1 Introduction

Registered nurses (RN) play a crucial role in preparedness for and in care of patients during disaster response [1]. In Sweden, recent events such as the COVID-19 pandemic and recent and ongoing wars and conflicts have highlighted the need for RNs to adopt an all-hazards approach and to be capable of responding to various types of disasters [2]. Examples of disasters include floods, storms, outbreaks of infectious diseases, mass casualty incidents, terrorist attacks, and armed conflicts. However, there is no single agreed-upon definition of a disaster. Therefore, in this study a disaster is defined as ‘serious disruptions to the functioning of a community that exceed its capacity to cope using its own resources’ [3].

Being ready to respond to disasters and resource-constrained conditions is a crucial area of responsibility for RNs [4, 5]. Disaster preparedness encompasses various aspects including familiarity with disaster plans and standard operating procedures for caring for individuals with diverse health care needs affected by disasters, effective communication strategies, education and training, and ensuring the availability of functional emergency equipment [6]. To promptly assist as many people as possible, RNs must possess the necessary competencies [1], while ensuring that each individual feels affirmed, respected, and well-cared for [7].

However, there are differing opinions regarding the components of effective disaster response education [8]. Some emphasize the importance of learning about emergencies, teamwork, triage, on-site and hospital care and treatment, as well as transportation of injured individuals [9], while others highlight the significance of communication, disaster management, resource mobilization, health economics, risk analysis, epidemiology, ecosystem health, and leadership skills [10]. Previous research on competencies and readiness in disaster response, as well as in disaster nursing indicates that both RNs and RN-students lack sufficient education, a shortage that has persisted for a considerable time [11,12,13,14,15]. Simultaneously, research also emphasizes the crucial need for RNs to be educated in disaster response to ensure readiness [16].

In Sweden, the National Board of Health and Welfare (NBHW) has been tasked with creating a national curriculum for disaster response. The educational content emphasizes trauma care, Chemical/Biological/Radiological/Nuclear (CBRN) events, disaster medicine, and supporting individuals experiencing a crisis related to the disaster event as well as the role of healthcare in civil and military defence [17]. Consequently, RNs are integral to Sweden’s total defence [18]. The scope of the education can vary and may include basic knowledge or more specific training depending on the healthcare areas in which the RN works, such as ambulance care, emergency department or theatre care [17].

To the best of our knowledge, there are no studies that have examined the extent to which universities and university colleges provide education to Swedish RNs and specialist RN-students in disaster response.

2 Aim

The aim of this study was to investigate the extent to which education for RN and specialist RN is responsive to the NBHW national curriculum for disaster response.

3 Methods

3.1 Design

This study employed a descriptive cross-sectional survey of the universities and university colleges in Sweden that offer RN and specialist RN educational programs. The design was chosen to examine the occurrence of education in disaster response based on the NBHW national curriculum [17].

3.2 Study setting and participants

In Sweden, higher education is primarily conducted at state universities or university colleges. Additionally, there are individual, non-governmental education providers, typically smaller in size, focusing on specific areas such as art or nursing [19]. Approximately 50 universities or university colleges exist in Sweden, with 25 offering education towards RN and specialist RN.

In Sweden, RN education is a 3 year program at the basic level leading to both a bachelor’s degree and registration as a nurse. RNs can then choose to apply for an additional 1 year program at advanced level to attain a specialist degree in nursing and a 1 year master’s degree [20]. There are 11 different healthcare areas in which RNs can specialize, including Prehospital emergency care, Anaesthesia care, Intensive Care, Theatre Care, Primary Health Care, Oncology Care, Psychiatric care, Paediatric Care, Elderly Care, Medical Care and Surgical Care. Additionally, universities and university colleges have the option to offer specialist education in additional healthcare areas, such as In-hospital emergency care [20]. Swedish universities and university colleges have significant autonomy in designing learning objectives and educational content to align with national degree objectives [20]. Currently, only a few specialist nursing programs (such as prehospital emergency, anesthesia, intensive, and theatre care) require students to demonstrate their ability to apply their knowledge in disaster response [20].

