Introduction

Background

Disasters can be divided into natural and social disasters. They can occur due to natural causes, such as typhoons or earthquakes, or human activities, such as chemical spills [1]. According to the 2020 Global Natural Disaster Assessment Report, 1,313 major natural disasters occurred globally in 2020, and affected 123 countries and regions [2]. In addition, according to the Center for Research on the Epidemiology of Disasters, the costliest natural disasters since the 1900s included the Yangtze River Floods in China, the Kumamoto earthquake in Japan, and Hurricane Matthew in the United States, which caused an estimated economic damage of approximately $2 to $10 billion [3]. Additionally, the COVID-19 pandemic has caused hundreds of millions of cumulative confirmed cases worldwide since 2020, and the number of cumulative COVID-19 deaths worldwide is estimated to be approximately 7 million as of mid-2023 [4]. As for major social disasters around the world, they include the Chernobyl nuclear disaster in the former Soviet Union, the Bhopal disaster in India, and the Deepwater Horizon oil spill in the Gulf of Mexico in the United States, and these accidents resulted in tens of thousands of deaths and the large-scale destruction of ecosystems [5]. In recent years, extreme natural disaster events have become more frequent due to climate change, and social disasters such as industrial accidents have occurred more frequently globally due to industrialization, affecting more than 2.6 billion people over the past decade [6].

Nurses are professionals who account for the largest proportion of people responding to disasters, and play an important role in effectively responding to disasters [7]. Nurses are specially trained to provide first aid and treatment to disaster victims in large-scale public health emergencies, and it has been reported that their interventions in crisis situations can lead to a 50 to 70% reduction in mortality rates [8]. In disaster situations, nurses prepare for crises both as healthcare professionals and as individuals, and perform various activities, such as providing essential interventions to the injured, triage and evacuation of the injured, crisis management, exercising leadership, and assessment and rehabilitation of survivors [7]. However, nurses have been found to face problems such as inadequate preparedness, insufficient training, and ethical and legal challenges in responding to disasters [9].

In disaster response, disaster nursing competency is essential for nurses to provide comprehensive and holistic nursing to victims. The International Council of Nurses and the World Association for Disaster and Emergency Medicine have presented a framework of core competencies in disaster nursing, and this framework serves as a basic framework for disaster nursing education and practice by presenting standard competencies for the four phases of disaster management: risk reduction, preparedness, response, and recovery [10]. However, a review of previous studies on disaster nursing competencies reveals that different studies used different categories and terms, so it is difficult to compare or comprehensively analyze disaster nursing competencies presented in the existing literature [11]. Moreover, due to the lack of an established system of keywords that explain core competencies in disaster nursing, there are limitations in understanding and integrating the knowledge structures of the overall literature [10]. Consequently, as it is not easy to clearly understand the degree to which particular competencies were emphasized or identify competencies not sufficiently addressed in research, it is difficult to provide a practical foundation for follow-up research and curriculum development.

Recently, as there has been increasing interest in disasters, various studies on disaster nursing have been conducted. However, there has been a lack of efforts to systematically and comprehensively analyze the literature of disaster nursing research [11,12]. Systematic and scoping reviews that attempted to comprehensively analyze disaster nursing research have been published, but each of the previous studies has some limitations. Previous systematic literature reviews have limitations in that they focused on specific subareas of disaster nursing rather than taking a comprehensive approach, and thus analyzed only a relatively small number of papers. For example, Tas & Cakir [13] focused only on the knowledge and responses of nurses and analyzed 17 papers, and Said & Chiang [14] analyzed only 12 papers, focusing only on the knowledge and skills of nurses. A study by Al Thobaity et al. [11] also analyzed a limited number of 12 papers on disaster nursing competencies. Meanwhile, Hugelius’s [15] scoping review analyzed over 100 papers on disaster nursing, but since this study was conducted by a single researcher, it is highly likely to involve a subjective intervention in analysis. Moreover, its qualitative, summary-focused descriptions have limitations in terms of quantitative analysis. Lastly, Molassiotis [12] attempted to objectively analyze disaster nursing research using network analysis. However, because the study included only publications up to 2019, recent major disasters such as the COVID-19 pandemic were not captured.

