Introduction
Today, it is common to hear reports of disasters occurring across the globe. Immediately following a disaster, there is a critical period to triage initial casualties and address the most critically injured in a systematic and effective manner.Reference Oldenburger, Baumann and Banfield 1 , Reference Tekeli-Yesil 2 Medical teams responding to disasters must function quickly and effectively in circumstances that can be dynamic and volatile. Teams also may be faced with limited resources and significant need.Reference Oldenburger, Baumann and Banfield 1 To better support medical teams in the field and improve the outcomes for casualties, it is important to identify the characteristics that facilitate medical team function and the training required to develop them. This study examined the key characteristics and training that enable medical teams to function effectively, with a specific focus on low-resource settings because these areas are disproportionately impacted by disaster.
Methods
A scoping review mapping the current state of the literature regarding medical teams in the context of disaster response was conducted.Reference Schulz, Koenig and Nojj 3 In addition to consulting previously published scoping review articles, the recognized methodological framework of Arksey and O’Malley was used, along with more recent critiques of the scoping review methodology.Reference Schulz, Koenig and Nojj 3 - Reference Daudt, van Mossel and Scott 6 The methodological framework was comprised of five sequential steps: (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results.Reference Armstrong, Hall, Doyle and Waters 4 According to these authors, a scoping review provides a synopsis of the literature without prescribing a specific weight to any individual article.Reference Armstrong, Hall, Doyle and Waters 4 To facilitate the final steps of charting and collating, the methods of Braune and ClarkeReference Martin-Misener, Valaitis and Wong 7 were used for a thematic analysis of the selected articles. The research questions were as follows: What are the characteristics of medical teams responding to disaster in low-resource settings? What training do medical teams go through to develop these characteristics?
A combination of keywords and subject headings were selected: medical team; characteristics; disaster; and response. Low-resource settings and low- and middle-income countries (LMICs) were added to focus on the context of low-resource settings in the first question. The keyword training was added to answer the second question.
The initial literature search was conducted between December 2014 and January 2015 using three online databases: Google Scholar (Google Inc.; Mountain View, California USA); PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); and Web of Science (Thomson Reuters; New York, New York USA). To be included, articles had to be available in full text through the university’s access rights, available in English, and published since 2010 (Figure 1). Articles were excluded for not having a focus on teams in the disaster setting or for not providing a description of team activities and experiences. Articles referring to the training of teams were kept as a sub-group to examine how characteristics developed.
Search Strategy. Abbreviations: DART, Disaster Assistance Response/Relief Team; DMAT, Disaster Medical Assistance Team.
Results of the first search demonstrated the need to revise the search strategy to widen the scope and find additional relevant articles. New terms were added (emergency; humanitarian; relief; Disaster Medical Assistance Team or DMAT; Disaster Assistance Response/Relief Team or DART; traits; and attributes), while low-resource settings and LMICs were removed. Five additional databases were searched: CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Global Health (EBSCO Information Services; Ipswich, Massachusetts USA); JSTOR (ITHAKA; New York, New York USA); ProQuest (Ann Arbor, Michigan USA); and PsychInfo (American Psychological Association; Washington DC, USA), and articles published since 2005 were included. This revised search was conducted between February 2015 and May 2015.
Article selection began with a title review followed by an abstract review. A review of the reference lists of key articles was conducted. This led to a hand search of three relevant journals (Annals of Emergency Medicine, Disaster Management & Response, and Inter-Professional Care). General article data were reported followed by a description of recurrent themes. All selected articles were uploaded to the qualitative analysis software ATLAS.ti Version 7 (ATLAS.ti Scientific Software Development GmbH; Berlin, Germany) and an inductive thematic analysis was used for coding and summarizing the data. Selected articles were read in full and then re-read. This was followed by making notes and coding passages from articles on characteristics that were explicitly identified or implicitly described through first-hand experiences.Reference Martin-Misener, Valaitis and Wong 7 The software program was used for dictating notes and coding the articles for retrieval and analysis. Two authors reviewed the coded data, discussed the characteristics, and grouped them into thematic areas. Two systematic reviews investigating the literature on medical team training and development for the disaster context were selected in the review.Reference Braune and Clarke 8 , Reference Subbarao, Lyznicki and Hsu 9 Both systematic reviews were analyzed separately and each contained only one article found in the literature search.
