doi:10.1111/j.0361-3666.2008.01084.

Chemical, biological and radiological

incidents: preparedness and perceptions
of emergency nurses
Julie Considine Senior Research Fellow, Deakin UniversityNorthern Health
Clinical Partnership, Australia and Belinda Mitchell Clinical Risk Coordinator,
The Northern Hospital, Australia

Despite their important role in chemical, biological and radiological (CBR) incident response,
little is known about emergency nurses perceptions of these events. The study aim was to
explore emergency nurses perceptions of CBR incidents and factors that may influence their
capacity to respond. Sixty-four nurses from a metropolitan Emergency Department took part.
The majority were willing to participate in CBR incidents and there was a positive association
between willingness to participate and postgraduate qualification in emergency nursing. Willing
ness decreased, however, with unknown chemical and biological agents. One third of participants
reported limitations to using personal protective equipment. Few participants had experience
with CBR incidents although 70.3 per cent of participants had undergone CBR training. There
were significant differences in perceptions of choice to participate and adequacy of training between
chemical, biological and radiological incidents. The study results suggest that emergency nurses
are keen to meet the challenge of CBR incident response.
Keywords: CBR (chemical, biological and radiological) incidents, decontamination,
disasters, disaster planning, emergency nursing, terrorism

Introduction
Despite the important role of emergency nurses in disaster preparedness and, in par
ticular, in response to chemical, biological or radiological (CBR) incidents, little is
known about emergency nurses perceptions of CBR incidents or the effect of extra
neous influences on their ability to respond should such an incident occur. Over
recent decades, terrorism and epidemics have changed the focus of disaster man
agement, both nationally and internationally. Historically, disaster preparedness in
Australia has focused on responding to natural disasters (Smith, 2006), and in the
past three decades, disasters in Australia have mostly been the result of natural events
(bushfires, storms and floods), transport accidents or mass murders. Terrorism has
become more prominent since events such as the Tokyo subway sarin gas attack
(1995), World Trade Center attacks (2001), and bombings in Bali (2002 and 2005),
Istanbul (2003), Madrid (2004), Egypt (2005) and London (2005).
These terrorist events have had a number of notable features that have changed the
landscape of disaster preparedness. During the Tokyo sarin gas attack, more than
70 per cent of the 5,510 people who sought emergency care did not have significant
Disasters, 2009, 33(3): 482497. 2009 The Author(s). Journal compilation Overseas Development Institute, 2009.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

Chemical, biological and radiological incidents

chemical exposure; as many as 80 per cent of those seeking emergency care selfpresented or were brought to the Emergency Department (ED) by others so were not
decontaminated prior to ED arrival (Victorian Department of Human Services,
2007). Further, secondary sarin exposure occurred in approximately ten per cent of
responders (hospital staff and emergency services personnel) highlighting the con
sequences of lack of preparedness for both the community and healthcare workers
(Victorian Department of Human Services, 2007). During the World Trade Center
attacks, large numbers of emergency services personnel were killed, resulting in a
reconsideration of safety measures for emergency services personnel, particularly
those in command and control roles. Although the 2002 Bali bombing was an offshore event, it had far reaching effects on Australian hospitals as the injured were flown
initially to Darwin and then transferred to burns centres in Perth, Melbourne,
Brisbane, Adelaide and Sydney.
Awareness of epidemics has also increased as a result of Severe Acute Respiratory
Syndrome (SARS) and avian influenza. The 200203 SARS outbreak had world
wide effects with 8,098 SARS cases across 26 countries, which resulted in 774 deaths
(WHO, 2004) including a number of healthcare professionals and hospital workers.
The other unique feature of SARS was that the majority of cases were acquired in
hospital environments (Booth et al., 2003). Avian influenza (H5N1) is also a major
concern among the international disaster preparedness community. Recent estimates
from the World Health Organization from 200307 are that there have been 630 cases
of avian flu in 12 countries resulting in 382 deaths (WHO, 2007). However, epide
miologists estimate that if an avian influenza pandemic occurs, up to 40 million lives
could be lost worldwide (Smith, 2006).
CBR incident management is now an important feature of emergency nursing.
As nurses are the largest health workforce, disaster preparedness of emergency nurses
is pivotal to the hospital systems capacity to respond to CBR incidents. There are a
number of issues affecting emergency nurses capacity to support their organisations
disaster plan in the event of a CBR incident. First, the focus of disaster prepared
ness in Australia is on prepared communities and individual self-reliance (Abrahams,
2001; Smith, 2006). As nurses may be active in their community disaster plan, there
may be tension between personal, community and professional obligations during
a disaster. Second, personal risk associated with infectious diseases became clearly
apparent during the SARS epidemic and raises the possibility of nurses avoiding
responding to an infectious disease outbreak to decrease risk of transmission to self or
significant others and avoid quarantine-induced separation from family and friends
(Cameron and Rainer, 2003). Third, given the high number of females in the nurs
ing workforce, it is reasonable to assume that a large number of nurses have carer
responsibilities, either for children or elders. Despite staff responsiveness being a key
contingency in many hospital disaster plans, carer responsibilities may make it diffi
cult to remain at the end of a shift or come to work when rostered off. Finally, not
all staff are able to don personal protective equipment (PPE) and local CBR training
has shown that many female medical and nursing staff are too small for the chemical
resistant suits and are unable to achieve adequate face mask seal.

