Authors

  1. Millet, Clair P. DNP, APRN, PHCNS-BC
  2. Porche, Demetrius J. PhD, DNS, FACHE, FAANP, FAAN

Abstract

Hurricane Katrina made landfall on the Louisiana coast on August 29, 2005. Since 2005, there has been a dramatic increase in natural, infectious, and man-made disasters. It is more evident that nursing leaders and administrators need to be prepared for all hazards. The purpose of this article is to provide nursing administrators with a perspective of state-level leadership during a natural disaster and to suggest recommendations based on lessons learned during Hurricanes Katrina, Rita, Gustav, and Ike in 2005. These come from a state governmental public health and a state nursing school within an academic health sciences center.

 

Article Content

IN 2005, Hurricane Katrina, a designated category 5 hurricane, landed on the Gulf Coast of Louisiana, causing widespread destruction and despair. As a natural disaster, Hurricane Katrina precipitated a systematic impact on formal state systems and infrastructures that had a significant impact on the health, welfare, and safety of Louisiana residents. Leadership was a critical element for saving lives and restoring essential formal state systems and infrastructures. Unfortunately, management and leadership plans and systems were stressed to the point of collapse and failure.

 

During this natural disaster, multiple forms of leadership existed or emerged, formal and informal, to constrain the outcomes of this natural disaster. Both crisis management and crisis leadership were essential to mitigating the effects of Katrina. Crisis management is defined as specific activities that occur during and after a crisis, such as developing disaster plans, conducting disaster drills, and identifying roles and responsibilities needed during a natural disaster. In contrast, crisis leadership, while inclusive of crisis management, also pertains to all activities that occur before, during, and after a crisis to ensure appropriate prevention, containment, and recovery. Crisis leadership extends to promotion of a vision for the future after the resolution of the natural disaster. At the core, a differentiating element is that crisis leadership must provide influence, create a vision, remain mission focused, and manage individuals and systems to ensure a positive outcome that sustains life and infrastructure.

 

The purpose of this article is to provide nurse executives with a perspective of state-level leadership during natural disasters and to suggest recommendations based on lessons learned during Hurricanes Katrina, Rita, Gustav, and Ike since 2005. These come from a state governmental public health and a state nursing school within an academic health sciences center.

 

DISASTER LEADERSHIP

Leadership is the ability to influence others. Leaders and followers engage in a dynamic relationship focused on the alignment and achievement of personal, professional, and organizational missions. Leaders provide necessary direction and guidance. Espoused characteristics of a leader, who may be either a formal or informal leader, are trust, confidence, and effective communication. Byrd1 proposed that 5 essential leadership skills are anticipating, visioning, value congruence, empowerment, and self-understanding. Leaders provide leadership as an individual within an organizational system, but organizational systems and infrastructures must support their activities.

 

During a natural disaster, collapse of organizational systems and infrastructures poses additional challenges to a formal leader's ability. Effective crisis leadership has been described as transformative, transactional, charismatic, and situational.2 In times of a crisis, there can be an emergence of new, often informal, leaders.

 

A crucible is a place, time, situation, or incident characterized by the intellectual, social, economic, or political forces that provides an individual with an intense or meaningful experience utilized in future behaviors. A crucible promotes the development of resilience and durability.3 The ability of an individual to find meaning and learn from a crucible is considered a reliable indicator and predictor of leadership. A crucible forces an individual to focus on "what" really matters at that point in time in that specific situation. The authors of this article suggest that Hurricane Katrina served as a crucible moment in Louisiana in which leaders had to react and preserve human life and to then restore the community's infrastructure.

 

EXPERIENCES

The crucible leadership moment of Hurricane Katrina is explored below from 2 differing but similar perspectives, those of state governmental public health professionals and those of state nursing school leaders within an academic health sciences center. The defining crucible for both was the collapse of a state's infrastructure.

 

State public health and health care system

Catastrophic events include natural and man-made disasters. These events are usually very complex and typically create medical surge capacity needs for multiple health care systems. Prolonged catastrophic events often overwhelm an already overburdened health care system. The propensities for natural disasters in Louisiana over the last decade have certainly intensified. During Hurricanes Katrina and Rita in 2005, and Gustav and Ike in 2008, there were not enough medical providers to care for the most vulnerable Louisiana populations. Local and state medical response assets were rapidly exhausted and federal and out-of-state medical assistance was a necessity. One asset needed was a cadre of advanced practice nurses.