Report
The search yielded over 100,000 hits (CINAHL: 3,579; Global Health: 24; Google Scholar: 17,400; JSTOR: 26,500; ProQuest: 81,237; PsychInfo: 227; PubMed: 3,255; and Web of Science: 1,495). A title review was conducted of the first 1,000 results from each database (sorted by relevance). A combined 6,251 articles were included in the title review, yielding 138 articles. Of these, another 93 were excluded for either not addressing the research questions (n=77) or being duplicates (n=16). The reference-list review provided 24 additional articles, while the hand search provided five new articles. From the first reading, general information was collected and recorded, and another 41 articles were excluded.
Summary of Articles
A final 33 articles were selected. Fourteen were research articles and included 10 qualitative studies, two systematic reviews, and two descriptive studies. The remaining 19 articles were descriptive and focused on the experiences of providing medical care in the disaster setting. Eleven were from low-resource settings. Nine focused on the training of medical teams for disaster. Three key points emerged from the literature. First, few formal studies existed on medical teams in disaster. Second, one-half of the current disaster literature was based on experiences in the United States. Third, of the 11 articles from LMICs, the majority were concentrated on the 2004 tsunami in Asia (n=2) and the 2010 earthquake in Haiti (n=6).
Characteristics
An inductive thematic analysis was completed by reading the selected articles in full and developing a coding process of recurrent themes selected through explicit identification in research and implicit identification through narratives of descriptive articles.Reference Martin-Misener, Valaitis and Wong 7 Abstracted themes that occurred concurrently or were described similarly in the literature were grouped together for further discussion. The following theme groups were formed: (1) adaptability, flexibility, and improvisation; (2) creativity and innovation; (3) experience and training; and (4) leadership and command structure. Table 1 provides a definition of each of the recurrent themes.
Definitions of Recurrent Theme Groups
Note: Definitions were retrieved from http://www.merriam-webster.com/.
a Although the themes stress and coping were not one of the main thematic groups identified, they were identified within the sub-group of the literature.
Adaptability, Flexibility, and Improvisation
The most common characteristics cited in the literature were adaptability (n=18), flexibility (n=12), and improvisation (n=14), with some articles expressing a combination of these three characteristics. They are described separately; however, it should be noted that these characteristics frequently were identified in the coding process as inter-related and interchangeable.
In relation to team members’ roles, a nurse in Haiti explained adaptability as “adapt[ing] to your environment and be[ing] willing to change your role to achieve your goals.”Reference Williams, Nocera and Casteel 10 (p21) In their study of medical response to the 2004 tsunami, Robertson et al. noted the critical need for team members “being able to improvise and adapt to constantly changing circumstances.”Reference Lau 11 (p342) Adaptability, as described in the literature, is similar to the dictionary definition: “able to change or be changed in order to fit or work better in some situation or for some purpose.”Reference Robertson, Dwyer and Leclercq 12 It highlights the importance of making changes based on new challenges.
