Disaster Preparedness Among Nurses in China: A Cross-Sectional Study

ABSTRACT Background Increasingly frequent global disasters such as coronavirus disease 2019 pose a threat to human health and life. The World Health Organization has called on countries to formulate detailed plans to prepare for disasters. It is critical to investigate and evaluate the disaster preparedness of nurses. Purpose This study was designed to investigate the disaster preparedness and psychological condition of nurses in China and analyze the significant factors influencing their disaster preparedness. Methods A cross-sectional survey was conducted in 2020, and 1,313 nurses were enrolled using convenience sampling. The study questionnaires were distributed and collected via a networking platform equivalent to Amazon Mechanical Turk. The disaster preparedness of the respondents was measured using the Disaster Preparedness Evaluation Tool, the Hospital Anxiety and Depression Scale was used to evaluate anxiety and depression status, and a self-designed questionnaire developed based on a review of the literature was used to explore the potential factors of influence on disaster preparedness. Results The average score for disaster preparedness among the participants was 186.34 (SD = 40.80), which corresponded with a moderate level, especially in skill (mean score = 42.01, SD = 12.39). Items with higher scores included support for the government, personal protection, and health education, whereas items with lower scores included nursing leadership in the community, capacity to cope with chemical or biological attacks, and assessment of posttraumatic stress disorder. Disaster preparedness was negatively related with mental health, including depression and anxiety. The main factors affecting disaster preparedness included educational background, nursing specialty, prior disaster training, prior disaster rescue experience, and depression level. Conclusions/Implications for Practice The disaster preparedness of Chinese nurses must be improved. More attention should be paid to disaster preparedness in nurses, and future tailored interventions are urgently needed to promote nursing leadership in the community, the ability to cope with chemical or biological attacks, and posttraumatic stress disorder assessments. Moreover, relieving negative emotions to promote the mental health of nurses should receive greater attention.


Introduction
The coronavirus disease 2019  pandemic is a serious global public health disaster, with over 12 million confirmed cases and 517,877 confirmed deaths worldwide as of July 3, 2020 (World Health Organization, 2020). As no effective medicine is currently available, interventions focused on contact tracing, quarantine, and social distancing are crucially important. On the basis of the transmission dynamics of the COVID-19 postpandemic period, Kissler et al. (2020) noted that prolonged or intermittent social distancing may be required into 2022. The above unfavorable conditions of COVID-19 may lead to new challenges for disaster preparedness.
Disaster preparedness is defined as the reserve of knowledge and capacity to effectively respond to disasters (United Nations Office for Disaster Risk Reduction, 2015), which is the foundation of disaster nursing. Within the disaster nursing capacity framework, nursing disaster preparedness may be divided into three dimensions (knowledge, skills, and postcrisis management) and four periods (prevention, preparedness, response, and recovery;International Council of Nurses, 2009). To improve disaster preparedness capabilities, healthcare workers should be a priority focus (Hattori et al., 2021;Lee & Kang, 2017;Rattanakanlaya et al., 2016). Nurses play various roles at each stage of a disaster, including as caregivers, rescuers, educators, coordinators, and managers (Y. Zhang et al., 2016). The Disaster Nursing Specialized Committee of the Chinese Nursing Association has attached importance to developing disaster nursing, aiming to enhance the disaster response abilities of nurses since 2009 (Li et al., 2015). A recent review showed that a disconnect had emerged in disaster nursing development in China and that inadequate focus has been given to disaster prevention, preparedness, and recovery (Y. Y. Zhang et al., 2018). Moreover, studies have reported Chinese nurses as being insufficiently prepared and not confident in their ability to respond to disasters, especially with regard to their disaster nursing skills (Xu et al., 2016;Zhen & Yu, 2014). During the current pandemic, medical systems guided by the Chinese government have paid great attention to disaster response skills training, with a large number of nurses trained, especially in Hubei Province, which first reported and detected COVID-19 (Y. . Thus, assessing the disaster preparedness of Chinese nurses in the post-COVID-19 era is urgently needed. Many factors (e.g., disaster-related training, disaster response experience, educational status, department type; Jang et al., 2021;Labrague et al., 2018) have been shown to be related to disaster preparedness in nurses. Increasing attention has been recently given to the psychological health of healthcare workers, with depression and anxiety identified as potentially important risk factors affecting the disaster preparedness of nurses. As one of the most important disaster responders, nurses, although sharing a similar environment to survivors, face more significant challenges than survivors (Boswell, 2014). Besides, nurses experience more serious mental health disorders than other healthcare workers based on their emotional bonding with victims (Naushad et al., 2019). Depression and anxiety in nurses have been found to co-occur with disasters at respective rates of 30.3% and 25.8% (Pappa et al., 2020). Depression leads to hopelessness, which may reduce one's motivation to respond to disaster (Bodas et al., 2017). The avoidance behaviors associated with stressful experiences may appear and decrease disaster preparedness (L. James, 2014). Furthermore, the findings of several studies indicate an association between anxiety and a decline in disaster preparedness in various situations, including conflict (Bodas et al., 2017) and heatwaves and flooding (Mishra & Suar, 2012). Meanwhile, psychological education has been shown to positively affect general disaster-preparedness self-efficacy and perception (Kılıç & Şimşek, 2019). Thus, depression and anxiety in nurses may negatively impact their disaster preparedness (L. E. James et al., 2020). In this study, depression and anxiety in nurses along with other factors including disaster-related training, disaster response experience, educational status, and department type are hypothesized to significantly influence nurses' disaster preparedness.
Therefore, this study aimed to clarify the current status of disaster preparedness in nurses who have experienced the COVID-19 pandemic and to identify the influencing factors of nursing disaster preparation.

