Disaster planning in the healthcare setting requires consideration of surge capacity, specifically the community’s ability to provide care for a rapid increase in numbers of patients having varied conditions. Adequate staffing is a key component of surge capacity. If fewer than anticipated healthcare personnel report to work in response to a disaster, safety and sustainability of the care provided may be jeopardized. In this article we discuss the need for essential personnel following a disaster, review the literature related to adequate disaster staffing, and share our study examining both the ability and willingness of healthcare personnel to report to work during a disaster and identified barriers to this reporting. We conclude by noting that healthcare personnel experience multiple barriers affecting ability and willingness to report to work during a disaster, with responsibility for children producing the greatest number of significant differences. Strategies for addressing these barriers are provided.
Keywords: surge, surge capacity, disaster planning, disaster preparedness, emergency preparedness, report to work, hospital staff, staffing, ability to report, willingness to report, essential personnel, healthcare system preparedness, survey design
Disaster planning in the healthcare setting requires consideration of surge capacity, specifically the community’s ability to provide care for a rapid increase in numbers of patients having varied conditions. Adequate staffing is a key component of surge capacity. If fewer than anticipated healthcare personnel report to work in response to a disaster, safety and sustainability of the care provided may be jeopardized. If fewer than anticipated healthcare personnel report to work in response to a
disaster, safety and sustainability of the care provided may be jeopardized.
Healthcare organizations routinely develop disaster plans. Embedded in most plans is the assumption that sufficient staff will be available to carry out the details of the disaster plans. Yet researchers have only recently begun to address the staff-sufficiency component of surge capacity (Balicer, Omer, Barnett, & Everly, 2006; Cone & Cummings, 2006; Davidson, et al., 2009; Grimes & Mendias, 2010; Masterson, Steffen, Brin, Kordick, & Christos, 2009; Qureshi, et al., 2005). Failure to address the basic question of ‘who will be available to perform necessary care during the disaster’ will limit the effectiveness of disaster planning and will ultimately affect the health and safety of patients.
In this article we will discuss the need for essential personnel following a disaster, review the literature related to adequate disaster staffing, and share our study examining the ability and willingness of healthcare personnel to report to work during a disaster. We will conclude by noting that healthcare personnel experience multiple barriers affecting their ability and willingness to report to work during a disaster, with responsibility for children being the dominant barrier. Strategies for addressing these barriers are provided.
Need for Essential Personnel Following a Disaster
Organizations have begun to recognize that ensuring adequate healthcare
personnel is essential for surge capacity. Disaster planning in the healthcare setting requires consideration of the community’s ability to provide care for increased numbers of patients in varied conditions. This ability is referred to as ‘surge capacity,’ which has been described as the “ability to expand care capabilities in response to sudden or more prolonged demand” on the healthcare system (The Joint Commission, 2003, p.19). Key components of surge capacity are the ‘four S’s,’ which are personnel (staff), supplies and equipment (stuff), facilities (structure), and integrated management policies and processes (systems) (Adams, 2009; Barbisch & Koenig, 2006).
Organizations have begun to recognize that ensuring adequate healthcare personnel is essential for surge capacity. The Office of the Assistant Secretary for Preparedness and Response (ASPR) has established a Medical Surge Capacity and Capability (MSCC) project to promote public health and medical system resiliency and to maximize the ability to meet health care demands during a surge event (ASPR, n.d.). The Agency for Healthcare Research and Quality (AHRQ) and disaster planning experts have previously issued calls for the prioritization of research addressing healthcare system preparedness (AHRQ, n.d.; Phillips, 2006), as well as behavioral studies of personnel involved in surge response (Rothman, Hsu, Kahn, & Kelen, 2006; Schultz & Koenig, 2006). With the exception of increasing interest in exploration of staff availability during an influenza pandemic, little research has focused on the staff component of surge capacity and barriers related to staff responding in time of disaster and public health emergencies. Additionally, most research studies have been limited to specific settings, such as the emergency department (ED), public health department, or a single hospital. Hence, our research sought to focus on factors influencing staff decision making with regards to disaster scenarios precipitating a patient surge in a large, multi-hospital network.
