Critical deficits in CBRNE preparedness: A nationwide assessment of Jordanian healthcare providers’ knowledge,skills,and training gaps

Abstract

Objective:

To evaluate the current level of chemical, biological, radiological, nuclear, and explosive preparedness among healthcare professionals in Jordanian hospitals. This assessment concentrated on evaluating their understanding of chemical, biological, radiological, nuclear, and explosive policies, self-reported proficiency in using personal protective equipment, the extent of their training, and their perceived preparedness in various chemical, biological, radiological, nuclear, and explosive areas.

Methods:

A cross-sectional survey of 298 healthcare providers from 5 Jordanian hospitals evaluated chemical, biological, radiological, nuclear, and explosive policy awareness, personal protective equipment competency, and training levels. Hospital preparedness was assessed via roundtable discussions with 30 representatives (emergency physicians, infection control specialists, etc.) using the validated Canadian Center for Emergency Preparedness survey.

Results:

The findings showed that 59.1% of healthcare providers reported no hospital chemical, biological, radiological, nuclear, and explosive policy, with only 21.1% having access to it. Competency decreased with personal protective equipment complexity, and most lacked decontamination training (68.5%) and chemical, biological, radiological, nuclear, and explosive drills (76.8%). Biological preparedness was rated highest (59%), while chemical and radiological preparedness were inadequate (30% and 21%). Trained healthcare providers had significantly higher preparedness levels (p < 0.001).

Conclusion:

Critical gaps in policy awareness, personal protective equipment skills, and multidimensional preparedness highlight systemic vulnerabilities. Mandatory training, policy standardization, and resource allocation are urgently needed to strengthen Jordan’s chemical, biological, radiological, nuclear, and explosive response capacity.

Keywords

CBRNE preparedness healthcare providers PPE competency

Introduction

Environmental hazards resulting from chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents can overwhelm healthcare systems and threaten public health. Adequate preparedness is crucial for effective response, yet many healthcare providers (HCPs) lack sufficient knowledge, skills, and training in this area.¹ Globally, environmental hazards present an increasing threat to public health, with CBRNE incidents being a particularly complex type of human-caused disaster.^1–3 The consequences can include significant morbidity and mortality, as well as substantial disruption to societal functioning. Effective disaster management requires comprehensive preparedness, including robust hospital infrastructure, resource availability, and well-trained healthcare personnel.^4,5

Despite the serious threats posed by CBRNE incidents, the preparedness levels among HCPs and hospitals in Jordan remain poorly understood. A substantial percentage of HCPs lack awareness of CBRNE policies and protocols, leading to inadequate emergency responses.^3,6 Significant variability in hospital and HCP preparedness, driven by gaps in knowledge, skills, resource limitations, and weak policies, threatens public health and hampers effective crisis management. Without proper preparedness, delayed or inappropriate responses could increase morbidity and mortality during CBRNE events.⁶ The role of HCPs extends beyond immediate response; it encompasses comprehensive planning, training, and collaboration with various sectors, including public health agencies, emergency services, and community organizations.⁷ Incident-specific training combined with regular risk assessments can enhance preparedness to effectively manage CBRNE threats. Effective communication and coordination are critical, as initial decision-making during these incidents typically falls to local clinical leaders who must navigate unique challenges.⁸

The presence of environmental hazards necessitates prompt and effective management strategies. For instance, in cases of radiation exposure, immediate decontamination is critical to mitigating health risks such as radiation sickness.⁹ Chemical exposures require the identification of threats and assessment of contamination levels to develop appropriate response protocols, including the use of personal protective equipment (PPE) for first responders. HCPs’ essential role in preparedness and response includes developing incident-specific training and comprehensive risk assessments to enhance community resilience against CBRNE threats.¹⁰ PPE competence among HCPs is tiered, ranging from Level A, offering the highest protection for skin, eyes, and airway in situations with identified or potential biological, liquid, or vapor chemical hazards, to Level D, the lowest level which is to provide minimum safeguards. Levels B and C provide varying degrees of respiratory and skin protection in scenarios where the hazards are known, or when responding to radiological incidents, respectively, with Level C being that with less protection.

