Nurse Education in Practice 15 (2015) 63e67

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Development, implementation and evaluation of a disaster training

programme for nurses: A Switching Replications randomized
controlled trial
Theodoros Pesiridis*, Panayota Sourtzi, Petros Galanis, Athena Kalokairinou
Faculty of Nursing, University of Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Background: Training efforts in disaster education need to provide updated knowledge, skills and
Accepted 1 February 2014 expertise to nurses through evidence-based interventions.
Aim: The purpose of the study was the development, implementation and evaluation of an educational
Keywords: programme for nurses regarding the provision of health care during disasters.
Disaster nursing education Methods: A randomized controlled trial using Switching Replications design was conducted for the
Randomized controlled trial
evaluation of the programme. 207 hospital-based nurses were randomly assigned into intervention
Training programme
(n ¼ 112) and original control (n ¼ 95) groups. Changes between groups and over time were measured by
Effectiveness
questionnaire and used as the outcome measure to demonstrate effectiveness of the training
intervention.
Results: The intervention improved nurses’ knowledge and self-confidence levels while no significant
changes were detected in behavioral intentions. A significant increase in the mean knowledge score was
observed in both groups in times 2 and 3 compared to time 1 [pre-test: 6.43 (2.8); post-test: 16.49 (1.7);
follow-up test: 13.5 (2.8)], (P < 0.002). Changes in knowledge between intervention and control group
were significantly different (P < 0.001) with a large effect size (eta-squared ¼ 0.8).
Conclusions: The training programme was feasible and effective in improving nurses’ knowledge con-
cerning disaster response.
Ó 2014 Elsevier Ltd. All rights reserved.

Introduction Although a variety of disasters in recent years have brought

The past few years mankind have witnessed many natural and
man-made disasters that have influenced the life of billions around
the globe. It is estimated that only in the past decade, about 2
million people lost their lives due to a disaster, 4.2 million were
injured, 33 million left homeless and about 3 billion people affected
due to any disasters (EM-DAT, 2013). The impact and ongoing na-
ture of many of these events highlight the need for nurses to be
prepared to work effectively in disaster situations. The meaning
and definitions of disasters are broad and varied, depending on the
scientific perspective (Fung et al., 2009). Noji (1997) describes di-
sasters quite simply, as “events that require extraordinary efforts
beyond those needed to respond to everyday emergencies”.
* Corresponding author. 39, Patriarchou Gregoriou E’, 15122 Athens, Greece.
Tel.: þ30 210 8053663, þ30 210 7461449.
E-mail addresses: teopesiridis@gmail.com, teopesiridis@nurs.uoa.gr
(T. Pesiridis).
disaster education to the forefront, yet, disaster nursing knowledge
has been characterized as “inadequate” in many countries (Weiner,
2006; O’Sullivan et al., 2008; Veenema et al., 2008; Powers and
Daily, 2008). Furthermore, the issue of inadequate disaster
nursing education and the lack of standard competencies for nurses
in order to provide efficient nursing care during catastrophic events
became a political issue in the United States after Hurricane Katrina
(Couig et al., 2012). To address the new challenge, several nursing
schools have developed certificate and master’s degree pro-
grammes the past decade focused in disaster preparedness and
management (Stanley, 2007). In addition, organizations and health
care institutions have to become learning organizations, providing
the skills and knowledge to its workforce (Holland and Lauder,
2012). To meet the goal of preparing registered nurses regarding
the provision of care during disasters, training programmes have
developed and implemented worldwide, as part of the continuing
professional development (Hsu et al., 2004). Although a series of
training programmes, aiming to improve nurses’ capability of
disaster preparedness have been carried out, in many cases it

