FEMA courses.

When asked how satisfied they were with the understanding of their role in disaster

response, either man-made or natural, or on a humanitarian mission after FEMA course

completion, (a) 16.7% of respondents were extremely satisfied, (b) 28.6% were moderately

satisfied, (c) 16.7% were slightly satisfied, (d) 21.4% were neither satisfied or dissatisfied, (e)

9.5% were slightly dissatisfied, and (f) 7.1% were moderately dissatisfied with their

understanding of the role as an RN or APRN provider on deployment. The variance of the results

for respondent satisfaction with their role understanding was 0.19 with a standard deviation of

0.43. These values indicate the distance from the mean value is small and most respondents had

some level of satisfaction of their role understanding after FEMA course completion. When

asked how they perceive the quality of patient outcomes was affected after completion of the


FEMA courses, 23.8% perceived positive patient outcomes increased while 76.2% reported they

perceived no difference in patient outcomes based on their completion of the FEMA training.

The variance of the results for how completion of the FEMA courses affected patient outcomes

was 0.19 with a standard deviation of 0.43. These values indicate the distance from the mean

value is small and most respondents do not feel their patient outcomes were positively or

negatively affected by completion of the FEMA courses.

When asked if they would recommend completion of the FEMA courses to colleagues,

responses varied widely. The variance of the results was 7.95 with a standard deviation of 2.82.

These values indicate the distance from the mean value is large and responses varied. A total of

42 respondents answered the survey question. Upon closer evaluation, detractors for

recommending the FEMA training were 19, passive responses regarding recommending the

training were 14, and promoters for recommending completion of the FEMA training were nine.

The values indicate a net promoter score (NPS) of negative 23.8%. Therefore, the NPS, as a

feedback tool, points out that those who do not feel strongly regarding recommending FEMA

course completion and those who do not recommend FEMA course completion vastly outnumber

those respondents who would recommend course completion to others.

Respondents were asked what they believed to be the most useful portions of the FEMA

IS-100, IS-200, IS-700, and IS-800 courses and why. General themes from the responses include

the usefulness of the FEMA courses in understanding the emergency response framework

including the (a) chain of command, (b) collaborative role of various agencies and disciplines

during a disaster, (c) general response framework so when a disaster occurs a baseline

understanding exists, so focus could be on clinical roles, and (d) importance and route of

communication through the appropriate chain of command in the Incident Response System.

Compiled responses received from respondents are included in Table 3.


Table 3

Most Useful Portions of FEMA Courses

The overall understanding of the emergency response framework.

I took the courses years ago and don’t remember the specifics. It was helpful to learn of the ICS structure and where we as patient care providers fall.

These courses provide a basic understanding and expectations when deploying to a federally declared disaster under incident command system.

All of the above provide general knowledge.

Learning the chain of command.

It has been 4 years since I have taken these courses, so retaining this information is extremely difficult and therefore hard for me to respond to this question. I do not think that the training has an impact on those performing direct care, as we all follow chain of command. It is those in leadership roles that more closely follow and hopefully understand their roles in the ICS structure as they set up the chain of command.

IS-100 gives a good introduction to the incident command system and gives a solid foundation for the system.

The basic explanations.

The overall explanation of the ICS structure is helpful to know who is in what role and the chain of command. How the teams are activated, etc. is also of benefit.

These courses do help prepare responders for a response mission in terms of framework for the response command.

Command structure since it provided me an overall understanding of who was in charge. This helped alleviate concerns, so I could devote my time to patient care.

They are courses you take and forget. I was trained by the army whose motto is when not working your actual job you train, train, train. so when you work all the training is second nature. The FDA and the PHS do not train like this. it is a one, time, done training. Of course the PHS would love to but doesn't have the money. don't get me wrong, I deployed many times and was a nurse, charge nurse, nurse director and dental clinic director all of which were great. with great patient outcomes but none of it had to do with FEMA training. it had to do with jumping in with a smile and doing any work that needed to be done, always with a positive attitude.

Understanding the structure which allows PHS officers to better understand their role.


Command structure because you need to know who to report to during the response.

Gain a better understanding of the ICS and response.

Knowing the incident command structure is a vital part of deployment as well as the roles each member on the team plays.

I took these courses too long ago to remember all the details.

Just the overall presentation of how the ICS structure is intended to work and how it interacts with all the agencies.

The role of the federal government in working with nongovernmental agency in disaster response. The purpose and role of government response in the incident command structure. You need to understand the role of each stakeholder during a disaster so that the best response can be implemented.

Structure and how communication moves through out. Roles and responsibilities of each section.

