“I never doubted that I made a difference”

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UPPSALA UNIVERSITY Department of Neuroscience

Faculty of Physiotherapy Research Methodology IV Bachelor´s Thesis, 15.0 c

“I never doubted that I made a difference”

Personal experiences from physical therapists working after the earthquakes in Nepal.

“Jag tvekade aldrig på att jag gjorde skillnad”

Personliga erfarenheter från fysioterapeuter som arbetade efter jordbävningarna i Nepal.

Authors

Matilda Roempke Lindström Mimmie Öhrn

Jan 2021

Supervisor

Sara Frygner-Holm Ph.D, Reg. Physiotherapist

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Abstract

Background: Earthquakes and other natural disasters have increased over recent years, more people around the world are living with disabilities. The physical therapists have an important role to increase function and restore quality of life. Although it is stated that early

rehabilitation intervention is an essential part of the health response there is limited information about the work and the experiences from physical therapists.

Aim: The aim of this study is to examine physical therapists’ experiences after the earthquakes in Nepal 2015.

Design: This study had a qualitative exploratory design, based on five individual semi- structured interviews using the communication platform zoom. The data was analysed by a qualitative content analysis and had an inductive approach.

Result: The physical therapists’ describes a chaotic situation, the psychological vulnerability in patients made it challenging to motivate and keep the patients focused on their

rehabilitation. The huge influx of patients made it hard for the physical therapists to manage their time and led to compromised treatments and the need of early discharge of patients. The physical therapists had dual experiences about their role in the healthcare teams. There was a clear system on how to prioritize the patients based on severity of injuries.

Conclusion: This study showed that physical therapists in Nepal had an important role from acute care to follow-up after the earthquakes. The study provides an insight from physical therapists in disaster settings and may contribute to identify barriers in performing their work tasks in future disaster settings.

Keywords: physical therapy, experiences, earthquake, Nepal.

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Sammanfattning

Bakgrund: Jordbävningar och andra naturkatastrofer har ökat de senaste åren, fler människor runt om i världen lever med kvarstående funktionshinder. Fysioterapeuterna har en viktig roll genom att öka funktionen och återställa livskvaliteten hos dessa patienter. Även om det tydligt anges att en tidig rehabiliteringsinsats är en väsentlig del av arbetet finns det begränsad

information om erfarenheterna från fysioterapeuter.

Syfte: Syftet med denna studie är att undersöka fysioterapeuters erfarenheter efter jordbävningarna i Nepal 2015.

Metod: Denna studie hade en kvalitativ utforskande design, baserad på fem individuella semistrukturerade intervjuer med hjälp av kommunikationsplattformen zoom. Data analyserades med kvalitativ innehållsanalys och hade en induktiv ansats.

Resultatsammanfattning: Fysioterapeuterna beskriver en kaotisk situation, den psykologiska sårbarheten hos patienter gjorde det svårt att motivera och hålla patienterna fokuserade på deras rehabilitering. En stor tillströmning av patienter gjorde det svårt för fysioterapeuterna att hantera sin tid och detta ledde till att behandlingar behövde kompromissas och ökade behovet av tidig utskrivning av patienter. Fysioterapeuterna hade tvetydiga erfarenheter av sin roll i vårdteamet. Det fanns ett tydligt system för hur man skulle prioritera patienterna baserat på svårighetsgraden av skador.

Slutsats: Denna studie visar att fysioterapeuter i Nepal hade en viktig roll för patienten efter jordbävningarna, en roll som sträcker sig från akutvården till uppföljning. Studien ger tydlig insikt i hur fysioterapeuterna upplevde sitt jobb vilket skulle kunna bidra till identifiering av hinder för fysioterapeuter i utförandet sina uppgifter vid framtida katastrofsituationer.

Nyckelord: physical therapists, experiences, earthquake, Nepal.

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Innehåll

Abstract ... 0

Sammanfattning ... 1

Introduction ... 1

Background ... 1

Natural disasters... 1

Rehabilitation after natural disasters ... 1

The earthquakes in Nepal... 2

The work of physical therapists after the earthquakes in Nepal ... 3

Problem statement... 4

Aim ... 4

Question formulation ... 4

Method ... 5

Design ... 5

Sample ... 5

Data Collection ... 5

Data analysis ... 6

Ethical considerations ... 7

Result ... 7

Background information about the participants ... 7

Result presentation ... 8

Important to educate about the need of rehabilitation ... 10

Psychological vulnerability hindered ... 10

Countless patients and inadequate resources ... 11

Prioritizing and triaging of patients ... 11

Disposition and perception of time. ... 12

PT intervention put on hold initially. ... 13

Dual experience of the teamwork ... 14

Collaboration with foreign teams ... 14

Perception about the profession ... 15

Usual protocols were inadequate or non-existing ... 15

Prevention and follow up ... 16

Discussion ... 17

Result summary ... 17

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Result discussion ... 17

Method discussion ... 20

Ethical consideration, generalizability, clinical application ... 22

Conclusion ... 23

References ... 23

Appendix 1 ... 26

Interview guide ... 26

Appendix 2 ... 27

Information letter ... 27

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1

Introduction

Earthquakes and other natural disasters have increased over recent years, more people around the world are living with disabilities for the rest of their lives (1,2). The physical therapists have an important role to increase function and restore quality of life. Most of the published information about physical therapists working in natural disasters are based on experiences from high developed countries (3). Asia has the highest reported frequency of natural disasters, mostly affecting rural communities. The consequences of a natural disaster in developing countries are often far worse, acute care and rehabilitation resources in such settings are often limited even prior to the natural disaster (3,4). Therefore, it is important to get more information regarding the work and experiences of physical therapists working after natural disasters in developing countries. World Confederation of Physical Therapy (WCPT), have identified a need to advocate the presence of physical therapists in all phases of a natural disaster and to strengthen and promote their role (4).

Background

Natural disasters

A natural disaster is defined as “a situation or event caused by nature, which overwhelms local capacity, necessitating a request to a national or international level for external assistance; an unforeseen and often sudden event that causes great damage, destruction and human suffering” (1). Natural disasters include earthquakes, floods, tidal waves (tsunamis), landslides, hurricanes, volcanic eruption and droughts (2).

