Common domains of nurses’ competencies in public health emergencies: a scoping review

Background A public health emergency can cause large numbers of deaths in a short period, with devastating social, economic and health consequences. Nurses are the main healthcare providers during such emergencies, and their competencies affect the control and outcomes of the situation. Studies on nurses’ competencies in public health emergencies vary between countries and healthcare systems. Therefore, we conducted a scoping review to identify the common domains of nurses’ competencies in public health emergencies worldwide. Methods We searched the PubMed, CINHAL, Scopus, Web of Science, Science Direct, Embase, Cochrane Library, WanFang and ECRI databases from their inception to 2023. All published articles on nurses’ competencies in public health emergencies that were published in English and Chinese were included. We mainly analyzed and synthesized nurses’ competencies, assessment instruments and the training described in the included studies. Results A total of 27 competency domains were identified following an analysis and summary. The most frequently cited domains were communication skills, self-protection skills, basic knowledge of a public health emergency, laws and ethics and the capacity for organizational collaboration. The Disaster Preparedness Evaluation Tool and the Emergency Preparedness Information Questionnaire were the most commonly used tools for assessing competencies. Most training was conducted online and the content that was covered varied by country. Conclusions Given the significant roles and responsibilities of nurses in public health emergencies, knowing the domains of their competencies is essential to evaluating, developing, and conducting clinical training. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-023-01655-5.


Background
A public health emergency is defined as the occurrence or imminent threat of a disease or health condition (e.g., an infectious disease or bioterrorist attack) that poses a significant risk of death, injury or long-term or permanent disability in a large number of people [1].A public health emergency has the potential to cause large numbers of deaths in a short period of time, with devastating social, economic and health consequences [2].It challenges the preparedness and capacity for responses by governments, hospitals, clinics, public health institutions and academic researchers [3].How to respond to a public health emergency has become a vital issue for governments and international organizations worldwide [4].
Once a public health emergency occurs, the health department must initiate a medical rescue quickly and efficiently to minimize casualties and health hazards.Nurses have multiple roles and responsibilities in public health emergencies; they work with limited resources in fast-paced environments and perform critical tasks, such as triage and first aid [5,6].It is challenging for inexperienced nurses to be involved in rescues without training.
Competency is defined as a combination of the knowledge, skills and abilities required to perform a specific task [7].Determining nurses' competencies would be helpful for making preparations to provide training and to conduct research [8].Several countries have formulated competency sets in accordance with the characteristics of their healthcare system and the types of public health emergencies or disasters.In the United States (US), hurricanes, terrorist attacks and bioterrorism have increased attention to disasters; hence, studies have focused on the competencies associated with disasters.In China, most studies have focused on infectious diseases because of the outbreak of major infectious diseases.
Two reviews have outlined nurses' competencies in disasters [9,10], but both of them only described the competencies of each of the included studies, and did not group.These competency domains might not have been sufficient or specific to encounters with infectious disease outbreaks.The outbreak of COVID-19 highlighted the importance of enhancing nurses' competencies [11][12][13], many studies have been conducted to identify competencies that should be required [14][15][16].Thus, it was vital to conduct a scoping review to analyze and synthesize the existing research to identify the most common domains of nurses' competencies during public health emergencies with the intent of improving formal education and training programs for nurses.

Design
A scoping review method was used, incorporating explanations, interpretations, and summaries of quantitative and qualitative literature to address research questions.This approach allows for review to extract different data and develop them in a meaningful, transparent, and systematic way [17].The iceberg model was used as a theoretical basis, guiding the competency domain identification process [18].The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews) checklist was used to guide the writing of this review [19].

Search method
We searched the PubMed, CINHAL, Scopus, Web of Science, Science Direct, Embase, Cochrane Library, Wan-Fang and ECRI databases.The search for grey literature included the BASE and Opengrey dababases.The search terms and Boolean strings used in PubMed are presented in Table 1.
Articles that met the criteria for inclusion in the scoping review: (1) were published from the inception of the database to 2023, (2) were written in English or Chinese, (3) consisted of qualitative and quantitative studies, policy documents and grey literature and (4) focused on nurses' competencies that were developed or described in response to public health emergencies.Articles with the following characteristics were excluded from the scoping review: (1) the full text was unavailable, (2) the study did not focus on nurses (i.e., doctors, laboratory engineers, pharmacist) or (3) the study did not address competencies.

