Novice nurses play a workflow part in responsibility among an overwhelming of patient. This emphasizes the need for nurses to have comprehensive decision-making skills, especially in disaster management. However, in practice, clinical decision-making remains a challenging issue for novice nurses working in the Emergency Room (ER). This review was conducted to synthesize the strategy that novice nurses need to do in clinical decision-making in the ER during a disaster. This review used an integrative literature review approach to identify (n=16) relevant scientific articles. Six online databases (ScienceDirect, Proquest, Sage Journals, PubMed, Willey Library, and EBSCO) were utilized to identify articles published between 2013 and 2023. The gathered articles were selected using the PRISMA method by removing duplicate articles and those that did not align with the review’s objectives. The PRISMA flowchart was used to illustrate the evidence search process. Out of a total of 2,264 identified articles, sixteen articles are relevant for review. The review revealed that clinical decision-making requires careful consideration in several aspects which focused on determining the priorities of triage, assessment, diagnostic skills, and communication skills in teamwork during a disaster in the ER. This review provides evidence that the accuracy of clinical decision-making is a major influence on patient outcomes during disaster management. In conclusion, comprehensive training and more education for novice nurses about disaster precision nursing in the future are needed to reduce errors in decision-making.

Given the high number of disaster victims in Aceh in 2004, Indonesia is now labeled as the third most disaster-prone country out of 192 countries by the World Risk Index.1 Highlighting the experience of dealing with disasters, disaster management often intersects with emergency response management, which involves the Emergency Room (ER) as the primary gateway for complex initial care.2 According to Wang et al, Emergency Response (ER) management can be defined as specialized and technical medical efforts aim at rescuing disaster victims.3 Furthermore, research conducted by Al Harthi et al revealed that disaster management in the ER should involve all stages of disaster response, not just emergency response.4 Therefore, ER disaster management becomes a high-standard emergency care provider.

In urgent situations with a high number of casualties, ER nurses play a central role in saving patients during disasters, including triage, assessment, management, and treatment.5 ER nurses, as substantial components, should also be involved in all stages of disaster management, such as risk analysis, pre-disaster planning, crisis response, and risk mitigation during disasters.6 Novice nurse play a workflow part in responsibility among an overwhelming of patient. To achieve holistic disaster care, nurses are now emphasized in disaster preparedness management, which refers to optimizing response and recovery efforts that significantly impact patient care outcomes.7 This underscores the need for good teamwork support among all nurses to achieve a unified response in disaster management.

Interestingly, some countries currently lack expert nurses in disaster response, leading to novice nurses being placed in the ER.8 Furthermore, research by Fernandez-Basanta revealed that during disasters, there is often an imbalance between the number of healthcare workers and victims, leading to novice nurses participating in disaster response.9 According to Geekiyanage et al, novice nurses can be defined as individuals who have recently graduated and do not have adequate practical experience to apply their cognitive and psychomotor skills to new situations.10 Furthermore, research by Perpina et al explained more broadly that someone working for less than five years can be categorized as a novice nurse.11 During the transition to clinical practice, novice nurses often face challenging situations that can lead to barriers such as failure to identify patients, assessment errors, and decision-making errors.12 The potential for errors compared to experienced nurses will always be an issue. Moreover, in emergency disaster situations, novice nurses face transition challenges that can result in emotional pressure, self-concept, high risk, and decision-making doubts.13 Adequately prepared nurses will reduce vulnerability to errors in clinical decision-making.

However, emergency response implementation is not limited to that; understanding decision-making challenges and the potential for errors must be identified. So far, the decision-making process for novice nurses tends to be hampered in making accurate assessments due to time pressure and case complexity.14 A combination and utilization of resources and tools by nurses to achieve common goals, including decision-making in emergency disaster response in the ER.15 Meanwhile, in the Ncube study, decision-making in disasters is an effort to save more lives of disaster victims.16 In crowded conditions, the urgency of triage accuracy, team communication skills, proper assessment, and diagnostic skills determine the best outcome of decision-making interventions.17 The need for comprehensive decision-making skills for novice nurses should be considered. Interestingly, there are currently no specific guidelines for novice nurses designed for clear clinical decision-making during disasters to reduce errors. Therefore, this review was conducted to synthesize the strategies novice nurses need to employ in clinical decision-making in the ER during disasters.

