Emergency Preparedness Experiences by Emergency Managers

Doctoral Dissertation Originally published by

Walden

University 2019

Abstract

This qualitative research focused on the emergency preparedness (EP) rule implementation in rural hospitals in the Pacific Northwest. A new law has been implemented that requires hospitals to comply with Medicaid and Medicare law. Learning about the implementation and preparedness process could help rural regions in the Pacific Northwest better prepare for emergencies and comply with the law. The purpose of the study was to gain increased understanding of how the new EP rule of 2016 impacts rural hospitals’ preparedness in the Pacific Northwest. The theoretical framework was complexity theory. This study focused on the lived experience of emergency managers who have been working on the implementation of the new EP rule in rural hospitals in the Pacific Northwest. Using a phenomenological approach, 8 in-depth phone and face — to — face interviews were conducted. Selection criteria included working as emergency preparedness managers in rural hospitals in the Pacific Northwest. The verbatim transcripts of interviews were analyzed by first cycle analysis, used concept and descriptive coding to find common themes. The findings of the study included that small rural hospitals working on EP need more support and help that include financial needs, resources, staff preparedness improved communication and more exercises local communities including every individual living in the community are also responsible for their own preparedness. This inquiry could help understand the effects of the new EP rule for rural hospitals; it could identify gaps in research that could support rural hospitals and surrounding communities; it could affect positive social change by applying the research evidence to additional health care settings.

Dedication

To all of the people working in EP that support the need of many in case of a disaster hits. Truly thank you for all you do. Also, to my family, my grandmother Nagy Borbala who always wanted me to get a doctorate education. To my mother Pecsvari Borbala who always been supportive of me studying. My spouse Maggie and my children Andras and Andrea who supported me throughout this journey and encouraged me during difficult times. My sisters who checked in with me time to time how things are going. My friends who kept encouraging me to keep on going. Thank you, could have not done it without you.

Acknowledgements

I would like to thank Dr. Frazier Beatty my committee chair for continuous encouragement and support throughout the dissertation process. Professor, there are no words that I could say that would show enough gratitude for your support. I truly appreciate everything you have done for me. My committee member Dr. German Gonzalez. Professor thank you for your guidance and support throughout the dissertation process.

To all my family and friends who stick by me staying up long hours and not spending enough time with them because I had to study. It has been a long road, thank you for all your patience and support throughout this journey.

Chapter 1: Introduction to the Study

Introduction

In the past 10 years the United States experienced devastating disasters including tornadoes, influenza pandemic, floods, fires, an anthrax attack, terrorist attacks, disease outbreaks such as enterovirus and Ebola (Office of the Federal Register, 2016). VanVactor (2016) and Ripoll et al. (2015) discussed data between 2010 to 2014 including over 300 major disasters, including 330 natural disasters globally in 2013, 60 emergencies, and 240 fire management declarations. Disaster declarations are due to earthquakes, extreme temperatures, flooding, fires and wild fires, hurricanes and tropical storms, severe storms, snow storms, tornadoes, tsunamis, and other events (VanVactor, 2016). Current hazards in Oregon include flooding, landslides, bioterrorism, drought, earthquakes, extreme heat, tsunamis, wildfires, windstorms, and winter storms (Oregon Health Authority, n.d.). To prepare the country for natural and man-made disasters, in the year in 2016 a new Emergency Preparedness (EP) Rule became law for health care facilities in the United States (Office of the Federal Register 2016). This EP rule is in effect today. Data from global disasters show that EP is necessary to prevent or decrease the health impact including death and disability due to future catastrophic events (Lucchini et al., 2017). Savoia et al. (2017), in their systematic literature review looking at 156 studies in public health EP from 2009–2015, found that there is a gap in the literature regarding information-sharing between organizations as well as communication with the public, including creating information for diverse audiences. EP is not practiced the same way in every county, and this creates dissimilar levels of preparedness to respond to an emergency. Bin Shalhoub, Khan and Alaska (2017) found that hospitals have different levels of readiness, and there is a need for improvement in EP education and training. Looking at the progress in public health EP from 2001–2016, Murthy, Molinari, LeBlanc, Vagi, and Avchen (2017) found that 20% of jurisdictions have difficulty coordinating public health agencies and the healthcare system because of barriers to training, financial sustainability, and lack of or incomplete EP plans. Valesky et al. (2013) found that hospitals underreport their surge capacity, indicating that the available beds reported and the beds available show great discrepancy and could create inadequate knowledge during a disaster related to surge capacity. Zusman and Marghella (2013) found that many hospitals are not prepared for disasters and only about one third of hospitals were planning to upgrade their disaster preparedness infrastructure. Little is known about how barriers to training, financial sustainability, and completion of EP plans affect rural coastal communities in the Pacific Northwest region.

In this study, qualitative interviews were conducted with rural healthcare professionals in the Pacific Northwest regarding their experiences and perceptions of the implementation of the EP Rule. Topics included communication, information-sharing, education, training, practice, metrics development, criteria development, and barriers. The societal impact of this study could include increased direct social impact, including communication and collaboration between the EP managers in the Pacific Northwest region (Bornmann, 2013). Additional social change implications could include policy and protocol changes; changes in current training and education related to emergency preparedness; increased knowledge of EP coordinators and other stakeholders based on research findings on how other hospitals in the region address emergency preparedness. Sections of Chapter 1 cover the following topics: background information to the study, the purpose of the study, research questions, brief review of framework, definition of terms, assumptions, limitations, scope of the study, significance of the study, implications for social change and a summary.

