The Journal of Continuing Education in Nursing

CNE Article 

Qualitative Analysis of the Lived Experience of First-Time Nurse Responders in Disaster

Sallie J. Shipman, EdD, MSN, RN, CNL; Marietta P. Stanton, PhD, RN, BC, CNL, NEA-BC, CMAC, CCM, FAAN; Stephen Tomlinson, PhD; Linda Olivet, DSN, RN; Ann Graves, PhD, RN; Douglas McKnight, PhD; Patricia M. Speck, DNSc, APN, FNP-BC, DF-IAFN, FAAFS, FAAN

Abstract

The study purpose was to examine the reflections of the lived experiences of nurses in shelters or temporary community medical clinics responding for the first time to a civilian disaster. The disaster-nursing literature echoes the need for development of disaster content in the nursing curriculum. However, little thematic analysis-supporting curriculum from the lived experience of first-time responders exists in the literature. This study's purpose is to identify the essential thematic knowledge and skills necessary to provide care to disaster survivors in communities and for determining the themes necessary to formulate education in emergency preparedness curricula. A narrative inquiry, with a phenomenological analysis, to explore the lived experiences of nurses who responded once to a community disaster was the methodology used to identify themes. Thematic findings demonstrated a lack of prior knowledge about volunteering during a disaster response, that previous mass casualty exercises did not help with their actual responses, and that the participant RNs identified specific and assessment skills necessary for disasters.

J Contin Educ Nurs. 2016;47(2):61–71.

How to Obtain Contact Hours by Reading This Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must: 

  1. Read the article, “Qualitative Analysis of the Lived Experience of First-Time Nurse Responders in Disaster,” found on pages 61–71, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
  3. Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until January 31, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Objectives
  • Describe the experiences of first-time nurse responders to actual disasters in community shelters or temporary medical clinics.
  • Identify themes the first-time nurse responders suggest for a practical disaster curriculum for the generalist nurse.
Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Do you want to Participate in the CNE Activity?

Abstract

The study purpose was to examine the reflections of the lived experiences of nurses in shelters or temporary community medical clinics responding for the first time to a civilian disaster. The disaster-nursing literature echoes the need for development of disaster content in the nursing curriculum. However, little thematic analysis-supporting curriculum from the lived experience of first-time responders exists in the literature. This study's purpose is to identify the essential thematic knowledge and skills necessary to provide care to disaster survivors in communities and for determining the themes necessary to formulate education in emergency preparedness curricula. A narrative inquiry, with a phenomenological analysis, to explore the lived experiences of nurses who responded once to a community disaster was the methodology used to identify themes. Thematic findings demonstrated a lack of prior knowledge about volunteering during a disaster response, that previous mass casualty exercises did not help with their actual responses, and that the participant RNs identified specific and assessment skills necessary for disasters.

J Contin Educ Nurs. 2016;47(2):61–71.

How to Obtain Contact Hours by Reading This Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must: 

  1. Read the article, “Qualitative Analysis of the Lived Experience of First-Time Nurse Responders in Disaster,” found on pages 61–71, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.
  2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.
  3. Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until January 31, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Objectives
  • Describe the experiences of first-time nurse responders to actual disasters in community shelters or temporary medical clinics.
  • Identify themes the first-time nurse responders suggest for a practical disaster curriculum for the generalist nurse.
Disclosure Statement

Neither the planners nor the authors have any conflicts of interest to disclose.

Do you want to Participate in the CNE Activity?

On April 27, 2011, a Category IV tornado (on the Enhanced Fujita scale) decimated the Tuscaloosa, Alabama, community. Statewide, 241 fatalities occurred, with more than 60 in two major urban counties (The Birmingham News, Press Register, & The Huntsville Times, 2011; Wallace & Ross, n.d.). Thirty-eight of 67 Alabama counties depended on emergency resources, which were stretched during this particular disaster (Wallace & Ross, n.d). The deceased and the injured seeking help arrived at local hospitals. The initial hospital response was intense and catastrophic to the community because the number of injuries was unusually high, but the mass causality surge was temporary. The community disaster response for the displaced citizens seeking housing in shelters persisted for several weeks and, for some, continues today.