Since natural disaster often occurs unexpectedly and with great devastation, it is resulting in both human mass injuries and complex disabilities. The disasters result in destruction of local health infrastructure, and often occurs in rural areas with underdeveloped healthcare (3). More than 100 000 lives worldwide are estimated to be lost to natural disasters every year (1). There has been an increasing number of severe natural disasters in the world during the recent years and it is estimated that 97% of these have occurred in low-resourced countries (1).

Rehabilitation after natural disasters

Acute response plans with the focus on saving lives and treating acute injuries are getting a lot of attention in disasters, meanwhile rehabilitation often has been neglected (4). With an

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2 increasing number of natural disasters happening and lessons learned from them, there is now more focus on the role of rehabilitation in disaster management (1). More studies are made regarding the work of rehabilitation professionals in a disaster and several studies recommend that rehabilitation in any humanitarian disaster should be initiated as soon as possible and it should be continued in the community over the long term to restore function and enhance participation to survivors (4–6). Another important component for successful rehabilitation and management of patients is a multidisciplinary approach (5). It is important to have solid communication and teamwork between the professions to manage the victims both physical and psychological wounds.

Earthquakes are the most destructive type of natural disasters and have a huge impact on the healthcare system. It is often accompanied with large numbers of musculoskeletal injuries such as fractures and crush injuries (7,8). The study written by Lu-Ping et al (9) demonstrated that more than half of the patients who were arriving at hospitals near the epicentre of the earthquake had multiple injuries, the most frequent combination were two fractures (9). The numbers of deaths after earthquakes have decreased in recent years due to medical advances in acute field medicine, instead there are more people living with disability after earthquakes.

The increasing number of people living with newly acquired disabilities is in a short period of time added to the total number of people with disabilities in the country. This creates a great stress to the healthcare system in many of the affected communities who often are poorly prepared for the challenges in regards to rehabilitation and care (10).

The earthquakes in Nepal

In the spring of 2015 two major earthquakes struck Nepal, both with an amplitude over 7 on the Richter scale (11). Nepal has comparably low-quality standards in buildings and

infrastructure, which makes the country vulnerable to earthquakes. Up to 90% of healthcare facilities in the affected areas were partly or completely destroyed (11).

The damage after the earthquakes in 2015 are estimated to 8,699 deaths, over 22,000 injuries and 505,000 homes completely perished (12). The injuries occurred from collapsing houses, falling objects and falls from running or jumping out from buildings (13). Of the injuries 70%

were fractures, the most common fractures were the spine, pelvis, upper and lower limbs, other injuries were spinal cord injuries, traumatic brain injuries, crush injuries and peripheral nerve damage. In Nepal the epicentre of the earthquakes were located in the more rural areas

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3 of the country and some of the affected villages were located 4- to 5- days walk from a main road (13).

The work of physical therapists after the earthquakes in Nepal

Physical therapy is a relatively new profession in Nepal and there are currently approximately 2,000 physical therapists active in the country (14). The greater number of physical therapists are stationed in Kathmandu whilst a minority is working in the more rural areas of the country (13).

Physical therapists have an important role together with the rest of the health service team to decrease mortality and morbidity, reduce length of stay in hospital, improve quality of life and increase functional outcomes (15). A large amount of the victims after an earthquake are suffering from more than one injury, which requires health service teams to be prepared to care for patients with multiple injuries (9).

A commonly used method for assessing a patient’s medical conditions is triage. When using the method a health professional sorts patients accordingly to their medical conditions based on anamnesis, symptoms and vital parameters, to optimally use the limited available resources (10). It is known that in some hospitals in Nepal, the triage systems was implemented the same day as the first earthquake (8). Early communication of rehabilitation capability within the healthcare team is important and may impact upon triage and the medical management of severe trauma cases (15). There is not to this date one triage system that is implemented in disaster acute care worldwide. The circumstances in each country such as type of disasters and resources in health care should determine the method for most effective triaging of patients. Although there is no protocol to follow, the health professional in charge of triaging should consider vital signs, the patient's major problem, or the resources and facilities needed to respond to the patients’ needs (16).

Although it is stated that early rehabilitation intervention is an essential part of the health response there is limited information about the work physical therapists did after the

earthquakes in Nepal (17). The Nepal Physiotherapy Association (NEPTA) listed some of the work that was made by the physical therapists during this time, including mobilization and positioning of patients and prescribing exercises (8). Other important roles that the physical therapist had, beyond their regular everyday work, regarding the patients in the immediate aftermath following the earthquakes, were the involvement of screening and discharging

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4 patients and helping with acute-injury management (13). Physical therapists have also

reported that they have been diverted from their usual role to take on paramedical roles in health facilities during the immediate aftermath of the disaster. Some of their temporary work duties have then been to transport patients, dressing wounds or sterilizing equipment (15).

Problem statement

The number of natural disasters are increasing around the world, hence more people will live the rest of their life with long-term functional consequences of an injury. In any natural disaster physical therapists should be flexible and work to support the multidisciplinary team, though this should not undermine the critical rehabilitation role that they have as part of an emergency response (15).

Even though studies emphasize that rehabilitation has an important role in the disaster response system, there is a lack of knowledge of the subjective experiences of the working professionals, including physical therapists, in the aftermath of a natural disaster. In addition, there is also limited information about how the health professionals, and specifically the physical therapists, managed to prioritize amongst the injuries in this chaotic setting or experienced the teamwork.

The rehabilitation professionals are part of the solid core of the healthcare system and an important promoter for health following natural disasters. The experiences and needs of these professionals are essential to improve preparations and responses to a future upcoming disaster (18).

Aim

The aim of this study is to examine physical therapists’ experiences after the earthquakes in Nepal 2015.

Question formulation

How did physical therapists in Nepal experience the work and their role in the healthcare team at the time following the earthquakes?

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5

Method

Design

This study had a qualitative method with descriptive and exploratory design. The study is based on semi- structured interviews where the aim was to reach a deep and detailed

understanding of physical therapist’s experiences of their work after the earthquakes. The data is collected from interviews with people who shared direct quotes about their experience, perceptions and thoughts (19).

