Strengthening Healthcare Readiness: Lessons from Frontline Nurses in a South African Tertiary Hospital for Future Pandemic Preparedness

Abstract

Background:

The World Health Organization and the International Council of Nurses both support nurses’ involvement in health policymaking, including readiness planning for public health emergencies. South Africa’s frontline nurses often have limited involvement in healthcare policymaking, even though nurses comprise 56% of the country’s total public healthcare workforce and 87% of its skilled health professionals. This has implications for the quality and safety of nursing care provided during past and anticipated future pandemic events.

Objective:

This purpose of this study was to evaluate frontline healthcare professionals’ perspectives on pandemic preparedness in South Africa to inform policy improvements.

Methods:

Four focus groups with registered nurses (n = 11) and semi-structured interviews with disaster committee members (n = 4) were conducted. A review of existing disaster policies contextualized the findings, which were analyzed using qualitative content analysis guided by a health policy framework

Results:

Four key categories emerged that described barriers to working in a disaster context: working outside of role and scope, insufficient staffing, mental health impacts, and lack of training for disasters and pandemics, all of which contribute to challenges in pandemic preparedness.

Conclusions:

Despite being the majority of the health workforce, South African nurses often lack influence in disaster planning. This study highlights how systemic challenges in a resource-limited hospital setting—such as chronic staffing shortages, insufficient inclusion of nurses in disaster policy development, and lack of tailored mental health support—compromised pandemic preparedness. Interventions such as peer-led mental health support, bedside microteaching, and nurse-informed policies could strengthen future pandemic readiness. These findings offer practical, scalable solutions for similar low-resource settings and underscore the importance of involving frontline nurses in disaster policymaking.

Introduction

Emerging and re-emerging infectious diseases are a risk to health and health security worldwide [1]. The World Health Organization and the International Council of Nurses both support nurses’ involvement in health policymaking, including healthcare readiness planning. But despite the ubiquity of disasters, including pandemics, and the importance of key stakeholder feedback in policymaking, frontline nurses in low-resource settings often have limited involvement in such planning, even though they often make up the majority of the public health workforce. Global health and policy organizations have developed disaster readiness frameworks with consideration for the needs of healthcare systems in resource-limited contexts, yet neither addresses the unique disaster-related needs of nurses [2,3]. Further, the International Council of Nurses has developed a framework to guide nursing practice during disasters, though the document’s generalizability may be limited by the fact that the authors were predominantly from high-income countries [4].

Healthcare readiness refers to the ability of healthcare systems, institutions, and providers to prepare for, respond to, and recover from various health-related emergencies, disasters, or public health crises [8]. It involves the capacity to maintain continuity of care, provide necessary medical services, and adapt to increased demands or changing conditions during both routine operations and crisis situations. Accepted standards are that healthcare readiness plans take an all-hazards approach, in which hospitals and health systems prepare for challenges common to all types of disasters, including pandemics. This approach is promoted as a cost-effective preparedness tool in resource-limited settings [2,3,9,10]. Such plans should also outline use of an incident command structure, which describes a hospital’s chains of reporting and communication during a crisis [2,4,10,11]. Plans should ensure sufficient staff, space, supplies, and systems to support continuity of care during a sudden surge of patients and should make provisions to maintain the safety of staff and the physical infrastructure of the hospital during an incident. Hospital staff should receive adequate disaster-related training, with regular drills that include after-action evaluations to identify opportunities for readiness planning improvement [2,4,10,11].

In South Africa, healthcare professionals have long highlighted a need for the healthcare sector to transition to proactive disaster preparedness planning that incorporates key stakeholder feedback into strategic planning and policy development [5]. Despite this, South Africa’s frontline nurses often have limited involvement in healthcare readiness policymaking, even though nurses comprise 56% of the country’s total public healthcare workforce and 87% of its skilled health professionals [5–7]. This raises concerns about whether existing South African readiness policies are meeting the needs of frontline healthcare providers. Additionally, this has implications for the quality and safety of care provided during disaster events. Therefore, an opportunity exists to evaluate the strength of existing healthcare readiness policies in South Africa from the perspectives of frontline nursing staff and disaster committee members. The purpose of this paper was to evaluate the perspectives of pandemic preparedness from frontline registered nurses in South Africa, with the goal of developing recommendations for policy improvement.