Worldwide, 529 disasters occurred in 2013 (International Federation of Red Cross and Red Crescent Societies, 2014). It is not a matter of if a disaster will occur, it is a matter of when. Future responses depend on the ability of health care communities to analyze and learn effective responses to catastrophic events. Disaster prepared-ness is needed in nursing curricula (Khalaileh, Bond, & Alasad, 2012; Veenema, 2013). Littleton-Kearney and Slepski (2008) discussed the possibilities and importance of a framework for emergency preparedness curricula. Information exists regarding disaster response competencies (Agency for Healthcare Research and Quality, 2005; World Health Organization, 2008), but training materials remain unavailable (Chiu, Polivka, & Stanley, 2011). A significant gap remains between basic standards for emergency preparedness curriculum and the undergraduate RN. The current research queried the lived experiences of RNs who responded after disasters in a civilian environment for the first time, for the purposes of seeking themes to establish a foundation absent in the literature.

Background

A disaster is an event that forces a community outside the safety of everyday life and is often overwhelming and unexpected (Johns Hopkins Bloomberg School of Public Health, 2013). A major disaster is defined by the Federal Emergency Management Agency (FEMA, 2013b) as:

any natural catastrophe (including any hurricane, tornado, storm, high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought), or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance.

Emergency preparedness is an all-encompassing term that describes an all-hazards approach that communities use to prepare and respond to a disaster (Centers for Disease Control and Prevention, 2013; FEMA, 2010; Johns Hopkins Bloomberg School of Public Health, 2013). One concern is that in every disaster involving people, overarching public health needs require the use of RNs.

The lived-experiences of first-time RN participants provide “clinical wisdom” for undergraduate nursing students through actual experiences (Hall & Powell, 2011, p. 1), enhancing disaster curriculum. Reflection is powerful and helps learners progress to a higher level of understanding (Benner, Sutphen, Leonard, & Day, 2010). The lessons learned improve nursing practice and disaster response (FEMA, 2013a; Hammad, Arbon, & Gebbie, 2011; May & Bigham, 2012; Slepski, 2007; Weeks, 2007). RNs' role is essential in disaster response, including involvement in the processes of emergency preparedness planning and response (Littleton-Kearney & Slepski, 2008). Drills and mock disasters fill gaps, providing simulated disaster experiences for students and practicing nurses (Carter & Gaskins, 2010; Kaplan et al., 2012; Khalaieh et al., 2012). However, disaster simulation is difficult and infrequently available (Chiu et al., 2012).

The lived experience of nurses responding in disaster is available (Hammad et al, 2011; May & Bigham, 2012; Slepski, 2007; Weeks, 2007) but scarce. The literature highlights the importance of training RNs for all-hazards responses (e.g., water, shelter, transportation, injury, and others; Association of Community Health Nursing Educators, 2008; Veenema, 2013). Disaster education research and outcomes provide validity to emergency preparedness curricula (Littleton-Kearney & Slepski, 2008; Veenema, 2013). For the RN to respond competently during the disaster response and recovery phases, basic knowledge and skills preparation are necessary (Baack & Alfred, 2013; Hammad et al., 2011; Khalaieh et al., 2012). The lack of thematic foundations about the first-time RN response to disaster revealed a gap in education and preparation that this investigator (S.J.S) used to pose the following research question: What are the themes of the lived experiences of RNs in community shelters or temporary medical clinics who are responding to disasters for the first time?

Purpose

The purpose of the current study is to describe the lived experience, via narrative analysis, of RNs who have worked in a community disaster shelter or temporary medical clinics for the first time. To establish thematic content, the study included a purposeful sample of first-time RN disaster responders located in disaster shelters or temporary medical clinics because these sites are often where a large number of nurses function after a disaster. Participants described their lived experiences, leading to the collection of personal RN histories, along with extracted knowledge and skills from participants. The research design relied on analysis of thematic content related to these shared histories. The goal of the analysis was to find new meanings, suggesting content to prepare nursing students for disaster response.

