The frequency and magnitude of disasters have increased significantly over the last 30 years, a trend that is expected to continue.1 Factors such as overpopulation and increased urbanization,2 climate change,3 the spread of communicable infectious disease with increased travel and commerce,4 and the ongoing threat of terrorism5 magnify the susceptibility to and effects of disaster situations. Although such issues provide strong impetus to federal, state, and local governments to prioritize and improve health system preparedness and response capacities, lessons learned from recent disasters demonstrate persistent gaps in education, training, and leadership at all levels.6–12 Recognizing the need to further enhance health system capability to respond to disasters, in October 2007 President Bush signed Homeland Security Presidential Directive-21.13 With this directive, the president calls on the nation to promote the establishment of a discipline that recognizes the unique principles in disaster-related medicine and public health; provides a foundation for the development and dissemination of doctrine, education, training, and research in this field; and better integrates private and public disaster health systems.
The emerging discipline of disaster medicine and public health preparedness is inclusive and comprises all health care and public health professions whose expertise supports the capability of health systems to prepare for, respond to, and recover from disasters and other public health emergencies. Those educated and trained in this discipline provide care, leadership, and community guidance in all phases of a disaster. They are also critical agents who interface with public safety and emergency management personnel, government agency officials, legislators, and policymakers, as well as help coordinate civilian and military disaster response assets. Because of the immense variation in the nature and magnitude of specific disaster events, the boundaries of the discipline are imprecise at best. As a guiding framework, the list of 37 target capabilities established by the US Department of Homeland Security provides a useful context for health system response entities.14
To prepare health professionals to respond appropriately, and to assist professional schools and continuing education providers to meet this challenge, various organizations and universities have developed competencies for health professionals and other emergency responders. To date, these efforts have been limited primarily to individual specialties or targeted professionals such as physicians,15–18 nurses,15, 19 emergency medical technicians,15 public health workers,20–Reference Hites, Lafreniere and Wingate25 hospital-based health care workers,26–29 practicing clinicians,30 volunteer health professionals, 31–33 and students in health professions. Reference Markenson, Di Maggio and Redlener34–36 As yet, little effort has been devoted to the integration of these competencies across health specialties and professions that have a stake in disaster medicine and public health preparedness. This has resulted in a lack of definitional uniformity across professions with respect to education, training, and best practices, thus limiting the establishment of this discipline at an operational level. To address these gaps, the American Medical Association convened an expert panel to develop a consensus-based educational framework and competency set from which educators could devise learning objectives and curricula tailored to the needs of all health professionals.
METHODS
A systematic review was conducted to identify competencies and other educational and training guidance for professionals in the disaster health system. PubMed, Google Scholar, FirstSearch, and Excerpta Medica were searched for English-language articles published from January 2004 to July 2007 using the terms disaster, public health emergency, mass casualty, training, education, course, competencies, public health, emergency medical services, and healthcare. In addition, an Internet search using the terms disaster, public health emergency, and mass casualty was merged with training, course, competencies, public health, emergency medical services, and healthcare to compile published competencies outside the peer-reviewed literature. Additional citations were identified via the “related articles” link provided on the PubMed and Google Scholar sites. Information also was derived from manual review of references cited in relevant journal articles, reports, and textbooks; examination of Web sites of federal agencies and relevant stakeholder organizations; and direct communication with recognized experts in this field. The search was designed to augment a recent comprehensive literature review funded by the Agency for Healthcare Research and Quality to identify educational competencies for health care workers in disasters.26
Retrieved articles and reports that met the search criteria were submitted for structured review and analysis by an American Medical Association 18-person expert working group (EWG). Publications were scored (from 0 for no relevance to 3 for fully relevant) according to the extent to which they included disaster training competencies relevant to health professionals (item 1), and whether such competencies were supported by identifiable training objectives (item 2). Articles with a score of 3 on item 1 and a score of 2 or more on item 2 were chosen for further review and analysis. The EWG reviewed selected publications for relevance to all health professionals in a disaster and identified potential learning gaps.
The EWG developed competencies based on adaptation of Bloom's cognitive taxonomy.Reference Bloom, Englehart and Furst37 In accordance with this taxonomy, a new conceptual educational framework was derived according to 6 levels of learning (knowledge, comprehension, application, analysis, synthesis, and evaluation) to enable health professionals to achieve the highest appropriate level of proficiency within each competency. The framework was created to accommodate the development of courses and curricula to meet the diverse education, training, and job requirements of all target professions.