Background

Oregon Health Authority (n.d.a) and Ramsey, Hamilton and Miller, (2017) explained that the new EP rule affects 17 different types of health care facilities in Oregon. The facilities must implement the new EP rule by 2018, otherwise they would lose federal dollars, which can be up to 30% of their income from Medicaid and Medicare and their contract could be terminated. Cagliuso (2014) and Cagliuso (2014a) provided information on the EP in hospitals and stakeholders’ views on preparedness and found the following emerging themes: the necessity for funding, the essential elements of collaboration, communication, coordination. In role of the government the study participants had mixed views and the need for hospital leadership buy-in for success was identified concludes that future studies are needed for additional support in EP. Seale (2010), in the narrative description after Hurricanes Rita and Ike, found that additional staff preparation and planning was needed for successful EP. This article highlighted previous gaps in preparedness and support needed for future EP implementation. Taschner, Nannini, Laccetti and Greene (2017) examined EP policy and practice in Massachusetts hospitals and found these emerging themes: standardized training needs, importance of communication and collaboration, effects of creating financial burden for hospitals. This study by Taschner et al. (2017) showed the need for future research and identifies funding and training needs for hospitals with new EP rules and policies that require implementation (Laccetti & Greene, 2017). A study looking at EP for nurses found that nurses had difficulties with EP terms and activities, ethical issues, and access to resources (Hodge, Miller, & Dilts Skaggs, 2017). This study outlined the need for additional support and education for nurses in a rural hospital to prepare for disasters. Alzahrani and Kyratsis (2017) examined nursing preparedness in hospitals and found training variances, including the lack of awareness and knowledge of emergency disaster preparedness plans among nurses. The need was identified for communication outreach, education, and skill development; the study showed the need between consistent EP training and education in hospital EP. Markiewicz et al. (2010) the study results found a positive effect on communication, disease surveillance, EP and response with an epidemiologist present; recommendation for similar programs in other communities for EP indicating a potential solution for communication between hospitals and public health agencies is having an epidemiologist on staff. Paganini et al. (2016) examined EP in Italy and found that emergency room physicians lack knowledge on what to do during a disaster; education and training needs were identified. Italy has a policy for hospital preparedness that needs to be followed like the EP rule in the U.S., yet the study found inadequate disaster preparedness in the hospital’s ED department — an indication of a potential gap between EP rule and implementation (Paganini et al. 2016). This research study planned to explore how the new EP law affecting hospital preparedness in the Pacific Northwest could contribute to the learning of EP in rural areas. The research study was needed to explore the effects of the EP rule in the rural Pacific Northwest and increase the understanding of hospital EP by learning from the experiences of EP managers.

Problem Statement

The United States has been through devastating disasters (Federal Register, 2016). In 2016, a new EP Rule went into effect and is still in effect today (Federal Register, 2016). EP is essential to prevent death and disability and to decrease adverse health outcomes in disasters (Lucchini et al. 2017). Savoia et al. (2017) found a gap in the literature related to communication breakdowns. Bin, Shalhoub, Khan and Alaska (2017) found inconsistencies between levels of readiness, and a need for additional EP training. Murthy, Molinari, LeBlanc, Vagi and Avchen (2017) found coordinating problems in public health agencies and healthcare systems and identified the need for additional training, financial sustainability, and additional support to complete EP plans. Valesky et al. (2013) found underreporting in surge capacity creating a discrepancy during a disaster. Zusman and Marghella (2013) found that inadequate preparedness for disasters included the lack of knowledge on how barriers to training, financial sustainability, and completion of EP plans affect rural coastal communities in the Pacific Northwest region. The gaps in the literature included the areas of disaster education, communication barriers, including patterns and effectiveness (Savoia et al. 2017; Paganini et al. 2016; Alim et al. 2015; Hammad et al. 2017; Woods, 2016; Fagbuyi et al. 2016; Seale, 2010; Shipman et al. 2016; Palttala et al. 2012). Gaps also include disaster planning, preparation, development, training and education for staff, preparedness in the ED department (Savoia et al. 2017; Paganini et al. 2016; Alim et al. 2015; Hammad et al. 2017; Woods, 2016; Fagbuyi et al. 2016; Seale, 2010; Shipman et al. 2016; Palttala et al. 2012). Additional gaps included preparedness for children, knowledge, role definition for nurses in a disaster, and long-term evaluation of disaster training effectiveness (Savoia et al. 2017; Paganini et al. 2016; Alim et al. 2015; Hammad et al. 2017; Woods, 2016; Fagbuyi et al. 2016; Seale, 2010; Shipman et al. 2016; Palttala et al. 2012).

Purpose

The purpose of this qualitative research study was to increase the understanding of the new EP rule and its implications in rural hospitals’ preparedness in the Pacific Northwest, including identification of common themes emerging amongst health care facility EP personal. The intent of the study was to explore the lived experiences of the EP managers in the rural Pacific Northwest. The phenomenon of interest was to learn about the lived experiences of EP managers in the rural Pacific Northwest, and how those experiences relate to the EP rule implementation and to the EP process. The identified themes can help identify potential barriers, and can create supportive recommendations for health care facilities, including hospitals that are undergoing the implementation and maintenance process of the EP rule.

Research Questions

The following two research questions guided the study:

RQ 1. How will the lived experiences of the emergency preparation for emergency managers that work in rural hospitals in the Pacific Northwest influence the implementation of the new EP rule for the area?

RQ 2. What can be learned from the lived experiences of EP managers in the Pacific Northwest regarding the EP process?

Framework

Complexity theory looks at individual parts of any system and how they work together (Thrift, 1999). The theory works with multiple level systems, addresses the complexity of interactions of systems, systems’ parts; unpredictability within these systems. The theory also works for community health systems and organizations such as hospitals (Hilhorst, 2003; Paley & Eva, 2011; Thrift, 1999).

EP requires multiple systems to work together. A complex system can be unpredictable in its behavior, just like disasters and emergencies, such as earthquakes, depending on the current situation that arises (Comfort, 1995; Hilhorst, 2003; Plsek & Greenhalgh, 2001). Complexity theory would work well for looking at EP in the hospital setting and how the preparedness rule implementation affects the Pacific Northwest community. Reed et al. (2018) had developed a SHIFT-evidence framework based on complexity theory in healthcare systems including three strategic principles with 12 simple rules. The principles of the framework will be explained in more detail in Chapter 2 and they include elements to act scientifically and pragmatically, embrace complexity, and to engage and empower (Reed et al. 2018). Reed et al. (2018) described the importance of complex systems thinking in understanding the experiences people have works well together with the planned research of EP managers and their experiences because hospitals and EP are complex systems. More detailed explanation of the framework is outlined in Chapter 2.

