Disaster Collaborative Exercises for Healthcare Teamwork in a Saudi Context

A collaborative simulation exercise, using a collaborative instrument to exhibit stability and practice transitions, overlaps, seamlessness, and creative thinking, through a standardized pattern.

This research employed two theoretical models to evaluate teamwork development and bridge the gap between knowledge and practice: (1) the integration of team members (Hall and Weaver 2001), and (2) team maturity (Sandberg 1997). These theoretical frameworks contribute to helping the HCWs integrate and collaborate in their work to overcome challenges (Makaram 1995). In addition, both frameworks support Petrie’s (1976) recommendation for “idea dominance,” which emphasizes that the members should be able to recognize their successes and achievements, individually and as part of the team. The choice of these classical frameworks is based on the characteristics of the organizational culture in Saudi. These frameworks explain not only idealistic teams but also the challenges of collaboration and change within a team in terms of degrees of integration and maturity.

The Hall and Weaver (2001) framework explains how the ability of teamwork brings various team members to work together to achieve a common goal. The interaction model highlights three main theoretical categories through which teamwork exists in an organization: multi-professional, interprofessional, and trans-professional. In a multi-professional team, every team member has a specialized role for which he or she is best suited (Hall and Weaver 2001). In an interprofessional team, every team member specializes in a specific role, but there are interactions between team members. In a trans-professional team, every team member has a specialized role, has the freedom to interact with other team players, and is prepared to act on behalf of any other team member when needed (Hall and Weaver 2001; Berlin et al. 2012). Such interactions require certain collaborative elements (Phattharapornjaroen et al. 2022). The Sandberg (1997) model of team maturity assesses the achievement of a team with organizational objectives. According to this model, teams can be immature, mature, or overripe. In contrast to a mature team, an immature team is characterized by a loose interconnection between team members, a subdivision within groups, and a high degree of individualism with no focus on the primary objective and the organization’s mission. An overripe team is rigid, with its team members lacking flexibility and excluding new members (Sandberg 1997). Therefore, the organization should strive to ensure that its team operates under the maturity category (Sandberg 1997; Berlin et al. 2012). Such maturity may be estimated using an instrument such as CSCATTT (Phattharapornjaroen et al. 2022).

The definition of collaboration in this study is based on teamwork’s integration and maturity, which define collaboration as a mix of activities and procedures shared among multiple levels (organizational and individual). It entails communication to yield shared responsibility and decision making (Castañer and Oliveira 2020) and creates interactivity by using a practical instrument like CSCATTT used as a planning and evaluation tool (Lozano et al. 2021). Integration and maturity are regarded as closely connected to collaboration, that is, an integrated and mature team will collaborate properly (Berlin 2014). In contrast, a non-integrated, immature, or overripen team may have severe difficulties in collaboration, and they will minimize their task-driven reciprocity and nurture a parallel and disintegrated behavior (Rogers and Mulford 1985; Whetten 1985; Berger and Luckman 1991). Berlin and Carlström (2008) have explained through a model the way team members correspond to organize and coordinate tasks in collaboration across three levels; the sequential method refers to the distribution of tasks by doing one after another in successive order, while with the parallel method team members from different disciplines meet and perform different tasks and activities simultaneously (Berlin and Carlström 2008). Finally, in the synchronous method, the team members come together to share the workload and accomplish tasks (Berlin 2010).

One hundred HCWs from 10 hospitals belonging to the Ministry of Health in Najran, Saudi Arabia, were voluntarily enrolled in the 3LC training courses, held three times and on separate days with the same structure consisting of lectures and simulation scenarios, between October and November 2020. Najran is exposed to natural and human-made hazards, such as flash floods in wadis, fires, sandstorms, the Covid-19 pandemic, and armed conflicts (Saudi-Yemen Border). All staff engaged in disaster and emergency management in various positions and levels, who were present throughout the entire courses, were included. Other HCWs were excluded.

