- Email: [email protected]
Orlando Health Nurse Leaders Reflect on the Pulse Tragedy
Orlando Health Nurse Leaders Reflect on the Pulse Tragedy Jayne Willis, MSN, RN, NEA-BC, CENP, and Louise Philp, MSHA, BSN, RN, CCRN
I
n the predawn hours of Sunday, June 12, 2016,
dozens of people hit by gunfire poured into Orlando Regional Medical Center’s (ORMC) emergency
department
(ED)
in
Orlando, Florida. The largest mass-casualty
shooting
in
American history happened just a
few
blocks
from
ORMC,
Orlando Health’s flagship hospital and the region’s only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency.
PREPAREDNESS ORMC was the first designated level one trauma center in the state of Florida. For over 30 years, Orlando Health has strategically invested in the Trauma Program to ensure readiness when the community needs it most. A team of individuals, including nurse leaders, has been dedicated to the development and maintenance of a disaster readiness program. This includes long-standing relationships with community partners, law enforcement, and emergency management systems (EMS).Years of disaster planning and the evolution of www.nurseleader.com
this culture of collaboration contributed to the successful outcome of this tragic event. In fact, staff cited mass-casualty incident drills as the core reason for results achieved during this incident. In March 2016, just months prior to the Pulse tragedy, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter. Although historically some staff dread giving up 4 hours for these drills, the critical importance is now somberly understood by all.
Nurse Leader
319
During the Pulse event, nurse leaders participated in the Hospital Incident Command System (HICS) in roles they had practiced in previous drills. Nursing resources were allocated to ensure the seamless delivery, coordination, and transition of care without comprising the quality of care. Considering the event occurred less than half a mile from the ED, the current disaster plan had to be rapidly adapted since patients arrived without announcement and without EMS triage. Thirty-six patients arrived in 36 minutes during the first wave of the tragedy. This required the nursing team to be innovative in simultaneously triaging patients, staffing multiple operating rooms, and decompressing the ED by discharging and expeditiously moving patients to various levels of care. The greatest advice the nursing and ORMC team can offer to other hospitals is: practice, practice, practice, and take it seriously. By drilling different scenarios and testing systems to the point of failure, areas of opportunity are identified for improvement. Full-scale mass-casualty drills with community partners allow for testing of triage and system throughput. Takeaway Simulation training is another way to prepare. Simulation drills dealing with specific injuries can be practiced with the interprofessional team: building teamwork, trusting relationships, and team confidence. Debriefing after the drill to gain insight from the frontline is a key component of preparation.
TEAMWORK A core value in the Orlando Health Nursing Professional Practice Model is collaboration: working together for a com-
320
Nurse Leader
mon purpose. Teamwork is deeply embedded in the culture. Forty-four total victims were brought to Orlando Health on that fateful Sunday, and 35 survived. In the days following the incident, not a single patient was lost after those initial lifealtering hours. There is no doubt that teamwork contributed to this incredible success. When the first Pulse victim arrived in the Emergency Department, 32 staff members were on duty. Learning that there were more victims, nurse leaders immediately elevated staff levels to 51 in the ED, pooling staff from our other hospitals. From there, the “Pulse team” was born, and an attitude of all-hands-on-deck permeated, not just at ORMC, but throughout the entire Orlando Health system. Physicians, residents, and nurses placed tourniquets, dressed wounds, and inserted tubes. Guest Services helped hold pressure on bleeding wounds. Environmental Services turned over exam rooms quickly despite massive amounts of blood, and Security rapidly unloaded patients from vehicles. One team member said, “We went where our hands could be helpful, it didn’t matter if it was your traditional role or not.” Four hundred forty-one units of blood, platelets, and plasma were administered on June 12th, and 28 surgeries were performed that morning. To date, 76 operations have been performed on those patients, and it is anticipated some will continue to need more surgery in the future. Although there is tremendous grief for the victims who could not be saved, the traumatized survivors, as well as their loved ones, the collective team is proud of their performance. They were only able to accomplish what they did because they were a solid team that came together. As an organization,
October 2017
