Enhancing Disaster Preparedness Through Tabletop Disaster Exercises: A Scoping Review of Benefits for Health Workers and Students

Introduction

Disasters are still a worrying trend in the 21st century. Based on data from the Global Natural Disaster Assessment, it was reported that 367 major natural disasters (excluding epidemic diseases) occurred worldwide in 2021, affecting 127 countries and regions. In 2022, more than 140 disaster events occurred in the Asia-Pacific region causing more than 7500 deaths, affecting more than 64 million people, and having an economic impact.¹ Indonesia is one of the countries with a very high risk of disasters, with 3239 natural and non-natural disasters occurring throughout 2023.² In addition, the COVID-19 pandemic has been the most trending global disaster to date.³

The damage caused by disasters is not only limited to physical aspects but also impacts mental, social, economic, political and cultural well-being in the affected areas.^1,4 Asia-Pacific was the region most affected by disasters in the 2020–2021 period with the parameter of the most significant number of significant disasters, namely 333 cases with the number of people affected as many as 108.7 million and as many as 12,565 people died.³ In addition, earthquakes also caused significant damage, with losses estimated at $12 billion, especially in Japan, China, the Philippines, and the Islamic Republic of Iran.¹

Due to the many severe impacts that arise from disasters, an appropriate strategy is needed to reduce the impact of disasters.¹ The strategy to reduce the impact of disasters is to prevent new “disasters” after a disaster occurs, which has developed from a focus on emergency response to a more holistic prevention strategy.⁵ Government Regulation No. 21 of 2008 states that disaster management includes disaster management planning, disaster risk reduction, prevention, integration in development planning, disaster risk analysis requirements, disaster risk analysis requirements, implementation and enforcement of spatial planning, education and training, and disaster management technical standard requirements.⁶ A critical focus in disaster impact management is education and training for both health service providers and students.^7–9

Health workers, including nurses, have an important role in disaster emergency response by applying knowledge and skills to minimize the impact of disasters and the health and life risks to victims.^10,11 Their role is divided into three stages: before, during, and after a disaster. Beforehand, they must be trained in clinical skills and crisis management. They provide emergency communications, manage triage areas, and organize evacuations during a crisis.¹⁰ Afterwards, they provide individual care, support the reconstruction of facilities, provide psychological support, and assist in rehabilitation. This demonstrates the vital role of nurses, from preparation to recovery, in ensuring effective services for victims and affected communities.¹⁰

In addition to health workers, adolescents play an essential role in disaster risk reduction.¹² Teenagers, especially students, need to gain adequate knowledge regarding disasters and adapt to the post-disaster environment through disaster preparedness education to build disaster-aware behaviour that will continue into adulthood.^12–14 These findings highlight the urgency of implementing holistic disaster education for students so that they can prepare themselves to face the challenges of diverse disasters more effectively. In addition, previous studies have reported limitations in the proficiency of nurses and students related to various types of disasters, such as tsunamis, radiation, and bioterrorism in several countries.¹¹ Therefore, further development in disaster management education is needed to improve the readiness of nurses and students to face global challenges related to disasters.^11,15

Disaster preparedness is an essential element of an effective health system, especially in the face of emergencies that may threaten public safety.¹¹ One effective method for enhancing preparedness is through tabletop disaster exercise, which enable health workers and students to gain practical skills in managing a disaster response.^15,16 Previous studies reported that tabletop and operational approaches improved nurses’ disaster preparedness more effectively than lecture-based education.¹⁷ Furthermore, the results of a recent systematic review reported a gradual increase in the number of disaster nursing education and training programs adopting a variety of approaches and technologies, one of which is the use of the tabletop exercise method.¹⁵ Thus, using a tabletop exercise approach can be a strategy to improve nurses’ readiness to face various disaster situations.

