R E S E A R C H B R I E F S

The Importance of Instruction on Mass Casualty Incidents inBaccalaureate Nursing Programs: Perceptions of Nursing FacultyKristin K. Whitty, PhD, RN; and Michael F. Burnett, PhD

ABSTRACTThis study examined whether a

relationship exists between masscasualty incident knowledge andperceived importance of incorporat-ing competencies regarding masscasualty incidents into baccalaure-ate nursing programs by faculty inLouisiana. A total of 285 educators inbaccalaureate nursing programs inLouisiana were asked to complete thesurvey instrument; usable surveyswas collected from 166 participants(58%). Results indicated participantshad limited training and life experi-ences regarding mass casualty inci-dents, as well as limited knowledgeof mass casualty incidents. However,participants perceived mass casualtyincident instruction as important forinclusion in nursing curricula. Therewas a positive relationship betweenself-perceived knowledge of mass ca-sualty incidents and perceived impor-tance of including these competencies

Received: July 3, 2007Accepted: March 2, 2008Posted: March 27, 2009Dr, Whitty is Assistant Professor, School

of Nursing, College of Nursing and HealthSciences, Southeastern Louisiana Univer-sity, Hammond, and Dr. Burnett is Professorand Director, School of Human ResourceEducation and Workforce Development,Louisiana State University, Baton Rouge,Louisiana.

Address correspondence to Kristin K.Whitty, PhD, RN, Assistant Professor, Schoolof Nursing. College of Nursing and HealthSciences, Southeastern Louisiana Universi-ty, Box 10781, Hammond, LA 70402; e-mail;kwhitty@selu.edu.

doi:10.9999/01484834-20090416-10

into the nursing curriculum. Thesefindings suggest schools of nursingtake steps to identify or train a poolof educators who can teach mass ca-sualty incident preparation.

How would today's medicalcommunity react to historicaldisasters such as the erup-tion of Vesuvius in 79 AD that buriedthe towns of Herculaneum and Pom-peii ("79 AD Eruption of Vesuvius,"n.d.), the black plague of 1348 ADthat took as much as 50% of Europe'spopulation ("Black Death," 2001), orthe great fire of London in 1666 AD("Great Fire," 2004) that destroyedmore than 13,000 houses and build-ings? Disasters, either natural or manmade, have occurred since the begin-ning of civilization and may strikeat any time or place. An average ofone disaster per week occurs globallyrequiring international assistance,and since 1976, the number of feder-ally declared disasters in the UnitedStates has averaged 34 per year(Veenema, 2003). Whether occurringnaturally from environmental forcesor generated by humans, disastershave placed extraordinary stresses onsociety's ability to deal with the cata-strophic effects of such events.

In the event of a bioterrorist at-tack, health care professionals willbe first responders for victims whowill require prophylaxis and treat-ment. Niirses, with a licensed pool of2.9 million in the United States, com-prise the largest group of health careprofessionals. The roles of profession-al nurses in a disaster setting varybecause nurses practice in assorted

settings and have diverse educationalbackgrounds and varied experiences.When disaster happens, all nursesmay be called to participate; however,there are few or no requirements toeducate RNs on coping with large-scale trauma in a community affectedby a disaster.

Literature ReviewDisaster nursing involves pre-

paredness for and response to natu-ral or man-made events that affectan entire community or communitiesusually involving massive numbersof casualties and extensive propertydamage (Beaton, 2002). During disas-ter situations, nursing interventionsoften have occurred without clearinstruction. Nurses who volunteeredduring the 1985 Puerto Rico floodingreported a lack of direction of nursingroles (Rivera, 1986). Following thisexperience, nurses recommended in-clusion of basic guidelines for disasternursing services in nursing curricula.

Mitani, Kuboyama, and Shiraka-wa (2003) explored the issues andconcerns that nurses faced whenasked to respond to the 1995 GreatHansbin-Awaji Earthquake event inJapan. Most nursing personnel re-ported they needed direction becausethey were accustomed to working inan environment with clearly defined,expected duties.

Suserud and Haljamae (1997) com-pared the performance and psycho-logical experiences of two groups ofSwedish nurses involved in disasternursing. Nurses who were educatedfor specific disaster situations copedbetter mentally and consistently pro-

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vided better care in emergency situa-tions than did nurses who lacked di-saster education. In addition, thenurses who lacked disaster educationoften doubted their own competenceand indicated a lack of confidencein their ability to perform adequatetreatment to victims.

