MILITARY MEDICINE, 174. 5:479, 2009

Humanitarian Nursing Challenges: A GroundedTheory Study

CDR Angelica LC. Almonte, NC USN

ABSTRACT In response to the 2004 tsunami disaster in the Indian Ocean, the U.S. Navy deployed teams aboardthe USNS Mercy to provide aid during Operation Unified Assistatice (OUA). To date, few research .'iiiidies have exam-ined how Navy nurses prepared for and clinically performed during this relief operation. The current article describestbe challenges faced by Navy nurses throughotit QUA. A purposive convenience sample was recruited; 11 participated.Data were collected from interviews, observalions, field notes, memos, and a demographic tool. Information was cat-egorized, coded, compared to incoming dala, then analyzed using .Strauss and Corbin's open coditig. axial coding, andselective coding methods. A (heoretical model was developed lo illustrate how participants experienced ihe mission.Key lessons learned were Ihat most were unprepared lor providing pedialric care, and saying "No" in delivering care.Recommendations include: deployment of advanced-practice nurses (specialists in pediatrics and well-mental health)and predeployment training on moral distress.

INTRODUCTIONMt)re than ever before, a "marked increase in the number ofnatural disasters (Hoods, droughts, earthquakes, hurricanes),along withgreater levels of loss of life, property, and materialdamage'" is apparent.' Damages associated with these types ofcatastrophes are worsened when tragedy hits underdevelopedcountries with dense populations that are already precariouslyvulnerable and burdened with extreme poverty, environmen-tal degradation, less developed infrastructure, and inadequateemergency preparedness.'

The U.S. military has routinely played a major rolein humanitarian assistance efforts throughout the world.

Nursing Research & Analysis, Naval Medical Center San Diego. BIdg 6.Deck 4. 34800 Bob Wilson Drive. San Diego. CA 92134.

Previous pre.scntations: ( 1 ) Poster presentation and ribbon winner al theKaren Rieder Research/Federal Nursing Poster Session during AMSUS atS;ill Lake City. UT. Title: "Humanitarian Nursing Challenges: A GroundedTheory Research ,Sludy on Navy Nurses" Expériences."

(2) Podium presentation at the 2007 Annual American Academy ofAmbulatory Care Nursing's Conference in Las Vegas. NV on March 29-ApHI 2. 2()O7. Title: "A Research Study: Navy Nurses' Experiences in aTsunami Relief & Huniiinitariiin Mis.sion."

^^) Poster display at the 22nd Annual .Academic Research Competiticm.Naval Medical Center San Diego in San Diego, CA on April 12 and 13, 2007.Tille: "Navy Nurses' Hxperiences in Tsunami Disaster Relief: A GroundedTheory Research Study—Preliminary Results" (2nd display).

l4) Poster prescntalion and ribbiin winner at the 20lh Annual PacificNursing Research Conference in Honolulu. Hawaii un March 22-24. 2007.Title: "Navy Nurses' Experiences in Tsunami Disaster Relief: A GroundedTheory Research Study—Final Results."

(5) Poster presentation and ribbon winner at the 2(X)6 Sigma Theta TauInlemational Honor Society Nursing Ody.sscy Conference in Ontario. CAon October 2(i and 27. 2006. Title: '"Navy Nurses' Experiences in TsunamiDi.sasler Relief: A Grounded Theory Research Study—Preliminary Results."

The views expressed in this article are those of the author and do noi reflectthe official policy or position of the Department of the Navy. Department ofDefen.'ie. or the United States Government.

This manuseripi wa.s received for review in May 2008. The revisedmanuscripl was accepted for publication in February .'Í