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Given the important role of emergency nurses in disaster preparedness and response
to CBR incidents it is important to examine further issues that may affect emer
gency nurses capacity to respond to CBR incidents. Conflict between personal, com
munity and occupational obligations during a CBR incident is not fully understood
and most hospital disaster plans are developed with the assumption that all staff will be
willing and able to work should a CBR incident occur. Further, despite an absence of
objective data about staff capacity to don PPE, most hospital disaster plans are under
pinned by an assumption that all staff can actively participate in decontamination.

Aims
The aim of this study was to explore the issues related to disaster preparedness of emer
gency nurses. The primary outcome of the study was emergency nurses perceptions
of CBR incidents. Secondary outcomes were the effects of the following character
istics on emergency nurses perceptions of CBR incidents:
demographic characteristics and social circumstances,
employment characteristics and PPE limitations, and
CBR training and experience.

Method
Design
An exploratory descriptive design was used for this study.
Setting
The study was conducted in the ED of a hospital in metropolitan Melbourne, Victoria.
This 39 cubicle facility provides care to both adult and paediatric patients and is a
designated metropolitan trauma centre in the Victorian State Trauma System. During
2006, the annual presentation rate was approximately 65,000 patients: children com
prised 25 per cent of ED presentations and the admission rate was 29 per cent. Over
the past five years, this ED has responded to numerous mass casualty, chemical and
biological incidents. For example, almost 200 patients with gastrointestinal symp
toms following ingestion of contaminated food at a social event; 45 paediatric patients
(including a number of intellectually disabled children) following an ozone leak at
a local swimming pool; 11 factory workers with skin, eye and respiratory symp
toms after a container breakage that resulted in the mixing of a number of chemicals;
and 20 airport staff and members of the public following a suspected chemical leak.
In addition to current global security challenges and emerging infectious diseases,
the expansion of industrial areas surrounding the study site, major events held in
Melbourne (Commonwealth Games, Grand Prix) and a high risk of bushfires in sur
rounding rural areas increase the potential for CBR incidents.

Chemical, biological and radiological incidents

Participants
Participants were recruited during ten study information sessions during nursing inservice education time over a four week period in March 2007. The sessions were
scheduled to capture nurses from all shifts and days of the week. At the time of data
collection, there were 90 nurses on the ED roster, 64 of whom attended the study
information sessions. The remaining nurses were not captured during the informa
tion sessions due to sick leave, annual leave, ED workload issues and infrequent
working hours.
Instrument
In the absence of an existing data collection tool suitable for this study, a disaster pre
paredness survey was developed by the researchers. The survey had four sections.
Section 1 asked for demographic data and aimed to examine social and geographi
cal influences on disaster response. Section 2 detailed employment characteristics
including experience, level of appointment and educational preparation. Section 3
included questions about CBR training and experience, and limitations to the use of
PPE. Section 4 asked for participants perceptions of CBR incidents using the follow
ing statements:
i) I feel that my training has adequately prepared me to participate in an incident.
ii) I feel that I have a high level of choice about whether I participate in an incident.
iii) I believe that staff should be able to choose whether or not they participate in
an incident.
iv) I am willing to actively participate in an incident.
v) I would feel comfortable participating in an incident with a known agent.
vi) I would feel comfortable participating in an incident with an unknown agent.
Participants were asked to rate their perceptions on a 5 point Likert scale as follows:
1 = strongly disagree, 2 = disagree, 3 = no opinion, 4 = agree and 5 = strongly
agree. Participants were asked to rate responses to statements i) to vi) in relation to
chemical and biological incidents. Statements i) to iv) were asked in relation to
radiological incidents only.
A panel of ED key stakeholders (associate nurse unit manager, nurse unit man
ager and operations director) were asked to review the survey to establish content
and face validity. The panel was asked to comment on content, identify misleading
or ambiguous questions, and comment on ease of completion and clarity of writing
style. This process identified minor typographical and grammatical errors that
were corrected prior to the pilot study. The survey was piloted on 25 emergency
nurses of various demographic profiles and levels of emergency nursing experience
from a neighbouring ED. One minor change to Section 1 was made following the
pilot study. All pilot participants agreed that the survey was easy to complete and
the majority completed the survey within 15 minutes. Analysis of the pilot study data
showed similar responses indicating that questions are interpreted in the way in which
they were designed.