On September 11, 2001, nursesin the New York area immediatelyreported to work, and the New YorkState Nurses Association reportednurses from across the country vol-unteered to help (North DakotaNurses' Association, 2001). Nursesreported there were no policies orprocedures, no routines or sched-ules, and no instruction or direction{Gatto, 2002). Following the Septem-ber 11th terrorist attacks, Orr (2002)reported that although many nursesreceive training in first aid and in-fectious disease outbreaks, as well astraining related to fires, multiple ve-hicle accidents, and plane and traincrashes, most health care profession-als lack formal preparation to re-spond to mass casualty disasters andthat few educational institutions orhealth care facilities provide courseson mass casualty incidents or disas-ters of this scale.

Although others expect a knowl-edgeable nursing response, researchshows most nurses are not preparedfor mass casualty incidents or disas-ters, and their ill preparation is nottheir fault (Chaffee, Conway-Welch,& Sabatier, 2001). Many nurses cur-rently licensed to practice nursing,which includes the current pool ofnurse educators, have not receivedthis needed education. Regardingmass casualty preparation, there areno educational competencies man-dated for existing nursing curricula,and there are no mandatory continu-ing educational courses that exist forthe current nursing pool (Gebbie &Qureshi, 2002).

Rose and Larrimore (2002) sur-veyed 291 health care staff on knowl-edge and awareness of chemical andbiological terrorism. Findings dem-onstrated 53% of the participantsclaimed a willingness to work duringa terrorist event; however, only 23%answered knowledge questions cor-

rectly and indicated feeling confidentto render such care.

A 3-year national study by Wein-er, Irwin, Trangenstein, and Gordon(n.d.) found that 79% of nurse edu-cators selected curriculum plans asthe best place to increase emphasison disaster preparedness; however,nationally, nursing programs pro-vided limited curriculum content indisaster preparedness. In additional,this study found that approximately75% of the nursing faculty felt inad-equately prepared in the area of di-saster preparedness. Hilton and Al-lison (2004) noted nurse educatorswho are ill informed in education andtraining hesitate in incorporating di-saster preparedness into the nursingcurriculum.

The purpose of nursing programsis to graduate nurses equipped withthe basic knowledge and skill to con-tribute to the health and quality oflife of the individuis and commu-nities in which they serve. Nurseeducators are challenged to developrelevant curricula to equip novicenurses for new roles and responsi-bilities needed for entry-level prepa-ration. In a study of disaster nursingcurriculum development. Bond andBeaton (2005) found botb practicingnurses and nursing students indicat-ed a strong need for disaster nursingcontent. This indicates formal educa-tional practices regarding mass casu-alty preparation needs to be includedas part of tbe undergraduate nursingtraining.

PurposeThe primary purpose of this study

was to examine the relationship be-tween faculty knowledge of educa-tional competencies regarding masscasualty incidents and the importancethey place on including these compe-tencies in baccalaureate programs inLouisiana. The research objectiveswere to:

Evaluate the perceived knowl-edge of educational competenciesregarding mass casualty incidentsamong nurse educators currentlyteaching in accredited baccalaiireateprograms.

Examine the importance of in-corporating educationed competenciesregarding mass casualty incidentsinto the current curricula of accred-ited baccalaureate programs by nurseeducators.

Determine whether a rela-tionship exists between the level ofknowledge and the overall level of im-portance of incorporating educationalcompetencies regarding mass casual-ty incidents into the current curriculaof accredited baccalaureate programsas perceived by nurse educators.

MethodParticipants

The target population for this studywas the faculty of accredited bacca-laureate nursing programs currentlyteaching theory or clinical courses orboth. The accessible population con-sisted of nurse educators employedfull-time by January 1, 2006, in allaccredited baccalaureate nursing pro-grams in Louisiana.

First, a list of each baccalaureatenursing program currently accreditedby the state board of nursing was ob-tained. A list of nurse educators hold-ing current teaching positions alongwith current e-mail addresses of thelist of educators was obtained fromeach institution's faculty directoryand verified by correspondence witha representative of the dean's officeof each program. After the populationframe of 285 educators of baccalau-reate nursing programs was estab-lished, a census sampling techniquewas used for the design of this study.The study was approved by the uni-versity's institutional review boardprior to data collection.

