Nurses’ Perception of Readiness for Mass Casualty Events Involving Children

Nurses are the largest group of health-care providers and have always played an important role in a hospital’s response to disasters (Labrague et al., 2017; Al Khalaileh et al., 2009; O’Sullivan et al., 2008; Yousefi et al., 2016). As disasters and mass casualty events increase in frequency and severity, nurses’ preparedness to respond is of critical importance in reducing negative health consequences amongst affected populations (Labrague et al., 2017). In particular, children are of important consideration as they experience higher morbidity and mortality rates than their proportional population representation in disasters, due to their unique vulnerabilities and health requirements (Burke et al., 2010; Mason & Anderson, 2009).

The ability for hospitals to respond to mass casualty events reflects a nation’s overall level of emergency preparedness (Ferrier, n.d.). Historically, emergency management has military roots in civil protection and defense. Over time, there has been an evolution towards an all-hazard approach, including public health emergencies (Quarantelli, 2000). In terms of meeting medical needs during times of disaster, few preparedness efforts were focused on acute care in hospitals. Today, there are no national hospital emergency preparedness standards in Canada. While health care in Canada is provincially administered, a limited number of studies have demonstrated that education through a national hospital preparedness program increased nurses’ knowledge, attitude, and performance in real incidents (Yousefi et al., 2016).

A National Assessment of Emergency Planning in Canada’s General Hospitals was conducted between October 2000 and February 2001. Ferrier (n.d.) found that hospitals across the country reported a general lack of understanding in emergency management principles, and concluded that despite having an emergency plan in place, hospitals were unable to make the connection between hazard and risk identification. Furthermore, Ferrier (n.d.) also concluded that hospitals made assumptions about evacuations, communication, and patient care without exercising or testing processes. Without an understanding of basic emergency management concepts, including plans that address a variety of emergency scenarios, hospitals likely do not have the capacity to operate successfully during an emergency (VanVactor, 2012). In addition, plans were written without consultation or collaboration with partners, which led to agencies making assumptions about expectations and further creating logistical and operational gaps (Ferrier, n.d.).

While Registered Nurses (RNs) have been recognized as making positive impacts on many aspects of both patient care and the health-care system, little is known about their preparedness for responding to mass casualty events involving children (Canadian Nurses Association, 2013). Education through a national hospital preparedness program can increase nurses’ knowledge, attitude, and performance in real incidents, increasing their ability to respond to events (Yousefi et al., 2016). In addition, federal programs with funding models and national standards for hospitals can also provide consistency for all hospitals across the country while bringing together public health care and hospitals for a coordinated response, improving a country’s overall preparedness (Taschner et al., 2017; Watson et al., 2017). When national programs invest in frontline staff, there are clear positive outcomes for patients, the health-care system, and the nation overall.

On a daily basis, hospitals in Canada operate over-capacity, with patients on stretchers in hallways becoming a norm. Chronic nursing staff shortages are predicted to worsen in the next decades (Dauphinee, 2009; Gausche-Hill, 2009; Goodhue et al., 2013). Without extra staff to call in to respond to pediatric mass casualty events, hospitals will quickly become overwhelmed. Furthermore, training for preparedness also becomes more difficult without additional staff to cover patient care during exercises and drills, when staff can barely cope with normal volumes of patients on a daily basis (Goodhue et al., 2013).

Children have unique developmental needs compared to their adult counterparts (Gaushe-Hill, 2009; Ginter et al., 2006). However, there is an assumption that when resources are limited, patient care that is appropriate for adults is also suitable for children (Burke et al., 2010; Fox & Timm, 2008; Ginter et al., 2006). This can result in severe negative outcomes for pediatric patients, who are not simply “smaller versions” of adults. Infants and toddlers are, for the most part, non-communicative, and young children may have difficulties articulating their needs and emotions in an emergency, relying on caregivers to provide and advocate for them (Gaushe-Hill, 2009; Ginter et al., 2006). During a mass casualty event, caregivers may be separated from their children, and healthcare providers may need to provide care for children who are afraid and separated from those who know them best. Barthel et al. (2013) explains that children who are impacted by a disaster fare better the earlier they are reunited with their caregivers. Ginter et al. (2006) discuss how children need support to understand their experience and work through their emotions after a disaster, which is often overlooked in disaster preparedness planning. For example, several studies indicate that children not given the opportunity to work through the traumas of a disaster experience are at an increased risk of developing symptoms of post-traumatic stress disorder and other psychological concerns later in life (Fox & Timm, 2008; Gausche-Hill, 2009; Peek, 2008). Hospitals’ emergency preparedness must include staff with the capability and competency to provide developmentally appropriate care for both children and adults who present to the Emergency Department during mass casualty events.

Gaps in the system persist as few programs address the unique circumstances that come with responding to a mass casualty event where children are involved (Fox & Timm, 2008). Hospitals across Canada are left on their own to develop hospital-wide emergency preparedness programs, including self-funding preparedness. This often pushes emergency preparedness to a low priority, delegated as an afterthought assignment to whomever is able in the organization.

In a study by Kaji & Lewis (2006) on hospital preparedness, researchers surveyed hospital personnel and found that due to a lack of multi-agency collaboration to develop mutual aid agreements, as well as a limited surge capacity, hospital preparedness is perceived as minimal (Kaji & Lewis, 2006). In another study by Rassin et al. (2007), Emergency Department physicians and nurses were surveyed to measure perceptions of their hospital’s preparedness for mass casualty events involving children, and mass casualty events involving only adults. Respondents reported lower levels of preparedness for mass casualty events involving children compared to mass casualty events with only adult patients. They also reported feeling unprepared to cope emotionally with children impacted by disasters, to such an extent that they may not respond to the hospital’s calls for help during a disaster (Rassin et al., 2007). A significant positive correlation was found between professional seniority and the ability to cope with pediatric mass casualty events in terms of knowledge and skill, but not in nurses’ perception of their ability to cope with mass casualty events involving children (Rassin et al., 2007). An Israeli evaluation of the role of nurses during mass casualty events pointed to their significant roles in both clinical and managerial leadership (Admi et al., 2011). Labrague et al. (2017) conducted a systematic review of peer-reviewed publications between 2006 and 2016 that measured nurses’ preparedness for disaster response. Only one study in the review included Canadian nurses, and only one study included pediatric nurses. O’Sullivan et al. (2008)’s work studied French- and English-speaking nurses across Canada using a web-based survey. Less than half of the respondents indicated that their hospitals had an emergency plan, with almost 40% of respondents either reporting that they did not know or leaving the question unanswered (O’Sullivan et al., 2008). Overall, nurses reported low confidence toward the preparedness of Canadian healthcare institutions, with nurses from Ontario and Quebec reporting the highest levels of confidence (O’Sullivan et al., 2008).

This research study seeks to understand nurses’ perceptions of emergency preparedness regarding mass casualty events involving children, and to consider how empowerment related to preparedness may be positively correlated with knowledge and skill (Kuokkkanen & Leino-Kilpi, 2000; Wong & Laschinger, 2012). Under the structural empowerment theory, we use nurses’ perceptions of preparedness to inform us of the education and training initiatives required to prepare nurses for such events. Several previous studies focused on nurses working in one department, such as the Emergency Department or an Intensive Care Unit, where both children and adults are seen. This study is unique, however, in that it examines the perception of readiness of pediatric-trained nurses in one organization across different in-patient and out-patient departments. Results will inform current training and practices for Code Orange type situations, including mass casualty events involving children in Canadian hospitals, in addition to addressing education gaps among nurses in order to meet the needs of children and their families during a mass casualty event.