bioterrorism

Use the resources available to you as a Thomas Edison State University student to find three articles relating to one of the topics listed below. Using any of the Research Resources ——See attachments Below.

Pounds of cure
O’Connell, Kim A
The American City & County; Jun 2003; 118, 6; ProQuest Central
pg. HS8
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
In Case of Attack, Just How Prepared Is Health
System?
Groark, Virginia . New York Times , Late Edition (East Coast); New York, N.Y. [New York, N.Y]28 Oct 2001:
CT.1.
ProQuest document link
ABSTRACT (ABSTRACT)
Officials in municipalities like Greenwich and Stamford are posting bioterrorism information on their Web sites.
Health directors in towns like West Hartford are updating their emergency response plan to include procedures for
bioterrorism. Laboratory technicians are being trained to spot biological agents and state agencies are meeting to
identify short- and long-term needs.
Meanwhile, the State Health Department is instituting procedures that should help it detect bioterrorism. It has
asked hospitals and doctors to be on the lookout for unusual disease clusters and told them to contact the
department immediately should they come across smallpox, anthrax or other disease associated with bioterrorism,
said William Gerrish, spokesman for the health department. They have also been told to be on the lookout for E.
coli and salmonella, which potentially could be related to bioterrorism.
In fact, the demand for information about bioterrorism suddenly has put people like Dr. David Cone, the emergency
medical services chief at Yale-New Haven Hospital, in high demand. Dr. Cone, whose job requires him to be up to
date with the latest information on bioterrorism, has been fielding calls from groups who want doctors to give
lectures on the subject.
FULL TEXT
ON a recent weekday afternoon, when most state employees were heading home, nearly a dozen workers filed into
a first-floor conference room in the State Department of Public Health to watch a talk show on television.
They weren’t there to see a program on relationship advice or watch celebrities pitch their latest projects. Instead,
they tuned into a 75-minute presentation given by doctors from Centers for Disease Control and Prevention.
The topic? Anthrax.
With the disease surfacing in Florida, Washington and New York, such lectures are becoming common as the state
makes preparations to handle a bioterrorism incident should one happen in Connecticut. There are some, however,
who say more can be done.
”I think Connecticut could be better prepared,” said United States Representative James H. Maloney, a Democrat of
Danbury, who has proposed legislation that would put a full-time civil response team in every state to help handle
such incidents.
In fact, the threat of bioterrorism was considered implausible for so long that doctors like Richard Barse, who
practices internal medicine in New Haven, haven’t read about it in decades.
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 1 of 6
”I hadn’t thought about it for 25 years, if ever,” added Dr. Barse, who said three patients have asked him about
anthrax and how to treat it. ”After this came out, I had to look it up again.”
Across the country, the situation is not much different. Federal, state and local health officials are scrambling to
put surveillance measures in place, establish effective communication tools and educate health care providers as
well as an anxious public.
In the process, they are encountering a host of logistical issues. Federal agencies overlap, laws vary from state to
state and a large percentage of hospitals and clinics are privately owned, meaning they may cooperate, but are not
necessarily required to comply, with government directives.
”The system is simply not set up for what we are trying to do,” said Dave McIntyre, deputy director for research for
the Anser Institute for Homeland Security, a not-for-profit organization based in Arlington, Va. ”It is not designed
for one person to stand at the top and shout orders like in the Army and down at the bottom all the privates do
what they are told.”
Mr. McIntyre did not know enough about Connecticut to comment on its preparedness, but, he said, the good news
is that in the past few weeks states and the federal government have making progress.
”It is not fixed nationwide,” Mr. McIntyre said. ”It is not fixed in any particular state. But we are in much better
condition than we were six months ago.”
In Connecticut, state and local authorities as well as health care providers are busy training, educating and setting
up surveillance systems that will enable the state to respond effectively to a bioterrorism incident.
Officials in municipalities like Greenwich and Stamford are posting bioterrorism information on their Web sites.
Health directors in towns like West Hartford are updating their emergency response plan to include procedures for
bioterrorism. Laboratory technicians are being trained to spot biological agents and state agencies are meeting to
identify short- and long-term needs.
While some of the preparations began at least two years ago, the pace quickened after the Sept. 11 attacks on the
World Trade Center and the Pentagon. It stepped up another notch when reports of people becoming infected with
anthrax began to surface.
”One of the things we need to bear in mind is that if anybody had asked us last year, ‘Are these concerns that we
need to worry about?’ we would probably all say, ‘Maybe. But they are probably light years away,’ ” said State
Senator Toni Harp, a Democrat of New Haven, who is co-chairwoman of the Public Health Committee of the State
Legislature. ”And even though the Department of Public Health has been working on developing this system for the
past couple of years, the reality is that no one knew that we would need everything to be up and running so
quickly.”
”It will be much better in a month, even better still in a quarter, and six months from now it will be perfect,” she
said. Then she added, ”Near perfect.”
One difficulty Connecticut faces is its penchant for home rule. The state, which has 169 municipalities, has all but
dismissed county government.
That has to change, because there are not enough resources to go around, said John T. Wiltse, director of the State
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 2 of 6
Office of Emergency Management.
”The barriers need to be broken down at the local level,” he said. ”To equip and fully and completely train 169
municipalities does not make common sense. We need to work smarter and more on a regional approach.”
”The days of coming into a municipality and having either departments that don’t get along or five or six separate
fire departments that do not report to a single entity, single chief, those days, we need to get beyond,” he added.
Local fire and police chiefs have raised the same issue with Gov. John G. Rowland, according to his spokesman,
Dean Pagani.
”They were really concerned about the fact that they may be able to communicate with the town next to them, but
they may not be able to communicate with the town two or three towns over,” Mr. Pagani said. ”And if you are
talking about a chemical agent, the next town over may not be good enough.”
In response, Mr. Rowland ordered last week the creation of an inter-agency group to determine the equipment and
training needs of the emergency workers who first respond and recommend ways to improve field
communications between agencies. The group would include representatives of local police and firefighters
associations.
In addition, Mr. Rowland asked the Department of Public Safety to work with local police and fire departments to
develop and train a Connecticut Urban Search and Rescue Team, which could be used regionally, Mr. Pagani said.
Having so many individual governments can pose a particular challenge when disseminating information, which is
critical when responding to bioterrorism. The state has 103 local health districts, some of which are part-time. Until
a few years ago, not all of them had a computer.
Using a federal grant, the state has created a health alert network, which links all of the districts with the state
through computers and fax machines. In its third year, the grant is helping to establish ”secure communication
networks” so local health departments can talk to state and federal authorities should a bioterrorism incident
occur, said Patricia Checko, co-chairwoman of the health department’s health alert network advisory committee
and director of health for the Bristol-Burlington Health District. The system is almost in place, she said.
