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Weathering the storm: challenges to nurses providing care to nursing home residents during hurricanes
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Applied Nursing Research 22 (2009) e9 – e14 www.elsevier.com/locate/apnr
Weathering the storm: challenges to nurses providing care to nursing home residents during hurricanes Kathryn Hyer, PhD, MPPa,⁎, Lisa M. Brown, PhDb , Janelle J. Christensen, MAc , Kali S. Thomas, MAa b
a School of Aging Studies, MHC-1300 University of South Florida, Tampa, FL 33620, USA Department of Aging and Mental Health, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa, FL 33612, USA c Department of Anthropology, University of South Florida, Tampa, FL 33620, USA Received 19 September 2008; accepted 8 November 2008
Abstract
This article documents the experience of 291 Florida nursing homes during the 2004 hurricane season. Using quantitative and qualitative methods, the authors described and compared the challenges nurses encountered when evacuating residents with their experiences assisting residents of facilities that sheltered in place. The primary concerns for evacuating facilities were accessing appropriate evacuation sites for residents and having ambulance transportation contracts honored. The main issue for facilities that sheltered in place was the length of time it took for power to be restored. Barriers to maintaining resident health during disasters for those who evacuated or sheltered in place are identified. © 2009 Elsevier Inc. All rights reserved.
1. Introduction and background Emerging themes in the nursing and public health literature suggest that nursing homes (NHs) face many challenges as they attempt to provide care to their residents during hurricanes. During Katrina, NHs were not recognized as health care providers by emergency management offices (Hyer, Brown, Berman, & Polivka-West, 2006; Hyer, Polivka-West, & Brown, 2007) had difficulty recruiting staff to care for residents during disasters (Dosa, Grossman, Wetle, & Mor, 2007) and experienced prolonged power failure (Brown, Hyer, & Polivka-West, 2007; Castro, Pearson, Berstrom, & Cron, 2008; Laditka et al., 2007; Laditka et al., 2008). Although Florida did not experience the same level of devastation as wrought by 2005 and 2008 hurricanes in Louisiana and Texas, in 2004, it was affected by four major hurricanes (Charley, Frances, Ivan, and Jeanne) within a 44day period. All of Florida's 67 counties were declared disaster
areas at least once during this hurricane season, and 64 were declared disaster areas 2 or more times (FEMA, n.d.). The ability of NHs to respond to multiple events within a short period is important as the country increasingly recognizes the need to build health care disaster capacity and coordinate care across multiple providers. With looming worries about pandemic flu, potential for acts of terrorism, and continued threat from natural disasters such as wildfires, tornados, and hurricanes, it is critical to build and sustain a coordinated infrastructure of disaster preparedness that includes NHs. This article documents the experience of 291 (43% of all) community-based Florida NHs during the 2004 hurricane season. Specifically, it explores the challenges nurses encountered when evacuating residents or caring for those who sheltered in place. This is the first study that provides detailed information about how the hurricanes affected nurses' ability to provide clinical care to NH residents.
2. Method ⁎ Corresponding author. Tel.: +1 813 974 3232. E-mail addresses: [email protected] (K. Hyer), [email protected] (L.M. Brown), [email protected] (J.J. Christensen), [email protected] (K.S. Thomas). 0897-1897/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2008.11.001
2.1. Data collection and sample A survey of NH administrative staff was conducted in the 4 months after the 2004 hurricanes. Respondents were
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recruited at long-term care association-sponsored regional meetings during October–November 2004. In addition, questionnaires were mailed to the association membership roster (N = 519) along with a $5.00 gift card; a cover letter explaining the study and containing the elements of informed consent was also included. A reminder letter was mailed to potential respondents 14 days later requesting return of the quesitonnaire. We received 328 (63%) responses, of which 291 (89%) indicated that they were directly impacted by at least one of the storms. All respondents completed an eight-page questionnaire consisting of 47 structured and 2 open-ended questions. The structured questions addressed specific topics such as whether their facilities evacuated, and if so, where they sheltered during (or after) the storms. Additional questions related to whether NHs lost utilities during the storms (e.g., electricity, telephone, and water), maintained sufficient staff coverage, and had adequate generator support; other questions addressed their ability to transfer residents to local hospitals. One hundred fifty-two (52%) provided written responses to the two open-ended questions: (a) “Please feel free to write about your experience during these hurricanes (specify which hurricanes apply),” and, (b) “Please add other comments that would help us improve hurricane response and recovery support of facilities such as yours.” Below we report findings from the qualitative and quantitative analyses. 2.2. Data analyses All quantitative analyses were preformed using SPSS Version 16.0 (Chicago, IL). Using univariate analyses, descriptive information about nurses' experiences was generated. Qualitative responses were transcribed and coded by hand. To answer our research question, “Were there different experiences between NHs that evacuated compared to those that sheltered in place during the 2004 hurricane season?” the quotes were divided into two categories: (a) those that evacuated and (b) those that sheltered in place. From this point on, an inductive approach (informed by grounded theory) was used to develop codes within and among the quotes (Cresswell, 1998). During the open coding, the texts were analyzed for reoccurring themes, patterns, and structures (ibdm).
3.1. Evacuation Of the 291 NHs, 48 (16%) facilities evacuated residents for at least one of the four storms. Most of the respondents expressed concern about the evacuation process. The analysis revealed three themes when evacuating residents before or during a storm: (a) seeking shelter in the storm, (b) transportation and time, and (c) staffing. 3.1.1. Seeking shelter in the storm The literature reflects that evacuation of NH residents during a storm is difficult and fraught with unpredictability (Dosa, Hyer, Brown, Artenstein, & Mor, 2008). The experiences of NHs evacuating and seeking shelter for their residents and staff reflect uncertainty about the benefits of evacuation, the inherent volatility of storms, difficulty in having transfer agreements honored, and the strain on residents when evacuating on crowded highways. Florida disaster plans require NHs to have transfer agreements with other NHs in the event that evacuation is required. Respondents reported that many sheltering facilities “were not usable” despite signed contracts. One facility explained that, although it had made arrangements with another facility during Charley, “we quickly learned that no one could accommodate our facility.…The devastation was so great in Florida that all facilities were full.” Other respondents revealed that agreements made with other facilities prior to the storm were not honored: “Transfer agreements were ineffective. Chain facilities took care of their own, leaving us to look for alternative location to evacuate to.” Secondly, facilities expressed concern about the distance they had to travel to find a safe evacuation area: As in some cases during Charley, the area our county was told to evacuate to was mid-state. [Mid-state] was hit worse than our county. In essence, evacuation is a huge effort and may actually be worse for the residents (living in shelters, change in routine, no way of knowing where hurricane would go).
