THE DEVELOPMENT OF A COMPETENCY-BASED PROGRAMME FOR MANAGEMENT OF DISEASE OUTBREAKS Linette Engelbrecht A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements of the degree of Doctor of Philosophy Johannesburg, 2024 ii DECLARATION I, Linette Engelbrecht declare that this thesis, which is being submitted for the degree of Doctor of Philosophy at the University of the Witwatersrand, Johannesburg, is my own work. It has not previously been submitted for any degree or examination at any other university. Signature: This 2nd day of September 2024 HREC Protocol Number: M210603 iii DEDICATION This dissertation is dedicated to every single person who survived COVID-19, to every single person living in the aftermath, despite their losses, and most importantly, this dissertation is dedicated to those who did not survive the pandemic. iv PUBLICATIONS AND PRESENTATIONS Engelbrecht, L., Schmollgruber, S., Crous, L. 2022. The Needs of Specialist Nurses during Disease Outbreak Events: A Scoping Review. Federation of Infectious Diseases Societies of South Africa. 4th Annual Conference. 4 November 2022. Durban: South Africa. Engelbrecht, L., Schmollgruber, S., Crous, L. 2023. Experiences During In-depth Interviews: Flipping Roller's Funnel. Centring Ubuntu Health Care in Society 5.0: A Transdisciplinary Agenda During COVID-19 and Beyond. 13th -15th September 2023. University of Pretoria, Groenkloof Campus: Pretoria. v ACKNOWLEDGEMENTS It is with gratitude that I complete this process, which would have not been possible without the help of the following persons:  My supervisors, Prof Shelley Schmollgruber and Dr Lizelle Crous for their academic guidance throughout the course of this thesis.  The participants included in the study who were willing to share their experiences. vi ABSTRACT Purpose: The purpose of this study was to develop, a competency-based programme for the management of disease outbreaks. Method: The study utilized an exploratory sequential mixed method approach, using both qualitative and quantitative methods to develop a competency-based program. This study was conducted in South Africa, Gauteng, whilst the country was experiencing the third COVID-19 wave (May 2021 – October 2021), the fourth COVID-19 wave (December 2021 – April 2022), and the fifth (May 2022 – July 2022), as well as the post-pandemic phase. The study was conducted in three phases namely: Phase One: Exploratory phase, Phase Two- Development of the programme Phase Three- Validation of the programme. In phase one, a scoping review on the existing literature was conducted using the Joanna Briggs Institute methodological approach. Following this were individual in-depth interviews with purposively sampled health care professionals as well as professional nurses. Through reflexive thematic analysis themes were identified for inclusion in the Delphi-survey in the next phase. For the second phase, a Delphi-survey was developed based on the data from phase one. The Delphi-survey consisted of two rounds whereby categories were identified to be included in the competency-based curriculum. A programme, consisting of ten modules was developed using the Backward design. In phase three the programme matrix was validated by experts. Results: A total of 62 publications were included in this study. Three categories and eight sub-categories were identified as needs of nurses during disease outbreaks. In-depth interviews with health care professionals resulted in the development of eight themes and 21 sub themes (challenges) of nurses. The in-depth interviews with nurses resulted in the development of 11 themes (challenges) of nurses. The results of the scoping review and in- depth interviews were used to develop a Delphi-survey. Experts in this two-round Delphi survey validated the domains and statements. The results of the Delphi-survey was used to develop a programme matrix consisting of ten modules, which was validated by three experts. vii Conclusion: A competency-based programme was developed based on the challenges nurses experienced working through the COVID-19 pandemic. This program could contribute to the development of disease outbreak competent nurses. Key words: Competency-based programme, disease outbreak, COVID-19, challenges, nurses. viii TABLE OF CONTENTS Page DECLARATION ii DEDICATION iii PUBLICATIONS AND PRESENTATIONS iv ACKNOWLEDGEMENTS v ABSTRACT vi TABLE OF CONTENTS viii LIST OF FIGURES xvi LIST OF TABLES xvii LIST OF ABBREVIATIONS xx GLOSSARY xxii CHAPTER ONE: ORIENTATION TO THE STUDY 1 1.0 INTRODUCTION 1 1.1 BACKGROUND OF THE STUDY 1 1.2 PROBLEM STATEMENT 5 1.3 RESEARCH QUESTION 5 1.4 AIM OF THE STUDY 6 1.5 OBJECTIVES OF THE STUDY 6 1.6 CENTRAL THEORETICAL STATEMENT 6 1.7 SIGNIFICANCE OF THE STUDY 6 1.8 PARADIGMATIC ASSUMPTIONS 7 1.8.1 Meta-theoretical Assumptions 7 1.8.2 Theoretical Assumptions 9 1.8.2.1 Theoretical definitions 10 1.8.2.2 Operational definitions 12 1.9 LAYOUT OF THE THESIS 14 1.10 SUMMARY 15 CHAPTER TWO: REVIEW OF LITERATURE 2.1 INTRODUCTION 16 ix 2.2 EPIDEMIOLOGY OF DISEASE 17 2.2.1 Coexistence of Humans and Disease 17 2.2.2 Understanding Disease 18 2.2.3 A Fragile Ecosystem 19 2.3 DISEASE OUBREAK PREPAREDNESS 20 2.3.1 Disease Outbreak Management 22 2.3.2 The Cost of Disease Outbreaks 24 2.4 NURSES AS RESOURCE DURING DISEASE OUTBREAKS 25 2.4.1 The Expanding Role of the Nurse during Disease Outbreaks 28 2.4.2 Competence and Competency 28 2.4.3 Disease Outbreak Competencies of Nurses 30 2.4.4 Disease Outbreak Training Opportunities for South African Nurses 39 2.5 2.5.1 LEGISLATION, STRATEGIES AND GUIDELINES International Health Regulation 40 41 2.5.2 2.5.2.1 Nursing Legislation Nursing in South Africa 41 43 2.6 ETHICAL CONSIDERATIONS DURING DISEASE OUTBREAKS 45 2.6.1 Ethical Theories 45 2.6.2 Ethical Principles 46 2.7 SUMMARY 47 CHAPTER THREE: RESEARCH METHODS 48 3.1 INTRODUCTION 48 3.2 RESEARCH PARADIGM 48 3.2.1 Mixed Methods 48 3.2.2 Multi-phased Approach 49 3.3 METHODS 49 3.3.1 Exploratory Strategies 49 3.3.2 Sequential Strategies 50 3.3.3 Qualitative Research 50 3.3.4 Quantitative Research 51 3.4 CRITICAL REALISM AS THE RESEARCH PARADIGM 52 3.4.1 The Ontological Assumptions of Critical Realism 52 3.4.2 The Epistemological Assumptions of Critical Realism 53 3.4.3 Judgmental Rationality 54 3.4.4 The Relevance of Critical Realism in the Health care Environment 54 x 3.5 PHASE ONE: IDENTIFICATION OF THE NEEDS OF NURSES 56 3.5.1 Step One: Objective 1 – Scoping Review 56 3.5.2 Scoping Review Method 57 3.5.2.1 Research design 57 3.5.2.2 Research question 57 3.5.2.3 Inclusion and exclusion criteria 57 3.5.2.4 Literature search 58 3.5.2.5 Selection of publications 58 3.5.2.6 Data charting process 58 3.5.2.7 Synthesis and analysis of results 58 3.5.3 Step Two: Objective 2 – In-depth Interviews with Health Care Professionals 59 3.5.3.1 Research design 60 3.5.3.2 Study population and sample 60 3.5.3.3 Preparation for the in-depth interviews 60 3.5.3.4 Pilot testing of the question guide 62 3.5.3.4.1 Planning for the in-depth interviews 64 3.5.3.5 Conducting of interviews 65 3.5.3.6 Reflexive thematic analysis 65 3.5.4 Step Three: Objective 3 – In-depth Interviews with Professional Nurses 66 3.5.4.1 Research design 66 3.5.4.2 Study population and sample 66 3.5.4.3 Preparation for the in-depth interviews 67 3.5.4.4 Conducting of interviews 67 3.5.4.5 Reflexive thematic analysis 69 3.5.5 Phase Two Step 1: Objective 4. Delphi Survey 70 3.5.5.1 Research design 70 3.5.5.2 Study population and sample 70 3.5.5.3 Development of Delphi-survey 71 3.5.5.4 Pilot study 72 3.5.5.5 Data collection 73 3.6 PHASE TWO: OBJECTIVE 5 DEVELOPMENT OF THE PROGRAMME 75 xi 3.6.1 Development of the Programme 75 3.6.2 Identification of Modules 75 3.6.3 Designing of the Modules 75 3.7 PHASE THREE: OBJECTIVE 6 VALIDATION OF THE PROGRAMME MATRIX 76 3.7.1 Research Design 76 3.7.2 Study Population and Sample 76 3.7.3 Data Collection Method and Procedure 77 3.7.4 Data Analysis 77 3.8 THE APPLICATION OF CRITICAL REALISM IN THE STUDY 77 3.9 VALIDITY, RELIABILTY AND TRUSTWORTHINESS 80 3.10 ETHICAL CONSIDERATIONS 81 3.10.1 Permission to Conduct the Study 81 3.10.2 Informed Consent 81 3.10.3 Anonymity and Confidentiality 81 3.10.4 3.10.5 Safety and Security of Data Participant Risk 82 82 3.11 SUMMARY 82 CHAPTER FOUR: SCOPING REVIEW 83 4.1 INTRODUCTION 83 4.2 THE SCOPING REVIEW 83 4.2.1 Review Objective and Question 83 4.2.2 Inclusion and Exclusion Criteria 83 4.2.3 Information Sources and Search Strategy 84 4.2.4 Selection of Sources 85 4.2.5 Data Extraction 86 4.2.6 Synthesis of the Data 87 4.3 RESULTS 107 4.3.1 Characteristics of the Publications 107 4.3.1.1 Publications per database 107 4.3.1.2 Countries of origin 107 4.3.1.3 Year of publication of sources 108 4.3.1.4 Nurse categories included in the sources 109 4.3.1.5 Methodologies represented in the sources 109 xii 4.3.1.6 Data collection methods represented in the sources 110 4.4 BASIC CONTENT ANALYSIS 110 4.5 DISCUSSION OF FINDINGS 112 4.5.1 Characteristics of the Publications 112 4.5.2 Categories and sub Categories from the Content Analysis 114 4.5.3 Summary of Key Findings 115 4.6 SUMMARY 117 CHAPTER FIVE: IN-DEPTH INTERVIEWS AND LITERATURE CONTROL 118 5.1 INTRODUCTION 118 5.2 IN-DEPTH INTERVIEWS WITH HEALTH CARE PROFESSIONALS 118 5.2.1 Demographic Data of the Participants 119 5.2.2 Themes and Sub-themes 120 5.3 IN-DEPTH INTERVIEWS WITH NURSES 121 5.3.1 Demographic data of the participants 121 5.3.2 Themes and Sub-themes 123 5.3.2.1 Theme 1: Nursing resources 123 5.3.2.2 Theme 2: Clinical skills 125 5.3.2.3 Theme 3: Interpersonal skills 132 5.3.2.4 Theme 4: Intrapersonal skills 141 5.3.2.5 Theme 5: Physical challenges 146 5.3.2.6 Theme 6: Communication and information management 150 5.3.2.7 Theme 7: Community profiling and resources 155 5.3.2.8 Theme 8: Financial management 158 5.3.2.9 Theme 9: Preparation of the infrastructure 160 5.3.2.10 Theme 10: PPE management and precautionary measure 163 5.4 ALIGNMENT OF FINDINGS WITH SCOPING REVIEW RESULTS AND DELPHI STATEMENTS 167 5.5 APPLICATION OF CRITICAL REALISM (CAUSATION) 186 5.6 EXPERIENCES OF NURSES IN DISEASE OUTBREAK MANAGEMENT 186 5.7 SUMMARY 186 xiii CHAPTER SIX: TRIANGULATION AND DELPHI SURVEY 187 6.1 INTRODUCTION 187 6.2 DEVELOPMENT OF THE DELPHI SURVEY 187 6.3 SELECTION OF PARTICIPANTS 188 6.4 DELPHI STUDY – ROUND ONE 188 6.5 DEVELOPMENT OF DELPHI-SURVEY ROUND TWO 204 6.5.1 Participants in Delphi Round Two 222 6.5.2 Results of Round Two 225 6.6 SUMMARY 228 CHAPTER SEVEN: DEVELOPMENT AND VALIDATION OF THE COMPETENCY-BASED PROGRAMME 229 7.1 INTRODUCTION 229 7.2 DEVELOPMENT OF THE PROGRAMME 229 7.2.1 Identification of Modules 229 7.2.2 Designing of the Modules 234 7.2.3 The Programme Matrix 235 7.3 THE PROGRAMME MATRIX 236 7.4 VALIDATION OF THE PROGRAMME 259 7.4.1 Development of a Validation Document 259 7.4.2 Selection of Experts 259 7.4.3 Validation Findings 260 7.4.4 Summary of the Results from the Programme Validation Phase 262 7.5 SUMMARY 263 CHAPTER EIGHT: DISCUSSION, JUSTIFICATION, STRENGTHS, LIMITATIONS AND CONCLUSIONS 264 8.1 INTRODUCTION 264 8.2 PHASE ONE OF THE STUDY 264 8.2.1 Step One: The Scoping Review – Objective 1 264 8.2.2 Step Two: In-depth Interviews with Health Care Professionals – Objective 2 265 8.2.3 Step Three: In-depth interviews with Nurses – Objective 3 266 8.3 PHASE TWO OF THE STUDY 271 8.3.1 Step One: Delphi-SURVEY – Objective 4 272 xiv 8.3.2 Step Two: Development of a Competency-based Programme – Objective 5 272 8.4 PHASE THREE OF THE STUDY 273 8.4.1 Step One: Validation Phase – Objective 6 273 8.5 LIMITATION OF THE STUDY 275 8.6 RECOMMENDATIONS 275 8.6.1 Recommendations for Clinical Practice 275 8.6.2 Multidisciplinary Education 276 8.6.3 Recommendations for Nursing Education 276 8.6.4 Recommendations for Further Research 276 8.7 CONCLUSION 277 REFERENCES 