Davidson, Judy E. DNP, RN, FCCM; Sekayan, Ani BSN, RN; Agan, Donna EdD; Good, Linda PhD, MN, RN, COHN-S; Shaw, David MD; Smilde, Renee MD
In the past decade, focus on hospital disaster preparedness has heightened. The American College of Emergency Physicians (2007), The Joint Commission (2007), and the Department of Health & Human Services (2006) have published guidelines and recommendations regarding hospital staffing during disasters (Cone & Cummings, 2006). In October 2007, San Diego experienced the worst fire in its history with five fires burning a combined 368,446 acres (Wildfires, 2007), threatening thousands of homes, and resulting in evacuation of 500,000 people. Stretches of essential freeways were closed, blocking off some areas completely to inlet or outlet. The fires presented a disaster of unprecedented community impact. This study's hospital experienced a 10.6% no-show rate on the first day of the fire versus 0.60% on a similar workday the previous year; this represents a 17-fold increase in fire-related no-shows (S. Maldonado, personal communication, February 12, 1978). Proactively addressing staff concerns increases the likelihood of being able to staff the emergency department (ED) following a natural disaster such as a fire.
The purpose of this study was to describe factors influencing the decision to come to work during the San Diego fires and explore drivers affecting that decision.
Disasters can be of two types, classified as (a) conventional or natural disasters (e.g., wildfires, hurricanes, floods, major accidents, earthquakes) and (b) nonconventional disasters (e.g., chemical, biological, radiological, and nuclear events or infectious agents), resulting in the threat of exposure, infection, illness, or contamination to emergency healthcare workers (Smith, 2007). The response to disaster may be dependent upon the type of disaster; however, study of fire-related disaster has been minimal (Cone & Cummings, 2006; Hoyt & Gerhart, 2004).
The 2007 San Diego wildfire was not the first large fire in San Diego County history. During the October 2003 wildfire, 10% of San Diego County burned, consuming more than 4,000 acres and affecting 2,500 residential, commercial, and industrial facilities (Hoyt & Gerhart, 2004). Sixteen people were killed, including one firefighter. A description of the 2003 experience validated that the staff decision to come to work was an important element in being able to meet organizational disaster needs and that administrators should consider developing a script clearly describing why additional staff might be needed during a disaster (Hoyt & Gerhart, 2004). The reader is also referred to two reviews of the literature for a more complete synopsis on employee response to disasters (Good, 2007; Smith, 2007). These reviews suggested that it was not realistic for organizations to assume that staff would be willing to work when faced with a major emergency or a disaster.
Following the terrorist attacks of September 11, 2001, barriers to staffing were identified (Table 1). Moreover, fear for personal and family safety contributed to the reluctance of healthcare workers to report to work during terrorist events (Smith, 2007). French and colleagues (French, Sole, & Byers, 2002) studied the needs and concerns of nurses in response to Hurricane Floyd. The nurses were simultaneously disaster victims and caregivers of victims faced with the conflict between family and work commitments. French et al. concluded that family safety, pet care, and personal safety at work were of primary importance to employees. Basic needs of food, water, sleep, shelter, and rest were secondary concerns. Nurses also experienced fear in response to real threats. Unfortunately, employees were required to report to work or face consequences of reprimand or discipline, and those who did not report for hurricane duty were terminated for job abandonment per hospital policy (French et al.). From the experiences of Hurricane Katrina, Buttross (2006) gleaned that leaders needed to account for the emotional needs of employees if they were going to be able to staff a hospital during a disaster, including provisions for childcare. After an analysis of (survey) evacuation responses during a hurricane, Piotrowski stated that employers should abstain from adding unnecessary burden to staff during and immediately following a natural disaster (Piotrowski et al., 1997).
Published anecdotes following the September 11, 2001, disaster described that staff might come to work following a disaster to support each other despite personal tragedy (Dutton, Frost, Worline, Lilius, & Kanov, 2002). The decision to report to work might be stronger when leaders demonstrated compassion about the situation. However, leaders who demand “work as usual” might experience an erosion of staff loyalty. Cone and Cummings (2006) found that healthcare workers were most likely to report to work after natural disasters than after manmade disasters. Furthermore, the availability of telephone and e-mail service; transportation assistance; and pet, child, and elderly care might enhance the ability and willingness of hospital staff to work and stay at the hospital during a disaster.