3. Results
A third problem was that hospitals were not always willing to take residents with critical illness: “In preparation for the storms we attempted to place our dialysis patients at hospitals because we were unable to determine if we could get them to dialysis as required. No hospitals would take our residents.” One third of all surveyed facilities (n = 97) who sought to protect their special needs residents during a storm indicated that they were unable to transfer residents to hospitals, posing risk for the frailest elders during a hurricane.
The primary concerns for facilities that evacuated or sheltered in place were the constant challenges of keeping elderly residents safe and healthy while preparing, experiencing, and recovering from a hurricane. During the axial stage of analysis, the reasons for these concerns were identified; the facilities that evacuated identified finding transportation and an appropriate place to evacuate as two central issues affecting resident care, and those who sheltered in place noted significant nursing challenges because of power outage.
3.1.2. Transportation and time Previous literature has explored the difficulty with evacuating NH residents (Hyer et al., 2007; Laditka et al., 2007). Even if appropriate shelters were located and the residents with the greatest need were admitted to the hospital, a significant concern remained: the difficulty of accessing transportation resources. Several respondents cited that a serious problem was transporting residents who required stretchers. One respondent expressed this simply: “Evacuating
K. Hyer et al. / Applied Nursing Research 22 (2009) e9–e14
stretcher residents was the most difficult part of the evacuation. Transportation [was] difficult to obtain.” A respondent elaborated on how the issue was resolved: During Hurricane Frances, we evacuated; during the evacuation we had 14 residents that needed stretcher transport, [however] we were unable to get transport companies to assist. We had to borrow 2 stretcher vans and make several trips to take those residents to the receiving facilities. This process took over 16 hours.
For most facilities, this was a time-consuming process, and in one instance, transporting residents who required stretchers “took almost 20 hours!” Issues regarding transportation include the difficulty and time that it takes to evacuate residents that require stretchers. In addition, a major concern is the number of staff members required for such an evacuation. 3.1.3. Staffing Twenty individuals discussed staffing problems, and most (n = 12) spoke highly of staff performance during facility evacuations, lauding the extra effort put forth to ensure that residents would receive necessary care. Ninety-six percent of respondents indicated that they had sufficient staff coverage for the 2004 hurricanes. Evacuation often required substantial time commitments from staff: “Multiple staff members volunteered additional hours which was necessary for caring for special needs evacuees.” Even when speaking highly of staff conduct, it is clear that there were some difficulties fully staffing a facility from preparation through storm recovery. Thus, although facilities reported adequate staff at the beginning of the storm or during evacuation, as the requirements for ongoing care continued, maintaining staff was a challenge. For example, one respondent described, “[t]he core group of staff [as] ‘outstanding’ in what they did during that time…we evacuated 98 residents and gave care for six days with resident's mattresses on the floor while short staffed.” One administrator reported that they had to “mandate all staff participate in evacuation. Those that did not respond were terminated.” It is unclear how frequently evacuating facilities terminated employees. However, this respondent volunteered that 15 employees had been terminated and voiced the concern that, “If we had not been firm, no one would have responded for a second storm.” 3.2. Sheltering in place Most of the NHs (n = 235) did not evacuate for a hurricane in 2004 and instead chose to shelter in place. “Sheltering in place” requires another unique set of concerns. Several themes emerged from the data indicating that the greatest challenges to resident care during and after the hurricanes include (a) adequate staffing and (b) challenges to providing resident care during power outage. 3.2.1. Adequate staffing Like NHs that evacuated, facilities that were able to shelter in place frequently spoke highly of staff dedication during storms. However, unlike evacuating facilities, almost
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all (99%) NHs that sheltered in place indicated that they had sufficient staff members for the four hurricanes. One respondent explained that, “[a]ll our staff was invited to stay and bring families and pets. We had more staff than necessary. Management and personnel was prepared to stay in house when necessary.” Over two thirds (69%) of the facilities that sheltered in place reported that they allowed staff and families to shelter at their facility. This aided in having more staff present during the hurricane. Another provider further explained the following: The staff was excellent. They were very cooperative and willing to stay for the duration. No one complained and kept doing their job as the professionals they are. This included dietary, house keeping, nursing, and all personnel. I was very proud of them for putting our residents first.
Although administrators expressed overall satisfaction with staff performance, some facilities cited staffing as a concern during the hurricane season: “[The] primary issue was staffing—employees not coming in during Charley.” This respondent also discussed how this issue was addressed. After this storm, we had meetings discussing employees' obligation to come in during emergency and bring family members if necessary. We used progressive discipline to address absenteeism during storms and replaced some staff as a result.
3.2.2. Challenges to resident care due to power outage In facilities that did not evacuate, the most frequently cited challenge to resident care provision was the loss of power. In 2004, respondents reported 868 days of power loss. Although almost 74% of the facilities had generators, some found that they were inadequate in providing appropriate care for residents over an extended length of time. According to respondents, NHs were not considered a priority in power restoration after the hurricanes which significantly exacerbated the difficulty of providing resident care. One facility “went without power for ten days during the first storm and five days for the second.” Several respondents expressed the frustrations with power companies, “which, contrary to media reports, did not classify nursing facilities as priority hook-ups.” One respondent suggested that, “[NHs] should be considered a medical facility and given more priority!” Another reported that the power company told them that “we were not a ‘priority’ to re-establish power. They actually suggested I move the ‘old people’ to a hospital.” A third respondent expanded on the fragile health status of NH residents and the lack of respect for their work: The only issue we have is the amount of time we were without electricity. The pizza shop, coin laundry, and Circle K one block away had power two days after the storm. We went six days without electricity and no-one gave us the time of day. The hospital dumps their patients to us prior to the storm hitting and then they are the first to get electricity. Well, we should be treated the same way as our patients were critical too and need the comfort of cool air and electricity.