Several studies have reported that disaster education using the tabletop method can effectively improve knowledge, disaster preparedness, and other outcomes.^18–22 The TDE simulation method is a simulation approach that uses media in the form of a disaster event map image projected onto a flat surface such as a board or table, which is then supported by a disaster scenario.^21,22 Participants then engage in assigned roles to handle situations according to previously prepared scenarios.²² TDE has proven to be very effective in assisting disaster victims efficiently and effectively during emergency disaster management conditions.¹⁴

Based on the literature search, until now, no review study has specifically synthesised research results related to the potential of the tabletop exercise method in disaster preparedness for students and health workers. Previous studies only highlighted various SimEx exercises in emergency and disaster medicine and evaluated the challenges and obstacles in practical implementation, so this study does not explicitly discuss the potential of using tabletop exercises,²³ and previous similar studies are still in the form of review protocols.²⁴ Therefore, in the face of the increasing need for disaster preparedness, additional review studies are needed to identify the potential of tabletop exercise methods in improving disaster preparedness in health workers and students.

Material and Methods

Study Design

The scoping review was conducted following the Arksey and O’Malley framework.²⁵ The PRISMA Extension for Scoping Reviews (PRISMA-ScR) was used to identify the use of TDE methods to improve the skills of nurses or health workers in disaster preparedness. A scoping review is a flexible methodological technique for exploring new, rapidly developing topics.²⁶ This design has a more comprehensive conceptual reach to explain relevant research results with a framework consisting of 5 core stages, including identifying review questions, identifying relevant research results, selecting studies, mapping data, compiling, summarizing and reporting results.²⁶

Eligibility Criteria

The process of selecting articles for this review was carried out by authors based on the PRISMA Extension for Scoping Review (PRISMA-ScR) (see Figure 1).²⁷ Research questions and eligibility criteria for research articles using the PCC (Population, Concept, and Context) approach. The research question of this review is “What is the potential of tabletop disaster exercise in improving disaster preparedness skills among health workers and students?”

Figure 1 PRISMA Flow Diagram. Note: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons.27.

P (Population): Health workers or Students

C (Concept): Tabletop exercise or Tabletop disaster exercise

C (Context): Disaster Preparedness

In this review, full-text articles that were not accessible, not in English, and secondary studies were excluded. The inclusion criteria in this review were full-text articles that were accessible and published in English and primary studies (original articles). Then, this review has no criteria for limiting the year of publication because it looks comprehensively at the potential for using TDE in improving the skills of nurses or health workers in disaster emergency response and preparedness.

Data Collection and Analysis

Search Strategy

Identification of articles was carried out systematically using five main databases: CINAHL: Medline Ultimate, PubMed, ScienceDirect, Scopus, and Taylor and Francis, and also one search engine such as Google Scholar. The selection of these five databases was based on their comprehensive coverage and relevance to the scope of the research. These five databases are well known and widely used to access high-quality, relevant articles in the fields of health, medicine and social sciences. The keywords were “health workers OR health professionals AND nursing student OR Student AND tabletop exercise OR tabletop disaster exercise AND Disaster preparedness”. The author used the Boolean operators “AND“ and ”OR” to trim or expand the search results for various tenses.

Study Selection

Three authors independently selected studies that met the eligibility criteria. Using the Mendeley reference manager, the author checked for duplication in the initial selection process. Then, another author checked the title, abstract, and full text for relevance to the research topic and set inclusion and exclusion criteria. Furthermore, the author decided on whether there was a discrepancy in the election results. The results of the analysis and extraction were checked again by another to ensure that the articles met the inclusion criteria. All authors have no differences of opinion regarding the eligibility of the articles analyzed in this review.

Data Extraction and Analysis

In this review, data extraction from the studies is analyzed using a table that can describe in detail all the results related to the topic discussed. The information presented in the extraction table is related to the characteristics of the study: author, design, country, sample, intervention, comparison and research results. All included research is primary research. Therefore, data analysis was carried out thematically with an exploratory descriptive approach. The data analysis process begins with the identification and presentation of data obtained in the form of tables based on the reviewed articles. After obtaining the data, all authors analyze and explain each finding based on the review results. Finally, the authors recheck the included studies to ensure and minimize errors.

