Existing Approaches to Chemical, Biological, Radiological, and Nuclear (CBRN) Education and Training for Health Professionals: Findings from an Integrative Literature Review

Strengthening emergency department response to chemical, biological, radiological, and nuclear disasters: A scoping review

INTRODUCTION

Natural hazards resulting in disasters are increasing globally, impacting communities and disrupting industries. In addition to planning for these natural hazard disasters, emergency departments (EDs) should prepare for chemical, biological, radiological, and nuclear (CBRN) incidents that result in surges of patient presentations. Chemical, biological, radiological, and nuclear incidents differ in preparedness to natural hazards, requiring an understanding of patient management and health system-related challenges.

METHODS

This scoping review used the Arksey and O'Malley five-step framework. Manuscripts were retrieved from four databases and search engines using keywords relating to impacts on the ED from real world CBRN event(s). Analysis focused on the characteristics of CBRN event, ED impact, and lessons learnt against four surge capacity domains that including staff, stuff, space, and systems.

RESULTS

A total of 44 paper were included in this review. Most of the incidents were chemical in nature (n = 36/44, 81.8 %). The majority of CBRN incidents were accidental (n = 34/44, 77.3 %). Between 1 and 1470 people (Mdn=56, IQR: 18-228) presented to an ED from each event. Most patients were discharged from the ED, but this was variably reported. Some key lessons related to secondary exposure to ED staff, repurposing spaces, and coordination of CBRN incidents.

CONCLUSION

With the increasing number of CBRN incidents, strategies to strengthen EDs and limit the impact from a surge in patient presentations are paramount. An understanding of local CBRN risk to inform a top-hazards approach to CBRN preparedness, and the implementation of pre-emptive CBRN clinical pathways is recommended. Additionally, strategies should be implemented to protect staff from the risk of secondary exposure to a CBRN event. These strategies may include adequate education, training, and personal protective equipment for staff.

Introduction to Treating Patients Exposed to Chemical, Biological, Radiological, and Nuclear (CBRN) Threats: A Military Medical Case-Based Curriculum

Introduction

Ensuring proficiency in responding to, evaluating, and treating chemical, biological, radiological, and nuclear (CBRN) casualties is a critical component of military medical student education. To meet this objective, we developed a case-based CBRN curriculum that can serve as a model to address potential curricular gaps for civilian prehospital, UME, and GME programs.

Methods

The curriculum was administered in two sessions, 1 month apart, each with individual student preparation, including an optional asynchronous online module and a review of clinical practice guidelines. Session one consisted of a 2-hour introductory lecture, followed by a student reflection. Session two consisted of a 1-hour small-group case study, designed as a multimodal exercise with a corresponding computer-based worksheet and knowledge check.

Results

Forty-five teams consisting of three to four second-year medical students (N = 170) completed the sessions and course survey. Sixty-four percent of student teams were extremely or quite satisfied with what they learned, 62% found the materials very or quite relevant to their needs, and 69% rated the instructional materials as extremely or quite understandable. Student feedback included designating additional time for worksheet completion.

Discussion

A case-based training on CBRN patient care earned positive ratings for the clarity of instruction, the impact on students as learners, and the feasibility of the training. Future training evolutions could track student completion of prework, extend the allotted time for activity completion, and evaluate curricular effectiveness through pre-post measurement of students' confidence in their ability to care for a CBRN patient.

Repurposing FDA-approved drugs to treat chemical weapon toxicities: Interactive case studies for trainees

The risk of a terrorist attack in the United States has created challenges on how to effectively treat toxicities that result from exposure to chemical weapons. To address this concern, the United States has organized a trans-agency initiative across academia, government, and industry to identify drugs to treat tissue injury resulting from exposure to chemical threat agents. We sought to develop and evaluate an interactive educational session that provides hands-on instruction on how to repurpose FDA-approved drugs as therapeutics to treat toxicity from exposure to chemical weapons. As part of the Rutgers Summer Undergraduate Research Fellowship program, 23 undergraduate students participated in a 2-h session that included: (1) an overview of chemical weapon toxicities, (2) a primer on pharmacology principles, and (3) an interactive session where groups of students were provided lists of FDA-approved drugs to evaluate potential mechanisms of action and suitability as countermeasures for four chemical weapon case scenarios. The interactive session culminated in a competition for the best grant "sales pitch." From this interactive training, students improved their understanding of (1) the ability of chemical weapons to cause long-term toxicities, (2) impact of route of administration and exposure scenario on drug efficacy, and (3) re-purposing FDA-approved drugs to treat disease from chemical weapon exposure. These findings demonstrated that an interactive training exercise can provide students with new insights into drug development for chemical threat agent toxicities.

