The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 67
Bioterrorism Knowledge and Educational
Participation of Nurses in Missouri
Terri Rebmann, PhD, RN, CIC, and Lisa Buettner Mohr, MPH, CHES
As the largest group of health care professionals and
ones who play an integral role in the provision of
health care, nurses are integral to bioterrorism preparedness. According to the American Nurses Association
(2008), it is the responsibility of every professional nurse
to maintain a state of professional readiness for emergencies. In addition, bioterrorism preparedness has been
identified as a necessity for nurses at all levels of expertise and in all areas of practice (Rebmann, 2006). However, although bioterrorism training programs have been
developed, few nurses are receiving or participating in
these activities (Katz, Nekorchuk, Holck, Hendrickson,
Imrie, & Effler, 2006).
Perceived barriers to bioterrorism education have
been examined. Researchers indicated that barriers to
receiving bioterrorism education have been found to
vary, depending on occupation (Shadel, Chen, Newkirk,
Lawrence, Clements, & Evans, 2004; Shadel, Rebmann,
Clements, Chen, & Evans, 2003; Sterling et al., 2005). A
lack of training opportunities and a lack of time were the
two most commonly reported barriers to receiving bioterrorism education among infection control and public
health professionals (Shadel et al., 2003, 2004), whereas
physicians cited a lack of continuing education units and
perceived responsibility as significant barriers (Sterling
et al., 2005). There were no published articles that described perceived barriers to bioterrorism preparedness
education in nurses working in many health care settings
and fields, such as medical-surgical units, academia, or
administration. It is likely that infection control and
public health nurses have more access to bioterrorismrelated education because of the nature of their job duties; therefore, their barriers to education may be different from those of nurses working in other settings. It is
Background: Nurses are integral to bioterrorism preparedness, but nurses’ bioterrorism preparedness knowledge has not been evaluated well.
Methods: Missouri Nurses Association members (1,528)
were studied in the summer of 2006 to assess their bioterrorism knowledge and the perceived benefits of education as
well as barriers to education.
Results: The response rate was 31%. Most respondents
(60%, n = 284) received no bioterrorism education. Nurses
who were nurse practitioners (t = -2.42, p < .05), were male
(t = -2.99, p < .01), or were on a planning committee (t =
-1.96, p = .05) had received more education than other nurses. The most commonly cited barrier to education (46.6%,
n = 221) was not knowing where to obtain training. One third
of respondents (31.2%) reported no interest in receiving bioterrorism education in the future. Nurses’ average score on
the knowledge test was 73%. The most commonly missed
questions pertained to infection control and decontamination
procedures.
Conclusion: Bioterrorism preparedness training should
be offered through continuing education and nursing school
curricula.
J Contin Educ Nurs 2010;41(2):67-76.
abstract
Dr. Rebmann is Associate Director for Curricular Affairs, Institute
for Biosecurity, and Assistant Professor, Division of Environmental and
Occupational Health; and Ms. Mohr is Research Assistant and Data
Analyst, Saint Louis University, St. Louis, Missouri.
Supported in part by American Nurses Foundation grant 300286.
The authors thank the members of the Missouri Nurses Association
for their participation in this study.
Address correspondence to Terri Rebmann, PhD, RN, CIC, Assistant Professor, Division of Environmental and Occupational Health,
Saint Louis University, School of Public Health, 3545 Lafayette Avenue, Suite 361, St. Louis, MO 63104.
doi:10.3928/00220124-20100126-04
68 Copyright © SLACK Incorporated
important to identify barriers to education in a variety
of nursing specialties so that interventions can be developed to bridge these gaps.
Most previous research on bioterrorism preparedness
measured self-assessed knowledge or perceived needs and
abilities, such as asking participants to rank their level of
confidence in their ability to meet a competency rather
than using an objective measure of knowledge, such as a
multiple-choice or true-or-false question (Alder, Clark,
White, Talboys, & Mottice, 2004; Kerby, Brand, Johnson, & Ghouri, 2005; Mosca, Sweeney, Hazy, & Brenner,
2005; Wisniewski, Dennik-Champion, & Peltier, 2004).
Kerby et al. (2005) measured public health professionals’
confidence in meeting the Centers for Disease Control
and Prevention bioterrorism preparedness competencies
for public health clinical staff. Mosca et al. (2005) used
the Centers for Disease Control and Prevention bioterrorism preparedness competencies to measure school
nurses’ perceived readiness and found that most do not
consider themselves ready for such an event. Wisniewski
et al. (2004) also used a competency-based instrument
to assess nurses’ disaster readiness by listing knowledgebased questions generated from emergency preparedness
competencies (International Nursing Coalition for Mass
Casualty Education, 2003) and having participants rate
their level of familiarity with each competency. None of
these studies measured nurses’ knowledge of emergency
preparedness using an objective measure; all relied on individuals’ perceived readiness, which may not accurately
reflect their knowledge of bioterrorism preparedness
(Katz et al., 2006).
