Chief Nursing Officer

How I Heard

My family loves to travel and was spending a week in Reykjavik, Iceland. On June 12, 2016, we were standing at a popular tourist site, Geysir Hot Springs, waiting to watch the lively Strokkur geyser spout. Strokkur explodes every few minutes spouting scalding water 100 feet into the air.  Cell phone service had been sporadic so I was surprised when my phone alerted me that I had a series of text messages. As I looked down at the messages my gut turned; simultaneously the geyser erupted. My husband and I pieced together the messages we were both receiving from friends and colleagues. The messages informed me that a mass-casualty shooting event had occurred at the Pulse nightclub and dozens of victims were being treated at Orlando Health Orlando Regional Medical Center (ORMC). The number of deaths reported kept rising with every message I received. I began to panic. How could the chief nursing officer (CNO) of Central Florida’s only Level One Trauma Center be 3,500 miles away in a remote location when her beloved hospital and nursing staff were experiencing one of the largest mass shootings in the history of the United States? I called Carlos Carrasco, the chief operating officer of ORMC, from the gift shop of the tourist attraction where I could get the best phone reception. He assured me that the team had the situation under control, but I could hear the devastation in his voice. Although I was confident in the team, I was desperate to be there. The tears flowed.

Synopsis

As the CNO of ORMC, I am responsible for oversight of nursing and the quality of patient care. I strive to be a transformational leader who fosters a healthy work environment, including promoting teamwork, collaboration and resiliency. It is well documented that highly engaged, well-trained nurses make a significant difference in patient outcomes. 

I started at Orlando Health in 1982, and spent the majority of my career in critical care, where I found my clinical passion working with the trauma population. I took pride in being affiliated with the area’s only Level One Trauma Center. Over a 34-year career, I participated in dozens of emergency mass casualty preparedness drills. In March 2016, just months prior to the Pulse tragedy, I served as the chief operations officer for Corporate Incident Command during a full-scale, community mass-casualty exercise for Central Florida.

Response

During the Pulse event, nurse leaders participated in the Hospital Incident Command System (HICS) in roles they had practiced in previous drills. Nursing resources were allocated to ensure the seamless delivery, coordination and transition of care without comprising the quality of care. Considering the event occurred less than half a mile from the ED, the current disaster plan had to be rapidly adapted because patients arrived without announcement and without EMS triage. Thirty-six patients arrived in 36 minutes during the first wave of the tragedy. This required the nursing team to be innovative in simultaneously triaging patients, staffing multiple operating rooms and decompressing the ED by discharging and expeditiously moving patients to various levels of care.

When the first Pulse victim arrived in the ED, 32 staff members were on duty. Learning that there were more victims, nurse leaders immediately elevated staff levels to 51 in the ED, pooling staff from our other hospitals. From there, the “Pulse team” was born, and an attitude of all-hands-on-deck permeated, not just at ORMC, but throughout the entire Orlando Health system. Physicians, residents and nurses placed tourniquets, dressed wounds and inserted tubes. Members of the Guest Services team helped hold pressure on bleeding wounds. Environmental Services turned over exam rooms quickly despite having to sanitize them for massive amounts of blood and Security rapidly unloaded patients from vehicles. One team member said, “We went where our hands could be helpful. It didn’t matter if it was your traditional role or not.” Four-hundred-forty-one units of blood, platelets and plasma were administered on June 12, and 28 surgeries were performed that morning.

Lessons Learned

Nurse leaders quickly realized the deep emotional impact of this mass-casualty event on the entire team. Although the trauma nurses and inpatient nurses were clinically strong and frequently deal with difficult situations, including death, this was of a different and far greater magnitude. Counseling sessions were held around the clock for weeks, totaling more than 1,200 sessions.

Although Orlando Health had anticipated the impact of the clinical aspect of a mass-casualty incident, the organization had never anticipated the effect of the aftermath. This came in many forms, including international media interest and visits from well-wishers, including politicians, celebrities, sports figures and the general public. At times, the staff and patients were overwhelmed with all of the attention. When this occurred, nurse leaders actively advocated for the privacy of patients and staff.

Conclusion

I still struggle with not being there for the day of the Pulse event. In fact, the biggest complaint from team members was that no one called them. Two things helped ease my emotions. First, the director of patient and guest services emailed me a thorough update while I was still in Iceland and acknowledged how hard it must be not to be at the hospital. She told me how proud I should be of the ORMC nurses. The second thing happened upon my return. When I apologized to ORMC’s chief surgical quality officer for not being there, he looked me in the eye and said with sincerity, “You were here.” Although I wasn’t physically present on the day of the event, he gave me hope that my years of leadership influence had contributed to the successful outcomes we achieved during this horrific event.

In the time that has elapsed since the 2016 tragedy, the Orlando Health nursing team has been applauded on the national and international stages for their heroic initial response and for the care provided in the days and months that ensued. As nurse leaders reflect on lessons learned, successes can be attributed to 3 major themes: preparedness, teamwork and a culture of resiliency.

Key Takeaways

Preparedness: The greatest advice the nursing and ORMC team can offer to other hospitals is to practice, practice, practice and take it seriously. By drilling different scenarios and testing systems to the point of failure, areas of opportunity are identified for improvement. Full-scale, mass-casualty drills with community partners allow for testing of triage and system throughput.

Teamwork: Nurse leaders must ensure that teamwork across the organization is achieved by building trusting relationships and developing processes that allow teams to work together. Interprofessional teams working together without hierarchical structures will lead to success. Although these efforts are often considered soft skills, they will be the foundation for building a culture of trust and resiliency.

Resiliency: Proactively building team resilience is rarely considered as part of disaster planning, but can easily be accomplished as an ongoing initiative by nurse leaders. By definition, resilience is the ability to return to a state of normalcy — or to “bounce back” from adversity or trauma — and remain focused and optimistic about the future. Building a culture of resiliency comes from a transformational leadership approach that supports the frontline team’s involvement in decision-making and problem solving.