InstrumentThe instrument used to collect

data was a questionnaire designed bythe researcher (K.K.W.). The first partof the instrument identified 51 coreknowledge and competencies regard-ing mass casualty incidents related tothose identified by the InternationalNursing Goalition for Mass CasualtyEducation Competency Committee(2003). For perceived level of knowl-edge scale, pEirticipants were asked

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to rate their knowledge on a 5-pointscale (1 = not at all knowledgeable,2 = slightly knowledgeable, 3 = fairlyknowledgeable, 4 = quite knowledge-able, 5 = very knowledgeable). Cron-bach's alpha internal consistencymeasure for the knowledge scale was0.985, indicating an excellent esti-mate of reliahility {George & Mallery,2003).

Participants were asked to rate theimportance of each item for inclusionin the haccalaureate nursing curricu-lum on a 5-point scale (1 = not at allimportant, 2 - slightly important, 3 =fairly important, 4 = quite important,5 = very important). Cronhach's alphainternal consistency measure for theImportance scale was 0.989, indicat-ing an excellent estimate of reliability(George & Mallery, 2006).

The second part of the instrumentcollected information on selected per-sonal and professional characteristicsof the participants. Content validityof the instrument was established bya panel of experts consisting of sixnurse educators who were formerlyor currently employed part-time inaccredited baccalaureate nursingprograms and had expertise in re-search design. Afler revisions weremade to the instrument based onthe input from the panel of experts,the instrument was field tested by asample of nurse educators teachingin programs other than the baccalau-reate level.

The instrument for data collec-tion was delivered using an onlinesurvey delivery service that pro-vided an Internet link to the instru-ment. In addition, the researchersent a paper version of the coverletter and questionnaire addressedto each faculty member. The acces-sible population of 285 educatorsin Louisiana baccalaureate nursingprograms was asked to complete thesurvey.

ResultsSample

Usable data was collected from166 participants (58%). Of the164 participants who indicated theirage, 49 respondents (30%) were age

44 and younger, 65 respondents (40%)were age 45 to 54, and 50 respondents(30%) were age 55 and older. Of the160 participants who provided theiryears of nursing employment, 111 re-spondents (69%) indicated they had^21 years experience as a nurse and49 respondents (31%) had ^20 yearsexperience.

For the 161 participants who pro-vided their years of employment as anurse educator, 29% (ra = 47) reportedhaving worked as a nurse educator for11 to 20 years. The breakdown for theremaining participants was almostequally divided, with 25% (n = 40)employed less than 5 years, 23% (n =37) employed 5 to 10 years, and 23%(n = 37) employed 21 years or longer.

Of the 162 participants who re-ported their primary teaching area,59% in = 95) indicated adult healthwas their primary teaching area. Thebreakdown for the remaining respon-dents was fairly equally dispersed,with the primary teaching area ofother for 15% (n = 24), child healthfor 10% in = 16), woman's health for9% (n = 15), and mental health for 7%in = 12). The majority (n = 16) of re-spondents who listed "other" specifiedcommunity health as their primaryteaching area.

Level of KnowledgeRespondents were asked to rate

their perceived level of knowledge of51 items pertaining to mass casualtyincidents on a 5-point scale. The fol-lowing breakdown of scores was usedto interpret the results: 1 to 1.49 = notat all knowledgeable, 1.50 to 2.49 =slightly knowledgeable, 2.50 to 3.50 =fairly knowledgeable, 3.51 to 4.50 =quite knowledgeable, and 4.51 to 5 =very knowledgeable.

Participants responded as beingquite knowledgeable for 6 items, fair-ly knowledgeable for 28 items, andslightly knowledgeable for 17 items.The six items rated highest in per-ceived knowledge were: demonstratebasic first aid skills (mean = 4.13,SD = 0.99), demonstrate personalprotective equipment (mean = 4.01,50 = 1.1), perform head-to-toe as-sessment (mean = 3.63, SD = 1.2),demonstrate higher order nursing

skills (mean = 3.61, SD = 1.33), dem-onstrate safe medication administra-tion (mean = 3.55, SD = 1.28), andassess and monitor during trans-port (mean = 3.53, SD = 1.15). Thesix items rated lowest were: defineterms relevant to mass casualty in-cidents (mean = 1.86, SD = 1.12),discuss chain of custody during acrime scene (mean = 2.06, SO =1.20), demonstrate use of emergencycommunication (mean = 2.10, SD =1.18), describe the incident commandsystem (mean = 2.13, SD = 1.27), de-scribe standards of handling humanremains (mean = 2.15, So = 1.22),and describe decontamination pro-cedures (mean = 2.17, SD = 1.21).Mean overall knowledge score was2.82 (So = 0.94).