Review of Literature
Adequate staffing throughout the various continuum-of-care settings is essential in the event of a disaster or other public health emergency. Findings of several research studies have revealed both that healthcare workers experience a variety of barriers regarding their reporting to work during an emergency and also that the number of available staff will likely be less than anticipated (See Table 1) (Balicer, Omer, Barnett, & Everly, 2006; Davidson, et al., 2009; Grimes & Mendias, 2010; Masterson, Steffen, Brin, Kordick, & Christos, 2009; Qureshi, et al., 2005; Qureshi, Merrill, Gershon, & Calero-Breckheimer, 2002). Most studies have focused either on a specific scenario, such as pandemic influenza, or on a specific practice setting and population, such as emergency department personnel. Barriers to ability... include transportation problems, childcare, eldercare,
and/or pet care obligations. Barriers to willingness... include fear and concern
for family and self and personal health problems.
Researchers studying healthcare workers’ ability and willingness to report to work during time of disaster have identified barriers for both ability and willingness (Qureshi, et al., 2005). Barriers to ability to report to work in time of disaster include transportation problems, childcare, eldercare, and/or pet care obligations. Barriers to willingness to report to work in time of disaster include fear and concern for family and self and personal health problems (Qureshi, et al., 2005). These findings are consistent with other studies in which nurses have reported concerns related to conflict between family and work roles, family safety, pet care, and personal safety in the event that they are required to respond during a disaster (Davidson, et al., 2009; French, Sole, & Byers, 2002; Mitani, Kuboyama, & Shirakawa, 2003; O'Boyle, Robertson, & Secor-Turner, 2006). ‘Ability’ involves a capacity to respond, while ‘willingness’ is an attitude and implies an element of personal choice (Qureshi, et al., 2005). Researchers have suggested that willingness is affected by multiple factors, including perceived threat and perceived efficacy. Perceived threat relates to the specific scenario. Perceived efficacy is healthcare workers’ feeling that their response will make a difference in the disaster (response efficacy) and that the healthcare workers have the confidence that they can carry out the necessary behavior (self-efficacy) (Barnett, et al., 2009). Various forms of risk perception theory and the extended parallel process model have been suggested for use in the beginning exploration of response willingness in specific scenarios (Barnett, et al., 2005; Barnett, et al., 2009).
If fewer healthcare workers than anticipated report to work following a disaster, patient care and safety, staff health and safety, and sustainability of surge capacity will be jeopardized. Additional research in this arena is therefore essential to ensure adequate preparedness, care quality, and safety for patients and staff.
The Study
In this study we sought to identify ability, willingness, and barriers regarding the reporting of essential personnel to the work setting following a disaster. Specific aims of this study were to:
- determine ability and willingness of healthcare personnel in a Midwestern healthcare system to report to work in time of disaster, and
- identify barriers to the ability and willingness of healthcare personnel in a Midwestern healthcare system to report to work in time of disaster.
Method
This descriptive, exploratory study utilized survey methodology to examine the ability and willingness of healthcare personnel in a Midwestern healthcare network to report to work in a variety of disaster scenarios (See Table 2) in order to identify factors that would pose significant barriers to their reporting to work and to identify demographic factors that might influence these barriers. The survey was based on the ‘Disaster Survey’ created by Qureshi et al. (2005) and was modified with permission. Qureshi’s Disaster Survey has been used with many subjects in a variety of hospitals and consistent results have been obtained (Qureshi, personal communication, October 20, 2006). The survey assesses participants’ ability and willingness, based on an answer of ‘yes,’ ‘no,’ or ‘not sure,’ to report to work during various disaster scenarios. Qureshi’s Disaster Survey includes a broad range of scenarios consistent with the ‘all hazards’ approach to hospital disaster planning; we believed it was important to utilize a comparable range of scenarios in our study. The first author had previously modified Qureshi’s Disaster Survey for use in Southwestern United States (U.S.) hospitals, while adding both a pandemic influenza scenario to be consistent with current trends and also a tornado with flooding scenario to be consistent with hazard vulnerability analysis in the region. Nurses familiar with hospital disaster planning examined the scenarios to determine face validity, and an online version of this survey was piloted with practicing nurses to obtain feedback on ease of completing the online format.
A similar modification process took place with the current study. Working from the initially modified survey, the second author of this article worked with members of the Kettering Health Network Nursing Research Council to develop comparable scenarios that were reflective of the unique vulnerabilities of the geographic region that the healthcare network served and to determine face validity. The survey was distributed in both online and paper formats during the research study reported below.
