EDMG541Wk5
Rawono1
Communication_during_mass_casu.pdf
Communication during mass casualty decontamination:
highlighting the gaps Holly Carter
Emergency Response Department, Health Protection Agency, Salisbury, UK
John Drury School of Psychology, University of Sussex, Brighton, UK
G. James Rubin Institute of Psychiatry, King’s College London, London, UK
Richard Williams Welsh Institute for Health and Social Care, University of Glamorgan,
Pontypridd, UK, and
Richard Amlôt Emergency Response Department, Health Protection Agency, Salisbury, UK
Abstract
Purpose – Effective communication has been recognised as an important issue for the management of incidents involving decontamination; evidence shows that failure to communicate effectively may result in increased public anxiety and non-compliance. This paper aims to examine current provision for communicating with members of the public during decontamination, to facilitate the development of improved responder communication strategies. Design/methodology/approach – To examine the current provision for communicating with members of the public, the authors reviewed open source decontamination guidance documents for responders, as well as published reports of emergency preparedness exercises involving decontamination. Findings – The review of decontamination guidance documents showed that specific guidance for professional responders on how to communicate with the public during incidents that involve decontamination could be improved. Similarly, the review of published decontamination exercises shows that a stronger emphasis on communication with members of the public is needed, in addition to the use of exercises to evaluate the effectiveness of communication strategies. Originality/value – The present research summarises existing evidence relating to how communication strategies employed by responders can shape public responses to decontamination. Analysed alongside current decontamination guidance for emergency responders, this evidence highlights potential gaps in planning for communicating with members of the public during decontamination. It is hoped that this will promote an increased understanding of the importance of communication during these types of incidents, which will in turn facilitate the development of more comprehensive responder communication strategies.
Keywords Decontamination, Communication, CBRN, Responder guidance, Planning, Exercise
Paper type Literature review
The current issue and full text archive of this journal is available at www.emeraldinsight.com/2047-0894.htm
International Journal of Emergency Services
Vol. 2 No. 1, 2013 pp. 29-48
r Emerald Group Publishing Limited 2047-0894
DOI 10.1108/IJES-06-2012-0026
Holly Carter is funded by a Health Protection Agency R&D PhD Studentship. G. James Rubin is funded under the terms of a Career Development Training Fellowship issued by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the funders.
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Mass casualty decontamination
Introduction Communicating with the public during chemical, biological, radiological, and nuclear (CBRN) incidents Incidents involving chemical and biological agents are not a new phenomenon. Examples of large-scale CBRN incidents include: a radiation incident in Goiania, in which 249 people were contaminated, with 112,000 others seeking radiation monitoring (International Atomic Energy Agency, 1998); a nuclear accident at Three Mile Island (Baum et al., 1983); missile attacks on Israel during the Gulf War, using scud missiles believed at the time to be fitted with chemical warheads (Bleich et al., 1992); a Sarin release by the Aum Shinrikyo cult on Tokyo’s subway system (Okumura et al., 1998); and anthrax attacks in the USA in 2001 (Regis, 2001).
Improvements in technology, as well as the increasing threat of new forms of terrorism, have increased the risk of incidents involving these types of agents (Alexander and Klein, 2006). CBRN weapons could be particularly devastating, due to their unfamiliar and often invisible nature, and the increased fear and anxiety that this could generate (Cornish, 2007; DiGiovanni, 1999; Regis, 2001). It has been suggested that public reactions to incidents involving CBRN agents may include panic (Cornish, 2007); public unrest (Clarke et al., 2008); aggression (Koenig et al., 2008); and demoralisation (Holloway et al., 1997). It has also been suggested that CBRN incidents may be especially likely to result in multiple unexplained symptoms (MUS) (Pastel, 2001). This phenomenon has been well documented following CBRN incidents (Carmeli et al., 1991; Holloway et al., 1997; Pangi, 2002; Vogt and Sorensen, 2002). CBRN incidents have also been shown to put people at increased risk of ongoing psychological symptoms (Baum and Fleming, 1993; Pangi, 2002).
It has been suggested that in many cases, anxiety may actually be caused by interventions which are intended to protect the public, such as decontamination (Holloway et al., 1997). Increased public anxiety during incidents involving decontamination can result in non-compliance with recommended decontamination procedures (Hanley, 1999). Responders should therefore ensure that the management strategy which they employ serves to reassure members of the public that the decontamination process is safe and effective. It has been argued that this should involve providing the public with practical information about how they should decontaminate themselves (Taylor et al., 2009), as well as communicating openly with members of the public about the nature of the threat and the efficacy of the decontamination process.
