Taking Healthcare by Storm: Industry Insights with Sophie Campbell & Debra Wright

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Sophie Campbell, MSN, RN, CRRN, RAC-CT, CNDLTC, Executive Director of Pennsylvania Association of Directors of Nursing Administration (PADONA), and Debra Wright, a Quality Improvement Specialist at Quality Insights.

Sophie and Deb discuss the evolution and challenges of nursing leadership in long-term care, including the impacts of COVID-19, partnerships to improve care and training, and efforts to combat negative perceptions and recruit new talent. They emphasize the importance of education, flexibility, and interdisciplinarity in addressing the higher acuity of admissions and the need for ongoing infection prevention and control.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-041825-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

Hello, everyone. And welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, Medical Director of Quality Insights. And I am very excited to be joined by our two guests today. excited to be joined by Sophie Campbell. She is the Executive Director of PADANA. Which stands for the Pennsylvania Association of Directors of Nursing Administration and our own famous Deborah Wright who works with us here at Quality Insights.

So with over 30 years of experience, Ana's dedicated to supporting nursing leaders in long-term care across Pennsylvania, offering critical education, leadership development, and Advocacy. In our conversation today, we'll dive into the state of nursing leadership, post COVID, the challenges facing the nursing workforce in long term care, and the impactful partnerships Padana has fostered to improve care.

And training for professionals, I will say the long term care population is the most vulnerable right now in our country. And we are facing a shortage of all staffing in long term care facilities, especially nurses. So Padana is working to support and educate this workforce. Sophie is going to offer her.

valuable advice for those looking to pursue a career in nursing leadership and how nursing leaders are addressing challenges in long term care today. So, Sophie, Deb, thank you so very much, both of you, for spending some time with us today. I know your, your schedules are busy, so thank you so much for joining us.

Thank you, Dr. Storm. It's a pleasure to be here. So we're gonna jump right in. Can you tell us about the core mission of PADANA and how it supports long term care professionals in Pennsylvania? Well, the core mission, if you look at our website, it says on the website, we're committed to supporting post acute professionals by providing resources, professional development, advocacy, and collaboration to enhance the quality of care and services to our seniors.

But in a nutshell, what we do is, We invest all of our resources to support, especially nurse leaders and administrators through education and information, everything we do is directed towards post acute professionals and their growth and development. We try to do the work for them, but ensure that they have the information and the education that they need to do their jobs so that they can spend more time with their team members and their residents and family members.

I will say it's something that is so very important. We know that nurses in long term care are busy. They, even nursing leaders in facilities maybe that they were hired to work on quality improvement in other areas and they're called to maybe do clinical tasks like  take on a cart  on a haul.

So, I you know, I have to say that you have an important mission and to really provide this education for them in a way that works. So I really appreciate what you do as I see it. Yeah. So as I said, Madonna has been serving the longterm care sector for a long time since 1988. how have you seen the role of nursing leaders evolve over the years, especially in light of the challenges brought on by the COVID 19 pandemic?

Well, I think the role of nursing leaders has evolved from when I first became a nurse leader or in nursing leadership. I think it's evolved, and I think it would have done so even without the pandemic. I think the generations have changed, and I think that the folks who are moving into the nursing leadership positions have changed, and what they're looking for is different.

They're more invested. They're more engaged. And I'm not saying that I wasn't, but not everyone was. A lot of times, nursing leadership was there to do tasks. They weren't there to be invested. They weren't there to be engaged. They didn't want to know the business of long term care. Now, nursing leadership wants to know the business of long term care, and they understand that it's not just clinical.

There's also a business side to it. The pandemic helped them to understand that a little bit more because of everything that we went through with the PPE and not being able to get PPE and some of the stories I heard through the pandemic of how people were getting their PPE, but it's amazing what they would do for their facilities, for their staff, for their residents, but they did it.

They're invested, they're engaged. But they also wanna know more about the business side when PNA provides education related to legal. things that are happening in long term care. We have nurse leaders who are really interested in that. They want to know more about it. They want to know how they can protect their facilities, how they can protect themselves and their team members.

