Introduction
There has been a considerably heightened focus on preparation for disasters within health care since the terrorist attacks of September 11, 2001 in New York (USA). Other recent global disasters include pandemics and natural disasters, including tsunamis, earthquakes, and hurricanes.Reference Gowing, Walker, Elmer and Cummings 1 Health professionals and health support staff have a responsibility to respond to disasters to preserve the safety of the community.Reference Al Khalaileh, Bond and Alasad 2 - Reference Abatemarco, Beckley, Borjan and Robson 5 Internal disasters affect health services, whereas external disasters impact the need for health care; for example, infectious disease outbreaks or other mass-casualty incidents.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 - Reference Nyamathi, Casillas and King 9 Health professionals include the professions of nursing, medicine, dentistry, pharmacy, other allied health professionals, paramedical or emergency medical technicians (EMTs), public health workers, hospital scientists, and other occupations which are commonly considered to be health professionals. Support staff include the non-health professional staff who work in health care services, including cleaners, security guards, orderlies, nursing assistants, food services assistants, cooks, chaplains, clerical staff, and other staff commonly considered health support staff.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Bartley, Fisher and Stella 10
This integrative literature review aimed to review both qualitative and quantitative research to gain a current understanding of research conducted and the current state of knowledge.Reference Tebruegge, Pantazidou and Ritz 11 , Reference Whittemore and Knafl 12 The review will be used to inform future research and the development of knowledge which can be used by health services, professionals, or disaster planers to better prepare health professionals and support staff for disasters.
Report
Methods
A keyword search from January 1, 1980 to the present, using Cumulative Index of Nursing and Allied Health Literature (CINAHL; produced by EBSCO Information Services; Ipswich, Massachusetts USA), Medline database via OVID (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), JBI Connect (Johana Briggs Institute; University of Adelaide; South Australia), Cochrane database (The Cochrane Collaboration; Oxford, United Kingdom), ERIC (Educational Resource Information Centre; Institute of Education Sciences; Washington, DC USA), and ProQuest Social Sciences Journals (Ann Arbor, Michigan USA) was conducted in February 2015. The articles selected from the above searches (based on tittle, keyword, and abstract review) resulted in a total of 117 articles after duplicates were removed (Table 1).
Table 1 Literature Review Search Strategy
Abbreviation: MMAT, mixed-method appraisal tool.
a Research articles, focused on preparation of health professionals or support staff
b 50% MMAT score determined for inclusion after consultation with doctoral supervisors.
Eighty-two articles were discarded during full reading and quality appraisal of articles primarily as they were not on the topic (eg, focused on health services rather than professionals/support staff); they were not primary research articles; or they did not receive a mixed-method appraisal tool (MMAT) score of 50% or higher when quality appraised. The MMAT has been developed to appraise qualitative, quantitative, or mixed-method studies.Reference Kumar 13 For the purposes of this review, research articles needed to achieve a MMAT score of 50% or higher to be included. This provided a balance of including quality research and having adequate volume to allow a broad exploration of themes and methods identified in existing research. A total of 36 primary research articles were included in the integrative review.
Review and analysis of the main themes, research methods, and findings was undertaken for 36 articles, including the identification of gaps in knowledge. A data table was created based on this review, which is available from the primary author.
Results
Thirty-six articles were selected for inclusion in the review, of which 28 articles were quantitative, eight were qualitative, and there were no mixed-method studies. Only five articles were rated as 100% using the MMAT and a further 15 were rated at 75% (missing one of the criteria). Sixteen were rated at 50% (missing two criteria), and studies rated below this were not included in the review (Table 2). Overall, there was a lack of quality of research articles that reported investigating preparation of health professionals and support staff for disasters.
Table 2 MMAT Ratings of Reviewed Literature
Abbreviation: MMAT, mixed-method appraisal tool.
