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Common Domains of Core Competencies for Hospital Health Care Providers in Armed Conflict Zones: A Systematic Scoping Review

Published online by Cambridge University Press:  27 April 2020

Zakaria A. Mani Open the ORCID record for Zakaria A. Mani [Opens in a new window] ,
Lisa Kuhn  and
Virginia Plummer
Zakaria A. Mani*
Affiliation:
School of Nursing and Midwifery, Monash University, Frankston, Australia Disaster and Emergency Administration in Gizan, Ministry of Health, Saudi Arabia
Lisa Kuhn
Affiliation:
School of Nursing and Midwifery, Monash University, Frankston, Australia Monash Health, Clayton, Australia
Virginia Plummer
Affiliation:
School of Nursing and Midwifery, Monash University, Frankston, Australia Peninsula Health, Frankston, Australia
*
Correspondence: Zakaria Mani, RN, MN, PhD Candidate, Monash University, School of Nursing and MidwiferyFaculty of Medicine, Nursing, and Health Sciences, Moorooduc Highway, Frankston3199, Australia, E-mail: Zakaria.mani@monash.edu
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Abstract

Introduction:

High rates of mortality and morbidity result from disasters of all types, including armed conflicts. Overwhelming numbers of casualties with a myriad of illnesses and patterns of injuries are common in armed conflicts, leading to unpredictable workloads for hospital health care providers (HCPs). Identifying domains of hospital HCPs’ core competency for armed conflicts is essential to inform standards of care, educational requirements, and to facilitate the translation of knowledge into safe and quality care.

Objective:

The objective of this study is to identify the common domains of core competencies among HCPs working in hospitals in armed conflict areas.

Methods:

A scoping review was conducted using the Joanna Briggs Institute framework. The review considered primary research and peer-reviewed literature from the following databases: Ovid Medline, Ovid EmCare, Embase, and CINAHL, as well as the reference lists of articles identified for full-text review. Eligibility criteria were outlined a priori to guide the literature selection.

Results:

Four articles met the inclusion criteria. The studies were conducted in different countries and were published from 2011 through 2017. The methods included three surveys and one Delphi study.

Conclusion:

This review maps the scope of knowledge, skills, and attitudes required by HCPs who are practicing in hospitals in areas of major armed conflict. Incorporation of identified core competency domains can improve the future planning, education, and training, and may enhance the HCPs’ response in armed conflicts.

Keywords

armed conflictscompetencecompetencyhealth care providershospitals
Type
Special Report
Information
Prehospital and Disaster Medicine , Volume 35 , Issue 4 , August 2020 , pp. 442 - 446
Copyright
© World Association for Disaster and Emergency Medicine 2020

Introduction

Disasters of all types, including armed conflicts, are associated with high mortality and morbidity rates.1-Reference Levy and Sidel3 There were approximately 261,000 deaths in the three years from 2014-2017 reported as a direct result of 49 armed conflicts world-wide.Reference Dupuy and Rustad4

Major armed conflicts are associated with overwhelming numbers of casualties, often with unpredictable illnesses and injuries, leading to an unpredictable workload for health care providers (HCPs). Large-scale disasters are often more difficult for HCPs to manage than previous incidents they have been exposed to professionally.Reference Conlon and Wiechula5 One of the greatest challenges is that disaster and major incident preparedness have not been well-addressed in nursingReference Al Thobaity, Plummer, Innes and Copnell6,Reference Al Khalaileh, Bond and Alasad7 and medical literature.8,Reference Bajow, Djalali, Ingrassia, Ageely, Bani and Della Corte9 An understanding of the competencies necessary for HCPs to manage issues that arise from disasters is paramount to the provision of efficient and safe care, thereby reducing mortality and morbidity.