Research Design

The research design for this study was a qualitative; it used a phenomenological approach that focuses on the lived experiences of individuals, in this case, EP managers. Phenomenology looks at the specific phenomena of interest, in this case of the EP rule, its implementation, and the lived experience of the EP managers (Patton, 2015; Ravitch & Carl, 2016). The goal of the study was to explore the experiences of the EP managers and the phenomenological approach fits this exploration well (Patton, 2015; Ravitch & Carl, 2016). The phenomenological approach is a research philosophy and a research method focusing on the lived experiences of the individual (Patton, 2015; Rudestam & Newton, 2015; Ravitch & Carl, 2016). Phenomenology seeks a deep understanding of the phenomena and getting in depth interviews from participants is a way to get at those experiences (Patton, 2015; Rudestam & Newton, 2015; Ravitch & Carl, 2016). The data were collected through in-depth interviews and observation of participants through the interview process (Ravitch & Carl, 2016).

To follow the phenomenological approach for this study, I developed interview questions with prompts to stimulate in-depth responses from participants (Patton, 2015). The interviews were recorded and transcribed verbatim (Ravitch & Carl, 2016). The transcribed interviews were checked with participants for accuracy. The first step in data analysis was looking for emerging codes, categories and themes from the data (Ravitch & Carl, 2016). Data analysis included a first cycle analysis that helped identify similarities in the context from the transcripts; the next step was to begin coding the data, included concept coding and descriptive coding (Laureate Education, 2016a). The participants were selected based on their lived experience of the new EP rule implementation; the protocol for the study included only participants with first-hand experiences (Patton, 2015). The procedures followed a phenomenological approach throughout the study and focused on the experiences of the EP managers who participated in the study (Patton, 2015).

Sources of data for this research included in-person interviews that were open ended with key informants; EP managers working in rural hospitals, where the new EP rule was being implemented in the Pacific Northwest (Rudestam & Newton, 2015). Qualitative data included words and ideas, such as transcript notes from interviews, records, and documents related to EP rule (Rudestam & Newton, 2015). Additionally, observations throughout the interview including hand gestures, facial expressions, and pauses could provide additional insight into the emotional state of the participant. Data collection was an iterative process (Ravitch & Carl, 2016). Fieldwork and data collection memos, including researcher reflections, were additional elements included in the data collection (Ravitch & Carl, 2016).

Definitions of terms

Complexity: Complexity and complex thinking related to disasters refers to the multipart systems and sub systems between nature and science (Hilhorst, 2003).

Complexity Theory: Interactions between society and nature are unpredictable related to societal changes and chain of events (Hilhorst, 2003).

Emergency Preparedness: A coordinated and continuous process where public health systems, communities, individuals create a well -prepared community, prevent, respond and recover from public health emergencies (Nelson, Lurie, Wasserman, & Zakowski, 2007).

EP Rule: Centers for Medicare and Medicaid (CMS) EP rule requires 17 different type of organizations to implement certain elements as part of their EP based on their risk assessment (Elko, 2017). Preparedness elements include: emergency plan, policies, procedures, communication plan, training and testing (Elko, 2017).

Disaster: A disruption of a community’s ability to function related with its own resources because of losses that can be material, economic, environmental or human (Boyd el al. 2017).

Man-Made Disaster: A disaster that was created by humans including but not limited to conflicts, famine, displacement, terrorism, industrial accidents (IFRC, n.d; Boyd et al. 2017).

Natural Disaster: A disaster created by nature including but not limited to earthquakes, landslides, tsunamis, floods, wild fires, diseases (IFRC, n.d; Boyd et al., 2017).

Humanitarian Emergency: A disaster that is resulting in the need of international support (Boyd et al. 2017).

Lived Experiences: An experience or experiences of an individual who lived through a phenomenon (Creswell, 2014).

Phenomenology: A qualitative research inquiry from psychology and philosophy built on the lived experience of individuals whom experienced the phenomenon being discussed (Creswell, 2014).

Resilience: The ability to bounce back after being stressed and become stronger by learning new skills and investing in future preparedness and recovery (Egli, 2013).

Assumptions of the Study

This study was based on three assumptions. First, that rural EP managers in the Pacific Northwest were willing to provide interviews related to their experiences for this study. Second, that the EP managers were honest with their answers, did not omit relevant information from the questions, and there was no manipulation with the answers. Third, that I was honest, followed research protocol, and represented the meaning the participants want to covey. Assumptions are necessary because if the assumptions are true, they provide a support for the conclusion of the study (Browne & Keeley, 2007).

Limitations of the Study

Limitations of the study include that this study was only looking at rural areas in the Pacific Northwest and each area in the United States can be different based on the availability of hospitals, responders, funding and density. Because of the limited rural hospitals in the Pacific Northwest the study findings may not be applicable to other areas in the United States. Limitations on transferability include that a qualitative research is not meant to be generalizable but to develop statements based on the context explored, in this case EP (Ravitch & Carl, 2016). Limitations of dependability include the requirement for consistency with all data collection, transcribing and coding data (Ravitch & Carl, 2016). Addressing limitations of the study related to dependability was achieved by using qualitative fields notes, using an interview guide, being consistent with data collection, collecting data in person with recordings, being transparent with coding, reflections and documentation and summaries of codes, possible themes, as well as the research process in general (Ravitch & Carl, 2016). To address limitations of the study related to transferability I transcribed the verbatim interviews, grouped them, created codes, then based on the codes created themes, which enhanced intercoder reliability and validity (Patton, 2015). Personal bias can influence outcome. I remained objective, open, attentive, professional, transcribed interviews verbatim, wrote down personal feelings during the interview process and disclosed my feelings as part of the study (Ravitch & Carl, 2016).

Scope of the Study

The range of the study was limited to the rural Pacific Northwest area of United States. The sample of the study included EP managers who have worked in rural hospitals since the EP rule was implemented. No other participants from EP were considered for this study. The focus of the study was chosen as a result of discussion of need for this type of research in the area with Oregon Health Authority Planning Section Chief and Deputy Director Health Security Preparedness and Response Program, Eric Gebbie (personal communication, December 1, 2017), and by a preliminary literature review.

