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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.


Introduction
Increasing Chemical, Biological, Radiological, and Nuclear (CBRN) threats are a public health challenge in China. China has experienced 200e600 accidents every year in hazardous chemical industry, 1 frequent emerging epidemics 2 (e.g. coronavirus disease 2019, severe acute respiratory syndrome (SARS), H5N1, and African swine flu), more than 43 planned nuclear reactors, 3 and unpredictable terrorism attacks. China has invested heavily in the development of CBRN medical response capacity including the CBRN Medical Response Teams (CBRN-MRTs) designed to be deployed on the site.
Despite the fact that public health responders adequately respond to the clinical or public health aspects of disasters, they are not always prepared or trained to work in a real hazardous environment and complex temporary situation. 4 The unique nature of intense working relationships and particularly austere environment requires not only technical skills but also non-technical competencies. A body of previous studies has explored the components of non-technical competency for health workers in a critical environment. 5e10 It has been established that interpersonal, social, and cognitive skills play an important role in response performance. 11 Those non-technical competencies broadly involve a range of knowledge, attitude, and skills in communication, 12e14 collaboration, 15,16 leadership, 17e19 situation awareness, 12 and other individual personal attributes. 20 However, the literature search revealed relatively few studies specifically focusing on public health staff working at a CBRN incident site.
Complicating a straightforward emergency response is the addition of CBRN factors that add an extra layer of complexity to the emergency response. 21 CBRN emergencies cause trauma on a large scale and demand complex responses including triage, monitoring, diagnosis, decontamination, and self-protection for public health workers. 11,22 CBRN mass casualty situations are normally chaotic. Casualties may have single or multiple injuries or may have conventional injuries that are complicated by CBRN exposure (such as in a toxic spill or nuclear power plant accident). The treatment of CBRN casualties should reflect the conventional incident and casualty management paradigms with additional safety and treatment considerations. 23 CBRN incidents present different challenges for all responders, necessitating the rapid decontamination and treatment of a significant number of casualties while taking critical measures to ensure the well-being of the personnel managing the incident. 24 CBRN events have an additional 'fear factor' and expose responders to potential agents and possible hazards, and it has been reported that health professionals may not respond to CBRN events as willingly as they would to a conventional disaster event. 25e27 There are differences in particular context and nature among various disasters, so it is difficult to define a consistent set of competencies across disciplines and jurisdictions. The present study aims to define and identify specifically non-technical competencies for on-scene public health workers in CBRN disasters.

Study participants
A qualitative study was performed in China involving interviews with key informants in the field of health response to CBRN disasters. Semistructured in-depth interviews were used to seek deep perspectives of the experts. A purposive sampling approach was conducted to ensure that included interviewees could reflect on their experiences training and working in a CBRN-MRT. Those public health responders who had significant on-scene experience and direct involvement in real CBRN disaster management or fullscale disaster drills were involved. To increase data quality, the sample was also interprofessional, representing diverse healthcare professions on the team. In addition, several academic experts were included based on their relevant study background.

Data collection
The interview took place by phone or face-to-face in the respective institutions with a single interviewer and lasted 30e60 min. Open-ended main questions were asked to gain insights into requirements of non-technical competencies for an onscene medical responder in CBRN emergencies. To ensure that the interviewees elaborated on their experiences, the interviewer also explored with additional probing questions. Questioning was informed and evolved according to responses of the interviewees. The interview guide is presented in Appendix 1.
This study used a constructivist grounded theory approach encompassing the notion that interpretation of the data is coconstructed by interactions between participants and researchers. As per grounded theory, analysis occurred alongside data collection and was able to inform the next interview and develop an emergent understanding of the themes and findings. Substantive coding facilitated the process of theoretical sampling and directed the evolution of the interview guide. As interviews were conducted and coded, the competencies were revised iteratively. Theoretical sampling was carried out until the researchers reached theoretical saturation, that is to say, when conducting more interviews would add little value to the research and when data saturation was achieved and the interviewing ceased.

Data analysis
Each interview was recorded, transcribed, and imported into NVivo 10 software (released in 2012 by QSR International). The usual grounded theory approach to data analysis was undertaken. The initial coding stage was undertaken during data collection and theoretical coding stages. The lead author then reviewed each transcript again to yield final codable passages and undertook validity checks. Moving on to theoretical coding, codable passages similar in meaning content were merged into larger units as subcompetencies, which were further condensed into competency domains. The questions that were used during coding initially inquired about 'what specific competency or subcompetency is these data a study of?' followed with 'what competency category does these data indicate?' Domains and subcompetencies were refined through comparable responses. A second author conducted cross-verification of the whole data to minimize missing an important competency category and optimize the rigor of the study. Disagreements in coding were resolved by discussion between the two reviewers. Discussions among all researchers were also used to develop the relationships between analytic themes of the competency domain.

Interview participants' characteristics
A total of 20 experts from across the nation participated in the interviews. The demographics of interviewees are summarized in Table 1. Most of them had a master's or doctoral degree (70%) and worked in the Centers for Disease Control and Prevention or hospitals (70%), with a median age of 46 years (range from 32 to 75 years), and a median of 20 years of practice in the field of CBRN emergency (range from 4 to 40 years). Half of them were specialized in preventive medicine or public health administration, covering multiple professions.

Identified non-technical competencies
A total of 159 codable passages were produced from the interview transcript. Eight non-technical competency domains were identified: (1) situation awareness, (2) communication skills, (3) collaboration, (4) resource management, (5) task management, (6) cultural, ethnic, and legal competency, (7) austere environment skills, and (8) physical stamina. Table 2 contains detailed descriptions of these domains with definition of the competency domain, subcompetencies, and illustrative examples from the interview transcripts.