Level of ImportanceRespondents were asked to rate

the level of importance of 51 itemspertaining to mass casualty incidents.The following breakdown of scoreswas used to interpret the results: 1to 1.49 = not at all important, 1.50to 2.49 = slightly important, 2.50 to3.50 = fairly important, 3.51 to 4.50 =quite important, and 4.51 to 5 = veryimportant.

Participants perceived 50 items asquite important, and 1 item as fairlyimportant. The six items rated high-est were: demonstrate basic first aidskills (mean = 4.5, SD = 0.77), demon-strate personal protective equipment(mean = 4.46, SD = 0.83), demon-strate safe medication administra-tion (mean = 4.37, SD - 0.90), per-form head-to-toe assessment (mean =4.29, SD = 0.89), use chnical judg-ment in assessment (mean = 4.26,SD - 0.99), and assess and monitorduring transport (mean = 4.22, SD =0.94). The items rated lowest in im-portance were: define terms relevantto mass casualty incidents (mean =3.35, SD = 1.21), identify resourcesfor media releases (mean = 3.52,SD = 1.14), discuss chain of custodyduring a crime scene (mean = 3.63,SD = 1.15), describe role as nurseepidemiologist (mean = 3.70, SD =1.08), describe the incident commandsystem (mean = 3.78, SD = 1.14), anddemonstrate use of emergency com-

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munication (mean = 3.81, SD = 1.27).Mean overall importance score was4.02 {SD = 0.80).Relationship Between Level ofKnowledge and Level of Importance

Findings revealed similarities initems were rated the highest in thelevel of knowledge and those ratedas the most important, as well asthe items that were rated lowest inknowledge and of least importance.Five of the six items rated as high-est were the same in both scales, andfour of the six rated as lowest werethe same in both scales. Althoughsimilarities existed between rat-ings of individual items of perceivedknowledge and level of importance,differences were noted in their rela-tive positions on the rating scale.Not only were means of the indi-vidual items lower in the knowledgescale compared with the importancescale, but the overall mean score forknowledge of 2.82 was lower than theoverall mean score for importance of4.02.

The relationship between perceivedlevel of knowledge and level of impor-tance was significant and measuredmoderate (Davis, 1971) in a positivedirection and magnitude when corre-lated using the Pearson correlation,r (162) = .33, p < 0.001. The natureof the association was such that themore knowledge the educators per-ceived that they had regarding corecompetencies for mass casualty in-cidents, the higher the level of im-portance they placed on inclusion ofthese competencies into the nursingcurriculum.

Conclusion and Implicationsfor Nursing Education

Just as emergency departmentnurses are trauma trained for the in-evitable, nurses who are generalistsneed to receive training for the inevi-table because when disaster strikes,it often occurs in such magnitudethat an enormous pool of nurses willbe needed. In the event of chemical orbiological warfare, the response mustbe rapid and coordinated with local,state, and federal agencies to con-

294

trol widespread panic and minimizedeath.

Nurse educators employed full-time in baccalaureate-level programsin Louisiana demonstrated limitedknowledge regarding mass casualtyincidents. Nursing education is be-ing faced with a workforce that didnot receive adequate instruction formass casualty preparation. This isverified by the findings of tbis study;tbe overall mean score for knowledgeregarding mass casualty incidentswas 2.82, with nurse educators' rat-ings being fairly knowledgeable orlower on 45 of the 51 items on thequestionnaire. Findings from thisstudy are similar to those reported byRose and Larrimore (2002) in which23% of health care respondents an-swered knowledge questions correct-ly regarding chemical and biologicalterrorism.

Nurse educators employed full-time in baccalaureate-level programsin Louisiana perceived mass casualtyincident instruction as quite impor-tant for inclusion in nursing curri-cula. This is verified by the findingsthat the overall mean score for im-portance was 4.02, with participantsrating 50 of the 51 items as quite im-portant or higher. These findings aresimilar to a previous study by Bondand Beaton (2005), who reportedboth student and practicing nursesindicated a strong need for disasternursing content.