Sample

For this study five physical therapists who were working in Nepal in the aftermath of the earthquakes that occurred in 2015 were interviewed. The physical therapists who participated in the interviews were recruited by using a convenience sampling. To find eligible informants, an email was sent from our supervisor to a university in Nepal. A list of seven names of physical therapists working in different settings were sent to the authors from a Professor at the university in Nepal. The physical therapists from the list were contacted via email by the authors. From the list of seven names, five were willing to participate and four were included in the study, the fifth responded to the email too late. The fifth participant who was included in the study, was contacted through an email sent from the authors to a university hospital in Nepal, the hospital forwarded the authors request to the participant via email. The participant responded to the authors and accepted participation. All participants received an information letter with the email containing the request for participation (appendix II).

Inclusion criteria:

• Physical therapists that were working during the aftermath of the earthquakes in Nepal 2015.

• Being able to communicate independently in English.

Data Collection

The data was collected from five semi-structured interviews in English that were conducted through the communication platform Zoom. Duration of the interviews varied between 17 to 43 minutes. Before the interviews a pilot interview was conducted, this participant was found

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6 by personal contact from a physical therapist student who had internship in Nepal 2017. The purpose with the pilot interview was to see the adequacy of interview guide and identify any problems using the communication platform. After the pilot interview, some changes in the interview guide was made and data from the interview was not included in the result. The changes included removing two questions to reduce the length of the interview and because the questions did not contribute to further valuable information. Interviews were recorded on a password protected computer that were used when conducting the interview and also with a password protected smartphone to have as a backup. The interviews followed a semi-

structured interview guide (appendix I) with open- ending questions using the following question areas; Experience of their work after the earthquake and their role in the health team.

Follow up questions were asked when the authors found it necessary for clarity or interesting.

The authors were both present during the interviews and led three interviews each, including the pilot interview. The author who did not lead the interview participated by taking notes and were also allowed to ask follow- up questions.

Data analysis

Qualitative content analysis was used, with an inductive approach (20). Transcriptions were performed shortly after the interviews by the author leading the interview. The pilot interview was transcribed by both authors with the intention of reassuring the resemblance of the ways the authors were conducting the transcription. The following interviews were then transcribed separately. The transcriptions were made verbatim and pauses, laughing and other sounds were included in the transcription to avoid losing a deeper meaning of the content. The content was red several times by both authors to maintain an over all sense of the transcribed interviews. Both authors were separately analysing the text to get an individual view of the content and then divided it into condensed meaning units without losing the core and

thereafter the condensed meaning units were labelled with a code. The condensed and coded material was later compared by both authors together to achieve consensus. The codes were sorted into subcategories and categories with focusing on staying close to the manifested data.

The categories were formed with information from the transcription, subcategories and the latent meaning from the interviews. During the analyse process, the authors repeated and compared all the steps with the transcribed material from the interviews. The analyse went back and forth between condensed meaning units, codes and subcategories to produce

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7 categories without losing the essence of the material. Table I presents a view of the data analysis process.

To increase the credibility of the results, the supervisor Sara Frygner-Holm was asked to triangulate the categories and subcategories. In table 1, an example of the data analysis process is demonstrated.

Table I. Example of the data analysis process, from meaning unit to category

Meaning unit Condensed

meaning unit

Code Sub- category

Result

Background information about the participants

The interviewed physical therapists were two women and three men. They were all working at different facilities and treated patients who sustained injuries from the earthquakes. The facilities were public hospital, specialised rehabilitation centres and non-governmental organisations. The physical therapists were working over a period from two days to nine

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8 months after the earthquakes. Three of the participants were working at their usual

workplaces and the other two were working at temporary and new positions within disaster relief.

Result presentation

An overview of the result is presented in Table II. The result consists of 11 categories and 27 subcategories. A description of the categories and subcategories including citation follows the table. In the result presentation, the physical therapists’ codes are inserted after the citations.

Table II. The table present categories, subcategories and codes

Categories Subcategories Codes

Important to educate about the need of rehabilitation

- Low acknowledgement of rehabilitation

- Hard to recruit women

- People did not understand the need for rehabilitation

- Women acceptance of disability compromised recruitment Psychological vulnerability

hindered

- Challenges with fear - Impact on interventions - Physical therapists’ personal challenges

- Fear of another earthquake.

- Worst challenge was aftershocks - Low motivation due to

upsetting situation - Hard to leave the family

- Difficult handling my own trauma at work

Countless patients and inadequate resources

- Hard to work with limited resources

- Difficult with huge inprox of patients

- Early discharge necessary

- Lack of manpower lead to huge effort - Lack of equipment

- Even less resources in rural areas - Making PT efficient in spite of low resources

- Patient inprox created chaos - Patients everywhere

- Even subacute patients increased - Not enough space for all the patients - Had to enable early discharge, lack of space

- Early discharge made possible by relatives

Prioritizing and triaging of patient

- The prioritized patients

- System to triage patients in place

- Some Areas prioritized - Involvement in patient screening

- Prioritized children, pregnant women and severely injured patients

- Existing system to triage the patients - Later on no need for triaging

- Started in the most affected areas - Leading screening team

- Screening need for surgery - Member of the screening team

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9 Disposition and perception

of time.

- Long days, too many patients.

- Challenge to compromise patients’ treatments

- Working long days - Hard to manage my time - Lack of time with patients

PT interventions put on hold initially

- Safety for patients and staff and acute care priority

- Major role in patient transportation.

- Evacuating patients and equipment outside

- Avoiding going to the patients - Waiting with treatments until patients were safe

- Supporting acute care teams

- Proper transportation very important - Educated army and police

transportation technique Dual experience of the

teamwork

- Positive experiences

- Negative experiences

- Satisfied with the teamwork - Satisfied with systematic work - Teamwork; important components - Lack of communication decreased efficiency of PT

- Initially teamwork hard

- Low acknowledgement the hardest part

Collaboration with foreign teams

- Collaboration fruitful

- Challenges collaboration

- Collaboration for the patient’s sake

- Learning from foreign teams - Collaboration developed over time - Foreign colleagues trained new physios - Clashes due to culture and

expectations

- Difficult to understand intentions - Collaboration had to work

Perception about the profession

- We made a difference

- Inexplicit work tasks

- Challenging to work outside expertise

- Proud of my work - Increased quality of life

- We were confused about the work tasks

- Hard to manage patients outside my expertise

Usual protocols were inadequate or non-existing.

