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Hurricane Harvey

One Hospital's Journey Toward Organizational Resilience

Ybarra, Nan DNP, MBA, RN, NEA-BC

Author Information
The Journal of Perinatal & Neonatal Nursing: July/September 2019 - Volume 33 - Issue 3 - p 246-252
doi: 10.1097/JPN.0000000000000424
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Abstract

The memories of recent natural disasters, hurricanes and wildfires, combined with human-made disasters of mass shootings, remain sharply present during the past 2 years. The ability of hospitals to provide care and thrive during times of crisis is imperative with threats seemingly ever looming. The teams providing care, living in these communities, are impacted along with those seeking care. Resilience is vital for care providers to flourish during times of stress.

In examining 1 hospital's experiences and performance during Hurricane Harvey, 3 common leadership behaviors contributing to organizational resilience, adaptability, empowerment, and social justice, are analyzed using the strategic technique of strengths, weaknesses, opportunities, and threats (SWOT) analysis. Strengths, weaknesses, opportunities, and threats is a framework that identifies strengths and weaknesses and examines opportunities and threats. It allows for reflection and introspection of transpired events, which help ensure a more robust response in the future.1 In addition to this analysis, the purpose of this article is to document the journey of this hospital toward organizational resilience and to identify key lessons learned that could impact other hospital organizations when disasters strike in the future.

BACKGROUND

Approximately 50 miles north of the Gulf Coast is the Texas Medical Center in Houston. Hurricanes are a way of life for those who choose to live near the coast and residents have typically weathered many storms. On August 25, 2017, Hurricane Harvey made landfall in Texas.

Within this hospital, there are 2 emergency response teams: the ride out team and the relief team. The teams are primarily self-selected and defined well in advance of hurricane season. Both teams are composed of nursing, ancillary, and environmental team members. The frontline managers are responsible for ensuring that the teams are composed and able to provide care or services as needed.

The ride out team remains in the hospital caring for patients and performing other essential items during the initial period of crisis. This team has approximately 18 hours of notification prior to hurricane landfall to report for duty. The relief team reports to the hospital for duty after the initial crisis has passed, conditions for travel are safe, and assumes patient care responsibilities and hospital operational work. The relief team does not stay in house; they are able to come and go from work as normal. This team works for a period approximately equal to the number of shifts worked by the ride out team after which normal staff scheduling is resumed.

The devastating phenomenon of Hurricane Harvey was unique due to the slow-moving nature of the storm. Unprecedented amounts of rainfall extended the time of the team in the hospital caring for patients, with the ride out team taking up to 5 nights and 6 days, much longer than previous storms. Uncertainty about family and possessions, in addition to the changing acuity of patients, increased stress and anxiety in many of those on the ride out team.

Patient throughput in the hospital was a concern with no postpartum patients being discharged because of flooding. Staff had to ensure that labor rooms remained open to receive laboring patients. Patients arrived to the hospital via boats and rescue services for immediate intrapartum care; 29 infants were born at the hospital during Hurricane Harvey. Time did not stand still and care for mothers and infants continued to occur during the record-breaking flooding.

The time between caring for patients and lying awake worrying about family and homes resulted in decreased time to decompress. The words ingenuity and flexibility were mantras as plans shifted from hour to hour. Living with the unplanned and unexpected became the norm.

The stress did not end once the ride out team was able to return home. It was at this time that the relief team came into work. This team experienced anxiety and uncertainty while evacuating or remaining in place during the flooding. To shift the hospital back into its previous operational state, they had to pick up every ounce of reserve once the initial crisis passed and flood waters receded. This involved ensuring that patients scheduled for medical procedures, such as induction of labor and scheduled cesarean births, were informed to come into the hospital and care was initiated for women. In addition, providing care for women in spontaneous labor, women experiencing unexpected complications and managing all phases of care were goals of returning the hospital to a normal operational state.

