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Volume 8
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Health Promotion |
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In this Issue Health Promotion Commentary: Nurses as Champions of Health Promotion Original Research
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The Lived Experience of Nurses Providing Care Deborah Frank, PhD, ARNP, MFT Linda Sullivan ARNP, BC, DSN ABSTRACT The purpose of this research was to explore the lived experiences of nurses who provided care to those in need during Hurricane Katrina. A qualitative; methodology using a phenomenology framework was employed, with taped telephone interviews used to elicit nurses perceptions of their experience. A convenience sample of nine nurses who provided care during Hurricane Katrina was needed to reach saturation. Data analysis was based on van Kamm’s methodology. The description of the lived experience unfolded sequentially with responses to the situation including (1) chaos, (2) reality check (3) reorganizing, (4) stabilizing, and finally, (5) planning for the future. The themes, which emerged, suggest that the lived experience mirrored the phases of nursing process. Implications for nursing practice were discussed. Introduction In 2005, the Gulf Coast was the target of an unprecedented number of hurricanes, resulting in massive destruction of property and resources which took an emotional toll on residents and the people who helped care for them. The most devastating of these events was Hurricane Katrina, which struck the Gulf Coast, destroying the city of New Orleans, and rendering thousands of people in Louisiana and Mississippi homeless, jobless and without basic necessities such as food, water, electricity or health care.1 In the aftermath of Hurricane Katrina, nurses were among the multitude of volunteers/disaster workers who were called upon to aid those who were impacted by the storm. Providing health care to the victims was particularly difficult as hospitals had been virtually destroyed, unsanitary conditions prevailed in overcrowded shelters, and necessary medical supplies and medicines were not readily available. Furthermore, many of these nurses were from the very area where destruction had occurred and had experienced personal losses from the hurricanes. These nurses worked in a variety of settings, putting aside their own personal losses to provide nursing care. The experiences that encompassed these tasks comprised the lived experience of providing care and this study explored that experience. Purpose The magnitude of damage and destruction experienced in the 2005 hurricanes was a horrific experience for this nation. The impact of this experience on the nurses who cared for those who were impacted by the storm can only be imagined by others. The purpose of this research was to understand the lived experience of nurses that participated and provided care during Hurricane Katrina. By understanding the experiences of these nurses it was anticipated that health care providers could better prepare for future episodes in similar situations where nursing services will be required. Methodology Phenomenology is the study of one’s conscious experiences of the world whose aim is to reveal aspects hidden from usual viewpoints.2 The design for this study was qualitative, phenomenological as the primary aim of the research was to facilitate an understanding of the phenomena from the perspective of those being studied. Instrumentation Although the researchers served as the primary tool for this study, a semi structured interview guide was also utilized to elicit perceptions relative to personal, cognitive, and physical responses of nurses who provided care during the hurricanes of 2005. The tool consisted of 5 questions that facilitated conversation with the participants. The guide was reviewed for content validity by a panel nurses expert in qualitative research. Setting The setting for this study was the Southeast United States including the states of Mississippi, Louisiana, Alabama and Tennessee. Population and Sample The population included all nurses who provided care during the hurricanes of 2005 in the southeast United States and who responded positively to advertisements for subjects via the Internet and through personal connections. Saturation was reached with a sample size of nine. Data Collection Procedure Permission to conduct the study was obtained through the Institutional Review Board at Florida State University. Following that approval, advertisements were placed on the state boards of nursing websites in Louisiana and Mississippi. Advertisements were also placed on the Sigma Theta Tau (Nursing Honor Society) and various other advanced practice blackboards within those selected states. Respondents were asked to participate if they met the following criteria: they were licensed registered nurses, over the age of 18, and participated in care giving efforts related to the hurricanes of 2005 in the southeast United States. Email addresses and phone numbers were provided for them to contact the researchers if they were interested in participating. The respondents were then contacted by phone, informed consent was ascertained and a telephone interview was scheduled. Participants were also emailed a copy of the study description and informed consent. Participants were asked for first names, phone numbers and/or email addresses. Only the researchers had access to that information. Each participant was assigned