This is not something that was always there. They also want to be at the table with administration. They want to be heard. They want their nurse leaders are now more dynamic. They want to support their team members. But for them, that means that they've got to be at that table and they've got to know what's happening in the facility in all aspects.

It's no longer just their department. It's how do all the other departments impact us. And again, we felt that a lot more during the pandemic because everybody impacted everybody else. And we looked at our residents confined to their rooms during the pandemic and looked at the other departments and said, what can you do for these people?

So I think we learned that we're not just nursing where we're the whole group of team members, the interdisciplinary team and nursing sees themselves  as not the head of that team, not just a part of that team, but a leader within that team.  And They don't, they want to know more about those roles.

And I think as we've evolved in nursing leadership, we're looking for more kindness, more fairness for our team members. So I think nursing leadership isn't just saying, I'm here to be your director. I'm here to be your director of nursing. And a lot of times when I hear directors of nursing saying, I see myself as a nursing leader versus a director of nursing.

That's so wonderful because it tells me where we've gone in nursing leadership. I'm not the director. I am the leader of this department. So  that's where I see it. And I think we would have gone there without the pandemic. But I think the pandemic gave us a little bit of a shelf. I absolutely love that.

Nursing leaders and I would agree. I was reading an article recently that talked about health care leadership and that many of the roles in health care leadership are not filled by health care providers like physicians and nurses. And so there's a little bit of a disconnect, I think, when you have health care leadership that hasn't served a direct clinical role and doesn't understand really what that direct clinical role means in the scheme of leadership.

So I, I really love that term  nurse leader. So Padana has built several meaningful partnerships. I spoke with some individuals who were involved in the Pennsylvania teaching nursing home collaborative. They came on the podcast. I was lucky enough to have them as guests. So can you share more about how these collaborations help improve the quality of care in nursing homes across Pennsylvania?

Thank you for asking. But Donna is so proud of our partnerships. We are so excited about the partnerships and every partnership that Madonna has is valuable to our members  and that's the most exciting part about it. We have a partnership with the teaching nursing home collaborative and the exciting part about that is we're able to assist nursing homes.

We are on the side of the nursing homes, not that their sides, but we're working with the nursing homes to assist them  To see why it's important to bring schools of nursing to bring students into the facility and some of that is you just have to say to them, help them to see why you're so excited about geriatrics, why you're so excited about working in a nursing home.

And sometimes that's all it takes to say, yeah, let's bring these students here and then we can learn from each other. So that's partnership. We're also p Pennsylvania Bureau of Ep the Department of Health us in providing a lot of members related to infect control, patient safety a way. We've partnered with We're partnered with Long Term Care Rise and AMI Rise, and through that partnership, we're assisting to bring education to the nurse leaders in long term care.

Many of them are new nurse leaders, or nurse leaders who have been in their roles for three years or less, but have never had the education. And it's education on tasks and things that They're being asked to do as nurse leaders, but it's not stuff that's taught in nursing schools. It's not anything that's taught in orientation, but there are things that they need to do as nurse leaders.

So pulling on, on our experience, on my experience as a nurse leader and sharing that information with them and even giving them those little, okay, reading between the lines, this is what this means. But trying to lighten their workload, lighten their burden by saying, this is how to do it. So here's the roadmap to get to where you need to go.

And your manager is going to expect this from you. Your facility is going to expect this from you. We also have several partnerships with consulting companies. It's a long list of consulting companies that we have partnerships with because they assist us with education and they're always happy when we contact them.

Could you provide education on X or our members are starving for information on a B or C. But another partnership that we're really excited about and grateful for is our  partnership with the Q. I. O. With quality insights and that partnership has really assisted us and it's benefited our members through education and one of the people Deb Wright is on our board are put on a board.

So Deb, if I could turn it over to you for a few minutes to talk about being involved with Madonna and being a partner for Madonna. Or I mean, Madonna has been an organization that I've been involved when in one way or another, quite frankly, for almost all of my nursing career, I had a fantastic director of nursing that was such a mentor to me and got me involved in Madonna very early on in my career.

