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Knowledge of Nurses in Hospital Preparedness in Emergency Response in Saudi Arabia: Basis for Staff Program Development

Jocelyn M Medina*, Mohammed Saeed Essa Aljohani, Khadega Ahmed Hefnawy Alhefnawy

Medical Surgical Department, Taibah University, Madinah City Kingdom of Saudi Arabia

Abstract: Objective: The study assessed the level of knowledge of nurses in hospital emergency response based on WHO standard and determine what staff program development may propose to enhance the knowledge of nurses in hospital emergency response. Methods: The study utilized quantitative type of research and used the descriptive evaluative design. Results: Results of the study revealed that respondents are knowledgeable in 2 categories of hospital preparedness in emergency response, the safety and security (WM=2.5443, SD=.13295)) during MCI and the human resource during MCI (WM=2.9266, SD= .13901). Conclusion: With the findings of the study the respondents need to have more training related to hospital preparedness in emergency response. The training should focus on incident command system, communication, triage during MCI, surge capacity during MCI, continuity of essential service, logistics and supply and post disaster recovery. The training should situate the Health Emergency Response Recovery Plan (HERRP) and policy of hospital, covering all-hazard approach based on their risk assessment.

Keywords: knowledge of nurses in hospital preparedness

Received February 19, 2021; Revised March 22, 2021; Accepted March 30, 2021

Citation: Jocelyn M Medina, Mohammed Saeed Essa Aljohani, Khadega Ahmed Hefnawy Alhefnawy, Knowledge of Nurses in Hospital Preparedness in Emergency Response in Saudi Arabia: Basis for Staff Program Development. American Journal of Nursing Research, 9 (3). 85-93. January 2021. doi:10.12691/ajnr-9-3-3

1. Background of the Study

Hospital is an institution with twenty - four hours of health services for injured and sick people. The healthcare provider's role is limited to treating injured and ill people and during a disaster with Mass Casualty Incident (MCI). In these incidents, their knowledge and skills are essential in providing their services in the community. All healthcare providers that include the nurses who occupy a significant number of employees in the health care institution must be aware of their roles during disasters. Knowledge in hospital emergency response is vital to prepare them for any disaster that may arise.

There is a global issue regarding disasters. Other researchers stated that climate change influences the different disasters that occur in different countries. Ghazali et al. [1] noted that climate change hampered inflation in the normal temperature to the oceans' troposphere, which influences the weather phenomena. Climate change affects natural disasters and is expected to induce a rise in humanitarian crises. Likewise, the given report of Extreme Events and Disasters (SREX) by international panel climate change (IPCC) forecast a further increase in the twenty-first century, that includes the increasing frequency of heat waves, ascending wind speed of tropical cyclone, and expanding density of droughts.

Saudi Arabia is one of the countries that experienced the effect of climate change. The said country recently experienced severe flooding. According to Asia News (2019), Saudi Civil Defense report flooding in Madinah Region the civil defense team rescued last February 8, 2019, 111 people. Moreover, last January 27, 2019, 12 people died; 271 people rescued 137 were evacuated from Tabuk Region.

In other areas, 50 homes in Iraq's Najaf province have been swept away by severe floods. The Iranian Red Crescent Society (RCS) gave emergency shelter for 800 people after heavy rain in Southern and Western provinces. Saudi Arabia experiences not only floods; Riyad and Jeddah have also experienced strong winds and sandstorms.

Furthermore, Saudi Arabia also experienced a human-made disaster. According to world news (2015), 107 people died in the collapse of a crane in Mecca's Grand mosque. Likewise, in the world-middle east news, last September 24, 2015, 717 died in Saudi Arabia because of Hajj stampedes. Another deadliest occurred in the pilgrim incident, where 863 people were injured during the incident at Mira, which occurred during Hajj.