When asked what they liked least about the FEMA IS-100, IS-200, IS-700, and IS-800

courses, respondents were provided the opportunity to document their thoughts in a free text

field. General themes from the responses include areas liked least in the FEMA courses

including the (a) lack of clinical role training, (b) length and tediousness of the online material,

(c) lack of updates to online classes and lack of hands on training since courses are only offered

virtually, (d) lack of education on the emotional toll on responders, and (e) lack of a requirement

for annual retraining for the Incident Command System. Compiled responses received from

respondents are included in Table 4.

Table 4

Items Liked Least About FEMA Courses

Could be more dynamic self-paced learning.

Not really relevant to practice.


The courses are not medically oriented and do not define the role of health care.

Took too long to complete.

I do not remember I took the courses a while ago.

Should be done after you deploy so you have a frame of reference.

I can't say I didn't like anything about any of the courses. They are all very helpful.

Not updated.

There is no accurate understanding of how this works in the live setting. I don't feel confident that I would be able to know the role of nursing within the FMS for the mission without being with an experienced provider that has done this multiple times. Test questions are also horrible.

These courses do not address any clinical skills for first responders (I don't think that is their purpose). The courses are INCREDIBLY dry.

Not interactive.

Long and some were dry.

A lot of material to read. Recommend Demonstration in a class room with Officer participation.

One time shot, not in person, not backed by hands on training.

I took those courses a while ago and have no comment.

It does not prepare for the emotional and psychological aspects of the disaster.

The time it takes to complete the training.

I took these courses too long ago to remember all the details.

Would like to see more training on the specific duties, tasks, expectations related to each level of the ICS structure.

Too long. I think that there needs to be an annual update required of Officers since there may be long time periods when you don't deploy and you forget the information and many of the roles for the team players.

The course presentations were not user friendly.

Maybe some built in scenarios.


When asked what training topics they would like to see in future education of disaster

deployments, respondents were provided the opportunity to document their thoughts in a free

text field. General themes from the responses include recommended areas for training including

the (a) specific clinical role training, (b) post disaster mental and physical health risk assessment,

(c) specific disaster training such as hurricane or flood response, (d) partners officers collaborate

with when deployed to a disaster such as the Disaster Medical Assistance Teams (DMAT) from

each state, and (e) training specific to needs of the growing population of lesbian, gay, bisexual,

and transgender (LGBT) arriving in shelters for care. Compiled responses received from

respondents are included in Table 5.

Table 5

Future Trainings Recommended

Nurse responder courses.

More patient focused modules.

An evaluation should be done to see what the learning needs are for nurses deploying and education should be developed based on the results of the needs assessment.

Post-Disaster specific health risks.

Psychological impact to providers.

Clinical related information.

I would like to see more nitty gritty of how this works, maybe have a course geared towards trauma and PHS nursing, how to mesh in with the DMAT teams since that is happening much more frequently. Learn how decisions to activate the FMS are made now that there is new administration. Maybe even a live face to face course. Thank you!

Basic clinical skills refreshers for those who need it; Mass casualty triage; Disaster specific trainings such as: CBRNE, Hurricane/flood response, etc.

Setting up an FMS station.

It is hard with money, constrictions and our 'regular" jobs so I do not have a good answer.Perhaps short mandatory update training which is user friendly.


Types and roles of federal deployment teams to include PHS teams.

Psychological effects of disasters on healthcare workers

I think the training provided to me as a tier 1 team member have been instrumental in preparing me for disaster deployments.

How to function as one unit when several deployment teams or rosters (DMAT, RDFs, Tier 3) are tasked with a joint mission. Processes for making good use of time when deployed and waiting for tasking from ASPR for a mission. Training for specific deployment roles such as OPS, Command (due to the fact that often officers are put in those roles and are not experienced in performing that role). This would make deployments go much smoother all around. Training on dealing with drug abuse, overdose, etc. in the deployment settings.

Include training on how to appropriate address increase population of LGTB in disaster response and domestic violence. I think this is important because Officers may not routinely encounter these issues in their workplace and are not adequate prepared or have knowledge on how to handle issues that are in these patient population.

Training needs to go beyond being satisfied with online training, placing people in an operational environment requires hands on practical training; exactly like a military model.

Chapter V: Discussion

Strengths and Limitations

Multiple strengths exist in the research. The tool, although not previously established,

was designed with the input of subject matter experts, the Maryville University doctoral project

chair, and input from the Maryville University IRB team. After input on recommended changes

was incorporated, the project incorporating the tool received IRB approval. The project was

conducted strictly as outlined in the approved IRB documents. The research data was collected

through the Qualtrics electronic survey collection program which (a) mitigated any researcher

bias, (b) insured data was collected the same way from each respondent, and (c) allowed for

comprehensive evaluation of data with minimal chance for human error.


