Over the past 15 years, the United States (US) has experienced several large-scale disasters, requiring nurses within healthcare systems to improve crisis response. The ability to manage emergencies and disasters must be a cornerstone of daily healthcare operations. Nurse leaders and frontline clinical nurses experience and expect change within the care environment; in fact, they respond to critical situations daily. Emergency preparedness requires nurses to not only sustain an expected level of performance but also exceed expectations by performing in the presence of obstacles. There is an abundance of commentary on how nurses have provided exemplary care during the disasters known as Hurricanes Katrina, Sandy, and Harvey.1–3 During Hurricane Harvey, perinatal nurses were found to be creative when faced with the critical needs of mothers and infants. Nurses ensured mothers with placenta percreta or patients with fetal intervention were housed at the hospital in the childbirth education classrooms to ensure they had access to the right level of care. Nurses knew these patients needed to be near the appropriate institution with available medical staff to care for their unique needs. Yet, in a national survey, nurses reported feeling unprepared and in need of education in order to feel competent to respond to events.4
Nationally, disasters can be local related to a water main break in a hospital, a mass casualty event in a community such as a shooting, or a hurricane that has an immediate effect on a healthcare community with long-term influence on the supply chain of goods and pharmaceuticals. Global health events such as outbreaks of the Ebola or Zika virus disease have demonstrated the importance of systems working together across nations to ensure the safety of many people. Disasters affect patients and families as well as the workforce equally, depending on the magnitude of the event. Nurses Code of Ethics requires that nurses strive to provide care with dignity to citizens and protect nurses in all circumstances.5 To meet these professional responsibilities, it is imperative that healthcare organizations continuously engage interdisciplinary teams to implement and sustain systems designed to respond to internal and external emergencies. Why is it that nurses are able to perform their duty to care for patients during disasters? Smith and Wolf6 stated that resiliency is a core competency of nurse leaders. Resiliency is present within all nurses and is the ability to cope with a crisis and then have the ability to return to a precrisis state.7 A disaster creates additional burdens on nurses psychosocially due to work and home demands; yet, nurses continue to provide care despite these stresses and many obstacles.8 There is a deeper reason as to why nurses are resilient during disasters. Nurses possess a personality trait that motivates them to endure challenges and be successful over time. This trait is known as grit.
DISASTERS AND THE GRIT PERSONALITY
Emergency preparedness for a healthcare system requires a commitment to everyday excellence. The Joint Commission9 acknowledges that disaster management needs to be an essential element of a hospital's operations. The standards require evidence of engagement of senior leadership and frontline staff, from all disciplines, in creating and sustaining emergency management action plans. Nurses naturally perform during emergencies as they are trained to use critical thinking and judgment to provide interventions, monitor for deviations, and create corrective action care plans for multiple patients on a daily basis.
Disasters create additional demands on the ability to provide care. During Hurricane Katrina, there were endless examples of how nurses provided care to vulnerable populations while under tremendous personal stress.10 Nurses had to determine how to care for patients in the presence of limited to no resources, no electricity, and uncertainty whether or when they could evacuate to another hospital. Nurses moved patients to unconventional areas (garages, stairwells, and helistop) in the heat to improve the environment and prepare for evacuation. Disasters create situations whereby nurses need to provide services under different situations to achieve the same outcomes regardless of the problems created by the crisis. During Hurricane Harvey, because of disrupted supply chains, pediatric nurses at the largest combined women and children's hospital in the US, had to ration specific intravenous fluids by working with pharmacists to ensure conservation yet appropriate treatment. This evaluation of care protocols resulted in the healthcare system's ability to maintain supply of intravenous fluids well beyond the crisis period. Nurses contribute their clinical knowledge and judgment to make these critical decisions to overcome such obstacles to provide care. What is different about nurses that helps drive them to success during traumatic events?
A personality trait that may be present in nurses that makes this type of performance occur is grit. Grit is the noncognitive personality trait that compels a person to achieve goals and objectives despite obstacles.11,12 Duckworth12 defined grit as passion and perseverance over time to achieve goals. These 2 related traits are measured by assessing effort and tenacity, and interest and obsession, in the presence of challenges.13 These 2 traits are measured by assessing attitude and behavior characteristics in the domains of consistency of interest and perseverance of effort using questions such as “my interests change from year to year” and “I have overcome setbacks to conquer an important challenge.”11 Being passionate, or having sustained interest in a subject, propels a person with grit to endure continued practice to achieve mastery. Nurses who have grit are not necessarily gritty about a specific task in nursing yet have the personality of being gritty that makes them passionate about nursing. Grit is different from other traits that are linked to achievement such as intelligence, creativity, charisma, or vigor. Individuals with grit may not be as intelligent as others yet are more successful in comparison.11 The difference underlying this temperament is motivation.14 Nurses are highly motivated to care for others and having grit allows them to continuously improve their competency to care over time.