Method

Sample, Design, and Data Collection

A narrative inquiry study requires the researcher to focus on a small number of participants to enhance the uniqueness of each story (Hoogland & Wiebe, n.d.; Kear, 2012). The literature supported the recruitment of 10 participants, based on other narrative inquiry studies. The frequency of disasters in Alabama, Florida, Georgia, Louisiana, Mississippi, and Tennessee directed the recruitment of RN participants from the southeastern United States. They were first-time disaster responders and participated in different types of disasters (e.g., tornadoes, hurricanes, floods) and locations that were declared a major disaster (FEMA, 2015; Lindsay & McCarthy, 2015). Access and recruitment of participants occurred cooperatively with local hospitals, health departments, and the American Red Cross. Employee information at lead agencies helped to identify potential participants. An e-mail or postal service letter invited the responders to participate in the study.

During interviews with participants, a snowball technique of recruitment, in which participants were asked to recommend other potential participants, led to three additional participants. A preliminary telephone screening determined that 10 participants met the inclusion criteria of 17 potential nurse participants who volunteered in disaster shelters or temporary medical clinics during their first and only emergency response. Inclusion criteria required only RNs who were 19 years and older, working at least one shift during a disaster, worked in a shelter or clinic, and the shelter or clinic was open for more than 2 days. After being determined to be eligible, the RNs consented to participate. To preserve anonymity, the researcher (S.J.S.) assigned alias designation via the location of the shelter or community medical clinic, using classification from the National Center for Health Statistics 2006 Urban–Rural Classification Scheme for Counties (Centers for Disease Control and Prevention, 2014). Each participant chose the location of the interview.

Disasters are traumatic, and responders remembering the traumas experience difficult emotions. The risk of emotional distress resulted in the researcher retaining a certified counselor to be available for counseling. Outside of potential emotional distress from reliving the experience, the study posed minimal risk to the participants. The researcher obtained institutional review board approval prior to any participant interviews. Compensation for participant participation during and after the interview included refreshments, comfort measures, and a $20 Visa® gift card, funded out of pocket by the investigator.

Measures

Narrative inquiry was the method used to record stories from nurses who responded for the first time in community disaster shelters or medical clinics. Narrative inquiry involves a reflective dialogue and structured analysis of the meaning of the lived experience (Clandinin, 2007) and was the methodological tool to explore the beginning perceptions of functioning in a disaster situation through the eyes of and with the words of the first-time nurse responder working in a disaster shelter or clinic. The researcher paired narrative inquiry with a phronetic approach to increase the level of generalizability (Clandinin, 2007; Hoogland & Wiebe, n.d.; Landman, 2012). The perceptional recordings in the procedure were the foundations for thematic analysis of the lived experience of the first-time RN responding to disaster.

The researcher ensured a secluded setting protecting the participant's privacy and confidentiality. The face-to-face digitally audiotaped interviews lasted 45 to 80 minutes, with the possibility of a second 10- to 15-minute interview for clarification, if needed. The investigator used an open-ended and participant-driven interview style to ask predetermined questions, with acceptance and recording of participant-driven deviations from the interview question topic. Table 1 lists the interview questions.

Interview Questions

Table 1:

Interview Questions

Analytic Strategy

In the beginning and during the entire analysis process, a decision trail provided an auditable account of the data collection and analysis process (Ahern, 1999; Clandinin, 2007; Sanders, 2003). Field jottings chronicled during the interviews, resulted in field notes developed immediately following the interview. The recorded and verbatim transcriptions of questions and answers from interviews were data for qualitative analysis. The recordings of data did not include the participant's name. Other anonymous data destruction, which included audiotapes, occurred after the data analysis completion. Colaizzi's (1978) seven steps for phenomenological data analysis, used commonly in nursing research (McGarry et al., 2013; Sanders, 2003; Shaw & Bosworth, 2012), provided the methodologic framework for constant comparison of joint coding and analysis.

In transcript analysis, the literature recommends reflection through listening and reading transcripts (Sanders, 2003). The investigator allowed for time between each review, which provided separation from data, to gain a clear understanding of meaning. A description and incorporation of all ideas and themes to explain the investigated phenomena provided the basis for the data outcomes (Colaizzi, 1978; Sanders, 2003). Transcription coding included identifying themes, placing data into categories.