After theoretical lectures, the participants in the 3LC exercise courses were divided into four groups, consisting of physicians, nurses, and support services workers. They received the necessary instructions to complete a side-by-side exercise in two simulated scenarios. In these micro-exercises, CSCATTT was used to enable the standardized management of DPHE. Scenarios were adopted from two realistic events within a hospital context (Fig. 1). The management time started when the scenario was presented by the exercise leaders during each scenario exercise. After the completion of the allotted time for working on the scenario, each team demonstrated how it tackled the situation on its own. The exercise leaders then gave the participants a rapid recap of the scenario. Following that, each table’s attendees were asked to consider what they could have done differently if the same scenario was presented once again. Everything that participants did in the scenarios and their performances was observed and registered by the exercise leaders at each team table.

Microsoft Excel was used to analyze quantitative data in the observational approach and the interview data were analyzed by directed content analysis suggested by Hsieh and Shannon (2005). The strength of a directed approach to content analysis is its ability to support and expand a theoretical framework, which aims to conceptually extend a framework and help the authors focus on the research question (Hsieh and Shannon 2005). Based on distinctions in the role of theory, Potter and Levine-Donnerstein (1999) suggested categorization as a deductive analysis. In the early stages of the analysis, we focused on gaining a more comprehensive understanding of the data regarding the research phenomena, which is the condition for teamwork building among HCWs in Saudi Arabia with the intent of handling DPHEs.

The results of semistructured interviews with 20 of the HCWs, which show various perceptions, were divided into four themes: overall impression and improvement of performance; multi-, inter-, and trans-professional teamwork and collaboration; immature, mature, and overripe team dynamic; and future development and vision of Saudi Arabian emergency response and preparedness. The HCWs reported a high level of improvement in knowledge and practice, skills, confidence, and team building following the implementation and hot wash-up discussion after each scenario. HCWs indicated that collaboration exercises using the CSCATTT instrument were crucial for developing their knowledge and practice and could help them prepare for disasters and unforeseen events.

The participants reported that the trans-professional team developed because they understood the scenarios. They underscored that they developed their skills and knowledge of disaster management because of the attempts they made in Scenario 1. On the theoretical framework of team maturity by Sandberg (1997), several participants indicated that immaturity in Scenario 1 was due to the team members not having the same knowledge and skills. While in Scenario 2, they become mature because of gaining knowledge, training, and resolving challenges that result in individual and team development. Overripe team members sought control over every aspect and showed less flexibility but in the end, the rest of the team took control of the situation, and with no disagreement. Moving into the future, the HCWs reported that the 3LC exercise is vital for collaboration and CSCATTT is a necessary instrument for evaluation of the outcomes in disaster management.

In this study, the use of 3LC as a collaborative exercise and CSCATTT as a collaborative tool improved participants’ knowledge, skills, integration and collaboration, and confidence, through repeated exercise. According to Al-Hunaishi et al. (2019), disaster training may improve self-efficacy and increase willingness to participate and work in DPHEs. Although the HCWs were not confident to act in Scenario 1 of this study, they understood the necessary steps of action in Scenario 2. Thus, continuous training can increase HCWs’ knowledge and efficiency, thus their confidence in handling victims of unexpected DPHEs (Sultan et al. 2020; Bistaraki et al. 2011; Cariaso-Sugay et al. 2021). Although there is disagreement among scholars over the meaning of trust, most practitioners and scholars concur that there is a connection between trust and collaboration (Ross and LaCroix 1996; Dirks and Ferrin 2001) and that trust is one of the key requirements for effective collaboration (Kouzes and Posner 2003). Continuous training may increase HCWs’ trust and willingness to work in cross-sectoral capacities to handle DPHEs (Burnett and McGuire 2020). The combination of 3LC and the CSCATTT instrument has recently illustrated improvement in role distributions, enhancing the professional thinking in the field to respond to DPHEs by strengthening staff confidence, and lessening their internal fear of making mistakes (Sammut et al. 2001; Phattharapornjaroen et al. 2020). The exercise leaders’ observations based on CSCATTT showed special attention to collaboration development (Borell and Eriksson 2013), regarding all elements of the instrument to guarantee command and control formation, role identification, and the assessment of short- and long-term consequences in planning and management of DPHEs. The exercise also offered multiagency discussions and learning opportunities from the mistakes in a safe environment that offers the trial of new tactics, establishing a sense of security and order across sectors (Andersson et al. 2013). The distribution of tasks based on CSCATTT reduced hierarchical communication, coordination, and collaboration, and obstacles and ambiguity in the team (Sammut et al. 2001), as reported by Phattharapornjaroen et al. (2020) who emphasized that CSCATTT as a collaborative instrument minimizes organizational barriers in favor of a collective increase in skills and reduction in limitations, and allows transition between various strategies needed, depending on the situation and leadership types (Sammut et al. 2001; Kahn et al. 2017).