The inclusion criteria were all universities or university colleges in Sweden that offer RN and specialist RN educational programs (n = 25), all received invitations for participation.

3.3 Data collection

A paper-based questionnaire was sent to the deans of faculty (n = 25) in November 2023. Alongside, an informational letter and a pre-addressed envelope for questionnaire return were included. If no response was received within approximately 4 weeks, a follow-up questionnaire, accompanied by a brief reminder seeking their participation, was sent. After 2 reminders, 72% (n = 18) of the universities or university colleges had responded. No dropout analysis was performed in accordance with research ethics and the principle of voluntary participation. There were no meetings or physical contact between authors and the deans of faculty.

3.3.1 Questionnaire development

The data collection was accomplished by using a questionnaire comprising 7 background questions (i.e., University or University College; If they had discussed the new report from NBHW on disaster preparedness curriculum; If there was a designated teacher for pursing disaster preparedness education) and 29 questions related to disaster response (Based on the NBHW national curriculum [17]). The questionnaire covered areas such as: Trauma care, care of victims of CBRN events, disaster medicine, crisis support and the role of healthcare in civil and military defence. Response options included ‘Yes,’ ‘No,’ and ‘Do not know.’ If the response was 'Yes,' participants were asked to specify their answer based on the learning activity (lecture, seminar, exercise, group work, or other) and where the teaching took place (nursing program, specialist nursing program, or as a self-contained course).

The questionnaire underwent one round of pre-testing by six individuals: one clinical nurse working in an acute care setting, four nurse educators, and one police educator from a university in western Sweden. They evaluated the questionnaire's user experience and assessed the relevance and clarity of the questions in terms of wording, scope, and usefulness. Content validity index scores for items and scales were used to assess the questionnaire [21]. The mean value for the relevance was for scales 0.94 and for items 0.97.

3.4 Statistical analysis

The Statistical Package for Social Science® (SPSS) version 28 [22] was used for data entry, coding, and analysis. Descriptive statistics, including frequency and frequency distributions, were utilized to describe the results.

3.5 Ethical considerations

This study collected information at the institution/department level, so no sensitive individual information such as gender, year of birth, etc., was collected. Therefore, the possibility of tracing data to individuals was very low. The risk of physical or psychological discomfort was also assessed as low, as the data collected pertained to the education provided regarding disaster response and not the individual educators' skills, teaching methods or their choice of educational content.

To protect the data from unauthorized access, only the first and last author had access to the survey data. Other co-authors had access to coded data during the data analysis. The code key was saved on an external hard drive, restricted data access was granted to the first author.

3.5.1 Compliance with ethical standards

This study was performed in accordance to the national act of the Swedish Code of Statues (Ethical Review of Research Involving Humans) [23] and therefore no ethical review was warranted as no sensitive data of human subjects were collected. Additionally, the study was performed in accordance with the principles outlined in the Declaration of Helsinki (Ethical Principles for Medical Research Involving Human Subjects) [24].

Written information about the study was provided, as was information that participation was voluntary. Participants were assured confidentiality and the right to withdraw from participation at any time without providing an explanation. Informed consent to participate was considered obtained if the participants completed and submitted the survey.

4 Results

Overall, 18 (72%) responses were collected, with an equal distribution between University College and University respondents, forming the basis for the following results. The results will be presented under two main categories: disaster response and total defence.

Half of the respondents (n = 9, 50%) had discussed the NBHW national curriculum for disaster response. Meanwhile, the majority (n = 11, 61%) reported having a teacher designated for educating on disaster response, and almost all respondents (n = 15, 83%) engaged in some form of learning activity in related to disaster response. Reasons for the absence of disaster response included; previously having such activities but replacing them with other acute care-related activities, teaching disaster response only in basic RN education due to curriculum constraints in specialist RN education, and a lack of knowledge or a simplistic view of the current global situation.

