Nurses’ Readiness for Emergencies and Public Health Challenges—The Case of Saudi Arabia

This study was aimed at assessing the readiness of 200 emergency nurses in the southern part of Saudi Arabia in the management of public health emergencies, major incidents, and disasters by using quantitative research through a self-reporting validated questionnaire containing 10 different dimensions. All registered nurses working in emergency departments who were willing to participate, of all ages and gender groups, were included. Nurses who were not present during the study period because of vacation or maternity leave, nurses at the managerial level, and nursing aides were excluded. The participating nurses reported good knowledge in almost all investigated aspects of the theoretical dimensions of emergency management. However, they revealed perceived weaknesses in practical dimensions of emergency management and difficulties in assessing their own efforts. There was a significant correlation between qualification and the dimensions of emergency preparedness, epidemiology and surveillance, isolation and quarantine and critical resources, which indicates a need for strengthening their practical contribution as well as their theoretical knowledge. Educational initiatives combining theoretical and practical aspects of emergency management may provide an opportunity to examine nurses’ knowledge, skills, and abilities continuously in an environment with no harm to patients.


Introduction
The increasing incidences of public health emergencies and disasters necessitate global awareness, multiagency collaboration, and emergency system readiness to respond [1]. Major incidents and disasters (MIDs) might be inevitable, but they can be mitigated by performing an appropriate risk and vulnerability assessment (RVA) as the foundation for creating a disaster response plan [2]. Risks and vulnerabilities causing a public health emergency or an MID may vary in different countries; however, the current coronavirus 2019 (COVID- 19) pandemic has clearly demonstrated how a local outbreak can influence the spread of a disease and how it can result in lessons learned for global benefits. A response

Study Design
This study employed a descriptive quantitative design using a validated questionnaire to assess the knowledge and awareness among licensed nursing staff of preparedness to respond to emergencies and specific healthcare scenarios.

Questionnaire
This study used the Emergency Preparedness Information Questionnaire (EPIQ) to assess the disaster preparedness of nurses [18]. EPIQ contains a variety of topical areas, of which two are relevant for the present study, i.e., (1) the 10 specific competency dimensions related to preparedness in the case of large-scale emergency events and (2) self-assessed familiarity across these competency areas. EPIQ is the only reliable and validated tool in the literature that evaluates nurses' perceived familiarity of emergency preparedness and disaster response core competencies. It uses familiarity as an important measure of the acquisition of new information. Wisniewski et al. developed EPIQ by performing an extensive search in the literature, combined with nurses' perceptions of perceived familiarity with these capabilities. They also sought to determine preferred education methods and demographics for future educational endeavours. EPIQ has been validated by psychometric testing and used in several studies aiming to measure levels of disaster preparedness and provides a comprehensive analysis of the topic of study since it covers broad areas [19,20]. It works to individually assess all areas of healthcare and delves into in-depth information relevant to the research. Additionally, it is simple to read and interpret and provides a user-friendly interface.

Setting
The research was conducted at the Ministry of Health's (MOH) hospitals (n = 10) in the Najran region, located in the southern part of the KSA.

Population and Sample
All nurses at the 10 hospitals included in the study were informed about the study by the nursing office director at each hospital. The participants were randomly included from the list of nurses working in each emergency department (ED), thus avoiding the bias of choosing a specific group. They were ensured that their participation was voluntary, they could withdraw from the study whenever they decided to, and the obtained data were handled confidentially. They received basic information about the study and its goals, and informed consent was obtained from each participant. A power analysis with a standardised statistical power of 0.80 and medium effect size of 0.5 premediated the appropriate sample size to 200 nurses. The self-completion questionnaire was presented to the participants through the SurveyMonkey website.