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Ethical considerations
This study was approved by the Human Research and Ethics Committee at the
study site.

Data collection
The disaster preparedness survey was used to collect data. During study information
sessions described previously, emergency nurses were presented with information
about the study and those who consented to participate were given the survey to
complete. Consent was implied by completion and return of the survey.

Data analysis
Data was analysed using the computer software package SPSS 15.0. Descriptive sta
tistics were used to describe the findings, and relationships between variables were
examined using Chi square, correlations and Wilcoxons test. To simplify data analysis,
participants responses to Section 4 of the survey were collapsed to negative responses
(strongly disagree and disagree), neutral responses (no opinion) and positive responses
(agree and strongly agree).

Results
There were 64 participants with an average age of 34.25 years (SD = 9.63, range: 22
to 57). As expected, the majority of participants were female (n = 54, 84.4 per cent).
The majority of participants lived with other people: partner (n = 30, 6.9 per cent),
family (n = 18, 28.1 per cent) or housemates (n = 5, 7.8 per cent); only ten participants
(15.6 per cent) lived alone. Occupations of other householders were highly variable
and only few participants lived with other emergency services or paramedical per
sonnel: police officers (partner n = 4, housemate n = 1), other nurses (partner n = 3,
housemate n = 2), ambulance paramedics (partner n = 2) and doctors (partner n = 2).
Twenty-eight participants (43.7 per cent) had children: infants (n = 5), preschoolers
(n = 6), primary schoolers (n = 12) and secondary schoolers (n = 10). Three par
ticipants lived with children who were at work or university. Twenty-three par
ticipants (37.5 per cent) reported carer responsibilities for children and no participants
reported carer responsibilities for others such as the elderly or disabled. Participants
ratings of social supports that assisted with carer responsibilities were: excellent (n = 7),
good (n = 11), fair (n = 9) and only one participant rated their social supports as poor.
Participants were asked to report on the feasibility of working beyond the end of
their shift in the event of a disaster or CBR incident. Working beyond a rostered shift
was reported as no problem by 27 participants (42.2 per cent), probably possible
by 20 participants (31.3 per cent), difficult by 9 participants (14.1 per cent), and

Chemical, biological and radiological incidents

Table 1 Participants level of appointment

Level of appointment

Registered nurse

43

67.2

Clinical nurse specialist

11

17.2

Nurse manager/associate nurse manager

6.2

Clinical nurse educator

1.6

Nurse practitioner

1.6

Not stated

6.2

Source: authors elaboration.

impossible by one participant (1.8 per cent). Of the ten nurses who reported diffi
culties working beyond a rostered shift, eight (80 per cent) had carer responsibilities
for children. In contrast, of the 47 nurses who reported working beyond the end of
a shift to be no problem or probably possible, only 12 (25.5 per cent) had carer respon
sibilities for children ( 2 = 10.399, df = 1, p = 0.002).
Employment characteristics
Participants had an average of 11.8 years of nursing experience (SD = 10.1) and 6.6
years of emergency nursing experience (SD = 6.0). The majority of participants had
direct patient care roles and participants levels of appointment are shown in Table 1.
Participants worked an average of 60.4 hours per fortnight (SD = 20.6). The majority
of participants held a Bachelor of Nursing (n = 45, 70.3 per cent) and 39 participants
(67.3 per cent) held postgraduate qualifications in emergency nursing.
CBR incident response
Participants perceptions related to CBR incidents are shown in Tables 2, 3 and 4.
The majority of participants gave positive responses about their willingness to par
ticipate in a CBR incident, and the frequency of positive responses was unaffected by
incident type (chemical n = 50; biological n = 54; radiological n = 48) ( 2 = 0.756,
df = 2, p = 0.685). In terms of choice to participate, radiological incidents had the
lowest number of positives for both personal choice and others choice when compared
with chemical and biological incidents (Table 5). Responses comparing comfort with
known agents versus unknown agents for chemical and biological incidents were
similar, with a significant decrease in positive responses for comfort with unknown
chemical or biological agents (Table 6).
There was a positive association between willingness to participate in CBR inci
dents and postgraduate qualification in emergency nursing. Of the 41 participants
willing to participate in all three types of incidents (chemical, biological and radio
logical), 31 nurses (75.6 per cent) held postgraduate qualifications, compared with

