Developing a Disaster Management Plan and Implementing Educational Program at Emergency Unit

Introduction

Numerous emergencies and disasters occur every day around the world. While emergencies and disasters are used interchangeably, researchers and practitioners denote distinctive differences. Disasters are catastrophic, deadly, and disruptive events that occur when hazards interact with vulnerabilities requiring extensive resources. Disasters have a more significant impact on individuals, families, organizations, and societies (Fan, et al., 2021).

Emergencies are small disasters with limited impact and required resources. Disasters can be caused by natural, technological, political, economic, or human-made causes. When hazards interact with vulnerable people and weak infrastructure, they result in harm, damage, and disruption. To prevent and minimize the consequences of these vulnerabilities; people, communities, and governments have to create many preventive and recovery strategies. Regardless of the adopted approaches, the final goal is to manage disasters effectively (Al Kurdi, 2021).

Disaster management; is the body of policy and administrative decisions and operational activities pertain to the various stages of a disaster at all levels. Disaster management approaches may vary between countries depending on hazard profile, policies, vulnerabilities, and risk reduction plans. Also, the disaster management cycle illustrates the ongoing process by which governments, businesses, and civil society plan for reducing the impact of disasters, react during and immediately following a disaster, and take steps to recover after a disaster has occurred (Carada, 2020).

Appropriate actions at all points in the cycle lead to greater preparedness, better warnings, reduced vulnerability, or the prevention of disasters during the next iteration of the cycle. The complete disaster management cycle includes the shaping of public policies and plans that either modify the causes of disasters or mitigate their effects on people, property, and infrastructure (Carada, 2020).

 Therefore, the care of casualties from a disaster requires the health care provider to integrate into the larger, predominantly nonmedical multidisciplinary response. This demands a knowledge base far greater than medicine alone. To operate safely as part of coordinated disaster response, either in a hospital or in the field, an understanding of the basic principles of emergency management is necessary.  To respond properly and efficiently to disasters, all health care personnel should have a fundamental understanding of the principles of disaster management (which incorporates emergency management in its practice) and what their particular role would be in the response to different types of disasters (Ciottone, 2016).

So, educational programs had a pivotal role in reducing disasters and achieving human security, and to achieve sustainable development. Previous studies have shown the positive effects of education in disaster risk management. All people who have been taught about the phenomenon of disasters and how to react to those situations have proved to be able to respond promptly and appropriately, thereby warning others and protecting themselves during times of emergencies (Yanger, 2018).

Significance of the Study

Nowadays, the concept of the disaster becomes threatened the whole society like a ghost, because there are no plans for the preparedness of any disaster and the element of surprise is the majority of each event that threaten the life of the entire human race.  In 2018 a fire broke out inside Al Hussein University Hospital which resulting in one patient death due to cardiac arrest during the fire, and 60 patients were transferred to neighboring hospitals; which consider part of medical negligence in hospitals due to the absence of supervision and monitoring by the concerned authorities.

This was not only a terrible incident alone, but there are many fires in other places such as Al-Qasr Al-Aini Hospital in January 2017 and Al-Abbasiya Hospital in May 2018. Through my experience as an assistant lecturer, over a period of last four years, it was observed that the Minia University Hospital departments haven't disaster management plan, and all health care team were not aware of the safe transfer of patients, which may expose patients to the injury during evacuation.

So, the researcher decided to conduct this research titled by develop a disaster management plan and implement an educational program for the Emergency Unit.

Aim of the study:

The aim of the study is to develop a disaster management plan and to implement an educational program for the Emergency Unit.

Research Hypotheses:

• It is expected that the preparedness, expectation, and awareness of study subjects about disaster management will be increased after implementing the educational program.
• It is expected that the disaster management plan will be applicable to be followed after the   validation of the plan.

Subjects and Methods

Research Design:

A quasi- experimental research design was utilized in this study.

Setting

The study was conducted at the Emergency Unit, Minia University Hospital.

Subjects

• All available health care team was included in study subject (total no = 69) who work in the Emergency Unit at Minia University Hospital, and they were classified as follows; nursing personnel (40), physicians (20), and workers (9).
• A purposive sample of (31) who are experts in the disaster management plan to take the advantages and benefits of jury group experience in the field of disasters; and obtaining the validity and applicability of the proposed disaster management plan in the emergency unit.

Tools of data collection:

Three tools were used in this study; an Interview Questionnaire, Observational Checklist, and Opinionnaire Sheet.

