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Nursing children after a disaster: A qualitative

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Journal for Specialists in Pediatric Nursing

ORIGINAL ARTICLE

Nursing children after a disaster: A qualitative study of nurse

volunteers and children after the Haiti earthquake jspn_338 242..253

Elizabeth Sloand, Grace Ho, Rachel Klimmek, Anthony Pho, and Joan Kub
Elizabeth Sloand, PhD, PNP-BC, is an Assistant Professor and Coordinator, Pediatric Nurse Practitioner Track; Grace Ho, RN, BSN, is a PhD Student; Rachel
Klimmek, RN, BSN, OCN, is a PhD Candidate, Johns Hopkins University, School of Nursing, Baltimore, Maryland; Anthony Pho, MSN, MPH, NP-C, is a Staff
Associate in Medicine, Weill Cornell Medical College, New York, New York; and Joan Kub, PhD, APHN, BC, is an Associate Professor, Johns Hopkins
University, Schools of Nursing, Medicine, and Public Health, Baltimore, Maryland, USA

Search terms Abstract

Children, disaster nursing, Haiti, pediatric
nursing, qualitative.
Author contact
Esloand1@jhu.edu, with a copy to the Editor:
roxie.foster@UCDenver.edu
Disclosure: The authors report no actual or
potential conflicts of interest.
First Received November 15, 2011; Revision
received January 8, 2012; Accepted for
publication March 5, 2012.
doi: 10.1111/j.1744-6155.2012.00338.x
Purpose. The purpose of this study was to explore the experiences of nurse
volunteers caring for children after the Haiti earthquake in January 2010.
Design and Methods. This descriptive qualitative study using in-depth
interviews focuses on the experiences of 10 nurse volunteers.
Results. Four themes emerged: hope amid devastation, professional com-
promises, universality of children, and emotional impact on nurses.
Practice Implications. Nurses who volunteer after natural disasters have
rich personal and professional experiences, including extremes of sadness
and joy. Nurse volunteers will likely need to care for children. Nurses and
humanitarian agencies should prepare for the unique challenges of
pediatric care.

On January 12, 2010, a 7.0-magnitude earthquake
struck Haiti with an epicenter 15 mi from the capital
of Port-au-Prince (PAP). An estimated 222,570
people were killed, 300,000 were injured, and 1.3
million displaced (U.S. Geological Survey, 2011).
The baseline poverty in Haiti further exacerbated the
situation. Haiti is the poorest country in the Western
Hemisphere, with 80% of the population living
below the poverty line and more than half living in
abject poverty (Central Intelligence Agency, 2011).
The magnitude of the disaster, exacerbated by
poverty, culminated in one of the most tragic
humanitarian crises in recent history.
In the wake of this disaster, thousands of nurses
and healthcare volunteers traveled to Haiti to assist
in humanitarian relief efforts, providing care that
ranged from emergency trauma to community
primary care. Since then, many publications describ-
ing these individuals’ experiences have appeared in
the literature (Burnweit & Stylianos, 2011; Deckel-
baum, 2010; Goodman, 2010; Huffman, 2011; Lau,
2010). A search of peer-reviewed literature pub-
lished from the time of the earthquake through
August 2011 revealed that all of the publications
are anecdotal in nature. There was no original
research using scientific methods that systematically
explored volunteers’ experiences. In addition, none
of the publications specifically addressed the issues
faced by nurses caring for children.
Research that focuses on the pediatric population
in disasters is generally lacking (Fallat, 2009; La
Greca, Silverman, Vernberg, & Roberts, 2002). The
importance of a child-oriented approach is high-
lighted when we examine the statistics of the Haiti
earthquake records. In one general field hospital in
PAP, the median age among all injured patients
was 24 years, and approximately 30% of all those
seen were infants through 14 years old (Centers for
Disease Control and Prevention, 2010). Domesti-
cally and internationally, children comprise a vul-
nerable population that requires special attention
during a disaster situation. At the local level, Strat-
ton (2010) discussed the vulnerability of children
and pediatric capacity in Seattle, Washington.
Nationally, two organizations echoed the special
needs of children in disasters: the National