An interesting review by Lemyre et al. (2010) highlights the need for responders to provide accurate information to the public during CBRN incidents, even informing them when certain factors or potential consequences are unknown. As Lemyre et al. point out, appropriate communication about risk and protective factors should result in reduced public uncertainty. This should increase the public’s levels of trust in responders, reduce public stress, and consequently increase public compliance with recommended behaviours. However, although attempting to apply this information to incidents involving decontamination, Lemyre et al. spend little time discussing the acute phase of an incident, during which decontamination would take place. Instead, they focus on preparation and training prior to an incident, as well as potential psychosocial consequences following an incident. They therefore focus on the longer- term implications of communication strategies during CBRN incidents. In contrast, the current paper focuses exclusively on communication strategies during the acute phase of a decontamination incident, and how communication from responders can affect public behaviour.
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Communicating with the public during incidents involving decontamination specifically Decontamination showering is the process employed by emergency responders to remove a contaminant from the skin of potential victims. During an incident involving decontamination, responders divide the scene of potential contamination into three zones: the hot zone, which is the area in which the CBRN contamination has occurred; the warm zone, which is the area surrounding the hot zone, in which the potential for cross-contamination may be present; and the cold zone, where no risk of contamination is expected (New Dimension Regional Team, 2003). Decontamination showers are set up by responders between the warm zone and the cold zone, and no-one within the warm zone is allowed to enter the cold zone without first undergoing decontamination. Decontamination showering serves two main purposes: to remove the contaminant from the victim’s skin, and thus prevent further absorption; and to reduce the risk of secondary contamination, which can result from previously uncontaminated people coming into contact with someone who is contaminated. It has also been suggested that decontamination may provide psychological comfort for victims[1], if managed correctly (US Army Soldier and Biological Chemical Command (SBCCOM), 2003).
Decontamination showering is a relatively new method of managing civilian incidents involving CBRN agents. The focus on this method increased following the Sarin release on the Tokyo subway in 1995, during which decontamination of victims was required. Planning for decontamination has also increased since the attack on the World Trade Centre in 2001 demonstrated the willingness of terrorists to use unconventional means to kill large numbers of people. In the UK this increased focus on decontamination planning led to the development of New Dimension decontamination units in 2003. These are specialised showering tents, operated by the Fire and Rescue Service, which are capable of showering up to 150 people per hour (Devon and Somerset Fire and Rescue Service, 2010). Similar methods of water-based decontamination have also been adopted in other countries, such as Germany and the USA (Kuhar and Bomm, 2009), although innovative new methods of dry decontamination are currently under investigation in Japan (Saito, 2010). To date, only one large-scale incident involving decontamination has been reported (Okumura et al., 1998). However, several smaller-scale incidents involving decontamination have been reported, from which lessons can be identified in the event that a large-scale incident were to occur.
One of the most detailed case studies of a real-life incident involving decontamination was produced by the US Fire Administration, and describes a suspected white powder release at the headquarters of B’nai B’rith, an international Jewish organisation, in Washington, DC (United States Fire Administration, 1997). This incident was later revealed to be a hoax, but not before the decontamination of 30 people, including civilians, fire and rescue service personnel, and police officers, had taken place.
Several issues became apparent during this incident: non-compliance: some of the police officers refused to undergo decontamination, and became aggressive, with one police officer striking one of the decontamination officials; MUS: several people complained of headaches, dizziness, and other minor ailments, although the incident was later established to be a hoax; re-contamination of cold zone: some of the police officers did not fully understand the nature of the incident, and moved in and out of the hot zone, which would have resulted in repeated re-contamination had the incident not been a hoax.
Non-compliance during incidents that require decontamination has been reported elsewhere. Hanley (1999) described a pesticide contamination incident, resulting in
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Mass casualty decontamination
25-30 people being decontaminated. Emergency responders used force during this incident to ensure that everyone complied with decontamination procedures, and victims complained that their concerns about privacy and dignity were disregarded. Consequently, the decontamination process during this incident was especially stressful for those affected, most of whom were women, and non-compliance was widespread:
They said to take off all my clothes. I left my underwear on. I said “I’m not taking them off ” (Hanley, 1999).
However, rather than being met with reassurance, non-compliance during this incident was met with force, with personnel forcibly removing the clothes from victims who would not comply. One woman commented that “it felt like we were raped”. A concerning finding from this incident was that some people actively did not seek treatment “because they didn’t want to be stripped and hosed down”. Victims in this incident therefore appeared to have no trust in the emergency responders who conducted the decontamination, and did not believe that the responders were acting in their best interests. This incident clearly shows the potential for non-compliance with decontamination showering, especially if victims feel they are not treated with respect and dignity, and if trust in the emergency services is lacking. It also indicates that decontamination procedures can actually be more stressful for members of the public than the threat of contamination itself, if not handled correctly.