Significance

This qualitative inquiry aimed to develop a better understanding of the effects of the new EP rule on rural hospitals. Hospitals provide a critical role in EP (Kaji, Koenig, & Lewis, 2007). Understanding what has been working and what barriers arise while implementing and maintaining preparedness helped to fill the gaps in current EP needs of rural communities in the Pacific Northwest leading to practice and potential protocol and policy change in emergency preparedness. The findings also support EP managers practice in rural areas throughout the United States.

Using this qualitative inquiry to learn about EP in the health care facilities could be reapplied as support and learning for other facilities across the state and country. This study has implications for positive social change by practice: applying the evidence that was found in the research to practice in additional health care settings and identifying potential gaps for future research to support the health care facilities in the Pacific Northwest (Laureate Education, 2015). The study findings and results can be used to inform stakeholders including policymakers, which could result in a change in existing policy and protocols surrounding EP in the Pacific Northwest. Another implication is advocacy: raising awareness about how health care facilities are doing with the new EP rule implementation. Finally, positive social change impact includes the chance that the completed study could provide increased knowledge and support for Pacific Northwest hospitals and communities to be better prepared for emergencies by learning from the experiences of EP managers in the field.

I believe that this study was able to (a) help provide information on the implementation process of EP and highlight areas that work well and areas that need improvement; to (b) support additional rural hospitals in the Pacific Northwest and other rural areas in the United States. The preparedness in rural areas ultimately saving lives.

Positive social change as a potential outcome of the study can be decreasing morbidity and mortality in the Pacific Northwest. Rural areas can be fragile and cut off from urban areas in the time of disaster and being prepared can help individuals and communities survive an emergency. The intention of this study was to highlight important areas in EP that can help rural hospitals and communities make their process smoother and help to build resiliency in the hospital setting as well as in the community. Learning about the EP mangers experiences highlighted areas that work well in the community, and areas where support is needed. Based on the experiences from the Pacific Northwest, other rural communities could change their decision-making process related to what is working in those communities and how that understanding could be applied to improve EP in their community. Emergencies and disasters are part of everyday life all over the United States. The more hands-on experiences learned, the more individual communities can be prepared and thus recover after a disaster. Additionally, gaps found through this research suggest future phenomenological studies in the area of EP in rural communities.

Summary

The goal of the study was to explore the lived experiences of EP managers related to the EP rule who were working in the rural Pacific Northwest. Currently there is a limited understanding of the lived experience of, and preparedness effects for, EP managers working in a hospital setting. This study sought to highlight the lived experiences, possible gaps and future directions in rural emergency preparedness. Chapter 1 explored the background information to the study, the purpose of the study, research questions, brief review of framework, definition of terms, assumptions, limitations, scope of the study, significance of the study, implications for social change.

Chapter 2 includes an introduction, literature search strategies, a more detailed theoretical framework discussion, a detailed literature review and a conclusion. Chapter 3 provides an introduction, information on the research design, nature of the study with a rationale, participant selection, instrumentation, sources of data, interview questions, research analysis, participant’s rights, and a chapter summary. Chapter 4 will include an introduction, information on the pilot study conducted, setting, demographics, data collection, data analysis, trustworthiness, results of the study and a summary. Chapter 5 will include an introduction section, interpretation of findings, limitation of study, recommendations, implications and a conclusion.

Walden University College of Health Sciences 2019

Review Committee

Dr. Frazier Beatty, Committee Chairperson, Public Health Faculty

Dr. German Gonzalez, Committee Member, Public Health Faculty

Dr. Melissa Green, University Reviewer, Public Health Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

References

Ablah, E., Konda, K. S., Konda, K., Melbourne, M., Ingoglia, J. N., & Gebbie, K. M. (2010). EP training and response among community health centers and local health departments: results from a multi-state survey. Community Health, 35(3), 285–293. doi: 10.1007/s10900–010–9236–7

Adini, B., Laor, D., & Aharonson-Daniel, L. (2014). Factors affecting preparedness and capacity to manage pandemic influenza: perceptions of healthcare managers. Public Health, 128(8), 703–708. doi: 10.1016/j.puhe.2014.06.002

Alim, S., Kawabata, M., & Nakazawa, M. (2015). Evaluation of disaster preparedness training and disaster drill for nursing students. Nurse Education Today, 35(1), 25–31. doi: 10.1016/j.nedt.2014.04.016

Alzahrani, F., & Kyratsis, Y. (2017). Emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses’ perceptions in hospitals in Mecca, Saudi Arabia. BMJ Open, 7(4), e013563. doi:10.1136/bmjopen-2016–013563

Anthony, K. E., Sellnow, T. L., & Millner, A. G. (2013). Message convergence as a message-centered approach to analyzing and improving risk communication. Applied Communication Research, 41(4), 346–364. http://dx.doi.org/10.1080/00909882.2013.844346

Baack, S., & Alfred, D. (2013). Nurses’ preparedness and perceived competence in managing disasters. Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 45(3), 281–287. http://dx.doi.

org/10.1111/jnu.12029. doi: 10.1111/jnu.12029

Baker, S. E., Edwards, R., & Doidge, M. (2012). How many qualitative interviews is enough? Expert voices and early career reflections on sampling and cases in qualitative research. Retrieved from National Centre for Research Methods: http://eprints.ncrm.ac.uk/2273/4/how_many_interviews.pdf

Bennett, D. Phillips, B.D. & Davis, E. (2017, March). The future of accessibility in disaster conditions: How wireless technologies will transform the life cycle of emergency management, Futures, 87, 122–132, https://doi.org/10.1016/j.futures.2016.05.004

Ben Natan, M., Nigel, S., Yevdayev, I., Qadan, M., & Dudkiewicz, M. (2013). Nurses’ willingness to report for work in the event of earthquake in Israel. Journal of Nursing Management. doi:10.1111/jonm.12058

Bin Shalhoub, A. A., Khan, A. A., & Alaska, Y. A. (2017). Evaluation of disaster preparedness for mass casualty incidents in private hospitals in Central Saudi Arabia. Saudi Medical, 38(3), 302–306. doi:10.15537/smj.2017.3.17483

Bornmann, L. (2013). What is social impact of research and how can it be assessed? A literature survey. American Society for Information Science and Technology, 64. 10.1002/asi.22803.

