RESEARCH ARTICLE
How did the Canterbury Earthquakes Affect Physiotherapists and Physiotherapy Services? A Qualitative Study Hilda Mulligan*, Catherine M. Smith & Sandy Ferdinand Centre for Health, Activity and Rehabilitation Research School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand
Abstract Background and purpose. The recent earthquakes in Canterbury New Zealand ended lives and resulted in disruption to many aspect of life for survivors, including physiotherapists. Physiotherapists often volunteer vital rehabilitation services in the wake of global disasters; however, little is known about how physiotherapists cope with disasters that affect their own communities. The purpose of this study was to investigate how the Canterbury earthquakes affected physiotherapists and physiotherapy services. Methods. We use a General Inductive Approach to analyse data obtained from purposively sampled physiotherapists or physiotherapy managers in the Canterbury region. Interviews were audio-recorded and transcribed verbatim. Results. We analysed data from interviews with 27 female and six male participants. We identified four themes: ‘A life-changing earthquake’ that described how both immediate and on-going events led to our second theme ‘Uncertainty‘. Uncertainty eroded feelings of resilience, but this was tempered by our third theme ‘Giving and receiving support’. Throughout these three themes, we identified a further theme ‘Being a physiotherapist’. This theme explains how physiotherapists and physiotherapy services were and still are affected by the Canterbury earthquakes. Discussion. We recommend that disaster planning occurs at individual, departmental, practice and professional levels. This planning will enable physiotherapists to better cope in the event of a disaster and would help to provide professional bodies with a cohesive set of skills that can be shared with health agencies and rescue organizations. We recommend that the apparently vital skill of listening is explored through further research in order for it to be better accepted as a core physiotherapy skill. Copyright © 2014 John Wiley & Sons, Ltd. Received 30 August 2013; Revised 18 March 2014; Accepted 1 June 2014 Keywords disasters; earthquakes; physical therapists *Correspondence Dr Hilda Mulligan BSc (Physiotherapy), MHSc, PhD, Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand. E-mail: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1597
Introduction Whilst the city of Christchurch in New Zealand was still recovering from a large earthquake (magnitude 7.1 on the Richter scale) that struck the region of Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Canterbury early in the morning of 4 September 2010, a further earthquake of magnitude 6.3 occurred on 22 February 2011 at 12.50 pm. This earthquake was shallow, close to the city centre and generated the greatest ground acceleration forces recorded to date in
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New Zealand and even worldwide (Tonkin and Taylor, 2012). That it occurred in the middle of the working day, when office buildings were fully occupied, contributed to the loss of 185 lives, most from the collapse of two multi-storey buildings (The Press, 2011). Immediate effects on infrastructure included loss of power, water, sewerage and communication networks. The central city was cordoned off and a state of emergency declared. Over 6000 people were injured, and whilst many of the injuries were minor, 142 individuals were admitted to Christchurch Hospital, with significant injuries (Ardagh et al., 2012). During the next 12 months, the region suffered another two particularly large and damaging quakes, and a multitude (in excess of 10 000) quakes of smaller magnitude. Damage to the built environment and the on-going nature of the quakes has resulted in social and economic consequences for large numbers of Christchurch residents. Communities have been disrupted with the closure of work places and schools and the loss of sport and leisure activities. For many people, every aspect of their daily lives changed, from where they live and work to how they saw their future (McColl and Burkle, 2012; Thornley et al., 2013). Resilience in response to these earthquakes was reported to be maintained and strengthened by participation in the disaster response and recovery, by having connectedness within the community, by having the opportunity to engage in decision making in the response and recovery phases and by being provided with external support from organizations outside of the community (Thornley et al., 2013). The contribution of health care providers in disasters is to assist communities to maintain resilience by providing medical support (Huggard, 2011). Although this did occur in Christchurch (Dolan et al., 2011; Ardagh et al., 2012), the medical professionals who provided health care in the Canterbury earthquakes found there to be a toll on both their personal and work aspects (Tovaranonte and Cawood, 2013), because they were living through the disaster and its effects themselves. Indeed, that having to provide care for others whilst living through the disaster oneself may be overwhelming for health care professionals, has been reported in other literature (Huggard, 2011). There is very little literature about physiotherapists assisting in major disasters around the world. However, the World Confederation for Physical Therapy has developed a policy statement about the potential role
of physiotherapy in disaster scenarios (World Confederation for Physical Therapy, 2014). Little is known, however, about the experiences of physiotherapists who live through disasters in their own communities. Our study therefore aimed to explore the impact of the Canterbury earthquakes on physiotherapists and their services from the perspective of living through the disaster itself. This will inform recommendations for the role of physiotherapy in future disaster planning and implementation.
Method Study design, recruitment and participants This qualitative interview study recruited physiotherapists and physiotherapy managers who were working in Christchurch on the day of the earthquake. We advertised for volunteers for the study in the local professional body newsletters, in hospital physiotherapy departments and via word of mouth. In order to address the stated aim, we purposively selected from those who volunteered to gain representation of a range of health care settings. The University of Otago Human Ethics Committee provided ethical approval for the study, and participants provided written consent. Data collection We drafted semi-structured interview questions via discussions amongst the research team. We piloted these with three physiotherapists who would have met inclusion criteria for the study. Minor modifications were made to the questions following their feedback. We conducted individual or group interviews depending on participant preference, at their preferred venue, between 10 and 15 months after the February earthquake. One member of the research team (HM) conducted the first interview, with a second member of the team (SF) also present to facilitate a consistent approach for subsequent interviews. We asked participants how the quakes had affected them both personally and professionally, whether physiotherapists played a part in implementing the response to the disaster, how physiotherapy services were affected by the disaster and how living through such a disaster was perceived in relation to provision of care and services. The interviews were audio-taped, transcribed word for word by a paid transcriber and cleaned by the research team to remove identifying information. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Data analysis Our data analysis was guided by the General Inductive Approach (Thomas, 2006). Analysis began with all of the researchers independently reading early transcripts to identify and code categories that pertained to the research aim. The research team met after five transcripts had been coded to agree on the emerging categories. The agreed categories were transferred into NVivo, a software programme for qualitative data management. As analysis continued, new categories were identified, added to the coding template and links identified between categories. A summary of the emerging findings was then developed into themes. The themes were
Table 1. Demographic detail of participants Male Female Age bands (years) 20–30 31–40 41–50 51–60 >60 Service area Physiotherapy business (owner) Physiotherapy business (employee) Public hospital service—managers Public hospital service employees—acute Public hospital service employees—rehab Public health service employees—home rehabilitation a
1 2 3
4 1 1
One of whom was the only non-physiotherapist participant.
