Introduction
Background
A disaster can be defined as an event that relies on the need for external resources to maintain operation capacity of essential services, following an interruption of the normal functioning of a community or service.1 One such resource includes the mobilization of health professionals, including nurses, to provide assistance to establish, maintain, or re-establish an operational heath service to the effected community following a disaster event.Reference Ranse, Hammad and Ranse2 It is acknowledged that, internationally, nurses are actively involved in the health assistance to disasters. In addition to assisting when disasters happen, nurses are involved in many other aspects of disaster health, including being providers of disaster education, undertaking research, and developing policy.
There is an increasing amount of literature pertaining to the work of nurses in disasters. In particular, this literature has included personal anecdotes, reflections, and accounts of single case studies from single disastrous events.Reference Moynahan3, Reference Chiarella4 More recently, the amount of exploratory research pertaining to disaster nursing is increasing. Issues explored in the literature include the willingness of nurses to assist in disasters,Reference Arbon, Ranse and Cusack5-Reference Adams and Berry7 the role of nurses in disasters,Reference Ranse and Lenson8-Reference Suserud and Haljamae10 leadership,Reference Chally, Hernke and Scaz11-Reference Johnson14 competencies,Reference Daily, Padjen and Birnbaum15, Reference Gebbie and Qureshi16 and educational preparedness of nurses.Reference Burstein17-Reference Williams, Nocera and Casteel22
While the volume of research and evaluation of disaster research pertaining to nursing is increasing, it is beneficial to have an agreed list of research areas that would assist the larger nursing population in enhancing the theoretical understanding of disaster nursing. This enhanced understanding of disaster nursing would better prepare the nursing population to assist in, and take a leading role in, nursing aspects of disasters.
Aim
The aim of this research was to determine the international research priorities for disaster nursing.
Methods
Design
This research addressed its aim by implementing a three-round Delphi technique interspersed with controlled feedback that sought to gain the most reliable ranking of research priorities in the field of disaster nursing. This design is appropriate for many reasons. It is a method for structuring a group's communication process, allowing a group of individuals as a whole to deal with a complex situation.Reference Keeney, Hasson and McKenna23 It provides relevant and accurate information to facilitate decision making and determining the extent of agreement over a given issue such as research priorities for the field of disaster nursing.Reference Keeney, Hasson and McKenna23 There is currently a lack of international empirical evidence for research priorities in the field of disaster nursing, and this study will address this gap.Reference Mackway-Jones and Carley24
Data Collection
Round One
The first round of this research was held at the 18th World Congress on Disaster and Emergency Medicine, May 2013 in Manchester, United Kingdom. Participants of this round included members of the World Association for Disaster and Emergency Medicine (WADEM) Nursing Section. All participants (N = 37) voluntarily contributed to this round, which was conducted as a workshop to generate statements relating to possible research questions. During this workshop, 39 statements were generated. Following the workshop, the researchers reviewed all statements. Once reviewed, duplicate statements were combined while some statements were split, yielding a total of 38 statements from round one.
Round Two
Nursing members from WADEM and the World Society of Disaster Nursing (WSDN) were recruited in a purposive manner using an e-mail distributed via the existing membership databases of WADEM and WSDN. Those wishing to participate voluntarily followed a link in the invitation e-mail, directing them to an online survey tool relating to this research project. The survey included simple demographic information and a list of statements generated in round one. Participants were asked to rank the research statements using a 5-point Likert scale with 1 representing the term “strongly disagree,” 2 “disagree,” 3 “neither disagree nor agree,” 4 “agree,” and 5 representing the term “strongly agree.”
Round Three
Recruitment of participants for the third round was similar to that in round two: an invitation e-mail was sent to all nursing members of WADEM and WSDN. As each survey was anonymous and voluntary, this round may have included and/or excluded participants from the previous round. Additionally, this round included new statements that were suggested by the participants of round two and that were different from those already listed as statements from the first round.
