Background: Natural and manmade disasters are becoming more common and are creating increasingly complex response challenges. In Sweden, the responsibility for disaster management and disaster preparedness lies with the regions. Disaster preparedness includes the provision of training and exercises in medical command and control to establish the ability to create surge capacity. Resilience can serve as a theoretical perspective to identify crucial capabilities for managing disasters and can be defined within the domain of disaster medicine, as the ability to withstand, absorb, and react to the impact of disasters while preserving and augmenting essential health services, and subsequently recovering to the system’s original state or adapting to a new one. Research on resilience in medical command and control may contribute to evidence-based teaching and training for medical incident command. The aim of this thesis is to contribute to new knowledge about resilience in medical command and control and how to implement resilience in disaster management teaching and training.  

Methods: This thesis is based on four studies using a mix of qualitative and qualitative methods with both deductive and inductive approaches. In study I, a within-group pretest–posttest design was used to examine 13 head nurses´ general and specific self-efficacy before and after an intervention of three short computer-based simulation exercises. Study II was a case study focusing on a regional medical incident command taking part in a capability development program combining education, training, and exercises. In study III, an experienced medical incident command participated in a functional exercise and behaviors were captured through observations, video, and audio recordings. Using the markers and strategies analytic framework, observable behavior that exemplified resilient practice were identified. Study IV was a semi-structured, retrospective, in-depth interview study with an inductive design relying on the Critical Decision Method   

Results: Study I showed an increase in head nurses´ general but not specific self-efficacy. They also exhibited improved management skills, as indicated by shorter time-to-treatment for both trauma patients and in-hospital patients in the last exercise. Study II offers an example of how a resilience concept can be introduced to, contextualized, and operationalized with medical incident command personnel through a combination of education, training, and exercises. Study III shows an empirical link from resilience concepts to observable behaviors during an exercise in medical command and control. Study IV identified factors affecting decision-making in medical command and control during the early phase of COVID-19.  

Conclusions: The results contribute valuable insights to the understanding of challenges, strategies, education, and training methods related to resilience in medical command and control. 

Introduction:

The Covid-19 pandemic strained most of the world’s health care organizations to, and sometimes beyond, their limits. To anticipate, coordinate, mobilize, and prioritize hospital resources, Sweden’s health care regions established regional medical command and control teams according to the medical major incident structure. This command structure was initially developed based on an all-hazards approach focused primarily on sudden mass casualty incidents with a relatively short time frame. Covid-19 management was active for several months with a most intense operations period during the spring of 2020. This study aimed at identifying competence needs by employing a co-creative approach with members of the staff involved in the pandemic management.

Method:

Data was collected and analyzed using a modified Delphi consensus method. The respondents were subject matter experts serving in the regional medical command and control teams during the COVID-19 pandemic. One workshop was held to gather opinions, which were included as statements in a consensus survey and answered by the participants after the first workshop. A second workshop was held to discuss statements that did not reach initial consensus in the survey and establish final consensus.

Results:

The consensus agreed statements were sorted into five themes, which constituted the collective agreement of medical command and control core abilities. The five core competence themes were: Situation report, Team organization, Co-operation, Competence management, and Analysis. The consensus agreed statements highlighted competencies needed for creating situation reports, organizing medical command and control teams, effective cross-organization co-operation, decision-making, and medical intelligence analysis.

Conclusion:

The core competencies of medical command and control identified in the present study can be used to further affirm current learning objectives and to formulate future learning objectives for education and exercises. The evaluation approach could potentially be used as a post-incident review to fine-tune an organization’s training plan.

Introduction:The Covid-19 pandemic strained health care organizations to their limits, and sometimes beyond. Different countries took different approaches to minimize the effects of the pandemic, both to protect public health and to safeguard the capability of the health care system.

A collaborative project between Sweden and Bosnia-Hercegovina with the aim to share and learn from experiences of managing the COVID-19 pandemic from a medical command and control perspective, initiated in 2021.

The project departed from three theoretical stances: sociotechnical systems perspective, experiential learning theory, and organizational learning theory. Framing the problem using a holistic systems approach, compared to focusing on individual experts, allows for understanding interactions on a system level. Hence, could these theories contribute to supporting individuals' learning and organizational change?

Method:A two-day workshop involving participants from both Swedish and Bosnian (N=21) medical command and control allowed for the exchange of experiences and another's perspective on similar challenges. During the workshop, two themes were addressed: common operational picture and evaluation. First, an introductory presentation was held, then the theme was discussed and reflected upon in small groups. After this, the groups presented their conclusions, and a full group discussion was moderated.

Results:The discussions resulted in participants sharing perspectives on the selected themes, providing personal insights and experience, allowing for deepened and increased understanding of the theme. In spite of major differences between the Swedish and the Bosnian health care systems and Covid-19 approaches, several shared conclusions were identified. For example, reflections on decision processes and strategies, as well as interest in improving the crisis organization.

Conclusion:Exposing participants to different views on well-known processes and challenges allows for reflecting, verbalizing, and reaching a deeper understanding. By displaying a culturally differently organized way of approaching the challenges the contrast is even more evident.

This paper presents an analysis of situation reports used and created by a crisis management team within the Swedish healthcare sector during the early phase of the COVID-19 pandemic. The analysis was conducted through a deductive content analysis, where categories were identified based on the concepts of common operational pictures, sensemaking, and situation awareness. In the analysis, support for all identified categories was found. Based on the analysis and the concepts, future recommendations regarding what type of information that ought to be included in situation reports were created. These recommendations include, amongst others, the categories of consequences, how it is perceived by the public, objectives, status and implications of information, future scenarios, actions, resources, and work procedures.

Resilience has in recent decades been introduced as a term describing a new perspective within the domains of disaster management and safety management. Several theoretical interpretations and definitions of the essence of resilience have been proposed, but less work has described how to operationalise resilience and implement the concept within organisations. This case study describes the implementation of a set of general resilience management guidelines for critical infrastructure within a Swedish Regional Medical Command and Control Team. The case study demonstrates how domain-independent guidelines can be contextualised and introduced at an operational level, through a comprehensive capability development programme. It also demonstrates how a set of conceptual and reflective tools consisting of educational, training and exercise sessions of increasing complexity and realism can be used to move from high-level guidelines to practice. The experience from the case study demonstrates the value of combining (1) developmental learning of practitioners’ cognitive skills through resilience-oriented reflection and interaction with dynamic complex open-ended problems; (2) contextualisation of generic guidelines as a basis for operational methodological support in the operational environment; and (3) the use of simulation-based training as part of a capability development programme with increasing complexity and realism across mixed educational, training and exercise sessions. As an actual example of a resilience implementation effort in a disaster medicine management organisation, the study contributes to the body of knowledge regarding how to implement the concept of resilience in operational practice.