278 APPENDICES APPENDIX A Classification of infectious diseases 310 APPENDIX B Research methods of the study 312 APPENDIX C Information sheet for In-depth Interviews 313 APPENDIX D Participant consent sheet 315 APPENDIX E Informed consent for audio-recording 316 APPENDIX F Distress protocol 317 APPENDIX G Demographic data sheet 319 APPENDIX H Interview guide for in-depth interviews with Health Care professionals 320 APPENDIX I Delphi Round 1: Invitation, information and consent 321 APPENDIX J Delphi Round 2: Invitation, information and consent 324 APPENDIX K Ethical clearance certificate 327 APPENDIX L Search strategy on PubMed 328 APPENDIX M List of references of sources per category 330 APPENDIX N Example of voice recordings with participants 347 xv APPENDIX O Field notes of interviews 359 APPENDIX P Participant verification codes – Delphi survey 363 APPENDIX Q Validation tool for competency-based disease outbreak management programme 368 APPENDIX R Information letter and consent sheet for expert validation 374 APPENDIX S Outline for validation of a disease outbreak management programme 376 APPENDIX T Postgraduate approval of study title 381 xvi LIST OF FIGURES Figure 1.1 Map of South Africa 3 Figure 2.1 Figure 2.2 Figure 2.3 Figure 2.4 Presentation of the literature Components of the disease outbreak management phases Disease outbreak legislation Ethical considerations during disease outbreak 16 23 41 45 Figure 3.1 The sequential phases of this study 50 Figure 3.2 The stratified ontology of the critical realist 53 Figure 4.1 Search terms 85 Figure 4.2 PRISMA ScR 86 Figure 4.3 Number of publications since 2005 108 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 7.1 Figure 8.1 Figure 8.2 Figure 8.3 Figure 8.4 Figure 8.5 Figure 8.6 Nurse categories included in the sources Methodologies of publications included in the scoping review Data collection methods Publications per country The content of the program after triangulation of the data Contributions of ICU nurses Contributions of ED nurses Contributions of perioperative nurses Contributions of nursing managers to the themes Contributions of nurse educators Contributions of the health care professionals 109 110 110 112 229 267 268 269 270 270 271 xvii LIST OF TABLES Table 2.1 Findings of studies relevant to staff-patient-ratios and disease outbreaks 25 Table 2. This provincial distribution of nursing manpower per province in South Africa 27 Table 2.3 Alignment of IPC core competencies in disaster nursing version 2.0 with generic competency framework for advanced nurse practitioners in South Africa 32 Table 2.4 Incident and disaster practice for emergency room nurses 39 Table 2.5 South African guidelines and strategies relevant to disease outbreak management 43 Table 3.1 Research methods according to the phases of the study 49 Table 3.2 Research phases, steps, and objectives 51 Table 3.3 The ontology of critical realism applied to disease outbreak nursing 55 Table 3.4 Application of the JBI Framework for content analysis 59 Table 3.5 The interview protocol stages 61 Table 3.6 Comparison between the first and revised questionnaire for Health care professionals 63 Table 3.7 In-depth interview roster for health care professionals 64 Table 3.8 In-depth interview roster for nurses 68 Table 3.9 Participants included in the first Delphi round 71 Table 3.10 The comparison of original and revised statements included in the Delphi survey 72 Table 3.11 The application of Critical Realism in the study 77 Table 3.12 Quality criteria in this study 80 Table 4.1 Eligibility criteria 84 Table 4.2 Publications included in the scoping review 88 Table 4.3 Sources according to country and data base 107 Table 4.4 Categories and sub categories of the findings 110 Table 4.5 Results of the content analysis and basic statistical calculations 111 xviii Table 4.6 Number of publications aligned with disease outbreaks 113 Table 5.1 Health care professional representation 119 Table 5.2 Demographic data of health care professionals 119 Table 5.3 Themes and sub themes of nurse challenges according to health care professionals 120 Table 5.4 Professional nurses included in in-depth interviews 121 Table 5.5 Demographic data of professional nurses 121 Table 5.6 Theme 1: Nursing Resources 123 Table 5.7 Theme 2: Clinical Skills 125 Table 5.8 Theme 3: Interpersonal Skills 132 Table 5.9 Theme 4: Intrapersonal Skills 141 Table 5.10 Table 5.11 Table 5.12 Table 5.13 Table 5.14 Table 5.15 Table 5.16 Table 5.17 Table 6.1 Table 6.2 Table 6.3 Table 6.4 Table 6.5 Table 6.6 Table 6.7 Table 7.1 Table 7.2 Table 7.3 Theme 5: Physical Challenges Theme 6: Communication and Information Management Theme 7: Community Profiling and Resources Theme 8: Financial Management Theme 9: Preparation of the Infrastructure Theme 10: PPE Management and Precautionary Measures The results of the scoping review, in-depth interviews, and potential items in the Delphi Potential Delphi statements Sections included in the Delphi-survey Participants included in the first Delphi round Demographic characteristics of expert panel of participants Score results and components in Delphi Round 1 Comparison of statements and design of Delphi-survey 1 and Delphi-survey 2 Score results of the domains in Delphi-survey Round Two Results of Delphi-Round 2 Alignment of the results of the Delphi-survey with the Programme Matrix Credit allocation per module Validation results of the Programme Matrix 146 151 155 158 161 163 168 183 187 188 189 191 207 222 223 230 236 260 xix Table 8.1 Comparison of the Programme Matrix with the ICN Core Competencies in Disaster Nursing Version 2.0 273 xx LIST OF ABBREVIATIONS CDC Centres for Disease Control and Prevention ED Emergency Department ICN International Council for Nurses ICU Intensive Care Unit IPC Infection Prevention and Control SANC The South African Nursing Council WHO World Health Organization 3P2R Framework Pandemic Prevention Preparedness Response and Recovery Framework ACLS Advanced Cardiovascular Life support AIDS Acquired Immunodeficiency Syndrome ALOS Average Length of Stay AMR Antimicrobial Resistance ARDS Adult Respiratory Distress Syndrome BLS Basic Life Support BRICKS Inter-governmental organization between Brazil, Russia, India, China, South Africa, Egypt, Ethiopia, Iran, and the United Arab Emirates BTIR Bed-Turn over Distance Rate BTR Bed-Turnover Rate CBC Competency-based Curriculum CDC Centers for Disease Control and Prevention CHW Community Health Workers CINAHL Cumulated Index to Nursing and Allied Health Literature COVID-19 Corona Virus Disease – 2019 CPR Cardiopulmonary Resuscitation DRR Disaster Risk Reduction ED Emergency Department EPI Epidemic Preparedness Index GPMB Global Preparedness Monitoring Board HIV Human Immunodeficiency Virus HMR Hospital Mortality Rate HPC Health & Care Professions Council HR Human Resources ICD The International Classification of Disease ICN International Council of Nurses ICU Intensive Care Unit IPC Infection Prevention and Control IDI In-depth Interview INR International Health Regulation JBI Johanna Biggs Institute xxi JD-R MODEL Job Demand-Resource Model LO Learning Outcome MCQ Multiple Choice Question Mhealth Mobile Health Platform MNCH Maternal, Newborn, and Child Health NDoH National Department of Health MEURI Monitored Emergency Use of Unregistered and Experimental Interventions NHLS National Health Laboratory Service NICD National Institute for Communicable Diseases NIOH National Institute for Occupational Health NIOSH National Institute for Occupational Safety and Health NIPEC Northern Ireland Practice and Education Council for Nursing OR Operating Room PCC Population (participants), Concept and Context PHEI Public Health Emergency of Interest POE Portfolio of Evidence PPE Personal Protective Equipment PRET Preparedness and Resilience for Emergency Threats PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analysis PRISMA-SCR Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Scoping Review PTSD Post-traumatic stress syndrome SAHPRA South African Health Products Regulatory Authority SANC South African Nursing Council SANDF South African National Defense Force SARS-Cov-19 Severe Respiratory Syndrome Coronavirus 2 SDG Sustainable Development Goals SFDRR Sendai Framework for Disaster Risk Reduction SPAR States Parties Self-assessment Annual Reporting Tool SWOT Strengths, Weaknesses, Opportunities and Threats Analysis TB Tuberculosis WHO World Health Organization xxii GLOSSARY Disease Outbreak: A disease outbreak is defined as the occurrence of a disease, or an unexpected increase of a confirmed disease or health-related behaviour not usually present in a specific geographical area or health care setting. Disease Outbreak Management: Disease Outbreak Management refers to a planned continuous cycle of events, purposefully maintained by multiple role players to detect, prevent, treat and review environments, human and animal life, contagious or non- contagious diseases, which has the potential to cause, or has caused a disease outbreak with the specific focus on minimizing its effect on human and animal life and the environment. Epidemic: Epidemic is described as the increase of a disease in a specific geographical area that is not aligned with the normal occurrence of the disease. Frontline Worker: Frontline Worker was used in referral to military troops when referring to dangerous however important and essential work which puts people at risk. However, since the COVID-19 pandemic outbreak, the term has been adapted to refer to medical staff, including nurses. Pandemic: Pandemic is described as an epidemic that occurs in more than one country, crossing international border. The geographical scale of an endemic determines if it can be referred to as a pandemic and not the severity of the disease. Pandemic-ready nurse: Pandemic-ready nurse suggests that nurses display the ability to respond effectively to any health care crises. Programme Matrix: Programme Matrix or a matrix map displays the learning outcomes, program objectives and learner activities as they are aligned for the whole curriculum in a transparent way. xxiii Scope of Practice: Scope of Practice refers to the roles, responsibilities and activities of different levels of nurses in which they are regarded as competent and provides the milieu of their level of accountability. Surge Capacity: Surge Capacity is the ability of an organization or country to comply with the increased demands of an abnormal situation. 1 CHAPTER ONE ORIENTATION TO THE STUDY 1.0 INTRODUCTION The Corona Virus Disease-19 pandemic demonstrated that the ability of a disease to spread globally is only a plane ride away, which not only reveals the vulnerability of humankind but also highlights the need for a disease outbreak-competent workforce. Disease outbreaks have resulted in more than 308 million reported global deaths in the last century (Bloom and Cadarette, 2019). This thesis intends to develop a competency-based programme on the management of disease outbreaks. The rationale behind this study was the health care workforce and industry reaction to the COVID-19 pandemic in 2019. In every post endemic; -epidemic, and -pandemic phase, the health care workforce is expected to learn from mistakes and successes and address the challenges experienced in preparation for the next pandemic (World Health Organization, 2023a). For nurses, the COVID-19 pandemic was their first experience working during an infectious disease outbreak of this magnitude. Nurses are the major task force during an outbreak and are expected to demonstrate knowledge, leadership skills, and resilience during a health crisis (Baack and Alfred, 2013). In South Africa, generic disease outbreak curricula for nurses have been included in disaster management modules in infection prevention and control and emergency nursing programmes. However, there is no programme based on pandemic experiences of health care professionals in South Africa. Nursing educators should make use of this post-pandemic phase to provide opportunities for the last disease outbreak workforce to inform curriculum and programme developers on the content of such programmes. This chapter presents an orientation and background to the study. The problem statement, purpose of the study, research objectives and significance of the study will be described. The researcher’s assumptions will be discussed, and conceptual terms will be defined. 