Tool I: Interview Questionnaire, this tool was adopted from Mostafa, (2003) &Mostafa, (2009) and modified by the researcher to assess study subjects' knowledge, expectation, and awareness of the disaster preparedness in the study setting. This tool was included four parts as follows:

1^st part the personal data of the studied subjects (nursing personnel, physicians, and workers); it was including (age, gender, marital status, and years of experience).

2^nd part: Preparedness for Internal Disasters a Questionnaire (PIDQ); this part consisted of (41) multiple- choice questions to assess knowledge of study subjects about the various aspect of internal disaster preparedness. The responses (answer) were as (1 for correct scored, and zero for incorrect). The scoring system of this part was classified as follows; low knowledge level, if the study subject had scored (<50%), moderate knowledge level (≥50% to ≤75%), and high knowledge level (>75%).

3^rd part Disaster Expectation Assessment (DEA); this part was used to assess the study subjects' expectations regarding the possible occurrence of disaster in the setting. This part consisted of (18 items) categorized into (2 subscales) namely, natural disasters, and manmade disasters. The responses were rated on (3) points Likert scale as (high=3, moderate =2, and low=1). The expectation score of this tool was divided as follows; low expectation of disaster ranged from (18 to 29), the moderate expectation of disaster ranged from (30 to 41), and high expectation of disaster ranged from (42 to 54). 

4th part: Awareness of the Internal Disaster Preparedness (AIDP); to assess the study subjects' awareness regarding the internal disaster preparedness. This part consisted of ( 174 items) categorized into ( 9 subscales) namely, Disaster Preparedness Plan, Nurse Role, Documentation System, Training, Hospital Preparedness, Hospital Prevention Measures, Preparation for Outage of Power, Earthquake Preparedness Measures, and Evacuation Plan. The responses were checked as ("yes"=1, "no"= 0, don't know= 0). The awareness score divided as follows; low awareness level of the internal disaster preparedness if study sample had score (<50%), moderate awareness level of the internal disaster preparedness, if the score was (≥50% to ≤75%), and high awareness level of the internal disaster preparedness, if the score was (>75%).

Tool II: Observational Checklist, this tool was developed by Mostafa, (2003), and it was modified by the researcher and used to check the availability of various resources needed for internal disaster management in the Emergency Unit of Minia University Hospital. This tool consisted of (174 items) categorized in (5 subscales) namely, Medical devices, permanent supplies, Consumables Supplies, Medication emergency locker, and crash cart. The responses were checked by (Yes =1, and No = zero) for following categories (1) availability, (2) working effectiveness, (3) presence of different size / concentrations, (4) accessibility, and (5) quality of storage. The scoring system for the tool was divided as follows: low if the score was (<50%), moderate if score was (≥50% to ≤75%), and high if score was (>75%) for each category and for the total score of the tool.

Tool III: Opinionnaire Sheet, this tool were developed by Mekky, (2009), to assess the validity of designed proposed plan by the jury group, and it was be modified by the researcher. The tool divided into three parts in this study:

1^st part the personal data for jury group; it was including (age, gender, marital status, and years of experience).

2^nd part the face validity of the proposed disaster plan; this part consisted of (9 items) categorized into (6subscales).

3^rd part the content validity of the proposed disaster plan; this part consisted of (123 items) categorized into (11subscales). The scoring system of this tool was divided as follows: Each item was assessed on (4) points likert scale as (Very high = 4, High = 3, Moderate = 2, low =1), the range seems to be:

• ·Low validity levels of a proposed plan by the jury group if the score ranging from (1 to 132).

• Moderate validity levels of a proposed plan by the jury group if the score ranging from (133 to 264).
• High validity levels of a proposed plan by the jury group the score ranging from (265 to 396).
• Very high validity levels of a proposed plan by the jury group if the score ranging from (397 to528).

Validity and reliability

The tools of the interview questionnaire, observational checklist, and opinionnaire sheet were tested for validity by five jury experts in the nursing administration field who are experts in disaster management. The jury consisted of one professor and one Assistant Professor at the Department of Nursing Administration - Faculty of Nursing - Minia University, and three Assistant professors, Department of Nursing Administration - Faculty of Nursing - Tanta University.

Internal consistency of the interview questionnaire and opinionnaire sheet was assessed by Cronbach's alpha coefficient. The reliability for the tools was (0.965) for Interview Questionnaire, and (0.977) for Opinionnaire Sheet.

