Nurses' experiences of responding to a health care disaster or adventitious crisis: a systematic review of qualitative evidence.

Abstract

Centre conducting review Louisiana Center for Evidence-Based Nursing an Affiliate Centre of the Joanna Briggs Institute at Louisiana State University Health Sciences Center (LSUHSC) School of Nursing (SON) Review Question/Objectives The purpose of this systematic review is to systematically review and synthesise research literature reporting nurses' experiences of responding to a health care disaster or adventitious crisis. This review aims to answer the following specific question: What are nurses' experiences of responding to a health care disaster or adventitious crisis? Background It is inevitable that disasters and adventitious crises will continue to occur across the globe. Over the past ten years, loss of human life due to disasters increased from 600,000 to 1.2 million people with a 17 percent increase of people affected by disasters 1. Additionally, the risk of disasters worldwide will continue due to such factors as global warming/climate change, increased building in areas that are vulnerable to disasters, lack of warning systems, inadequate transportation to assist people in evacuation, and the loss of natural resources 2. Since nurses are one of the largest groups of healthcare workers providing care and services for a disaster or adventitious crisis, nurses will continue to have a role in these events 3. It is essential that we learn from their experiences to improve our knowledge, skills, and readiness, and identify the needs and perceptions of the nurses who respond to disasters and adventitious crises. Healthcare disasters and adventitious crises are difficult to prepare for, and each event has unique features and various levels of response. In particular, an adventitious crisis is defined as a rare, accidental and unexpected tragedy that may affect an entire community or population that often results in long term psychological effects4; exactly what has occurred in New Orleans in the United States since Hurricane Katrina. Throughout history, nurses have been present at the frontline of disasters and crises, treating and caring for the injured, and counselling and supporting those who have suffered losses. Nurses work in devastating conditions with the injured, families of victims, and those displaced by disasters and adventitious crises. Customary resources that are absent in disasters or adventitious crises may include electricity, water, food, oxygen, medication, supplies, and communication systems 5. Typical nursing standards of care involving patient assessment and safety, medication administration and security, documentation and infection control may be altered, placing patients at risk but nurses should continue to be obligated by professional legal requirements in providing care in extreme situations in order to care for survivors and save as many lives as possible6.In response to Hurricane Katrina and other recent disasters such as 9/11 or the Pakistan Earthquake, the American Nurses Association (ANA) developed the document Adapting Standards of Care Under Extreme Conditions: Guidance for Professionals During Disaster, Pandemics, and Other Extreme Emergencies6 that provides recommendations for the individual nurse, health facilities, practice sites, and emergency response planners in times of extreme conditions. This document outlines recommendations to follow when faced with scarce resources. A disaster or adventitious crisis is a life-altering experience, vastly different from any other situation in which a nurse may have worked 7. Nursing care may not be provided in a typical hospital or clinic environment, but in different settings such as a special needs shelter, a field hospital, a make-shift nursing unit in a parking garage, or a first aid station. The nurses may be assigned to different roles such as a triage nurse or managing a special needs shelter, which may be unfamiliar to most nurses8. Nurses may volunteer to work in a disaster area in a foreign country where the culture and values of the community is unfamiliar 9. The transition from working in a familiar environment to disaster situations or adventitious crises is challenging, difficult and precarious, causing nurses to become confused and frustrated when their expectations do not coincide with the realities of the situation and with what their previous job responsibilities have been 7. In disasters or adventitious crises, nurses may lack knowledge in competencies and gaps in education preventing recruitment of nurses to respond to a disaster; therefore, the importance of training and educating nurses in disaster nursing is essential10. Mental health issues experienced by disaster survivors and responders, including nurses, can be considerable, resulting in social, physiological and psychological conditions 11. It has been reported that slightly more than 50 percent of individuals who have experienced a disaster will develop some type of psychiatric symptoms immediately after the event; with a decrease to 41 percent in ten weeks and 22 percent by one year post disaster 12. Often the role of the nurse in a disaster is one of both healthcare worker and