Exercises based on the trans-professional approach to DPHE management enable HCWs to work under different conditions, adapting to the dynamics of disasters (Al-Hunaishi et al. 2019; Melin Emilsson et al. 2020) and learning to work towards a unanimous goal. Developing team bonds, they can work as a team in severe conditions and understand each other’s capabilities and limitations (Sasangohar et al. 2020). This transition was seen in this study between the first and second scenarios.

The concept of immature behavior in this study referred to HCWs with inadequate knowledge and skills (Miller et al. 2018). However, as they were trained, they acquired relevant knowledge and skills, as demonstrated in Scenarios 1 and 2, when the immaturity of most HCWs vanished and almost every one of them was mature enough to take part in the event at the end of Scenario 2. Repeating scenarios can help the team members move from immaturity to maturity without becoming overripe, and simultaneously avoid overripe team members, who do not fit into the team due to tribal and clan traditions and other factors that influence teamwork (Sandberg 1997; Joseph 2000; Yaseen 2010; Tlaiss and Kauser 2020). However, according to Hathaway et al. (2022), more research may point out remedies for developing mixed teams of former overripe members to become mature. It is also important to bear in mind that one traditional behavior, which shows a preference for preserving group harmony, may be successful during teamwork in some situations, while it could be detrimental in other situations (Weick 1990; Aldulaimi 2019).

Healthcare workers need to understand how their traditions and beliefs may positively impact teamwork and collaboration in emergency management based on the CSCATTT strategy (Phattharapornjaroen et al. 2020; Lozano et al. 2021). According to this study’s findings, although some team members were overripe or immature, others were mature and ready to work as a team. As Abu Alsuood and Youde (2018) have observed, Saudi culture emphasizes the need for leaders to help their followers prioritize continuous improvement. Leaders are also typically expected to guide their followers instead of relying on an instructional approach. These traditions are likely to affect how teams in the health sector operate, including those that manage emergencies. Therefore, efforts to promote collaboration and teamwork in emergency management should consider how traditions associated with Saudi culture influence teams operating in the health sector (Assbeihat 2016). Continuous training allows HCWs to share ideas, knowledge, and skills in disaster management (Buljac-Samardzic et al. 2020).

The future of disaster management relies on the awareness of HCWs and public members. More scenarios and hot wash-up seminars will create more awareness about collaboration among HCWs and enable them to work efficiently and manage the DPHEs (Carpenter 1995). This study, like previous studies, has confirmed that collaboration exercises in disaster management contribute to a sufficient degree of the knowledge and skills needed for healthcare teams in their preparedness, self-efficacy, confidence, and willingness to work (Berlin and Carlström 2015; Khorram-Manesh, Berlin et al. 2016; Khorram-Manesh, Lupesco et al. 2016; Calovi 2018; Magnussen et al. 2018; Sørensen et al. 2019; Simon et al. 2021). In addition to training HCWs, public awareness of disaster management in how to mitigate the risks for DPHEs can improve the management system in Saudi Arabia. To educate the public to act at various levels of DPHEs management or even to raise their awareness of any event to lessen the negative effects of any incidents, the CSCATTT elements can be employed (Khorram-Manesh et al. 2017; Khorram-Manesh 2019; Glantz et al. 2020). Public campaigns can be conducted in schools, markets, religious venues, and other public places to help the public understand and prepare for their role in the management of DPHEs globally.

The first limitation of this study is the sample size (Noyes et al. 2018). However, the results may indicate a trend and pave the way for future research. Second, the approach selected for this study could be biased because of the involved researchers’ preferences. Hence, evidence supporting a theory may be easier to get across than evidence refuting it (Ruggiano and Perry 2019). Third, the interview responses by HCWs could also be biased depending on their attitude and view of the subject matter and the persuading act of the interviewer (Hsieh and Shannon 2005). Finally, how the data are collected can affect their accuracy (Sherif 2018).