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only three of the 12 participants (25 per cent) not willing to participate in all incident
types (2 = 10.338, df = 1, p < 0.004). There were no significant correlations between
willingness to participate in CBR incidents and age, adequacy of social supports,
nursing or emergency nursing experience, level of appointment, CBR experience or
time since last CBR training. There were also no significant associations between
willingness to participate in a CBR incident and carer responsibilities for children.
Table 2 Participants perceptions related to chemical incidents
Negative

Neutral

Positive

1. I feel that my training has adequately prepared me to participate

30

46.9

3.1

22

34.4

2. I feel that I have a high level of choice about whether I participate

16

25.0

0.0

39

60.9

3. I believe that staff should be able to choose whether or not they participate

3.1

3.1

50

78.1

4. I am willing to actively participate

4.7

1.6

50

78.1

5. I would feel comfortable participating with a known agent

14.9

1.6

44

68.8

6. I would feel comfortable participating with an unknown agent

27

42.2

3.1

25

39.1

Source: authors elaboration.

Table 3 Participants perceptions related to biological incidents

Negative

Neutral

Positive

1. I feel that my training has adequately prepared me to participate

27

42.2

0.0

26

40.6

2. I feel that I have a high level of choice about whether I participate

17

26.6

0.0

37

57.8

3. I believe that staff should be able to choose whether or not they participate

4.7

3.1

48

75.0

4. I am willing to actively participate

6.3

0.0

0.0

54

84.4

5. I would feel comfortable participating with a known agent

12.5

1.6

44

68.8

6. I would feel comfortable participating with an unknown agent

25

39.1

3.1

26

40.6

Source: authors elaboration.

Table 4 Participants perceptions related to radiological incidents

Negative

Neutral

Positive

1. I feel that my training has adequately prepared me to participate

15

23.4

3.1

37

57.8

2. I feel that I have a high level of choice about whether I participate

34

53.1

1.6

19

29.7

3. I believe that staff should be able to choose whether or not they participate

16

25.0

1.6

37

57.8

4. I am willing to actively participate

6.3

3.1

48

75.0

Source: authors elaboration.

Chemical, biological and radiological incidents

Table 5 Positive responses related to choice by incident type

Chemical

Biological

Radiological

p*

I feel that I have a high level of choice about whether I

participate

39

60.9

37

57.8

19

29.7

< 0.001

I believe that staff should be able to choose whether or

not they participate

50

78.1

48

75.0

37

57.8

< 0.001

Note: * Chi square.

Source: authors elaboration.

Table 6 Positive responses related to known versus unknown agents by incident type
Chemical

Biological

p*

I would feel comfortable participating with a known agent

44

68.8

44

68.8

< 0.001

I would feel comfortable participating with an unknown agent

25

39.1

26

40.6

< 0.001

Note: * Wilcoxons test.

Source: authors elaboration.

PPE limitations
One third of participants (n = 19, 29.7 per cent) reported a physical limitation to
donning Level C PPE. Specific limitations included poor suit fit (n = 7), poor mask fit
(n = 7), claustrophobia (n = 5), pregnancy (n = 1), glasses or beard that prevents adequate
mask seal (n = 3), and respiratory or cardiovascular illness (n = 3). Interestingly, 13
of these participants still reported being willing to participate in CBR incidents.
CBR training and experience
The majority of nurses reported undertaking CBR training (n = 45, 70.3 per cent).
However, the average time to last training was 19.2 months (SD = 12). In terms of
previous experience with CBR incidents, 14 participants (21.8 per cent) reported
active participation in a chemical incident, five of whom were required to don per
sonal protective equipment. Eleven participants (17.2 per cent) reported previous
participation in a biological incident, three of whom were required to don personal
protective equipment. It should be noted that two of the same participants reported
previous experience in donning PPE for both chemical and biological incidents.
Only one participant (1.5 per cent) had active participation in radiological incidents,
in which personal protective equipment was not required.
There were significant differences in perceptions of training adequacy for each
incident type (Tables 2, 3 and 4). Radiological incidents elicited the highest number
of positive responses related to training adequacy (n = 37, 57.8 per cent) followed
by biological incidents (n = 26, 40.6 per cent) and chemical incidents (n = 22, 34.4