With this different incident in Saudi Arabia, both natural and human-made disasters, the nurses' knowledge in hospital emergency response is strongly important and necessary for every health institution. Abdelalim & Ibrahim [2] cited a lack of knowledge and practices but a respectable level of attitude regarding disaster preparedness and neutral familiarity with emergency preparedness. Likewise, Alzahrani & Kyratsu [3] stated high clinical role awareness among emergency nurses. Still, they have limited knowledge and awareness on the broader emergency and disaster preparedness plan, including the key elements of their hospital strategies for managing mass gathering.

Alraga [4] mentioned that in contempt of the number of disasters that have already happened, Saudi Arabia's kingdom still no multi-sectorial state department that facilitates effective health management. Nofal, Alfayyad, Khan, Azeri and Abu-Shareen [5] the level of knowledge of healthcare providers was satisfactory, and the level of attitude, practice, and familiarity in preparedness during the disaster was neutral. Shabbir, Afzal, Sarwer Gilani, and Waqas [6] nurses' knowledge on disaster management and emergency preparedness were good, but practices were lacking in the hospital setting. Thus, the hospital has deficiencies in practices in disaster management and emergency preparedness.

With this issue, the researchers' interest is timely because of the different incidents that happened in the Kingdom of Saudi Arabia. Both human-made and natural disasters include the global pandemic of COVID 19. Assessing the nurses' level of knowledge in hospital emergency management may determine what program development may propose to enhance the readiness of nurses during MCI.

2. Significance of the Study

According to the World Health Organization (WHO) [7], Globally, many countries experience emergencies and disasters. Thus, to ensure that health sectors are resilient to the effect of such an emergency, an effective national emergency program is important and paramount to disaster preparedness. Bin Shalhoub, Khan, and Alaska [8] most of the weaknesses were apparent in education, training, and monitoring of hospital staff preparedness for disaster emergency occasions. In Saudi Arabia, Alsaidi [9] stated during the world quality day, one of the strategic objectives of the national transformation program 2020 vision is to adopt a national plan for an emergency response to public health threats according to international (WHO) standards. The study will assess the level of knowledge of nurses in hospital emergency response based on WHO standards and determine what staff program development may propose to enhance the knowledge of nurses in hospital preparedness in emergency response. With this study, hospital administrators may analyze the importance of hospital preparedness. Thus, this study may guide the administrator and education department to develop a program for all healthcare providers in preparing health institutions for any kind of Mass Casualty Incident (MCI) related to man-made or natural disasters. Furthermore, a policymaker may be used as a basis for policy improvement on the hospital preparedness in emergency management.

3. Objective of the Study

The study assessed the level of knowledge of nurses in hospital emergency response based on WHO standards and determine what staff program development may propose to enhance the knowledge of nurses in hospital emergency response.

4. Methods of the Study

The study utilized quantitative method, specifically, the researcher used descriptive-evaluative design. This was used to evaluate the assessment of the respondents on their level of knowledge in hospital emergency response system. Furthermore, the researchers used questionnaires adapted from World Health Organization (WHO) Emergency response checklist. The instrument was translated in Arabic for clear understanding and reliability test was done using Cronbach’s alpha.

5. Sample and Setting

The study was conducted in one city of Saudi Arabia with selected hospitals. The respondents were nurses; the total participants were 286 nurses from different hospitals. Purposive sampling was used based on the inclusion criteria, both male and female are included in the study, at least 6 months and above working in their own institution, all positions are included, technician, staff nurses, head nurse and supervisors, as long that they are assign at ER, general ward, critical care units, operating and recovery area. The nursing administrators and chief nurse, and other nurses assigned at the ancillary department were excluded in the study.

6. Ethical Consideration

The study was submitted in the researchers’ institution, the study passed the ethical requirements of Ethics Review Committee (ERC). The ERC allowed the researchers and conducted the survey in selected hospitals in one city of Saudi Arabia.

7. Data Analysis

The researcher utilized both online survey and actual distribution of questionnaires.

The level of knowledge was assessed using four (4) point Likert scale, 4 is very knowledgeable (VK), 3 knowledgeable (K), 2 not knowledgeable (NK) 1 very not knowledgeable (VNK). Data gathered were analyzed using SPSS, frequency and percentage were used to interpret the profile of the respondents, Weighted mean and standard deviation was used to determine the level knowledge of the respondents on the hospital. ANOVA test was utilized to identify the significant difference between profiles of the respondent when compared with the assessed knowledge on hospital preparedness in emergency management.