Data Collection and Processing
Collected data were stored at the hospitals' research centres. Nurses answered the questionnaires on a specific research day to prevent response influence. The respondents were asked to provide correct information. The information provided was subject only to research, and the researcher could not disclose the respondents' identities at any time, no matter the circumstances. The included participants were registered nurses working in EDs who were willing to participate, in all age and gender groups. Nurses who were not present during the study period because of vacation or maternity leave, nurses at the managerial level, and nursing aides were excluded.
All data concerning the 10 emergency preparedness competency dimensions were analysed by the authors. The primary investigator was responsible for collecting data and categorising them for further analysis by the teammate. Each dimension consisted of a number of questions, in which participants could indicate their familiarity with a topic based on a five-point Likert scale (see results).

Ethical Approval
For this study, an ethical committee certificate of approval was obtained from the Institutional Review Board at the General Directorate of Health Affairs in the Najran region (IRB Log Number 2020-27 E-Date of approval: 1 July 2020).

Statistics
The homogeneity of the items in the subscales of the EPIQ was analysed by calculating Cronbach's alpha using Statistical Package for the Social Sciences (SPSS) software version 20. Cronbach's alpha was 0.98, which shows high internal consistency and, according to Brace, Kemp and Snelgar [21], is considered satisfactory. Other results are descriptively presented in actual numbers and percentages. A Kolmogorov-Smirnov test was used to explore normality. As a result of skewness in the data, Spearman's rho was used to test co-variation. Means were compared using the Mann-Whitney U and Kruskal-Wallis tests. Statistical significance was recognised at p < 0.05, and all tests were two-tailed.

Results
Of the 200 nurses who answered the questionnaire, 181 (90.5%) were female and 19 (9.5%) were male. A majority of the respondents (45.5%) were 22-30 years old. About 39% of the nurses were 31-40 years old, while the remaining 15.5% were 40 years old or older. About 93.5% of the nurses had a Bachelor of Science in Nursing (BSN), 6% had a Master of Science in Nursing (MSN), and 0.5% had a Doctor of Philosophy (PhD) in Nursing. Most of the practicing nurses, especially those in EDs within MOH hospitals, possessed undergraduate qualifications from MOH-certified education and training institutions. About 12% of the nurses had more than 16 years of experience within EDs, 20% had 11-15 years of experience, and 34% had 6-10 years of experience, while the remaining 34% had 1-5 years of experience.
The remaining results of the study were categorised into the following 10 dimensions, which denote the extent to which nurses are aware of disaster risks and preparedness. Each dimension consisted of several questions, in which nurses were asked to indicate their familiarity with a topic based on a five-point Likert scale as follows: very familiar (5), somewhat familiar (4), familiar to neutral (3), somewhat unfamiliar (2), and not familiar (1). The positive threshold was 'familiar to neutral' to 'very familiar'. Table 1 shows that most of the participants had good knowledge (familiar to very familiar) in most items of these dimensions: signs and symptoms (different biological agents: 49.5%, and better for Anthrax: 75%), modes of transmission (56.5%), antidote and adverse reaction (66% and 69.5%, respectively). However, participants seemed to be uncertain about their practical capabilities, skills, and evaluations of their own actions, including necessary first aid interventions such as ventilation and oxygen administration during a public health emergency (32% and 39.5%, respectively).  Table 2 shows that a majority of the nurses surveyed had good knowledge regarding what they needed to do during a large-scale emergency. They also appeared to have good knowledge about the emergency operations plan (EOP), Incident Command System (ICS), physical locations of all entities, the importance of medical decision-making, etc.  Table 3 shows nurses' approaches to the assessment of affected people's health following a crisis and their familiarity with ethical issues in MIDs, such as during triage. Overall, they claimed that they had good knowledge and understanding of these issues.  Table 4 shows nurses' knowledge in mitigating the further outbreak of a disease. Overall, most of the nurses claimed that they had good knowledge in handling the administrative measures needed in chemical, biological, radiological, and nuclear (CBRN) surveillance. In Table 5, nurses evaluated their knowledge of isolation and quarantine issues. Most of the surveyed nurses seemed to have good knowledge in these areas.  Table 6 shows that most of the nurses had good knowledge of the decontamination process in their hospitals, including the use of personal protective equipment (PPE).    Table 8 shows that a majority of the nurses had good knowledge of appropriate and necessary psychological support during MIDs, claimed that they could provide health counselling/education in issues related to chemical, biological, radiological, nuclear, and explosive (CBRNE) agents, and could communicate with, identify, and evaluate youth and adults with post-traumatic stress disorder (PTSD).  Table 9 shows nurses' knowledge in handling special populations affected by a disaster. A majority of nurses claimed to have good knowledge and understanding of the unique needs and expectations required for care of vulnerable groups.  Table 10 shows the ability of nurses to access critical resources during an MID. They seemed to have good knowledge and capabilities to perform necessary measures in all areas within this dimension. The results of normality, measured with the Kolmogorov-Smirnov test, indicated the data to be significantly skewed (sig. 0.00). As a result of the skewness and the fact that the data were ordinal and presented as ranks, a non-parametric test, Spearman's rho, was chosen to measure bivariate correlations. The variables of age, qualification, and experience were tested for the 10 studied dimensions of nurses' familiarity responses. Significant correlations were found in the correlations on qualification and dimensions of Emergency Preparedness (sig. 0.006), Epidemiology and Surveillance (sig. 0.008), Isolation and Quarantine (sig. 0.000) and Critical Resources (sig. 0.019). All significant correlations represented a small to moderate association (Critical Resources, 0.185-Isolation and Quarantine, 0.266) ( Table 11). The psychological issues dimension was significant when correlated to age (sig. 0.029), qualification (sig. 0.026), and experience (sig. 0.027). The correlations represented a small association (0.154-0.158) ( Table 12).