Data Analysis
Debate exists in the literature pertaining to the most appropriate way to analyze Delphi studies.Reference Keeney, Hasson and McKenna23 However, the major statistics used in Delphi studies are measures of central tendency, in order to present information concerning the collective position of participants.Reference Keeney, Hasson and McKenna23, Reference von der Gracht25 For this research, a research priority was considered if a statement had a mean score of four or greater. The statements from round one were all included in round two; those from round two that were considered a priority were subsequently included in round three. Again in round three, data analysis was undertaken using means of central tendency, whereby statements were considered a priority if a mean score of four or greater was achieved.
Protection of Human Participants
This research was considered and approved by the University of Canberra Human Research Ethics Committee, reference 13-07. Participants were approached via WADEM and WSDN. The researchers on this project did not directly contact any participant or nonparticipant. Participation in this research was voluntary and anonymous. Written consent was obtained from participants in round one. Consent was implied for rounds two and three where participants completed the online voluntary and anonymous survey. Nursing members of WADEM and WSDN who were nonparticipants of this research were not known to the researchers.
Findings
Participant Demographics
The participant demographics from all rounds of this research are outlined in Table 1.
Table 1 Participant Demographics
Research Statements
Round One
A total of 38 final statements were included in the first round of this project (Tables 2-5).
Table 2 Education, Training, and Curriculum Research Statements
aThis statement was only included in round three as it was generated in round two.
bThis statement was only included in round two as it did not reach consensus to progress to round three.
Table 3 Psychosocial Research Statements
aThis statement was only included in round three as it was generated in round two.
Table 4 Strategy, Relationship, and Networking Research Statements
aThis statement was only included in round three as it was generated in round two.
bThis statement was only included in round two as it did not reach consensus to progress to round three.
Table 5 Clinical Practice Research Statements
aThis statement was only included in round three as it was generated in round two.
bThis statement was only included in round two as it did not reach consensus to progress to round three.
Round Two
Of the 38 statements included in this round, 24 were considered a priority. During this round, 12 additional statements were generated by participants. Nine of these statements were added to the existing 24 consensus statements, while three were not added as they were repetitive of existing statements. Overall, 31 statements progressed to be included in round three.
Round Three
Of the 31 statements included in this round, 27 were considered a priority. The top ten priority statements and their associated areas of research are highlighted in Table 6.
Table 6 Top Ten Research Statements and Research Areas
Education, Training, and Curriculum
The topic of education and curriculum development was highlighted to be of particular interest in the early stages of this Delphi research project. This is evidenced by the 21 research statements that were generated pertaining to this topic. However, it is noteworthy that only 38% (n = 8) of the 21 statements were considered a priority (Table 2), and only two emerged within the top ten research priorities for disaster nursing (Table 6).
Psychosocial
All statements (100%, n = 5) regarding psychosocial aspects of disaster nursing were ranked as a priority area (Table 3) and all psychosocial aspects of disaster nursing appeared in the top ten consensus statements. Additionally, psychosocial aspects of disaster nursing constituted the top three research statements overall. This was the only research area to achieve this level of prioritisation.
Strategy, Relationship, and Networking
While 64% (n = 9) of statements in this category were ranked as a priority (Table 4), only one research statement pertaining to strategy, relationship, and networks appeared in the top ten priority statements.
Clinical Practice
The majority of statements (71%, n = 5) relating to clinical practice were highlighted as a priority research statement (Table 5). Furthermore, two statements relating to disaster nursing clinical practice appeared in the top ten statements of research priorities.
Discussion
Participant Demographics
The participants of this research are representative of multiple countries from multiple continents, highlighting the international viewpoint of this research. The majority of the participants held either a Masters Degree, Doctoral Degree, or were Doctoral candidates. Additionally, most had been involved in the field of disaster nursing for more than eight years, and involved in nursing for more than 18 years.