The attribution of competence to HCPs in disaster literature is defined as the basis of being effectively qualified or competent in response to all types of disasters.Reference Birnbaum and Daily10 Core competencies function as the basis of research in standards development, education, and assessment that help to maintain quality and safety in the care HCPs provide to survivors of the armed conflict and other disasters.Reference Gebbie, Hutton and Plummer11,12

Disaster core competencies for HCPs have evolved in response to necessity and over a prolonged period of time. Their development has been organic in response to a myriad of different types of disasters. The most common disaster core competencies include detection of and response to an incident, triage, understanding the use of an incident command system, isolation, surveillance and epidemiology, decontamination, communication, psychological support, care of special populations, ethics, access to resources, and documentation.Reference Hsu, Thomas, Bass, Whyne, Kelen and Green13-Reference Walsh, Subbarao and Gebbie15 These competencies are essential domains for HCPs during disaster planning, preparedness, response, and recovery.Reference Hsu, Thomas, Bass, Whyne, Kelen and Green13-Reference Walsh, Subbarao and Gebbie15

While great attention has been afforded to disaster core competency research,Reference Sangkala and Gerdtz2,Reference Bajow, Djalali, Ingrassia, Ageely, Bani and Della Corte9,Reference Hsu, Thomas, Bass, Whyne, Kelen and Green13-Reference Daily, Padjen and Birnbaum16 little is known about the evidence regarding HCPs’ core competencies in man-made disasters, particularly those working in hospitals in the context of major armed conflict. This is despite the acknowledgement that competence of HCPs in this setting is of critical importance.Reference Schultz, Koenig, Whiteside and Murray14 Therefore, the objective of this study is to identify the common domains of core competency among HCPs working in hospitals in armed conflict areas.

Method

A systematic scoping review methodology guidance that was developed by members of the Joanna Briggs Institute (JBI; Adelaide, Australia) had been adapted, which included: identifying the objective of the study; identifying the inclusion and exclusion criteria; and developing a search strategy, followed by extraction and charting of the results.17,Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares18 In addition, the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and explanation were followed (Supplementary File 1; available online only).Reference Tricco, Lillie and Zarin19 Unlike systematic review, the scoping review is a systematic approach that is conducted to present an overview or to map the available evidence underpinning research area.Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares18,Reference Tricco, Lillie and Zarin19

Inclusion and Exclusion Criteria

This review included original research articles specific to the core competencies of HCPs who practiced in hospitals in areas of major armed conflict. The Population, Concept, and Context (PCC) for conducting scoping reviewsReference Peters, Godfrey, Khalil, McInerney, Parker and Soares18,Reference Tricco, Lillie and Zarin19 was adopted: the population was HCPs, the concept was core competencies, and the context included hospital settings in areas of armed conflict.

Types of Studies

Primary research published in full text in peer-reviewed journals, in English language, over the last 10 years from 2009 through 2019, were reviewed against listed inclusion criteria. The International Council of Nursing (ICN; Geneva, Switzerland) and World Health Organization (WHO; Geneva, Switzerland) jointly published the Disaster Nursing Competencies framework in 2009, and they encourage the review and revision of core competencies. All articles that met the review aim and eligibility criteria were extracted for full-text review.

Types of Population

The population of interest included any HCPs who practiced in hospitals in areas of armed conflict, including nurses, physicians, pharmacists, medical technicians, and medical military personnel.

Concepts

Literature that focused on core competencies, competence or competency domains, knowledge, skills, and attitudes of HCPs in hospitals in areas of armed conflict were considered. The specific concept of confidence was excluded, acknowledging it is in co-relationship with the concept of competence, yet the two do not equate.

Context

The context of interest for this review was hospital settings in areas of armed conflict internationally. An armed conflict is defined as a contested incompatibility involving government and/or territory over which the use of armed force between the two military forces has resulted in at least 25 battle-related deaths.20 The contexts of the frontline and staging posts were excluded from the review as were the scenes of conflicts.

Moreover, humanitarian incidents resulting from mixed disaster and armed conflicts, or those including deployment contexts only, rather than hospital settings, were excluded.

Search Strategies

A systematic search of the databases was utilized to identify keywords in accordance with the defined PCC concepts.17,Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares18 A limited preliminary search was undertaken in Ovid Medline (Ovid Technologies; New York, New York USA) to identify the relevant keywords and subject headings. The keywords and subject heading terms identified were then added to the PCC concepts map (Supplementary File 2; available online only).