Discussions
In this paper, we assessed the readiness of emergency nurses in the southern region of the KSA in the management of public health emergencies, major incidents, and disasters. The reasons for such evaluation were the continuous exposure of the region to both man-made and natural disasters and the advanced educational backgrounds of the nursing staff.
The results of this study indicate a good preparedness in all theoretical dimensions of MID management, including emergency preparedness terms and activities, Incident Command Systems and their role in MID management, ethical issues in triage, epidemiology and surveillance, isolation and quarantine, decontamination, communication issues, psychological issues, management of special/vulnerable populations, and assessment of critical resources. However, the nurses appeared to be uncertain about their skills and practical performance and the evaluation of their own abilities. These results are opposite to what was reported earlier from the KSA [16] and thus confirm a good theoretical knowledge and a need for practical opportunities. Bearing in mind that 93.5% of nurses had a BSN, 6% had an MSN, and 0.5% had a PhD in nursing and that most of the practicing nurses (66%) had more than five years of experience, these results might be indicative of a need for further educational initiatives to improve the skills and practical performance of all nurses working in the management of MIDs [6][7][8][9].
The quantitative nature of this study and the collected data provide an understanding of the preparedness of nurses working at MOH hospitals in the southern region of the KSA and reveal both strengths and weaknesses that can be implementable and relevant in other regions and countries.
The current COVID-19 pandemic has demonstrated difficulties in MID management, such as resource scarcity and medical decision-making, which seem to be more complicated in practice than in theory [22]. The EPIQ questionnaire enabled the researchers to capture various dimensions of disaster preparedness and response in nursing environments [23]. However, the nurses' lack of confidence in their own skills and performance should be considered a critical shortcoming. Several studies have shown that healthcare workers who are confident in their own level of competence are more likely to react effectively in real crises than those who are not [24][25][26][27][28]. Nurses' theoretical knowledge, such as their ability to identify the signs and symptoms associated with highly infectious biological and chemical agents, is essential for enhancing disaster preparedness; however, this theoretical knowledge should be incorporated in practical performance to yield a robust preparedness. Proper education and training in an environment where nurses can act without hesitation, make mistakes with no harm to patients, and establish contact with necessary agencies without getting rejected will enable them to attain the required knowledge and skills to identify and report signs and symptoms that are unclear and to treat and intervene with necessary and evaluable measures [4,[29][30][31][32]. Such performance and collaborative action will ensure their confidence in their response activities as key players in an MID.
Nurses' emergency preparedness is determined by their familiarity with their organisation's emergency operations plan (EOP), which allows them to follow the recommended procedures for crisis intervention from a healthcare perspective [33]. Nurses' knowledge of the ethical, legal, cultural, psychological, and safety dimensions of emergency response is critical for effective intervention and recovery [23,34]. Planning to address the needs of special populations is a strategic dimension of emergency response and recovery initiatives [17]. Effective communication during an emergency is essential for ensuring nurses' collaboration with other stakeholders involved in a crisis event. The epidemiology and surveillance aspects of disaster management require streamlined communication among various departments and agencies [17].
Most of the nurses in this study reported knowledge of and familiarity with all aforementioned dimensions. However, since MIDs are rare events, they have no chance to evaluate their theoretical and practical abilities in a real situation. Simulation exercises may offer a chance to examine these abilities in a safe environment with no harm to patients [4,35,36]. These exercises may also offer an opportunity to raise their awareness about pandemics, quarantine, isolation, the use of PPE, and other critical resources to foster recovery and minimise the spread of highly infectious diseases. A majority of nurses in this study understood the methods for isolation but lacked adequate knowledge concerning the community quarantine process and the impact it may have on the mental health of both affected people and workers. This finding supports earlier findings by McCarthy [23,37], which as part of building modern contemporary emergency nurses, argued the need for nurses to increase their understating of procedures performed and competency in practice. This shortcoming would be addressed in collaborative simulation exercises [4].
In this study, there was a significant correlation between qualification and the dimensions of emergency preparedness, epidemiology and surveillance, isolation and quarantine, and critical resources. These findings are in accordance with Gladston, who reported a significant correlation between nurses' perceptions and qualifications [38], and similar to studies showing statistically significant associations between the dimensions of psychological issues and age, qualification and experience [38][39][40][41].