The study’s setting was a Midwestern, community-based, healthcare network located near a high-value terrorism target, specifically the flagship Military Base for the U.S. Air Force which is within 10 to 20 miles of most of the acute care centers that make up the health network in which the survey was conducted. Although not officially confirmed by the military, area hospitals and local disaster planners ‘understand’ that this base is a primary military target for terrorism. The network is one of two major health networks in the area servicing a population of approximately 1.6 million people spread over nine counties. At the time of data collection, the network consisted of six inpatient facilities ranging in size from 60 to 420 beds.
The sample consisted of nurses and other clinical and non-clinical healthcare staff, including personnel from respiratory therapy, radiology, social services, admissions, security, plant engineering, systems operation, nutrition services, and environmental services, who were employed by this Midwestern healthcare network, and who were considered to be ‘essential personnel’ during a disaster. Determination of who was considered essential personnel was gleaned through examination of the network’s Hospital Incident Command System (HICS) management chart for disaster response. Permission was obtained from the Kettering Health Network Institutional Review Board and Texas Christian University Institutional Review Board prior to implementation of the study. Over 2700 employees, of which approximately 1500 were RNs representing groups critical to a disaster response, were invited to participate in the survey. Power analysis indicated a sample size of 898 was needed to detect a small effect size (< .01) when performing statistics to test for differences among groups.
To maximize participation, we decided to invite all members of the ‘essential’ workgroups to participate in the survey. The workgroups known to have organizational email accounts that were regularly accessed, based on supervisor report of department norms, were emailed an online survey link. Those who did not have an email account or did not access an email account regularly were asked to complete a paper version of the survey. Surveys were introduced by an information sheet that explained the study’s purpose, benefits, risks, and the participant’s privacy and rights protections. Completion of the survey implied consent to participate. All responses to the survey were anonymous. After initial distribution, three reminders were sent to employees to encourage participation. Ultimately 1342 employees responded to the survey, for a response rate of 50% based on the known number of surveys distributed.
An additional sampling technique occurred serendipitously. As results began to come back, it became obvious that ‘snowballing’ had occurred, since participants indicated positions that were not included in the original sample of essential personnel, such as staff educators, faculty, chaplains, pharmacists, and physicians. Since the majority of invitations were sent via email, it is possible that participants forwarded the email and/or the survey link to other staff whom they thought should be included or might be interested. Our actual response rate is thus somewhat unclear, since we do not know how many staff actually came into contact with the survey link. Despite this potential limitation to our statistical analysis, a potential benefit of the snowball sample was that it resulted in an even greater cross section of personnel than was originally intended.
Findings
The majority of participants was employed fulltime (80.3%) and on an 8- or 12-hour day shift (71.3%). Nearly half (49.8%) reported being responsible for children and a majority (70.1%) were responsible for pets or livestock (See Table 3). We will present below the details of our findings related both to ability and willingness to report, along with barriers to reporting.
Ability and willingness to report. Ability to report (for all participants) ranged from a low of 71.1% (n=972) for tornado/flooding to 90.6% (n=1216) for an explosion with mass casualties (See Table 4). Willingness to report (for all participants) ranged from a low of 69.1% (927) for a radiologic event to 93% (n=1248) for an explosion with mass casualties (See Table 5).
Responsibility for children produced the highest number of significant and
meaningful differences...To determine if various obligations, family situations, or type of position produced a difference in ability or willingness to report to work during a disaster, we tested for differences between each scenario and responsibility for children, responsibility for pets/livestock, responsibility for elders, type of position, and having a spouse or partner expected to report to work during the same scenario using X2.Participants in other studies have identified these obligations as potential barriers to disaster response, and different response rates in personnel in clinical positions have been noted (Qureshi et al., 2005). Responsibility for children produced the highest number of significant and meaningful differences, including both ability to report to work during all scenarios except winter weather, and willingness to report to work during all scenarios except winter weather and an influenza pandemic (See Tables 6 and 7). Other significant and meaningful differences occurred with responsibility for elders and ability to report during a chemical terrorism event; spouse/partner required to report to work with ability to report during a chemical terrorism event; and clinical position with ability and willingness to report during a chemical terrorism event and smallpox outbreak. No significant and meaningful differences were noted with responsibility for pets/livestock and any of the scenarios.
