Overestimated, still less than competent: A cross-sectional study concerning emergency department registered nurses’ disaster preparedness

Major incidents continue to pose a threat to health care systems by overwhelming them with a sudden surge of patients. A major factor impacting a hospital's surge capacity is the skills, abilities, and knowledge of emergency department registered nurses. The level of disaster nursing competency they possess affects patient safety and outcome. ED RNs' ability to accurately assess their competency and knowledge is imperative for mitigating the effect of major incidents. ED RN’s perception of overall disaster preparedness has not been thoroughly addressed. The aim of this study was to assess emergency department registered nurses' self-perceived disaster preparedness. The study was a cross-sectional study. A self-assessment questionnaire based on the results of a study identifying specic disaster nursing competencies for emergency department registered nurses was distributed to all emergency department registered nurses at six participating hospitals between January 10 th to February 19 th of 2019. A ve-point Likert-type scale was used to assess competency.


Background
Major incidents (MI) threaten to overwhelm the health care system by causing a sudden surge of patients in need of health care, [1][2][3][4][5]. Hospitals play critical roles in providing care during MIs [6,7]. Vital strategic measures include increasing facilitating surge capacity through the allocation of resources, level of hospital response, and activating alternative, time-effective triage systems [8,9]. Hospital's surge capacity is determined by several factors (staff, stuff, structure, and system,). In relation to staff, front line responders, such as emergency department (ED) registered nurses' (RN) skills, knowledge and abilities are essential for providing quality care and minimizing excess morbidity and mortality [10][11][12]. A sudden surge of patients to EDs places responsibility on frontline responders often requiring RNs to quickly adapt to meet needs from a wide variety of events as stipulated by the all-hazards approach utilized in disaster response plans [9,13]. ED RNs often hold strategic managerial positions in the disaster management plan, emphasizing the nurses' roles in disaster response [12].

Disaster nursing
The International Council of Nurses (ICN) recognizes the importance of nurses' disaster competency in mitigating the effects of MIs, by outlining general disaster core competencies, and emphasizing the need for speci c disaster core competencies [13,14]. Disaster nursing is de ned as the ability to apply and adapt the application of competencies to a large variety of events with limited resources to mitigate the effects of an MI [14]. Registered nurses constitute the largest group of medical professionals and emergency department RNs are among the rst to receive, assess, and treat victims from a major incident. Thus, underscoring ED RNs' role in patient safety [4,15]. It is generally recognized that ED RNs' disaster competencies, during and after a major incident are crucial [14,16]. ED RNs' ability to accurately assess their competency, knowledge gaps and needs is imperative for patient outcomes [17].
National doctrines and health organizations stipulate the need to both develop disaster medicine competencies for a broad range of possible incidents and evaluating preparedness [18,19]. Despite its importance, little attention has been given to evaluating ED RNs' disaster nursing competencies possibly.
Evidence supports that self-assessments, although subjective are a valid measurement of competency and are often used to evaluate RN clinical competency [17,20]. Previous studies employing selfassessment instruments to evaluate RNs' disaster preparedness have reported moderate to low levels of disaster preparedness [21][22][23][24][25][26][27]. However, ED RNs' perception of overall disaster preparedness has not been addressed. There are to our knowledge, no prior studies assessing ED RNs' perceptions of their disaster competencies in relation to disaster preparedness and as measured by an instrument constructed speci cally for ED RN's.

Aim
The aim of the current study was to assess emergency department registered nurses' self-perceived disaster preparedness.

Methods
Study design: A cross-sectional study using descriptive and inferential statistics.
Participants and Setting: All seven major emergency departments in the region of Stockholm, Sweden were invited to participate.
Six accepted. The study period was January 10 th to February 19 th of 2019. Inclusion criteria were all emergency department registered nurses employed at the respective Eds. Nurses employed by independent sta ng agencies were excluded due to them not having an email address connected to the hospital.

The questionnaire
The questionnaire used to evaluate preparedness was a questionnaire based on competencies essential for RNs working in the ED during an MI as identi ed through expert consensus [28]. The questionnaire had three parts; 9 items concerning general background, 60 items relating to self-assessment, and two questions relating to knowledge of surge and disaster response. The 60 items concerning nurses' selfassessed disaster competencies used a ve-point Likert-type scale. The self-assessment scale, which corresponded to Benner's stages of clinical competence (1=Novice, 2= Advanced beginner, 3= Competent, 4=Pro cient, 5= Expert [29]) was explained and de ned in the questionnaire.
A pilot study was conducted with registered nurses enrolled in emergency nursing and ambulance masters' programs at Sophiahemmet University. The aim of conducting the pilot study was to assess comprehension of the items, understanding of the Likert-type scale used as well as to assess the amount of time required to complete the questionnaire. A total of 15 questionnaires were completed. Participants suggested adjustment of some of the wording of the items to aid in clarity. The questionnaire took between 7-20 minutes to complete. The authors analyzed feedback and edited items to decrease lexical ambiguity.