The integrative literature review analysis method was used in the development of this study. This method allows the authors to organize, synthesize, and report the results of published articles with the aim and scope of decision-making for novice nurses in disaster management in the ER. Articles were systematically selected using the guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses for Integrative Review (PRISMA method).18 This methodology involves five review steps, as outlined, including formulating research questions, searching and identifying relevant studies, selecting relevant studies, mapping and analyzing data, and composing a summary of the results, which are then interpreted in this integrative review.

This review was conducted by searching articles in six online databases: ScienceDirect, Proquest, Sage Journals, PubMed, Wiley Library, and EBSCO, published between 2013 and 2023. This selection used predetermined inclusion and exclusion criteria. Article searches were performed using the keywords “AND and OR” to combine words or with the use of quotation marks (“) for similar words. The keywords used was “novice nurse AND clinical decision making AND ER OR ED” or (“disaster decision making-novice nurse and ER” OR “decision making-novice nurse”) AND (disaster management OR disaster decision making) AND (newly registered nurse).

The inclusion criteria for this integrative review were as follows: (1) involving novice or newly registered nurses, (2) articles are published in international journals, (3) journal publication years are between 2013 and 2023, (4) original research articles, (5) articles written in English, and (6) articles discussing the decision-making of novice nurses during disaster management in the ER. The exclusion criteria were (1) books, modules, undergraduate theses, master’s theses, dissertations, and scientific papers, and (2) articles that could not be accessed in full. Selecting articles using keywords in six online databases resulted in (n=16) articles. This review explored titles, abstracts, and the availability of full texts that met the inclusion and exclusion criteria. The selected articles align with the objectives of this review. The article selection process was summarized by the PRISMA 2020 guideline (Figure 1).

Article quality assessment can improve the quality of integrative literature reviews. There are several quality assessment tools used according to the design of each study; the Centre of Evidence-Based Medicine (CEBM) appraisal tools was used to assess the quality of cross-sectional studies, with a list of 12 questions; meanwhile, in qualitative studies, the Critical Appraisal Skill Program (CASP) was used in this review consisting of 10 questions; to assess experimental studies, this review uses the Joanna Briggs Institute (JBI) Critical Appraisal tool which consists of 9 questions. Overall, the quality of all research articles included in this review was rated as moderate, as the studies demonstrated significant and strong results. Articles of quality assessment is summarized in (Supplementary Materials, Table 1, 2, and 3).

The data mapping process evolved during the review as the author considered specific data to be extracted to help answer the questions of this review. Data mapping was focused on the decision-making of novice nurses during emergencies in the ER. Then, the data that came closest to answering the questions were transcribed into a table containing (author, years, country, study objective, research design, instrument used, and results). Data extraction of selected articles is summarized in (Supplementary Materials, Table 4).

The search on six online databases yielded 2,264 articles. Subsequently, the authors screened articles published from 2013 to 2023 and removed duplicate data, resulting in 2,162 articles. The authors then selected 81 articles after excluding those with irrelevant titles and abstracts that did not align with the research objectives. Out of these articles, 42 articles were excluded based on criteria such as not discussing decision-making among emergency room nurses during disaster management, participants not being emergency room nurses, articles in languages other than English, and not being original research. After assessing their suitability, 16 articles were included in this scoping review for discussion. The articles reviewed originated from Iran (n=4), Sweden (n=2), Turkey (n=1), Saudi Arabia (n=2), Indonesia (n=2), Southern California (n=1), Switzerland (n=1), New South Wales (n=1), Bangladesh (n=1), and South Korea (n=1).

Participants in this study were predominantly novice nurses working in the emergency room with less than 5 years of work experience. A small portion consisted of experienced emergency room nurses who had worked for more than 5 years. All the research articles were conducted in the hospital emergency room environment. Furthermore, this review generated the following key themes regarding decision-making which are summarized in (Table 5). The theme of this integrative review discusses clinical decision-making in novice nurses in managing disasters in the ER. In this regard, decision-making is broken down into five main aspects most needed in disaster management, including patient physical assessment, disaster triage priorities, diagnostic skills, team communication skills, and emergency care.