According to the 2001 Joint Chiefs of Staff publication, "JointTactics, Techniques and Procedures for Foreign Human-itarian Assistance." the purpose of our foreign humanitarianassistance is to "relieve or reduce the results of natural or man-made disasters or other endemic conditions, such as humansuffering, disease, or privation that might present a seriousthreat to life or that can result in great damage to or loss ofproperty."- Because our military is uniquely equipped andstructured and is trained to rapidly respond, it has a long, proudtradition of providing disaster relief assistance overseas. Withan eye on the future, the Chairman of the Joint Chiefs of Staff(CJCS), in his guidance for 2007-2008, articulated his priori-ties and strategic objectives. To meet the precedence of prop-erly balancing global strategic risk, he directed that we buildrelationships through Theater Security Cooperation and locuson capacity building, humanitarian assistance, frameworks forimproving governance, and cooperation in enforcing the ruleof law. Aligned with the CJCS" guidance, the Chief of NavalOperations' plan for the upcoming year recognizes that to bethe global preeminent maritime force, the Navy will conducta spectrutn of operations ranging from combat to humanitar-ian assistance.^ The U.S. Navy Medicine team has a distin-guished history and promising future of supporting this rangeof operations, and as part of this team. Navy Nurse Corps ofti-cers are deployed to serve in various operational and humani-tarian theaters.^ In her address to the Senate AppropriationsCommittee in March 2007, the Director of the Navy NurseCorps. Admiral Bruzek-Kohler. discussed the military rele-vance of Navy nurses in caring for the citizens of the worldthrough humanitarian missions. She proudly highlighted thatwhen Navy nurses engage in humaniiarian missions, theyreflect America's generosity, compassion, and goodwill.''

To prepare for future military humanitarian missions.Navy nurses and other authorized personnel will likely titin toresources and lessons learned from past humanitarian assistanceand disaster relief missions. Although il is clear that military

MILITARY MEDICINE. Vol. 174. May 2009 479

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Humanitarian Nursing Challenges

nurses will be among the first responders in prospective disas-ters, recent research shows that military nurses are not alwayscertain of "how to access previous after-action reports for reviewand use in improving training."'' Accounts by milit;iry nursesshow that the content of such after-action reports are believedfo be positively skewed and rarely contain items related tonursing practice and that they specifically lack "detailed infor-mation on nursing practice, training, leadership, logistics, com-munication, supply systems, and psychological issues [that]would be helpful for nurses to improve pertormance."^

Today, when preparing for humanitarian deployments,military nurses are able to turn to readily available informa-tion in such peer-reviewed journals as Militan' Medicine andthe Joint Center for Operational Analysis Journal, both ofwhich dedicated entire issues in the past year to medical les-sons learned during natural disaster relief operations. MilitaryMedicine \s 2006 October supplement focuses on anecdotal les-sons learned from the 2004 tsunami, mostly by exploring reliefeffoils aboard the hospital ship USNS Mercy during OperationUnified Assistance (OUA); a narrative is provided by LCDRPryor, a U.S. Public Health Service nurse.' RN Yates, a ProjectHope volunfeer. describes humanitarian nursing efforts aboardthe USNS Mercy during OUA in the 2005 issue of MedsurgNursing: official journal of the American Academy of Medical-Surgical Nurses.^ An extensive review of the literature revealsthaf scholarly research on military nurses" experiences inhumanitarian assistance and disaster relief is relatively scarcewhen compared to the wide variety of reports found on the roleof the military nurse in combal situations. Moreover, experi-ences of Navy nurses during OUA aboard the USNS Mercyhave not been explored, analyzed, or described from a researchperspective. Few studies have examined natural disaster reliefefforts and humanitarian assistance efforts from a nursing per-spective, and even fewer have examined nurses' experiences,preparation, practice, and collaboration required to providecompetent care to the disaster stricken. Although U.S. mili-tary nurses have long participated in humanitarian missions.the paucity in the availability of publicly accessible research intbis area supports the need for such a study.

As a positive step toward filling a knowledge gap. the authoradds to the literature by examining how Navy nurses prepared,trained, performed, and worked with nurses from a nongovern-mental organization (NGO) aboard the USNS Mercy duringOUA. This article provides a description of the humanitariannursing challenges faced by the study's participants.

Significance and AimsThe impact of the most powerful earthquake that eruptedbeneath the Indian Ocean on December 26. 2(M)4 cannot beunderstated; the event triggered a deadly tsunami that dev-astated 11 Asian and African countries and killed more than280,000 people, displaced over I million, and affected thelives of nearly 5 million more.' Unprecedented media cover-age prompted what many consider the largest global human-itarian effort of our generation.'" The U.S. Navy responded

by providing humanitarian aid through Operation UnitedAssistance. In a historic "first" on the hospital ship USNSMercy, the U.S. Navy deployed a team consisting of mem-bers from the Navy, the U.S Public Health Service, the ProjectHope (a nongovernmental organization), and a civilian mari-ner crew to provide aid,"

OUA aboard the USNS Mercy included four missionswithin a 5-month deployment: tsunami disaster relief in BandaAche; humanitarian assistance in Alor Indonesia and Dili. EastTimor; earthquake disaster relief on Nias Island; and humani-tarian assistance in Papau New Guinea. The objectives of tbisresearch study were: {1 ) to explain U.S. Navy nurses" experi-ences during OUA—how they prepared, clinically performed,and worked with nongovernmental organization nurses and(2) to construct a grounded theory.

