Psychological first aid training of nurses for disaster preparedness : a non-equivalent control group study

Abstract

Background: Disasters and the magnitude of destruction they create are ever increasing worldwide. Disasters have substantial physical and psychological effects on community and responders. Many studies have reported psychological trauma and long-lasting psychological problems, such as post-traumatic stress disorder (PTSD) and acute stress disorder (ASD), among responders. Therefore, it is important to prepare responders psychologically to better respond to disasters. Nurses contribute the largest number of healthcare providers and have major roles in disaster response and care; they must be prepared psychologically and physically to better respond to disasters. Psychological attention should be involved in any preparedness activity to limit the negative psychological outcomes of disasters, such as stress, depression, and PTSD. Psychological first aid (PFA) training may enable the trainees to provide supportive presence to mitigate acute distress and assess the need for continued care. In particular, the training may contribute to strengthening the psychological preparedness of nurses for disasters. Aims: The primary aim was to investigate psychological preparedness for disasters among nurses and a PFA training programme for such preparedness. The objectives were to examine psychological preparedness for disasters among nurses with disaster field experience in terms of self-efficacy, dispositional optimism, self-esteem, trait-anxiety, and PTSD; and to evaluate the effects of the modified PFA training programme on improving psychological preparedness of nurses for disasters. The programme is believed to be able to enhance or improve nurses' psychological preparedness when compared with a control group. Methods: The study involved two parts. Part one was an anonymous international cross-sectional online survey, targeting member nurses through different nursing organisations. Based on the adopted theoretical framework (Malkina-Pykh & Pykh, 2013; Zulch, Morrissey, Reser, & Creed, 2012), the instruments of this part included demographic information, Psychological Preparedness for Disaster Threat Scale (PPDTS), PTSD Diagnostic Scale for DSM-5, and personality variables in the General Self-Efficacy Scale (GSE), The Life Orientation Test (LOT), State-Trait Anxiety Inventory (STAI), and Self-Esteem Scale (SES). The second part was a non-equivalent control group study with two arms, which took place in the West Bank, Palestine. According to the power analysis, 84 nurses were required for each arm. In the intervention group, nurses received the modified RAPID-PFA training for a duration of total nine hours (two hours per week). The control group is wait-listed. Both groups were asked to complete a pre-test (T0) and post-test (T1) upon programme completion. The set of evaluation tools included a PFA self-report survey, and the set of instruments as used in part one. Ethical approval was obtained from the Human Subjects Ethics Application Review System (HSEARS) of The Hong Kong Polytechnic University, and the An-Najah National University in Palestine before data collection. Confidentiality and anonymity of participation were ensured for all participants. Data analysis: Statistical analysis was performed using SPSS, version 25 (IBM, 2017). Descriptive statistics was used to summarise the participant characteristics participants. Normality of the PPDTS distribution was evaluated with skewness and kurtosis from the Shapiro-Wilk test. The Alpha was set at the level of p < .05. For part one: Mann-Whitney test was used to identify the relationship between binary variables and PPDTS scores. Kruskal-Wallis Test with post hoc adjustment was performed to identify the relationship between categorical variables and PPDTS scores. Spearman's rho correlation was used to investigate the relationship between the PPDTS and continuous variables, and Chi-Square to investigate the relationship between the PPDTS and categorical variables. Multiple regression was used to assess possible predictors of PPDTS. For part two, Chi-square and Mann-Whitney U test were used to check for any significant group differences in demographics and outcome variables between the intervention and control groups at baseline. The ITT principle was applied for analysis. Generalized Estimating Equations (GEE) model was used to assess any changes in the outcome variables between the intervention and control groups across the pre- and post-test study period (i.e. group-by-time interaction effect). For the sensitivity analysis, missing data were replaced by values generated by imputations. Sub-group analyses with Wilcoxon signed-rank test, after checking the distribution of normality, were used to evaluate any differences between the post-test mean scores of primary outcomes within the respective intervention and control groups. Mann-Whitney U test was also used to compare those scores at different time points between the groups. Effect size estimates were calculated for the mean differences using Cohen's d, relating the mean score differences to the pooled standard deviation (Cohen, 1988). Results: The results of part one from 88 participants revealed a moderate level of psychological preparedness (M = 43.1). Only around half had received training related