1.1 BACKGROUND OF THE STUDY COVID-19 is an infection caused by the severe acute respiratory syndrome Coronavirus 2 or Severe Respiratory Syndrome Coronavirus 2, and many countries are still challenged to manage different mutations of 2 the disease. At the time of this writing (4 February 2021), 2.27 million deaths and 104 million cases of COVID-19 have been reported globally. Other than COVID-19, the World Health Organization (WHO) also monitored Lassa fever, cholera, yellow fever, monkey pox, plaque, ebola, and anthrax outbreaks early in 2021 (World Health Organization, 2021a). The aforementioned is a reminder of the potential of other epi-or pandemic outbreaks to emerge if the diseases are not managed. It is estimated that most countries will experience a large-scale emergency every five years, including new diseases and seasonal diseases (World Health Organization, 2019a). This study was conducted in South Africa whilst the country was experiencing the third COVID-19 wave (May 2021 – October 2021), the fourth COVID-19 wave (December 2021 – April 2022), and the fifth (May 2022 – July 2022), as well as the post-pandemic phase. A total of 45 344 deaths and 1.46 million confirmed cases were reported by South Africa (Worldometer, 2023). Similar to other countries, South Africa buckled under the demands of the COVID-19 pandemic due to a shortage of resources, including nursing resources. South Africa is a multi-ethnic, religious and cultural country situated in the most southern point in Africa, often referred to as the ‘rainbow nation’, still experiencing the effects of a 48year Apartheid regime, which ended in 1994 after the first democratic election. South Africa has a population of 60 414 496, with a median age of 26.6 years, female life expectancy of 65.7 years, male life expectancy of 59.9 years. A total of 69% of the population is urbanized (Worldometer, 2023). Further, the country is divided into nine provinces. Gauteng, with a population of 15 099 422, is the most densely populated province, followed by Kwa-Zulu Natal with a population of 12 423907, Mpumalanga with a population of 5 14 3 324, Western Cape with a population of 7 113 776, Eastern Cape with a population of 6 676 691, Limpopo with a population of 5 941 439, North West Province with a population of 4 186 984, Free State with a population of 2 921 611, and Northern Cape with a population of 1 308 734 (Statistica, 2022). A map of South Africa is included in Figure 1.1. 3 Figure 1.1 Map of South Africa The multi-ethnic profile of South Africa, confirmed during the 2022 census, consists of Black Africans = 49.1 million, Indian and Asian = 1.56 million, Colored = 5.34 million, and White = 4.639 million. The South African population density in 2021 was 48.96 inhabitants/km². A total of 83% of the population lives in formal dwellings, 12 % in informal dwellings, and 4.3% in traditional dwellings (Statistica, 2022). The 4 297 informal settlements in South Africa comprise 2 million households, the majority situated in Cape Town, eThekwini, and Johannesburg (Mail and Guardian, 2023). Informal settlements are known for their lack of infrastructure, e.g., pipeline water and sanitation, waste disposal, and pest control services. Control of the living environment is important in the prevention of disease outbreaks and is discussed in detail in chapter two. The World Bank reported that South Africa has the highest inequitable income distribution coefficient in the world, with a Gini score of 0.67 representing the deviation in income distribution in a country (The Word Bank, 2022). This is significant as there is a direct association between poverty and compliance with precautionary measures, especially over extended periods of time (Dukhi, Manyaapelo, Mokhele, et al., 2021). Most South Africans (77.9%) regard themselves as Christians, 4.4% as Traditional African, 1.6% as Muslim, 1% as Hindu, and 0.1% as Jewish. A total of 10.9% of the population do not associate themselves with any specific religion (Find Easy, 2023). This is important as the role 4 of religions in strengthening disease outbreak communication to community members has been acknowledged (Sisti et al., 2023). It was estimated that 7.8 million people will be living with HIV in South Africa in 2021, a total of 13% of the global HIV cases (World Health Organization, 2021b). According to the Institute for Health Metrics and Evaluation SA, the leading cause of death in South Africa is HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome), TB (Tuberculosis), diarrheal diseases, lower respiratory tract infections, and neonatal disorders (Institute for Health Metrics and Evaluation SA, 2022). In 2022 54 00 people died of TB, of which 57% were living with HIV. It was estimated that South Africa has the highest incidence of multi-drug-resistant tuberculosis. In 2022, a total of 280 000 patients fell ill due to TB in South Africa (Tomlinson, 2023). A study conducted in 2023 confirmed a new multi-morbid disease cluster under South Africans, which includes HIV, hypertension, and anemia (Roomany, van Wyk, and Cois et al., 2023). The vulnerability of the population, already challenged with complex disease profiles, combined with an infectious disease outbreak, exerts additional pressure on the health care system and health care workers. The World Health Organization estimated that most countries will experience a large-scale emergency every five years, including new diseases and seasonal diseases (World Health Organization, 2019a). On 28 May 2023, South Africa had 4 076 463 confirmed COVID-19 cases; a total of 61 362 active COVID-19 cases; 3 912 506 recoveries; and a total of 10 595 deaths due to COVID-19 disease (Worldometer, 2023b). During the pandemic, South Africa had a two-tiered, unequal health care system, with public hospitals serving 70% of the population compared to 30% in the private sector (The Conversation, 2023). South Africa could provide the citizens of the country with 400 public and 200 private health care facilities, with ten major teaching hospitals, and an estimated capacity of 3300 to 7000 intensive care (ICU) beds in the private and public hospitals combined (Cowan and Evans, 2020), and a total of 125 390 general hospital beds (Investec Focus, 2020). On 20 June 2020, the South African- Investec Focus projected a shortage of 20 000 ICU beds as well as 17 000 ventilators to manage the expected influx of infected patients (Investec Focus, 2020). Data collected between March 2020 and April 2021 indicated that South Africa had 169 678 COVID-19-related admissions, of which 6364 (3.8%) were health care workers. It is estimated that 60% of the South African population depends on traditional healers and cures available at well-established traditional healers’ markets (The Conversation, 2023). 5 South Africa has a shortage of health care professionals and nurses with disease outbreak management skills. The WHO recommended ratio for medical practitioners is 30 per 10 000 people. In South Africa, the ratio was 3.2 medical practitioners per 10 000 people for the year before the COVID-19 outbreak (Investec Focus, 2020). In 2019, a total of 286 116 nurses were registered at the South African Nursing Council (SANC), and 112 161 registrations included an additional qualification (South African Nursing Council, 2019). During the COVID-19 pandemic, an online survey of South African Nurses concluded that only 47.4% of the 5 530 participating nurses indicated confidence in their own knowledge to manage during the pandemic and called for a focused approach to infection prevention and control training of nurses (Dukhi et al., 2020). On 5 May 2023, the Director General of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, declared the COVID-19 pandemic no longer a public emergency but cautioned that it is still regarded as a public threat after a global cumulative caseload of 765 222 932, and 6 921 614 reported deaths (World Health Organization, 2023a). As restrictions and COVID-19 caseloads diminished, every country focused on re-building sectors that have been severely impacted by the pandemic, including education, agriculture, trade and economics, and tourism. The health sector, although depleted of resources, had to recuperate and is currently focusing on public health responsibilities it was not able to fulfil during the pandemic. It is estimated that South Africa had a surgical backlog of 150 00 surgical procedures in 2021 due to the pandemic (Chu, Bertels, and Goliath, 2021) and a 29% reduction in pediatric cardiac surgeries (Aldersley, Brooks, Human et al., 2023). 1.2 PROBLEM STATEMENT Disease outbreaks have had a profound global impact, resulting in millions of deaths and revealing significant gaps in the capacity of health systems, especially in African countries. These gaps include insufficient resources for training Health care Workers and a lack of dedicated programmes for disease outbreak event education, highlighting a pressing need for enhanced preparedness. 1.3 RESEARCH QUESTION The overarching research question for this study was: How can a disaster outbreak programme be developed based on health care professionals’ experiences during the last pandemic? 6 1.4 AIM OF THE STUDY The study aimed to develop a competency-based programme tailored for South African nurses to address their challenges in managing disease outbreaks, thereby enhancing their readiness and capacity to respond effectively to such events. 1.5 OBJECTIVES OF THE STUDY Specific objectives for the study were: • To conduct a comprehensive scoping review to identify the educational needs of nurses during outbreaks. • To elicit the challenges experienced by nurses during the COVID-19 pandemic through in-depth interviews with a cohort of health care professionals. • To elicit the challenges encountered by nurses during the COVID-19 pandemic through in-depth interviews with a group of professional nurses. • To triangulate the data based on the information obtained in the study (a scoping review and in-depth interviews). • To develop a programme based on the insights derived from the preceding steps. • To assess the validity and effectiveness of the developed programme through validation by a panel of national experts. 1.6 CENTRAL THEORETICAL STATEMENT Understanding the challenges of nurses during a disease outbreak provides insight into the content and design of a competency-based programme on disease outbreaks, which will best prepare nurses for disease outbreak events. 1.7 SIGNIFICANCE OF THE STUDY The impact of infectious diseases on health care systems demands that nurses are competent in the management of disease outbreak events to enhance the surge capacity of a country. COVID- 19 had and still has a negative impact on the Sustainable Development Goals (SDG). Goal Three refers to global good health and well-being, as it aims to end epidemics, Acquired Immunodeficiency Syndrome (AIDS), Tuberculosis (TB), malaria, neglected tropical diseases, 7 hepatitis, water-borne diseases and other communicable diseases by 2030 (World Health Organization, 2023a). The interconnectedness between the COVID-19 pandemic and every country’s economy, health, agriculture, food, education, environment, social justice, and inequality is well documented. A disease outbreak-competent nursing workforce will contribute to a country’s ability to meet SDG Goal Three in successfully managing disease outbreaks. This study is the first to determine the challenges South African nurses experienced during the recent pandemic in developing a competency-based programme on disease outbreaks for nurses. 