Nurse Education in Practice xxx (2014) 1e7

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Nurse Education in Practice

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Chinese nurses' relief experiences following two earthquakes:

Implications for disaster education and policy development
Zhou Wenji a, 1, Sue Turale b, *, Teresa E. Stone c, Marcia A. Petrini a
a
HOPE School of Nursing, Wuhan University, Wuhan City, Hubei Province, China
b
Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
c
Yamaguchi University Faculty of Nursing, Ube, Yamaguchi, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Disasters require well trained nurses but disaster nursing education is very limited in China and evidence
Accepted 29 June 2014 is urgently required for future planning and implementation of specialized disaster education. This de-
scribes the themes arising from narratives of Chinese registered nurses who worked in disaster relief
Keywords: after two major earthquakes. In-depth interviews were held with 12 registered nurses from Hubei
Disaster nursing Province. Riessman's narrative inquiry method was used to develop individual stories and themes, and
Disaster relief
socio-cultural theory informed this study. Five themes emerged: unbeatable challenges; qualities of a
Narrative inquiry
disaster nurse; mental health and trauma; poor disaster planning and co-ordination; and urgently needed
Earthquakes
Nursing education
disaster education. Participants were challenged by rudimentary living conditions, a lack of medical
equipment, earthquake aftershocks, and cultural differences in the people they cared for. Participants
placed importance on the development of teamwork abilities, critical thinking skills, management
abilities of nurses in disasters, and the urgency to build a better disaster response system in China in
which professional nurses could more actively contribute their skills and knowledge. Our ndings concur
with previous research and emphasize the urgency for health leaders across China to develop and
implement disaster nursing education policies and programs.
2014 Elsevier Ltd. All rights reserved.

Background
Disasters occur daily around the globe, causing dramatic im-
pacts on individuals, families and communities (World Health
Organization [WHO] and International Council of Nurses [ICN],
2009), and their effects are worse in Asia where the largest global
share (40.3%) of reported natural disasters occurs annually (Vos
et al., 2010), including the Chinese Wenchuan (2008) and Yushu
(2010) earthquakes. The Wenchuan 8.0-magnitude earthquake
(also called the Sichuan Earthquake) caused 87,476 deaths, many
injuries, and damages worth z US85 billion (McClean, 2010).
Over 25 days post-earthquake there were many aftershocks
(Parsons et al., 2008), and more than 15,000 geohazards: landslides,
rock falls, debris ows, trafc blockages and heavy rain (Yin et al.,
2009; Central Government, People's Republic of China [CGPRC],
2008). The Yushu 7.1-magnitude Earthquake in Qinghai Province
* Corresponding author.
E-mail addresses: 912210150@qq.com (Z. Wenji), INReditor@icn.ch (S. Turale),
teriston@yamaguchi-u.ac.jp (T.E. Stone), petrinima2012@gmail.com (M.A. Petrini).
1
Tel.: 86 1501 8719 457.
caused 2698 deaths (People's Daily Online, 2010), and
100,000
injured (Ni et al., 2010). It occurred 4000 m above sea level affecting
30,000 square kilometers (Deng et al., 2010) where mostly Tibetan
people live. Problems included limited access by road; heavily
damaged health facilities; altitude sickness for rescuers; cultural
differences; and language barriers that were challenges for rst
responders (CGPRC 2010a; CGPRC 2010b). The most seriously
injured had to be transferred long distances to Xining, Chengdu,
Lanzhou, and Xi'an City (CGPRC 2010c).
China enacted the Response Plan for Earthquakes after these
disasters, sending teams of doctors and nurses to designated areas.