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Respondents had several reasons to be concerned about the delay in power restoration as it caused an inability to sufficiently support residents. Generators were insufficient to run air conditioning units for an extended time. For example, one respondent wrote, “It was hot outside and without sufficient generator power the internal [building] temperature began to be a problem prior to the electricity being turned back on.” Providing clean linens and other laundry services was another challenge: “During Frances we found no laundry on emergency power.” Without laundry services, NHs cannot wash soiled linens, a particular concern for residents who are incontinent (Laditka et al., 2006; Perkovic, Seff, & Rothman, 2007). One facility indicated that after the storms they purchased a separate generator dedicated to laundry alone: Maintaining laundry supply was a major issue without power [during Frances] so we bought the largest noncommercial washer with a generator dedicated to & alone plus clothes pins which helped tremendously for Jeanne. In other instances, no power meant that routine medical procedures and medication distribution had to be done by flashlight: NHs in our area were not considered “priority” when restoring power. We lost power during Charley & Frances. During Charley—my staff gave patient care, passed medications & administered treatments with flashlights without complaints.
4. Discussion Our study sought to explore the different experiences of 291 Florida NHs during the 2004 hurricane season. We presented the perspectives of nurses and highlighted their struggles and concerns in meeting the pressing needs of vulnerable NH residents during disasters. In particular, we examined the factors that impacted NHs that evacuated as compared with those that sheltered in place, the difficulty in accessing transportation, managing staff during all phases of the storms, and maintaining resident care without electrical power. The following discussion describes how these difficulties affect resident care and well-being during a disaster. We believe that understanding the impact of disasters and how care might be better organized will enable providers, residents, and advocates to ensure a culture change in the status of NHs during disasters. 4.1. Those that evacuated The decision to evacuate is a key component of the disaster plan. Ideally, evacuation is a decision that requires extensive evaluation of multiple risks because evacuations place residents at risk for adverse consequences. Facilities in our study chose to evacuate because they were in flood zones or believed that the building could not sustain the anticipated winds. For those evacuating, our research identified three reoccurring themes while evacuating: seeking shelter, having reliable transportation, and staffing.
4.1.1. Finding shelter Our study highlights the significant challenges for NHs seeking shelter for residents. There appears to be a lack of receiving facilities availability. Multiple respondents expressed deep concern over the Florida requirement to evacuate to “like” facilities when there were not enough available beds in other NHs to accommodate their residents. Brown, Hyer, and Polivka-West (2007) noted the importance of having several preexisting agreements with other “receiving” facilities. Certainly, a requirement for multiple receiving facility contracts recognizes that an average 120-bed facility cannot expect to evacuate all its residents to a single facility. This implies that residents, equipment, and staff would have to be split up among several receiving facilities. The impact of transfer, the breakup of potential social networks, and the disruption of worker–residents relationships on residents' psychological well-being is unknown. These are areas that should be explored in future research. 4.1.2. Transportation Our findings illustrate that evacuation transportation is difficult to obtain, especially stretchers and ambulances. Furthermore, evacuating residents is both time consuming and arduous for residents and staff. Our findings also captured the importance of partial evacuations based on residents' medical conditions. Residents who need dialysis may need to be transferred to a hospital because the dialysis center might not be accessible for days after the hurricane, endangering the residents' lives. Hospice residents near death and other high-risk residents, who are medically unstable, can deteriorate quickly when care is disrupted or compromised. Nursing home access to evacuation transportation is now recognized as a major obstacle during disasters. 4.1.3. Staffing Evacuation of residents provides unique challenges and is stressful for staff and residents alike. Although most respondents who evacuated spoke highly of staff performance, others expressed concerns about staff failing to show up for work in the event of hurricanes. Hurricanes are forecasted days in advance and require extensive preparation of the NH physical plant, including boarding of windows, securing fuel for generators, and cleaning grounds of debris. NHs must acquire sufficient cash, food, water, supplies, equipment, oxygen, and medications to maintain residents, staff, and additional family members, regardless of whether the facility shelters in place or evacuates. If evacuation is likely, staff members create resident wristbands, assemble medical records in waterproof folders, tag resident's equipment and supply needs, and help residents pack their personal belongings. Some food, water, and supplies must accompany residents because the bus trip is long and the receiving facility cannot be expected to have sufficient medications, supplies, and specialized equipment for unknown residents. Staff members must help with these
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preparations, yet they still need personal release time to arrange for their own personal home and family needs. Sometimes, staff members, like facilities, prepare for hurricanes that change course or intensity. The unpredictable nature of the storms takes its toll; staff members reported that they were exhausted as they prepared for and responded to multiple events during a 6-week period. 4.2. Sheltered in place Again, many of the issues found in the 2004 hurricanes in Florida echoed the concerns found after hurricane Katrina in 2006 (Dosa et al., 2007). Significant problems in staffing and lack of electricity restoration (not being on the priority restoration list) are crucial issues that need to be addressed. 4.2.1. Adequate staffing Although most of the facilities praised their staff, some who sheltered in place also indicated that there were staffrelated difficulties. Most of the preparation duties highlighted for staff preparing to evacuate also occur in NHs that chose to shelter in place. The building must be prepared for the storm; and extra supplies, food, and equipment must be procured. Many NHs that chose to shelter in place allowed staff to bring in their families and animals. Consequently, play and rest areas for staff, families, pets, and resident family members must also be established. Our findings highlight the need for NHs to ensure that staff members recognize their obligation to work during disasters when they are hired. The Florida Health Care Association Nursing Home Guide recommends that staff be informed at orientation about the importance of working during disasters and reminded throughout the year. To enhance the likelihood that staff can respond for duty, facilities are encouraged to help staff members develop personal disaster plans. Allowing children and pets to accompany staff to the facility are also recommended practices. Finally, disaster guides need to include plans for deployment of staff over the extended time of the storm (preparation, event, and recovery). The logistics of preparation and the time after the storm until a facility returns to normalcy can be a week or longer, depending upon the intensity and ability to have electrical power restored. The careful management of staff allows residents to receive care from staff members who are reasonably fresh and who can be attentive for the duration of the event. 4.2.2. Impact on residents and implications for health Air conditioning and temperature regulations are not luxury items for frail individuals who have medical conditions. Older adults are particularly vulnerable to heat stroke because the body's cooling mechanisms become less efficient with age (Environmental Protection Agency, 2007). In the event of prolonged power outages, the use of air conditioning becomes a challenge as it strains generator power. Should the generators fail, residents are in danger of having heat stroke, to which they are vulnerable (Brown, Rothman, & Norris, 2007). It is important that power
