Are you ready? The preparation of Swedish nursing students for disaster nursing in armed conflicts

Abstract

The growing global instability has increased the demand for healthcare and disaster response skills among registered nurses (RNs). However, research shows that RNs are not sufficiently prepared for disaster situations. Although RNs are responsible for managing injuries during armed conflicts in accordance with International Humanitarian Law (IHL), nursing education lacks specific training in this area. A national survey revealed that only two universities in Sweden offer IHL-related education for nursing students. These findings highlight the urgent need to revise nursing education in Sweden to better prepare RNs for the challenges posed by global crises, including armed conflicts.

Registered nurses (RNs) have a long and distinguished history of fulfilling their duties both domestically and internationally in response to all-hazard disasters. This aligns with the International Council of Nurses (ICN) ethical codes for nurses which states that RNs have a responsibility to address and mitigate the consequences of injuries; for example, during armed conflicts. ¹ However, research indicates that RNs, with or without specialist education, are not sufficiently prepared to manage disaster situations. In a recent study, we found that most of the universities and university colleges in Sweden have down-prioritized education regarding disaster nursing in general and specifically in terms of armed conflicts. The reason for this is that neither real disasters, nor armed conflicts have taken place in the vicinity of Sweden for a long period of time; however, a ‘naive view of the world among the faculty staff’, was also mentioned. ² Furthermore, the study concludes that the provided education focused on standard healthcare practices in peacetime, rather than adopting a more comprehensive perspective such as nursing care in heightened preparedness and armed conflicts. Simultaneously, the ICN and World Health Organization (WHO) have published a competency description outlining the necessary competencies for disaster nursing. In this competency description, it is emphased that health systems and healthcare delivery in disaster situations such as armed conflict are only successful when RNs possess the fundamental disaster competencies and their capability to respond rapidly and effectively. ³

The deteriorating global situation, noticeable both in Sweden's immediate vicinity and across Europe, is characterized by instability and unpredictability. ⁴ To maintain resilience, it is crucial for the healthcare systems to be prepared to deal with potential mass casualties and disruptive health crises. ⁵ For example, in the event of an armed conflict involving Sweden, tens of thousands of people could be injured simultaneously, and, being a NATO ally, Sweden must be prepared to assist with healthcare in other countries. This implies significant surge in the demand for healthcare and disaster response competencies. Hence, the readiness of civil healthcare in anticipation of armed conflicts becomes paramount and constitutes a cornerstone of Sweden's total defense strategy. ⁵ Additionally, in recent armed conflicts, unfortunately, there have been reports of frequent attacks on healthcare personnel, even though they according to international humanitarian law (IHL) are under protection of International Committee of the Red Cross. According to the WHO database, surveillance system for attacks on health care there were 1523 attacks on healthcare in a total of 19 countries in 2023. Since the war in Ukraine began, the WHO has recorded 1995 attacks as of 1 September 2024. ⁶

A crucial aspect for RNs working in armed conflict is knowledge of IHL. When prioritizing individuals requiring healthcare during armed conflicts, it is essential for RNs in both military and civilian healthcare systems to adhere to the provisions outlined in IHL. For example, triage can be more challenging in armed conflict compared to peacetime triage. In addition to caring for all patients in need, RNs must also provide care for those who may be hostile towards them such as wounded enemy soldiers. Furthermore, RNs have a responsibility to address and mitigate the consequences of injuries during armed conflicts. Preparedness involves responding to emergencies, detecting threats, and reducing or eliminating injuries and fatalities. This necessitates that nursing education prepares students for armed conflicts and instills respect for IHL. It is important for RNs to know what obligations and rights they have when being involved in armed conflicts. Nevertheless, there are no guarantees being protected for attacks even if the RNs have been educated in IHL.

It can be presumed that there is a lack of specific education, such as the application of IHL in armed conflicts, within nursing education. Therefore, we conducted a cross-sectional national survey to examine the occurrence of education in IHL among undergraduate and postgraduate nursing students at all universities and university colleges in Sweden. Out of 25 universities and university colleges, 18 responded. The survey focused on whether education was provided in the following areas: (1) Preparedness of the civil healthcare system in the event of armed conflicts; (2) The basic principles found in IHL; (3) The relationship between IHL and human rights; (4) How armed conflicts may be fought and what weapons may be used; (5) Principles for protection of victims of armed conflicts; (6) What protected personnel categories are there in armed conflicts (7) Healthcare and IHL, (8) Which are the distinguished emblems and what they aim to protect, and (9) Consequences when violating IHL. The results indicated that only two of these universities and university colleges provided any form of education aimed at preparing nursing students to organize civilian healthcare in accordance with IHL. The research findings present significant concerns because the civilian healthcare organization is a crucial component of the Swedish total defense structure. A lack of knowledge regarding strategies and applicable of IHL would be detrimental to both patients and RNs as well another healthcare workers. Disaster nursing should be regarded as both an essential and integral part of undergraduate and postgraduate nursing education in Sweden. In our research, we also offered the option of describing reasons why disaster nursing was not included in the curriculum. The responders provided reasons such as it not being specified in the national examination requirements, absence of teachers dedicated to the subject, time constraints within the curriculum, teachers’ lack of expertise, perceived irrelevance and insufficient time allocated in the syllabus.

In conclusion, the findings of the ‘Are You Ready’ project reveal that the curriculum designed to prepare future RNs predominantly emphasizes standard healthcare practices. Nevertheless, the results suggest a significant deficiency in the curriculum regarding the preparation for civil defense and the comprehension of RNs rights and obligations in the context of armed conflict, and the potential risks thereof. Consequently, RNs may not be adequately prepared and might lack the necessary competence and readiness to respond effectively in armed conflicts. There is an urgent need to revise nursing education in Sweden to better prepare RNs for the challenges posed by today's global landscape, including the occurrence of armed conflicts. To address these issues, disaster nursing and IHL should be integrated into nursing curricula. Therefore, the ‘Are you ready’ team suggests a nationwide program, structured in modules like CPR training, with basic disaster preparedness and IHL modules for undergraduate and postgraduate RNs with basic or specialized, role-specific education for caring action in armed conflict settings.