Yet some local health district directors, like Ms. Checko, are concerned that they have not received a protocol that
explains what they are expected to do.
That makes it difficult to assess whether the individual districts are prepared, said Paul Hutcheon, director of
health for the Central Connecticut Health Office and president of the Connecticut Association of Directors of
Health.
”It’s important for all of us to know our role, our responsibilities and once you know that you can determine
whether you have the training and the resources to meet the roles and responsibilities that have been given to
you,” he said. ”Those are the pieces, I think, that are lacking right now.”
Ms. Harp said meetings are being set up to address that concern.
Connecticut also does not have a full-time civil response team, something that Mr. Maloney would like to change.
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 3 of 6
He recently proposed legislation that would enable each state, territory and the District of Columbia to have at
least one team.
Consisting of 22 full-time National Guard members, the teams are designed to work with local emergency response
providers. They have special training in areas like logistics and access to high-tech equipment that can provide
secure communications and other devices that can detect biological agents. Congress has authorized 32 teams,
but the only ones in the Northeast are located outside of Boston and Albany, Mr. Maloney said. Connecticut has a
team that consists mostly of part-time personnel.
Under Mr. Maloney’s proposal, if a disaster strikes, a local team would be able to respond more quickly. Since they
would be based in the state, they would be integrated with the local emergency response providers.
”It’s the right thing to do not only for Connecticut but for every state in the country,” Mr. Maloney said.
Meanwhile, the State Health Department is instituting procedures that should help it detect bioterrorism. It has
asked hospitals and doctors to be on the lookout for unusual disease clusters and told them to contact the
department immediately should they come across smallpox, anthrax or other disease associated with bioterrorism,
said William Gerrish, spokesman for the health department. They have also been told to be on the lookout for E.
coli and salmonella, which potentially could be related to bioterrorism.
In addition, state health officials are meeting with hospital laboratory workers and educating them so they can
identify potential bioterrorism agents, Mr. Gerrish said. And the state is asking hospitals to submit daily reports of
their admissions.
The medical community is undertaking its own initiatives. The Connecticut Hospital Association has distributed
resource binders to hospitals. The Connecticut State Medical Society is fine-tuning how it communicates with
doctors and hopes to develop a list of doctors’ e-mail addresses. And many hospitals, like the University of
Connecticut Health Center in Farmington, are offering lectures on bioterrorism.
In fact, the demand for information about bioterrorism suddenly has put people like Dr. David Cone, the emergency
medical services chief at Yale-New Haven Hospital, in high demand. Dr. Cone, whose job requires him to be up to
date with the latest information on bioterrorism, has been fielding calls from groups who want doctors to give
lectures on the subject.
”It used to be, ‘Yea, it’s never really going to happen to us,” said Dr. Cone who will speak to the New Haven Medical
Association next month. Now, he said, ”They’re banging down the door.”
Photograph
One of the projects that Save the Children, the charity based in Westport, participated in was building a water
reservoir, above, in Afghanistan. (Save the Children); Emergency workers prepare to enter the Hartford Post Office
after a white substance was recently found there. The state is trying to coordinate its efforts in responding to
bioterrorism threats. (Steve Miller for The New York Times)(pg. 1); Emergency workers suit up before going into the
Hartford Post Office recently after a substance was found in a package. (Steve Miller for The New York Times)(pg.
4)
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 4 of 6
DETAILS
Subject:
Biological &chemical terrorism; Anthrax; Public health; Emergency preparedness
Location:
Connecticut
Publication title:
New York Times, Late Edition (East Coast); New York, N.Y.
Pages:
CT.1
Number of pages:
0
Publication year:
2001
Publication date:
Oct 28, 2001
column:
Over There . . . Over Here
Section:
14CN
Publisher:
New York Times Company
Place of publication:
New York, N.Y.
Country of publication:
United States, New York, N.Y.
Publication subject:
General Interest Periodicals–United States
ISSN:
03624331
CODEN:
NYTIAO
Source type:
Newspapers
Language of publication:
English
Document type:
Feature
ProQuest document ID:
431872434
Document URL:
https://search.proquest.com/docview/431872434?accountid=40921
Copyright:
Copyright New York Times Company Oct 28, 2001
Last updated:
2017-11-15
Database:
ProQuest Central
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 5 of 6
Bibliography
Citation style: APA 6th – American Psychological Association, 6th Edition
Groark, V. (2001, Oct 28). In case of attack, just how prepared is health system? New York Times Retrieved from
https://search.proquest.com/docview/431872434?accountid=40921
Database copyright  2019 ProQuest LLC. All rights reserved.
Terms and Conditions
Contact ProQuest
PDF GENERATED BY SEARCH.PROQUEST.COM
Page 6 of 6
Bioterrorism Knowledge and Educational
Participation of Nurses in Missouri
Terri Rebmann, PhD, RN, CIC, and Lisa Buettner Mohr, MPH, CHES
abstract
Background: Nurses are integral to bioterrorism preparedness, but nurses’ bioterrorism preparedness knowledge has not been evaluated well.
Methods: Missouri Nurses Association members (1,528)
were studied in the summer of 2006 to assess their bioterrorism knowledge and the perceived benefits of education as
well as barriers to education.
