We developed a concept of full-scale disaster simulation exercises and tested it in several pilot hospital pharmacies. The two different scenarios used were comparable in terms of the similar numbers of steps occurring as the scenarios developed and the level of impact they would have on hospital pharmacies. The hospital pharmacy teams greatly appreciated all the full-scale simulation exercises, and all the chief pharmacists responded that this type of training was very useful for them, their staff, and their institution. These sentiments are also found in the literature, which reports that teams of healthcare professionals generally receive simulations well, describing them as a useful way to improve their practice and knowledge [10, 34]. In addition, these full-scale simulations highlighted the importance of pharmacy in disaster response through two realistic scenarios validated by physicians. It is also worth noting that the importance of pharmacies and pharmacy teams during disasters were especially confirmed by the current COVID-19 pandemic [13,13,14,15,16,17,19].
During the second full-scale simulation, staff actions and responses improved. The percentage of required actions performed increased significantly between exercises 1 and 2, and the quality of those actions did as well. Research attempting to prepare pharmacists for humanitarian missions had actually highlighted that simulation was the most effective training because it authentically reproduced their future working environment and readied them for specific situations [39]. Furthermore, the literature also reports that simulation improved teamwork behaviors [40] and enabled a better transfer of acquired competencies to practice [36].
One significant result of the first simulation exercise was that hospital pharmacy chiefs initiated the development of disaster plans (SOPs) if their unit did not have one. The first full-scale simulations raised awareness of the importance of preparedness. Furthermore, they highlighted key points and gaps in preparedness by making disaster situations seem like realistic possibilities, and they showed hospital pharmacy chiefs the potential benefits of being able to implement SOPs. These issues were also underlined in a table-top exercise for hospital pharmacy staff in Australia [41]. Only one of our participating pharmacies already had SOPs for a disaster before the first simulation, but their percentage of required actions taken, and their quality were nevertheless rather similar to those of the other hospital pharmacies. The only significant difference was the time required to move into disaster management mode (time required to gather a disaster management team): this pharmacy was indeed faster. It seems that having a SOP improved reaction times (mainly the time needed to switch to disaster management mode) but without necessarily making staff actions and responses much more efficient in the absence of training. The other pharmacies managed the switch to a disaster management mode much faster during the second full-scale simulation (after having set up SOPs). This underlined that although having SOPs is a precious starting point, it is not enough on its own. More importantly, it is necessary to test and train it [42].
Communication and disaster management were the two hospital pharmacy activities that showed the greatest improvements between the two exercises, but they nevertheless continued to be the two activities with the lowest scores. This is probably because these skills are far more specific to crises than to pharmacy. Other publications have also identified these two activities as weaknesses [43,44,45]. The classic pharmacy work, even during a disaster, of logistics and clinical pharmacy scored higher than communication or disaster management, probably because those activities are based on staff’s day-to-day knowledge and procedures. One important issue highlighted by the exercise assessors was the separation of flows of disaster-related requests to the pharmacy from routine flows of requests—this required significant improvements. Skills in communication and disaster management were two key points that should certainly be worked on. One option to improve communication would be to train staff in structured communication (mainly restating requests for action to demonstrate comprehension) and integrate it into their day-to-day work. Table-top exercises could be a cheaper means of working on these specific issues [46].
Communication is an essential element of disaster management [47, 48] but it is very often cited as a difficult one to get right [48,49,50,51]. Keeping communication effective during a disaster is even more challenging than normal, but it helps enormously in providing an efficient response. Communication gives the direction of information flow and clearly informs staff about their roles in the disaster. Briefings must channel information upwards to inform decision-makers and downwards to ensure implementation [48]. There are several alternative means of communication to facilitate operations in disaster situations, such as the Zello app (a walkie-talkie smartphone application) [47], fixed-line telephones, email, websites, radio announcements, newsletters, or still others [46]. Failure to communicate properly can have significant negative consequences [46], such as anxiety and panic, among staff due to their lack of understanding of the situation [52].
Another important element is the leadership structure. To be effective in a disaster, chief hospital pharmacists or other leaders should manage and communicate desired outcomes more than the methods or processes used to attain them [48]. A clear, hierarchical, disaster management structure improves communication [46]. In fact, the prehospital settings of major disaster incidents should be coordinated and managed by a specific and appropriate structure in situ [50, 53]. In the hospital setting, the chief pharmacist or his deputy, as that leader, must quickly identify the problem and its healthcare implications and then make adequate decisions, implement management tools, and communicate effectively. Following up on and monitoring the missions and tasks that staff have carried out or still have to carry out within a specific timeframe is essential [8, 53]. The weaknesses in disaster management observed in the present study could have been caused by a lack of awareness and knowledge among hospital pharmacy staff: they may have thought that disaster management was an issue reserved for prehospital disaster locations or emergency departments. The chief pharmacist or his replacement must evaluate and report critical information about the disaster incident. Figure 2 illustrates the key questions that they should ask themselves in response to a disaster in order to ensure appropriate disaster management [48].
Necessary management outputs include defining situational missions and objectives, distributing action plans, giving briefings and issuing situation reports, and optimizing resource use. The disaster management hierarchy should operate vertically and deliver roles and responsibilities[48]. As the literature describes, planning regular briefings to transmit essential information to staff (or team leaders) as a disaster unfolds is highly recommended, as is getting feedback from the field. This information return ensures that the pharmacy chief maintains overall situational awareness. Trained or experienced disaster management team members and regularly updated information and situational dashboards can greatly support disaster leadership [8]. These leadership structures should also be applied in hospital and pharmacy environments, as was shown by the current COVID-19 pandemic [20, 54, 55]. In the present study, SOPs called for and resulted in the use of dashboards in the second simulation, but staff must still become more familiar with using them.
Outside of this study’s framework, one hospital pharmacy performed a third full-scale simulation to determine whether the improvements observed in the second exercise were still valid six months later (data not shown). Indeed, despite the simulation was leaded by a different pharmacist, this final simulation showed that the improvements had been maintained. In addition, the third scenario used focused more on institutional risks (flood, power failure, ventilation failure, etc.) because hospitals must also take into account the types of situations that can happen on their own sites and have immediate consequences on their patients [52, 56, 57]. Therefore, these risks must be considered and prepared for by integrating them into disaster plans, and staff must be trained on how to deal with them [52, 56].
Altogether, these results would suggest to the others healthcare professionals involved in hospital disaster management to include the pharmacy department in their disaster plan and to develop a partnership with it. Indeed, this study has highlighted the importance that such a department has in logistics and clinical drug management during disaster. In this context and in view of the development of this aspect within the pharmacy and to facilitate links with the other hospital departments, it would be useful to identify a respondent for this thematic in each pharmacy.
However, this study has some limitations. First, the number of participating pharmacies was small. It would be useful to expand the number of participants to see whether our results remain similar across the country. Secondly, hospitals C and D experienced the first wave of the COVID-19 pandemic between their first and second full-scale simulations. This may have increased the pharmacy’s awareness and preparedness independently of the drills performed within the framework of our study. Thirdly, although the profiles of the staff at work during the first and second scenarios were quite similar across all the pharmacies, neither their composition nor demographics were recorded, and their initial training levels were not precisely assessed and compared between the two exercises. However, the study’s aim was to evaluate pharmacy preparedness as a whole, not that of the staff themselves. Finally, the evaluation of staff actions and responses was done by human assessors. Evaluations were structured to limit subjectivity, but evaluations can vary and are not always fully reproducible [27].