Nurses, the largest group of health care workers globally, play a key
role in disaster relief (Yang et al., 2010). As frontline health care
providers, in rst responding they work in on-site coordination of
care, provide care and information, and are educators, mental
health counselors, or triage ofcers (Chan et al., 2010). Nurses after
disaster relief have signicant and unforgettable experiences and
are thus key informants to plan disaster efforts in the future. While
China experiences signicant disasters annually, there are no pol-
icies for disaster nursing per se and virtually no disaster nursing
training (Zhang, 2009), except for military nurses, and there is

http://dx.doi.org/10.1016/j.nepr.2014.06.011
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Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
2 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7

limited disaster nursing research. Uncovering nurses' experiences consider other questions to ask the next participant to encourage
regarding disaster relief is important to inform future relief efforts meaningful narratives. Interviews were conducted until data
and the development of programs to enable nurses to participate saturation was achieved (Holloway and Wheeler, 2010).
with some condence in future events. The only thing that is
certain about disasters is that they will occur again, and nurses Data analysis, rigor and trustworthiness
need to be better prepared to face them (Turale, 2014).
Interviews were transcribed verbatim, then repeatedly read and
Research design interpreted in light of the theoretical framework and research
questions. Riessman's (2008) narrative inquiry method resulted in
Aim two types of ndings. Firstly a narrative that captured the essential
points of each participant's story was written, and was validated or
Describe the experiences of Chinese nurses who worked in modify by each participant, since member checking assists greatly
disaster relief after the Wenchuan and Yushu earthquakes, and with validity of qualitative studies (Holloway and Wheeler, 2010)
their views about future disaster nursing education/training Secondly, themes were developed from the 12 narratives after
programs. comparing similarities and differences between the narratives, and
these were then veried by participants, and it is those themes that
Research questions are discussed in this paper. Translation and back-translation was
then undertaken by bilingual translators, and the nal English
1. What were the disaster experiences of nurses from Hubei expression edited by the native English-speaking researchers. An
Province who worked in disaster relief during the Wenchuan audit trail was kept throughout analysis and the rst researcher
Earthquake, or the Yushu Earthquake? constantly checked her work with her experienced qualitative
2. How prepared did nurses from Hubei Province feel for their supervisor.
disaster work, considering the skills, knowledge, and attitudes
required? Ethical considerations
3. What advice could these nurses provide to inform the future
development of disaster nursing in China? Wuhan University HOPE School of Nursing gave research ethics
approval and permission was obtained from each hospital where
participants were located. Verbal and written explanations were
Theoretical framework given to all participants and written informed consent obtained.
Assurances about condentially were given, including the right to
This qualitative study utilized narrative inquiry and in-depth withdraw from the study at any time without penalty. Because of
interviews. Socio-cultural theory and Riessman's (2008) narrative potential participant distress during interviews in recounting
method informed the study. When storytellers or participants want disaster experiences, preparations were made for mental health
to provide narratives, they select the events (or experiences) counseling, but this was not required. Pseudonyms are used here to
important to them and meaningful to a particular audience, and protect identities.
construct their story by organizing, connecting and evaluating a
sequence of events. Afterwards, researchers can construct stories
Findings
from the participants' texts. How new understandings are con-
structed and how we engage with one another is always situated
All participants, one male and 11 female, worked in hospitals
within a sociocultural context. Sociocultural theory in this study
prior to disaster deployment. Only ve had voluntarily joined the
allowed for consideration of the contexts of the participants and
earthquake disaster relief efforts; the remainder were assigned and
the people they cared for in the earthquake disasters.
had little choice about deployment. Demographic data is displayed
in Table 1.