Pilot Study           

The pilot study was conducted on (10%) of study subjects in which they were selected randomly from the study setting in order to check and ensure the clarity and applicability of the tools; as well as to identify obstacles and problems that may be encountered during data collection and estimate the time needed to fill the questionnaires.

For tools (I, II) the pilot study was conducted with an interview questionnaire sheet on (seven of study subjects) as two physicians and five nursing personnel. And in the light of the pilot study findings, no modification was done in the tools and the tools had its final form; so the pilot study results were included in the actual study results.

For the tool (III) the pilot study was done on (three of jury group) who is expert in the disaster management; and according to their modification on the tool, the subjects who participated in the pilot study were excluded from the actual study.

Procedure

Official permissions were obtained from the Dean of Faculty of Nursing at Minia University and from the Director of Minia University Hospitals to carry out the study. The study was conducted in five phases; Assessment phases, designing phase, validity phase, implementation phase, and evaluation phase.

Phase (I): Assessment:     

• Reviewing the literature as well as assessing the Emergency Unit of Minia University Hospital was done as an initial step to obtain information regarding disaster preparedness and management and modify the study tools.
• Then the validity of the tools was done by a five jury who are expert in disaster management from the field of Nursing Administration.As well as the pilot study for the tools were done.
• Reviewing the scientific literature using textbooks, e-books, journals, periodicals, and websites, to initiate a draft for the proposed disaster management plan.
• An interview with the director of the Emergency Unit and the nursing director at Minia University Hospital was done by the researcher to obtain their permissions to conduct the study after explaining the purpose of the study.
• The researchers established a rapport with health care team as physicians, nurses, and workers of the Emergency unit- Minia University Hospital, and obtain their consent after explaining the importance and purpose of the study.
• A pre-test was done to all available health care team who work at the Emergency unit of Minia University Hospital using tool (I). The data was collected in two months from the beginning of October 2019 to the end of December 2019.
• The researcher clarified items of questionnaire tool to the participants if they asked to enable them to understand the questionnaire. This tool filled from each study subject within (20 to 40) minutes.
• Then the researcher assessing the various resources needed for internal disaster management for the Emergency unit of Minia University Hospital by using tool II (observational Checklist) which filled within 30 to 40 minutes in the presence of the nursing director or assistant director of the unit.

Phase II: Designing the plan:

• After reviewing the literature and analyzed the pretest of study subjects (nursing personnel, physicians, and workers) data, the researcher developed a proposed plan for disaster management for the Emergency Unit of Minia University Hospital.
• The researchers establish rapport with all available jury groups who have experience in the disaster management plan, and obtain written consent to participate in the study after explaining the importance and purpose of the study.
• Then the validity of tool III (Opinionnaire Sheet) was obtained by three juries who have experience in the disaster management plan.
• Accordingly, the proposed content of the disaster management plan was designed by the researchers as the initial phase which presented to the supervisors for examining the content coverage, the sequence of elements, clarity, fit, applicability, wording, length, form, and overall appearance; then making the modification.

Phase III: Validity of proposed plan:

• The proposed disaster management plan was presented to the jury group to express their opinion on the content of the plan.
• A jury group consisted of (31) evaluated the validity and reliability of the proposed disaster management plan by using the opinionnaire sheet (tool III).
• Then the statistical analysis of the opinionnaire sheets from the jury group was done to measure the validity and reliability of the proposed plan.
• In the initial form; the content of the proposed disaster management plan consisted of (109 items) categorized into (9 subscales). After the modifications of the jury group and statistical analysis there were (14) invalid items omitted and added two domain, and (28) items.
• In the final form of the proposed disaster management plan content consisted of  (123) items categorized into (11 subscales) as follows: an introduction of the Minia University Emergency Hospital, the emergency cases in the disaster management plan, Disasters generally, the proposed disaster management plan, the stages of disaster management in the proposed plan, the stages of implementing the proposed disaster management plan, the content of the proposed evacuation plan , different types of disasters with the proposed plan, scenario facing a fire inside of Emergency unit at Minia University Hospital at intensive Care Department, job cards for the tasks and responsibilities of all employees, and an engineering diagram of the Emergency unit at Minia University Hospital is clear and comprehensive.
• After completing the design of the proposed disaster management plan, a guided booklet was prepared about internal disasters at the Emergency Unit of Minia University Hospital which encompasses all important information about the proposed disaster management plan.

