Descriptive Analysis

There has been a gradual and significant increase in relevant publications since 2006, with a peak in 2019-2021 when 16 out of 37 (43.2%) of the articles were published.

Several types of disasters were investigated in these 37 papers, including 15 papers that addressed infectious disease-related disasters (COVID-19 [11]; Ebola [2]; and non-specific infections [2]), followed by nine papers addressing disasters caused by extreme weather events (EWEs) like hurricanes (3), non-specific EWE (3), flood (2), and typhoon (1). There were five papers regarding mass-casualty incident (MCI)/terroristic attack/bombing, two earthquakes, and one bushfire. Five studies addressed non-specific disasters.

Following the application of the quality appraisal tools, 22 articles were included. Out of these 22 articles, two addressed non-specific disasters and 20 investigated specific disaster types. These specific disasters included infectious diseases (10: COVID-19 [6], Ebola [2], and non-specific infections [2]); EWE (7), and MCI/terroristic attacks/bombing (3; Supplementary Table 4; available online only).

Thematic and Content Analysis

First, the various frameworks and theories addressed in the literature were summarized; second, the adopted thematic and content analysis approach was explained; and third, the learning opportunities were depicted.

Frameworks and Theories—The system standards, theories, and frameworks adopted or addressed in the included articles were recognized and summarized (Supplementary Table 5; available online only). In addition, those relevant to resilience, disaster management, public health, quality and accreditation, or organizational management were depicted as follows.

Four studies adopted the PDSA quality cycle. ^{Reference El Sayed, Chami and Hitti1,Reference Brandrud, Bretthauer and Brattebø30–Reference McDaniels, Chang, Cole, Mikawoz and Longstaff32} Ten thematic categories described by Meyer, Bishai ^{Reference Meyer, Bishai and Ravi33} as the resilient health systems components and included “core health system capabilities/capacities, infrastructure/transportation, financing, barriers to care, communication/collaboration/partnerships, leadership/command, surge capacity, risk communication, workforce, and workforce infection control.” ^{Reference Meyer, Bishai and Ravi33} Five categories were identified by Walton, Navaratnam ^{Reference Walton, Navaratnam, Ormond, Gandhi and Mann34} as themes for the UK’s emergency departments during COVID-19. These themes were departmental reconfiguration, clinical pathways, governance and communication, and workforce personal protective equipment (PPE). Eleven essential elements of public health emergency preparedness in the Resilience Framework for Public Health Emergency Preparedness (RFPHEP) ^{Reference Khan, O’Sullivan and Brown35} were adopted by Aliyu, Norful ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8} to explore clinical staff’s preparedness for the COVID-19 pandemic. The RFPHEP included governance and leadership, planning process, collaborative networks, community engagement, risk analysis, surveillance and monitoring, practice and experience, resources, workforce capacity, communication, and learning and evaluation. ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8} The “four S’s” Casiraghi adopted the theory of surge capacity. ^{Reference Casiraghi, Domenicucci and Cattaneo36}

Adopted Thematic and Content Analysis Approach—The significant learning opportunities within the three major disaster types encountered in included articles were analyzed in two sections, including four themes adapted from a hybrid method developed by Ali, Desha. ^{Reference Ali, Desha, Ranse and Roiko26} This model merges the essential elements of the Hospital Safety Index (HSI) and Pan America Health Organization (PAHO) that should be included in evaluating hospital resilience ^{Reference Ali, Desha, Ranse and Roiko26,Reference Murshid, Riaz, Islam and Haque37,Reference Sunindijo, Lestari and Wijaya38} as follows:

• - The functional/operational section (staff/HCWs; system/emergency and disaster management).

• - The physical section: non-structural safety elements (eg, architectural safety, infrastructure protection, critical systems, equipment, and supplies) and structural safety elements (eg, building integrity and previous occasions and dangers affecting building safety).