a code that corresponded to her audio taped interview. Transcribed interviews were identified by code only. Data Analysis The recordings were transcribed on one half of each page (the left side) vertically with each line being numbered. The right side of the page was used for field notes by the researchers. Analysis of the data was accomplished following van Kaam’s methodology2 and included the 6 major operations that were the guiding principles for data analysis. These operations are: (1) eliciting descriptive expressions, (2) identifying common elements, (3) eliminating expressions not related to the phenomena, (4) formulating a hypothetical definition of the phenomenon, (5) checking the hypothetical definition with original descriptions, and (6) specifying the structural definition. Use of this methodology allowed the researchers to more fully describe and analyze the psychological structure of the human experience.2 It provided the researchers an opportunity to explore, in a holistic manner, the emergence of themes and patterns of the lived experiences of these nurses. Results The sample consisted of nine female nurses. All were Caucasian, ranging in age from 38 years to 63 years. Over half (n=5) were married, with one-third (n=3) divorced and one single. Six of the participants had at least one child living with them at the time. Educational backgrounds of the nurses varied, with four participants holding a Bachelor of Science, two reporting a Master of Science, and three reporting being advanced practice nurses with a doctorate in nursing. Specialty areas identified included critical care, public health, maternal child and emergency room. This was the first experience working during a hurricane for the majority of the participants (n=6). However, four of the participants had previous experience with other types of disasters such as car accidents, tornados, floods, and disasters in other countries. Over half (n=5) were volunteers, while the remaining four were deployed by their employers to provide care at their particular site. The nurses provided care for an average of nine days, ranging from one day to 14 days. Six nurses provided care for nine or more days. Description of the phenomena The description of the lived experience unfolded sequentially with initial responses to the situation including (1) “chaos”, (2) “reality check “, comprehending the reality of the chaos including systems failure”, (3) “reorganizing,” as they made sense of the experience from a professional and personal perspective and were then able to begin planning novel coping strategies, (4) “stabilizing”, that time period when nurses initiated care within the constraints of the situation, and finally, (5) “planning for the future” including reflection about, and evaluation of the experience. These 5 themes: chaos, reality check, reorganizing, stabilizing, and planning for the future, described this lived experience for the nurses. Chaos The nurses’ initial responses to the disaster and the care giving environments included a range of emotions including excitement, nervousness, fear, and being overwhelmed. Nurses described their responses. “At first the thought of helping was exciting, but it blows your mind when you get there.” “I was nervous and scared but it was safer than I expected”. “Getting there had a huge impact on me with so much devastation and no more homes, no casinos or restaurants. So much need and so few resources—it scared me—how could I help?” “Where to begin—it was overwhelming, horrific”. “It was tough, people were shell shocked-they didn’t know what to do or where they should go””. “I thought “what am I getting into” and there I was right in the middle of it.” One participant was impacted most by the responses of others. “Seeing a strong person, who should be in control, (sheriff) break down and be shattered, that was true evidence of the chaos around us”. This first theme, “chaos”, was one in which the all of the nurses were profoundly affected by their initial responses to the catastrophe. While some could articulate the need for immediate action, for most it was a period of having to allow this disaster to register within themselves before they could begin providing care. Reality check The nurses’ initial responses gave way to a “reality check”. This was the process during which the nurses began to comprehend the enormity of the problems they faced, which included the monumental devastation and danger that were present, coupled with the realization there were minimal resources and supplies available to remediate these situations. The emotional impact of these realizations on the nurses seemed most evident during this time. At first, this emotional impact appeared to be almost paralyzing, as the total enormity of the situation truly registered within them. Nurses used words such as “overload”, “continuously being overwhelmed”, “a nightmare”, “total devastation and horrific”, to describe their reactions. Statements such as “this was not as bad as they say in the papers, it is WORSE” or “the enormity of the numbers, the needs and the level of frustration- no one could have imagined this “ typified their responses. While personally overwhelmed and trying to reconcile their own feelings regarding the reality of the situations, the nurses were still acutely aware of the distress and needs of others. Nurses related “Trying to get people resettled was really hard because there was so much that wasn’t anymore—it was really awful. I can’t believe how it made me feel”. “--What could I do?