Nurses are the frontline health care providers during disasters. Those who receive proper disaster training demonstrate greater confidence, as well as improved disaster knowledge, skills, attitudes, preparedness, and competency.Reference Brewer, Hutton and Hammad 1 Such training empowers nurses to deliver optimal care, support, and guidance to individuals and communities affected by disasters, ultimately helping to save lives and minimize the overall impact of such events.Reference Labrague, Hammad and Gloe 2 , Reference Chiang, Ting and Chao 3 Training programs built on a solid theoretical foundation are crucial for enhancing nurses’ preparedness in disaster management.Reference Uemura, Miyazaki and Okuda 4 It promotes a cohesive, systematic approach to training, effectively integrating new knowledge with established practices.Reference Hsu, Li, Bayram and Levinson 5 , Reference Sofyana, Ibrahim and Afriandi 6 While existing research has primarily focused on the outcomes of disaster training, there remains a significant gap in understanding the theoretical foundations and content that underpin these educational programs. Clearly identifying the theories and core components used in disaster nursing training programs is essential for the development of standardized, evidence-based curricula. To address this gap, this review systematically examines the theoretical frameworks and content utilized in disaster training programs for nurses worldwide.
Materials and Methods
This systematic review followed the PRISMA 2020 Statement guidelines and was conducted through the following steps: 1) formulating the research question; 2) identifying relevant studies; 3) selecting the studies; 4) organizing the data; and 5) compiling, summarizing, and reporting the results. A systematic search was conducted by the primary author in this study using keywords, MeSH terms, and Boolean operators to identify studies published in English and Bahasa over the past decade. The literature searched covered 5 electronic databases: CINAHL, Cochrane, Google Scholar, PubMed, and Web of Science.
Setting study eligibility criteria in a systematic review ensures that the studies are relevant, comparable, and of adequate quality to provide meaningful insights into the research question. The eligibility criteria for this systematic review were: (a) reports of disaster training programs for nurses; (b) experimental, randomized controlled trials, or quasi-experimental studies; (c) training programs grounded in a theoretical framework; and (e) publications in English or Bahasa. English publications were included for broader scientific accessibility, while Bahasa was included due to Indonesia’s high disaster risk and the prevalence of relevant local research. This language scope may introduce some bias, but it ensures relevance and feasibility within the review’s context. The exclusion criteria were as follows: (a) studies without full-text availability, (b) conference abstracts, (c) studies published more than 10 years ago, (d) non-RCTs designs, (e) studies not focused on nurses, (f) duplicate entries, and (g) studies lacking a theoretical basis.
Data extraction is a crucial step in ensure that all necessary details are collected in a standardized manner to assess quality, compare results, and draw conclusions. In this systematic review, the data extraction process was independently conducted by 2 authors to reduce potential bias and ensure consistency. Any disagreements were resolved through discussion or consultation with a third reviewer. Inter-rater reliability was assessed using Cohen’s Kappa, yielding a value of 0.80, which indicated substantial agreement between reviewers.
A total of 1303 articles were initially identified across 5 databases: Web of Science (n = 262), PubMed (n = 768), CINAHL (n = 171), Cochrane (n = 30), and Google Scholar (n = 72). After screening titles, abstracts, and full texts according to the inclusion criteria, 14 articles were included in the final analysis (Figure 1). Data extracted included author(s), publication year, country of origin, study design, sample characteristics, and key findings that met the inclusion criteria. Research quality of the 14 selected studies was evaluated using the Critical Appraisal Skills Programme (CASP) for Randomized Controlled Trials. The CASP tool includes 11 items assessing study design, methodology, results, and applicability. Each item was scored as “Yes” (1 point) or “No/Can’t Tell” (0 points), yielding a total score ranging from 0-11. Scores were categorized as low (0-4), moderate (5-8), or high (9-11) quality (Table 1).
Flow diagram for this study.
Characteristics of included studies in systematic review
PS: A score range of 0-3 indicates low research quality for the reviewed article, 4-8 indicates moderate quality, and 9-11 indicates high quality, as assessed by the CASP tool.