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per cent) ( 2 = 9.929, df = 2, p = 0.007). Although fewer than half the nurses in this
study felt adequately prepared for chemical or biological incidents, there was still a
high degree of willingness to participate in both incident types: 59.6 per cent of
nurses (n = 31) willing to participate in a chemical incident and 52.9 per cent (n = 27)
willing to participate in a biological incident reported neutral or negative responses
to adequacy of training.
Analysis of relationships between willingness to participate, training adequacy,
previous experience and time since last training showed significant correlations for
chemical incidents but not for biological or radiological incidents. For chemical
incidents, there were weak positive correlations between training adequacy and
both willingness to participate (rs = 0.279, p = 0.043) and amount of previous experi
ence in chemical incidents (rs = 0.373, p = 0.007). There was a negative correlation
between training adequacy for chemical incidents and months since last CBR train
ing (rs = -0.317, p = 0.050). For chemical incidents there were no significant correla
tions between willingness to participate and CBR incident experience or time since
last training, and for biological or radiological incidents there were no significant
correlations between positive reports of training adequacy, willingness to participate,
CBR incidents experience or time since last training.

Discussion
CBR incident response
The major finding from this study was that the majority of emergency nurses were
willing to participate in CBR incidents and their willingness to participate was not
affected by type of incident, physical limitations of PPE use, perceptions of train
ing adequacy, demographic, employment or social characteristics. The majority of
participants (73.5 per cent) reported being able to respond to CBR incidents beyond
normal working hours, although staff with carer responsibilities for children reported
increased difficulty remaining at the end of a shift.
The strong trend towards participation in CBR incidents by emergency nurses is
congruent with the findings of other studies, particularly those related to the 200203
SARS outbreak, when healthcare professionals continued to work despite significant
risk of illness and death (Reid, 2005). It may be argued that CBR incidents raise
moral and ethical issues for nurses when balancing duty of care against personal risk.
There are suggestions that altruism and heroism may underpin the willingness of
healthcare professionals to participate in disasters and CBR incidents (Downie, 2002;
McKay, 2002; Reid, 2005). However, during the SARS crisis, healthcare professionals
from all disciplines and non-professional support staff continued to work despite
the risk of illness (Reid, 2005), casting doubt that altruism and heroism are limited
to healthcare workers. Contemporary disaster management emphasises the impor
tance of a systems approach (Emergency Management Australia, 2000). On this basis,
Reid (2005) is critical of duty of care being reduced to individual moral commitment
to altruism, and argues that reductionism of duty of care ignores the responsibility