The researcher established trustworthiness and validity in the study through (a) acknowledgment of researcher biases and subjective judgments, (b) prolonged engagement with the data, (c) verification of data with the participants, (d) using verbatim examples from the participants (Sanders, 2003), and (e) reflexive bracketing (Ahern, 1999). There was no need for second interviews, but five participants required slight clarifications. The participants reviewed their verbatim transcripts, the participant-specific brief description, and summation of the overall themes derived from the interview analysis to ensure validity. The investigator provided an option of debriefing the study's findings. No participants requested a debriefing.

Results

The participants included one African American individual and nine Caucasian individuals. The mean age of the sample was 47 years, and the median was 48 years. The mean participants' experience at the time of the disaster was 18.6 years and the median was 16.5 years, ranging from 10 months to 33 years. Table 2 provides demographics of the sample. At the time of the disaster, two participants worked in nursing management (one charge nurse and one nurse manager), three in direct patient care (one clinic, one medical–surgical, and one intensive care), one was in an undergraduate baccalaureate nursing education program, one was in a graduate nursing education program, and three were in community college associate degree nursing education programs. The highest educational degree and advanced certification held for the participants included one Associate Degree in Nursing, three Bachelor of Science in Nursing degrees, three Master of Science in Nursing degrees, two Doctor of Philosophy in nursing degrees, and one Doctor of Nursing Practice degree. Site distribution included three temporary community medical clinics located in areas directly impacted by the disaster, and the seven shelters were located in safe zones outside of the disaster area. Nine of the locations were located indoors: two schools, one community activity center, two community colleges, and four churches. One location was a temporary outdoor tent, and two of the participants worked in more than one site. The nurses' description of their experiences in response to the research question delineated three overarching themes: the role of the nurse, knowing the plan, and growth experience. Table 3 provides an overview of formulated meanings and theme clusters.

Characteristics of the Sample (N = 10)

Table 2:

Characteristics of the Sample (N = 10)

Theme Clusters and Formulated Meanings

Table 3:

Theme Clusters and Formulated Meanings

The Role of the Nurse

Theme one, the role of the nurse, was the major theme of this research. All of the interviewed respondents described their medical response as “like a clinic,” “basic triage,” or “first aid.” The six participants who worked in the shelter also described operations as a medical clinic. Respondent A labeled nursing operations as “more like a clinic…than a shelter of support.” Four of the participants who were in medical clinics in areas directly affected by the disaster described what they did as “basic first aid” or “clinic” operations. The participants reported that mass casualty triage of severe cases “evacuated out” before they arrived on location. Prior experience in an urgent care or emergency department setting was beneficial, as described by four of the participants. Respondent E stated:

My triage abilities came in handy when I could say I've asked this patient enough questions and this is how we can help you today without going [into] too much because I couldn't know everything about them and I couldn't know every problem they had in the clinic. My job was to help them immediately with the most important needs that they had for that day because they can come back the next day if they so choose.

In response to the experience in temporary community medical clinics or shelters, the participants highlighted themes that included organization, physical assessment, psychosocial needs, and resourcefulness.

Organization. Extremely important for all 10 nurses participating in the reflection portions of the study, three ranked organization as the “number one” priority. The participants had differing views in regard to organization and comfort level in the community disaster setting, which depended on whether they received a brief orientation (two participants), worked with an nurse experienced in disaster (three participants), or had past experiences in a travel, urgent care, or emergency department (six participants). Five of the participants in this study did not receive an orientation to their nursing role. Respondent H noted that the nurse “need[s] to be able to organize or compartmentalize different things at one time…[and must] stay organized to do that.” Prioritizing and critical thinking in shelter and clinic activities was essential, as noted by all of the participants. Respondent H stated that nurses have to “prioritize…know what you've got to do first. You've got to know what the problem of your patients [is and]…you've got to critically think, what do I need to do first?”