Vogt and Sorensen (2002) collected findings from several relatively small-scale incidents that resulted in decontamination of members of the public and emergency services personnel, in order to generate recommendations for emergency services personnel. Conclusions which can be drawn from this report include: increased/ improved communication: responders should make more effort to inform and communicate openly with the public throughout the incident, to reduce any anxiety which they may feel about the decontamination process; increased explanation: responders should clearly explain why the decontamination process is necessary, to reduce uncertainty and confusion experienced by members of the public, and to increase the public’s trust in emergency responders; provision of information: providing information about the possible psychological reactions which people may experience following potential exposure helps to increase people’s understanding of their own reactions, and may also help to reduce the potential for future distress; communication issues associated with personal protective equipment (PPE): responders need to be aware of the difficulty of communicating with victims while wearing PPE, and should aim to reduce this difficulty; protect victims’ dignity and modesty: responders should make every effort to protect victims’ modesty and dignity, as failure to do so may decrease victims’ trust in emergency responders, and may therefore result in non-compliance. It is essential that victims perceive that responders are acting in their best interests. If victims feel that responders have an agenda they are less likely to comply with recommended decontamination procedures.
Similar conclusions have been drawn in a number of reviews, research studies, and case studies. These suggest that the management of CBRN incidents/incidents requiring decontamination can be improved by: increased provision of accurate, practical information from responders during the incident (Fontana, 1998; Holloway et al., 1997; Sternberg, 2005; Stone, 2007; Wray et al., 2004); protection of victims’ modesty (Cole, 2000; Holloway et al., 1997); reassurance about the nature of the hazard (Cornish, 2007); provision of loudspeakers for communication with members of the public, to
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reduce communication issues associated with PPE (MacIntyre et al., 2000); and provision of follow-up information about possible long-term effects, and where to go for further treatment/advice (MacIntyre et al., 2000; Wessely, 2005).
Many guidance documents have been developed to help emergency responders to manage incidents which require decontamination. Given the finding that communication strategies are essential to the successful management of incidents involving decontamination, it would be expected that communication strategies should feature prominently in guidance documents for responders about decontamination. Open source decontamination guidance documents were therefore reviewed, to assess whether they provide emergency responders with appropriate guidance on communicating with victims during incidents which require decontamination.
It is also important that communication strategies within decontamination guidance documents are tested during emergency preparedness exercises[2], to ensure that suggested communication strategies are adhered to by responders, and that they are successful in improving the management of potential victims. Published reports of emergency preparedness field exercises involving decontamination were therefore reviewed alongside the decontamination guidance documents for responders, to identify whether any communication plans outlined within the guidance documents are being tested during decontamination field exercises.
Method Review of decontamination guidance documents A search of the open literature was conducted to identify any relevant guidance documents. Documents were deemed to be relevant if they were dedicated to providing information to emergency responders about the management of incidents requiring decontamination. The search was limited to documents which were available in the open literature, and which were produced in English. Consequently, the guidance documents identified were limited to those from the UK, the USA, and Australia, and did not include any classified documents. The search was also limited to documents which were produced after the 9/11 terrorist attacks in the USA in 2001, due to the increased emphasis on planning for decontamination following these incidents.
The search strategy began with a broad Google search, using the search terms: “mass decontamination AND guidance”, “mass decontamination AND protocol”, “mass decontamination AND policy”, “mass decontamination AND strategy”, “CBRN AND decontamination AND guidance”, “CBRN AND decontamination AND procedures”, and “responders AND mass decontamination AND guidance”. Due to the high volume of results generated, the search was limited to the first ten pages from each set of results. All results were scanned, to identify any of relevance. Following the initial Google search, web sites of relevant organisations were searched, including those of the UK Fire and Rescue Services, the Metropolitan Police, the UK Ambulance Services, the US Federal Emergency Management Agency (FEMA), the European Commission, the World Health Organization, and the North Atlantic Treaty Organization. These searches generated 17 guidance documents which met the inclusion criteria.
The guidance documents returned by this search were reviewed to identify descriptions of public or crowd management, any guidance on how emergency responders should communicate with the public, and any efforts made to suggest what information the public would need during decontamination, including how best to provide this information. These guidance documents are presented in Table I and are taken from the UK: New Dimension Regional Team, Home Office, HM Government,
33
Mass casualty decontamination
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Table I. Decontamination guidance documents for responders
34
IJES 2,1
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Table I.