Other project strengths are evident from the data collected from respondents. Many of the

respondents had completed the same number of FEMA modules therefore, mitigating the risk

that data would be skewed by having a large deviation in exposure to the modules. There was a

wide range in age, areas of the country licensed in, age, race, and sex of respondents. This

variance in demographic information strengthened the research since it increases the

generalizability to the entire PHS RN and APRN responder group. Additionally, respondents

exhibited a wide range in the number of disaster management situations they had been deployed

to. This mitigated the risk that the responses were guided more by personal experience on

deployment than on the perceptions of the value of the FEMA training courses.

Several limitations exist in the research. The initial data collection plan included posting

the survey invitation and link on the PHS Nurse Professional Advisory Committee (NPAC)

Facebook page for respondents to opt-in for participation. This was to be the primary site which

would deliver the invitation to the most PHS nurse officers. Unfortunately, due to the time

constraints of the data collection, layers of clearance to obtain permission to post on the NPAC

Facebook page, and the occurrence of multiple disasters in the Fall of 2017 requiring PHS

disaster response, ultimately the survey invitation was not able to post on the NPAC page. The

posting on other Facebook sites yielded 45 usable participants however I believe if posted on the

NPAC site more responses to the survey would have been obtained.

An additional research limitation was the inability to perform pre and post surveys. It was

impossible to have a nurse officer complete the survey, wait for them to deploy, and have the

nurse officer complete the survey again. If the length of the study period was increased, the

richness of data surrounding the perception of patient outcomes may have been enhanced.

Future, larger scale studies of the concept should incorporate pretested survey questions and both

pre- and post-online module completion surveys.


Implications for Research and Practice

The research data provides clear implications for practice. The data, although derived

from the PHS RN or APRN population, could be indicative of the perceptions of other groups of

RN and APRN responders across the United States. Data collected revealed the respondents felt

the completion of four online FEMA disaster preparedness modules led to a better understanding

of the PHS RN and APRN responder of their role in disaster management. However, most

respondents did not view the modules as important to complete or as affecting patient outcomes.

Most respondents would not recommend completion of the FEMA modules to colleagues. This

clearly outlines the need for change in the disaster management training provided to RN and

APRN responders.

Numerous benefits of the project to disaster management response exist including

highlighting training needs so decisions can be made to positively affect disaster victims and

responders. Training changes could affect all RN and APRN providers who respond to disasters.

Additionally, other disciplines who also utilize the FEMA training modules for disaster

preparedness could benefit from changes to disaster management education. Increasing the

understanding of RN and APRN providers of the issues unique to disaster management response,

may lead to an increase in positive patient outcomes and have far-reaching ramifications for RN

and APRN nurse disaster responders and their patients. Furthermore, the findings could increase

positive patient outcomes through more focused training for providers. Resiliency of responders

could potentially increase further increasing positive patient outcomes. The ability to improve

patient outcomes in a natural or man-made disaster, humanitarian response, or disease outbreak

response is the most significant contribution of the project to practice.


Recommendations

The need for provider role understanding in disaster management situations crosses

healthcare disciplines. Adequate preparation for a disaster response includes education and

training on functional roles. Articulated roles increase efficiency and effectiveness. Training

increases the effectiveness of RN and APRN providers responding to disasters as they transition

to the role the role of disaster management responder when a catastrophic event occurs. Through

evaluating providers’ perceptions of the effect of their training on patient outcomes, assumptions

about the value of the training are made. The purpose of the project, to gain an understanding of

the RN and APRN provider’s perception of the value of completing four specific FEMA IS

training modules on increasing positive patient outcomes, requires additional research. The

disaster management community could benefit from the reevaluation of the current FEMA

training modules with input from subject matter experts and educators on the best ways to

modify offerings to meet the needs of RN or APRN responders. Additionally, the tool utilized in

the project should be further tested and utilized in other studies to confirm true validity and

reliability. This data could benefit the discipline of nursing, disaster management responders, and

disaster victims.


References

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Attachment A: IRB Approval Letter

Date: October 27, 2017

To: Ms. Melissa Hulett – Doctoral Candidate, Nursing Practice

From: Dr. Robert Bertolino, Chair, Institutional Review BoardDr. Tammy M. Gocial, Integrity Officer for Institutional Review Board

RE: IRB Review of Protocol #17-30Title: "Advanced Practice Nurses and Patient Outcomes in Disaster Response"

CC: Dr. Catherine Hogan – Assistant Professor of Nursing and Project Chair

This is to inform you that your application to conduct research has been reviewed and accepted by the Maryville University Institutional Review Board. You are now authorized to begin the research as outlined in your proposal.