1471-5953/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2014.02.001
64 T. Pesiridis et al. / Nurse Education in Practice 15 (2015) 63e67
remains unclear if these training programmes are effective (Wang
et al., 2008). Furthermore, evidence-based disaster training is
necessary to improve the effectiveness of nurses’ response to di-
sasters (Burstein, 2006; Williams et al., 2007). Moreover, educa-
tional interventions ought to describe in a clear manner its
objectives, content, evaluation methods and effect size through
scientifically rigorous research (Rahm Hallberg, 2006; Borglin and
Richards, 2010). The purpose of the study was the development,
implementation and evaluation of an educational programme
regarding the provision of health care during disasters and emer-
gencies in hospitals, by nurses.
Methods
The objectives of the study were to: (1) assess nurses’ baseline
knowledge and behavioral intentions to provide health care during
disasters; (2) develop and deliver a training programme in disaster
education to hospital-based nurses; (3) improve nurses’ knowl-
edge, skills and willingness to respond; and (4) evaluate the
effectiveness of the training programme (before training, imme-
diately after training and 5e6 months later). A randomized
controlled trial (RCT) and, specifically, a Switching Replications
design e two-group experiment with three waves of measurement,
using an intervention and a control group, with parallel pre- and
post-tests and then, the roles are switched and the intervention is
applied to the control while the initial intervention group becomes
the control e was used (Trochim, 2000). This study was approved
by the institutional review boards of each participating hospital.
Sample
Participants in the study were selected from two tertiary public
hospitals in Athens and Thessaloniki metropolitan areas in Greece,
using systematic random sampling. The sample was consisted of
207 registered general nurses. In particular the intervention group
consisted of 112 nurses and the original control group of 95 nurses.
Sample size
A priori power analysis and sample size calculations showed that
176 participants (88 in each group) were required in order to have a
90% chance of detecting as significant (at the 5% level) an absolute
increase in score equal to 5%. Sample size was calculated with 90%
power and 95% confidence interval.
Intervention design
A systematic development of evidence-based nursing inter-
vention was used based on the model of van Meijel et al. (2004).
The first step aimed at examining the evidence already available in
the literature about disaster training programmes for nurses. A
qualitative study in 87 senior nursing students about disaster
training was carried out with the aim to explore gaps in knowledge
before graduation (Pesiridis et al., 2013). Additionally, fifteen
registered nurses and nursing directors, who did not participate in
the training, were interviewed, using an interview guide with
open-ended questions with the purpose to explore nurses’ training
needs regarding the provision of health care during disasters.
The training programme was designed by an educational board
of academics who were experts in public health and community
nursing after examining the above results carefully. In brief, the
final programme consisted of the following domains: (1) defini-
tions and essentials about disaster management; (2) national
emergency plans during disasters, such as fire, earthquake, flood,
drought, extreme temperature, epidemic and the chain of
command; (3) nurses’ role during disasters and emergencies; (4)
triage algorithms; (5) hospital evacuation procedures and safe
transfer of patients; (6) decontamination procedures and (7) the
proper use of personal protective equipment (PPE) during Chemi-
cal, Biological, Radiological and Nuclear (CBRN) incidents. Various
training methods were planned, including case studies, workshops,
tutorials, group discussions, role playing, demonstration and
lecturing as the least used training method. The length of the
programme was set at 8 h during one day.
Procedures
An accompanying letter explaining the purposes of the study
and an informed consent form was attached to each numbered pre-
test questionnaire. Head nurses from each nursing ward were
informed about the study and the randomization procedure and
invited to distribute the questionnaires to nurses and collect them
in sealed envelopes one week later. Nurses were then randomly
assigned to intervention and control groups in each hospital. The
training programme was conducted on separate days for each
group. The first day, participants in the intervention group attended
the 8-h training programme and a post-test was distributed and
returned completed after the end of the programme. The following
day the implementation of the training programme was repeated to
the original control group but unlike the intervention group, a
second pre-test was distributed prior to the training while a post-
test was distributed and returned completed at the end of the
programme. For the follow-up test, a questionnaire was distributed
by the researchers, 5 months after the training. Participants in both
groups completed the same survey questionnaire in all measure-
ments of the study.
Implementation of the training programme
The intervention was conducted by the principal investigator for
all groups at the training center of each hospital which was
equipped with audiovisual aids for training purposes and a light
meal was provided to the participants during the breaks, free of
charge. At the beginning of the training each participant received a
copy of the programme slides and a copy of the National Emergency
Response chain of command attached by the nurses’ role during
emergencies and disasters as described in the national plan for
hospitals. The last session was delivered by the hospitals’ Infection
Control Nurse on the use of different PPE during CBRN incidents. A
demonstration was conducted on the proper donning and removal
of PPE according to Centers for Disease Control and Prevention
(CDC, 2012) followed by clinical practice by participants.
Survey development/validation
A questionnaire was developed to estimate knowledge levels
and behavioral intentions of nurses, regarding the provision of
health care during disasters. Knowledge score was estimated, by
using a knowledge scale, consisting of 19 dichotomous (True/False)
items based on the content of the training programme. If the cor-
rect answer was given, the participant received one point, whereas
an incorrect answer received zero points. To assess behavioral in-
tentions (BI) of nurses, Ajzen’s Theory of Planned Behavior (TPB)
was applied (Ajzen, 1991), following guidelines for constructing a
short version of a TPB questionnaire (Ajzen, 2002). Twelve items
were used in the final BI scale, three for generalized intention, and
additional nine for the predictor variables of the TPB theory which
were attitudes, subjective norms and perceived behavioral control.
All items were answered on a seven-point Likert scale, ranging
from 1 (strongly disagree) to 7 (strongly agree). Demographic
 T. Pesiridis et al. / Nurse Education in Practice 15 (2015) 63e67 65