Results

Study Selection

A total of 1180 articles were initially identified from five databases and one search engine, but 874 were removed due to duplication, leaving 306 articles. After screening by title and abstract, 209 articles were eliminated as irrelevant, leaving 42 articles for further review. Of these, an additional 27 articles were removed for not meeting the inclusion criteria, leaving 15 articles for eligibility assessment. In the final stage, three more articles were excluded, one for being a secondary study and two for not discussing tabletop exercises. Then, 12 articles were eligible for inclusion in the review (see Figure 1).

Characteristics of the Included Studies

In this review, most of the studies analyzed had experimental designs (pre-experimental, quasi-experimental, and RCT) (n=8) (See Table 1). The included studies were conducted in various countries, such as Indonesia (n=3), the United States (n=2), Korea, Australia, Iran, India, Qatar, and Greece. The included population consisted of health workers, including nurses, pharmacists, doctors, residents, paramedics, hospital administrators (n=238), and students (n=385), with a total of 623 participants.

Table 1 Data Extraction

Study Outcome

Table 2 shows that several outcomes were successfully identified in this review. The outcomes are divided into two populations: students and Health Workers. The student population’s outcomes consist of knowledge, attitude, self-confidence, and disaster preparedness. Meanwhile, when viewed from the population base of health workers, there are seven outcomes: knowledge, awareness and competence, understanding of the role in disaster management, readiness and attitude, performance, triage skills, confidence, and perceived confidence of ability to manage disaster incidents.

Table 2 Summary of Disaster Emergency Response Skills Based on Population

Tabletop Disaster Exercise Method

In this review, there were two categories of TDE methods. These methods were divided based on online and offline implementation (see Table 3). Most studies practice this TDE method directly (offline) with participants, and almost all of them conduct simulations based on prepared scenarios. Disaster scenarios include natural disasters (cyclones, earthquakes, floods, and others) and non-natural disasters (emerging infectious diseases, mass casual incidents, and fire).

Table 3 Tabletop Disaster Exercise Methods

Discussion

This review identifies the potential of using tabletop disaster exercises (TDE) to improve the disaster preparedness of health workers and students. The review results showed that TDE has great potential to improve students’ knowledge, attitudes, and disaster preparedness, as well as readiness, knowledge, attitudes, competence, confidence, and understanding of the role of health workers in disaster management and triage skills of health workers.

TDE is a specific learning method for responding to disasters by simulating disaster location maps, which aims to improve the competence and abilities of groups trained in disaster management.⁷ TDE can be carried out in a special room or classroom that allows for simulation of the preparedness of various disaster management elements.²⁸ This simulation has various benefits, including increasing the role, knowledge and skills in disaster management.²⁹ TDE also triggers effective teamwork that enables the proper knowledge and attitudes in each training session to be directly applied during a disaster or extraordinary event.³⁰

This review’s findings conclude that the TDE method’s potential as a strategy to improve disaster preparedness in students and health workers is quite significant. In the student population, this review found that the TDE method effectively improved knowledge and attitudes in providing victim management in disaster response simulations, roles in disasters, and identifying strengths and weaknesses in managing disasters,^7,14 and improving disaster preparedness.¹³ Therefore, these findings support the further development of disaster management education curriculum so that it will significantly contribute to facing global challenges related to disasters.