Contextually, flexibility is defined by a team’s ability to address new challenges, but adaptability and flexibility are described in the literature as interdependent rather than discrete characteristics. One article found that team members “adapted their skills accordingly,” 13 (p544) while another reported that “while the teams initially had been organized to provide front-line medical assistance, they actually functioned as hospital reinforcement.”Reference Laverick, Kazmi and Ahktar 14 (p619) Flexibility was also seen in organizational changes precipitated by patient needs:
[Transition] from an improvised medical disaster response to a well-organized health clinic occurred much more easily than anticipated. Very important to the success of this transition were . . . these providers [who] easily switched from “emergency response” mode into “a day at the clinic’ mode.”Reference Benner, Stephan and Renard 15 (p521)
Studies focusing on improvisation cited examples of teams improving air quality by covering vents with plastic and substituting prehospital medications for surgical procedures.Reference Laverick, Kazmi and Ahktar 14 , Reference Hamilton, Gayagan and Smart 16 Responders indicated they modified their roles to address challenges and find creative solutions. In situations where resources were limited, responders had to improvise and use materials not associated with the task.Reference D’Amore and Hardin 17 For example, transporting critical patients while manually ventilating them with a bag-valve mask because mechanical ventilation was unavailable.Reference Webb, Beverly, McMichael, Noon and Patterson 18 It was recognized in the literature that adaptability is a necessary, non-technical skill for surgeons in disaster situations.Reference Cohen and Mulvaney 19 Rehabilitation therapists who responded to the 2010 earthquake in Haiti commented, “You really gotta think, ‘Ok. I don’t have any tools here, so what can I do to really help these patients?’”Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 20 (p334)
Consequences associated with adapting to challenges also were discussed in the literature. One article reported that “medical teams had to adapt and downgrade some procedures.”Reference Laverick, Kazmi and Ahktar 14 (p619) Practice that is below normal medical standards, such as manual versus mechanical ventilation,Reference Webb, Beverly, McMichael, Noon and Patterson 18 transfer of patients without monitoring equipment, and intravenous drips held by hand,Reference Braune and Clarke 8 create a moral dilemma. However, while improvisation may not be optimal for patients, teams must be willing to adapt in order to carry out the key tenet of triage: the greatest good of the greatest number.Reference Klappa, Audette and Do 21
Creativity and Innovation
Eleven articles provided examples of teams demonstrating characteristics of creativity and innovation. These characteristics normally were described through the use of physical resources when resources were limited, or appropriate equipment was not available. A nurse in Haiti commented, “We would face new situations that [required] us to think outside the box to devise new solutions to problems.”Reference Iserson and Moskop 22 (p493) Surgical procedures required “the ability to think outside the box” 13 (p546) and “inventing new solutions, or adapting old solutions to new situations.”Reference Cohen and Mulvaney 19 (p383) A nurse stated, “We had to be creative . . . we constructed [splints and slings] from bandages and string.”Reference Williams, Nocera and Casteel 10 (p20) A responder remarked, “Sometimes we didn’t have the right equipment . . . but we made it work the best that we could.”Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 20 (p334) In one study, the lack of resources necessitated the use of glove fingers or intravenous lines for drainage.Reference Laverick, Kazmi and Ahktar 14 The literature demonstrates that creativity and innovation cannot be divorced from adaptability, flexibility, and improvisation. Kendra and Watchendorf found that creativity was vital for addressing the needs of the World Trade Center (New York, USA) disaster, particularly creativity based on prior knowledge.Reference Ketchie and Breuilly 23
Experience and Training