So then when I joined Quality Insights, I reached out to Padana to see how we could better collaborate with each other and on certain initiatives. And Sophie and Candice were just so welcoming and willing to work together. We've done a number of great things, but I think the most successful has been getting the infection control boot camp for leader education out there to so many new IPs with the constant turnover.

It's just an educational opportunity that is proven to be so impactful to the nursing homes, not only for those new IPs and directors of nursing and NHAs. But also a good reminder for all of us that have been in the industry for a long time. I think that everything that we've gone through over the recent years, it's like we were constantly drinking from a fire hose, as they would say, and then you add in that constant turnover.

It's just been ever changing. And Padana has just continued to change as everything has changed in our industry. So I think many of us are now just looking to simply get back to the basics. And this program has helped with that with so many of the other programs that Padana has for the long term leaders and frontline staff.

It's just not  the nursing, the directors of nursing, but it's, it's, all the nurses can benefit from the education that Padana offers. I will agree. I was been lucky to participate in several conferences that Padana has organized and I've just enjoyed, I will say, maybe I'm a little strange, but when I get a request to do a conference session, make a presentation, I really enjoy learning   and really honing in on my  information and skills in that area.

And I think the conferences that, that Padana's organized have just been just fantastic. So kudos, kudos to you, Sophie. So thank you so much. You're welcome. So what is the current state of nursing leadership in nursing homes post pandemic? I hate this. Keep saying post pandemic. So just where we are now and what new skills or strategies have emerged is critical and important for managing care teams  currently during this time.

Well, I think the pandemic, if we go back to that, it's forced  and it's required nurse leaders to see infection prevention and control in a different way.  It's forced them to look at always being prepared. It's made it a little bit easier for them to talk about preparedness with management because before it was infection prevention and control.

It's all nursing and we learned with the pandemic. It's not all nursing that yeah. Other departments need to be involved. It's a whole facility effort. It's a team sport, as I always say.  So I think the pandemic has really brought that to light and brought it forward. But I think nurses have been required to adjust their thinking, to adjust their strategies, and to adjust their skill sets.

Admissions are entering the facilities with higher acuity. We're getting more admissions.  They're seeing more equipment and different types of equipment. Things that, that back in the day when I started in long term care we didn't see all of that stuff. Residents don't want to stay.

They want to go back home.  When we used to keep a resident for a long time the length of stay now is 7 to 14 days. So nursing leaders have to help their team members adjust to that. It's not getting to know the resident anymore as one of our family. It's assisting them to get back to their family.

Families are different. They want more information. They don't trust the medical team and nursing's partway between the medical team, no offense Dr. Storm but  the nursing's partway between the medical team and  the residents. So they're kind of the middle of the Oreo in trying to. Share with the resident what the doctor is really saying and then share with help the resident to talk to the doctor, ask their questions and share with the doctor where the resident really is and what they're thinking.

And that didn't happen before because they weren't as acutely ill when they came to nursing home. So they're thinking in a different way, but also the staff is different now. So it's forced nursing leaderships that nursing leadership to think differently. Staff are looking for different things in the hiring process.

It's not the money or the insurance anymore, but they're looking for time off. They're looking for what can I do with my family? That's hard to do when you're you've got shifts and where you've got to, you've got people to take care of. You're not taking care of widgets. You're taking care of people.

So they're having to adjust in that way. So again, I think, The pandemic has contributed in a large way to the staffing challenges because a lot of people left nursing as a result of the pandemic. Some of our staff members died during the pandemic and that expounded on what we're dealing with.

But I also think, and I just need to throw this out there because this is a pet peeve of mine. I also think that social media and  TV  has just. it's made it even more negative for someone to come into health care and especially to come into the nursing home to come into long term care, both residents as well as staff members.

 People look at nursing homes now is it's a place to die. That's where it was. We changed that and people still look at that in a lot of ways. And I don't think social media or tv shows are helping us because they're portraying this negative view of what we are, a negative perspective of what we are in the nursing home.

And I think nursing leaders have to combat that every day in interviews and with family members and even with residents. So I think that's a big part of their job as well. A hundred percent. I agree.   I really have a hard time with that as well because I feel, I just love the feeling of walking into a nursing home.