Search outcomes
Figure 1 depicts the process of selecting the articles for this scoping review.A total of 3153 titles were identified through a database search and other sources.After we screened the titles and abstracts, 84 studies were retained for a full-text review, of which 30 were included in the scoping review.All of the studies were read and screened independently by two of the study's authors, in accordance with the inclusion and exclusion criteria, and disagreements were resolved by consensus or by a third author.

Quality appraisal
The Joanna Briggs Institute Critical Appraisal Checklist for text and opinions [15], reporting prevalence data [20], quasi-experimental studies [21], cohort studies [22] and qualitative research [23] were used to conduct a quality assessment of the scoping review.Two reviewers independently assessed each included study, and any

Data extraction
The extracted data consisted of information about the studies, including the country where the research was conducted, competencies, models and methods of competencies, instruments and training, etc.Data were analyzed using Microsoft Excel and we used the following procedure to identify competency domains.First, we developed an initial set of competency domains.All of the reviewers listed competency domains independently after reading all of the included studies.We retained the identical domains, discussed different domains and eventually developed an initial set of competency domains.Second, two of the reviewers independently listed all of the competencies mentioned in all of the included studies; any disagreement was resolved through consensus or by a third reviewer.Third, two reviewers coded studies and competencies to identify them.We encoded the selected studies using the letter "S" followed by three numbers, with "S001" as the code to identify the first study.We encoded the agreed upon competencies as the letter "C" followed by three numbers, with "C001" as the code to identify the first competency (e.g., "C123 S010" could be identified as competency 123 belonging to study 10).After a group discussion, we assigned all competencies to the specific domain with which they most closely aligned and considered whether we needed to make changes to the initial set of competency domains.The frequency of each competency domain was counted to identify the domain with the most competencies.

Results
The 30 papers that were examined in this scoping review were conducted in 12 countries: China, the US, India, Korea, Syria, South Africa, England, Turkey, Kenya, Canada, Slovenia and Israel.The characteristics of the included studies are presented in Tables 2, 3 and 4

Identified competencies
We identified 590 competency indicators by analyzing and summarizing the competencies mentioned in the included studies, and we sorted them into 27 competency domains.Based on the iceberg model, the competency domains were divided into three major dimensions: knowledge, skills, and personal characteristics (Table 5).
After counting the frequency of the competency domains mentioned in the studies, the five most-cited competency domains were found to be communication skills, self-protection skills, basic knowledge of public health emergencies, laws and ethics and capacity for organizational collaboration.Self-protection skills mainly included the proper use of personal protective equipment (PPE), hand hygiene, infection control principles and medical waste disposal skills.Effective communication with physicians, patients and their families were expected of nurses, in addition to a basic knowledge of public health emergencies, mainly including definitions, categories, etiology, epidemiology, prevention and control.Issues related to laws and ethics were attended to within the legal and ethical framework of public health emergencies.The capacity for organizational collaboration included coordination, teamwork, collaboration and organization.
Literature reviews, in-depth interviews, key informant interviews, questionnaire surveys and the Delphi approach were used to identify competencies, of which the Delphi technique was used most often.Related theories included the iceberg theory, the onion theory, the Miller hierarchy, the Prevention, Preparedness, Response and Recovery Model (PPRR Model), the Three-phase Emergency Response Theory and the World Health Organization framework for taking action on infectious disease outbreaks.The PPRR Model was used most often.

Assessment instruments
The instruments used to assess nurses' competencies during public health emergencies were as follows: ( Nurses' Association [56].
The DPET and EPIQ were the most commonly used assessment tools; they were widely used in different countries.The NPDCC was used in Turkey, Iran and China and the DNPRC was used in Korea though less often.The DNCC was used in the Kingdom of Saudi Arabia and Slovenia, and the Core Emergency rResponse Competency Questionnaire was widely used in China.