Data collection
An email with information detailing the study and a link to the questionnaire was sent to hospital managers for distribution. Hospital managers then mailed the information and link to ED RNs. Data collection was completed using a closed link to Google Forms® which was emailed to the participants. The questionnaire was closed two weeks after a third reminder.

Data analysis
Data from the online questionnaire was rst transferred to Microsoft® Excel® for O ce 365, coded and then imported to IMB® SPSS® version 26.0 for analysis. To explore possible underlying relationships of items, or variances between items measuring competency, an exploratory factor analysis was conducted [30]. Internal reliability of the instrument was assessed using Cronbach's α. In addition to descriptive statistics, the Mann-Whitney u-Test, Kruskal-Wallis, were used to assess differences between groups and means. Correlation analysis was conducted using spearman's tau-b correlation and chi-squared.
The response alternative "uncertain" was treated as user missing data resulting in dichotomization of prior MI response experience, disaster medicine education at the bachelor's level, and education level (bachelor and advanced). This also reduced the number of categories for "frequency of training" from ve to four.

Ethical Considerations
Ethics approval was obtained by the Swedish Ethical Review Authority Diary number 2018/2142-31. Each participant was provided a description of the study and informed that participation was voluntary, and anonymity assured.

Background data
Seven hospitals were invited to participate; one declined. The study population according to ED management was comprised of a total of 372 registered nurses employed at the six participating emergency departments. A total of 140 nurses answered the questionnaire resulting in a response rate of 38% (n=140/372). The majority of the nurses (70.4%) were between the ages of 26-44. 65% percent of nurses had more than ve years of nursing experience. 40% percent of the participants reported having prior major incident experience. 30% of the registered nurses had advanced degrees within a variety of specialties. In addition, 54.6% of registered nurses had disaster medicine as a part of their bachelor's curriculum (Table 1).    A correct answer in relation to alternative triages systems was positively correlated with education (ρ=.007). 73.3% of the RNs with advanced degrees answered correctly as compared to 47.9% with bachelor's degrees answering correctly. In addition, frequency of training was also positively correlated (ρ=.000) to a correct answer concerning alternative triage systems (Table 5). There was no correlation between underlying factors such as education and correctly answering the question concerning how hospital response (state of disaster) affects level of care (table 6).

Result Discussion
The main result of the current study was that nurses appear to overestimate their overall preparedness for working during a major incident. Nurses' perception of their preparedness was "less than competent" according to Benner's stages of clinical competence. However, this was signi cantly higher than the Total Disaster Competency score which was closer to "advanced beginner" than "competent".

Self-assessment of competency for rare events may impact evaluation
Means for the three subdimensions indicate that disaster preparedness was "less the competent". A possible explanation for the low means may be that ED RNs rarely are exposed to certain situations or medical conditions. For example, many of the components that make up the subdimension with the highest mean (2.89) "Staff, Stuff, Structure, System" may more closely mirror many of the competencies ED RNs incorporate during normal circumstances. In contrast, competencies related to infrequent events such as chemical spills, pandemics, biological, and radiological events were lower (2.00) "CBRN" than the other two subdimensions.
Similarly, many ED RNs in the current study have limited contact with pediatric patients. This may explain the lower mean (2.17) for the subdimension "speci c patient groups". While RNs in this study may be aware that they lack pediatric competency, this may also indicate both a discrepancy between experience and knowledge. For example, under normal circumstances, pediatric patients are referred to speci c hospitals for care, which minimizes nurses' contact with these age groups. However, during an MI, regular routines may be circumvented. Previous studies have indicated that hospitals closest to the incident sight may receive a majority of patients from the incident. ED RNs may receive patients of various ages and medical conditions within minutes of an incident and often before hospitals have been alerted [3][4][5]. This may further highlight a gap between knowledge and experience.
According to the results in the current study, ED RNs may erroneously assume that normal standards and regulations apply under extraordinary circumstances, possibly negatively affecting patient outcomes.
Further affecting self-assessment in this study, is that RNs were asked to assess their competency for MIs, events that the majority had little or no experience with. This may lead to RNs neglecting to account for factors such as stress when assessing abilities [31] and increase the likelihood of overestimating abilities. In addition to possibly indicating the competency is lower than measured, the lack of selfawareness may impede an active pursuit to ll knowledge gaps, improve or maintain necessary skills, which may negatively impact patient outcome during an MI [32][33][34].