victim 5. Crisis debriefing can assist in providing nurses with relief and some closure after the event. After each disaster or adventitious crisis, nurses endure conditions that leave a devastating mark and their reluctance to respond to future disasters is a concern. In the ANA Issue Brief, the author poses the question of whether registered nurses have an ethical and legal “duty” to respond to a disaster situation and provide assistance. Such concerns that nurses face are safety (Will the hospital be safe? How can I care for my family?), ethical (How will the nurse handle difficult situations regarding life and death?), and legal (Is the nurse's license protected?). The report emphasises that nurses must be professionally and personally responsible to be prepared, make plans for their families, and be cognisant of the ethical issues that they might face in a disaster or crisis where decisions will have to be made based on scarce resources 13. Davidson et al14 conducted a phenomenology study to identify what factors influence staff to report to work during a disaster. The results of the study indicated such factors as family and personal safety, past experience, caring environment and vulnerability played a decisive role in whether the nurse reported to work or not. Key features distinguish a disaster from a healthcare disaster, and from an adventitious crisis. A health care disaster occurs within the context of a disaster, and represents the one aspect most familiar to nurses and often influences how nurses respond in a disaster. Factoring in adventitious crises creates a more robust depiction of the event and experience, since the focus is on the community and the long-term psychological effects. Lessons learned are key to understanding the nurses' experiences. The cumulative experiences of nurses inform nursing science and better equip nurses to respond to healthcare disasters and adventitious crises. In understanding nurses' experiences of responding to a health care disaster or adventitious crisis, it is important to discuss the disaster continuum and the associated phases. The disaster continuum includes three major phases whereby several models exist using different terminology. Veenema's Disaster Nursing Timeline identifies the phases as: preimpact, impact and postimpact15; the ICN model entitled Disaster Management Continuum refers to the phases as pre-incident, incident and post-incident16, and in the Jennings Disaster Nursing Management Model the phases are described as pre-disaster, disaster occurs, the disaster, and client/population outcomes17. Whatever terminology is used, there is consensus that the disaster continuum is a continuous process that provides the structure for the disaster timeline and the activities that need to be accomplished during each phase of the disaster15. Pre-incident involves the activities that mitigate or prevent the impact of a disaster and includes preparing the community for a disaster or adventitious crisis. The incident cycle includes activating your personal or organisation emergency response plan, which outlines the critical activities that need to be accomplished during a disaster or adventitious crisis. Recovery, rehabilitation, reconstruction and evaluation resulting from the disaster and adventitious crisis are the components involved in the post incident cycle. Within a disaster management program there are five phases: mitigation/prevention, preparedness, response, recovery, and rehabilitation. Each of these phases has distinct activities that are crucial for a successful emergency management program and where nurses play a vital part in the success of such a program. A preliminary search of Medline, CINAHL, and the JBI Library of Systematic Reviews was performed and no existing or ongoing systematic review on this topic was identified. A systematic understanding of how nurses experience a healthcare disaster and adventitious crisis is proposed. Definition of terms Central to this review are the key terms: Disaster Health Care Disaster Nurses' experience Adventitious crisis For the purposes of this review, these terms are defined as follows: Nurse: refers to a person trained in the scientific basis of nursing who meets certain standards and holds a licence and/or is certified by a nationally recognised certifying body to practice nursing. Nurses that will be included in this study are licensed practical nurses, professional registered nurses, and advanced practice registered nurses. Nurses' experiences: examining the lived experiences of nurses who have responded to healthcare crises and/or adventitious crises in order to gain understanding of the essential “truths” (i.e., essences) of the experience and the sequelae. Disaster: “refers to an event or situation that is of greater magnitude than an emergency; disrupts essential services such as housing, transportation, communication, sanitation, water and health care; and requires the response of people outside the community affected” 18. Health care disaster: any incident that overwhelms the resources of the health care system, locally and regionally, and the effects are expected to last for more than 96 hours19. Adventitious crisis: a rare accidental and unexpected tragedy