Of the 28 quantitative researches evaluating disaster preparedness interventions only, two were randomized controlled trials.Reference Olson, Scheller, Larson, Lindeke and Edwardson 8 , Reference Pace, Pluye and Bartlett 14 One was a small study of only 14 emergency medical residents,Reference Pace, Pluye and Bartlett 14 and in the second, participants were selected from one university nursing school.Reference Olson, Scheller, Larson, Lindeke and Edwardson 8 Although participants were randomized into a control or intervention group, the results were not generalizable due to the bias created by the small sample size or the selection pool of participants.Reference Olson, Scheller, Larson, Lindeke and Edwardson 8 , Reference Pace, Pluye and Bartlett 14
The majority of quantitative studies included in this review were pre- and post-test studies or post-test studies using a convenience sample and a single cohort.Reference Baack and Alfred 4 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Yang, Xiao, Cheng, Zhu and Arbon 7 , Reference Nyamathi, Casillas and King 9 , Reference Andreatta, Maslowski and Petty 15 - Reference Chiu, Polivka and Stanley 26 These studies demonstrated that any intervention improves perceived disaster preparedness or knowledge/behavior in disasters exercises or post-tests. A weakness of these studies was that they involved a single, non-randomly selected sample, and the interventions couldn’t be compared to other interventions for effectiveness. Therefore, the results couldn’t be generalizable due to the non-random selection and single group design. The interventions couldn’t be validated as they were not compared to a control group.Reference Al Khalaileh, Bond and Alasad 2 , Reference Baack and Alfred 4 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Yang, Xiao, Cheng, Zhu and Arbon 7 , Reference Nyamathi, Casillas and King 9 , Reference Andreatta, Maslowski and Petty 15 - Reference Chiu, Polivka and Stanley 26
The remaining 10 quantitative studies collected data using surveys or tests which evaluated the health professionals’ or support staff’s attitudes, knowledge, perceived knowledge, or intended behaviors towards disasters.Reference Gowing, Walker, Elmer and Cummings 1 - Reference Robison 3 , Reference Bartley, Fisher and Stella 10 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 - Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32 The studies were non-randomized, convenience samples, so caution was required before applying these learnings to disaster preparedness at other sites and in other contexts.Reference Gowing, Walker, Elmer and Cummings 1 - Reference Robison 3 , Reference Bartley, Fisher and Stella 10 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 - Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32
Eight of the research articles included in the literature review were qualitative articles, and of these, three collected data using questionnaires or surveys with qualitative open-ended questions; three included interviews; and two involved focus groups (Table 3).Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33 - Reference Djalali, Ingrassia and Corte 39 A strength of these studies was that they were able to identify data on the preparedness needs of health professionals, including those that had participated in disasters or from those considered to be experts.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33 - Reference Djalali, Ingrassia and Corte 39
Table 3 Methodology in Reviewed Literature
Analysis
The content and methods of disaster preparedness were extracted from the research articles. In terms of content, studies evaluated types of preparedness programs and assessed health professionals’ knowledge and skills they believed they need, either in anticipation for or following disasters. Broadly, some studies identified that either clinical or technical disaster skills combined with structural disaster knowledge are important.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Nyamathi, Casillas and King 9 , Reference Worrall 16 , Reference Qureshi, Gershon and Merrill 21 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 Some studies focused on only clinical or technical disaster preparedness.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Worrall 16 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Arbon, Ranse and Cusack 33 Additionally, some studies identified that content could be based on national or international competencies.Reference Reznek, Smith-Coggins and Howard 20 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Arbon, Ranse and Cusack 33 , Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38 , Reference Djalali, Ingrassia and Corte 39 The methods of disaster preparedness programs included online learning, didactic, self-learning, disaster exercises, or blended learning involving more than one method of teaching or learning. All of the methods of preparation led to an improvement in perceived disaster preparedness, disaster knowledge, or attitudes.Reference Robison 3 - Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Yang, Xiao, Cheng, Zhu and Arbon 7 - Reference Nyamathi, Casillas and King 9 , Reference Pace, Pluye and Bartlett 14 , Reference Andreatta, Maslowski and Petty 15 , Reference Wetta-Hall, Berg-Copas, Jost and Jost 17 - Reference Chiu, Polivka and Stanley 26 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Nasrabadi, Naji, Mirzabeigi and Dadbakhs 37
Two pre-developed tools were used and repeated in the quantitative research articles included in the review to measure preparedness or perceived preparedness for disasters. One tool, the “Emergency Preparedness Information Questionnaire” (EPIQ), focuses on the measurement of perceived preparedness of nurses for disasters.Reference Robison 3 , Reference Andreatta, Maslowski and Petty 15 , Reference Melnikov, Itzhaki and Kagan 28 A second tool, the “Simple Triage and Rapid Treatment System” (START), focuses specifically on measuring performance during disaster triage for health professionals.Reference Pace, Pluye and Bartlett 14 , Reference Chiu, Polivka and Stanley 26
Primary research also measured attendance at work during disasters or perceived willingness to attend work for health professionals and support staff. The factors influencing this could vary and will be outlined later; however, this was important to consider as significant numbers of staff may not attend work during disasters, which would influence the capacity of health systems to effectively manage disasters.Reference Robison 3 - Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Bartley, Fisher and Stella 10 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Glow, Colucci, Allington, Noonan and Hall 23 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Fung, Loke and Lai 30 , Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32
The main themes were extracted from the research articles included in the review. There was evidence that health professionals and support staff are underprepared for disasters.Reference Robison 3 - Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Andreatta, Maslowski and Petty 15 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Chiu, Polivka and Stanley 26 - Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36 , Reference Nasrabadi, Naji, Mirzabeigi and Dadbakhs 37 These themes are elaborated upon in the following discussion.