Physical Assessment. All of the participants described advanced or expert physical assessment skills as being necessary, although they were a novice in disaster response. Terms used to describe what they did included “history,” “gathering of information,” “vital signs,” and “general assessment.” Two of the participants specifically mentioned the term “ABCs… airway, breathing, circulation” and how ABCs were “the first” priority. The participants noted that the tools they used in the field were limiting, such as the blood pressure cuff, stethoscope, and glucometer. One nurse stated, “every sense that you have…sight…hearing, and…touch” are the necessary physical assessment nursing skills to monitor health daily, but these are utilized even more in disasters, when access to medical equipment is limited. Chronic illness, such as mental illness, diabetes, hypertension, respiratory, and minor injuries, chronic wounds, and pain management issues, along with the medications needed to treat such conditions, were widespread and mentioned in all of the interviews.

Psychosocial Needs. The participants personally reflected about both negative and positive emotions as a result of their disaster experience. Although none of the participants required referral to counseling (available as part of the study), Respondent J recommended that nurses who respond in a disaster should receive “some type of psychological preparation.” Respondent E said, “You need to be ready for…[the] emotional piece of” the disaster response. Respondent G thought that “knowing how to handle [yourself in a disaster]…might…have helped, [saying,] we had some [responders who]…had nightmares for a while.” Although there were many negative themes, the overall participant consensus from experiencing the disaster response first-hand was mostly positive. All of the participants said they would respond again, with several saying they would be more “aggressive” next time with volunteering. Overall, the participants experienced personal growth from their disaster response on both personal and professional levels, which left them with the desire to help others again in the future.

Psychosocial needs of the evacuees were a pivotal part of the role of the nurse and were noted by all of the participants. The effects on the community and evacuee were substantial, leading to positive and negative evacuee accounts from the participants. Nurses played an essential role in meeting the psychosocial needs of the disaster survivors, who were often described as “overwhelmed” and “stunned.” Allowing the disaster victims to talk about their experiences was essential, as determined by all participants, with six specifically mentioning the words, “their story.” All participants noted the significance of the nurse listening to and communicating with the disaster survivors. Participants described the disaster survivors as having “a lot of stress,” and they mentioned that the nurse needed to let them “tell their story,” “sit there and…cry,” “because everybody had a story...even if you had heard this same type of story from every [disaster victim]….”

Resourcefulness. Even in the best circumstances, disaster situations are often chaotic; therefore, resourcefulness and flexibility with regard to role of the nurse may be the most important trait for the nurse. Often, nurses are not educated or experienced to handle disasters. Respondent B, a disaster responder, explained that the nurse in the disaster response realizes the situation is “beyond your control [and]…you have to just learn… to…roll with the punches.” Other phrases used by participants to describe the resourcefulness in the role of the nurse were “not a picture perfect world in that situation,” “dealing with limited resources,” “would rig it up [and]...make it work,” “sometimes you have to makeshift,” “everything is not script black and white [or] step by step,” “function in spite of being out of your norm,” and “being out of your box.”

No participants participated in mass casualty triage during their disaster response. All reflected that they believed mass casualty “should be” included in a disaster curriculum at the undergraduate level, but the degree of focus differed with the participants. Three participants believed a “good triage nurse” could be “invaluable” in the initial “mass casualty” part of the disaster, whereas the other seven held the view that “just…the concept of” mass casualty was sufficient for the generalized nurse. Although all participants mentioned and deemed the “concept of triage” or “basic triage” as being essential, several pointed out that the nurse's role is “not pulling [victims] out of the rubble” on the front line with the first responders (i.e., fire, police, emergency medical service). Respondent D said, “I'm not the first responder.… I am the second responder…the cleanup crew [or]…the person that takes care of everything and settles everything down.” Respondent H stated that one of the “biggest thing[s] [a nurse in the community response should know] is…more than likely they are not going into a mass casualty” triage situation, such as nurses who were working in the hospital directly hit by the 2011 Joplin, Missouri, tornado or a nurse who lives in an area directly affected by the disaster.

Knowing the Plan

Knowing the plan was the second overarching theme derived from the participant accounts and recommendations. Respondent C stated that nursing students “need to understand you have to have a plan [and planning]…can't wait until a disaster happens.” Respondent I described the meaning of the recipe:

We have like a red box...[which is the hospital's] emergency box and in it…for example, let's say the power goes off. There's something in there to tell them everything they need to do…. It is…a disaster thing…. You go in and it's kind of like the recipe of what to do.