Few studies have measured nurses’ knowledge of
bioterrorism preparedness by using an instrument that
contains competency-based knowledge questions with
a right-or-wrong answer approach that may more accurately assess readiness (Katz et al., 2006; Rose &
Larrimore, 2002). Rose and Larrimore (2002) assessed
nurses’ preparedness for a chemical or biological terrorism attack using two items to measure nurses’ knowledge of bioterrorism preparedness: the ability to name
two potential biological weapons and the ability to identify the transmission method for anthrax. Results from
this research indicated that the vast majority of nurses
could not name two potential biological weapons, and
fewer than half knew the transmission method for anthrax (Rose & Larrimore, 2002). Katz et al. (2006) used
a knowledge-based questionnaire consisting of a series
of clinical questions, such as symptom identification and
disease diagnosis, to assess the bioterrorism knowledge
of Hawaiian physicians and nurses. This study reported
that nurses answered only 60% of the items correctly on
average, although nurses who had received more bioterrorism preparedness education had higher scores than
nurses who had received less education (Katz et al., 2006).
A 2008 study of nursing students in Italy used a combination of clinical-based questions and general bioterrorism preparedness items to assess nurses’ bioterrorism
knowledge and found that knowledge levels were low
in this population (De Felice, Giuliani, Alfonsi, Mosca,
& Fabiani, 2008). Researchers have identified non-disease-specific bioterrorism preparedness and response
information that nurses need to know (Nyamathi, King,
Casillas, Gresham, & Mutere, 2007), but only the study
by De Felice et al. (2008) measured nurses’ knowledge
of these topics, and their study population was student
nurses. Examples of such non-disease-specific bioterrorism preparedness knowledge include reporting incidents, environmental decontamination, epidemiological
indicators of a bioterrorism attack, and the use of personal protective equipment (Nyamathi et al., 2007).
It is important for all U.S. nurses to become better
prepared for disasters, including bioterrorism attack.
Certain areas of the country have an increased risk of
natural disasters, including hurricanes in coastal regions
and floods in the Midwest. Missouri sits on a major
fault line and is at increased risk for a future earthquake.
However, all areas of the United States are believed to be
at risk for bioterrorism. Regardless of where a bioterrorism attack occurs, all parts of the United States could be
affected because of weather conditions that might carry
the pathogen or because infected patients could travel to
other areas and spread disease. It is vital that Missouri
nurses become prepared for bioterrorism and other disasters and for their preparedness needs to be assessed.
BACKGROUND
The current study identified perceived benefits of bioterrorism-related education and barriers to receiving this
education, evaluated nurses’ knowledge regarding nondisease-specific aspects of bioterrorism preparedness,
and described variables (based on nurses’ work location,
work setting or specialty, education level, age, and gender) associated with these perceived benefits and barriers. It was also hypothesized that Missouri nurses will
not have received much bioterrorism-related education,
although it was anticipated that a large proportion of
members of the Missouri Nurses Association (MONA)
would have participated in the free training CD-ROM
program that was sent to them. It was further hypothesized that nurses who are members of disaster planning
teams and those who work in infection control or public
health would report receipt of more bioterrorism education than nurses who are not planning committee members and those who work in other settings or fields.
The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 69
Methods
The current study was a cross-sectional design consisting of a mailed survey sent to a convenience sample
of registered nurses in Missouri. The instrument, with a
cover letter and a self-addressed stamped envelope, was
mailed to all 1,528 MONA members in July 2006. Missouri nurses were chosen as the sample because MONA
distributed a free bioterrorism educational CD-ROM
program to their members in 2005. It was believed that
many of the MONA members would have participated
in the free bioterrorism preparedness program sent to
them; thus, they would have had at least one opportunity to receive bioterrorism-related education. The cover
letter gave an Internet address for an online version of
the survey administered through Test Pilot® on a secure
server so that subjects had the option of completing the
survey online; the questions for the online and penciland-paper surveys were identical.
Surveys were coded so that participation could be
tracked; surveys did not include names or other identifying information. A modified Dillman’s Total Design
Method was used to maximize response rates (Dillman,
2007). Three weeks after the instruments were mailed, a
reminder postcard was sent to nonresponders to encourage them to return their surveys or complete the instrument online. Nonresponders were sent a second copy
of the survey and a cover letter approximately 14 weeks
after the initial mailing to maximize the response rate.
The Saint Louis University institutional review board
reviewed and approved the study.
Instrument
The instrument measured bioterrorism preparedness
knowledge, perceived benefits of this education and
barriers to receiving bioterrorism preparedness education, and bioterrorism preparedness education received.