Results
This review identified 14 studies utilizing various theoretical frameworks for disaster nursing training programs, reflecting a wide range of approaches to enhancing nurses’ disaster preparedness and competencies. The ICN Framework emerged as the most frequently used model, likely due to its global relevance and comprehensive approach to disaster nursing education. It provides a structured model encompassing all disaster phases—prevention, preparedness, response, and recovery—while emphasizing cultural sensitivity, ethical decision-making, leadership, and collaboration. 7 For instance, Al-Qbelat et al. used the ICN Framework in an 8-hour online training program for 50 emergency nurses in Jordan, covering disaster preparedness, triage, decontamination, basic trauma life support (BTCLS), and advanced trauma support. The training, assessed using the Disaster Preparedness Evaluation Tool (DPET), led to significant improvements in knowledge and preparedness.Reference Al-Qbelat, Subih and Malak 8 Similarity, a study in Iran applied the ICN Framework to evaluate a nurse empowerment program, focusing on community-centered care, triage, patient safety, infection prevention, cultural competence, and psychological support, also yielding positive outcomes.Reference Aliakbari, Pirani and Heidari 9
Other frameworks were each used in a single study, reflecting the diversity of theoretical underpinnings in current disaster training programs. The Bioterrorism Guidelines and Bioterror Infectious Disease Response Guidelines from the Korea Disease Control and Prevention Agency focused on agent identification, surveillance systems, and interagency coordination.Reference Kim and Lee 10 A study in South Korea applied this framework in a 3-week training program, resulting in significant improvements in participants’ knowledge and response competencies.Reference Chang and Kim 11
The Malkina-Pykh Mixed Model, grounded in systems theory, supports the assessment and management of emergencies by integrating human, technological, environmental, and social factors.Reference Roudini, Khankeh and Witruk 12 , Reference Said, Molassiotis and Chiang 13 In Palestine, a modified version of this model was used to evaluate psychological preparedness and personality traits following Psychological First Aid (PFA) training, demonstrating positive outcomes in mental health support during emergencies.Reference Malkina-Pykh and Pykh 14
The WHO PFA framework emphasizes compassionate, immediate psychological care through a non-intrusive, supportive approach aimed at reducing distress and promoting recovery.Reference Everly and Lating 15 In a South Korean study involving 75 nurses, training based on this model significantly improved PFA competence and self-efficacy.Reference Kim and Choi 16
The NLN/Laerdal Simulation Model utilizes high-fidelity simulations to develop both technical and emotional skills in disaster response.Reference Smith, Farra and Hodgson 17 A study in South Korea training 40 emergency nurses using this model reported significant improvements in critical thinking, teamwork, and triage skills under high-stress conditions.Reference Noh, Oh and Kim 18
The Hospital Preparedness for Disasters framework focuses on operational readiness, including triage, resource management, and psychosocial support.Reference Beyramijam, Rasouli-Ghahfarokhi and Fathollahzadeh 19 A study conducted in Iran applying this model demonstrated substantial improvements in nurses’ preparedness for disaster response.Reference Najafi Ghezeljeh, Mohammad Aliha and Haghani 20
CHPTER’s Emergency Preparedness Training Program uses a structured, interactive curriculum encompassing disaster medicine, emergency response, public health, and crisis leadership.Reference Scott, Smith and Jones 21 A 2018 study titled Preparing for the Surge employed lectures, group discussions, and scenario-based learning, significantly enhancing disaster knowledge, comfort, and performance skills among health care providers.Reference Scott, Madden and Wahlquist 22
The Clinical Practice of Emergency Medicine Model centers on triage, communication, patient safety, and professional development.Reference Counselman, Borenstein and Chisholm 23 Aluisio et al. used this model in a randomized trial in Iran to train nurses in disaster triage, leading to improved decision-making and practical triage performance.Reference Aluisio, Daniel and Grock 24
The NCDMPH Framework provides training resources and research to strengthen situational awareness, communication, and decision-making in disaster contexts.Reference Walsh, Subbarao and Gebbie 25 Farra et al. implemented this framework through a hybrid online and in-person program, resulting in improved preparedness scores.Reference Farra, Gneuhs and Hodgson 26
Van Meijel’s Model focuses on disaster-specific clinical skills and decision-making.Reference van Meijel, Gamel and van Swieten-Duijfjes 27 A 2015 study used this model to design a training program targeting chemical, biological, radiological, and nuclear (CBRN) response, which led to significant knowledge gains among nurses.Reference Pesiridis, Sourtzi and Galanis 28