So  I would agree. I think that's everybody's job who works in long term care to kind of combat that idea that a nursing home is where people go to die. It's not, not the case. So I was, we talked a little bit about the pandemic. It placed an immense pressure on the nursing workforce. You talked about some colleagues who passed away in the pandemic.

 And I think a lot of nurses left  whether that was directly from the pandemic, I will argue that it may be from  what happened after the pandemic is a lot of, there was a lot of  talk that  COVID really didn't exist or it wasn't that bad or all of those kinds of things. So, so let's talk a little bit.

about the current state of the nursing workforce in long term care and the efforts that PADANA is undertaking to support retention and recruitment in this field. Well, we can start with the easy one, but Donna does post nurse leadership positions to our website in order to assist with the recruitment process.

We can't post every position that a nursing home has, but if it's a leadership position and we've posted administrator positions and infection prevention is position. If it's a nurse leader position or a leadership position, we posted on our website. And we have heard that nurse leaders go to the padana website to look for positions especially in the state of Pennsylvania.

So that's great.  So that's one of the things we do. We also sent out an e newsletter every other week and it provides information from leading healthcare sources to help our nurse leaders to help nursing leadership to see what's going on out there so that they can Reach out and do different things and know what's happening in the workforce to talk about where the staffing challenges are and to know what you know, the different generations are looking for when they come in for a position we've had people who have done education for Madonna to talk about the different generations.

These people do hiring and recruitment for a living and we've had them come in and talk about that and what should. the facilities be looking for and what should the facilities pay attention to and listen for when they're doing interviews. And that has really helped our nursing leadership.  Not only from a, what type of an ad should I be placing to what should my ad say, but also what should I say in the interview process?

What are the questions I should ask? And what the answers I should give when people ask me the questions or what should I, find out from them what's important to them. But in addition to that, the other thing that we're doing is we're supporting them by trying to take some of the burden from them so that they can do more with recruitment and retention.

And I think if the nurse leaders, if nursing leadership is educated and informed and they can take that to their team members. Their team members are more likely to stay because they're going to be informed and they're going to know what's happening in the facility with the disease processes. When you have infection preventionists who can go to the infection preventionist boot camp  for eight hours and learn all of the things that they learned and take it back to their jobs are, I don't want to say easy, but they're easier.

It takes  the burden off them and it allows them. to be able to function at their capacity because they've learned this and they don't have to go out and find it. They came to education for eight hours and they learned it and they feel supported and they feel valued and they feel invested in and that's retention.

That's where we're going to keep the staff. So I think the education does help. What I have also heard is when a lot, a lot of our nurse leaders attend education, they bring a team with them. So the nurse leader registers, but they bring a team with them so that other folks are hearing the education. And then they take pieces of the education that put on is provided and they've attended.

And they take it in bite sized pieces to their staff meetings and they educate their team members, which again, the more they know, the more they're, the better they're going to do at their jobs, the less of a burden their jobs are going to feel like, and that's retention. Recruitment. Again, I think we've got to change the perception of nursing homes.

We've got to change what we do and how we do it and who we are and who comes into a nursing home. I think that's a big part of recruitment and the teaching nursing home collaborative. And that's why we're so excited about that initiative as well. And to be partnered with them is bringing those students into the nursing home and showing them there's a little sticker that you can get.

It says old people are cool. I believe that wholeheartedly. I believe that ever since I got into long term care, old people are cool. And I think it's great to show the students because students always think they've got to go into med surge, but anywhere they go, they're going to see. Folks who are geriatrics.

They're going to see these old people. So it doesn't matter if they're in home care or if they're in a clinic or if they go to a doctor's office or if they go to long term care, even in med search, you're going to see people who are over the age of 65. So they need to feel comfortable with geriatrics.

And if we can do that for them in the nursing home, that's going to help with recruitment, but it's also going to help with recruitment. them being able to assist the geriatric person wherever they are. Yeah. And it's so meaningful. This population of patients, I will say it is very meaningful work.