Experience (n=9) and training (n=10) generally were perceived as supporting the characteristics previously cited.Reference Lau 11 , Reference Kendra and Watchendorf 24 , Reference Djalali, Khankeh, Öhlén, Castrén and Kurland 25 Responders emphasized that experience was the foundation for adaptability, including adaptation of a triage system where none previously existedReference Slepski 26 and using resources not typically associated with a task.Reference Laverick, Kazmi and Ahktar 14 Experience was also a critical element for team leadership. Team members with previous disaster experience or training understood each member’s role and the overall purpose of the team, which allowed them to easily transition to a leadership position.Reference Slepski 26
Leadership and Command Structure
Leadership (n=12) and command structure (n=14) were discussed frequently in relation to team functioning.Reference Jackson and Little 27 They could be developed on an ad hoc basis or through prior training or experience.Reference Hamilton, Gayagan and Smart 16 , Reference Kendra and Watchendorf 24 , Reference King, North and Larkin 28 - Reference Connelly 30 However, experience from an earthquake response highlighted the challenges of teams formed on an ad hoc basis. In this disaster, patients were arbitrarily evacuated from the area without proper triage.Reference Markenson, DiMaggio and Redlener 31
Yet there are significant differences between structured clinical environments and disaster situations wherein team leaders working in volatile conditions must assess the needs of patients, clinicians, and external stakeholders.Reference Webb, Beverly, McMichael, Noon and Patterson 18 , Reference Jackson and Little 27 , Reference Catlett, Kirsch, Scheulen, Cole and Kelen 29 Team leaders were likewise responsible for facilitating teamwork by “effectively directing and delegating to others and refraining from micromanagement.”Reference Jackson and Little 27 (p335) Connelly described the need for “an unambiguous chain of command with clear standards of patient care and accountability.”Reference Catlett, Kirsch, Scheulen, Cole and Kelen 29 (p6) Aitken et al. noted the importance of a clear command structure, defined leader, and autocratic leadership style.Reference Djalali, Ingassia and Della Corte 32 However, organizational research findings contend that successful team management and coordination require the combination of agility and discipline, describing agility as adaptability, creativity, and flexibility and discipline as a system of leadership and organizational and command structure.Reference Aitken, Leggat, Robertson, Harley, Speare and Leclercq 33
Influence of Settings
Medical teams in low-resource settings had to adapt to compensate for the lack of supplies and materials compared to the normal health care setting.Reference Williams, Nocera and Casteel 10 Responders in Haiti emphasized the need for knowledge and skills: “We had more equipment back at the hotel but nothing of the kind found in UK emergency departments, and it soon became clear that our biggest assets were our basic clinical assessment skills.”Reference Williams, Nocera and Casteel 10 (p19) Prior experience in disaster humanitarian settings, or the military, also was perceived as useful.Reference Williams, Nocera and Casteel 10 , 13 , Reference Kendra and Watchendorf 24 , Reference King, North and Larkin 28
Stress and Coping
Increased stress (n=12) and coping (n=5) were seen as unique to the low-resource setting and often were related to the disaster exasperating previous socio-economic challenges in the area (eg, poverty and lack of adequate health services). In addition to limited resources and having to adapt to difficulties, team members experienced significant intrapersonal challenges. Responders noted, “Working in a disaster zone is inherently physically and mentally stressful,”Reference King, North and Larkin 28 (p7) and the overwhelming destruction “[left] even the most seasoned responder speechless.”Reference Iserson and Moskop 22 (p493) They also felt guilty leaving when so much need still existed and questioned whether they had done enough.Reference Willems, Waxman, Bacon, Smith, Peller and Kitto 20 Australian responders observed that medical team leadership involves maintaining the welfare of team members because of the stress they endure.Reference Djalali, Ingassia and Della Corte 32 Other articles shed light on mechanisms to deal with stress and reduce its effects such as humor and sleep.Reference Webb, Beverly, McMichael, Noon and Patterson 18 , Reference Cohen and Mulvaney 19 , Reference Catlett, Kirsch, Scheulen, Cole and Kelen 29
Development and Training of Teams
Nine articles provided information on the development of teams and team characteristics as reflected in the recurrent themes.