- Demands of the unusual situation

- Have to think outside the box - Find alternative ways to prevent immobility complications

- Working without existing blueprint Could not follow the usual protocols Prevention and follow ups - Preventing disability most

important

- Follow up in

community/patients’ home

- Working hard to prevent secondary complications.

- Preventive work was most important - Keep in contact and monitoring patients

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10 - Screening needs for PT in rural

community

- Rehabilitation in the community and patients’ home

Important to educate about the need of rehabilitation

This category consists of two subcategories Low acknowledgement of rehabilitation and Harder to recruit women. The physical therapist had an important role in educating people about the benefits of continuous rehabilitation and follow-up on their injuries to improve quality of life. They faced challenges with a low acknowledgement of need for rehabilitation in patients. Physical therapists found it more challenging to recruit women to rehabilitation.

Reasons for this were that women were more likely to accept their disability, compared to men who are the primary breadwinner of the family. Physical therapists needed to educate women about the benefits of not letting an untreated disability prevent them from starting businesses or looking for jobs.

“In terms of gender it was difficult to recruit females because they were like. They were more less like, we do not have to go outside to fetch for your family, so we are good with this level of disability that we have. So it was very difficult to recruit female to understand the need of rehabilitation” (PT 4)

Psychological vulnerability hindered

This category consists of three subcategories Challenges with fear, Impact on interventions and Physical therapists’ personal challenges. The physical therapists had to deal with a lot of challenges during the aftermath of the earthquakes and one of the hardest was the fear of another earthquake and the aftershocks. The fear was consistent for a very long time and had a negative impact on both patients, personnel and treatment. The patients were very frightened and stressed due to the earthquakes. Many of them had lost loved ones, their homes and also acquired injuries. Because of this, it was a challenge to motivate the patients to perform rehabilitation and to make them understand why physical therapy was important.

The physical therapists were not just working as caregivers during this time, they were also victims themselves. When they were called in to work two days after the earthquakes there

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11 were still aftershocks and that made it very hard to leave their own families. The physical therapists expressed that it was very challenging to work with their own psychological trauma and at the same time manage the patients’ stress.

“Everywhere people were panicked even I was myself panicked.. with my own problems my own house was a problem and at the same time we used to go for the work and at the same time patients complained about their problem.” (PT 5)

Countless patients and inadequate resources

This category consists of three subcategories Hard to work with limited resources, Difficult with a huge influx of patients, Early discharge necessary. Limited resources refer to the lack of equipment such as crutches and arm slings but also a lack of manpower for taking care of the patients. In rural areas of Nepal the inadequate resources were an even more striking problem, it was a big challenge to make the resources available to all regions. Using local resources to make physical therapy efficient was crucial. Treating patients with inadequate resources was challenging and affected many parts of the work.

“But because lack of resources, because lack of equipment, even a job to mobilised the patient, I only had one wheelchair to mobilise 10 patients so that that somehow looked like our team work didn't work because we had all the plans to do this, will do that, but then because of lack of resources we failed to do so.” (PT 2)

The huge amount of new patients that came at once created a chaotic situation, over one day the amount of patients almost doubled at the workplace. Patients were placed in every corner of the buildings and treated in any available space since there were not enough beds for everyone. Even in the subacute phase the number of patients increased since they came from out- treat centres. Due to the huge influx of patients it was necessary to discharge patients before their treatment was completed. This was made possible by involving the patients’

caretakers and by modifying the treatment and exercise protocols.

Prioritizing and triaging of patients

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12 This category consists of four subcategories Prioritized patients, System to triage patients in place, Some areas prioritized and Involvement in patient screening. In almost every facility in Nepal, there was a triage system that allocated patients to the right health facility. Some of the physical therapists therefore received patients who had already been allocated and screened whilst others were a part of the triage team at their workplace. The physical therapists’ had a role in the screening process and were involved in such decisions as whether a patient needed surgery or should get conservatory treatment. The huge influx of patients was a load on the doctors who were normally leading the screening of patients, and therefore the physical therapists had to lead the screening teams instead.

“So since the doctors were very much busy and the only competent profession that could screen the patient. was a physiotherapist. There was a discussion and the third day of the earthquake that okey the screening has to be given to the physios. So, I was leading the screening…” (PT 2)

The physical therapists expressed no difficulties in which patients to prioritize. Prioritized patients were the ones with most severe injury, children and pregnant women. In a later phase of rehabilitation, some physical therapists were working at rehabilitation facilities out in the communities. They tried to find patients in need and recruit them for rehabilitation. This search started in the areas that were most affected by the earthquake. Here there was no need to triage patients.

Disposition and perception of time.

This category consists of the two subcategories Long days, Too many patients and

Challenging to compromise patients’ treatment. The physical therapists expressed that it was very hard to manage their time and they had to work very long days, and in some cases nights, to be able to do all their work. Not only was there a lot of patients, but the time spent with every patient increased due to the patients’ psychological stress interfering with efficient interventions. One way mentioned to make time efficient was to use already admitted patients in a later stage of rehabilitation to help the new patients by giving them reassurance and comfort.

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“So listening to them (the patients) and giving reassurance to them and meanwhile treating them was like a bit challenging for us, and as well for me as I was so much involved in other activities like team meetings or planning how to educate, what things…., reporting,

monitoring, writing. Yeah. So that managing was quite challenging” (PT 1)

Another difficult part the physical therapists had to face was to compromise the treatment of the patients. The length of the treatment had to be shortened due to lack of space since there were new patients coming in every day with more severe injuries.

“We couldn´t, we didn't want to you know... victims to get compromised treatment, we wanted to give maximum treatment to victims but we had to manage in a day or in couple of days. So compromising, withhold compromising treatment, managing patients in a short period of time was challenging.” (PT 3)

PT intervention put on hold initially.

This category consists of two subcategories that includes Safety for patients and staff, Acute care priority and Major role in patient transportation. The initial few days the priority was not on the typical physical therapeutic interventions, the first priority was to safely evacuate the patients and equipment outside. To protect the personnel, they had to avoid going to the patient's room due to the risk of buildings collapsing during aftershocks or a second

earthquake.