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Mass casualty decontamination
Ambulance Service, National Policing Improvement Agency, London Emergency Services Liaison Panel (LESLP), NHS; the USA: Governor’s Office of Emergency Services, FEMA, US Army Edgewood Chemical Biological Center, US Army Soldier and Biological Chemical Command (SBCCOM), US Army, Navy, Airforce, and Marine corps; and Australia: State Government Victoria.
Each guidance document was rated based on how much information was provided about a communication strategy. Ratings given were: poor (no information about communication strategy); basic (mention that communication is necessary, but no further detail); moderate (some attempt to outline the information that victims will need); detailed (full communication strategy). These ratings are also presented in Table I.
Review of published emergency preparedness exercises involving decontamination A search of published exercise reports was conducted to identify accounts of emergency preparedness exercises involving decontamination. A report was deemed to be relevant if it described an exercise in which mass decontamination was carried out in response to a simulated CBRN incident. Three search engines were used: Scopus, PubMed, and Google Scholar. Five search terms were used: “decontamination AND exercises”, “preparedness AND exercises”, “mass decontamination”, “decontamination AND drills”, and “preparedness AND drills”. For Scopus and PubMed, all identified abstracts were read, to identify papers of relevance. For Google Scholar, the first ten pages of results were read, due to the high volume of results generated. Reference lists of identified articles were also scanned to identify relevant exercises. This search strategy identified 13 relevant exercise reports, which are summarised in Table II. Ten of the reports were published in academic journals, one was published in an online newspaper article, one was taken directly from a UK Fire Service web site, and another
Author(s) Year Country Scenario
Communication strategy tested
FitzGerald et al. 2003 USA Deliberate chemical agent release No Schleipman et al. 2004 USA Detonation of a radiation dispersal
device Partially
Al-Damouk and Bleetman
2005 UK Chemical agent incident No
Edwards et al. 2006 Australia Bomb blast and chemical release Partially Grant 2007 USA Hydrogen fluoride explosion and
contamination No
Okumura et al. 2007 Japan Chemical agent release Partially Turner et al. 2007 UK Contaminant release from road
traffic accident Yes
Snyder and Sobieski
2008 USA Terrorist detonation of nuclear device
Partially
Lenz and Richter 2009 Germany Biohazard exposure No Taylor et al. 2009 USA Not described Yes Fertel et al. 2009 USA Radiation exposure No Hayes 2010 UK Chemical leak No Devon and Somerset Fire and Rescue Service
2010 UK Chemical release through air- conditioning
Yes Table II. Published papers describing field exercises involving mass decontamination
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IJES 2,1
was published within the Health Protection Agency Chemical Hazards and Poisons Report.
Each exercise paper was rated based on whether a communication strategy was tested. Ratings given were: no (no information about whether a communication strategy was tested); partially (some mention of communication with victims, but no detail about what this involved); yes (details of communication strategy provided). These ratings are also presented in Table II.
Results Findings from decontamination guidance documents Findings from the guidance documents are described under three headings: guidance on likely public behaviour during incidents involving decontamination; guidance on communication strategies for managing members of the public; and guidance on specific information which members of the public are likely to require.
Guidance on suggested public behaviour during incidents that require decontamination. Five of the guidance documents specifically suggest that victims of CBRN incidents are likely to panic, or behave in a disorderly or aggressive way (Abeel, 2006; Home Office, 2004; Lake et al., 2009; London Emergency Services Liaison Panel (LESLP), 2007; New Dimension Regional Team, 2003). Suggestions about victims’ behaviour include:
In the case of mass decontamination, and if there is impatience to enter the decontamination facility, responders could face public disorder (Home Office, 2004, p. 24).
Risks to CBRN responders include harm from secondary devices, confused, violent, or rowdy victims (New Dimension Regional Team, 2003, p. 12).
The threat from such a device (to release hazardous materials) is significant, not only as a result of its activation, but also in the fear and panic that it would create within society (LESLP, 2007, p. 56).
The idea that the public cannot cope with emergencies or disasters, and that their behaviour will be maladaptive and require coercive or paternalistic control, reflects the assumptions of the vulnerability approach to emergency preparedness (Furedi, 2008). The implication is that the public will be unable to make sensible use of any information provided to them.
The need to “control” victims is an issue which is raised in seven of the guidance documents (Abeel, 2006; Home Office, 2004; Lake et al., 2009; New Dimension Regional Team, 2003; Schulze and Lake, 2009; South Western Ambulance Service NHS Trust, 2010; State Government of Victoria, 2007). Ideas about controlling victims during incidents involving decontamination include:
Gaining control of victims is a difficult task, but rapidly gaining control is critical to getting victims to quickly perform the critical first step in mass decontamination (Lake et al., 2009, p. 4).