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companies recognize the importance of restoring electricity to NHs, which are home to large numbers of vulnerable elderly populations. Lack of laundry facilities during a power outage may seem to be a minor issue; however, infection control, smell, and residents' quality of life are compromised if clean linens are not available. If a facility is faced with a prolonged power outage, generator power must also be able to fuel laundry facilities. Although this is an adequate solution, generator functioning can be unreliable, again suggesting a greater need for NHs to be considered a priority in power restoration. Federal regulations only mandate emergency electrical power for lighting entrances, exits, and life support systems (Allen, 2006). Respondents recognized that prolonged power outages challenge staff and create potentially dangerous conditions. Nursing staff did not want to administer medications by flashlight but had no choice. Our study suggests that regulations should require sufficient generator power to run air conditioning, laundry, and lighting. Although this study presents nurses' experiences in providing resident care, it is important to note its limitations. The qualitative data included responses that are brief and lack the richness of in-depth interviews or focus groups. In addition, given the survey format, researchers were unable to probe or have respondents elaborate on comments. The survey was administered after a four-storm hurricane season and participants might not recall accurately the experiences during each hurricane. In addition, it remains unclear what NH staff members consider to be a “sufficient” number of staff members during emergency situations. Some respondents indicated that their facility had “sufficient staff” but later noted that they were “short staffed.” A potential reason for this discrepancy is that, although facilities were staffing above the minimum mandated requirement, they did not have sufficient staff members to perform the numerous additional duties related to hurricane preparation, response, and recovery and therefore “felt” as though they were short staffed. Further research is needed to better understand what staffing levels are necessary during a hurricane. However, these study limitations are strongly outweighed by the innovative nature of the research and the depth of the findings. Using mixed method, this article addresses the unique experiences and challenges to resident care for 291 NHs during a hurricane season. In 2004, Florida had 670 NHs, and our study captures the experiences of 43%. In addition, our study represents 32,811 beds, close to half of Florida's certified NH beds. Analysis of this large, representative sample enhances the findings' generalizability.
5. Conclusion Although meteorology has improved hurricane tracking and forecasting, the course and intensity of these storms remain unpredictable. The decision to evacuate must be made long before a storm is projected to strike. The further
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the distance and time to landfall, the more uncertain the path of the hurricane. Evacuation takes many hours, and the earlier an evacuation begins, the more likely facilities will obtain appropriate transportation. Increasingly, administrators, clinicians, and emergency operations personnel question the wisdom of total resident evacuation (Dosa et al., 2008). Partial evacuation of residents with complex medical needs more study. Nursing homes that choose to shelter in place need power restored quickly, access to generator fuel when supplies run low, and recognition as medical facilities. Most NHs are equipped with generators; however, few have sufficient generator power to sustain appropriate care for a prolonged time. It is important that NHs, NH associations, emergency management, and policy makers take heed of these findings and help maintain the safety of NH residents during nature's fury. References Allen, J. E. (2006). Nursing home federal requirements: Guidelines to surveyors and survey protocols (6th ed.) New York: Springer Publishing Company. Brown, L. M., Hyer, K., & Polivka-West, L. (2007). A comparative study of laws, rules, codes and other influences on nursing homes' disaster preparedness in the Gulf Coast states. Behavioral Sciences and the Law, 25(5), 655−675. Brown, L., Rothman, M., & Norris, F. (2007). Issues in mental health for older adults during disasters. Generations, 31(4), 25−30. Castro, C., Pearson, D., Berstrom, N., & Cron, S. (2008). Surviving the storms: Emergency preparedness in Texas nursing facilities and assisted living facilities. Journal of Gerontological Nursing, 34(8), 9−16.
Cresswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage Publications. Dosa, D. M., Grossman, N., Wetle, T., & Mor, V. (2007). To evacuate or not to evacuate: Lessons learned from Louisiana nursing home administrators following hurricanes Katrina and Rita. Journal of the American Medical Directors Association, 8(3), 142−149. Dosa, D., Hyer, K., Brown, L. M., Artenstein, A., & Mor, V. (2008). The controversy inherent in managing frail nursing home residents during complex hurricane emergencies. Journal of American Medical Directors Association, 9(8), 599−604. Environmental Protection Agency. (2007). “It's too darn hot”—planning for excessive heat events: Information for older adults and family caregivers.Washington, DC: Author (Publication No. 100-F-07-025). FEMA. (n.d.). Florida disaster history. Retrieved August 24, 2008 from http://www.fema.gov/news/disasters_state.fema?id=12. Florida Health Care Education and Development Foundation. (2008). Emergency management guide for nursing homes. Tallahassee, FL: Florida Health Care Association. Hyer, K., Brown, L. M., Berman, A., & Polivka-West, L. (2006). Establishing and refining hurricane response systems for long-term care facilities. Health Affairs, 25(5), w 407−w 411. Accessed May 26, 2008, from http://content.healthaffairs.org/cgi/content/abstract/ hlthaff.25.w407v1?rss=1. Hyer, K., Polivka-West, L., & Brown, L. (2007). Nursing homes and assisted living facilities: Planning and decision making for sheltering in place or evacuation. Generations, 31(4), 29−33. Laditka, S. B., Laditka, J. N., Xirasagar, S., Cornman, C. B., Davis, C. B., & Richter, J. V. E. (2007). Protecting nursing home residents during emergencies or disasters: An exploratory study from South Carolina. Prehospital and Disaster Medicine, 22(1), 42−48. Laditka, S. B., LAditka, J. N., Xirasagar, S., Cornman, C. B., Davis, C. B., & Richter, J. V. E. (2008). Providing shelter to nursing home evacuees in disasters: Lessons from Hurricane Katrina. American Journal of Public Health, 98(7), 1288−1293. Perkovic, V., Seff, L., & Rothman, M. B. (2007). Planning for and responding to special needs of elders in natural disasters. Generations, 31(4), 37−41.
