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Preparing to respond: Irish nurses' perceptions of preparedness for an influenza pandemic
International Emergency Nursing 26 (2016) 3–7
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Preparing to respond: Irish nurses’ perceptions of preparedness for an influenza pandemic Caroline McMullan PhD, MPhil, BA(hons) (Associate Dean for Teaching and Learning) a,*, Gavin D. Brown MSc, BSc(hons) (Research Officer) a, David O’Sullivan MSc, BSc(hons), PDip (Chief Emergency Management Officer) b a b
Dublin City University Business School, Dublin, Ireland Health Service Executive, Cork, Ireland
A R T I C L E
I N F O
Article history: Received 4 June 2015 Received in revised form 13 October 2015 Accepted 24 October 2015 Keywords: Influenza Pandemic Hospital preparedness Pandemic planning Nurses’ risk perception Emergency management
A B S T R A C T
Introduction: The aim of this research was to garner opinion on: the concerns of nurses in respect of the key issues that they may face in the event of an influenza pandemic; the perceived impact of an influenza pandemic on these nurses; and the current level of perceived preparedness in their hospital. Of particular significance is the fact that data for this study were gathered from nursing staff during a period when there was a heightened risk of an outbreak. Methods: The data for this study were gathered using a structured, self-administered questionnaire, which was distributed to 127 nurses. A response rate of 72% was achieved. The questionnaire was based on the instrument used by Wong et al. in their 2008 study of preparedness for an avian influenza pandemic in Singapore. Results: Although the results reveal a number of concerns raised by nurses, it is clear that the majority (90%) view treating and caring for influenza patients as core to their role. While recognising their professional responsibilities, they reveal apprehension about certain aspects of their work, such as an increased likelihood of infection, added workload and pressures, an increased concern for those close to them who could become infected as well as the overall increase in stress levels at work. The extent of professional and personal preparedness, together with the concerns and perceptions of nurses, could affect the hospital’s overall capacity to respond and these concerns should be addressed by those responsible for the development of pandemic response plan. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The World Health Organisation (1999) describes an influenza pandemic as an event in which the human population has no immunity against the disease, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness. Highly pathogenic influenza pandemics have occurred at unpredictable intervals approximately three to four times per century. These, according to Gust et al. (2001), have caused untold morbidity and mortality, in addition to considerable social disruption and economic impact. Healthcare continues to face radical challenges and the evolution of emerging and re-emerging diseases heighten the impact of such challenges (Jones et al., 2008). At the outbreak of SARS (2003/ 2004) there was a paucity of information about the aetiology, mode
* Corresponding author. Dublin City University Business School, Dublin, Ireland. Tel.: 00353 1700 8250; fax: 00353 1 700 5446. E-mail address: [email protected] (C. McMullan). http://dx.doi.org/10.1016/j.ienj.2015.10.004 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
of transmission and physiological impact of the disease. However, its rapid clinical course, its impact on healthcare workers (both personally and professionally) and the fear arising from the risk of occupational exposure have been the focus of subsequent research. The outcomes of these studies, as well as those relating to other infectious diseases, should therefore be incorporated into the planning for future infectious disease outbreaks so that hospitals and healthcare workers are better prepared to deliver an appropriate response. There is no doubt that acute hospitals will “form the cornerstone” of the response to pandemic influenza in most countries and that hospitals will “face pressures to deal with large numbers of patients with pandemic influenza in addition to “routine” medical emergencies and, where capacity exists, the continuation of nonemergency care” (Pandemic Influenza Expert Group, 2008, p. 12). As is the case across the globe, the Irish healthcare system’s ability to cope during an influenza pandemic will depend, to a large extent, on the number of healthcare workers, including nurses who are able and willing to work through such an outbreak. Planning for major emergencies in Ireland assumes that once a pandemic is
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confirmed, the Irish Health Service Executive will care for the large number of patients impacted and will only provide essential care for other patients. Guidance based on modelling data submitted by the UK Scientific Pandemic Influenza Advisory Committee Subgroup on Modelling (2008) estimates staff absenteeism at between 30% and 35% at the peak of a pandemic because of illness and/or caring responsibilities. Ireland estimates similar rates of absenteeism from work. Such estimates take into account the cumulative effect of factors such as staff illness, possible school closures and the resultant need to look after children, caring for elderly relatives, and a possible disruption to public transport. In planning for a pandemic, emergency and nurse managers, among others, should give consideration not only to the planning of a response and recovery operation but also to the people who will be required to respond. As Reissman et al. (2006) note: “Without adequate planning and preparations, an influenza pandemic in the 21st century has the potential to cause enough illnesses to overwhelm current public health and medical care capacities at all levels, despite the vast improvements made in medical technology during the 20th century.” (p. 1) The aim of the study was to capture the perspectives of nurses who were involved in planning for an influenza pandemic within an Irish acute general hospital. The research was completed so that their opinions, perspectives, and fears could be captured with a view to enhancing preparedness for infectious disease outbreaks. 