Orlando Health has experienced many remarkable moments out of this tragedy, but some of the fondest are in listening to nurses who were on the frontlines. They do not speak of what they did personally; instead, they talk about how well their fellow team members performed or how another area really stepped up. Although 417 team members initially responded that Sunday, it is believed that all 16,000 team members supported Pulse efforts in some capacity. The number 1 complaint received from team members was that “no one called me in the middle of the night to come in to assist.” In the hours that immediately followed the Pulse tragedy, the internal communications department provided updates to team members that continued for many weeks. Additionally, the nurse leaders and executives were highly visible to the teams throughout the event and communicated goals frequently. This visibility and communication was accomplished by leader rounding, frequent staff huddles, as well as the use of the hospital intranet. Through establishing and communicating goals early in the HICS process, team priorities were aligned. Relationships with the frontline team were cultivated before the incident allowing the team to be comfortable giving feedback to leaders. Frequent updates and constant communication connected organizational leaders, team members, and the community. Just days after the event, while hospital team members, the community and nation were still grappling with the news of this catastrophic event, David Strong, president and CEO, sent a very raw and genuine message to the Orlando Health family via video. In it, he reiterated what team members felt: everyone was a part of the Pulse response because every team member at Orlando Health has had a part in building the culture, systems, and processes that allowed the organization to perform duties so well. Most importantly, he recognized what everyone was feeling: the normal had changed. Although one would not wish this new normal upon anyone, there was pride that everyone came together as a team and served the community when they needed it most—the bond as a workfamily was now even stronger. Takeaway Nurse leaders need to invest in building relationships among interprofessional teams. Without a doubt, it makes a significant difference when faced with life and death situations.
CULTURE OF RESILIENCY Proactively building team resilience is rarely considered as part of disaster planning, but can easily be accomplished as an ongoing initiative by nurse leaders. By definition, resilience is the ability to return to a state of normalcy or to “bounce back” from adversity or trauma and remain focused and optimistic about the future.1 Building a culture of resiliency comes from a transformational leadership approach that supports the frontline teams’ involvement in decision-making and problem solving. Nurse leaders quickly realized that they could not underestimate the emotional impact of this mass-casualty event on the entire team. Although the trauma nurses and inpatient www.nurseleader.com
nurses were clinically strong and frequently deal with difficult situations including death, this was of a different and far greater magnitude. In the aftermath of the initial rescue operation, a second event occurred: hundreds of family members flooded ORMC, looking for unaccounted loved ones. Addressing the needs of both the victims and the families became overwhelming. Many of the victims and families were Spanish speaking only. Working with others, nurse leaders acted quickly to coordinate resources to support the team, and the patients and families. They brought in grief counselors for the staff. They offered translators and victim advocates for patients and families. Counseling sessions were held around the clock for weeks, and services are still available for team members. To date, over 1,200 sessions have been provided allowing nurses and team members to heal. Although Orlando Health had anticipated the impact of the clinical aspect of a mass-casualty incident, the organization had never anticipated the impact of the aftermath. This came in many forms, including international media interest and visits from well-wishers, including politicians, celebrities, sports figures, and the general public. At times, the staff and patients were overwhelmed with all of the attention. When this occurred, nurse leaders actively advocated for the privacy of patients and staff. The outpouring of support from the community boosted morale for the tirelessly hard-working teams. Heartwarming cards, letters, banners, and gifts arrived from nursing and hospital colleagues around the country. The community support was awe-inspiring as gifts of food and gratitude arrived for months after the tragedy. There was an avalanche of pizza. ORMC’s lobby was wallpapered in signed banners and posters thanking the team. These gestures built resilience as staff felt supported by the community and nation. The importance of receiving support from outside the organization is now understood, and ORMC has adopted the practice of sending signed banners of support from the hospital team to other organizations that have experienced tragic events. As thousands of mourners visited the campus to honor the victims of Pulse, they left mementos. These honorariums included 49 wooden crosses honoring those who had perished.
Nurse Leader
321
These mementos were collected in a ceremony and have been archived in the Orlando History Museum. Around the 6month anniversary of the shootings, a ceremony was held to respectfully retire the banners from the hospital lobby. A permanent memorial was erected on the Orlando Health campus on the 1-year anniversary as staff from all around the organization gathered to support each other in a private event at ORMC. The nurse leadership team feels strongly that being intentional with supporting the nursing teams has led to their ability to deal effectively with the stress and aftermath of the Pulse tragedy. Nurse turnover was not experienced due to the event. Shortly after the event, Orlando Health announced the decision not to bill survivors of the Pulse nightclub massacre for out-of-pocket medical expenses. Organizational pride soared, which was reflected in record team member engagement scores later that summer. Additionally, Orlando Health’s patient experience scores reached all-time highs.