Training
Training can prepare nurses for future public health emergencies by helping them improve their competencies and acquire new ones.The focus of training is different in each country due to differences in their healthcare systems and cultures.The basic training curricula for public health emergencies in the US focused on emergency preparedness for public health nurses and was introduced in 2002.However, training in China mostly began during the COVID-19 outbreak and focused on nurses' professional and technical skills, especially critical care skills and knowledge of PPE.Most of the training, which was conducted online used relevant training methods, including virtual reality simulation and mobile-video online learning.Just-in-time education was also a common training strategy.It is an educational method based on work, in which a person is trained at a time that is close to the actual clinical event [57].Rapid cycle deliberate practice includes immediate directional feedback, which allows brief corrective instructions to be given to the learner and is followed by a repeated attempt of the learner to master the learning task [58].

Discussion
Until now, no unified standards have been formulated for nursing competencies in public health emergencies.However, this scoping review focused on identifying nurses' competencies regarding public health emergencies and summarizing relevant evaluation instruments and training practices to improve formal education and training programs for nurses.

Identification of common domains of competencies
The most-cited competency domains in this scoping review were communication skills, self-protection skills, basic knowledge of public health emergencies, laws and ethics, and the capacity for organizational collaboration.Hospitals often exhibit poor communication as well as a lack of planning, empowerment, motivation, a common language, and emergency-trained nurses [59].Effective communication is crucial for supporting nurses through extended periods of crisis, and relevant communication strategies should be developed [60][61][62].To prevent the spread of infectious diseases in pandemics, it is vital for nurses to implement protective measures in order to reduce infection risk [63].During SARS-Cov-2, training and demonstrations for donning and doffing PPE safely was the best way for nurses to prevent infection [64].Therefore, there is a need to strengthen the training of healthcare workers to prepare them for the next outbreak.
The basic knowledge of public health emergencies mainly include disease-related epidemiology: etiology of disease, origin, incubation period and transmission; quarantine, contacts and contact tracing principles; related diagnostic tests; signs and symptoms of disease; infection control and prevention strategies; and evidence-based drug use.Nurses are required to know and abide by the laws regarding professional responsibility, licensure, and volunteering for public health emergencies.Ethics and value as a concept was the core element in the resilience framework for public health emergency preparedness [65].It was essential for a country to respond effectively to public health emergency [66][67][68].According to the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements, nurses are expected to practice with compassion and respect for patients and to commit to them [69].A public health emergency rescue usually relies on an interdisciplinary team and multisectoral collaboration, with the capacity for good organizational collaboration that can improve rescue efficiency [70,71].
Researchers often use methods and theoretical frameworks to develop a competency set.The Delphi method, which has been widely used in nursing practice, was a useful tool for identifying competencies because it promotes ownership and increasing acceptance of the consensus generated by the process [72][73][74].The Delphi method, which was used in many of the included studies established a panel of experts, and conducted anonymous surveys on specific topics using structured questionnaires in successive rounds.And researchers analyzed and amended the content based on expert recommendations until consensus was reached [75].A comprehensive approach to the identification of competencies was often used, based on the previous literature, which combined Delphi methods with interviews to ensure the integrity and scientific accuracy of the information.The research areas of experts should include public health, infectious diseases, critical care, medicine, emergency nursing and nursing management.The experts who participated in public health emergencies are preferred.Interviews may involve specialists, nurses or patients.The steps for identifying competencies in China were to: choose a theoretical framework, analyze and summarize the literature and qualitative interviews; refine the entries and formulate the initial competency set; make revisions using Delphi expert consultation and reach a consensus to finalize the competency set.The process in the US involved using the Delphi method to identify competencies, and then conducting a focus group to assess the identified competencies.Competencies were primarily determined by researchers or clinicians in China, and by associates in the US.The competency model was often based on a theoretical framework, and the PPRR Model was the most cited framework [76].The PPRR model was used in disaster risk reduction and emergency management, outlining various stages of the disaster cycle [77].In this review, we used the iceberg model to synthesize identified competency because the personal characteristics were not included in the PPRR model.The iceberg model is also widely used to develop nurse competency model [78,79].