Discussion
Health Professional and Support Staff Preparedness
Research studies indicate that health professionals and support staff may not be adequately prepared for disasters. Studies often cited an increased focus on disaster preparedness following the terrorist attacks of September 11, 2001, so this under-preparedness may be in spite of an increased focus on preparedness in recent years. It is important to note that most research conducted has been evaluating nursing, medical, public health, or ambulance staff, so there is less understanding of other health professionals and support staff preparedness or disaster knowledge.Reference Gowing, Walker, Elmer and Cummings 1 , Reference Robison 3 - Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Andreatta, Maslowski and Petty 15 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Chiu, Polivka and Stanley 26 - Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Burke, Goodhue, Chokshi and Upperman 31 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36 , Reference Nasrabadi, Naji, Mirzabeigi and Dadbakhs 37
The health care response for various types of disasters can be different. Health professionals and support staff may vary in their level of preparedness or perceived level of preparedness depending on the type of disaster. Several surveys of nursing and medical staff in the United States, Jordan, China, Israel, Hong Kong, and Iran indicate that while perceptions of preparedness can be low for disasters, health professionals and support staff can feel less prepared for one form of disaster over another or with aspects of managing disasters.Reference Gowing, Walker, Elmer and Cummings 1 , Reference Robison 3 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Andreatta, Maslowski and Petty 15 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 - Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Burke, Goodhue, Chokshi and Upperman 31 For example, three studies which all used the EPIQ tool to evaluate perceived preparedness of nurses in relation to a range of disaster situations identified that while preparedness was generally low, nurses felt less prepared for biological disasters and quarantine procedures.Reference Robison 3 , Reference Andreatta, Maslowski and Petty 15 , Reference Melnikov, Itzhaki and Kagan 28
The perceived or actual knowledge or skills required for disasters may be inadequate, even for tasks which may be considered routine during normal care. For example, EMTs felt unprepared to use a respiratory mask during a bioterrorism exercise and physicians, nurses, and EMTs were unable to accurately triage trauma patients using the START system during exercises.Reference Baack and Alfred 4 , Reference Chiu, Polivka and Stanley 26 It is important that health professionals and support staff are prepared to use skills in the disaster situation when the outcomes of not being prepared may be more significant for the patient or health care worker.Reference Baack and Alfred 4 , Reference Chiu, Polivka and Stanley 26
The skills needed to care for patients in the disaster situation can also be different than in routine settings.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36 During care in remote locations following earthquakes, Registered Nurses (RNs) can feel overwhelmed and underprepared to provide the care required. The injuries can be beyond the scope of normal emergency nursing care, and this can be confounded by working in the absence of normal hospital resources.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36
During disasters, it is necessary to work outside normal practice areas and with disciplines and specialists that one does not normally work with. It is important that health professionals and support staff are also prepared for the psychological aspects of disasters. Staff may not be adequately prepared to cope with psychological aspects of disasters; for example, providing psychological support.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Nasrabadi, Naji, Mirzabeigi and Dadbakhs 37
Staff must also be prepared to care for themselves and their families during disasters. Staff may need to walk for hours, carry heavy equipment, sleep in tents, use improvised bathroom facilities, and eat food from ration packs.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33 A study of support or ancillary staff identified the main concern following disaster training was how to tell their family members that they would be involved in providing disaster care.Reference Abatemarco, Beckley, Borjan and Robson 5 Physical fitness, practice in disaster environments, and personal disaster planning will likely improve performance in these situations.
