Healthcare worker competencies for disaster training

Although healthcare worker training has long been accepted as an integral part of disaster preparedness, traditional training practices have not been systematically developed, rigorously examined or objectively tested. Only in recent years, under the increased scrutiny of accelerated institutional and governmental preparedness efforts, has the emerging sciences of emergency preparedness and medical education converged and a body of evidence concerning effective practices for healthcare workforce education begun to arise. The development of higher standards for workforce education based on evidence-based practices, sound educational theory and quantitative outcome measures represents an important gap to be filled in national preparedness efforts.

Providing the estimated twelve million healthcare workers in the United States with effective disaster preparedness training poses several major challenges. First, best practices to be taught must be identified and recognized. Second, specific target audiences and the content they should be taught must be defined. Instructional content should be tailored to meet the training requirements for different job categories. Effective multidisciplinary disaster response demands acquisition and application not only of factual knowledge but also complex concepts, multi-level decision making, and specific technical skills. The evaluation of whether these skill sets have been efficiently conveyed and effectively acquired presents its own inherent challenges. Finally, differences among healthcare workers such as prior training, work experience, baseline abilities and cultural background directly impact training effectiveness and must be taken into consideration for the training of large groups. The application of a systematic, competency-based approach can provide the solid foundation to build a comprehensive program of training and evaluation required to meet these challenges.

As there is currently no accepted standard for healthcare worker training in disaster response, a number of programs have adopted different formats to achieve their stated training and educational goals. Several well-recognized courses and related training materials have been aimed at improving standardization and accessibility [1–4]. To date, these practical courses fulfill an important demand but have not yet been validated or incorporated as part of standard medical training. A recent systematic literature review noted the difficulty in drawing firm conclusions about the effectiveness of specific types of hospital disaster training due to the limited numbers of studies, marked heterogeneity of training methods and weaknesses in study design and evaluation [5]. In 2001, a consensus panel of disaster medicine experts strongly recommended that education on disasters should be formalized and evidence-based and that evaluation of education and interventions must be improved [6]. Given this rapidly developing field, a number of competencies and recommendations have been made public over the past several years for clinicians, hospital workers, hospital leaders, nurses, public health workers and, health professions students but each offer considerably less detail in terms of describing measurable objectives to conduct competency-based training [7–11]. The development of professional standards and educational programs based on both the evidence and sound educational theory remains an important gap to be filled. In this paper, we propose a competency-based approach with specific measurable objectives derived by a national expert panel as a paradigm for healthcare worker disaster preparedness and response training.

This article focuses on the development of key competencies and terminal objectives for training of all healthcare workers in disasterpreparedness. A competency was defined as a complex combination of knowledge, attitudes, and skills demonstrated by individuals that are critical to the effective and efficient function of an organization [12]. A terminal objective was defined as the demonstrable performance following the completion of a set of instruction.

The development of competencies for healthcare worker disaster response training and education incorporated an evidence-based consensus building process with the following steps: (1) review of literature on relevant content areas; (2) structured review of existing competencies, national level courses and published training objectives; (3) synthesis of new cross-cutting competencies; (4) expert panel review; (5) refinement of new competencies and; (6) development of testable terminal objectives for each competency using similar processes covering requisite knowledge, attitudes and skills.

Synthesis of new competencies

Current educational theory on training, curriculum and competency development was reviewed with recognized educational experts and incorporated into the development process [13–15]. Each existing competency set was reviewed for appropriateness to the target audience, defined as all healthcare workers. The core concepts from each existing competency set were identified and abstracted with grouping of common elements. A new set of cross-cutting competencies and terminal objectives were drafted and internally reviewed by the team. (Figure 1) The term, "cross-cutting", is used here to describe the competencies which may be applied to related, but distinct target audiences within the field of healthcare workers. Such groups may include, but are not limited to first receiver physicians, first receiver nurses, other first receiver staff, critical event leadership, non-first receiver physicians, nurses, technical support staff and administration.

The literature search revealed relatively few articles describing educational competencies for training of healthcare workers in disaster preparedness and response. Several described the development process and competencies for health professions students, public health workers and, nurses in emergency response [11, 16–24]. However, no articles were identified that outlined disaster training competencies with specific measurable objectives. Outside of the peer-reviewed literature, the structured review of existing courses and competencies identified six sets of published competencies pertaining to the disaster training among different types of healthcare professionals, including public health workers, medical students, first receivers and registered nurses [25–30]. In spite of their importance, none included specific measurable objectives in addressing the broader spectrum of healthcare workers.

Following review and synthesis of the core concepts from the published competencies described above, seven new draft competencies were evaluated by the expert panel. No additional competency areas were suggested by the expert panel. Expert panel opinion in the form of comments and scores ranging from one (strongly agree) to five (strongly disagree) were compiled. For clarity, each of the proposed competencies averaged a score of 2.8 or less (range 1.4 – 2.8). Regarding the relevance for the defined target audience, each of the proposed competencies scored 2.1 or less (range 1.4 – 2). In terms of importance, each of the proposed competencies scored 2.5 or less (range 1.0 – 2.5). For clarity, each of the proposed terminal objectives averaged a score of 2.5 or less (range 1.2 – 2.5). The scores for relevance of the proposed terminal objectives ranged from 1.1 – 3.6.

Through this process, a total of seven cross-cutting competencies and twenty-one terminal objectives for critical event training of all healthcare workers were developed. Since disaster training must integrate multi-disciplinary training with different levels of training, a cross-cutting competency approach can serve as a valuable starting point. Cross-cutting competencies can form the basis for standardized training and unify the disciplines and skill levels involved.