—they had nothing—they were scared and I felt scared—no phones—crap all over the place -no place to feel safe…secure”.. “My ability to concentrate and focus altered, as I began to see and feel so much for these people—it just got so hard”. Nurses also began comprehending the breakdown of those systems that they expected to be there to help them. Not only were they feeling overwhelmed, but the structures and organizations they turned to for guidance were experiencing the same. Nurses reported “The system was overwhelmed—workers could come and would not know how to help, no one could tell them what to do—a delayed system—really paralyzing—truly overwhelming, “ “Seeing so many people with so many initials was overwhelming—every time you turned around someone with a jacket and new initials—I did not know what these people did”. “Even the Board of Nursing was overwhelmed and could not tell us where to go, although we were waiting for an assignment, the board could not ok our credentials and this too hampered our effectiveness as nurses willing to help in a critical time of need.” The process of a reality check for these nurses seemed to be completed when they could better “comprehend the incomprehensible” of what had happened. It was at this juncture nurses began to wonder how they could intervene effectively. While one nurse was “relieved to leave the situation,” most talked about formulating a plan of how to deal with devastation and overwhelming needs that were obvious. In this phase, the nurses realized they were no longer operating in the ordinary world of health care. There were no systems in place or resources from which to get help, only themselves and other volunteers in a sea of need, often facing what seemed like an insurmountable task of providing care. Reorganizing In the next phase, “reorganizing” the nurses began to creatively restructure their thinking to see how they could be effective. There was recognition that novel ways to handle situations were needed and that resources were not necessarily going to be distributed fairly. Nurses noted “You had to be flexible”, “We usually had supplies but I knew that others did not”. “No power (electricity), fear felt by everyone, horrible working conditions, no sanitation, facing the unknown of what might happen- people terrified for themselves and their families, Portapottys, IV bags to clean up, survival improvisations, no food, no showers. One truly needed to have a plan to deal with this much destruction”. To be able to effectively provide care to those in need, the nurses recognized they had, to some extent, to dissociate from their own feeling and emotions. As one nurse stated “emotions are put in check and you do what you know you can do”. They also began to mobilize their own support systems. .Nurses described how “We walked in pairs for safety as agitation from folks all around hospital grew”. “We worked hard as a team to do what needed to be done. People from all walks of life worked together”. “Everyone pulled together from housekeeping to administrators, even though we were all terrified for our own families and ourselves.” Thus, during the process of reorganizing, nurses were able to plan how they could best provide care in their environment. Stabilizing “Stabilizing” the next identifiable theme, was that time period when the nurses implemented plans of care based on their nursing knowledge as well as the resources available, which were at best, less than minimal. The nurses utilized their creativity and problem solving capabilities to provide care anyway they could. Common statements were “We learned to sit in the dark,” We had no power, so we used flashlights.” and. “We improvised and did not waste materials/resources ” or “We ignored the fact that there was no charting—no power and no rules,” “Of course we knew we were breaking the law-,you do what you need to do, setting aside policy and rules that did not apply.” Nurses drew on known interventions and adapted them to the situation. One nurse stated “I adapted my own interventions, just like I would do in the office, seeing people, getting organized and providing counseling. “We were an island alone and had to adapt and keep on going”. Another elaborated “So while the system did not help us, I did my time and created my own role –going into community, problem solving, putting out fires, buying meds with my own money, educating, providing conflict resolution, grief counseling, being a liaison with hospitals. Then I started the real work , listening to staff at hospitals, prioritizing who really needs help, because it seems that everyone did”. Thus, in this phase actions were prioritized and care was given in a holistic manner, while adapting to the environment. While implementing care, nurses still had to struggle with their own moral /ethical values. Nurses described responses such as “I got angry at people not responding.” “ Some whining about no ice when that was so minimal next to other needs I saw.” “ Complaining about standing in line over and over again, snatching and grabbing”. “ Are people good or evil—a duality of split in me? How do we judge people when they respond to stress, trying to survive, but then abuse the system—do we judge them???” Moral ethical issues also surfaced in dealing with the health care systems. In many instances, with systems breaking down, the nurses were faced with trying to implement care , only to have their efforts stymied by others. Red Cross policy prevented some nurse practitioners