1. Introduction
Disasters are events that disrupt the daily activities of people and result in economic and human losses [1]. Turkey, despite being a country that prone to disasters, has lower ability to deal with disasters [2]. Disasters put immense strain on healthcare resources [3, 4]. In the event of a disaster, healthcare workers paly important role in abating the negative effects of disasters on the survivors [3, 5]. Nurses are one of the most important human resources in combating the after-effects of the disasters. They have important roles such as preparedness and intervention against disasters, effective management, delivering healthcare following a disaster, and working for the health and wellbeing of society [6, 7]. They also have special roles in long-term disaster recovery. In the event of a disaster, the executives, decision makers, and public healthcare workers are thought to have willingness [8] or obligation [4] to work. In the United States, a study showed that 25 nurses were suspended or terminated from their jobs due to their unwillingness to work after Hurricane Francis [4]. During the severe acute respiratory syndrome epidemic in 2004 in Hong Kong, 16% of family physicians spent less time with patients, 7% avoided to perform physical examinations, and 19% of physicians working in public clinics stayed at home to protect their families from the epidemic [9]. A study in Qatar showed that 88.1% of the nurses stated their willingness to take care of COVID-19 patients, while 11.9% stated their unwillingness. The two significant predictors of nurses’ willingness are knowledge level and expected remuneration [10]. Additionally, studies have shown that having family members in need of care is an important factor in nurses’ willingness to work during disasters [4, 11, 12, 13, 14].Nurses may express their unwillingness to work in situations where they are unable to hear from their families. They may feel tired or psychologically unwell because of their working conditions; these can also affect their willingness to work during disasters [15]. 
In the case of extensive damage from a disaster, nurses are expected to face shortages, have multiple tasks, and work with damaged equipment. In such situations, competency is more important. Nurses who are expected to work where there is lack of resources must have adequate knowledge of disasters and ability to apply their knowledge [16]. If there were no nurses with willingness to work during a disaster, it would be impossible to have effective disaster response. Therefore, willingness and competence are equally important. Even if be sufficiently capable, nurses with unwillingness to work are likely to be unable to efficiently respond to a disaster which shows the importance of determining their willingness and competency [17]. 
Despite the existence of studies that consider willingness and competence of nurses together [18, 19, 20, 21], there is a need for more considerations in a wider scale. No study was found in Turkey that tackles these considerations. Therefore, this study aims to determine the willingness and competence of nurses in public hospitals of Bolu city in Turkey, find socio-demographic and other factors related to their willingness and competence, and assess the relationship between their willingness and competence during disasters.

2. Materials and Methods
Study design and samples
This is a descriptive epidemiological study. The study population comprised of 599 nurses working in public hospitals of Bolu city; 318 in Izzet Baysal State Hospital (Central Unit, Obstetrics and Pediatrics Unit, Köroglu Unit), 57 in AIBU Izzet Baysal Physical Treatment and Rehabilitation Training and Research Hospital (Central Building, AIBU Building), 167 in AIBU Izzet Baysal Training and Research Hospital, and 57 in AIBU Izzet Baysal Mental Health and Illnesses Training and Research Hospital. No permission could be obtained from AIBU Izzet Baysal Mental Health and Illnesses Training and Research Hospital to distribute the questionnaires. Therefore, 57 nurses working in this department were excluded. Of the remaining 547 nurses, 311 (56.8%) were able to be included in the study. Because the study was based on voluntary participation, no sampling was conducted.

Study variables
Independent variables were socio-demographic characteristics of nurses (age, gender, hobbies, phobias, etc.) and their disaster-related characteristics (experience of a disaster, knowledge of disaster, etc.). Dependent variables were nurses’ willingness to work during disasters and nurses’ competence.

Data collection tools
Data were collected from 15/11/2019 to 15/02/2020. After obtaining informed consent from the volunteered nurses and providing necessary information to them, the data collection tools were distributed among them. In order to collect data, a researcher-made 35-item questionnaire for assessing willingness to work during disasters and the questionnaire assessing basic competences of nurses in preparation for disasters [22] were used. In the willingness to work during disasters questionnaire, there were 15 items surveying socio-demographic characteristics, 2 items surveying hobbies and phobias, 8 items surveying the experience of working during disasters, 3 items assessing the health status, 3 items about family, and 4 items assessing willingness to work in disasters (total of 35 items). Using 15 items rated on a three-point Likert scale (1=Disagree, 2=No idea, and 3=Agree), the total score of the questionnaire was determined. Higher score indicates higher willingness.
The questionnaire assessing basic skills of nurses for preparation for disasters has 45 items prepared based on competences recommended by International Nursing Coalition for Mass Casualty Education [23]. Its subscales include critical diagnostic skills (Items 1-4), special diagnostic skills (Items 5-23), general diagnostic skills (Items 24-27), technical skills (Items 28-37), and communication skills (Items 38-45). The items are rated based on a five-point Likert scale as follows: 1=Needs to be taught, 2=I can do it with help, 3=I can do it, 4=I can do it easily, 5=I can do it and teach others. The total score ranges from 45 to 225. Higher scores represent higher preparedness for disasters. Reliability of this scale has been examined using correlation test, Cronbach’s alpha coefficient, and test-retest method. Total score correlation coefficient of the scale is between 0.27 and 0.81, and its Cronbach’s alpha coefficient is 0.96 [22].