Results: The response rate was 31%. Most respondents
(60%, n = 284) received no bioterrorism education. Nurses
who were nurse practitioners (t = -2.42, p < .05), were male (t = -2.99, p < .01), or were on a planning committee (t = -1.96, p = .05) had received more education than other nurses. The most commonly cited barrier to education (46.6%, n = 221) was not knowing where to obtain training. One third of respondents (31.2%) reported no interest in receiving bioterrorism education in the future. Nurses’ average score on the knowledge test was 73%. The most commonly missed questions pertained to infection control and decontamination procedures. Conclusion: Bioterrorism preparedness training should be offered through continuing education and nursing school curricula. J Contin Educ Nurs 2010;41(2):67-76. ever, although bioterrorism training programs have been developed, few nurses are receiving or participating in these activities (Katz, Nekorchuk, Holck, Hendrickson, Imrie, & Effler, 2006). Perceived barriers to bioterrorism education have been examined. Researchers indicated that barriers to receiving bioterrorism education have been found to vary, depending on occupation (Shadel, Chen, Newkirk, Lawrence, Clements, & Evans, 2004; Shadel, Rebmann, Clements, Chen, & Evans, 2003; Sterling et al., 2005). A lack of training opportunities and a lack of time were the two most commonly reported barriers to receiving bioterrorism education among infection control and public health professionals (Shadel et al., 2003, 2004), whereas physicians cited a lack of continuing education units and perceived responsibility as significant barriers (Sterling et al., 2005). There were no published articles that described perceived barriers to bioterrorism preparedness education in nurses working in many health care settings and fields, such as medical-surgical units, academia, or administration. It is likely that infection control and public health nurses have more access to bioterrorismrelated education because of the nature of their job duties; therefore, their barriers to education may be different from those of nurses working in other settings. It is s the largest group of health care professionals and ones who play an integral role in the provision of health care, nurses are integral to bioterrorism preparedness. According to the American Nurses Association (2008), it is the responsibility of every professional nurse to maintain a state of professional readiness for emergencies. In addition, bioterrorism preparedness has been identified as a necessity for nurses at all levels of expertise and in all areas of practice (Rebmann, 2006). How- Dr. Rebmann is Associate Director for Curricular Affairs, Institute for Biosecurity, and Assistant Professor, Division of Environmental and Occupational Health; and Ms. Mohr is Research Assistant and Data Analyst, Saint Louis University, St. Louis, Missouri. Supported in part by American Nurses Foundation grant 300286. The authors thank the members of the Missouri Nurses Association for their participation in this study. Address correspondence to Terri Rebmann, PhD, RN, CIC, Assistant Professor, Division of Environmental and Occupational Health, Saint Louis University, School of Public Health, 3545 Lafayette Avenue, Suite 361, St. Louis, MO 63104. doi:10.3928/00220124-20100126-04 The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 67 A important to identify barriers to education in a variety of nursing specialties so that interventions can be developed to bridge these gaps. Most previous research on bioterrorism preparedness measured self-assessed knowledge or perceived needs and abilities, such as asking participants to rank their level of confidence in their ability to meet a competency rather than using an objective measure of knowledge, such as a multiple-choice or true-or-false question (Alder, Clark, White, Talboys, & Mottice, 2004; Kerby, Brand, Johnson, & Ghouri, 2005; Mosca, Sweeney, Hazy, & Brenner, 2005; Wisniewski, Dennik-Champion, & Peltier, 2004). Kerby et al. (2005) measured public health professionals’ confidence in meeting the Centers for Disease Control and Prevention bioterrorism preparedness competencies for public health clinical staff. Mosca et al. (2005) used the Centers for Disease Control and Prevention bioterrorism preparedness competencies to measure school nurses’ perceived readiness and found that most do not consider themselves ready for such an event. Wisniewski et al. (2004) also used a competency-based instrument to assess nurses’ disaster readiness by listing knowledgebased questions generated from emergency preparedness competencies (International Nursing Coalition for Mass Casualty Education, 2003) and having participants rate their level of familiarity with each competency. None of these studies measured nurses’ knowledge of emergency preparedness using an objective measure; all relied on individuals’ perceived readiness, which may not accurately reflect their knowledge of bioterrorism preparedness (Katz et al., 2006). Few studies have measured nurses’ knowledge of bioterrorism preparedness by using an instrument that contains competency-based knowledge questions with a right-or-wrong answer approach that may more accurately assess readiness (Katz et al., 2006; Rose & Larrimore, 2002). Rose and Larrimore (2002) assessed nurses’ preparedness for a chemical or biological terrorism attack using two items to measure nurses’ knowledge of bioterrorism preparedness: the ability to name two potential biological weapons and the ability to identify the transmission method for anthrax. Results from this research indicated that the vast majority of nurses could not name two potential biological weapons, and fewer than half knew the transmission method for anthrax (Rose & Larrimore, 2002). Katz et al. (2006) used a knowledge-based questionnaire consisting of a series of clinical questions, such as symptom identification and disease diagnosis, to assess the bioterrorism knowledge of Hawaiian physicians and nurses. This study reported that nurses answered only 60% of the items correctly on average, although nurses who had received more bioter68 rorism preparedness education had higher scores than nurses who had received less education (Katz et al., 2006). A 2008 study of nursing students in Italy used a combination of clinical-based questions and general bioterrorism preparedness items to assess nurses’ bioterrorism knowledge and found that knowledge levels were low in this population (De Felice, Giuliani, Alfonsi, Mosca, & Fabiani, 2008). Researchers have identified non-disease-specific bioterrorism preparedness and response information that nurses need to know (Nyamathi, King, Casillas, Gresham, & Mutere, 2007), but only the study by De Felice et al. (2008) measured nurses’ knowledge of these topics, and their study population was student nurses. Examples of such non-disease-specific bioterrorism preparedness knowledge include reporting incidents, environmental decontamination, epidemiological indicators of a bioterrorism attack, and the use of personal protective equipment (Nyamathi et al., 2007). It is important for all U.S. nurses to become better prepared for disasters, including bioterrorism attack. Certain areas of the country have an increased risk of natural disasters, including hurricanes in coastal regions and floods in the Midwest. Missouri sits on a major fault line and is at increased risk for a future earthquake. However, all areas of the United States are believed to be at risk for bioterrorism. Regardless of where a bioterrorism attack occurs, all parts of the United States could be affected because of weather conditions that might carry the pathogen or because infected patients could travel to other areas and spread disease. It is vital that Missouri nurses become prepared for bioterrorism and other disasters and for their preparedness needs to be assessed. BACKGROUND The current study identified perceived benefits of bioterrorism-related education and barriers to receiving this education, evaluated nurses’ knowledge regarding nondisease-specific aspects of bioterrorism preparedness, and described variables (based on nurses’ work location, work setting or specialty, education level, age, and