8. Results of Analysis

8.1. Frequency and Percentage of Respondents’ Profile

Table 1 revealed the statistical analysis of the profile of the respondents was based on the area of assignment, years of service, highest educational attainment, and the training attended related to hospital preparedness in emergency response. The total respondents were 286; 25.9% were assigned to the emergency room (ER), 39.5% were assigned general ward unit, 27.6% were assigned from the critical care unit, 7 % were from the operating room.

In terms of their years of service, 38.8 % were 6 to 10 years, 30.1% has 2to 5 years of service, 17.5% has 11 to 15 years of service, 9.4 % has 6 months to 1 year of service, and 4.2 5 has 16 to above of service, with regards to their highest educational attainment, 85.7% were bachelor’s degree holder, 9.8 % has master’s degree units .7 % were graduated of master’s degree, and there are 3.8 % who were diploma holder.

The statistical result in terms of the seminar attended, 25.5 % attended the mass casualty incident drill, 8.7% attended the emergency management, 5.6% attended the hospital incident command system, 2.8% attended the biohazard risk disaster, no one attended the rapid damage assessment, contingency planning, and critical stress management.

Table 1. Frequency and percentage of respondent profile

8.2. What is the Level of Knowledge of the Respondents in Hospital Preparedness on Emergency Response?

As of the knowledge of the respondents in hospital preparedness, using weighted mean and standard deviation, the respondents were assessed based on nine categories, command control during mass casualty, communication during mass casualty, safety and security during mass casualty, triage during mass casualty, surge capacity during mass casualty, continuity and essential services during mass casualty, continuity of essential services during mass casualty, human resources during mass casualty, logistic and supply management during mass casualty and post-disaster recovery. Among the nine categories, respondents are knowledgeable in two areas in safety and security during mass casualty, human resource during mass casualty, while the seven categories such as command control, communication, triage, surge capacity, continuity of essential services, logistics, and supply management and post-disaster recovery during mass casualty were answered not knowledgeable.

Furthermore, as revealed in Table 2, that command control during mass casualty has a total grand mean of 2.4837 and standard deviation of .18608, which means that the respondents are not knowledgeable in command control during mass casualty; among the variables, respondents are knowledgeable in 4 areas, strategies related to planning and implementing hospital incident action plan, (WM = 2.8462, SD= .18608) staff role in emergency response activities (WM= 2.6748, SD .55174) contingency plan for hospital command control if a local person is not available (WM = 2.6678, SD=.57870) and appropriate coordination related to response activities, (WM= 2.65503, SD= .49924) vis-a-vis the respondents are NK on three areas the designated hospital command center for effective means of communication (WM= 2.0035, SD = .42301) and the structure of hospital command control system or the hospital command system (2.0594 SD = .48843). Facilitation of hospital incident command system or command control will be more effective and efficient during mass casualty incidents if staff nurses are knowledgeable. According to Bahrami et al. [10], to improve hospital readiness and response appropriately during accidents and disasters, the decision-makers should increase the knowledge of the hospital incident command system. Likewise, Shootari et al. stated that with the facilitation of hospital incident command system management will have an appropriate and efficient in controlling events and disaster because of avoidance of confusion and undecidedness during the events.

In communication during mass casualty, the weighted mean was 2.2446 with a standard deviation of .17543, which means that the respondents are NK. Moreover, with variables the said category respondents were knowledgeable in 2 areas the spoke person appointed to coordinate hospital communication (WM = 2.8322, SD = 0.40151) and availability of back-up system (WM=2.9231, SD= 0.27977) 5 areas were NK, the designated space for a press conference, key messages in preparation for disaster scenarios (WM=2.2867, SD = 0.49732) mechanism of information exchange (WM = 2.3392 SD = 0.49732) roles and responsibilities within incident action plan (WM = 2.1503, SD=0.46087) and mechanism for the appropriate processing and information (WM=2.2483 SD= 0.55396). Ow Yong, Xi n, Wee [11] mentioned that a critical component of planning and response during the pandemic, which is considered as biological incidents, was the emergency risk communication. Likewise, Kapur, Bezek, and Dyal [12] stated that communication is a vital component of response and recovery during and after a disaster situation.

