Final Report

„PPssyycchhoo--ssoocciiaall SSuuppppoorrtt ffoorr CCiivviill PPrrootteeccttiioonn FFoorrcceess CCooppiinngg wwiitthh CCBBRRNN“

Grant Agreement 070401/2010/579071/SUB/C4 (01 February 2011 – 31 January 2013)

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1 Table of Contents

1 Table of Contents ........................................................................................................ 1

2 Background ................................................................................................................. 2

3 Summary of the project implementation process ..................................................... 3

3.1 Overview of the process ....................................................................................... 3

4 Evaluation of the project implementation process ................................................... 4

5 Activities ...................................................................................................................... 4

6 Presentation of the technical results and deliverables ............................................ 6

6.1 The Berlin conference on CBRN and Psycho-social Support ............................... 7

6.1.1 Working Group: Media and Crisis Communication ........................................ 8

6.1.2 Working Group: Training Needs for First Responders and Hospital Staff....... 9

6.1.3 Working Group: Impact of CBRN Incidents on First Responders, Hospital Staff and Volunteers .................................................................................... 10

6.2 Study of the current situation in the EU MS regarding CBRN and PSS .............. 11

6.3 Study of the interface between the affected (first responders, members of the public) and hospital staff ..................................................................................... 13

6.4 Curricula and teaching material for pilot training courses (including exercises) for first responders and hospital staff ....................................................................... 15

6.4.1 Pilot training courses for first responders and PSS experts ......................... 15 6.4.2 Pilot Training courses for hospital staff ........................................................ 20

6.5 The final conference in Madrid ........................................................................... 23

6.6 Recommendations ............................................................................................. 24

6.6.1 Recommendations for the Guidelines for First Responders Coping with CBRN .......................................................................................................... 25

6.6.2 Recommendations regarding the training of first responders and hospital staff ............................................................................................................ 25

6.7 Visibility: Information brochure / material ............................................................ 29

7 Evaluation of the technical results and deliverables .............................................. 30

7.1 General lessons learnt ....................................................................................... 30

7.2 Strengths ............................................................................................................ 30

7.3 Possible challenges and/or improvements to be tackled through further action .. 31

7.4 Recommendations to stakeholders, partners, authorities in charge, National and EU institutions .................................................................................................... 31

8 Follow-up ................................................................................................................... 32

9 List of Annexes.......................................................................................................... 33

10 List of Abbreviations ................................................................................................. 34

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2 Background

The risk regarding Chemical, Biological, Radiological and Nuclear situations has increased over the last years in almost all EU Member States. Civil protection personnel deployed in disaster response operations under CBRN conditions are exposed to additional risks and pressures that may constitute a heavy psychological strain. Experience shows that the adequate use of insights regarding psycho-social support help to facilitate crisis management and response in several respects: (1 ) to enable the responders to cope competently with extremely difficult and unfamiliar operations such as CBRN incidents, (2) to avoid long term effects of psycho-social stress for operational responders, (3) to improve the co-ordination during the mission, (4) to take care of the basic needs of individuals affected (e.g. promote sense of safety, exert calming influence etc.), (5) to foster co-operation with affected individuals, and (6) to facilitate a qualified risk and crisis communication. Nevertheless, in most EU Member States psycho-social crisis management is not yet part of the training programme for CBRN specialists. During its two years’ implementation (1st February 2011 to 31st January 2013), the project undertook to address this training deficit by developing and testing a training programme for operational personnel (including volunteers) who may have to cope with CBRN incidents. For this purpose, a multi-national partnership was formed by the project beneficiary the German Federal Agency for Technical Relief (THW), with the following organisations:

• AB1: Centre of Psycho-traumatology, Hospital Maria-Hilf GmbH Krefeld (Germany),

• AB2: Stichting Impact, landelijk kennis en adviescentrum psycho-sociale zorg na rampen (the Netherlands),1

• AB3: Dirección General de Protección Civil y Emergencias, Ministerio del Interior (Spain),2

• AB4: German Federal Office of Civil Protection and Disaster Assistance (BBK), (Germany).

The project partners agreed to achieve a range of specific outcomes and results during the joint implementation of the project. First and foremost, two pilot training courses were to be developed for first responders and hospital staff, each with a specific curriculum and corresponding teaching material. The experiences and insights gained during the implementation of the pilot courses which were repeated twice, were expected to lead to recommendations for institutions willing to undertake similar training. This centrepiece of the project was to be supported by a study on the current situation in EU Member States regarding CBRN and Psycho-social Support,

1 In June 2011 AB2 Stichting Impact merged with the Arq Psychotrauma Expert Group. The partnership within the framework of this project remained unchanged by this step. 2 AB3 officially joined the project in June 2011, taking over from a partner from Italy.

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based on expert interviews, in addition to a study on the interface between contaminated responders and hospital staff. Finally, the deliverables of the project included: the adaptation of the “Guidelines for Uniformed Services” to CBRN, a report on the current state of preparedness of hospitals in Germany and an adapted disaster management plan for hospitals. Two international conferences, the first at the beginning and the second towards the end of the project, offered the opportunity for gaining additional input and discussing the final outcomes in an interdisciplinary settup. 3 Summary of the project implementation process

3.1 Overview of the process

Overall, the different stages of the project were implemented according to plan. At the beginning, however, one of the major milestones – the first international conference - was delayed by some weeks, because of the unexpected necessity to replace one of the project partners who had been responsible for implementing this activity (Activity E.2). It was necessary for the Co-ordinating Beneficiary to take over this task in order to keep the project on track and a replacement project partner was installed officially in June 2011. This step led to an Amendment of the Grant Agreement which was duely signed on 8/7/2011. As a consequence, the first conference was organised by THW and held in Berlin from the 12th to 14th of July 2012. At the same time, it was agreed that the replacement Associated Beneficiary would be responsible for the organisation of the final conference of the project to be held in Madrid in September 2012 (Activity E.4). As a consequence of this change of the two activities between THW and the new Spanish partner, the project plan could be implemented without significant delays. However, there was a certain beneficial impact on the project budget, as the 2nd conference could be organised at lesser costs than budgeted, by selecting the Spanish National School for Civil Protection in Madrid as venue for the event. In general, all resources were used according to plan. The partners made full use of their share of the budget and only minor amendments to the original budget became necessary during the process of implementation. Each of the targeted results and deliverables were achieved fully and, to the satisfaction of the project partners, significant and positive interest from the targeted communities of first responders, CBRN experts, traumatologists and experts for psycho-social support was received throughout the project’s duration. Indeed, from the outset the positive response from the stakeholders involved, provided many additional opportunities for the dissemination of the project’s concerns and outcomes. All beneficiaries gave presentations on various occasions at international conferences across Europe, in Russia and even in Japan (see annex 1).