Every participant in this study noted the importance of the nurse knowing the plan in their health care agency and community.

Only one participant specifically mentioned the Emergency Management Agency, which is the agency responsible for maintaining county and state emergency operations plans (FEMA, 2010, 2014). One of the participants in particular, who was a nursing instructor, did not realize her affected county had a disaster plan, stating, “I do not think we had…[a plan when the tornados hit] in April.”

Respondent E said that students must learn and understand the significance of knowing the disaster plan by getting in contact with the “disaster management person” in the facility where they are working. Respondent B stated, “if they work for a particular organization they [will]…already have a role defined in…their disaster plan” and they should know their role in the plan. Respondent I thought that only the importance of knowing their role in the emergency plan should be stressed, explaining further that as a “[nurse], you need to do blah, blah.... [The nurse] doesn't need to know the whole picture really, but [the nurse]…needs to know that in an emergency…to do what [their supervisor in the disaster]…tells” them to do. Three participants recommended development of disaster “guidelines” or a “protocol to follow” that would include “call list,” contact “phone numbers,” “supplies,” “building layout,” and “what to expect.”

“Growth”: Experience

During the interviews, the participants spontaneously addressed the amount of nursing experience needed to respond in a disaster situation. Nine of the participants recommended a range of years of nursing experience needed to respond independently as a nurse during a disaster, which ranged from 6 months to 3 years, with a mode of 2 years. Theme three involved their personal growth through their experiences in the disaster. Respondent E's account of her experience sums up the responses related to the growth theme:

You can take a brand new nurse into [a disaster]…situation and [they]…would learn a ton of things. But…take…some-body who is a little bit experienced, and they do what I call grow, which is where you really learn.

Respondent G, who had 5 years of nursing experience at the time of the disaster, believed:

The first year out of nursing school…you are not capable of seeing the big picture and drawing conclusions [and]…it takes a good a year…to feel like you have your head on your shoulders in any aspect of nursing, anywhere.

Respondent D, an experienced nurse, stated:

What saved me is 33 years of nursing and common sense of what to do…. I could still assess [victims] whether you direct me or not…. [The younger nurses] did not seem like they had any kind of understanding of what they should be doing…. They were just milling…walking around, [and]...just aimlessly kind of bumping into each other.

Respondent F said:

I asked questions [in the shelter, using]...common sense and my basic nursing training, but I'm a seasoned nurse…. A newbie probably would have just stood there waiting for somebody to tell them what to do.

Discussion

Nurses are not trained to respond to community disaster, which revealed a lack of prior knowledge about how to volunteer and what to expect during a disaster response. In this study, none of the nurses responded directly to a mass casualty incident or knew how to volunteer before the disaster. Further, all described the disaster response “like a clinic.”

The study also discovered that a majority of nurse participants noted previous experience in mass casualty exercises did not help them with their actual community response. Eight participants participated in a hospital drill or mass casualty incident exercise at work or nursing school. Of those eight, six said the exercise did not help them with the disaster response in the community. Instead, they were trained for the emergent setting, not realistic to the community response following disaster unless they experience the disaster first hand. Respondent I, who had extensive disaster training before responding and worked in a community medical clinic, stated, “No, it didn't help me with this [disaster response], because it's totally different” with mass casualty versus the community response. Respondent F said her mass casualty exercise experience “might have helped me if I had went [sic] to the emergency room, but no it didn't” in the shelter. The actual experience from this study reflected “clinic” activities and monitoring individuals in emotional distress with existing health problems without the use of equipment, records, or medications was noted in all of the participants' experiences.

All nursing students, nurses, emergency department nurses, and public health personnel need training for disasters (Chiu et al., 2012), but emergency preparedness is an extremely complicated system that requires years for proficiency. Undergraduate nursing programs prepare nurses to practice as a competent, safe practitioner or a generalist nurse (National Council of State Boards of Nursing, 2015). Undergraduate nursing curricula in emergency preparedness is deficient in community response preparedness, creating an absence of realistic responses during disaster. Conversely, based on these first-time nurses' actual accounts during a disaster response, the recommendation is to significantly scale back the focus from mass causality to a focus of community response, which is needed for generalist nurses. The findings from the lived experiences of these first-time nurse responders highlight the need for the creation of streamlined practical curricula for the generalized nurse.