gender) associated with these perceived benefits and barriers. It was also hypothesized that Missouri nurses will not have received much bioterrorism-related education, although it was anticipated that a large proportion of members of the Missouri Nurses Association (MONA) would have participated in the free training CD-ROM program that was sent to them. It was further hypothesized that nurses who are members of disaster planning teams and those who work in infection control or public health would report receipt of more bioterrorism education than nurses who are not planning committee members and those who work in other settings or fields. Copyright © SLACK Incorporated Methods The current study was a cross-sectional design consisting of a mailed survey sent to a convenience sample of registered nurses in Missouri. The instrument, with a cover letter and a self-addressed stamped envelope, was mailed to all 1,528 MONA members in July 2006. Missouri nurses were chosen as the sample because MONA distributed a free bioterrorism educational CD-ROM program to their members in 2005. It was believed that many of the MONA members would have participated in the free bioterrorism preparedness program sent to them; thus, they would have had at least one opportunity to receive bioterrorism-related education. The cover letter gave an Internet address for an online version of the survey administered through Test Pilot® on a secure server so that subjects had the option of completing the survey online; the questions for the online and penciland-paper surveys were identical. Surveys were coded so that participation could be tracked; surveys did not include names or other identifying information. A modified Dillman’s Total Design Method was used to maximize response rates (Dillman, 2007). Three weeks after the instruments were mailed, a reminder postcard was sent to nonresponders to encourage them to return their surveys or complete the instrument online. Nonresponders were sent a second copy of the survey and a cover letter approximately 14 weeks after the initial mailing to maximize the response rate. The Saint Louis University institutional review board reviewed and approved the study. items. The final 62-item instrument consisted of four subscales measuring the following: perceived benefits (6 items), perceived barriers (14 items), bioterrorism preparedness education received (4 items), and bioterrorism preparedness knowledge (38 items). Next, 20 Saint Louis University Hospital nurses pilot tested the final 62-item instrument. Feedback from pilot testing was used to refine the instrument further, such as revising confusing wording or skip patterns. Instrument The instrument measured bioterrorism preparedness knowledge, perceived benefits of this education and barriers to receiving bioterrorism preparedness education, and bioterrorism preparedness education received. Knowledge-based questions were derived from existing core competencies for bioterrorism and emergency readiness (Columbia School of Nursing, 2001, 2003a, 2003b; International Nursing Coalition for Mass Casualty Education, 2003). Questions on perceived benefits of bioterrorism preparedness education and barriers to this education and participation in bioterrorism education were derived from two bioterrorism surveys used in earlier studies (Shadel et al., 2003, 2004) and from a literature review. A group of eight researchers from across the country with expertise in bioterrorism provided feedback on the content validity of the instrument. The content validity index was computed for each item; items with a content validity index of less than 0.80 were deleted (Lynn, 1986). Of the original 98 items, 16 were revised and 35 were deleted, so that the final instrument had 62 Data Collection Survey questions regarding perceived benefits of bioterrorism preparedness education and barriers to this education were based on a five-point Likert-type scale (strongly disagree to strongly agree). Scores on the 6 perceived benefit questions and 14 perceived barrier items were summed to provide overall scores for benefits and barriers subscales. Higher scores on these subscales indicated a higher perceived benefit to receiving training (maximum score: 30) or a higher number of perceived barriers to education participation (maximum score: 70), respectively. Coefficients for internal consistency, Cronbach’s alpha, were calculated for the perceived benefits and perceived barriers subscales. Cronbach’s alpha was .86 for perceived benefits, .91 for perceived barriers, and .88 for bioterrorism knowledge, providing evidence of internal consistency for these subscales. Cronbach’s alpha could not be calculated for the four education participation items because, conceptually, it would not be expected that the items on the education participation subscale would be internally consistent (Ferketich, 1990). Cronbach’s alpha also could not be calculated for internal consistency of the entire survey because the questionnaire items did not conceptually fit together into an overall construct and there was no associated total score (Knapp, 1991). The instrument measured bioterrorism education by asking participants about two types of educational initiatives: traditional education (i.e., in-service training or lectures) and reading journal articles. An overall bioterrorism education participation score was calculated by adding the education variables (receipt of traditional education and journal articles read), providing a continuous variable. Scores for bioterrorism education participation were limitless. Other bioterrorism preparedness education items included whether the respondent had watched or participated in the free nursing bioterrorism preparedness CD-ROM program that MONA sent to its members in 2005 and the intent to pursue bioterrorism preparedness education in the future. The bioterrorism knowledge component of the questionnaire consisted of 38 true-or-false items, with one point awarded for each correct answer; higher scores in- The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 69 Table 1 Number (PercentAGE) of Missouri Nurses Association Respondents by Age, Gender, Education Level, Work Setting, and Work Location Characteristic N (%) Age (yr) < 30 11 (2.4) 31 to 40 20 (4.3) 41 to 50 144 (31.3) 51 to 60 190 (41.3) > 61
95 (20.7)
Gender
Female
Male
446 (96.7)
15 (3.3)
Highest level of education
Diploma
24 (5.2)
Associate’s degree
30 (6.4)
Bachelor’s degree
97 (20.8)
Master’s degree
Doctorate
275 (59.0)
40 (8.6)
Nurse practitioner
Yes
165 (35.4)
No
301 (64.6)
Work setting
Ambulatory care
98 (22.0)
Academic/research
79 (17.7)
Retired
50 (11.2)
Medical-surgical
33 (7.4)
Administration
31 (7.0)
Community/public health
25 (5.6)
Mental health
24 (5.4)
Emergency department
19 (4.3)
Critical care
18 (4.0)
Long-term care
18 (4.0)
Obstetrics
16 (3.6)
Home health
9 (2.0)
School (K-12)
9 (2.0)
Pediatrics
7 (1.6)
Infection control
5 (1.1)
Operating room
5 (1.1)
Work location
70
Urban
164 (36.9)
Rural
151 (34.0)
Suburban
129 (29.1)
Type of institution
For-profit
124 (29.4)
Not-for-profit
298 (70.6)
Note. Items had various denominators because of inconsistent or
missing data. Respondents who selected multiple options within an
item (e.g., work location: urban, rural, or suburban) were excluded
from analysis for those items.
dicated higher knowledge levels. The maximum possible
bioterrorism knowledge score was 38. The instrument
also included demographic questions, such as age, gender,
education level, nurse practitioner status (nurse practitioner vs. not a nurse practitioner), work location (rural,
urban, or suburban), work setting or specialty (e.g., academic, emergency department, infection control, retired),
membership in an employer disaster planning committee,
and employer’s profit status (for-profit vs. not-for-profit).
Nurses’ work setting or specialty was condensed to four
groups for data analysis: (1) academic, (2) clinical fields,
(3) infection control or public health, and (4) retired. Infection control and public health were separated from
other clinical specialties because nurses working in these
areas are more likely to have had exposure to bioterrorism
education and training because of the nature of their job
duties (Rebmann & Mohr, 2008).