Navy nurses" experiences in OUA aboard the USNS Mercyis significant because the scope of the deployment was unprec-edented, and the historic joint mission was nol the last of itskind. Since 2005, subsequent collaborative efforts were madeamong Navy. NGOs, and federal services nurses aboard theUSNS Mercy. USNS Comfort. USS Pellilieu. USS Boxer,and USS Kearsarge during 2006. 2{X)7. and 2008 humanitar-ian aid voyages. This research study's added knowledge basewill be of benefit to the global community of nurses becauseit has potential to inform and improve future worldwide reliefefforts aboard U.S. Navy hospital ships and other platformsacross many disciplines.

METHODS

DesignA descriptive qualitative design using a grounded theoryapproach was used to study the experiences of Navy nursesduring disaster relief and humanitarian missions aboard a hos-pital ship. Because the OUA nursing phenomenon was rei*atively unknown at the time, grounded theory methodok)gypresented as an ideal model, as it makes great contributionsto knowledge in an area where little research has been done.'-lnstitutional Review Board approval was received beforestudy commencement. All participants gave informed consentand were requested not to share identifying information dur-ing the interviews.

Sample and ParticipantsTwenty-live to 30 U.S. Navy nurses were on hoard the hospi-tal ship at any given time, participating in various phases ofthe mission. Eligibility criteria for inclusion in this study wereactive duty Navy nurses who had deployed aboard the USNSMercy during any part of the OUA mission, who were willingto participate in the study, and who were able to recall and talkabout experiences aboard the USNS Mercy for any portion ofthe OUA deployment.

Purposeful strategies for the selection of participantswere employed. A convenience sample of Navy nurses was

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TABLE Patient Demographics

Number of Nurses

GenderFemaleMale

Age Uliiring OUA)Rank (durinj; OUA)Deployment Days

65

11ItII

Range

23-51ÜI-Ü534-155

Mean

38.103

129

recruited through posted and emailed advertisements, as wellas by word of mouth referrals.

Eleven Navy nurses consented to participate in the researchstudy, Participants spent an average of 122 days deployedaboard ihe USNS Mercy, with a range of 34 to 155 days. Table Ishows participant demographics. Details of the primary clini-cal roles during the deployment are shown in Figure 1.

Data CollectionThe research study's plan entailed the simultaneous collection,organization, and analysis of data and results in a theoreticalformulation of the experiences being explored per groundedtheory methodology.'-" A premise of nursing experiences,clinical practices, clinical preparation, and iiiteragency collabo-ration involved in a humanitarian assistance and disaster reliefmission aboard a hospital ship was developed through analysisoí transcripts of tape-recorded interviews fface-to-face and tele-phone conversations) and other contributing data (observations,held notes, and memos). Table II lists interview questions andresponse prompts used by the principle investigator. Interviewstook place more than a year after the deployment's end.

Data were collected, coded, categorized, and compared toincoming data, as is fundamental to grounded theory's con-stant comparative method.'-'^ The study resulted in a theo-retical formulation of the experiences being explored. Datacollection continued until the theoretical ideas that hademerged from continuous analysis and theoretical samplingevolved into grounded theory.'^"

Data AnalysisStrauss and Corbin's methodology of open coding, axial cod-ing, and selective coding as conducted by the principle inves-tigator and verified by a research team of consultants was usedto analyze data. The principle investigator examined each lineof data to define and categorize information through open cod-ing, then focused on the participants' view of reality throughline-by-line coding." Resulting data were divided into seg-ments and re-examined for commonalities that reflected likecategories or themes. Once categorized, data were examinedfor properties such as specific attributes or subcategories.Throughout this process the constant comparative method,where cunent data are compared to incoming data, was uti-lized." Techniques included: analysis of words, phrases, orsentences; analysis through making comparisons; and the useof questions. In axial coding, the research team progressed

FIGURE 1. Primary clinical roles during ihe deployment.

to discussion of the interconnections between categories andsubcategories. The team collaborated in selective coding,focusing coding efforts, and discussing •"conditional matrixas an analytic diagram that maps the range of conditionsand consequences related to the phenomenon or category."'''Subsequently, a theory grounded in the participants' data,which explained the phenomenon studied through a vi.sualmodel, was formed. Several research team meetings were heldto review and verify the coded data, concepts and categories,and levels of abstraction of the developing theory. The theorythat emerged actually came from the prescribed analysis of thedata itself, "grounded" in the data collected and not taken froma priori research.