For the purpose of this study, significance was considered to be any p value less than .05 and a meaningful difference was 5% or greater. Cramer’s V was calculated to determine the strength of the effect (See Tables 6 and 7). Any Cramer’s V < 0.1 indicates a weaker effect, suggesting that such results could be due to the large sample size. Because not all calculations produced significant and meaningful differences, however, we felt that it was still important to examine and discuss any results that were both significant and meaningful even when Cramer’s V indicated a weaker effect.
A greater proportion of those with no responsibility for children were found to be able and willing to report for multiple scenarios. A greater proportion of those with responsibility for children were ‘not sure’ if they would be able to report during multiple scenarios compared with those without responsibility for children (See Tables 6 and 7).
The relationship between ability to report during a chemical terrorism event and whether the participant had responsibility for elders was significant, Χ2(2) = 15.45, p = .000. A greater proportion of those who had no responsibility for elders indicated they would be able to report (86.7%) compared to those with responsibility for elders (81.3%). Participants reported multiple barriers to their ability and willingness to
report to work. Common themes expressed in response to an open-ended prompt of
‘other’ included the safety of family and significant others, responsibility for
a spouse with healthcare needs and/or disability, the effect of the disaster on
self and/or family, transportation limitations, and concurrent work or voluntary
obligations.
The relationship between ability to report during a chemical terrorism event and whether the participant had a spouse/partner expected to report to work during a disaster was significant, Χ2(2) = 10.16, p = .006. A greater proportion of those who did not have a spouse/partner expected to report to work during a disaster would be able to report (87.5%) compared to those whose spouse/partner would be expected to report to work (81.7%). In addition, a greater proportion of those whose spouse/partner would be expected to report to work during a disaster were not sure if they would be able to report to work during a chemical terrorism event (16.6%) compared to those whose spouse/partner was not expected to report to work (10.4%).
The relationship between ability to report during a chemical terrorism event and whether the participant had a clinical position was significant, Χ2 (2) = 8.53, p = .014. A greater proportion of those who held a non-clinical position indicated they would be able to report (88.8%) compared to those who held a clinical position (83.5%).
The relationship between willingness to report during a chemical terrorism event and whether the participant held a clinical position was significant, Χ2 (2) = 8.54, p = .014. A greater proportion of those who held a non-clinical position indicated they would be willing to report (85%) compared to those who held a clinical position (79.2%).
The relationship between ability to report during a smallpox outbreak and whether the participant had a clinical position was also significant, Χ2(2) = 7.76, p = .021. A greater proportion of those who held a non-clinical position would be able to report (89.4%) compared to those who held a clinical position (84%). Additionally, a greater proportion of those who held a clinical position were not sure they would be able to report (13.6%) compared to those who held a non-clinical position (8.8%).
Finally, the relationship between willingness to report during a smallpox outbreak and whether the participant held a clinical position was significant, Χ2 (2) = 12.39, p = .002. A greater proportion of those who held a non-clinical position indicated they would be willing to report (84.8%) compared to those who held a clinical position (77.1%).
Barriers to reporting. Participants reported multiple barriers to their ability and willingness to report to work. Common themes expressed in response to an open-ended prompt of ‘other’ included the safety of family and significant others, responsibility for a spouse with healthcare needs and/or disability, the effect of the disaster on self and/or family, transportation limitations, and concurrent work or voluntary obligations. In response to specific prompts related to reasons they would be unable to report to work, 30.1% (n= 404) of participants reported childcare responsibilities and 19.3% (n = 259) reported pet/livestock care as potential barriers (See Table 8). In response to specific prompts related to reasons they would be unwilling to report to work, concern/fear for family (45.8%, n = 615) and concern/fear for self (30%, n= 402) were the most frequently reported barriers (See Table 8).
Discussion...between 10-30% of personnel were either unwilling or unable to report to work
in various disaster scenarios.
The purpose of the study was to examine the ability and willingness of healthcare personnel in a Midwestern healthcare system to report to work in time of disaster and to identify barriers to their ability and willingness to report. We found that between 10-30% of personnel were either unwilling or unable to report to work in various disaster scenarios. Additionally, participants identified multiple factors that would affect their decision to report to work. Among these factors were concern for safety of family and significant others, concern for personal safety, responsibility for children or other family members, responsibility for pets or livestock, transportation limitations, and concurrent work obligations....a greater proportion of non-clinical personnel, compared to clinical
personnel, indicated being able and willing to work during a chemical terrorism
event or smallpox epidemic.
