Attending the scene of a major incident is a profound experience [1], and one that perhaps nobody can ever be truly prepared for [2]. The sights, sounds and smells of these inherently distressing and chaotic scenes can be all encompassing experiences and yield the potential to damage the mental health of emergency service responders; irrespective of their level of experience, knowledge, or training [1, 3, 4, 5, 6]. Major incident training typically represents only a small facet of the curriculum and the concept of emotional preparedness overlooked. Learning materials typically focus on its more tangible and unique facets, such as mass-casualty triage and the Joint Emergency Services Interoperability Programme (JESIP) principles [7].
Higher education delivery is more than simply introducing theoretical concepts to learners [8]; it is about facilitating opportunities for knowledge application within communities of professional practice [9, 10]. Experiential learning theories build upon the pedagogy of social constructivism whilst situating experience at the core of the learning process [8, 9, 11]. For example, if we wanted a group of clinicians to be proficient in intubation, we would arrange a theatre placement for them. To hone skills in intravenous cannulation, an emergency department experience might be facilitated; and if we wanted conversance in obstetric and gynaecological procedures we would organise shifts in a birthing suite. Safely equipping the future workforce with the requisite skillset to manage mass-casualty incidents is more challenging. Educators are well aware of the widespread benefits of embedding practice-based learning within curricula [8, 10, 12, 13, 14], although it would be neither safe or ethical to arrange ‘warzone’ placements for students, or wait for the next major incident to be declared and ask that they be deployed.
Undertaking computer-based exams and/or completing academic assignments does not clinically and emotionally prepare learners for real-world practice within this field because it fails to cultivate the disposition of ‘antifragility’ [15]. This term depicts the notion that through exposure to stressors, volatility and randomness, growth will occur; the only caveat being that the metaphorical load placed upon a learner must not surpass their personal threshold [16]. A simple analogy of this concept is an individual lifting weights in the gym. If appropriately conducted, the process will cause microscopic tissue damage, resulting in repair and hypertrophy – and lead to developments in strength over time [17]. In the case of training emergency service professionals, we suggest that traditional face-to-face lecturing does not adequately test clinical acumen and emotional strength without dovetailing it with hands-on practical experience, in dynamic learning environments.
Technological advancements in virtual reality equipment and interactive human mannequins have acted as a catalyst in propelling innovations within simulation [18,19,20]. During the height of the pandemic, a need to harness confidence in digital technologies became a necessity for education [21] in order to ensure clinical competencies were achieved when hospital and community-based placements came to a standstill. A growing body of evidence has showcased the widespread benefits of simulation learning activities within healthcare education [8, 10, 12, 13, 15, 19, 25], but few studies have explored its value within major incident training. The Department of Health recommend Category 1 responders (a person or professional body listed in Part 1 of the UK’s Civil Contingencies Act 2004, as responsible for providing a core major incident response) are subjected to a minimum of one ‘live’ simulation exercise every three years, a table-top exercise every year and to participate in a communications cascade test every six months [22]. How elaborately and proficiently training institutions execute simulation is variable; but irrespective of this, exercise participants commonly report not having the information or resources required for the simulation to run in ‘real-time’ and this will lead to periodic interruptions whilst event organisers offer advice or direction. We suggest that when ‘role-play reality’ is interrupted, the value of the learning experience is diminished.
Creating ultra-realistic, immersive exercises which not only look like ‘movie-sets’ and are scripted to prevent these breaks in role-play reality is however hugely time-consuming, expensive and will naturally place a significant burden on over-stretched training departments [12, 13]. Even if institutions recognise the value this level of simulation can provide, rarely will it represent a strategic priority. Curriculum influencers will also opine that as major incidents are rare events, time and resource allocation should be minimised so that topics more commonly encountered in routine clinical practice can have a greater focus. Further barriers associated with health and safety, risk management, sustainability, General Data Protection Regulation (GDPR), ensuring parity and equal opportunities for every participant, further challenges implementation [5]. As a result, it is notoriously difficult to provide students with experiences within this realm; and thus, novel and innovative approaches continue to be sought by clinical educators.
Training emergency service staff to be effective in a major incident is vital in today’s volatile world. The UK Threat Level is currently classified as ‘SUBSTANTIAL’, indicating an attack is likely [23]. MI5 Director General, Ken McCallum recently reported that thirty-one terrorist attacks had been thwarted in the last four years; and today the organisation is running seven times as many investigations as it was in 2018 [24]. Whilst the accomplishments of British intelligence services should be celebrated, it is perhaps inevitable that it is only a matter of time before one event slips through the metaphorical net. The evolution of modern terrorism is nothing short of frightening and the noticeable shift from the complex and meticulously planned attacks of 9/11 and 7/7 to more simplistic lone-wolf attacks, are extremely difficult to predict, prevent and respond to [25]. The reality is that emergency service personnel will be first amongst those on-scene; many of which will be junior or inexperienced and thus, there is a pressing need to appropriately train and equip these individuals clinically and emotionally.
Responding to acts of terrorism represents just one aspect of major incident management that frontline responders could endure [22]. Accidents involving hazardous goods, road traffic collisions, aviation or rail disasters, structural collapses and natural disasters represent several further examples [26]. Major incidents typically happen quickly and unexpectedly [28] and thus, when a responder makes their way to the scene they will have had very little time to assimilate, predict and prepare for what awaits them.
Acute Stress Disorder (ASD) and Post-Traumatic-Stress-Disorder (PTSD) are unfortunately overtly common conditions seen in emergency service workers; and a recent UK ambulance service study showcased that ≤ 39% of the workforce suffer from PTSD [28]. World renowned physician and traumatologist Dr Robert Scaer explains that PTSD predictably emerges following exposure to traumatic event/s when an individual is forced to reside in a position of “relative helplessness” [29]. Predictable pre-cursors for PTSD are assault, robbery, being raped, abused or tortured, subjected to military combat environments; or attending a major incident. It is also noteworthy that witnesses and direct victims of these events can be affected in the exact same way. PTSD is categorised as a mental health disorder [30], yet the condition affects every system of the human body and will often lead to the development of chronic health conditions severe enough to threaten an individual’s livelihood in every way imaginable. Experts will explain the PTSD sufferer’s symptoms are simply a normal reaction to an abnormal event [29,30], but this notion provides little comfort to the patient or their family and friends. Therapies to support PTSD sufferers have gained traction in recent years, yet primary diagnostic awareness is often poor. Slow referrals or long waiting lists to see specialists can result in sufferers not receiving help in a timely manner, which can sadly result in mental health crises; and in extreme cases lead to suicide [1]. In summary, it is evident that a research-knowledge gap exists surrounding effective cultivation of emotional readiness in Category 1 responders and a need for further research is required.
Our primary aim was to improve clinical acumen, emotional preparedness and mental resilience amongst Category 1 responders in readiness to attend real-world major incidents. The secondary aim was to devise some best-practice recommendations to help improve teaching and learning practices in major incident training.