Boyd, A. T., Cookson, S. T., Anderson, M., Bilukha, O. O., Brennan, M., Handzel, T….Gerber, M. (2017). Centers for Disease Control and Prevention public health response to humanitarian emergencies, 2007–2016. Emerging Infectious Diseases, 23(13). https://dx.doi.org/10.3201/eid2313.170473

Brand, S. L., Fleming, L. E., & Wyatt, K. M. (2015). Tailoring healthy workplace interventions to local healthcare settings: A Complexity Theory-Informed workplace of well-being framework. The Scientific World, 340820. doi:10.1155/2015/340820

Browne, N.M. & Keeley, S.M. (2007). Asking the Right Questions. A guide to critical thinking. Upper Saddle River, NJ: Pearson Education.

Byng, R., & Jones, R. (2004). Mental health link: the development and formative evaluation of a complex intervention to improve shared care for patients with long-term mental illness. Journal of Evaluation in Clinical Practice, 10(1), 27–36.

Cagliuso, N. V. (2014). Stakeholders’ experiences with US hospital emergency preparedness: Part 1. Business Continuity & Emergency Planning, 8(2), 156–168.

Cagliuso, N. S. (2014a). Stakeholders’ experiences with US hospital emergency preparedness — Part 2. Business Continuity & Emergency Planning, 8(3), 263–279.

Cagliuso, N. V. (2012). Stakeholders’ experiences with U.S. hospital EP (Order №3519439). Available from Dissertations & Theses @ Walden University.

Catalino, J., Jr. (2015). The impact of federal emergency management legislation on at-risk and vulnerable populations for disaster preparedness and response (Order №3702737). Available from Dissertations & Theses @ Walden University. (1686122879).

Charney, R., Rebmann, T., & Flood, R. B. (2014). Working after a tornado: a survey of hospital personnel in Joplin, Missouri. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science, 12(4), 190–200. http://dx.doi.org/10.1089/bsp.2014.0010

Christian, M. D., Kollek, D., & Schwartz, B. (2005). Emergency preparedness: What every health care worker needs to know. CJEM: Canadian Association of Emergency Physicians, 7(5), 330–7.

Cirkovic, M., Sandberg, A., & Bostrom, N. (2010). Anthropic shadow: observation selection effects and human extinction risks. Risk Analysis: International, 30(10), 1495–1506. doi: 10.1111/j.1539–6924.2010. 01460.x

Comfort, L. (1995). Self-organization in disaster response and recovery. The Maharashta, India, earthquake of September 30, 1993. Natural Hazards Research and Applications Information Center, Quick Response Reports №74. University of Colorado, Boulder, Colorado. Retrieved from https://scholarcommons.usf.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=1041&context=fmhi_pub

Creswell, J. W. (2014). Qualitative, quantitive, and mixed methods approaches. Thousand Oaks, CA: Sage Publications.

de Cassia Nunes Nascimento, L., Vignuda de Souza, T., Oliveira, I. S., de Montenegro Medeiros de Moraes, J. R., Cordeiro Burla de Aguiar, R., & Faria da Silva, L. (2018). Theoretical saturation in qualitative research: an experience report in interview with schoolchildren. Revista Brasileira De Enfermagem, 71(1), 228–233. doi:10.1590/0034–7167–2016–0616

Egli. D. S. (2013). Beyond the storms: strengthening preparedness, response, & resilience in the 21st century. Strategic Security, 6 (2),32–45 (2013), doi: 10.5038/1944–0472.6.2.3

Egli, D. S. (2014). Beyond the storms: strengthening homeland security & disaster management to achieve resilience. Homeland Security Review, (1), 101.

Elko, J. (2017). CMS EP rule: required processes to have in place: make sure your organization has processes in place as soon as possible. Health Care Compliance, 19(6), 25–58.

Encyclopedia Britannica. (2019). Pacific Coast, region, North America. Retrieved from https://www.britannica.com/place/Pacific-Coast

Errett, N. A., Barnett, D. J., & Thompson, C. B., et al. (2013). Assessment of medical reserve corps volunteers’ emergency response willingness using a threat- and efficacy-based model. Biosecurity Bioterror,11(1):29–40. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3612278/

Fagbuyi, D. B., Schonfeld, D. J., Krug, S. E., Chung, S., Fisher, M. C., Needle, S. M., & Disaster Preparedness Advisory. (2016). Medical countermeasures for children in public health emergencies, disasters, or terrorism. Pediatrics, 137(2). doi: 10.1542/peds.2015–4273

Goss, T. (2017). Emergency managers’ perceptions of all-hazards pandemic planning effectiveness in north Texas (Order №10641382). Available from Dissertations & Theses @ Walden University. (1970753944).

Gossip, K., Gouda, H., Yong Yi Lee, Firth, S., Bermejo III, R., Zeck, W., … Jimenez Soto, E. (2017). Monitoring and evaluation of disaster response efforts undertaken by local health departments: a rapid realist review. BMC Health Services Research, 17, 1–11. https://doi-org.ezp.waldenulibrary.org/10.1186/s12913-017-2396-8

Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An experiment with data saturation and variability. Field Methods, 18(1), 59–82. doi:10.1177/1525822X05279903

Halcomb, E. J., & Davidson, P. M. (2006). Is verbatim transcription of interview data always necessary? Applied Nursing Research, 19(1), 38–42. doi: 10.1016/j.apnr.2005.06.001

Hammad, K. S., Arbon, P., Gebbie, K., & Hutton, A. (2017). Moments of disaster response in the emergency department (ED). Australasian Emergency Nursing, 20(4), 181–185. doi: 10.1016/j.aenj.2017.10.002

Hilhorst, D. (2003). Responding to disasters. Diversity of bureaucrats, technocrats and

local people. International Mass Emergencies and Disasters, 21(1),

37–56.