1.8 PARADIGMATIC ASSUMPTIONS Creswell (2022) describes a research paradigm as the beliefs and values of the researcher that influence how the research is approached and conducted and highlights how the researcher engages with the research process (Creswell, 2022). The paradigmatic assumptions of this study include the meta-theoretical and theoretical assumptions, which are discussed in the following section. 1.8.1 Meta-theoretical assumptions This study’s meta-theoretical and theoretical foundations stem from Fawcett’s expanded nursing theory. Fawcett further developed her earlier work in 1984, elucidating the nursing paradigm through the concepts of a) Person, b) Environment, c) Health, and d) Nursing. Expanding upon these concepts, Fawcett refined them into theoretical assumptions within Nursology: a) Human Beings, b) Global Environment, c) Planetary Health, and d) Nursologist activities (Fawcett, 2022). In a proposal to rename nursing as nursology in 2015, Fawcett contended that this terminology better reflects nursing as a distinct discipline, encapsulates its evidence-based foundation as a “scholarly identity”, and facilitates the differentiation between medicine and the art of nursing (Fawcett et al., 2015). • Human Being Human beings are multi-dimensional entities with needs that include the physical, social, and psychological dimensions, as well as the ability to make decisions related to their health and sickness and contribute to the survival of humankind. Human beings refer to all individuals, groups, communities, and nations, irrespective of culture, beliefs, religion, age, race, gender, or gender orientation, who either contribute or refrain from contributing to their own and global health (Fawcett, 2022). In this study, the nurses are acknowledged as complex human beings 8 with their own cultural and religious beliefs, as members of communities, and as personally challenged by the same potential and actual disease outbreak events in the communities they serve. • Global Environment The global environment is described as the ‘external’ that surrounds the human being. Roper, Logan, and Tierney (2000) divided the global environment into a) The local and global atmosphere, which includes light, sound, organic and inorganic particles, dust, microorganisms, pollen, and the ozone layer. b) The natural environment includes trees, plants, weather, animal life, rain, sunshine and wind. c) The built environment, which includes housing structures, water reservoirs, waste management plants, markets, aeroplane interiors, air conditioning systems, water and waste systems in buildings, as well as pest control (Roper et al., 2000). In this study, the global environment is regarded as the physical surroundings of all human beings that can either challenge or support health. The hospital-built environment can either be therapeutic or cause the patient harm. Crucial resources, e.g. quality water, electricity, functional sanitation, medical waste systems, and clean air, have become a luxury rather than a basic requirement in many communities and health care environments in South Africa. • Planetary Health Planetary health is described as ‘life-in-action’ concerning the global environment, which either supports health or challenges heath. Kuehnert, Fawcett, De Priest et al (2022) describe five environments established and controlled by human beings that contribute to planetary health and include: a) Cultural environment explained as life-ways of cultural populations, practices, beliefs, and values of populations reflected in their health behaviors. b) Socioeconomic environment that includes social health and economic stability, driven by income, education, gender, race and occupation; financial structures. c) Political environments include processes of decision making, policies, and politics. d) Educational Environments that include the population’s access to education and quality of learning. e) Health care environment that includes access to health care for all members of the population and quality of the care rendered (Kuehnert et al., 2022). In this study, the researcher believes that the behaviours, attitudes, and beliefs, as well as the commitment of both the patient and nurse towards disease and treatment thereof, are embedded in their own social and cultural belief systems, and it is important to acknowledge as the South African population is a mosaic of cultures and religions. Financial aspects, e.g. cost of treatment, including the appropriation of health care resources, 9 political will to support and fund health care related projects (including the training of health care professionals), and contribution to planetary health. • Nursologist Activities Practice skills traditionally regarded as inherent to nursing (nursology), are awareness, openness, empathy, caring, touching, understanding, responsibility, trust, acceptance, self- recognition, and dialogue (Paterson and Zderad, 1976). Soon thereafter, Donaldson and Cowley confirmed that nursing activities demand a deep understanding of human beings as well as diseases and are not just superficial performances of clinical procedures (Donaldson and Cowley, 1978). The scientific nursing process of assessment, nursing diagnosis development, planning, intervention, and evaluation of patients in collaboration with the multidisciplinary team is the centre of all nursing activities (Fawcett, 2022). Acknowledging the wholeness of humans, being conscious of them, and caring for human beings have previously been described as unique identifiers that separate nursing from other disciplines (Cowling, Smith, and Watson, 2008). Assessing the nursologist activities of a disease outbreak nurse practitioner is a challenge as disease outbreak nursing is not acknowledged as a specialist nursing qualification within nursing (nursology) in South Africa. During the COVID-19 pandemic, nurses were expected to overstep the boundaries of their own scope of practice in an attempt to address the patient’s needs. Having deep insight into the complex human beings and disease profiles, combined with consciousness and caring, has been described as the distinguishing factor that separates nursing from other disciplines (Cowling, Smith, and Watson, 2008). For the purpose of this study, the disease outbreak nursing (nursology) activities (disease outbreak nursing) is concerned with precautionary responsibilities (continuous risk assessment), the preparation for and treatment of (clinical and non-clinical), the patient and communities risk and infected with an infectious disease, within a multidisciplinary framework, as well as the initiation and contribution to research initiatives related to the disease including the update of skills and activities, self-care and development of the nursing practitioner (nursologist). 1.8.2 Theoretical assumptions The theoretical assumption in this study is based on the theoretical framework of The Adult 10 Learning Theory, also referred to as Andragogy Learning, described by Malcolm Knowles in 1968, as well as the Critical Realism Theory of education as described by Bhaskar in 1975. The characteristics of andragogic learning theory are based on the following assumptions as described by Livingston and Cummings-Clay in 2023: • Adults learn differently from children; • Adults have experiences and existing knowledge about the learning content; • Continuous learning of adults is motivated by their needs and interests; • Adults are autonomous learners and self-directed; • Adults respond well to problem-based learning activities; • Adults have the need to apply learned content to real life situations; • Adults respond to the facilitation of learning and not teaching. (Livingston and Cummings-Clay, 2023) The critical realism approach to learning as well as andragogic learning theory, is interrelated in that the critical realists believe that: • Learning and knowledge depend on social interaction and are imperfect and robust (Khazem, 2018). This refers to previous experiences, problem-based activities, and the immediate application of new content as described in andragogic learning. • Science depends on social context and is a continuous process (Khazem, 2018). This refers to the social and work experiences of nurses as well as the immediate application of new knowledge (theory clinical integration) referred to in andragogic learning theory. Both andragogic and critical realism learning assumptions are applied throughout this study in the identification of challenges (learning needs) of nurses, as well as the development of the competency-based programme on disease outbreaks. 1.8.2.1 Theoretical definitions The definitions below indicate the way in which the following terms are used in the context of the study. Disease Outbreak: The occurrence of a disease or an unexpected increase of a confirmed disease or health-related behaviour not usually present in a specific geographical area or health care setting (World Health Organization, 2010a). 11 Disease Outbreak Management: A planned continuous cycle of events, purposefully maintained by multiple role players to detect, prevent, treat, and review environments, human and animal life, and contagious or noncontagious diseases, which has the potential to cause or have caused a disease outbreak with the specific focus on minimizing its effect on human and animal life and the environment (Institute of Environmental Science & Research Limited; Updated 2012). Epidemic: The increase of a disease in a specific geographical area is not aligned with the normal occurrence of the disease (Centers for Disease Control and Prevention, 2015a). Pandemic: An epidemic that occurs in more than one country, crossing international borders. The geographical scale of an endemic determines if it can be referred to as a pandemic and not the severity of the disease (The International Epidemiology Association’s Dictionary of Epidemiology, 2008). Surge Capacity: The ability of an organization or country to comply with the increase in demands of an abnormal situation (Hamele, Neymayer, Sweney, et al., 2018). Pandemic-ready nurse: A nurse displays the ability to respond effectively to any health care crisis (Veenema, 2018). Frontline worker Frontline Worker was used in referral to military troops in “important and dangerous [positions]” doing “essential work that puts [them] at risk” (Oxford Advanced Learner Dictionary, 2020). However, since the COVID-19 pandemic outbreak, the term has been adapted to refer to medical staff, including nurses. 12 Scope of Practice Scope of Practice refers to the roles, responsibilities, and activities of different levels of nurses in which they are regarded as competent and provide the milieu of their level of accountability (Health & Care Professions Council (HCPC), 2021). Curriculum Matrix Curriculum Matrix or a matrix map displays the programme and learning outcomes, programme objectives, and learner activities as they are aligned for the whole curriculum transparently (Al-Eyd, Achike, Agarwal, et al., 2018). 