Materials and Methods

This descriptive, qualitative study explored perspectives of pandemic preparedness from frontline registered nurses and disaster committee members in South Africa. Institutional Review Board approval was received from the University of X, the University of X Biomedical Research Ethics Committee and the X Department of Health. This study adhered to consolidated criteria for reporting qualitative research (COREQ) guidelines [12]. This project was guided by Aday et al.’s health policy evaluation framework, which describes the cyclical process through which policy and related contextual factors interact to influence health outcomes [13].

Participants included the hospital’s frontline registered nurses as well as its disaster management committee members. Frontline nurses were defined in this study as nurses who provide direct patient care, often as the first point of contact for patients and families, and who play a critical role in assessing, treating, and managing health conditions. In South Africa, registered nurses must complete either a four-year nursing college diploma or a four-year university degree and represent the highest level of generalized nursing practice [14]. Selection criteria were English-speaking registered nurse hospital employees who provided direct patient care in either the adult intensive care unit, the emergency department, an adult medical acute care unit, or an adult surgical acute care unit. These care settings were chosen to capture diverse perspectives on pandemic preparedness. The disaster committee members (nurses and doctors) are responsible for all aspects of the hospital’s healthcare readiness planning.

Setting

The study was conducted at an urban Provincial Tertiary Hospital serving a catchment area of 4.5 million people. The hospital offers tertiary services to the Western half of KwaZulu-Natal, which includes five health districts with a total population of 4.5 million. The hospital faces a number of resource limitations on a daily basis including daily rolling electricity blackouts, or “loadshedding;” [15] a national shortage of critical care and perioperative nurses; limited intensive care unit capacity, and financial constraints that limit the availability of equipment and supplies.

Interview Guide

The project’s discussion guides were adapted from interview guides used during the project team’s prior work exploring home healthcare nurses’ experiences providing care during and after disasters and informed by Aday et al.’s health policy evaluation framework [16–18]. The adapted instruments were informed by key structures and processes related to disaster preparedness in the hospital setting (such as communication infrastructure, training, and workforce supports) and were refined by a panel of registered nurses from the US and South Africa with expertise in disaster nursing and qualitative research. The final interview guide was constructed for a goal interview length of 45 to 60 minutes. The interview and focus group instruments are available in the Appendix.

Ethical considerations

All members of the research team were nurses by training, as were most of the study participants and most were female. Given these shared professional and gender identities, the researchers may have brought an insider perspective to the study. This positionality may have facilitated better rapport with participants and provided a deeper understanding of the context, language, and dynamics of the nursing profession. Further, the lead researcher had previously conducted research at the hospital site and was able to leverage existing relationships to engage hospital administration initially. While these relationships supported access and coordination, it also introduced the potential for bias related to familiarity with the setting and care was taken to avoid undue influence or coercion in the recruitment process. To address and mitigate potential biases, several strategies were employed. The study received IRB approval from both universities involved in the study as well as the hospital, ensuring appropriate ethical oversight. Additionally, the research team engaged in reflexive practices throughout the study, critically examining how their shared professional identities and prior relationships might shape data collection, interpretation, and analysis. These efforts helped maintain the integrity and objectivity of the research process while acknowledging the value and complexity of the insider perspective. Hospital administrators were informed of the study but were not involved in identifying or selecting individual participants. Instead, the study steam shared study information and an invitation to participate with potential nurse participants through general email communications and unit notice boards. Participants were informed that participation was entirely voluntary, would have no bearing on their employment or professional evaluations, and could be discontinued at any time without consequence. Focus group recruitment was initiated after obtaining permission from each unit’s nurse manager to disseminate information about the project during scheduled inservice times. Informed consent was obtained from each participant prior to beginning the focus group and interviews. Written informed consent was obtained from all participants prior to the start of interviews. Emphasis was placed on confidentiality, autonomy, and the non-hierarchical nature of the study relationship. The interviewers were not affiliated with the participants’ hospitals, thereby minimizing power imbalances.

Trustworthiness

To ensure rigor, the study followed established criteria for trustworthiness, including credibility, dependability, confirmability, and transferability. Credibility was supported using a structured content analysis approach and reflexive practices to acknowledge potential biases. Dependability and confirmability were enhanced through an audit trail and regular team discussions during data analysis. Transferability was addressed by providing rich contextual detail about the setting and participants to allow readers to assess relevance to other contexts.