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4 Evaluation of the project implementation process

The excellent co-operation with the Commission, and with the core group, lent additional support to the beneficiaries. The core group members had been selected for their expertise in the topic, for their extensive professional networks and their extensive potential as multipliers across Europe. The members were:

• Mr. Ralph Dunger, THW State Association Bremen / Lower Saxony

• Ms Dorota Merecz, Nofer Institute of Occupational Medicine, Poland

• Mr. Carsten-Michael Pix, German Firefighters Association

• Ms Moya Wood-Heath, British Red Cross Six core group meetings were held as planned, although not all members could attend all meetings. In order to maintain a high level of communication among partners and core group members, telephone conferences were held at regular intervals. In general, it can be concluded that the composition of partner organisations and core group was very well balanced and contributed positively to the smooth integration and interaction of the various project activities of each partner. The only relevant major difficulty that occurred during the implementation process was the replacement of one of the associated partners, at the beginning of the project. This incident, however, had no negative effect on the activities and their outcomes, as explained above. 5 Activities

As already stated above, the positive response from experts and institutions across Europe to the objectives and to the specific approach of the project were particularly encouraging. As a consequence, the project partners considered that their assumption confirmed that there was, indeed, a perceived deficit regarding the training for first responders and hospital staff in CBRN response. This impression was also supported by the expert interviews carried out in Action A.1. The first international conference (Action E.2) profited greatly from its interdisciplinary design and underpinned the emergence of a wide network of specialists who contributed directly to the activities of the project and/or facilitated the dissemination of its results. The contacts established during this event also resulted in identification of relevant interview partners for Action A.1 who were either interviewed during the Conference or were recommended by participants. In addition, the heightened interest shown in the project led to several publications by project team members including an article published in ‘Crisis Response, Vol 3, 2011 (see annex 2). Furthermore, this interest can be seen as a positive indicator for the European value added by the project. As questions had been raised at the beginning over the decision to hold the pilot training courses (Task C) in German, this result is all the more gratifying. Being aware of the limitations generated by the choice of the German language as the language of the project, the project team members had doubled their efforts to include German speaking participants from other European Partner States, this was largely successful: Participants in both of the training

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courses for first responders came not only from Germany but also from Austria, Luxembourg, the Netherlands and Spain. The international character of the training courses proved to be very beneficial as it offered plenty of opportunities to exchange experiences across borders. Of course, it should be remembered that if the training courses should they later be adopted by other countries, they are very likely to be held with national participants only. Nevertheless, the process of developing these pilot courses profited significantly from the multinational input of its participants. With a view to the follow-up of the project, the partners had decided to emphasise the role of potential multipliers of the project results during the final international conference in Madrid (Action E.4). The participants in this event were therefore chosen from among those who had actually attended the pilot training and from first responders’ training institutions. As a consequence, the second conference had a less academic character than the first, but put practical issues into the foreground. Most of the experts interviews were carried out (Action A.1) by Impact (AB2), as planned, within the first nine months of the project. Nevertheless, the project partner seized every additional opportunity to access the expertise of experts by interviewing them, even during the second half of the implementation phase. By December 2012, part two of the planned site visits remained outstanding: one in Romania and the second in the USA. The interviews were intended to permit an assessment of the current situation in the EU Member States regarding dealing with CBRN incidents and the training of first responders and hospital staff. Clearly the qualitative approach applied in this case, using a relatively limited sample of interviews, led to different insights than a broad statistical survey would have produced. Its merit lies rather in highlighting individual expertise and in drawing attention to relevant fields of action based on singular but significant experiences. Parallel to the interviews, Impact carried out an annotated literature survey, listing 16 publications, each supplemented with an abstract in English (see annex 3). Whereas training combined with exercises takes place at regular intervals for most first responders, CoP (AB1) undertook something new when offering a pilot training for psycho-social competence in CBRN incidents for hospital staff (Action C.4). Its design had to take into account the specific situation of a full medical hospital that cannot afford major disruptions to its daily business operations. In order to reach the relevant staff, the training had to be much shorter. The training lasted one day including the practical exercise. The fact that the training, inspite of tight schedules, attracted a significant number of staff representing a broad range of responsibilities, shows not only that there was a perceived deficit regarding the capability to cope with major CBRN incidents, but also a strong motivation to close this gap. The participants’ feedback was so positive, indeed, that it was decided to repeat the training for a third time. One of the positive outcomes of this activity was also the increased and deepened co-operation between the hospitals and the local fire brigades in the area of CBRN preparedness. Besides the training events for hospital staff, CoP also carried out an analysis of the current state of preparedness regarding CBRN incidents and hospital disaster management. This activity also comprised a literature research and standardised interviews among leading hospital managers and physicians responsible for

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emergency rooms or intensive wards. In addition, a CBRN stress response model was developed that serves as a basis for a modified disaster management plan for hospitals. These tasks were implemented by CoP as planned. THW as Co-ordinating Beneficiary was mainly responsible for developing in close co-operation with its partner BBK (AB4), the curriculum for the pilot training for first resonders and to implement the courses twice, each time with different participants (Task C). The general idea was to adapt the curriculum and the practical exercises according to the experiences of the first pilot. This approach was indeed useful and several improvements could be made, based on the feedback of the participants. As a consequence, the training was extended to three days instead of two, thus leaving more time for the practical training. Another improvement was in the evaluation sheets for the participants. Fortunately, all participants in the two pilot courses were extremely motivated to contribute their maximum to the development of the training. The project team received very valuable input from them. The regular evaluation of the interim results by the project partners helped to formulate solid recommendations pertaining to aspects related to their being put into practice (i.e. transferability) (Task D). Overall, the various activities of the project were well inter-related and succeeded each other in a way that facilitated mutual synergies. 6 Presentation of the technical results and deliverables

The original proposal suggested six key results that were to be expected as outcomes of the project:

• Study of the current situation in the EU Member States regarding CBRN and PSS

• Study of the interface between contaminated responders and hospital staff

• Two international conferences

• Curricula and teaching material for pilot training courses (including exercises) for first responders and hospital staff

• Recommendations

• Information brochure / material In the following section these deliverables are described and evaluated mainly in chronological order.

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6.1 The Berlin conference on CBRN and Psycho-social Support

The first International conference took place in Berlin from the 12 to 14 July 2012 under the title ‘Psycho-social Support for Civil Protection Forces – Improving Resilience through Training’ (Action E.2). The interest in the topic of the conference attracted a lot of attention. As a consequence, more participants than originally planned were invited. The importance of the topic was underlined by Mrs. Pilar Gallego, then General Director of the Civil Protection and Emergency Department of the Spanish Ministry of the Interior who provided the welcome address at the conference and Mr. Norbert Seitz, General Director of the Civil Protection and Crisis Management Department of the German Ministry of the Interior who provided the farewell address. 70 experts from 21 EU Members States participated in the conference; a wide range of experts active in the domains of CBRN incidents and/or psycho-social support and from across the European Union (EU MS/EEA) were brought together including: Civil protection, fire brigades, police, rescue services, medical/psychological services, hospitals, research and the media.

Pilar Gallego, GD, Ministerio del Interior, ES Plenary session

Group picture Norbert Seitz, GD, Federal Ministry of the Interior, DE

This was the first time that experts representing first responders, academia and psycho-medical professions from across Europe were offered a joint platform for debate and the exchange of knowledge. As the participants’ feedback showed, this

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experience was very much appreciated. It also became apparent that the different target groups were and still are in the process of finding a common language, a fact that would commend the creation of more opportunities of this kind. The overall purpose of the conference was to furnish relevant background information and to provide additional input that could be useful for delivering the core task of the project, i.e. the design of pilot training courses for first responders and hospital staff. In addition to listening to various presentations on the topic from different perspectives, the participants came together in four working groups that dealt with more specific aspects of CBRN Incidents and Psycho-social Support such as: Media & crisis communication, training needs for first responders and hospital staff and the impact of CBRN incidents on first responders, hospital staff and volunteers (see Annex 4 for full conference programme). During the working group sessions the participants took a closer look at perceived challenges, identified training needs and examples of good practice. The key findings are summarised below.

