Beyond protocols: the "double burden" and ethical dilemmas of nursing home professionals facing hurricane risk

Climate change is intensifying hurricane threats to insular territories, with nursing homes facing particular challenges in protecting vulnerable residents. Recent evidence demonstrates increased mortality and hospitalization among nursing home residents following hurricane exposure; significant gaps persist between formal planning and operational reality in long-term care facilities. To explore nursing home professionals' perceptions and practices facing hurricane risk in Guadeloupe, and identify factors influencing organizational resilience and emergency preparedness.

Qualitative descriptive study using semi-structured interviews analyzed through Braun and Clarke's reflexive thematic analysis, guided by the Age-Friendly 4M framework as a sensitizing conceptual lens. Four nursing homes in Guadeloupe (French Caribbean), 50-120 beds. Fourteen healthcare professionals (directors, nurse coordinators, registered nurses, nursing assistants, and coordinating physicians) interviewed January-March 2025. Data were analyzed inductively using six-phase reflexive thematic analysis. Credibility was enhanced through professional profile triangulation and contextual field notes. This study adhered to COREQ guidelines.

Five themes emerged, organized along two overarching dimensions (structural determinants and human experiential responses) bridged by compensatory dynamics: (1) insufficient operational preparedness despite formalized protocols; (2) psychological burden linked to work-family role conflict; (3) ethical dilemmas between resident safety and autonomy; (4) critical infrastructural vulnerabilities; and (5) compensatory solidarity dynamics. Organizational resilience largely depended on individual commitment and informal networks rather than structural support.

Hurricane preparedness in Caribbean nursing homes reveals significant implementation gaps between protocols and operational reality. Sustainable disaster response requires systematic training to address moral distress, psychological support mechanisms, infrastructure modernization, and ethical decision-making frameworks.