Participant Recruitment and Data Collection

Four focus groups were conducted with frontline registered nurses employed at the project site (n = 11). One focus group was conducted on each of the following units: the emergency department (ED: n = 3), the adult intensive care unit (ICU: n = 3), an adult medical acute care unit (MW: n = 3), and an adult surgical acute care unit (SW: n = 2). Four semi-structured individual interviews were then conducted with members of the hospital’s disaster committee (DC: n=4). Each focus group and interview were moderated face-to-face in English by up to two trained members of the project team using a semi-structured discussion guide (see Appendix) and began with a statement of confidentiality and set ground rules for the session. Focus groups and interviews took place in secure, private rooms at the project site to maximize participant confidentiality. Focus groups and interviews lasted between 30 and 60 minutes and were recorded with permission using a digital voice recorder.

Data Analysis

Semi-structured interview and focus group data were managed and analyzed manually using Microsoft Excel. Excel was used to organize transcripts, assign codes, and group data into categories to support the content analysis process. Interview and focus group audio recordings were first transcribed by a HIPAA-compliant transcription service. After removing identifying information from the transcripts, including the mention of a specific facility, other clinician, or family member, the transcripts were formatted for coding in Excel. The analytic approach was guided by Erlingsson and Brysiewicz’s (2017) qualitative content analytic method [19] which provided a structured and transparent framework for coding, condensation, and category development. This approach enabled a thorough and systematic analysis of the data while ensuring alignment with established qualitative methods. Two trained members of the project team independently identified meaning units, codes and categories from each transcript. These members met weekly over Zoom to discuss and refine codes and categories and arbitrate differences. The project team then discussed and reached consensus on the results.

Results

Participants were registered nurses, female, aged 31 to 45, with a diploma in Nursing as their highest educational qualification. Most reported that they had not received any formal disaster training, and most had between 6 and 15 years of work experience. See Table 1 for demographic representation.

Table 1. Demographic Characteristics.

Characteristic	n
Professional Group
Registered Nurse	13
Physician	2
Level of Education
Diploma	13
University Degree	2
Additional Disaster Training
Yes	2
No	13
Years in Occupation
0 – 5	2
6 – 10	4
11 – 15	4
16 – 20	2
21+	3
Gender
Female	13
Male	2
Age (Years)
18 – 30	1
31 – 45	8
46 – 60	6

Qualitative content analysis of interview and focus group transcripts generated four categories:

Working outside of role and scope

During the pandemic, nurses found that they had no options but to complete tasks that were generally the role of other professions.

“It changed because you find yourself doing things that you are not supposed to do.” (SW)

Some support staff did not have the training or comfort level to work effectively in the COVID unit. Therefore, tasks nurses completed were far below their training, because they had no other choice.

“Just like you become a porter… becomes eh, eh, eh a GO or whatever. As a registered nurse, sometimes we’re just having that problem instead of administering of medication or whatever.” (SW)

“And then, in most cases we had no cleaners watching ours, so sometimes we have to clean up the messed patient and then you clean the ward.” (ICU)

Other times, they were asked to do tasks above the scope of their training.

“I think even because the registered nurse that are working there because they were not even trained for looking after ICU patients.” (ICU)

“It’s very stressful to look after a ventilated patient while you’re not even ICU trained or even experienced.” (ICU)

“I think they’re putting a lot of pressure to us as registered nurses because whatever orders… given they’re waiting outside and then they just gonna communicate with us while they were outside. So, all the work is for the RN that is inside. Even if they want us to prone, then we must do the proning. It’s hardly ever [we] see the doctors coming inside the COVID unit so that we can prone the patient.” (ICU)

In both types of cases, nurses conveyed being already overwhelmed with their given responsibilities, and completing the work of other providers or support staff was an additional burden.

“Because it hit suddenly and then everyone was in a panic and we didn’t really know what to do. And we just started making these adjustments that didn’t really make sense.” (ED)

Insufficient staffing

Another common concern verbalized by participants was staffing shortages:

“It was very bad. It was very tough and, yeah, it was very bad. And, yeah, it was hectic because we were too… we were [the] short of staff. (MW)

Limited staffing also led participants to voice issues about potentially unsafe patient to provider ratios and changes in surgical capacity.