The level of such extensive destruction gave rise to the need to honestly examine the resilience residing within the teams and to evaluate strengths and weaknesses within the hospital, community, and individuals. It encouraged a sense of inquiry into bolstering organizational resilience and a meditation on thriving during a prolonged state of disruption.

Can healthcare facilities optimize functioning when destruction occurs, and the impact is so far and wide that the effect on the healthcare teams is overwhelming? How can resilience in organizations be nurtured and fostered so that members can continue the work of caring while ensuring self-care occurs as well?

ORGANIZATIONAL RESILIENCE

The ability of healthcare organizations to thrive during a disaster is critical. Care of patients must remain seamless, and care of the healthcare team members must also be a priority. Organizational resilience is the ability to thrive amid adversity and unpredictability.2–5 It is an active measure and not merely a passive reaction to stress. Taking a proactive stance on how adversity impacts the hospital is vital to its ability to be resilient.

The value of adversity is that one can find deeper meaning, despite the harshest experiences. It provides an opportunity to grow personally from those experiences even while suffering.5 This belief concludes that adversity builds resilience, empowerment, and self-actualization.

Adaptability is an indicator of resilience; profound stressors applied to a system reveal existing vulnerabilities.4 As organizations experience increasing stressors from climate, violence, and human-made disasters, the ability to proactively assess resilience and ensure the institution can absorb variability and stress is paramount. The model of reactivity is taxing and costly in terms of emotional capital and psychological resources.4–8

In regard to resilience, hospitals with the ability to quickly shift from centralized to decentralized decision-making are ahead of the curve. Institutions possessing this ability can withstand more strain to the system and found to be more resilient.4,5 Systems deeply steeped in hierarchal decision-making hinder the ability to be agile and creative when disasters occur.

SWOT ANALYSIS OF CRISIS LEADERSHIP

As noted in Figure 1, commonly identified leadership behaviors in resilient organizations include adaptability, empowerment, and social justice. These characteristics are identified across different sectors, communities, and groups.4,6,9,11–16Table 1 details a SWOT analysis evaluating these leadership behaviors of resilience within this particular hospital during the disaster of Hurricane Harvey.

Figure 1.
Figure 1.:
Organizational resilience; leadership behaviors.
Table 1. - SWOT analysis of crisis leadership
Strengths Weaknesses Opportunities Threats
Adaptability
On-site leaders 24/7 for support and relief of team members
Creative strategies for hours spent performing patient care
Lack consistent messaging during first days of disaster Emergency response teams initiated with clarity and in advance of storm at 18 h prior to landfall
Cap on auto-deduct eliminated during crisis mode
Mixed messaging regarding initiation of emergency teams
Different standards for leaders versus team members related to sleeping arrangement and showering
Empowerment
Team members empowered to problem solve and create own solutions
Creation of discharge unit
Huddles q8 h to discuss operational state
Issues list created and addressed with face-to-face messaging
Decisions made by the organization that decreased individual autonomy
Limited areas for team to perform hygiene care resulted in long wait times for showers that resulted in decreased respite
Active staff participation in Emergency Preparedness Committee Planning
Social Justice
Donation paid holiday hours to those socioeconomically impacted at a greater scale Lack of food choices for team members
Lack of planning for contract service employees
Lack of designated sleeping/respite area for contract employees
Employee Assistance Program counselors on-site during crisis providing PFA to assist with emotional needs (psychological first aid)
Consideration and actions to ensure inclusion of diversity in emergency preparedness
Auto-deduct cap initially held in place during crisis
Overall lack of appreciation to diverse workforce and appreciation for differences in lifestyles

Adaptability

How well a hospital responds to a crisis is associated mainly with the leadership team.4–15 Leadership that is agile, flexible, and able to provide clarity is critical in developing an organization's resilience.2–16 The ability to imbue humanity and administrative tasks required is a vital component to successfully leading an organization during a time of crisis and in regaining a sense of normalcy. Leaders who empower teams are leaders who contribute to an organization's resilience.4,15–17 Allowing for change and rapid decision-making to occur when emergencies happen enables teams to best function and thrive in times of crisis.4,14–20