Figure 1. Themes, their derivations and relationships
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3 6 6 10 2 5a 3 2 3 12 2
presented to a group of 15 physiotherapists in Christchurch, about half of whom had been study participants. The study participants all strongly identified with the themes, and furthermore, the physiotherapists who had not been participants in the study agreed that the themes represented a valid picture of their own experiences.
Results We interviewed 6 men and 27 women via 27 individual and two group interviews (one with two participants and one with four participants). All participants were physiotherapists, except for one physiotherapy manager (see Table 1). We identified four themes: ‘A life-changing earthquake’ that described how both immediate and ongoing events led to our second theme ‘Uncertainty’. Uncertainty eroded feelings of resilience, but this was tempered by our third theme ‘Giving and receiving support’. Throughout these three themes, we identified a further theme ‘Being a physiotherapist’. This theme explains how physiotherapists and physiotherapy services had been and still were affected by the Canterbury earthquakes. The themes, their derivations and their relationships are shown in Figure 1. Theme 1: A life-changing earthquake Participants’ descriptions of the most damaging earthquake on the afternoon of 22 February 2011 were of a life-changing and surreal environment of ‘bedlam’, with ‘unbelievable’, ‘shocking’, ‘disturbing’ and
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‘heart-wrenching’ scenes. Participants witnessed buildings fall, vehicles crushed, roads cracked and rippled, bridges broken and rubble and/or liquefaction (silt seeping up from underground) blocking the way. These factors coupled with traffic gridlock as people tried to get to their homes or families made travel difficult or impossible. It was really hard … to get out of the area… roads… bridges and the approach to the bridges [had] all collapsed … had to walk a couple of kilometres home through raw sewage on the street (Participant 5) Participants described the sights and sounds of humans in trouble with words such as ‘sobbing’, ‘ghastly screaming’, ‘panic’, and ‘freaking out’. One of the most distressing sights was that of many badly injured persons or bodies being brought out of buildings or into hospitals. The timing of the February event meant that most physiotherapists were at work. Our participants remembered feeling torn between providing support to colleagues and patients, or worrying about the safety of family members who they had not been able to contact at the time because communication networks were down. This resulted in a life-changing internal struggle about having done or not done the right thing at the time. In my head I decided that if he [husband] was dead I would deal with it later and I was just going to deal with what was in front of me (Participant 4)So …at the end of the drive way…right to town? Left to home? And I eventually said ‘OK…it’s left to home’. But the physio in me was thinking of all those things in town that I might have been able to help with so that’s why I went back’ (Participant 25).… found out that two patients had been left in the ward because they were actually in the process of dying and one unfortunately [here the participant had a very long pause] died without anyone there because everyone had left (Participant 28) Theme 2: Uncertainty In the subsequent months, participants experienced uncertainty, leading to a perceived lack of stability in professional and personal life. Uncertainty came not only from the extended on-going seismic activity with
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its continued impact on the built environment, their disbelief at the enormity of the damage to their city, but also from the fragmentation of health services and working teams and the change in personal circumstances. Our ward shakes, and we kind of wonder if it always shook. I don’t actually think it did shake, but I don’t even know who to ask [about whether it’s safe being there] (Participant 3) There were the people who were really significantly affected who knew life wasn’t going to be the same, but as time went on, I think everyone felt they were being absorbed into [the earthquakes and their effects on life] one way or another, and I think that started placing that horrible cloud over people that was difficult to see the way through. So the reality for people has kind of come in instalments (Participant 33) Many of our participants described new and unusual patient presentations, such as crush injuries, ‘pothole neck’ (from driving on badly damaged roads), ‘shovel shoulder’ (from repeatedly shovelling liquefied silt from houses, driveways and roads) and stress-related muscular pain and spasms. They also described a sharp increase in patients with breathing pattern disorders, as well as patients with ‘broken-heart’ syndrome (a stress cardiomyopathy brought on by an emotional trigger), and patients with high levels of distress and anxiety. Most of our participants described uncertainty within their personal lives. Many participants’ homes were damaged beyond repair (for example, out of a staff of 42 in one physiotherapy department, eight members had lost their homes because of earthquake damage), and others were left uncertain as to the viability of their homes. Daily life and work were that much more challenging, leaving little energy for empathy with patients or decision making about physiotherapy practice. I think at the moment I struggle to feel sympathetic to many other people because I’m still busy trying to sort out myself! I haven’t only got an earthquake and the house stuff, I’ve got a sick uncle and a granddad that’s sick…so if you gave me anything else, I’d be like ‘no, I don’t actually want to deal with that thank you’ (Participant 2) Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Participants who owned their own business identified how the drop in patient numbers meant uncertainty about their ability to maintain a viable business and to pay their employees. They attributed the drop in patient numbers to the fact that patients did not rank their own health care needs as important when faced with day-to-day challenges such as no electricity, sewerage or clean water. Theme 3: Giving and receiving support Besides providing ‘usual’ physical care for patients, most of our participants spoke at length about the high level of psychological support they were providing to their patients through the telling and sharing of earthquake experiences. However, because this level of support took extra time and effort, participants frequently felt overwhelmed. Moreover, they regarded the provision of psychological support for patients, via the action of listening to patients’ stories and experiences, more as a courtesy than a core physiotherapy skill. I think we have incredible counselling skills because we listen and we care. The number of people who say I was the first person who listened to their story. And I do think we need to let the powers that be know that physios are good counsellors as well because that became our role and every patient took longer because of that. (Participant 19) As well as providing psychological support via the listening to patients’ stories, many of our participants had offered support in more practical ways within their own communities. Well people would come in for physio, they were having a shower, plugging their laptops and phones in and having soup, and having treatment! (Participant 5) Although some of our participants had sought counselling services themselves, they related how it had not been easy to find the time (particularly in the public hospital environment) to visit a counsellor during work hours. Participants described many offers of work support from physiotherapists from all around New Zealand in the immediate days following the February earthquake. However, personal weariness combined with uncertainty about procedures to be followed for Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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the recruiting of staff made immediate uptake of these offers impossible. Participants suggested, however, that offers of assistance at a later stage to assist with the feeling of overwhelming tiredness even months after the February quake would have been useful. What do they need for infection control? Do they need MRSA clearance? What [other] clearance is needed? Who would pay for air tickets? Who would orientate them? All of that became too much for me to sort out right there and then…I really needed help at least two or three months down from the earthquake (Participant 4) Nevertheless, it was apparent that many of our participants did receive support from many sources in various forms. It came from neighbours, friends and local communities, in the form of practical support (for example a generator to provide power) as well as social and psychological support. Support was also evident from the government, from professional bodies and from colleagues. Participants with their own business had worked hard to support their staff, often at personal financial loss, and many had offered support such as practicing space to colleagues who had lost premises, even though they were usually in competing businesses. When physiotherapists were able to network with others, this had helped to relieve stress by providing an opportunity to debrief and support each other in the new environment. Even to the extent that we heard from the [registering body for physiotherapists] that Canterbury physiotherapists were not going to be audited [for their continuing professional development practice for the year]. I just about burst into tears when I read that email because it was just so lovely (Participant 6) Many participants described how small things took on meaning. As an example, one participant was extremely grateful for the week’s free lunches provided at the hospital where she worked. This was useful because the supermarket where she usually shopped had been closed, and there was neither tap water nor sewerage available in her own community. In addition, many of our participants who worked in the public system spoke of how, despite a seemingly inflexible workplace policy with regards to post earthquake leave, their line managers had been as supportive, flexible and fair as