In total, nine different RN education programs were identified as incorporating disaster response education, including undergraduate RN education and specialist RN education in emergency care, ambulance care, intensive care, anaesthesia care, operation theatre care, district care, midwifery, and occupational health. Overall, eight different learning activities were reported.

4.1 Disaster response

All topics in the questionnaire were addressed by the participants, though some were more commonly covered than others. The most frequently utilized learning activities were traditional lecture formats, seminars, and application exercises. Application exercises were predominantly used for practical skills such as applying tourniquets or pressure bandages, as well as for practical work involving protective gear while in the treatment of contaminated patients or practicing various reflection methods for “after action review”. Seminars were the second most common choice for learning activities, while clinical practice was the least utilized (Table 1).

Table 1 Questionnaire and learning activities for disaster response
Full size table

The most commonly addressed topics in relation to disaster response were as follows: (1) Disturbances in society that could trigger disaster response (n = 15, 83%), (2) Healthcare organization and leadership in various care facilities (n = 15, 83%), (3) Healthcare cooperation with other authorities (governmental/non-governmental) during disaster response (n = 15, 83%), (4) Triage and prioritization of wounded/ill patients at the incident scene during various levels of resource deficits (n = 16, 89%), (5) Triage and prioritization of wounded/ill patients at care facilities/hospitals during various levels of resource deficits (n = 15, 83%), and (6) Life-saving treatments such as manual restoration of airways, recovery position placement, application of pressure bandages or torniquets, and stabilization of fractures (n = 15, 83%).

The least commonly addressed topics in relation to disaster response were as follows: (1) Supply of necessary healthcare products (e.g., pharmaceuticals, blood-products, materials) during extensive events (n = 5, 28%), (2) Backup systems for healthcare operational reliability (e.g., IT structure, communication, power, and water supply) (n = 4, 22%), (3) Assessment and treatment of patients exposed to extreme weather conditions (n = 3, 17%), and (4) Working with protective equipment while managing patients contaminated with chemical substances or ionized radiation (n = 4, 22%).

4.2 Total defence

Teaching related to total defence was less frequently conducted compared to disaster response education. The most commonly employed learning activity were the traditional lecture format. The least utilized learning activities were quizzes, clinical practice, and take-home examinations (Table 2).

Table 2 Questionnaire and learning activities for total defence
Full size table

The most common topics in total defence education were as follows: (1) Principles for healthcare provision during heightened alert and war (n = 9, 50%), and (2) Assessment and care of a person with contagious diseases or exposed to biological warfare (n = 8, 44%).

The least common topic in total defence education was: (1) The armed forces’ healthcare organization and its function in armed conflicts (n = 2, 11%).

5 Discussion

Based on the findings, the discussion will focus on the following aspects: (1) Specialist RN education and disaster preparedness, (2) Ensuring preparedness for disaster response, and (3) Operating under resource constraints.

5.1 Specialist RN education and learning activities related to disaster preparedness

In Sweden, there are 11 different healthcare areas for specialist RN education (Prehospital emergency care, Anaesthesia care, Intensive Care, Theatre Care, Primary Health Care, Oncology Care, Psychiatric care, Paediatric Care, Elderly Care, Medical Care and Surgical Care). Additionally, universities or university colleges can add a twelfth program of their choosing, resulting in several additional specialist RN education programs throughout Sweden [20]. However, not all universities or university colleges in Sweden offers specialist RN education within all areas, so such analysis was not conducted in this study. Apart from the more commonly expected specialist education programs focusing on various areas of acute care, midwifery and district care educations were mentioned. However, none of the respondents mentioned specialist RN educations specifically tailored towards paediatric or elderly care. While most of the specialist RN areas have guidelines for specific competencies needed, each university or university college can decide on the curriculum for each program independently, resulting in variations in program content across Sweden.

This study examines various learning activities related to disaster preparedness. However, it becomes evident that these activities may have different interpretations across different universities or university colleges. For instance, a seminar might also be considered an application exercise, and it could be challenging to conduct an application exercise without any prior lecture accompanying it. Several respondents indicated that they employ a combination of learning activities, which is generally perceived as beneficial for learning [25].