1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.07.007
Takeaway Nurse leaders must ensure that teamwork across the organization is achieved by building trusting relationships and developing processes that allow teams to work together. Interprofessional teams working together without hierarchical structures will lead to success. Although these efforts are often considered soft skills, they will be the foundation to building a culture of trust and resiliency.
CONCLUSION Sharing learning from the Pulse event has been therapeutic for the Orlando Health team. Nurses and nurse leaders have been interviewed, written articles, and presented at numerous professional organizations around the country. Awards and accolades are too many to count, and the team is honored to share their powerful story and associated lessons learned. The work is the work nurses are called to do every day for the community. Although Orlando Health was well prepared to respond to a tragedy such as Pulse, it was beyond the imagination to expect that anything of this magnitude would occur in Orlando. The team encourages every organization to think about how to optimally prepare for the unexpected: plan, prepare, influence a culture of teamwork and resilience. In the words of Sarah Duran, BSN, RN, who was working as the ED charge nurse the night of the shootings stated, “I don’t think anyone can fully prepare for anything on the scale of what happened in Orlando, but with a good foundation of protocols in place, a strong staff, constant vigilance, and great teamwork, a hospital can be successful in handling a mass-casualty incident.” NL Reference 1. Dyer JG, McGuinness TM. Resilience: analysis of the concept. Arch Psychiatr Nurs. 1996;10:276-282.
Jayne Willis, MSN, RN, NEA-BC, CENP, is vice president of nursing for Orlando Health and chief nursing officer for Orlando Regional Medical Center in Orlando, Florida. She can be reached at [email protected]. Louise Philp, MSHA, BSN, RN, CCRN, is patient care administrator for trauma, neuroscience and emergency services for Orlando Regional Medical Center.
322
Nurse Leader
October 2017
I
n the predawn hours of Sunday, June 12, 2016,
dozens of people hit by gunfire poured into Orlando Regional Medical Center’s (ORMC) emergency
department
(ED)
in
Orlando, Florida. The largest mass-casualty
shooting
in
American history happened just a
few
blocks
from
ORMC,
Orlando Health’s flagship hospital and the region’s only level one trauma center. The gunman had opened fire at Pulse, a popular gay nightclub, during a crowded Latin night. Due to the close proximity of the nightclub to ORMC, first responders loaded victims into police cars and the backs of trucks, and transported them to the ED. The shooting resulted in the treatment of 44 total victims in just a few hours’ time, testing the effectiveness of the disaster planning preparedness and the resiliency of team members. Nurse leaders played an important coordinating role during the unfolding disaster, and interprofessional collaboration became crucial to ensure that patients received optimal care. In the time that has elapsed since the 2016 tragedy, the Orlando Health team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork, and a culture of resiliency.
PREPAREDNESS ORMC was the first designated level one trauma center in the state of Florida. For over 30 years, Orlando Health has strategically invested in the Trauma Program to ensure readiness when the community needs it most. A team of individuals, including nurse leaders, has been dedicated to the development and maintenance of a disaster readiness program. This includes long-standing relationships with community partners, law enforcement, and emergency management systems (EMS).Years of disaster planning and the evolution of www.nurseleader.com
this culture of collaboration contributed to the successful outcome of this tragic event. In fact, staff cited mass-casualty incident drills as the core reason for results achieved during this incident. In March 2016, just months prior to the Pulse tragedy, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter. Although historically some staff dread giving up 4 hours for these drills, the critical importance is now somberly understood by all.
Nurse Leader
319
During the Pulse event, nurse leaders participated in the Hospital Incident Command System (HICS) in roles they had practiced in previous drills. Nursing resources were allocated to ensure the seamless delivery, coordination, and transition of care without comprising the quality of care. Considering the event occurred less than half a mile from the ED, the current disaster plan had to be rapidly adapted since patients arrived without announcement and without EMS triage. Thirty-six patients arrived in 36 minutes during the first wave of the tragedy. This required the nursing team to be innovative in simultaneously triaging patients, staffing multiple operating rooms, and decompressing the ED by discharging and expeditiously moving patients to various levels of care. The greatest advice the nursing and ORMC team can offer to other hospitals is: practice, practice, practice, and take it seriously. By drilling different scenarios and testing systems to the point of failure, areas of opportunity are identified for improvement. Full-scale mass-casualty drills with community partners allow for testing of triage and system throughput. Takeaway Simulation training is another way to prepare. Simulation drills dealing with specific injuries can be practiced with the interprofessional team: building teamwork, trusting relationships, and team confidence. Debriefing after the drill to gain insight from the frontline is a key component of preparation.