The research conducted, to date, indicates that, despite an increased focus on disaster preparedness in recent times, health professionals and support staff could further improve their preparedness for the safety of the community and themselves. There is a need to further evaluate the preparedness of health professionals and support staff to determine their level of preparedness for disasters of various types. It is important to understand the preparedness of all health care disciplines, which may be required to provide disaster care, and it is noted that the research reviewed was limited to a focus on medical, nursing, paramedical/EMT, and public health staff.Reference Baack and Alfred 4 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference McKibbin, Sekula, Colbert and Peltier 29
Disaster Content
Disaster education programs outlined and evaluated in the research articles can be broadly divided into three types of programs: those that are based on established competencies;Reference Andreatta, Maslowski and Petty 15 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38 , Reference Djalali, Ingrassia and Corte 39 those that cover clinical or technical knowledge;Reference Baack and Alfred 4 , Reference Worrall 16 , Reference Chiu, Polivka and Stanley 26 and programs which cover clinical, technical, or structural disaster knowledge.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Nyamathi, Casillas and King 9 , Reference Andreatta, Maslowski and Petty 15 , Reference Wetta-Hall, Berg-Copas, Jost and Jost 17 , Reference Subbarao, Bond, Johnson, Hsu and Wasser 19 - Reference Pryor, Heck and Norman 22 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 34 , Reference Djalali, Ingrassia and Corte 39 An additional area of content, which is predominantly explored in qualitative research which allowed health professionals with experience working in disasters to highlight important skills for them, is that of non-clinical and non-technical skills or abilities that can enhance the performance of health professionals during disasters. These skills could be described as the human skills, such as resilience, team work, and physical fitness, that enable health professionals to work well in disasters.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33
Established Competencies
Using training programs based on national standards or competencies to prepare staff can have benefits for both the community and health professionals and support staff. The community needs to be aware that they are safe to receive care from health professionals or facilities at all times, including during disasters.Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38 Health professionals also benefit when they have defined standards to learn and work from. If a different level of care is to be provided during times of disaster, then it will protect both the health professional and the community if this level of care is advocated as part of training or preparation based on national standards or competencies.Reference Reznek, Smith-Coggins and Howard 20 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38
A good example to highlight this is the care provided during pandemics or mass-casualty disasters. If patients are given different care during disasters, as it is perceived to be in interest of the individual or community, then it is best that this is based on a national competency rather than the individual clinical opinion of individuals, aid groups, or institutions.Reference Reznek, Smith-Coggins and Howard 20 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38 During the international response to the 2010 Haiti earthquake, it has been noted that some aid groups were not providing care to usual standards, including having properly qualified personnel or equipment to perform the expected care required, including sterilization of equipment between procedures.Reference Hawley, Hawley, Ablah, St Romain, Molgaard and Orr 38 It is important that during times of disaster, health professionals and support staff are properly qualified and prepared for and perform to national or international standards.
Clinical or Technical Skills
To help individual patients during disasters, health professionals and support staff need the clinical or technical skills to provide this care.Reference Baack and Alfred 4 , Reference Worrall 16 , Reference Chiu, Polivka and Stanley 26 Pre- and post-test quantitative single cohort studies suggested training programs provide useful information for health professionals related to clinical or technical skills. An example of a clinical skill which is important during mass-casualty disasters is triage. Effective triage means that the greatest number of patients will receive life-saving treatment within the time frame required by each disease or condition.Reference Chiu, Polivka and Stanley 26 Training programs designed to improve disaster triage for nursing, EMT, or medical residents significantly improved triage accuracy in post-test or virtual reality simulated exercises in three studies.Reference Al Khalaileh, Bond and Alasad 2 , Reference Pace, Pluye and Bartlett 14 , Reference Chiu, Polivka and Stanley 26 Triage and other clinical skills, including hydration and pain management, were improved by 30% in a post-test following disaster burn care education.Reference Worrall 16 While there is no research demonstrating improved performance in real disasters, theoretically, if clinicians applied the learnings to a real disaster, lives could be saved.