2. Methodology This research uses a case study methodology where quantitative data were collected, using a structured questionnaire, from nurses working in an acute general hospital located in the south of Ireland. Data were collected at a time when there was a heightened risk of an influenza outbreak. This provided an opportune time to conduct the research as the hospital nursing staff were in the process of planning and preparing for an outbreak. There were 127 nurses working in this acute care setting, and all of these nurses were expected to have exposure to the ongoing preparedness and readiness planning. The data collection focused on the personal and professional concerns of nurses, the perceived impact that a pandemic could have on these nurses, and the overall level of preparedness within the hospital. Given the research question, and a desire to survey the opinions of all 127 nurses employed at the hospital, it was decided that rather than employing a similar approach to the scholars Ki and Maria (2013), who conducted interviews with ten nurses during the human swine influenza outbreak (SARS) in Hong Kong, gathering data via a questionnaire would best suit the research objectives. The work of Wong et al. (2008) in particular informed the design of the questionnaire as they had researched healthcare workers’ concerns, the perceived impact and preparedness levels in relation to the avian influenza pandemic of 2006. The questionnaire used in this study was derived, with permission, from the Wong et al. study (2008) published in Annals, Academy of Medicine, Singapore. While accepting the reliability, validity and overall robustness of the original study, a pilot study was nonetheless completed to ensure the questionnaire suited the slightly different subject matter, pandemic influenza rather than avian influenza, and any cultural differences between Singapore and Ireland. It was felt that this additional pilot study would provide a further check on the clarity and quality of the survey. The results of this pilot, completed with a sample of nurses drawn from a different hospital in the same geographic location, were positive and no methodological issues were identified. The self-administered, paperbased questionnaire was distributed to all 127 nurses working in
an Irish hospital. 91 nurses completed the survey, which amounts to a response rate of 72%. 2.1. Demographics A brief review of the demographics of the 91 respondents showed that they are broadly in line with the gender breakdown of nurses in Ireland, as 99% of respondents were female and 1% were male. The Irish Nursing Board (2010) report of 2010 stated that 4.7% of general nurses registered in Ireland were male. In this study, 76% of respondents had more than ten years of nursing experience while 24% had nine years or less. All 91 respondents held a recognised nursing qualification. 3. Results The findings of this study are divided into three core topics: concerns, perceived impact, and the level of preparedness for an influenza pandemic. 3.1. Concerns regarding an influenza pandemic The majority of nurses (87%) felt that their job would put them at an increased risk of exposure, while just under half of them (48%) were afraid of actually contracting pandemic influenza. Notwithstanding these concerns, 65% considered the risk of contracting influenza to be “part of their job.” In spite of the additional risk posed, only 4% suggested that the risk emanating from an influenza outbreak would make them look for other work. However, 24% felt they would understand if their colleagues resigned due to the perceived risk from an influenza outbreak. There were mixed views among respondents as to whether they felt confident that their employer would look after their needs if they became ill with influenza. 42% felt confident they would be taken care of by their employer. It is important to recognise that nurses belong to family units and/or communities that will also be at risk during a pandemic. Therefore, it was considered pertinent to review non-work-related concerns regarding an influenza pandemic. The findings show that 67% of respondents were worried that because of their job, people close to them would be at an increased risk of contracting influenza. The nurses voiced concerns for children (77%), spouse/ partner (71%), work colleagues (68%), parents (66%), and close friends (66%). While nurses expressed concern for family, friends and colleagues, this study also found that the nurses believed that people close to them would be worried for the nurses’ own health (78%). This highlights the importance of taking into account a wide range of stakeholders when planning for the effects of a pandemic on hospital staff. It is recommended that the hospital communications strategy includes methods to provide relevant information and guidance not only to staff but also their families and other relevant stakeholders. It is particularly important to provide information regarding the resources that will be put in place to support the nurses (and their families) during a pandemic. 3.2. Perceived impact on personal and professional life A number of questions were asked to gauge the respondents’ perceptions surrounding the impact of an influenza outbreak on their personal and professional life (see Table 1 for results). A large proportion of respondents reported no fear of telling either their family or other people about the risks to which they could be exposed (76% and 68% respectively). With regard to the staffing levels needed to cope with a pandemic, 86% of respondents felt there would be inadequate staff in
C. McMullan et al. / International Emergency Nursing 26 (2016) 3–7
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Table 1 Perceived impact of influenza pandemic on personal life and work. Statement
Agree (%)
Disagree (%)
Skipped (%)
Given my exposure, I would be afraid that my family are placed at an increased level of risk. I would avoid telling other people about the nature of my job. People would avoid me because of my job. People would avoid members of my family because of my job. I would have an increase in workload. There would be inadequate staff at my hospital to handle the increased volume of work. I would have to work extra hours. I would feel more stressed at work. There would be more conflict among colleagues at work.