Applied Nursing Research 22 (2009) e9 – e14 www.elsevier.com/locate/apnr
Weathering the storm: challenges to nurses providing care to nursing home residents during hurricanes Kathryn Hyer, PhD, MPPa,⁎, Lisa M. Brown, PhDb , Janelle J. Christensen, MAc , Kali S. Thomas, MAa b
a School of Aging Studies, MHC-1300 University of South Florida, Tampa, FL 33620, USA Department of Aging and Mental Health, Louis de la Parte Florida Mental Health Institute, University of South Florida, Tampa, FL 33612, USA c Department of Anthropology, University of South Florida, Tampa, FL 33620, USA Received 19 September 2008; accepted 8 November 2008
Abstract
This article documents the experience of 291 Florida nursing homes during the 2004 hurricane season. Using quantitative and qualitative methods, the authors described and compared the challenges nurses encountered when evacuating residents with their experiences assisting residents of facilities that sheltered in place. The primary concerns for evacuating facilities were accessing appropriate evacuation sites for residents and having ambulance transportation contracts honored. The main issue for facilities that sheltered in place was the length of time it took for power to be restored. Barriers to maintaining resident health during disasters for those who evacuated or sheltered in place are identified. © 2009 Elsevier Inc. All rights reserved.
1. Introduction and background Emerging themes in the nursing and public health literature suggest that nursing homes (NHs) face many challenges as they attempt to provide care to their residents during hurricanes. During Katrina, NHs were not recognized as health care providers by emergency management offices (Hyer, Brown, Berman, & Polivka-West, 2006; Hyer, Polivka-West, & Brown, 2007) had difficulty recruiting staff to care for residents during disasters (Dosa, Grossman, Wetle, & Mor, 2007) and experienced prolonged power failure (Brown, Hyer, & Polivka-West, 2007; Castro, Pearson, Berstrom, & Cron, 2008; Laditka et al., 2007; Laditka et al., 2008). Although Florida did not experience the same level of devastation as wrought by 2005 and 2008 hurricanes in Louisiana and Texas, in 2004, it was affected by four major hurricanes (Charley, Frances, Ivan, and Jeanne) within a 44day period. All of Florida's 67 counties were declared disaster
areas at least once during this hurricane season, and 64 were declared disaster areas 2 or more times (FEMA, n.d.). The ability of NHs to respond to multiple events within a short period is important as the country increasingly recognizes the need to build health care disaster capacity and coordinate care across multiple providers. With looming worries about pandemic flu, potential for acts of terrorism, and continued threat from natural disasters such as wildfires, tornados, and hurricanes, it is critical to build and sustain a coordinated infrastructure of disaster preparedness that includes NHs. This article documents the experience of 291 (43% of all) community-based Florida NHs during the 2004 hurricane season. Specifically, it explores the challenges nurses encountered when evacuating residents or caring for those who sheltered in place. This is the first study that provides detailed information about how the hurricanes affected nurses' ability to provide clinical care to NH residents.
2. Method ⁎ Corresponding author. Tel.: +1 813 974 3232. E-mail addresses: [email protected] (K. Hyer), [email protected] (L.M. Brown), [email protected] (J.J. Christensen), [email protected] (K.S. Thomas). 0897-1897/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.apnr.2008.11.001
2.1. Data collection and sample A survey of NH administrative staff was conducted in the 4 months after the 2004 hurricanes. Respondents were
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K. Hyer et al. / Applied Nursing Research 22 (2009) e9–e14
recruited at long-term care association-sponsored regional meetings during October–November 2004. In addition, questionnaires were mailed to the association membership roster (N = 519) along with a $5.00 gift card; a cover letter explaining the study and containing the elements of informed consent was also included. A reminder letter was mailed to potential respondents 14 days later requesting return of the quesitonnaire. We received 328 (63%) responses, of which 291 (89%) indicated that they were directly impacted by at least one of the storms. All respondents completed an eight-page questionnaire consisting of 47 structured and 2 open-ended questions. The structured questions addressed specific topics such as whether their facilities evacuated, and if so, where they sheltered during (or after) the storms. Additional questions related to whether NHs lost utilities during the storms (e.g., electricity, telephone, and water), maintained sufficient staff coverage, and had adequate generator support; other questions addressed their ability to transfer residents to local hospitals. One hundred fifty-two (52%) provided written responses to the two open-ended questions: (a) “Please feel free to write about your experience during these hurricanes (specify which hurricanes apply),” and, (b) “Please add other comments that would help us improve hurricane response and recovery support of facilities such as yours.” Below we report findings from the qualitative and quantitative analyses. 2.2. Data analyses All quantitative analyses were preformed using SPSS Version 16.0 (Chicago, IL). Using univariate analyses, descriptive information about nurses' experiences was generated. Qualitative responses were transcribed and coded by hand. To answer our research question, “Were there different experiences between NHs that evacuated compared to those that sheltered in place during the 2004 hurricane season?” the quotes were divided into two categories: (a) those that evacuated and (b) those that sheltered in place. From this point on, an inductive approach (informed by grounded theory) was used to develop codes within and among the quotes (Cresswell, 1998). During the open coding, the texts were analyzed for reoccurring themes, patterns, and structures (ibdm).
3.1. Evacuation Of the 291 NHs, 48 (16%) facilities evacuated residents for at least one of the four storms. Most of the respondents expressed concern about the evacuation process. The analysis revealed three themes when evacuating residents before or during a storm: (a) seeking shelter in the storm, (b) transportation and time, and (c) staffing. 3.1.1. Seeking shelter in the storm The literature reflects that evacuation of NH residents during a storm is difficult and fraught with unpredictability (Dosa, Hyer, Brown, Artenstein, & Mor, 2008). The experiences of NHs evacuating and seeking shelter for their residents and staff reflect uncertainty about the benefits of evacuation, the inherent volatility of storms, difficulty in having transfer agreements honored, and the strain on residents when evacuating on crowded highways. Florida disaster plans require NHs to have transfer agreements with other NHs in the event that evacuation is required. Respondents reported that many sheltering facilities “were not usable” despite signed contracts. One facility explained that, although it had made arrangements with another facility during Charley, “we quickly learned that no one could accommodate our facility.…The devastation was so great in Florida that all facilities were full.” Other respondents revealed that agreements made with other facilities prior to the storm were not honored: “Transfer agreements were ineffective. Chain facilities took care of their own, leaving us to look for alternative location to evacuate to.” Secondly, facilities expressed concern about the distance they had to travel to find a safe evacuation area: As in some cases during Charley, the area our county was told to evacuate to was mid-state. [Mid-state] was hit worse than our county. In essence, evacuation is a huge effort and may actually be worse for the residents (living in shelters, change in routine, no way of knowing where hurricane would go).