“It’s only maybe two of us inside looking after eight patients.” (ICU)

“That means I’m going to be doing more surgery than what I should do because the alternative is… the safe alternative to selective non-operative management just means I need to go and cut them open and look and I don’t have the Theatre capacity.” (DC3)

Participants relayed concerns that the minimal staffing levels would lead to an inability to provide basic care in the event that a second disaster should occur.

“We have a shortage of staff. As you can see, we are very few. If the disaster comes now [during COVID], what are we going to do?” (SW)

“You saw how reluctant people were to come out on call or be called out for whether it was overtime to fill in. So, if we had more disasters during another pandemic, that would be a major problem where staffing was concerned.” (DC1)

Participants also reported that opportunities for training were limited during the pandemic since staff were diverted to caring for patients instead of taking the time to complete trainings.

“It’s difficult to have training all the time because it’s time consuming and it takes up a lot of resource and effort and then most of the staff, you know, they’ve got clinical work now after COVID, so the backlog is high. “ (DC2)

“What that translates to is where must we find the time to train the clinical staff? Okay. How can I take two nurses out of every ward when I’ve only got one nurse for a six-bed cubicle? And then still expect my antibiotics, my analgesia, my observations to be done on time. I don’t know how you’re supposed to do that.” (DC3)

Lack of preparedness

Core elements of working with a highly infectious disease, such as donning and doffing personal protective equipment, were not well understood by staff before the start of the pandemic.

“Most of them [other nurses] they are dying, and we don’t know how to work because it was a new thing to us which was mm, mm, no one knows about how to don [PPE], how to work when we are inside, how to work when we are outside. So, to me, we found it was very difficult to cope.” (MW)

In stark contrast to this perspective, members of the disaster committee described that the disaster plan was available and comprehensive and included plans for a pandemic.

“We had a plan before COVID. So, when COVID came, it’s just… it was just an infectious disease disaster focus.” (DC2)

Nurses described the need for knowledge on the new types of nursing care needed to care for COVID-19 patients, highlighting the need for training on how to complete specific procedures.

“And we are not familiar with CPAP...with this oxygen...this CPAP”. (SW)

Participants stated there was a lack of disaster training in general due to demands of the pandemic.

“It’s difficult to have training all the time because it’s time consuming and it takes up a lot of resource and effort and then most of the staff, you know, they’ve got clinical work now after COVID, so the backlog is high.” (DC2)

A similar sentiment was echoed, that the amount of training for staff was severely limited during this time.

“I don’t think there can ever be too much training, but I do think that it’s pretty dismal.” (DC3)

Nurses reported disaster training was put on hold due to the demands of the pandemic.

“We were all called last year to attend, yeah, for training. And we have not been called, um, back again as yet for further training of that (COVID).” (DC4)

Mental health impacts

Nurses reported being overwhelmed by the high volume of mortality during the pandemic.

“On my side emotionally, COVID was not nice… seeing people… I’m making example. Seeing, um, four deaths in a day is not nice.” (ICU)

“We were traumatized because of the patients were dying left and right and center.” (MW)

They also described a need for psychological and mental health supports.

“You needed psychology consultants which we didn’t have. Some of us lost our relatives. Some of us lost colleagues but we didn’t have anything.” (ICU)

However, although wellness activities were available, participants reported these events were not well-attended.

“Yeah, we have [psychological support] in the hospital…. but we don’t go…. we don’t know why but we need [it] sometimes because it’s hard in the wards. Not even the COVID time. But it’s hard how we work now…[harder] than the older days.” (MW)

Discussion

This qualitative analysis of the perceptions of registered nurses and disaster committee members at a tertiary hospital in South Africa during the COVID-19 pandemic revealed gaps affecting the nursing workforce that can be leveraged to support policy change at an institutional, national and international level. These findings can also inform disaster mitigation, preparedness, response and recovery initiatives specific to pandemic preparedness. Robust hospital disaster preparedness policies informed by key stakeholders are increasingly important for hospitals in low- and middle-income countries. Although nurses make up most of South Africa’s public health workforce, its frontline registered nurses often have limited involvement in hospital disaster policymaking [5–7]. Our findings reveal a disconnect between nursing leadership and frontline nurses in their levels of awareness of policies, as seen in other studies of nursing and policymaking [20, 21, 22]. This raises issues about how to implement existing hospital pandemic preparedness policies to better meet the needs of the country’s frontline registered nurses in South Africa, as well as in other low-resource settings. This study also has implications for the quality and safety of nursing care provided during disaster events.