This study attempted to comprehensively analyze studies on disaster nursing competency published up to 2024 by using a network analysis method. Network analysis is an analytical method used to systematically analyze relationships between concepts in order to gain an objective and comprehensive understanding of research trends [16]. This analysis method is a technique that connects keywords appearing in research to construct a keyword network and explain phenomena. Network analysis is not simply a method for measuring the frequencies of occurrence of concepts, but it also allows us to identify the most influential key concepts in the entire text and analyze their roles in terms of their relationships with other concepts. Additionally, by visually presenting the connections between concepts, network analysis can provide a better intuitive understanding of complex relationships, making it possible to identify key concepts and easily explore relationships between concepts [16]. Therefore, this study aimed to identify the key concepts in disaster nursing research by comprehensively analyzing research papers published up to the present day in the field of disaster nursing, and to suggest directions for the development of disaster nursing research by presenting quantitative data on the connections between key concepts in disaster nursing research.

Aims and objectives

This study aimed to analyze keywords in the studies on disaster nursing competency published up to the present day to identify trends in research on disaster nursing competencies. The specific objectives of this study are as follows:

1) To identify publication trends in studies on disaster nursing competencies published to date;

2) To identify frequently occurring keywords in studies on disaster nursing competencies published to date, and analyze the characteristics of the keyword network.

Methods

Study design

This study is a retrospective descriptive study to analyze the keywords in research papers on disaster nursing competencies published to date as of September 15, 2024.

Subjects and data collection

Research papers were selected based on the PRISMA guidelines [17]. To collect papers, a literature search was performed using five databases: CINAHL, Cochrane, Embase, PubMed, and Web of Science. The search targets were the articles in English published up to September 15, 2024, when the literature search was performed, without any restrictions on year of publication. The keywords used in the search were ‘disaster and nursing,’ ‘preparedness,’ ‘competencies,’ ‘response,’ ‘drill,’ ‘ability,’ ‘capability,’ ‘roles,’ ‘function,’ ‘knowledge and skills,’ and ‘willingness and barriers.’

In this study, the population of disaster nursing research is nurses, including general nurses, nurse assistants, and advanced practice nurses or nurses for disaster nursing; the contexts of disaster nursing research are the nursing skills, knowledge, competencies, or abilities of nurses; and the concepts of disaster nursing research are natural disasters, such as earthquakes and tsunamis, and social disasters, such as bioterrorism and nuclear accidents. The research papers used in the analysis included quantitative studies, qualitative studies, mixed-methods studies, and literature reviews. Materials such as conference abstracts and news articles were excluded from analysis because they were not relevant to the research questions.

The selection of research papers was conducted according to the inclusion and exclusion criteria. First, one author reviewed the research titles and abstracts for the initial section of papers. Afterward, another author independently evaluated the titles and abstracts of the selected papers. The finally selected papers were fully reviewed after obtaining their full texts. If any disagreement occurs during the evaluation process, an agreement was reached through discussion with a third author. A total of 256 papers and 1,318 keywords were analyzed through the paper selection process (Figure 1).

Data analysis

To analyze the keywords of the selected research papers, word cloud analysis and text network analysis were performed using NetMiner 4.0.

1. Preprocessing process

The preprocessing process includes proofreading, elimination, and control to refine concepts. ‘Proofreading’ includes standardizing singular and plural nouns and spacing, and ‘elimination’ refers to removing concepts with a high frequency but a low analytical value or no analytical significance. Finally, ‘control’ involves integrating synonyms or terms with similar meanings into appropriate representative concepts.

To prevent any subjective bias in the preprocessing process, the researcher tried to minimally modify the existing keyword list, and three researchers made the lists of synonyms, designators, and exclusion words through discussion.