242 Journal for Specialists in Pediatric Nursing 17 (2012) 242–253

© 2012, Wiley Periodicals, Inc.
E. Sloand et al. Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
Commission on Children and Disasters (2010) in
their Report to the President and Congress, and the
National Association of Pediatric Nurse Practitioners
(2011) in their recent position statement. Interna-
tionally, Farfel and colleagues (2011) reported on a
pediatric field hospital in PAP after the earthquake
and discussed the unique challenges of caring for
children in a disaster.
This study sought to fill part of the knowledge gap
about nurse volunteers who care for children in
disaster situations. It aimed to answer the question:
What were the experiences of the nurse volunteers
who cared for children after the 2010 Haiti earth-
quake? This study illuminates the impact of the
earthquake on children and their caregivers through
the eyes of the nurses who cared for them. With its
focus on nurses and their experiences with children
postdisaster, this research is important because it
takes a scientific approach to nurses’ experiences
and will help inform nurses who consider volunteer-
ing in future humanitarian missions. The study also
informs aid agencies on how to improve the disaster
response system for affected children.
DESIGN AND METHODS
This research project used an exploratory descriptive
study design because little is known about the topic
of study (Sandelowski, 2010). The Johns Hopkins
Medicine Institutional Review Board approved this
research study.
Study participants
The nurse volunteers were purposively selected by
the research team. Nurse volunteers were invited to
participate based on the following criteria: (a) being
a licensed nurse who volunteered in PAP, Haiti, or on
the U.S. Naval Ship Comfort, the American hospital
ship that anchored off the coast of Haiti; (b) serving
in Haiti between January and June of 2010; (c) pro-
viding direct patient care for at least 1 week; and (d)
being willing to discuss his or her experience as a
volunteer nurse. Snowball sampling was used to
identify potential participants. With this purposive
sampling method, the researchers can find potential
participants by asking other participants. This
method helped produce a maximum variation
sample for this study, one that was diverse with
respect to nursing experience and type of clinical
site. Clinical sites included hospital setting, commu-
nity clinic, and the hospital ship. This diverse sam-
pling helped give us a deep understanding of the
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
phenomenon we were studying: the experiences
of nurse volunteers during a humanitarian crisis
(Patton, 1990). Informed consent was obtained
prior to each interview. No incentives or gifts were
given for participation.
Data collection and analysis
The data for this study are from a larger study that
included 12 participants who were nurse volunteers
in Haiti. The purpose of the larger parent study was
to explore the experiences of nurses who volun-
teered to serve in Haiti after the earthquake of
January 2010. Semi-structured interviews took
place in-person whenever it was possible (n = 6).
Some were conducted over the telephone (n = 4)
when participants were not able to do the in-person
interviews. In-person interviews were conducted at
the participants’ place of choice. The interviews
ranged from 60 to 90 min in length and were con-
ducted by four interviewers. Interviews were con-
ducted after volunteers returned home; most were
done 8–10 months after they returned, and one was
conducted 5 months after return.
An interview guide was developed by three nurses
who served in Haiti as volunteers and a qualitative
research expert. The interviewers were all members
of the research team so they were very familiar with
the study overall and the sampling technique. Inter-
viewers were trained by a qualitative research
expert to ensure consistency in conducting inter-
views. The training included interview techniques,
strategies to avoid bias, and rehearsing with the
interview guide. A sample of interview questions
and probes are listed in Table 1. Participants were
asked for their permission to audio-record the inter-
view; all agreed. The audio recordings were tran-
scribed verbatim by one member of the research
team. The interview transcripts were verified for
accuracy by the respective interviewers prior to
analysis. A qualitative data analysis computer
Table 1. Sample Interview Questions and Probes
• When you think back on your time there, what thoughts, images,
or words come to mind?
• Describe a typical day for you in Haiti.
• What kinds of patients did you encounter, and what was that like
for you?
• Did you encounter any challenges during your time there?
• Is there anything else you would like to tell me about your
experience that we haven’t already talked about?
243
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
system, NVivo9 (QSR International, 2011), was used
to assist with data management.
The investigators first worked with transcripts
from the parent study. After multiple readings and
coding, the investigators determined that most of
the nurses (10/12) made specific references to their
work with children that stood out from the main
study and warranted special attention. This discov-
ery led to the decision to conduct a subgroup analy-
sis that was pediatric-specific and included 10 of the
original 12 participating nurses. Two of the partici-
pants were males and eight were females. Education
and experience varied widely. Four were registered
nurses (RNs), six were nurse practitioners, and all
earned academic degrees that ranged from an Asso-
ciate’s Degree in Nursing to Doctor of Nursing
Practice. Most (8/10) had prior humanitarian work
experience. A summary of the characteristics of
these 10 participants is presented in Table 2.
The investigators (ES and GH) extracted all child-
specific data and analyzed it using strategies
described by Corbin and Strauss (2008). We began
by reading all of the data to gain a grand view. After
several readings, we performed independent open
coding with two transcripts, and compared and con-
verged codes to subsequently create a codebook. We
then coded independently and discussed emerging
ideas while identifying recurring and predominant
concepts. In subsequent readings and many
in-depth discussions, the investigators searched for
underlying meanings within the data. Common
themes across interviews emerged as data were
compared vertically (within the transcript) and hori-
zontally (across different transcripts). We carefully
considered these themes and how they were related
and interconnected. These relationships helped
suggest a common story embedded in the data.
The researchers confirmed themes through analy-
sis of memos and field notes to get the truest picture
of the experiences of the nurses. Throughout the
analysis, the investigators explored thoughts, feel-
ings, and emotions that arose while working with
the data and analysis. This was important because
the principal investigator has volunteered in Haiti
on many occasions both before and after the earth-
quake. Thus, the researchers triangulated these
multiple data sources to provide the most complete
view of the nurses’ experiences in this context.
Trustworthiness
The investigators employed the four criteria (i.e.,
credibility, transferability, dependability, and con-
244
E. Sloand et al.
firmability) described by Lincoln and Guba (1986) to
ensure trustworthiness of this study. Prolonged
immersion, reading the data multiple times, vertical
and horizontal comparisons, peer debriefing
between the investigators, and consulting with two
experienced qualitative research experts supported
the credibility of study findings. A dense description
of participant characteristics, as shown in Table 2,
supported the results’ transferability. A clear audit
trail that outlined sampling, data collection, coding,
and analytic strategies supported the dependability
of this study. Confirmability of results was supported
by the investigators’ use of reflexivity (i.e., use of
memos and peer debriefing to uncover feelings,
thoughts, and emotions during coding and analysis).
Employing reflexivity was salient as one’s own pre-
conceptions may affect the results, and a self-critical
attitude on the part of the researcher is required to
uncover and acknowledge these preconceptions
(Thomas & Magilvy, 2011).
RESULTS
The nurses spoke strongly and compellingly in the
interviews, which was not surprising given the
severity of the earthquake conditions combined
with Haiti’s underlying poverty and sociopolitical
disarray. The nurses described experiences and feel-
ings that were powerful and oftentimes difficult. It
was hard for them to care for children in the harsh
conditions of post earthquake Haiti, and that diffi-
culty came through in the interviews. Four themes
emerged from the data: devastation was expected
but rare glimmers of hope?, professional compro-
mises and unsettling results, universality of chil-
dren, and emotional impact on nurses.
Theme 1: Devastation was expected but rare
glimmers of hope?
The nurses saw firsthand how the earthquake had a
devastating impact on Haiti’s children. The country’s
baseline poverty, compounded by the disaster’s
massive damage, left its children with few to no
resources and basic necessities. The nurses gave
many descriptions of this impact. For example, one
nurse responded:
The destruction was mind-boggling. The poverty, there’s
just no words for the poverty, you know, tents every-
where and mud everywhere and children everywhere
and barefoot, dirty children everywhere . . . It was just
rubble . . . there wasn’t anything. There’s an orphanage
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
 E. Sloand et al.

© 2012, Wiley Periodicals, Inc.