Data Analysis
Data from the pencil-and-paper version of the instrument were entered using the double-entry method
to ensure accuracy. Online data from Test Pilot® were
downloaded into a Microsoft Access database. Online
and pencil-and-paper data were merged and checked for
duplication. SPSS software, version 14.1, was used for all
analyses. Respondents whose answers were inconsistent
(i.e., multiple options selected within an item, such as work
location: urban, rural, or suburban) were excluded from
analysis for those items. Although 474 nurses responded
to the survey, the descriptive statistics had different denominators because of inconsistent or missing data. Descriptive statistics were computed for each question and
used to describe nurses’ perceived benefits of bioterrorism-related education and perceived barriers to receiving
this education, participation in bioterrorism education,
and bioterrorism knowledge scores. Independent samples
t tests were conducted to compare bioterrorism education received by nurses’ gender, employer profit status,
nurse practitioner status, and membership in a planning
team because these were dichotomous groups. One-way
analysis of variance was used to evaluate group differences between nurses’ bioterrorism knowledge scores and
Copyright © SLACK Incorporated
Table 2
Missouri Nurses’ Perceived Benefits of bioterrorism education and Barriers to Receiving
Bioterrorism Education
M (SD)a
Frequency of
Agreement With
Statement
N (%)b
Bioterrorism preparedness advances my knowledge
4.63 (0.65)
450 (94.90)
Getting better prepared for bioterrorism will decrease my family’s risk of getting sick or
dying after an attack
4.33 (0.77)
420 (88.60)
Getting better prepared for bioterrorism will decrease my chances of getting sick or dying
after an attack
4.32 (0.80)
417 (88.00)
Getting better prepared for bioterrorism will decrease my patients’ risk of getting sick or
dying after an attack
4.26 (0.80)
405 (85.40)
Getting better prepared for bioterrorism will increase my chances of detecting an attack
before surveillance would recognize it
4.07 (0.94)
369 (77.80)
Getting better prepared for bioterrorism makes me feel more safe
3.98 (1.03)
344 (72.60)
I do not know where to get training
3.15 (1.42)
221 (46.60)
There is no administrative financial support for training at my work
3.37 (1.28)
210 (44.30)
There are no disaster exercises available
2.56 (1.23)
115 (34.30)
I feel uncomfortable or stressed when thinking about bioterrorism
2.76 (1.24)
161 (34.00)
My work schedule does not provide time for training
2.72 (1.21)
124 (27.20)
Bioterrorism preparedness is not currently a priority for me
2.47 (1.19)
113 (23.80)
There are no training opportunities available
2.51 (1.19)
103 (21.70)
I am too busy for training
2.29 (1.11)
71 (15.00)
It is not within the scope of my responsibilities
2.07 (1.15)
66 (13.90)
There is little one can do to lessen the impact of an attack
1.98 (1.07)
59 (12.40)
Training is too expensive
2.46 (0.97)
46 (9.70)
I have no interest in bioterrorism preparedness
1.77 (1.05)
40 (8.40)
Training will take too long
2.28 (0.98)
36 (7.60)
Bioterrorism training is all the same; I am not learning anything new
2.07 (0.98)
30 (6.40)
Perceived Benefit Item
Note. a1 = strongly disagree; 2 = disagree somewhat; 3 = neutral; 4 = agree somewhat; 5 = strongly agree. bAgree somewhat or strongly agree.
nurses’ perceived benefits and barriers by work location,
work setting or specialty, education level, and age; post
hoc evaluation was performed using the Scheffe test, with
Bonferroni correction to control for experiment-wise error rate. It is commonly accepted practice to assume an
underlying interval-scaled distribution for an ordinal-like
scale, such as the ones used in the current study. This allows parametric (e.g., analysis of variance) analysis to be
performed (Velleman & Wilkinson, 1993).
n = 298), and were between 41 and 60 years (72.6%, n =
334) (Table 1). Approximately one third of the respondents
were nurse practitioners (35.4%, n = 165). Participants
had an equitable representation across work locations: urban (36.9%), rural (34.0%), and suburban (29.1%). Nurse
respondents listed a variety of work settings or specialties,
including academic institutions, hospitals, community
health roles, and retirement. Participants’ demographic
characteristics are shown in Table 1.
Results
Overall, 474 of 1,528 (31.0%) petitioned participants
responded to the survey. Most respondents were female
(96.7%, n = 446), had a bachelor’s degree or higher (79.8%,
n = 372), worked at a not-for-profit institution (70.6%,
Nurses’ Perceived Benefits of Bioterrorism
Education
Almost all nurses (97.5%, n = 462) reported agreeing with at least one benefit to becoming better prepared
for bioterrorism, and 61.0% (n = 289) agreed with all
The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010
71
Table 3
Missouri Nurses’ Participation in Bioterrorism Education, Perceived Barriers to
participation, and Knowledge Scores in Relation to Work Setting or Specialty
Academic
Survey Item
n
a
M (SD)
Clinical Fields
Infection Control
and Public
Health
n
M (SD)
n
M (SD)
Retired
n
M (SD)
p
Plan to pursue bioterrorism
educationb,e,f,g,h
103
3.04 (0.90)
240
3.03 (0.81)
27
2.30 (0.82)
39
3.36 (0.93) < .001 Number of bioterrorism in-services or lectures attended 110 6.37 (28.60) 256 3.20 (14.90) 30 3.47 (7.07) 50 1.26 (3.56) NS Number of bioterrorism-related journal articles readf,h,i 110 2.63 (3.79) 256 2.59 (8.04) 30 7.70 (16.72) 50 1.22 (1.62) < .01 Knowledge scorec,e,g,h 110 28.6 (2.76) 256 27.82 (3.68) 30 28.6 (2.58) 50 There is no administrative financial support for bioterrorism preparedness training at my workd,f 110 3.37 (1.31) 253 3.47 (1.28) 30 2.73 (1.51) 42 25.12 (8.01) < .001 3.12 (0.89) < .05 Note. aItems had various denominators because of inconsistent or missing data, such as selecting more than one answer option. b1 = in the next month; 2 = in the next 6 months; 3 = in the next year; 4 = I do not plan to pursue bioterrorism education. cMaximum knowledge score = 38. d1 = strongly disagree; 2 = disagree somewhat; 3 = neutral; 4 = agree somewhat; 5 = strongly agree. eSignificant difference between academic and retired. fSignificant difference between clinical fields and infection control and public health. gSignificant difference between clinical fields and retired. hSignificant difference between infection control and public health and retired. iSignificant difference between infection control and public health and academic. NS = not significant. six of the perceived benefits. The benefits that showed the highest level of agreement were “bioterrorism preparedness advances my knowledge” and “getting better prepared for bioterrorism will decrease my family’s risk of getting sick or dying after an attack.” Table 2 shows nurses’ agreement with the perceived benefits items. The mean benefits score was 25.6 (range = 6 to 30, sd = 1.56) out of a possible score of 30, indicating that most nurses agreed with almost all of the benefits to receiving bioterrorism preparedness education. There was no difference between the number of perceived benefits reported and nurses’ age, education level, work location, or work setting or specialty. Nurses who worked at a nonprofit agency (t = -117.23, p < .001), nurse practitioners (t = -121.40, p < .001), males (t = -126.60, p < .001), and those who are members of the disaster planning committee for their facility (t = -118.70, p < .001) reported a higher number of perceived benefits than other nurses. Barriers to Nurses Receiving Bioterrorism Education Most nurses (85.0%, n = 403) identified at least one barrier to receiving bioterrorism education, and approximately half (46.0%, n = 217) reported two to four barriers. The four most commonly cited barriers were as follows: (1) “I do not know where to get training”; (2) “there is no administrative financial support for training at my work”; (3) “there are no disaster exercises avail72 able”; and (4) “I feel uncomfortable or stressed when thinking about bioterrorism.” Table 2 shows nurses’ agreement with