During emergency team planning that occurred months prior to hurricane season, the leadership team planned to put into place 24-hour leadership presence during a disaster. This plan was put in place to ensure that all team members felt supported and able to engage with leaders while working. This proactive thinking required that the ride out team be weighted with an increased number of leaders. The leaders huddled 3 times daily to ensure that the same messaging across units was being delivered, and a unified presence was felt across the hospital. The importance of a single source of information was critical as hours and days spent during ride out increased and emotions became frayed with further lack of sleep.

Forward-thinking leadership allowed the hospital to house the highest risk patients on the premises prior to landfall of Hurricane Harvey. Women with known morbidly adherent placentas, fetuses requiring immediate surgical care upon delivery, and women with congenital cardiac conditions requiring critical care during delivery and postpartum in addition to other high-risk conditions and diagnoses were housed on-site. The plan to enter the facility before hurricane landfall was discussed at the advent of hurricane season and well communicated to patients and families.

A rigorous sense of self-awareness is associated with increasing an organization's resilience.16 This ensures that leaders are responsive to the needs of those they serve and are aware of their reactions and impulses in time of crises.4,14–18 As the time spent on the ride out team increased, stress levels increased. Leadership noting the increased level of stress worked to provide an environment that would allow for more time for the team to decompress.

An example of working to reduce the stress involved the creation of 6-hour working shifts as the crisis prolonged. This allowed for increased downtime and more time to decompress and connect with families via phone or virtual visits. The ability to decrease time worked was enabled by forward-thinking leaders in increasing the number of team members assigned to the ride out team by the frontline managers and is noted as a strength in the SWOT analysis.

Ensuring that excess team members were included on the ride out team allowed for flexibility in working hours. This also afforded teams in place to have a real sense of downtime after working 3 days in a row. This also provided a sense of empowerment and determination over how downtime would be spent. This allowed for a sense of self-determination that served to augment resilience.14

The universal or immediate intervention known as psychological first aid can be employed to help foster resilience and reduce the likelihood of psychiatric sequelae. This is a model used by the navy when members suffer a traumatic event.6 This model is built on forming relationships, supplying both psychological and material aids to provide stabilization and allowing for practical assistance coupled with emotional care.

Decreasing distress and aid adaptation in times of disasters, tragedies, or emergencies is the goal of psychological first aid. Five principles are utilized to help achieve adjustment by focusing on safety, including both physical and psychological, calming, connectedness, empowerment, and hope.6,7 This is a model that could be employed by leadership during times of crisis to provide initial support to healthcare teams. The inclusion of psychological first aid is noted as an opportunity in the SWOT analysis.

Group meals and time spent communing as a hospital provided a sense of community, which is shown to help foster resilience.2 The leadership presence during these times provided an opportunity to serve the team and give a bit of respite and relief. Movie nights, board games, and long hours spent discussing what would occur upon leaving the hospital helped sustain the team. Leadership presence and leadership adaptability allowed the professional care team members to have a safe space while experiencing a disaster.

Empowerment

Empowerment of individuals to act is a hallmark of a resilient organization.12 A large, diverse population focused on situational awareness and leveraging strengths helps facilities persevere when others falter.4–12 Eliciting feedback from team members on a variety of factors provides a different lens to view concerns.4,12 One of the critical components for organizations to build resilience, as a part of everyday culture, resides in the encouragement of team members to endorse and determine the pathway for well-being.11

In this hospital during Hurricane Harvey, the ability to leave the hospital quickly became an impossibility due to the unprecedented flooding. Throughout this time the leadership team, tasked with caring for mothers and infants and healthcare team members, employed every skill necessary to promote resiliency and maintain a sense of normalcy. Empowering the teams to voice concerns, adapting to rapidly changing events, and finding strength in the diversity of the team helped pull the hospital through such a life-changing event.