Table 2. Participant Characteristics

Interview Certifications/ Experience as RN Prior humanitarian Work environment in Interview

ID Age Gender licensures (in years) work experience Haiti (type of site) Length of stay format

RN1 25 Female PNP, MPH First year as NP Yes Emergency room tents 16 days Phone
ICU tents

Journal for Specialists in Pediatric Nursing 17 (2012) 242–253

Primary care clinic
RN2 54 Male MSN-PNP, CRNP 5 Yes Hospital—pediatrics 16 days Phone
RN3 37 Female ADN 6 No Hospital—pediatrics 14 days (2 trips of 7 days) Phone
Hospital—adult ICU
RN4 24 Female RN 2.5 Yes USNS Comfort 14 days Phone
RN5 30 Female MSN/MPH, FNP 2.5 Yes Primary care clinic; 16 days In person
Emergency room (1 day)
RN6 26 Female RN, CPEN, TNCC 3 Yes Hospital—emergency 16 days In person
Primary clinic (1 day)
RN7 26 Male CCRN 3 Yes Hospital—emergency 16 days In person
RN8 55 Female CNS, ANP, GNP 5 years Yes Primary care clinic 16 days In person
as NP Hospital—adult ICU
RN9 56 Female ANP, DNP 34 No Hospital—emergency 12 days In person
Primary care clinics
RN10 55 Female PNP, CRNP, DNP 34 Yes Hospital—emergency 10 days In person
Primary care clinic—peds

Note: Humanitarian work experience is defined as having worked in resource-poor countries (e.g., medical missions) or domestic/international disaster response. RN, registered nurse; ADN,
Associate Degree in Nursing; CPEN, certified pediatric emergency nurse; ANP, adult nurse practitioner; PNP, pediatric nurse practitioner; DNP, Doctor of Nursing Practice; CRNP, certified regis-
tered nurse practitioner; GNP, geriatric nurse practitioner; CNS, clinical nurse specialist; FNP, family nurse practitioner; MSN, Master’s in Nursing; MPH, Master’s in Public Health; TNCC, trauma
nursing course certified; CCRN, critical care registered nurse; ICU, intensive care unit; NP, nurse practitioner; USNS, U.S. Naval Ship.