Statistical analysis
The data collected from 311 nurses entered into SPSS v. 21 software. Normality of the data distribution was examined by calculating kurtosis and skewness coefficients; the coefficients with values between -1.5 and +1.5 indicate normal distribution of data [24]. Homogeneity of variance was tested by Levene’s test. Since all independent variables were observed to have normal distribution, the mean differences of independent variables with two subcategories were analyzed using t-test, while the mean differences of independent variables with three or more subcategories were analyzed using ANOVA. Effects of independent variable on dependent variable was measured with eta squared (ƞ2) coefficient which ranges between 0 and 1; ƞ2=0,01 represents small effect size, ƞ2=0,06 represents medium effect size, and ƞ2=0,14 represents large effect size [25]. 
Due to the normal distribution of data, the relationship between two study variables was examined using Pearson correlation test whose results were interpreted using the method proposed by Kirk [26] and Büyüköztürk [25] where r ≥0.90 represents very high correlation, r=0.70-0.89 represents high correlation, r=0.69-0.30 represents medium correlation and r ≤0.29 represents low correlation. Cronbach’s alpha coefficient was used for determining the reliability of the instruments that were used in the study. Its value for the questionnaire of willingness to work during disasters was obtained 0.96; for the questionnaire of competences, it was obtained 0.98.

3. Results
Participants had a mean±sd age of 33.86±8.4 years, ranged 20-58 years. Most of participants were female (n=265, 85.2%), married (n=205, 65.9%), and with a bachelor’s degree (n=221, 71.3%). Participants were mostly working in the emergency departments (n=33, 14.2%). The mean±sd work experience of nurses was 12.48±9.24 years (ranged from 1 to 40 years) years. Most of them had a work experience of 16-40 years (n=101, 32.5%). Most of them (n=226, 73.9%) reported that they were enjoying their work as a nurse. The income level of most of participants (n=192, 61.9%) was moderate. Most of them (n=188, 60.5%) had children and 76 nurses stated that their children were the most important reason that refrained them from working in disasters. Most participants (n=294, 94.5%) had received disaster training either from their organization or from other resources. Most participants (n=188, 60.6%) had knowledge of the hospital disaster plan (HDP) and 32.7% had active roles in the HDP. 
Most of participants (n=152, 49%) had no idea about working during disasters. Earthquake was the most prevalent disaster where the participants had willingness to work (n=148, 47.6%), while infectious diseases were the least common disaster where participants wanted to work (n=137, 44.1%). In the questionnaire of competences, the most common answer was “I can do it”.
Female nurses had a mean willingness score of 29.79 while male nurses had a willingness score of 32.74. This difference statistically significant (t=-2.04; P<0.05). The mean willingness score of single and married nurses was 31.69 and 29.47, respectively. This difference was statistically significant (t=2.05; P<0.05). Marital status could explain 1% of the variance in total willingness score (ƞ2=0.01) (Table 1).

According to the results in Table 1, the mean willingness score of nurses with phobias (22.28) was found to be significantly lower than that in nurses without phobias (31.82) (t=3.48; P<0.05). Phobias explained a small part of variance in total willingness score (ƞ2=0.04). The mean willingness score of nurses with hobbies (33.69) was found to be significantly higher than that in nurses without hobbies (29.06) (t=-3.98; P<0.05). Hobbies explained a small part of variance in total willingness score (ƞ2=0.05). The mean willingness score of nurses with children (29.26) was found to be significantly lower than that in nurses without children (31.71) (t=2.34; P<0.05). Having children explained a small part of variance in total willingness score (ƞ2=0.02). The mean willingness score of nurses with family member who discouraged them from working during disasters (27.01) was found to be significantly lower than that in nurses with no preventing member (31.58) (t=4.14; P<0.05). It explained 5% of the variance in total willingness score (ƞ2=0.05). The mean willingness score of nurses with membership in NGOs (38.8) was found to be significantly higher than that in nurses without NGO membership (29.94) (t=-3.07; P<0.05). NGO membership explained 3% of the variance in total willingness score (ƞ2=0.03).The mean willingness of nurses who had knowledge of HDP (31.15) was found to be significantly higher than that in nurses with no knowledge of HDP (28.80) (t=-2.24; P<0.05). Knowledge of HDP explained 2% of the variance in total willingness score (ƞ2=0.02).
The willingness scores based on vocational experience (F(3,307)=2.22; P>0.05) and age (F(2,308)=1.93; P>0.05) were not statistically significant. The mean willingness scores based on educational level were as follows: 31.03 for nurses with high school education, 29 for nurses with an associate degree, 30.53 for nurses with a bachelor’s degree, and 27 for nurses with a postgraduate’s degree. The willingness scores based on educational level were significantly different (F(3,306)=1.05; P>0.05). The mean willingness scores based on the income level were as follows: 29.17 for low-income nurses, 30.29 for middle-income nurses, and 30.94 for high- income nurses. The willingness scores based on the income level (F(2,307)= 0.56; P>0.05) and based on working departments were not statistically different (F(18,213)=1.06; P>0.05) (Table 2).