Sample
Five themes are presented below and the process of emerging
themes from the study is shown in Fig. 1:
A convenience sample of 12 registered nurses from four hospi-
tals in Wuhan, Hubei Province were recruited. Potential partici-
pants were nominated by hospital directors, or through snowball Table 1
sampling by other participants. Inclusion criteria were: being Demographics of the participants (n 12).
assigned through their hospital to the Wenchuan or Yushu Earth- Number
quake relief; and working for at least 24 h in the designated disaster
Age (year)
zone(s). 25e30 3
31e40 5
Data collection 41e46 4
Education level
Bachelor degree 11
Interviews were conducted in Chinese in 2010, digitally recor- Associate college degree 1
ded in private and ranged 50e97 min in length, 63 min on average. Area of specialty
Field-notes were written and included in data analysis. De- Perioperative nursing 2
mographic data was requested, including age, gender, number of Surgical nursing 8
Pediatric and surgical nursing 1
years worked, qualications and education, marital status, and
Surgical and geriatric nursing 1
specialization. Broad questions asked of all participants were: Tell Length of nursing service (year)
me about your disaster experiences; How prepared did you feel to 1e5 2
undertake these nursing experiences? and Do you have any 6e10 3
advice as to how nurses should be prepared for disasters in the 11e20 2
21e30 5
future? After analyzing one interview, the researcher would

Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7 3

Fig. 1. Example of how themes were extracted from the narratives.

Unbeatable challenges
Nurses from across China were sent to the Yushu Earthquake
zone, where late snow was falling, and on arrival were told they
would engage in rear-area relief work. Our participants, from the
plains of China, were transported directly to higher plateau areas of
Yushu and Xining where altitude sickness was an unexpected
challenge that affected their immediate ability to provide care:
Just going there, wow, I really felt really out of breath. Before I
inhaled oxygen, I felt it was so unbearable. (Chunhua)
Jiu also had altitude sickness in Xining. When she spoke and
walked fast, or felt excited, she would gasp and felt hypoxic.
Aftershocks, mud, landslides, heavy rain, lack of shelter, poor
living conditions, and lack of medical resources also tested partic-
ipants, as they dealt with massive numbers of casualties. It was very
hot in daytime, and at night very cold during Wenchuan earth-
quake relief. In the rst days, some could only manage a few hours
of sleep. Although some participants believed they had good
emergency nursing skills, they were frustrated at not being able to
provide much needed care:
There was neither sufcient equipment or medicine. Only penicillin
was available, but it did not work. It was very hot inside the tent
and I saw that the patient was gasping, but all I could do was fan
him. (Shier)
Participants tried to put personal feelings aside during their
work, but faced ethical dilemmas when giving care. For example, Shi
experienced personal danger during earthquake aftershocks while
panicked patients awaited her assistance. Taking risks was part of
the job for her and others, but for Shi a huge personal challenge was
trying to overcome her inner fears as she protected a patient on the
operating table with her body during an aftershock:
You asked me if I was afraid? after he and I helped the patient, I
tell you, I was somewhat scared
Er had ethical and professional challenges about leaving injured
elders who refused to leave their destroyed residences, and espe-
cially when there were language difculties:
Just like that elderly man said, I would rather die in that place
(his destroyed home). He was not willing to go anywhere. I told

Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
4 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7
him that he (should) come to our hospital, that conditions there
were better but he would not leave.
In Yushu and Xining there were the twin challenges of cultural
differences and language barriers. Tibetan patients would not allow
the Han Chinese nurses to change their clothes or wash their
bodies, because their culture prohibited this; they were suspicious
about the nurses, and regular washing was not their daily routine
because of the lack of water and harsh climate of Tibet. Liu felt
helpless about giving good care:
I thought I was not competent. there was a language barrier
between us. In this aspect, it was a little bit tough, that feeling of
being beyond my ability.
Qualities of a disaster nurse
Our participants lacked disaster nursing experience; but had to
be committed and in good physical and psychological health to try
to work competently. Resilience to deal with environmental con-
ditions was so important. After the Wenchuan Earthquake, Shier
explained:
We did not have any tents at rst, and later on we were so tired that
we lay down on cotton wadding on the ground. Then it rained and
we woke up to nd ourselves in water.
Participants, such as Yi, placed high importance on professional
skills and good health:
professional skills must be strong you must be in good health
above all. Good health at least means you are not afraid of hardship
in work
Traveling long distances to the disaster zones required patience.
