The associated factors of disaster literacy among nurses in China: a structure equation modelling study

Disasters often happen unexpectedly leading to serious human, material, economic and environmental losses and impacts [1]. The world has witnessed various unprecedented disasters and public emergency such as COVID-19 pandemic, Ebola outbreak, Zika virus disease and regional wars. It was reported that over 42,000 health professionals fought in the frontline during the peak of the pandemic in Wuhan China in 2020, of which 68% were nurses [2]. As the largest group of healthcare professionals, nurses tend to actively engage in national disaster response and public safety. However, disaster emergency usually sharply contrasts with routine clinical practice and involves challenges of totally new contexts. For example, nurses reported feeling powerless to deal with patients’ conditions during the COVID-19 crisis [3], which might lead to high prevalence of emotional, physical, and mental exhaustion. As shown in a large-scale nationwide survey, 34%, 55.5% and 41.8% nurses reported burnout, depression and anxiety, respectively [4]. A recent qualitative study found that nurses attached importance to disaster literacy as crisis management goes beyond being mere clinical nursing and consists of multidimensional skills such as coordination, problem-solving and social responsibilities [5]. Another umbrella review indicated that disaster literacy is essential for empowering nurses to make critical decisions, collaborate with other professionals, and communicate effectively in emergencies. This is not only crucial for responding to the immediate medical needs but also for handling the psychological and emotional challenges nurses face in the aftermath of such events [6]. Therefore, their disaster literacy serves as a critical component to enhance effective disaster risk management and strengthen public health emergency preparedness and response [7].

Literacy is a complex and dynamic concept with a broader meaning of being knowledgeable or educated in a specific area and a common view as the abilities to read and write text [8]. It should be noted that literacy is not equivalent to the acquisition of knowledge, skill and ability only. Instead, it encompasses the capacity to utilize psychosocial resources effectively in complex situations and integrate knowledge, attitude and values in problem-solving [9]. It is important to distinguish disaster literacy from other types of literacy (e.g., health literacy) and literacy in general. Although there are various definitions of disaster-related literacy such as disaster prevention literacy defined by Chen et al. [10] and disaster risk literacy defined by Hung et al. [11], these concepts only focus on individual’s competencies for survival purpose in the context of disaster risk. In 2014, Brown et al. proposed a conceptual definition of disaster literacy referring to individuals’ capacity to identify, comprehend and utilize information to make decisions in prevention, preparation, response, and recovery when encountering a disaster [12]. Recently, Çalışkan et al. proposed a more comprehensive definition and integrated model of disaster literacy exhibiting the phases of disasters and the perspective of life course [13]. It emphasized that individual’s skills and ability in the phase of prevention, preparation, response, and recovery are shaped throughout life. This conceptual framework informs public health nursing practice. Adapted from previous literature, nurses’ disaster literacy means that they are equipped with the knowledge and skills, confidence and responsibility as well as the ability of decision-making to handle stressful situations and take action against risk reduction [14]. However, previous studies have shown that nurses have insufficient disaster literacy. A cross-sectional study in Sweden found that nurses in Emergency Department had low level of disaster competency and may overestimate their disaster preparedness [14]. Similarly, another study in Turkey showed that nurses were not prepared for disasters due to a lack of training [15]. This evidence implied that nurses with limited disaster literacy may struggle to provide appropriate care during emergencies and experience heightened stress and anxiety when they feel unprepared for disaster situations. This could further negatively impact patient outcomes during a major incident. Therefore, understanding the associated factors of disaster literacy in nurses would inform what strategies can be taken to better prepare nurses for effective response to disasters.

The Social-Ecological Model is a well-established framework that examines the complex interplay of multiple systems that influence one’s behaviour [16]. From the individual perspective, psychological resilience and self-efficacy are important factors as they play a role in individuals’ ability to adapt to and cope with stressors as well as maintain a positive attitude. When responding to disasters, nurses often face tremendous psychological pressure and may suffer from negative emotional problems such as depression, anxiety and post-traumatic stress disorder [4]. However, nurses with higher level of psychological resilience and self-efficacy are more likely to be confident about their understanding of the crisis [17], have perceived competence and exert effective coping strategies in disaster events [18]. Moreover, research has shown that there is a positive association between self-efficacy and psychological resilience [19, 20]. Self-efficacy could empower individuals to face difficulties with confidence and adaptability, indicating that resilience can be potentially built by strengthening self-efficacy. As psychological resilience and self-efficacy are dynamic recourses, enhancing these individual factors would improve nurses’ response efficacy and disaster preparedness [21] and thus may influence disaster literacy.