245
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
across the street that was collapsed and all the children
were in tents, literally pitched on top of the rubble . . . a
lot of children who would really beg for food. (RN10)
Many parents and caregivers reported various
physiologic stress responses in their children, such as
bedwetting and nightmares. For some children,
however, the impact of the earthquake was much
more severe. The nurses noted conditions that
ranged from coughs, earaches, diarrheal illness,
feeding problems, and rashes, to severe dehydration
and malnutrition, malaria, asthma exacerbations,
and pneumonia. Physical traumas were also
common and, as the nurses reported, ranged from
minor scrapes and bruises to horrendous wounds,
debilitating injuries and burns, uni- or bilateral
amputations, and severe facial and skull fractures.
These children’s health problems ranged from mild
and chronic to acute and severe, but nonetheless
required consistent and quality care from parents or
caregivers. Many Haitian children lost their health
or their families, and some lost both. RN4 shared:
A lot of them just didn’t have, they had nobody, and
then they were, they had what little they had—their
own health—was just completely crushed, literally
. . . They had devastating, devastating physical injuries
and, . . . in the pediatric ward, a lot of the kids there,
their parents were dead, or they didn’t know where
they were . . . a lot of them didn’t have anybody taking
care of them . . . they’re in a strange environment. It’s a
hospital . . . they were overwhelmed . . . scared. (RN4)
Compounding the loss of their caregivers, a
chaotic and crime-rampant environment also jeop-
ardized the children’s safety and well-being. One
nurse cared for a girl who exhibited signs of sexual
and physical abuse. The lack of infrastructure to
handle these types of abuse cases in Haiti made it all
the more difficult for her to report and remediate the
situation, as she recalled:
It was really, it was a really difficult experience because
of the child . . . just broke your heart . . . I think it’s
traumatic any time you see a child that’s been abused
like that. (RN9)
Most of the children were severely negatively
impacted by the earthquake, but some nurses noted
that there were a few unexpected cases where the
earthquake actually had a positive impact. In these
circumstances, children with illnesses prior and
unrelated to the earthquake were “found” or “dis-
covered” because of the earthquake. One nurse
explains about a young boy:
246
E. Sloand et al.
It was kind of ironic because he was found, the earth-
quake caused him to be found because he was just
[living] in the streets, and he ended up being diagnosed
with a rare skin disorder—that he’d have so much
cancer all over him they had to remove his eye and he
was just really malnourished, but . . . it was a good story
‘cause . . . he was able to come to the States and he was
adopted . . . He actually wasn’t injured by the earth-
quake at all. . . . because of the circumstances, he was
found. (RN4)
Due to the influx of medical assistance, children
were also getting access to primary care. For
example, one nurse practitioner saw a set of
newborn twins who were not breastfeeding well.
She asked the mother to return to the clinic multiple
times and initiated breastfeeding education and
guidance while monitoring the infants’ growth. She
explained:
That was one of those cases where it had nothing to do
with the earthquake at all. It was just babies being born
and they were small . . . I always think about those
twins actually. I was thinking about them recently
hoping that they, you know, made it. (RN5)
The earthquake’s impact on Haiti’s children
cannot be overstated. Contrary to common expecta-
tion, however, we learned through the nurse inter-
viewees that not all children shared negative
experiences. While the disaster imposed destructive
and devastating consequences on most, for a select
few, the earthquake became an unexpected life-
changing event for the better.
To further understand the earthquake’s impact on
Haiti’s children, we also analyzed how the earth-
quake affected parents and child caregivers. In a
majority of the cases, parents and caregivers in Haiti
exhibited attitudes and practices that one would
expect to see anywhere else in the world—they
cared for and protected their children.
I found . . . as I’ve experienced with parents in every
place where I’ve worked, the parents just want to take
good care of their kids. (RN5)
Another nurse described how the parents were
often at the hospital continually, taking care of the
children, getting them up, bathing, and feeding
them.
The Haitian’s love for children and their celebra-
tion for life and family were paramount despite their
difficult and unfortunate circumstance. One emer-
gency nurse observed:
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
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E. Sloand et al. Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
We give them pregnancy tests and they’d [be told they
will] have a baby and they’re all excited and they start
crying and they’re grateful and I’m like, you just lost
everything you have and you’re happy that you’re
having a baby and . . . it was hard for me to understand
but . . . family’s everything to them . . . (RN7)
Many children were displaced and separated from
their loved ones. Parents or caregivers with children
in intensive/hospital settings often served as proxy
caregivers to orphaned children. For example, one
nurse saw mothers gathering around and praying
over an orphaned child. She explained, “They were
acting as a mother for all the children, like beautiful to
watch, and I’ll never forget” (RN4). Relatives often
assumed the parenting role: “I saw a couple babies
whose mothers had died in the earthquake and now
have family members taking care of them” (RN1).
But the future of these orphaned children remains
uncertain. In such a poor environment so severely
lacking in most resources, adults could barely satisfy
their own life-sustaining needs, let alone take care of
a child who is not their own, as one nurse recalled:
I do remember at one point, one mom, it wasn’t a mom,
it was an aunt or a cousin of a woman who died in the
earthquake had this newborn baby and she actually
handed the baby to me and said, “Will you take her back
with you to the United States because I can’t care for
her, there’s nothing I can do for her.” (RN1)
This nurse knew that the baby was sick and was
not thriving, but she had to give the infant back. She
reports, “It was absolutely heartbreaking to have to
give the baby back and say I can’t do that . . . so
those were, those were really tough times. . . .”
Death and loss were a common and persistent
occurrence in post-earthquake Haiti, and children
and pregnant women were particularly vulnerable.
One nurse practitioner who arrived in Haiti 2
months after the earthquake described:
I returned to the parents, I carried down a number of
children who died . . . there were pregnant women
who died, there were pregnant women whose babies
died right after they gave birth . . . (RN2)
While parental death leaves an orphaned child
with an uncertain future, the death of a child is
equally heartbreaking. An emergency room (ER)
nurse described one of her most memorable
moments with a 14-year-old girl:
There was one girl that had actually came in the day
before, they said it was like viral illness . . . and then she
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
came back and was completely altered . . . I was
working night shift that night and we had worked on
her for about 8 hours and then she passed away. And to
see the mom running with her in the street and stuff was
really sad, really challenging. (RN6)
Some nurses saw a paradoxical occurrence where
select parents, particularly mothers, detached from
the child. For example, RN3 described her experi-
ence working with a set of newborn twins where the
mother had difficulty feeding one of them and “just
gave up on him” (RN3). As a result, the baby became
severely malnourished. The mother later returned
and “. . . basically the mom handed over the baby to
them” (RN3). In other cases, women attempted to
terminate their pregnancies via dangerous means.
Being a mother in this time of chaos and uncertainty
was not easy. One nurse explained the experience of
a new mother:
The baby was delivered and, they monitored them for
an hour, maybe 2 hours, and they said okay, you can go
home, and she got on the back of a motorcycle and
drove home, . . . with the bumpy road at the back of a
motorcycle holding the baby . . . (RN8)
Another overwhelming consequence of the earth-
quake was its impact on parents and children as a
family unit. One particular woman’s family was
broken by the earthquake:
We took care of another woman who was on our ward
because she, she had given birth . . . it’s a newborn baby
and she was not bonding with the baby because what
had happened was during . . . the quake . . . she was
9-months pregnant and . . . she had dug through the
rubble to find her children and her husband. She
came across each of her children, each of her dead chil-
dren, . . . she dug them out. (RN4)
Theme 2: Professional compromises and
unsettling results
There were severe limitations of supplies and medi-
cations, personnel, referral sources, and a range of
other resources throughout the healthcare sites in
Haiti. For the nurses caring for children, there were
additional child-specific needs that made the prob-
lems even more acute. Children need smaller sizes of
certain equipment, such as nebulizer masks and
intubation materials. They often need liquid medi-
cines and syringes or small cups to properly dispense
medications. Pediatric expertise that helps ensure
optimum care to children was another area of unmet
need. Infants and children are more fragile in
247
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
general, which made them more vulnerable to mal-
nutrition and dehydration. Nurses reported that the
lack of proper pediatric resources oftentimes pushed