Research Statements
Education, Training, and Curriculum
Interestingly, the statements of consensus pertaining to education, training, and curriculum focused on researching the way in which disaster nursing is taught and who teaches it, rather than what to teach, such as in the intricacies of competencies or curriculum. This is not surprising as current disaster nursing literature has extensive discussions about education, training, and competencies.Reference Daily, Padjen and Birnbaum15, Reference Gebbie and Qureshi16, Reference Gebbie, Hutton and Plummer26, Reference Littleton-Kearney and Slepski27 Additionally, all statements pertaining to disaster nursing and undergraduate curriculum did not reach consensus. As such, the research suggests that disaster aspects of nursing curriculum are not a research priority area for disaster nursing. Furthermore, this may be the case as the current literature pertaining to disaster content in undergraduate and postgraduate curriculum has been explored in the literature.Reference Usher and Mayner20, Reference Ranse, Shaban and Considine21
Psychosocial
As evidenced in the findings, psychosocial aspects of disaster nursing are highlighted as the primary key research priority area for disaster nursing. Psychosocial care relates to both the psychosocial or mental health needs of the community and to the psychosocial or mental health wellbeing of nurses who assist in disasters. There are established links between extreme weather events, such as bushfires, heatwaves, flooding, droughts, and earthquakes, resulting in an increased incidence of mental health problems, such as depression.Reference Speldewinde, Cook, Davies and Weinstein28 The mental health impacts of disasters are particularly well recognized within populations such as rural people, farmers, and rural men.Reference Saniotis and Irvine29 The immediate and enduring adverse mental health impacts of both environmental and natural disasters are associated with emotional distress related to experiences of fear and loss, and later trigger longer-term helplessness and depression.Reference Warsini, Mills and Usher30 Furthermore, there are a number of published works pertaining to the psychosocial needs of communities following disasters and the longitudinal psychosocial effects of disasters.Reference Carr, Lewin and Webster31 However, the link between nurses in a disaster and the psychosocial needs of a community pre, during, and post disaster is scantly reported in the literature.Reference Ranse and Lenson8 This link is an area that could be the focus of further research, particularly in exploring the nurses’ role in enhancing the psychosocial wellness of a disaster affected community. When considering the nurses themselves, limited literature discusses the psychosocial wellbeing of nurses.Reference Zhen, Huang and Jin32, Reference Shih, Liao, Chan and Gau33 As such, future research should focus role of nurses in providing psychosocial support during disasters and the psychosocial wellbeing of nurses who assist in disasters.
Strategy, Relationship, and Networking
When compared to other research areas, strategy, relationship, and networking represented an area with the least focus as a priority research area from this research. However, of those statements that were identified as a research priority, these relate to the need to work collaboratively and strategically in a coordinated approach to researching education, curriculum, psychosocial aspects of care, and clinical practice. Possibly, the research statements associated with this research area are tenuous and less concrete than those seen in other areas.
Clinical Practice
Statements related to patient safety, standards of care, and use of evidence in disasters were highlighted as priority statements in the research area of clinical practice. It is no surprise that disaster nursing clinical practice is an area of research priority, as the subspecialty of disaster nursing is in its infancy, and due to the nature of disasters, the understanding of clinical practice in this context is underdeveloped. Personal anecdotes, reflections, and descriptive accounts of nursing in disasters commonly discuss an aspect of clinical practice.Reference Ranse and Lenson8, Reference Zhen, Huang and Jin32 In particular, the clinical aspects of care in a disaster are discussed in the broader health perspective of the health response, instead of focusing specifically on the nursing role in providing clinical care.Reference Palmer, Stephens and Fisher34-Reference Halpern, Rosen and Carasso36 As such, it is reasonable to expect that further research pertaining to clinical practice would be a logical progression from the current understanding in the literature. This research should be undertaken using an all-hazards approach to develop a comprehensive understanding of nursing practice in all disaster contexts.
Study Limitations
This research was undertaken with nurses who have membership with WADEM and/or WSDN. As such, the participants in this research may not represent all nurses who have insights into disaster nursing. For example, if this research was undertaken using a different recruitment strategy, such as recruiting participants from a different nursing association or society, the statements and level of consensus may have been different.
Conclusion
This is the first international study to generate research statements and consensus regarding the research priorities for disaster nursing over the next five years. Using a workshop to generate statements and two survey rounds, a number of consensus research priorities for disaster nursing were identified. Overall, the key research priority area identified pertains to the psychosocial aspects of disaster nursing. The research areas of clinical practice, education, training, and curriculum were identified as lower priority for disaster nursing research. Finally, the areas of strategy, relationship, and networking were identified as the lowest research priority areas.