Moreover, social support is conceptualized as an interpersonal process with a focus on thriving, which helps individuals cope successfully with adversities [22]. A considerable body of research has shown that there is a significant negative correlation between social support and various mental health problems [23‐25]. This indicates that good social support can effectively reduce the occurrence of traumatic experience in nurses and motivate them to respond to disaster events. Meanwhile, the association between social support and psychological recourses such as resilience and self-efficacy in nurses is well-documented [26, 27]. For example, a recently study showed that perceived social support has a positive impact on psychological resilience and self-efficacy [28].It is plausible that social support can enhance an individual’s psychological resources. Nurses with higher level of social support are more likely to utilize assistance from family, friends and colleagues and gain confidence and courage to face adversity [27]. This indicates that they may be more willing to be engaged in difficult tasks such as disaster events and have higher level of disaster literacy.

In terms of organizational and societal factors, culture fundamentally shapes how people respond to crises such as the COVID-19 pandemic. Collectivism, as a cultural value, defines individuals as parts of groups and emphasizes prioritization of collective goals [29]. Collectivist cultures often emphasize strong social bonds and shared responsibilities. A study on 240 nurses during COVID-19 found that collectivism will affect nurses’ willingness to care. Nurses with higher levels of collectivism have stronger ties with society and are more likely to respond to disasters [30]. Besides, collectivism can predict positive coping style and lower psychological maladjustment during the COVID-19 [31]. When facing challenges, people work together toward common objectives, fostering resilience at the individual level [32]. This evidence indicates its pathways through interpersonal and individual resources. With the globalization, disaster events are more serious than at any time. In the face of major disasters, no individual or country can survive alone. Major disasters often overwhelm the resources and capabilities of any single entity. Collective action and international cooperation are essential to effectively respond to and recover from such events [33]. Existing evidence indicates that nurses who embrace collectivism are more likely to prioritize group goals over individual ones, leading to better teamwork and more effective disaster response [34]. Therefore, collectivism would be an important factor associated with disaster literacy both directly and indirectly.

During the post-COVID era, it is necessary to enhance nurses’ disaster literacy for future preparation. However, there is a paucity of research in this field. The Social-Ecological Model recognizes the interplays of individual, interpersonal and societal factors. Collectivism, social support, resilience, and self-efficacy all play crucial roles in shaping human behavior within this framework. Understanding the influencing factors of disaster literacy based on the Social-Ecological Model would inform multilevel interventions to promote preparedness and efficacy in crisis management. This study aims to examine the factors associated with disaster literacy in nurses from micro (individual), meso (interpersonal) and macro (organizational and societal) levels and analyze the influencing mechanisms among these factors. The hypotheses are shown in Fig. 1.

Self-designed survey was used to measure participants’ basic information including gender, age, education level, marital status, years of working, job position, department and experience in disaster events.

Clinical Nurses Disaster Literacy Scale was used to assess nurses’ disaster literacy. It was developed by Zhang et al. [36] based on disaster literacy conceptualization [6] and health literacy theory [37]. There are 34 items and three subscales including functional (e.g., knowledge and skills), interactive (e.g., motivation and confidence), and critical (e.g., analyze and apply information) literacy. It was rated by Likert 10-point scale from 1 (completely disagree) to 10 (completely agree), with higher scores indicating higher level of disaster literacy. The validated Chinese version was used [36]. The Cronbach α of this scale in our study was 0.985.

Collectivism Scale was used to measure nurses’ collectivism [38] including 32 items and four subscales: vertical collectivism, horizontal collectivism, vertical individualism and horizontal individualism. Vertical Collectivism emphasizes hierarchy within the group (e.g., It is important that I respect the decisions made by my groups) whereas horizontal Collectivism focuses on equality within the group (e.g., If a coworker gets a prize, I would feel proud). Vertical Individualism recognizes individual autonomy (e.g., It is important that I do my job better than others) whereas horizontal Individualism values individual uniqueness (e.g., I often do my own thing) [38]. It was rated by Likert 5-point scale from 1 (completely disagree) to 5 (completely agree), with higher scores indicating higher level of collectivism. The validated Chinese version was used [39]. The Cronbach α of this scale in our study was 0.957.

Perceived Social Support Scale was used to assess nurses’ social support [40] including 12 items and three subscales: the support from friend, family and others. It was rated by Likert 7-point scale from 1 (completely disagree) to 7 (completely agree), with higher scores indicating higher level of social support. The validated Chinese version was used [41]. The Cronbach α of this scale in our study was 0.980.

The 10-item brief Connor-Davidson Resilience Scale [42] was used to measure nurses’ psychological resilience. It was rated by Likert 5-point scale from 0 (never) to 4 (always), with higher scores indicating higher level of psychological resilience. The validated Chinese version was used [43]. The Cronbach α of this scale in our study was 0.960.

General self-efficacy scale was used to measure nurse’ self-efficacy [44]. It includes 10 items rated by Likert 4-point scale from 1 (completely disagree) to 4 (completely agree), with higher scores indicating higher level of self-efficacy. The validated Chinese version was used [44]. The Cronbach α of this scale in our study was 0.947.