The competence scores of female nurses (124.49) was found to be significantly lower than that in male nurses (138.22) (t=-2.46; P<0.05). Nurses’ gender explained 2% of the variance in total competence score (ƞ2=0.02). The competence scores of single and married nurses was 132.48 and 123.43, respectively. This difference was statistically significant (t=1.99; P<0.05). Marital status explained 2% of the variance in total competence score (ƞ2=0.02). The competence score of nurses with hobbies (135.88) was found to be significantly higher than that in nurses without hobbies (123.38) (t=-2.75; P<0.05). Hobbies explained a small portion of variance (5%) in total competence score (ƞ2=0.05). The competence score of nurses who had roles in HDP (135.53) was found to be significantly higher than that in nurses with no roles in HDP (122.19) (t=-3.16; P<0.05). Having a role in HDP explained 3% of the variance in total competence score (ƞ2=0.03) (Table 3).

Age, educational level, income, vocational experience, or hospital department were not found to have any significant relationship with competence of nurses (P>0.05) (Table 4).

A low correlation was observed between competence and willingness (r=0.19, P=0.01).

4. Discussion
In recent years, disasters have caused more damages to our country and other countries worldwide. Magnitude and frequency of both man-made and natural disasters are increasing over time [27]. Nurses, who constitute the largest group of healthcare workers, play important role in saving lives during unforeseen disasters. Therefore, as the frequency of disasters increases, the need for medical resources and nursing workforce increases [28]. In this study, it was found out that 49% of nurses were undecided about working during disasters. Therefore, it is necessary to develop interventions to this group to increase their willingness. Most of nurses had willingness to work in case of earthquake (n=148, 47.6%) while infectious disease pandemic was the least favorable disaster (n=137, 44.1%). This indicated that their willingness to work was lower in cases of disasters that pose a risk to their personal health. They were more willing to work during disasters that affect other members of society, and had no tendency to put themselves or their loved ones at risk. Many studies have been conducted on the effects of different disasters on willingness to work [4, 29, 30, 31, 32, 33, 34]. 
In this study, the nurses who were single, male, with no phobias, with hobbies, with no children, with no one to discourage them, with membership in NGOs, and with HDP knowledge had more willingness to work during disasters. Fung et al. showed that males had no willingness to work during disasters compared to females, especially during infectious disease pandemics [11]. Other studies had similar results compared to our study [4, 31, 34, 35, 36]. This result was also valid with respect to having competence to work during disasters. Our results showed that male nurses had significantly higher competency compared to female nurses. This may be because women also have to do childcare and housework. On other hand, man are more active outdoor due to social roles. In Turkey, during COVID-19 pandemic, the notice of “flexible work hours and administrative leave” for healthcare personnel was sent to governorships of all 81 major cities by the Ministry of Health [37]. In this notice, there was no attention to gender sensitivity, while gender is a factor affecting willingness and competence of healthcare workers to work during disasters. A study on 888 healthcare workers by Burke et al. showed that single nurses were 1.5 times more willing to work during a disaster [38]. This may be due to the fact that married nurses have more household responsibilities. As it was indicated, nurses with no children had significantly more willingness to work during disasters. 
It was observed in this study that disaster training was not a significant factor for the willingness and competence of nurses. This needs more in-depth studies for further understanding. Contrary to this study, Lanziolotti et al. found that doctors and nurses with more information on biological agents were more willing to work during biological disasters [32]. Additionally, a study by DiMaggio et al. showed that healthcare workers with prior disaster training were more willing to work during radiological, chemical, and biological disasters [39]. There are other studies that have shown that nurses with disaster training have better understanding of disaster preparedness [20, 30, 40]. It was observed in our study that disaster experience was not a significant factor for the willingness and competence of nurses. Contrary to this result, a study in Yemen by Al-Hunaish et al. showed that prior experience of disasters was the significant factor of willingness to work during infectious disease pandemics [31]. Evaluation of this result by further studies can be beneficial. 
In a study by İnal and Kaya, NGO membership was found to be a factor affecting the willingness to work [41], which is consistent with our results. Disaster-related NGOs play important roles in preparation, damage control, intervention, and recovery during disasters. Therefore, the membership in this organizations can be effective in clarifying the responsibilities of nurses during disasters and increasing their awareness. In our study, the nurses who had someone that can discourage them from working during disasters had significantly lower willingness. Similar to this result, many studies have shown that having a dependent person is a significant factor on willingness to work during disasters [4, 11, 12, 14, 31, 42, 43, 44]. One study showed that 21% of healthcare workers believed that the nurses without children should be first responders during a flu pandemic [44]. HDP knowledge was another significant factor that affected the willingness and competence of nurses; those with a knowledge of HDP were better aware of their responsibilities and, therefore, had more willingness. This is consistent with other studies [30, 45].