State law provides some options for controlling people that choose not to undergo decontamination (Abeel, 2006, p. 99).
The use of physical barriers may prove effective in gaining initial control of victims and preventing the spread of contamination (Lake et al., 2009, p. 4).
Several of the guidance documents therefore reveal an underlying assumption that victims will behave obstructively, or will be excessively anxious, and so will need to be controlled by emergency responders.
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Guidance on communication strategies for managing members of the public during decontamination incidents. Ten of the 17 guidance documents acknowledge the need to consider communication with members of the public during incidents involving decontamination (Abeel, 2006; Amos et al., 2010; Federal Emergency Management Agency (FEMA), 2003; Home Office, 2004; Lake et al., 2009; Lillie et al., 2006; New Dimension Regional Team, 2003; SBCCOM, 2003; Schulze and Lake, 2009; State Government of Victoria, 2007). However, even those which do acknowledge the need for communication with the public vary widely in the amount of detail they provide to responders about communication plans. The amount of information about communication strategies ranges from a few sentences recommending that information be provided to victims (Home Office, 2004) to several pages of in-depth description about what information victims will need, how information can be provided, and how responders should communicate with the public (Abeel, 2006).
Abeel (2006) suggests that responders and the public will view the severity of the situation differently, and that it is therefore essential that the threat and the need to follow instructions are communicated quickly to victims, in “a positive and reassuring manner” (p. 45). This is the only guidance document which not only suggests what information victims will need, but also how responders should communicate with the public. For example, it suggests that the following factors should be emphasised when communicating with the public, to encourage trust and credibility: “competency/professionalism, care, empathy, compassion, respect, understanding, organization, commitment, knowledge, encouragement of involvement, and honesty” (p. 42).
A specific communication issue addressed in some of the guidance documents is the difficulty which responders are likely to face in communicating with the public whilst wearing PPE (FEMA, 2003; New Dimension Regional Team, 2003). This is important, as although some of the guidance documents do suggest information which victims will need during incidents requiring decontamination, they do not address how it should be provided by responders who are wearing PPE. Some guidance documents suggest that information can be provided over loudspeakers, or through written/ pictorial information (Abeel, 2006; Amos et al., 2010; Lillie et al., 2006; New Dimension Regional Team, 2003; Schulze and Lake, 2009). These may be useful techniques for providing generic information to victims. However, they may not be adequate for ensuring that victims’ specific concerns and questions are addressed, and that they are reassured by emergency responders.
Guidance on specific information which members of the public are likely to require during incidents involving decontamination. Four of the guidance documents include some description of the type of information which the public might need during incidents involving decontamination. Suggested information needs include: why decontamination is beneficial (Abeel, 2006; Home Office, 2004; Lake et al., 2009; New Dimension Regional Team, 2003); how victims can clean and protect themselves (Abeel, 2006; FEMA, 2003; Lake et al., 2009); and the nature of the harmful substance involved (Abeel, 2006). Four documents also suggest that follow-up information should be provided to victims after an incident, including information on possible symptoms, as well as where to go if further medical assistance is needed (Abeel, 2006; Lake et al., 2009; New Dimension Regional Team, 2003; Schulze and Lake, 2009). However, while a few of the documents have attempted to provide guidance on the types of information which may be necessary, this is generally brief, with no suggestion about why this information might be necessary, or how it can be provided.
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Abeel (2006) again goes further than the other guidance documents in outlining exactly what sort of information victims’ might need. For example, it is suggested that necessary information includes:
Why are they here, what is going on, how bad is the “stuff”, are we in harm’s way, what are you doing about it (Abeel, 2006, p. 44).
This document also contains a comprehensive list of questions and concerns which members of the public might have, and suggests ways in which responders can answer these questions, and reduce any concerns about the decontamination process.
Seven of the decontamination guidance documents recognise that it is important to consider victims’ modesty and privacy during the decontamination process (Abeel, 2006; Amos et al., 2010; Diamond, 2010; FEMA, 2003; Lillie et al., 2006; New Dimension Regional Team, 2003; State Government of Victoria, 2007), with three documents specifically highlighting, albeit only briefly, the fact that cultural issues may affect victims’ willingness to undress in public and take part in the decontamination process (Abeel, 2006; Amos et al., 2010; New Dimension Regional Team, 2003).