Discussion
Systematic development of a competent medicine workforce prepared for a CBRN crisis requires a targeted non-technical competency framework used to guide workforce planning, recruitment, placement, assessment, and demand-driven training. 8,28,29 The present study developed 8 non-technical core competencies specifically required for first-line public health responders in CBRN emergencies. As per the similarities and differences in response methods between CBRN emergencies and other general disasters, those identified competencies are discussed in three groups: common, enhanced, and specialized non-technical competencies.

Common non-technical competencies
The challenges posed and the response requirement for CBRN and accidental incidents differ but are similar or the same in many respects. For that reason, some of the competencies explored within this study are equally applicable to both situations and can be implemented for all levels of incidents. Some components of non-technical competencies identified through this study thus confirmed correlations with the common skills defined in prior research involving health professionals working in general critical situations, including communication, 12e14,17,30 collaboration, 15,16,31 and cultural competencies. 32 Owing to widespread public concern about mass casualties and diverse participation of multiple professions, public health responders in CBRN incidents are required to do well in communicating internally and externally, along with interprofessional and intra-agency collaboration within complex managerial structures. 11,13,16,26,33 Understanding of cultural backgrounds, ethical principles, and regulations is also necessary for CBRN public health responders to deal with common interest conflicts and dilemmas. 22 In addition, this study added specific understanding of those common competencies by description of the corresponding subcompetencies that are required in the CBRN context.

Enhanced non-technical competencies
Compared with other disasters, emphasis and enhancement should be placed on the competencies of situation awareness, resources management, and task management. CBRN missions in contrast have often involved unknown or unidentified substances, with a greater emphasis on the need to identify the substance through sampling and intelligence collection. Situation awareness of public health responders thus plays a more important role because responsive actions are based on timely recognition of the uncertain status and trends of CBRN harm closely correlated with dynamic weather conditions and the geographical environment. 33 CBRN events, usually leading to mass casualties, have the potential to rapidly overwhelmdor threaten to exceeddthe local capacity available to respond, and therefore, public health responders during CBRN disasters should also do better in resource management of detection devices and special reagents needed in CBRN responses which are characterized with more diversity, precision, and vulnerability to environmental impact. 11 Task management not only directly affects response performances, which has been widely cited in the previous literature, 8,9 but also may have indirect influence by affecting other non-technical competencies. Most of the interviewees indicated that having a good knowledge of professional task procedures and standards is a type of fundamental nontechnical competency that can make contributions to better communication, collaboration, and mental quality. This finding suggests that effective CBRN training should integrate and synchronize courses based on non-technical and technical competency.

Unique non-technical competencies
Because rescuers and victims are continually under life threats from CBRN contamination, responders must take measures to protect the airway, skin, and eyes before entering the contaminated area, which is a unique and indispensable component of emergency response. 22 Austere environment skills involving physical/psychological self-care are definitely perceived as a priority for the CBRN public health responders because limitations to the use of personal protective equipment (PPE) are restriction of physical activity, heatrelated illness, dehydration, and psychological effect. Most study participants started their discussions with personal safety considerations and skills in a hot or warm zone, and psychological selfcare was also highlighted as essential for medical workers at high risk of suffering severe stress or even anxiety disorders from the fear of CBRN hazards. In addition, overwhelming workloads are frequently encountered by medical staff dressed in heavy PPE in austere hazardous environments, where they encounter an influx of patients. In contrast to prior studies, 9,15,19 physical stamina was frequently discussed in this study as a non-technical competency that makes a substantial contribution to response performance.

Limitations
The present qualitative study is subject to several limitations. The raw data were the expressed opinions of a purposive sample of experts. Although inclusion criteria for subjects were based on their experience in the field of CBRN responses and their varying backgrounds, it is possible that a potential source of bias exists in respondents. Second, the interpretivist framework raises questions about the validity of the findings and empirical generalizability of the study, although validity checks on the coding and data analysis are allowed. Finally, this qualitative study was intended to identify categories, not to quantify their relative importance to the participants.
Further studies should continue to identify and validate potential non-technical competencies using multiple approaches based on a broader sample to explore the attributes of effective public health responders in new CBRN emergencies. With the changing characteristics of CBRN incidents, the competency framework should keep updating to match the emergent needs of response and to advance the evolvement of workforce development processes. More efforts are also needed to explore relative contribution of each non-technical competency to the comprehensive  performance of public health responders and relationship among those competencies. Moreover, studies could be conducted to further classify competencies by phases of the CBRN management and to delineate levels of proficiency needed based on occupations.

Conclusions
Non-technical competencies are as critical as technical ability for the health workers to respond effectively in CBRN emergencies. There are specific requirements in non-technical competencies for public health responders in CBRN events besides some common competencies. Those identified competencies could be useful to develop a workforce for CBRN emergencies, such as outlining competency-based training and updating job description for recruitment. The proposed competency framework can be used to support developers of public health emergency preparedness training initiatives by ensuring that public health professionals are able to demonstrate the non-technical knowledge and skills needed for successful performance when preparing and responding to CBRN incidents. It can also help update and revise job descriptions as well as orient public health practitioners to their emergency roles and responsibilities. The changing practical context and requirements for CBRN responses in the future demand the constant updating and redefining of the competency framework.

Ethical approval
This project was approved by the Ethics Committee of Academy of Military Medical Sciences. All the interviewees gave their consent before the interviews and agreed to the dialog being recorded using audio equipment. The participants were assured that their participation would be voluntary and anonymous.

Funding
This study was supported by the Project of Logistics Research (no. BWS16J013).