characteristics, previous training and working experience in di- Table 2

sasters were assessed by 14 additional questions. The final version Demographic characteristics (n ¼ 207).

of the instrument was pretested in 23 postgraduate and doctoral Characteristic Intervention Original Total
students and pilot-tested by 31 registered nurses. group control group n ¼ 207 (%)
Internal consistency and reliability of the knowledge scale items n ¼ 112 (%) n ¼ 95 (%)

were assessed using Kuder-Richardson formula (K-R 20) for Gender

dichotomous questions and was equal to 0.75, while test-retest Male 14 (12.5) 12 (12.6) 26 (12.2)
Female 98 (87.5) 83 (87.4) 181 (87.8)
reliability (instructional sensitivity) was assessed using the Intra-
Marital status
class Correlation Coefficient and was found equal to 0.8 (p < 0.001). Single 34 (30.4) 17 (17.9) 51 (24.6)
Construct validity of the TBP constructs (generalized intention, Married 72 (64.3) 74 (77.9) 146 (70.5)
attitudes, subjective norms, perceived behavioral control) was Divorced 5 (4.5) 2 (2.1) 7 (3.4)
Windowed 1 (0.9) 2 (2.1) 3 (1.4)
assessed by conducting a confirmatory factor analysis. Internal
Dependent children
consistency of each TBP construct was assessed using Cronbach’s a Yes 62 (55.4) 64 (67.4) 126 (60.9)
(Table 1). No 50 (44.6) 31 (32.6) 81 (39.1)
Dependent others except children
Data analysis Yes 16 (14.3) 17 (17.9) 33 (15.9)
No 96 (85.7) 78 (82.1) 174 (84.1)
Level of education
Continuous variables are presented as mean (standard devia- University 7 (6.3) 5 (5.3) 12 (5.8)
tion, SD), while categorical variables are presented as absolute (n) Technological Institution 105 (93.7) 90 (94.7) 195 (94.2)
and relative (%) frequencies. Student’s unpaired t-tests and one- Other qualifications except Bachelor’s in Nursing
Yes 53 (47.3) 48 (50.5) 101 (48.8)
way ANOVAs were used to identify differences in demographic
No 59 (52.7) 47 (49.5) 106 (51.2)
mean scores. Concerning one-way ANOVAs, subsequent post hoc Specify qualifications
tests were corrected with a Bonferroni procedure for multiple Nursing specialty 35 (31.3) 40 (42.1) 75 (36.2)
comparisons. Repeated-measures analysis of variance was used to 2nd degree except Nursing 12 (10.7) 5 (5.3) 17 (8.2)
test differences in knowledge and behavioral intention between MSc, PhD studies 13 (11.6) 12 (12.6) 25 (12.1)
Working department
pre-test, post-test and follow-up test. Post hoc paired t-tests, with
Internal medicine 35 (31.3) 30 (31.6) 65 (31.4)
least significant difference corrections, were used to identify sig- Surgical 38 (33.9) 37 (38.9) 75 (36.2)
nificant pair wise differences in mean test scores. Relationships Pediatric 4 (3.6) 7 (7.4) 11 (5.3)
between pre-test knowledge score and demographic characteris- Psychiatric 6 (5.4) 2 (2.1) 8 (3.9)