By addressing the gaps in knowledge and training, this could enhance the capacity of HCPs to respond effectively to environmental hazards.¹¹ This study addresses a crucial gap in understanding CBRNE preparedness in Jordan, a region with potential for both deliberate and accidental CBRNE incidents. CBRNE events pose a significant threat to public health and safety, requiring a prepared healthcare workforce. The need to assess CBRNE preparedness in Jordanian hospitals is evidenced by the country’s proximity to regional conflicts and the lack of awareness of policies, training, and confidence among healthcare professionals, as demonstrated by our study’s findings. This provides a strong, evidence-based rationale for the study’s purpose. This study addresses a critical need to assess and improve CBRNE preparedness in Jordanian hospitals. Thus, this study addresses the following research questions:

What is the level of knowledge among Jordanian HCPs regarding CBRNE policies and procedures in their respective hospitals?

How competent do Jordanian HCPs perceive themselves to be in utilizing different levels of PPE related to CBRNE events?

What is the extent of CBRNE-related training received by Jordanian HCPs, and how does training impact their perceived preparedness?

What are the perceived levels of preparedness across different CBRNE dimensions in Jordanian hospitals?

Is there a difference in CBRNE preparedness levels between the trained group (HCP who had participated in any kind of formal CBRNE-specific major incident training, regardless of when it occurred) and the untrained group (HCP who reported that they had never received any CBRNE-specific training)?

Methods

Design

A cross-sectional survey was conducted in this study, encompassing five Jordanian hospitals located in the middle, north, and south regions of Jordan. Our purposeful selection of hospitals was a strategic choice to ensure a representative mix of Jordan’s diverse healthcare landscape. We intentionally included hospitals from different regions and sectors (governmental, military, and private) to provide a more realistic and comprehensive view of preparedness across the country.

Sample and setting

The study collected data from two groups across five hospitals. The first group consisted of 298 HCPs. The inclusion criteria were nurses or physicians, with over a year of experience from the emergency department (ED), intensive care unit (ICU), operation room (OR), and burn unit (BU). These units were chosen because they are critical for managing CBRNE casualties. Excluding HCPs with less than a year of experience or those on leave ensured participants were well-oriented with their hospital’s facilities. Furthermore, we intentionally have focused on nurses and physicians as the primary responders to a CBRNE incident, which allowed for a detailed analysis of the core clinical workforce. This approach provides a strong foundation for future research that can include a wider range of healthcare roles.

The sample size for Group 2 was 30 and was selected using a purposive sampling approach. The inclusion of six key representatives from each of the five hospitals was strategically chosen to ensure the assessment was based on the input of key personnel with direct knowledge of the hospital’s policies and resources. This targeted method, which included emergency physicians, quality personnel, and safety officers, allowed the group to collaboratively complete the Canadian Center for Emergency Preparedness (CEEP) survey in roundtable discussions, gathering relevant institutional data.⁴

Study measures

The study employed three measures:

To understand the context of CBRNE preparedness, the study measured demographic and clinical characteristics of the 298 participating HCPs. Data collected included profession (nurses/physicians), gender, age, educational level, primary unit of work (ED, ICU, OR, and BU), and years of experience. Measuring these characteristics allowed for the evaluation of preparedness levels across diverse roles, experience levels, and hospital settings, providing a foundation for understanding variations in CBRNE-related disaster preparedness within the Jordanian healthcare system.