Hodge, A. J., Miller, E. L., & Dilts Skaggs, M. K. (2017). Nursing self-perceptions of EP at a rural hospital. JEN: Emergency Nursing, 43(1), 10–14. doi: 10.1016/j.jen.2015.07.012

Hodge, J., G, Jr, & Gostin, L., O. (2017). Revamping the us federal common rule: Modernizing human participant research regulations. JAMA, 317(15), 1521–1522. Retrieved from http://dx.doi.org/10.1001/jama.2017.1633

IFRC (n.d.). Types of disasters: Definition of hazards. Retrieved from https://www.ifrc.org/en/what-we-do/disaster-management/about-disasters/definition-of-hazard/

Jacob, S. A., & Furgerson, S. P. (2012). Writing interview protocols and conducting interviews: tips for students new to the field of qualitative research. The Qualitative Report,17(42), 1–10. Retrieved from http://nsuworks.nova.edu/tqr/vol17/iss42/3

Jovchelovitch, S., Bauer, M. W., (2000) Narrative interviewing. In M. W. Bauer, and G. Gaskell,., (Eds.). Qualitative researching with text, IMAge and Sound: a practical handbook (pp. 57–74). London, UK: SAGE.

Kaji, A. H., Koenig, K. L., & Lewis, R. J. (2007). Current hospital disaster preparedness. Journal of the American medical association, 298(18), 2188–2190.

Kezar, A. k. (2014). Higher education change and social networks: A review of research. Higher Education, 85(1), 91–125.

Laureate Education (Producer). (2015). Social impact of a dissertation [Video file]. Baltimore, MD: Author.

Laureate Education (Producer). (2016, a). First cycle coding: Structural coding [Video file]. Baltimore, MD: Author.

Laureate Education (Producer). (2017). Voices from the field [Interactive media]. Baltimore, MD: Author.

Lanard, J., & Sandman, P. M. (2014). Ebola: Failures of imagination. Retrieved from http://psandman.com/col/Ebola-3.htm.

Landman, A., Teich, J. M., Pruitt, P., Moore, S. E., Theriault, J., Dorisca, E., et al. (2015). The Boston marathon bombings mass casualty incident: one emergency

department’s information systems challenges and opportunities. Annals of Emergency Medicine, 66(1), 51–59. http://dx.doi.org/10.1016/j.ann emergmed.2014.06.009

Leider, J. P., DeBruin, D., Reynolds, N., Koch, A., & Seaberg, J. (2017). Ethical guidance for disaster response, specifically around crisis standards of care: A systematic review. American Public Health, 107(9), e1–e9. https://doi-org.ezp.waldenulibrary.org/10.2105/AJPH.2017.303882

Levinson, D. L. (2014). Hospital EP and response during superstorm Sandy. U. S. Department of Health and Human Services, Washington, DC. Retrieved from: http://oig.hhs.

gov/oei/reports/oei-06–13–00260.pdf

Liu, B. F. Fowler, B. M., Roberts, H. A., & Herovic, E. (2018). Keeping hospitals operating during disasters through crisis communication preparedness. Public Relations Review, 44(4), 585–597. doi: 10.1016/j.pubrev.2018.06.002

Liu, B. F., Fraustino, J. D., & Jin, Y. (2016). Social media use during disasters: How information form and source influence intended behavioral responses. Communication Research, 43(5), 626–646. http://dx.doi.org/10.1177/0093650214565917

Long, K. M., McDermott, F., & Meadows, G. N. (2018). Being pragmatic about healthcare complexity: our experiences applying complexity theory and pragmatism to health services research. BMC Medicine, 16(1), 94. https://doi-org.ezp.waldenulibrary.org/10.1186/s12916-018-1087-6

Luscumb, J. M. (2017). Willingness of nurses to respond after Alaskan earthquake: Systematic literature review (Order №10257330). Available from Dissertations & Theses @ Walden University. (1896557477).

Lucchini, R. G., Hashim, D., Acquilla, S., Basanets, A., Bertazzi, P. A., Bushmanov, A., & … Todd, A. C. (2017). A comparative assessment of major international disasters: the need for exposure assessment, systematic emergency preparedness, and lifetime health care. BMC Public Health, 17(1), 46. doi:10.1186/s12889–016–3939–3

Markiewicz, M., Bevc, C. A., Hegle, J., Horney, J. A., Davies, M., & MacDonald, P. M. (2012). Linking public health agencies and hospitals for improved emergency preparedness: North Carolina’s public health epidemiologist program. BMC Public Health, 12,141. doi:10.1186/1471–2458–12–141

Martin, E., Nolte, I., & Vitolo, E. (2016). The four Cs of disaster partnering: Communication, cooperation, coordination and collaboration. Disasters, 40(4), 621–643. http://dx.doi.org/10.1111/disa.12173

Mason, M. (2010). Sample size and saturation in PhD studies using qualitative interviews. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research, 11(3), article 8. Retrieved from http://www.qualitative-research.net/index.php/fqs

Math, S. B., Nirmala, M. C., Moirangthem, S., & Kumar, N. C. (2015). Disaster management: mental health perspective. Indian Psychological Medicine, 37(3), 261–271.

McDermott, S., Martin, K., & Gardner, J. D. (2016). Disaster response for people with disability. Disability and Health, 9(2), 183–185. https://doi-

Melnikov, S., Itzhaki, M., & Kagan, I., (2014). Israeli nurses’ intention to report for work in an emergency or disaster. Nursing Scholarship, 46(2), 134–42. doi: 10.1111/jnu.12056

Mellow, M. A., Bloch, D., & Grimes, J. (2018). The CMS final rule for EP implementation deadline is here: Is your facility prepared? Defense Counsel, 85(1), 1–5.

Murthy, B. P., M. Molinari, N., LeBlanc, T. T., Vagi, S. J., & Avchen, R. N. (2017). Progress in public health emergency preparedness — United States, 2001–2016. American Public Health, 107S180-S185. doi:10.2105/AJPH.2017.304038

Myers, D. M., & Neuman, M. (2007). The qualitative interview in IS research: Examining the craft. Information and Organization, 17(1), 2–26.