Although most nurses stated that they had competency to accomplish most tasks by themselves, there is a need to improve their skills. The plans for disaster training should include materials that can improve nurses’ competence. In a study by Back and Alfred, it was found that most nurses had a lower perception of their skills for intervening during a disaster and that their perception scores were lower than average [18]. In a study by Zeren, a positive relationship was found between critical thinking and general diagnostic skills, and between critical thinking and technical skills [46]. Based on these results, nurses’ skills should be comprehensive. Therefore, it is important that nurse learn all related skills and put apply them thoroughly. Nurses stated high confidence in their abilities during natural disasters, but low confidence in their abilities during hazardous material incidents and in terror attacks or wars. It can be extrapolated that since earthquakes are the most common disasters in Turkey, their awareness and competence in preparation during earthquakes is higher [47]. Back and Alfred showed that competent nurses were more likely to have real life experience of working during disasters and in shelters [18].
In the present study, nurses participating in HDP programs had higher competence to work during disasters. This result was expected as HDPs are important tools for reinforcing duties and responsibilities during disasters. In a study that evaluated preparedness of nurses in a public hospital, comparison of basic preparedness skills of nurses based on their gender, marital status, and educational level showed no significant difference, while comparison of their skills based on age, vocational experience, working department, and disaster experience revealed a significant difference [48]. On the other hand, Jiang et al. showed the importance of nurses’ working department, prior education, current state of employment, and attitude as the indicators of their competence [49]. Furthermore, our results showed that nurses with hobbies had higher competence. Activity and mobility can make problem-solving faster during disasters. No any studies was found on investigating the effect of hobby variable to compare the results. 
In this study, a correlation was found between nurses’ competence and willingness. This indicates that the steps taken for increasing nurses’ competence can increase their willingness. Other similar studies also found that willingness of nurses to work during a disaster is an important indicator of their competence in disaster preparedness [18, 20]. Some studied have also shown that knowledge and willingness have a positive relationship with each other [10, 50, 51].
This study had some limitations. It is limited to nurses employed in public hospitals in the center of Bolu city; therefore, the results cannot be generalized to the whole population of the country.

5. Conclusions
Most nurses in Turkey are undecided about working during disasters. They are mostly willing to work during an earthquake, while are less willing to work during pandemics. There is a low correlation between nurses’ competence and willingness to work during disasters. Any steps that are taken for increasing their competence can increase their willingness. Medical centers should consider that nurses have willingness to work during different disasters and should appoint them based on the situation. The centers can provide childcare or elderly care services to the nurses to increase their willingness and competence in working during disasters. They should consider the nurses’ marital status and that whether they have children or not. Nurses should be given active roles in HDP programs and have updated information about the subject. Willingness and competence of working during disasters should be examined together and appropriate legal and practical measures should be taken in the field. Because of gender role beliefs, male nurses have more willingness and competence to work during disasters. Therefore, gender sensitivity should be taken into account in the selection of nurses to work during disasters.

Ethical Considerations
Compliance with ethical guidelines
Permission of the ethics board (Protocol No: 2019/49) was acquired for the conduct of this study by Çanakkale Onsekiz Mart University School of Graduate Studies. Permission to use “Basic Qualifications Scale in Nurses' Preparedness for Disaster” for measurement was acquired.

Funding
The paper was extracted from the MSc thesis of the first author, Department of Disaster Education and Management, Graduate Education Institute, Çanakkale Onsekiz Mart University 

Authors' contributions
Conceptualization and Supervision: Ebru Inal Onal; Methodology: Both authors; Investigation, Writing-original draft, and Writing-review & editing: Both authors; Data collection: Kübra Gizem Kugum; Data analysis: Both authors.

Conflict of interest
The authors declared no conflict of interest.


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