Initially, a sizeable open conference room was set up as the sleeping area, and common showering areas were determined. It was quickly noted that the large open centralized area did not allow for quiet rest, nor did it provide a space for unit team members to decompress and express concerns as a work unit. The common showering areas led to long line waits and decreased time for respite. This approach led to team members feeling dismayed, created a sense of helplessness, and resulted in a high level of feeling disempowered within the teams.

Dissatisfaction with sleeping and showering areas was voiced during the daily operational huddles comprising clinical team members and management. It was also quickly identified that leaders were not required to sleep in the designated centralized area. The inequity of the situation was voiced by team members and validated by hospital management.

The management team quickly adapted the rules and empowered healthcare members to sleep on the units, per their request, which helped foster a sense of camaraderie. This modification proved critical for the well-being of the team. The initial designation of a central sleeping area removed a sense of decision-making capability among the team. It also highlighted the importance of recognizing and endorsing social justice. Teams were also empowered to determine showering areas and downtime routines and encouraged to voice concerns with an expectation that management would address.

Patient care was provided without incident and as time progressed, one hospital unit was closed as an acute care area and remade into a discharge unit. The unit housed low-risk mothers and infants who remained in the hospital solely due to travel being impossible or homes being uninhabitable. Women and infants were discharged from the system as an inpatient, so no billing charges were incurred, and relocated to one centralized area. These changes empowered families to assume a sense of well-being and control the environment as much as possible.

The impetus to create a discharge unit came directly from the clinical team members. The team was empowered to operationalize the idea and troubleshoot issues such as medications and food provided for those listed as discharged and still rounding on patients to ensure that needs were met. This level of empowerment allowed the team to create solutions for well patients, reallocate resources to patients requiring acute care, and provide an opportunity to network across services.

Patients were provided medications for self-administration, meals, and care for any immediate needs. Hospital rooms became a space of respite allowing for as much a sense of normalcy as possible for new families. The creation of the discharge unit allowed for fewer nursing staff needed per shift as the number of women and infants requiring acute inpatient nursing care was decreased.

Social justice

Diversity enables the organization to leverage strengths from lived experiences and appreciation of socioeconomic and cultural differences. This appreciation allows for varied responses and understanding and promotes social justice. Having a sense of community and appreciation for social justice is a fundamental characteristic of resilient organizations and communities.15 It ensures a broader base of support and representation of different viewpoints and leverages collective strengths.4,5,8–13

The hospital teams experienced tremendous stress due to long hours worked, anxiety, and uncertainty. The emotional toll experienced by some members of the hospital proved overwhelming and coping skills compromised.19,24 The inclusion of Employee Assistance Program personnel on-site during the crisis would have been beneficial. This was an area of weakness identified in the SWOT analysis as the time spent in the hospital caring for patients was extended.

Hospital employees experiencing financial strain or economic insecurity were not provided enough consideration during emergency preparedness planning. This lack of consideration is noted as a weakness, opportunity, and threat in the SWOT analysis. The inability of hospital or contract employees to purchase food was never considered during emergency preparedness planning meetings. The cap on auto-deduct from paychecks (a hospital policy) did not allow those without cash on hand or credit cards to make food purchases. Contract employees had no planned sleeping arrangements, linens from home, or common area to commune. The socioeconomic diversity of the workforce was not fully appreciated in emergency preparedness planning.

After the initial crisis of Hurricane Harvey departed and the widespread devastation was revealed, the hospital granted 36 paid hours of leave to all employees. This allowed those who needed additional time off to begin recovery efforts. It allowed for emotional rest and provided the entire workforce the ability to take paid time off without worry.