Nurse educators are accountableto their students, communities, andsociety at large to prepare graduatesto work in an environment where thepotential for mass casualty disasteris no longer a low probability event.The current environment dictates anadjustment of the curricula to includecontent regarding disaster prepara-tion to provide nursing students withthe knowledge and skills required toparticipate in a national emergencyresponse. If the curriculum is l, it istime to prioritize content and removeless essential elements. Inclusion ofmass casualty incident training andcore competencies into nursing curri-cula is long overdue. Further researchis needed to determine the best place-ment in the curriculum.

The findings of this study verifiedthere is a positive relationship be-tween perceived knowledge of masscasualty incidents and importance ofinclusion of these competencies intothe nursing curriculum. The moreknowledge nurse educators perceivedthey had regarding core competen-cies for mass casualty incidents, thehigher the level of importance theyplaced on inclusion of these compe-tencies into tbe nursing curriculum.A perception that their knowledgeis low will have an impact on theirwillingness and ability to effectivelyincorporate this content into the cur-riculum. Similarly, Hilton and Alli-son (2004) reported nurse educatorswho are ill informed in educationand training hesitate in incorporat-ing disaster preparedness into thenursing curriculum.

Deans of nursing schools shouldtake immediate steps to identify apool of educators who can teach, orwith instruction are willing to teach,mass casualty incident preparation.This selected cadre must be trainedimmediately by professionals iden-tified as knowledgeable and highlyexperienced in mass casualty inci-dents such as those currently serv-ing in the armed forces, U.S. Depart-ment of Homeland Security, NationalNurses Response Team RNs, and Na-tional Guard, as well as volunteersfrom agencies such as the AmericanRed Cross and emergency medicalresponse teams. In a large-scale di-saster, the cooperation of the civilianand military sectors will be vital increating an environment of coordi-nated responses with delineation ofroles, responsibilities, and leader-ship.

Until a cadre of nurse educa-tors acquire and disseminate thisinformation, the profession will notbe equipped with a group of self-confident, competent nurses whocan prepare the future generation ofnurses for disasters of all types.

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Hilton, C, & Allison, V. (2004). Disasterpreparedness: An indictment for actionby nursing educators. The Journal ofContinuing Education in Nursing, 35,59-65.

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G E O R G E

U N I V E R S I T Y

Assistant Dean ofDoctoral Studies-School of Nursing

George Mason University, College ofHealth and Human Services. Schoolof Nursing is seeking an AssistantDean for Doctoral Studies. Thistenured position is available for thefall of 2009.

George Mason University is a dyna-mic and growing university, recentlynamed by U.S. News & WorldReport as the #1 national universityto watch on its list of Up-and-ComingSchools. Mason was cited as aschool that has recently made themost promising and innovative chan-ges in academics, faculty, students,campus or facilities.

This is an exciting nursing leadershipopportunity. The Assistant Dean willhelp set the direction for the future ofdoctoral studies in the school. A newD.N.P. (Doctor of Nursing Practice)program is planned to complementthe Ph.D. program that currentlyboasts over 50 students, with 13graduates in the spring of 2009.

Applicants are expected to have adefined research focus and potentialfor securing extramural funding. Re-search agendas that link with currentinitiatives and research teams in pal-liative care, disability and chronic ill-ness, obesity/nutrition, emergencypreparedness, forensic nursing, vul-nerable populations, and gerontologyare particularty desirable. While priorexperience in higher education is notrequired, the successful candidatewill have a record of scholarship andevidence of teaching ability consis-tent with the rank of tenured FullProfessor at a research university.

Required: Applicant must be a regis-tered nurse with a doctorate innursing (Ph.D., D.N.S. or D.N.P.).and have a record of publicationsand history of extramural fundingconsistent with tenure at the rank ofFull Professor.

George Mason University is an equalopportunity/affirmative actionemployer dedicated to the goal ofbuilding a culturally diverse facultyand staff. Women and minority can-didates are particularly encouragedto apply. Questions may be directedto Mimi Mahon, Ph.D.. A.P.R.N.,F.A.A.N. and Chair of the SearchCommittee at: mmahon@gmu.edu or703-993-1932.

Piease apply for position F8652zat http://jobs.gmu.edu/.