Phase IV: Implementation of the program:

•  According to the content of the proposed disaster management plan an educational program was planned for the study subjects (physicians, nurses, and workers). Also, the booklet was distributed at the beginning of the educational program for all study subjects.
• The program has been implemented by dividing the study subject into three categories according to their specialties (physician, nurses, and workers). The study subjects were divided according to their categories (physicians, nurses, and workers) into small sub-groups; each small sub-group included from four to five members.
• There were (two) groups of each study subjects trained each day during morning and evening shifts according to their scheduled and break time. Each group attended (10) sessions that lasted for (8) weeks during November and December (2020).
• At the beginning of the each session, the researcher made a summary of the previous session. Additionally, at the end of each session, the researcher summarized the content of the session and asked the study subjects for any question.

Phases V. Evaluation

At the end of the program implementation for the study subjects (physicians, nurses, and workers) the researcher collected the post-test by using the interview questionnaire sheet (preparedness, expectation, and awareness of internal disaster management); this data was collected during January 2021.

Ethical considerations

• This study was granted approval by the Ethical Committee of the Faculty of Nursing, Minia University.
• Informed consents were obtained from all the participants before the data collection.
• The study participants were reassured that their participation was voluntary and they had the right to withdraw from the study at any time if they want that.
• The study participants were reassured that their anonymity was maintained although the study and collected information wouldn't be used except for the purpose of this study and written consent was obtained.

Statistical Analysis

Data entry and statistical analysis were performed using computer software, the statistical package for social sciences (SPSS), version 22. Suitable descriptive statistics were used such as; frequency, percentage mean and standard deviation was utilized in analyzing data pretended. The chi-square test was used to detect the relation between the variables. In addition, a correlation coefficient (r) test was used to estimate the close association between variables. The level of significance (p-value) threshold of significances was fixed at the (5%) > 0.05 indicates non-significant while ≤ 0.05 indicates significant relationship.

Cronbach's alpha is a measure of internal consistency, that is, how closely related a set of items are as a group. It is considered to be a measure of scale reliability so the internal consistency of the Opinionnaire Sheet was assessed with Cronbach's alpha coefficient. Cronbach's alpha coefficient of (0.00) indicates no reliability and a coefficient of (1.00) indicates perfect reliability. However, a reliability coefficient of (> 0.70) is acceptable (Bujang et al., 2018).

In addition, the Goodness of Fit Index (GFI) is a measure of fit between the hypothesized model and the observed covariance matrix. The adjusted goodness of fit index (AGFI) corrects the GFI, which is affected by the number of indicators of each latent variable (Donthu et al., 2021).

The GFI and AGFI range between 0 and 1, with a value of over (0.9) generally indicating an acceptable model fit. Relative fit indices (also called “Incremental Fit Indices” (IFI) and “Comparative Fit Indices” (CFI) compare the chi-square for the hypothesized model to one from a “null”, or “baseline” model. This null model almost always contains a model in which all of the variables are uncorrelated, and as a result, has a very large chi-square (indicating poor fit) (Grotzinger, et al. 2019).

Relative fit indices include the normed fit index and comparative fit index. CFI values range from (0) to (1), with larger values indicating better fit. Previously, a CFI value of (0.90) or larger was considered to indicate an acceptable model fit (Mihalca, 2021).

Root Mean Square Error (RMSE) is the standard deviation of the residuals (prediction errors). Residuals are a measure of how far from the regression line data points are. Root mean square error is commonly used in forecasting, and regression analysis to verify experimental results (Ulloa et al. 2018).

Results

Table (1): Percentage distribution of personal data of study subjects (physicians, nurses and workers) (n=69)

Table (1) shows regarding age that all (100.0%) of the physicians as well (80%) of nurses' group age between (20- < 30) years; (77.7%) of the worker group age between (30-< 40) years.For the gender (90%) of the physicians, as well as (70%) of nurses group are males; while (88.9%) of workers group are females.

Regarding marital status, there are (75%) of the physicians as well as (55%) of nurses group are single; while (66%) of the worker group married. Speaking about years of experience, all (100%) of the physicians, (80.0%) of nurses group as well as (66%) of workers group have (1-< 10) years of experiences. 

Table (2): Percentage distribution of personal data of jury group

Table (2) shows regarding age of jury group that (77.4%) of them are in the age group between (30-< 40) years; for the gender, there are (61%) of them are males.  Regarding marital status, there are (84%) of jury group married; about years of experience, there are (68%) of the jury group have (10 - 19) years of experiences.

Table (3) Cronbach's Alpha values, mean and standard deviations for the proposed disaster management plan

Note : * an excellent reliability; cronbach's @ of ≥0.9 is excellent ; Cronbach's @ of ≥0.8 is good; Cronbach's @ of ≥0.7 is acceptable Cronbach's @ of ≥0.6 is questionable, Cronbach's @ of ≥0.5 is poor and Cronbach's @ of ≥0.4 is unacceptable.