The resultant draft educational framework and competencies were submitted to the following stakeholder organizations for review:
• American Academy of Family Physicians
• American Academy of Pediatrics
• American College of Physicians
• American College of Emergency Physicians
• American College of Surgeons
• American Hospital Association
• American Nurses Association
• American Osteopathic Association
• American Psychiatric Association
• Emergency Nurses Association
• Medical Reserve Corps
• National Association of County and City Health Officials
• National Association of Emergency Medical Services Physicians
• Uniformed Services University of the Health Sciences
After stakeholder review, the draft educational framework and competencies were revised to incorporate feedback, and then reviewed further by the National Disaster Life Support Education Consortium (NDLSEC). The NDLSEC comprises professionals from 75 public and private organizations with an interest in disaster preparedness, professional education, and curriculum development. Consensus was ensured through a 3-stage Delphi process with the EWG (after the initial expert panel review, after the selected stakeholder review, and after the NDLSEC review). The work was funded through the Health Resources and Services Administration bioterrorism training program, which is now under the auspices of the Office of the Assistant Secretary for Preparedness and Response.
RESULTS
The literature search revealed 71 articles in the peer-reviewed literature and 20 publications without peer review (eg, after-action and government reports) published after January 2004 for initial review. After 2 levels of structured analysis, 4 peer-reviewed articlesReference Parker, Barnett and Fews23,Reference Barnett, Everly, Parker and Links24,26,Reference Markenson, Di Maggio and Redlener34 and 4 publications not peer reviewed27,28,31,35 were selected by the EWG for further consideration. To ensure a comprehensive and thorough review, other published clinical and public health competency sets were included for comparative assessment.14–Reference Gebbie and Merrill22,Reference Hites, Lafreniere and Wingate25,29,30,Reference Combs32,33,36 In addition, the EWG reviewed several after-action reports from hurricanes Katrina and Rita to identify potential learning gaps for health system responders that are not addressed in existing educational competency sets.7–9,Reference Slepski38–43
…this educational framework will contribute to any potential basis for the credentialing or certification of volunteer health professionals, such as the Medical Reserve Corps
During the review process, 2 major issues were identified. First, existing published competencies are limited primarily to the workplace, a specific discipline, or a practice setting. They lack information needed to address a coordinated health system response to a disaster. Second, existing competency sets lack the interdisciplinary rigor that would make them relevant to all health professionals regardless of their experience and background, or prior roles in a disaster. In particular, defined competencies for health system leaders in a disaster are lacking.
Competency Design and Development
The EWG determined that existing competency sets need to be expanded to include issues such as public health law, ethics, risk communication, cultural competence, mass fatality management, forensics, contingency planning and response, the civilian–military relationship, and crisis leadership. The EWG also determined that the competencies must be comprehensive and appropriately address vulnerable individuals and populations (eg, children, pregnant women, frail older adults, people with disabilities) who may be subject to increased adverse health effects during a disaster.
Development of Competency Domains
As a first step, the EWG sought to identify and define the broad overarching competency domains relevant to all health professionals in a disaster using the literature review of existing competencies as background. After final review, 7 competency domains were identified, which encompass all of the target audiences of those responsible for a coordinated health system response. These domains are
• Preparation and Planning
• Detection and Communication
• Incident Management and Support Systems
• Safety and Security
• Clinical/Public Health Assessment and Intervention
• Contingency, Continuity, and Recovery
• Public Health Law and Ethics
Delineation of Core Competencies in Accordance With Bloom's Taxonomy
The next step was to merge the cognitive domains derived from Bloom's taxonomy with an educational model that allows health professionals to demonstrate competency according to their expected role and level of involvement in a disaster. The EWG defined 19 core competencies that are relevant to all health professionals (Table 1).
Core Competencies for All Health Professionals in a Disaster
Delineation of Health Personnel Categories
The EWG identified 3 broad, yet distinct, personnel categories that encompass all health professionals: informed workers/students, practitioners, and leaders. Personnel would be expected to perform at different levels of proficiency depending on their experience, professional role, level of education, or job function across the core competencies. This framework allows for all of the health professions to be represented in each category, and recognizes the diversity of expected job functions and educational requirements for each health profession involved in disaster planning and response.
The health personnel categories establish increasing standards for each core competency. Health professionals can demonstrate proficiency in each category at the following levels based on their educational needs, experience, professional role, and job function in disaster planning, mitigation, response, and recovery:
• Informed Worker/Student: These are health professionals and students who require awareness and understanding of particular aspects of disaster planning, mitigation, response, or recovery. These people should be able to describe core concepts or skills but may have limited ability or need to apply this knowledge.
• Practitioner: These are health professionals who are required to apply clinical or public health knowledge, skills, and values in disaster planning, mitigation, response, and recovery. Within this category, distinct educational tracks could be defined and developed to meet recommended or required proficiency standards (eg, basic, intermediate, advanced).
• Leader: These are senior executives (CEO, COO, CFO), directors, managers, and department heads with administrative decision-making responsibilities, leadership functions, and policymaking roles in disaster planning, mitigation, response, or recovery. Within this category, distinct educational tracks could be defined and developed to meet various leadership roles and functions in a disaster (eg, incident command leaders, health executives, government leaders).