 

Advanced Practice Nursing in Louisiana

According to the Louisiana State Board of Nursing (LSBN), an "advanced practice registered nurse" or "APRN" is a licensed registered nurse who has completed an accredited graduate-level education program preparing the individual in 1 or more APRN roles and population foci; is certified by a nationally recognized certifying body in 1 or more roles and population focus; and who meets the criteria for an advanced practice registered nurse as established by the board.4 A nurse licensed as an APRN in Louisiana practices in one of the following functional roles: certified nurse midwife (CNM), nurse practitioner (NP), clinical nurse specialist (CNS), and certified registered nurse anesthetist (CRNA). Advanced practice registered nurses, by virtue of their education, qualifications, competencies, knowledge, skills, and abilities are uniquely poised to lead and directly contribute to a public health medical response effort. Louisiana laws regulating APRN practice require exploration into the practice site and into the collaborating physician's credentials before granting a license. The LSBN delineates scope of practice according to the nurse practice act and specifies the legal authority for APRN practice.

 

In 2005, for Hurricanes Katrina and Rita, there was no mechanism in place to allow license portability for out-of-state, non-Louisiana licensed APRNs to respond and practice at the level of their education and out-of-state licenses. This was regardless of their certification, scope of practice, skills, and abilities. Therefore, out-of-state APRNs were allowed to respond only as generalist registered nurses (RNs). Notably, the number of clinicians with the ability to diagnose, treat, and prescribe to vulnerable populations was largely insufficient. Being unable to utilize APRNs in this role exacerbated the shortage problem.

 

As a result of this inefficient utilization of trained and practicing volunteer out-of-state APRNs, the LSBN promulgated rules in March 2007. This rule provided a mechanism for the LSBN staff to issue disaster relief temporary permits to out-of-state RNs and APRNs who were not currently licensed in the state of Louisiana. This rule allowed out-of-state APRNs to perform gratuitous or nongratuitous nursing services in the state of Louisiana during a declared public health emergency.5

 

These newly promulgated rules were not truly tested until 2008, when Hurricanes Gustav and Ike landed on Louisiana with a full coastal impact that included the entire southern region of the state bordered by the Gulf of Mexico. While the collaborating physician agreement for the APRN was addressed in the rules promulgated in March 2007, non-Louisiana licensed APRNs who arrived to respond had multiple challenges and extreme difficulty in finding an appropriate collaborating physician as defined by the LSBN. In addition, the issue of prescriptive authority and prescribing privileges was not addressed in the LSBN 2007 rules. Consequently, the out-of-state APRNs were, once again, not utilized to their full practice authority. The APRNs that assisted in the state's response efforts functioned only as generalist RNs, as they had done in the 2005 state response efforts. This reinforces the need to address the ability to efficiently and effectively utilize the skills of APRNs who cross state lines to address the demand for medical response during disasters.

 

The National Council of State Boards of Nursing approved the nurse licensure compact (NLC), in 1998, granting reciprocal licensure to nursing professionals from participating compact states. The NLC is a mutual recognition model first implemented on January 1, 2000. Currently, there are 25 states participating in the NLC. Under the NLC mutual recognition model, practice across state lines is allowed unless the nurse is under discipline or in a monitoring agreement that restricts practice across state lines. The NLC allows RNs and licensed practical/vocational nurses to have 1 license in his or her state of residency and to practice in other states, subject to each state's practice laws and discipline. The APRNs are not included in this compact because Louisiana is not a compact state.

 

While it is accepted that all nurses can contribute to disaster preparedness during the disaster cycle, their roles and, in particular, APRN roles are not well defined in public health medical emergencies and disasters. Roles such as triage; direct care, including diagnosis and treatment; or care management of large numbers of patients should be anticipated during public health medical emergencies and disasters. No systematic examination of the preparedness of nurses or other individual health care providers and their response capabilities during a large-scale disaster event has been conducted.6

 

State academic health sciences center school of nursing

During Hurricane Katrina, the Louisiana State University School of Nursing was completely engulfed by water in the New Orleans metropolitan area. There was damage to the nursing school building, infrastructure, and operational systems. The nursing school administration, faculty, staff, and students were not prepared for this magnitude of destruction. Faculty, staff, and students were impacted by the event in their personal, educational, and employment lives. Faculty, staff, and students evacuated the impacted area and were relocated throughout the country. Immediately after the disaster, the nursing school administration was faced with dispersed staff; the need to rebuild and restore essential operational functions; and temporary location in Baton Rouge. These were their realities while beginning to recover and rebuild their campus in New Orleans.

 

The leadership challenges caused by this scenario were daunting. Faculty had dual responsibilities of facilitating the restoration of the nursing school while rebuilding their personal lives and homes. The nursing school had no physical office or classrooms available. Most faculty and students had evacuated without uniforms, textbooks, and clinical supplies (stethoscopes, penlights, clipboard). Several faculty members did not have access to their prepared lectures or to computers. Clinical learning experiences were necessary but available only in health care facilities that did not have prior clinical affiliation agreements with the nursing school. Some students and faculty were without housing in the relocated city of Baton Rouge.