Design and Sample
This was a cross-sectional study. Convenience sampling was used to recruit nurses from Grade III hospitals in Hubei, Zhejiang, Liaoning, and Sichuan Provinces in China from April 21 to May 5, 2020. Hubei province was the first place in the world to report and detect COVID-19. According to the Hospital Grading System, Grade III hospitals maintain the highest level of medical and nursing competence in China (National Health Commission of the People's Republic of China, 2011). The inclusion criteria were (a) being a registered nurse and (b) willing to participate in the study. Nurses who were on vacation or in training at other hospitals were excluded. G*Power 3.1 was used to calculate the sample size. The minimal significance α and statistical power (1 − β) were set as .05 and 0.99, respectively. F 2 was set as 0.15 (medium). Calculations were performed for linear multiple regression analysis, and the required sample size was defined as 341, including a 20% sample loss rate buffer.

Disaster preparedness
The Disaster Preparedness Evaluation Tool (DPET), developed by Bond and Tichy to measure nurses' disaster preparedness, addresses knowledge, skills, and postdisaster management (Tichy et al., 2009). The Cronbach's alpha for the overall scale, knowledge subscale, skills subscale, and postdisaster management subscale were .91, .93, .93, and .91, respectively (Xu et al., 2016). Zhen and Yu (2014) translated the questionnaire into Chinese (DPET-C). The DPET-C consists of three dimensions and 45 items (knowledge: 13 items, skill: 11 items, and postdisaster management: 21 items). Each item is scored using a 6-point Likert scale, with scores ranging from 1 (strongly disagree) to 6 (strongly agree). Total possible scores for the scale range from 45 to 270 (13-78 in the knowledge dimension, 11-66 in the skill dimension, and 21-126 in the postdisaster management dimension), with higher scores reflecting better disaster preparedness. Items scores of 1-2.99, 3-4.99, and 5-6 indicate poor, moderate, and good disaster preparedness status, respectively. The DPET-C is widely used in China and has been shown as reliable, with an overall Cronbach's alpha of .87.

Anxiety and depression
Anxiety and depression were measured using the Chinese version of the Hospital Anxiety and Depression Scale (HADS; Leung et al., 1999). The HADS, developed by Zigmond and Snaith (1983), is a widely used scale to measure an individual's level of anxiety and depressive symptoms. HADS is a 14-item instrument with two 7-item subscales that respectively measure anxiety and depression. Each item is scored using a 4-point Likert scale ranging from 0 to 3. Total possible subscale scores range from 0 to 21, with higher scores indicating higher levels of anxiety or depression. A systematic review by Bjelland et al. (2002) identified that a cutoff score of 8 for anxiety and depression and achieved an optimal balance between sensitivity and specificity. The Chinese version of HADS has been validated in The Journal of Nursing Research Ying WANG et al. Chinese populations and showed good reliability and validity (Leung et al., 1999).