The level of the emergency health workers professionals' knowledge about chemical, biological, radiological, and nuclear (CBRN) hazards: The case of Turkey

BACKGROUND

It is crucial that emergency health workers respond to people exposed to chemical, biological, radiological and nuclear agents appropriately and in a timely manner.

OBJECTIVE

This study aims to find out how much Turkish emergency health workers know about chemical, biological, radiological, and nuclear hazards, as well as identify what possible factors contribute to their level of knowledge.

METHOD

The data were collected from 321 participants using a personal information form as well as a questionnaire about chemical, biological, radiological and nuclear hazards prepared in accordance with the literature.

RESULTS

The results revealed that the place of residence and status of choosing the profession willingly showed no difference in terms of being trained on chemical, biological, radiological and nuclear hazards (p >  0.05). Likewise, the participants under the age of 25 years, who were single and had a tenure of less than 10 years highly believed that they did 'not have a sufficient grasp of chemical, biological, radiological and nuclear hazards'. Women also highly believed that they did 'not have a solid grasp of chemical, biological, radiological and nuclear hazards.'

CONCLUSIONS

Healthcare professionals who work in high-risk zones should be given compulsory training about chemical, biological, radiological and nuclear hazards so that they become more aware of how to best deal with such situations.

Live agent training as an important process safety measure to strengthen resilience in hazardous (CBRN) work situations

Various occupational groups as well as emergency responders are important human factors in combating incidents and emergencies in a broad range. Negative deviations from a process-safe condition should be detected and transformed into a safer condition to prevent negative consequences. Therefore, training and education of personnel is an important measure in this case as well as a major influencing factor on the vulnerability to errors during operations and their resilience. From lack of training to incorrect execution due to excessive stress, fear, or unfamiliar situations, it is important to counteract this with targeted training under conditions that are as close to reality as reasonably achievable. Realistic training situations involving live agents allow to recognize mistakes or inadequacies not only in personnel but also in material or in mission planning and to create a more effective working environment. Many violations of work guidelines are due to well-intentioned deviations from nonexecutable standard operation procedures that have never been tested. Repeated, progressive training under real hazardous conditions can help to strengthen mission readiness and resilience of teams. It better prepares them for their dangerous activities.

Managing CBRN mass casualty incidents at hospitals-Find a simple solution for a complex problem: A pilot study

OBJECTIVE

Chemical, biological, radiological, and nuclear (CBRN) incidents are a major challenge for emergency medical services and the involved hospitals, especially if decontamination needs to be performed nearby or even within the hospital campus. The University Hospital Wuerzburg has developed a comprehensive and alternative CBRN response plan. The focus of this study was to proof the practicability of the concept, the duration of the decontamination process, and the temperature management.

METHODS

The entire decontamination area can be deployed 24/7 by the hospitals technical staff. Fire and rescue services are responsible for the decontamination process itself. This study was designed as full-scale exercise with 30 participants.

RESULTS

The decontamination area was ready for operation within 30 minutes. The decontamination of the four simulated patients took 5.5 ± 0.6 minutes (mean ± SD). At the end of the decontamination process, the temperature of the undressed upper body of the training patients was 27.25 ± 1°C (81.05 ± 2°F) (mean ± SD) and the water in the shower was about 35°C (95°F).

CONCLUSION

The presented concept is comprehensive and simple for a best possible care during CBRN incidents at hospitals. It ensures wet decontamination by Special Forces, while the technical requirements are created by the hospital.

Mapping study for health emergency and disaster risk management competencies and curricula: literature review and cross-sectional survey

BACKGROUND

With the increasing threat of hazardous events at local, national, and global levels, an effective workforce for health emergency and disaster risk management (Health EDRM) in local, national, and international communities is urgently needed. However, there are no universally accepted competencies and curricula for Health EDRM. This study aimed to identify Health EDRM competencies and curricula worldwide using literature reviews and a cross-sectional survey.