“Aftershocks was continuous…. we could feel shocks even these days. You know, it was continued. So ehm it was risky sometimes going inside the room you could feel the shocks and then again run away.” (PT 3)

During the initial time, the physical therapists’ role was first supporting acute care teams and proper transportation. Proper transportation was an important and major role that included education about the subject. Physical therapists educated patients about the importance of properly mobilizing themselves and they also educated the army and police in proper transportation of patients to reduce the risk of secondary complications. The importance of safe transportation is described due to its ability to prevent secondary complications.

“for people who were initially incomplete …. They had very high chances of becoming complete injuries because of the lack of proper transport techniques” (PT 1)

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14 Dual experience of the teamwork

This category consists of two subcategories Positive experiences and Negative experiences.

Most of the physical therapists expressed that the teamwork was hard during the first few days but improved rapidly with time. Positive experiences included both satisfaction with the systematic work at the workplace and with the multidisciplinary work. In settings where the professions were used to working in multidisciplinary teams, teamwork was not an issue in spite of the stressful situation.

“It was a perfect, teamwork within all these disciplines and we were able to rehabilitate people much better just because we had all these teams working together in the same area”

(PT 4)

The negative experiences were partly due to lack of communication which decreased the efficiency of physical therapy and made the teamwork hard initially. In Nepal, at the time, the role of physical therapists was not identified and this was also a contributory factor that made teamwork hard.

Collaboration with foreign teams

This category consists of three subcategories: Challenges collaboration, Collaboration for the patient’s sake, Collaboration fruitful. The collaboration was challenging in the beginning, some aspects were different cultures and expectations, not being able to understand the intention of some foreign teams.

“But with some foreign teams we observed that some were just oriented for data or some were just oriented to patient management and somebody. I mean we did not know their intentions initially so it was difficult to come to a balance initially…” (PT 1).

There were some clashes with the foreign colleagues during this stressful period of time, this had to be set aside to be able to give the patients the best care possible and over time an understanding and cooperation developed.

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“So initially it was a challenge to communicate with the foreign team but eventually we had to move on, you know we had to do it for our patients… “(PT 1)

Things that made the collaboration fruitful was the chance to learn things from new team members who had special knowledge and were experts within the field. The foreign

colleagues helped in teaching new physios who were hired after the earthquake and that was a huge help in the response.

Perception about the profession

This category consists of the three subcategories We made a difference, Inexplicit work tasks and Challenging to work outside my expertise. The sub-categories include perceptions on the importance of their role, working in a chaotic setting and with patients outside of their areas of expertise. It was clear that the physical therapists felt they made a huge difference for the patients and were proud of their work. The work physical therapist did in the immediate aftermath of the earthquake and the rehabilitation several months after increased the quality of life for the patients.

“Yeah there was never a day I doubted that I was making a difference. In terms of patients, people who had stopped farming after the earthquake they were able to go back to

farming…....there was a little girl who was not able to go back to school she was able to go back to school. There was a particular mother who had been limited to only household duties she was able to start her farming, start her sewing business so yeah it was a perfect thing, at least in my eyes that we could have done for them.” (PT 4)

When the earthquake struck Nepal it created a situation that the physical therapists never before had been exposed to. The first hours and days are described as chaotic and left the physical therapists feeling confused in their role and the work tasks. The large number of patients also resulted in a patient variety in the different departments in hospitals and they could not always be allocated properly based on their types of injuries. The physical therapists therefore had to meet the challenge of treating patients who were not in their area of expertise which gave a feeling of inadequacy.

Usual protocols were inadequate or non-existing

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16 This category consists of one subcategory Demands of the unusual situation. Where the physical therapists express their experience of working in an usual setting and the demands on alternative ways to work. The influx of patients created queues with patients laying with severe injuries waiting for a surgery. Some of them were in tracktions while waiting. For these patients with severe fractures the physical therapist had to find new ways to prevent second degree complications related to bed immobility, The protocols that they have been following at their workplace and studied in books were not useful since all the guidelines are based on the fact that patients are getting their surgery immediately.

“The surgeries were being delayed and you are not used to providing all the prevented work, because immediately surgeries will be cared out and you are supposed to mobilise that patient. But you can not mobilize that patient because he has severe fractures or severe injuries and still you have to perform you preventing majors. Now how are you supposed to do that? You definitely need some alternative methods, you definitely need to you know think the other ways ... you have not studied that in books you have not studied that in any any of the protocols” (PT 2)

Prevention and follow up

This category consists of two subcategories; Preventing disability most important and Follow up in community/patients’ homes. The physical therapists describe the prevention of second- degree complications and long-term disability as the most crucial thing they could do for their patients. Spinal cord injuries were a common sight in patients after the earthquake and

physical therapists had a major role in preventing them from further damage that will affect the rest of their lives.

To be able to handle the follow up for so many patients, physical therapists describes different ways to cope with this. Some had continuous telephone follow up, others report about

rehabilitation services and educating about complications provided in patients' homes. In more rural areas there was more of an outreach service that alerted physical therapists and they came to screen for the need of physical therapy.

“The community outreach workers would go, they would identify needy people in the community nurses would screen them for any comorbidities, for which we should be careful

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17 while they would be in our facility. Physical therapist would screen the need for physical therapy.” (PT 4)

Discussion

Result summary

In this study, the physical therapists experience of the work and their role in the healthcare team were explored. The immense part of the physical therapist's work was to educate about the urgency of rehabilitation and to motivate patients when their psychological vulnerability hindered. The limited resources and countless patients made the work challenging and forced them to discharge patients too early, with help from caregivers and family. There were systems on how to prioritize among the huge number of patients arriving at once and the physical therapist had a major role in screening patients. Time with every patient was reduced to a minimum and the physical therapists had to compromise their treatments. The

collaboration within the team was expressed with dual experiences but the consensus was that it rapidly improved over time. The physical therapist expressed feelings of both proudness and inadequacy over their work in the disaster setting the unusual situation forced them to think outside the box.

Result discussion

In Nepal, physical therapy is a relatively new profession and is not very identified in the country and therefore the population has very little knowledge about rehabilitation(14). When interviewing the physical therapists, they confirmed this and described a low

acknowledgement about the need for rehabilitation within the patients. In the article from Klappa et al they describe the same issue after the earthquake in Haiti. A lot of the Haitian population were not familiar with rehabilitation. They thought if you are sick you are supposed to lie in bed, there was no understanding for the active part of the healing process (21). Physical therapists' role in educating the patients about the need of rehabilitation in acute care is therefore particularly important when patients with mild to moderate injury are

unlikely to remain in hospital for a longer period of time. A holistic patient and family education and advice prior to discharge is critical (15). It was said in our interviews that women were harder to recruit to rehabilitation. One reason for this was that women had accepted their level of disability because they were not the breadwinners of the household. By making them understand the importance of their health and starting rehabilitation in the acute

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18 phase these patients can go back to their work or everyday chores and thereby increase their quality of life.