It is understood that this project will be conducted in full accordance with all applicable sections of the IRB guidelines as published by Maryville University. It is also understood that the IRB will be notified immediately of any proposed changes that may affect the status of your research proposal. As the principal investigator(s), you are required to notify the Maryville University IRB of any adverse reactions that may develop as a result of this study. Finally, when your research has concluded (or if you conclude the study sooner than anticipated), please complete the Protocol Closure Form. If informed consent processes were a part of your proposal, an approved, stamped version is attached to this document.

Good luck on your research.


Attachment B: Survey Questions


Attachment C: Informed Consent

INFORMED CONSENT

Research Project Title: Advanced Practice Nurses and Patient Outcomes in Disaster Response

You are being asked to participate in a project conducted through Maryville University by Melissa Hulett, MSBA, MSN, FNP-BC, RN, CPH, researcher, Doctor of Nursing Practice student working under the direction of Dr. Catherine Hogan, chair, Assistant Professor of Nursing. Everyone who agrees to participate must provide consent to do so.

The overall purpose of this research is to determine if completion of four online disaster preparedness modules developed by the Federal Emergency Management Agency (FEMA) leads to a better understanding of the RN and APRN responder of their role in disaster management and if you perceive that completing this training leads to more positive patient outcomes.

Your participation will involve completion of an online survey. The amount of time of your participation will be 7 to 10 minutes.

There are no physical, psychological, social/economic, or legal risks associated with this research. Every study holds the risk of a breach in confidentiality.

To minimize risks, we will employ the following safeguards: (a) all data are being collected anonymously, (b) internet protocol addresses will not be collected, and (c) data collected will be destroyed at the completion of the project.

The possible benefit to completion of this study is the knowledge gained regarding RN and APRN providers' perception of the effect on patient outcomes of completion of the available FEMA IS-100, 200,700, and 800 courses. We do not promise you will receive benefits from this study.

To maintain confidentiality about your personal records the researcher will electronically store study data anonymously during the research on password protected devices.

The results of this study will be printed in a doctoral project; shared with my project chair; shared with the Maryville University community through a presentation that is a requirement of the DNP program; and shared as a poster session at a Public Health Service conference.

If you have any questions regarding this study, or if any problems arise, you may call the researcher, Melissa Hulett at 252-635-7702. You may also ask questions, state concerns regarding your rights as a research subject, or express any feelings of pressure to participate by contacting: Dr. Robert Bertolino, Chair of the Institutional Review Board at Maryville University, (314) 529-9659.


Maryville University recognizes its federally mandated responsibility to ensure that research be conducted in an ethical and scholarly manner, respecting the rights and welfare of all the human participants. Any research misconduct including but not limited to fabrication, falsification, or plagiarism in proposing, performing and reviewing research, or in reporting research results, should be reported to Dr. Tammy Gocial, the Research Integrity Officer at Maryville University at (314) 529-6893.

Maryville University investigators and their colleagues who are conducting research, recognize the importance of your contribution to the research studies which are designed to improve patient treatment outcomes and provide provider role clarity in a disaster setting. Maryville University investigators and their staffs will make every effort to minimize, control, and treat any complication that may arise as a result of this research.

By returning the survey completed in whole or in part, you indicate that you are at least 18 years of age and have read and understand this form and have had an opportunity to ask questions about the research project. You are agreeing to participate in a study based on the information presented to you. You may choose to withdraw at any time without prejudice or penalty. You may print a copy of this page, which will include the name and phone number of the researcher and the IRB at Maryville University, should you have any questions.

______________________________________ __________________ ______________Researcher’s signature Date Phone Number

The date approval stamp on this consent form indicates that the project has been reviewed and approved by the Maryville University Institutional Review Board.

Institutional Review BoardProtocol #17-30Initiation Date: October 27, 2017Termination Date: October 26, 2018Approved by: Tammy M. Gocial, Ph.D.


Appendix D: Facebook Invitation

This is your invitation to take part in a voluntary research survey begin conducted as part of a Doctor of Nursing Practice Project!

Are you a Public Health Service NURSE Officer who has deployed in the last 10 years?

Would you like to contribute to advancing knowledge on how Nurses perceive patient outcomes?

If you answered yes to both questions, please “Ctrl+Click” to follow the link below to view the Informed Consent and take part in the survey. Participation is voluntary and will take approximately five minutes of your time.

https://maryville.az1.qualtrics.com/jfe/form/SV_3aYvtRzlvcWVDyl


Appendix E: Graphical Representation of Data

Graph a


Graph b


Graph c


Graph d


Graph e


Graph f


Graph g


Graph h


Graph i


Graph j


Graph k


Graph l


Graph m


Graph n

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