Specifically, proofreading included capitalizing the first letter of every word, removing special characters, and standardizing spacing to ensure consistency in spacing. Elimination work included removing unnecessary concepts and duplicate words. Characteristic keywords commonly found in all papers, such as disaster and nursing, were excluded. In addition, words related to research methods, such as qualitative research, literature review, and cross-sectional study, were excluded, and words indicating countries or geographical locations, such as China, Brazil, Saudi Arabia, Korea, developing countries, and countries with a high risk of disasters, were also excluded. Research methods and the above-mentioned geographical terms were excluded from the analysis because they were not included as keywords in all the papers and thus their inclusion in analysis could lead to incorrect results. For all the papers, the study design and the country in which the research was conducted were analyzed separately, and presented as general characteristics. Finally, synonyms or similar terms that express the same meaning but describe it differently were integrated into a single representative keyword (Appendix 1). Through these processes, 1,318 keywords were finally extracted.

2. Word cloud

After refining the concepts, a word cloud was generated to analyze the finally selected keywords. In a word cloud, the colors, arrangement, and overall shapes of words are not important, and text size indicates the frequency of occurrence of a keyword. In other words, a larger font size indicates a higher frequency of occurrence of a word.

3. Text network analysis

A text network analysis was conducted using the finally selected keywords through the refinement of concepts. To facilitate the interpretations of the research results, only 44 words with a link frequency of two or more were included in the analysis. The number of words to be included in the link generation range was set to two.

In the text network analysis, the degree centrality and betweenness centrality of keywords were analyzed. Degree centrality measures the number of connections that a specific key word has, and a higher value of degree centrality indicates that the key word plays a more central and important role within a network. Betweenness centrality is a measure of how much a specific keyword plays a role of connecting other nodes within a network. A higher value of betweenness centrality indicates that the relevant keyword plays an important role in connecting other keywords. In a text network analysis diagram, the size of a node represents the level of degree centrality, the colors of nodes are used to distinguish the categories of keywords, and the solid line indicates the co-occurrence relationship of two keywords [18].

Results

General characteristics of the analyzed research papers

1. Temporal trends

The publication rate of research on disaster nursing competencies showed a tendency of increasing significantly over time. From 2002 to 2019, 1 to 11 papers were published annually. However, over a period from 2020 to 2024, the number of research papers published per year increased significantly, reaching 26 to 34 papers per year (Figure 2).

2. Geographical distribution

The analyzed research papers on disaster nursing competencies originated from 32 countries in total. United States, China, and Iran had the highest numbers of publications, and more than 30 papers were published in each of the three countries (Figure 3).

3. Study design

In terms of study design, the analyzed research articles included a total of 87 quantitative studies (34.0%) and 68 qualitative studies (26.6%). In particular, cross-sectional studies accounted for the largest proportion, followed by qualitative studies, literature reviews, and historical studies (including limited literature reviews, expert opinion papers, and analyses of institutional or individual experiences) in descending order (Table 1).

Keyword frequency analysis and word cloud

The results of the frequency analysis of 317 keywords are shown in Table 2 and Figure 4. ‘Nurses’ was found to be the most frequently occurring keyword, followed by ‘preparedness,’ ‘disaster nursing,’ ‘competency,’ ‘education,’ and ‘management,’ with each appearing more than 30 times. Among the analyzed keywords, a total of 34 keywords appeared five or more times in research papers.

Keyword network analysis

To quantitatively examine the position of each keyword within the network, this study analyzed the levels of degree centrality and betweenness centrality of keywords, and the top 10 words are shown in Table 3. ‘Nurses’ had the highest degree centrality value at 0.53, indicating that it was connected to the greatest number of other keywords in the entire network. After ‘nurses’, ‘preparedness’ was the second most frequently occurring word, followed by ‘competency,’ ‘disaster nursing,’ ‘education,’ and ‘management,’ showing that topics related to nurse-centered disaster preparedness, competency, education, and management formed the main axes of the research. ‘Nurses’ also had the highest betweenness centrality value at 0.42, indicating that this keyword has a central position in the flow of information within the network. After ‘nurses’, ‘preparedness’ had the second highest betweenness centrality value, followed by ‘competency,’ ‘disaster nursing,’ and ‘management.’