TEAMWORK A core value in the Orlando Health Nursing Professional Practice Model is collaboration: working together for a com-
320
Nurse Leader
mon purpose. Teamwork is deeply embedded in the culture. Forty-four total victims were brought to Orlando Health on that fateful Sunday, and 35 survived. In the days following the incident, not a single patient was lost after those initial lifealtering hours. There is no doubt that teamwork contributed to this incredible success. When the first Pulse victim arrived in the Emergency Department, 32 staff members were on duty. Learning that there were more victims, nurse leaders immediately elevated staff levels to 51 in the ED, pooling staff from our other hospitals. From there, the “Pulse team” was born, and an attitude of all-hands-on-deck permeated, not just at ORMC, but throughout the entire Orlando Health system. Physicians, residents, and nurses placed tourniquets, dressed wounds, and inserted tubes. Guest Services helped hold pressure on bleeding wounds. Environmental Services turned over exam rooms quickly despite massive amounts of blood, and Security rapidly unloaded patients from vehicles. One team member said, “We went where our hands could be helpful, it didn’t matter if it was your traditional role or not.” Four hundred forty-one units of blood, platelets, and plasma were administered on June 12th, and 28 surgeries were performed that morning. To date, 76 operations have been performed on those patients, and it is anticipated some will continue to need more surgery in the future. Although there is tremendous grief for the victims who could not be saved, the traumatized survivors, as well as their loved ones, the collective team is proud of their performance. They were only able to accomplish what they did because they were a solid team that came together. As an organization,
October 2017
Orlando Health has experienced many remarkable moments out of this tragedy, but some of the fondest are in listening to nurses who were on the frontlines. They do not speak of what they did personally; instead, they talk about how well their fellow team members performed or how another area really stepped up. Although 417 team members initially responded that Sunday, it is believed that all 16,000 team members supported Pulse efforts in some capacity. The number 1 complaint received from team members was that “no one called me in the middle of the night to come in to assist.” In the hours that immediately followed the Pulse tragedy, the internal communications department provided updates to team members that continued for many weeks. Additionally, the nurse leaders and executives were highly visible to the teams throughout the event and communicated goals frequently. This visibility and communication was accomplished by leader rounding, frequent staff huddles, as well as the use of the hospital intranet. Through establishing and communicating goals early in the HICS process, team priorities were aligned. Relationships with the frontline team were cultivated before the incident allowing the team to be comfortable giving feedback to leaders. Frequent updates and constant communication connected organizational leaders, team members, and the community. Just days after the event, while hospital team members, the community and nation were still grappling with the news of this catastrophic event, David Strong, president and CEO, sent a very raw and genuine message to the Orlando Health family via video. In it, he reiterated what team members felt: everyone was a part of the Pulse response because every team member at Orlando Health has had a part in building the culture, systems, and processes that allowed the organization to perform duties so well. Most importantly, he recognized what everyone was feeling: the normal had changed. Although one would not wish this new normal upon anyone, there was pride that everyone came together as a team and served the community when they needed it most—the bond as a workfamily was now even stronger. Takeaway Nurse leaders need to invest in building relationships among interprofessional teams. Without a doubt, it makes a significant difference when faced with life and death situations.