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possible with regards to the possibility of sharing workload to allow for staff to take time off to see to their personal and family’s needs. Over time, many participants realized that their resilience was wearing thin. One participant describes a moving account of no longer having the capacity to support a close family member: I was sitting downstairs on the couch and I looked to him and I was crying and I just wanted a cuddle and some comfort and we just looked at each other, and he had nothing to give me and I had nothing to give him (Participant 4) In contrast, one of our participants described displaying outwardly strong behaviour even though he felt that his inner resilience was eroded in terms of his mental health and lack of sleep. This was reinforced during many of our interviews when we discovered that our participants had assumed that because their colleagues’ professional behaviour had allowed them to be at work, they were therefore ‘doing alright’. Theme 4: Being a physiotherapist Being a physiotherapist strongly influenced the actions and decisions of all of our participants, and this theme weaves its way as a concept through the other themes of a life-changing event, uncertainty and support (see Figure 1). Many of our participants who worked in the hospitals voiced feelings of frustrations and redundancy because they did not feel able to contribute to evacuation, rescue and first-aid procedures in the immediacy of the situation. I have to confess that first afternoon when we were standing around, I felt … useless. We weren’t directed to specifically help with evacuation and things (Participant 6) In the days following the February quake, this sense of redundancy continued because there appeared to be no clear plan to best utilize their services and skills. For example, one hospital had such enormous damage to its infrastructure that it was unable to accept new patient admissions. Consequently, despite being ‘at work’, participants felt guilty because they were not deployed to share the load with others who worked in more needy services. The most stressful [thing] was turning up to work when you felt you should be doing something
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more important, more helpful somewhere else (Participant 1) Yet, being a physiotherapist also drove actions towards helping and supporting patients in need. This description from one participant who made the decision to take a vulnerable patient home embodies the strong commitment to patients following the life-changing February earthquake. I finally got her to her home and we stood outside and I said, ‘are you okay to go in’, and she said ‘yes, I will go in, come in with me’, so we carefully went in through the doorway. Everything was devastated, everything was on the floor, the door was skew-wiff, the walkway in was all skew-wiff, and I said ‘I’m not happy to leave you here, can we go next door? Who do you know that you can get support with’? So we went next door and [discussed how] we all need to be together, and they agreed, so I left her with the neighbours. Then I had this tedious 3 hour journey home, not knowing exactly what my parents were like, what my kids were like. It’s dealing with what I had to, and I just had to hope that somewhere else someone was dealing with my stuff. (Participant 17) Participants had, however, found it challenging to be professional and to provide support and assistance in the face of on-going uncertainty, stress and feelings of mental overload. [following one large aftershock] I got halfway through my …consultation, and realized that my head was somewhere else (Participant 18). From our analysis, it was apparent that some physiotherapists were in a position to be adaptable and flexible in their approach to the use of health care resources and in their approach to providing physical care for patients. For example, one participant had arranged an ad hoc teleconference to arrange emergency assistive equipment (wheelchairs and hoists) for individuals with disability at emergency shelters. Others took business into the community, for example into the three relief centres set up around Christchurch. Many participants who had their own business had waived the patient surcharge for a time. In addition, where participants had been able to liaise with participants from Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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different health services, this had helped to speed up the delivery of equipment such as portable toilets and services for older people who were frail and less mobile. When specifically asked about possible physiotherapy roles in future disaster situations, our participants offered suggestions such as the triaging of musculoskeletal injuries in emergency areas. Their suggestions did not include the role of psychological support.
Discussion Our study explored the impact of a life-changing disaster for physiotherapists living through the Canterbury earthquakes. It identified how the resilience of being a physiotherapist was bolstered by being able to give and receive support and yet eroded through on-going uncertainties. Resilience, described as the ability to cope when circumstances change considerably (Greene and Greene, 2009), is known to develop in relation to support received from others, for example, from the government and from social cohesion from within one’s own community (Wilson et al., 2008). Participants in our study also found that resilience was built from the balance of being able to give and receive. The literature also identifies that resilience is related to self-support in the form of pre-planning; when un-expected occurrences happen, this pre-planning helps one cope with the uncertainty (Kalemoglu et al., 2005; Rami et al., 2008; Wilson et al., 2008; Te Brake et al., 2009; Admi et al., 2011). This highlights the necessity for physiotherapists to plan for unexpected events. A recommendation we make based on the experiences of our participants is for health care providers, including physiotherapists to contribute to the development of disaster management plans. As part of this we recommend a review of communication strategies as these were seen as crucial in the immediate post-quake phase. There was an overwhelming offer of support from physiotherapy colleagues around the country. However, while living through the immediate aftermath of the earthquake, participants found that it was difficult to process this help. It would therefore seem useful for physiotherapy units to plan as to how best to respond and then utilize such offers of help. One suggestion would be to provisionally book colleagues’ services for a future date instead of declining an offer of assistance. Many participants in our study described feelings of redundancy and frustration. These feelings have been described by other physiotherapists following disasters. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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A study by Harrison (2007) used interviews with four physiotherapists who had first-hand experience of manmade disasters (in the United States of America). In the immediate emergency following these events, physiotherapists described not being sure of their role at the time and that a barrier to playing a useful role was the reluctance of disaster response organizations to recognize and promote the role of physiotherapy (Harrison, 2007). On reflection, all participants in Harrison’s study could identify several key roles for physiotherapists, including triage and treatment of musculoskeletal injuries, first aid and respiratory aid. In contrast, although triage may be a role suited to the skills of a physiotherapist, many of our participants who had tried to help in areas worst affected were either turned away or asked to do tasks that they had no training for. This may relate to the lack of preplanning for the inclusion of physiotherapists in disaster management. Guidelines for physical therapists in disaster management have been written in order to inform the wider disaster response community about the specific skills and ways in which physical therapists could assist (Waldrop, 2002). Based on the experiences of our participants and those of physiotherapists following disasters in other countries, we recommend that New Zealand physiotherapists contribute towards a disaster management document which clearly outlines both physical and listening skills. This would allow physiotherapists to provide an important contribution to both immediate and on-going disaster response policy. We further recommend that the physiotherapy profession present this document to both health and rescue organizations. Recovery is related not only to the rebuilding of infrastructure (e.g. houses, buildings, roads and services) but also requires psychological recovery. The need for wide-ranging mental health support following both manmade and natural disasters is well documented (van Ommeren et al., 2005; Dhar et al., 2007). Our study identified that physiotherapists in the Canterbury region had provided important psychological support to patients and colleagues in both the immediate and longer term aftermath of the quakes via the action of listening to their stories. Whilst many of our participants acknowledged that talking with patients was an inherent characteristic of being a physiotherapist, they did not recognize this as being a crucial post-disaster role for them, nor did they identify it as ‘worthwhile’ or even a core part of physiotherapy.