METHODS

Literature reviews in English and Japanese languages were performed. We searched MEDLINE, EMBASE, CINAHL (English), and the ICHUSHI (Japanese) databases for journal articles published between 1990 and 2020. Subsequently, a cross-sectional survey was sent to WHO Health EDRM Research Network members and other recommended experts in October 2021 to identify competency models and curricula not specified in the literature search.

RESULTS

Nineteen studies from the searches were found to be relevant to Health EDRM competencies and curricula. Most of the competency models and curricula were from the US. The domains included knowledge and skills, emergency response systems (including incident management principles), communications, critical thinking, ethical and legal aspects, and managerial and leadership skills. The cross-sectional survey received 65 responses with an estimated response rate of 25%. Twenty-one competency models and 20 curricula for managers and frontline personnel were analyzed; managers' decision-making and leadership skills were considered essential.

CONCLUSION

An increased focus on decision-making and leadership skills should be included in Health EDRM competencies and curricula to strengthen the health workforce.

Psychological, cognitive, and physiological impact of hazards casualties' trainings on first responders: the example of a chemical and radiological training. An exploratory study

Background

First responders are among the first to respond to hazards casualties. They might operate in volatile, uncertain, complex, and ambiguous (VUCA) environments. While they have underlined the need to improve their knowledge and training to face these environments, there are few data regarding the stress induced by these trainings. Chemical, biological, radiological, and nuclear (CBRN) hazards casualties' trainings seem to be a good model of "in vivo" stress. First responders must operate in a hostile and encountered environment with a CBRN protective equipment that places demand on their psychological, cognitive, and physiological capacities. Current research recognizes that the activity of the parasympathetic system (PSS) can be used as an objective marker of stress adaptation, measured as heart rate variability (HRV).

Objectives

To compare between baseline and simulation the evolution of the parasympathetic activity (primary outcome), anxiety, emotions, cognitive load, and body posture awareness (secondary outcomes).

Methods

A total of 28 first responders attended to three simulated scenarios requiring CBRN management of casualties. One day before simulation, we collected HRV data (baseline). The simulations' day (pre-, post-simulation) we collected anxiety score (STAI-Y B), emotions (SPANE), cognitive load (NASA TLX), body posture awareness (PAS) and HRV. The morning after we collected the PAS score (recovery). We compare data' evolution between different times of the simulation.

Results

(i) A high level of anxiety at baseline [Median 51 (46; 56)] which decreased between pre- and post-simulation (p = 0.04; F = 2.93); (ii) a post-simulation decrease in negative feelings (p = 0.03); (iii) a decrease in body awareness after simulation which returned to the initial level at recovery (p = 0.03; F = 3.48); (iv) a decrease in mean RR between baseline, pre- and post-simulation (p = 0.009; F = 5.11). There were no significant difference between times on others analysis of HRV.

Conclusion

Prior to simulation, participants experienced anticipatory anxiety. Simulations training practiced regularly could be one way to combat anticipatory anxiety.

Nurses' preparedness to respond to COVID-19 and associated factors after the outbreak in China

AIM

Nurses are key staff in the response to the COVID-19 epidemic. The aim of present study was to assess Chinese clinical nurses' preparedness levels for COVID-19 after the outbreak, as well as the associated demographic factors.

DESIGN

The design was a cross-sectional survey.

METHODS

We distributed an online questionnaire to nurses from five eastern coastal area hospitals. The questionnaire collected demographic information, and included the nurses' preparedness to respond to COVID-19 questionnaire (NPR COVID-19).

RESULTS

The total mean NPR COVID-19 score was 200.99 (standard deviation = 33.60), and the psychological approaches subscale had the lowest mean score. Education and training were positively associated with the NPR COVID-19 score. Nurses' characteristics, such as seniority, job category and educational level, were entered into the NPR COVID-19 regression model, and seniority (≤5 years) showed the strongest negative association with NPR COVID-19 scores (standard coefficient = -0.20).

CONCLUSIONS

Chinese nurse's preparedness to respond to COVID-19 was adequate. Nurses with less than 5 years of work experience, nursing researchers and diploma-educated nurses reported feeling a low preparedness to respond to COVID-19. These nurses should receive specific training.