Many people donated “Harvey Days” to those socioeconomically impacted on a more significant scale. Networks created during times of disaster help form a shared identity, which lends itself to a greater proclivity to help or provide assistance to others occupying the same shared identity. It is social justice in action and demonstrates an appreciation of the diversity of its workforce.2,4 Grief experienced in tragedy levels a community and those rich in diversity and possessing a sense of social justice at its core are associated with higher levels of resilience.5

DISCUSSION

The experience of Hurricane Harvey imparted this hospital lesson of resilience and operational readiness. The ability to provide seamless care, facilitate women giving birth with complex health issues, and modify hours worked revealed the clinical expertise, agility, and dedication the hospital has to the community, patients, and each other. The relief team responded quickly to relieve the ride out team members and operations were normalized within a shortened time period.

A formal debriefing session with clinical team members and leaders occurred. One key lesson learned included preparing for lengthier stays than anticipated. Coping mechanisms were tested, and having team members from the Employee Assistance Program on-site to respond would have benefitted several team members.

Having consistent leadership presence on every unit 24 hours per day was vital in helping assert a calming presence on the units and promoting a feeling of team connectedness. Leaders promoting a single message were critical as time remaining in house lengthened and living in a state of prolonged disruption continued. Rumors began to spread and stories were created. Consistent messaging and scheduled rounding by the director of nursing helped assuage fears and anxieties of the ride out team.

Inconsistency across the system regarding initiating emergency response teams resulted in confusion and a delay in employing needed human resources. Proactively initiating emergency response teams allowed for ride out teams to go home and prepare for the hospital stay, prepare their homes, and allowed teams to be in place before the flooding occurred. There was a hesitancy to initiate response teams across the system. As a result of the confusion, the hospital system simplified the emergency response notification. A simplified emergency response activation was created instead of varying levels of emergencies. The prior complex messaging was ineffective and frustrating for the staff tasked with working on the ride out team.

Having different standards for leadership versus team members during times of crisis is an element that organizations must take note.16,19,22 The decision to allow teams to sleep on the units during ride out might seem minor, but it was of great import to the team. The distinction between sleeping arrangements of leadership and staff highlighted a deficiency of social justice as disasters tend to do.2 What appears minor is amplified when adversity is experienced; the threshold for tolerating inequality is decreased when emotions are heightened.2,9,11–17 Inclusion of staff members, representation from contract services, and diversity on the emergency preparedness team are recommendations for change.

As emergency preparedness and resilience become a common language in organizations, the ability to understand better what that means requires more inquiry. Consideration for shifting from reactive to proactive will require reflection and honest conversations about the organization's leadership style, tolerance for risk, willingness to impart decision making to others, and the composite of the workforce.7 This is substantial work and will require patience, and understanding this work is a pathway constantly evolving. The process itself might test the hospital's resilience and ability to withstand change.7–24

The need to have a proactive approach to emergency preparedness coupled with resilience is the pathway for organizations to thrive.20–24 The reactive approach with normalization is taxing on the workforce, the community, and the organization's ability to succeed. Conducting an honest assessment of how resilient an organization is will strengthen a hospital's ability to withstand disasters and thrive during times of stress.3,7,23,24

The definitions of resilience are changing as organizations are faced with more incidents and the need to be a resilient workplace is increased. Ensuring that leadership focus is firmly embedded in the empowerment of others is a critical pathway.16–25 As healthcare facilities become increasingly complex and concerns are spread across multiple areas, input from various lenses, viewpoints, and responses is necessary.4,23 The importance of adaptability, empowerment, and social justice cannot be overstated during a crisis.12,16,21–25 Having these tenets in place will help promote organizational resilience.4,23

CONCLUSION

The experience of Hurricane Harvey provided insight into one hospital's journey toward organizational resilience. By using SWOT as one method of analysis, key lessons and improvements in organizational resilience were realized.

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Keywords:

adaptation; emergencies; leadership; natural disasters; resilience

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