Nelson, C., Lurie, N., Wasserman, J., & Zakowski, S. (2007). Conceptualizing and defining public health emergency preparedness. American journal of public health, 97 Suppl 1(Suppl 1), S9–11.

North, C.S. & Pfefferbaum, B. (2013). Mental Health Response to Community Disasters A Systematic Review. Journal of American Medical Association. 2013;310(5):507–518. doi:10.1001/jama.2013.107799

NVivo (2019). Organize material into themes with coding in NVivo 9. NVivo Tutorial Video. Retrieved from https://www.youtube.com/watch?v=O9eTvP3E5TE

NVivo (2019, a). Find themes and analyze text in NVivo 9. NVivo Tutorial Video. Retrieved from https://www.youtube.com/watch?v=ypo6lrpwDZ8

Obaid, J. M., Bailey, G., Wheeler, H., Meyers, L., Medcalf, S. J., Hansen, K. F., . . . Lowe, J. J. (2017). Utilization of functional exercises to build regional EP among rural health organizations in the US. Prehospital and Disaster Medicine, 32(2), 224–230. doi: http://dx.doi.org.ezp.waldenulibrary.org/10.1017/S1049023X16001527

Federal Register US (2016). Medicare and Medicaid programs; EP requirements for Medicare and Medicaid participating providers and suppliers. Retrieved from https://www.federalregister.gov/documents/2016/09/16/2016-21404/medicare-and-medicaid-programs-emergency-preparedness-requirements-for-medicare-and-medicaid

OHSU Oregon Office of Rural Health (2019). Rural and frontier hospitals. Retrieved from https://www.ohsu.edu/xd/outreach/oregon-rural-health/rural-frontier-facilities/hospitals/index.cfm

OHSU Oregon Office of Rural Health (2019, a). Directory of Rural and frontier hospitals. Retrieved from https://www.ohsu.edu/xd/outreach/oregon-rural-health/rural-frontier-facilities/hospitals/hospital-directory.cfm

Oregon Demographics (2019). Oregon counties by population. Retrieved from https://www.oregon-demographics.com/counties_by_population

Oregon Health Authority (n.d.). Current hazards. Health security, preparedness, and response. Retrieved from http://www.oregon.gov/oha/PH/PREPAREDNESS/CURRENTHAZARDS/Pages/index.aspx

Oregon Health Authority (n.d., a). Providers/suppliers facilities impacted by the EP rule. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/17-Facility-Provider-Supplier-Types-Impacted.pdf

Paganini, M., Borrelli, F., Cattani, J., Ragazzoni, L., Djalali, A., Carenzo, L., & … Ingrassia, P. L. (2016). Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and management capacity. Scandinavian Trauma, Resuscitation and Emergency Medicine, 24(1), 101. doi:10.1186/s13049–016–0292–6

Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice (4th ed.). Thousand Oaks, CA: SAGE.

Paek, H., Hilyard, K., Freimuth, V., Barge, J., & Mindlin, M. (2010). Theory-based approaches to understanding public emergency preparedness: implications for effective health and risk communication. Health Communication, 15(4), 428–444. doi:10.1080/10810731003753083

Paganini, M., Borrelli, F., Cattani, J., Ragazzoni, L., Djalali, A., Carenzo, L., & … Ingrassia, P. L. (2016). Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and management capacity. Scandinavian Trauma, Resuscitation and Emergency Medicine, 24(1), 101. doi:10.1186/s13049–016–0292–6

Paley, J., & Eva, G. (2011). Complexity theory as an approach to explanation in healthcare: a critical discussion. International Nursing Studies, 48(2), 269–279. doi: 10.1016/j.ijnurstu.2010.09.012

Palttala, P., Boano, C., Lund, R., & Vos, M. (2012). Communication gaps in disaster management: perceptions by experts from governmental and non-governmental organizations. Contingencies & Crisis Management, 20(1), 2–12. https://doi-org.ezp.waldenulibrary.org/10.1111/j.1468-5973.2011.00656.x

Phillips, A. H. (2018). Exploring burnout and perceived stress in emergency managers during deployments (Order №10748976). Available from Dissertations & Theses @ Walden University. (2027325598).

Plsek, P. E., & Greenhalgh, T. (2001). Complexity science: The challenge of complexity in health care. BMJ (Clinical Research Ed.), 323(7313), 625–628.

Pourvakhshoori, N., Norouzi, K., Ahmadi, F., Hosseini, M., & Khankeh, H. (2017). Nursing in disasters: A review of existing models. International Emergency Nursing, 31, 58–63. doi: 10.1016/j.ienj.2016.06.004

Rahm, D., & Reddick, C. G. (2011). US city managers’ perceptions of disaster risks: consequences for urban emergency management. Contingencies & Crisis Management, 19(3), 136–146. doi: 10.1111/j.1468–5973.2011.00647.x

Ramsey Hamilton, C., & Miller, D. (2017). The new CMS EP final rule and its impact on healthcare in 2017. Healthcare Protection Management, 33(1), 77–81.

Ravitch, S. M., & Carl, N. M. (2016). Qualitative research: Bridging the conceptual, theoretical, and methodological. Thousand Oaks, CA: Sage Publications.

Reed, J. E., Howe, C., Doyle, C., & Bell, D. (2018). Simple rules for evidence translation in complex systems: A qualitative study. BMC Medicine, 16(1), 92. https://doi.org/10.1186/s12916-018-1076-9

Ripoll Gallardo, A., Djalali, A., Foletti, M., Ragazzoni, L., Della Corte, F., Lupescu, O., . . . Ingrassia, P. (2015). Core competencies in disaster management and humanitarian assistance: A systematic review. Disaster Medicine and Public Health Preparedness, 9(4), 430–439. doi:10.1017/dmp.2015.24

Rivera-Rodriguez, E. (2017). Role of the nurse during disaster preparedness: A systematic literature review and application to public health nurses (Order №10636520). Available from Dissertations & Theses @ Walden University. (1964397933).

Roets, L. (2017). Protection of the human research participant: A structured review. South African Medical, 107(10), 847–853. doi:10.7196/SAMJ. 2017.v107i10.12533

Rowlands, T., Waddell, N., & Mckenna, B. (2015). Are we there yet? A technique to determine theoretical saturation. Computer Information Systems, 56(1), 40–47.