Personal characteristics data
Data on potential factors influencing disaster preparedness were collected using a self-designed questionnaire developed based on a review of the literature. These factors included age, marital status, educational background, hospital location, department, work seniority, professional title, nursing position, COVID-19 work experience, volunteering to work on the front lines of COVID-19, prior disaster response experience, and prior disaster education/training experience.

Statistical Analysis
Data were imported from the network platform into IBM SPSS Statistics 20.0 (IBM Inc., Armonk, NY, USA) for analysis. Descriptive statistics were used for demographic characteristics, disaster experience, level of disaster preparedness, anxiety, and depression. Categorical characteristics were described using absolute and relative frequencies. Numerical variables were described using mean and standard deviation. Differences in disaster preparedness among groups with different levels of depression and anxiety, demographic information, and disaster experience were compared using Pearson's correlation analyses, independent sample t tests, and one-way analyses of variance. Variables with p < .1 in the above tests were input into the multivariable linear regression model to determine the predictors of disaster preparedness. Significance was determined at p < .05 with a 95% confidence interval.

Data Source and Ethical Considerations
The study was approved by the institutional ethics review board of the hospital (No. TJ-IRB20200379). Before recruiting participants, the study title, research purpose, inclusion criteria, exclusion criteria, and informed consent were posted online via the office automation systems of these hospitals. Participation in the survey was anonymous and voluntary, and nurses were informed that they were free to participate in the study or not and that they could withdraw from the study at any time. The researchers submitted the informed consent and questionnaire online and created a link on a professional online questionnaire survey, evaluation, and voting platform in China. The link was forwarded by the head nurse of each hospital. Participants received the link and then filled out the questionnaires on the website platform. The survey ended when nurses completed and submitted the questionnaire as instructed.

Results
One thousand three hundred sixty-seven nurses submitted completed questionnaires. Fifty-four submissions were excluded because of illogical answers, leaving 1,313 valid questionnaire data sets (96.0%) available for analysis.

Characteristics of Participants
Most of the participants were 26-34 years old (53.1%), female (97.5%), married (56.4%), and educated to the undergraduate level (90.9%). About half of the sample were recruited from hospitals in Hubei Province (59.6%), with the remaining 40.4% recruited from Zhejiang (n = 494), Liaoning (n = 12), Sichuan (n = 7), and other provinces (n = 18). Most had volunteered to work on the front lines of COVID-19 (67.0%), whereas 34.4% had actual frontline experience. Participants with prior disaster response experience and disaster education/training experience accounted for 3.9% and 28.9% of the sample, respectively, whereas those with prior infectious disease response and infectious disease education/ training experience accounted for 2.4% and 16.0% of the sample, respectively (Table 1).

Disaster Preparedness of Chinese Nurses in the Post-Coronavirus-Disease Era
The mean scores for overall disaster preparedness, knowledge, skills, and postdisaster management were 186.34 AE 40.80, 57.27 AE 11.61, 42.01 AE 12.39, and 87.06 AE 19.96, respectively. The average item score was 4.14 AE 0.91, indicating a moderate level of disaster preparedness. In addition, the average sores for each item in the knowledge, skills, and postdisaster management subscales were 4.41 AE 0.89, 3.81 AE 1.13, and 4.14 AE 0.95, respectively. Details on the Top 3 items with the highest and lowest score in each dimension of disaster preparedness are presented in Tables 2 and 3. The item with the highest score was "In case of a disaster situation, I think that there is sufficient support from officials at the county, regional, or national government level." Meanwhile, the item with the lowest score was "I would be considered a key leadership figure in my community during a disaster situation."