23 31 32 14 90 86 65 76 64
76 68 67 84 9 12 34 23 35
1 1 1 2 1 1 1 1 1
their workplace to handle the increased demand and surge in activity following an outbreak. Likewise, 90% of the nurses surveyed believe they would have an increased workload during a pandemic and 65% agreed that they would have to work extra shifts to help cover this increased volume of work. Perhaps linked to this increased pressure and work rate, respondents felt that a pandemic would lead to increased levels of stress (76%) and conflict (64%) in their workplace. 3.3. Preparedness for influenza pandemic More than half of the nurses surveyed (60%) perceived the hospital to be prepared for an influenza pandemic. 85% of respondents indicated that they had received training in infection control in the hospital, with 71% confirming that this had occurred during the “past six months.” Over three quarters of respondents (77%) confirmed that the hospital had a pandemic preparedness plan, even though some were not aware of its content. At an individual level, 53% felt they were “personally prepared for a pandemic influenza outbreak.” Less than half of the nurses (46%) felt that they had adequate training on the use of Personal Protective Equipment (PPE). The majority of nurses (82%) noted, however, that they did have someone to turn to if they were unsure how to use specific PPE. Just 11% of nurses confirmed that they had received the seasonal influenza vaccination within the past six months, despite 59% of respondents acknowledging that they had been advised to do so by their employer. With regard to personal preparedness outside the hospital setting, 13% of nurses had bought influenza medication and 4% had bought masks for use outside of work. 4. Discussion This study assessed the concerns, perceived impact and preparedness of Irish nurses for an influenza pandemic. The findings of this study reflect a similar pattern to findings in other studies conducted in countries and continents such as Canada, Asia, U.K., U.S. and Australia; and undertaken by researchers including Maunder et al. (2003); McGillis Hall et al. (2003); Grace et al. (2004); Ho et al. (2005); Kwek et al. (2004); Nickell et al. (2004); Maunder et al. (2005); Qureshi et al. (2005); Ehrenstein et al. (2006); Mounier-Jack and Coker (2006); O’Boyle et al. (2006); Tam et al. (2007); Wong et al. (2008); Ives et al. (2009); Seale et al. (2009); and Ki and Maria (2013). Similar studies also found that nurses are willing to provide care during an influenza pandemic and accepted the increased risk of contracting influenza as part of their job as healthcare workers (see, Ehrenstein et al., 2006; Hogg et al., 2006; Shaw et al., 2006; and Wong et al., 2008). Danger to personal health was identified as one of the most prevalent concerns among Singaporean-based healthcare workers during SARS (Kwek et al., 2004). Similarly, this study of Irish nurses preparing for an influenza pandemic revealed that they too perceived that their occupation placed them at a higher risk of
contracting influenza. Their concerns were comparable to those expressed by healthcare workers during avian influenza epidemics – Wong et al. (2008) found that 82.7% of health care workers felt that their job put them at greater risk of exposure, whereas Ki and Maria (2013), who studied SARS, found that only four out of ten emergency nurses interviewed in a Hong Kong hospital were concerned for their own personal health and their susceptibility to infection. However, Ki and Maria (2013) report six out of the ten nurses interviewed showing concern for their family members – a higher result than that emanating from this study. The study conducted by Wong et al. (2008) found an even greater level of concern for family members, with concern for children, spouse/partner and parents being expressed by over 95%. These are important findings that could affect a nurse’s ability and/or willingness to work in the event of an influenza pandemic. The risk to nurses and illness rates must be considered within the major emergency planning process. This study also highlights the paradoxical situation between how healthcare workers might feel about their duty to care for patients and their personal duty to care for themselves and their families. Sokol (2006) emphasises that, “the term ‘duty to care’ [. . .] is, at best, too vague and, at worst, ethically dangerous” (p. 1238). Ruderman et al. (2006) contend that this conflict between personal and professional duties of care could potentially affect the level of availability of healthcare workers in the event of an influenza pandemic and consequently should be addressed in pandemic planning. Increased stress levels caused by the heavier workload, extended working hours, increased number of shifts, and the lack of personnel to cope with the surge in clinical activity were predicted by the nurses in this study. Furthermore the respondents suggested that the staffing levels needed to cope with a pandemic were unlikely to be provided within their hospital. Ki and Maria (2013) asked ten nurses a similar question relating to staffing levels during a pandemic, and found that all agreed that staffing levels were an issue – with nine staff members attributing this to increases in patient attendance. Wong et al. (2008) found that 78.6% of the health care workers surveyed agreed that there would be an increased workload, with 58% suggesting that there would be inadequate staffing levels. Research indicates that stress levels can be reduced by mobilising resources and facilities to support and enable nurses to discuss their fears, anxieties and concerns. Maunder et al. (2003) and Wilson et al. (2005) assert that psychosocial support for healthcare workers and associated measures to manage the psychological impact of an influenza pandemic are extremely important in the pandemic planning process. Such measures could take the form of counselling (United States Department of Health and Human Services, 2005); education (Maunder et al., 2008); provision of PPE; incentives to maintain levels of service and encourage morale (Maunder et al., 2003), provision of accommodation on site and effective communication with families (McGillis Hall et al., 2003; O’Boyle et al., 2006). All of the aforementioned measures could prove crucial in maintaining