Task shifting has a long history in the African health workforce and typically refers to the redistribution of tasks from health workers with higher qualifications to those with shorter training and fewer qualifications to make more efficient use of the available human resources [23]. Past research however been shown that task shifting may negatively impact the health workers in terms of their sense of agency and their ability to carry out their work, and its potential implications therefore need to be carefully considered [24].

Participants described how the hospital is functioning at what might meet the definition of a disaster or near-disaster capacity daily, or as one nurse put it, “every day is a disaster.” Examples of ongoing resource limitations included: daily rolling electricity blackouts; an ongoing national shortage of critical care and perioperative nurses, overwhelmed intensive care unit capacity and financial constraints that prevent the availability of equipment and supplies, such as limited CT scan capacity and transport ventilators. As a result, participants noted that the hospital struggled to provide high quality patient care daily, regardless of the presence of a pandemic, disaster or mass casualty event. Qualitative studies of frontline nurses during the pandemic specially also described similar outlook, with several describing working conditions as “it’s like we are at war”[23, 24]. What meets the definition of a disaster versus a major incident differs across countries and communities. Major incidents are defined as an event or situation with a range of serious consequences, which require special arrangements to be implemented by one, or more emergency responder agency [25]. In the resource-limited environment of this study, most events were considered a major incident, while those involving national capacity efforts were considered disasters.

Nurses in this study described staffing limitations that left them working in potentially dangerous patient care situations. Unsafe patient to provider ratios or in situations where they were asked to take on roles that both overburdened them as well as placed them in situations that were out of their scope of practice were commonly described. This was not unusual globally for nurses during the pandemic [28–30]. While the need for safe and equitable staffing should go without question, a substantial shift in health workforce policy is needed for this to become the norm. Like many areas globally, the public health sector in South Africa has experienced a shortage of healthcare workers for a number of years and this problem was worsened by the Covid-19 pandemic and thus to survive future pandemics, this shortage needs urgent attention [26].

Across South Africa, nurses already are already adept at being resourceful, creative and adaptative to meet daily challenges. While there is much to learn from low resource settings where nurses have no choice but to innovate to find alternative solutions to temporarily overcome immediate challenges, there remains limited evidence-based studies [26]. Important considerations noted in one such study involve using task-shifting in a way that does not place additional burdens on nursing staff, developing disaster focused technology and changing established ways of clinical practice [31].

The mental health implications of working through the pandemic require closer evaluation to look for innovations that fit the needs of frontline nursing staff [28, 29, 32]. That nurses described devastating mental health impacts during the pandemic, but declined to attended hospital-sponsored wellness events calls for deeper exploration. Nursinginformed wellness events are needed that do not place an additional burden on frontline nursing staff. While addressing mental health needs of the nursing workforce is a complex issue, peer-support, such as building relationships or relying on existing relationships that are already in place, may be an important consideration for the development of interventions in staffing-constrained environments [33, 34, 35]. The importance of building resilience in the workforce must be emphasized in terms of the benefits for the organization, namely improving the quality and safety of care to the patients as well as staff retention [36, 37].

Healthcare workers report feeling better prepared for pandemics if they can access up-to-date, consistent and clear information [38, 39]. “Just-in-time” training has long been used in crisis settings to provide critical information and training at the time it is most needed, often using educational modalities and settings that meet the needs of the workforce [40]. This method of education using microteaching delivering bite sized chunks of knowledge, even at the bedside when appropriate, can better support safe clinical practice. Identifying practice leaders to develop these microteaching interventions could be part of the preparedness plan. Regardless, providing preparedness training should address known education gaps, and be specific and nimble. Importantly, as seen in this study, there is a need for educational interventions to include all staff—janitorial, nutrition and administration, as this would bolster the preparedness of the entire healthcare team.