Liu explained:
we sat on a green freight train especially arranged by Wuhan
Railway. There was no hot water , the space was very narrow and
we stayed on the train for two days one night, or two days two
nights.
Participants felt better able to manage when they believed they
were exible, adaptable and able to adjust care when resources
were scarce, for instance:
when it came to xation (of fractures), I thought of the card-
board box for instant noodles. and I made use of that (Shi)
Collaboration was needed between new colleagues from all over
China, but not every team tasked with caring for poverty-stricken
and traumatized people from a different culture was successful in
working together:
There were differences but we could not go to say they were not
right If we spoke out we were afraid that they would think, (that
we were) the people from a big place (who) looked down upon
them. (Chunhua)
Despite some teamwork difculties, participants felt they suc-
ceeded in their work, especially if they had sound professional
knowledge and ability to compromise. For example, in Chunhua's
story she nally compromised with new colleagues by keeping
face, a Chinese expression and value where maintaining pride or
Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
honor is esteemed. Other qualities identied as important for
disaster nursing include critical thinking, problem solving, and
organizational abilities. Disaster nursing also required outstanding
management in chaotic situations, and while not every nurse was
required to possess this, its value was inestimable especially when
dealing with challenges and coping with mass casualties and their
transfer for the rst time:
If there is something more (that was needed), it was organiza-
tional ability. this is an ability that can only be obtained through
experience. We had to dispatch (patients) on site, but we did
extremely well and were rated as an advanced group by the Min-
istry of Public Health. (Shi).
Mental health and trauma
Participants saw many hyper-vigilant and traumatized people
who had suffered injuries, and/or lost family members or homes.
They believed that mental health knowledge and support were
vitally important in disaster relief, however they lacked this, and
had not been trained to offer counseling and support to victims or
their own colleagues. Shisan said:
What should be done in the later phases (of the disaster) was
relatively vague to us at that time. This was our realization: disaster
education for mental health trauma must, must be given.
In the Wenchuan disaster zone there were >6000 aftershocks,
three >6-magnitude, and constant dangers from ooding of high
lakes formed after the rst earthquake. These ongoing dangers
added to mental health issues. For example, Shi witnessed some
highly alert patients so psychologically traumatized they would
panic at the slightest vibration, the slight swinging of something, or
the sound of running water. Some patients ran out of the hospital
regardless of personal safety, leaving behind their infusion bottles,
and staff were powerless to stop them. Participants too were
affected by the moods of disaster victims and the ongoing disaster,
and consequently some suffered mental health ill effects. Wu
explained that in addition to the complex disaster work there were
also concerns about a distressed fellow nurse:
He had asked to come, but after he went there his mood was just
very unstable so we had to look after him.
Most participants tried to regulate their own emotional health
during their disaster work, and sublimate their feelings after they
returned home, but often they could not overcome their sad feel-
ings. Four years later Yi's experience of smelling rotting bodies from
a destroyed kindergarten was still disturbing her, and she might
have had undiagnosed and untreated post-traumatic stress disor-
der (PTSD):
there is a disaster and although it is very dangerous, after you go
there you do feel there is a shadow in your mind. But you may just
think, oh dear, I went, I once went there. No matter how much my
contribution was, I helped the people there. I think in my heart that
feeling is still very good. Anyway, sometimes I feel myself very
fragile. Really, just feel very fragile.
Poor disaster planning and co-ordination
All participants spoke about poor co-ordination of disaster ef-
forts, including lack of knowledge about national or provincial
hospital disaster plans. They believed it took too long to deliver the
 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7
relief teams from neighboring provinces because of multiple layers
of bureaucracy. Further, too many under-prepared health workers
were sent to the disaster areas and were not utilized effectively, and
this was a waste of resources.