All identified keywords and subject headings were used to systematically search and obtain related articles from Ovid Medline; Ovid EmCare (Elsevier; Amsterdam, Netherlands); Embase (Elsevier; Amsterdam, Netherlands); and CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA) databases. The reference lists of the articles selected for full-text review were also reviewed for additional research papers.

Literature Identification

Systematic database searches resulted in identification of 984 articles (Ovid Medline n = 284; Ovid EmCare n = 196; Embase n = 454; and CINAHL n = 50). A total of 469 duplicated articles were deleted, leaving 515 articles, plus an additional 25 articles identified from the manual reference list search, resulting in a total yield of 540 articles. Titles and abstracts of the identified articles were each read to assess them against the defined eligibility criteria, and articles that were obviously not related or ineligible were removed. A total of 137 articles were read in full by two reviewers independently. Failure to agree between the reviewers was resolved by discussion or by adjudication from a third reviewer. Four articles met the objective of this research and were included in the scoping review.Reference Linney, Kernohan and Higginson21-Reference Oun, Hadida and Stewart24 The search strategy outcome is presented in Figure 1.

Table 1. Core Competency Domains for HCPs in Armed Conflict Areas

Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosion; HCPs, health care providers; PPE, personal protective equipment.

Results

Extracting and Charting the Result

Four research papers that examined hospital HCP core competencies in areas of armed conflict were included with data extracted into an annotated table.17,Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares18 This table was used to capture the details of authors, year of publication, country, research design, population, and core competency domains findings (Table 1).17,Reference Peters, Godfrey, Khalil, McInerney, Parker and Soares18 Due to the objective of this study and the nature and heterogeneity of the core competency domain findings, the identified domains were mapped in Table 1.

Studies reported in the selected papers were completed in four countries, including Libya, Iraq, the United Kingdom, and Northern Ireland from 2011 through 2017. The study by Linney, et al from the United Kingdom identified competencies for HCPs during armed conflicts involving chemical, biological, radiological, nuclear, and explosive (CBRNe) incidents.Reference Linney, Kernohan and Higginson21 Using an anonymized online Delphi study approach, experts reached consensus on 46 items for acute hospital HCPs, which were cross-referenced to the 10 core competencies.Reference Linney, Kernohan and Higginson21 Another study conducted by Mitchell, et alReference Mitchell, Kernohan and Higginson22 in 2012 found similar competency domains to those reported by Linney, et al.Reference Linney, Kernohan and Higginson21 Both the UK and Northern Ireland studies shared the same lead author. Mitchell, et alReference Mitchell, Kernohan and Higginson22 used a competency questionnaire in Northern Ireland and identified 10 competency domains, along with 40 competency questions: 27 were knowledge-based, eight related to skills, and five were attitude-based items.Reference Mitchell, Kernohan and Higginson22 Linney, et al and Mitchell, et al recommend a national blueprint to CBRNe competencies for HCPs to guide programs and increase consistency to reduce morbidity and mortality.

In 2012, Donaldson, et al conducted a questionnaire with emergency department physicians in Iraq during armed conflict.Reference Donaldson, Shanovich and Shetty23 A total of eight competency domains were identified in this study. The most commonly listed core competency domains were security, safety, resources management, and ambulance services.Reference Donaldson, Shanovich and Shetty23 Finally in 2017, Oun, et al implemented a questionnaire to physicians in Libya to identify the knowledge of blast injury management among hospital physicians.Reference Oun, Hadida and Stewart24 There were 10 competency domains identified,Reference Oun, Hadida and Stewart24 contributing important knowledge to management in the context of the hospital setting during armed conflict.

The terminology and structures of core competency domains were generally inconsistent among the selected papers. However, the most common core competency domains were blast and bullet injuries, CBRNe, disaster plan, command and control, safety, security, personal protective equipment (PPE), decontamination, communication, surge capacity, triage, ambulance services, transportation, and frequent drills.

Discussion

This systematic scoping review mapped the domains of core competency that were required for hospital HCPs in the context of armed conflict. Four articles included in this study reported common core competency domains. Each competency domain being a key domain for standard of care, education, and training of hospital HCPs in the context of the armed conflicts.

