What would you do in the following situations?
* You're a staff nurse in a trauma center and a single parent of a toddler. When 20 patients with severe acute respiratory syndrome are admitted to your facility and a disaster is declared, do you report to work?
* A hurricane has devastated your community, severely damaging your home and belongings. You and your dog are living in your car. Do you report to work?
* A train carrying toxic chlorine gas has derailed near your home, and you and your elderly mother are forced to evacuate. Casualties are arriving at the community hospital where you work. You want to report to work as scheduled, but you and your mother have no place to live. Do you report to work?
* You are a volunteer on a disaster assistance response team that's being deployed for two weeks to another state affected by a major earthquake. But you're also scheduled to work at the home health care agency where you're a full-time employee. Do you report to work or volunteer?
When disaster strikes a community, the demand for health care and social services can be staggering. For example, the 2005 Gulf Coast hurricanes, Katrina and Rita, led to the evacuation of more than 4 million people, the destruction of more than 100,000 homes and at least eight hospitals, and more than 1,200 deaths.1 Nurses are important figures in disaster response, but as members of the community they are as vulnerable as anyone else to property damage, injury (to themselves or a family member), or displacement, which could make it difficult for them to report to work as scheduled. Disasters can produce ethically challenging situations, including the triage of patients when resources are limited, the quarantine of infectious patients, and the mandatory administration of medication (in response to an epidemic or bioterrorism). But one of the most difficult dilemmas a nurse may face is being forced to choose whether to report to work or to care for oneself, one's family, or personal property. The public health implications of the decision are significant: if too few health care workers report to work during a disaster, patients will not receive the care they need.
WHEN DUTIES CLASH
In a disaster, nurses may find that personal and professional responsibilities clash. This issue can be viewed as a conflict between “duties of fidelity”—that is, the moral obligations to honor one's promises and commitments.2 Duties of fidelity may involve complex relationships with multiple commitments and promises.3 When a conflict like this occurs, a nurse can feel caught “in the middle,” unable to keep commitments made to each party.4 There are several ethical considerations that might be used to determine priorities when confronted with such a problem, each of which might lead to a different decision. (See The Ethical Dilemma, page 57.)
The ANA's Code of Ethics for Nurses with Interpretive Statements (2001) offers conflicting guidance in this situation. One provision states “The nurse's primary commitment is to the patient, whether an individual, family, group, or community.”5 This seems to suggest that a nurse should report to work in a disaster. But another provision of the code states “The nurse owes the same duties to self as to others. …”5
THE IMPACT OF DISASTER ON THE HEALTH SYSTEM
Hospital resources can be overwhelmed by the demands placed on them in a disaster—especially if the hospital itself is damaged. For example:
* Eight months after Hurricane Katrina flooded New Orleans, only 15 of the area's 22 hospitals were open, with only 2,000 out of a total of 4,400 inpatient beds available.6
* Sacred Heart Hospital in Pensacola, Florida, was struck by Hurricane Ivan in September 2004. Because of power outages and damage to homes, many hospital staff stayed in the hospital; more than 4,000 people occupied the 449-bed facility at one time.7
* Flooding from Tropical Storm Allison in June 2001 inundated the Memorial Hermann Hospital in Houston, causing catastrophic failure of all hospital systems. No staff could enter or leave the hospital for several days.8
* Eight hospitals in the Los Angeles area were evacuated because of damage from the January 1994 Northridge earthquake.9
The IMPACT OF DISASTER ON NURSES
In 2002 French and colleagues, a group of three nurse researchers, described emergency nurses' concerns regarding duty in a disaster—Hurricane Floyd, which hit Florida in 1999—and the conflicts they had experienced.10 Participants reported that they felt they needed to meet family commitments but also had professional obligations. These nurses identified personal and family safety and pet care as primary concerns while at work during the disaster. When nurses were asked about coming to work in a disaster, they made statements such as “If my family is secure, then I would come”; “Family comes first”; “If my dogs are not welcome, I am not coming either”; and “I would rather lose my job than be here during a category [five] storm.”10
A 2005 study by Columbia University researchers uncovered specific barriers that would prevent health care workers, including nurses, from reporting to work in a catastrophe.11 The study examined both the ability (a logistical issue) and the willingness (an ethical issue) of health care workers to report to work in various types of disasters. These findings, summarized below, are important considerations for individual nurses and their employers. A number of these problems can be tempered or reduced by planning. Barriers to reporting to duty found in Qureshi and colleagues' study include the following (supporting findings of other researchers are also cited):
Personal and family safety. The researchers found that the most frequently reported reason for a hospital employee being unwilling to report to duty in a disaster was fear and concern for her own and her family's safety. In order to feel willing and able to leave home and return to work after a traumatic event like a disaster, it's important that people have a sense of safety.12 There are actions that hospitals and other employers can take to ensure the safety of workers in a disaster, including training in the use of personal protective equipment and providing social support services during the disaster response.