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essential services and the integrity of the healthcare system during an influenza pandemic. The seasonal influenza vaccination was also not widely used, with nurses reporting low uptakes within the past six months of the study. Although the routine seasonal influenza vaccine will not protect against a pandemic strain of influenza, Mondo (2005) proposes that vaccination against seasonal influenza should still be actively promoted in people most likely to come into contact with a pandemic strain, including healthcare workers such as nurses, in order to minimise the risk of co-infection and viral genetic reassortment. Given the nurses’ concerns regarding their increased risk of contracting influenza during a pandemic, the provision of adequate and appropriate protective measures may provide an element of reassurance to them. Such actions may help nurses feel better prepared, maintain their morale and possibly mitigate against increased absenteeism during an influenza pandemic. The need for confidence in the employer’s commitment to look after their staff, particularly if they became ill during the course of a pandemic, was highlighted in a number of studies. This was particularly evident in Toronto in the aftermath of the SARS epidemic (Registered Nurses Association of Ontario, 2003; University of Toronto Joint Centre for Bioethics, 2003). There were mixed views among respondents in this study as to whether they felt confident that their employer would look after their needs if they became ill with influenza during the course of an influenza pandemic; with 42% agreeing. This finding emphasises the requirement for a hospital’s preparedness plans to consider not just the needs of patients but also their staff members. This is in line with findings from McGillis Hall et al. (2003); the Registered Nurses Association of Ontario (2003); the University of Toronto Joint Centre for Bioethics (2003); Kwek et al. (2004); O’Boyle et al. (2006); and Wong et al. (2008). Findings suggest that by addressing these concerns in advance of an outbreak the hospital management team could increase the availability of nursing staff during a pandemic. Organisations should address issues such as medical treatment, psychosocial and psychological interventions; communication; preparedness of staff; PPE; medications; vaccinations; education and training; facilities for staff, including accommodation on site and transport; support measures for families and dependents of staff; income protection, early detection and warning systems for staff (Crupi and Asnis, 2003; Hui et al., 2007; Ren and Hung, 2005; Tan, 2003). Should these factors be incorporated within a hospital preparedness plan, the findings of this study, and others, suggest that such provisions will at least reduce, if not eliminate the fears, concerns, uncertainties and absenteeism among the nursing population. 5. Conclusion Major emergencies will always create challenges for a health service, both in terms of the scale of added clinical activity and increased demands on the workforce and available resources. Moreover, when a major emergency is caused by an infectious disease these challenges are magnified for the health professionals who will be expected to lead the response. It is vital that the fears and concerns of the healthcare workforce should be considered by emergency managers. Nurses by virtue of their close proximity to the patient on a constant basis, 24 hours a day, seven days a week, are at a higher risk of exposure. Yet their role is fundamental in providing patient care. It is therefore vital that they would be the focus of research as a specific cohort. While many of the concerns and perceptions reported by this group are shared among other members of the health care team, there are some issues that have a greater relevance to nurses. This study provides a brief insight into these fears and concerns. It also provides insight into nurses’ perception of preparedness. By considering the points raised by those in the front line of health care provision, emergency
managers shall be better placed to manage these fears, improve the working environment for these staff and provide a more effective level of care to the community. Conflict of Interest None declared. References Crupi, R.S., Asnis, D.S., 2003. Meeting the challenge of bio-terrorism: lessons learned from West Nile virus and anthrax. American Journal of Preventive Medicine. 21 (1), 77–79. Ehrenstein, B.P., Hanes, F., Salzberger, B., 2006. Influenza pandemic and professional duty: family of patients first? A survey of hospital employees. BMC Public Health. 6, 311. Grace, S.L., Hershenfield, K., Robertson, E., Stewart, D.E., 2004. Factors affecting perceived risk of contracting SARS among academic physicians. Infection Control and Hospital Epidemiology. 25 (12), 1111–1113. Gust, I.D., Hampson, A.W., Lavanchy, D., 2001. Planning for the next pandemic of influenza. Reviews in Medical Virology. 11 (1), 59–70. Ho, S.M., Kwong-Lo, R.S., Mak, C.W., Wong, J.S., 2005. 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Ren, J.J., Hung, J.S.H., 2005. The role that symptom surveillance plays in coping with public health laboratory of part provinces in China. Chinese Journal of Preventive Medicine. 39, 56–57. Ruderman, C., Tracy, C.S., Bensimon, C.M., Bernstein, M., Hawryluck, L., Shaul, R.Z., 2006. On pandemics and the duty to care: Who’s duty? Who cares? BMC Medical Ethics. 7, 5. Seale, H., Leask, J., Po, K., MacIntyre, C.R., 2009. Will they just pack up and leave? Attitudes and intended behaviour of hospital health care workers during an influenza pandemic. BMC Health Services Research. 9, 30. Shaw, K.A., Chilcot, A., Hansen, E., Winzenberg, T., 2006. The GP’s response to pandemic influenza: a qualitative study. Family Practice. 23 (3), 267– 272. Sokol, D.K., 2006. Virulent epidemics and scope of healthcare workers’ duty of care. Emerging Infectious Diseases. 12 (8), 1238–1241. Tam, D.K.P., Lee, S., Lee, S.S., 2007. The impact of SARS on avian influenza preparedness in healthcare workers. Infection. 35 (5), 320–325. Tan, X.D., 2003. The Prevention and Control of Public Health Emergencies. Science and Technology Publishing House, WuHan, China.