The psychological vulnerability in patients affected their capacity to perceive and understand information about rehabilitation. The psychological vulnerability that develops after a disaster is determined by aspects that occurred before, during and after the disaster. People are not affected by personal aspects alone, but also by social and cultural aspects (22). Patients were dealing with fear of another earthquake and how this may impact on their family and

relatives, but also how the disaster has impacted their society. Will they have a job to go back to after this? The physical therapists describe a feeling of panic and that it was hard for them to leave their families. There are no studies carried out to explore emotional and

psychological experiences of physical therapists in disaster relief (21). Although, it is worth noting that in disaster management, local physical therapists and other health professions continue to work even though their own and their families’ lives are affected by the disaster (15).

In a disaster setting it is bound to be a huge influx of patients in all health facilities. One effect of the increase of patients is a lack of resources. In the article by Landry et. al (10) it is

mentioned that Nepal had stockpiles of equipment and mobility aids prior the earthquakes, but these were probably higher distributed in the urban areas than in the rural areas. The

earthquake made a huge impact on the infrastructure and therefore it was even more difficult to allocate these resources to the more rural areas. This is consistent with the experiences from the physical therapists in this study, although lack of resources was mentioned as a huge effort in all the settings where the participants worked, regardless of location. The physical therapists were all saying that working with low resources and manpower was a huge effort and was a big contributor to the long days of work.

Even though the role of physical therapists were not very acknowledged prior the earthquakes or even during the acute management they had several important roles. One of these roles that the physical therapists had in the acute phase was being a part of triaging. There is no

worldwide existing blueprint or protocol on how to triage patients in disaster settings triage patients therefore bring ethical dilemmas and also puts a lot of pressure on the health workers (23,24). In Haiti, military forces had to make their own triage system and expressed a lot of ethical dilemmas in this setting (24). Having an existing triage system when working in a disaster setting has been said to help health workers with their ethical dilemmas and

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19 management of patients (11,25). In this study, none of the physical therapists expressed any difficulties with prioritizing or triaging of patients. The authors had assumed this to be more of a challenging issue. The fact that there was an existing triaging and prioritizing system at each facility and that the triaging were made by, or with, other professions is a possible reason why the physical therapists felt no difficulties in this matter. Difficulties with prioritizing seem to be more related to the challenges with managing the time such as working long days, compromising patients’ treatment and discharging them too early, doing both physical

therapeutic interventions and logistic tasks at the same time.

The initial few days after the earthquakes, the physical therapists had to withhold the typical physical therapeutic interventions. The physical therapists felt they had a major role in educating both patients and acute response workers in proper transportation of the patients.

Proper transportation is a very important component of acute care management to prevent long term disability and should be implemented in disaster preparedness plans (4,10).

When working in a disaster setting, it is crucial that the teamwork is functioning. The patients often need multidisciplinary care to get the best outcome possible. One challenging factor regarding teamwork was the fact that the role of physical therapists was not identified that much in Nepal at the time of the earthquake and this made their role in the disaster setting further undervalued. According to Waldrop et al. (16) the persons in charge at hospitals hesitate to use physical therapists in disaster settings because they are not sure how to utilise them in the best way. People don't think of physical therapists or their role in this setting. One reason for this is that physical therapists in a disaster setting tend to devalue their own skills (16). There is more research regarding the importance of rehabilitation in disaster response now and it is getting more acknowledged and will probably set a more solid role for the physical therapists ahead.

The physical therapists also described challenges and a few clashes with the collaboration with foreign teams, especially in the beginning. This is something that can be found from a study from another disaster management setting (26). The obstructions to successful

teamwork with foreign teams is, lack of interprofessional understanding, autonomy struggles and role stress. “Role stress” refers not only to the stress of the workload and lack of time, but also to the demands of performing new tasks unrelated to the profession. Role stress can convert minor disagreements into major clashes (26).

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20 The physical therapists describe different perceptions about their profession both the feeling of confusion and inadequacy in the immediate aftermath of the earthquake but also a feeling of pride. Physical therapists describe that their work made a huge difference for the patients.

Similar view is reported from a study by Klappa et. al. (21) where the physical therapist describes the fact that being responsible for another human being and trying to make their lives better and support their lives was the reason for involving themselves in work within disaster settings.

When working in a disaster setting it is impossible to follow the usual protocols. Physical therapists in this study describe a confusing initial phase and expressed that it was hard to work without existing protocols or blueprints. It is concluded in the article by Landry et. al.

(17) that the knowledge and experience from the earthquakes in Nepal should be used to effectively implement future strategies to reduce the effects of natural disaster related to disability. In addition, the WCPT report from 2016 (15) stated that there is a need to establish a global framework of, and standards for, physical therapy preparedness. The establishment of protocols in disaster setting is an ongoing process and will most likely contribute to a higher quality in patient care and a better work environment for the physical therapists.

The physical therapists were working hard to prevent secondary complications in the acute phase. Measures to enable follow up were also required to ensure continuous rehabilitation. It is known that rehabilitation in any humanitarian disaster should be continued in the

community over the long term to restore function and enhance participation to survivors (4–

6). In this study, it was acknowledged that healthcare professionals at the hospital kept contact with the patients and healthcare workers in the communities after discharge to enhance

continued rehabilitation. Despite this effort, there were still people in the communities who did not receive rehabilitation. This could be the effect of the low acknowledgement about rehabilitation as discussed above or possibly an indication that the strategies for follow up needs to be improved.