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Furthermore, our participants felt that they were under-prepared for the sheer volume of this type of support. Following the Kashmir earthquake in 2005, Dhar et al. described how hospital staff had initially considered having to repeatedly listen to peoples’ stories as a waste of time, and yet were better able to understand patient behaviours as a result of offering this listening ‘service’ (Dhar et al., 2007). Historically, physiotherapy has closely aligned itself with the values and world view of the medical profession and, generally speaking, continues to prioritize clinical reasoning and physical skills which are supported by the framework of evidence-based medicine (Carpenter and Suto, 2008). Juxtaposed with this standpoint is the undeniable fact that physiotherapists, in the course of their intervention, are exposed to the narratives of their patients. There has been little research exploring the role and/or effects of listening in physiotherapy. Two aspects of our study could be considered as limitations. First, readers need to be aware that the study’s authors lived through the February earthquake themselves. Indeed, we found it emotionally taxing to undertake this study, and in part, this was because of the need to consciously not validate participants’ responses to our questions within our own experiences of the earthquakes. However, despite our attempts, it is inevitable that our experiences may have influenced the analysis. Second, we purposively sampled participants but did not consider the extent to which individual participants’ personal losses may have influenced their descriptions.
Implications for physiotherapy practice We recommend that individuals, physiotherapy departments and business owners develop their own specific disaster management plan and, through these plans, contribute towards a central disaster management document which clearly outlines the skills that will enable physiotherapists to provide an important contribution in the event of a natural or manmade disaster. We further recommend that the physiotherapy professional bodies communicate this contribution to both health and rescue organizations. We would suggest that listening as an important aspect of physiotherapy practice requires further investigation.
Acknowledgements We wish to acknowledge our participants for their time and effort in sharing their experiences with us. We also wish to thank Dr Denise Powell for assistance with data management and Stefan Peters for the figure. REFERENCES Admi H, Eilon Y, Hyams G, Utitz L. Management of Mass Casualty Events: The Israeli Experience. Journal of Nursing Scholarship 2011; 43: 211–219. Ardagh MW, Richardson SK, Robinson V, Than M, Gee P, Henderson S, Khodaverdi L, Mckie J, Robertson G, Schroeder PP, Deely JM. The initial health-system response to the earthquake in Christchurch, New Zealand, in February, 2011. Lancet 2012; 379: 2109–15. Carpenter C, Suto M. Qualitative research for occupational and physical therapists: A practical guide. Oxford: Blackwell, 2008. Dhar S, Halwai M, Mir M, Wani Z, Butt M, Bhat M, Hamid A. The Kashmir earthquake experience. European Journal of Trauma and Emergency Surgery 2007; 1: 74–80. Dolan B, Esson A, Grainger PP, Richardson S, Ardagh M. Earthquake disaster response in christchurch, New Zealand. Journal of Emergency Nursing 2011; 37: 506–9. Greene R, Greene D. Resilience in the face of disasters: Bridging Micro-and Macro-Perspectives. Journal of Human Behavior in the Social Environment 2009; 19: 1010–1024. Harrison RM. Preliminary investigation into the role of physiotherapists in disaster response. Prehospital & Disaster Medicine 2007; 22: 462–5; discussion 466. Huggard P. Caring for the Carers: the emotional effects of disasters on health care professionals. Australasian Journal of Disaster and Trauma Studies 2011; 2: 60–62. Kalemoglu M, Keskin Ö, Ersanli D. Analysis of an emergency department’s experience. Internet Journal of Rescue & Disaster Medicine 2005; 4: 9. Mccoll GJ, Burkle FM, JR. The new normal: twelve months of resiliency and recovery in Christchurch. Disaster Medicine & Public Health Preparedness 2012; 6: 33–43. Rami JS, Singleton EK, Spurlock W, Eaglin AR. A school of nursing’s experience with providing health care for Hurricane Katrina evacuees. ABNF Journal 2008; 19: 102–106. Te Brake H, Dückers M, De Vries M, Van Duin D, Rooze M, Spreeuwenberg C. Early psychosocial interventions after disasters, terrorism, and other shocking events: guideline development. Nursing & Health Sciences 2009; 11: 336–343. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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The Press. Christchurch Earthquake, The Lost. The Press, Christchurch, 2011. Thomas DR. A general inductive approach for analysing qualitative evaluation data. American Journal of Evaluation 2006; 27: 237–246. Thornley L, Ball J, Signal L, Lawson-Te Aho K, Rawson E. Building Community Resilience: Learning from the Canterbury earthquakes. 2013. Available: https://www. familyservices.govt.nz/documents/working-with-us/ programmes-services/connected-services/supportingcanterbury/building-community-resilience-report.pdf [Accessed 5th March 2014]. Tonkin & Taylor Earthquake Commission: Canterbury Earthquake 2010 and 2011. 2012. Land report as at 29 February 2012.