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United Kingdom Scientific Pandemic Influenza Advisory Committee Subgroup on Modelling (2008) Modelling summary. http://advisorybodies.doh.gov.uk/ spi/minutes/spi-m-modellingsummary.pdf accessed 12/04/2010 United States Department of Health and Human Services (2005) HHS pandemic influenza plan. http://www.hhs.gov/pandemicflu/plan/ accessed 14/02/2010 University of Toronto Joint Centre for Bioethics, 2003. Ethics and SARS: Learning from the Toronto Experience. A Working Group Report. University of Toronto, Toronto, Ontario, Canada. Revised 13 August 2003. Wilson, N., Baker, M., Crampton, P., Mansoor, R., 2005. The potential impact of the next influenza pandemic on a national primary care medical workforce. Human Resources for Health. 3 (7), 1478–1491. Wong, T.Y., Koh, G.C.H., Cheong, S.K., Lee, H.Y., Fong, Y.T., Sundram, M., et al., 2008. Concerns, perceived impact and preparedness in an avian influenza pandemic: a comparative study between healthcare workers in primary and tertiary care. Annals Academy of Medicine. 37 (2), 96–102. World Health Organisation, 1999. Influenza Pandemic Preparedness Plan: The Role of the World Health Organisation and Guidelines for National and Regional Planning. World Health Organisation, Geneva, Switzerland.
Contents lists available at ScienceDirect
International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n
Preparing to respond: Irish nurses’ perceptions of preparedness for an influenza pandemic Caroline McMullan PhD, MPhil, BA(hons) (Associate Dean for Teaching and Learning) a,*, Gavin D. Brown MSc, BSc(hons) (Research Officer) a, David O’Sullivan MSc, BSc(hons), PDip (Chief Emergency Management Officer) b a b
Dublin City University Business School, Dublin, Ireland Health Service Executive, Cork, Ireland
A R T I C L E
I N F O
Article history: Received 4 June 2015 Received in revised form 13 October 2015 Accepted 24 October 2015 Keywords: Influenza Pandemic Hospital preparedness Pandemic planning Nurses’ risk perception Emergency management
A B S T R A C T
Introduction: The aim of this research was to garner opinion on: the concerns of nurses in respect of the key issues that they may face in the event of an influenza pandemic; the perceived impact of an influenza pandemic on these nurses; and the current level of perceived preparedness in their hospital. Of particular significance is the fact that data for this study were gathered from nursing staff during a period when there was a heightened risk of an outbreak. Methods: The data for this study were gathered using a structured, self-administered questionnaire, which was distributed to 127 nurses. A response rate of 72% was achieved. The questionnaire was based on the instrument used by Wong et al. in their 2008 study of preparedness for an avian influenza pandemic in Singapore. Results: Although the results reveal a number of concerns raised by nurses, it is clear that the majority (90%) view treating and caring for influenza patients as core to their role. While recognising their professional responsibilities, they reveal apprehension about certain aspects of their work, such as an increased likelihood of infection, added workload and pressures, an increased concern for those close to them who could become infected as well as the overall increase in stress levels at work. The extent of professional and personal preparedness, together with the concerns and perceptions of nurses, could affect the hospital’s overall capacity to respond and these concerns should be addressed by those responsible for the development of pandemic response plan. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The World Health Organisation (1999) describes an influenza pandemic as an event in which the human population has no immunity against the disease, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness. Highly pathogenic influenza pandemics have occurred at unpredictable intervals approximately three to four times per century. These, according to Gust et al. (2001), have caused untold morbidity and mortality, in addition to considerable social disruption and economic impact. Healthcare continues to face radical challenges and the evolution of emerging and re-emerging diseases heighten the impact of such challenges (Jones et al., 2008). At the outbreak of SARS (2003/ 2004) there was a paucity of information about the aetiology, mode
* Corresponding author. Dublin City University Business School, Dublin, Ireland. Tel.: 00353 1700 8250; fax: 00353 1 700 5446. E-mail address: [email protected] (C. McMullan). http://dx.doi.org/10.1016/j.ienj.2015.10.004 1755-599X/© 2015 Elsevier Ltd. All rights reserved.