Knowledge-based questions were derived from existing core competencies for bioterrorism and emergency
readiness (Columbia School of Nursing, 2001, 2003a,
2003b; International Nursing Coalition for Mass Casualty Education, 2003). Questions on perceived benefits
of bioterrorism preparedness education and barriers to
this education and participation in bioterrorism education were derived from two bioterrorism surveys used in
earlier studies (Shadel et al., 2003, 2004) and from a literature review. A group of eight researchers from across
the country with expertise in bioterrorism provided
feedback on the content validity of the instrument. The
content validity index was computed for each item; items
with a content validity index of less than 0.80 were deleted (Lynn, 1986). Of the original 98 items, 16 were revised
and 35 were deleted, so that the final instrument had 62
items. The final 62-item instrument consisted of four
subscales measuring the following: perceived benefits (6
items), perceived barriers (14 items), bioterrorism preparedness education received (4 items), and bioterrorism
preparedness knowledge (38 items). Next, 20 Saint Louis
University Hospital nurses pilot tested the final 62-item
instrument. Feedback from pilot testing was used to refine the instrument further, such as revising confusing
wording or skip patterns.
Data Collection
Survey questions regarding perceived benefits of bioterrorism preparedness education and barriers to this education were based on a five-point Likert-type scale (strongly
disagree to strongly agree). Scores on the 6 perceived benefit questions and 14 perceived barrier items were summed
to provide overall scores for benefits and barriers subscales. Higher scores on these subscales indicated a higher
perceived benefit to receiving training (maximum score:
30) or a higher number of perceived barriers to education
participation (maximum score: 70), respectively.
Coefficients for internal consistency, Cronbach’s alpha, were calculated for the perceived benefits and perceived barriers subscales. Cronbach’s alpha was .86 for
perceived benefits, .91 for perceived barriers, and .88 for
bioterrorism knowledge, providing evidence of internal
consistency for these subscales. Cronbach’s alpha could
not be calculated for the four education participation
items because, conceptually, it would not be expected that
the items on the education participation subscale would
be internally consistent (Ferketich, 1990). Cronbach’s alpha also could not be calculated for internal consistency
of the entire survey because the questionnaire items did
not conceptually fit together into an overall construct
and there was no associated total score (Knapp, 1991).
The instrument measured bioterrorism education by
asking participants about two types of educational initiatives: traditional education (i.e., in-service training or
lectures) and reading journal articles. An overall bioterrorism education participation score was calculated by
adding the education variables (receipt of traditional education and journal articles read), providing a continuous variable. Scores for bioterrorism education participation were limitless. Other bioterrorism preparedness
education items included whether the respondent had
watched or participated in the free nursing bioterrorism
preparedness CD-ROM program that MONA sent to
its members in 2005 and the intent to pursue bioterrorism preparedness education in the future.
The bioterrorism knowledge component of the questionnaire consisted of 38 true-or-false items, with one
point awarded for each correct answer; higher scores in-
70 Copyright © SLACK Incorporated
dicated higher knowledge levels. The maximum possible
bioterrorism knowledge score was 38. The instrument
also included demographic questions, such as age, gender,
education level, nurse practitioner status (nurse practitioner vs. not a nurse practitioner), work location (rural,
urban, or suburban), work setting or specialty (e.g., academic, emergency department, infection control, retired),
membership in an employer disaster planning committee,
and employer’s profit status (for-profit vs. not-for-profit).
Nurses’ work setting or specialty was condensed to four
groups for data analysis: (1) academic, (2) clinical fields,
(3) infection control or public health, and (4) retired. Infection control and public health were separated from
other clinical specialties because nurses working in these
areas are more likely to have had exposure to bioterrorism
education and training because of the nature of their job
duties (Rebmann & Mohr, 2008).