The CBRNE HCP Assessment Questionnaire used in this study comprises 27 items on knowledge and 8 items on skills, designed to evaluate HCPs’ CBRNE preparedness. Test-retest validation demonstrated high reliability (86%–98% response consistency), with scores ⩾70% indicating adequate knowledge based on expert consensus.¹²

The CEEP for Hospital Preparedness Survey: The CEEP survey was used to evaluate hospital preparedness across biological, chemical, and radiological/nuclear dimensions. The instrument demonstrated high reliability (Cronbach’s α = 0.94) and was validated through expert review.¹¹

Data collection procedure

The study was conducted between January and June 2024. Data collection involved two main procedures:

HCP data collection: The primary outcome of our study was to assess the level of CBRNE preparedness among healthcare professionals. The key variables measured were CBRNE knowledge, skills, training, and policy awareness. The selection of 298 HCPs for this study using a questionnaire delivered via online survey platforms (Google Forms and email) was guided by a power analysis to ensure sufficient statistical power to detect meaningful differences or associations. We treated the healthcare professionals as a single population to determine the minimum sample size needed for a cross-sectional, descriptive study. This approach allowed us to draw conclusions about the overall preparedness of the population from which the sample was drawn.

The sample size was calculated using a standard formula for estimating a population proportion with a specified level of confidence and margin of error. Using a 95% confidence level, a margin of error of 5%, and a population proportion of 50% (as a conservative estimate), the minimum required sample size was determined. Additionally, considering the diverse roles (nurses and physicians) and units (ED, ICU, OR, and BU) included, this sample size offers adequate representation to capture variability across different departments and shifts. This robust sample size enhances the study’s validity, ensuring that the findings are statistically significant and reflective of the broader HCP population within the selected hospitals.

A pilot test of the questionnaire was conducted on 15 HCPs (about 5% of the total sample) to assess clarity, wording, and time required for completion before full data collection.

2. Hospital data collection: For Group 2, the CEEP survey was collaboratively completed by a group of 30 senior representatives. From each of the five hospitals, six administrators and senior-level staff, including emergency physicians, quality personnel, and safety officers, participated in a face-to-face roundtable discussion. The goal was to reach a unified and authoritative consensus on each question, which was then recorded as the hospital’s official response. This approach ensured that the assessment reflected the collective expertise of key stakeholders with direct knowledge of their institution’s CBRNE policies and procedures.

Statistical analysis plan

All data were analyzed using IBM SPSS Statistics, Version 29.¹³ The analysis plan included both descriptive and inferential statistics to address the study’s aims. We used descriptive statistics to summarize the demographic data of the healthcare professionals and the CBRNE preparedness ratings. Means and standard deviations were used for continuous variables (e.g., age), while frequencies and percentages were used for categorical variables (e.g., profession, gender, policy awareness). To test for significant differences in preparedness levels between different groups, we used independent samples t-tests to compare preparedness scores between two groups (e.g., male versus female, trained versus untrained). Additionally, we used the Chi-square test of independence to examine the association between categorical variables (e.g., training status and awareness of decontamination procedures). The statistical significance for all tests was set at a p-value < 0.05.

Ethical considerations

The study prioritized ethical research practices by securing the requisite ethical approvals from the affiliated hospitals (IRB approval number (RMS, TF/1/IRB/2694)). Written consent was obtained from participants in Group 1 (HCP = 298). Participation in the roundtable discussion (Group 2, N = 30) was considered as consent to participate. The researchers maintained exclusive access to raw data, and only aggregated data were reported to ensure confidentiality. These measures were implemented through numerical coding. The research design was governed by the Declaration of Helsinki principles, which minimized potential risks to participants. The objective of the investigation was to mitigate any potential distress or injury.

Results

Participants’ sociodemographic factors

A total of 312 responses were examined carefully before analysis. Incomplete and contradictory responses were discarded (n = 14). Table 1 presents the characteristics of the 298 participants in this study. The sample was nearly balanced between males and females, with a mean age in the early thirties. Most participants were nurses, with the rest being physicians. They were drawn from hospitals in both central and peripheral regions of the country. The participants were mostly from the ICU and ED, with smaller groups from the OR and BU. Most held a bachelor’s degree, and professional experience was fairly distributed across three groups.

Table 1.

Participants’ characteristics (N = 298).