So I, yes. So I'm going to talk about.  Big thing now, vaccines. So nursing leaders play a significant role in addressing vaccine hesitancy and misinformation in long term care. So we're just talking about vaccines in the long term care world, which are important because we have individuals who are vulnerable are at and at risk.

To be hospitalized. And we know if people get hospitalized with illnesses and more, they're more likely to die, have less quality of life. And we know that vaccines can help  protect our nursing home residents from going to the hospital, getting very sick and dying. So what steps can nurse leaders take to ensure that their teams, their residents and families feel informed and confident in making vaccination decisions?

Educate  educate.    I can't say that enough. I think educating residents, staff, families, even physicians regarding the vaccines, there's so many great posters that are out there from the CDC and from CMS and from patient safety authority and even the QIO. And so, so many great posters to put out there regarding vaccinations, but to start that education and keep that education going year round regarding vaccinations and  Not so much  we're forcing you to get vaccinated  but also sharing with them  in terms of education, what is RSV all about?

What is influenza all about?  These words are tossed out there, but if we don't share with the residents and with the families what this means  and how significant it can be, and the fact that they're in a communal environment and your dad loves to go to activities. Your dad loves to go eat in the dining room and we want him to be safe and we want him to be protected.

Just those kinds of things. Not to scare them, but to educate  and  that's a big difference. I think in some facilities, we try to scare the families. We try to scare the residents, but it's more important to educate them  and that again is we put Donna sends out so much information that providers can use that nursing leadership can use as is.

It's there. It's done for you. Use it. But that education is significant so that they understand what the nursing home environment is all about and that how much dad or mom or grandma or whoever appreciates that environment and that the vaccination will be important. And even for the staff members. Yeah, I would agree a hundred percent.

So I'm going to ask both of you this question. So Sophie, I'll ask you first, but Deb, I would love to hear how you feel as well. What advice would you give to someone who is considering pursuing a career in nursing leadership, particularly in long term care? And what would you tell them what skills and experiences are most valuable for success in the field?

Well, I have two words with an exclamation point after it. Do it.    I feel very strongly about nursing leadership. It's such a, it's a different world, but it's a phenomenal part of nursing. It's a phenomenal part of what we do in long term care. And I love long term care. Most of my career has been in long term care.

I've had a number of different roles in long term care, but  it's fantastic. But what skills do they need? Be flexible. be present, be engaged, be a servant leader.  All of those things are so important in long term care. We're not there to take care of our residents. We're there to be present for our residents.

We're there to be in our residents homes.  And it's a whole different environment than in the hospital when they're guests in our hospital, but we're guests in their homes. And it's looking at things very differently learn as much as you can about leadership and take advantage of education, like what Padana offers like what the QIO offers so that you can learn about  Leadership, because leadership is leadership, but nursing leadership is little more specific, but learn as much as you can, but if you can bring those skills, not skills, but those qualities of being flexible, being present, being engaged and being a servant leader, I think that it goes a long way in nursing leadership, and it goes a long way in the nursing home.

Yeah, I absolutely agree. And I think we've seen the nursing leaders change over time as Sophie was saying earlier. So If you're, I guess I have two, two paths of an answer with this. If you're going in to be a nurse leader in longterm care, and we're seeing a lot of leaders do that, that are coming right from the hospital.

If that's the path that you're taking, then you have to be present. Just like Sophie was saying, you need to be present with the staff that you're leading so that you're making the decisions that. impact them and the jobs that they're doing to care for the residents that are living in the home. If you're that leader that has worked your way up the ladder, then that is sometimes just as great because now you can say, I've done this.

I've walked in your shoes. Now let's walk in the shoes together and I can make a difference for all those years that I've worked  in the facility. So I think there are a number of ways that, that people become nurse leaders. And I absolutely agree with Sophie. It's about being present. It's about being present with the type of leader that you are and learning what the long term care environment's all about.

I mean, it's the heaviest regulated industry almost, and But yet we're taking care of people and we're taking care of their lives and we want to make it meaningful for them. So it's, I absolutely, I think Sophie's comment was just absolutely spot on. It's about being present wherever you're working.

