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In response to the terrorist attacks in America, Spain and London, the

Government compiled specific guidance for health-care organisations within the United Kingdom (see section 1.4.7).

A key component of emergency preparedness, as recognised in The Emergency Planning Guidance (DH, 2005) and Contest (HM Government, 2009) is risk and threat. These terms are often used interchangeably, however this section offers definitions and describes how they interrelate and impact on preparedness. Risk and threat impacts on practitioners perceived importance of emergency preparedness, in addition to

organisational preparedness strategy. Examination of key definitions, the implications of these concepts and how they impact on healthcare workers experience are now examined.

Risk, threat & vulnerability

Understanding the concept of ‘risk’, ‘threat’ and ‘vulnerability’ in the context of emergency planning is critical because these concepts potentially impact on resource allocation such as finance, time and staffing levels. In addition, staff perceptions may be formed through their own individual risk and threat assessment, although the literature rarely refers to developing such understanding and we have little insight into the individual level of

perception. This section considers the various definitions of risk, threat and vulnerability, reviews the importance of the concept of risk in emergency planning, and will evaluate how clinical personnel view risk and the current threat in this context.

The term ‘risk’ is poorly defined in academic literature and is often used interchangeably with terms such as hazard, threat and danger (Turner, 2001). An understanding of the term ‘risk’ must occur, to allow

comprehension of related concepts such as risk analysis, threat levels and related operational consequences of the associated risk. Although within this context, risk to the individual is rarely considered, rather the focus is on community or population risk.

Risk can be defined as “the possibility of something bad happening; a

situation that could be dangerous or have a bad result” (Oxford English

event or incident. However, it does not differentiate between controllable risk (such as the risk of a tree falling on a house) and uncontrollable risk (unnatural, human-made uncertainties such as terrorism). Emergency preparedness, within health-care, typically focuses on uncontrollable risk (Beck, 2002), which is more challenging to plan for due to its unpredictable components. There is a perception at Government level that the global threat of an overwhelming incident remains high, especially in areas with a high footfall, for example sporting events and other mass gatherings. However, despite the heightened state of preparedness and planning, the potential risk may be immeasurable until an actual event happens. Few studies have considered the way individual practitioners manage or

experience perceptions of unpredictable or unmanageable risk (Arbon et al, 2011. Balicer et al, 2010. Fischer et al, 2010).

A subject specific definition, used within emergency preparedness guidance, is that risk is “the product of the likelihood of harmful consequences arising

from particular identified hazards or threats and the potential impact of these upon people, services and the overall environment. It is a measure of the potential consequences of a contingency against the likelihood of it occurring.”

(DH, 2005). This definition suggests a continuum of risk, with the concept of likelihood, so the professional can view an area as low, medium and high risk and alter their work dependant on this.

Whilst this perspective of risk is determined at Government level, individual risk perception appears subjective, possibly influenced by personal

experience,personal demographics and their professional training and role. This concept is used within risk assessment documentation and is a

recognised approach in the Health & Safety environment. It is unclear whether paramedics view this concept as a continuum and what impact this viewpoint may have on practice. This personal perception may be important when considering willingness to work and willingness to engage with this area, in addition to perceiving these formal grading scales as credible information. Few studies have addressed the need for this understanding (Connor, 2014. Damery et al, 2009. Basta et al, 2009).

These definitions view risk and threat from a strategic planning viewpoint whereas individual health-care workers may have different opinions on the risks and threat impact on their work and their lives. These risks include impact on their family, their health, their home and infrastructure (personal factors rather then generic regional issues). It is essential to determine whether they (the healthcare workers) perceive the threat and risk to be real, and to determine what it is composed of, as this is a probable factor as to their willingness to engage with the emergency preparedness aspect of their role (Connor, 2014. Frumkin, 2011. Ehrenstein et al, 2006), and to use components of their experience to inform the dimensions of practice.

Within different professional fields, the term ‘risk’ has different meaning and differing impacts, so clarity of context must be determined (Gin et al, 2014. Beck, 2006. Beck, 2002). For example, within the health-care field the risk may be to human life (the general public and health-care workers), whereas

in banking there may be financial impact and in the area of Government the risk could be to business continuity or to infrastructure (buildings and roads).

The term ‘threat’ is often used interchangeably with risk despite having different meanings in the context of emergency preparedness. Threat can be defined as:- “the intent and capacity to cause loss of life or create adverse

consequences to human welfare (including property and the supply of

essential services and commodities), the environment or security” (DH, 2005).

Willis (2007) suggests that ‘threat’ is only present when both ‘intent’ and ‘capability’ are combined. Threat assessment is carried out on an ‘informal’ and routine basis within the ambulance service (for example, what is the threat of a solo responder attending a mental-health patient), as well as the more structured threat assessment (risk-benefit of purchasing equipment). Threat assessment is also a key component of terrorism planning. Assessing threat fits in with the risk assessment process, where future actions are identified. However, rarely does the threat narrative acknowledge the individual practitioner and how a professional conceptualises and manages the threat to themselves in relation to emergency preparedness.

The term ‘vulnerability’ is often used alongside ‘risk’ and ‘threat’ and can be defined as “the manifestation of the inherent state of the system (eg) physical,

technical, organisational, cultural) that can result in damage if attacked by an adversary” (Haimes, 2004; p699). In relation to emergency preparedness,

vulnerable during the process. For instance, after the terrorist bombings in London, it was noted that interagency communication was vulnerable (Lady Justice H, 2011). Vulnerability could be thought of in the context of how individual paramedics respond. However, vulnerability is rarely conceived in this way. This susceptible area requires further exploration, due to its known vulnerability, in future planning.

These terms are rarely differentiated due to their theoretical connection to the ‘risk’ concept. These links are highlighted by a model, proposed by Willis (2007), which demonstrates the links between threat, vulnerability and consequence resulting in the concept of risk.

Figure 3. Risk as a concept (Willis, 2007).

Whilst this simple conceptual model visually displays the relationship between these areas, a limitation is the lack of context and emphasis on the categories. For example, if the threat is perceived as greater, it can not be

determined, using this model, if an organisation who has ensured

preparedness is more vulnerable. Two key things in relation to context are planning and preparation, but this model is at a high conceptual level and does not attempt to account for the type of complexity relevant to

emergency preparedness. This model also just displays a concept with no consideration of the individual within this model and how each of these areas impacts on these responders. In reality, they may perceive threat as greater importance than vulnerability, if their training enables them to feel confident and it is unclear on how this would then impact on their risk perception.

1.5.5 Summary

This review shows emergency preparedness in a political context describing some of the key strategic, political and contextual issues. While much of the literature focuses on organisational and policy levels, with some early theorisation, a striking absence is the lack of focus on the individual worker in the context of definitions, policy and guidance. Limited evidence exists on how these individuals view or use strategic level guidance to impact on their personal professional role but overall it provides a limited insight into their experiences and perceptions (Baack & Alfred, 2013. Boyd et al, 2012.Ali, 2008. Carr et al, 2006). This may reflect the status of emergency

preparedness, which is still in its infancy. The current social context has been explored along with the review of the terms ‘risk’ and ‘threat’ and the impact of these on an organisation, rather than on the individual responder where there has been less focus. How an individual responds in an

emergency may be the key to successful operationalization of policy, yet we currently know little about this.

The next section considers the paramedic and their experience of emergency preparedness.

1.6 Experiences of healthcare professionals and emergency