Another example of an essential clinical skill to reduce mortality and morbidity during bioterrorism or a pandemic is the wearing of masks and other personal protective equipment (PPE) for paramedics and EMTs. Following the respective educational programs designed to provide information on when to wear PPE, paramedics and EMTs scored significantly higher in post-test studies evaluating decisions on when and how to wear masks. As EMTs were more confident when to wear PPE, the studies also demonstrated an improvement on the intention of the health care workers to report to work.Reference Baack and Alfred 4 , Reference Glow, Colucci, Allington, Noonan and Hall 23 If these results were translated to a real-life disaster situation, the lives of health workers and the community could be saved through less transmission of pandemic or bioterrorism organisms.
Clinical or Technical Skills and Disaster Management Structures
Courses which cover both disaster skills and structural knowledge can increase the post-test scores of the participants. It is important that health professionals and support staff are prepared in both the structural aspects of disasters management; for example, communication lines during disasters, and also the technical or clinical skills, such as triage. A number of research articles evaluated participants’ perceptions or knowledge following completion of disaster preparedness courses which focus on clinical, technical, and disaster management structures. These studies were not randomized, there were no control groups, and the course content was often based on nonstandard competencies, so the true benefits would need to be evaluated knowing the generalizability and accuracy of the training programs.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Nyamathi, Casillas and King 9 , Reference Andreatta, Maslowski and Petty 15 , Reference Wetta-Hall, Berg-Copas, Jost and Jost 17 , Reference Subbarao, Bond, Johnson, Hsu and Wasser 19 - Reference Pryor, Heck and Norman 22 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 , Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 34 , Reference Djalali, Ingrassia and Corte 39 An additional benefit of teaching structural disaster information is that the health professionals and support staff will have some knowledge of their role within the organization during disasters. This includes, for example, who to communicate with, where to source resources from, and improving collaboration with other health professionals or staff for all types of disasters.Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 34 The technical or clinical content of disaster preparation may vary depending on the role of the employee; however, all groups need to know about disaster communication structures. Providing this preparation before disasters occur can promote the ability and willingness of support staff to work during disasters as staff need to know their organization is prepared for disasters.Reference Abatemarco, Beckley, Borjan and Robson 5
Human Skills
None of the disaster preparedness courses evaluated in research literature covered the non-clinical, non-technical, or non-structural disaster skills or knowledge. These skills, however, are important to promote health professionals and support staff to function effectively during disasters. Qualitative research reviewed, which enabled health professionals to answer open-ended questions, has highlighted some important human skills.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33 , Reference Wetta-Hall, Fredrickson, Ablah, Cook and Molgaard 35 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36
“Austere environment skills” require health professionals to maintain their own health while living in rough conditions, which may include sleeping in tents, digging a latrine, and undertaking practical hygiene should showers not be available.Reference Arbon, Ranse and Cusack 33 The ability to work well within a team, work with different occupational groups, be physically fit, and stay positive in difficult circumstances are essential if the health professionals are to protect their own wellbeing and provide optimal care for the community.Reference Thorne, Oliver, Al-Ibrahim, Gucer and McDiarmid 6 , Reference Arbon, Ranse and Cusack 33 , Reference Wetta-Hall, Fredrickson, Ablah, Cook and Molgaard 35 , Reference Pitts, Lynch, Mulholland, Curtis, Simpson and Meacham 36 It is important to prepare health professionals and support staff to develop these non-clinical, non-technical, and non-structural human skills if health professionals and support staff are going to function effectively during disasters and prevent mortality and morbidity.
