Disaster preparedness and needed competencies among critical care nurses: a scoping review

Each year, millions of people around the world are affected by natural and man-made disasters [1] including floods, storms, biological pandemics, and earthquakes [2, 3]. The number of disasters surged from 4,212 between 1980 and 1999 to 7,348 between 2000 and 2019 [4], collectively claiming 1.2 million lives [4]. Disasters can be understood as large-scale events that disrupt societal functioning and lead to significant human, economic, and environmental consequences that exceed the capacity of affected communities to manage with available resources [5]. As a direct consequence, healthcare organisations become overcrowded, resulting in severely compromised access to care, even in the most advanced health systems [6, 7].

Within this strained environment, critical care (CC) nurses, such as those working in intensive care units (ICU), emergency departments (ED), operating rooms (OR) and post-anaesthesia care units (PACU), play a crucial role. They are among the first to provide life-saving interventions under high-acuity situations in extreme circumstances [8‐11]. CC nurses often perform nursing interventions under time pressure, limited resources, and elevated emotional as well as physical stress [8]. Therefore, their ability to employ disaster nursing activities quickly and competently is essential to patient survival [12]. This requires a set of core competencies, defined as the essential knowledge, skills, abilities, and values needed to function safely and effectively in disaster contexts [13]. Research, although not specifically focused on CC nurses, has shown that the application of defined competencies, such as clinical decision-making, communication, leadership, and psychological resilience, can reduce injury-related mortality by 50–70% among people involved in a disaster [11] and enhance the overall efficiency and quality of disaster relief efforts [11, 14]. In order to guide training and minimal standards to improve nurses’ response to a disaster as part of Emergency Medical Teams (EMTs), the International Council of Nurses (ICN) developed a set of disaster nursing competencies in 2009, which were subsequently updated in 2019 [15]. These disaster competencies (DCs), however, were developed for nurses in general and are not differentiated by clinical setting, nor tailored to the unique roles and responsibilities of CC nurses during disasters. Although the ICN competencies offer a foundational framework, they fall short of capturing the acuity-driven, technology-dependent and time-critical nature of CC practice during disasters. CC nurses must stabilise physiologically unstable patients, operate advanced organ-support technologies, and make rapid, high-stakes clinical decisions under resource scarcity [16, 17]. Disaster preparedness (DP) among nurses was widely studied in reviews, highlighting low to moderate preparedness [18‐20]. However, the reviews didn’t specifically address CC nurses, resulting in a lack of evidence about their DP. Additionally, there is limited aggregated evidence about the specific knowledge, skills, and competencies that CC nurses require for adequate DP ensuring effective care during disasters [21]. Therefore, it is crucial to explore the current state of CC nurses’ preparedness and the identified necessary competencies to inform and guide future effective clinical strategies in responding to disasters.

A total of 1,843 records were retrieved through the database search. After removing duplicates, 970 unique records remained and were imported into Covidence for screening (Additional File 2). During the screening process, 2 additional duplicates were identified and excluded—both by Covidence and through manual review. In total, 968 records were screened by title and abstract, of which 150 were selected for full-text review. Following full-text assessment, 93 studies were excluded based on predefined eligibility criteria. Additionally, five studies were identified through backward and forward citation search. Ultimately, 62 studies met the inclusion criteria and were assessed for final review (Fig. 1). A summary of the extracted data from these studies is available in Additional File 3.

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This scoping review examined the extent of DP among CC nurses by assessing reported levels of perceived preparedness and the core DCs required for effective response. Overall, most CC nurses demonstrated low to moderate preparedness, with only a few studies reporting high DP levels. The thematic analysis further identified four overarching domains of DCs: (1) clinical critical care competencies, (2) operational readiness and coordination, (3) public responsibility in disaster preparedness, and (4) intrinsic capacities for disaster response. These themes reflect the complex and multidimensional nature of disaster nursing within the CC context.

Although CC nurses are expected to operate effectively under extreme conditions, the current evidence suggests that their level of DP remains suboptimal. This observation is consistent with earlier systematic reviews, which examined DP among nurses more broadly. For example, Labrague et al. reported that nurses often feel unprepared and insecure in disaster response [20]. Similarly, Labrague & Hammad concluded in a review focusing on nurses in disaster-prone countries that inadequate knowledge and skills left nurses ill-equipped to manage such situations [18]. Similar to our findings, both reviews showed that previous disaster response experience, disaster-related education and training, and higher academic qualifications were positively associated with increased preparedness [18, 20].

Nevertheless, even when such factors are present, they do not consistently translate to high levels of preparedness at the group level. While most studies indicated that CC nurses possess a basic understanding of disaster response and benefit from educational interventions, significant gaps remain, particularly in advanced competencies, such as CBRN knowledge, bioterrorism response, leadership, and structured communication. This is especially striking given the global focus on pandemic preparedness following COVID-19 and the rising numbers of natural disasters [19]. A key limitation in interpreting these findings is that DP was often measured as a general construct in the CC environment, rather than in relation to specific scenarios (e.g., pandemics, armed conflict, mass casualty events). This lack of contextualization makes it difficult to assess whether CC nurses are adequately prepared for the full spectrum of disasters.