For the safety and security during MCI, the grand mean was 2.5442 with a standard deviation of 0.13295. This means that the respondents are knowledgeable. With the areas of variables, respondents were VK in 2 areas, three areas were responded as knowledgeable, and five areas were NK. Respondents are VK in management of hazardous material and infectious control (WM=3.2727, SD 0.44614) and implemented procedures to secure collection of confidential information (WM=3.4545, SD= 0.50579) with this result of very knowledgeable of respondents in hazardous materials and infectious control just because the 97.2% of nurses attended Biohazard risk disaster. Moreover, respondents are knowledgeable about facility access points, triage sites, and other areas of patient flow (WM=2.5874, SD= 0.52754) and mechanism of escorting medical personnel (WM=2.9266, SD= 0.30049) on the other way they are NK in appointed hospital security team (WM= 2.2343, SD= 47130 defined measures for safe and efficient hospital evacuation (WM= 2.3601 SD=.50230) procedures for integrating law enforcement radioactive (WM=2.0629, SD= 0.29539) and biological decontamination (1.9615, SD= 0.19264). Safety and security have significant factors in crowd control. If more people are involved or victims during MCI, both victims and health providers are not safe in many ways. Therefore, to ensure safety and security, crowd control must be facilitated during MCI.

Crowd control is important in all kinds of disasters, either natural disasters or human-made disasters. Yamin M, Basahel A, and Abi Sen A. [13] stated that the management of crowd must take measures in all hospitals or health institutions to prevent the spreads of contagious diseases and viruses; this is very timely with the global pandemic of coronaviruses. Likewise, the nurses and other healthcare providers must know any decontamination procedures to prevent spreads, either chemical or biological incidents. Fentiman [14] mentioned that to destroy infectious agents or other organic matter or any contaminants decontamination process can effectively remove the harmful agents and prevents the spread of infection.

Regarding the triage, during MCI, the total grand mean was 2.3750 with a standard deviation of 0.12739, which means that nurses were NK. With this category, respondents assessed that they NK in 5 areas and K in 2 areas. The respondents are knowledgeable on the triage officer who are designated to oversee the operations during mass casualty (WM=3.1888, SD= 0.39204) and the triage area with a proximity to essential resources MCI (WM = 3.0000 SD= 0.53639). Furthermore, the areas wherein they are not knowledgeable are identified entrance and exit routes from triage (WM= 2.3357, SD= 0.53566), identified contingency site for triage and MCI (WM= 2.0734 SD =0 .26129) identified alternative waiting area (WM= 2.0874 SD= 0.29507), established protocol of MCI triage (WM= 2.1678 SD 0.39267), mechanism of hospital emergency response plan used in triage (WM= 2.1049 SD= 0.30696) protocols on hospital process when disaster plan is activated (WM= 2.1094 SD= 0.33244). Clarkson & Williams [15] cited that during MCI triaging is a vital and fluid process which adjure a certain degree of pre-incident training. The study of Lampin [16] cited that physicians are lacking in performing triage skills. With the resulting study, health worker providers should be knowledgeable in triage skills during mass casualty incidents to rapidly classify the most injured victim and able to assure timely and appropriate management for those who need urgent care.

For the surge capacity during mass casualty, the total grand mean was 2.3004 with a standard deviation of 0.12162, which means that the respondents are NK in surge capacity of the hospital during mass casualty incidents. But on the other way, with variables of surge capacity during MCI, respondents were knowledgeable about three areas, the designated areas for patient overflow (WM= 3.2028 SD= 0.47476), available vehicles and resources required for patient transport (WM = 3.1713 SD 0.39561), and the available treatment capacity and demand (WM= 2.7036 Sd= 0.55985). Smithll & Gebhart [17] stated that to manage supply and demand in the hospital, developing a surge capacity makes a difference. Therefore, health institutions' employees and staff must be knowledgeable in hospitals' surge capacity programs during mass casualty to mitigate the number of patients seeking services. Shen, Jiang, and He [18] mentioned that reshape standards of care centralize response precision support for medical surge capacity from external efforts and advance the level of response that can be utilized to achieve surge capacity.