Disaster Preparation or Training Methods
Multiple or Blended Methods of Training
Using blended training methods can improve the performance and knowledge of health professionals and support staff. It is possible to impart or receive different types of knowledge or skills using different delivery methods.Reference Baack and Alfred 4 , Reference Reznek, Smith-Coggins and Howard 20 - Reference Pryor, Heck and Norman 22 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25
As demonstrated in the next four studies to be highlighted, using disaster exercises or practical training is common preparation for disasters. As it is unpredictable when disasters will occur, disaster exercises allow staff to practice for disasters which can enhance decision making, practical skills, and promote collaboration between staff and external agencies. Exercises can be costly and labor intensive; however, they can be effective, particularly when paired with other forms of training. Most exercises also include handouts, plans, or didactic lectures to brief participants.Reference Qureshi, Gershon and Merrill 21 , Reference Pryor, Heck and Norman 22 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24
Courses or training sessions involving nurses, physicians, administrators, and EMTs which included disaster exercises or practical training and didactic lectures were evaluated in a pre-/post-test single cohort studies. Post-tests identified significantly increased scores which included measures of triage, PPE, communication, and incident command system knowledge.Reference Baack and Alfred 4 , Reference Qureshi, Gershon and Merrill 21 , Reference Pryor, Heck and Norman 22 , Reference Gershon, Vandelinde, Magda, Pearson, Werner and Prezant 24
In two single cohort, pre- and post-test studies involving public health nurses, participants received didactic training supported by either online learning modules or handouts of sample plans and competency expectations. Post-tests in both studies indicated the programs had improved the confidence and knowledge public health nurses had to respond to disasters.Reference Reznek, Smith-Coggins and Howard 20 , Reference Collander, Green, Millo, Shamloo, Donnellan and DeAtley 25 Lectures, in-services, workshops, handouts, and more recently online learning modules are common forms of preparation which can help prepare staff for disasters.
The criticisms of didactic courses, workshops, discussions, and disaster exercises are that they can be expensive and labor intensive to run.Reference Pace, Pluye and Bartlett 14 Clinicians, academics, and other health professionals and support staff are also generally busy and managing the time to leave the workplace to attend lectures or exercises may not be practical.Reference Nyamathi, Casillas and King 9
Self-Learning
Self-learning, using books, videos, or computer-based online learning may have time and cost advantages, provided educational needs are also met or exceeded. Most studies that have been completed have been pre-/post-test single cohort studies, measuring primarily physicians, nurses, and EMTs. All studies have demonstrated improved outcomes following participants undertaking the self-learning activity.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Yang, Xiao, Cheng, Zhu and Arbon 7 - Reference Nyamathi, Casillas and King 9 , Reference Pace, Pluye and Bartlett 14 , Reference Andreatta, Maslowski and Petty 15 , Reference Wetta-Hall, Berg-Copas, Jost and Jost 17 , Reference Chiu, Polivka and Stanley 26
One study conducted by Thorne et alReference Abatemarco, Beckley, Borjan and Robson 5 is significant as it compared four non-randomly assigned groups undertaking different versions of disaster training and it focused on support staff. Participants were assigned to four groups; workbook, video, lecture, and small group discussion. The work book and video were self-directed learning and the lecture and small group discussion were instructor-guided. All groups recorded statistically significant improvements in attitude and knowledge questions. There was no significant difference in outcomes between the four learning groups. Therefore, the self-directed workbook or video are as effective as the two more expensive options which required an expert facilitator and group teaching.Reference Abatemarco, Beckley, Borjan and Robson 5 In studies evaluating self-directed learning strategies, including a hospital disaster education video, reading a government disaster manual, or a paper-based bioterrorism learning package, have also been demonstrated to be effective to improve post-test or survey outcomes for medical and nursing professionals.Reference Nyamathi, Casillas and King 9 , Reference Andreatta, Maslowski and Petty 15 , Reference Wetta-Hall, Berg-Copas, Jost and Jost 17 Notably, the video which was designed for emergency medical registrars was only 15 minutes in length and could easily be fitted into the busy clinical workload.Reference Nyamathi, Casillas and King 9 The government disaster manual was a pre-existing document and therefore the cost would be minimal.Reference Andreatta, Maslowski and Petty 15 Preparedness for health professionals and support staff can be both cost effective and realistically scheduled into a clinician’s busy workload while still providing required learning outcomes.