Competency 7

Demonstrate the knowledge and skills needed to fulfill your role during a critical event

Healthcare workers responding to a critical event require specific knowledge and skills. These encompass triage, personal protection, decontamination, and treatment. Injury pattern recognition and syndrome recognition that suggests the use of particular agents is essential to correct response.

TO7.1 – (Triage Skills)

Given an institutional scenario and descriptions of mock victims, the participant will be able to apply knowledge and skills concerning disaster triage systems to rapidly assign victims to appropriate triage categories. To be successful, the participant must recognize the appropriate triage system and correctly assign triage levels to all victims within a given timeframe.

TO7.2 – (PPE Skills)

Given a critical event scenario and descriptions of mock victims in a simulation, the participant will be able apply knowledge and skills concerning personal protective equipment (PPE) to successfully select, don, and monitor the appropriate level of PPE. To be successful, the participant must recognize levels of PPE as well as correctly choose and simulate utilization of the appropriate level of protection.

TO7.3 – (Decontamination Skills)

Given a critical event scenario, the participant will be able to apply knowledge and skills regarding decontamination to select, demonstrate, and monitor the correct method(s) of decontamination. To be successful, the participant must correctly identify the decontamination level as well as select and demonstrate appropriate decontamination techniques.

TO7.4 – (Diagnosis/Treatment)

Given a description of a patient presentation in a critical event scenario, the participant will be able to apply knowledge and skills regarding critical event diagnosis and treatment to identify critical event related syndromes and causative agents and select the appropriate treatment(s). To be successful, the participant must correctly diagnose the presented clinical syndrome, identify the causative agent and select the appropriate treatment(s).

One of the highest priorities identified by the disaster response community in recent years has been to "develop standards and guidelines for education and training in the multi-disciplinary health response to major events that threaten the health status of a community" [31]. The need for rapid and effective disaster training of healthcare staff at all levels is now widely recognized and mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [32]. However, differences among healthcare workers such as cultural and educational backgrounds, prior training, work experience and abilities all contribute significant challenges to the standardization of disaster training and education. Training requirements for each job description requires appropriate modification of educational content. Furthermore, effective disaster response demands that selected healthcare workers be equipped not only with knowledge but specific technical skills and decision-making abilities. A competency based approach provides the framework to conduct this type of flexible training.

Competency based approaches to training have been widely implemented and have gained acceptance in medical education in recent years. The advances of competency based education have been well described in the literature [33–38]. For example, the Accreditation Council for Graduate Medical Education (ACGME) has implemented core competency projects to facilitate physician training in specific knowledge and skills. Accordingly, this model has been endorsed by a number of organizations including the American Board of Medical Specialties [33]. This trend reflects an increased focus on curriculum design, establishment of measurable outcomes, adequacy of training, and program evaluation.

The application of competency based education for training healthcare workers in disaster response and other public health emergencies is a relatively new concept. Given the rapidly developing nature of the disaster field, several competency sets have recently become available since this process was conducted. For example, the Columbia School of Nursing, Center for Health Policy and the National Center for Disaster Preparedness at the Columbia University Mailman School of Public Health have described competencies for hospital workers, hospital leaders, clinicians, and nurses as part of a broader competency development program that began with the competencies for public health workers [7]. While competency statements for public health workers, medical students, and various hospital staff in emergency preparedness have been previously outlined, important differences exist in the derivation methods, degree of inclusiveness in development processes, level of detail and how the term competency is defined [25–30]. However, to our knowledge, this is the first set of cross-cutting competencies with specific measurable objectives derived using evidence-based consensus building techniques that addresses the training of all healthcare workers in disaster response. To this end, we have incorporated a systematic review of all existing related competencies and peer-reviewed literature, nationally recognized disaster courses, educational theory and expert panel consensus.

Deriving training content from a single set of cross-cutting competencies offers both theoretical and practical advantages over utilization of distinct competency sets for each type of healthcare worker being trained. First, the multidisciplinary nature of critical event preparedness and response and the importance of an integrative approach to training can not be overstated. All healthcare workers require training to develop the fundamental knowledge and skills to function independently but also to act in part of a coordinated response effort. Cross-cutting competencies unite the common underpinnings of requisite training for all healthcare workers; a departure from historically discipline-focused training.

Given the importance of problem solving and decision-making skills, the cross-cutting competencies and terminal objectives are designed to emphasize higher levels of learning such as synthesis and performance, rather than strictly knowledge acquisition [13]. In accordance with educational theory, each terminal objective was constructed so that performance may be readily tested or evaluated [13–15]. Each terminal objective can be easily mapped to the most appropriate target audience(s), with different target audiences receiving the content that will allow that group to best fulfill the relevant competency statement as applied to their job. For example, critical event leadership has different training needs from front-line physicians who in turn have different training needs from community-based practitioners. Thus, while cross-cutting competencies apply to all healthcare workers, certain terminal objectives such as those related to PPE and decontamination skills deemed essential for first receivers would be unlikely required of healthcare administrators.

Future steps will include application of this structured evidence-based process to further divide each terminal objective into enabling objectives, a series of clear statements of component knowledge, skills and/or attitudes, each with easily measurable and well-defined performance characteristics.

The cross-cutting competencies and accompanying objectives developed using this systematic evidence-based consensus building approach may serve as a paradigm for healthcare worker disaster training and education. While reaching similar general conclusions to other competency work that has been conducted, this framework offers the opportunity for greater standardization in training and evaluation by facilitating a uniform approach to derivation of objectives, content and evaluation.