Method discussion

A qualitative study was chosen as the purpose was to describe physical therapists subjective experiences (27). Due to the absence of earlier research this study is conducted with an inductive approach. Both authors approached this study open-minded and with curiosity. By engaging in reflexivity during the formation of the interview guide, follow-up questions, data collection and analyses, the authors have tried to be aware of and minimize the risk of

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21 personal subjectivity to interfere with the analyses of the interviews and the findings. This was the first time for the authors to go through with a qualitative study. The authors strengthen the studies credibility by clearly describing the method and result. It is also considered a strength that the content analysis is done correctly through continuous

supervision from an experienced researcher. Olson et al (28) determines the importance of the study's purpose, method, result and analysis process is correlating throughout the whole process. For the trustworthiness of the study individual analyses from the transcribed interviews were conducted by the authors. After individual condensation and coding the authors compared their results, discussed differences in interpretations to reach consensus. It is considered to increase the studies dependability by ensuring that more than one perspective is taken into account, therefore triangulation with the authors supervisor were implemented.

The collection of the physical therapists was made through convenience sampling, this ensured that the participant had good awareness and insight about the subject. Four of the physical therapists were contacted after their names had been provided by a professor at a university in Nepal, this could have influenced the result and is a risk of bias. The names provided by the professor were not contacted by the professor prior to our email and therefore the risk of bias is considered decreased. The included physical therapists were working in different settings and hospitals and therefore cover a more varied aspect of their experiences.

One pilot interview was conducted before the 5 interviews, the content of the interview guide showed to be adequate, but the number of questions had to be reduced due to the length of the interview.

When the material was transcribed the authors noticed that there were areas of the interviews that would have required follow up questions or further explanations. This was missed during the interviews due to language confusion and dialect differences. The area that was missed was too intricate to send follow up questions by email. If this study would be carried out again a professional interpreter could be an option.

The physical therapists were asked to recall events that occurred 5 years ago and this may impact the accuracy of the answers such as diminishing some events and overstate others. As discussed in another study, looking back at an experience after time of reflection may provide different perspectives and may have influenced the result of the study (21).

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Ethical consideration, generalizability, clinical application

The physical therapists received an information letter (appendix II) prior to the interview. The letter contained information that the interviews were voluntary, confidential and that they had the right to withdraw their participation at any time. A possible ethical issue is that the

physical therapists were asked if they had any questions before the interview started, but the authors did not explicitly ask if the physical therapists had read and understood the

information letter. Another thing to take into consideration is that the physical therapists may be reluctant to talk about things that were difficult during this time, especially when it

included co-workers or the workplace. There might be a risk that the physical therapists are afraid that the information provided would give a negative view about the workplace. The same issue is considered about their own work, they might not want to mention negative aspects of their own work. The authors chose not to describe further specifics about the participants or their workplace, knowing this might affect the trustworthiness of this study.

The benefit of making the participants feel comfortable to speak freely without readers being able to connect participants to their quotes was more important to the authors. Asking them about what was difficult was an important part of the study to be able to describe a wider perspective of the situation and to receive potential for improvement.

Today there are few studies, known to the authors, that enlighten the experiences of physical therapists working during or after a natural disaster. This and the small sample makes it hard to compare the results in this study to other settings. Type of natural disaster, resources of the country, the acknowledgement of the profession are some variables that may contribute to variety of experiences of working in a disaster setting. Keeping this in mind, the authors believe it is up to the reader to determine the generalizability of this study.

Although rehabilitation has been getting low attention in earlier research on disaster relief, all physical therapists were describing the importance of a physical therapist in acute care

management. Rehabilitation in early disaster management will improve function and overall quality of life for injured patients. Consequences of early implemented rehabilitation is people being able to go back to work and contribute to the economy and welfare of the community and country, therefore it is crucial that the physical therapist has a solid place in acute care teams. Getting an insight from these health professionals may help identify the existing barriers in performing work tasks in this type of setting. Hopefully, this will contribute to

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23 continuous improvement and status for physical therapists in disaster management plans for any potential future disaster, resulting in higher quality care for patients.

Conclusion

The aim of this thesis was to explore the experiences of physical therapists working after the earthquakes in Nepal, mainly regarding the work and the role in the team. The results

demonstrate that there were many challenges for the physical therapists such as low resources, prioritizing time and motivating patients to rehabilitation. They also felt a sense of

contribution to something important in a disaster setting and had a role as a physical therapist from acute care to follow-up after the earthquakes.

References

1. Khan F, Amatya B, Gosney J, Rathore FA, Burkle FM. Medical Rehabilitation in Natural Disasters: A Review. Arch Phys Med Rehabil. 01 september 2015;96(9):1709–27.

2. Reinhardt JD, Li J, Gosney J, Rathore FA, Haig AJ, Marx M, et al. Disability and health- related rehabilitation in international disaster relief. Glob Health Action. 16 augusti 2011;4:7191.

3. Amataya B, Galea. M, Li. J, Khan .F. Medical Rehabilitation in disaster relief: Towards a new perspective. J Rehabil Med 2017; 49: 620–628

4. Rathore FA, Gosney JE, Reinhardt JD, Haig AJ, Li J, DeLisa JA. Medical Rehabilitation After Natural Disasters: Why, When, and How? Arch Phys Med Rehabil. 01 oktober 2012;93(10):1875–81.

5. Keshkar S, Kumar R, Bharti BB. Epidemiology and impact of early rehabilitation of spinal trauma after the 2005 earthquake in Kashmir, India. Int Orthop. 01 oktober

2014;38(10):2143–7.

6. Sheikhbardsiri H, Yarmohammadian MH, Rezaei F, Maracy MR. Rehabilitation of vulnerable groups in emergencies and disasters: A systematic review. World J Emerg Med.

2017;8(4):253–63.

7. Bar-On E, Abargel A, Peleg K, Kreiss Y. Coping with the Challenges of Early Disaster Response: 24 Years of Field Hospital Experience After Earthquakes. Disaster Med Public Health Prep. oktober 2013;7(5):491–8.

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24 8. Moitinho de Almeida M, Schlüter B-S, van Loenhout JAF, Thapa SS, Kumar KC, Singh R, et

al. Changes in patient admissions after the 2015 Earthquake: a tertiary hospital-based study in Kathmandu, Nepal. Sci Rep. 18 mars 2020;10(1):1–9.

9. Lu-Ping Z, Rodriguez-Llanes JM, Qi W, van den Oever B, Westman L, Albela M, et al.

Multiple injuries after earthquakes: a retrospective analysis on 1,871 injured patients from the 2008 Wenchuan earthquake. Crit Care. 2012;16(3):R87.