Some of the more recent guidance documents on decontamination (2006-2010) provide a stronger emphasis on communication with the public than do many of the earlier guidance documents (2002-2006). This may be because decontamination is a fairly new intervention, and as such a lot of emphasis has been placed on developing the technical aspects of decontamination, with communication with the public being seen as a side issue, to be addressed once the technical aspects of decontamination had been perfected.
Findings from emergency preparedness field exercises involving decontamination The exercise reports were reviewed to identify any evidence that communication strategies were tested, and if so, how successful they were in facilitating the management of victims during these exercises. Six of the 13 identified exercise papers make no mention of how communication strategies were employed, or what information simulated victims were provided with (Al-Damouk and Bleetman, 2005; Fertel et al., 2009; FitzGerald et al., 2003; Grant, 2007; Hayes, 2010; Lenz and Richter, 2009).
Four of the exercise papers mention basic communication strategies, such as the type of information which victims were provided with (Edwards et al., 2006; Okumura et al., 2007; Schleipman et al., 2004; Snyder and Sobieski, 2008). An example of the type of information provided about communication strategies in these papers can be taken from Schleipman et al. (2004) “Patients were cared for and advised of radiation risks and protective measures” (p. 26). This kind of statement does not allow the reader to understand what information was provided, how it was delivered, who it was delivered by, and how it was received by simulated victims.
Of the 13 published reports, only three indicate that their exercise in any way set out to test responders’ communication strategies (Devon and Somerset Fire and Rescue Service, 2010; Taylor et al., 2009; Turner et al., 2007). Of these three exercise reports, Taylor et al. (2009) provide the greatest detail about communication strategy, with a large part of their report being devoted to describing the communication strategies used, and the results of these. Taylor et al. identify a range of shortcomings in the communication strategies used during the exercise, as well as potential ways of solving these. To identify ways of improving communication strategies, Taylor et al. decontaminated simulated victims who were either physically disabled, deaf, or non- English speaking, and subsequently conducted focus groups with them, to establish
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any communication issues, as well as any suggested improvements to communication. Their findings on communication were applicable across all populations, and included: although it was an exercise, participants felt anxious, and stressed the need for increased information; participants wanted specific information about how to proceed through the decontamination shower; and participants wanted reassurance that the decontamination process had been successful. From these findings, the authors drew the following conclusion:
Staff must explain effective decontamination: that clothing removal eliminates 80% of the contaminant, that the solvent used is the one most highly recommended, and that a quick shower with a sponge is standard practice (Taylor et al., 2009).
This paper indicates how beneficial exercises can be for improving communication strategies during incidents involving decontamination, and highlights the fact that opportunities to test communication strategies during exercises have largely been wasted.
While few of these exercises set out to test their communications procedures, several of them were useful in highlighting communications issues associated with the use of PPE, such as the difficulty which responders had in making themselves heard by the public (Al-Damouk and Bleetman, 2005; Okumura et al., 2007; Schleipman et al., 2004; Taylor et al., 2009; Turner et al., 2007). However, this was often mentioned only briefly, with little attempt to suggest ways in which communication difficulties could be overcome. The paper by Turner et al. (2007) does highlight a recommendation that non-verbal communication should be enhanced (e.g. through the use of pictorial instructions), in order to “gain the quickest and most efficient response” (p. 22) from members of the public.
Another issue which is apparent in some of the exercise papers is that there is an assumption that crowd members will panic, and will behave uncontrollably. For example, FitzGerald et al. (2003) ask “would scared, hysterical individuals be able to comprehend the rational need to remove clothing as part of decontamination?” (p. 210). Participants in some of these exercises appear to have behaved in a hysterical, uncontrollable way, disrupting emergency responders’ attempts to manage the incident. This confounded exercise players’ attempts to manage crowd members, with any attempts at communication largely being ignored. This was the case during an exercise at a hospital in Australia, during which responders made several unsuccessful attempts to communicate with the public (Edwards et al., 2006). Unfortunately, there is not enough detail given in the papers to ascertain whether participants were briefed to behave in this way, or whether they behaved in this way because they believed that it is how people would behave in a real incident. This issue needs to be addressed, to ensure that exercise participants behave as realistically as possible.
Discussion Few real-life incidents requiring decontamination have been analysed, but those which have reveal that successful communication with members of the public is vital for maintaining public trust in emergency responders, and so ensuring compliance with decontamination procedures.
However, the guidance documents reviewed for this paper show a disappointing lack of emphasis on communication strategies. They contain great detail about the physical and technical aspects of decontamination, but often neglect to provide responders with information about how best to communicate with the public.