3. Results
A third problem was that hospitals were not always willing to take residents with critical illness: “In preparation for the storms we attempted to place our dialysis patients at hospitals because we were unable to determine if we could get them to dialysis as required. No hospitals would take our residents.” One third of all surveyed facilities (n = 97) who sought to protect their special needs residents during a storm indicated that they were unable to transfer residents to hospitals, posing risk for the frailest elders during a hurricane.
The primary concerns for facilities that evacuated or sheltered in place were the constant challenges of keeping elderly residents safe and healthy while preparing, experiencing, and recovering from a hurricane. During the axial stage of analysis, the reasons for these concerns were identified; the facilities that evacuated identified finding transportation and an appropriate place to evacuate as two central issues affecting resident care, and those who sheltered in place noted significant nursing challenges because of power outage.
3.1.2. Transportation and time Previous literature has explored the difficulty with evacuating NH residents (Hyer et al., 2007; Laditka et al., 2007). Even if appropriate shelters were located and the residents with the greatest need were admitted to the hospital, a significant concern remained: the difficulty of accessing transportation resources. Several respondents cited that a serious problem was transporting residents who required stretchers. One respondent expressed this simply: “Evacuating
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stretcher residents was the most difficult part of the evacuation. Transportation [was] difficult to obtain.” A respondent elaborated on how the issue was resolved: During Hurricane Frances, we evacuated; during the evacuation we had 14 residents that needed stretcher transport, [however] we were unable to get transport companies to assist. We had to borrow 2 stretcher vans and make several trips to take those residents to the receiving facilities. This process took over 16 hours.
For most facilities, this was a time-consuming process, and in one instance, transporting residents who required stretchers “took almost 20 hours!” Issues regarding transportation include the difficulty and time that it takes to evacuate residents that require stretchers. In addition, a major concern is the number of staff members required for such an evacuation. 3.1.3. Staffing Twenty individuals discussed staffing problems, and most (n = 12) spoke highly of staff performance during facility evacuations, lauding the extra effort put forth to ensure that residents would receive necessary care. Ninety-six percent of respondents indicated that they had sufficient staff coverage for the 2004 hurricanes. Evacuation often required substantial time commitments from staff: “Multiple staff members volunteered additional hours which was necessary for caring for special needs evacuees.” Even when speaking highly of staff conduct, it is clear that there were some difficulties fully staffing a facility from preparation through storm recovery. Thus, although facilities reported adequate staff at the beginning of the storm or during evacuation, as the requirements for ongoing care continued, maintaining staff was a challenge. For example, one respondent described, “[t]he core group of staff [as] ‘outstanding’ in what they did during that time…we evacuated 98 residents and gave care for six days with resident's mattresses on the floor while short staffed.” One administrator reported that they had to “mandate all staff participate in evacuation. Those that did not respond were terminated.” It is unclear how frequently evacuating facilities terminated employees. However, this respondent volunteered that 15 employees had been terminated and voiced the concern that, “If we had not been firm, no one would have responded for a second storm.” 3.2. Sheltering in place Most of the NHs (n = 235) did not evacuate for a hurricane in 2004 and instead chose to shelter in place. “Sheltering in place” requires another unique set of concerns. Several themes emerged from the data indicating that the greatest challenges to resident care during and after the hurricanes include (a) adequate staffing and (b) challenges to providing resident care during power outage. 3.2.1. Adequate staffing Like NHs that evacuated, facilities that were able to shelter in place frequently spoke highly of staff dedication during storms. However, unlike evacuating facilities, almost
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all (99%) NHs that sheltered in place indicated that they had sufficient staff members for the four hurricanes. One respondent explained that, “[a]ll our staff was invited to stay and bring families and pets. We had more staff than necessary. Management and personnel was prepared to stay in house when necessary.” Over two thirds (69%) of the facilities that sheltered in place reported that they allowed staff and families to shelter at their facility. This aided in having more staff present during the hurricane. Another provider further explained the following: The staff was excellent. They were very cooperative and willing to stay for the duration. No one complained and kept doing their job as the professionals they are. This included dietary, house keeping, nursing, and all personnel. I was very proud of them for putting our residents first.
Although administrators expressed overall satisfaction with staff performance, some facilities cited staffing as a concern during the hurricane season: “[The] primary issue was staffing—employees not coming in during Charley.” This respondent also discussed how this issue was addressed. After this storm, we had meetings discussing employees' obligation to come in during emergency and bring family members if necessary. We used progressive discipline to address absenteeism during storms and replaced some staff as a result.
3.2.2. Challenges to resident care due to power outage In facilities that did not evacuate, the most frequently cited challenge to resident care provision was the loss of power. In 2004, respondents reported 868 days of power loss. Although almost 74% of the facilities had generators, some found that they were inadequate in providing appropriate care for residents over an extended length of time. According to respondents, NHs were not considered a priority in power restoration after the hurricanes which significantly exacerbated the difficulty of providing resident care. One facility “went without power for ten days during the first storm and five days for the second.” Several respondents expressed the frustrations with power companies, “which, contrary to media reports, did not classify nursing facilities as priority hook-ups.” One respondent suggested that, “[NHs] should be considered a medical facility and given more priority!” Another reported that the power company told them that “we were not a ‘priority’ to re-establish power. They actually suggested I move the ‘old people’ to a hospital.” A third respondent expanded on the fragile health status of NH residents and the lack of respect for their work: The only issue we have is the amount of time we were without electricity. The pizza shop, coin laundry, and Circle K one block away had power two days after the storm. We went six days without electricity and no-one gave us the time of day. The hospital dumps their patients to us prior to the storm hitting and then they are the first to get electricity. Well, we should be treated the same way as our patients were critical too and need the comfort of cool air and electricity.