each of the perceived barriers. The mean barriers score was 34.3 (range = 15 to 58, sd = 2.29) out of a possible score of 70, indicating that most nurses agreed with approximately half of the barriers to receiving education. There was no difference between the number of perceived barriers reported and nurses’ age, education level, or work location. However, nurses working in infection control or public health reported fewer barriers to receiving bioterrorism education than nurses working in academic (F (3) = 4.16, p < .05) or clinical settings (F (3) = 4.16, p < .01). In addition, nurses who worked at a for-profit agency (t = -74.64, p < .001), non-nurse practitioners (t = -78.12, p < .001), and those who are not members of the disaster planning committee for their facility (t = -77.86, p < .001) reported a higher number of perceived barriers to receiving education than other nurses. Nurses who worked in clinical settings were more likely to report a lack of financial administrative support to receive bioterrorism education than infection control or public health nurses (Table 3). Nurses’ Participation in Bioterrorism Education More than half (60%, n = 284) of respondents reported that they had not participated in or received any bioterrorism-related education in the form of in-services or lectures. Of those who had attended bioterrorismCopyright © SLACK Incorporated related in-services or lectures, most had participated in three or fewer programs. Approximately 12% attended one educational program (n = 55), 10% participated in two (n = 46), and 6% took part in three (n = 29). There was no significant difference between nurses’ work setting or specialty and the number of bioterrorism-related in-services or lectures attended. Nurses who worked at a nonprofit agency (t = -2.48, p < .05), nurse practitioners (t = -2.42, p < .05), males (t = -2.99, p < .01), and those who are members of the disaster planning committee for their facility (t = -1.96, p = .05) reported participation in significantly more educational programs than nurses who work at a for-profit organization, non-nurse practitioners, and those who are not members of planning committees, respectively. Journal Articles as a Form of Bioterrorism Education More than one third of all nurses (38.8%, n = 184) reported that they had not read any journal articles about bioterrorism preparedness or bioterrorism-related agents. Of those who reported reading bioterrorism-related journal articles, most had read three or fewer (70.1%, n = 202). Nurses working in infection control or public health reported having read more bioterrorism-related journal articles than nurses working in all other fields (F (3) = 4.81, p < .01). Table 3 shows significant differences between nurses’ work setting or specialty and the number of journal articles they read. In addition, nurses who worked at a nonprofit agency (t = -3.01, p < .01), nurse practitioners (t = -3.00, p < .01), males (t = -4.75, p < .001), and those who are members of the disaster planning committee for their facility (t = -2.46, p < .05) reported having read a significantly higher number of bioterrorism-related journal articles than other nurses. Nurse practitioners reported participation in significantly more bioterrorismrelated educational initiatives (in-services or lectures and journal articles) than non-nurse practitioners, respectively (t = 3.80, p < .001). There was no significant difference between the number of educational initiatives attended or bioterrorism-related journal articles read and nurses’ age, education level, or work location. months; 31.2% (n = 148) reported that they do not plan to get this training. Table 3 shows differences between nurses’ work setting or specialty and their likelihood of pursuing bioterrorism education in the future. Nurses’ Bioterrorism Knowledge Nurses’ average score on the bioterrorism knowledge test was 27.7 of a maximum possible score of 38 points (73%). Knowledge scores ranged from 0 to 36 points (SD = 4.37), with most nurses scoring poorly on the test. Nurses scored highest on questions pertaining to having a personal response plan and dispersion techniques for biological agents. The most frequently missed questions fell into one of six categories: (1) infection control, (2) decontamination procedures, (3) response procedures, (4) incident command system, (5) reporting an incident, and (6) quarantine. There was no difference between bioterrorism knowledge score and education level, work location, or amount of bioterrorism education received previously. Nurses who were 61 years or older (F (3) = 11.30, p < .001) and retired nurses (F (3) = 8.57, p < .001) had lower knowledge scores than younger nurses and those who were employed. Nurses who worked at a nonprofit agency (t = -157.90, p < .001), nurse practitioners (t = -133.20, p < .001), males (t = -142.70, p < .001), and those who are members of their facility’s disaster planning committee (t = -144.20, p < .001) had higher knowledge scores than nurses working at a for-profit organization, non-nurse practitioners, and those who are not members of planning committees, respectively. Table 3 shows differences between nurses’ work setting or specialty and their bioterrorism knowledge scores. Plan to Receive Bioterrorism Education in the Future Only 8.6% (n = 41) of nurses reported that they had watched or participated in the free nursing bioterrorism preparedness CD-ROM program that MONA sent to its members in 2005. Approximately one third of nurses (36.1%, n = 171) reported that they plan to pursue bioterrorism preparedness education in the future, and 19.8% (n = 94) plan to receive this training in the next 6 Discussion The findings of the current study indicate that the Missouri nurses who participated believe that bioterrorism preparedness education is beneficial for a variety of reasons, including advancing knowledge and decreasing their family members’ risk of getting sick or dying after a bioterrorism attack. However, despite the reported perceived benefits to receiving education, the majority of Missouri nurses in the current study indicated that they have not attended any bioterrorism preparedness-related in-services or lectures. One third of Missouri nurses in the current study also reported that they have not read any journal articles related to bioterrorism preparedness or bioterrorism-related agents or diseases. The reasons for low participation in bioterrorism-related training programs are unclear, but are likely associated with a lack of awareness about available educational opportunities (a frequently cited barrier). Nurse practitioners, The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 73 male respondents, and those who are members of their facility’s disaster planning committee reported receiving more bioterrorism preparedness education in the form of in-services or lectures than other nurses. Most of these findings were not anticipated, based on the authors’ original hypotheses. The reasons why nurse practitioners’ responses were different from those of non-nurse practitioners are unclear. It may be an issue of access to bioterrorism-related educational programs, job obligations, or interest in the topic. More research needs to be done in this area to better determine the factors that relate to receiving bioterrorism-related education. The Missouri infection control and public health nurses in the current study reported reading more bioterrorism preparedness-related journal articles than nurses working in other fields. Retired nurses and those working in clinical fields or academia reported reading few journal articles on bioterrorism preparedness. This may be because infection control and public health journals publish more articles on bioterrorism preparedness, or it may be related to other factors, such as nurses’ personal choices regarding educational format preference. Because two thirds of all Missouri nurses included in the current study reported a plan to pursue bioterrorism-related education at some point in the future, more bioterrorism educational