Univariate Analyses of Disaster Preparedness
Independent sample t tests and one-way analyses of variance indicated statistically significant differences in disaster preparedness scores among nurses with different educational backgrounds, departments, frontline COVID-19 volunteering status, prior disaster response experience, and prior disaster education/training experience ( p < .001; Table 4).
Furthermore, the mean scores for anxiety and depression and were, respectively, 4.61 AE 3.00 and 3.58 AE 3.20, whereas the occurrence of depression (HADS-A ≥ 8) and anxiety (HADS-D ≥ 8) were 16.1% and 11.4%, respectively. On the basis of the results of Pearson's correlation analyses, disaster preparedness was negatively associated with anxiety (r = −.163, p < .001) and depression (r = −.235, p < .001).

Regression Analyses of the Factors of Disaster Preparedness
A multiple linear regression model was computed to avoid confounding factors, and variables that had a significant Disaster Preparedness Among Nurses VOL. 31, NO. 1, FEBRUARY 2023 correlation with disaster preparedness were retained in the model. According to the results of the regression analyses, educational background (junior college and undergraduate), department (including pediatrics, intensive care unit [ICU], and other departments), prior disaster education/ training experience, frontline COVID-19 volunteering status, and depression explained 11.7% of the total model variance. After adjusting for collinearity, depression was found to be negatively correlated with disaster preparedness, and prior disaster education/training experience and volunteering to serve on the front lines of COVID-19 were shown to be positively related. The disaster preparedness of junior college and undergraduate nurses were significantly higher than that of postgraduate nurses. Nurses from departments of pediatrics, ICU, and other departments had lower disaster preparedness than emergency nurses (Table 5).

Discussion
This cross-sectional study was conducted to assess Chinese nurses' perceptions of disaster preparedness as well as potential influencing factors. In general, the strong organizational capabilities and sufficient support of the Chinese government make nurses feel confident in response to a disaster (The Lancet, 2020; Q. . However, the participants in this study reported a moderate level of disaster preparedness, with lower scores for questions related to disaster skills. The results showed that participants had lower abilities related to chemical/biological attack response and posttraumatic stress disorder (PTSD) assessment. As public health educators, the leadership role of nurses in the community was found to be inadequate.
The results of this study indicate that nurses with higher educational levels had significantly lower disaster preparedness. Junior college and undergraduate nurses had better disaster preparedness than postgraduate nurses. Two cross-sectional surveys (Xu et al., 2016;Yang et al., 2015) of Chinese nurses also supported this negative association between educational level and disaster preparedness. In addition, recent research (Jang et al., 2021) exploring the influencing factors affecting disaster response readiness in nurses from the Republic of Korea suggest that educational status is negatively associated with nurses' disaster response readiness in clinical management. However, our results are inconsistent with a study conducted in hospitals in Malaysia (Ahayalimudin & Osman, 2016), which found a positive association between educational level and disaster preparedness knowledge and practice skill in nurses. The possible reason for these inconsistencies in results may be that postgraduate nurses report a lower nursing competence, especially in clinical practice (Wangensteen et al., 2018). In addition, given the bias inherent in convenience sampling, nurses of different educational statuses in this study were similar in age (Table 6). Junior college and undergraduate nurses master higher skill levels and receive more hands-on experience and more education and training in daily work, which are all important to effective disaster preparedness (Labrague et al., 2018). In this study, participants who worked in emergency departments scored highest overall on disaster skill preparedness, which is consistent with prior research (Hodge et al., 2017;Nilsson et al., 2016). The work of the emergency de-partment involves multiple systems of knowledge that overlap significantly with disaster care knowledge and skills. Thus, these nurses have acquired rich first aid knowledge, skills, and experience in their work that may prepare them better for emergencies than nurses in other departments (Nilsson et al., 2016). In addition, the results of this study In case of a disaster situation, I think that there is sufficient support from officials at the county, regional, or national government level.   The Journal of Nursing Research Ying WANG et al. also indicate that nurses in ICUs, pediatrics, and other departments lack emergency knowledge, skills, and experience and are thus significantly less prepared for disasters than their emergency department peers. Thus, it is imperative that hospitals conduct hierarchical and targeted nursing training based on the nature and needs of each department. Besides, hospitals may strengthen interdepartmental cooperation and knowledge and skill sharing so that each department can play an important role in disaster relief. The result of multiple regression analyses showed prior disaster education/training experience to be significantly and positively associated with higher levels of perceived competence in disaster preparedness. This finding aligns with prior research showing that properly trained healthcare workers cope with disaster events more efficiently than untrained healthcare workers in hospitals (Goniewicz et al., 2021). Most of the disaster management knowledge and skills of nurses are acquired from practical exercises and disaster training (Al Thobaity et al., 2015). In this study, only 3.9% and 28.9% of participants, respectively, had disaster response and disaster education/training experience. Disaster education/training was shown to be inadequately available. Therefore, it is necessary to carry out disaster and emergency education for nurses regularly to help nurses better cope with disaster situations (Öztekin et al., 2016) and to improve their self-efficacy and self-confidence (Chandra et al., 2014). Self-efficacy may be defined as an individual's belief in their ability to cope with difficult life events, which has a positive correlation with disaster situations . In addition, the availability of training programs was another important issue that relates to the objective disaster preparedness and disaster response capabilities of nurses. Prior research has shown workshops, seminars, and simulations to be effective forms of related training.
Disaster Preparedness Among Nurses VOL. 31, NO. 1, FEBRUARY 2023 associated with disaster preparedness competence in this study. According to Deci and Ryan's (2000) self-determinism theory, the four factors influencing engagement are individual differences, self-regulation of behavior, perceived competence, and healthcare climate, which may affect how an individual responds to disaster events. In this study, "volunteering to work on the front lines of COVID-19" reflected selfregulation behaviors, thus making this an important predictor of disaster preparedness . Nurses who actively participate in disaster management and help others may indicate a motivation to learn knowledge and skills related to disaster preparedness . These nurses have a high sense of self-efficacy and believe in their own ability to deal with difficulties (Baack & Alfred, 2013). These implications indicate that interventions, including disaster training and psychological support, should be strengthened for nurses who are less willing to respond to disasters. The participants in this study with depressive symptoms had lower average scores for disaster preparedness than their peers without depressive symptoms. Previous research has found the most common mental disorders among disaster-affected populations and disaster relief workers in disaster situations to be PTSD, depression, and grief (Ahayalimudin & Osman, 2016). Mental disorders may affect not only a person's ability to recover from disasters but also their ongoing disaster preparedness (L. E. James et al., 2020). In addition, the literature indicates that mental state is an intermediary factor and that the impact of disaster preparedness interventions on disaster preparedness is mediated by mental state (L. E. James et al., 2020). The International Council of Nurses also believes that disaster nursing competencies must include the psychological elements and competencies of nurses (Hutton et al., 2016). In this study, depression was found to affect perceived disaster preparedness, which suggests that the psychological status of nurses should be considered and assessed to improve their performance in disaster response.

