Perceived Attitudes and Staff Roles of Disaster Management at CBOCs

Methods

In this qualitative study, in-depth semistructured key informant (KI) interviews (N = 3) and focus group discussions (N = 20) guided by risk perception theory and the Andersen Behavioral Model of Health Services Use were conducted and analyzed using grounded theory methods to contextualize the potential of local clinics in disaster response.^13-15 To optimize breadth of viewpoints on this issue, participants were selected by theoretical sampling methods to explore perceptions of leadership and line staff.

Study Location

Health care providers and support staff from 3 southern California CBOCs that are contracted by the local VA to provide primary care services (ie, internal medicine, geriatrics, women’s health, mental health, and some specialty care services) to veterans were recruited for this study. The CBOCs are generally connected with a VHA local hospital in their region, offer services 5 days a week, and are closed on weekends and federal holidays. Some VA CBOCs participate in telehealth remote services connected to their regional hospital to help manage their patient populations. The CBOCs are managed by a medical director and a clinic manager and report to their respective VISN, and each VISN reports to the VHA Central Office in Washington, DC.^13,15 The CBOC staff includes physicians, nurse practitioners, physician assistants, registered nurses (RNs), licensed vocational nurses (LVNs), medical assistants, front office staff, social workers, case managers, counselors, pharmacists, and nonclinical staff.

In this case, the CBOCs are contracted by Loma Linda University Health to manage care of the veterans and agree to care for nonveterans in a disaster. The CBOCs contracted or not all fall under the criteria as set forth in VHA Handbook 1006.1. This handbook criteria indicate that CBOCs must maintain appropriate emergency response capability. Additionally, VHA Handbook 0320.1 states that the CBOC is responsible for developing, implementing, evaluating, and improving a CBOC Comprehensive Emergency Management Program (CEMP) and for participating in the VAMC Emergency Management Committee. The scope of the VISN-wide CEMP integrates VAMC and VISN EM programs to coordinate and enhance operations during planned and unplanned events.

Study Design and Sample

After receiving institutional review board approval, 3 in-depth semi-structured clinic leadership KI interviews and 3 clinic staff (RNs, LVNs, health technicians, and nursing assistants) focus group discussions (N = 20, 1 per CBOC) to follow up on information gleaned from the analyses of the initial KIs were conducted. To provide continuity, all were conducted by the same trained facilitator who used a semistructured KI outline with questions and probes based on the guiding study framework.

Data Collection and Content Analysis

Interviews and focus group discussions were audio recorded and transcribed verbatim and then analyzed using grounded theory methods. Line-by-line coding was done to develop an initial inductive codebook, which was then organized into final codes. Once the codebook was developed, it was applied to all transcripts.

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Transcripts and resulting codes were reviewed 3 times by independent reviewers to validate data, ensure accuracy, and delete any information that might identify participants. Pseudonyms were used to represent the participants by perspective (eg, nurse, MD) to avoid confusion in data analysis. A 4-stage data analysis approach was used: (1) immersion in the raw data by listening to tapes and reading manuscripts and notes in order to list key ideas and recurrent themes using a constant comparison method; (2) indexing by applying the thematic framework systematically to the data using and seeking new, unanticipated emerging codes; (3) arranging the data in codes and concepts/themes that represent the thematic framework of EP in clinics; (4) identifying a thematic framework for EP using codes that identified key issues, concepts, and themes that can be referenced and derived from the text.

Results

The Table describes the 4 primary emerging themes and corresponding quotes: (1) EP barriers, including lack of direction, training, and tools, which would result in negative outcomes; (2) perceived personal and clinic risk for a disaster, including negative outcomes and personal family safety; (3) perceptions of roles and responsibilities in EP, including intent to participate in DM at various staffing levels as well as patient expectations for care; and (4) existing resources that influence EP and the ability to survive a disaster collectively.

Emergency preparedness barriers. Although most respondents realized their potentially critical role in an emergency, they expressed recurrent barrier themes centered on their perceived lack of training, lack of tools to function, and lack of direction to be effective in a disaster response. Lack of knowledge of EP was identified as a great need by multiple participants. One participant stated, “Lack of information is so destructive. If you don’t know how to keep yourself from those things you don’t know…such as in a situation that’s going to be tragic, it is because of a lack of information or a lack of training. And I see that so many times…Mandate that we do our classes, so we know what we’re doing.” Another stated in reference to lack of skills, “I haven’t experienced any drills or anything like that. So I know what is going to happen here.”