Data Analysis
Data from the pencil-and-paper version of the instrument were entered using the double-entry method
to ensure accuracy. Online data from Test Pilot® were
downloaded into a Microsoft Access database. Online
and pencil-and-paper data were merged and checked for
duplication. SPSS software, version 14.1, was used for all
analyses. Respondents whose answers were inconsistent
(i.e., multiple options selected within an item, such as work
location: urban, rural, or suburban) were excluded from
analysis for those items. Although 474 nurses responded
to the survey, the descriptive statistics had different denominators because of inconsistent or missing data. Descriptive statistics were computed for each question and
used to describe nurses’ perceived benefits of bioterrorism-related education and perceived barriers to receiving
this education, participation in bioterrorism education,
and bioterrorism knowledge scores. Independent samples
t tests were conducted to compare bioterrorism education received by nurses’ gender, employer profit status,
nurse practitioner status, and membership in a planning
team because these were dichotomous groups. One-way
analysis of variance was used to evaluate group differences between nurses’ bioterrorism knowledge scores and
Table 1
Number (PercentAGE) of Missouri Nurses
Association Respondents by Age,
Gender, Education Level, Work Setting,
and Work Location
Characteristic N (%)
Age (yr)
< 30 11 (2.4)
31 to 40 20 (4.3)
41 to 50 144 (31.3)
51 to 60 190 (41.3)
> 61 95 (20.7)
Gender
Female 446 (96.7)
Male 15 (3.3)
Highest level of education
Diploma 24 (5.2)
Associate’s degree 30 (6.4)
Bachelor’s degree 97 (20.8)
Master’s degree 275 (59.0)
Doctorate 40 (8.6)
Nurse practitioner
Yes 165 (35.4)
No 301 (64.6)
Work setting
Ambulatory care 98 (22.0)
Academic/research 79 (17.7)
Retired 50 (11.2)
Medical-surgical 33 (7.4)
Administration 31 (7.0)
Community/public health 25 (5.6)
Mental health 24 (5.4)
Emergency department 19 (4.3)
Critical care 18 (4.0)
Long-term care 18 (4.0)
Obstetrics 16 (3.6)
Home health 9 (2.0)
School (K-12) 9 (2.0)
Pediatrics 7 (1.6)
Infection control 5 (1.1)
Operating room 5 (1.1)
Work location
Urban 164 (36.9)
Rural 151 (34.0)
Suburban 129 (29.1)
Type of institution
For-profit 124 (29.4)
Not-for-profit 298 (70.6)
Note. Items had various denominators because of inconsistent or
missing data. Respondents who selected multiple options within an
item (e.g., work location: urban, rural, or suburban) were excluded
from analysis for those items.
The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 71
nurses’ perceived benefits and barriers by work location,
work setting or specialty, education level, and age; post
hoc evaluation was performed using the Scheffe test, with
Bonferroni correction to control for experiment-wise error rate. It is commonly accepted practice to assume an
underlying interval-scaled distribution for an ordinal-like
scale, such as the ones used in the current study. This allows parametric (e.g., analysis of variance) analysis to be
performed (Velleman & Wilkinson, 1993).
Results
Overall, 474 of 1,528 (31.0%) petitioned participants
responded to the survey. Most respondents were female
(96.7%, n = 446), had a bachelor’s degree or higher (79.8%,
n = 372), worked at a not-for-profit institution (70.6%,
n = 298), and were between 41 and 60 years (72.6%, n =
334) (Table 1). Approximately one third of the respondents
were nurse practitioners (35.4%, n = 165). Participants
had an equitable representation across work locations: urban (36.9%), rural (34.0%), and suburban (29.1%). Nurse
respondents listed a variety of work settings or specialties,
including academic institutions, hospitals, community
health roles, and retirement. Participants’ demographic
characteristics are shown in Table 1.
Nurses’ Perceived Benefits of Bioterrorism
Education
Almost all nurses (97.5%, n = 462) reported agreeing with at least one benefit to becoming better prepared
for bioterrorism, and 61.0% (n = 289) agreed with all
Table 2
Missouri Nurses’ Perceived Benefits of bioterrorism education and Barriers to Receiving
Bioterrorism Education
Perceived Benefit Item M (SD)a
Frequency of
Agreement With
Statement
N (%)b
Bioterrorism preparedness advances my knowledge 4.63 (0.65) 450 (94.90)
Getting better prepared for bioterrorism will decrease my family’s risk of getting sick or
dying after an attack
4.33 (0.77) 420 (88.60)
Getting better prepared for bioterrorism will decrease my chances of getting sick or dying
after an attack
4.32 (0.80) 417 (88.00)
Getting better prepared for bioterrorism will decrease my patients’ risk of getting sick or
dying after an attack
4.26 (0.80) 405 (85.40)
Getting better prepared for bioterrorism will increase my chances of detecting an attack
before surveillance would recognize it
4.07 (0.94) 369 (77.80)
Getting better prepared for bioterrorism makes me feel more safe 3.98 (1.03) 344 (72.60)
I do not know where to get training 3.15 (1.42) 221 (46.60)
There is no administrative financial support for training at my work 3.37 (1.28) 210 (44.30)
There are no disaster exercises available 2.56 (1.23) 115 (34.30)
I feel uncomfortable or stressed when thinking about bioterrorism 2.76 (1.24) 161 (34.00)
My work schedule does not provide time for training 2.72 (1.21) 124 (27.20)
Bioterrorism preparedness is not currently a priority for me 2.47 (1.19) 113 (23.80)
There are no training opportunities available 2.51 (1.19) 103 (21.70)
I am too busy for training 2.29 (1.11) 71 (15.00)
It is not within the scope of my responsibilities 2.07 (1.15) 66 (13.90)
There is little one can do to lessen the impact of an attack 1.98 (1.07) 59 (12.40)
Training is too expensive 2.46 (0.97) 46 (9.70)
I have no interest in bioterrorism preparedness 1.77 (1.05) 40 (8.40)
Training will take too long 2.28 (0.98) 36 (7.60)
Bioterrorism training is all the same; I am not learning anything new 2.07 (0.98) 30 (6.40)
Note. a1 = strongly disagree; 2 = disagree somewhat; 3 = neutral; 4 = agree somewhat; 5 = strongly agree. bAgree somewhat or strongly agree.