This study was conducted at an urban teaching hospital in the southwestern United States following institutional review board approval. Minimal probes were used in a focus group to allow the participants to share feelings and experiences (Burns & Grove, 2005). By using the subset of phenomenology, entitled phenomenography, the lived experience was explored assuming that people would experience the same event and have differences in their responses because of their individualized worldviews (Sjorstrom & Dahlgren, 2002). Phenomenography differs from phenomenology because it does not seek to find a single truth or phenomenon, but rather to describe the different ways that people interpret, perceive, or experience that phenomenon. In this fire-related study, contextual issues surrounding the decision to come to work during a disaster were explored.
A standing forum, called the Schwartz Center Rounds, provides an opportunity for caregivers to discuss difficult emotional and social issues that arise from caring for patients (Schwartz Center, 2007). Kenneth B. Schwartz, a healthcare attorney, established the rounds before his death “dedicated to strengthening the relationship between patients and caregivers in the changing healthcare system,” presently sponsored in more than 129 hospitals (Schwartz Center). The research described in this article was based on data collected from all of the attendees present during the November 9, 2007, rounds that followed the October 21–26, 2007, wildfires. Results were confirmed with participants following analysis.
The major risk to the study was confidentiality. Even though the names of the participants were not recorded into the summary or records, because of the nature of the disclosures, identification of the participants was possible. A secondary risk was that of stimulating anxiety or concerns through disclosing or listening to the disclosure of others. Trained psychologists were present at the rounds to assist affected employees as needed.
Inclusion criteria included all those in attendance at the Schwartz Center Rounds who were willing to share the lived experience of making a decision to come to work versus stay at home during the San Diego wildfires. Three people, an ED physician, a nurse, and an ancillary professional, were asked to present their own stories before the discussion was opened up to the audience. This purposive sampling ensured the inclusion of staff and physicians who both came to work and those who did not. A total of eight participants were consented prior to entering the room. Signature was waived to protect confidentiality of the participants.
Recorded Field Notes
The research team recorded field notes of responses and reactions to the discussion. The facilitator for the program was a trained focus facilitator and psychologist who used preplanned probes to begin the discussion (Table 2).
Analysis was conducted including the classic steps of phenomenography (Table 3). A summary of the findings was written and shared with the participants from the purposive sampling for validation.
Eight participants provided testimony to their experience. Three themes were identified: tension, the caring culture, and the need to help (Table 4). Concepts at the intersection of decision points were identified.
The respondents reflected on the tension between personal and professional commitments and loyalties. All respondents mentioned that their first inclination was to assess the physical safety and emotional well-being of themselves, their family, their pets, and next, the safety of their property: “I have dogs, cats, and horses … I could not even think about coming to work.” Participants reported negotiating with their spouses who wanted them to stay home for emotional and physical support. Participants were torn between caring for their families and wanting to work to support and care for their coworkers, some of whom were severely affected by the fires. Additional family tension occurred as employees took in evacuated friends and coworkers. Once the safety of family and property was assured, others felt they might be of more help for the community outside of work than for the hospital. There was clearly tension between coworkers; one participant felt others “dismissed” what she had gone through in staying off work to evacuate her animals and sensed anger and resentment from the coworker who had to cover in her absence. Some employees who lived in the high-risk areas reported distraction from patient care by the ongoing need to watch or listen to the developments in the disaster areas. Their decision to stay at work was influenced with the change in direction of the fires or the need to organize the move back home.
A Caring Culture
A second theme identified in the decision to report to work was the employees' perception of the organization's “caring.” The employees' direct supervisors' supportive actions made a strong impression. Several participants discussed the connection they felt by being called as part of their department's “phone tree” communication process. One participant shared her response to her supervisor's phone call: “She called to see if I was OK—this really made me feel like I work at a wonderful place.” Added to positive impressions generated through supervisors' actions, participants praised the caring behavior of coworkers. As an example: “He was such a role model—even though he had lost his home [to the fire], he came into work. I was just so touched by what he did.”