6.1.1 Working Group: Media and Crisis Communication It became very clear from the discussions that ‘communication’ is indeed a key element in rescue operations and all the more in CBRN situations. Uncertainty was identified as one of the most serious challenges in CBRN situations leading to fear, altered risk perceptions and to even more insecurity. This applied not only to lay persons but also to first responders. Attention was drawn to the fact that first responders and hospital staff who are deployed in CBRN incidents need to be able to fulfil their tasks with a clear mind that is unencumbered by worries about their families and friends. In order to achieve this they must be well informed and able to advise about risk and safety matters. However, in the course of events, more often than not assumptions prevail over facts and key decisions are taken on the basis of assumptions. Even if the hazardous material involved has been identified its real long term effects and consequences cannot be fully known. Not least, because in most cases there are no definite standards regarding safe concentration thresholds of detrimental substances and agents. While it is of utmost importance to give adequate and reliable information to the public and to rescuers alike, it is extremely difficult to communicate effectively, due to its complex scientific and/or technical character. In addition, the point was raised of possible conflicting interests of scientists and politicians in these matters. Reference was also made to the fact that most people believe strongly in popular myths and misapprehension about disasters, particularly in the prevalence of panic, although there is no scientific evidence for it. Another key word that occurred frequently in the debates was ‘trust’. The participants of this working group insisted on the importance of the trustworthiness of messengers and their sources. Who will be most trusted (persons, institutions) will largely depend on the target groups and circumstances. Overall, the experts recommended to:

• Communicate! Communicate! Communicate!

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• Centralise information in order to avoid confusion and establish, in advance, an information strategy and structure

• Define appropriate trustworthy messengers

• Establish trust in the message and the messenger

• Be honest – it is better to say ‘I don’t know’ than to provide wrong information

• Show compassion and responsibility

• Show that you are in control.

6.1.2 Working Group: Training Needs for First Responders and Hospital Staff Among the challenges identified by the members of this working group was the question of availability of psycho-social support in addition to the fact that there still is a high threshold for first responders to ask for support and to use available PSS structures. This may vary depending on the type of service (police, fire fighters, military, medical staff) and it is also likely that cultural factors may have an influence on attitudes regarding PSS. There was a general consensus in the group that PSS should be included in the standard crisis management process and, therefore, be trained. Regarding the issue of training for first responders and hospital staff it was suggested that the theoretical and practical training sessions should above all convey knowledge and techniques to participants that will enable them to feel in control and to act effectively. In this context, the importance of practical exercises was highlighted as part of the training. According to the experts, the scenarios should be as realistic as possible. This led to the recommendations to

• Have joint exercises for those forces that have to co-operate in a CBRN incident

• Use actors instead of colleagues

• Wear actual Personal Protective Equipment (PPE)

• Train communication skills

• Encourage role play and change of perspectives

• Treat PSS not as a simple add-on but as an integral part of the incident management.

The members of the working group underlined the fact that, generally, hospital staff are much less used to exercises than rescue forces. While hospital staff are very familiar with dealing with infection, the ‘B’ in CBRN, they are much less so when it comes to coping with larger chemical or radiation incidents. As CBRN incidents have a low probability but potentially very severe consequences, they are usually not part of the hospitals’ training routine. In addition, having an exercise within a complex institution like a hospital has its own peculiarities and specific challenges. For instance, medical staff and non-medical personel (from different levels of hierarchy) should take part in the training. All this should be taken into account when designing training courses for this specific target group.

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6.1.3 Working Group: Impact of CBRN Incidents on First Responders, Hospital Staff and Volunteers

The experts of this working group perceived major challenges in the domain of legal aspects and issues of insurance, financial support in case of long-term injuries, rehabilitation and vocational disabilities. If these questions are not dealt with satisfactorily, the resulting worries will have a negative impact on the motivation and performance of first responders deployed in CBRN incidents. Difficulities arising in this area afterwards may have the effect of producing a “secondary trauma”, a risk that should be kept as low as possible. A key term used in this context was ‘disaster bureaucracy’, meaning the necessity to provide administrative tools and structures that enable the relevant authorities to keep track of critical incidents and their impact on first responders over the short, medium, and long term. As to the training, the group emphasised again the necessity to strengthen the capability of the trainees to maintain their psycho-social resilience and the feeling of being in control and competent. There was a general consensus that CBRN should be dealt with by CBRN specialists and PSS by PSS specialists, but that it would be useful to train liaison personnel from both teams together in order to create a greater awareness for both topics among both groups. In addition, the participants in this group recommended to:

• Offer more practical training in order to become more familiar with CBRN equipment, specific risks and communication skills while wearing protective suits

• Foster more team work

• Offer specific stress management

• Inform more thoroughly about PSS and integrate it into disaster management procedures.

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Overall, it can be said that the conference received overwhelming positive feedback from the participants (see annex 5) and created an excellent basis for the following project activities. As one participant put it: “A first step is done! We have to go on.” Almost 70% of the participants returned a completed evaluation sheet which can be regarded as a very good result.

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6.2 Study of the current situation in the EU Member States regarding CBRN and PSS

To assess the situation in the EU Member States regarding CBRN incidents in the sense of preparedness, response, and support for responders 23 ‘qualitative’3 expert interviews were carried out by Impact/Arq during site visits in different EU Member States, in Israel,4 and in the USA. Experts from the following countries were interviewed:

• Italy (12th – 15th of April 2011)

• France (21st – 22nd of November 2011)

• United Kingdom (21st - 23rd of June 2011)

• Germany (4th – 7th of July 2011)

• Israel ( 15th – 19th of January 2012)

• Poland (21st – 24th of February 2012)

• Romania (17th – 19th of December 2012)

• United States of America (20th – 24th of December 2012) For the expert interviews, a semi-structured questionnaire was developed. In this way it was possible to collect the information from different sources in a systematic way, and to be open to information for the specific expertise of the expert. It is worth restating that the interviews were not expected to deliver a comprehensive description of the situation of CBRN preparedness and response in a specific country but to highlight and draw attention to possibly rare/singular but highly significant aspects. The key questions focussed on the type of CBRN incidents that occurred in the country over the last few years, on the availability of psycho-social care for first responders and hospital staff, and on important lessons for the future. First of all, it became apparent that there still is no common understanding about what is to be considered as a “CBRN incident” as compared to a hazardous material incident (HazMat).5 The most significant difference between a conventional HazMat incident and a CBRN event seems to be the potential for large numbers of victims. Responders may be required to control, triage, decontaminate, treat, track and 3 Empirical research uses either a quantitative or a qualitative approach. The qualitative method is characterised by more openness and flexibility using semi-structured questionnaires with open questions. It is specifically interested in the individual, subjective experience and does not seek to measure quantitative empirical facts. 4 Impact/Arq used the participation in an international conference on Preparedness and Response to Emergencies and Disasters in Israel for further interviews. 5 In the UK, for example, a CBRN incident refers to a deliberate act and the police are then co-ordinating the response, whereas HazMat incidents are led by the Fire and Rescue Service on a daily basis.