Rubin, H. J., & Rubin, I. S. (2012). Qualitative interviewing: The art of hearing data (3rd ed.). Thousand Oaks, CA: SAGE.

Rudestam, K. E., & Newton, R. R. (2015). Surviving your dissertation: A comprehensive guide to content and process (4th ed.). Thousand Oaks, CA: Sage.

Sandborn, B. (2017). Hurricane Harvey lessons are a roadmap for hospital disaster response. Healthcare Finance. Retrieved from http://www.

healthcarefinancenews.com/news/hurricane-harvey-lessons-are-roadmap-hospital-disaster-response.

Sargeant, J. (2012). Qualitative research part II: Participants, analysis, and quality assurance. Journal of Graduate Medical Education, 4(1), 1. doi:10.4300/JGME-D-11–00307.1

Savoia, E., Lin, L., Bernard, D., Klein, N., James, L. P., & Guicciardi, S. (2017). Public health system research in public health EP in the United States (2009–2015): Actionable knowledge base. American Public Health, 107e1-e6. doi:10.2105/ AJPH.2017.304051

Seale, G. S. (2010). EP as a continuous improvement cycle: perspectives from a postacute rehabilitation facility. Rehabilitation Psychology, 55(3), 247–254. doi:10.1037/a0020599

Seidman, I. (2012). Interviewing as qualitative research: A guide for researchers in education and the social sciences (3rd ed.). New York, NY: Teachers College.

Shah, G. H., Newell, B., & Whitworth, R. E. (2016). Health departments’ engagement in EP activities: The influence of health informatics capacity. International Health Policy & Management, 5(10), 575–582. doi: 10.15171/ijhpm.2016.48

Shento, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63–75. Retrieved from https://pdfs.semanticscholar.org/452e/3393e3ecc34f913e8c49d8faf19b9f89b75d.pdf

Shipman, S. J., Stanton, M. P., Tomlinson, S., Olivet, L., Graves, A., McKnight, D., & Speck, P. M. (2016). Qualitative analysis of the lived experience of first-time nurse responders in disaster. Continuing Education in Nursing, 47(2), 61–71

Smith, J., & Firth, J. (2011). Qualitative data analysis: the framework approach. Nurse Researcher, 18(2), 52–62.

Sobelson, R. K., Wigington, C. J., Harp, V., & Bronson, B. B. (2015). A whole community approach to emergency management: Strategies and best practices of seven community programs. Emergency Management (Weston, Mass.), 13(4), 349–357. doi:10.5055/jem.2015.0247

Statistics Solutions (2017). What is credibility in qualitative research and how do we establish it? Retrieved from http://www.statisticssolutions.com/what-is-credibility-in-qualitative-research-and-how-do-we-establish-it/

Sutton, J., & Austin, Z. (2015). Qualitative research: Data collection, analysis, and management. The Canadian Hospital Pharmacy, 68(3), 226–231. doi:10.4212/cjhp. v68i3.1456

Taschner, M. A., Nannini, A., Laccetti, M., & Greene, M. (2017). EP policy and practice in Massachusetts hospitals. Workplace Health & Safety, 65(3), 129–136. doi:10.1177/2165079916659505

Thompson, D. S., Fazio, X., Kustra, E., Patrick, L., & Stanley, D. (2016). Scoping review of complexity theory in health services research. BMC health services research, 16, 87. doi:10.1186/s12913–016–1343–4

Thrift, N. (1999). The place of complexity. Theory, Culture & Society, (3), 31.

Turner, D. W. (2010). Qualitative interview design: A practical guide for novice investigators. The Qualitative Report, 15(3), 754–760. Retrieved from http://nsuworks.nova.edu/tqr/

Valesky, W., Roblin, P., Patel, B., Adelaine, J., Zehtabchi, S., & Arquilla, B. (2013). Assessing hospital preparedness: comparison of an on-site survey with a self-reported, internet-based, long-distance tabletop drill. Prehospital and Disaster Medicine, 28(5), 441–444. doi:10.1017/S1049023X13003580

VanVactor, J. D. (2016). Healthcare logistics in disaster planning and emergency management: A perspective. Business Continuity & Emergency Planning, 10(2), 157–176.

Veenema, T. G., Griffin, A., Gable, A. R., MacIntyre, L., Simons, R. N., Couig, M. P., … Larson, E. (2016). Nurses as leaders in disaster preparedness and response — a call to action. Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 48(2), 187–200. doi: 10.1111/jnu.12198

Walden University (n.d.). Email — format Consent Form for Practice Interview.

Walden University (n.d., a). Office of research and compliance: IRB requirements for selecting participants.

Wallace, J. R. (2016). Field test of a peer support pilot project serving federal employees deployed to a major disaster. Social Work & Christianity, 43(1), 128–141.

Washington State Department of Health (n.d.) Rural Health. Designated critical access hospitals. Retrieved from https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/RuralHealthSystems/CriticalAccessHospitals/DesignatedCriticalAccessHospitals

Washington State Department of Health (n.d., a) Rural Health. Critical access hospitals. https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/RuralHealthSystems/CriticalAccessHospitals

Woods, C. L. (2016). When more than reputation is at risk: How two hospitals responded to Ebola. Public Relations Review, 42(5), 893–902. http://dx.doi.org/10.1016/

j. pubrev.2016.10.002.

Wood, N. J., Jones, J., Spielman, S., & Schmidtlein, M. C. (2015). Community clusters of tsunami vulnerability in the US Pacific Northwest. Proceedings of the National Academy of Sciences of the United States of America, 112(17), 5354.

World Population Review (2019). Population of cities in Oregon 2019. Retrieved from http://worldpopulationreview.com/states/oregon-population/cities/

Zusman, E. E., & Marghella, P. D. (2013). Disaster management in the era of lean healthcare. Neurosurgery, 72(2), N11-N14. doi: 10.1227/01.neu.0000426210. 89959.f5. Retrieved from https://academic.oup.com/neurosurgery/article/72/2/N11/2417826