A content analysis was applied within each theme based on nine learning areas (LAs). These LAs were developed by adapting the RFPHEP and represent the different learning opportunities that emerged in the hospitals during or after disasters (Table 1).

Table 1. The Nine Learning Areas (LAs) and Their Description

Abbreviations: LA, learning area; RFPHEP, Resilience Framework for Public Health Emergency Preparedness.

Results of Thematic and Content Analysis of the Included Studies

Staff/HCWs—The findings in this study indicated several stressful factors affecting the physical and mental wellness of the hospital HCWs. During the Ebola virus epidemic in Sierra Leone (2014), HCWs suffered from being infected, isolated from their families, having trauma due to observing their colleagues’ death, struggling with an increased stress and workload, as well as a trust breakdown between them and their neighbors/communities (LA 5). ^{Reference Raven, Wurie and Witter39} Similarly, Hurricane Sandy (2012) led to considerable psychological stress for the majority of the HCWs following the destruction of homes, loss of power, evacuation, and lack of water and food (LA 5-7). ^{Reference Toner, McGinty and Schoch-Spana40}

Disasters such as Hurricane Harvey (2017) or the early phases of the COVID-19 pandemic confused and frustrated the staff, who questioned the systems’ inconsistency in initiating the emergency response, their hospitals’ disaster response capability, and the frequently changing delivery care policies (LA 1). Additionally, staff were left without assurances in the dark, hearing gossip about the expected patients’ surge, and insufficiency of resources and PPE (LA 4 and LA 6). ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8,Reference Ybarra10}

Significant resilience of HCWs was demonstrated in stressful infectious diseases working conditions (LA 5). ^{Reference Walton, Navaratnam, Ormond, Gandhi and Mann34,Reference Raven, Wurie and Witter39,Reference Balay-odao, Alquwez, Inocian and Alotaibi41} Besides, their age, experience, and confidence in public health authorities contributed positively to their resilience (LA 5). ^{Reference Toner, McGinty and Schoch-Spana40} The HCWs’ coping strategies during disasters included their sense of duty, religion, family and peer support, resources availability, and the risk allowance motivation (LA 1 and LA 6); communication platform availability (LA 1, LA 3, and LA 4); and orientation, training, and workshops boosting the staff’s confidence and performance regarding their conjoined stigma (LA 5). ^{Reference Ybarra10,Reference Drevin, Alvesson, van Duinen, Bolkan, Koroma and Von Schreeb16,Reference Raven, Wurie and Witter39–Reference Yi-Feng Chen, Crant and Wang42} For example, during the Ebola outbreak, caesarean section surgery continued at Sierra Leone public hospitals due to the intrinsically motivated staff performing this surgery, despite infection risks and stigmatization (LA 5). Moreover, the staff surgery performing capacity increased by hospital support from non-governmental organizations and the World Health Organization (WHO; Geneva, Switzerland) agencies that provided the PPE, sterilization equipment and diagnostics, and facilitated the infection prevention and control implementation (LA 1 and LA 6). ^{Reference Drevin, Alvesson, van Duinen, Bolkan, Koroma and Von Schreeb16}

The terroristic attack in Norway and Mumbai underlined the need for public hospital strengthening. It highlighted the significance of HCWs’ continuous training and education in providing them with the experience, knowledge, and skills required for making rapid decisions enduring extreme situations (LA 5). ^{Reference Brandrud, Bretthauer and Brattebø30,Reference Roy, Kapil, Subbarao and Ashkenazi43}