5.2 Ensuring preparedness for disaster response

As disasters or armed conflicts do not affect all people equally, factors such as age can determine how individuals are affected, with children and elderly persons widely recognized as particularly vulnerable [26, 27]. Therefore, it is noteworthy that disaster response education does not seem to be included in specialist RN education programs aimed at children and the elderly. This is especially notable considering the increasing interest in such education and preparedness [28], as well as the fact that the United Nations has been conducting such initiatives worldwide for over three decades [29].

While only a few of the specialist RN educational programs include a curriculum aimed towards disaster response, it is noteworthy that the educational programs focusing on disaster response are mostly within the scope of acute care. This observation becomes intriguing when considering some of the more recent major incidents in Sweden [30, 31]. The RNs and other healthcare staff who initially rushed to attend those injured were not from the acute care chain, but rather from the proximally located healthcare centres. This implies that RNs with or without specialist education, such as in Primary Health Care, also have a high probability of encountering situations and patients during disasters or terrorist events. To be adequately prepared and ensure safety during work, as well as to deliver appropriate triage and treatment in such situations, a comprehensive understanding of disaster response and anticipated outcomes is essential. However, research indicates that undergraduate nursing students in Sweden receive only approximately four hours of disaster medicine education, and most of the students questioned rated their knowledge and readiness in this area as insufficient [11].

5.3 Operating under resource constraints

A criterion for disaster response is the insufficient resources to provide care as under normal circumstances. However, it appears that the Swedish healthcare system is already under pressure to provide timely and appropriate care within set goals even in normal conditions. Moreover, there is a question of how the healthcare system is already operating at the limits of its capacity. Nevertheless, despite the daily challenges in the operative care, it seems that Swedish healthcare has an assessed ability to respond to short-term extraordinary disturbances [32]. With Sweden’s recent membership in NATO, this development imposes additional responsibilities on the military, civil, and total defence sectors, including mass casualty incidents [33]. Consequently, this situation directly impacts the preparedness of RNs and, by extension, the education they receive. Therefore, it is imperative for Swedish universities and university colleges to offer education that prepares RNs for an all-hazards approach and equip them to encounter and manage various types of disasters.

5.4 Limitations and strengths

The survey was sent to the deans of faculty; however, the authors do not have knowledge of whether it was the deans or someone else (individual or group) at the university or university college who responded to the survey. Another limitation was that the responses often only reflected one of the educational programs at the university or university college, likely because only one person answered the survey. If the survey had been directed to each of the educational programs individually, it might have provided a more detailed basis for this study. Finally, the response rate was 72% which is considered good for surveys and a strength for this study [34]. One should also keep in mind that using percentages to describe only a few participants could be misleading.

6 Conclusions

The findings of this study suggest that RN education lacks the opportunity to adequately prepare RNs for disaster response and armed conflicts. Additionally, the education provided tends to focus primarily on the acute care spectrum of specialist RN education rather than taking a broader perspective. Consequently, RNs and specialist RNs may not be as prepared as desired, and that they might lack the competence and readiness to act effectively in case of a disaster.

6.1 Implications

Based on the presented results, the following conditions are suggested to strengthen RNs’ disaster preparedness and the capabilities:

  • Implement disaster response as a mandatory topic in the national curricula for higher education, regardless of whether the student are studying at the undergraduate or specialist level.

  • RN education programs should ensure that RN students competencies align with the NBHW national curriculum for disaster response through appropriate learning activities.

  • Ensure the availability of qualified teachers in disaster response who are responsible for developing and delivering disaster response education. Additionally, provide these teachers with ongoing professional and educational development opportunities in disaster response.

  • Additional research on this topic is required. It is suggested to investigate which aspects of disaster preparedness are necessary for RNs and various specialist RNs. Additionally, exploring what RNs and specialist RNs receive from the employers in terms of disaster preparedness could also be of interest.