Limitations

The first limitation, which could also be viewed as strength of this study, included difficulty in locating participants who had responded in only one disaster. The limitation led to the expansion of inclusion criteria to include temporary community medical clinics. Another aspect of the first limitation is that larger samples of nurses who have responded during disaster are needed to determine whether the nurse who has responded in only one disaster in the community is indeed a rare occurrence. Another limitation is regional, given that the majority of the participants were in the southeastern region of the United States. A study replication in other areas of the United States and internationally would further explore the role of the nurses during first-time disaster responses. The length of time between the nurse's disaster response and the interview could also cause a limitation due to variances in memory of past events. The qualitative method of narrative inquiry specifies a limited number of participants interviewed, and the small number of participants in this study results in the limitation of generalizability.

Conclusions

Benner et al. (2010) defined advanced and expert skills as occurring after years of experience. All of the participants in the current study used advanced or expert skills in physical assessment, even though they were a novice to the disaster response, implying the environment does not rob the nurse of the skill set. The reflective nature of the inquiry helped to frame the nurses' thinking about their growth in a disaster environment, thus helping the participants verbalize their perception of a new level of expertise in disasters. Reflections about lessons learned are necessary to improve nursing practice and disaster response. One participant's summary of the experience included:

I really think that at least one time in every nurse's life [they]…should try to [work in a disaster response]…because you just learn from it…grow from [the experience,]…and… learn how to appreciate…the [response in the field or the] other side of the fence.

The Quality and Safety Education for Nurses (n.d.) website articulates the “value [in] seeing health care situations 'through patients' eyes'” (“Patient-Centered Care,” line 1). The narrative accounts reported in this article will benefit nursing education but also will have significance for nurses in practice. Every nurse will not have the opportunity to respond to a mass casualty disaster, but all nurses should be prepared for the possibility of a disaster affecting their community.

One of the participants in this study stated, “I think anyone can respond in spite of experience, everyone has something to contribute, no matter if [they] are a student or veteran nurse.” Looking through the eyes of the first-time nurse responder revealed new meanings about mass disaster and suggests realistic practical content to prepare nursing students for community disaster response. Emergency preparedness is a complex topic in nursing and is ever-changing, with new terms and acronyms, which is challenging to the full-time emergency preparedness planner and impossible for the nurse educator without previous experience in the field of emergency preparedness. The World Health Organization (2008) recommended that nurse educators teaching emergency preparedness be supported and trained by emergency preparedness experts. The gap between nursing real-world practice and what is taught in the classroom is well documented (Benner et al., 2010; Institute of Medicine, 2012; Slaikeu, 2011). The current study provides evidence to bridge the gap between actual disaster response experiences and realistic emergency preparedness content in undergraduate nursing curricula.

References

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Interview Questions

Participant race, age, and sex.

Describe your experience in nursing.

How long have you been a nurse?

What disaster did you work in?

Why did you choose to respond to the disaster?

Tell me everything that you think I need to know in order to understand the nurse's role in responding to disaster situations for the first time?

Describe your experience working as a nurse in a shelter after a disaster.

Did I capture all of what you were saying?

Are there any other details or pieces of information that you would like to add?

What do you believe went wrong during the disaster in regard to the response?

What would you change to address what went wrong?

What do you believe went right during the response to the disaster?

What are the most important things other nurses could learn from what went right during the disaster response?

Can you tell me about any training you received in how to respond to disasters?

If yes, how did it help you during the response?

If no, what type of training do you think would have helped you in the response?

How do you think disaster preparedness could be incorporated into basic nursing practice?

How would you prioritize your recommended disaster training topics for use with undergraduate nursing students?

How do you think disaster preparedness could be incorporated in undergraduate curricula?