Creating realistic nerve agent victim profiles for computer simulation of medical CBRN disaster response

In the last decades, Chemical, Biological, Radiological and Nuclear (CBRN) threats have become serious risks prompting countries to prioritize preparedness for such incidents. As CBRN scenarios are very difficult and expensive to recreate in real life, computer simulation is particularly suited for assessing the effectiveness of contingency plans and identifying areas of improvement. These computer simulation exercises require realistic and dynamic victim profiles, which are unavailable in a civilian context. In this paper we present a set of civilian nerve agent injury profiles consisting of clinical parameters and their evolution, as well as the methodology used to create them. These injury profiles are based on military injury profiles and adapted to the civilian population, using sarin for the purpose of illustration. They include commonly measured parameters in the prehospital setting. We demonstrate that information found in military sources can easily be adjusted for a civilian population using a few simple assumptions and validated methods. This methodology can easily be expanded to other chemical warfare agents as well as different ways of exposure. The resulting injury profiles are generic so they can also be used in tabletop and live simulation exercises. Modeling and simulation, if used correctly and in conjunction with empirical data gathered from lessons learned, can assist in providing the evidence practices for effective and efficient response decisions and interventions, considering the contextual factors of the affected area and the specific disaster scenario.

Exploring pre-hospital healthcare workers' readiness for chemical, biological, radiological, and nuclear threats in the State of Qatar: A cross-sectional study

Background

Hazardous Material-Chemical, Biological, Radiological, and Nuclear (HazMat-CBRN) incidents, though infrequent, are environmentally precarious and perilous to living beings. They can be deliberate or accidental or follow the re-emergence of highly contagious diseases. Successful management of such incidents in pre-hospital settings requires having well-trained and prepared healthcare workers.

Aims

This study aimed to explore the reliability and validity of a satisfaction survey, answered by Specialized Emergency Management (SEM) personnel from a national Middle Eastern ambulance service, with a "Hazardous Material Incident Management" course offered to them as a continuing professional development activity and seek their opinion regarding Hamad Medical Corporation Ambulance Service personnel needs for other HazMat-CBRN related training topics.

Method

In the cross-sectional study, we conducted an online satisfaction survey for this group of course participants to obtain their feedback as subject matter experts. Aiken's content validity coefficient (CVC) was calculated to assess the content validity. Cronbach's α coefficient was determined to explore the survey's reliability. IBM®-SPSS® version 26 was utilized to explore the data.

Results

The SEM satisfaction survey demonstrated important satisfaction with the implemented training with its robust reliability and content validity (Cronbach's α = 0.922 and CVC = 0.952). The participants also recommended additional related topics.

Conclusion

Sustaining and reinforcing the HazMat-CBRN Incident Management course was strongly recommended, considering the increase of HazMat-CBRN threats worldwide.

Risques nucléaires, radiologiques, biologiques et chimiques (NRBC) : la « chaîne de survie NRBC » et son acronyme « DUST DAHO », un outil cognitif destiné aux primo-intervenants non spécialistes pour la prise en charge des victimes les premières heures

Les risques terroristes nucléaires, radiologiques, biologiques et chimiques (NRBC) constituent une menace permanente. Les primo-intervenants seront probablement des personnels non spécialisés face à un événement de cette nature. À l’extérieur ou à l’accueil des hôpitaux, leur rôle sera pourtant décisif sur le plan tactique afin de mettre en œuvre les premières mesures et minimiser les effets sur la population. Acquérir et entretenir un niveau de formation suffisant pour un risque d’occurrence rare, pour agir efficacement en tenue de protection dans un contexte aussi stressant sont des défis pédagogiques et organisationnels pour nos services. En 2019, la brigade de sapeurs-pompiers de Paris conceptualise la « chaîne de survie NRBC » regroupant les cinq actions essentielles à mener par les primointervenants en cas d’événements NRBC. Ces tâches, indissociables, sont représentées sous la forme d’une chaîne constituée de cinq maillons : 1) Décontamination d’urgence pour limiter l’intoxication et la contamination ; 2) Recherche de symptômes pour identifier l’agent et alerter les secours ; 3) Administration précoce des traitements pour réduire la morbi mortalité ; 4) Décontamination approfondie pour protéger le système de santé ; 5) Évacuation vers l’hôpital. En 2020, l’acronyme « DUST DAHO » est ajouté pour optimiser la mémorisation et la restitution des cinq maillons de cette chaîne. Cet outil cognitif s’adresse à tous les acteurs, soignants ou non, à l’extérieur ou à l’accueil de l’hôpital, quel que soit l’agent NRBC en cause. Il pourrait également être un outil de communication précieux pour le grand public en cas de crise.