One likely explanation for the low to moderate DP levels lies in the absence of structured and sustainable educational programs specifically tailored to the CC nursing context. This was also noted in previous literature, highlighting ongoing deficits in curriculum development, institutional support, and interprofessional simulation opportunities [20, 91]. Without systematic investment in educational infrastructure, training programs, and supportive policies, individual experience alone is unlikely to close the DP gap [91].

Interestingly, a small number of studies in this review did report high levels of DP among CC nurses. Notably, these studies consistently involved participants who had completed disaster-specific education and training programs, often including simulation-based learning or structured curricula. Studies by Li et al., Noh et al., and Sa’d and Malak demonstrated that targeted training interventions enhanced both perceived and demonstrated DP [37, 38, 57]. These findings confirm that education and training are effective mechanisms for strengthening disaster preparedness and nursing capabilities [91, 92].

Systematically integrating DP content into CC nursing education and professional development is highly recommended. As shown in this review, DCs encompass clinical care, operational coordination, public health responsibility, and intrinsic capacities. Developing these competencies cannot rely solely on informal experience or incidental learning; instead, they require structured, evidence-based educational approaches. However, persistent barriers—including a shortage of qualified educators, a lack of dedicated programs, limited exposure to real-world disaster scenarios, insufficient policy support, and constrained resources such as time, staffing, and funding—continue to hamper progress [92, 93].

The four DCs themes offer a comprehensive foundation for CC nurses to become adequately prepared for disaster response, reflecting the multidimensional demands associated with these situations. As such, they offer a valuable starting point for guiding education, training, and policy. The competencies identified in this review closely align with the ICN framework competencies to guide nurses globally in all phases of disaster management: mitigation, preparedness, response, and recovery [15]. Also, the ICN framework describes competencies that go beyond basic nursing care and require a combination of clinical expertise, decisiveness, communication, ethical conduct, and leadership [15]. Similarly, reviews by Al Thobaity et al. and the more recent work by Motsepe et al. confirmed the relevance of key competencies such as disaster planning, communication, ethical practice, decontamination and safety, use of the ICS, psychological care, and triage [94, 95]. These findings align closely with our results and support the cross-contextual importance of these domains.

Our findings reveal a distinct contribution of Theme 1, “Clinical critical care competencies during disaster situations,” which differentiates our framework from existing general disaster nursing models such as the ICN competencies. Whereas the ICN framework primarily targets nurses deployed as part of national or international EMTs and therefore emphasises policy development, organisational responsibility, and legal coordination across borders [15], Theme 1 focuses on the direct provision of high-acuity care at the clinical bedside. Specifically, Theme 1 encompasses rapid clinical stabilisation, high-stakes decision-making under uncertainty, and the management of patients with single- or multi-organ failure, reflecting the specialised, high-acuity and time-critical nature of CC. These specialised and time-critical competencies go beyond what is articulated in the general ICN domains [15] and close an important gap by defining disaster-specific clinical requirements for CC nurses working within their own institutions as well as in external emergency settings. Importantly, our findings align with those of a Level III nurse, as defined in the ICN framework. This may indicate that CC nurses in possession of the identified competencies, actually function at a level comparable to that of internationally deployable disaster nurses. One possible explanation is that working in a CC department already places high demands on clinical leadership, decision-making under pressure, technical skills, and ethically sound practice [96]. Moreover, CC nurses frequently serve on the frontline during disasters, such as in large-scale infectious disease outbreaks or mass casualty events, making them uniquely positioned to respond swiftly and competently in volatile and resource-limited settings [11].

Our review uniquely contributes to the existing literature by identifying “intrinsic capacity for effective disaster response” as a distinct competency domain (Theme 4). This domain encompasses individual attributes such as self-preparedness, stress resilience, critical thinking, and moral courage. While such attributes may be implicitly assumed in existing frameworks, including the ICN competencies, they are not consistently defined or operationalised as a separate competency domain; in contrast, our analyses explicitly acknowledged and defined intrinsic capacity as such. This gap highlights the importance of personal resilience and moral leadership as essential components of effective disaster care provided by CC nurses [96]. Additionally, this underlines the role of CC nurses as patient advocates, especially in ethically complex disaster scenarios. A recent scoping review further underscores the psychological burden experienced by disaster nursing rescue workers [97]. Their findings reinforce the need to formally cultivate intrinsic competencies (e.g., stress resilience and moral courage) as essential components of disaster nursing. They also emphasise the importance of psychosocial support mechanisms into DP frameworks, ensuring that CC nurses are not only technically prepared, but also psychologically equipped to manage the emotional demands of disaster care [97].

This scoping review shows that critical care nurses often feel insufficiently prepared for effective disaster response. The four identified disaster competency domains represent essential, context-specific requirements for disaster nursing within high-acuity critical care settings. To advance the field, these domains must now be translated into measurable, critical care–specific performance indicators that can directly guide the development of competency-based curricula, simulation training, and assessment tools. Establishing such indicators is crucial for systematically strengthening disaster preparedness among critical care nurses and ensuring a more resilient critical care workforce in future crises.