Based on our study’s findings, we have several recommendations for future research. First, exploring how day to day functioning at what was described in this study as near-disaster capacity daily impacts nurses’ ability to respond to actual disaster or pandemic events and whether redefining “disaster” in context-specific terms may improve preparedness planning. Additionally, given the disconnect noted between frontline nurses and hospital leadership about pandemic preparedness policies, future studies could examine strategies to improve communication, policy dissemination, and frontline engagement in policymaking. Since task-shifting is common but can place undue burden on frontline providers, identifying task-shifting models that maintain safety and scope of practice can improve workplace place satisfaction and system efficiency. Studies of task-shifting in sub-Saharan Africa have found improved efficiency but require clear success indicators and learning plans to be sustainable[41, 42].

Finally, investigating the implementation and effectiveness of “just in time,” microteaching and bedside-based education models during pandemics could help create tailored preparedness training strategies across healthcare teams.

Policy Implications

Strengthening hospital disaster preparedness requires integrating nurses’ insights into policy development at institutional, national, and international levels to ensure policies are both practical and sustainable in resource-limited settings[3]. Two international disaster frameworks have been developed with consideration for the unique needs of healthcare systems in resource-limited contexts, yet neither addresses the unique disaster-related needs of nurses [2, 3]. While the International Council of Nurses has developed a disaster framework to guide nursing practice during disasters and pandemics, the document’s generalizability may be limited by the fact that the authors were predominantly from high-income countries [4]. There is a need for international disaster frameworks to be informed by frontline nurses from low- and middle-income countries, specifically those nurses who work in resource-constrained settings. Health system leaders in South Africa should create formal mechanisms for involving frontline nurses in disaster policy development at the hospital-level, such as nurse-led advisory councils or rotating nurse representation on disaster committees. Ensuring that such structures are inclusive of frontline nurses can improve the uptake of policy at the patient-care level and confirm that policies are actionable and have real world relevance in clinical practice. To do this, policies must also be accompanied by implementation plans that account for resource constraints and allow adaptation to both the local and hospital context. While nursing workforce shortages are well known at the policy level, the effects are acutely felt at the hospital level, as our study and others have described [43‘ 44]. These shortages must be addressed through both high-level strategic workforce investments and clear protocols that prevent unsafe staffing and task shifting. Research on mental health during the COVID-19 pandemic exposed the extreme stress that frontline providers experienced, leading to job dissatisfaction and burnout [45, 46]. Policy emphasizing the importance of mental health supports for frontline providers who are impacted by disasters and pandemics are needed to ensure a healthy workforce that is ready to take on such challenges. These supports must go beyond optional wellness sessions to include evidence-based and peer-led models integrated into clinical practice. Finally, financial resources are critical to fully establishing the feasibility and sustainability of any policy change [47, 48].

Limitations and strengths

Our study has limitations, including its focus on a single site, which may limit the generalizability of the findings. Recall bias may also be a concern, as participants’ reflections may have been influenced by evolving public perceptions and emerging knowledge about the pandemic[49]. Additionally, the reliance on self-reported data and the absence of perspectives from other frontline health providers may constrain the interpretation to system-level insights. Finally, the way questions were presented to the focus groups, along with interviewers present in the room, are a potential source of bias. Nevertheless, this study is one of the few to systematically explore nurses’ perspectives on pandemic preparedness in South Africa and offers valuable insights to inform future research and policy development.

Conclusion

This study has demonstrated that the perspectives of frontline registered nurses can be utilized to inform and improve policy related to and pandemic preparedness. As South Africa and similar low-resource settings continue to face significant healthcare challenges, the resourcefulness and adaptability of nurses should be recognized and leveraged by policy makers. Future pandemic preparedness efforts must not only focus on systemic gaps but also empower frontline nurses as key stakeholders in disaster response and resilience building.

• Infectious diseases and other disasters are a risk to health and security globally

• Nurses in South Africa have limited involvement in disaster preparedness policy

• Disaster contexts provide challenging workplaces for nurses in South Africa

• Policy improvements for disaster preparedness can alleviate burden felt by nurses

Appendix: Focus Group Discussion Guide and Semi-Structured Interview Guide

Focus Group Discussion (45 minutes)

Questions for participants who have worked during a disaster

If participants have NOT worked at this hospital during a disaster, SKIP to question 13.