Hsu, et alReference Hsu, Thomas, Bass, Whyne, Kelen and Green13 developed a disaster core competencies approach for all HCPs because the nature of disaster management is related to situations requiring cooperation between HCPs. Furthermore, evidence suggested that management of man-made disasters required core competencies for all involved HCPs.Reference Daily, Padjen and Birnbaum16,Reference Miner, Childers, Alperin, Cioffi and Hunt25 Therefore, the identified core competency domains in this study are specified in armed conflict contexts and is therefore useful to inform HCP practice. However, the level of competency required for different professionals may differ depending on the situation, their role, and the tasks required of them.Reference Daily, Padjen and Birnbaum16

The most core competencies identified as essential for HCPs in armed conflicts were similar to those reported in disaster core competencies research.12,Reference Hsu, Thomas, Bass, Whyne, Kelen and Green13,Reference Daily, Padjen and Birnbaum16,Reference Al Thobaity, Plummer and Williams26,Reference Al Thobaity, Williams and Plummer27 However, some of the universal disaster core competencies of the ICN and WHO12 were not mentioned in this study. Those competencies were ethical and legal practice, care of the vulnerable population, psychological care, and long-term care for the individual and the community.

This study has highlighted several competency domains of planning and preparedness related to HCPs in armed conflicts. These domains are required for HCPs to enhance their response in armed conflict incidents effectively. For instance, when situations deteriorate suddenly in disasters, the staff should be able to respond, communicate, and manage the situations based on their knowledge, skills, and attitudes that they learned in the planning and preparedness phases.Reference Schultz, Koenig, Whiteside and Murray14 Planning and preparedness domains play an important role in mitigating risks, enhancing prevention, and reducing morbidity and mortality rates in armed conflicts. In order to enhance the ability of HCPs to initiate the disaster planning, they should participate in the planning development and demonstrate the application of the required skills in the frequent drills.Reference Al Thobaity, Plummer and Williams26,Reference Wexler, Gilbert, Hakkinen and Mohapatra28

More recent attention has focused on the CBRNe management in armed conflicts. A number of authors have identified competency domains of CBRNe management in this study.Reference Linney, Kernohan and Higginson21,Reference Mitchell, Kernohan and Higginson22 Those domains included identifying the signs and symptoms of patient exposure to CBRNe, how to perform decontamination effectively, and how to manage contaminated waste. Another essential competency is staff understanding of how and when to use PPE properly to protect themselves, patients, and others. This was considered to be a crucial core competency in the research described by MartinReference Martin29 and Veenema, et alReference Veenema, Walden, Feinstein and Williams30 that enhanced the readiness of the staff to safely respond to disasters. Familiarity of using decontamination equipment and procedures was required for HCPs to maintain their own and patient safety.Reference Al Thobaity, Plummer and Williams26

There are relatively few studies investigating HCP competence in the context of armed conflict. A possible explanation for this may be the dynamic and changing nature of armed conflict fieldwork and potential risks to researcher safety and security. Therefore, there is abundant room for further research in the armed conflict context. Future studies in different types of armed conflict and in different hospital and health care types, focusing on the range of vulnerable groups and employing various methods such as comparative studies, are recommended.

Limitation

This systematic scoping review included literature written in English only. Only peer-reviewed primary literature was included, and therefore, secondary resources and grey literature were excluded.

Conclusion

This is the first systematically conducted scoping review that identifies common core competency domains for hospital-based HCPs in areas of armed conflict. It provides a map of the evidence on the essential scope of knowledge, skills, and attitudes required for hospitalized HCPs in armed conflict areas. The identified common competency domains for HCPs included management of blast and bullet injuries, CBRNe, disaster plan, command and control, safety, security, PPE, decontamination, communication, surge capacity, triage, ambulance services, transportation, and frequent drills. Future development on implementation of these core competency domains as the standard of care, supported by workplace education and drills for hospital HCPs, is likely to enhance outcomes of response to armed conflicts.

Conflicts of interest

none

Supplementary Material

To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X20000503

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Figure 0

Table 1. Core Competency Domains for HCPs in Armed Conflict Areas

Figure 1

Figure 1. Flow Diagram of Search Results.18

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