ICU 15 (13.4) 13 (13.7) 28 (13.5)
tics were assessed with multivariate linear regression analysis. In
Emergencies 14 (12.5) 6 (6.3) 20 (9.7)
case of regression models, beta coefficients and 95% confidence Previous disaster training
intervals (CI) were estimated. All tests of statistical significance Yes 11 (9.8) 7 (7.4) 18 (8.7)
were two tailed, and P values <0.05 were considered as significant. No 101 (90.2) 88 (92.6) 189 (91.3)
Exception was one-way ANOVAs where p values <0.004 were Professional experience in disasters
Yes 17 (15.2) 10 (10.5) 27 (13)
considered as significant since Bonferroni correction was applied.
No 95 (84.8) 85 (89.5) 180 (87)
Data were analyzed using The Statistical Package for the Social Participation in a hospital drill the past 5 yr
Sciences for Windows, Version 20.0 (IBM SPSS Corp., Armonk, NY). Yes 8 (7.1) 4 (4.2) 12 (5.8)
No 104 (92.9) 91 (95.8) 195 (94.2)
Age [Mean, (SD)] 44 (7.52) yr 45 (6.53) yr 45 (7.15) yr
Results
Years working as 20 (7.97) yr 20 (7.49) yr 20 (7.79) yr
RN [Mean, (SD)]
The response rates for phases 1 and 2 of the study were 100%
and 5 months later 78.7%. Demographic characteristics of both
groups are shown in Table 2.
(b ¼ 0.11; 95% CI ¼ 0.05e0.17; P < 0.001). No statistically significant
relation was detected between pre-test knowledge score and other
Knowledge levels
demographic characteristics. A repeated measures ANOVA was
applied to investigate changes in knowledge over time. After
Knowledge levels of nurses were low before training. Out of a
training, a significant increase in the mean knowledge score was
possible 19 points in the knowledge scale, respondents’ mean
observed in both groups in times 2 and 3 compared to time 1 [pre-
knowledge score was 6.43 (2.8) points. The most commonly missed
test: 6.43 (2.8); post-test: 16.49 (1.7); follow up test: 13.5 (2.8)],
questions were related to the appropriate decontamination pro-
(P ¼ 0.002). No statistically significant relation between time and
cedures of patients who were exposed to CBRN agents (98.4%), the
demographic characteristic was detected. A large effect size (eta-
proper use of PPE (97.1%) the chain of command during emergen-
squared ¼ 0.8) was observed. Also, repeated measures ANOVA was
cies and to whom a head nurse ought to refer (82%). Concerning
applied to investigate changes in knowledge between groups. In
pre-test knowledge scores, those who had attended a course in
that case, changes in knowledge between intervention and control
disaster management the past 5 years had a significantly higher
group in times 1 and 2 were significantly different (Table 3) and a
mean score than those who had not attended such courses
large effect size (eta-squared ¼ 0.8) was observed.