1.8.2.2 Operational definitions The explanations below indicate the way in which the following terms are measured in the study. Challenges: Challenges are described as tasks that demand a noticeable level of difficulty for an individual to perform (Oxford Advanced Learner’s Dictionary, 2020). In this study, challenges refer to tasks that the nurses experienced as difficult to perform during a disease outbreak and include clinical and nonclinical tasks. Competence: Competence refers to the ability to perform a task well (Oxford Advanced Learner’s Dictionary, 2020). In this study, competence refers to nurses’ ability to perform tasks required by patients in a disease outbreak. Competency: Competency refers to skills (technical) an individual requires to perform a task (Oxford Advanced Learner’s Dictionary, 2020). In this study, competency refers to the combined set of skills required to perform/ complete a task, e.g., chest compressions and rescue breathing during cardiopulmonary resuscitation (CPR). 13 Competent: Competent refers to the performance of a skill to a certain level (Oxford Advanced Learner’s Dictionary, 2020). In this study, nurses’ competent levels are categorized as a) Novice, b) Advanced Beginner, c) Competent, d) Proficient, and e) Expert (Benner, 1984). Nurse Manager: Nurse Manager refers to a skilled nurse professional with the role of building and maintaining multi sectoral relationships, supporting and representing nursing staff on managerial and boardroom levels with the purpose of coordinating the health care facility (International Council of Nurses, 2019). Nurse Educator: Nurse Educator refers to the specialist field of nursing whereby a professional nurse focuses on the training and education of all levels of nurses and is registered as such by the South African Nursing Council (South African Nursing Council, 2020). Perioperative Nurse: A perioperative nurse is a professional nurse who has acquired the technical skills required in perioperative nursing, integrates inter professional education and aligns quality improvement strategies with quality surgical care within a multi-disciplinary environment (Vangie, 2022). Intensive Care Nurse: An intensive Care Nurse is a specialist professional nurse who cares for a critically ill patient in a complex technological environment, facilitating multi-disciplinary collaboration for holistic patient- centred care (South African Nursing Council, 2014). Emergency Department Nurse: Emergency Department Nurse refers to a specialist professional nurse who provides priority emergency care as the first responder in the pre-hospital and inter-hospital environment, managing life threatening patient problems (South African Nursing Council, 2020b). 14 Specialist Nurse: A specialist nurse is a nurse who has in-depth knowledge and expertise in a specific area of nursing and a postgraduate diploma in the specific area (South African Nursing Council, 2021). For the purpose of this study, the specialists include intensive care nurses (ICU), perioperative nurses (OR), emergency department nurses, nursing educators, and nursing administrators. Expert Nurse: Professional Nurse: An expert has been defined as a person who has at least 20 years of practical experience in a specific field of study, working in a multicultural environment, and has portrayed advanced leadership skills that include research, teaching, and clinical/ practical technique (Grisham, 2008). “A professional nurse is a person who is qualified and competent to independently practise comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice” (South Africa (Republic), 2020c). 1 Programme Outline: Programme Outline is an official document providing the framework of the programme. In this study, the programme outline provides information about the programme objectives, module outline, credit allocation, and an explanation of the stages of competence. 1.9 LAYOUT OF THE THESIS The thesis is organized into the following chapter layout. Chapter One: Orientation of the study Chapter Two: Literature review Chapter Three: Research Methods Chapter Four: Scoping Review Chapter Five: In-depth interviews and literature control Chapter Six: Triangulation of data via Delphi Survey 1 For the purpose of this study, ‘professional nurses’ are differentiated from ‘health care professionals’ which include all members of the health care profession such as medical doctors, anesthetises, and physiotherapists. 15 Chapter Seven: Development and validation of the competency-based programme Chapter Eight: Discussion of the study, justification, strengths, limitations and the Conclusion 1.10 SUMMARY In this chapter, an orientation to the study was given, and the background of the study, the research rationale, the research question and the objectives were detailed. The significance of the study was explained, the researcher’s assumptions were discussed in detail, and the terms of reference were explained. In the following chapter, the literature review of the study will be discussed in greater detail. 16 CHAPTER TWO REVIEW OF THE LITERATURE 2.1 INTRODUCTION In this chapter a discussion on topics that are related to the outbreak of diseases and nursing are discussed. The epidemiology and the epidemiology of disease, infectious disease classification, the disease process, and its interrelatedness with the ecosystem is included. Disease outbreak preparedness, the management of diseases and an overview of the cost implications of disease outbreaks is discussed. A detailed discussion of the role of the nurse, the competencies required and disease outbreak training opportunities in South African is included. Disease outbreak legislation and a discussion of legislation in South Africa is offered. Ethical considerations during disease outbreaks are covered with examples by referring to the COVID- 19 pandemic. The diagram below demonstrates how this chapter will unfold. See figure 2.1. Figure 2.1: Presentation of the literature 17 2.2 EPIDEMIOLOGY OF DISEASE The term epidemiology is defined as “the study of the occurrence and distribution of health- related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems” (Portia, 2008). Both epidemiology of disease (disease specific information) and epidemiology as a discipline are the foundation of public health. Descriptive, analytical, and experimental epidemiological data is essential in disease research. Statisticians are essential in working high volumes of data, into a visual representation thereof presented in tables and charts for interpretation. 2.2.1 Coexistence of Humans and Disease It is Winston Churchill who paraphrased Santayana in a 1948 House of Commons speech when he said that “those that fail to learn from history are doomed to repeat it” (Churchill, 1948). Our current understanding of diseases, disease processes, and cures rests on the shoulders of philosophers, theorists, historians, as well as scientists who, over centuries, dedicated their lives to the treatment of illness including the documentation and publication thereof. Although Tuberculosis has been cultured in mummified body remains dating back as early as 3400 B.C., the outbreak of Typhoid fever in 430 B.C. in Athens is the earliest recording of a pandemic to date (Saleem and Azher, 2013). Two nurses who contributed to our current understanding of infection prevention and disease outbreak management by meticulously documenting their experiences between 1887 and 1910 are Lize Lillington and Florence Nightingale. In the notes from Elize Jane Lillington, a district nurse from the United Kingdom in 1887, she describes the treatment of smallpox, typhoid, and scarlet fever. Her writings also included a detailed description of the nursing rules she had to abide by when nursing patients with infectious diseases (Royal College of Nursing, 2024). The most acknowledged nurse to date is Florence Nightingale (1820 – 1910), also referred to as ‘The Lady with the Lamp’, who devoted herself to the improvement of health and treatment of disease. In 2020, more than a century after her death, Heather Gilber compared Nightingale’s Environmental Theory, with Infection Prevention and Control principles described during the COVID-19 pandemic. Similarities included: hospital planning and design, environmental hygiene, the scope of practice of nurses, staff allocation, nursing observations, clinical procedures, patient triage, collaborative care, sanitation, immunization, public health responsibilities, IPC training and 18 education, research, epidemiology, as well as the description of the role of management and nursing leadership (Gilber, 2020). Florence Nightingale deserves to be acknowledged as the first disease outbreak specialist nurse. The realization that a global approach is required to combat disease and promote health resulted in the establishment of The Centre for Disease Control and Prevention (CDC) in the United States in 1946. Two years later, The World Health Organization (WHO) was established within the United Nations Framework with the purpose, of improving the global health of all living beings, eradicating disease, and implementing structures to ensure sustainable resources, and research. Currently, a total of 149 countries are member states of the WHO. Both these organizations were instrumental in providing guidance and support during the last COVID-19 pandemic. 2.2.2 Understanding Disease Understanding diseases is mankind’s only defense against demise from infectious disease outbreaks. Disease is a broad term and is described as a state of dis-ease (an absence of ease, or comfort) rather than explaining what it is not, than what it is for humans, animal, and plant life (Nelson and Williams, 2014). Britannica defines disease or illness as ‘Any harmful deviation from the normal structural or functional state’ (Burrows and Scarpelli, 2024). A synthesized definition of a disease is the inability of a microbial-invaded or injured host to maintain homeostatic mechanisms. Global standardization of diagnosing diseases is essential to ensure the statistical validity of the data provided by different countries. The International Classification of Disease (ICD-11) framework, first developed and often revised by the World Health Organization (WHO), provides a comprehensive, systematic coding framework to ensure that diagnoses; disease; and injury criteria are applied universally when diseases are reported. This online system allows for every health care professional and country to provide detailed information on diseases which is essential for a robust information system. This current edition allows practitioners to update their diagnostic skills; provides an improved version of diagnosing diseases in the primary health care setting; makes provision for bacterial resistance options, has an updated HIV section; includes rare diseases; has options listed for pre-and post-intervention evaluation strategies and; include traditional Medicine in Chapter 26 (World Health Organization, 2024a). https://www.britannica.com/contributor/William-Burrows/428 https://www.britannica.com/contributor/Dante-G-Scarpelli/2604 19 In diagnostic microbiology terms, the causative pathogen (bacteria virus, fungus, parasite, or prion), of a disease is described according to a complex formal taxonomy for microorganisms which consists of seven classification levels (Domain, Phylum, Class, Order, Family, Genus, Species and, Sub-species). Infectious diseases caused by the pathogen are described by referring to clinical symptoms, causative organism (based on microbiology), mode of transmission, and reservoir. A summary of this classification of infectious disease is presented in Appendix A. Disease progression periods, are pathogen-specific, and depend on the interaction between the a) causative agent; b) the process of transmission; c) the host, and; d) the environment (Bonita, Beaglehole, Kjellstrom, 2019). The progression periods of a specific disease dictate diagnostic and surveillance strategies. The phases are included below.  