Discussion

Because disasters are events that occur suddenly and violently, it is imperative to prepare hospital staff to respond. ^{Reference Ingrassia, Pigozzi and Bono3} As proxies for actual disasters, exercises can offer hospital staff effective training and an opportunity to practice. ^{Reference Hsu, Jenckes and Catlett11–Reference Wallace, Gillett and Wright13} However, designing and conducting such full-scale MCI exercises require significant time and resources. ^{Reference Gillett, Peckler and Sinert1,Reference Olsén, Hallberg and Mattsson14} Additionally, the number of EPs is usually limited in the exercise. To gain the most out of these exercises, 1 possibility is to create a greater learning effect from the exercises for participants other than EPs. ^{Reference Olsén, Hallberg and Mattsson14} As the first quantitative research study regarding the benefits of participating as an LAP in a disaster exercise, this study indicated that acting as an LAP is effective for improving staff confidence and knowledge. Therefore, being an LAP in the exercise could provide an additional training method for hospital staff in the future. The lack of staff involvement in hospital disaster preparedness is a worldwide problem. ^{Reference Bartley, Stella and Walsh15} Our results indicated that being an LAP may solve this problem. Moreover, disasters do not occur frequently, and repeated training is necessary to maintain hospital staffs’ ability to respond to disasters. ^{Reference Summerhill, Mathew and Stipho16} However, the repeated experience of being an EP may increase staff workload. Based on these study results, hospital staff can also benefit from being LAPs to increase the effectiveness of the training exercises.

The management of an MCI requires confidence and knowledge. However, previous research and our results indicated that hospital staff lack confidence in MCI management, ^{Reference Madge, Kersey and Murray17} which may be due to a lack of training or MCI exercises. ^{Reference Madge, Kersey and Murray17} Previous studies have indicated that the confidence of disaster exercise players increased after exercise participation. ^{Reference Summerhill, Mathew and Stipho16,Reference Sena, Forde and Yu18,Reference Skryabina, Reedy and Amlȏt19} Our results revealed that the level of confidence increased after the MCI exercise only for the EP and LAP groups. This result indicated that exercise participation, regardless of whether it is as a player or mock patient, can increase confidence. LAPs can become more confident by analyzing disaster management through, for example, being triaged and treated as mock patients ^{Reference van Soeren, Devlin-Cop and Macmillan20}

In addition to confidence, hospital staff need adequate knowledge of disaster medicine and familiarity with the EOP to manage an MCI successfully. Our pre-exercise survey revealed a low score for DMK and EOPF for all 3 groups, which may indicate insufficient staff training, supporting the findings of another study. ^{Reference Madge, Kersey and Murray17} Some studies have also pointed out the poor knowledge levels of hospital disaster plans and response protocols among hospital staff. ^{Reference Bartley, Stella and Walsh15,Reference Skryabina, Reedy and Amlȏt19} However, disaster exercises and pre-exercise preparation as educational opportunities can improve preparedness. ^{Reference Bartley, Stella and Walsh15,Reference Skryabina, Reedy and Amlȏt19} Our results also indicated that the LAPs’ DMK improved significantly after the MCI exercise.

The principles of adult learning may explain this finding. The first assumption of adult learning is that participants need to know why they are learning. ^{Reference Winskog, Tonkin and Byard21} In an MCI exercise, LAPs need to present clinical symptoms and signs to EPs. More importantly, LAPs need to understand the meaning of their role and why it is important in MCI exercises. ^{Reference Bryan, Kreuter and Brownson22} This need gives LAPs a reason for learning. The authentic nature of the MCI simulation differs from the passive reception of knowledge through a lecture, and the role of an LAP offers nurses a motivation to acquire knowledge actively. The MCI exercise thus provided an opportunity for these learners to reflect upon the material being learned and practice their knowledge in the exercise. ^{Reference Kose, Unver and Tastan7,Reference van Soeren, Devlin-Cop and Macmillan20,Reference Winskog, Tonkin and Byard21} This may also suggest the importance of the motivation created by participation in the exercise.

Olsén et al. compared the learning effects of EPs and observers and found that both players and observers could learn from exercises. ^{Reference Olsén, Hallberg and Mattsson14} In that study, the authors pointed out that EPs learn through experience and observers learn from an overview perspective. ^{Reference Olsén, Hallberg and Mattsson14} Like exercise observers, LAPs can observe what EPs are doing during the exercise. Through observation, LAPs can learn from finding errors in aspects of the care that they receive and the disaster response of EPs. ^{Reference Gist, Daniel and Grock4} Moreover, they can gain new insights when relating the performance of EPs to how they would have acted. ^{Reference Olsén, Hallberg and Mattsson14} However, observers may perceive a decrease in the realism of the exercise due to a lack of participation. ^{Reference Harder, Ross and Paul23} In contrast to observers, LAPs can observe EPs while participating in an exercise. Therefore, LAPs may learn from the aspects of being both a player and an observer.

To participate in the disaster exercise, EPs need to review the EOP before the exercise. On the other hand, the nature of using LAPs in the exercise to test the disaster plan may motivate LAPs to review the EOP. Although the EOPF scores increased in all 3 groups in our results, the pre- and post-exercise scores of the NP group were lower than the scores of the other 2 groups. It can be assumed that MCI exercises can promote EOP reading and increase familiarity with the EOP for both participants and nonparticipants, but the effectiveness can be increased while participating in the exercise, regardless of the role.

Our pre-exercise survey was conducted after the role assignment. The assignment may provide motivation for learning to LAPs and NPs, because they need to know about disaster medicine and EOP. Due to the need to participate in the exercise, LAPs and NPs might feel less confident and try to read EOP and learn some disaster medicine before the exercise. This may explain the pre-exercise survey results. In addition, the role assignment and exercise participation may also cause LAPs and NPs to learn from the exercise. This may lead to the difference after the exercise.

In addition to the exercise itself, pre-exercise preparation programs are also important for LAPs to learn. In some cases, the programs include lectures or briefings for all exercise participants, including EPs and LAPs. The pre-exercise activity may contribute to learning by addressing the importance and relevance of the issues that learners must address during the exercise. ^{Reference Skryabina, Reedy and Amlȏt19} In addition, LAPs are trained before the exercise by experts in emergency and disaster medicine to portray disaster patients. ^{Reference Ingrassia, Pigozzi and Bono3} This pre-exercise training for LAPs may become another interactive format with specific educational goals. ^{Reference Mavis, Ogle and Lovell10} Furthermore, a postexercise debriefing offers participants an opportunity to discuss what happened during the exercise and identify what lessons could be learnt from it. By participating in the debriefing, LAPs may reflect on what happened during the exercise, which may transform their experience into learning. ^{Reference Olsén, Hallberg and Mattsson14} As LAPs in the current study participated in the pre-exercise lecture and post-exercise debriefing, this may explain the significant improvement in their knowledge and EOPF after the MCI exercise.