to psychological preparedness, with a strong association between psychological preparedness training and PPDTS (U = 259, p < 0.01). The results suggest nurses' need for psychological preparedness training and pre-disaster planning in order to strengthen their disaster response. In addition, the personality variables that were investigated demonstrated their importance for inclusion in studying psychological preparedness. In part two, five hospitals were randomly arranged to form two arms of the study, with a total of 168 nurses (n = 75 for intervention and control groups respectively after attrition at baseline). Workplace, PFA evaluation (on attitudes, skills, and knowledge), T-Anxiety, and PTSD, were significantly different (p < 0.05) between the two groups at baseline. With these as the covariates, the results of the adjusted GEE model based on ITT revealed that the PFA training imposed significant group-by-time effect (p < 0.05) on PPDTS, GSE, LOT, and SES. Multiple imputation by fully conditional specification (FCS) was performed to substitute the missing data for sensitivity analysis to compare the results generated between two models based on the ITT and per protocol (PP) principles. The result revealed that the adjusted GEE model (ITT) had essentially similar group, time, and group-by-time effects among the outcome measures, except for a better group effect of LOT and group-by-time effects of LOT and GSE (p < 0.05), but fewer group and group-by-time effects of SES, when compared to the original model (PP). Significant group-by-time effect of PPDTS (p < 0.05) as the primary outcome was observed in the adjusted model with ITT only. For post hoc analysis, the means of PPDTS showed greater improvement in the intervention group than in the control group at post-test (T1) (M = 43.09 and 31.96 respectively, p < 0.01). There were also statistically significant differences between the intervention and control groups in GSE, LOT, and SES at post-test (p < 0.05). Discussion: The PFA training improved psychological preparedness, and this may help to build nurses' capacity in terms of their ability to adapt to current and future disasters. These capacities include increased self-efficacy, self-esteem, and optimism. The results suggest that nurses can improve their psychological preparedness if they receive the proper training. From the PFA training, their attitudes and behaviours may be enhanced to anticipate and manage their cognitive and emotional responses to disasters. As noted by Morrissey and Reser (2003), psychologically prepared individuals can focus on situational preparedness, such as household planning for disasters. In turn, they can reduce the risk of injury or death, as the safety inside their houses is ensured. They are also able to manage their feelings and concerns during the stressful time of a disaster, and have the confidence to deal with these types of situations. Studies have suggested that people with higher psychological preparedness tend to have more effective stress management during a disaster event, and decreased mental health problems in the aftermath (Morrissey & Reser, 2003; Roudini et al., 2017). The PFA training of nurses not only enhances the mental health support they provide to victims during disasters, but also benefits the mental health of nurses themselves. Nurses in Palestine practise in a unique context, with experiential and cultural differences in psychological distress, of daily trauma and injuries surge and caring for people due to conflicts in the region. The added scenarios in PFA training were developed based on the real experiences of nurses, patients, and the community. Nurses have been given practice opportunities during the training through these scenarios. Such a modification in the training would have helped them to optimise deeper learning experiences from their daily living conditions, which may improve their decision making and the application in practice (Verkuyl et al., 2019; Verkuyl et al., 2020) to deal with these types of conflict situations. Furthermore, the debriefing and discussion sessions of nurses with one another during the scenario learning may more effectively motivate and facilitate their cognitive and affective learning, and the development of psychological preparedness. Conclusion: From part one of the study, it is found that psychological training is associated with better psychological preparedness. This corresponds to the second part of this study, which aimed to investigate the effectiveness of psychological preparedness through psychological first aid training of nurses for disasters. Other outcome variables also showed better scores in the intervention group at post-test. Significance: Nurses, particularly in Palestine, need to be competent in preparedness for psychological issues during disasters in order to deliver effective care, and for themselves in psychological preparation and self-caring. The PFA training is promising in improving nurses' psychological preparedness. The training could be considered to facilitate this goal. Meanwhile, it is recommended to further investigate this intervention with larger RCTs to achieve generalisability of the results. Hospital administrators, must continue identifying ways to enhance nurses' psychological preparedness, and to support suitable training interventions to improve such preparedness.