The Korean Triage and Acuity Scale (KTAS) serves as the foundation for a triage-focused training program aimed at improving communication, decision-making, and emergency performance.Reference Kim, Kim and Ohn 29 In a South Korean study, Moon et al. reported significant improvements in triage competency following KTAS-based training.Reference Moon and Cho 30
Knowles’ Adult Learning Theory emphasizes self-directed learning, the use of prior experience, and practical, problem-solving opportunities.Reference Knowles, Holton and Swanson 31 A study in Malaysia applied this theory to a training program for health care professionals, yielding positive results in triage confidence and practical skills.Reference Ghazali, Abdullah and Moy 32
The NHFPC Framework from China emphasizes preparedness, disaster management, and strengthening health care systems.Reference Li, Xu and Zhou 33 Lee et al. implemented an online training based on this framework that focused on fire safety and emergency prevention, resulting in notable improvements in health care workers’ safety knowledge.Reference Lee, Fu and Cai 34
Overall, the ICN Framework demonstrated the most frequent use and broadest applicability among the reviewed studies. It offers a broad, internationally recognized structure that integrates competencies in preparedness, response, recovery, and mitigation. This makes it particularly adaptable across diverse health care settings and disaster scenarios. In contrast, the diversity of other frameworks reflects an ongoing lack of standardization in disaster nursing education. While each model offers unique strengths—ranging from psychological support to triage accuracy—their comparative effectiveness remains largely underexplored. Additionally, the ICN framework emphasizes both individual and system-level competencies, which may contribute to more robust and transferable training outcomes compared to other models that focus primarily on clinical procedures or localized protocols. In addition, these findings emphasize the need for further evaluation and the integration of best practices to guide the development of a unified, evidence-based approach to disaster nursing training.
Discussion
This study systematically reviewed disaster training programs for nurses, highlighting various theoretical frameworks and content used over the past decade. These programs cover topics like disaster competency, response, preparedness, psychological support, triage, simulation models, and educational frameworks. Despite varying strengths and challenges, all frameworks aimed to deliver structured, comprehensive disaster training programs.
The ICN framework is recognized for its comprehensive approach to disaster competency training, emphasizing the knowledge, skills, and attitudes needed for nurses to effectively respond to disasters.Reference Huh and Kang 35 It provides clear guidelines that integrate disaster preparedness into nursing practice, focusing on individual competencies and the health care system readiness. Two studies used the ICN framework for nurse training, as it offers a globally recognized, evidence-based model for disaster preparedness, response, and recovery, overall readiness.Reference Banajah 36 , Reference Hutton, Veenema and Gebbie 37 While enhancing areas like risk assessment, emergency response, triage, and psychosocial support, the ICN framework help nurses provide effective care during crises. 7 However, its implementation can be challenging in resource-limited settings and may require adaptation to fit cultural contexts, which could impact its global standardization.
In contrast, the Bioterrorism Guidelines are more focused in scope, offering detailed, protocol-driven strategies for detection, treatment, and coordination in the context of bioterrorism.Reference Kim 38 While these guidelines are practical for highly specific threats, they may lack the broader competency development emphasized in the ICN framework and require significant contextual adjustments for use in national systems such as South Korea’s. This comparison illustrates that while the ICN framework supports a more comprehensive and transferable training model, context-specific guidelines like those for bioterrorism offer depth in targeted areas but may fall short in preparing nurses for a wide range of disaster scenarios.
When comparing the psychological support components, frameworks such as the Malkina-Pykh Mixed Pykh Model, the WHO model, and Van Meijel et al.’s crisis intervention model provide culturally sensitive, evidence-based guidance but face limitations in sustained application due to the need for specialized mental health personnel. This gap highlights an area where integration across models could be beneficial—for instance, embedding mental health protocols within broader simulation or competency-based frameworks to create more well-rounded training. The Malkina-Pykh Mixed Pykh Model offers a holistic approach from qualitative and quantitative aspects to disaster psychological response, integrating psychological, physical, and environmental dimensions.Reference Said, Molassiotis and Chiang 13 , Reference Malkina-Pykh and Pykh 14 Its adaptability, scientific rigor, and use of technological tools make it valuable, but its complexity can be overwhelming in resource-limited settings.