Regarding continuity of essential services during MCI, the grand mean was 2.3700 with a standard deviation of .9829, which means that the respondents are NK in this aspect of action during mass casualty incidents. In the said category, two aspects were respondents are K and 5 were NK. Vis- a- vis respondents are knowledgeable in some part to facilitate the continuity of care, the list of hospitals services ranked in order of priority (WM= 3.0385 SD= 0.19264), and how to coordinate with authorized health personnel and neighboring health institution and private practitioner on defining roles and responsibilities to ensure continuous provision of services. (WM=2.9895, SD =0.10206). During mass casualty incidents, hospital services must be continued no matter how many patients were admitted. Feizolahzadeh, Vaezi, Mirzaei, and Khankeh [19] Hospital commonly encountered barriers in providing services, to name such was the accost in the pre-hospital system, deficient of disaster paradigm, poor coordination and cooperation, lack of hospital preparedness, incapable of using available resources and capacities, and inadequate planning. Overall, good hospital preparedness has a better continuity of services during mass casualty incidents.

In terms of human resource during mass casualty, the grand mean was 2.9266 with standard deviation of 0.13901 which means that the respondents are knowledgeable. Despite of knowledgeable is some aspects, respondents were VK in some areas, on the updated contact numbers of staff contact list (WM= 3.3147, SD = 0.48731) clear policy on staff sick leave (WM = 3.3462, SD= 0.47658) contingency plan for life saving needs (WM= 3.3497 Sd= 0.47770) staffing requirements and distribution of personnel (WM= 3.31839, SD= .46659) and the provided training in areas of potential increased clinical demand (WM= 3.2972 SD= 0.45783). Therefore, with this result hospital were prepared in human resource and staffing system during MCI. This was similar with the study of Gabbe et. al [20] that hospitals are prepared regarding human resource, and they have the data base of trained staff in emergency management.

For the logistics and supply management during mass casualty the grand mean was 2.4569 with standard deviation of.13852 which means that the respondents were NK. With the variables of the given category despite of being not knowledgeable in some variables, vis – a vis they are knowledgeable in 2 areas, provision of essential medication supplies (WM=3.0140, SD= 0.41015) and hospital storage and essential stockpiling of supplies. (WM= 2.9650 SD= 0.24866) This knowledge was essential to provide a timely management for the patients who need immediate care, this was in line with the study Gabbe et al [20] during mass casualty incident, 55% of the staff reported that they are aware of the presence of stored resources.

Furthermore, in post disaster recovery during MCI the grand mean was 1.8151 with standard deviation of 0.13560 which means that the respondents were NK. All areas in this category were NK. With this result in compliments with the study of Gabbe et.al wherein 74 % of staff involved in mass casualty incident had training and education on professional debriefing. In any traumatic event debriefing is helpful for the individual more advantage for the healthcare provider who is at service to the patients in the hospital. Ibrahim, Kamsani, and Arnizalshak [21] cited that, debriefing was designed to facilitate typical recovery, resilience, and personal development.

Table 2. Assessment of respondents on knowledge on hospital preparedness in emergency response

8.3. Using ANOVA to Determine the Significant Difference between Level of Knowledge of the Respondents on the Hospital Preparedness Compare to Their Profile?