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Tovaranonte P, Cawood TJ. Impact of the Christchurch earthquakes on hospital staff. Prehospital & Disaster Medicine 2013; 28: 245–50. Van Ommeren M, Saxena S, Saraceno B. Aid after disasters. BMJ 2005; 330: 1160–1. Waldrop S. Physical therapists’ vital role in disaster management. PT: Magazine of Physical Therapy 2002; 10: 42. Wilson SA, Temple BJ, Milliron ME, Vazquez C, Packard MD, Rudy BS. The lack of disaster preparedness by the public and it’s [sic] affect [sic] on communities. Internet Journal of Rescue & Disaster Medicine 2008; 7: 15. World Conferedation for Physical Therapy. Disaster management [Online]. 2014. Available: http://www.wcpt. org/disaster-management [Accessed 13th March 2014.
How did the Canterbury Earthquakes Affect Physiotherapists and Physiotherapy Services? A Qualitative Study Hilda Mulligan*, Catherine M. Smith & Sandy Ferdinand Centre for Health, Activity and Rehabilitation Research School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand
Abstract Background and purpose. The recent earthquakes in Canterbury New Zealand ended lives and resulted in disruption to many aspect of life for survivors, including physiotherapists. Physiotherapists often volunteer vital rehabilitation services in the wake of global disasters; however, little is known about how physiotherapists cope with disasters that affect their own communities. The purpose of this study was to investigate how the Canterbury earthquakes affected physiotherapists and physiotherapy services. Methods. We use a General Inductive Approach to analyse data obtained from purposively sampled physiotherapists or physiotherapy managers in the Canterbury region. Interviews were audio-recorded and transcribed verbatim. Results. We analysed data from interviews with 27 female and six male participants. We identified four themes: ‘A life-changing earthquake’ that described how both immediate and on-going events led to our second theme ‘Uncertainty‘. Uncertainty eroded feelings of resilience, but this was tempered by our third theme ‘Giving and receiving support’. Throughout these three themes, we identified a further theme ‘Being a physiotherapist’. This theme explains how physiotherapists and physiotherapy services were and still are affected by the Canterbury earthquakes. Discussion. We recommend that disaster planning occurs at individual, departmental, practice and professional levels. This planning will enable physiotherapists to better cope in the event of a disaster and would help to provide professional bodies with a cohesive set of skills that can be shared with health agencies and rescue organizations. We recommend that the apparently vital skill of listening is explored through further research in order for it to be better accepted as a core physiotherapy skill. Copyright © 2014 John Wiley & Sons, Ltd. Received 30 August 2013; Revised 18 March 2014; Accepted 1 June 2014 Keywords disasters; earthquakes; physical therapists *Correspondence Dr Hilda Mulligan BSc (Physiotherapy), MHSc, PhD, Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin 9054, New Zealand. E-mail: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1597
Introduction Whilst the city of Christchurch in New Zealand was still recovering from a large earthquake (magnitude 7.1 on the Richter scale) that struck the region of Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Canterbury early in the morning of 4 September 2010, a further earthquake of magnitude 6.3 occurred on 22 February 2011 at 12.50 pm. This earthquake was shallow, close to the city centre and generated the greatest ground acceleration forces recorded to date in
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New Zealand and even worldwide (Tonkin and Taylor, 2012). That it occurred in the middle of the working day, when office buildings were fully occupied, contributed to the loss of 185 lives, most from the collapse of two multi-storey buildings (The Press, 2011). Immediate effects on infrastructure included loss of power, water, sewerage and communication networks. The central city was cordoned off and a state of emergency declared. Over 6000 people were injured, and whilst many of the injuries were minor, 142 individuals were admitted to Christchurch Hospital, with significant injuries (Ardagh et al., 2012). During the next 12 months, the region suffered another two particularly large and damaging quakes, and a multitude (in excess of 10 000) quakes of smaller magnitude. Damage to the built environment and the on-going nature of the quakes has resulted in social and economic consequences for large numbers of Christchurch residents. Communities have been disrupted with the closure of work places and schools and the loss of sport and leisure activities. For many people, every aspect of their daily lives changed, from where they live and work to how they saw their future (McColl and Burkle, 2012; Thornley et al., 2013). Resilience in response to these earthquakes was reported to be maintained and strengthened by participation in the disaster response and recovery, by having connectedness within the community, by having the opportunity to engage in decision making in the response and recovery phases and by being provided with external support from organizations outside of the community (Thornley et al., 2013). The contribution of health care providers in disasters is to assist communities to maintain resilience by providing medical support (Huggard, 2011). Although this did occur in Christchurch (Dolan et al., 2011; Ardagh et al., 2012), the medical professionals who provided health care in the Canterbury earthquakes found there to be a toll on both their personal and work aspects (Tovaranonte and Cawood, 2013), because they were living through the disaster and its effects themselves. Indeed, that having to provide care for others whilst living through the disaster oneself may be overwhelming for health care professionals, has been reported in other literature (Huggard, 2011). There is very little literature about physiotherapists assisting in major disasters around the world. However, the World Confederation for Physical Therapy has developed a policy statement about the potential role
of physiotherapy in disaster scenarios (World Confederation for Physical Therapy, 2014). Little is known, however, about the experiences of physiotherapists who live through disasters in their own communities. Our study therefore aimed to explore the impact of the Canterbury earthquakes on physiotherapists and their services from the perspective of living through the disaster itself. This will inform recommendations for the role of physiotherapy in future disaster planning and implementation.
Method Study design, recruitment and participants This qualitative interview study recruited physiotherapists and physiotherapy managers who were working in Christchurch on the day of the earthquake. We advertised for volunteers for the study in the local professional body newsletters, in hospital physiotherapy departments and via word of mouth. In order to address the stated aim, we purposively selected from those who volunteered to gain representation of a range of health care settings. The University of Otago Human Ethics Committee provided ethical approval for the study, and participants provided written consent. Data collection We drafted semi-structured interview questions via discussions amongst the research team. We piloted these with three physiotherapists who would have met inclusion criteria for the study. Minor modifications were made to the questions following their feedback. We conducted individual or group interviews depending on participant preference, at their preferred venue, between 10 and 15 months after the February earthquake. One member of the research team (HM) conducted the first interview, with a second member of the team (SF) also present to facilitate a consistent approach for subsequent interviews. We asked participants how the quakes had affected them both personally and professionally, whether physiotherapists played a part in implementing the response to the disaster, how physiotherapy services were affected by the disaster and how living through such a disaster was perceived in relation to provision of care and services. The interviews were audio-taped, transcribed word for word by a paid transcriber and cleaned by the research team to remove identifying information. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Data analysis Our data analysis was guided by the General Inductive Approach (Thomas, 2006). Analysis began with all of the researchers independently reading early transcripts to identify and code categories that pertained to the research aim. The research team met after five transcripts had been coded to agree on the emerging categories. The agreed categories were transferred into NVivo, a software programme for qualitative data management. As analysis continued, new categories were identified, added to the coding template and links identified between categories. A summary of the emerging findings was then developed into themes. The themes were
Table 1. Demographic detail of participants Male Female Age bands (years) 20–30 31–40 41–50 51–60 >60 Service area Physiotherapy business (owner) Physiotherapy business (employee) Public hospital service—managers Public hospital service employees—acute Public hospital service employees—rehab Public health service employees—home rehabilitation a
1 2 3
4 1 1
One of whom was the only non-physiotherapist participant.