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transport hundreds of patients. In general, most interview partners were of the opinion that the emergency management would be more or less the same in both cases. When asked about recent CBRN incidents in their country, most experts recalled industrial or transport accidents that involved hazardous chemical material, problems with toxical waste or nuclear radiation related to nuclear power plants or hospital waste. Several interview partners made reference to the Litvinienko case in the UK as an example of using radioactive material in a criminal context. The investigation that followed was treated as an ordinary criminal investigation, but in its wake the authorities were confronted with unprecedented worries from the public resulting from real or perceived contamination. As for the state of preparedness, the picture emerging from the interviews is very heterogeneous. Overall, for smaller incidents at local level, the response capability seems to be adequate and well trained. This is less clear when it comes to larger CBRN events characterised by their high complexity involving many different organisations at local, regional, and state level. Fortunately, most countries to date have been spared such an experience. Consequently, there is little knowledge based on practical experience or, as one interview partner put it: “Expertise is only developed after a disaster”. Regarding the availability of psycho-social support for first responders coping with CBRN, the interviews showed that much still needs to be done in this area. While in some countries authorities and decision makers are very aware of the necessity to include PSS in the general emergency management in order to increase the resilience of the responders, in other countries the (self-)perception of the ‘heroic’ firefighter who does not need such a support still seems to prevail. Especially where there is a powerful military tradition among the responders there seems to be the opinion that a strong team spirit is all that is needed to cope with stressful events. It also appears that, generally speaking, the main focus is often put on the psycho-social support for the affected victims and somewhat less so on the needs of the operational forces. There is a general agreement among the experts that the major challenges arising from larger CBRN incidents lie in dealing with their complexity in combination with a high uncertainty and a general lack of knowledge. When asked about relevant lessons for the future, their recommendations centre on the strengthening of the personal resilience of the first responders. In this context, the importance of successful communication based on credibility and trust is again underlined in addition to sound leadership and command. Another key word that arises frequently is ‘interoperability’: The different operational services (police, fire fighters, ambulance services etc.) should be able to talk to each other by radio and not only ‘up and down within their own organisations’. Also, everyone should be familiar with each others procedures, as for example ‘a dirty bomb scene is also a crime scene’. Apart from that, the experts emphasise the necessity of robust training and continuity in training in order to develop skills and routine. They strongly advocate inter-agency training and exercises that include all relevant players in CBRN response. In their opinion, more action is needed in the field of the better

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management of risk perception of the public in addition to that of the first responders themselves.

*** Besides carrying out the expert interviews, Impact/Arq conducted a literature review pertaining to guidelines for first responders in case of CBRN incidents. Seventeen scientific publications in the English language that appeared between the years 2001 and 2011 were studied for this purpose. The findings largely support the views of the experts who were interviewed by Impact/Arq (see annex 6):

1. Contrary to the fears of most decision makers, in a CBRN incident, overwhelming panic reactions are not very likely to occur, neither in the afflicted population nor in the first responders nor in the first receivers (i.e. health care providers and hospital staff).

2. Factors that contribute to enhanced professional commitment include repeated training, pre-briefing, having a clear plan of action, and familiarity with professional roles and responsibilities.6

3. Training and exercises should enable responders as much as possible to promote through their activities a sense of safety, calm, self and group efficacy, connectedness and hope.

4. Family members of emergency responders will require honest and up to date information on dangers, personal protective equipment and safety measures, mission assignment etc. (e.g. a call centre).7

5. Improper risk communication can have long-reaching consequences by increasing anxiety and reducing trust in government, experts and other authorities who are responsible for the public communication. More research is needed in the area of (public) risk perception and vulnerability assessment.

6. Disaster contingency planning should integrate psychological, social, emotional and behavioural insights.

7. Pre-event planning should prepare for dealing with spontaneous volunteers in addition to large numbers of ‘worried well’ (i.e. those who are concerned they are ill without medical/physical evidence).

6.3 Study of the interface between the affected (first responders, members of the public) and hospital staff

The overall objective of this task was to improve the psycho-social competence of hospital staff by integrating PSS in the disaster management plans of hospitals.

6 Dodgen, D. et al. „social, Psychological, and behavioral Responses to a Nuclear Detonation in a US City: Implications for Health Care Planning and Delivery“, Disaster Medicine and Public Health Preparedness 2011, Vol. 5, Suppl. 1, p. 57 7 Ibid., p. 58

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Therefore, a model of stress response reactions among hospital staff was elaborated by the project partner (AB1) Centre of Psychotraumatology, Hospital Maria-Hilf GmbH Krefeld (CoP). The model developed by CoP is adapted to the specific circumstances and conditions of CBRN incidents and can be integrated into core curricula for PSS training for the target group of hospital staff (see annex 7). It has to be mentioned, however, that the model has not yet been empirically tested. The approach for the model is based on the attachment theory developed by the psychologist John Bowlby and other psychologists starting from the late 60s. It is a concept in developmental psychology that concerns the importance of "attachment" in regards to personal development. Specifically, it makes the claim that the ability for an individual to form an emotional and physical "attachment" to another person gives a sense of stability and security necessary to take risks, branch out, grow and develop as a personality.8 According to Bowlby, an attachment behavioural system is triggered early on by perceived threats in order to motivate people to move closer to ‘attachment figures’. This attachment system is defined as a goal-correcting behavioural system that is primarily activated by discrepant experiences, such as acute threats, particularly by unfamiliar situations or strangers. Attachment behaviour includes all behaviours that serve the purpose of ensuring proximity or accessibility to an attachment figure. The phenomenon of the ‘secure base effect’ describes an attachment pattern where, in the presence of an ‘attachment person’, comfort and reassurance are increased and fear is decreased. As elaborated by the project partner CoP, two specific aspects should be considered in the case of CBRN events:

a. The highly increased psychological stress of those affected by a CBRN situation, and

b. the fact that the attachment behaviour is strongly influenced by mimic, tone of voice, gender characteristics, size and shape of a person - elements that are difficult to determine when confronted with someone wearing PPE.

In the view of CoP, both aspects constitute a severe challenge for the responders’ capability ‘to promote through their activities, a sense of safety, calm, self and group efficacy, connectedness and hope’ (see above, 6.2, point 3). CoP conclusions are in full accordance with the findings of Impact/Arq. Consequently, CoP recommends to

• integrate the psychological needs of hospital staff in the emergency management planning and to

• offer adequate training opportunities for this target group in order to improve hospital preparedness.

