Reflecting on the challenges encountered by nurses at the great Kermanshah earthquake: a qualitative study

Earthquake is one of the most destructive natural disasters. Based on the international Emergency Events Database (EM-DAT), the rate of earthquakes is growing all around the world so that 792 cases have been reported between 1987 and 2015 [1]. As a developing country in Asia, Iran is one of the top 10 seismic countries in the world [2]. On the night of 12th of November 2017 at 21:48 local time, a devastating earthquake magnitude 7.3 on the Richter scale struck the region near the Iran–Iraq border in the West of Iran [3]. In this event, there were 620 deaths, 8,000 wounded, 70,000 homeless, 4,700,000 affected by it, and ≥ 12,000 damaged buildings [4]. After a natural disaster incidence, a surge in the demand for health and treatment services takes place [5] significance of nurses during a disaster is obvious since nurses are usually and constantly involved in disaster response by being the biggest group of human resources of health care providers in disasters [6]. Nurses often work in difficult conditions with restricted resources and always have more problems and challenges in their work [7]. Studies have shown that the nurses who provide care services to earthquake victims encounter several challenges like resource shortages [8], personal and family safety concerns [9], health problem management [10], and moral challenges [11]. Given the high risk of earthquakes in different regions of Iran and involving the nurses in these crises [9, 12], it is essential to have fundamental insights about these challenges. The issues and challenges faced by nurses in providing care to earthquake victims have not been examined comprehensively [13]. Based on the experiences of the participants, we can achieve a basis for programming and policymaking in health care systems to face critical situations. The present study elaborated on the challenges faced with by nurses in providing care to the victims of the Kermanshah earthquake 2017.

Data analysis led to the development of 5 categories and 14 subcategories. The categories emerging from the data analysis were included (1) Organizational and managerial challenges (2) human resources (3) infrastructure (4) educational system, and (5) ethical. These categories with their subcategories are explained in the following tables (Tables 1 and 2).

In this study, the nurses’ experience regarding the challenges faced of providing care to earthquake victims was examined. Semi-structured interviews were performed and the data analysis yielded five categories. Organizational and managerial challenge was one of the main extracted categories. According to the participants, different organizations like the ministry of health, the Red Crescent Society, and other relief organizations were in responsible dispatching health, treatment and service forces to offer services to the disaster areas.These organizations worked independently and there was no coordination among them and each of them considered themselves as the leader of providing services in this conditions.

The finding of this study was supported by previous studies. In Pouraghaei study conducted Azerbaijan earthquake in 2012, it was revealed that the lack of coordination among organizations as one of the main challenges [17]. Another study by Li et al. on Sichuan earthquake in China, pointed to the lack of collaboration among disaster relief teams and insufficient leadership [18]. Apparently, one of the challenges of modern age, given the type of disasters, is the necessity of an integrated system to face disasters.

Human resources challenge was another extracted category in this study. The participants highlighted issues like lack of welfare facilities for care givers like accommodation facilities, nutrition, bathrooms, and negligence of mental health of nurses. Other studies have reported similar concerns in nurses like personal safety, adequate food, water, and accommodations [19, 20]. Hugelius et al. noted that providing psychological support was one of the main elements in nursing services in the face of disasters [21]. In addition, Salmani et al. noted that volunteers’ potential problems and their physical and mental status should be assessed during and after disasters [22]. The participant mentioned ineffective call and distribution of relief forces in the regions hit by the earthquake, lack of uniform, and their concerns about safety of their families. Studies on Sichuan earthquake in China and the Bam earthquake have highlighted poor human resource organization as well [18, 19]. Despite the fact that health and treatment personnel were present in the region, they were not known to officials and clients in the early days. In the case of the Bam and Azerbaijan earthquakes, some of the volunteers did not have uniform and ID card [17, 19]. When providing care in critical situations, providing dress is fundamental to distinguish the health providers.

Despite the valuable role of nurses in the earthquake region, they and their families received no mental, financial, and emotional support. Similar problems have been reported in other studies [9, 17, 23]. Nursing Organization can take steps in this regard by providing protection and support for nurses and their families during disasters as incentives for nurses. Such services solve the concerns in nurses and improve their capability to provide health services.

Another main category was infrastructural challenges. The participants had experienced several challenges in this field. Ardalan et al. reported that due to communicational problems and the demolition of three health centers and 89 local clinics failed to play an efficient role during the first phase of reaction to Azerbaijan earthquake [24]. Infrastructure disruption after disasters have been mentioned in several study as a serious challenge [25, 26].

Another extracted challenge was about education system. Many of the participants acknowledged the lack of skills and knowledge for providing health care in disaster and absence of a comprehensive education program in this regard. A systematic review in 2017 showed that nursing curricula has a limited amount of disaster-related content, so they were not ready to work in disasters; most of the reviewed studies were from Asian countries [27].

Like many other countries, crisis nursing education is not completely developed in Iran and nurses do not have the knowledge and skill to work in disasters due to lack of education [13]. Empowerment of nurses and improvement of their awareness can be a major step to provide timely and proper services to victims during disasters. Theoretical and practical educations should be a part of nursing program to improve performance of nurses during disaster.

Another category based on the experiences of nurses was moral challenges. Some of the participants mentioned situations full of moral challenges and that they had no education in this regard. Moral challenges in providing care to the victims while the safety of nurse is at risk were discussed. These findings are consistent with other studies on nurses who helped earthquake victims and faced with moral challenges [9, 11, 28]. Studies have shown that serious lack of resources and hard situations create moral challenges like whether or not washing equipment with drinking water is a right thing to do. Similarly, nurses in our study also reported such practices as using one forceps for multiple injuries [8, 29]. Moral preparedness of nurses who are the front line of providing care services during disaster neglected and they suffer the consequences of different professional and moral challenges afterwards [9].

There are several limitations that should be considered when interpreting the findings of study. The main limitation of qualitative studies is the lack of generalizability of the results, to which our study is not an exception. The results may be specific to this environment and culture.The study findings are a reflection of the experiences of a small group of nurses attending an earthquake zone in one province of Iran. To alleviate this limitation, the participants were selected from different provinces with maximum diversity. Despite providing rich information of the concept under study, the time gap between the actual experiences and the interviews could also cause concerns about accuracy of the recollections.

The nurses faced with several challenges in providing care to earthquake victims. Five main categories of these challenges were extracted that need serious, efficient, and effective intervention to ensure better care services in similar situations in the future. Similar challenges had been experienced in previous earthquakes like the Roudbar, Bam, and Azerbaijan earthquakes. But few lessons from these earthquakes have been consistently applied in earthquake disaster management practices. Many of the lessons from the great earthquake disasters of previous did not become ‘‘Lessons Learned. ’’ To the contrary, these lessons were identified again in Kermanshah earthquake in Iran. In other words, we re-experience the experience. Given the crisis nursing status in Iran, better curriculum planning and implementation, revision of nursing curriculum, and establishing crisis nursing national team (professional pre-identified volunteers) are essential measures to improve professional competence of nurses in the face of disasters.