TDE also has the potential to improve various important aspects of disaster preparedness for health workers, including nurses. Previous studies reported that TDE can improve health workers’ understanding of the basic principles of hospital disaster management for natural and non-natural disasters such as pandemics, provide an overview of hospital disaster plans, and explain hospital incident command systems and communication strategies.^9,21,22 TDE also has the potential to increase health workers’ awareness, readiness, competence, performance and self-confidence in dealing with disasters.^{19,21,22,31,32}

The most essential thing in disaster preparedness is forming the best team to react effectively in a disaster situation.³³ Therefore, various skills and experiences are needed in responding to disaster events.⁷ Knowledge will improve good preparation for disasters.^9,34,35 Simulations and discussions facilitate an overview of the division of roles and responsibilities in disaster management.⁷ In addition, health workers must also possess triage skills because this will make it easier for them to prioritize someone who needs transportation, evacuation and treatment in the field or hospital.³⁶ Meanwhile, self-confidence will increase management capabilities when a similar disaster incident occurs.^19,34,35,37 These capabilities must be developed to form a better team in disaster management.²¹ Therefore, through the TDE method, these capabilities can be increased and optimized so that health workers are ready to face future disasters.

The factors influencing the implementation of learning with the TDE method are very diverse. The knowledge and skills of participants, such as medical personnel in the context of disasters, play a vital role in the success of TDE.⁷ In addition, the readiness of organizations such as hospitals to face crises and awareness of the importance of exercises such as TDE also influence the implementation of this method.³¹ A well-designed and effective training program in terms of management planning can improve participants’ understanding of disaster response.³⁸ Another factor that is no less important is the availability of resources, including time, facilities, and training materials.^15,39 Finally, a good understanding of the disaster scenarios used in TDE and the ability of participants to respond to them realistically are also essential factors in the success of this method.^7,9 By considering all these factors, TDE implementation can be more effective in improving preparedness and response to emergency or disaster situations.

While the TDE has excellent potential for improving many important aspects of disaster preparedness, this method has some drawbacks. The lack of realism in the exercise may limit the ability of participants to provide a true test of the capabilities of the crisis management system during an emergency.¹⁴ TDE tends to only superficially test team plans, procedures, and capabilities without practical demonstration.¹⁴ However, this method also has many advantages, such as being easy to do and being able to bring together various professions that have never worked together before, enabling cross-disciplinary collaboration.⁷ In addition, lower costs, easier availability of facilities and equipment, and greater participation of learners in disaster education.²⁰ Although its implementation has many limitations, the TDE method’s use in increasing disaster preparedness is effective both online and offline.³⁷ Due to the various advantages and benefits obtained from the application of the TDE method, this review has provided a comprehensive overview so that it is hoped that it can become an alternative method in developing disaster management curricula both in educational institutions and in the health practitioner environment.

Strengths and Limitations of Study

There are several limitations to this review. First, the limited research with experimental design on this topic means that the results of this research extraction are still considered less comprehensive. Second, the participants recruited are still very few and quite heterogeneous (health workers and students) due to the limited research on health workers. However, this review does not limit the publication year criteria so that the author gets comprehensive pooled data. In addition, this review also divides the two outcomes based on the population so that this can minimize the bias effect of using the TDE method. Then, the novelty of this review lies in the extraction of Table 3, which presents the characteristics of TDE commonly used based on the articles analyzed so that this will make it very easy for readers to understand the essence of the TDE method.

Conclusion

This review concludes that from the 12 articles analyzed, the use of the TDE method has great potential in improving various aspects of disaster preparedness in health workers and students. TDE can be utilized in diverse disaster scenarios, both natural and non-natural, including infectious disease outbreaks such as pandemics. The findings of this review underscore the potential of TDE to significantly enhance disaster preparedness, emergency response, and the ability of health workers and students to effectively manage disaster situations. This method improves not only the practical skills but also the confidence of participants in responding to emergencies.

These results suggest that TDE can play a pivotal role in developing and strengthening disaster management capacities in healthcare settings and educational institutions. It provides an effective means to equip students and health workers with essential skills and knowledge in handling disaster situations. This review illustrates how TDE can be integrated into training programs, offering a comprehensive approach to disaster management education. It also presents an alternative for academics and healthcare practitioners to develop curricula focused on disaster response, with TDE as a central component of both the teaching process and ongoing education. Given the limited number of experimental studies evaluating TDE, the author suggests that future research is needed to increase the generalizability of the findings, ensuring that the renewal of information and improvement of service quality can be optimized.