Figure 1. Themes, their derivations and relationships
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3 6 6 10 2 5a 3 2 3 12 2
presented to a group of 15 physiotherapists in Christchurch, about half of whom had been study participants. The study participants all strongly identified with the themes, and furthermore, the physiotherapists who had not been participants in the study agreed that the themes represented a valid picture of their own experiences.
Results We interviewed 6 men and 27 women via 27 individual and two group interviews (one with two participants and one with four participants). All participants were physiotherapists, except for one physiotherapy manager (see Table 1). We identified four themes: ‘A life-changing earthquake’ that described how both immediate and ongoing events led to our second theme ‘Uncertainty’. Uncertainty eroded feelings of resilience, but this was tempered by our third theme ‘Giving and receiving support’. Throughout these three themes, we identified a further theme ‘Being a physiotherapist’. This theme explains how physiotherapists and physiotherapy services had been and still were affected by the Canterbury earthquakes. The themes, their derivations and their relationships are shown in Figure 1. Theme 1: A life-changing earthquake Participants’ descriptions of the most damaging earthquake on the afternoon of 22 February 2011 were of a life-changing and surreal environment of ‘bedlam’, with ‘unbelievable’, ‘shocking’, ‘disturbing’ and
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‘heart-wrenching’ scenes. Participants witnessed buildings fall, vehicles crushed, roads cracked and rippled, bridges broken and rubble and/or liquefaction (silt seeping up from underground) blocking the way. These factors coupled with traffic gridlock as people tried to get to their homes or families made travel difficult or impossible. It was really hard … to get out of the area… roads… bridges and the approach to the bridges [had] all collapsed … had to walk a couple of kilometres home through raw sewage on the street (Participant 5) Participants described the sights and sounds of humans in trouble with words such as ‘sobbing’, ‘ghastly screaming’, ‘panic’, and ‘freaking out’. One of the most distressing sights was that of many badly injured persons or bodies being brought out of buildings or into hospitals. The timing of the February event meant that most physiotherapists were at work. Our participants remembered feeling torn between providing support to colleagues and patients, or worrying about the safety of family members who they had not been able to contact at the time because communication networks were down. This resulted in a life-changing internal struggle about having done or not done the right thing at the time. In my head I decided that if he [husband] was dead I would deal with it later and I was just going to deal with what was in front of me (Participant 4)So …at the end of the drive way…right to town? Left to home? And I eventually said ‘OK…it’s left to home’. But the physio in me was thinking of all those things in town that I might have been able to help with so that’s why I went back’ (Participant 25).… found out that two patients had been left in the ward because they were actually in the process of dying and one unfortunately [here the participant had a very long pause] died without anyone there because everyone had left (Participant 28) Theme 2: Uncertainty In the subsequent months, participants experienced uncertainty, leading to a perceived lack of stability in professional and personal life. Uncertainty came not only from the extended on-going seismic activity with
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its continued impact on the built environment, their disbelief at the enormity of the damage to their city, but also from the fragmentation of health services and working teams and the change in personal circumstances. Our ward shakes, and we kind of wonder if it always shook. I don’t actually think it did shake, but I don’t even know who to ask [about whether it’s safe being there] (Participant 3) There were the people who were really significantly affected who knew life wasn’t going to be the same, but as time went on, I think everyone felt they were being absorbed into [the earthquakes and their effects on life] one way or another, and I think that started placing that horrible cloud over people that was difficult to see the way through. So the reality for people has kind of come in instalments (Participant 33) Many of our participants described new and unusual patient presentations, such as crush injuries, ‘pothole neck’ (from driving on badly damaged roads), ‘shovel shoulder’ (from repeatedly shovelling liquefied silt from houses, driveways and roads) and stress-related muscular pain and spasms. They also described a sharp increase in patients with breathing pattern disorders, as well as patients with ‘broken-heart’ syndrome (a stress cardiomyopathy brought on by an emotional trigger), and patients with high levels of distress and anxiety. Most of our participants described uncertainty within their personal lives. Many participants’ homes were damaged beyond repair (for example, out of a staff of 42 in one physiotherapy department, eight members had lost their homes because of earthquake damage), and others were left uncertain as to the viability of their homes. Daily life and work were that much more challenging, leaving little energy for empathy with patients or decision making about physiotherapy practice. I think at the moment I struggle to feel sympathetic to many other people because I’m still busy trying to sort out myself! I haven’t only got an earthquake and the house stuff, I’ve got a sick uncle and a granddad that’s sick…so if you gave me anything else, I’d be like ‘no, I don’t actually want to deal with that thank you’ (Participant 2) Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Participants who owned their own business identified how the drop in patient numbers meant uncertainty about their ability to maintain a viable business and to pay their employees. They attributed the drop in patient numbers to the fact that patients did not rank their own health care needs as important when faced with day-to-day challenges such as no electricity, sewerage or clean water. Theme 3: Giving and receiving support Besides providing ‘usual’ physical care for patients, most of our participants spoke at length about the high level of psychological support they were providing to their patients through the telling and sharing of earthquake experiences. However, because this level of support took extra time and effort, participants frequently felt overwhelmed. Moreover, they regarded the provision of psychological support for patients, via the action of listening to patients’ stories and experiences, more as a courtesy than a core physiotherapy skill. I think we have incredible counselling skills because we listen and we care. The number of people who say I was the first person who listened to their story. And I do think we need to let the powers that be know that physios are good counsellors as well because that became our role and every patient took longer because of that. (Participant 19) As well as providing psychological support via the listening to patients’ stories, many of our participants had offered support in more practical ways within their own communities. Well people would come in for physio, they were having a shower, plugging their laptops and phones in and having soup, and having treatment! (Participant 5) Although some of our participants had sought counselling services themselves, they related how it