Tsunami survivors experienced complex trauma and grieving process says new study

People who survived the Indian Ocean tsunami or lost loved ones in the disaster went through a complex process of trauma and grief, according to research published in the latest Journal of Advanced Nursing.

In-depth interviews carried out over the course of a year by nurse researchers found that a number of common themes emerged when they talked to people about their emotions and attitudes to life following the tragedy.

They hope that these will provide useful guidance to help nurses and other healthcare professionals to deal with traumatic events in the future.

The emotions expressed by the study participants ranged from the initial pleasure of being on a dream holiday, through to the trauma of the event, their grief and loss and the way that families pulled together to come to terms with what had happened.

Although the final death toll will never be known, the earthquake off the coast of Sumatra on 26 December 2004, and the resulting tsunami, are estimated to have killed somewhere in the region of a quarter of a million people.

They included 543 Swedish tourists, including 140 children under the age of 18. A further 66 Swedish children lost at least one parent.

"We carried out one-to-one and group interviews with 19 people recruited in collaboration with the Swedish Red Cross to find out how the event had affected them" explains lead author Dr Maj-Britt Raholm from Haugesund University College, Norway. "The paper just published in the Journal of Advanced Nursing looks at their initial reactions to being caught up in this international tragedy and we will be reporting our longer term findings in due course."

The team, which also included experts from the Karolinska Institute in Stockholm, started the interviews with the 13 women and six men, aged from 24 to 67 years, 21 months after the tsunami. Interviews were undertaken a further five times, at eight-week intervals.

Twelve of the people they spoke to were on holiday when the tsunami struck. They included a man who lost his daughter and his mother and a couple who lost their child. The other seven participants were at home in Sweden. Some lost as many as four family members, including children, in the tragedy.

"The experiences of the tsunami survivors and their relatives revealed a comprehensive picture, which broke down into three distinct phases" says Dr Raholm.

"These can be summarised as experiencing the core of existence, a changed understanding of life and the power of communion."

The researchers found that the survivors and relatives spoke of nine chronological themes:

1. Being in paradise
   They described their initial surroundings as paradise. On the morning of the tsunami many of them were already by the sea or in restaurants. "We celebrated Christmas Eve there and it was fantastically beautiful. You kind of felt really safe" said one. "We were going to celebrate my husband's 50th birthday" added another.

2. Experiencing the inconceivable
   Suddenly people were screaming and panicking, they didn't know what was happening and the concept of a tsunami was unfamiliar. They knew something was terribly wrong and then they saw a massive grey wall of water.

3. The struggle to survive
   The force of the water consumed everything in its path and people felt they were approaching death. But some described a mysterious feeling of a giant light and calmness when they surfaced from the water. They fought to stay alive, desperately worried about family and friends. "I was angry and frustrated. I couldn't accept the thought that it would end like this" said one.

4. Helping others
   Many people didn't realise how badly they were hurt, due to shock and adrenalin. Everyone did what they could to help others. "There were all these injured people to look after" said one survivor, adding "we laid the dead bodies in a row so that they would have a funeral."

5. Experiencing unbearable suffering
   Survivors felt guilty about not having found relatives, not being able to help others and even climbing over children to escape death. Leaving Thailand without finding their child made one couple feel like a failure. God was questioned, but not blamed. One survivor had recurrent dreams about a badly injured baby she cared for.

6. Concentrating on searching
   In the aftermath, the key priority for many was to find missing friends and relatives. They visited hospitals and mortuaries and scanned thousands of pictures. One parent spoke of the frustration, the smell of death and the endless mortuary visits to find a daughter who is still missing. Another spoke of the joy at seeing their youngest daughter on the roof of a car, being cared for by local Thai residents.

7. Finding meaning in the midst of meaninglessness
   People sought solace in having a clear task, like finding family members or helping others. Locals risked their lives to save both the living and the bodies of the dead, often in the same boat. Being close to organised strangers brought great solace and conversations and contact with other survivors were brief but meaningful. "In the bus to Bangkok…there was an old man who couldn't walk, we had an elderly lady, we kind of had our group and we stayed together" said one survivor.

8. Powerlessness and grief at home
   Relatives at home felt desperately isolated and some described it as being in a closed off room. Getting the news that a loved one had died was associated with pronounced physical and mental sensations, like a heavy body and amnesia. "I threw myself on the floor and wanted to rip the skin from my body" said one woman. "The papers wrote about them but it wasn't part of our reality" said another.

9. Healing and solitude
   Common grief and loss united people and brought together even broken relationships. When the survivors returned, relatives became very protective. One survivor became closer to their siblings. "It is pretty strange that something good came out of this horrible experience" they said. Solitude was also important. One survivor went on lots of fast-paced walks "during which I processed my thoughts to keep the panic in check."

Feedback from disasters like the tsunami are essential as they can help to shape future care, say the authors.

"Healthcare professionals have an important role to play in caring for the victims of major disasters, as the effects can last for many years and in some cases people never recover from them" says Dr Raholm.

"We believe that it is important that nurses and nursing students have the knowledge they need to care for patients who have gone through life-changing traumas.

"We hope that our research will provide insight into the complex experiences and needs of those directly involved in major disasters like the 2004 tsunami. The more we learn from disasters that have already happened, the better prepared we can be for those that will inevitably happen in the future."

• The immediate lived experience of the 2004 tsunami disaster by Swedish tourists. Raholm M B, Arman M and Rehnsfeldt A. Journal of Advanced Nursing. 63.6, 597-606 (September 2008).

• Journal of Advanced Nursing is read by experienced nurses, midwives, health visitors and advanced nursing students in over 80 countries. It informs, educates, explores, debates and challenges the foundations of nursing health care knowledge and practice worldwide. Edited by Professor Alison Tierney, it is published 24 times a year by Blackwell Publishing Ltd, part of the international Blackwell Publishing group. www3.interscience.wiley.com/journal/118486802/home

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