of transmission and physiological impact of the disease. However, its rapid clinical course, its impact on healthcare workers (both personally and professionally) and the fear arising from the risk of occupational exposure have been the focus of subsequent research. The outcomes of these studies, as well as those relating to other infectious diseases, should therefore be incorporated into the planning for future infectious disease outbreaks so that hospitals and healthcare workers are better prepared to deliver an appropriate response. There is no doubt that acute hospitals will “form the cornerstone” of the response to pandemic influenza in most countries and that hospitals will “face pressures to deal with large numbers of patients with pandemic influenza in addition to “routine” medical emergencies and, where capacity exists, the continuation of nonemergency care” (Pandemic Influenza Expert Group, 2008, p. 12). As is the case across the globe, the Irish healthcare system’s ability to cope during an influenza pandemic will depend, to a large extent, on the number of healthcare workers, including nurses who are able and willing to work through such an outbreak. Planning for major emergencies in Ireland assumes that once a pandemic is
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confirmed, the Irish Health Service Executive will care for the large number of patients impacted and will only provide essential care for other patients. Guidance based on modelling data submitted by the UK Scientific Pandemic Influenza Advisory Committee Subgroup on Modelling (2008) estimates staff absenteeism at between 30% and 35% at the peak of a pandemic because of illness and/or caring responsibilities. Ireland estimates similar rates of absenteeism from work. Such estimates take into account the cumulative effect of factors such as staff illness, possible school closures and the resultant need to look after children, caring for elderly relatives, and a possible disruption to public transport. In planning for a pandemic, emergency and nurse managers, among others, should give consideration not only to the planning of a response and recovery operation but also to the people who will be required to respond. As Reissman et al. (2006) note: “Without adequate planning and preparations, an influenza pandemic in the 21st century has the potential to cause enough illnesses to overwhelm current public health and medical care capacities at all levels, despite the vast improvements made in medical technology during the 20th century.” (p. 1) The aim of the study was to capture the perspectives of nurses who were involved in planning for an influenza pandemic within an Irish acute general hospital. The research was completed so that their opinions, perspectives, and fears could be captured with a view to enhancing preparedness for infectious disease outbreaks. 2. Methodology This research uses a case study methodology where quantitative data were collected, using a structured questionnaire, from nurses working in an acute general hospital located in the south of Ireland. Data were collected at a time when there was a heightened risk of an influenza outbreak. This provided an opportune time to conduct the research as the hospital nursing staff were in the process of planning and preparing for an outbreak. There were 127 nurses working in this acute care setting, and all of these nurses were expected to have exposure to the ongoing preparedness and readiness planning. The data collection focused on the personal and professional concerns of nurses, the perceived impact that a pandemic could have on these nurses, and the overall level of preparedness within the hospital. Given the research question, and a desire to survey the opinions of all 127 nurses employed at the hospital, it was decided that rather than employing a similar approach to the scholars Ki and Maria (2013), who conducted interviews with ten nurses during the human swine influenza outbreak (SARS) in Hong Kong, gathering data via a questionnaire would best suit the research objectives. The work of Wong et al. (2008) in particular informed the design of the questionnaire as they had researched healthcare workers’ concerns, the perceived impact and preparedness levels in relation to the avian influenza pandemic of 2006. The questionnaire used in this study was derived, with permission, from the Wong et al. study (2008) published in Annals, Academy of Medicine, Singapore. While accepting the reliability, validity and overall robustness of the original study, a pilot study was nonetheless completed to ensure the questionnaire suited the slightly different subject matter, pandemic influenza rather than avian influenza, and any cultural differences between Singapore and Ireland. It was felt that this additional pilot study would provide a further check on the clarity and quality of the survey. The results of this pilot, completed with a sample of nurses drawn from a different hospital in the same geographic location, were positive and no methodological issues were identified. The self-administered, paperbased questionnaire was distributed to all 127 nurses working in
an Irish hospital. 91 nurses completed the survey, which amounts to a response rate of 72%. 2.1. Demographics A brief review of the demographics of the 91 respondents showed that they are broadly in line with the gender breakdown of nurses in Ireland, as 99% of respondents were female and 1% were male. The Irish Nursing Board (2010) report of 2010 stated that 4.7% of general nurses registered in Ireland were male. In this study, 76% of respondents had more than ten years of nursing experience while 24% had nine years or less. All 91 respondents held a recognised nursing qualification. 3. Results The findings of this study are divided into three core topics: concerns, perceived impact, and the level of preparedness for an influenza pandemic. 3.1. Concerns regarding an influenza pandemic The majority of nurses (87%) felt that their job would put them at an increased risk of exposure, while just under half of them (48%) were afraid of actually contracting pandemic influenza. Notwithstanding these concerns, 65% considered the risk of contracting influenza to be “part of their job.” In spite of the additional risk posed, only 4% suggested that the risk emanating from an influenza outbreak would make them look for other work. However, 24% felt they would understand if their colleagues resigned due to the perceived risk from an influenza outbreak. There were mixed views among respondents as to whether they felt confident that their employer would look after their needs if they became ill with influenza. 