 

During this crucible time period, some formal titular leaders did not respond to the crisis situation, creating a leadership and management void within the nursing school. Therefore, recovery of the nursing school was dependent upon the emergence of leaders from within the faculty. These emergent faculty leaders were challenged with securing: (1) physical space to hold classrooms, (2) clinical affiliations with new institutions to conduct clinical learning experiences, (3) equipment to conduct clinical laboratory experiences, (4) student's access to educational resources such as textbooks, paper, and other supplies, (5) clinical uniforms, (6) stethoscopes, bandage scissors, penlights, and (7) housing. However, within 4 weeks, they were able to resume classes in a movie theater prior to the daily matinees!

 

NEED FOR LEADERSHIP-EVOLUTION OF EMERGING LEADERSHIP

The School of Nursing's experience provided overwhelming evidence that leadership is critical to the successful survival of an organization during a disaster. Formal leadership during a disaster may not respond or may not be available. Existing formal leadership can collapse. During a disaster, leaders need to provide the support, comfort, and trust required from their followers, whether these are formal or informal leaders. As stated earlier, new leaders may emerge at this time.

 

Emergence is a large- scale change that occurs within a situation. During the process of emergence, which occurs in stages, a system of influence evolves. Porche7 describes the emergence of leadership that may transpire during a disaster. First, emergent leadership involves networking and connecting with other persons. Then, the benefit of the connection to the team is recognized and utilized to influence teams working together toward a common mission, purpose, or goal. Emergent leadership is a by-product of interaction between personality and the demands of the contextual situation. Emergent leadership during a natural disaster appears to be an evaluation of the leadership role as a means of filling a gap or leadership void in a given situation.8

 

DISCUSSION/LESSONS LEARNED/RECOMMENDATIONS

The leadership lessons learned from previous disasters that created a leadership crisis situation are multiplicative. The following recommendations are rooted in lessons learned:

  

* Nurses who make the decision to respond to an emergent situation or disaster and care for the medical needs of victims may face significant barriers and limitations that should be understood before they cross state lines. Many state nursing licensing agencies have disaster contingencies that allow for a generalist RN to provide nursing services in another state during times of crisis and disaster.9 This disaster contingency is usually based on a precisely defined nurse practice act for the RN. There is currently no such contingency for the APRN crossing state lines to respond to public health medical emergencies and disasters.

 

* The Federal National Response Framework should be utilized for clear communication during disaster deployments, and all responders should be communicating and collaborating through the Incident Command System. In the Hurricane Katrina After Action Report and Recommendations, it was reported that medical volunteers and well-intentioned nursing personnel caused concern, confusion, and lack of collaborative understanding of the Nurse Practice Act within the Incident Command System tasked with providing a coordinated incident effort.8 Society, collectively, will greatly benefit from a coordinated effort and a clearly defined scope of practice for nurses during disaster events. A defined scope of practice for APRNs could support legal practice and serve to eliminate the role confusion to other providers, subsequently improving care to vulnerable populations during a public health medical emergency or disaster.

 

* The development of standardized, formal emergency preparedness, response, and recovery educational core competencies with competency-based objective evaluation is critical. Before 2001, few nurses received any formal education in the areas of emergency preparedness or disaster response. Disasters such as the natural disasters discussed and the increasing propensity for disasters over the last decade have demonstrated that the lack of knowledge in disaster response and management creates confusion among those responding while causing delays in an effective response.

 

* Thorough policy analysis must be conducted at the local, state, and federal levels relative to public health medical emergencies and disaster. Policy analysis of state legislation and nursing practice act rules and regulations are essential before disaster strikes. Legislation and nursing policy guide practice during public health medical emergencies and disaster. Nurses should assist with the development of policies and planning related to response during disasters. Deficiencies and gaps in emergency preparedness and response plans and the policies that govern them can be discovered only through very thoughtful analysis, identification of problems, and actions for resolution. Unresolved issues of legal, ethical, and professional considerations related to disaster remain a challenge. If not addressed pre-event, these could hamper the ability of nurses to respond. Legal protections, such as liability coverage, license verification and credentialing, as well as defined scope of practice and crisis standards of care for nurses, particularly APRNs, should be ensured.

 

* Nurse leaders must promote disaster preparedness at the workplace and encourage and emulate personal and professional preparedness. Nurses should participate in all-hazards disaster training, drills, and exercises to become better prepared for disasters. By increasing awareness and knowledge of public health medical emergencies and disasters, nurses can strengthen efforts that can be invaluable and most importantly, lifesaving.