The novelty was profound during disasters as hospitals’ clinical teams and staff members continuously created profound innovative ideas (LA 5 and LA 8) and practical problem-solving strategies in dealing with and coping with challenges (eg, patient surge and lack of PPEs, treatment protocols, or caring plans [LA 2 and LA 6]). ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8,Reference Cariaso-Sugay, Hultgren, Browder and Chen31,Reference Singh, Coker and Vrijhoef44} Changes and modifications of official hierarchies empowered the clinical staff care delivery in the face of uncertainty and allowed them to adopt an “all hands on deck.” ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8} The existing areas were converted into isolation sections, employees were redistributed to other work areas, supplies and equipment were strategically detailed, and educational endeavors were initiated (LA 3, LA 5, LA 6, and LA 8). ^{Reference Cariaso-Sugay, Hultgren, Browder and Chen31} In the same way, some nurse leaders responded to COVID-19 in novel ways and swayed from normal operations. Hence, a nurse manager labelled the suspected or confirmed COVID-19 cases as “blue patients” as an innovative strategy to keep patient confidentiality (LA 5 and LA 8). ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8} In addition, extraordinary clinicians and nurses collaborated to develop a flow chart and separate lanes for better patient management (LA 4 and LA 8). ^{Reference Casiraghi, Domenicucci and Cattaneo36}

System/Emergency and Disaster Management—Concerning COVID 19 emergency response, a great significance of well-defined leadership, flexibility, and robust communication methods in responding to ever-changing clinical situations were reported in the UK (LA 1 and LA 4). ^{Reference Walton, Navaratnam, Ormond, Gandhi and Mann34} Moreover, there was a genuine need for more communication in the US regarding policies, resources, patient management, and family visits (LA 4), as well as for continuous monitoring and evaluation of the disaster plans regarding the infected cases numbers; staff needs, safety, education and training, infection prevention compliance, and surveillance; and resources and patient care delivery (LA 2 and LA 3). ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8} Similarly in Singapore, a lack of a shared definition and decision making of surge threats led to replicating procedures (LA 1). The management was honest, reflecting their transparency principles (LA 1). Nevertheless, the top-down communication flow and instructions from authoritative persons to assigned members were inapplicable and unsuccessful (LA 4). ^{Reference Singh, Coker and Vrijhoef44}

Many challenges were reported in the literature. ^{Reference El Sayed, Chami and Hitti1,Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8,Reference Casiraghi, Domenicucci and Cattaneo36,Reference Gao, Wu and Li45} Flooding in the UK caused health care disruption and, hence, institutional challenges in recognizing vulnerable and at-risk individuals. These effects highlighted the limited health care system preparedness and response capacity to the future changing climate risks (LA 2). ^{Reference Singh, Coker and Vrijhoef44,Reference Landeg, Whitman, Walker-Springett, Butler, Bone and Kovats49} The challenges in a terroristic attack in Beirut included three significant areas: an enormous influx to the emergency department of patients before plan activation, non-essential personnel, family members, and media personnel at the department entrance (LA 1 and LA 8); delay in plan activation and medical supplies deployment (LA 2 and LA 6); and inefficiency or inadequacy of patient registration, paper-based information systems, coordination, existing patients managing, and personnel roles due to ambiguity (LA 3-5). ^{Reference El Sayed, Chami and Hitti1}

Hospital decision makers fulfilled the effective health crisis response measures and needs in various ways; for instance, by increasing the staff in the incident command center (LA 5) and sharing planning experiences with the scientific community (LA 1 and LA 4). ^{Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8,Reference Casiraghi, Domenicucci and Cattaneo36}

In Saudi Arabia, the hospital preparedness and response were based on the urgent governmental and public health authorities’ actions and adequate funds allocation. These actions led to hospital readiness and compliance with the WHO and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) policies and procedures; staff, medicines, and equipment availability; and staff, patients, and visitors’ safety (LA 1, LA 5, and LA 6). ^{Reference Balay-odao, Alquwez, Inocian and Alotaibi41} Hospital resources represented one of four factors that contributed widely to the hospital’s total disaster resilience ability (LA 6). Other factors included hospital safety, hospital disaster medical care capability, and hospital disaster management mechanism (LA 1 and LA 7). ^{Reference Zhong, Hou and Clark11}

Organizational Learning and Evaluation (LA 9)