Phase 1: Incubation Phase: The pathogen enters the host via direct or indirect transfer through inhalation, indigestion, or absorption and starts to multiply. The host is unaware of the exposure and is asymptomatic.  Phase 2: Prodromal Phase: The pathogen is colonized, establishes an intracellular lifestyle, and crosses host barriers resulting in multiplying in the host. The host starts to present with symptoms  Phase 3: Illness Phase: The host presents with typical symptoms, and pathogen particles start to decrease. The host starts to be vulnerable to secondary infections.  Phase 4: Convalescence Phase: The host recuperates and physical homeostasis is restored. The host of an infectious disease has the potential to be contagious at any phase. 2.2.3 A Fragile Ecosystem The relationship between humans, disease, animals, and the environment has been acknowledged through the ages, and yet we have not been able to manage it successfully. Since 1980, 75% of all new or emerging infectious diseases were zoonotic infections e.g. AIDS, SARS (Severe acute respiratory syndrome), MERS (Middle East respiratory syndrome), Nipah Virus, Avian influenza, EVD (Ebola virus disease), Influenza A virus (H1N1), and COVID-19 (World Health Organization, 2020a). Vector-borne diseases e.g. Malaria, Zika virus, Dengue, West Nile Virus, Chihungunya, and Yellow fever, account for 17% of all infectious diseases. The abovementioned causes over one billion human infections and more than one million deaths every year (World Health Organization, 2020a). The control of the physical 20 environment is crucial. An example of an outbreak caused by a compromised environment presented in 2019, when 1500 people were diagnosed with campylo bacteriosis in Askøy Norway, caused by water from a mountain reservoir that was damaged during unexpected heavy rainstorms in the same region (Hyllestad, Iversen, MacDonald et al., 2020). An example of three human activities that disrupt the balance between humans, the environment, and microorganisms are human migration, anti-microbial therapy misuse, and environmental exploitation, and is discussed below.  According to the High Commissioner for Refugees, a total of 110 million refugees were listed globally by mid-2023. Disease prevention in refugee camps is challenging as refugees are usually physically compromised due to stress, exhaustion, and undernourishment. Outbreaks of Tuberculosis (TB), Human Immunodeficiency Virus (HIV), Hepatitis B and C, Measles and Diphtheria as well as polio are but a few that have been reported (Taha, Durham, and Reid, 2023).  Human compliance with pharmaceutical treatment strategies limits the treatment options for infectious diseases. The WHO estimated that anti-microbial resistance (AMR) was responsible for 1, 27 million global deaths in 2019, which is caused by antibiotic misuse and overuse (World Health Organization, 2023).  Economic activities supporting the livelihoods of humans, and threatening the environment (ecosystem) are mining, deforesting, oil extraction, and wetland drainage. Since the ice age, the earth has lost one third of its forests (Ritchie and Rosner, 2021), and half of its wetlands since 1900 (Davidson, 2014). Disease outbreak occurrences have changed due to the changing interaction between animals, plants, fungi, and bacteria (biotic) as well as changes in sunlight, air, water, and temperature (abiotic) (World Health Organization, 2020a). With the global population reaching 8 045 311 447 on 9 January 2024, natural ecosystems are placed under more pressure (Worldometer, 2024). 2.3 DISEASE OUTBREAK PREPARDNESS Surge Capacity is defined as the ability of a country to manage a disease outbreak, and meet its non-disease outbreak responsibilities. Global initiatives and previous results of disaster preparedness audits are discussed below. https://www.worldometers.info/world-population/ 21 A study investigating the commitment of the African states to the SFDRR (Sendai Framework for Disaster Risk Reduction), was initiated in 2010 and concluded that 18% of the African countries reported no implementation of their DRR (Disaster Risk Reduction) strategy (van Niekerk and Coetzee, 2020). The same study also concluded that disaster mortality increased by 13 % in the periods 2015 – 2016 and 2017 – 2018. This was caused by the EVD outbreak in West Africa, landslides in Sierra Leone, flood losses due to El Nino, industrial disasters, Cholera outbreaks in refugee camps in Sudan, and droughts (van Niekerk and Coetzee, 2020). A SPAR (States Parties Self-assessment Annual Reporting Tool) survey conducted in 2020, indicated that only 25% of the countries included in the study could score an acceptable level for availability of resources and skilled health care workers (Kandel, Chungong, Omaar, et al., 2020). According to the Global Security Index in 2019, the average surge capacity score of all the countries was 40.2 out of a possible 100. In 2021 the average score of all the countries was 38.9, a decrease of 1.3. United States of America, Australia, and Finland were listed as the best prepared, with North Korea, Yemen, and Somalia listed as the least prepared. South Africa scored 45.8 points, 1.7 lower compared with the 2019 report. The Global Security Index report of 2021 concluded that all countries are ‘dangerously unprepared' for any future epi- and pandemics and that health care systems have not been strengthened nor changed since the COVID-19 pandemic. More alarmingly the authors are of the opinion that no country has the capacity to manage any disease outbreak event larger than the COVID-19 pandemic (Bell and Nuzzo, 2021). Measuring the pandemic preparedness of a country requires a comprehensive multi-phase approach, which involves numerous stakeholders in a complex health care system environment (Kandel et al., 2020). Frameworks, scoring systems, and indicators have been developed to determine the surge capacity of a country or health care institution. A summary of the frameworks is presented.  According to the WHO Hospital Preparedness for Epidemics Report, surge capacity is based on: a) human resources; b) equipment and supplies; c) specific skills and expertise in specialist areas, and d) management of resources (World Health Organization, 2014a).  In 2015, The Sendai Framework for Disaster Reduction was adopted by 187 member states of the United Nations. In Africa, all 55 countries, under the leadership of the 22 Africa Union (AU), adopted the framework, adding five additional targets in 2018. The revised Sendai framework is referred to as the Tunis Declaration in Accelerating the Implementation of the Sendai Framework for Disaster Risk Reduction and the Africa Regional Strategy for Disaster Risk Reduction (SFDRR) in 2018. The SFDRR provides comprehensive guidelines to private sectors, governmental and non-governmental organizations, academic institutions, and local authorities in adopted countries, but is a non-legal binding framework. This framework includes a) Understanding disaster risks; b) Strengthening risk governance; c) Investment in disaster risk reduction; d) Enhancing disaster preparedness through training, and drills, and; e) Integration of priorities into education systems (United Nations, 2015).  The Global Security Index focuses on: a) Prevention; b) Detection; c) Reporting; d) Rapid Response and; e) Health Systems (World Health Organization, 2014a).  A study published in 2019, used the Epidemic Preparedness Index (EPI), to assess the national level preparedness of 188 countries, indicating that the likelihood of an isolated disease outbreak event becoming a global problem is high. The indicators used in the EPI are: a) economic resources; b) public health communication; c) infrastructure; d) public health systems and; e) institutional capacity (Oppenheim, Galivan, and Madhav, 2019).  The State Party Annual Reporting (SPAR) process was initiated by the WHO and combined external evaluation tools, after-action reviews, and simulation exercises as indicators for disaster readiness (Global Health Security Agenda Team, 2024). In South Africa, The National Department of Health published The Ideal Hospital Realisation and Maintenance Framework Manual (Version 2, August 2023), with quality indicators for public hospitals. A total of 16 criteria in the framework are relevant to disaster preparedness at the hospital level (South Africa (Republic), 2023). No audit results on the compliance of hospitals in South Africa have been published to date. 2.3.1 Disease Outbreak Management The WHO reported approximately 1200 disease outbreak events between 2012 and 2017 in 168 countries, and an additional 352 disease events in 2018 (World Health Organization, 2020a). 23 are discussed below: The objective of disease outbreak management is to minimize the effect of the disease on the population involved through multidisciplinary collaboration and optimized utilization of available resources (Institute of Environmental Science and Research, 2012). The oscillating reciprocity, and interdependency of the phases of the disease outbreak cycle is determined by the real-time epidemiological data that represents the disease cycle in a community. The phases of the disease management cycle are presented in figure 2.2. The phases Figure 2.2: Components of Disease Outbreak Management Phases The phases are discussed below: Preparation includes the development of a disease outbreak response or strategy for the health care institution, including district provincial, and national level, and preparation of physical and human resources, including policies and procedure development. Preparation is a continuous process. 24 Surveillance refers to the generation and communication of continuous risk information to detect the potential for disease outbreaks and throughout disease outbreaks. Confirmation and Assessment refers to the verification of an outbreak, activation of the resources referred to in the planning component as well as additional resources as required, and prioritization of initiatives. Contact tracing is activated. Disease Outbreak Description is provided in epidemiological terms e.g. situation analysis, and descriptive epidemiology. Description of the index case and development of a unique disease definition is important for standardization of case reporting strategies. After the initial description, additional data is provided describing events for as long as the outbreak is active. Contact tracing is maintained throughout. A full Investigation comprises of analytical epidemiological data, and laboratory and environmental investigations. Data collection strategies are enforced. Contact tracing is maintained throughout. Control of the Outbreak is achieved through the successful treatment of the infected population, contaminated environment, and implementation of best clinical of treatment options at the time including surveillance strategies. Contact tracing is maintained throughout. Outbreak Communication includes interdisciplinary communication, publication of research findings and treatment protocols, communication with the public, and use of different communication methods. Contact tracing is maintained throughout. Outbreak Documentation is maintained through vigorous documentation and reporting strategies including paper based and electronic mediums. The Post-Outbreak Phase is ill defined, but it is acceptable to regard the time frame from the declaration that the disease is over or that an area or country is 'disease-free' until the next outbreak. In this phase continuous surveillance is maintained. 