Yeah, and I will say I can, yes, very heavily regulated, but that being present with the people some  are  have advanced age. So they're in the later part of their life. So  really providing the best quality of life  and home environment for them. So I appreciate both of your inputs.

It was very valuable. So last question, let's look ahead to the future of nursing leadership in long term care. Are there any upcoming initiatives or changes  that you're particularly excited about with Padana? How do you envision Padana's role evolving in the next five or 10 years? Are there any key areas of focus that the organization is going to be looking at  in terms of improving longterm care across Pennsylvania?

Well, there we've already made some big changes. Padana started out being, as our name says, the Association for Directors of Nursing Administration. And we've expanded. Nurse leaders are more than welcome. And we're looking at nursing leadership and the education that they need and the role that they play.

But again, I see that expanding everything. We now have members who are  infection preventionist, wound care nurses, supervisors not just directors of nursing.  And again, seeing themselves as nursing leadership versus seeing themselves as directors of nursing or assistant directors of nursing.

The facilities haven't changed the name, but there's, we haven't changed the name of Padana either, even though. We've changed our membership. So we're all evolving. I don't know if the name will ever change because it's so easy to say Madonna. But  we've evolved. And I think looking at five or 10 years from now, I think that's only going to grow.

But I see in terms of the future of nursing leadership. I think it's going to become the nurse. Nursing leadership is going to know more. They're going to need to know more. We have to make our own path. Nursing leaders have to make their own path  and they have their perspective of nursing has changed the way they look at things again, knowing the business, knowing all aspects of what's happening in the facility, being tied in with other departments, having that interdisciplinary focus, not just being where we're a nursing department, we're interdisciplinary.

We're interrelated. We have to work together or it's not going to happen for the resident. It's not going to happen for the facility. So all of those things I think are important. And in the next 5 to 10 years, I see those becoming more and more important. And I see. The role of nursing leadership evolving to the point of we're going to change nursing leadership is going to change what people think and how people think about long term care.

And it's, I think it has to start with nursing leadership because at as again, nurses are l have those crazy magazine sometimes that and some o can go to the library and that the crazy night nurse of those things. So  We've got to change the way people see nursing leadership and we've got to change the way people see long term care and nursing has to be at the forefront of that because it's where we work, it's what we do.

So nursing and long term care has got to work on making those changes and I'd like to see it happen in the next year, but I know that's really too energetic and enthusiastic, but if we could do that in the next three years, that would be fantastic. I love when I hear nursing leaders saying that they are sending letters to their congressman or sending letters to this committee or sending letters to this association because they see something that needs to change.

That didn't happen before and that needs to happen more and more often. People need to understand more about the long term care facility, more about long term care, but more about nursing leadership in long term care, who we are and what we do. And again, I think. Podcasts like this, Dr. Storm, I think are going to be great in getting that message out there.

And I think it, it helps for nursing leaders to hear that what they're doing is important and what they're doing is appreciated and they've got to keep doing it. I would agree. I'll say I was raised by a nurse and so I'm a huge fan and I, would agree you're, you are just the, you're instrumental, especially in long term care.

And I, I appreciate all the work, all the nurses that I've worked with over the years. So Sophie and Deb, thank you so very much for this conversation today. I've enjoyed it. Last, I guess, last question. If someone wants to find out more about Padana, how can they do that? They can go to our website, www dot Madonna dot com and everything is there.

There are multiple tabs there. They can find continuing education. Everything that we offer is there. They can find out about the organization, read about our mission and our vision and our philosophy. They can find out about our annual conference. They can find out about who our board members are and Deb's lovely picture will be there and they can, again, learn all about the organization.

We have everything available out on the website.  And then if they have any questions, they're more than welcome to call me. I am very excited to talk about Padona. As you can tell, I'm very excited to talk about what we do and certainly excited to talk about nursing leadership in long term care.

Wonderful. I do. I encourage anyone who is interested thinking about nursing leadership and long term care to check out the website. There's many valuable resources. Again, thank you, Sophie and Deb, for joining us today. I really appreciate it. Thank you for the opportunity. 

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.