During the SARS outbreak in Singapore, a learning opportunity stemmed from the lack of daily essential hospital supplies and PPEs and led to an enhancement in equipment and stockpiling preparedness since then (LA 6). Hence, when the next pandemic of Swine Flu struck, these resources were ready and accessible, and several hospitals autonomously stored PPEs and drugs for at least three days to have enough time to reorder in any sudden surge in Singapore (LA 1, LA 2, and LA 6). ^{Reference Singh, Coker and Vrijhoef44}

Italy suffered a high number of COVID-19 deaths among doctors, and many surgeons felt exposed to infection with an increased risk as the PPE supply was sometimes insufficient (LA 3, LA 5, and LA 6). For example, the Spedali Civili, one of the biggest hospitals in Italy, was highly impacted by COVID-19 infection. However, in its trauma hub, the organization and operational strategies of trauma service provided the health workers with all the mandatory PPE, and no new cases of infection were documented between the doctors and nurses in orthopedic wards and operating rooms (LA 3, LA 5, and LA 6). In addition, they had a well-defined strategy and protocols that supported the systems’ resilience and guided the staff members towards effective and high-quality care delivery (LA 1, LA 2, and LA 6). ^{Reference Casiraghi, Domenicucci and Cattaneo36}

The Deming cycle PDSA addressed the hospitals’ organizational learning in the included studies. Most of the studies completed either two or three stages of the Deming cycle. Out of 22 studies, eight conducted the first three Deming stages (PDS) with no further actions implemented. The remaining ten studies were either for one or two stages (P and/or D). Moreover, only four studies completed the entire Deming cycle (PDSA). These four studies adopted different approaches. For example, one of these studies included open-ended questions in the post-intervention survey to depict participants’ feedback and improve future interventions targeting disaster management as a part of the Quality Improvement project. ^{Reference Cariaso-Sugay, Hultgren, Browder and Chen31} This evidence-based educational leadership training aimed to enhance the disaster management knowledge and confidence of 50 nurse leaders to promote resilience, support of employees, and optimal patient outcomes. The results reported significant perceived knowledge and confidence development, with 33 participants completing the post-intervention survey. Hence, the nurse leaders were challenged to respond to the COVID-19 crisis in novel ways by varying their routine operations. In another study, the hospital planners learned from an earthquake experience and utilized it to complete the continuous improvement cycle. Thus, following the earthquake, they incorporated the recommendations developed by the hospital planners as a part of the hospital’s daily activities and monthly meetings of the Emergency Preparedness Committee. These actions eventually enhanced the hospital system’s resilience to future disasters. ^{Reference McDaniels, Chang, Cole, Mikawoz and Longstaff32}

Similarly in Lebanon, an analysis, summarizing, and debriefings were done following the terroristic MCI event to modify the hospital’s disaster preparedness plan. ^{Reference El Sayed, Chami and Hitti1} Finally, the fourth study addressed the success of the Emergency Medical Services in the local community hospital. Three external bodies evaluated it as successfully dealing with a terroristic attack in Norway. The study showed that the success elements included, but were not limited to, emergency preparedness and competence based on continuous planning, training, and learning. In addition, the involved hospital was one of “the pioneers in team training as part of a continuous quality improvement system.” ^{Reference Brandrud, Bretthauer and Brattebø30} Analysis of the finally included articles using the Deming cycle is presented in Table 2. ^{Reference El Sayed, Chami and Hitti1,Reference Aliyu, Norful, Schroeder, Odlum, Glica and Travers8,Reference Ybarra10,Reference Zhong, Hou and Clark11,Reference Drevin, Alvesson, van Duinen, Bolkan, Koroma and Von Schreeb16,Reference Brandrud, Bretthauer and Brattebø30–Reference Walton, Navaratnam, Ormond, Gandhi and Mann34,Reference Casiraghi, Domenicucci and Cattaneo36,Reference Raven, Wurie and Witter39–Reference Landeg, Whitman, Walker-Springett, Butler, Bone and Kovats49}

Table 2. Analysis of the Finally Included Articles (n = 22) using the Deming Cycle