Seven participants were assigned by their hospitals to join the
disaster relief receiving notice of their relief mission unexpectedly
and leaving Wuhan in a hurry. Not all nurses were well equipped
with medical supplies and most did not have time to prepare their
luggage, or basic survival equipment. Shier, for example, described
her difculties trying to buy bottled water en route to the disaster,
and having to keep this secure and rationed for team members.
Further, her team did not have any food for 24 h of their travel.
Participants believed that if proper disaster policies and plans had
been in place, then equipment and personal effects could have been
better organized. Chunhua said:
There were many things still unprepared but they said we should
go immediately. Then I was in a panic.
At both the earthquake zones, excessive numbers of personnel
from all over the country combined with limited resources and
poor organization, seemed to bring about extra burdens:
there were too many cars going there, and we stayed there for
two days but only received one patient. (Jiu)
Shisan and his colleagues saw some relief teams not having
work for several days but in contrast, in one marshaling spot
there were about 30,000 victims and 1000 workers. He described
fumbling about, not knowing what to do and tried his best to
organize priorities, such as working with the army to set up
toilets.
Urgently needed disaster education
No participants had received systematic disaster nursing
training, a matter that had a profound effect on their abilities to
contribute to relief efforts. They felt underprepared and empha-
sized the need for training. There was some concern about last
minute attempts to give instructions on the train to Xining, where
Liu heard about possible wild beasts and infectious diseases:
Anyway they also let us make mental preparation for these infec-
tious diseases. Oh, yes. There were still Tibetan mastiffs there, even
wild wolves and ferocious beasts. Anyway I felt a little scared after
hearing this. (Liu)
Chunhua and Shiyi lacked the skills to work in an ambulance
transporting victims; Er had difculty setting up the eld tent; and
others had scant knowledge and skills about mass casualty trans-
portation. Shisan's story summarized this theme well:
The rst thing in the education of disaster nursing is self-protection.
If you cannot protect yourself, you can protect no one. Disaster
knowledge was also something we lacked. Even as a rescuer
yourself, how do you choose a rescue method? Should I unload the
stone from the person's body, or wait till the arrival of professional
medical team members, or when enough safe equipment is avail-
able on site to take away the stone? Another thing, (we) must
establish is a sound relief process and system. There were too many
people going to that place, but they did not integrate their re-
sources well, which caused a great waste. I believe disaster edu-
cation should be very good. And the only hope is that disaster
training for nurses and doctors can (happen) and that this
knowledge can enter schools as early as possible.
Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
5
Discussion
Participants' narratives revealed their vivid experiences work-
ing in challenging, dangerous environments where threats of more
earthquakes and other events were ever-present. They explicated
nursing qualities required for disaster relief work including resil-
ience, problem solving, critical thinking, organizational ability,
adaptability, and strong professional knowledge and skills. All
indicated that they lacked relevant disaster knowledge and skills,
and prior disaster experiences, but they made great efforts to help
victims in the face of adversity, even though some had ethical and
professional conicts. These ndings are similar to Yang et al.
(2010), who also explored the experience of nurses in the Wen-
chuan Earthquake.
Disaster relief work under hard and dangerous conditions re-
quires nurses to possess good health, stamina and adaptability. To
be exible and ght against humidity, heat, noise, lack of sleep is
the mantra of disaster relief workers (Titus, 2011), so when leaders
select nurses for disaster relief, physical tness needs to be
considered (Jobe, 2011). The most common, inevitable challenge in
disaster relief is the scarcity of resources (Yang et al., 2010). In the
Chinese earthquake zones, trafc jams and damaged roads meant
that getting supplies, equipment and personnel was difcult and
delayed. It is common to see a health provider struggling between
needed supplies and available resources in a disaster (Nour, 2011).
With experience the participants became better skilled at using
limited resources, but there was a wide discrepancy in their length
of nursing experience and presumably skill levels prior to disaster
assignment. One participant had been qualied for just one year.
Guan et al. (2006) considered contingency ability relies on working
experience, and Yin et al. (2011b) argued that nurses with at least
three years' clinical experience are more suitable for disaster work.