from doing nurse practitioner functions. Frustration mounted as nurses could not provide the kind of help that they thought necessary. One nurse observed, “While help in third world countries seemed to be easily delivered, it was not here on the southern coast of the United States” “So many in need and we were working in a system that was not very organized”. Another stated “ I felt ridiculous when I could not prescribe as a nurse practitioner because of Red Cross policy. Policy got in the way. I am all for guidelines, but this was not the time to follow them”. The nurses found themselves becoming overwhelmed and frustrated with the Federal Emergency Management Association (FEMA.), illustrated by this nurse who noted “No one knew their role—making judgments they should not have, making decisions beyond their scope” . Nurses were often sent to places of extreme need, but there was little organization and sometimes, extras had to “find” ways to help. One nurse commented, “I had to find something to do and this was so frustrating, knowing that in so many areas there was more than anyone could handle.” Nurses observed agencies fighting with each other, state versus federal and, as several nurses explained “we were just public health- we were in the middle—resolving conflict and the differences were major issues for us and no one provided guidance or guidelines for us.”. Some nurses took on the task of conflict resolution “Lots of agencies were here and it took a learning experience and learning curve to work with them trying to find a tactful way of making their involvement positive, which was often the real challenge”. . Thus, despite policy confusion, agency conflict, and environmental hardships, nurses were able stabilize environments and be effective in providing care. Planning for the futureThe last phase of this experience, “planning for the future” describes the theme when nurses could begin evaluating the impact of the experience, both personally and professionally. The nurses could reflect upon what had happened, how they had impacted the situation and the outcomes of their efforts. During this process, nurses realized that that they had gone back to basic nursing skills, ignoring policies that were not working, setting aside the rules of a system clearly broken and becoming creative in providing care anyway they could. Capturing the views of these nurses were the comments “We worked hard as a team to do what needed to be done, people from all walks worked together.”. “This is what nursing is; doing what you need to provide care to people in need”. Professional pride was evident as these nurses reflected on their experiences. They expressed “ pride in their profession and their colleagues”, being able to help and give, recognizing the efforts other nurses from all over the southeast and working together as a team . Nurses identified their professional strength as filling a multitude of needs and roles regardless of specialty areas. A part of this pride came from the recognition that they were jacks of all trades while some of the physicians, it seemed, could not move out of their role For instance one nurse observed that, “a doc who was a pediatrician would not care for elderly who were the biggest part of the population in need. If he was a nurse that would never happen”. Clearly, these nurses perceived a sense of solidarity with each other as professional nurses. From a personal perspective, nurses reflected on their individual efforts to provide care. Nurses acknowledged feelings of guilt because they were not able to help all of those who were in obvious need.. Many wondered if they had done a good job, with reflections such as . “It is kind of strange what you think back on. You think about, did I do enough, was I helpful, why did this happen? and a lot of other stuff too”. The nurses said that talking about their experiences and feelings, and realizing what they had accomplished made it a “positive learning experience”, so that there was “less guilt because we had helped and done what we could no matter how small or large a contribution we had made.” However, despite these positive reflections, many nurses tended to minimize their contributions with comments such as, “ while it was an overwhelming experience, others had it so much worse—I was just a regular nurse, “I only worked one week,” “I only worked 24 hours” or,” I only worked two weeks”. Acknowledgement of changed professional relationships after the hurricane experience was another aspect of the evaluation process. Nurses described this with comments such as, “it was surreal to return to the hospital with those of us who were there having a closer bond than with those who did not come back to help”. “There seemed to be a different level of understanding between those who were there and those who were not”. “We know we won’t let each other down—it can’t be put into words—a bond, but no ostracizing of those who did not come back, just a different sense of trust among those who were there.” The nurses also engaged in self analysis of the impact of the experience on themselves as individuals. In this stage of planning for the future they noted such impressions as “it forced us to reevaluate our own strengths and resolve—could I go on if I lost everything—what are my values --what are my personal limits of coping?” “I used to complain; now I want to be a part of rebuilding. I used to get upset at little things, insignificant, now its like let it go and deal with the big things—now I am a calmer