Limitations
This study focussed on nursing staff working in emergency departments only and did not consider other nurses' roles and responses. The sample consisted overwhelmingly of women. The small number of male nurses was not a representative sample of the male population of nurses in the region. The non-parametric correlations provided some useful data possible to generalise to a broader population. However, when comparing means, the results were mainly non-significant. Repeated non-parametric tests on the data (Mann-Whitney U and Kruskal-Wallis Test) indicated the need for an extended study. Data for this study were collected in the Najran region only, which is one of 13 regions in Saudi Arabia, so there was a limitation to the ability to generalise the results to all parts of Saudi Arabia. Furthermore, this study focussed on nurses working in MOH hospitals, while nurses working in other agencies, such as Saudi Arabian Oil Company (ARAMCO) Medical Services, Security Forces hospitals, National Guard hospitals, and the Armed Forces Hospitals of Saudi Arabia were not included. Finally, self-reported surveys by nature have bias: response recall, the possibility that questions will be misinterpreted, and the possibility that respondents' perceived knowledge may not be what they actually know.

Conclusions
The aim of this study was to evaluate the theoretical and practical readiness of nurses in MID management. The results indicate that nurses working in Najran EDs in the southern part of the KSA have good theoretical knowledge but lack confidence in their practical performance. Several studies have shown the significance of self-confidence in healthcare workers' responses to real crises [24][25][26][27][28]. Since theoretical knowledge should go hand in hand with practical knowledge to achieve successful outcomes in MIDs, bolstering practical emergency preparedness exercises, for example, with scenario-based simulation exercises [4] may enhance nurses' readiness for crisis response.  Selection of the appropriate personal protective equipment when caring for patients exposed to CBRN agents 27 The decontamination procedures stated in your facility's emergency operations plan 28 The impact on the environment from a large-scale emergency event  Please provide an assessment of your overall familiarity with response activities/preparedness in the case of a large-scale emergency event