Delineation of Category-specific Competencies in Accordance With Bloom's Taxonomy
The EWG defined specific competencies within each core competency that describe the highest level of proficiency appropriate for each personnel category (Table 2).
Proposed Core and Group-specific Competencies for Health Professionals in a Disaster
Proposed Core and Group-specific Competencies for Health Professionals in a Disaster
Proposed Core and Group-specific Competencies for Health Professionals in a Disaster
Proposed Core and Group-specific Competencies for Health Professionals in a Disaster
Proposed Learning Matrix for All Health System Responders
The EWG recognized that health professionals vary in their expected roles and level of involvement in a disaster. Therefore, it developed a learning matrix that can be customized for any target audience to define proficiency requirements within each competency (Table 3). With this matrix, disaster health education and training programs can be created or modified to incorporate the competencies at the desired proficiency levels.
Example Learning Matrix: Hospital Administrator
DISCUSSION
The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of core learning domains and cross-competencies. The competencies can be applied to a wide range of health professionals who are expected to perform at different levels according to experience, professional role, level of education, or job function. This approach will lead to a common lexicon and improved standardization of training programs. Within this framework, health professionals will be better able to identify limits to their knowledge, skills, and authority in a disaster, as well as identify key system resources for referring problems or matters that exceed these limits.
This educational framework strongly supports the recommendations of Homeland Security Presidential Directive-21, and permits application within this rubric. This model allows for the identification and incorporation of the unique body of knowledge of disaster medicine and public health preparedness and provides for the broad dissemination of this knowledge base to various target professions. It also provides a practical and flexible framework for the education, training, and evaluation of all health professionals according to their expected role and level of involvement in a disaster. The framework defines consensus-based floor (informed worker/student) and ceiling (leader) levels of proficiency for all health professionals in disaster medicine and public health preparedness. It allows for the accumulation of knowledge and proficiency in any competency and personnel category, and progression between categories, as well. This correlates with the progression of applications in tactics, operations, and strategy.
…existing published competencies are limited primarily to the workplace, a specific discipline, or a practice setting. They lack information needed to address a coordinated health system response to a disaster.
Within personnel categories, distinct educational tracks can be further defined and developed to meet more specialized learning objectives, training requirements, and job needs. Within the practitioner category, for example, distinct learning tracks could be developed to meet specified job expectations in a disaster (eg, to meet basic, intermediate, or advanced levels of proficiency). In the leader category, separate tracks could be developed for incident command leaders, health executives, and government leaders to meet their various leadership roles and functions in a disaster. Although it is recommended that the core competencies for the informed worker/student be achieved by all potential health system responders before achieving the practitioner or leader proficiency levels, this decision will ultimately rest with credentialing and certification entities, as well as curriculum developers.
In accordance with the Pandemic and All-Hazards Preparedness Act,44 this educational framework will contribute to any potential basis for the credentialing or certification of volunteer health professionals, such as the Medical Reserve Corps. Conceptually, potential health system volunteers would be preregistered with documentation of their current proficiency status in disaster medicine and public health preparedness. This could promote the further evolution of the Emergency Services Advanced Registry for Volunteer Health Professionals and similar databases to facilitate the mobilization and deployment of well-prepared and well-trained health professionals for all disasters.
Next Steps
An important next step is the development of learning objectives and performance metrics for each category-specific competency. Presently, the educational framework and competencies are being vetted with the NDLSEC for incorporation into the National Disaster Life Support training program. Learning objectives and evaluation tools also are being developed through the NDLSEC for integration into future iterations of the National Disaster Life Support courses.
The educational framework and competencies still require validation, which will be accomplished by NDLSEC members and through incorporation into the National Disaster Life Support program. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina and can enhance preparedness for future disasters, preparedness is a process rather than an endpoint, and these competencies must be reviewed continually and refined over time.
Authors’ Disclosures
The authors report no conflicts of interest.
Acknowledgments
We appreciate the time and effort of Sandra R. Shefris, MLIS, and Yolanda Davis for conducting the literature search and compiling articles for the expert working group. We also wish to acknowledge the following individuals who provided critical review and feedback on this article: Sherri-Lynne Almeida, RN, DrPH, MSN, MEd; Jill A. Antoine, MD; Bruce S. Auerbach, MD; Richard T. Boland; Mona R. Bomgaars, MD, MPH; Arthur Cooper, MD, MS; Robert G. Darling, MD; Steven Diaz, MD; Gerald E. Harmon, MD; Jack Herrmann, MPH; Jack Horner; Heather Kaiser; E. Brooke Lerner, PhD; Mary Anne McCaffree, MD; Marsha Meyer; John A. Mitas II, MD; Glenn W. Mitchell, MD, MPH; Paul E. Pepe, MD, MPH; Cheryl Peterson, MSN, RN; Maurice A. Ramirez, DO; Charles L. Rice, MD; Roslyne D.W. Schulman; and Ruth Steinbrecher, MPH.