10. Landry MD, Sheppard PS, Leung K, Retis C, Salvador EC, Raman SR. The 2015 Nepal Earthquake(s): Lessons Learned From the Disability and Rehabilitation Sector’s Preparation for, and Response to, Natural Disasters. Phys Ther. 01 november 2016;96(11):1714–23.

11. Giri S, Risnes K, Uleberg O, Rogne T, Shrestha SK, Nygaard ØP, m.fl. Impact of 2015 earthquakes on a local hospital in Nepal: A prospective hospital-based study. PLOS ONE. 02 februari 2018;13(2):e0192076.

12. Goyet S, Rayamajhi R, Gyawali BN, Shrestha BR, Lohani GR, Adhikari D, et al. Post-

earthquake health-service support, Nepal. Bull World Health Organ. 01 april 2018;96(4):286–

91.

13. The Role of Physical Therapists in the Medical Response Team Following a Natural Disaster:

Our Experience in Nepal. J Orthop Sports Phys Ther. 31 augusti 2015;45(9):644–6.

14. Nepal: a profile of the profession | World Confederation for Physical Therapy [Internet].

[citerad 19 mars 2020]. Available from: https://www.wcpt.org/node/150128/cds

15. Word Confederation of Physical Therapy. WCPT Raport: The role of physical therapists in disaster management.[Internet] London: WCPT; 2016 [citerad 24 mars 2020]. Available from: https://asksource.info/resources/wcpt-report-role-physical-therapists-disaster- management

16. Waldrop. S. Physical Therapists’ Vital Role in Disaster Management. PT Magazine. Juni 1 2002;10(6)

17. Mousavi G, Ardalan A, Khankeh H, Kamali M, Ostadtaghizadeh A. Physical Rehabilitation Services in Disasters and Emergencies: A Systematic Review. Iran J Public Health. maj 2019;48(5):808–15.

18. Hugelius K, Adolfsson A, Örtenwall P, Gifford M. Being Both Helpers and Victims: Health Professionals’ Experiences of Working During a Natural Disaster. Prehospital Disaster Med.

april 2017;32(2):117–23.

19. Kristensson J. Handbok i uppsatsskrivande och forskningsmetodik för studenter inom hälso- och vårdvetenskap. 3:e uppl. Stockholm: Natur & Kultur. 2014.

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25 20. Höglund-Nielsen B., Granskär M. Tillämpad kvalitativ forskning inom hälso-och sjukvård.

3:e uppl. Lund: Studentlitteratur AB; 2017.

21. Klappa S, Audette J, Do S. The roles, barriers and experiences of rehabilitation therapists in disaster relief: post-earthquake Haiti 2010. Disabil Rehabil. 01 februari 2014;36(4):330–8.

22. Matsumoto K, Sakuma A, Ueda I, Nagao A, Takahashi Y. Psychological trauma after the Great East Japan Earthquake. Psychiatry Clin Neurosci. 2016;70(8):318–31.

23. Bazyar J, Farrokhi M, Khankeh H. Triage Systems in Mass Casualty Incidents and Disasters:

A Review Study with A Worldwide Approach. Open Access Maced J Med Sci. 12 februari 2019;7(3):482–94.

24. Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response. N Engl J Med. 18 mars 2010;362(11):e38.

25. Fardousi N, Douedari Y, Howard N. Healthcare under siege: a qualitative study of health- worker responses to targeting and besiegement in Syria. BMJ Open. 04 september 2019;9(9) 26. Unwitting Partners in Death—The Ethics of Teamwork in Disaster Management. AMA J

Ethics. 01 juni 2010;12(6):495–501.

27. Carter R, Lubinsky J, Domholdt E. Rehabilitation Research, Principles and Applications. 4:e uppl. Vol. 2011. Philadelphia: Saunders;

28. Olsson H, Sörensen S. Forskningsprocessen: kvalitativa och kvantitativa perspektiv. 3:e uppl.

Stockholm: Liber. 2011.

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Appendix 1

Interview guide Background variables

• Where were you working at the time of the earthquakes 2015?

• How long had you worked there before the earthquakes?

• Could you shortly describe your previous work experiences as a physical therapist?

1. We are here to learn about what it was like to work as a physical therapist during and after an earthquake. Could you tell us about how this was for you?

2. How did you experience your professional role after the earthquake?

- What was according to you the hardest part of your job during this time?

3. How did you experience the teamwork after the earthquakes?

- Can you tell us about a situation where the outcome of a teamwork effort did not fully live up to your expectations?

- Can you give an example of another time when the teamwork effort managed to live up to these expectations?

4. How did you experience the prioritizing among a large number of patients?

-What difficulties did you find in prioritizing your time/ work

5. What was according to you the most crucial or important you could do for the patient?

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Appendix 2

Information letter

Our names are Mimmie Öhrn and Matilda Roempke, we are physiotherapy students at Uppsala University in Sweden. Our original plan was to go visit Nepal during this fall and conduct the interviews there. Sadly, because of the current pandemic, we are not allowed to travel. Instead we are planning on doing the interviews from a distance using internet-based platforms or telephone, whichever is more convenient to you.

Aim of the study: To describe physical therapists experiences after the earthquakes in Nepal 2015. To deepen and explore their experiences about the work and their professional role during this time. The study is going to be based on interviews with 5 physical therapists that were working with patients that suffered injuries after the earthquakes.

You have received this letter because we are asking you to participate in this study.

Participation will involve an interview that will take about 30 min and the questions will be about your experiences as a physical therapist after the earthquakes in 2015.

The interview will be recorded on a password locked mobile and computer, the information and recording will be saved on password locked computers during the process of writing the thesis and then deleted. The material will be analysed by the interviewers and your identity will be kept anonymous. Neither personal information nor the name of your workplace will be identified in the thesis. The participation is of your own free will and you can at any time withdraw it, all the data will immediately be erased if you for any reason would like to withdraw from the study. You are free to correct or edit your answers during the interview.

If you have any questions or want to participate, please send an e-mail to one of these addresses.

matilda.rl@hotmail.com mimmie@wejkum.se Best regards

Matilda Roempke Mimmie Öhrn

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Supervisor in Sweden: Sara Frygner-Holm, Lic. Physical therapist.

Contact: sara.frygner-holm@neuro.uu.se