 

* Continuity of operations planning is crucial before disaster strikes. It is imperative for organizations to continue performance of mission critical functions under a diverse range of circumstances in a timely matter. Nurses serve as leaders in all phases of the disaster cycle at multiple levels and jurisdictions. This can be demonstrated within communities, actual disaster sites, and workplaces at local, state, national, and international jurisdictions. Elements of critical thinking are essential for problem solving, prioritization, and decision making that is required in disaster preparedness, response, and recovery. Types and styles of leadership exercised during disaster are often dependent upon the situation and/or type of disaster.

 

* A leadership infrastructure should be developed that provides a system of primary and secondary leaders to respond in the instance that any primary leaders are not capable of, or do not respond to, the emergent situation. If there is organizational capacity, a 4-deep succession planning is recommended for disaster planning and response.

 

* Communication systems should be duplicative and diverse to provide for multiple types of communication infrastructure collapses.

 

* Partnerships are crucial to disaster resilience. Public-private partnerships are essential during all phases of disaster. Government and private entities typically cannot respond alone.

 

* Disaster/crisis and business affiliation agreements should be negotiated with other health care or academic institutions should an entire health care facility or nursing school have to relocate and operate remotely. These formal agreements can provide the necessary legal protections, such as adherence to Health Insurance Portability and Accountability Act requirements.

 

* Policies and procedures should be developed that emphasize authority for declaration of an emergency, with a delineation of roles and responsibilities prior to, during, and after a disaster/crisis. Table 1 presents an academic exemplar. A time line that delineates activities required for emergency preparedness is critical. Table 2 presents an academic exemplar. A communication plan with duplicative communication systems in place prior to, during, and after a disaster is integral. For example, in an academic organization, the communication plan includes communication with faculty, staff, students, clinical affiliations, and local media.

 

* An emergency call-in-line for faculty, staff, and students, or on online communication system that provides synchronous and asynchronous communication should be established. Agency disaster rosters that include essential personnel information, such as primary and secondary contact information, are vital to continuity of operations.

 

* A resource and access plan is needed. This plan outlines contact information and procedures for securing access to business continuation resources such as computers, textbooks, uniforms, and clinical equipment.

 

* Further research is warranted in the emergency preparedness and disaster nursing field. Few research studies explore emergency preparedness or professional competency in any health care provider type, particularly for APRNs. Most of the work in disasters remains unreported in the literature and is known only through anecdotal or preliminary information.

 

CONCLUSION

It is essential that nurse leaders offer their unique talents, skills, and abilities in public health medical emergencies and disasters during all phases of disaster management. Nursing leaders should be prepared for imminent altered standards of care and dysfunctional operations in diverse settings during disaster. This article offers recommendations to nurse executives and others, based on lessons learned from 2 perspectives. The authors' aim is to help leaders and nurses prepare, respond, and recover during disaster situations.

 

REFERENCES

 

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4. Louisiana State Board of Nursing. Law governing the practice of nurses, Chapter 11, nurses, part I. Registered nurses. http://http://www.lsbn.state.la.us/Portals/1/Documents/rules/npafull.pdf. Published 2014. Accessed October 4, 2016. [Context Link]

 

5. Louisiana State Board of Nursing. Louisiana State Board of Nursing Rules and Regulations, title 46, Professional and Occupational Standards, part XLVII. Nurses, subpart 2. Registered nurses, subchapter C. Registration and Registered Nurse Licensure, Chapter 33: Section [S]3328, Disaster Perm. http://http://www.lsbn.state.la.us/Portals/1/Documents/rules/npafull.pdf. Published 2007. Accessed October 4, 2016. [Context Link]

 

6. Slepski LA. 'Emergency preparedness and professional competency among health care providers during hurricanes Katrina and Rita: Pilot study results'. Disaster Manage Response. 2007;5(4):99-110. doi:10.1016/j.dmr.2007.08.001. [Context Link]

 

7. Porche D. Emergent Leadership During a Natural Disaster: A Narrative Analysis of an Acute Health Care Organization's Leadership [dissertation]. Minneapolis, MN: Capella University; 2009. [Context Link]

 

8. Stokowski L. Ready, willing and able: preparing nurses to respond to disasters. http://http://www.medscape.com/viewarticle/579888_print. Published 2010. Accessed October 4, 2016. [Context Link]

 

9. Minnesota Department of Health. Hurricane Katrina after action report and recommendations. http://http://www.msdh.state.ms.us/msdhsite/_static/resources/1676.pdf. Published 2006. Accessed October 4, 2016.

 

crisis; disaster nursing; disasters; Hurricane Katrina; nurse leaders; nursing school; public health emergency