programs need to be developed and disseminated. This education must be competencybased and tied to terminal objectives that can be used to measure health care worker performance (Carrico, Rebmann, English, Mackey, & Cronin, 2008). Bioterrorism preparedness-related education should be offered in a variety of formats (e.g., lectures, in-services, journal articles, online courses) to meet nurses’ needs. The Missouri nurses included in the current study identified numerous barriers to receiving or participating in bioterrorism preparedness education. The most frequently cited barriers to receiving bioterrorism preparedness education were not knowing where to get such training and a lack of administrative financial support to attend these programs. Other frequently cited barriers to education included the lack of availability of bioterrorism preparedness educational programs and the feeling of stress or discomfort that nurses experience when thinking about bioterrorism. Not surprisingly, nurses in the current study who are members of their facility’s disaster planning committee reported more benefits of bioterrorism preparedness education and fewer barriers to receiving this education. Infection control and public health nurses in the current study reported fewer barriers to receiving bioterrorism preparedness education than nurses working in academic or clinical settings. This is likely a result of the nature of the duties of infection control 74 and public health nursing and the recent emphasis on bioterrorism preparedness in these fields, which could translate into more financial support for these activities and more programs offered to professionals working in these fields. Because the American Nurses Association has asserted that it is the responsibility of every professional nurse to maintain a state of professional readiness for emergencies, it is vital that nurses in all settings have access to bioterrorism preparedness education as well as financial support to encourage their participation. To do so, interventions must be developed to address barriers to education identified by the Missouri nurses in the current study. More information needs to be disseminated to nurses regarding available bioterrorism preparedness programs as well as educational materials related to all types of disasters. In addition, more financial support needs to be provided to aid nurses in pursuing these educational opportunities. Various free educational programs are available (Centers for Disease Control and Prevention, 1999, 2001; Institute for Biosecurity, 2005; Willshire & Hassmiller, 2007), but nurses may not be aware of their existence. An interesting finding from the current study is that a large number of Missouri nurses reported an interest in receiving bioterrorism education and identified a lack of available bioterrorism training opportunities as a barrier to receiving this education; however, few respondents reported participating in the free CD-ROM educational program mailed to members of MONA the previous year. It is not known why these nurses chose not to participate in the free educational program delivered to them, yet assert that they do not know where to obtain training materials. Future studies should focus on nurses’ access to these programs and decision-making regarding how and when participation in these educational programs takes place. Effective versus noneffective communication regarding available bioterrorism education should also be studied to determine the best ways to inform nurses about available training opportunities. Overall, Missouri nurses included in the current study scored poorly on the objective measure of their bioterrorism knowledge, as was hypothesized; the average score was 73%. Nurses in this study who work at a nonprofit agency, nurse practitioners, and those who are members of their facility’s disaster planning committee scored higher on the bioterrorism knowledge test than other nurses. The higher knowledge scores are most likely related to the fact that these groups of nurses also reported receiving more bioterrorism-related education than the other groups of nurses. Few nurses in this study scored high on the knowledge test (80% or greater). This finding is similar to previously published research that Copyright © SLACK Incorporated reported on nurses’ knowledge of clinical questions related to bioterrorism and found that the level of knowledge was low (De Felice et al., 2008; Katz et al., 2006; Rose & Larrimore, 2002). The bioterrorism knowledge test used in the current study was developed from bioterrorism core competencies (Gebbie & Quereshi, 2002) and thus measured a different component of bioterrorism knowledge than has been studied before (i.e., clinical knowledge about bioterrorism agents) in nursing students in Italy (De Felice et al., 2008). However, the findings were similar. Nurses need to improve their bioterrorism preparedness knowledge to provide competent care during a bioterrorism incident. Educational content should focus on the core competencies, particularly the areas identified in the current study as being the most frequently missed. The current study has a few notable strengths. It is the first study to examine nurses’ perceived benefits of receiving bioterrorism-related education and perceived barriers to receiving this education, delineate the amount and types of bioterrorism preparedness education that nurses have received, and evaluate U.S. nurses’ knowledge of nonclinical bioterrorism preparedness issues. A few limitations of the study must also be noted. One limitation is the potential issue of nonresponder bias. Individual characteristics of the nonresponders could not be assessed directly, a common issue in survey research. Another limitation is that participants were all members of MONA; thus, the findings may not be generalizable to all nurses nationwide. It is possible that nurses in other parts of the United States or in other countries may have responded differently to the survey questions, had higher knowledge scores, or received more bioterrorism education than nurses in Missouri. However, previous research indicated that knowledge of bioterrorism preparedness in health care providers in a variety of occupations, locations, and work settings is generally poor (De Felice et al., 2008; Kerby et al., 2005; Mosca et al., 2005; Wisniewski et al., 2004). These findings provide some evidence of the generalizability of the current findings. However, the generalizability of the findings of the current study outside of Missouri or to non-nurses is unknown. In addition, the findings may not be generalizable to all nurses in Missouri. It is possible that MONA members are different from non-MONA members in terms of their interest in, participation in, and access to bioterrorism preparedness education. MONA members include a wide variety of nurses working in various nursing fields or specialties and are likely reflective of the nursing population in general, but this cannot be known. Another limitation of the current study is the high proportion of nurse participants who reported hav- ing a master’s degree. Exact information on the education levels of Missouri nurses is not available, but the current study likely includes a better-educated group of nurses than would be expected. It seems likely that nurses with more formal education may be more willing to complete a survey about bioterrorism education and to have more knowledge about bioterrorism preparedness than nurses with less education, although this is not known. The high proportion of participants with advanced education may therefore limit the generalizability of the findings. A final limitation of the current study is the use of a trueor-false test for assessing nurses’ knowledge about bioterrorism. True-or-false tests are not as effective as other types of test design in assessing knowledge. Despite these limitations, the current study provides beginning work on examining nurses’ perceived benefits of bioterrorism preparedness education and perceived barriers to