them to find creative solutions to health manage-
ment problems.
Pediatric nurses described how they were not able
to use some of the available medicines confidently
because many pills were not scored to be accurately
broken into child-size doses. They lacked small
syringes that could be used to effectively hydrate a
severely ill infant; they lacked IV fluids and lines.
Limited supplies resulted in grim consequences for
children and very unsettled nurses. One ER nurse
explained: “What bothered me a lot is knowing that
the little 6-month-old baby could’ve survived if we
just had suctioning . . . small things like that that
you can’t help but, what bothers me the most is you
couldn’t do anything about it” (RN7). One nurse in
primary care explained the difficulties of caring for
a young boy who was wheezing and short of
breath: “There weren’t spacers or anything like
that . . . there was no electricity so we couldn’t set
up a nebulizer machine or anything like that” (RN1).
She cut a hole in the bottom of a plastic water bottle
to make a spacer for a metered dose inhaler. Later,
when the boy felt better, she was conflicted about his
discharge medicines: “I felt really awful sending him
home . . . just knowing that he had such a terrible
asthmatic exacerbation and I had no medication
other than steroids so I decided to . . . send him
home with an inhaler . . . [but] it’s the only one that
I had.” She worried about what to do when the next
child arrived with wheezing and she had no more
inhalers. She mused: “It was just tough sending kids
home knowing they didn’t have the medication
they needed.” A community clinic pediatric nurse
practitioner (PNP) discussed the serious limitation of
medicines: “You had medicines that really weren’t
what you would use or what you want to use, but if
they were close enough you would give it a shot
because it was that or nothing” (RN2). Substitutions
and trial and error were strategies that the nurses
used but were not completely comfortable with.
Even more basic than the lack of medicines and
supplies was the dramatic shortage of clean water
needed to reconstitute pediatric suspensions and
containers to put the medicine in. One PNP needed
to dispense medications after the clinic ran out of
water for mixing them so he had to explain to the
parents how to go home and mix the medicines with
clean water. “They would look at me and say well, I
don’t know where we can get any clean water. And
I’d say I understand, all I can say is if you can possibly
248
E. Sloand et al.
try somehow or find somebody and tell them you’ve
got this medicine, we don’t have any more water, we
don’t have any here now, so if there’s somewhere
you can find some . . .” (RN2). Nurses developed
treatment plans that parents were not likely to be
able to carry out, which was troubling because it is so
contradictory to nursing standards of practice. The
same PNP needed to give antibiotics to a mother for
her three children. The only containers available in
clinic were small paper cups, but he knew that using
those cups was a totally flawed solution: “I’m trying
to figure out . . . how she’s gonna walk out of there
carrying 4 or 5 Dixie cups with liquid medicine in
them that she’s supposed to give to these kids 2 or 3
times a day for the next 10 days.” He explained that
she was likely returning to a home that consisted of
four branches stuck in dirt and propping up a tarp or
old sheet; there are no chairs, counters, refrigera-
tors, or really anyplace to put the medicines. Time
and again, the nurses explained that their best avail-
able solution was woefully inadequate and that
really bothered them.
Children are different; they need caretakers, and it
was often not obvious who those caretakers would
be. A hospital-ship nurse found that the lack of reli-
able rehabilitative care for these seriously injured
children posed an ethical dilemma for her. At the
same time, she did not have the ability to improve
the situation. When she described discharging chil-
dren from the hospital ship, she noted: “Some of the
ethical issues I think that arose were in relation
to . . . where they were going to go or how they
were going to be taken care of afterwards and I just
felt very torn when they were taking some of these
kids to land . . . but at the same time, I don’t know
what else could have been done, it—was just a very
difficult situation . . . you just wished you could give
them all the resources that they needed” (RN4).
Professional pediatric nursing and medical exper-
tise were a critical resource that was lacking. Deci-
sions about the care of individual children were
affected. A hospital-based RN remembered a difficult
situation where a girl had continuous seizures, and
the whole team deliberated about whether to intu-
bate her or not. Unfortunately, they did not have
any pediatric nurses working in the intensive care
unit (ICU) that day and night, so they eventually
decided that intubation was not a viable option
because there would be no one to care for her on the
ventilator. Making this decision greatly diminished
the girl’s chance for survival. Later, the same nurse
reports being the only nurse working night shift in
the neonatal ICU with six babies who needed feed-
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
E. Sloand et al. Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
ings every three hours, which was impossible for her
to do. Her best solution was creative: she recruited
other volunteer physicians and nurses who were not
scheduled to work that night and showed them
what to do as she supervised. As a pediatric nurse,
she was often moved to work during her time off:
“. . . we would wander around to the hospital tent
side . . . to the pediatric tent . . . to see if they
needed any help because a lot . . . of the nurses
there had no peds experience . . . and then [I] just
waited for day shift to come” (RN3). Knowing there
was a lack of pediatric proficiency, she helped out
until her scheduled shift began. Lack of pediatric
expertise also affected the ethical decision-making of
the nurse who cared for a severely dehydrated
infant; if there were more personnel to care for the
children at the clinic, he could have spent much
more time with the infant and mother rehydrating.
But instead he reluctantly chose to move on to
the other children. Time and time again, nurses
described how the limited pediatric expertise caused
them to be creative and sometimes give more com-
promised care than they would have wanted.
Theme 3: Universality of children
Children have characteristics and behaviors that are
universal. Regardless of the circumstances that they
find themselves in, children laugh, play, hug, give
love, and seek security. Pediatric nurses expect
these behaviors in hospital units and health centers
in the United States. The nurse volunteers in Haiti,
however, seemed surprised that these same traits
and behaviors were true for the children in Haiti
after the earthquake. Some nurses worked in out-
patient clinics and cared for children who suffered
the losses of parents, home, school, siblings, regular
routines, and a stable environment. Others worked
in acute hospital settings and cared for children
who suffered life-threatening injuries in addition to
the losses of parents, home, school, siblings, regular
routines, and a stable environment. Time after
time, the nurse volunteers found that the children
had a ready smile or a hug for them in spite of their
circumstances.
Nurses commented on the resilience of the Haitian
people, but it seemed to be even more pronounced
with respect to children. One nurse, working the
pediatric ward at PAP hospital, asserted: “. . . that’s
why I like pediatrics because the kids . . . have such
resilience anyways anywhere . . . it doesn’t matter
what country or . . . where they come from, kids are
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
the same, they bounce back, they love, . . . they
have so much life you know, [they] want to live and
experience” (RN3).
When talking about the children, some nurses
specifically used the word “love.” One nurse dis-
cussed the severely injured children she cared for on
the hospital ship, including those with multiple
amputations and serious crush injuries to the face
and extremities, and said:
“I think what really, really touched me though is that
they were so loving still, and . . . we would reach out to
them and they were scared—but at the same time, it’s
like love took a language all its own . . . they were able
to feel the love. . . .” (RN4)
The same nurse talked of love as a communication
vehicle that broke the language barrier, which was
critical because the children spoke Haitian Creole
and translators were not always available. She was
describing the language barrier as one of her biggest
challenges given the importance of talking with chil-
dren on their level to comfort them and calm them,
but added: “. . . just being able to hold them . . . I
was always walking around with a child in my
arms or a child holding onto me and . . . that com-
fort, . . . that physical touch, just the love. . . . It has
a language that surpasses any other language, so we
were able to communicate. . . .” (RN4)
Children are ready to play if they have the oppor-
tunity. They will play with toys or they will make up
games with or without toys. While this is not surpris-
ing to anyone who interacts with children, it is stun-
ning that these traits persist against the backdrop
of devastation in post-earthquake Haiti. The
community-based PNP who was caring for a child
suffering a severe asthma attack had very little treat-
ment capacity, and the best she could do was give
two puffs of a beta-adrenergic inhaler every few
minutes. She explained:
“I had him sitting in the corner of the clinic . . . and
between every patient I would go over there to give him
a couple more puffs. I gave him a piece of paper and a
crayon and every time I went over there I would give
him a different color crayon and I remember after about
30 minutes . . . he was standing right there next to me
holding up this picture and gave it to me and I still have
it so it was all the different colors you can see like where