. ***

8 Cf. www.psychologistworld.com/developmental/attachment-theory.php

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In addition and as supportive action to the above task, the project partner CoP carried out interviews with German hospitals pertaining to the current state of preparedness for CBRN incidents. The questions focused on the hospital’s internal information policy, key positions in case of a CBRN incident, available support to staff including PSS, and availability of PPE to hospital staff. The survey reached the clear conclusion that the majority of hospitals are not sufficiently prepared to cope with larger CBRN incidents (see annex 8). Based on the activities described above and on a review of the scientific literature, CoP elaborated also a new emergency management plan for hospitals broadened to include PSS for hospital staff coping with CBRN incidents (see annexes 9 and 10). In preparation for the task of developing a pilot training course for hospital staff, a further survey was carried out among the hospital staff in order to learn more about their current state of awareness and knowledge about CBRN, and about their specific needs regarding information and training. The results of the interviews will be dealt with in more detail below (see 6.4.2).

6.4 Curricula and teaching material for pilot training courses (including exercises) for first responders and hospital staff

The task of developing, implementing and evaluating pilot training courses for first responders and hospital staff (Task C) constitutes the pivotal activity of the project. Its starting point was the assumption that there still is a deficit in the domain of training for CBRN response, particularly when it comes to integrating psychological needs, social, emotional and behavioural aspects. The results obtained in the activities described above firmly supported this presumption. The objective of the pilot courses to be developed and implemented during the project, was to ‘enable responders, as far as possible, to promote through their activities a sense of safety, calm, self and group efficacy, connectedness and hope’ (see above, 6.2, point 3). The idea behind it was that by enabling the responders to resort to these skills during CBRN interventions their stress would be reduced and they would thus be in a position to operate more efficiently and in a better co-ordinated way.

6.4.1 Pilot training courses for first responders and PSS experts The project partners THW (CO) and BBK (AB4) began with the concept of a training course for first responders that would last 2 days of which almost a full day would be dedicated to practical exercises. The training was to be held at the Academy for Crisis Management, Emergency Planning and Civil Protection (AKNZ) in Ahrweiler. As for the target group, it was decided to invite leading operational staff (including volunteers) from civil protection organisations which are deployed in CBRN operations (e.g. fire brigades, police, etc.), together with psycho-social first aid specialists and mental health experts in charge of psycho-social aftercare. The decision to have a mixed group of participants was taken on the basis of the outcomes of the Berlin conference (cf. 6.1.2) and the other project activities described above. The intention was to provide a deepened understanding of the

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specifics of CBRN conditions for experts of PSS and a better understanding of the scope of PSS and the support it is able to offer for operational staff. In view of the transferability of the results, both partners invited German speaking participants from other European Member States (cf. above p. 5). In a first step, THW and BBK created a curriculum for the first pilot course that contained all necessary details for the training:

• Duration

• Level

• Target group and requirements

• Purpose

• Need

• Overall learning objective

• Assessment of success

• Suggestion for further training to retain skills / maintain qualification

• Overview of the chapters: - Content - General learning objective - Individual topics - Required time frame - Type of training (theoretical or practical).

As stated above (cf. p. 7), based on the participants’ feedback, several alterations had been made regarding the design of the second course. (For the final curriculum please refer to annex 11.) Also the invitation letter for the participants had become more precise about the envisaged target groups and the overall objective of the training. The practical part of the training was of utmost importance to THW and BBK. Three different scenarios were developed and exercised in a large work room on the premises of the AKNZ training school.

The exercise hall

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Scenes taken from the exercise (in front of and behind the decontamination tent)

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The main purpose of the exercises was to train the communication skills of first responders wearing PPE; to let them experience what kind of behaviour is helpful to motivate people, who are victim of a CBRN event, to co-operate and to be supportive. In addition, the exercise should give them the opportunity to understand better the work of psycho-social staff. As for the PSS personnel, the aim was also to train their communication skills and, at the same time, to make them more familiar with the specificalities of CBRN situations and the role first responders have to play in them. It was explained to the participants at the beginning that the intention of the exercises was not to train the actual decontamination procedures.

Each of the three scenarios lasted about 10 – 15 minutes and involved both target groups. They included a transport road accident involving hazmat, an industrial accident and a terrorist attack with a ‘dirty bomb’. Some of the participants acting as observers and marked by wearing orange vests, took notes of their perceptions. In addition, one of the trainers filmed the activities during the exercise. This material was later analysed and discussed in the plenary during the final evaluation session on the last day of the course. The availability of filmed sequences proved to be very helpful for recalling specific situations and the feelings they had created in the players.

Due to factors such as the limited space inside the hall, time constraints, and the finite availability of specific types of CBRN PPE, the exercises suffered from certain artificiality. This ‘flaw’ probably cannot be avoided altogether but should be addressed explicitly and explained to the participants during the briefing before the exercises. It is, very important that the scenarios are not designed in a way that forces the first responders and PSS experts to act in conflict to their professional standard operating procedures (SOP).

A very efficient way to add extra reality to the exercise was employing professional actors rather than using colleague participants for playing the roles of the victims. The actors were hired from a local theatre and played their roles with huge enthusiasm and creativity. They had received only a very cursory briefing on the specific situation they had to act in, shortly before the exercise. During the action, they immersed completely into their roles which created many dramatic and highly emotional moments. As the participants later confirmed, this had added a lot of reality to the exercise and engendered an unusual challenge to the players. There is another advantage in employing professional actors that makes it worthwile to plan for their inclusion when designing such a training course. In this case, the actors proved to be excellent feedback providers. Each short exercise was immediately followed by a lengthy round of feedback provided by each actor (see photo on the right). They were able to describe in detail how they felt in the interaction with the different players. They

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could explain what had helped them to co-operate and what had not. This was extremely important and valuable for the first responders as they usually do not have the chance to meet a ‘victim’ after the person has entered the decontamination process. Reassuring remarks from the actors helped to remove doubts some responders had about the emotional impact of their action. In addition, the actors, as an ordinary citizen, would not be aware of the usual procedures applied during a CBRN incident. Therefore, they reacted in a co-operative way only in response to behaviour that was indeed appropriate to induce co-operation under disturbing and stressful circumstances.

The actors (front row) give their feedback to the participants in the exercise

The theoretical sessions of the pilot course were intended to broaden and deepen the existing professional expertise of both target groups particularly with regard to the psycho-social aspects of CBRN incidents. This meant that both groups first started with seperate sessions on CBRN response for PSS personnel and on PSS for first responders. In separate working groups, the participants reflected on their mutual perception of each others’ roles and modes of operation. The discussions that followed in the plenary were helpful in creating a productive atmosphere of open-mindedness and ‘rapprochement’.

Overall, the theoretical part of the course was divided into seven chapters, whose contents were treated in a range of specific presentations:

1. Special stress factors 2. Reactions of the affected in CBRN situations 3. Skills in psychological first aid while wearing PPE 4. Basic skills regarding group and crowd psychology

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5. Operational procedures in CBRN situations (for PSS staff) 6. Post-intervention psycho-social aftercare 7. Risk and crisis communication 8. (Optional: Stress management)

After the training, each participant received a signed certificate of which an example can be found in annex 12.

From the feedback of the participants to the training organisers, it became apparent that they appreciated:

• the practical exercises

• exercising with professional actors

• the opportunity to learn more about and handling different types of PPE

• the bringing together of both target groups (first responders and PSS personnel)

• having separate sessions for each target group for the topics they are less familiar with (e.g. the scope of PSS resepctively SOP for CBRN response)

• activating teaching methods (more group work, less powerpoint presentations)

• having enough time for exchange of experience (esp. in a group of interrnational participants)

• the good overall organisation.