The Desire to Help
During the fires, public officials instructed the public to stay home, including any nonessential, nonemergency personnel, and many government agencies, schools, and private businesses closed. However, as part of a plan to manage potential surges in the demand for emergency medical treatment during the disaster, hospital leadership expected all capable hospital staff to report to work. Although many nonessential hospital services (such as elective procedures) were cancelled, the intention was to reassign personnel from closed areas to essential open departments, to ensure coverage for employees who were unable to report to duty, and to operate special disaster-related services (e.g., childcare). This strategy was not clear to all staff and, as a result, some who viewed their particular role as nonessential felt that they should stay home as instructed through the media.
Once personal, family, and pet safety was established, many participants expressed the desire to help those affected by the fires. They recalled considering where they would be most useful. Some felt strongly drawn to be at the hospital: “I felt the need to get in to work to be a support to them.” “I knew I needed to be there for the patients.” One participant whose home was in the danger area (and was authorized by her supervisor to stay home) expressed feeling conflicted: “I felt uncomfortable and guilty not coming to work on Sunday when things were starting to ‘heat up.’”
Concepts at the Intersection of Decision Points
Several concepts emerged contextualizing the decision to come to work and are identified in italics throughout this section. The participants collectively began the decision to come to work with a universal introspective question, “Am I safe and is my family safe?” Family was defined by these participants to include pets. In fact, the testimony of pet owners was more emotionally laden than of those who described the safety of children, elders, or spouses. When considering family safety, the concept of vulnerability was identified as an important decision point. If vulnerable members of the family (including pets) were taken care of, a decision to come to work could be entertained. If vulnerable family members were at risk, the staff member would not consider coming to work. Pets were considered more vulnerable than humans were, and large pets (e.g., horses) that were difficult to transport were perceived as most vulnerable. Vulnerability was further defined by proximity to the event. Multiple participants described “seeing the fires licking over the mountain.” Being so close as to see the flames heightened the sense of danger. Once it was determined that the employee and family members were safe, values regarding commitment were considered.
Participants weighed commitment to self, family, organization, and community. Personal values ranking importance of one commitment over another was individual to the employee. Perceived importance of the person's role during a disaster was a secondary driver to commitment. For instance, one participant struggled with the decision to come to work versus volunteering in the community. Her decision included the fact that the hospital was not in immediate danger, but many community members were. Her final decision filtered down to the fact that she had played an important hospital role in the last community disaster that had been a positive, rewarding experience. She felt her skills at disaster management would be better served in the hospital. Past experience helped form the decision in the now. Similarly, a physician described his role as captain of the ship. His wife was not in danger and he felt he had no option but to come to work, “I had done a lot of relief work in the past, but I never thought I would do it in my own town.” He reflected on his positive past experience with relief work that formed the strength of his value to serve at work. On the contrary, a worker who felt that her skills were not necessary during a disaster weighed the decision to come to work lower than her role to maintain safety for her pets. In her words, “No one needs a stat swallow. If I had come to work and knew that the flesh had burned off them, I would never be able to work here again. You would have lost me.”
Connectivity to the hospital during the disaster influenced the weighting of the decision. One employee explained that she had been called by her supervisor activating a disaster phone tree. She could not come to work then because she was not safe, but she remembered the call with some guilt because a colleague had to fulfill her role in continuing the tree further. The verbal connection with her supervisor, and her caring manner in that connection, entered her mind when she decided to work the next day.
Several comments were made about the essence of time in decision making. On the first day of danger, the decision was different from day 2 or day 3. One employee commented that by day 2 in a shelter, she could not take the images on television any longer and came to work for her own health. Further, employee needs depended upon time. Even though there was a day 1 of the fire, it spread in a way that one employee's first day of danger was the same as on day 5 of the disaster. When most were out of danger, the fire spread and affected a completely different group, thus implying that day 1 level of support needed to be available to staff throughout the disaster and could not predictably lessen over time. The cycle of decision making was iterative depending on the nature of the fire (Fig 1).