The network structure visualizing the co-occurrence relationships between keywords is shown in Figure 5. ‘Nurses’ are located at the center of the network and are broadly connected to the keywords corresponding to various concepts and contexts. ‘Preparedness’ performed the role of a key entry point, simultaneously connecting the group of concepts related to education and training, such as education, curriculum, training, skills, and keywords related to on-site responses, such as mass casualty incident (MCI), emergency nursing, and disaster planning.

Discussion

This study examined the general characteristics of research papers on disaster nursing competencies published up to September 15, 2024, including the number of publications by year, geographical distribution, and research design, and performed keyword frequency analysis and text network analysis. Through these analyses, this study aimed to identify overall prevailing trends in research on disaster nursing competencies and consider the future directions of disaster nursing research.

For the analyzed papers, the number of research papers published per year was found to have been increasing rapidly since 2020. More specifically, in the area of research on disaster nursing competencies, less than 10 papers were published annually from 2002 to 2019, but the number of annual publications has increased to approximately 30 papers per year since 2020. This increase in publications in disaster nursing competency research is thought to be related to the outbreak of COVID-19 in December 2019 and the World Health Organization (WHO)’s declaration of COVID-19 as a pandemic in March 2020 [19]. Previous studies have also shown an increase in disaster nursing research related to COVID-19, and a number of studies on nurses’ roles and challenges in responding to COVID-19 were published [20,21].

Regarding geographic frequency, the number of papers published per year was highest in the United States, followed by China, and Iran, and approximately 30 or more papers were published in each of the three countries. This result was consistent with a previous study that analyzed trends in disaster nursing research over the past decade [15]. The United States and China are representative countries actively conducting disaster-related research [12]. Iran has a high risk of large-scale earthquakes since it is geographically located on a major fault line, and it is a region where natural disasters such as floods and droughts occur frequently. Therefore, in Iran, a large number of studies have been conducted in the field of disaster-related research to address this disaster vulnerability [22].

Regarding study design, 87 papers (34.0%) employed quantitative approaches, of which 77 used a cross-sectional design. Qualitative approaches were adopted in 68 papers (26.6%). This finding is consistent with a previous study that found a low frequency of literature reviews and historical studies in disaster nursing research [12]. Additionally, this finding is also consistent with a prior study reporting that previous researches mainly used surveys to measure willingness to respond to disasters and the degree of preparedness among nurses [15]. Qualitative studies mainly utilized interview methods to describe nurses’ experiences in responding to disaster situations. Specifically, qualitative research was conducted on lessons from disaster experiences and suggestions for improving disaster nursing education and training [12]. In this study, among the analyzed articles, only 9 papers (3.5%) were intervention studies, indicating that only a small number of intervention studies related to disaster nursing competencies were conducted. This result is also consistent with a previous study reporting that intervention studies were very rare [15]. This finding suggests that research is needed to develop and evaluate interventions from clinical and theoretical perspectives to enhance nurses’ practical disaster nursing competencies. It is believed that if a disaster nursing competency enhancement program is implemented based on the results of intervention studies, it will not only improve the quality of nursing but also contribute to improving the safety of nurses in responding to disasters [23].

Regarding the results of keyword analysis, the words commonly included in the top four words in frequency analysis as well as the analyses of degree centrality and betweenness centrality in network analysis were ‘nurses,’ ‘preparedness,’ ‘competency,’ and ‘disaster nursing.’ The results of this analysis will be described below in the order of the population, concept, and context of disaster nursing research.