The WHO framework provides accessible, evidence-based psychological support and culturally sensitive approaches ideal for a broad range of responders, but may not address long-term psychological needs, especially in resource-poor areas. 39 Van Meijel et al.’s model also offers structured psychological interventions during crises but requires trained mental health professionals, which may be scarce during large-scale emergencies.Reference Corry, Clarke and While 48
Simulation-based frameworks like the NLN/Laerdal Simulation Model, CHPTER, and KTAS prioritize hands-on, experiential learning. The NLN/Laerdal Simulation Model focuses on active learning and realistic simulations in disaster training, emphasizing high-fidelity simulations to improve decision-making, problem-solving, and critical thinking.Reference Jeffries, Rodgers and Adamson 40 Its strengths include collaboration, feedback, and debriefing, enhancing learner engagement. However, the high cost of simulation equipment limits its widespread use, and while effective for clinical skills, it may not fully address the psychological and emotional complexities of real-life disaster scenarios.Reference Cowperthwait 41 , Reference Olaussen, Heggdal and Tvedt 42 Similarity, the CHPTER framework focuses on hands-on training through simulation, but its resource demands such as time, personnel, and funding may limit its application in resource-limited settings.Reference Scott, Madden and Wahlquist 22 In contrast, the KTAS provides a simple system for triage training, promoting fast decision-making in emergencies.Reference Park, Kim and Yoon 44 However, it may overlook complex medical conditions, leading to oversimplified triage decisions in some cases.Reference Kim, Oh and Im 45
Frameworks grounded in public health and interdisciplinary collaboration, such as the NCDMPH and NHFPC, take broader system-level approaches. The NCDMPH framework is useful for disaster response and preparedness, emphasizing interdisciplinary collaboration and communication in disaster response, with a strong focus on adult patient care.Reference Dobalian, Stein and Radcliff 46 However, this framework is limited on vulnerable populations, particularly children and the elderly.Reference Altman, Gulley and Rossi 47 Other frameworks, like NHFPC, integrate disaster education with public health and family planning, offering a holistic approach to disaster response. The strength of NHPC lies in its comprehensive nature, addressing both immediate needs and recovery, but its implementation can be challenging due to varying health care systems and resources.Reference Li, Xu and Zhou 33 The Hospital Preparedness for Disasters plan enhances institutional coordination but often struggles in underfunded settings and tends to neglect the psychological needs of patients and providers. Reference Kim, Kim and Ohn 29 , Reference Ainsley 43 Complementing these, the Clinical Practice of Emergency Medicine model addresses both physical and mental health during crises, yet its effectiveness is constrained by the need for specialized training and substantial resources.Reference Counselman, Borenstein and Chisholm 23 In contrast, Knowles’ Theory of Adult Learning supports self-directed, experience-based disaster education, promoting adaptability and learner engagement. Nonetheless, its reliance on individual motivation and autonomy may limit its applicability in high-pressure or resource-limited environments. Reference Hammond and Collins 49
Conclusion
Synthesis of these frameworks suggests that no single model fully addresses all dimensions of disaster training for nurses. A hybrid approach—combining the structured competencies of the ICN framework, the experiential depth of simulation-based training, and the systemic focus of public health models—may provide a more comprehensive and adaptable solution. To support this, nursing curricula should incorporate modular disaster training that integrates clinical, psychosocial, and system-level competencies, with simulation exercises and scenario-based learning as core components (Figure 2). Policymakers should prioritize the development of standardized yet flexible training guidelines that can be adapted across various health care settings and resource levels. Additionally, integrating mental health support into general disaster training—particularly for long-term care and vulnerable populations—should be a core requirement. Future research should focus on evaluating the effectiveness of such integrated models in diverse clinical and geographical contexts to inform evidence-based curriculum design and policy implementation.
A hybrid framework for disaster training for nurses.
Limitations
This systematic review provides valuable insights for designing education and training programs to enhance disaster knowledge, skills, and preparedness among nurses. However, it is important to note that the review is based on only 5 databases, focusing on full-text papers published in the past 10 years, including only English and Indonesian articles, and variability in study quality and methodological approaches across the included articles may have contributed to heterogeneity in the results. These limitations suggest that the conclusions drawn should be interpreted with caution, particularly when applying them to different cultural, linguistic, or health care settings. Future reviews should consider broader inclusion criteria and more diverse data sources to enhance the comprehensiveness and transferability of the findings.
Author contribution
ADS and YYL were responsible for planning, conducting literature searches, performing critical appraisal and quality assessments, and data extraction. ADS drafted the manuscript; and YYL reviewed, revised, and proofread it. All authors approved the final version for publication.
Funding statement
The authors stated they received no financial support from any institution or publisher for this systematic review.
Competing interests
The authors declared no conflicts of interest, authorship disputes, or competing interests related to this article.
Ethical standard
This systematic review used publicly available secondary data and did not involve animal or human subjects, so ethical approval was not required.