he added new colors in and it was just really cool.”
(RN1)
Scenes in Haiti were reminiscent of scenes in any
pediatric setting, including the way children run and
249
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
jump and climb around even if it is a small office or a
hospital room. One nurse reported: “. . . there’s one
little girl with . . . hepatitis A who had you know
eyeballs the color of this saucer and happy and
playing and running around, climbing into my lap,
crawling on me” (RN10).
In addition to love, play was another way that
nurses addressed the language barrier with the chil-
dren. An acute care nurse was working with a girl
who put a battery in her nose, which is a universal
pediatric situation in itself. She explains:
“. . . we spent a lot of time with her, we had some ENT
nurse practitioners that were there to . . . help get that
out . . . just being able to play with her even though
there was the language barrier, and give her stickers and
colors and stuff, . . . and seeing how much her mom was
enjoying spending time with her while she had all these
toys and stuff . . . that was fun.” (RN6)
Children in Haiti were like children encountered
anywhere in the world, with a resilient fiber that is
part of them. One of the community-based nurses
reflected: “Kids are incredibly resilient and I think
it’s become such a cliché—they talk about resiliency
of the Haitian people but these kids were remark-
able.” Later, she mused: “I don’t know that I saw a
little kid that didn’t crawl in my lap or give me a hug
or run around and play or beam when I gave them a
sticker so, these kids just are remarkable” (RN10).
Theme 4: The highs were higher and the lows were
lower: Emotional impact of disaster relief on
nurse volunteers
When asked to describe their experience in Haiti,
the nurses presented a wide range of emotional
responses. RN4 said, “We are all human. We all share
this common human experience.” Observing the
enormous loss and tragedy, the nurses were over-
whelmed with emotion.
Those kids, I’ll never forget them, they just will always
be on my, on my heart. (RN4)
I mean it was so many just wonderful, beautiful kids. I
don’t know that there was one more than any other that
grabbed your heart. There was one an hour that grabbed
your heart. (RN10)
Because of their great affection for children, how-
ever, seeing disaster’s devastating impact on them
triggered and magnified emotional reactions related
to feelings of uncertainty. The nurse volunteers
labeled the reality of their work as mind-boggling,
250
E. Sloand et al.
difficult, heartbreaking, and frustrating. On one
hand, these emotions appeared to stem from these
nurses’ uncertainty about whether they made the
right decisions and practiced to their fullest capabili-
ties despite the resource restraints. Many nurses
reported that if only they had more resources, be it
human capital, supplies, medications, or equipment,
many problems and deaths could have been resolved
or prevented. Even upon returning to the United
States, many nurses said those were the moments
that they remember and think about, as one
explained:
Most of the cases that stick in my mind are cases where
you kind of say, “Did I do everything that I
could’ve . . . ?” . . . that was part of taking care of
people in Haiti, was saying, “You know, this is not
ideal . . . am I making the right call?” (RN5)
As a result, the resource restraints and uncertainty
in their practices fostered a sense of hopelessness
among these nurses, as one PNP recalled, “You’re
almost helpless sometimes to help some of these
folks who have absolutely nothing” (RN2). Further,
the nurses also showed a resigned attitude because
they were simply not in control, as RN2 continued:
You try to do anything you possibly can to provide some
relief and such . . . I can tell you what, I just saw 2,000
kids in the last 16 days. I don’t think I hurt one of
them . . . maybe I helped some of them. (RN2)
On the other hand, the nurses’ emotions stemmed
from the worry and uncertainty they had for Haiti’s
children, particularly those who were severely
injured and/or orphaned. After the earthquake,
many children were displaced and their futures
were largely unknown, as a nurse who worked on
the Navy ship described:
I was just so sad and scared because I didn’t know what
would happen to them and just knowing what was out
there . . . you see these kids with just broken limbs and
amputated, amputated their limbs and you wonder how
they’re gonna survive in this environment. . . . where
they were gonna go or how they were gonna be taken
care of afterwards and I just felt, I felt very torn, when
they were taking some of these kids to land. (RN4)
Seeing the dim and uncertain future that Haiti’s
children faced, many of the nurses also reported that
parting with them was one of the toughest experi-
ences they have ever had. Some joked about wishing
they could take the children home with them. RN7,
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E. Sloand et al. Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
who worked in the ER for 16 days, had a particularly
heartfelt experience saying goodbye to a 12-year-old
boy:
This little kid that I met there . . . he lost his family and
he messed up his foot real bad and he came back and I
hooked him up with some crutches and all that
stuff . . . The last words he said to me was like, “Can I go
with you?” I was like crying like a little baby and just go
get on that helicopter and it’s like, why can’t we stay
longer? Very mentally and emotionally [and] . . . physi-
cally challenging. (RN7)
Despite the heavy emotional toll, the nurses
asserted an overall positive outlook. In fact, many
reported that working in Haiti was a life-changing
experience for the better. For one nurse in particular,
it served as the motivation for her to return to school
and pursue a higher degree, as she recalled:
I remember this one little kid, we brought him up to the
operating room and we put him under general sedation
to change all the dressings for all his amputations
and . . . you know, that’s one of the reasons I wanted
to become a nurse anesthetist . . . it was actually
that impetus that drove me to . . . apply to these pro-
grams . . . it was so powerful. (RN4)
In examining the themes overall, it was clear that
the nurses had a powerful experience professionally
and personally. They were deeply touched by the
children they cared for. They sometimes felt very
unsettled by the compromised care that they often
had to give the children, but still recognized the
common threads of caring for children regardless of
circumstances.
DISCUSSION
The findings of this study are consistent with much of
the literature, which details both a domestic and
international shortage of pediatric expertise during
disasters and crises. One scientific study of military
nurses explored the nursing practice challenges
encountered by Navy nurses responding to the
humanitarian crises after the Indian Ocean tsunami
in 2004 (Almonte, 2009). The nurses unanimously
felt unprepared to care for children in the disaster and
particularly challenged in dealing with child and
infant deaths. A similar study of military nurses
looked at nursing challenges in several worldwide
locations, including Afghanistan, Honduras, Iraq,
and Bosnia (Agazio, 2010). The investigators found
that children presented special challenges to the
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
Army nurses because they were generally unpre-
pared to care for children and did not have the proper
supplies and medicines. Nurses reported creative
strategies they used when adapting equipment,
similar to the nurses in our study. Interestingly, Farfel
and colleagues (2011) reported on the field hospital
in PAP and noted the need for pediatricians with
intensive care and surgical skills, but they do not
mention the need for pediatric nurses, which seems a
huge oversight given the essential contributions of
nurses in a hospital setting.
Nurses in prior studies have also reported ethical
dilemmas related to limited supplies. Agazio (2010)
found that Army nurses had limited supplies and
questioned themselves about how many supplies to
use and reuse because they were not sure when the
next shipment would be and what casualties they
might encounter before then. On the other hand,
Almonte (2009) found that nurses felt anguished
and ethically conflicted due to their limitations in
what they could do and how long they could stay at
a site to help. They felt overwhelmed about giving
treatment to some knowing that there were so many
more who would not receive treatment, and they
had to consciously think about the good they were
able to accomplish in order to live with the memory
of the many they could not help. Similarly, the find-
ings of this study are consistent with the many anec-
dotal reports of nurses who volunteered in Haiti.
Nurses reported serious shortages of essential sup-
plies, such as antibiotics, antiseptics, iodine, tetanus
vaccine, numbing agents, gauze, and fuel for gen-
erators (Adams, 2010; Amundson et al., 2010;
Etienne, Powell, & Faux, 2010; Lau, 2010; Merin,
Ash, Levy, Schwaber, & Kreiss, 2010; Pierre-Pierre,
2010; Vanholder, Gibney, Luyckx, & Sever, 2010).
Similar to our study, one report noted the ethical
challenges that arose from providing care under
severe circumstances where it was impossible to
triage everyone seeking care (Merin et al., 2010).
Due to a high demand and high patient turnover,
many in the steady stream of acutely ill patients
were admitted, treated, and discharged almost
immediately and well before complete recovery,
which was very difficult for many of the healthcare
workers (Merin et al., 2010). Again, this is consis-
tent with our study findings.
Reporting positive experiences of nurse volunteers
is unusual in the scientific literature regarding
humanitarian health workers. Researchers mostly
report on the challenges and difficulties that nurses
encounter (Agazio, 2010; Almonte, 2009). One
exception is the study of New Zealand nurses who
251
Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake E. Sloand et al.