2.3.2 The Cost of Disease Outbreaks Between 1980 and 2013, a total of 219 countries reported more than 12 000 human infectious disease outbreaks. The estimated cost of the Ebola Virus outbreak in Guinea, Liberia, and Sierra Leone in 2015 was $ 356 million (Bartsch, Gorham, Lee et al., 2015). Due to the financial implications of COVID-19, the Global Preparedness Monitoring Board (GPMB) was 25 initiated by the WHO and World Bank. The objective of GPMB is to ensure global preparedness for disease outbreaks based on economic indicators. According to the GPMB report, health care emergency ecosystems are complex and ineffective if countries are inequitable, unaccountable, and divided (World Health Organization, 2021a). This implies that there is no immediate solution funded by only a few, but that every country (government), irrespective of income status has to commit to invest in their country’s health, social and economic challenges during non-disease outbreak periods to be able to manage the burden of an outbreak. 2.4 NURSES AS RESOURCE DURING DISEASE OUTBREAKS During the COVID-19 pandemic, The World Health Organization State of the World Nursing Report (2020) confirmed that 59% of the global health sector consists of nurses and is the largest occupational group of professionals (World Health Organization, 2020b). The International Council of Nurses estimates a 13 million shortage of nurses post the COVID-19 pandemic. It also reported the death of 3000 nurses, related to SARS-CoV-2. Most countries reported a 20% increase in non-retiring resignations of nurses post COVID-19, and a total of 4, 7 million nurses are expected to retire within the next 10 years (Buchan and Catton, 2023). Standardized staff-patient ratios are a challenge due to differences in staff competence and patient acuity levels. Planning for staffing during disease outbreaks is even more complex due to the usual sudden influx of patients with high acuity levels. Studying the findings of research relevant to staff-patient ratios and infection prevention and control practices could guide the development of staff-ratio frameworks for disease outbreaks. Purposefully selected studies published between 1999 and 2023, relevant to disease outbreaks and staff-patient-ratio are presented in the table below. See Table 2.1. Table 2.1 Findings of Studies relevant to staff-patient ratios and disease outbreaks. Publication Findings Vicca, A.F. (1999). Nursing staff workload as a determinant of methicillin resistant Staphylococcus aureus spread in an adult intensive therapy unit. Journal of Hospital Infection. 1999. Vol.43.109– 13. doi: 10.1053/jhin.1999.0246. Nurse understaffing contributed to the increase of methicillin resistant Stahylococcus aures in an ICU unit. This study was conducted over 19 months. 26 Harbarth, S., Sudre, P., Dharan, S,Cadenas, M, Pittet. (1999). Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infection Control Hospital Epidemiology. 1999 Sep; 20(9):598-603. doi: 10.1086/501677. PMID: 10501256. Nurse understaffing in a neonatal intensive care unit, including over-crowding contributed to the outbreak of Enterobacter cloacae. Molecular studies identified 3 epidemic closed isolates. Andersen, B.M., Lindemann, R., Bergh. K., Nesheim, B.I., Syversen, G., Solheim, N., Laugerud, F. (2002). Spread of methicillin-resistant Staphylococcus aureus in a neonatal intensive unit associated with understaffing, overcrowding, and mixing of patients. Journal of Hospital Infections. 2002 Jan; 50(1):18-24. doi: 10.1053/jhin.2001.1128. PMID: 11825047. Untrained nurses (42%) and the use of non-permanent staff (62%) in a neonatal intensive care unit resulted in a methicillin-resistant Staphylococcus aureus outbreak in Oslo between March 1999 and June 1999. Laster, K.B., Sloane, D.M., McHugh, M.D., Cimiotti, J.P., Rimsan, K.A., Martin, B., Alexander, M., Aiken, L.H. (2021). Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. American Journal of Infection Control. Vol. 49. (2021). 868-873. Following the guidelines of a 1:4 ratio in New York, as well as SEP-1 Bundles, a patient has a 12% increase in in-hospital mortality when one (1) additional patient is assigned to every staff member. These aforementioned studies highlight the importance of complying with the non-disease outbreak staffing ratios and skills-mix as a preventative measure to prevent potential disease outbreaks. In 2019, a study conducted in South Africa concluded that only 25% of the nurses working in intensive care units in the country had an additional ICU qualification (Joynt, Gopalan, Argent et al., 2019). In 2019, the International Council of Nurses (ICN) and the Saudi Patient Safety Center published a White Paper on nurse staffing levels. This document presented recommendations on staffing ratios rather than mathematical formulas and ratios. The recommendations are included below:  Every health care provider should have a real-time data system providing staff, and patient acuity information;  The nurse must have the authority to make decisions, based on the information;  The nurse must be able to adjust staff allocations according to incidents;  Nursing skill-mix as well as their competency and training must be monitored;  Competency-based training must be prioritized; 27  Further research on staff and patient performance should be encouraged. (Saudi Patient Safety Center, 2019) This approach to staffing ratios allows nurse autonomy to take control of quality patient care and self-governance rather than following rules and formulas that do not accommodate the dynamic nursing environment. In South Africa, a total of 27 1047 qualified nurses were registered at SANC by the end of 2022 (South African Nursing Council, 2022a). There is no data available to confirm how many nurses are still practicing. The nursing workforce in Northern Cape, Mpumalanga, Eastern Cape, and North West are under a lot of pressure, followed by Western Cape, Free State, Gauteng, and Limpopo. The distribution of the nurses per province as well as the population ratio per nurse per province is included in Table 2.3. Table 2.2: The provincial distribution of nursing manpower per province in South Africa (2022). Province Total Nurses per Province Population per Nurse Ratio Eastern Cape 2766 245:1 Free State 12792 228:1 Gauteng 70691 228:1 Kwa Zulu Natal 66180 174:1 Limpopo 27639 215:1 Mpumalanga 14731 320:1 North West 17587 238:1 Northern Cape 3548 369:1 Western Cape 30615 236:1 Total 27 1047 (South African Nursing Council, 2022) According to the South African National Health Act. 61 of 2003 Regulations Regarding Communicable Diseases. No 30681, all health care providers (hospitals) must employ one Infection Control Officer (nurse) for every 200 beds in the service, without specification of the qualifications of the officer (South Africa (Republic), 2003a). It is not clear how many IPC Officers are employed in South African Hospitals. 28 2.4.1 The Expanding Role of the Nurse During Disease Outbreaks The ability to transform ill-defined environments into therapeutic or functional environments, as well as the manipulation of resources to complete a task, has been identified as an important competency of disaster nurses by the WHO as early as 2008 (World Health Organization, 2008). This was confirmed by the work of Carayon, Woolridge, Hose et al in 2018 who concluded that the ability of nurses to provide quality care in an ill-defined, unpredicted, environment depends on their ability to maintain, update, adjust, and apply their clinical, technical, and social skills (Carayon et al., 2018). During the last pandemic, nurses from all specialties were allocated to emergency and intensive care units due to staff shortages. These 'other nurses' could have been at Benner's competency stages 4 and 5 when working in their specialty, but possibly at stage two or three in disease outbreak nursing. Heiden, Bernild, Kikkenborg Berg et al (2023) described this unique situation by referring to all nurses as novices, during the first wave of COVID-19, as no one was competent in caring for patients infected with the SARS-CoV-2 virus (Heiden et al., 2023). This ‘other than ICU specialist’ nurse could have progressed faster through Benner’s stages compared to a novice nurse e.g. a first-year nursing student, through rapid-training programmes, although the focus was on the clinical performance of procedures and not knowledge integration during the outbreak. Nurses are considered as the main contributors to the successful preventative management of infectious disease management and are also the primary developers of treatment protocols related to clinical safety during disease outbreak events (Buheji and Buhaid, 2020). This same study concluded that frontline workers are the primary enactors of resilience during an outbreak and have the ability to adjust other role-players' behavior (Buheji and Buhaid, 2020). Choi, Jeffers, and Logsdon, 2020 expanded on this and added that the preventative role of the nurse includes measures to prevent misinformation, over-information, patient panic, and service preparedness (Choi et al., 2020). 2.4.2 Competence and Competency Nurse competence depends on the ability of the nurse to successfully respond to the health needs of the society. The differentiation between competence and competency is explained by Fukada (2018) by referring to competence as having the ability to perform a task and 29 competency as the successful performance of the task (Fukada, 2018). A concept framework developed in 2011 described competence according to 3 theories: a) Behaviorism through performing a skill and being evaluated through demonstrations; b) the Trait theory referring to critical thinking skills, psychological processes as well as knowledge of the individual; and c) Holism referring to a combination of cognitive, situational, professional experience, values and ethics (Takase, Teraoka, Miyakoshi et al., 2011). Definitions of competence often describe what the nurse should do rather than how the task should be performed. Terminology often includes: ‘understanding’; ‘knowledge application’; ‘intrapersonal relationships’; ‘people-centered care’; ‘patient-centered care’; ‘collaboration’; ‘ethical guided practice’; ‘continuous learning’; ‘quality care’; and ‘being clinically relevant.’ Benner included the stages of clinical competence in 1984, in her work From Novice to Expert (1984), and described how the task is performed in every stage. The 5 stages are explained below: Stage 1: Novice. The person has no knowledge or experience, displays no clinical confidence, and requires constant coaching to perform the task over an extended period of time. Stage 2: Advanced Beginner. The person is referred to as ‘marginally’ acceptable during the performance of the task, with the knowledge that is being developed as the task is performed. The person had experience in a similar clinical context, is efficient in some aspect of the skill, requires occasional guidance, and performs in or outside an acceptable time frame. Stage 3: Competent. The person has experience in similar clinical situations, performs with confidence in a coordinated fashion, and demonstrates efficiency. The person understands the challenge (problem) in abstract and analytical terms and plans deliberately to solve that problem and perform the task. The skill is completed within the acceptable time frame and she needs no support in completing the task. Stage 4: Proficient. The person contextualizes the task within the holistic sphere and understands the value it brings to the whole. She can modify her performance to accommodate the unexpected based on previous experience and can identify critical indicators within the task based on the changing environment, which demands high-level decision-making skills. 