Chemical, biological and radiological incidents

we . . . share to create and maintain structures that support people in fulfilling their
duties as health care professionals (2005, p. 357). While altruism may play some
part in emergency nurses willingness to participate in CBR incidents, obligation is
inversely proportional to risk and there is a point at which risk may rescind duty of
care (Reid, 2005).
If it is unreasonable to expect healthcare professionals to risk injury or death in
order to provide care (Reid, 2005), the willingness of emergency nurses to partici
pate in CBR incidents may be due to confidence in their CBR knowledge and skills.
This premise is supported by the significant positive association between willingness
to participate in CBR incidents and postgraduate qualifications in emergency nursing.
Willingness to participate in CBR incidents may therefore be related to educational
preparation and it may be argued that nurses with postgraduate qualifications are
better educated about use of PPE, agent specific risk, and organisational procedures
and systems, and therefore feel more confident in their ability to manage CBR inci
dents. Relationships between increased knowledge and/or confidence and willing
ness to participate in CBR incidents was also evident during the SARS outbreak
(Maunder et al., 2003). A descriptive study of the SARS outbreak in Toronto in 2003
showed differences between nurses working in a specialist SARS unit and nurses
caring for SARS patients in general medical units. There were no refusals to care
for patients by SARS unit nurses but medical unit nurses did refuse to care for
SARS patients needing respiratory isolation. SARS unit nurses appeared to experi
ence less distress than nurses on other units and reported feeling confident about
being well-equipped, . . . protected by isolation precautions and well supported in
the hospital as factors related to their willingness to care for SARS patients (Maunder
et al., 2003, p. 1249).
There was a significant decrease in comfort and therefore willingness to respond
in the case of unknown chemical or biological agents when compared with known
agents. The majority of nurses (68.7 per cent) had positive perceptions of comfort deal
ing with a known chemical or biological agent, but positive perceptions of comfort
decreased when participants were asked about unknown chemical and biological
agents. Uncertainty raises a number of issues for disaster planning and response.
Perceptions of risk are increased by uncertainty and during the SARS epidemic staff
perceptions of risk were exacerbated by media coverage, known deaths from SARS,
constantly changing infection control recommendations, and reported shortages of
essential equipment such as masks (Maunder et al., 2003). Early in the SARS epi
demic, the risk of illness was unknown, there was uncertainty about mode of trans
mission, and poor compliance with infection control procedures (Maunder et al.,
2003). Hospital administrators not only had to ensure a high standard of care for
patients with SARS but also had to consider the safety of healthcare professionals
providing this care (Maunder et al., 2003).
PPE limitations
A second major finding of this study was confirmation that not all staff have the
capacity to don PPE: 29.7 per cent of participants reported limitations to donning

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the equipment. PPE is categorised according to the level of protection provided and
this study focused on Level C PPE, which is used in Victorian public hospitals for
chemical incidents (Victorian Department of Human Services, 2007). Level C PPE
includes full-face mask with sealed visor, air purifying respirator, hooded chemicalresistant suits, under-suit clothing, double gloves (internal nitrile gloves and external
nitrile or butyl gloves), chemical resistant PVC boots and chemical resistant tape.
Working in Level C PPE is physically and psychologically demanding and staff
safety is a major consideration during a CBR incident. It is estimated that work
performance in Level C PPE is reduced by up to 50 per cent as a result of heat stress,
reduced manual dexterity, limited vision and impaired communication (Emergency
Management Australia, 2000; Luther et al., 2006). Both state and national guide
lines recommend limiting work time to 1530 minute periods depending on ambi
ent air temperature and signs of fatigue (Emergency Management Australia, 2000;
Victorian Department of Human Services, 2007). According to national PPE guide
lines, the following conditions exclude personnel from donning Level C PPE: diastolic
blood pressure over 105mm Hg, heart rate over 220 minus age, respiratory rate over
24 per minute, temperature greater than 38C or less than 36.5C, new ECG abnor
malities, open skin sores, large area of rash or significant sunburn or altered mental
status (Emergency Management Australia, 2000). In addition to pregnancy, the follow
ing illnesses within 72 hours also excludes staff from Level C PPE: nausea, vomiting,
diarrhoea, fever, upper respiratory tract infection, heat illness, or significant alco
hol intake (Emergency Management Australia, 2000). Previous estimates have stated
that 20 per cent of ED staff would be excluded from donning PPE at any given time
(Tan and Fitzgerald, 2002).
The Level C PPE exclusion rate reported in this paper was 29.7 per cent, signifi
cantly higher than previous estimates (Tan and Fitzgerald, 2002). It is important to
note that questions regarding PPE were limited to finite physical characteristics
and did not examine exclusion criteria such as vital signs, skin and hydration status
abnormalities, or medical history. The PPE limitation rate reported in this study may
therefore be a conservative estimate. Given that the majority of nurses reported will
ingness to participate actively in a CBR incident, findings also raise questions about
whether staff would under-report historical variables in order to support their colleagues.
Current guidelines suggest that an incident requiring decontamination of fewer
than 100 patients requires at least two teams of three people to don PPE. Current
disaster plans have four of these roles allocated to nurses (Victorian Department of
Human Services, 2007). The finding that at least one third of nursing staff are inca
pable of donning Level C PPE raises a number of issues in terms of organisational
capacity to respond to a CBR incident. With an average of 1214 nurses per shift,
the results of this study suggest that only eight to nine nurses would be eligible to
work in PPE. A shortage of nurses able to don PPE may have significant consequences,
such as: inappropriate allocation of staff roles in a CBR incident; nurses able to don
PPE working for longer than recommended times; decreased capacity to rapidly and
effectively decontaminate moderate to large numbers of patients; and delays to entry