• 1Did your job responsibilities change during the disaster? In what way?
• 2Did your patient population change during the disaster? In what way?
• 3What challenges did you experience while providing care during the disaster?
• 4Describe an example of an action taken by the hospital or your unit that improved your ability to provide high quality patient care during the disaster.
• 5Based on your experiences, what could this hospital or your unit do to better support registered nurses providing patient care during disasters?
• 6Describe any circumstances under which you accessed the hospital or your unit’s disaster plan. If you did not, what barriers prevented you from accessing the disaster plan?
• 7How would you describe the availability of staff, equipment, medicines, and materials you needed to provide patient care during the disaster? Tell me more.
• 8Did the hospital or your unit have a specific staffing structure for how its disaster response was organized? Tell me more.
• 9How would you describe any actions the hospital or your unit took to ensure your safety and/or the safety of your patients during the disaster? OR Tell me what you wish the hospital, or your unit had done to ensure your safety and/or the safety of your patients during the disaster.
• 10What provisions were made for the care of people who are disproportionately affected by disasters, such as women, children, older adults, patients with low incomes, indigenous groups, and patients with chronic diseases or disabilities?
• 11What kind of employer-provided training have you received that improved your ability to provide care during the disaster, and why was it helpful or not helpful?
• 12What kind of employer-provided training do you wish you had received during or prior to the disaster, and why?

SKIP to Question 24.

Questions for participants who have not worked during a disaster

• 13Tell me what you know about disaster policies at this hospital or on your specific unit.
• 14How might you find hospital or unit-specific disaster policies if you needed them during a disaster?
• 15How do you know when this hospital or your unit’s disaster policies have been revised and updated?
• 16What actions has this hospital, or your unit taken to prepare for disasters?
• 17Does the hospital or your unit have a specific staffing structure for how its disaster response will be organized? Tell me about it.
• 18How do you think this hospital, or your unit would respond if it experienced a surge in patients exceeding its maximum bed capacity?
• 19How do you think this hospital, or your unit would respond if a disaster prevented staff from reporting to work as scheduled? Is there a specific staffing plan in place?
• 20What actions do you think this hospital, or your unit would take to keep staff and patients safe during disasters?
• 21What types of resources does this hospital, or your unit have available to address a disaster? We are particularly interested in hearing about human, financial, structural, and administrative resources.
• 22Describe any disaster drills you have participated in at this hospital or on your unit.
• 23What kind of employer-provided disaster-related training would you find helpful, and why?

Concluding questions

• 24How would you describe this hospital’s overall preparedness for disasters? Why?
• 25What recommendations do you have to help improve the way that this hospital prepares for or responds to disasters?
• 26Is there anything I didn’t ask about that you think is important that would help inform this study?
• 27Do you have any questions about today’s discussion or the study?

Nurses & Disaster Policy Semi-Structured Interview Guide

Interview Discussion (60 minutes)

1. Tell me about your role at this hospital and how it relates to disaster preparedness.

   Probing Questions:

   1. How are you currently or how have you previously been involved in this hospital’s disaster preparedness or disaster risk management activities?
   2. Describe how you believe your role impacts this hospital’s preparedness for or its ability to respond to disasters.

2. What training or education have you had in preparing for or responding to disasters?

   Probing Questions:

   1. Tell me about any disaster preparedness or response trainings you have participated in at this hospital.
   2. What have you found helpful about this training or education, and why?
   3. If you have not had any prior training or education in this area, what kind of employer-provided training would you find helpful, and why?

3. What kinds of disasters is this hospital or your unit most likely to encounter? How do you know this?

4. How would you describe this hospital’s overall preparedness for disasters? Why?

   Probing Questions:

   1. What actions has this hospital, or your unit taken to prepare for disasters?
   2. What types of resources does this hospital, or your unit have available to address a disaster? We are particularly interested in hearing about human, financial, structural, and administrative resources.

5. Tell me what you know about disaster preparedness policies at this hospital or on your specific unit.

   If the participant is NOT familiar with hospital or unit disaster preparedness policies, proceed to question 5a and SKIP questions 5b-5g.

   1. If you are not familiar with the policies, how might you find this information if you needed it during a disaster?
      Probing Questions:
   2. How were the policies developed?
   3. What processes are in place to monitor the effectiveness of the policies?
   4. How do you know when this hospital or your unit’s disaster preparedness policies have been revised and updated?
   5. What are some of the policies’ strengths?
   6. What opportunities exist to improve the policies?
   7. Does the hospital or your unit have a specific staffing structure for how its disaster response will be organized? Tell me about it.
   8. What provisions do the policies make for people who are disproportionately affected by disasters, such as women, children, older adults, patients with low incomes, indigenous groups, and patients with chronic diseases or disabilities?