72 Copyright © SLACK Incorporated
six of the perceived benefits. The benefits that showed
the highest level of agreement were “bioterrorism preparedness advances my knowledge†and “getting better
prepared for bioterrorism will decrease my family’s risk
of getting sick or dying after an attack.†Table 2 shows
nurses’ agreement with the perceived benefits items. The
mean benefits score was 25.6 (range = 6 to 30, sd = 1.56)
out of a possible score of 30, indicating that most nurses
agreed with almost all of the benefits to receiving bioterrorism preparedness education. There was no difference between the number of perceived benefits reported
and nurses’ age, education level, work location, or work
setting or specialty. Nurses who worked at a nonprofit
agency (t = -117.23, p < .001), nurse practitioners (t =
-121.40, p < .001), males (t = -126.60, p < .001), and those
who are members of the disaster planning committee
for their facility (t = -118.70, p < .001) reported a higher
number of perceived benefits than other nurses.
Barriers to Nurses Receiving Bioterrorism
Education
Most nurses (85.0%, n = 403) identified at least one
barrier to receiving bioterrorism education, and approximately half (46.0%, n = 217) reported two to four barriers. The four most commonly cited barriers were as
follows: (1) “I do not know where to get trainingâ€; (2)
“there is no administrative financial support for training
at my workâ€; (3) “there are no disaster exercises availableâ€; and (4) “I feel uncomfortable or stressed when
thinking about bioterrorism.†Table 2 shows nurses’
agreement with each of the perceived barriers.
The mean barriers score was 34.3 (range = 15 to 58,
sd = 2.29) out of a possible score of 70, indicating that
most nurses agreed with approximately half of the barriers to receiving education. There was no difference
between the number of perceived barriers reported and
nurses’ age, education level, or work location. However, nurses working in infection control or public health
reported fewer barriers to receiving bioterrorism education than nurses working in academic (F (3) = 4.16,
p < .05) or clinical settings (F (3) = 4.16, p < .01). In addition, nurses who worked at a for-profit agency (t = -74.64,
p < .001), non-nurse practitioners (t = -78.12, p < .001),
and those who are not members of the disaster planning
committee for their facility (t = -77.86, p < .001) reported
a higher number of perceived barriers to receiving education than other nurses. Nurses who worked in clinical settings were more likely to report a lack of financial
administrative support to receive bioterrorism education
than infection control or public health nurses (Table 3).
Nurses’ Participation in Bioterrorism Education
More than half (60%, n = 284) of respondents reported that they had not participated in or received any
bioterrorism-related education in the form of in-services
or lectures. Of those who had attended bioterrorismTable 3
Missouri Nurses’ Participation in Bioterrorism Education, Perceived Barriers to
participation, and Knowledge Scores in Relation to Work Setting or Specialty
Academic Clinical Fields
Infection Control
and Public
Health Retired
Survey Item na M (SD) n M (SD) n M (SD) n M (SD) p
Plan to pursue bioterrorism
educationb,e,f,g,h
103 3.04 (0.90) 240 3.03 (0.81) 27 2.30 (0.82) 39 3.36 (0.93) < .001
Number of bioterrorism in-services or
lectures attended
110 6.37 (28.60) 256 3.20 (14.90) 30 3.47 (7.07) 50 1.26 (3.56) NS
Number of bioterrorism-related journal
articles readf,h,i
110 2.63 (3.79) 256 2.59 (8.04) 30 7.70 (16.72) 50 1.22 (1.62) < .01
Knowledge scorec,e,g,h 110 28.6 (2.76) 256 27.82 (3.68) 30 28.6 (2.58) 50 25.12 (8.01) < .001
There is no administrative financial
support for bioterrorism preparedness
training at my workd,f
110 3.37 (1.31) 253 3.47 (1.28) 30 2.73 (1.51) 42 3.12 (0.89) < .05
Note. aItems had various denominators because of inconsistent or missing data, such as selecting more than one answer option. b1 = in the next
month; 2 = in the next 6 months; 3 = in the next year; 4 = I do not plan to pursue bioterrorism education. c
Maximum knowledge score = 38. d1 = strongly
disagree; 2 = disagree somewhat; 3 = neutral; 4 = agree somewhat; 5 = strongly agree. eSignificant difference between academic and retired. f
Significant
difference between clinical fields and infection control and public health. gSignificant difference between clinical fields and retired. hSignificant difference between infection control and public health and retired. i
Significant difference between infection control and public health and academic. NS = not
significant.