42% felt confident they would be taken care of by their employer. It is important to recognise that nurses belong to family units and/or communities that will also be at risk during a pandemic. Therefore, it was considered pertinent to review non-work-related concerns regarding an influenza pandemic. The findings show that 67% of respondents were worried that because of their job, people close to them would be at an increased risk of contracting influenza. The nurses voiced concerns for children (77%), spouse/ partner (71%), work colleagues (68%), parents (66%), and close friends (66%). While nurses expressed concern for family, friends and colleagues, this study also found that the nurses believed that people close to them would be worried for the nurses’ own health (78%). This highlights the importance of taking into account a wide range of stakeholders when planning for the effects of a pandemic on hospital staff. It is recommended that the hospital communications strategy includes methods to provide relevant information and guidance not only to staff but also their families and other relevant stakeholders. It is particularly important to provide information regarding the resources that will be put in place to support the nurses (and their families) during a pandemic. 3.2. Perceived impact on personal and professional life A number of questions were asked to gauge the respondents’ perceptions surrounding the impact of an influenza outbreak on their personal and professional life (see Table 1 for results). A large proportion of respondents reported no fear of telling either their family or other people about the risks to which they could be exposed (76% and 68% respectively). With regard to the staffing levels needed to cope with a pandemic, 86% of respondents felt there would be inadequate staff in
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Table 1 Perceived impact of influenza pandemic on personal life and work. Statement
Agree (%)
Disagree (%)
Skipped (%)
Given my exposure, I would be afraid that my family are placed at an increased level of risk. I would avoid telling other people about the nature of my job. People would avoid me because of my job. People would avoid members of my family because of my job. I would have an increase in workload. There would be inadequate staff at my hospital to handle the increased volume of work. I would have to work extra hours. I would feel more stressed at work. There would be more conflict among colleagues at work.
23 31 32 14 90 86 65 76 64
76 68 67 84 9 12 34 23 35
1 1 1 2 1 1 1 1 1
their workplace to handle the increased demand and surge in activity following an outbreak. Likewise, 90% of the nurses surveyed believe they would have an increased workload during a pandemic and 65% agreed that they would have to work extra shifts to help cover this increased volume of work. Perhaps linked to this increased pressure and work rate, respondents felt that a pandemic would lead to increased levels of stress (76%) and conflict (64%) in their workplace. 3.3. Preparedness for influenza pandemic More than half of the nurses surveyed (60%) perceived the hospital to be prepared for an influenza pandemic. 85% of respondents indicated that they had received training in infection control in the hospital, with 71% confirming that this had occurred during the “past six months.” Over three quarters of respondents (77%) confirmed that the hospital had a pandemic preparedness plan, even though some were not aware of its content. At an individual level, 53% felt they were “personally prepared for a pandemic influenza outbreak.” Less than half of the nurses (46%) felt that they had adequate training on the use of Personal Protective Equipment (PPE). The majority of nurses (82%) noted, however, that they did have someone to turn to if they were unsure how to use specific PPE. Just 11% of nurses confirmed that they had received the seasonal influenza vaccination within the past six months, despite 59% of respondents acknowledging that they had been advised to do so by their employer. With regard to personal preparedness outside the hospital setting, 13% of nurses had bought influenza medication and 4% had bought masks for use outside of work. 4. Discussion This study assessed the concerns, perceived impact and preparedness of Irish nurses for an influenza pandemic. The findings of this study reflect a similar pattern to findings in other studies conducted in countries and continents such as Canada, Asia, U.K., U.S. and Australia; and undertaken by researchers including Maunder et al. (2003); McGillis Hall et al. (2003); Grace et al. (2004); Ho et al. (2005); Kwek et al. (2004); Nickell et al. (2004); Maunder et al. (2005); Qureshi et al. (2005); Ehrenstein et al. (2006); Mounier-Jack and Coker (2006); O’Boyle et al. (2006); Tam et al. (2007); Wong et al. (2008); Ives et al. (2009); Seale et al. (2009); and Ki and Maria (2013). Similar studies also found that nurses are willing to provide care during an influenza pandemic and accepted the increased risk of contracting influenza as part of their job as healthcare workers (see, Ehrenstein et al., 2006; Hogg et al., 2006; Shaw et al., 2006; and Wong et al., 2008). Danger to personal health was identified as one of the most prevalent concerns among Singaporean-based healthcare workers during SARS (Kwek et al., 2004). Similarly, this study of Irish nurses preparing for an influenza pandemic revealed that they too perceived that their occupation placed them at a higher risk of