Characteristics	N	%
Age (mean = 32.9, SD = 5.4)
Sex
Females	147	49.3
Males	151	50.7
Profession
Nurse	207	69.5
Physician	91	30.5
Hospital
KHMC	92	31
BH	60	20
JoH	23	8
KAUH	72	24
PHH	51	17
Current unit
ED	98	32.9
ICU	136	45.6
OR	40	13.4
BU	24	8.1
Educational level
Bachelor	249	83.6
Master	41	13.8
Doctorate	8	2.7
Experience
<6	113	37.9
6–10	92	30.9
>10	93	31.2

Table 2 summarizes the HCPs’ knowledge regarding CBRNE policy within their respective hospitals (N = 298). Most healthcare professionals reported that their hospitals did not have a defined CBRNE policy, and even among those who believed a policy existed, very few had actual access to the key documents. This highlights a significant gap between policy existence and staff awareness and access.

Table 2.

Knowledge questions regarding CBRNE policy (N = 298).

Questions	n	%
Does your hospital have a major CBRNE policy?
Yes	122	40.9
No	176	59.1
Having access to the major CBRNE policy?
Yes	60	21.1
No	238	79.9

Table 3 summarizes the self-reported skills of HCPs related to CBRNE disasters (N = 298). While all participants demonstrated competence in using PPE Level D, competence levels decreased significantly for more advanced PPE levels. Knowledge of decontamination equipment was also limited. A large percentage (69.1%) of participants had never received PPE Level B training, while similarly a large percentage has never received training in the decontamination set up, were never given any CBRNE incident training.

Table 3.

Evaluated skills related to CBRNE disasters (N = 298).

Questions	n	%
Do you have demonstrated competence in using
PPE Level D?	298	100
PPE Level C?	111	37.2
PPE Level B?	44	14.8
PPE Level A?	5	1.7
Do you know how to decontaminate equipment utilized in the decontamination room during a CBRNE incident?	6	20.5
When did you last receive PPE training in Level B?
Never	206	69.1
>5 years	19	6.4
1–5 years	37	12.4
<1 year	36	12.1
When did you last receive training in the setup of decontamination tent or in the running of the decontamination unit including utilizing all relevant equipment?
Never	204	68.5
>5 years	11	3.7
1–5 years	29	9.7
<1 year	54	18.1
When did you last receive any CBRNE-specific major incident training?
Never	229	76.8
>5 years	8	2.7
1–5 years	31	10.4
<1 year	30	10.1
Have you received any type of Blast injury training?	96	31.9
When did you last receive this Blast injury training?
Never	203	68.1
>5 years	11	3.7
1–5 years	29	9.7
<1 year	55	18.5
Have you participated in a CBRNE-specific major simulation exercise?	40	13.4

While overall biological preparedness was rated the highest, chemical and radiological preparedness received lower scores. Most hospitals rated their preparedness as poor or average, with only a small number giving an excellent rating in the chemical and radiological categories. This suggests a significant variation in preparedness levels across different dimensions (Table 4).

Table 4.

Preparedness levels across CBRNE dimensions in Jordanian Hospitals (N = 30).

Dimension	Number of questions	Mean	%	Preparedness status
Dimension	Number of questions	Mean	%	Poor, n (%)	Average, n (%)	Good, n (%)	Excellent, n (%)
Biological	86	51.2	59%	12 (40.0)	6 (20.0)	6 (20.0)	6 (20.0)
Chemical	42	12.8	30%	12 (40.0)	6 (20.0)	6 (20.0)	6 (20.0)
Radiological and nuclear	39	8.2	21%	10 (33.0)	8 (26.7)	9 (30.0)	3 (10.0)

Comparing trained and untrained HCPs, trained individuals demonstrated significantly higher levels of overall preparedness and greater confidence in performing decontamination procedures. In fact, a higher percentage of trained HCPs knew how to decontaminate compared to their untrained counterparts. There were no notable differences between the two groups based on gender or profession (Table 5).

Table 5.

Comparison between trained versus not trained HCPs on CBRNE.