With respect to the ‘population’ of disaster nursing research, ‘nurses’ were found to be the focus group in disaster nursing research, and this finding is consistent with the results of previous studies [15]. More specifically, in the frequency analysis, the terms of emergency nurses, public health nurses, and community health nurses appeared but they were ranked low in frequency. In the Core Competencies in Disaster Nursing presented by the International Council of Nurses, the core competencies are divided into three levels according to nurses’ roles and expertise levels [24]. However, the results of this study indicate that previous research was conducted mainly for general nurses corresponding to Level 1 nurses in terms of disaster nursing competencies. General professional nurses corresponding to Level 1 nurses refer to nursing educators and all nurses working in healthcare facilities such as hospitals, clinics, and public health centers, including new nurses. They are required to have basic knowledge about disaster nursing and perform basic nursing roles before, during, and after a disaster. However, the International Council of Nurses suggests that, in order to respond effectively to disasters, it is necessary to foster not only Level 1 nurses but also Levels 2 and 3 nurses. Specifically, according to the International Council of Nurses, Level 2 nurses (advanced or specialized nurses) are required to have the ability to provide nursing care, maintain teamwork, and communicate effectively at the site of a disaster. For Level 3 nurses (advanced nursing practice-specialists in disaster), they perform a leadership role in disaster situations, participates in policy decisions, and trains and guides other nurses [24]. Therefore, in future studies, it is necessary to go beyond research focused on Level 1 nurses, and focus on Levels 2 and 3 nurses who can perform roles related to communication, leadership, education, and policies.

With respect to the concepts frequently addressed in disaster nursing research, in relation to disaster nursing competency, ‘preparedness’ and ‘response’ showed high levels of frequency and centrality. This is consistent with previous research findings showing that, in terms of the four phases of the disaster management cycle, most studies on disaster nursing have been focused on the preparedness and response phases of disaster management, and there have been relatively fewer studies on the mitigation and recovery phases [12,15]. In particular, ‘preparedness’ has been the most common focus of disaster nursing research, and research on preparedness was conducted mainly with nurses and investigated their competencies required for disaster preparedness or explored their self-assessed level of disaster preparedness [15]. In relation to the response phase of disaster management, numerous qualitative studies have described nurses’ experiences in responding to actual disaster situations. These experiences were analyzed mainly in terms of the acquisition of personal and professional experience and personal growth [15]. Thus, in future research, in order to enable nurses to respond more effectively in disaster situations, it is necessary to investigate nurses’ actual performance levels and insufficient competencies through quantitative investigations of practical response activities, such as providing first aid, or performing nursing interventions for vulnerable populations. Further, experimental or intervention studies should also be conducted to verify the actual effectiveness of education, training, or intervention programs for improving inadequate response competencies. Although it was difficult to find prior studies that specifically analyzed the reasons for the lack of research on the mitigation and recovery phases, it was found that there are concerns that if research is conducted during the recovery phase, such research may hinder immediate emergency relief activities or burden the affected communities [25].

In addition, in the centrality analysis, ‘education’ and ‘management’, which are terms related to the ‘concept’ of disaster nursing research, were found to have a high centrality value, and this result is similar to the findings of previous research. Regarding ‘education’ related to disaster nursing, a previous study suggested that the first essential step in improving disaster nursing competency is to understand the key roles of disaster nursing through ‘education,’ and to this end, disaster nursing education at the undergraduate and graduate levels should be expanded at the national level to cultivate nurses with competencies for responding to disaster management [23]. However, it has been found that nurses still face various challenges in disaster nursing, including lack of experience in responding to disasters, lack of systematic education and research, and ethical dilemmas [9], and that nurses showed lack confidence in effectively responding to disasters [13]. In light of these findings, intervention studies regarding ‘education’ and ‘management’ should be conducted to improve nurses’ practical disaster nursing competencies. In this study, the concepts of ‘communication,’ ‘incident management system,’ ‘safety and security,’ ‘assessment,’ and ‘intervention’ among the eight core disaster nursing competencies presented by the International Council of Nurses [24] were not derived as major central keywords. This result may be due to the fact that specific concepts related to disaster nursing competencies were not dealt with in disaster nursing research or there is a lack of education on key practical skills required for improving the relevant core competencies. Thus, it is necessary to implement repetitive simulation-based training under the conditions similar to real-world situations, such as shortages of medical resources and personnel, communication disruptions, and mass occurrences of patients, and it is also required to provide case-based training that can provide collaborative experience with multidisciplinary teams.