Assessment of the effectiveness of a course in major chemical incidents for front line health care providers: a pilot study from Saudi Arabia

BACKGROUND

Mass chemical exposure emergencies are infrequent but can cause injury, illness, or loss of life for large numbers of victims. These emergencies can stretch and challenge the available resources of healthcare systems within the community. Political unrest in the Middle East, including chemical terrorist attacks against civilians in Syria and increasing chemical industry accidents, have highlighted the lack of hospital preparedness for chemical incidents in the region. This study aimed to evaluate the effectiveness of a course designed to empower frontline healthcare providers involved in mass casualty incidents with the basic knowledge and essential operational skills for mass chemical exposure incidents in Saudi Arabia.

METHODS

A mixed-methods approach was used to develop a blended learning, simulation enhanced, competency-based course for major chemical incidents for front line healthcare providers. The course was designed by experts from different disciplines (disaster medicine, poisoning / toxicology, and Hazard Material Threat - HAZMAT team) in four stages. The course was piloted over five days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia). The 41 participants were from different government health discipline sectors in the country. Pre- and post-tests were used to assess learner knowledge while debriefing sessions after the decontamination triage session and simulation-enhanced exercises were used for team performance assessment.

RESULTS

The overall knowledge scores were significantly higher in the post-test (69.47%) than the pre-test (46.3%). All four knowledge domains also had significant differences between pre- and post-test results. There were no differences in the pre and post-test scores for healthcare providers from the different health disciplines. A one-year post-event survey demonstrated that participants were satisfied with their knowledge retention. Interestingly, 38.3% had the opportunity to put this knowledge into practice in relation to mass chemical exposure incidents.

CONCLUSION

Delivering a foundation level competency-based blended learning course with enhanced simulation training in major chemical incidents for front line healthcare providers may improve their knowledge and skills in response to such incidents. This in turn can improve the level of national preparedness and staff availability and make a crucial difference in reducing the health impacts among victims.

Simulation in disaster nursing education: A scoping review

OBJECTIVES

Disasters are gradually increasing in type and frequency throughout the globe. Simulation is being used in disaster nursing teaching and training. The aim of this scoping review was to systematically map the extent and application of simulation in disaster nursing education.

DESIGN, DATA SOURCES AND METHODS

A scoping review was conducted using the model of Arksey and O'Malley as the methodological framework, extended by Levac. The following databases were systematically searched to identify relevant literature: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO from the launch of the databases to June 14, 2020, with a supplemental search on October 12, 2020. Two researchers independently screened the relevant articles selected and extracted the data.

RESULTS

Twenty-four studies were included in the scoping review. The research purpose varied widely. The 24 included studies examined nine disaster simulation scenarios. Eight types of simulation methods were identified, of which simulated patients and a mixed-simulation approach were the main methods. Only two studies used a randomized controlled trial design, and none of the rest studies were set up with control groups. Only 10 studies reported validated questionnaires with reliability tests being used. Debriefing was performed in 19 studies, and in 4 of those studies, the debriefing was structured. The reported outcomes were concentrated in Kirkpatrick's levels 1 (participants' satisfaction with the training experience) and 2 (whether participants actually benefited from the training).

CONCLUSION

This review found that simulation was well-recognised in disaster nursing education and training. However, insufficient designs and methods indicated that there was a lack of strong evidence, and high-level research on the application of simulation is needed in the field of disaster care.

Do Health-Care Students Know About Chemical Biological Radioactive Nuclear Weapons?

OBJECTIVE

The aim of this study was to determine the level of knowledge of students receiving different levels of health-care education (doctors, nurses, paramedics) on chemical, biological, radioactive, and nuclear weapons (CBRNW).