Characteristics	Not trained, n = 229	Trained, n = 69	Statistics	p-Value
Characteristics	M (SD)	M (SD)	Statistics	p-Value
Level of preparedness	2.14 (2.30)	4.61 (2.85)	t = −6.58	<0.001
Confidence in decontamination	2.40 (2.39)	4.67 (3.05)	t = −5.66	<0.001
	n (%)	n (%)
Gender
Male	121 (51.8)	30 (43.5)	χ² = 1.86	0.17
Female	108 (47.2)	39 (56.5)	χ² = 1.86	0.17
Profession
Nurse	156 (68.1)	51 (73.9)	χ² = 0.84	0.36
Physician	73 (31.9)	18 (26.1)	χ² = 0.84	0.36
How to decontaminate
No	176 (76.9)	61 (88.4)	χ² = 4.35	0.04
Yes	53 (23.1)	8 (11.6)	χ² = 4.35	0.04

Discussion

This study provides a comprehensive assessment of CBRNE preparedness among HCPs in Jordanian hospitals, revealing critical insights into their knowledge, skills, and training levels. The findings are significant as they highlight critical, systemic vulnerabilities in Jordan’s healthcare system, demonstrating that a lack of standardized policies and hands-on training for healthcare professionals could severely compromise the country’s ability to respond to a CBRNE event. Consistent with other study findings, our results reveal a mixed landscape, with both strengths and notable gaps requiring urgent action.^6,14 Most respondents were unaware of defined CBRNE policies in their hospitals, and even among those who are aware, the majority lacked access to policy documents. This indicates a systemic deficiency in institutional preparedness, which could hinder effective response during CBRNE incidents. Without clear and accessible policies and guidelines, HCPs may struggle to adhere to standardized protocols, potentially leading to mismanagement during emergencies. These results align with previous studies highlighting the lack of formalized disaster policies in low- and middle-income healthcare systems, underscoring the urgent need for policy development and dissemination.^15,16

The rationale for selecting specific specialties was based on their critical roles in the immediate clinical management of CBRNE casualties. We focused on HCPs from the ED, ICU, OR, and BU because these are the primary points of care for such patients. The study was intentionally limited to nurses and physicians as the core clinical workforce directly responsible for hands-on patient care and stabilization during these events. While we acknowledge the importance of administrative staff and other allied healthcare workers, our study’s scope was to provide an in-depth analysis of the front-line clinical responders. This targeted approach provides a strong foundation for future research that can include a wider range of hospital roles.

Competency in using advanced PPE was alarmingly low, with only 1.7% of HCPs proficient in Level A PPE and 14.8% in Level B. Given that higher-level PPE is essential for handling hazardous materials, this deficiency poses a severe risk to both healthcare workers and patients.¹⁷ Furthermore, only 20.5% of respondents knew how to decontaminate equipment, suggesting a lack of hands-on training in critical response skills. The high percentage of HCPs who had never received training in PPE Level B (69.1%), decontamination setup (68.5%), or CBRNE-specific incident response (76.8%) further emphasizes the need for structured, recurrent training programs. These findings echo global reports where inadequate training has been linked to poor emergency preparedness, reinforcing the necessity for competency-based education in CBRNE response.^17,18

Preparedness levels varied significantly across CBRNE dimensions, with biological incidents being the most addressed (59% rated as good or excellent) compared to chemical (30%) and radiological/nuclear (21%) events. This disparity may reflect a greater focus on infectious disease outbreaks (e.g., COVID-19) in recent years, while chemical and radiological threats remain under-prioritized.^19,20 The absence of “excellent” ratings in chemical and radiological preparedness highlights a critical vulnerability in Jordan’s healthcare system, particularly given the geopolitical risks in the region. These results suggest that preparedness strategies must be multidimensional, addressing all CBRNE threats rather than focusing disproportionately on biological hazards.