Three criteria were used to ensure the quality of the proposedinquiry: rigor, dependability, and credibility. Rigorwas addressedby the principle investigator who meticulously recorded everystep of the research process. Conscientious effoits were madeto keep a comprehensive audit trail. Memos kept during datacollection and data analysis were used during audit checks.A grounded theory mentor was consulted to perform and reviewthe research process as it unfolded and to ensure dependabilityof the findings. To ensure the resulting theory was empiricallygrounded in the data, credibility of the findings was achievedthrough "member checking." wherein participants were givenopportunities to review transcripts and validate that informationaccurately reflected their OUA experiences.

RESULTS

Grounded TheoryBeginning with the packing of seabags. readiness (definedthrough action and performance) emerged as the most

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TABLE II. List of Interview Questions and Prompts"

Question Probes

A. Tell me how you found out you had to deploy aboard the USNS Mercy.

B. Tell me about your experience during Operation Unified Assistanceaboard the USNS Mercy.

C. Tell me about the process by which you provided clinical nursing care.

D. Tell me about tbe process by which you worked with nurses fromProject Hope.

E. Tell me how OUA compared to other deployments you have experienced.F. Tell me how your OUA experiences have influenced your decision about

a career in the Navy.G. Looking back, if you could change one thing about your experience

during Operation Unified as.sistance. what would you change?H. Tell me about any issues encountered since your return from deployment.I. Is there anything else you would like to add about your

experiences that you bave not already included?J. What recommendations do you make for future disaster

relief/humanitarian deployments?K. What resciu-ch studies do you recommend

(clinical, policy, admin., training)?

—Tell about the process by which you prepared for OperationUnified Assistance aboard the USNS Mercy.

—Tell me about Ihe nature of your work role during OperationUnified Assistance aboard the USNS Mercy.

—Tell me what it was like lor you to be a military nurse duringOperation Unilied Assistance aboard the USNS Mercy.

(Training and Evidence-Ba.sed Practice)—Tell me how you provided nursing care on a daily basis.—Tell me about the puK'ess by which you prepared to pmvide clinical

care during O ieration Unilied Assistance aboard the USNS Mercy.—Tell me what il wa.s like lo provide nursing care.—Tell me what knowledge and skills were mosi helpful in providing

nursing care.—Tell me about experiences you were not prepared for.—Tell me what particular resources you wish you had.—Tell me about a difficult decision you had to make.—Tell me about a piuiicuhirly meaningful experience you had.—How did you tneasure success in providing clinical care?—How was it working with hospital corpsmen and MDs?— Tell me about what it was like working with the nurses from

an NGO.

"Interview questions changed as data were collected, focusing on emerging processes central to the phenomenon.

salient dimension and core category of this study. Thegrounded theory model illustrated liow Navy nurses expe-rienced this attribute during Operation Unified Assistancethrough the roles they played and the relationships theyencountered (Fig. 2). Adaptive mindsets, knovi'ledge, skillsets., and coping mechanisms contributed to mission readi-ness and proved signilicant in helping participants overcomechallenges faced during different phases of the operation.Readiness was influenced by each individual's ability to beprepared for each mission at hand. When prepared, partici-pants responded by navigating and negotiating their variousroles and relationships; this action led to optimized readi-ness, accomplishment, and contentment. When unprepared,participants found that unresolved reactions to circum-stances occurred, and that this led to distress, conflict, anddisconnectedness. As much as the participants attemptedto do their jobs well, some situations were loo difficult toprocess with their current skills and expertise. Although asmall number of participants reported helplessness in deal-ing with certain citcumstances, some found situations forwhich they were simply unprepared and were conseqtientlyunable to adjust, a cause for concern at more than 1 year

READINESS

FIGURE 2. Grounded theory of Navy nurses during OUA on the USNSMercy.

after the deployment. Throughout OUA deployment, nursesengaged in different jobs and relationships and continuedto encounter difficulties. Although the overall vision forthe mission was one of ambassadorship to "do good things"and "teach others how to fish," several overriding challenges

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were recognized by the participants while they were engag-ing in hunianitiirian nursing.