METHODS

This study was designed as a qualitative, descriptive, and cross-sectional research. The study reached 87.68% of the population. A survey form was created by the researcher in line with the literature. Ethical permission and verbal consents were obtained. The data were collected by face-to-face interviews.

RESULTS

It was observed that there was no difference between the enrolled departments, that the participants had very low levels of knowledge on the subject despite considering it a likely threat for Turkey, and that they thought the public and the health-care professionals in this field had insufficient knowledge. Sex, age, and field education were the variables that created a difference.

CONCLUSION

Training regarding CBRNW should be further questioned and individuals should receive ongoing training to increase and update their knowledge and skills.

Evaluating the Effectiveness of the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM): A Pilot Simulation Study With a Before and After Design

Background

With the occurrence of a number of major disasters around the world, there is growing interest in chemical disaster medicine. In South Korea, there is a training program for mass casualty incidents (MCI) and backup by legal regulations by the Framework Act on the Management of Disasters and Safety. However, there is no program focusing on chemical disasters. Thus, the authors newly created a program, the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM) in September 2019. This was a pilot study to verify the educational effect of the program.

Method

A pre/post study was conducted of a chemical MCI training program based on simulation. A total of 25 representative and qualified participants were recruited from fire departments, administrative staff of public health centers, and healthcare workers of hospitals in the Gyeonggi-do province of South Korea. They participated in a one-day training program. A knowledge test and confidence survey were provided to participants just before training, and again immediately following the training online. The authors compared improvements of pre/post-test results. In the tabletop drill exercise, quantified qualitative analyses were used to measure the educational effect on the participants.

Results

In the knowledge test, the mean (standard deviation) scores for all 25 participants at baseline and after training were 41.72 (15.186) and 77.96 (11.227), respectively (p < 0.001). In the confidence survey for chemical MCI response for all 25 participants, all the sub-items concerning personal protective equipment selection, antidote selection, antidote stockpiling and passing on knowledge to colleagues, zone setup and decontamination, and chemical triage were improved compared to the baseline score (p < 0.001). The tabletop exercise represented a prehospital setting and had 11 participants. The self-efficacy qualitative survey showed pre- and post-exercise scores of 64/100 and 84/100 respectively. For a hospital setting exercise, it had 14 participants. The survey showed pre/post-exercise scores of 26/100 and 73/100 respectively. Twenty-two (88%) participants responded to the final satisfaction survey, and their overall mean scores regarding willingness to recommend this training program to others, overall satisfaction with theoretical education, overall satisfaction with tabletop drill simulation, and opinion about whether policymakers need this training were all over 8 out of 10 respectively.

Conclusion

C-MCIREM, the newly created chemical MCI program, provided effective education to the selected 25 participants among Korean chemical MCI responders in terms of both knowledge and practice at a single pilot trial. Participants were highly satisfied with the educational material and their confidence in disaster preparedness was clearly improved. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.

Designing and Validation of the Nurses' Preparedness to Response to COVID-19 Questionnaire in Iran

OBJECTIVE

Nurses are considered key members to respond to incidents and disasters. As many patients are hospitalized during the coronavirus disease (COVID-19) pandemic, and nurses are directly in contact with these patients; their preparedness enables them to respond to this situation more effectively and protects their health. Therefore, the present study aimed to design and validate a questionnaire to measure the nurses' preparedness in response to COVID-19 in Iran in 2020.

METHODS

This study was a mixed research aiming to develop and validate a psychometric research instrument in 2020. Based on the review of the literature regarding COVID-19 and other viral respiratory infections, the items were extracted, rewritten, and validated. In the quantitative phase, the validity of the questionnaire was evaluated in terms of face, content, and construct validity, and its reliability was evaluated based on internal consistency and stability (Cronbach's alpha and Intra-class Correlation Coefficient [ICC]). To fill out the questionnaire, the nurses were selected by random sampling. Data analysis was done by the SPSS software, version 23 (IBM Corp, Armonk, NY).