Our study found that a greater proportion of non-clinical personnel, compared to clinical personnel, indicated being able and willing to work during a chemical terrorism event or smallpox epidemic. One potential reason for this difference is that non-clinical essential personnel, such as security, plant engineering, and administration, may have fewer people per department and thus have a greater expectation that each individual is critical to a disaster response. Perhaps these personnel are socialized to anticipate their ‘essentialness’ to a greater extent than clinical and clinical support staff who know their numbers are greater, resulting in more options for their being replaced. Another possibility is that clinical staff will have a greater prospect of exposure to infectious disease or chemical contamination due to their close proximity to patients. Future studies should explore these questions, especially since other study findings have differed from ours. Cone and Cummings (2006) found that clinical personnel were willing to respond to more disaster types than were non-clinical personnel. Qureshi et al. (2005) found that physicians and emergency medical technicians were more likely to be both willing and able to report for work during a disaster than any other personnel, including administrators, nurses, and clinical support staff.
Consistent with the findings of Qureshi et al. (2005), our study indicated that responsibility for childcare posed a significant barrier both to the ability and willingness of participants to report to work. Because significant differences in ability and willingness to respond in most disaster scenarios occurred with those who were responsible for children, the participating healthcare network would be well advised to consider the potential impact of an employee’s childcare responsibility on its overall surge capacity. Offering onsite childcare or partnering with childcare providers may need to be considered. Because significant differences in ability and willingness to respond in most
disaster scenarios occurred with those who were responsible for children...
Offering onsite childcare or partnering with childcare providers may need to be
considered.
When the various obligations were tested with the scenarios, the chemical terrorism scenario was associated with the greatest number of significant and meaningful differences. In future research, it would be useful to explore whether the participants were more concerned about the chemical event or about the prospect of terrorism in their community. Given that concern for safety of family and significant others was an important consideration for participants, study into the impact of the word ‘terrorism’ on participants’ responses could be valuable.
It is of interest that the concern for the safety of family and significant others was often repeated by participants as an ‘other reason’ that would affect either their ability or willingness to report to work. Some memorable comments echoing this concern included “May be dead,” “I may be getting out of Dodge with husband/pets,” and “My first priority is to make sure my family is safe.”
Limitations and Recommendations
Because these findings represent the responses of participants within a single health network in a specific geographic region, the findings have limited generalizability to the general population. Future research that includes random selection of participants in a variety of health networks and geographic regions may therefore be valuable.
Despite providing a hard copy option for staff without email access, participation from staff without email access was limited. Participation from staff working evening or night shifts was also limited. Therefore, our findings may not be representative of these subgroups.
Additionally, a survey may not be powerful enough to accurately predict actual behavior. Self-report of what one anticipates doing may be different from what one will actually do. Intention and planned behavior as described in the theory of planned behavior (Aizen, 1991) are influenced by multiple factors, including attitudes about behavior, beliefs related to subjective norms, and perceived behavioral controls. Although the theory of planned behavior has been used to predict actual behavior based on self-reported data, researchers acknowledge that such data are vulnerable to self-presentational bias (Armitage & Conner, 2001).The ‘halo effect’ (Nisbett & DeCampo Wilson, 1977) could have caused participants to report what might be considered heroic or what they thought the researchers or employers would like to hear. Despite anonymity of the survey, participants may have been afraid to report honestly for fear of employer retaliation, especially if their responses to ability or willingness to come to work would have been ‘no.’...disaster plans that are not tested rigorously enough to expose gaps will only
be plans on paper that offer an illusion of preparedness.
Although behavior in disaster drills may offer an indication of actual behavior in future disasters, disaster plans that are not tested rigorously enough to expose gaps will only be plans on paper that offer an illusion of preparedness (Adams, 2009; Milsten, 2000). It is possible that some participant responses were influenced by participation in previous disaster drills that lacked rigor and hence did not adequately simulate a real disaster.The need for drills to be realistic was emphasized by a study participant who contacted the investigators with the suggestion that disaster drills should be held without notification so that “people are truly going on with their personal lives as if their day was done” or on the weekend “when families are busy and it is not part of their work day” rather than “waiting at home because they know a drill is coming and [they] have to be available” (study participant, personal communication, 2010). The participant went on to observe that “disaster drills where people have a week or two to get a disaster manual out and review are just too predictable and easy and so not real life” (study participant, personal communication, 2010).