Table 1
Table 3
Reliability measures of TPB constructs (n ¼ 207).
Comparison between groups concerning knowledge scores (n ¼ 207).
TPB construct Cronbach’s a
Group Mean knowledge scores (SD) p < 0.001
Attitudes 0.783
T1 T2
Generalized intention 0.901
Perceived behavioral control 0.571 Intervention (n ¼ 112) 6.52 (2.9) 16.49 (1.7)
Subjective norms 0.926 Original control (n ¼ 95) 6.77 (2.7) 6.89 (3.2)
66 T. Pesiridis et al. / Nurse Education in Practice 15 (2015) 63e67
Nurses’ intention to provide health care during disasters
To determine nurses’ behavioral intentions concerning the
provision of health care during disasters, the total mean score of 3
generalized intention questions was estimated according to TPB.
Out of a possible 21 points, respondents scored high with a mean of
17.65 (3.5) points at pre-test. A multivariate linear regression
analysis with behavioral intention as the dependent variable and
the constructs of the TPB and knowledge score as the independent
variables revealed that subjective norms, perceived behavioral
control and baseline knowledge were strongly correlated. These
three predicting variables explained 70% of the variance in nurses’
intention to provide care to patients during disasters (Table 4). A
repeated measures analysis revealed that no significant improve-
ment in nurses’ behavioral intentions was observed after attending
the intervention and 5 months later (P ¼ 0.26). Also, there were no
significant differences in the mean behavioral intention score be-
tween intervention and original control groups (P ¼ 0.1).
Discussion
The results of this study revealed that nurses’ baseline knowl-
edge concerning disaster education was low while major gaps were
identified in several domains on the pre-test. This suggests that
disaster training is inadequate. This is not surprising, given that
such content has not been covered during undergraduate nursing
education and needs to be considered when determining appro-
priate disaster education and training for students and professional
nurses. Similar to our study, the majority of international studies
identified that knowledge regarding disaster education was rela-
tively low at baseline (Risavi et al., 2001; Slepski, 2007; Idrose et al.,
2007; Felice et al., 2008; Wang et al., 2008; Veenema et al., 2008;
Hammad et al., 2010; Bistaraki et al., 2011). In addition, our study
revealed the association between previous disaster training and
baseline knowledge, providing evidence that any limitation in
these areas can have a negative impact on knowledge.
A primary goal of the study was to improve baseline knowledge
of nurses regarding the provision of health care during disasters
and emergencies. Results from the study showed that the training
programme not only made positive shifts in knowledge but also
results of the follow-up survey showed that the knowledge
remained high 5 months after attending the programme. Several
studies were identified during the literature review involving the
effectiveness of different training interventions regarding disaster
education (Risavi et al., 2001; Harrington and Walker, 2003;
Qureshi et al., 2004; Baez et al., 2005; Elgie et al., 2005; Terndrup
et al., 2005; Idrose et al., 2007; Wang et al., 2008; Veenema et al.,
2008; Olson et al., 2010; Wang et al., 2010; Chan et al., 2010;
Scott et al., 2010; Bistaraki et al., 2011). Most of them were non-
randomized controlled trials and were different in study design,
testing tools, content and training methods. However, they all re-
ported increases in mean knowledge scores and behavioral inten-
tion, pre-test to post-test. Our study design adds to the literature in
a significant way, as one of the major problems in randomized
controlled trials, is the need to deny the training programme to
some participants (control group) through random assignment;
Table 4
Multivariate linear regression analysis with behavioral intention as the dependent
variable (N ¼ 207).
Independent variable b 95% CI
Subjective norms 0.77 0.69e0.84
Perceived behavioral control 0.12 0.04e0.21
Knowledge score 0.007 0.002e0.013
this is that the educational intervention was repeated to the orig-
inal control group after phase 2 and by the end of the study both
groups had attended the programme.
Although no significant interaction between the training pro-
gramme and nurses’ behavioral intentions was detected, our study
supported that the key constructs of the TPB contribute to pre-
dicting nurses’ intention to provide care to victims affected by di-
sasters. In the pre-test, subjective norms, perceived behavioral
control and knowledge contributed significantly to the prediction
of nurses’ intention as shown. These findings are consistent with
those of previous studies examining the positive relationship be-
tween baseline knowledge, perceived behavioral control and sub-
jective norms with nurses’ behavioral intentions (Levin, 1999;
O’Boyle et al., 2001; Armitage and Conner, 2001; Veenema et al.,
2008).
Limitations
Despite our efforts for scientific rigor in terms of validity and
reliability of the study, the training programme cannot be repro-
ducible, as a whole in other countries, because it was developed
according to the Greek National emergency plans.
Conclusions
The study findings provide evidence that nurses’ knowledge is
inadequate by recognizing major gaps concerning the provision of
care during disasters. Moreover, reveals that knowledge is one
critical factor in determining whether hospital-based nurses are
willing to provide care. The training programme met the antici-
pated objectives, by improving nurses’ baseline knowledge con-
cerning disaster education. In addition the study provides
important insights for health care institutions, hospital and nurse
administrators, suggesting that a brief educational intervention is
effective, feasible and has a long term impact on nurses’ knowledge.
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