RESULTS

The designed questionnaire included 9 dimensions and 50 items. The dimensions included (1) Incident Command System (ICS); (2) risk assessment and management; (3) information and communication management; (4) psychological approaches; (5) personal protective equipment; (6) prevention of contamination, isolation, and quarantine; (7) education and training; (8) patient management; and (9) features of the new coronavirus. The content and face validity of the questionnaire were approved by the specialists and experts of nursing and health in disasters and emergencies. The content validity ratio was > 0.7 for all items. The content validity index was also approved for all items. The Cronbach's alpha coefficient and ICC were respectively 0.71 and 0.72 for the total questionnaire. The total score was determined based on 5 ranges, including 50-89 (very low preparedness), 90-129 (low preparedness), 130-170 (medium-level preparedness), 171-210 (high preparedness), and 211-250 (very high preparedness).

CONCLUSION

Nurses' preparedness to respond to this pandemic requires multilateral measures. Measuring the nurses' preparedness can clarify the challenges in hospital measures taken to respond to this crisis. Evaluating the nurses, determining the challenges and priorities, and finding solutions to resolve them can improve the nurses' performance in providing health care services. Preparation of nurses during pandemics can reduce the damages to this group and maximize their efforts to protect the patients. Thus, health planners and policy-makers should try to promote the nurses' awareness and preparedness.

"Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine"

Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, "Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine," over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.

Exploring the non-technical competencies for on-scene public health responders in chemical, biological, radiological, and nuclear emergencies: a qualitative study

Objectives

The purpose of this study was to define and delineate specific non-technical competencies for first-line public health responders in Chemical, Biological, Radiological, and Nuclear (CBRN) emergencies in China.

Study design

A qualitative study was conducted in China involving interviews with key informants in the field of health response to CBRN disasters.

Methods

One-on-one in-depth interviews were carried out with 20 participants, including expert members of National Medical Response Teams for CBRN disasters, officials at emergency management authorities, and scholars of academic institutions related to CBRN emergency. Interviews were recorded using audio equipment, transcribed, and coded into codable passages as per grounded theory using NVivo software. Themes were identified within the transcriptions by using thematic analysis.

Results

A total of 159 codable passages were produced. Eight domains of non-technical core competencies were identified: (1) situation awareness, (2) communication skills, (3) collaboration, (4) resource management, (5) task management, (6) cultural competency, (7) austere environment skills, and (8) physical stamina.

Conclusions

The study identified a variety of competencies for on-scene public health responders in CBRN emergencies. The findings of this study could specifically benefit development of strategy and improvement of content of education and training. Further research that involves input from the disaster response community at large is needed for the validation of these competencies.

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Non-technical competencies affect performance of health response to Chemical, Biological, Radiological, and Nuclear (CBRN) disasters.

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Austere environment skills and physical stamina are priority non-technical competencies for on-site public health responders in CBRN events.

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Effective CBRN health emergency training should integrate and synchronize courses based on non-technical/technical competency.

Factors affecting hospital response in biological disasters: A qualitative study

Background: The fatal pandemics of infectious diseases and the possibility of using microorganisms as biological weapons are both rising worldwide. Hospitals are vital organizations in response to biological disasters and have a crucial role in the treatment of patients. Despite the advances in studies about hospital planning and performance during crises, there are no internationally accepted standards for hospital preparedness and disaster response. Thus, this study was designed to explain the effective factors in hospital performance during biological disasters. Methods: Qualitative content analysis with conventional approach was used in the present study. The setting was Ministry of Health and related hospitals, and other relevant ministries responsible at the time of biologic events in Islamic Republic of Iran (IR of Iran) in 2018. Participants were experts, experienced individuals providing service in the field of biological disaster planning and response, policymakers in the Ministry of Health, and other related organizations and authorities responsible for the accreditation of hospitals in IR of Iran. Data were collected using 12 semi-structured interviews in Persian language. Analysis was performed according to Graneheim method. Results: After analyzing 12 interviews, extraction resulted in 76 common codes, 28 subcategories, and 8 categories, which are as follow: detection; treatment and infection control; coordination, Resources; training and exercises; communication and information system; construction; and planning and assessment. Conclusion: Hospital management in outbreaks of infectious diseases (intentional or unintentional) is complex and requires different actions than during natural disasters. In such disasters, readiness to respond and appropriate action is a multifaceted operation. In IR of Iran, there have been few researches in the field of hospital preparation in biologic events, and the possibility of standardized assessment has be reduced due to lack of key skills in confronting biological events. It is hoped that the aggregated factors in the 8 groups of this study can evaluate hospital performance more coherently.