Altitude sickness was also a challenge. The Yushu Earthquake
zone ranged up to 4000 m above sea level (Deng et al., 2010) and
altitude sickness can occur from 1500 m (Glazer et al., 2005). Xining
was at 2261 m (Xining Municipal People's Government, 2012) and
participants had been transported from Wuhan's altitude of about
25 m directly to the plateau, without acclimatization. Knowledge
about altitude sickness, its prevention and treatment is critical if
disaster workers are going to altitude, and this was not the case in
this study.
From a socio-cultural perspective, those participants joining the
Yushu Earthquake relief met the twin challenges of cultural conict
and language barriers. Ineffective communications and explana-
tions made participants feel helpless or frustrated, such as when
elders refused to leave their destroyed residences, transferring
mass casualties, or working with colleagues from other parts of
China.
Disaster relief involves teamwork (Yang et al., 2010) and good
team spirit, but inevitably in the stress of a disaster, when col-
leagues from different locations meet, there are different opinions
and ways of doing thing. Recognizing and voicing concerns about
unsafe practices of self and others are more important than
keeping face since this directly relates to the quality of nursing
care (Song et al., 2010).
Similar to our study, Yang et al. (2010) found organizational and
management skills were important attributes of disaster nurses.
Our participants highlighted the lack of overall disaster organiza-
tion and recognized the value of nurses who could be leaders and
bring order to chaos. The ability to plan ahead as much as possible
to anticipate disaster relief is critical, and in this study it was
evident that prior preparation of staff, medical equipment and
supplies had not been considered by leaders. Participants were not
only educationally under-prepared they also lacked emotional
preparation; personal effects; and daily survival needs such as food
6 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7
and water. This is an important lesson for the future. Preparation
before disasters helps health providers better handle professional
and personal challenges (Owens et al., 2005). In this study, partic-
ipants believed there were neither plans nor systems to effectively
organize human resources at the assigned areas and emphasized
poorly organized disaster response systems to the two earthquakes.
Similar to an Iranian study (Khankeh et al., 2011) our participants
also found problems in organizing and coordinating massive
numbers of volunteers and groups, and lacked guidance because
there were few plans for health service provision and labor division
in disaster relief. Having a well-prepared health care system for
disasters can ensure lower numbers of fatalities (Andress, 2010)
and an easily accessible general disaster response plan is required
that can be used before and after the occurrence of disaster (Gebbie
and Qureshi, 2002). Whilst there are many National Response Plans
for different contingencies and disasters in China (CPGPRC n.d.),
these broad plans cover little about how medical team response
systems should work in disaster.
Ethical conict
Ethical conict between professional ethics and survival in-
stincts was variously described by participants such as giving care
during aftershocks when personal safety was at issue. To stay or
take ight in the face of danger is an ethical and professional issue,
and choosing ght or ight is determined by an individual's risk
assessment and their own value system (Iserson et al., 2008). Un-
like soldiers, reghters and policemen, health workers have no
training working in harsh or dangerous environments, and operate
within different professional and ethical dimensions. Although
they undertook their duties seriously, some participants found
themselves in ethically challenging situations without having given
prior consideration to the conicts or choices they might face.
Unfortunately little attention has been paid to the ethical pre-
paredness of those on the frontline of public health emergencies
and disasters (Johnstone and Turale, 2014). The assumption here is
that nurses who feel better prepared, and have some understand-
ing of the ethical implications of working under different standards
of care, may be more adjusted to care giving in disasters. Some had
little or no choice about going to the disasters and this may have
contributed to their feelings of helplessness: volunteering for duty
may create a different personal psychological and philosophical
approach/stance/outlook.