Chemical, biological and radiological incidents

into the ED where lifesaving interventions requiring high levels of manual dexterity
can take place. A possible solution to the lack of nurses able to don PPE may be to use
staff who are well trained in decontamination but less experienced in emergency
care to perform decontamination, in order to retain highly skilled emergency nurses
within the ED so they can use their best expertise in the management of decontami
nated patients who may require a range of interventions.
CBR training and experience
The third major finding of this study was significant deficiencies in CBR training:
21.9 per cent of participants reported no CBR training, and of those that had under
gone training, the average time to their last training was 19.2 months. Active par
ticipation in CBR incidents was reported by less than one quarter of the nurses
surveyed and previous experience in donning Level C PPE was reported by only
six nurses, reinforcing the notion that disasters are uncommon. The importance of
regular revision and practice for emergency responses is well known (basic life support,
advanced life support, fire and emergency procedures training). Current Victorian
recommendations are that hospitals must provide instruction and training in the
effective use, limitations and maintenance of PPE and clothing to all emergency depart
ment . . . staff , and recommend half-yearly refresher training (Victorian Department
of Human Services, 2007, p. 7). However, there are a number of barriers to fulfill
ing this recommendation including workload, lack of dedicated education time, and
other regular competencies requiring completion.
Disasters are unpredictable and infrequent events, and yet it is argued that responses
from healthcare providers should be structured and predictable (Halpern, 2005): this
can only occur with adequately resourced training. Disaster preparedness should there
fore include realistic plans for staff training to ensure maximum capacity to respond
to a CBR incident (Abrahams, 2001). Better integration into disaster plans of basic
principles used in everyday practice may be one strategy to increase the effectiveness
of CBR response. For example, effective infection control underpins epidemic man
agement, but the assumption that healthcare professionals are competent in basic in
fection control measures such as hand washing is questionable (Cameron and Rainer,
2003). Reinforcing the importance of routine practices and continued training in
even the basic elements of infection control is a key strategy to effective disaster man
agement (Cameron and Rainer, 2003). Such basic principles, however, are often
overridden by complex and exciting procedures such as donning PPE and setting up
decontamination showers.
In addition to the training issues highlighted in this study, the content of train
ing should be reviewed to ensure an effective organisational disaster response. An
important and often underestimated element of CBR training is how best to support
other staff and patients (Maunder et al., 2003). Anecdotal evidence would suggest that
these elements of disaster training are either not acknowledged or are not considered
within the normal realm of nursing practice. Staff and patient support is particularly
important in biological incidents and is illustrated by a study of a vancomycin-resistant

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enterococci (VRE) outbreak in an Australian hospital, which reported severe bur

den on nursing staff as nurses assumed the role of gatekeepers to patients, limiting
contact by staff and visitors (Mitchell et al., 2002).
The SARS epidemic also resulted in isolation of staff during a time when support
was needed (Maunder et al., 2003). Factors such as imposed or voluntary quarantine,
no personal contact with friends and family, self-imposed isolation for fear of con
tracting SARS, and reduction in face-to-face communication have added to the
psychological burden of personnel involved in biological disasters (Maunder et al.,
2003). The SARS outbreak also raised concerns among personnel about illness trans
mission to their families and significant others, creating conflict between their role
as healthcare professionals and that as parents, partners or family members (Maunder
et al., 2003). Adding to the psychological burden of this outbreak were reports of
feeling stigmatised in the community, suppressing ones identity as a healthcare pro
fessional, and requirements for healthcare professionals to provide care for colleagues
who had contracted SARS (Maunder et al., 2003). In addition, CBR incidents can
have significant impacts on staff not directly involved in the event. During the SARS
outbreak, staff deemed as non-essential and asked to remain at home reported feel
ings of isolation and helplessness (Maunder et al., 2003).
The final major finding of this study was that perceptions relating to choice to
participate and training adequacy varied according to incident type. There were
significantly lower perceptions of personal and collegial choice to participate in
radiological incidents than in chemical or biological events. Although perceptions about
adequacy of training were generally negative, participants felt most prepared for
radiological incidents and least prepared for chemical events. Responses related to
chemical incidents showed significant positive correlations between training ade
quacy and willingness to participate, and also between adequacy of training and
previous experience with chemical events. There are a number of possible explana
tions for these findings. First, willingness to participate in CBR incidents and feelings
about CBR training adequacy may be related to perceived risk. Patients exposed to
ionising radiation pose no risk to hospital staff and do not warrant specific precau
tions; patients contaminated by radiation do require activation of radiation precautions,
but likewise pose little risk to ED staff (Bushberg et al., 2007). In contrast, patients
suffering chemical contamination can pose significant risk to staff and thereby to
ED capacity to provide care. For example, in Australia over recent years there have
been a number of ED closures due to secondary chemical contamination (Luther et
al., 2006; Canestra cited in Tan and Fitzgerald, 2002, p. 196), and there have been
a number of cases reported in the international literature of staff members becom
ing seriously ill due to nosocomial organophosphate poisoning (Geller et al., 2001;
Stacey et al., 2004).
Second, alignment to usual practice may be a factor in perceptions of choice to
participate in CBR incidents and training adequacy. The response to radiological
incidents is more closely aligned to usual practice than the management of chemi
cal or biological incidents. Radiation precautions include assessment of severity of