this education as well as their bioterrorism knowledge. It is important to note that the current study used a cross-sectional design and thus cannot show a cause-andeffect relationship between any of the variables studied, including the relationship between receiving bioterrorism education and having bioterrorism preparedness knowledge. Prospective studies that examine knowledge gained from a specific educational program would better inform researchers of the effectiveness of that training. The crosssectional design used in the current study can illuminate nurses’ behavior and attitudes toward bioterrorism preparedness at the time of the study (2006), but cannot predict which educational programs would best prepare nurses for a bioterrorism attack. Future studies should examine knowledge gained from educational programs so that more effective training can be developed for nurses. The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 75 Conclusion Bioterrorism preparedness has become essential for nurses in all areas of expertise and practice, yet many nurses are not participating in bioterrorism preparedness educational opportunities. Some barriers to nurses’ participation in bioterrorism preparedness education have been outlined in the current article. Interventions must be implemented to address these barriers so that nurses in all specialties and work settings have access to bioterrorism preparedness training opportunities. A variety of educational program formats, such as in-services, lectures, journal articles, and online courses need to be developed to meet nurses’ needs. Bioterrorism preparedness training should be made available through continuing education programs and also should become a component of nursing school curricula using the identified core competencies as a basis for educational development. Participation in bioterrorism preparedness key points Bioterrorism Rebmann, T., Mohr, L. B. (2010). Bioterrorism Knowledge and Educational Participation of Nurses in Missouri. The Journal of Continuing Education in Nursing, 41(2), 67-76. 1 2 3 Nurses are integral to bioterrorism preparedness. 4 Missouri nurses report many barriers to receiving bioterrorism education, with a lack of knowledge about where to get training being the primary barrier. Most Missouri nurses have not received bioterrorism education. Missouri nurses have little knowledge of the nonclinical components of bioterrorism preparedness, as evidenced by scoring poorly on a knowledge test. education should translate into higher knowledge levels and a more competent work force. References Alder, S. C., Clark, J. D., White, G. L., Jr., Talboys, S., & Mottice, S. (2004). Physician preparedness for bioterrorism recognition and response: A Utah-based needs assessment. Disaster Management & Response, 2(3), 69-74. American Nurses Association. (2008). Adapting standards of care under extreme conditions: Guidance for professionals during disasters, pandemics, and other extreme emergencies. Retrieved from www.nursingworld.org/HomepageCategory/NursingInsider/ AdaptingStandardsofCareunderExtremeConditions.aspx Carrico, R. M., Rebmann, T., English, J. F., Mackey, J., & Cronin, S. N. (2008). Infection prevention competencies for hospital-based healthcare personnel. American Journal of Infection Control, 36(10), 691-701. Centers for Disease Control and Prevention. (1999). History of bioterrorism: An online video or podcast. Retrieved from www.bt.cdc. gov/training/historyofbt Centers for Disease Control and Prevention. (2001). Anthrax overview: An online training program. Retrieved from www.bt.cdc. gov/agent/anthrax/training/#slides Columbia School of Nursing. (2001). Bioterrorism & emergency readiness: Competencies for all public health workers. Retrieved from www.cumc.columbia.edu/dept/nursing/chphsr/pdf/btcomps.pdf Columbia School of Nursing. (2003a). Clinician competencies: During initial assessment and management of emergency events. Retrieved from http://cpmcnet.columbia.edu/dept/nursing/chphsr/pdf/ clinician-comps.pdf Columbia School of Nursing. (2003b). Emergency preparedness and response competencies for hospital workers. Retrieved from www. cumc.columbia.edu/dept/nursing/chphsr/pdf/hospcomps.pdf De Felice, M., Giuliani, A. R., Alfonsi, G., Mosca, G., & Fabiani, L. (2008). Survey of nursing knowledge on bioterrorism. International Emergency Nursing, 16(2), 101-108. Dillman, D. (2007). Mail and telephone surveys: The total design meth76 od. New York: Wiley-Intersciences. Ferketich, S. (1990). Internal consistency estimates of reliability. Research in Nursing and Health, 13, 437-440. Gebbie, K. M., & Qureshi, K. (2002). Emergency and disaster preparedness: Core competencies for nurses. American Journal of Nursing, 102(1), 46-51. Institute for Biosecurity. (2005). Bioterrorism preparedness for nurses (CD-ROM program). Available at www.bioterrorism.slu.edu/bt/ products.htm International Nursing Coalition for Mass Casualty Education. (2003). Educational competencies for registered nurses related to mass casualty incidents. Retrieved from www.aacn.nche.edu/Education/pdf/ INCMCECompetencies.pdf Katz, A. R., Nekorchuk, D. M., Holck, P. S., Hendrickson, L. A., Imrie, A. A., & Effler, P. V. (2006). Hawaii physician and nurse bioterrorism preparedness survey. Prehospital and Disaster Medicine, 21(6), 404-413. Kerby, D. S., Brand, M. W., Johnson, D. L., & Ghouri, R. S. (2005). Self-assessment in the measurement of public health workforce preparedness for bioterrorism or other public health disasters. Public Health Reports, 120(2), 186-191. Knapp, T. R. (1991). Coefficient alpha: Conceptualizations and anomalies. Research in Nursing and Health, 14, 457-460. Lynn, M. R. (1986). Determination and quantification of content validity. Nursing Research, 35(6), 382-385. Mosca, N. W., Sweeney, P. M., Hazy, J. M., & Brenner, P. (2005, November). Assessing bioterrorism and disaster preparedness training needs for school nurses. Journal of Public Health Management and Practice, S38-S44. Nyamathi, A. M., King, M., Casillas, A., Gresham, L. S., & Mutere, M. (2007). Nurses’ perceptions of content and delivery style of bioterrorism education. Journal for Nurses in Staff Development, 23(6), 251-257. Rebmann, T. (2006). Defining bioterrorism preparedness for nurses: A concept analysis. Journal of Advanced Nursing, 54(5), 623-632. Rebmann, T., & Mohr, L. B. (2008). Missouri nurses’ bioterrorism preparedness. Biosecurity and Bioterrorism: Strategy, Practice, and Science, 6(3), 243-251. Rose, M. A., & Larrimore, K. L. (2002). Knowledge and awareness concerning chemical and biological terrorism: Continuing education implications. Journal of Continuing Education, 33, 253-258. Shadel, B. N., Chen, J. J., Newkirk, R., Lawrence, S., Clements, B. W., & Evans, R. G. (2004). Bioterrorism risk perceptions and educational needs of public health professionals before and after September 11th, 2001: A national needs assessment survey. Journal of Public Health Management Practice, 10(4), 282-289. Shadel, B. N., Rebmann, T., Clements, B., Chen, J. J., & Evans, R. G. (2003). Infection control practitioners’ perceptions and educational needs regarding bioterrorism: Results from a national needs assessment survey. American Journal of Infection Control, 31(3), 129-134. Sterling, D. A., Clements, B., Rebmann, T., Shadel, B. N., Stewart, L. M., Thomas, R., et al. (2005). Occupational physician perceptions of bioterrorism. Journal of Hygiene and Environmental Health, 208, 127-134. Velleman, P. F., & Wilkinson, L. (1993). Nominal, ordinal, interval, and ratio typologies are misleading. American Statistics, 47, 65-72. Willshire, L., & Hassmiller, S. B. (2007). Disaster preparedness and response for nurses. Retrieved from www.nursingsociety.org/ Education/ContinuingEducation/Pages/ceonline.aspx Wisniewski, R., Dennik-Champion, G., & Peltier, J. W. (2004). Emergency preparedness competencies: Assessing nurses’ educational needs. Journal of Nursing Administration, 34(10), 475-480. Copyright © SLACK Incorporated Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.