Based on the Table 3, revealed that all 9 categories of hospital preparedness in emergency response compare to area of assignment the 8 categories the command control, (p-value = 0.0295) communication (p-value =0.1554) triage (p-value = 0.8557) surge capacity, (p value= 0.3495) continuity of essential service (p value= 0.4653) human resource (p value= 0.1457) logistics and supply (p value= 0.2963) and post-disaster recovery (p-value = 0.9530) only safety and security (p-value = 0.0295) which is less than p-value of 0.05 therefore, safety and security compare to area of assignment has significant difference. This means that knowledge on safety and security may differ from the area of assignment. All members of health institutions, despite your area of assignment, must be aware of safety and security, not only for the patient but also for themselves and their co-worker. Salamati & Kulatunga [22] mentioned that during a disaster, there would be a rapid increase of patients. Therefore, to provide the services needed, security and safety are the utmost priority.

Regarding years of service compared to the level of knowledge of respondents on the hospital preparedness in emergency response, only one category has less than 0.05 p-value the logistics and supply (p-value = 0.0075), which means they have a significant difference. Furthermore the 8 categories such as the command and control (p-value = 0.2239) communication (p-value = 0.1100) safety and security (p value= 0.7699) triage (p value= 0.1839) surge capacity (p value= 0.2094) continuity of essential services (p value= 0.5231) human resource (p value= 0.0719) and post-disaster recovery (p value= 0.2524) wherein all the category has more than 0.05 p-value, therefore there are no significant difference in all of these category when compare to years of service in the institution. The level of knowledge on triage and human resource has a significant difference on the highest educational attainment. The knowledge on logistics and supply may affect the respondents' years in service stay, the longer the service, the more knowledgeable in logistics and supply. Adiguzel [23] mentioned that during disaster events flow of patient's increases; therefore, as the supply and demand increases, the logistics department and supply chain network must be able to provide the need of the hospital. Nurses must know whom to approach and where to avail to provide the continuity of service needed.

For the highest educational attainment compared to the level of knowledge of the respondents on hospital preparedness, the two categories, triage (p value= 0.0057) and human resource (p value= 0.0189), presents a lower p-value than 0.05; therefore, there is a significant difference, on the other way the seven categories such as command control (p value= 0.6959) communication (p-value =0.9540) safety and security (p value= 0.5900) surge capacity (p value= 0.8875) continuity of essential services (p value=0.6537) logistics and supply (p value=0.8960) and the post-disaster recovery (p value= 0.2697) has more than p-value of 0.05 which means that there significant difference when to compare to the knowledge and highest educational attainment. The level of knowledge on triage and human resource will vary from highest educational attainment. The more they had a higher education decision making may enhance likewise if they had a degree of master specifically major in emergency management may enhance decision making during triage. Afaya, Azongo, and Yakong [24] stated that nurses improved their triage knowledge through experienced, training, and education.

Table 3. Significant difference between level of knowledge in hospital preparedness when compare the profile of the respondents

9. Conclusions

The study's findings revealed that the majority of respondents attended three pieces of training related to hospital preparedness in emergency response the incident command system, biohazard risk disaster, and emergency management. Moreover, with the result of the knowledge of the respondents in hospital preparedness in emergency response, they are knowledgeable in 2 categories the safety and security during MCI and the human resource during MCI. The other seven categories need to enhance their knowledge to strengthen the hospital's capacity in preparedness in emergency response. Hospitals' readiness and preparedness in emergency management will not only for a natural disaster but also emphasize biological hazards like the COVID 19 pandemic.

With regards to significant differences in the knowledge of respondents when compared to their profile, the area of assignment has a significant difference with safety and security; the year of service has significant difference on the logistics and supply, and education with the triage. Thus, all employees working in the hospital, including the newly hired, must have training and education through staff development not limited to safety and security but related to overall hospital preparedness in emergency management. The training should focus on an incident command system, communication, triage during MCI, surge capacity during MCI, continuity of essential service, logistics and supply, and post-disaster recovery. It should situate the Health Emergency Response Recovery Plan (HERRP) and policy of the hospital, covering all-hazard approach based on their risk assessment.

10. Limitation

The study's sample size was only limited to few hospitals that may influence the findings of the study. Likewise, the study participants were only limited to nurses, wherein during a disaster and emergency response, doctors and other medical health team are a vital part of the response team. Therefore, the researcher recommended that the study should include all teams responsible for emergency response during MCI.

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