Experiences abourd the USNS Mercy during OperationUniHed Assistance were repeatedly described by participantsas "rewarding" and being a "highiight" of their Navy careers.Positive superlatives were consistently used. The mission wasan opportunity they would never be able lo repeat, either inAmerica or in a Mtetime. The deployment was praised as "'oneof a kind" and "like no other experience."

Humanitarian NursingAlthough nol all participants were originally assigned to thehospital ship as an t)perational platform, they neverthelessacclimated to the hospital ship and its functions through ship-board orientation and unit-specific training, which includedtraining on biomédical equiptiient and paper charting.Proficiencies identified as most helpful in providing qualitypatient care were: ability to remain calm, flexible, cultur-ally sensitive, and diplomalic; skill in mediating and resolv-ing conflict; ability to stay physically fit; capability of caringfor patients of all ages: competency in staying well-roundedwith current clinical experience; skill in appropriately plac-ing nurses in workspaces that matched their clinical strengths;and aptitude in retaining basic psychosocial assessment andmedical-stn'gical nursing skills.

Pédiatrie Nursing ChallengesThe domain in which study participants unanimously foundthey were least prepared was that of pédiatrie nursing, andin particular, pédiatrie deaths. Participants identified fac-ing such challenges by scheduling and spreading pédiatrienursing experts across work shifts, conferring with specialtypediatricians deployed aboard the USNS Mercy who wouldspend Ihe night in the intensive care unit (ICU) when therewere critically ill children in the ICU, and relying on Navynunses* past pédiatrie nursing experience and relocating thesespecialists from previous primary worksjiaces to the ICUwhen needed.

A number of study participants verbalized the circum-stances they faced after learning children they had treatedhad expired. One recounted a painful experience withan infant's death whiie ashore in Banda Aceh, Indonesia:"Having babies die is very painful for me. And one of thehardest ones was when we walked in and there was thisinfant in an isolette struggling for life... I just stood therein just utter disbelief that this was happening right in frontof me and I cottld not do any thing..." Another nurseslated: "|The death of an infant] was hatd—and knowingin the United States, some of these babie.s would've lived.Its something I still wrestle with." One nurse summedup how most of the participants dealt with such deaths:•'I think for a while you suffer when you come back. A littlebit of what they call 'care giver exhaustion' ... 'compassionfatigue'... I still think 1 have some of that... I scheduled crit-ical incident debriefs and just talked it oui with myself and

got counseling. 1 didn't think I needed it... because I'm anurse, and 1 can handle anything." Participants identifiedthat they dealt with pédiatrie deaths by using critical inci-dent debriefs and the services of psychiatrists, .social work-ers, chaplains, and mostly, nurse colleagues.

Saying "No"A notable lack of preparedness for ethical conflicts was alsoidentified. Participants experienced anguish and often ver-balized their reactions when they were not able to stay longenough to provide certain humanitarian nursing procedures.They sometimes had to say "No" to delivering healthcareservices because of time constraints, a limited continuumof care in the host nation's infrastructure, mere volutnc. orgetting called away to respond to other emergencies. Theytold of the seemingly inadequate treatment they providedby using metaphors such as "'drop in the bucket" and "merebandaid." They described being overwhelmed as akin to"walking into a .stadium of 10.000—how can you touchair?" The experiences for those who went ashore were par-ticularly difficult and described as "heart breaking" or "likeplaying God."

One commented: "I don't think anybody deals with it. Youstill close your eyes, and you see the faces of those people youcouldn't help...all you could say is. 'I'm sorry...we wouldlike tohelp...btit we don't have the services to help you." Wetried to help the kids... it was very hard... felt like you wereGod—picking the ones you were going to save and ihe oneswho were going to die." Most participants conveyed thai theyhad to consciously think about the good they did; they toldstaff to think about the positives of the nursing care they gave."I try to remember, "Well, at least I did sotne good tor someof them.'"