that may affect an entire community or population, such as an earthquake, flood, or airplane crash. In addition to injuries, lost of life, and property damage, an adventitious crisis often results in long term psychological effects4. Inclusion criteria Types of participants The review will consider publications that include registered nurses who have worked in a disaster, healthcare disaster, or adventitious crisis (e.g. flood, hurricane, earthquake, tsunami, volcanic eruption, terrorist attack) in the years 1945 through 2011. Nurses that will be included in this study are licensed practical nurses, professional registered nurses, and advanced practice registered nurses. Phenomena of interest This review will examine the experiences of nurses in responding to a disaster, health care disaster, or adventitious crisis. Consideration will be given to, but not be limited to, the following challenges: reporting to work personal and family safety dwelling in uncertainty providing front line clinical care changing standards of care in health care disasters or adventitious crisis functioning with severely limited resources, communication triaging and providing care in a range of settings maintaining infection control crisis debriefing mental health sequelae Context Context will include a consideration of the cultural factors, including, but not limited to, geographic location, specific racial or ethnic considerations, gender based interests, detail about the setting (for example, acute care, primary health care, or the community) as they relate to the experiences reported in the studies. Types of studies This review will consider qualitative studies that focus on the experiences of nurses in responding to a health care disaster or adventitious crisis, including, but not limited to, designs such as phenomenology, grounded theory, exploratory descriptive, case study, ethnography, action research, and feminist research. In the absence of qualitative data, the review will consider expert opinion papers, discussion papers, and policy documents. Exclusion Criteria Non-nurse participants/subjects Quantitative Research Non-English articles Search strategy The search strategy aims to find both published and unpublished English language studies. Searches will be limited from 1945 to 2011 and each search will be performed from the inception of a database until the present. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. In the absence of qualitative data, the review will consider expert opinion papers, discussion papers, and policy documents. The databases to be searched include: CINAHL with full text Medline with full text PsycINFO Embase Health Reference Center Academic Expanded Academic ASAP Academic Search Complete Global Health Health Policy Reference Center ISI Web of Knowledge JSTOR Philosophers Index Social Services Abstracts Proquest Health and Medical Complete ScienceDirect The search for unpublished studies and ‘grey’ literature will include: ‘Grey Literature Report’ from New York Academy of Medicine ProQuest Dissertations and Theses Full Text Proceedings First Mednar Institute for Health & Social Care Research (IHSCR), AHRQ (Agency for Healthcare Research and Quality) Grey Source: A Selection of Web-Based Resources in Grey Literature HMIC (Health Management Information Consortium) NurseScribe Index to Theses WHOLIS: WHO Organization Library database Newspaper source plus Conference proceedings Documentaries WebPages of professional nursing and emergency management organisations Initial keywords to be used will be: Nurse* Disaster nurse* Disaster Nursing Health Care Disaster Nurses' Experience Adventitious Crisis All Hazards Approach Emergencies Crisis Response Mass Casualty Incidents Disaster cycle Terrorism Psychosocial Impact of event PTSD Ethical Dilemmas Feeling* Perception* Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). In the absence of qualitative data, the review will consider expert opinion papers, discussion papers, and policy documents, using the Joanna Briggs Institute Narrative, Opinion, and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix II). In the absence of qualitative research, data from expert opinion papers, discussion papers, and policy documents will be extracted using the standardised data extraction tool from the JBI-NOTARI (Appendix II). Data extracted from qualitative research will include specific details about the methodology, method, interventions, setting, geographical area, cultural information, participants, data analysis, author's conclusion, and reviewer's comments. Study findings related to nurses' experiences in responding to a healthcare disaster or adventitious crisis will be extracted. Data synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form. In the absence of qualitative data, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the conclusions will be presented in narrative form. Conflicts of interest No conflict of interest is anticipated. Acknowledgements The reviewers acknowledge the Louisiana State University Health Sciences Center, School of Nursing for support of this project; and Drs. Lisa Hopp and Leslie Rittenmeyer of the Indiana Center for Evidence- Based Nursing Practice for their guidance during this process.