Mental health in disaster nursing
Participants also identied that their lack of knowledge and
skills in mental health care and counseling after disasters added to
a sense of helplessness in caring for patients who were hyper-
vigilant, in states of panic, shocked or grieving. Mental health
knowledge is required to meet the psychological needs of disaster
victims (Grigg and Hughs, 2010; WHO and ICN 2009) as well as to
help colleagues. Authors such as Cui et al. (2011) have demon-
strated that relief workers, including nurses, have developed
symptoms of PTSD after a disaster and need special training in
mental health to cope with stresses (Xu, 2009) and it is important
to nd ways to support all disaster workers who experience psy-
chological problems (Adams, 2007).
Disaster education
Cultural conicts reect a lack of cultural competence
(McFarland, 2006) so we believe foundational understanding of
social-cultural knowledge and skills needs to be included in
disaster nursing education, and more fundamentally within
Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011
undergraduate nursing in China where it is negligible. Another
challenge for participants was mass casualty transportation, which
requires special skills training (Yin et al., 2011a). Disaster nursing
needs to include maintaining teamwork under stress, and critical
thinking is considered a competency for disaster health care pro-
viders in many studies (Daily et al., 2010).
The role of good management in disaster relief is indispensable
(Yin et al., 2011a) and organizational and management skills related
to materials and human resources are an important consideration
in the development of disaster nursing education.
Standardized disaster education will not only strengthen nurses'
disaster awareness but also help to make them feel less vulnerable
when facing challenges (Duong, 2009). In China, eld nursing has
usually only been taught in military medical colleges (Zhang, 2009).
All of our participants identied their knowledge and skill limita-
tions in the disaster zones. Based on the challenges they met,
participants believed disaster education should involve basic
knowledge about disasters and response systems, self-protection
skills, communication skills, mental health, working with other
cultures and mass casualty transportation. Moreover, they saw
teamwork, critical thinking, and management ability as critical.
They also mentioned professional rescue knowledge and skills, but
on occasion did not delineate between their role as health pro-
fessionals and the rescuers digging bodies from rubble. Powers
(2007) added that nursing education should be competency-
based and should also include teamwork ability, while Gebbie
and Qureshi (2002) advised implementation of continuous
disaster education and regular disaster response drills for the
nurses in hospitals. Drills of National Response Plan are also
required by the Chinese government (CPGPRC 2006) but to what
extent these involve nurses on a regular basis is not known.
Although this study produced rich data, ndings are limited as
participants came only from hospitals in Wuhan. Nurses from other
regions of China who worked in the disaster zones may have other
instructive and perhaps different experiences, and could be
involved in future studies.
Conclusion and implications
The participants met critical challenges and their rich narratives
described their lack of professional preparation to engage in
disaster work after two major earthquakes, but also the positive
qualities they brought to this work. China's history of high loss of
life and injury from large scale earthquakes and other disasters
highlights the urgent need for disaster nursing education and
training across the country. It is critical that Chinese authorities
reect on the skills explicated above to develop and fund more
effective plans, policies, research and education about disaster re-
sponses for nurses across the country. Nurses need to be intimately
involved in this process, including military nurses who have the
requisite disaster knowledge and skills. This will empower nurses
to feel more condent and competent to plan for, be involved in and
evaluate their work in future disaster responses.
Acknowledgment
Appreciation is expressed to the nursing directors and partici-
pants in the four hospitals in Wuhan city who have contributed to
the completion of this study. The rst author is also deeply grateful
to teaching coordinator Chen Xiaoli, and teaching faculty member
Yu Liping for their help in providing materials and contacting the
hospitals in Wuhan. Special acknowledgment and thanks are also
given to Zhou Guangrong, an Associate Professor majoring in
teaching English in Yunan University of Finance and Economics, for
doing the back-translation of all interview transcripts.
 Z. Wenji et al. / Nurse Education in Practice xxx (2014) 1e7 7

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Please cite this article in press as: Wenji, Z., et al., Chinese nurses' relief experiences following two earthquakes: Implications for disaster
education and policy development, Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.06.011