IMPLICATIONS FOR RESEARCH, EDUCATION, AND PRACTICE
Disclosed factors affecting the decision to come to work in this study sorted into full, partial, and no control, similar to how risk factors for heart disease are clustered to create treatment plans (Table 5). In heart disease, for example, if a patient is overweight, lifestyle modification may reduce heart disease risk. The authors propose that hospital leaders can test the organizational impact on factors influencing decisions to work in disaster planning and response.
Both preplanning and action by hospital leaders during the disaster could assist in moderating employee distress, but other variables could not be managed. Whereas immediate danger to an employee's home is outside the organization's influence, employee safety at the workplace is under institutional control. Child, pet, and dependent adult care could be preplanned and has been identified by others (Buttross, 2006; French et al., 2002; Qureshi et al., 2005). The participants in this fire-related study pointed out an unmet need for pet care and elder or spousal care. The organization did make arrangements with local veterinarians and animal shelters for emergency pet care as endorsed by the AAPCA (American Society for the Prevention of Cruelty to Animals, 2003) and provided evacuation housing. Continued research via focus group activity will be needed to evaluate why participants did not feel that these steps were adequate.
Qureshi et al. (2005) addressed transportation barriers to staffing a disaster proposing employee carpools with predetermined pick up points and arrangements by local agencies to provide transportation for essential personnel. They also suggested that distance might be modifiable by considering the proximity of personnel residence to the workplace as a factor in selection of new hires. Although transportation to work was not mentioned by any of our participants, transporting animals was an expressed concern.
Organizational image and connectedness are cultivated prior to the disaster and further defined by leadership actions during crisis. Several participants commented that the feeling of being part of the “work family” brought them to work. Leaders can unleash a compassionate response during times of disaster. Encouraging the sharing of caring expressions during crisis can contribute to the loyalty and attachment to the organization and foster the capacity to heal, learn, adapt, and excel (Dutton et al., 2002). English, president of TJX Companies, Inc, Framingham, Massachusetts, gathered his staff together to confirm the names of the victims shortly after seven of his employees were lost aboard one of the planes that hit the World Trade Center. Grief counselors were immediately called and relatives of the victims were transported from Europe and Canada. English personally greeted them at the airport. Although English allowed them to take time off, most employees reported to work to support each other. In contrast, following the same terrorist attacks, leaders at a publishing company resumed business as usual. One editor received a call at home demanding to know why she was late for a meeting while trying to help her young daughter make sense of what had happened. Additional unfortunate examples in which disaster response workers felt a lack of administrative support following past disasters yielded a reported reluctance to report to duty in future emergencies (French et al., 2002; Moore, Gilbert, Saunders, Bryce, & Yassi, 2005; Powell-Young, Baker, & Hogan, 2006). The caring theme identified in this fire-related study further validated that a caring expression from leadership might assist in securing hospital staffing during disaster.
Employees' self-perceived role and importance may be partially influenced by the words used during disaster callback systems. Traditionally, disaster callback systems and the assumption that hospital personnel would be willing and able to report to work in a disaster ultimately tests the facility's surge capacity. However, staffing plans generally do not address personnel's willingness to return to the workplace (Cone & Cummings, 2006). Our findings suggested that the phone tree might be more than a mechanism to call in staff and also served to form a caring connection with the employee during times of disaster. Managers and directors may establish loyalty by performing this duty themselves instead of delegating to staff.
To mediate spousal influences, managers, supervisors, and directors may ensure that opportunities exist for the employee to communicate with family while at work or allow spousal presence at the worksite. The need of the individual to help the community may be fulfilled by the opportunity to participate in organization-driven community assistance efforts at a time when organizational needs are met.
Education about the specific role an employee may fulfill during a disaster is essential (Hoyt & Gerhart, 2004). Educators may conduct yearly disaster drills that provide a realistic approach to likely geographical situations, and this is equally important (French et al., 2002). In this study on response to fire, employees who perceived a lack of importance during the disaster verbalized less intention to come to work.
This study further validates that the response to disaster may be contextually based upon family, safety, vulnerability, connectivity, perceived importance, past experience, and time. Employees will be saddled with tension between competing demands despite their desire to help. A caring connection may increase the likelihood of staff attendance to work. Concerns for pets, children, and dependent adults weigh into the decision to work during a disaster. It is plausible that these factors may be modifiable with creative preplanning by hospital leadership.
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