CULTURE OF RESILIENCY Proactively building team resilience is rarely considered as part of disaster planning, but can easily be accomplished as an ongoing initiative by nurse leaders. By definition, resilience is the ability to return to a state of normalcy or to “bounce back” from adversity or trauma and remain focused and optimistic about the future.1 Building a culture of resiliency comes from a transformational leadership approach that supports the frontline teams’ involvement in decision-making and problem solving. Nurse leaders quickly realized that they could not underestimate the emotional impact of this mass-casualty event on the entire team. Although the trauma nurses and inpatient www.nurseleader.com
nurses were clinically strong and frequently deal with difficult situations including death, this was of a different and far greater magnitude. In the aftermath of the initial rescue operation, a second event occurred: hundreds of family members flooded ORMC, looking for unaccounted loved ones. Addressing the needs of both the victims and the families became overwhelming. Many of the victims and families were Spanish speaking only. Working with others, nurse leaders acted quickly to coordinate resources to support the team, and the patients and families. They brought in grief counselors for the staff. They offered translators and victim advocates for patients and families. Counseling sessions were held around the clock for weeks, and services are still available for team members. To date, over 1,200 sessions have been provided allowing nurses and team members to heal. Although Orlando Health had anticipated the impact of the clinical aspect of a mass-casualty incident, the organization had never anticipated the impact of the aftermath. This came in many forms, including international media interest and visits from well-wishers, including politicians, celebrities, sports figures, and the general public. At times, the staff and patients were overwhelmed with all of the attention. When this occurred, nurse leaders actively advocated for the privacy of patients and staff. The outpouring of support from the community boosted morale for the tirelessly hard-working teams. Heartwarming cards, letters, banners, and gifts arrived from nursing and hospital colleagues around the country. The community support was awe-inspiring as gifts of food and gratitude arrived for months after the tragedy. There was an avalanche of pizza. ORMC’s lobby was wallpapered in signed banners and posters thanking the team. These gestures built resilience as staff felt supported by the community and nation. The importance of receiving support from outside the organization is now understood, and ORMC has adopted the practice of sending signed banners of support from the hospital team to other organizations that have experienced tragic events. As thousands of mourners visited the campus to honor the victims of Pulse, they left mementos. These honorariums included 49 wooden crosses honoring those who had perished.
Nurse Leader
321
These mementos were collected in a ceremony and have been archived in the Orlando History Museum. Around the 6month anniversary of the shootings, a ceremony was held to respectfully retire the banners from the hospital lobby. A permanent memorial was erected on the Orlando Health campus on the 1-year anniversary as staff from all around the organization gathered to support each other in a private event at ORMC. The nurse leadership team feels strongly that being intentional with supporting the nursing teams has led to their ability to deal effectively with the stress and aftermath of the Pulse tragedy. Nurse turnover was not experienced due to the event. Shortly after the event, Orlando Health announced the decision not to bill survivors of the Pulse nightclub massacre for out-of-pocket medical expenses. Organizational pride soared, which was reflected in record team member engagement scores later that summer. Additionally, Orlando Health’s patient experience scores reached all-time highs.
1541-4612/2017/ $ See front matter Copyright 2017 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2017.07.007
Takeaway Nurse leaders must ensure that teamwork across the organization is achieved by building trusting relationships and developing processes that allow teams to work together. Interprofessional teams working together without hierarchical structures will lead to success. Although these efforts are often considered soft skills, they will be the foundation to building a culture of trust and resiliency.
CONCLUSION Sharing learning from the Pulse event has been therapeutic for the Orlando Health team. Nurses and nurse leaders have been interviewed, written articles, and presented at numerous professional organizations around the country. Awards and accolades are too many to count, and the team is honored to share their powerful story and associated lessons learned. The work is the work nurses are called to do every day for the community. Although Orlando Health was well prepared to respond to a tragedy such as Pulse, it was beyond the imagination to expect that anything of this magnitude would occur in Orlando. The team encourages every organization to think about how to optimally prepare for the unexpected: plan, prepare, influence a culture of teamwork and resilience. In the words of Sarah Duran, BSN, RN, who was working as the ED charge nurse the night of the shootings stated, “I don’t think anyone can fully prepare for anything on the scale of what happened in Orlando, but with a good foundation of protocols in place, a strong staff, constant vigilance, and great teamwork, a hospital can be successful in handling a mass-casualty incident.” NL Reference 1. Dyer JG, McGuinness TM. Resilience: analysis of the concept. Arch Psychiatr Nurs. 1996;10:276-282.
Jayne Willis, MSN, RN, NEA-BC, CENP, is vice president of nursing for Orlando Health and chief nursing officer for Orlando Regional Medical Center in Orlando, Florida. She can be reached at [email protected]. Louise Philp, MSHA, BSN, RN, CCRN, is patient care administrator for trauma, neuroscience and emergency services for Orlando Regional Medical Center.
322
Nurse Leader
October 2017