Table (3) reveals that the total Cronbach's Alpha value for the proposed disaster management plan is (0.875) with good reliability; where the specific reliability coefficients of the proposed disaster management plan dimensions rang from (0.844 to 0.990).

Table (4): Goodness of fit indicator of proposed disaster management plan

 Note:  denote to significances (i.e . p˂ 0.05).,CFI: comparative fit index.,IFI incremental fit index.RMSEA:  root means squared error of approximation.

Table (4) presents that the value of the RMSEA index is (0.125), the CFI is (0.62) and IFI is (0.67) at the initial disaster management plan are reasonable compared with an acceptable value of two fit indices of the CFI and IFI which are (≥ 0.90). The final disaster management plan is satisfactory (X2 (515) = 1125, P-Value < 0.02*) in which the CFI and IFI increase slightly, but RMSEA decrease to (0.02*).

Figure (1): Total knowledge level of studied sample (physician- nurses- workers) regarding preparedness of disaster pre and post-program

Figure (1) presents that (75%) of the studied physician have a moderate knowledge level and (20%) have a low knowledge level in the pre-program; while in the post-program there are (70%) of them have a high Knowledge level and (30%) have a moderate knowledge level with highly statistically significant differences (P= 0.0001**).

Regarding the total knowledge level of Nurses, it was observed that (87.5%) of studied nurses have a low knowledge levels in pre-program; while in post-program (65%) of them have a high knowledge levels with highly statistically significant differences (P=0.0001**).

Also, regarding the total knowledge level of workers, there are (88.9%) of studied workers have a low knowledge level in pre-program; while in post-program (88.9%) of them have high knowledge level with highly statistically significant differences (P=0.0001**).

Table (5): Total expectation level of studied sample (physician- nurses- workers) regarding the possible occurrence of disaster pre and post program

Table (5) shows regarding total physicians' expectations, that (20%) of the studied physician have a high level of expectation in pre-program compared to (55%) have a high level of expectation in post-program with statistically significant differences (P-value = 0.04*). Regarding total nurses' expectations, there are (17%) of the studied nurses have a high level of expectation in pre-program compared to (50%) have a high level of expectation in post-program with highly statistically significant differences (P-value = 0.005*).

Also, regarding total workers' expectations, all (100%) of the studied workers have a moderate level of expectation in pre-program compared to (66.7%) have a high level; and (33.3%) have a moderate level of expectation in post-program with statistically significant differences (P-value = 0. 05*).

Figure (2): Total awareness level of studied sample (physician- nurses- workers) regarding preparedness of disaster pre and post-program

Figure (2): reveals regarding total awareness level of physicians, that (95.0%) of studied physicians have low awareness level in pre-program; while in post -program (90.0%) of them have high awareness level with highly statistically significant differences(P=0.0001**). Also, regarding the total awareness level of Nurses, (87.5%) of studied nurses have low awareness level in pre-program; while in post -program (80.0%) of them have high awareness level with highly statistically significance differences (P=0.0001**).

Table (6): Correlation between physicians, nurses and workers knowledge level with their expectation and awareness level regarding disaster pre and post-program

Table (6) reveals that there are fair positive associations for physician and nurses between their knowledge level in post-program and their expectation of natural disaster (r= 0.344 & P – value < 0.03*), and (r= 0.475 & P – value < 0.04*) respectively.  Also, the table shows that there is a fair positive association for physicians between their knowledge level in post-program and their expectation of man-made disaster (r= 0.412 & P – value <0.05*), and there is a moderate positive association between nurses knowledge level in post-program and their expectation of man-made disaster (r= 0.521 & P – value < 0.001**).

This table also presents a fair positive association between physician knowledge level in pre-program and their awareness regarding hospital disaster (r= 0.370 & P – value <0.019*), and nurses knowledge level of post-program and their awareness regarding hospital disaster (r=0 .469& P – value < 0.037*).

Table (7): The availability of various resources needed for internal disaster management for the emergency unit at Minia University Hospital

Table (7) reveals that the total resources needed for internal disaster management; regarding the availability of the resources, more than half (57.3%) of resources are available. For the resources work efficiently, the half of recourses (50.5%) are working efficiently. While the highest percentage of the resources have no different size (64.3%); no accessibility (56.9%); and not have proper storage (85.3%).