person—I grew a lot as a person”, Thus, most of the nurses felt that the experience of providing care had changed them forever. “Being prepared” was a major component of this phase. Some of the nurses reflected that, “Nurses need to be better prepared and have better planning to have what they need to help others and other nurses—agency collaboration is so essential, we didn’t have that this time but we need it if it happens again.” “Every nurse should be prepared to assist- I would go back! We too often sit back and do not get involved. Nurses make a difference and at least I can say I helped and all nurses who came made a difference”. All the nurses said that they “would do it again if they had to". Discussion This study explored the lived experience of nurses providing care during the hurricanes of 2005. The themes which emerged suggest that the lived experience mirrored the nursing process in several ways. (See Figure 1) The five steps of the nursing process include assessment, diagnosis, planning, implementation and evaluation.3 While these steps of the nursing process often overlap each other, so did the phases of the lived experience. In the first phase, “chaos” the nurses began to quickly “assess” the situation, but their personal responses to the enormity of the situation prolonged the assessment phase. The nurses realized that they not only did they not have resources, but that the system was broken and all previous ways of delivering health care would no longer apply. In the next phase,” reality check”, nurses had to put aside their own feelings and responses to begin to effectively “diagnose” the needs of their situations. While still attempting to assess the enormity of the needs that were present, the nurses now had to formulate diagnoses of the problems they were facing. It was also imperative to begin “reorganizing “or “ planning” to deliver care with whatever resources they had. This planning included restructuring their own thinking to work outside of the now non-existent system and policies. Utilizing their basic knowledge of nursing, the nurses became more creative and efficient in planning how to provide care with what they had. Planning resulted in “stabilizing” the care environment for those who sought help. During this stabilization phase, nurses were “implementing” care while overcoming many obstacles, not the least of which, were malfunctions in the system. Finally, the nurses began to “evaluate” what they had accomplished. This reflection was revealed in the theme of “planning for the future”.. Evaluation included review of both the positive and negative aspects of the experience, with many nurses discussing the failure of the system as a negative The needs for increased communication, and role clarification among involved agencies as well as for expedited responses by those same parties were identified as imperative for the successful response in future disasters. Personal evaluation was accomplished during this phase as well. Nurses were able to reflect on how the experience had changed their individual perspectives on life and values . Nurses commented on how these insights would affect their future behavior and outlook on their personal and professional life. Therefore, the phenomena can be defined as an overwhelming personal and global experience that required creative, tedious, and frustrating efforts on the part of those providing care. The lived experience involved utilizing knowledge of basic nursing care to provide assistance to those in need at a time when only basics were available. It was a rewarding, but challenging experience that had a definitive impact on these nurses,. The lived experience forced them to review their personal and professional priorities, making this a signature event in their lives. The lived experiences of the nurses described in this paper provide a unique addition to the literature on care providers responses to assisting those in need during disasters. Much of the literature has utilized survey methodology with the focus being on discovering care providers risk for compassion fatigue or post traumatic stress following their care providing experiences.4-9 This body of research offers suggestions for identifying those as risk for adverse reactions post care giving as well as for providing interventions to assist care givers of disaster victims. The current research adds to this body of literature by providing an in depth view of the experience of those providing caring during disasters without the assumption of negative outcomes for those providing care. The findings provide a holistic view of the experiences from the perspectives of those actually providing the care. Further, the lived experience of these nurses illuminates the processes of professional nursing practice. Summary The lived experience of these nurses crystallized the essence of nursing as caring for those who need to be cared for, in any situation, in a holistic manner, utilizing the resources at hand. The actions of the nurses illustrated that care was guided by the art and science of nursing. The themes which emerged were those which paralleled the nursing process : Chaos and assessment, reality check and diagnosing, ,reorganizing and planning, stabilization and implementation, and planning for the future and evaluation Simply stated, the lived experience of these nurses exemplified the profession of nursing at it highest level. Figure 1. Emerging Themes and Nursing Process
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