had not been easy to find the time (particularly in the public hospital environment) to visit a counsellor during work hours. Participants described many offers of work support from physiotherapists from all around New Zealand in the immediate days following the February earthquake. However, personal weariness combined with uncertainty about procedures to be followed for Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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the recruiting of staff made immediate uptake of these offers impossible. Participants suggested, however, that offers of assistance at a later stage to assist with the feeling of overwhelming tiredness even months after the February quake would have been useful. What do they need for infection control? Do they need MRSA clearance? What [other] clearance is needed? Who would pay for air tickets? Who would orientate them? All of that became too much for me to sort out right there and then…I really needed help at least two or three months down from the earthquake (Participant 4) Nevertheless, it was apparent that many of our participants did receive support from many sources in various forms. It came from neighbours, friends and local communities, in the form of practical support (for example a generator to provide power) as well as social and psychological support. Support was also evident from the government, from professional bodies and from colleagues. Participants with their own business had worked hard to support their staff, often at personal financial loss, and many had offered support such as practicing space to colleagues who had lost premises, even though they were usually in competing businesses. When physiotherapists were able to network with others, this had helped to relieve stress by providing an opportunity to debrief and support each other in the new environment. Even to the extent that we heard from the [registering body for physiotherapists] that Canterbury physiotherapists were not going to be audited [for their continuing professional development practice for the year]. I just about burst into tears when I read that email because it was just so lovely (Participant 6) Many participants described how small things took on meaning. As an example, one participant was extremely grateful for the week’s free lunches provided at the hospital where she worked. This was useful because the supermarket where she usually shopped had been closed, and there was neither tap water nor sewerage available in her own community. In addition, many of our participants who worked in the public system spoke of how, despite a seemingly inflexible workplace policy with regards to post earthquake leave, their line managers had been as supportive, flexible and fair as
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possible with regards to the possibility of sharing workload to allow for staff to take time off to see to their personal and family’s needs. Over time, many participants realized that their resilience was wearing thin. One participant describes a moving account of no longer having the capacity to support a close family member: I was sitting downstairs on the couch and I looked to him and I was crying and I just wanted a cuddle and some comfort and we just looked at each other, and he had nothing to give me and I had nothing to give him (Participant 4) In contrast, one of our participants described displaying outwardly strong behaviour even though he felt that his inner resilience was eroded in terms of his mental health and lack of sleep. This was reinforced during many of our interviews when we discovered that our participants had assumed that because their colleagues’ professional behaviour had allowed them to be at work, they were therefore ‘doing alright’. Theme 4: Being a physiotherapist Being a physiotherapist strongly influenced the actions and decisions of all of our participants, and this theme weaves its way as a concept through the other themes of a life-changing event, uncertainty and support (see Figure 1). Many of our participants who worked in the hospitals voiced feelings of frustrations and redundancy because they did not feel able to contribute to evacuation, rescue and first-aid procedures in the immediacy of the situation. I have to confess that first afternoon when we were standing around, I felt … useless. We weren’t directed to specifically help with evacuation and things (Participant 6) In the days following the February quake, this sense of redundancy continued because there appeared to be no clear plan to best utilize their services and skills. For example, one hospital had such enormous damage to its infrastructure that it was unable to accept new patient admissions. Consequently, despite being ‘at work’, participants felt guilty because they were not deployed to share the load with others who worked in more needy services. The most stressful [thing] was turning up to work when you felt you should be doing something
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more important, more helpful somewhere else (Participant 1) Yet, being a physiotherapist also drove actions towards helping and supporting patients in need. This description from one participant who made the decision to take a vulnerable patient home embodies the strong commitment to patients following the life-changing February earthquake. I finally got her to her home and we stood outside and I said, ‘are you okay to go in’, and she said ‘yes, I will go in, come in with me’, so we carefully went in through the doorway. Everything was devastated, everything was on the floor, the door was skew-wiff, the walkway in was all skew-wiff, and I said ‘I’m not happy to leave you here, can we go next door? Who do you know that you can get support with’? So we went next door and [discussed how] we all need to be together, and they agreed, so I left her with the neighbours. Then I had this tedious 3 hour journey home, not knowing exactly what my parents were like, what my kids were like. It’s dealing with what I had to, and I just had to hope that somewhere else someone was dealing with my stuff. (Participant 17) Participants had, however, found it challenging to be professional and to provide support and assistance in the face of on-going uncertainty, stress and feelings of mental overload. [following one large aftershock] I got halfway through my …consultation, and realized that my head was somewhere else (Participant 18). From our analysis, it was apparent that some physiotherapists were in a position to be adaptable and flexible in their approach to the use of health care resources and in their approach to providing physical care for patients. For example, one participant had arranged an ad hoc teleconference to arrange emergency assistive equipment (wheelchairs and hoists) for individuals with disability at emergency shelters. Others took business into the community, for example into the three relief centres set up around Christchurch. Many participants who had their own business had waived the patient surcharge for a time. In addition, where participants had been able to liaise with participants from Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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different health services, this had helped to speed up the delivery of equipment such as portable toilets and services for older people who were frail and less mobile. When specifically asked about possible physiotherapy roles in future disaster situations, our participants offered suggestions such as the triaging of musculoskeletal injuries in emergency areas. Their suggestions did not include the role of psychological support.