Transportation issues were identified by 33% of respondents as a potential barrier to reporting to work. Many health care agencies have plans to pick up employees from their homes during winter storms if they are unable to get to work. These plans are commonplace and can be extended to include plans for various disasters.
Care of children and the elderly. Twenty-nine percent of respondents indicated that responsibilities to children might prevent them from reporting to work, and 11% said that responsibilities to elderly relatives could also have this effect. Hospitals and other health care agencies have begun to recognize that employees are much more likely to report to work in a disaster (and, often, to stay for long periods) if services are provided to help them care for children and elderly relatives.
Pet care. Sixty-three percent of U.S. households have a pet,13 and Qureshi and colleagues found that 8% of respondents said the obligation to care for a pet might prevent them from reporting to duty. Similarly, the study by French and colleagues found that some nurses said they would not come to work if they did not have adequate care for their pets.10 An employer should develop a plan for employee pet care in advance of a disaster. Pets require space, nutrition, waste management, and monitoring. During the response to Hurricane Katrina, one nurse executive I know turned an inpatient unit into a pet-care unit, using volunteers to staff it. This significantly increased the number of nurses who reported to duty. The executive believes the pet care plan saved lives by making more nurses available to patients during the disaster.
Other work or volunteer obligations. Two and a half percent of respondents cited a second job as a potential barrier to reporting for duty. An employee with more than one job should, in advance, designate one job as the one she'll report to during a disaster. An employee who is a volunteer on a disaster assistance response team should have a prior written agreement to clarify what activities will be supported by the employer.
EMPLOYER DISASTER POLICIES
There are great disparities among hospitals and other health care agencies in the type of personnel policies in place regarding employees' rights and responsibilities in a disaster. French and colleagues found significant variability in how organizations adjust pay, manage discipline, and provide for staff members' basic needs, such as sleeping accommodations, meals, health care (including postdisaster mental health debriefing), and pet care.10 Some organizations may not make it easy for nurses to meet their professional obligations in a disaster. In some cases, disciplinary action may be taken against nurses who don't report to duty. For example, about 25 nurses at Florida Hospital–Ormond Memorial were fired or suspended for not reporting to duty during Hurricane Frances in September 2004.14
Cape Canaveral Hospital in Cocoa Beach, Florida, provides one example of responsible planning. That facility, which has had to deal with many hurricanes, has developed innovative employee policies and educational initiatives to clarify expectations and responsibilities. The goal of these policies is to hold employees accountable when the community needs them, without endangering them or their families. The hospital's expectations of employees are spelled out in brochures distributed each year, and meetings are held to review the policies. An exemption process is available to employees who meet certain criteria. Additionally, the hospital provides child care services for employees during disasters and encourages employees to make preparations at home so they can be ready when a disaster occurs.15
Emerging research is helping us understand how nurses and other health system employees behave in disasters. It's clear that some of the factors that may prevent nurses from reporting to work in a disaster can be mitigated. Prior planning is essential, on the part of nurses and their employers, to reduce the chance that a nurse will face an ethical dilemma under stressful circumstances.
Steps that both nurses and institutions can take to plan ahead.
How can a nurse make the right decision and avoid a conflict during a disaster? Preparedness is essential. Both the nurse and the nurse's employer should clarify their expectations before a disaster strikes. Both can take action in advance to reduce the chance that a nurse will have to face a difficult choice—or even disciplinary action—when a disaster occurs.
What Nurses Can Do
* Develop your own disaster plan that specifies who would care for your children, parents, or others who depend on you.
* Devise a plan for emergency pet care.
* Know exactly what your employment contract states about your obligation to report to duty in a disaster, as well as any exemptions from that obligation.
* If your employment contract does not address disaster response, ask your supervisor or human resources department for written disaster policies; if none exist, request that such policies be developed.
* Determine what types of support your employer will provide for you and your family in the event of a disaster. Inquire about this during employment interviews.
* Pack a disaster “go bag” with all the clothes and supplies you would need if called to work in an emergency.
What Employers Can Do
* Craft clear policies that delineate what the employer expects from employees during a disaster.
* Educate employees on what the organization expects and what the implications of certain choices will be.
* Develop a process for exempting employees with special needs from disaster response.
* Determine what services will be available to support employees who work during a disaster (for example, child care, elder care, pet care, meals, sleeping arrangements, health services, mental health care, communications, among others).
* Make agreements in writing with any employees who are volunteers with disaster response agencies.
* Determine which employees may not be available during a disaster, including those in the national guard, military reserve, or with a second employment obligation.
A Web site run by the San Francisco Office of Emergency Services and Homeland Security details how to make a disaster preparedness plan and build a disaster kit; though designed for residents of San Francisco, the site is useful no matter where you live. www.72hours.org
Columbia University National Center for Disaster Preparedness
Disaster resources for parents, schools, the elderly, and people with disabilities and mental health needs. www.ncdp.mailman.columbia.edu/program_citizen.htm
Humane Society of the United States
Diverse resources for people who have pets, horses, and livestock. Includes guidance on developing an emergency pet care plan. www.hsus.org (click on “Disaster Center”)