contracting influenza. Their concerns were comparable to those expressed by healthcare workers during avian influenza epidemics – Wong et al. (2008) found that 82.7% of health care workers felt that their job put them at greater risk of exposure, whereas Ki and Maria (2013), who studied SARS, found that only four out of ten emergency nurses interviewed in a Hong Kong hospital were concerned for their own personal health and their susceptibility to infection. However, Ki and Maria (2013) report six out of the ten nurses interviewed showing concern for their family members – a higher result than that emanating from this study. The study conducted by Wong et al. (2008) found an even greater level of concern for family members, with concern for children, spouse/partner and parents being expressed by over 95%. These are important findings that could affect a nurse’s ability and/or willingness to work in the event of an influenza pandemic. The risk to nurses and illness rates must be considered within the major emergency planning process. This study also highlights the paradoxical situation between how healthcare workers might feel about their duty to care for patients and their personal duty to care for themselves and their families. Sokol (2006) emphasises that, “the term ‘duty to care’ [. . .] is, at best, too vague and, at worst, ethically dangerous” (p. 1238). Ruderman et al. (2006) contend that this conflict between personal and professional duties of care could potentially affect the level of availability of healthcare workers in the event of an influenza pandemic and consequently should be addressed in pandemic planning. Increased stress levels caused by the heavier workload, extended working hours, increased number of shifts, and the lack of personnel to cope with the surge in clinical activity were predicted by the nurses in this study. Furthermore the respondents suggested that the staffing levels needed to cope with a pandemic were unlikely to be provided within their hospital. Ki and Maria (2013) asked ten nurses a similar question relating to staffing levels during a pandemic, and found that all agreed that staffing levels were an issue – with nine staff members attributing this to increases in patient attendance. Wong et al. (2008) found that 78.6% of the health care workers surveyed agreed that there would be an increased workload, with 58% suggesting that there would be inadequate staffing levels. Research indicates that stress levels can be reduced by mobilising resources and facilities to support and enable nurses to discuss their fears, anxieties and concerns. Maunder et al. (2003) and Wilson et al. (2005) assert that psychosocial support for healthcare workers and associated measures to manage the psychological impact of an influenza pandemic are extremely important in the pandemic planning process. Such measures could take the form of counselling (United States Department of Health and Human Services, 2005); education (Maunder et al., 2008); provision of PPE; incentives to maintain levels of service and encourage morale (Maunder et al., 2003), provision of accommodation on site and effective communication with families (McGillis Hall et al., 2003; O’Boyle et al., 2006). All of the aforementioned measures could prove crucial in maintaining
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essential services and the integrity of the healthcare system during an influenza pandemic. The seasonal influenza vaccination was also not widely used, with nurses reporting low uptakes within the past six months of the study. Although the routine seasonal influenza vaccine will not protect against a pandemic strain of influenza, Mondo (2005) proposes that vaccination against seasonal influenza should still be actively promoted in people most likely to come into contact with a pandemic strain, including healthcare workers such as nurses, in order to minimise the risk of co-infection and viral genetic reassortment. Given the nurses’ concerns regarding their increased risk of contracting influenza during a pandemic, the provision of adequate and appropriate protective measures may provide an element of reassurance to them. Such actions may help nurses feel better prepared, maintain their morale and possibly mitigate against increased absenteeism during an influenza pandemic. The need for confidence in the employer’s commitment to look after their staff, particularly if they became ill during the course of a pandemic, was highlighted in a number of studies. This was particularly evident in Toronto in the aftermath of the SARS epidemic (Registered Nurses Association of Ontario, 2003; University of Toronto Joint Centre for Bioethics, 2003). There were mixed views among respondents in this study as to whether they felt confident that their employer would look after their needs if they became ill with influenza during the course of an influenza pandemic; with 42% agreeing. This finding emphasises the requirement for a hospital’s preparedness plans to consider not just the needs of patients but also their staff members. This is in line with findings from McGillis Hall et al. (2003); the Registered Nurses Association of Ontario (2003); the University of Toronto Joint Centre for Bioethics (2003); Kwek et al. (2004); O’Boyle et al. (2006); and Wong et al. (2008). Findings suggest that by addressing these concerns in advance of an outbreak the hospital management team could increase the availability of nursing staff during a pandemic. Organisations should address issues such as medical treatment, psychosocial and psychological interventions; communication; preparedness of staff; PPE; medications; vaccinations; education and training; facilities for staff, including accommodation on site and transport; support measures for families and dependents of staff; income protection, early detection and warning systems for staff (Crupi and Asnis, 2003; Hui et al., 2007; Ren and Hung, 2005; Tan, 2003). Should these factors be incorporated within a hospital preparedness plan, the findings of this study, and others, suggest that such provisions will at least reduce, if not eliminate the fears, concerns, uncertainties and absenteeism among the nursing population. 5. Conclusion Major emergencies will always create challenges for a health service, both in terms of the scale of added clinical activity and increased demands on the workforce and available resources. Moreover, when a major emergency is caused by an infectious disease these challenges are magnified for the health professionals who will be expected to lead the response. It is vital that the fears and concerns of the healthcare workforce should be considered by emergency managers. Nurses by virtue of their close proximity to the patient on a constant basis, 24 hours a day, seven days a week, are at a higher risk of exposure. Yet their role is fundamental in providing patient care. It is therefore vital that they would be the focus of research as a specific cohort. While many of the concerns and perceptions reported by this group are shared among other members of the health care team, there are some issues that have a greater relevance to nurses. This study provides a brief insight into these fears and concerns. It also provides insight into nurses’ perception of preparedness. By considering the points raised by those in the front line of health care provision, emergency
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