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Moreover, decontamination guidance documents reveal a perception that members of the public will be prone to panic during incidents involving decontamination, and will therefore need to be “controlled”. This is of concern for three reasons. The first is that both recent case studies (Blake et al., 2004; Drury et al., 2009) and recent reviews of published evidence (Chertkoff and Kushigian, 1999; Clarke, 2002) argue against “mass panic” being a common reaction of the public in emergencies. The second is that crowd “disorder” is best understood as a function of relations between the crowd and the actions of some other group, rather than being a feature of crowds per se (Stott, 2003). Most crowds are peaceful and orderly; conflict only tends to occur when one group infringes on another’s definition of legitimate conduct. Third, relating these points to the observation that decontamination may produce as much public anxiety as the CBRN incident itself (Holloway et al., 1997), it can be argued that management strategies perceived as “controlling” and illegitimate may cause the public to exhibit the very “disorderly”, anxious, maladaptive behaviours they are meant to prevent. This was evident in the report by Hanley (1999), in which forceful behaviour by emergency responders resulted in a decrease in victims’ trust, and so decreased compliance with decontamination.
It would therefore be expected that control measures by the emergency services, such as physical barriers, might alienate victims, making them less likely to comply with recommended decontamination procedures. Also, it would be expected that assumptions about disorderly victim behaviour and the need for control would lead to emergency responders’ not providing members of the public with sufficient information about the situation, for fear that they would overreact and behave maladaptively (Drury, 2002). This could again prove counterproductive, as withholding information from the public has been shown to reduce compliance with recommended emergency measures (Perry and Lindell, 2003), as well as increasing public anxiety ( Jones et al., 2006).
However, while decontamination guidance documents do not currently provide responders with enough instruction on communicating with the public during decontamination incidents, there does appear to have been a gradual move towards an increased focus on communication in decontamination guidance documents between 2002 and 2010.
There is no direct evidence that any communication strategies outlined in the guidance documents are being tested during exercises, and it will therefore be impossible for responders to ascertain whether they are successful until a real incident occurs. The fact that ten out of the 13 identified exercise papers contained little or no mention of communication strategy highlights the lack of emphasis on communication across the field of decontamination as a whole. Clearly, there is much room for improvement across emergency preparedness exercises involving decontamination, as valuable opportunities for testing and improving communication strategies are being missed.
Exercises have been used to good effect to test communication strategies during radiation screening incidents, with findings indicating that repeated and open communications, as well as pre-prepared communication templates, are likely to enhance responders’ ability to successfully manage a radiation screening incident (Emery et al., 2008, 2009). The authors note the applicability of these findings to other types of CBRN disasters. Future exercises involving decontamination should therefore ensure that aspects of communication strategy are tested, and that lessons are identified which can be used to improve existing decontamination guidance. Also, it is
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essential that exercise participants are briefed to behave in a realistic way, rather than simply being told to “panic”, as this will not allow responders to test the effectiveness of their communication strategy. Most of the exercises reviewed for this paper were carried out either on the assumption that victims would passively undergo the decontamination process without question, or else that they would panic and behave in a disorderly way, thereby denying responders the opportunity to see what effect their communication strategies might have on public behaviour.
Limitations It should be noted that the review conducted for this paper was not exhaustive, and only guidance documents which are available in the open literature were used. However, it is assumed that any public-facing documents, such as the ones identified in this paper, would be more likely to contain a greater emphasis on communication strategies, and less emphasis on public order control strategies. Furthermore, if communication strategies are not being routinely tested and evaluated in exercises, as appears to be the case, it is likely that such communication strategies either do not exist, or are not sufficiently prioritised at the present time.
Another potential limitation is that the lack of emphasis on responder communication strategies within the published exercise papers does not necessarily mean that communication strategies were not tested within the exercise itself. It may be the case that responders’ communication strategies have simply been overlooked in the published paper or report. However, given that some aspects of the exercise are covered in detail in these papers, it seems likely that this lack of emphasis on communication was present during the exercise itself.
Conclusion Exercises offer the emergency services a valuable opportunity to test their communication plans and procedures during simulated decontamination incidents, but currently this opportunity is being lost. Where communication strategies are outlined in guidance documents, they need to be tested through exercising, to ensure that they are effective, and that responders are capable of carrying them out. Also, it is essential that exercise participants are briefed to behave in a realistic way. Most of the exercises reviewed for this paper were carried out either on the assumption that victims would passively undergo the decontamination process without question, or else that they would panic and behave in a disorderly way. It is important that future exercises address this, as if participants behave in an unrealistic way, it will not be possible for emergency responders to draw conclusions about the effectiveness of their communication strategy. Recent research suggests that combining experimental designs with exercise scenarios can present a useful way to test novel communication strategies (Amlôt et al., 2010), and it has been noted that further experimental studies should be conducted to test all aspects of decontamination protocols (Baker, 2010).