Trained HCPs demonstrated significantly higher preparedness levels and greater confidence in decontamination procedures compared to untrained staff.^1,21 This underscores the direct impact of training on competency and preparedness. However, the low proportion of trained HCPs (only 23.2% had received any CBRNE-specific training) indicates a severe gap in workforce preparedness. Notably, no significant differences were found between professions (nurses versus physicians) or genders, suggesting that training deficits are systemic rather than role-specific. These findings support the argument that mandatory, simulation-based CBRNE training should be integrated into continuing medical education for all HCPs.

Implementing solutions to improve CBRNE preparedness will require significant resources.²² Our recommendations for standardized, hands-on training, routine drills, and policy development will necessitate investment in training personnel, acquiring and maintaining specialized equipment, and dedicating protected staff time for these activities. While these are substantial commitments, we argue that the costs are a necessary investment in national security and public health. This perspective is supported by evidence from disaster management, which shows that skills like using PPE and decontamination are perishable and degrade without frequent, repetitive practice.²³ Continuous training is therefore essential for ensuring that healthcare professionals can respond effectively under pressure, thereby mitigating the severe human and financial costs of a major incident.

We agree that exploring less resource-intensive alternatives is important. One such alternative is a “train-the-trainer” model, where a small, expert cohort is responsible for maintaining the skills of the wider staff.^24-26 While this approach is more cost-effective, we have added a discussion of its potential limitations. This model could create knowledge gaps among the broader staff and is vulnerable if the small group of experts is unavailable during an event. Therefore, while a tiered training model could be a valuable supplementary strategy, it cannot fully replace the need for a comprehensive, continuous training program for all relevant personnel to ensure a resilient healthcare system.

The study’s strengths lie in its dual-group approach, which assesses preparedness from both individual healthcare professional and hospital-level perspectives, its strategic sample selection of five hospitals across diverse regions and sectors to enhance generalizability within Jordan’s healthcare system, and its comprehensive scope that evaluates policy awareness, skills, training, and perceived preparedness across biological, chemical, and radiological dimensions. The study’s limitations include its reliance on self-reported data, which may introduce response bias, and its focus on Jordanian hospitals, limiting generalizability to other regions. Nevertheless, the results provide actionable insights for policymakers. Immediate steps should include (1) developing and disseminating standardized CBRNE policies, (2) implementing mandatory hands-on training for all HCPs, and (3) conducting regular drills to reinforce skills. Future research should explore barriers to training uptake and evaluate the long-term retention of CBRNE competencies post intervention.

Conclusion

This study highlights significant gaps in CBRNE preparedness among Jordanian HCPs, driven by insufficient policies, training, and access to resources. This deficiency could hinder effective response coordination during an actual CBRNE event, underscoring the need for enhanced communication and dissemination of relevant policies to all hospital staff. Addressing these deficiencies requires a multi-faceted approach involving policy reform, targeted education, and investment in emergency response infrastructure. Strengthening CBRNE preparedness is not only crucial for Jordan but also for other nations facing similar challenges in disaster preparedness.

Supplemental Material

sj-docx-1-smo-10.1177_20503121251385060 – Supplemental material for Critical deficits in CBRNE preparedness: A nationwide assessment of Jordanian healthcare providers’ knowledge, skills, and training gaps

Supplemental material, sj-docx-1-smo-10.1177_20503121251385060 for Critical deficits in CBRNE preparedness: A nationwide assessment of Jordanian healthcare providers’ knowledge, skills, and training gaps by Muayyad Ahmad and Eman Qzih in SAGE Open Medicine

Footnotes

Acknowledgements

The authors thank all the HCPs who participated in this study.

ORCID iDs

Muayyad Ahmad

Eman Qzih

Ethical considerations

IRB approval number (RMS, TF/1/IRB/2694; on 27 March 2024).

Consent to participate

All the participants provided written informed consent.

Author contributions

Conceptualization: MA and EQ. Methodology: MA and EQ. Formal Analysis: MA. Investigation: EQ. Writing: MA and EQ. Writing: MA and EQ. Visualization: MA. Supervision: MA. Funding Acquisition: None. Project Administration: MA and EQ.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Data will be available upon request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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