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Respondents had several reasons to be concerned about the delay in power restoration as it caused an inability to sufficiently support residents. Generators were insufficient to run air conditioning units for an extended time. For example, one respondent wrote, “It was hot outside and without sufficient generator power the internal [building] temperature began to be a problem prior to the electricity being turned back on.” Providing clean linens and other laundry services was another challenge: “During Frances we found no laundry on emergency power.” Without laundry services, NHs cannot wash soiled linens, a particular concern for residents who are incontinent (Laditka et al., 2006; Perkovic, Seff, & Rothman, 2007). One facility indicated that after the storms they purchased a separate generator dedicated to laundry alone: Maintaining laundry supply was a major issue without power [during Frances] so we bought the largest noncommercial washer with a generator dedicated to & alone plus clothes pins which helped tremendously for Jeanne. In other instances, no power meant that routine medical procedures and medication distribution had to be done by flashlight: NHs in our area were not considered “priority” when restoring power. We lost power during Charley & Frances. During Charley—my staff gave patient care, passed medications & administered treatments with flashlights without complaints.
4. Discussion Our study sought to explore the different experiences of 291 Florida NHs during the 2004 hurricane season. We presented the perspectives of nurses and highlighted their struggles and concerns in meeting the pressing needs of vulnerable NH residents during disasters. In particular, we examined the factors that impacted NHs that evacuated as compared with those that sheltered in place, the difficulty in accessing transportation, managing staff during all phases of the storms, and maintaining resident care without electrical power. The following discussion describes how these difficulties affect resident care and well-being during a disaster. We believe that understanding the impact of disasters and how care might be better organized will enable providers, residents, and advocates to ensure a culture change in the status of NHs during disasters. 4.1. Those that evacuated The decision to evacuate is a key component of the disaster plan. Ideally, evacuation is a decision that requires extensive evaluation of multiple risks because evacuations place residents at risk for adverse consequences. Facilities in our study chose to evacuate because they were in flood zones or believed that the building could not sustain the anticipated winds. For those evacuating, our research identified three reoccurring themes while evacuating: seeking shelter, having reliable transportation, and staffing.
4.1.1. Finding shelter Our study highlights the significant challenges for NHs seeking shelter for residents. There appears to be a lack of receiving facilities availability. Multiple respondents expressed deep concern over the Florida requirement to evacuate to “like” facilities when there were not enough available beds in other NHs to accommodate their residents. Brown, Hyer, and Polivka-West (2007) noted the importance of having several preexisting agreements with other “receiving” facilities. Certainly, a requirement for multiple receiving facility contracts recognizes that an average 120-bed facility cannot expect to evacuate all its residents to a single facility. This implies that residents, equipment, and staff would have to be split up among several receiving facilities. The impact of transfer, the breakup of potential social networks, and the disruption of worker–residents relationships on residents' psychological well-being is unknown. These are areas that should be explored in future research. 4.1.2. Transportation Our findings illustrate that evacuation transportation is difficult to obtain, especially stretchers and ambulances. Furthermore, evacuating residents is both time consuming and arduous for residents and staff. Our findings also captured the importance of partial evacuations based on residents' medical conditions. Residents who need dialysis may need to be transferred to a hospital because the dialysis center might not be accessible for days after the hurricane, endangering the residents' lives. Hospice residents near death and other high-risk residents, who are medically unstable, can deteriorate quickly when care is disrupted or compromised. Nursing home access to evacuation transportation is now recognized as a major obstacle during disasters. 4.1.3. Staffing Evacuation of residents provides unique challenges and is stressful for staff and residents alike. Although most respondents who evacuated spoke highly of staff performance, others expressed concerns about staff failing to show up for work in the event of hurricanes. Hurricanes are forecasted days in advance and require extensive preparation of the NH physical plant, including boarding of windows, securing fuel for generators, and cleaning grounds of debris. NHs must acquire sufficient cash, food, water, supplies, equipment, oxygen, and medications to maintain residents, staff, and additional family members, regardless of whether the facility shelters in place or evacuates. If evacuation is likely, staff members create resident wristbands, assemble medical records in waterproof folders, tag resident's equipment and supply needs, and help residents pack their personal belongings. Some food, water, and supplies must accompany residents because the bus trip is long and the receiving facility cannot be expected to have sufficient medications, supplies, and specialized equipment for unknown residents. Staff members must help with these
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preparations, yet they still need personal release time to arrange for their own personal home and family needs. Sometimes, staff members, like facilities, prepare for hurricanes that change course or intensity. The unpredictable nature of the storms takes its toll; staff members reported that they were exhausted as they prepared for and responded to multiple events during a 6-week period. 4.2. Sheltered in place Again, many of the issues found in the 2004 hurricanes in Florida echoed the concerns found after hurricane Katrina in 2006 (Dosa et al., 2007). Significant problems in staffing and lack of electricity restoration (not being on the priority restoration list) are crucial issues that need to be addressed. 4.2.1. Adequate staffing Although most of the facilities praised their staff, some who sheltered in place also indicated that there were staffrelated difficulties. Most of the preparation duties highlighted for staff preparing to evacuate also occur in NHs that chose to shelter in place. The building must be prepared for the storm; and extra supplies, food, and equipment must be procured. Many NHs that chose to shelter in place allowed staff to bring in their families and animals. Consequently, play and rest areas for staff, families, pets, and resident family members must also be established. Our findings highlight the need for NHs to ensure that staff members recognize their obligation to work during disasters when they are hired. The Florida Health Care Association Nursing Home Guide recommends that staff be informed at orientation about the importance of working during disasters and reminded throughout the year. To enhance the likelihood that staff can respond for duty, facilities are encouraged to help staff members develop personal disaster plans. Allowing children and pets to accompany staff to the facility are also recommended practices. Finally, disaster guides need to include plans for deployment of staff over the extended time of the storm (preparation, event, and recovery). The logistics of preparation and the time after the storm until a facility returns to normalcy can be a week or longer, depending upon the intensity and ability to have electrical power restored. The careful management of staff allows residents to receive care from staff members who are reasonably fresh and who can be attentive for the duration of the event. 4.2.2. Impact on residents and implications for health Air conditioning and temperature regulations are not luxury items for frail individuals who have medical conditions. Older adults are particularly vulnerable to heat stroke because the body's cooling mechanisms become less efficient with age (Environmental Protection Agency, 2007). In the event of prolonged power outages, the use of air conditioning becomes a challenge as it strains generator power. Should the generators fail, residents are in danger of having heat stroke, to which they are vulnerable (Brown, Rothman, & Norris, 2007). It is important that power