Four articles focused on the competencies of health care providers in the disaster setting and emphasized competency development through formal education.Reference Braune and Clarke 8 , Reference Djalali, Khankeh, Öhlén, Castrén and Kurland 25 , Reference Jackson and Little 27 , Reference Connelly 30 One pilot study surveyed 200 experienced disaster responders from different health backgrounds to identify competencies they saw as most important.Reference Djalali, Khankeh, Öhlén, Castrén and Kurland 25 Another was a combined systematic review and expert working group consensus that identified a comprehensive list of competencies for disaster responders in health care.Reference Braune and Clarke 8
King et al. conducted focus groups with Emergency Medical Service leaders and compiled a list of attributes needed for disaster respondersReference Jackson and Little 27 that parallels themes identified in the analysis. For example, training and experience with the command structure to understand team member roles and the context of disaster response. Based on responder survey results, responders had to be creative to adapt to the dynamic environment of the disaster setting.Reference Djalali, Khankeh, Öhlén, Castrén and Kurland 25 In relation to role improvisation, one leader said, “When you get there you have to change from being a paramedic to being the scene manager”Reference Jackson and Little 27 (p335) and “[when a] plan goes out the window… you are going to have to adapt.”Reference Jackson and Little 27 (p336) Furthermore, responders “have to be flexible enough to recognize when a protocol isn’t working and they need something else.”Reference Jackson and Little 27 (p336)
One article identified the need to be creative and flexible, to apply skills and knowledge, to understand one’s role and function as part of the overall response, and to identify potential contingencies.Reference Connelly 30 Expert opinion surveys cited a lack of coordination among teams formed on an ad hoc basis. Respondents indicated that for teams to be better prepared and understand their capabilities prior to deployment, they should be formed as a team and train as such.Reference Markenson, DiMaggio and Redlener 31
Three articles focused on team training.Reference Subbarao, Lyznicki and Hsu 9 , Reference Harrald 34 , Reference Atack, Parker, Rocchi, Maher and Dryden 35 One qualitative study researched the effectiveness of an online disaster management and preparedness course and demonstrated education helped improve the participants’ understanding of their roles and overall team functioning during a disaster.Reference Harrald 34 A descriptive study investigated the effectiveness of virtual reality training for mass-casualty events; however, the study focused on individual and not team performance.Reference Atack, Parker, Rocchi, Maher and Dryden 35 A systematic review of health provider disaster training assessed the quality of study design and likelihood for bias and found that the majority of articles were of fair to poor quality with limited experiential learning. It concluded that “the available evidence is insufficient to determine whether a given training intervention in disaster preparedness for health care providers is effective in improving knowledge and skills in disaster response.”Reference Subbarao, Lyznicki and Hsu 9 (p221)
Discussion
Disasters occur unexpectedly and the need of the population affected necessitates assistance from functioning medical teams. There has been significant research on the functioning of teams in the clinical context and the development of effective training methods. However, there is limited research on medical teams operating in the disaster context. The unpredictability of disasters is a barrier to investigative study. Researchers cannot plan for a specific time or location in which a disaster might occur, and the volatile nature of disasters presents additional risks which may limit the ability to collect adequate data. This was evident in most of the descriptive literature found in the review.
Findings from the current study can be used to guide future research and development of effective team training. For example, existing evidence on medical teams in the institutional context could be reviewed to determine if there are similar recurrent themes. Although the context is different, it may provide a starting point for evaluating team functioning and development of effective training.
Limitations
The primary limitation of this review is the paucity of literature. Most articles were first person perspectives or retrospective analyses. Furthermore, the scoping review does not evaluate the quality of evidence or weight the evidence; these limitations may not provide an objective analysis of team functioning and performance. The scope of the review also was limited to full text articles available with the university’s access rights, and the first 1,000 articles sorted by relevance; however, articles beyond the first 1,000 were found to be highly irrelevant. The context of the literature was concentrated on specific disasters and locations such as the United States and Haiti. This concentration may limit the generalizability of the identified characteristics.
Conclusion
In summary, this scoping review was conducted to determine the characteristics of medical teams responding to disaster in low-resource countries and the training required to develop these characteristics. One of the important findings is that commonalities exist across disaster settings regardless of area, type of disaster, or who is involved. Concerning the development of characteristics, studies conducted to date identify some key competencies and experts in the field have provided some insight, but more information is required. Gaps in the literature highlight the need for further research.
Acknowledgements
The authors wish to thank Mary Crea-Aresnio, who provided the opportunity to participate in the initial literature for their scoping review, which helped to better apply the concepts.