Finally, the lack of evidence on how people actually respond during real decontamination incidents was notable. Such incidents occur surprisingly regularly, both as a result of accidental releases and during false alarms about deliberate releases (Page et al., 2010). These incidents represent an as-yet under utilised way to build up a robust evidence-base on how members of the public behave during real incidents that require decontamination. Analysis of these types of incidents would allow more realistic exercises to be designed and better guidance on successful communication strategies to be compiled.
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Notes
1. The UK New Dimension guidance for responders (New Dimension Regional Team, 2003) defines “victims” as “persons who are contaminated or partially contaminated with a substance, but who have not sustained any physical injuries” (p. 7). This is in contrast to “casualties”, who are “persons who may or may not be contaminated, but have sustained physical injury” (p. 7). As the focus of this paper is on managing uninjured people during decontamination incidents, and as it is common parlance in decontamination guidance documents, the term “victim” is used throughout.
2. The UK Cabinet Office describes an exercise as “a simulation of an emergency situation” (Cabinet Office, 2010), and lists three main aims of emergency preparedness exercises: to validate emergency response plans; to develop staff competencies and give them practice in carrying out their roles in the plans; and to test well-established procedures. It is essential for responders to exercise different aspects of their emergency response plans, to ensure that these are robust and effective should a real-life incident occur.
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About the authors
Holly Carter obtained an undergraduate degree in Psychology from Southampton Solent University in 2007. Following this, Holly worked for three years as a research assistant in the Behavioural Science Research Team at the Health Protection Agency. Specific areas of work included conducting field trials to evaluate mass decontamination procedures, evaluation of emergency preparedness exercises, assisting in the provision of guidance to the public following disasters and emergencies, and conducting interviews with people who had been affected by swine flu. Holly is currently undertaking a PhD which is funded by the Health Protection Agency. This PhD project aims to understand more about the way members of the public will behave during incidents involving mass casualty decontamination, examining how existing social psychological theories of crowd behaviour may be applicable to incidents involving mass casualty decontamination. Holly Carter is the corresponding author and can be contacted at: [email protected]
John Drury is Senior Lecturer in Social Psychology at the University of Sussex. His research interests focus on crowd conflict and mass emergency behaviour. Some of the crowd events he has researched and written about include the 1990 poll tax riot, the direct action campaign against the M11 link road (London), the London bombings of 7 July 2005, and the Fatboy Slim “Big Beach Boutique” party of 2002. He convenes a module on the psychology of crowd safety management for music industry professionals at Bucks New University.
G. James Rubin has been a researcher at the Institute of Psychiatry since 1999 and was awarded his PhD in psychology as applied to medicine in 2003 for his work on psychological factors affecting recovery from surgery. His research interests have since expanded to encompass the causes and treatment of the various modern illnesses that afflict Western societies, such as electrosensitivity and multiple chemical sensitivity, and the psychological impact of terrorism or major public health incidents. James is in charge of the day-to-day running of the Mobile Phone Research Unit at King’s College London and also runs a programme of research assessing how people react during major public health incidents. He currently holds a National Institute for Health Research (NIHR) Career Development Fellowship, which will allow him to study public reactions to any future major incidents which occur in the UK.
Richard Williams OBE TD has been a consultant child and adolescent psychiatrist in the NHS in the UK since 1980. He has become an international strategic leader of health service
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design and delivery, and been an independent government policy adviser since 1992. He is a Fellow of the Royal College of Psychiatrists and of the Royal College of Paediatrics and Child Health. He was awarded an OBE for services to medicine in 2010. Presently, he is a Consultant Child and Adolescent Psychiatrist with the Aneurin Bevan Health Board in Wales, Professor of Mental Health Strategy in the Welsh Institute for Health and Social Care in the University of Glamorgan, and Honorary Professor of Disaster Healthcare in the Robert Gordon University, Scotland.
Richard Amlôt leads the Behavioural Science team in the Emergency Response Department of the Health Protection Agency based at Porton Down. The Behavioural Science team contributes to the preparedness and response functions of the Emergency Response Department through a portfolio of ongoing national and international research projects concerning a range of issues including public and responder reactions to emergencies and disasters, including CBRN incidents. Research outcomes are focused on informing psychosocial support mechanisms and risk communication strategies aimed at promoting positive behavioural and psychological responses.
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