reported the overwhelming need they encountered of nurses caring for children in disasters. Systemic
in humanitarian work, and despite the minimalist documentation of nurse volunteer needs and condi-
treatment that they could provide, many children did tions could lead to the development of a preparation
heal (Zinsli & Smythe, 2009). They described emo- program or orientation for nurses who choose to
tional aspects of their service, and that pain and suf- respond to the call for volunteers in disasters. Such an
fering and love were all part of their experiences orientation should include a clear picture of the chil-
while volunteering (Zinsli & Smythe, 2009). They dren’s grim and difficult situations that will likely be
noted the joy they experienced when working with found, and the more limited capacity to help and “fix”
children in the midst of all the hardship, which was problems than most nurses would ordinarily have.
reflected in our study. In anecdotal accounts, some Humanitarian agencies ought to incorporate some
healthcare providers described the positive aspects of sort of support system for volunteer nurses when
their experiences. Nurses discussed developing cre- they return home.
ative solutions in a resource-poor environment,
including tying IV bags to trees, using branches as
splints, and creating traction using bricks from col-
lapsed buildings (Millender, 2010). One nurse hoped How might this information affect
to retain this creativity when she returned to her ER nursing practice?
job (Lau, 2010).
Skilled pediatric nurses will be needed in future
emergency humanitarian missions; the study
Limitations authors encourage them to respond when called
upon. Children will inadvertently be involved in
The nurses who participated in the study were not
disasters, and they are best cared for by those with
asked specific information about caring for infants
pediatric expertise. Nurses will likely find volun-
and children. Richer data might have been gener-
teering to be both professionally and personally
ated if such questions had been included in the inter-
rewarding. While some nurses may be concerned
view guide. Some of the interviews were conducted
about some of the difficulties and challenges of
by phone when an in-person interview was not pos-
working in a humanitarian crisis, they will also
sible, which may have affected the data collected.
encounter uplifting and joyful times when caring
Member checking, which is considered to be one of
for children. Some nurses may also feel uncertainty
the most robust ways to assure credibility, was not
about what they can contribute, but this study sug-
done. This may have strengthened the rigor of this
gests that the holistic, personalized care that is
study, although it is controversial and some experts
central to the nursing process will insure their
believe that the drawbacks of member checking
effectiveness and ability to make a difference for
limit its usefulness (Angen, 2010; McBrien, 2008).
the children and families they care for. Potential
Another limitation is the lack of transferability of
nurse volunteers, whether pediatric nurses or not,
results due to the small sample size and large varia-
should be prepared for ethical issues and related
tion in participant characteristics.
decision-making. They can also expect resources to
be limited and are advised to regularly schedule
PRACTICE AND RESEARCH IMPLICATIONS therapeutic debriefing during deployment and
upon return home. Nurses can also consider frame-
Because children require special care, they are one of
works for continuous quality improvement during
the most vulnerable groups in a crisis situation. There
deployment to facilitate the best care of children in
is a shortage of pediatric-experienced nurses serving
disasters. Nurse administrators and volunteers can
in postdisaster situations (Agazio, 2010; Almonte,
raise the awareness of humanitarian agencies
2009). As we plan for the next large-scale humanitar-
regarding child-specific needs, and such agencies
ian crisis, nurses must be prepared to address the
should be fully ready to care for children in a disas-
unique and specific needs of children. Humanitarian
ter situation. Further, humanitarian agencies
agencies must call upon nurses with pediatric exper-
should consider allocating or increasing the medi-
tise to improve the care that children receive in such
cations and supplies reserved for children so that
circumstances. Continued research on children and
nurses serving in crisis situations will have the
disasters would improve the outcomes of children
minimum necessary resources to care for their
suffering in humanitarian crises. A large quantitative
pediatric patients.
study would be helpful in further defining the needs