Nurses' training programs based on emergency competencies
Current training is mainly competency-based and focuses on nurses' knowledge and skills in public health emergencies.Since the outbreak of COVID-19, recent studies have shown that an increasing amount of attention has been paid to the cultivation of culture and personal characteristics competencies, which is consistent with the iceberg model of competency.Increasing cultural training will help promote nurses' initiative and willingness to provide nursing care during public health events.Personal characteristics, social roles and values, which play key roles in distinguishing individual behavior and performance, have often been ignored.Incorporating personal characteristics into assessments and training may help select nurses who are more suitable for front-line rescues and for practicing scientific competency-based human resource management.China has a collectivist culture, which emphasizes cohesion, duty and the achievement of group goals.Therefore, Chinese nurses have a high level of willingness to respond to public health emergencies and some Chinese nurses even believe they lived out their calling during COVID-19 [80].Some of the assessment instruments investigated in this review can be used to evaluate nurses' competencies and to develop relevant training.The DPET and EPIQ were the two most commonly used evaluation tools.The items of the DPET were used to assess the competencies of the nurses in at three disaster stages: the pre-disaster, mitigation and response and evaluation stages.The DPET has been translated and used in many countries, including Korea, Japan, Indonesia, China, Iran, Jordan, Thailand and Saudi Arabia [46,[81][82][83][84][85][86][87][88].Some of the studies verified the validity and reliability of these instruments in their respective countries [81,83,86].The EPIQ consists of two parts: the dimensions of personal information and disaster preparedness competencies.This instrument has also been used in other countries.(e.g., the United Kingdom, Malaysia, Saudi Arabia, Iran and Korea [89][90][91][92][93].

Implications for nursing management
Nursing managers should emphasize improvements in nurses' competencies in public health emergencies, strengthen relevant training and prepare for the next epidemic.Our identification of competency domains in this scoping review will foster the development of an education curriculum or clinical training program.Training methods and strategies that were synthesized in this scoping review can be used in clinical training to help nurses quickly master relevant skills, and the instruments for evaluating competencies can help nurse managers select competent nurses, ensure a high quality of care, provide feedback on training results and adjust relevant training programs.

Limitations
Conceptual limitations: this scoping review focused on nurse competency in infectious disease outbreaks, with relatively few studies on other disasters.Language biases: the languages of the included studies were limited to English and Chinese; hence, it is also necessary to determine the competencies reported in studies published in different languages.Implicit biases: the cultural backgrounds of the researchers may have influenced their perspectives.

Conclusion
This scoping review outlined the common domains of nurses' competencies in public health emergencies.Three dimensions with 27 competency domains were identified after they were analyzed and synthesized, and the most-cited competency domains were self-protection skills, communication skills, basic knowledge of public health emergencies, laws and ethics and capacity for organizational collaboration.The identified competencies may be helpful for developing an education curriculum and for conducting clinical training.The competency assessment instruments, training methods, and strategies synthesized in this scoping review will be useful for nursing management and future research.

articles were included in the scoping review after a quality appraisal was conducted. The results are presented in Additional file
1: Appendix I Table A I-V.

Table 2
Summary of the identified competencies in the included studies [30]n et al., 2021)[30]Formulated a competency index system of nurses in public health emergencies based on the Iceberg Model, including 27 indicators Literature review and Delphi approach (Lin et al., 2021) [31] Constructed an index system for community nurses' emergency public health emergency rescue capacity, including 51 competencies Literature review, qualitative interview and Delphi approach (Kan et al., 2018) [32] Established a core response competency index system for infectious disease emergencies, and comprised 38 indexes

Table 3
Summary of the included studies on training

Table 4
Summary of the cross-sectional included studies