Discussion Our study explored the impact of a life-changing disaster for physiotherapists living through the Canterbury earthquakes. It identified how the resilience of being a physiotherapist was bolstered by being able to give and receive support and yet eroded through on-going uncertainties. Resilience, described as the ability to cope when circumstances change considerably (Greene and Greene, 2009), is known to develop in relation to support received from others, for example, from the government and from social cohesion from within one’s own community (Wilson et al., 2008). Participants in our study also found that resilience was built from the balance of being able to give and receive. The literature also identifies that resilience is related to self-support in the form of pre-planning; when un-expected occurrences happen, this pre-planning helps one cope with the uncertainty (Kalemoglu et al., 2005; Rami et al., 2008; Wilson et al., 2008; Te Brake et al., 2009; Admi et al., 2011). This highlights the necessity for physiotherapists to plan for unexpected events. A recommendation we make based on the experiences of our participants is for health care providers, including physiotherapists to contribute to the development of disaster management plans. As part of this we recommend a review of communication strategies as these were seen as crucial in the immediate post-quake phase. There was an overwhelming offer of support from physiotherapy colleagues around the country. However, while living through the immediate aftermath of the earthquake, participants found that it was difficult to process this help. It would therefore seem useful for physiotherapy units to plan as to how best to respond and then utilize such offers of help. One suggestion would be to provisionally book colleagues’ services for a future date instead of declining an offer of assistance. Many participants in our study described feelings of redundancy and frustration. These feelings have been described by other physiotherapists following disasters. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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A study by Harrison (2007) used interviews with four physiotherapists who had first-hand experience of manmade disasters (in the United States of America). In the immediate emergency following these events, physiotherapists described not being sure of their role at the time and that a barrier to playing a useful role was the reluctance of disaster response organizations to recognize and promote the role of physiotherapy (Harrison, 2007). On reflection, all participants in Harrison’s study could identify several key roles for physiotherapists, including triage and treatment of musculoskeletal injuries, first aid and respiratory aid. In contrast, although triage may be a role suited to the skills of a physiotherapist, many of our participants who had tried to help in areas worst affected were either turned away or asked to do tasks that they had no training for. This may relate to the lack of preplanning for the inclusion of physiotherapists in disaster management. Guidelines for physical therapists in disaster management have been written in order to inform the wider disaster response community about the specific skills and ways in which physical therapists could assist (Waldrop, 2002). Based on the experiences of our participants and those of physiotherapists following disasters in other countries, we recommend that New Zealand physiotherapists contribute towards a disaster management document which clearly outlines both physical and listening skills. This would allow physiotherapists to provide an important contribution to both immediate and on-going disaster response policy. We further recommend that the physiotherapy profession present this document to both health and rescue organizations. Recovery is related not only to the rebuilding of infrastructure (e.g. houses, buildings, roads and services) but also requires psychological recovery. The need for wide-ranging mental health support following both manmade and natural disasters is well documented (van Ommeren et al., 2005; Dhar et al., 2007). Our study identified that physiotherapists in the Canterbury region had provided important psychological support to patients and colleagues in both the immediate and longer term aftermath of the quakes via the action of listening to their stories. Whilst many of our participants acknowledged that talking with patients was an inherent characteristic of being a physiotherapist, they did not recognize this as being a crucial post-disaster role for them, nor did they identify it as ‘worthwhile’ or even a core part of physiotherapy.
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Furthermore, our participants felt that they were under-prepared for the sheer volume of this type of support. Following the Kashmir earthquake in 2005, Dhar et al. described how hospital staff had initially considered having to repeatedly listen to peoples’ stories as a waste of time, and yet were better able to understand patient behaviours as a result of offering this listening ‘service’ (Dhar et al., 2007). Historically, physiotherapy has closely aligned itself with the values and world view of the medical profession and, generally speaking, continues to prioritize clinical reasoning and physical skills which are supported by the framework of evidence-based medicine (Carpenter and Suto, 2008). Juxtaposed with this standpoint is the undeniable fact that physiotherapists, in the course of their intervention, are exposed to the narratives of their patients. There has been little research exploring the role and/or effects of listening in physiotherapy. Two aspects of our study could be considered as limitations. First, readers need to be aware that the study’s authors lived through the February earthquake themselves. Indeed, we found it emotionally taxing to undertake this study, and in part, this was because of the need to consciously not validate participants’ responses to our questions within our own experiences of the earthquakes. However, despite our attempts, it is inevitable that our experiences may have influenced the analysis. Second, we purposively sampled participants but did not consider the extent to which individual participants’ personal losses may have influenced their descriptions.
Implications for physiotherapy practice We recommend that individuals, physiotherapy departments and business owners develop their own specific disaster management plan and, through these plans, contribute towards a central disaster management document which clearly outlines the skills that will enable physiotherapists to provide an important contribution in the event of a natural or manmade disaster. We further recommend that the physiotherapy professional bodies communicate this contribution to both health and rescue organizations. We would suggest that listening as an important aspect of physiotherapy practice requires further investigation.
Acknowledgements We wish to acknowledge our participants for their time and effort in sharing their experiences with us. We also wish to thank Dr Denise Powell for assistance with data management and Stefan Peters for the figure. REFERENCES Admi H, Eilon Y, Hyams G, Utitz L. Management of Mass Casualty Events: The Israeli Experience. Journal of Nursing Scholarship 2011; 43: 211–219. Ardagh MW, Richardson SK, Robinson V, Than M, Gee P, Henderson S, Khodaverdi L, Mckie J, Robertson G, Schroeder PP, Deely JM. The initial health-system response to the earthquake in Christchurch, New Zealand, in February, 2011. Lancet 2012; 379: 2109–15. Carpenter C, Suto M. Qualitative research for occupational and physical therapists: A practical guide. Oxford: Blackwell, 2008. Dhar S, Halwai M, Mir M, Wani Z, Butt M, Bhat M, Hamid A. The Kashmir earthquake experience. European Journal of Trauma and Emergency Surgery 2007; 1: 74–80. Dolan B, Esson A, Grainger PP, Richardson S, Ardagh M. Earthquake disaster response in christchurch, New Zealand. Journal of Emergency Nursing 2011; 37: 506–9. Greene R, Greene D. Resilience in the face of disasters: Bridging Micro-and Macro-Perspectives. Journal of Human Behavior in the Social Environment 2009; 19: 1010–1024. Harrison RM. Preliminary investigation into the role of physiotherapists in disaster response. Prehospital & Disaster Medicine 2007; 22: 462–5; discussion 466. Huggard P. Caring for the Carers: the emotional effects of disasters on health care professionals. Australasian Journal of Disaster and Trauma Studies 2011; 2: 60–62. Kalemoglu M, Keskin Ö, Ersanli D. Analysis of an emergency department’s experience. Internet Journal of Rescue & Disaster Medicine 2005; 4: 9. Mccoll GJ, Burkle FM, JR. The new normal: twelve months of resiliency and recovery in Christchurch. Disaster Medicine & Public Health Preparedness 2012; 6: 33–43. Rami JS, Singleton EK, Spurlock W, Eaglin AR. A school of nursing’s experience with providing health care for Hurricane Katrina evacuees. ABNF Journal 2008; 19: 102–106. Te Brake H, Dückers M, De Vries M, Van Duin D, Rooze M, Spreeuwenberg C. Early psychosocial interventions after disasters, terrorism, and other shocking events: guideline development. Nursing & Health Sciences 2009; 11: 336–343. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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