Seventeen out of eighteen participants in the second training said that they would recommend the course to colleagues. In that context, they offered to make special efforts to emphasise the messages to decision makers and superiors. For the full details of the evaluation sheets please refer to annex 13.

Further recommendations that emerged from the feedback of observers and participants will be specified in more detail below under point 6.6.

6.4.2 Pilot Training courses for hospital staff It was mentioned previously that the overall design of the pilot training course for hospital staff had to consider the specific working conditions of a fully operating hospital. Firstly, it was unthinkable to have a training that lasted for more than one day because this would constitute a major disruption to the necessary continuity of its services. This also meant that CoP had to prepare the ground very carefully in order to motivate the relevant staff members from various levels of hierarchy to spend their precious time for this activity inspite of their tight schedules. One also has to bear in mind that hospital staff are much less accustomed and inclined to regular exercises than first responders in general. For these reasons, CoP started the task by carrying out a survey among the hospital staff to learn more about their knowledge and attitudes when it comes to facing

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possible CBRN situations in a hospital. An additional survey among managing directors of five hospitals looked into the:

1. level of information available for the hospital staff 2. key positions in a CBRN situation and the eventual need for additional staff 3. support provided to the staff 4. availability of PPE for staff members 5. provisions regarding PSS during and after a CBRN incident.

The results of this enquiry led CoP to the conclusion that the state of preparedness of the hospitals cannot be considered as sufficient. For example, only one out of five hospitals has adequate PPE in stock and more than half of the hospitals (i.e. 60%) do not provide for sufficient support to their own staff in case of a CBRN situation. The full details of the survey can be found in annex 8. The enquiry that was carried out among staff members showed that although most people felt that they had some knowledge about CBRN they were not always sure about the quality of the information. However, 67 % claimed to have read the alarm plan of the hospital. When asked about the preferred breadth of information to be provided by the training, the vast majority (74%) wished to be informed about CBRN situations in a more general way and not in too much detail. Nevertheless, 92% of the questioned were of the opinion that regular training in this area (every second year) would be very useful. 87 % showed great concern regarding their own health in a CBRN situation. This was further supported by the fact that most of them had mixed feelings when asked about the safety provided by PPE and their ability to work effectively when wearing it. Regarding the practical exercise, only a fifth of personel questioned voted for role plays, 18% preferred psycho-education whereas more than a third opted for the discussion of case studies and another third for the watching of instructive videos (cf. annex 14). Based on the results of the survey CoP developed a curriculum for the pilot course comprising also practical exercises. The curriculum is included in annex 15.

Scene from the exercise at the hospital in Krefeld

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The pilot training was implemented twice by CoP, first in Krefeld then in Berlin, and lasted a full day from 09:00h to 17:00h. The practical exercises involved the same actors as in the training for first responders. Again, the advantages of employing professional actors became very evident to all involved. Due to active promotion the response from the targeted groups was very positive and the anticipated number of participants was achieved each time as intended.

Pilot training session for hospital staff in Berlin

The following content was covered by the training:

• introduction to CBRN and PSS

• disaster management plan and alarm plan of the hospital

• fundamentals regarding CBRN situations

• the interface hospital from the perspective of CoP

• results of the surveys

• general facts about psycho-traumatology

• specificalities of stress response in CBRN events

• typology of critical incidents

• CBRN from the perspective of intensive medical care

• practical exercises to train standard procedures (handover of patients). The training closed with a round of feedback from the participants. Both training courses in Krefeld and in Berlin were a huge success, in fact so much so that CoP decided to have a third training at the hospital in Berlin. For the detailed participants’ feedback see annex 16.

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6.5 The final conference in Madrid

The second international conference (Action E.4) was organised by the Spanish partner Dirección General de Protección Civil y Emergencias, Ministerio del Interior (AB3) in Madrid in September 2012. The overall purpose of this event was to present the project results obtained so far, to have them discussed, amended and approved by the experts taking part. Another important objective was to reach a consensus regarding the recommendations developed and proposed by the project partners. Finally, the conference was intended as a platform for developing ideas for the follow up of the project. For the conference agenda see annex 17. In view of the specific aims of the conference, the targeted group of participants differed from that group invited to the first conference in Berlin. This time, the project partners decided to address, primarily, first responders and hospital staff who had participated in the pilot training but also civil protection training institutes and decision makers because of their role as future multipliers. Nevertheless, some of the experts attended both events and were in a position to provide additional continuity. 52 experts from 15 EU Member States met in the Spanish National School for Civil Protection. The conference was opened by State Secretary Mr. Luis Aguilera (Spanish Ministry of the Interior) and Mr. Jürgen Weidemann, Head of Unit KM3 (German Ministry of the Interior). The closing ceremony was held by Mr. Ralph Tiesler, Vice President of the German Federal Office of Civil Protection and Disaster Assistance. As regards the design of the event, the project partners had put their focus on the presentation of the results with first hand reports from participants in the pilot training and on working group sessions in order to discuss and refine the recommendations and to develop ideas for a follow-up.

Madrid: Discussions in the plenary

At the end, the project team received 21 completed evaluation sheets. It was particularly encouraging to learn from this feedback that all found the project results either ‘very relevant’ (11) or ‘relevant’ (10) for their own work. To quote one participant: “I am free to choose the topics I cover with my students during classes

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and will certainly spend more time on CBRN incidents and the aspects of psycho-social support for first responders. Since I have 150 – 200 students every year – you can be sure that what I’ve learned here will be passed on to them!”

Result from the evaluation of the Madrid conference

Another participant summarised his assessment of the conference: “Keep up the good work! The project must be followed up and the EU should decide to recommend the implementation of some policies by all member states. During the working sessions it was obvious that every country has a different way of meeting these problems. We need a common language in order to build upon it and improve it.” The evaluation form together with a summary of the results, including the listed remarks to the open questions can be found in annex 18.

6.6 Recommendations

All experts who contributed at the different stages to the project underlined the importance of awareness raising, information and training, in order to strengthen the resilience of those who are directly or indirectly involved in a CBRN incident. This applies specifically to the first responders and the PSS personnel themselves, but is also relevant to their families and social networks. In general, the experts advocated a holistic approach: personal resilience combined with reliable professional and social skills, in combination with adequate administrative provisions and procedures, in addition to good crisis communication; together they form a solid basis for efficient disaster management and response. Consequently, the pilot training courses implemented by the project put the focus on the responders and on the skills that help them to maintain their resilience at a high level. Over the period of almost two years, the project partners gathered and developed recommendations (Task D) regarding:

• Guidelines for First responders Coping with CBRN

• Training of First Responders and Hospital Staff

• Project follow up

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The findings were discussed and finalised at the conference in Madrid as detailed in the following paragraphs. The recommendations for the follow up of the project will be treated further below in chapter 8. The complete overviews of all recommendations can be found in annex 19.

6.6.1 Recommendations for the Guidelines for First Responders Coping with CBRN

The key recommendations regarding the guidelines are:

• Create and develop an efficient communication strategy for first responders, their families and friends, decision makers, and the general public, based on honesty, reliability, and trustworthy messengers. Do not refrain from communicating out of fear of causing panic!