The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 73
related in-services or lectures, most had participated in
three or fewer programs. Approximately 12% attended
one educational program (n = 55), 10% participated in
two (n = 46), and 6% took part in three (n = 29). There
was no significant difference between nurses’ work setting or specialty and the number of bioterrorism-related
in-services or lectures attended. Nurses who worked at a
nonprofit agency (t = -2.48, p < .05), nurse practitioners
(t = -2.42, p < .05), males (t = -2.99, p < .01), and those
who are members of the disaster planning committee for
their facility (t = -1.96, p = .05) reported participation
in significantly more educational programs than nurses
who work at a for-profit organization, non-nurse practitioners, and those who are not members of planning
committees, respectively.
Journal Articles as a Form of Bioterrorism
Education
More than one third of all nurses (38.8%, n = 184) reported that they had not read any journal articles about
bioterrorism preparedness or bioterrorism-related agents.
Of those who reported reading bioterrorism-related
journal articles, most had read three or fewer (70.1%,
n = 202). Nurses working in infection control or public
health reported having read more bioterrorism-related
journal articles than nurses working in all other fields
(F (3) = 4.81, p < .01). Table 3 shows significant differences
between nurses’ work setting or specialty and the number of journal articles they read. In addition, nurses who
worked at a nonprofit agency (t = -3.01, p < .01), nurse
practitioners (t = -3.00, p < .01), males (t = -4.75, p < .001),
and those who are members of the disaster planning committee for their facility (t = -2.46, p < .05) reported having
read a significantly higher number of bioterrorism-related
journal articles than other nurses. Nurse practitioners reported participation in significantly more bioterrorismrelated educational initiatives (in-services or lectures and
journal articles) than non-nurse practitioners, respectively
(t = 3.80, p < .001). There was no significant difference
between the number of educational initiatives attended or
bioterrorism-related journal articles read and nurses’ age,
education level, or work location.
Plan to Receive Bioterrorism Education in the
Future
Only 8.6% (n = 41) of nurses reported that they had
watched or participated in the free nursing bioterrorism
preparedness CD-ROM program that MONA sent to
its members in 2005. Approximately one third of nurses (36.1%, n = 171) reported that they plan to pursue
bioterrorism preparedness education in the future, and
19.8% (n = 94) plan to receive this training in the next 6
months; 31.2% (n = 148) reported that they do not plan
to get this training. Table 3 shows differences between
nurses’ work setting or specialty and their likelihood of
pursuing bioterrorism education in the future.
Nurses’ Bioterrorism Knowledge
Nurses’ average score on the bioterrorism knowledge
test was 27.7 of a maximum possible score of 38 points
(73%). Knowledge scores ranged from 0 to 36 points
(SD = 4.37), with most nurses scoring poorly on the test.
Nurses scored highest on questions pertaining to having
a personal response plan and dispersion techniques for
biological agents. The most frequently missed questions
fell into one of six categories: (1) infection control, (2)
decontamination procedures, (3) response procedures,
(4) incident command system, (5) reporting an incident,
and (6) quarantine.
There was no difference between bioterrorism knowledge score and education level, work location, or amount
of bioterrorism education received previously. Nurses
who were 61 years or older (F (3) = 11.30, p < .001) and
retired nurses (F (3) = 8.57, p < .001) had lower knowledge scores than younger nurses and those who were
employed. Nurses who worked at a nonprofit agency
(t = -157.90, p < .001), nurse practitioners (t = -133.20,
p < .001), males (t = -142.70, p < .001), and those who are
members of their facility’s disaster planning committee
(t = -144.20, p < .001) had higher knowledge scores than
nurses working at a for-profit organization, non-nurse
practitioners, and those who are not members of planning committees, respectively. Table 3 shows differences
between nurses’ work setting or specialty and their bioterrorism knowledge scores.