Novice nurses have a complex role to play. They must be proficient in clinical physical assessment while responding to improve outcomes for affected populations.19 Nursing decision-making regarding the detection and response to a disaster event, perhaps further recognizing ED nurses as first responders. However, the results of a Delphi study showed that novice nurses’ knowledge of disaster management plans and competence regarding the signs and symptoms of various conditions at an early stage were considered important for detecting and caring for victims of rare events. As novice nurses, these findings appear to reflect the assessment that a key factor in successful disaster patient care is basic physical assessment knowledge.20 Decision-making in the physical assessment and care aspects for disaster victims needs to be adjusted to accommodate a sudden influx of patients.21 Decision making in this case has several processes, namely i) fast and accurate physical assessment; ii) assessment of exacerbation of the disease due to exposure to the agent; iii) assessment of local and global infections. Rapid assessment or assessment of patients in accordance with standard principles of first aid procedures can reflect complex decision making. Novice nurses must be skilled in analyzing the condition of incoming patients, synthesizing and evaluating interventions accurately.22 Novice nurses must comply with regulations in disaster situations and take them into account.23 Decision making is a challenge for novice nurses to provide nursing care to patients and be responsible for their own decisions.24 Nurses need to assess local infection, so they can quickly make the right care decisions. Assessment of disease exacerbations due to exposure to agents (e.g., toxic chemicals, radiation, or infectious agents) is an important clinical process in taking care for patients who may have been exposed to such agents.25 Evaluation of disease exacerbations due to exposure to agents requires various stages and considerations for decision making. Speed in assessment and treatment actions can be critical in cases of exposure to hazardous agents. Furthermore, the assessment of local and global infections involves assessing infections that affect individuals or populations at a local or global level.26 Nurses need to identify local infections, so they can quickly make appropriate treatment decisions.

Having disaster triage decision-making skills among all healthcare providers is critical to improving patient flow and impacting patient outcomes, especially during disasters. The results of a study by Azizpour et al. (2021) showed that decisions made with intuition or reasoning will drive rapid and accurate decisions. Novice nurses must be able to quickly identify priorities during triage using their clinical knowledge and skills in a crowded, noisy, and stressful environment.27 Slightly different from the study conducted by Ghanbari et al. (2021) decision-making must be based on ethical decision-making components in triage by considering the equity between prioritizing patients who require immediate medical needs and those who will give victims a greater chance of survival in their community.28 Novice nurses are responsible for the triage role in clinical settings. Rapid information gathering and accurate decision making such as clinical reasoning skills are essential for severity classification.29 Clinical decision making in prioritizing disaster triage has two dimensions, namely a) efficient and effective triage (urgent need, effective intervention, possibility of survival) and b) priority-oriented triage (special attention to vulnerable patients, prioritizing possible rescue for longer lives, prioritizing patients of productive age, prioritizing social efficiency, priorities based on possibilities in providing services and non-preferential priorities). Most participants in this study stated that principles alone are not enough to explain the ethical aspects of decision-making in disaster triage.30 The highest predictor is novice ER nurses who receive disaster triage education, showing higher decision-making abilities in problem-solving and strategic thinking.31 Through structured triage education, clinical reasoning abilities can be maximized to make decisions in line with the severity of disaster victims.32 Novice nurses need to prioritize patients with a higher chance of survival. In crowded ER situations with limited resources, the ability to prolong survival is one of the team’s goals. Even research conducted by Holmstrom et al (2020) used triage decision-making technology in priority setting, but it was considered to create conflict between nurses and tools. so that novice nurses view the tool as a support for the statements and decisions they make.33 Therefore this study supports previous research that clinical knowledge and skills are absolutely owned by novice nurses well.

Research findings by Winarti explained that decision-making is low in the diagnostic aspect. Novice nurses will often hesitate in making such decisions.34 Clinical decision-making in emergencies during disasters requires careful consideration. Gaps in decision-making during disaster preparedness reflect decision-making ambiguity. The study by Alharbi found that many nurses do not have a detailed understanding of disaster emergency response.35 Education and training are the main influences in reducing knowledge and decision-making gaps. Furthermore, Labrague et al emphasized the important role of this awareness in supporting disaster management decision-making in the ER.36 Disaster emergency response simulations help illustrate novice nurses in preparing them to provide care during disasters. Based on the weaknesses of novice nurses, one way to improve diagnostic skills is to try to master and improve the skills and knowledge they have by using operational training. Given that operational training is one method of empowering nurses, this diagnostic skills training needs to be highlighted in health service centers.37