Characteristics of the Sample (N = 10)

Variablen (%)
Age (years)
  30 to 392 (20)
  40 to 493 (30)
  ⩾505 (50)
Ethnicity
  Caucasian9 (90)
  African American1 (10)
Nursing experience at time of disaster (years)
  <11 (10)
  1 to 51 (10)
  6 to 101 (10)
  11 to 203 (30)
  >204 (40)
Disaster
  Hurricane Gustav3 (30)
  Super Storm Sandy1 (10)
  Hurricane Katrina1 (10)
  April 27, 2011, Alabama tornado5 (50)
Orientation to role
  None5 (50)
  No in ARC shelter; yes, in Community shelter1 (10)
  Worked with an experienced nurse3 (30)
  Brief orientation2 (20)
  Yes, but not formal2 (20)
Site type
  ARC/community college shelter3 (30)
  ARC/community shelter3 (30)
  Temporary community medical clinic4 (40)
Response to “How long do you think a nurse needs to work prior to responding?”
  6 months to 1 year1 (10)
  1 to 2 years3 (30)
  2 years4 (40)
  2 to 3 years1 (10)
  Did not give a numerical response1 (10)
Response to “Did you know how to volunteer prior to responding?”
  Yes0 (0)
  No10 (100)

Theme Clusters and Formulated Meanings

The Role of the NurseKnowing the Plan“Growth”: Experience
“Like a clinic”: Basic triage “Organization,” “prioritize,” and “critical thinking” “Organizing contact person” Physical assessment, chronic and acute illness, and medications   Medications   Mental illness   Ambulatory, diabetes, hypertension, and respiratory   Pain management   Chronic wounds and minor injuries   Over-the-counter medications and gastrointestinal issues Psychosocial needs: Community, evacuee, and nurse responder   Psychosocial assessment: “Listening”   Negative and positive accounts   Not knowing what to expect   Safety   Scope of practice/legal, nursing students   Family, personal, and health, “thankful”: empathy and change in the responder   “Roll with the punches”:   “Resourcefulness” and “flexible”The Emergency Operations Plan Communication and partner agencies   American Red Cross   Law enforcement and the National Guard   The health department and medical volunteers   The community, churches and other agencies Teamwork and community resilience Donations, staffing, and volunteeringDisaster content in curriculum Personal responder experience Simulation

Key Points

Disaster Response

Shipman, S.J., Stanton, M.P., Tomlinson, S., Olivet, L., Graves, A., McKnight, D. & Speck, P.M. (2016). Qualitative Analysis of the Lived Experience of First-Time Nurse Responders in Disaster. The Journal of Continuing Education in Nursing, 47(2), 61–71.

  1. The lack of thematic research outcomes supports continuous debate over emergency preparedness content that fluctuates in curriculum.

  2. This study provides evidence to inform thematic foundations about the knowledge and content necessary for actual disaster response by first-time RN responders.

  3. All of the interviewed respondents described their medical response as “like a clinic,” “basic triage,” or “first aid.” Prior to the disaster, none of the nurses responded directly to a mass casualty incident or knew how to volunteer.

  4. In response to the experience in temporary community medical clinics or shelters, the participants highlighted themes that included organization, physical assessment, psychosocial needs, and resourcefulness.

Authors

Dr. Shipman is Instructor, and Dr. Speck is Professor, The University of Alabama at Birmingham School of Nursing, Birmingham, Dr. Stanton is Professor, Dr. Olivet is Professor Emerita, and Dr. Graves is Associate Professor, The University of Alabama Capstone College of Nursing, Dr. Tomlinson is Professor, and Dr. McKnight is Professor, Educational Leadership and Foundations of Education, The University of Alabama College of Education, Tuscaloosa, Alabama.

This work was supported Sigma Theta Tau International Epsilon Omega Chapter Research Grant and the Sigma Theta Tau Epsilon Omega Chapter Roberson Award.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Dr. Teena McGuinness for her thoughtful review, feedback, and support in the preparation of the manuscript.

Address correspondence to Sallie J. Shipman, EdD, MSN, RN, CNL, Instructor, The University of Alabama at Birmingham School of Nursing, NB 328D, 1720 2nd Avenue South, Birmingham, AL 35294-1210; e-mail: sshipman@uab.edu.

Received: September 04, 2015

Accepted: November 02, 2015

10.3928/00220124-20160120-06

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