Self-learning involving online or virtual reality can also be effective for health professionals to prepare for disasters. Online learning or virtual reality can replace or partially replace the need for actual disaster exercises or other forms of training or preparedness that may be labor intensive and expensive to repeatedly deliver within health care.Reference Yang, Xiao, Cheng, Zhu and Arbon 7 , Reference Olson, Scheller, Larson, Lindeke and Edwardson 8 , Reference Pace, Pluye and Bartlett 14 , Reference Chiu, Polivka and Stanley 26
Emergency medicine residents were compared in pre- and post-tests results and triage performance in a live disaster exercise and a virtual reality disaster exercise with identical parameters. Both virtual reality and live exercises improved disaster performance with no significant difference.Reference Pace, Pluye and Bartlett 14 A non-randomized study to measure the performance of nurses and disaster management graduates effectively measured disaster performance between groups using online gaming simulation.Reference Yang, Xiao, Cheng, Zhu and Arbon 7
Online learning packages can also improve disaster knowledge. Registered Nurses randomly assigned to a computerized bioterrorism learning program or a standard (paper-based) bioterrorism learning program improved post-test scores and there was no significant difference between groups.Reference Olson, Scheller, Larson, Lindeke and Edwardson 8 A second study evaluated participants who completed two 15-minute online modules on disaster triage. Physicians and EMTs significantly improved post-test knowledge and correct triage of patients in a scenario following the online modules.Reference Chiu, Polivka and Stanley 26
Studies like these highlight that using computerized simulation disaster exercises or online educational modules can be an effective way to both educate and evaluate the performance of health professionals for disasters. Once programs have been set up, they can provide a practical way for health professionals to learn, practice, and evaluate disaster management knowledge.Reference Pace, Pluye and Bartlett 14
Tools and Methods Test Knowledge/Preparedness
While most studies measured knowledge, attitudes, or performance of health professionals, six studies in the review used validated tools. Three studies used the EPIQ. This tool is designed to comprehensively assess a nurse’s perceived knowledge of emergency preparedness and identify education and training needs. The tool has been used to measure perceived RN competence for disasters in Wisconsin (USA), Texas (USA), South Carolina (USA), and the United Kingdom.Reference Robison 3 , Reference Andreatta, Maslowski and Petty 15 , Reference Melnikov, Itzhaki and Kagan 28
Three additional studies within the literature review used the START system to teach and then assess competence for clinicians (physicians, nurses, and EMTs) in disaster triage.Reference Pace, Pluye and Bartlett 14 , Reference Pryor, Heck and Norman 22 , Reference Chiu, Polivka and Stanley 26 This tool is an algorithm designed to detect patients that have conditions that will cause them to die within one hour if not treated.Reference Pace, Pluye and Bartlett 14 , Reference Pryor, Heck and Norman 22 , Reference Chiu, Polivka and Stanley 26
It is important to have tools which can be used to evaluate disaster preparedness in order to ensure health professionals and support staff are prepared for disasters, and using tools improves reliability and transferability of results. Tools have their limitations, however, as the EPIQ was designed to measure perceived competence in RNs and the START system only measures triage performance.Reference Robison 3 , Reference Pace, Pluye and Bartlett 14 , Reference Pryor, Heck and Norman 22 , Reference Chiu, Polivka and Stanley 26 , Reference Melnikov, Itzhaki and Kagan 28 It is important to have a tool suited to measuring the disaster preparedness of all health professionals and support staff and a wider range of actual skills and knowledge required to facilitate quality preparedness and disaster care.