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companies recognize the importance of restoring electricity to NHs, which are home to large numbers of vulnerable elderly populations. Lack of laundry facilities during a power outage may seem to be a minor issue; however, infection control, smell, and residents' quality of life are compromised if clean linens are not available. If a facility is faced with a prolonged power outage, generator power must also be able to fuel laundry facilities. Although this is an adequate solution, generator functioning can be unreliable, again suggesting a greater need for NHs to be considered a priority in power restoration. Federal regulations only mandate emergency electrical power for lighting entrances, exits, and life support systems (Allen, 2006). Respondents recognized that prolonged power outages challenge staff and create potentially dangerous conditions. Nursing staff did not want to administer medications by flashlight but had no choice. Our study suggests that regulations should require sufficient generator power to run air conditioning, laundry, and lighting. Although this study presents nurses' experiences in providing resident care, it is important to note its limitations. The qualitative data included responses that are brief and lack the richness of in-depth interviews or focus groups. In addition, given the survey format, researchers were unable to probe or have respondents elaborate on comments. The survey was administered after a four-storm hurricane season and participants might not recall accurately the experiences during each hurricane. In addition, it remains unclear what NH staff members consider to be a “sufficient” number of staff members during emergency situations. Some respondents indicated that their facility had “sufficient staff” but later noted that they were “short staffed.” A potential reason for this discrepancy is that, although facilities were staffing above the minimum mandated requirement, they did not have sufficient staff members to perform the numerous additional duties related to hurricane preparation, response, and recovery and therefore “felt” as though they were short staffed. Further research is needed to better understand what staffing levels are necessary during a hurricane. However, these study limitations are strongly outweighed by the innovative nature of the research and the depth of the findings. Using mixed method, this article addresses the unique experiences and challenges to resident care for 291 NHs during a hurricane season. In 2004, Florida had 670 NHs, and our study captures the experiences of 43%. In addition, our study represents 32,811 beds, close to half of Florida's certified NH beds. Analysis of this large, representative sample enhances the findings' generalizability.
5. Conclusion Although meteorology has improved hurricane tracking and forecasting, the course and intensity of these storms remain unpredictable. The decision to evacuate must be made long before a storm is projected to strike. The further
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the distance and time to landfall, the more uncertain the path of the hurricane. Evacuation takes many hours, and the earlier an evacuation begins, the more likely facilities will obtain appropriate transportation. Increasingly, administrators, clinicians, and emergency operations personnel question the wisdom of total resident evacuation (Dosa et al., 2008). Partial evacuation of residents with complex medical needs more study. Nursing homes that choose to shelter in place need power restored quickly, access to generator fuel when supplies run low, and recognition as medical facilities. Most NHs are equipped with generators; however, few have sufficient generator power to sustain appropriate care for a prolonged time. It is important that NHs, NH associations, emergency management, and policy makers take heed of these findings and help maintain the safety of NH residents during nature's fury. References Allen, J. E. (2006). Nursing home federal requirements: Guidelines to surveyors and survey protocols (6th ed.) New York: Springer Publishing Company. Brown, L. M., Hyer, K., & Polivka-West, L. (2007). A comparative study of laws, rules, codes and other influences on nursing homes' disaster preparedness in the Gulf Coast states. Behavioral Sciences and the Law, 25(5), 655−675. Brown, L., Rothman, M., & Norris, F. (2007). Issues in mental health for older adults during disasters. Generations, 31(4), 25−30. Castro, C., Pearson, D., Berstrom, N., & Cron, S. (2008). Surviving the storms: Emergency preparedness in Texas nursing facilities and assisted living facilities. Journal of Gerontological Nursing, 34(8), 9−16.
Cresswell, J. W. (1998). Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage Publications. Dosa, D. M., Grossman, N., Wetle, T., & Mor, V. (2007). To evacuate or not to evacuate: Lessons learned from Louisiana nursing home administrators following hurricanes Katrina and Rita. Journal of the American Medical Directors Association, 8(3), 142−149. Dosa, D., Hyer, K., Brown, L. M., Artenstein, A., & Mor, V. (2008). The controversy inherent in managing frail nursing home residents during complex hurricane emergencies. Journal of American Medical Directors Association, 9(8), 599−604. Environmental Protection Agency. (2007). “It's too darn hot”—planning for excessive heat events: Information for older adults and family caregivers.Washington, DC: Author (Publication No. 100-F-07-025). FEMA. (n.d.). Florida disaster history. Retrieved August 24, 2008 from http://www.fema.gov/news/disasters_state.fema?id=12. Florida Health Care Education and Development Foundation. (2008). Emergency management guide for nursing homes. Tallahassee, FL: Florida Health Care Association. Hyer, K., Brown, L. M., Berman, A., & Polivka-West, L. (2006). Establishing and refining hurricane response systems for long-term care facilities. Health Affairs, 25(5), w 407−w 411. Accessed May 26, 2008, from http://content.healthaffairs.org/cgi/content/abstract/ hlthaff.25.w407v1?rss=1. Hyer, K., Polivka-West, L., & Brown, L. (2007). Nursing homes and assisted living facilities: Planning and decision making for sheltering in place or evacuation. Generations, 31(4), 29−33. Laditka, S. B., Laditka, J. N., Xirasagar, S., Cornman, C. B., Davis, C. B., & Richter, J. V. E. (2007). Protecting nursing home residents during emergencies or disasters: An exploratory study from South Carolina. Prehospital and Disaster Medicine, 22(1), 42−48. Laditka, S. B., LAditka, J. N., Xirasagar, S., Cornman, C. B., Davis, C. B., & Richter, J. V. E. (2008). Providing shelter to nursing home evacuees in disasters: Lessons from Hurricane Katrina. American Journal of Public Health, 98(7), 1288−1293. Perkovic, V., Seff, L., & Rothman, M. B. (2007). Planning for and responding to special needs of elders in natural disasters. Generations, 31(4), 37−41.