DISCUSSIONThe current study supports findings in the literature that bothnegative and positive aspects of humanitarian assistance anddisaster relief coexist. As with other relief workers in othersituations. Navy nurses experienced cultural, environmen-tal, and organizational negative Stressors during OUA; posi-tive aspects of both included such rewarding occasions as thatof providing good care for distressed patients and develop-ing strong relationships with patients and other workers.'•'^"'Another commonality among relief workcts in other circum-stances and nurses in this study was in identifying constrttc-tive coping mechanisms, including humor, social suppt)rt,counseling, and debriefing.'" -"^ Sentiments frotn the literatureregarding anecdotal reports from disaster relief and humani-tarian assistance missions, notably, the importance of clini-cal competence, collaboration, communication, compassion,innovation, flexibility, cultural awareness and respect, andpreparatory and ongoing training, were echoed.'' ""*

This study keenly adds to the literature on humanitarianwork from a nursing perspective. It gives voice to voices

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that have not been heard—highlighting the challenges of thisrewarding work. Participants were most unprepared for pro-viding pédiatrie care and most uncomfortable in saying "No"to care delivery. This study augments the literature in thepresentation of the details of challenges faced by its partici-pants. The study participants identified lessons learned andmade recommendations to include advanced practice nurses,specifically specialists in pediatrics and well-mental health,in humanitarian missions for staff support and reinforcement.In addition, the participants recommended that educationon moral distress and coping mechanisms be taught beforehumanitarian work.

The study's Navy nurses" accounts begin with the processof packing seabags, progress to reports of steaming west,and conclude with their engagement in humanitarian nurs-ing. The manner in which Navy nurses prevailed in gettingthe job done {the mission: readiness) is a testament to theirskills, knowledge, mindset, and coping abilities. Resultsfrom this study suggest that benefit would be derived fromthe institution of an entire program of research regardingtraining for nurses who will deploy in future humanitarianassistance and disaster relief tours. An integrated approachin which both qualitative and quantitative methods are uti-lized could result in a fuller understanding and conceptualmodel development in this study area. Initially, an additionalqualitative research study examining the experiences of theNGO nurses deployed during OUA and subsequent humani-tarian missions aboard the USNS Mercy. USNS Comfort,and other platforms could be undertaken. Given the increas-ing use of NGO personnel within the uniformed services,knowledge of how the NGO nurses experience the humani-tarian deployments aboard the hospital ships could well con-tribute to planning strategies for team building and skill mixin future missions.

Moral distress, defined as "a feeling state experienced whena person makes moral judgments about a situation in which heor she is involved, but does not act on those judgments," isexperienced by nurses who have been deployed during disas-ter relief and humanitarian assistance missions phases of adeployment.'" Examination of the concept of moral distressand its significance to this study area could provide anothervaluable basis for future research studies, and the need forfurther examination is suggested by this study. Specific com-ments on the salience of moral distress when confronting situ-ations in which little could be done to assist indigenous peoplelacking permanent health care resources were made by partic-ipants in the current study. Future research could be infortnedby the model of moral distress in military nursing developedby Fry. Harvey, Hurley, and Foley from interviews with13 Army Nurse Corps officers who had deployed to militarycrises, such as in war and humanitarian missions.''Qualitativestudies describing the moral distress phenomenon in Navynurses could be performed. Subsequent development of a reli-able and valid measure of moral distress in military nurseswould provide the basis for future model testing. Relationships

between moral distress and such related concepts as resilienceand suffering in providing disaster relief and humanitariancare aboard a hospital ship platform could provide a valuablebasis for planning intervention studies.

Research to identify and compare Stressors experienced byNavy nurses deployed to humanitarian missions with thoseexperienced by Navy nurses deployed in support of OperationIraqi Freedom is also recommended. Recognition of Stres-sors and coping mechanisms will assist in efforts to prepare,support, and facilitate optimal readiness and performancein humanitarian missions. This research study gave voiceto the challenges Navy nurses faced during such a mission.Participants touted the deployment as "rewarding," and oneindividual poignantly shared the following: "I try to remem-ber that an ounce of humanitarianism is worth a pound ofwar... that's what we did."

ACKNOWLEDGMENTSThe article is based upon the author's doctoral dissertation work. For Ihestudy's complete re.sult.s and findings, please refer lo the author's diK'toraldissertation titled "Navy Nurses' Experiences During üperation UnifiedAssistance Aboard the USNS Mercy: A Grounded Theory Study". Theauthor acknowledges ihc professional support of Dr. Jane Georges. Dr. LindaUrden, and CAPT Denise Boren, NC. USN (retired). Special heanfelt thank.sgo to Waine MacAllister: CAPT Jacqueline Rychnovsky, NC. USN; CDRAniia Smith. NC. USN; and Judy Christensen for tbeir editorial and artisticconlributions.

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