Willingness to Participate in Disasters
During disasters, health professionals and support staff may be even more important than in normal operational periods. A significant percentage of health professionals and support staff may not be willing nor able to participate in disaster care should they be required. Some studies have estimated that between 30% to 80% of health care workers will not wish to attend work during disasters.Reference Robison 3 - Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Bartley, Fisher and Stella 10 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Glow, Colucci, Allington, Noonan and Hall 23 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Fung, Loke and Lai 30
While some factors that influence willingness to attend work cannot be changed (such as the type of disaster), preparation strategies, including providing training and promoting organizational and personal planning, can promote health professionals and support staff to attend work. Health professionals or support staff who have attended education, training, or exercises in disaster management are more likely to attend work. This education includes disaster training in higher education programs or education in the workplace. If universities, education providers, or health services provide compulsory disaster education, health professionals and support staff may be more willing to attend work during disasters.Reference Robison 3 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Bartley, Fisher and Stella 10 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Glow, Colucci, Allington, Noonan and Hall 23 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32
When staff feel that their organization has a plan and can provide adequate support and protection, this promotes health professionals to attend work. This support and protection included providing adequate PPE, vaccination, antiviral prophylaxis, and access to information.Reference Bartley, Fisher and Stella 10 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference Fung, Loke and Lai 30 An additional factor related to planning that can influence willingness to attend work is when individuals have a plan for transportation to get to and from work and a plan for care of family members. Promoting health facilities, health professionals, and support staff to have plans in place can enhance willingness to attend work during disasters.Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference Fung, Loke and Lai 30 , Reference Zhiheng, Caixia, Jiaji, Huajie, Chao and Wannian 32
There is some understanding of the preparation factors that will promote health professionals and support staff to attend work, including education, protection from harm, and having an organizational or personal plan for transport and care of family members.Reference Robison 3 , Reference Abatemarco, Beckley, Borjan and Robson 5 , Reference Bartley, Fisher and Stella 10 , Reference Reznek, Smith-Coggins and Howard 20 , Reference Glow, Colucci, Allington, Noonan and Hall 23 , Reference Báez, Sztajnkrycer, Smester, Giraldez and Vargas 27 , Reference McKibbin, Sekula, Colbert and Peltier 29 , Reference Wetta-Hall, Fredrickson, Ablah, Cook and Molgaard 35 It is important these factors are incorporated into disasters preparedness to help prepare health care workers for disasters.
Limitations
Of the 36 studies included in the review, only five were rated as 100% using the MMAT. The majority of quantitative studies used convenience samples of health professionals and a pre- and post-test or survey to evaluate preparedness or the effectiveness of educational strategies to prepare health professionals. All research of this nature demonstrated improvements in preparation of the health professionals following implementation of a training program; however, due to research design, this improvement is hard to validate and generalize. Eight qualitative studies were included in the review which did produce rich data; however, only two were rated at 100% using the MMAT. It is important that future research evaluating disaster preparedness uses quality research design appropriate for the research to better inform preparedness.
The majority of studies were evaluating nurses, physicians, public health workers, or paramedics/EMTs. There are not much data regarding support staff or allied health professionals, such as physiotherapists, pharmacists, dieticians, laboratory scientists, radiographers, or dentists, who all have important roles to play in various disasters.
All of the research included in the review focused on preparation for or evaluation of external disasters such as pandemics or other mass-casualty incidents. No studies which met the inclusion criteria focused on preparation for or evaluation of internal disasters such as internal fire, floods, or utility failures affecting health services. How to best identify how health professionals and support staff can prepare for or share learnings from these internal disasters is an important area for future research.
The measurement of effective disaster preparation is also important. The tools identified in the review either focused on evaluating only one profession (ie, nursing) or focused on only one area of knowledge (ie, triage). Validated tools that measure a wide range of disaster competencies for a wide range of health professionals and support staff may be beneficial in measuring effectiveness of disaster preparation. Actual performance in disasters is also an import measurement. While the unpredictable nature of disasters can make this difficult to measure, efforts could be made to assess the usefulness of preparation for health professionals and support staff with reference to their performance in disasters.
The literature certainly suggests there may be areas for improvement, as despite an increased focus on disaster preparedness in recent years, many health professionals or support staff are not prepared for or able to attend work during disasters.
Conclusion
It is evident that disaster medicine, nursing, and health care are relatively new disciplines which have gained traction since the terrorist attacks in New York on September 11, 2001. The search strategy of this literature review dated back to January 1, 1980; however, the oldest research article in this review was published in 2003. Disasters are not new phenomena, although it appears within the health disciplines, publishing research to improve preparation may be new.
All methods and content included in disaster preparation appear to lead to improvements in the preparation of health professionals and support staff. Given the issues with research design, it is difficult to determine what content or methods of delivery are most effective. Important questions for future research will need to include what content should be delivered and how this should be provided. It will be equally important to identify differences in the needs of health professionals and support staff, and also differences in preparation required for different types of disasters, including internal disasters affecting health services. Additionally, it is important to include the whole interdependent health care team as participants in future research and disaster preparedness.
There is room for more research identifying best practice disaster preparedness for health professionals and support staff.