Discussion
The findings of the current study indicate that the
Missouri nurses who participated believe that bioterrorism preparedness education is beneficial for a variety of
reasons, including advancing knowledge and decreasing
their family members’ risk of getting sick or dying after a bioterrorism attack. However, despite the reported
perceived benefits to receiving education, the majority of
Missouri nurses in the current study indicated that they
have not attended any bioterrorism preparedness-related
in-services or lectures. One third of Missouri nurses in
the current study also reported that they have not read
any journal articles related to bioterrorism preparedness
or bioterrorism-related agents or diseases. The reasons
for low participation in bioterrorism-related training
programs are unclear, but are likely associated with a
lack of awareness about available educational opportunities (a frequently cited barrier). Nurse practitioners,
74 Copyright © SLACK Incorporated
male respondents, and those who are members of their
facility’s disaster planning committee reported receiving
more bioterrorism preparedness education in the form
of in-services or lectures than other nurses. Most of these
findings were not anticipated, based on the authors’
original hypotheses. The reasons why nurse practitioners’ responses were different from those of non-nurse
practitioners are unclear. It may be an issue of access to
bioterrorism-related educational programs, job obligations, or interest in the topic. More research needs to be
done in this area to better determine the factors that relate to receiving bioterrorism-related education.
The Missouri infection control and public health
nurses in the current study reported reading more bioterrorism preparedness-related journal articles than
nurses working in other fields. Retired nurses and those
working in clinical fields or academia reported reading
few journal articles on bioterrorism preparedness. This
may be because infection control and public health journals publish more articles on bioterrorism preparedness,
or it may be related to other factors, such as nurses’ personal choices regarding educational format preference.
Because two thirds of all Missouri nurses included in
the current study reported a plan to pursue bioterrorism-related education at some point in the future, more
bioterrorism educational programs need to be developed
and disseminated. This education must be competencybased and tied to terminal objectives that can be used to
measure health care worker performance (Carrico, Rebmann, English, Mackey, & Cronin, 2008). Bioterrorism
preparedness-related education should be offered in a
variety of formats (e.g., lectures, in-services, journal articles, online courses) to meet nurses’ needs.
The Missouri nurses included in the current study
identified numerous barriers to receiving or participating in bioterrorism preparedness education. The most
frequently cited barriers to receiving bioterrorism preparedness education were not knowing where to get such
training and a lack of administrative financial support to
attend these programs. Other frequently cited barriers to
education included the lack of availability of bioterrorism preparedness educational programs and the feeling of
stress or discomfort that nurses experience when thinking about bioterrorism. Not surprisingly, nurses in the
current study who are members of their facility’s disaster
planning committee reported more benefits of bioterrorism preparedness education and fewer barriers to receiving this education. Infection control and public health
nurses in the current study reported fewer barriers to receiving bioterrorism preparedness education than nurses
working in academic or clinical settings. This is likely
a result of the nature of the duties of infection control
and public health nursing and the recent emphasis on
bioterrorism preparedness in these fields, which could
translate into more financial support for these activities
and more programs offered to professionals working in
these fields.
Because the American Nurses Association has asserted
that it is the responsibility of every professional nurse to
maintain a state of professional readiness for emergencies,
it is vital that nurses in all settings have access to bioterrorism preparedness education as well as financial support
to encourage their participation. To do so, interventions
must be developed to address barriers to education identified by the Missouri nurses in the current study. More
information needs to be disseminated to nurses regarding
available bioterrorism preparedness programs as well as
educational materials related to all types of disasters. In
addition, more financial support needs to be provided to
aid nurses in pursuing these educational opportunities.
Various free educational programs are available (Centers
for Disease Control and Prevention, 1999, 2001; Institute
for Biosecurity, 2005; Willshire & Hassmiller, 2007), but
nurses may not be aware of their existence. An interesting
finding from the current study is that a large number of
Missouri nurses reported an interest in receiving bioterrorism education and identified a lack of available bioterrorism training opportunities as a barrier to receiving this
education; however, few respondents reported participating in the free CD-ROM educational program mailed to
members of MONA the previous year. It is not known
why these nurses chose not to participate in the free educational program delivered to them, yet assert that they do
not know where to obtain training materials. Future studies should focus on nurses’ access to these programs and
decision-making regarding how and when participation in
these educational programs takes place. Effective versus
noneffective communication regarding available bioterrorism education should also be studied to determine the
best ways to inform nurses about available training opportunities.
Overall, Missouri nurses included in the current
study scored poorly on the objective measure of their
bioterrorism knowledge, as was hypothesized; the average score was 73%. Nurses in this study who work at
a nonprofit agency, nurse practitioners, and those who
are members of their facility’s disaster planning committee scored higher on the bioterrorism knowledge test
than other nurses. The higher knowledge scores are most
likely related to the fact that these groups of nurses also
reported receiving more bioterrorism-related education
than the other groups of nurses. Few nurses in this study
scored high on the knowledge test (80% or greater). This
finding is similar to previously published research that
The Journal of Continuing Education in Nursing · Vol 41, No 2, 2010 75
reported on nurses’ knowledge of clinical questions related to bioterrorism and found that the level of knowledge was low (De Felice et al., 2008; Katz et al., 2006;
Rose & Larrimore, 2002).