252 Journal for Specialists in Pediatric Nursing 17 (2012) 242–253

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 E. Sloand et al. Nursing Children After a Disaster: A Qualitative Study of Nurse Volunteers and Children After the Haiti Earthquake
References
Adams, P. (2010). Relief agencies prepare for long haul
in Haiti. Lancet, 375, 539. doi:10.1016/S0140-
6736(10)60212-7
Agazio, J. (2010). Army nursing practice challenges in
humanitarian and wartime missions. International
Journal of Nursing Practice, 16(2), 166–175. doi:10.1111/
j.1440-172X.2010.01826.x
Almonte, A. L. (2009). Humanitarian nursing challenges:
A grounded theory study. Military Medicine, 174(5),
479–485.
Amundson, D., Dadekian, G., Gleeson, T., Hicks, T., Killian,
D., Kratovil, K., . . . Miller, E. J. (2010). Practicing
internal medicine onboard the USNS comfort in the
aftermath of the Haitian earthquake. Annals of Internal
Medicine, 152(11), 733–737.
Angen, M. J. (2010). Evaluating interpretive inquiry:
Reviewing the validity debate and opening the dialogue.
Qualitative Health Research, 10(3), 378–395. doi:10.1177/
104973230001000308
Burnweit, C., & Stylianos, S. (2011). Disaster response in a
pediatric field hospital: Lessons learned in Haiti. Journal
of Pediatric Surgery, 46(6), 1131–1139. doi:10.1016/j.
jpedsurg.2011.03.042
Centers for Disease Control and Prevention. (2010). Post-
earthquake injuries treated at a field hospital—Haiti,
2010. Morbidity and Mortality Weekly Report, 59, 1673–1677.
Central Intelligence Agency. (2011). The world factbook:
Haiti. Retrieved September 12, 2011 from https://www.
cia.gov/library/publications/the-world-factbook/geos/
ha.html
Corbin, J., & Strauss, A. (2008). Basics of qualitative research
(3rd ed.). Los Angeles: Sage.
Deckelbaum, D. L. (2010). The Haiti earthquake: A
personal perspective. Canadian Medical Association
Journal, 182(5), E241–E242.
Etienne, M., Powell, C., & Faux, B. (2010). Disaster relief
in Haiti: A perspective from neurologists on the USNS
comfort. Lancet Neurology, 9(5), 461–463. doi:10.1016/
S1474-4422(10)70091-0
Fallat, M. (2009). The impact of data on the pediatric
trauma and critical care research agenda. Journal of
Trauma, 67(2), S106–S107.
Farfel, A., Assa, A., Amir, I., Bader, T., Bartel, C., Kreiss, Y., &
Saqi, R. (2011). Haiti earthquake 2010: A field hospital
pediatric perspective. European Journal of Pediatrics,
170(4), 519–525. doi:10.1007/s00431-011-1423-8
Goodman, A. (2010). Ministry of touch—Reflections on
disaster work after the Haitian earthquake. New England
Journal of Medicine, 362(11), e37(1 –2). doi:10.1056/
NEJMp1002311
Huffman, J. (2011). Surgical palliative care in Haiti. Surgical
Clinics of North America, 91(2), 445–457. doi:10.1016/
j.suc.2011.01.001
Journal for Specialists in Pediatric Nursing 17 (2012) 242–253
© 2012, Wiley Periodicals, Inc.
View publication stats
La Greca, A. M., Silverman, W. K., Vernberg, E. M., &
Roberts, M. C. (2002). Helping children cope with disasters.
Washington, DC: American Psychological Association.
Lau, D. (2010). Disaster relief: Helping the survivors of the
Haiti earthquake. Emergency Nurse, 17(10), 18–21.
Lincoln, Y. S., & Guba, E. G. (1986). But is it rigorous?
Trustworthiness and authenticity in naturalistic
evaluation. New Directions for Program Evaluation,
1986(30), 73–84.
McBrien, B. (2008). Evidence-based care: Enhancing the
rigour of a qualitative study. British Journal of Nursing
(Mark Allen Publishing), 17(20), 1286–1289.
Merin, O., Ash, N., Levy, G., Schwaber, M. J., & Kreiss, Y.
(2010). The Israeli field hospital in Haiti—Ethical
dilemmas in early disaster response. New England Journal
of Medicine, 362, e38(1–3). doi:10.1056/NEJMp1001693
Millender, E. I. (2010). Haiti: A firsthand view. American
Journal of Nursing, 110(4), 22. doi:10.1097/01.NAJ.
0000370153.02729.29
National Association of Pediatric Nurse Practitioners.
(2011). Pediatric nurse practitioners’ role in disasters
involving children. Journal of Pediatric Health Care, 25,
9A–10A.
National Commission on Children and Disasters. (2010).
Report to the President and Congress. (AHRQ Publication No.
10-M037). Retrieved from http://cybercemetery.unt.
edu/archive/nccd/20110426214356/http://www.acf.
hhs.gov/ohsepr/nccdreport/index.html
Patton, M. Q. (1990). Qualitative evaluation and research
methods. London: Sage.
Pierre-Pierre, G. (2010). Going all out for Haiti. Nursing
Standard, 24(25), 18–19.
Sandelowski, M. (2010). What’s in a name? Qualitative
description revisited. Research in Nursing and Health, 33,
77–84. doi:10.1002/nur.20362
Stratton, S. J. (2010). Surge capacity implications and
geographic maldistribution of pediatric medical
resources in Seattle-King County. Prehospital and Disaster
Medicine, 25(3), 333–334.
Thomas, E., & Magilvy, J. K. (2011). Qualitative rigor or
research validity in qualitative research. Journal for
Specialists in Pediatric Nursing, 16, 151–155. doi:10.1111/
j.1744-6155.2011.00283.x
U.S. Geological Survey. (2011). Magnitude 7.0—Haiti
region. Retrieved from http://earthquake.usgs.gov/
earthquakes/recenteqsww/Quakes/us2010rja6.
php#summary
Vanholder, R., Gibney, N., Luyckx, V. A., & Sever, M. S.
(2010). Renal disaster relief task force in Haiti
earthquake. Lancet, 375, 1162–1163. doi:10.1016/
S0140-6736(10)60513-2
Zinsli, G., & Smythe, E. A. (2009). International
humanitarian nursing work: Facing difference and
embracing sameness. Journal of Transcultural Nursing, 20,
234–241. doi:10.1177/1043659608330351
253