• Establish a functioning ‘disaster bureaucracy’ that can provide the necessary data basis for compensations and supportive medical and/or psycho-social actions (in the short, medium and long term). Be aware that lasting quarrels with insurers and lawyers after an extremely stressful response operation are likely to provoke a so called ‘secondary traumatisation’ which diminishes a person’s resilience.

• Provide psycho-social support for first responders and their families, for example in combination with regular medical health checks.

• Make sure that PSS becomes an integral part at the strategic level. Consider including an expert on PSS in the crisis management staff.

• Provide for robust training, continuous training and ongoing development of new skills.

• Seek to train the inter-operability (joint inter-agency training and exercises to foster mutual knowledge of the SOP of all actors/agencies involved). Consider also cross-border training where it makes sense.

6.6.2 Recommendations regarding the training of first responders and hospital staff

When planning to design a similar training course for first responders or hospital staff the considerations should follow the usual steps, beginning with the clear identification of the target group(s) and the actual need The question “What shall be different after the training?” has to be answered and the need has to be well defined. It is important to keep in mind the future transferability of the training results into practice. This will not only have consequences for the content, methodology and didactics of the training, but also for the design of the evaluation forms and the way the overall success of the training can be measured. In addition, some thought should be given to the context in which the trainees will have to perform later, i.e. to their superiors and colleagues and their attitudes towards the training. The experience gained during the project showed that constant efforts had to be made by the project team to produce and maintain the required clearness of the concept. The feedback of participants in the pilot courses drew attention to the fact that the work environment has to be taken into account, too. In the case of this

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project, this specific aspect could be respected only imperfectly, due to its pilot character, the international background of the trainees, and the short time available. The following recommendations in this section are meant as support to organisations that plan to develop similar training for their staff. They are divided into the sections:

a) Learning objective b) Content of the training c) Methodology and didactics d) Organisational aspects.

Ad a) Learning objective:

• The overall aim of the training is to strengthen the resilience of the trainees who have to cope with CBRN situations, to enable them as much as possible to promote through their activities a sense of safety, calm, self and group efficacy, connectedness and hope (cf. above p. 13) in order to improve disaster management co-ordination and to reduce acute, mid- and longterm psychological stress.

Ad b) Content of the training

• All four dimensions of competence have to be addressed: the professional, the methodological, the social and the capacity to act efficiently.

• Therefore, the theoretical and practical training should provide: § Factual knowledge related to hazardous material § Mutual knowledge of operational crisis management procedures

(SOP) and command structures of key players involved in CBRN response (e.g.: hospital disaster management plan)

§ Basic knowledge of specific stress factors in CBRN incidents § Basic knowledge of human behaviour during and after CBRN

incidents § Knowledge about medical (human bio-monitoring) and psycho-

social aftercare for first responders and hospital staff § Communication skills (communication while wearing PPE,

psychological first aid, de-escalation, panic prevention, panic reduction)

§ Stress management techniques § Guidelines for risk and crisis communication § Intercultural competences.

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Ad c) Methodology and didactics:

• Offer training for mixed target groups (responders and PSS staff) for the sake of interoperability.

• Split target groups when appropriate in order to provide specific input for each group.

• Keep frontal presentations to a minimum, provide group work, encourage exchange, offer the opportunity to familiarise with different types of PPE.

• Dedicate at least one full day to practical exercises to train communication skills wearing PPE.

• For the exercises: split the participants into groups - responders/hospital staff, PSS personnel, and observers - in such a way that everyone gets the chance to perform at least once actively in one of the exercises.

• In case of hospital staff: take into account that hospital staff is less used to this type of practical exercise than first responders.

• Chose scenarios that are as realistic as possible, keep artificiality as low as possible.

• Make sure that trainees never have to act in contradiction to relevant SOP during the exercise.

• Whenever possible, use professional actors because they are not familiar with CBRN SOP and, therefore, behave much more like ordinary citizens. Professional actors can give unbiased feedback on what kind of action (behaviour, communication) inspired or helped them to co-operate.

• Invite participants in the exercises (responders and PSS personnel) to switch roles in order to change perspective and increase mutual understanding.

Ad d) Organisational aspects:

• Develop, in advance, information material on the course that is very clear on objectives, target group(s), expected advantages etc. and does not only speak to possible particpants but also explicitly addresses their superiors.

• Design the training in such a way that it allows enough time for the exchange among participants and for regular breaks. Keep in mind that the practical exercises are very demanding and exhausting.

• Try to contact and employ actors from local theatres or amateur theatre groups. They usually enjoy the opportunity to rehearse and strengthen their skills for improvisation. This does not need to be costly.

• Provide a solid briefing to the actors.

• Ask the actors to include scenes with children, migrants and elderly persons.

• Allow enough time to explain the scenarios to the participants and to let them prepare themselves for the exercises, to get into the PPE, organise their team, etc.

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• Provide evaluation sheets for observers that help them to focus their attention on personal interaction and communication skills and to note down their observations. Brief them carefully.

• If possible: film the exercises on video.

• Have a thorough feedback session after each exercise where the actors give their opinion on their feelings/emotions during the action and on what had helped them to be co-operative. Include also the feedback of the observers.

• Have a final round with all participants on the last day of the training where you analyse and discuss specific interactions that were filmed during the exercise.

• Develop evaluation sheets that are more than just “happy sheets” but provide valuable information on things that can and should be changed, on the learners’ satisfaction, and on their confidence in the transferability of the acquired knowledge into their work context.

• Choose carefully the space for the exercises (either indoor or outdoor), provide a decontamination tent, sufficient number of PPE for the responders, stretchers, blankets, water, screens for privacy, paper and other utensils for the PSS personnel behind the decontamination tent.

The exercise ground: Decon tent, PSS area (background on the right), warning tape barrier for observers

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Behind the decon tent: Psycho-social support area

The complete overviews on the recommendations regarding the training of first responders and hospital staff as discussed in Madrid can be consulted in annex 19.

6.7 Visibility: Information brochure / material

One of the first activities of the CO was to have a project logo created that appeared on all documents and publications usually in combination with the logos of all project partners including the EU Commission logo. In a second step, a leaflet on the project was printed (cf. annex 20) together with the cover pages for the two conference folders (see annex 21). As ‘give-aways’ a white cotton carrier bag and blue versatile ‘snoods’ (i.e.seamless tubular scarve) were produced for the participants at the conferences (see picture on the right and below).

Project give-aways Covers of conference folders

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As already described above, the project team members and partners had many opportunities to give presentations on the project in several European Member States (Austria, Germany, France, UK) and outside Europe (Israel, Japan, Russia). In addition, THW reported regularly on its homepage on the progress of the project and several articles were published in English and German (e.g. Crisis Response, Vol. 7, issue 3, 2011, THW Kompakt, March 2012). 7 Evaluation of the technical results and deliverables

Throughout the whole phase of implementing the various tasks and activities, the project partners received a lot of encouragement regarding the project’s key concern, that is to improve the resilience through a training of first responders and hospital staff who have to cope with CBRN incidents. There is a wide consensus among experts not only from academia, but also from civil protection organisations and hospitals, that the question of training for psycho-social skills and competences of responders for CBRN situations represented, until recently, a “blind spot”. This view was also shared by the participants in the pilot courses developed and implemented during the project. Until present time, the focus of almost all training in the area of CBRN response lay firmly on technical aspects (e.g. detection of toxic agents, SOP, properties of PPE, performance in PPE etc.). The project partners are confident that the products and results developed by the project are suited to respond to a real need and can be successfully adapted to specific national situations.