6. Tell me about your involvement in the creation or revision of disaster preparedness policies at this hospital or on your specific unit.

   If the participant has NOT been involved in disaster policy development or revision, SKIP to question 7.

   Probing Questions:

   1. What resources did you use during policy creation or revision?
   2. What did you find helpful during the process?
   3. What did you find challenging?
   4. How were members of the surrounding community involved in policy creation or revision?

7. Now I would like you to tell me about a time when you oversaw or provided care at this hospital during a disaster. Examples of disaster might include, but are not limited to, the COVID-19 pandemic, the summer 2021 riots, or the April 2022 flooding. Remember; please do not use patient or staff names or other identifying information.

   If the participant has NOT worked at this hospital during a disaster, SKIP to question 8.

   Probing Questions:

   1. How did your job responsibilities change?
   2. How did your patient population change?
   3. How would you describe the availability of the equipment, medicines, and materials you or your staff needed to provide care? Tell me more.
   4. What went well?
   5. What did not go as well as you would have liked?
   6. Based on your experiences, what recommendations do you have to help improve the way that this hospital prepares for or responds to disasters?

8. What could this hospital or your unit do to better support registered nurses providing patient care during disasters?

9. How would this hospital or your unit respond if it experienced a surge in patients exceeding its maximum bed capacity?

10. How would this hospital or your unit respond if a disaster prevented staff from reporting to work as scheduled? Is there a specific staffing plan in place?

11. What actions would this hospital or your unit take to keep staff and patients safe during disasters?

12. Is there anything I didn’t ask about that you think is important that would help inform this study?

13. Do you have any questions about the interview or the study?

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

No. Item	Guide questions/description	Reported on Page #
Domain 1: Research team and reflexivity
Personal Characteristics
1. Inter viewer/facilitator	Which author/s conducted the interview or focus group?	4
2. Credentials	What were the researcher’s credentials? E.g. PhD, MD	Title page
3. Occupation	What was their occupation at the time of the study?	Title page
4. Gender	Was the researcher male or female?	N/A
5. Experience and training	What experience or training did the researcher have?	4
Relationship with participants
6. Relationship established	Was a relationship established prior to study commencement?	N/A
7. Participant knowledge of the interviewer	What did the participants know about the researcher? e.g. personal goals, reasons for doing the research	N/A
8. Interviewer characteristics	What characteristics were reported about the inter viewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic	N/A
Domain 2: study design
Theoretical framework
9. Methodological orientation and Theory	What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis	3
Participant selection
10. Sampling	How were participants selected? e.g. purposive, convenience, consecutive, snowball	3
11. Method of approach	How were participants approached? e.g. face-to-face, telephone, mail, email	4
12. Sample size	How many participants were in the study?	4
13. Non-participation	How many people refused to participate or dropped out? Reasons?	N/A
Setting
14. Setting of data collection	Where was the data collected? e.g. home, clinic, workplace	4
15. Presence of non-participants	Was anyone else present besides the participants and researchers?	N/A
16. Description of sample	What are the important characteristics of the sample? e.g. demographic data, date	4
Data collection
17. Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?	3
18. Repeat interviews	Were repeat inter views carried out? If yes, how many?	N/A
19. Audio/visual recording	Did the research use audio or visual recording to collect the data?	4
20. Field notes	Were field notes made during and/or after the interview or focus group?	N/A
21. Duration	What was the duration of the inter views or focus group?	4
22. Data saturation	Was data saturation discussed?	N/A
23. Transcripts returned	Were transcripts returned to participants for comment and/or correction?	N/A
Domain 3: analysis and findings
Data analysis
24. Number of data coders	How many data coders coded the data?	4
25. Description of the coding tree	Did authors provide a description of the coding tree?	4
26. Derivation of themes	Were themes identified in advance or derived from the data?	4
27. Software	What software, if applicable, was used to manage the data?	N/A
28. Participant checking	Did participants provide feedback on the findings?	N/A
Reporting
29. Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified? e.g. participant number	4–7
30. Data and findings consistent	Was there consistency between the data presented and the findings?	7
31. Clarity of major themes	Were major themes clearly presented in the findings?	7
32. Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	7