30 Stage 5: The Expert. The person has a comprehensive understanding of the problem, is quick to assess a situation, has fluid and precise performance, and can perform within the unknown due to her ability to be highly analytical (Benner, 1984). Another framework first described in 1982 by Howel (in Cannon, Feinstein, and Friesen, 2010) focused on thinking patterns as learning of a new skill takes place from being unconsciously incompetent to consciously competent, and is often referred to as the Conscious Competence Ladder. Nurse competence in disease outbreaks came under scrutiny during the last pandemic. 2.4.3 Disease Outbreak Competencies of Nurses The ability of the nurse workforce to cope with the burden of infectious diseases comes under scrutiny during every disease outbreak event. In 2018, researchers reported that health care providers focus on quantitative nursing resources during a disease outbreak and not competency (quality) in infection prevention control, communicable disease outbreak management, and disaster preparedness (Hamele et al., 2018). During the COVID-19 pandemic, similar findings were presented, and nurses themselves raised concerns about their working conditions and clinical skills on social media platforms. Included below are the results and conclusions of purposefully selective studies, conducted since 2011, related to nurse performance and training during disease outbreak events.  In 2011, Fortaleza and Fortaleza (2011) reported that intensive care health care workers exhibited sub minimal knowledge of infectious disease management during the Influenza outbreak in Brazil (Fortaleza and Fortaleza, 2011).  The infection prevention practices of Emergency Care Nurses were described as inconsistent in a study conducted in 2014, in Hong Kong, during the Middle East Respiratory Syndrome (MERS) outbreak, when it was observed that 40% of the Emergency Care Nurses did not comply with personal protective equipment (PPE). One-fourth (23%) of the participants in the study did not comply with standard hand hygiene practices and the risk perception of disease threats, under the nurses included in the study is minimal (Chacko and Comacho, 2016).  In 2018, the State Party Annual Reporting (SPAR) survey indicated that most African countries either had little or non-sustainable capacity and resources in place to respond to health emergencies, including human resource training and development of health emergency management (Kandel et al., 2020). 31  Nurses in Africa are familiar with disease outbreaks and health disasters. Unfortunately, a study conducted in Ghana in 2017, highlighted that health care workers themselves are concerned about their disease outbreak knowledge and training, following an Ebola outbreak, resulting in recommended continuous training during outbreak-free times (Annan, Yar, Owusu et al., 2017). This was confirmed in a study conducted later in Nigeria after an Ebola outbreak (Ughasoro, Esangbedo, and Udorah, 2019).  A study conducted in Italy confirmed that inadequate nurse education and simulation drills contributed to the inability of the nurse workforce's capacity to render sustainable care for COVID-19 patients in Lombardy, Italy in 2020 (Grasselli, Pesenti, and Cecconi, 2020). The International Council of Nurses (ICN) declared that nurses should understand diseases and disease outbreaks as well as utilitarian principles to be effective during a disease outbreak. The ICN developed a set of competencies for disaster nursing (International Council of Nurses, 2019). The alignment between the ICN competencies and the competencies for the advanced nurse practitioners, stipulated by SANC is presented in the table below. See Table 2.4. 32 Table 2.3: Alignment of ICP Core Competencies in Disaster Nursing Version 2.0 (International Council of Nurses, 2019), with Generic Competency Framework for Advanced Nurse Practitioners in South Africa (South African Nursing Council, 2014). General Professional Nurse: Level I (ICP) Advanced or Specialized Nurse: Level II (ICP) Generic Competency Framework for Advanced Nurse Practitioners (SANC) Any nurse who has completed a programme of basic, generalized nursing education and is authorized to practice by the regulatory agency of his/her country Any nurse who has achieved the Level I competencies and is or aspires to be a designated disaster responder within an institution, organization or system A specialist nurse is referred to as a nurse who has in- depth knowledge and expertise in a specific areas of nursing, and has a post graduate diploma in the specific area Domain 1: Preparation and Planning Domain 1: Preparation and Planning 1.1 Maintains a general personal, family and professional preparedness plan 1.1 Participates with other disciplines in planning emergency drills/exercises at the institution or community level at least annually 2.1.2 Plans develops and implements needs-based programmes to promote health and well being 1.2 Participates with other disciplines in drills/ exercises in the workplace 1.2 Plans nursing improvement actions based on results of drill/ exercise evaluation 2.2.1 Gathers accurate and relevant objective and subjective data required for practice in specialty area through systematic Health and Nursing Assessment 2.2.3 Organizes, synthesizes, analyses and interprets data from different sources to derive nursing diagnoses and determine a care plan 2.3.1: Formulates an individualized comprehensive care plan with identified care outcomes based on nursing diagnoses, findings from a Nursing and Health Assessment, inputs from other health team members and Nursing Practice Standards 33 1.3 Maintains up-to-date knowledge of available emergency resources, plans, policies and procedures 1.3 Communicates roles and responsibilities of nurses to others involved in planning, preparation, response and recovery. 2.3.3 Establishes priorities for care in collaboration with other health care providers and health care users 1.4 Describes approaches to accommodate vulnerable populations during an emergency disaster or disaster response 1.4 Includes actions relevant to needs of vulnerable populations in emergency plans 2.4.4 Responds immediately and appropriately to emergency situations taking a leadership role and coordination of care for health care users with special care needs 1.5 Incorporates Level I core competencies in Disaster Nursing in any basic nursing education programme or refresher course 3.2.3 Participates in unilateral and multidisciplinary teaching and learning 4.6 Provides leadership in the development and implementation of Advanced Practice Education and professional development of learners and colleagues in the workplace Domain 2: Communication Domain 2: Communication 2.1 Uses disaster terminology correctly in communication with all responders and receivers 2.1 Plans for adaptable emergency/ disaster communication systems 3.1.6 Plans for dealing with disasters in advanced Practice Area 2.2 Communicates disaster-related priority information promptly to designated individuals 2.2 Includes emergency communication expectations in all orientation of nurses to a workplace 2.1.3 Develops and uses follow-up systems to ensure that health care users receive appropriate services 2.6.4 Communicates clear, consistent and accurate information verbally, or in written and electronic forms, that falls within the professional responsibility and maintain confidence in care 2.6.5 Facilitates access to information or refers requests to the appropriate person 34 2.6.6 Communicates and shares information including views of health care users, families with other health care team 2.3 Demonstrates basic crisis communication skills during emergency/disaster events 2.3 Collaborates with disaster leadership teams to develop event-specific media messages 2.2.4 Shares and documents findings accurately, complete and in a timely manner complying with Nursing Practice Standards in institutional policies 2.6.1 Initiates, develops and discontinues therapeutic relationships using a range of advanced communication and interpersonal skills 2.6.2. Maintains a relationship that respects the boundary between health care user and self 2.4 Uses available multi-lingual resources to provide clear communication with disaster-effected populations 2.4 Develops guidance on critical documentation to be maintained during disaster or emergency 2.3.5 Maintains current, accurate care plan and related records 2.5 Adapts documentation of essential assessment and intervention information to the resources and scale of emergency 2.4.2 Documents interventions and health care user responses accurately and in a timely manner Domain 3: Incident Management Domain 3: Incident Management 3.1 Describes the national structure for response to an emergency or disaster 3.1 Participates in development of organizational incident plans consistent with national standards 1.1.6 Leads and participates in activities related to improving access to the range of services required for effective specialist services 3.2 Uses the specific disaster plan including chain of command for his/her place of education or employment in an event, exercise or drill. 3.2 Participates with others in post-event (actual or exercise) evaluation 2.5.1 Monitors and documents progress towards expected outcomes accurately and completely 35 2.5.2 Evaluates progress towards planned outcomes, in consultation with health care users, families and/ or carers and health care team 3.3. Contributes observations and experiences to post- event evaluations 3.3 Develops action plans for improvement in nursing practice based on event assessment 2.5.3 Utilizes evaluation data to modify the care plan 2.5.4 Provides necessary support to the team members according to the identified gaps in the care provided 3.4 Maintains professional practice within licensed scope of practice when assigned to an inter-professional team or an unfamiliar location 3.4 Includes emergency planning guidance when reassigning staff or including unfamiliar colleagues or volunteers 4.14 Maintains accountability and responsibility when delegating aspects of care to others Domain 4: Safety and Security Domain 4: Safety and Security 4.1 Maintains safety for self and others throughout disaster/emergency event in both usual or austere environments 4.1 Implements materials that support nursing decision- making that maintains safety during disaster/ emergency events 3.1.2 Leads/ Participates in developing and adapting Nursing Practice Standards to the health care environment 4.2 Adapts basic infection prevention control practices to the available resources 4.2 Provides timely alternative infection prevention control practices applicable within limited resources 3.1.1 Promotes dissemination, use, monitoring and review of Nursing Practice Standards and best practice guidelines 4.3 Adapts regular assessment of self and colleagues during disaster event to identify need for physical or psychological support 4.3 Collaborates with others to facilitate nurses’ access to medical and/or mental health treatment, as other support services as needed 1.1.4 Consults with or refers to appropriate others when encountering situations beyond own competence 4.4 Uses Personal Protective Equipment (PPE) as directed through the chain of command in a disaster/ emergency event 4.4 Explains the levels/ differences in PPE and indications for use to nurses and others 3.1.5 Complies with infection prevention procedures and challenges breaches in other practitioner’s practice 4.5 Reports possible risks to personal or others’ safety and security 4.5 Creates an action plan to address and correct/ eliminate risks to personal or others’ safety and security 3.1.3 Uses appropriate assessment tools to identify actual and potential risks to safety and security, takes 36 appropriate action and reports concerns where necessary to relevant authority Domain 5: Assessment Domain 5: Assessment 5.1 Reports symptoms or events that might indicate the onset of an emergency in assigned patients/ families/ communities. 5.1 Assures tha