The bioterrorism knowledge test used in the current
study was developed from bioterrorism core competencies (Gebbie & Quereshi, 2002) and thus measured a different component of bioterrorism knowledge than has
been studied before (i.e., clinical knowledge about bioterrorism agents) in nursing students in Italy (De Felice
et al., 2008). However, the findings were similar. Nurses
need to improve their bioterrorism preparedness knowledge to provide competent care during a bioterrorism
incident. Educational content should focus on the core
competencies, particularly the areas identified in the current study as being the most frequently missed.
The current study has a few notable strengths. It is
the first study to examine nurses’ perceived benefits of
receiving bioterrorism-related education and perceived
barriers to receiving this education, delineate the amount
and types of bioterrorism preparedness education that
nurses have received, and evaluate U.S. nurses’ knowledge of nonclinical bioterrorism preparedness issues.
A few limitations of the study must also be noted. One
limitation is the potential issue of nonresponder bias. Individual characteristics of the nonresponders could not
be assessed directly, a common issue in survey research.
Another limitation is that participants were all members
of MONA; thus, the findings may not be generalizable
to all nurses nationwide. It is possible that nurses in other parts of the United States or in other countries may
have responded differently to the survey questions, had
higher knowledge scores, or received more bioterrorism
education than nurses in Missouri. However, previous
research indicated that knowledge of bioterrorism preparedness in health care providers in a variety of occupations, locations, and work settings is generally poor (De
Felice et al., 2008; Kerby et al., 2005; Mosca et al., 2005;
Wisniewski et al., 2004). These findings provide some
evidence of the generalizability of the current findings.
However, the generalizability of the findings of the current study outside of Missouri or to non-nurses is unknown. In addition, the findings may not be generalizable to all nurses in Missouri. It is possible that MONA
members are different from non-MONA members in
terms of their interest in, participation in, and access to
bioterrorism preparedness education. MONA members include a wide variety of nurses working in various nursing fields or specialties and are likely reflective
of the nursing population in general, but this cannot be
known. Another limitation of the current study is the
high proportion of nurse participants who reported having a master’s degree. Exact information on the education
levels of Missouri nurses is not available, but the current
study likely includes a better-educated group of nurses
than would be expected. It seems likely that nurses with
more formal education may be more willing to complete
a survey about bioterrorism education and to have more
knowledge about bioterrorism preparedness than nurses
with less education, although this is not known. The
high proportion of participants with advanced education
may therefore limit the generalizability of the findings.
A final limitation of the current study is the use of a trueor-false test for assessing nurses’ knowledge about bioterrorism. True-or-false tests are not as effective as other
types of test design in assessing knowledge. Despite
these limitations, the current study provides beginning
work on examining nurses’ perceived benefits of bioterrorism preparedness education and perceived barriers to
this education as well as their bioterrorism knowledge.
It is important to note that the current study used a
cross-sectional design and thus cannot show a cause-andeffect relationship between any of the variables studied,
including the relationship between receiving bioterrorism
education and having bioterrorism preparedness knowledge. Prospective studies that examine knowledge gained
from a specific educational program would better inform
researchers of the effectiveness of that training. The crosssectional design used in the current study can illuminate
nurses’ behavior and attitudes toward bioterrorism preparedness at the time of the study (2006), but cannot
predict which educational programs would best prepare
nurses for a bioterrorism attack. Future studies should examine knowledge gained from educational programs so
that more effective training can be developed for nurses.
Conclusion
Bioterrorism preparedness has become essential for
nurses in all areas of expertise and practice, yet many
nurses are not participating in bioterrorism preparedness educational opportunities. Some barriers to nurses’
participation in bioterrorism preparedness education
have been outlined in the current article. Interventions
must be implemented to address these barriers so that
nurses in all specialties and work settings have access
to bioterrorism preparedness training opportunities. A
variety of educational program formats, such as in-services, lectures, journal articles, and online courses need
to be developed to meet nurses’ needs. Bioterrorism
preparedness training should be made available through
continuing education programs and also should become
a component of nursing school curricula using the identified core competencies as a basis for educational development. Participation in bioterrorism preparedness
76 Copyright © SLACK Incorporated
education should translate into higher knowledge levels
and a more competent work force.
References
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key points
Bioterrorism
Rebmann, T., Mohr, L. B. (2010). Bioterrorism Knowledge and
Educational Participation of Nurses in Missouri. The Journal of
Continuing Education in Nursing, 41(2), 67-76.
1 Nurses are integral to bioterrorism preparedness.
2 Most Missouri nurses have not received bioterrorism education.
3 Missouri nurses have little knowledge of the nonclinical
components of bioterrorism preparedness, as evidenced by
scoring poorly on a knowledge test.
4 Missouri nurses report many barriers to receiving bioterrorism
education, with a lack of knowledge about where to get training being the primary barrier.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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