Chemical, biological and radiological incidents

contamination using a Geiger-Muller survey meter, decreasing exposure, decon

tamination by removal of clothing and washing the skin, limiting close contact
with contaminated patients, and utilisation of universal precautions with the addition
of double gloves to prevent cross-contamination (Bushberg et al., 2007). Manage
ment of patients with significant chemical contamination requires Level C PPE and
active decontamination prior to entry to the ED (Victorian Department of Human
Services, 2007). In addition, management priorities for a patient suffering radioac
tive contamination are assessment and treatment (Bushberg et al., 2007) that reflect
usual emergency nursing practice. However, decontamination is the priority for patients
with chemical contamination and given the technical difficulties of working in Level
C PPE, only limited resuscitative measures may be undertaken during decontami
nation (Stacey et al., 2004; Victorian Department of Human Services, 2007). This
paradigm shift conflicts with nurses usual instincts to assess and treat the critically
ill or injured.

Limitations
There were three major limitations that should be considered when interpreting the
study findings. First, participants in this study were self-selecting because they had
to consent to participate and this may be a source of sampling bias (Suen and Ary,
1989). The advantage of the sampling method employed in this study was that all
ED nursing staff who attended the information sessions had the same opportunity to
participate, acknowledging that it was not possible to control the individual choices
to participate. Second, there were a number of staff unable to attend the information
sessions, despite efforts by the researchers to capture staff from all shifts, and unfor
tunately these staff did not gain the opportunity to participate in the study. Third,
the study findings are based on self-reported data, which raises potential questions
about the reliability of the data. However, participants were assured of their confi
dentiality and anonymity, and the surveys were not coded, so participants had no
reason not to answer honestly. Finally, the study was limited by the sample size,
although it provided data from 71 per cent of nurses on the ED roster at the time of
data collection.

Conclusions
The results of this study show that emergency nurses generally had positive percep
tions about participation in CBR incidents. The vast majority of emergency nurses
were willing to participate in a CBR incident, suggesting that there will be ade
quate numbers of emergency nurses during these events. At least one third of the
emergency nurses surveyed were precluded from working in Level C PPE, so contin
gencies to overcome this potential limitation to ED incident response are paramount
in organisational disaster planning. Further, it is imperative that organisations collect

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objective data about factors that may impact on capacity to respond to CBR incidents
and use these data as a basis for disaster plans. This study highlights significant deficits
in CBR training that require attention at unit, organisational and government levels.
Training opportunities need to be maximised and appropriately resourced and inter
disciplinary training should occur at regular intervals. Disasters and CBR incident
response has added a layer of complexity to the already challenging and diverse scope
of emergency nursing practice. CBR knowledge and skills is yet another challenge
in this constantly evolving speciality and the results of this study would suggest that
emergency nurses are keen to meet this challenge and respond to the needs of both
local and global communities.

Correspondence
Julie Considine, School of Nursing, Deakin University, 221 Burwood Hwy, Burwood
3125, Victoria, Australia. Telephone: +61 3 9244 6175; e-mail: julie.considine@
deakin.edu.au.

Acknowledgements
This study was funded by the Ben Morley Scholarship, which is supported by the
College of Emergency Nursing Australasia and Tuta Health Care. The researchers
would also like to thank the Morley family for the opportunity to carry out this
research. Thanks also to the nursing staff in the Emergency Department at The
Northern Hospital for their participation and support of this research.

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