Communication between teams is needed in decision making to determine further actions. Numerical results indicate that personnel factors are categorized as low in the index.38 Furthermore, Chegini et al. (2022) suggested that all emergency nurses, both beginners, should understand the proper chain of command and who to communicate with and how to establish effective communication as it is considered a key component of identifying patients during a disaster event.39 Decision-making support and reflective assistance are mandatory support among fellow professionals in difficult situations. In-depth understanding influences clinical decision-making for novice nurses. Consistent with the findings of Ayenew et al, novice nurses’ strengths in decision-making lie in communication skills and critical thinking.40 Findings from the study by Considene et al. also showed that the need to communicate quality information within the team significantly affects subsequent decision-making actions.41 Therefore, its essential that every hospital develop alternative communication methods and provide nursing managers and staff with adequate knowledge on these alternatives and their uses to prepare them to operate efficiently during a disaster to prvent these situastions.42 Study conducted by amberson et al 2020, using a concise and relevant integrated information system according to the SBAR principle can be applied in any department especially disaster to develop more confident and prepared novice nurses. not only that, communication can also be done with all types of devices such as (telephone, fax, email, satellite phones, PDAs, etc).43 This idea considers the significant patient outcomes from the perspective of all ER nurses.

Decision making is also seen from the perspective of emergency care in disaster situations, where the process consists of: i) resuscitation decision making; ii) psychological management of patients; iii) individual and family care support. Resuscitation decision making during disaster management involves special considerations because in such situations, resources may be limited and many patients may require emergency care.44 Continuous monitoring of the patient’s condition is important. If the patient does not show improvement within a reasonable time, the nurse needs to consider stopping resuscitation measures. Identify individuals or groups who may need special psychological support, such as victims who have experienced major losses or health workers working under very high pressure.45 Although in the ER setting care is always focused on critical actions, the psychological support aspect during disaster care is very important, both for disaster victims because it often creates very stressful and potentially traumatic situations.46 Provide clear, accurate, and up-to-date information about the disaster situation, available treatments, and actions to be taken. Open communication can help reduce anxiety and increase understanding. Approach each individual and family by considering their specific needs for care. Individuals and families who are victims of disasters have different medical, nutritional or psychological support needs. From the various discussions above, although awareness of the clinical role of novice nurses in disaster response is reported to be high, a study conducted by Alzahrani and Kyratsis (2017) in Mecca showed limited emergency and disaster preparedness plans.47 The study explained that they were able to provide timely general clinical assessment and care; however, few of the novice nurses carried out their duties as part of providing supervision, prevention, leadership or psychological care in disasters.48 In contrast to other studies, there were indeed significant differences between nurses in their understanding of the basic elements of disaster management based on their level of experience.49 Therefore, novice nurses with less than five years of experience have a significant need to learn these components in order to be able to cope with disasters.50 In line with research findings in Indonesia which show that emergency disaster nurses have a moderate level of disaster preparedness.51 Previous disaster experience and disaster training or education are positively related to disaster preparedness. Meanwhile, ironically, this study shows that nurses lack the relevant competencies needed in responding to recent disasters. In this regard, this study also suggests that nurses specializing in emergency, trauma, and disaster care are generally underprepared in their ability to optimize disaster response and recovery efforts and patient outcomes during disasters.52 Similarly, the issues of surge in patient arrivals, communication problems, lack of adequate emergency care, lack of coordination between disaster areas and hospitals, lack of telecommunications, chaos, and triage difficulties are some of the other issues that need to be addressed in the current literature. In highlighting these issues, this study may provide a useful starting point for the development of an educational framework to prepare nurses and other health professionals to work in disaster situations.

The decision-making competencies identified in this study are expected to give more weight to previous competencies. Furthermore, this review can facilitate the identification of decision-making gaps in novice nurses, allowing training and the incorporation of disaster curriculum in education to be useful in the future. It also important to learn and teach technique which encourages nurses to improve their skill. Disaster scenarios and formal disaster preparedness training. The definition of nursing duties in nursing laws and regulations must also be determined update. Additional guidance specifically regarding novice nurse instruction and practies should be added to suit disaster nursing law. These findings provide a basis for novice nurses on how ethical decision-making can be achieved in disaster triage due to the large number of victims. Comprehensive training is required for decision-making and more education for novice nurses on precision disaster nursing in the future to reduce decision-making errors.