7.1 General lessons learnt

Reflectively on the project’s major milestones and achievements it should be said that without co-funding by the EU Commission it would have been quite unlikely or even impossible that such an endeavour could have been achieved. Nor could such solid results have been reached in just two years. The grant agreement offered the unique opportunitiy to make maximum use of interdisciplinary work based on an international network of experts, to develop new ideas and have them tested and refined.

7.2 Strengths

The strong points of this project include the very efficient and productive composition of the project team. Each partner contributed rich expertise related to the topic, brought in a vast network and was very familiar with the EU context and EU project requirements. They were supported by equally experienced members of the steering group. The project clearly was timely: due to the nuclear disaster in Fukushima, the topic of CBRN had generally gathered strength across Europe and the project approach was widely appreciated as new and promising; evidenced by the strong support shown by the German and Spanish General Directors for Civil Protection in Berlin and Madrid. It may also be interpreted as a good omen for the sustainability of the project’s outcomes.

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Another advantage was the interdisciplinary orientation of the project. Taking into account that a key request of stakeholders was for ‘inter-operability’, it is all the more regrettable that, up to date, very few platforms exist where the different disciplines meet and share their specific expertise on stress management, crisis communication and CBRN response. With the benefit of hindsight it can also be said that the decision to develop and implement the pilot courses in the German language proved to be right. It helped to keep the costs low without precluding multi-national participation.

7.3 Possible challenges and/or improvements to be tackled through further action

Notwithstanding the positive response from experts in the field and the encouraging feedback from participants in the pilot training, it should be understood that the process of taking up the idea, adapting and implementing it elsewhere, will be a long one. In this respect it will be crucial to win over the decision makers within relevant organisations. The project partners feel very much committed to maintain, expand and use their combined networks to this end over the next years. As regards the training courses in their present state, it will be necessary to adapt them to the specific needs and requirements of the interested organisation. The project’s products should be viewed as suggestions and modules that have the flexibility for tailor-made improvements. A particular challenge is the design of the scenarios for the exercises. As described above, it is very important to make scenarios as realistic and as close to the relevant SOP of all responders involved as possible. Due to the limitations of the exercise ground and other external factors, this may not always be totally achievable. In general, much remains to be done to promote awareness regarding psycho-social support for first responders. In many services, existing prejudices will need to be reduced in order for PSS to be widely accepted and used as an efficient tool to increase the resilience of first responders and to avert the harmful longterm effects of stress.

7.4 Recommendations to stakeholders, partners, authorities in charge, National and EU institutions

The issue of sustainability of the project achievements is a great concern for the project partners. The organisers of the final conference in Madrid dedicated one working group to the topic of recommendations for an effective follow-up of the project. The discussions in this goup concentrated mainly on the areas: Training, communication, awareness raising and networking. Finally, the participants agreed on the following key recommendations:

• Develop a communication strategy for sharing the project’s insights and achievements.

• Convince the decision makers: Make sure that the final report and the results of the project are widely disseminated across the EU member States among decision makers (at strategic level) and key authorities (civil protection, public

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health and hospitals), including the National Training Co-ordinators (NTCs) of the EU civil protection training programme.

• Create adequate promotion material for specific target groups (e.g. presentations, leaflets etc.)

• Offer the possibility to download the project report and other published results (e.g. guidelines, curricula etc.) from the partners’ websites.

• Make maximum use of each partners’ network to keep the network alive. Make use of the EU Exchange of Experts programme for this purpose.

• Include the topic in regular national CBRN training for first responders and hospital staff (not only regarding how to handle and work in PPE but also regarding the psychological impact it may have on the person using the PPE).

• Include national experts on CBRN as lecturers when delivering the training.

• Offer training to Managing Directors of hospitals in order to create awareness for the importance of the topic.

• Adapt the disaster management plans of hospitals to include the risk of “CBRN incidents”.

• Keep the Guidelines for Responders that were developed by the project up-dated by including emerging examples of good practice.

• Develop guidelines for risk and crisis communication.

• Initiate research on the current state of availability of psycho-social support for first responders in the EU Member States (including good practice examples and ways for promoting PSS).

8 Follow-up

While the majority of recommendations that were developed can, and will, be tackled by the project partners themselves, such as integrating the results into their own regular work, keeping them updated, and maintaining a high level of European networking in the domain ‘CBRN and PSS’, there are others that would benefit from other stakeholders taking action. In this context, a call for some research in the area of the current practice of PSS in EU Member States and for the development of guidelines for risk and crisis communication would be valuable. The Co-ordinating Beneficiary will start to publish the final report on the THW website immediately after having received the approval of the Commission. In addition, the report with all annexes will be sent to everyone who was involved in all stages of the project. THW and BBK also intend to publish a manual on the training courses in English language that will contain material and documents which could be helpful for anyone who plans to develop a similar training course. This manual will be available in printed form and as a download from each partners’ website. Experience from the THW project on ‘Volunteers in Civil Protection’ that ended in 2006 showed that it can take several years for the results to meet with renewed interest, due to new circumstances (e.g. European Year of Volunteering). The project

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partners will be prepared to contribute with long term commitment to the further development and dissemination of this specific topic “Psycho-social Support for Civil Protection Forces Coping with CBRN”. 9 List of Annexes

Annex 1: Overview of conferences where project partners participated in Annex 2: Publications on the project Annex 3: Survey on Literature (Impact/Arq) Annex 4: Programme of the international conference in Berlin Annex 5: Participants’ feedback on the conference in Berlin Annex 6: Findings of the expert interviews (Impact/Arq) Annex 7: Model of Stress response (CoP) Annex 8: Survey of hospital preparedness (CoP) Annex 9: Literature review (CoP) Annex 10: Adapted Emergency Plan for Hospital (CoP) Annex 11: Curriculum for training course for First Responders (THW) Annex 12: Model certificate for participants in the training Annex 13: Evaluation of the training for first responders (THW) Annex 14: Survey among hospital staff regarding the training (CoP) Annex 15: Curriculum of training for hospital staff (CoP) Annex 16: Evaluation of the training for hospital staff (CoP) Annex 17: Agenda of Madrid Conference Annex 18: Evaluation of Madrid Conference Annex 19: Recommendations of Madrid Conference Annex 20: Project leaflet Annex 21: Covers of conference folders

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10 List of Abbreviations

AB Associated Beneficiary

AKNZ Academy for Crisis Management, Disaster Planning and Civil Protection

BBK Bundesamt für Bevölkerungsschutz und Katastrophenhilfe

CBRN Chemical, Biological, Radiological, Nuclear

CO Co-ordinating Beneficiary

CoP Centre of Psychotraumatology

EEA European Economic Area

EU European Union

HazMat Hazardouous Material

MS Member State

NTC National Training Co-ordinator

PPE Personal Protective Equipment

PSS Psycho-social Support

SOP Standard Operating Procedures

THW Technisches Hilfswerk