Knowledge of triage and levels of hospital response
A lack of self-awareness is a well-known phenomenon. Prior studies show little or no correlation between perceived ability and reality [32][33][34].
Knowledge concerning basic principles of surge capacity and disaster response plans are prerequisites for an adequate hospital response and patient care during an MI. A large portion of the RNs in the current study had knowledge gaps concerning fundamental aspects of hospital response and surge capacity. All hospitals in the current study have disaster response plans as stipulated by law [35]. However, based on the results, nurses seem to incorrectly assume that the level of care is lowered when the hospital response level is raised to the state of disaster. This raises a concern for patient safety and may have legal rami cations since current legislation does not explicitly allow for health care to lower the level of care. Furthermore, nurses appear to not fully understand their hospital's surge capacity plan as assessed by the question concerning alternative triage systems. It is essential that RNs possess knowledge of their hospital's surge capacity and can apply it since patient volume during an MI may exceed an ED departments' normal daily volume within a few hours [3]. The current results indicate that ED RNs may be ill-prepared to facilitate surge capacity particularly during rare events such as MIs.

Factors associated with ED RN preparedness
While having an advanced degree was positively correlated to higher levels of competency, having formal disaster medicine education was negatively associated with competency. This apparent paradox may be explained in part by the Dunning-Kruger effect in which participants may overestimate their abilities due to a lack of self-awareness [36]. Yet another explanation may be that those with higher levels of expertise more accurately assess their abilities [17]. Their perception more closely mirrored reality, re ecting previous studies correlating accurate self-assessments with higher levels of expertise. [17].
Improved ED RN disaster preparedness may be achieved through frequent exercises and interactive training where skills and knowledge are evaluated.

Limitations
Competencies are comprised of skills, knowledge, and ability. Measuring competencies present challenges. A limitation of the current study is that competencies are measured using self-assessment.
The validity of self-assessments is an oft-discussed topic with particular focus on the correlation between self-assessments and actual ability [31]. There is evidence suggesting that self-assessments may be valid measurements of ability, correlating accuracy of self-assessments with expertise [17,20].
Another factor affecting the validity of self-assessments is the risk of participants' subjective interpretation of questions or terms used to measure competency [37]. Many studies apply Likert-type scales to assess self-evaluation of preparedness using measurements such as "how familiar" or "to what degree" [21,23]. Lexical ambiguity of key terms or lack of participants' mutual understanding of the scale used, may inhibit accurate measurements and negatively affect the reliability and validity of the results. The current study reduced the ambiguity of key terms by using a scale of measurement that was clearly de ned in the questionnaire. The study population in this study is occupationally homogeneous which may mutual understanding [38]. This mutual understanding motivated the use of Benner's stages of clinical competence in the current study to aid in self-assessment. By clearly correlating the ve-point Likert-type with the ve stages of competence corresponding with a ve-point Likert scale [29] lexical ambiguity may have been minimized and RNs' mutual understanding of the scale used increased, thereby increasing the validity of the results and the transferability of the results.
The internal consistency was high (α = 0.989) and was higher than previous studies using similar instruments [23][24][25]. The reduction to three dimensions plus the added clarity of scales and items may have been a contributing factor for the high level of internal reliability and indicate that this instrument is a psychometrically sound questionnaire for assessing registered nurses' self-assessed disaster preparedness.
A second limitation of this study is that data is treated at interval data. This was done to make results comparable with previous research and to more accurately re ect subtle yet important differences.
The generalizability of the results may be questionable due to the relatively low response rate.
Participation may have been negatively impacted by personnel being subjected to a large number of other studies at the time of the study. However, the response rate is of the same proportion as prior studies [25][26][27]. This may have been a reason one of the emergency departments opted to not participate in the study.

Conclusions
The current study indicates that ED RNs may overestimate their disaster preparedness. Although overestimating their preparedness, they assessed their overall preparedness as "less than competent".
Registered nurses with formal disaster medicine education may have a more realistic view of their competencies and preparedness. While experience, training, and education correlated with disaster preparedness, the results indicate ED RNs with advanced degrees may be better prepared. However, ED RNs may be ill-prepared to facilitate for the challenges MIs present.

Registered nurse
Declarations Ethics approval and consent to participate All representatives of the respective hospitals and participants were informed of the study in written form.
Participants were guaranteed con dentiality and informed that their participation was voluntary, and they could at any time withdraw without consequences.