Conclusions
In conclusion, the results of this research indicate that nurses are filled with security and confidence in responding to di-saster under the guidance of the Chinese government. However, the disaster preparedness of nurses in China in the post-COVID-19 context was found to be low to moderate, especially in terms of chemical or biological attacks, PTSD assessment, and roles in the community. The results revealed educational background, working department, disaster education/training experience, and experience on the COVID-19 front lines to significantly affect disaster preparedness in the participants. In addition, depression was found to correlate negatively with disaster preparedness. Therefore, the government, hospital administration, and nursing educators should prioritize the development and implementation of educational policies and training programs to improve the disaster preparedness of nurses. In the meantime, disaster nursing education should be improved and strengthened in the standard nursing curriculum. Furthermore, training programs should focus on practical disaster preparedness scenarios. In addition, the mental health status of nurses was shown to significantly affect disaster preparedness and thus should be monitored dynamically. Hospitals and health organizations should provide psychological interventions in a timely and comprehensive manner to improve the self-psychological adjustment ability of nurses.

Limitations
This research provides the basis for improving nurse training and education as well as related disaster response capabilities. However, multivariate analyses should be conducted in future studies to confirm the importance of the each identified factor of influence on nurses' knowledge, skills, and postdisaster management capabilities. Another limitation of this study was the limited scope of recruitment. Half of the participants in this study worked in Grade III hospitals in Hubei Province in Central China. As disaster preparedness is relevant to nurses nationwide, future research should explore the disaster preparedness of nurses throughout China. The Journal of Nursing Research Ying WANG et al.