Grit has been linked to adjectives that define the Big Five personalities.15 The Big Five factor structure was developed using more than 1500 traits, using 10 replications of different factor analytic procedures to reveal 75 descriptions of 5 factors.15 Further analysis of synonyms that describe positive and negative attributes within a 5-factor structure, consistently described 5 personalities with little variance; surgency (emotional reactivity toward a high positive affect), agreeableness, conscientiousness, emotional stability, and intellect. Each of these traits has positive and negative characteristics, which when evaluated, can provide a definition of one's personality.15 Of these characteristics, grit is believed to be a deeper form of being conscientious. Table 1 depicts the positive and negative terms of conscientiousness. The highest rated characteristics of conscientiousness are organization and efficiency. Indeed, these traits were frequently noted in Florence Nightingale's Notes on Nursing and have formed the foundation of the nursing profession.16
Table 1. -
Personality descriptive terms attributed to conscientiousnessa
Adapted with permission from Goldberg.15
In addition to these traits, research has demonstrated that grit entails having stamina.11 Stamina is what excels a person to continue to act despite obstacles to achieve a difficult goal. An example of grit is what differentiates cadets who are successful at the US Military Academy. Those displaying grit were 60% more likely to keep going and complete the rigorous summer training required before pursuing their academic careers. Grit in the form of fortitude or stamina, versus high intellect, was necessary to complete the physical, emotional, and mental task of this difficult training. People with stamina believe that when something is difficult, more practice is required to master it.12 Nurses demonstrate this stamina or tenacity daily and as such surpass expectations when a crisis arrives.
Stamina was vital to sustaining hospital operations during Hurricane Harvey. Over a period of 4 days, nurses worked rotating work/sleep 12-hour shifts maintaining the operations of a 700-bed women's and children's hospital. The teams were determined to ensure that all patients felt safe and that they would receive excellent care. The teams had to create continuous distractions to decrease the anxiety of the event for the children and parents such as putting on short skits, having ukulele sing-a-longs, and movies in alternative safe locations (the hospital is a 16-floor glass tower). At the same time, the hospital was surrounded by water, so there was no movement in or out. The nurses watched on TV as they saw their communities devastated by flood water. The nurse leaders knew that the overall nursing department was going to be profoundly affected by the floods well beyond the actual event. To begin healing, the nursing teams collaborated to identify replacement nurses to relieve those nurses whose homes could be salvaged or who needed to be reunited with displaced families. Throughout this time period, the nurses continued to create birth experiences for 59 families and provide care for countless critically ill children.
As previously stated, the 2 distinct components of grit are sustained interest and perseverance. Perseverance underpins extraordinary performance in the presence of passion. Cultivating an interest to be better at something or achieve a goal takes perseverance. A key element of pursuing goals with grit is having the feeling that work is purposeful.11 Passion is a focused interest on a subject or goal. Nursing has often been described as a purposeful profession of having a passion to care for others. The focused interest of nursing is grounded in the goals of Florence Nightingale—to place our patients in the best position possible to heal.16 Passion and purpose can be seen in the actions of nurses during disasters. Evacuating patients from a hospital is highly dependent on nursing teams. Evacuations are still considered rare events and, when drilled, lack the intensity of a real emergency. During Hurricane Sandy, nurses had to execute an evacuation plan with limited resources.3 The nurses knew this work was crucial and relied on each other to complete this arduous task. Nurses demonstrate grit as they have the capacity to “stick with things” and solve problems together. During a disaster, nurses know that their work matters and that they can rely on each other to move through the crisis.
Emergency preparedness depends on nursing and interdisciplinary peers to strive to perform with excellence regardless of the situation. Cultivating grit among nurse leaders and clinical nurses is essential to sustaining interest in emergency preparedness and perseverance when a disaster occurs. Table 2 outlines key leader and organizational actions based on Grit: The Power of Passion and Perseverance, which will help cultivate a workforce that is effective during and after a critical event.
Table 2. -
Actions that cultivate grita
Have a common purpose: Leading in times of uncertainty such as a disaster requires a daily culture of a common purpose to serve. To have a sense of service to others requires a culture of affirmation that nurses care deeply about nursing work. Nurses have an obligation to care for their patients. Leaders need to demonstrate, at all times, that they care deeply about the nurses.
Cultivate a gritty culture: If healthcare leaders desire grit in their nurses, they need to cultivate a gritty culture. Culture is an environment where people share the same values. If nurses work with a group of people who have common purpose and perseverance, industriousness and grit will follow.
Be inclusive: Expand the gritty culture to be one of inclusion. Build a system emergency program with clinical nurses as leaders. Including frontline clinical nurses in defining, testing, and sustaining a disaster program will ensure that the program of always being prepared is integrated into daily practice.
Develop grit: Recognize that having good talent is only as good as that talent, multiplied by effort, to become skillful. Skills are only productive if they are enhanced by effort to achieve solutions. Disasters require nurses to utilize their talent, with focused effort, to produce results in the presence of obstacles. Have this process of grit development as part of hospital daily safety huddles using daily challenges to cultivate perseverance.
Work on weaknesses: To ensure that with each crisis the system of care becomes better, work on identified weaknesses. Deliberate intentional practice on the team's identified opportunities leads to sustained success overtime. Emergency action plans require drills with robust participation and including providing disciplined feedback. This can be done on a small scale in situ at the unit level or at the system level. Practicing solutions to challenges will improve performance over time and build perseverance to solve new problems.
Adapted with permission from Duckworth.12
Healthcare systems need to build capacity within nursing teams to provide care regardless of the obstacles a disaster creates. To ensure all nurses meet these demands, nurse leaders and frontline clinical nurses need to develop and practice skills that will sustain them during times of crisis. Grit allows nurses to provide care with dignity and to care for themselves during a disaster. Encouraging all nurses to develop grit and to create a culture with grit at its core will ensure that nurses continue to lead during disasters.
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