Regarding the ‘context’ of disaster nursing research, among the analyzed keywords, ‘earthquakes,’ ‘mass casualty incident (MCI),’ ‘natural disasters,’ and ‘COVID-19’ showed high centrality. In previous studies, the context of disasters was not given sufficient consideration [12] or the contexts of disasters were examined by dividing them into natural and social disasters [26]. Thus, it is difficult to find studies that examined the contexts of disasters by considering natural and social disasters together like the present study, so there are limitations in comparing the results of this study with those of previous studies. However, ‘natural disasters’ is thought to show high centrality because both natural and social disasters cause ‘mass casualty incidents’, which refer to cases where many injuries and deaths occur due to a single incident [5,6], and they are also believed to have high centrality as research on COVID-19 has been actively conducted since 2020 [21]. Major types of natural disasters are earthquakes, typhoons, and tsunamis, and they are thought to be continuously studied in the area of disaster research [6]. In short, the analysis results suggest that ‘earthquakes,’ ‘MCI,’ ‘natural disasters,’ and ‘COVID-19’ showed high centrality values because they are disasters that cause human casualties and have a significant impact on psychological foundations and social infrastructure, leading to the situations where nurses’ roles and response capabilities emerge as important factors.

This study has the following limitations. First, because this study was conducted only with English-language papers, there is a possibility that studies in non-English speaking countries may have been omitted. Second, there is a possibility that similar concepts were separately represented in the process of integrating keywords, which may have led to somewhat distorted results. Third, because keyword analysis examines the frequency and connections of keywords, it has limitations in reflecting the contexts of research papers and the deeper meanings or semantic complexity of words. However, this study collected all the research papers related to disaster nursing competencies published to date, and conducted a keyword analysis with approximately 250 research papers. Through a keyword analysis, this study examined the overall trends and design biases in research on disaster nursing competencies, and presented a three-dimensional view of the interconnections among key concepts. The most significant outcomes of this study are that it identified research gaps in disaster nursing research conducted to date that need to be addressed in future studies, and also identified specific key areas that need to be considered in future research in order to enhance nurses’ disaster nursing competencies in the future.

Conclusions

This study comprehensively reviewed research papers on disaster nursing competency published to date, and analyzed them by applying keyword network analysis. The major strength of the present study is that this work addressed the drawbacks of prior researches that analyzed a limited number of articles or was conducted based on researchers’ subjective analyses. In addition, this study identified the population, concepts, and contexts in disaster nursing research through the identification and visualization of the centralities of keywords. Based on the results of this study, the following suggestions are made. First, considering that nursing interventions during the ‘mitigation’ and ‘recovery’ phases among all the disaster response processes have received relatively less attention in research, it is necessary to establish a more systematic theory and activate empirical research regarding nursing interventions for the ‘mitigation’ and ‘recovery’ phases of disaster management. Thus, there is a need for research to assess the level of disaster response knowledge among vulnerable groups, such as children, women, the elderly, and the disabled, and to develop educational programs for effective responses in case of disasters. Additionally, as nurses need to perform counseling and education as well as collaboration and coordination between health and social welfare organizations during the recovery phase, further research should be conducted to systematically identify competencies for these tasks, and to verify the effectiveness of education and intervention programs to strengthen these competencies.

Second, there is also a need for research to experimentally verify the effectiveness of intervention studies applying various education and training programs. Blended education programs that combine face-to-face and non-face-to-face learning methods have advantages in that they allow learners to participate in education without time or location constraints, and can promote learning persistence and self-directed learning through repeated learning or review. In addition, since such blended education programs can realistically reproduce disaster situations that are difficult to experience in real life, and thereby enhance learners’ immersion and situational response competency by incorporating simulation and virtual reality technologies into education, it is thought that they can serve as an effective approach or strategy.

Figure 1.

PRISMA diagram for literature selection.

Figure 2.

The number of publications by years.

Figure 3.

Map showing the distributions of publications.

Figure 4.

Word cloud of keywords.

Figure 5.

Network analysis of keywords

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Appendix

Figure & Data

References

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