Another potential limitation is that the winter scenario was too mild for a Midwestern locale and thus did not provide an adequate estimate of the effect of severe winter weather on staff availability. Although the Kettering Health Network Nursing Research Council revised the instrument that had been used in North Central Texas to be more consistent with Midwestern locations, the actual description of the scenarios remained unchanged. In future surveys conducted in locations accustomed to harsher winters, we recommend presenting a more severe winter scenario.
Participant responses may also have been biased, especially in the case of the snowball sample. Those who participated may have been more interested in the topic of disaster preparedness than those who did not participate and therefore their responses may not be reflective of the larger group.
Exploring ‘ability’ and ‘willingness’ to report to work involves the inherent challenge of being able to measure these qualities reliably. Providing only three options of ‘yes,’ ‘no,’ and ‘not sure’ does not allow for variations in the degree of uncertainty. Participants who were ‘not sure’ may be able or willing to report to work during an actual event; but without facing the actual circumstances, they may not have been willing to commit to doing so. A Likert scale approach might have provided greater insight into degrees of uncertainty.
Future Research
A growing body of literature discusses the duty and legal obligations of healthcare professionals to care for others during disasters, including pandemics (American Nurses Association, 2010; Davies & Zlotnik Shaul, 2010; Kane-Urrabazo, 2007; Malm, et al., 2008; Rolls & Thompson, 2007). In addition to caring for patients, however, healthcare professionals are obligated to care for themselves (ANA, 2001). They often have multiple roles, such as parent and spouse, with each role requiring its own obligations (Sokol, 2008). The competing obligations of duty to patients and duty to self and family produce an ethical dilemma for healthcare professionals when disaster occurs, particularly if the situation puts the healthcare professional at risk (ANA, 2010; Schroeter, 2008; Sokol, 2008; Stokowski, 2009; Twedell, 2009). Little ethical guidance has been provided for nurses to help them make a decision about which competing obligation outweighs another, especially if personal risk is increased due to a shortage of protective resources (Schroeter, 2008). Legal requirements for responding in a disaster vary from state to state and offer little assistance in making an informed decision about assumption of personal risk (ANA, 2010). ANA (2010) therefore had advocated for further efforts to develop legal protections for nurses practicing in disasters. In our study, liability concerns were not a major barrier to willingness to report (4.1%), but concern/fear for family safety (45.8%) and personal safety (30%) appeared to be important. Future researchers are encouraged to ask study participants what would compel them to come to work during a disaster.
Another area for further research is the differentiation between barriers to an immediate response and barriers to a sustained response to disaster. Those who have responsibilities, such as childcare, would find it difficult to report to work immediately but might be able to do so given sufficient lead time to make arrangements. On the other hand, temporary solutions that allow individuals to respond to a disaster in the short term may not be sustainable over extended periods of time. Further study in this area would be helpful in determining solutions that would enhance both short term and longer term surge capacity.
Conclusions and Recommendations
This study has increased our knowledge about the ability and willingness of clinical and non-clinical personnel of a Midwestern health network, a geographic region that has received limited attention in the literature, to report to work following a disaster. This study also offers the perspective of a broader scope of participants than have most studies in this arena because we obtained participation from personnel in clinical and non-clinical areas in multiple hospitals of a health network rather than restricting participation to a single practice setting or hospital.
Consistent with other study findings, we, too, have concluded that staff experience multiple barriers that affect their ability and willingness to respond when called during a disaster, with responsibility for children producing the greatest number of significant differences. Because of this, we recommend that to enhance surge capacity, healthcare institutions explore potential barriers that affect willingness and ability of staff to respond and consider ways to mitigate these barriers. Adams (2009) has suggested the following strategies for mitigating barriers:
- Personal disaster preparedness planning by all employees
- Disaster drills that include questions and answers about potential barriers
- Development of supportive services for staff, such as childcare
- Provision of safety precautions for staff, and
- Understanding of concurrent employment and voluntary obligation
Based on this study, the authors are considering additional studies to determine ability and willingness of healthcare staff to report to work in times of disaster, to identify barriers to their ability and willingness to report to work, and to explore the effect of potential solutions to barriers to staff ability and willingness to report to work.
Authors
Lavonne M. Adams, PhD, RN, CCRN
E-mail: L.adams2@tcu.edu
Dr. Adams is an Associate Professor in the Texas Christian University Harris College of Nursing & Health Sciences. She is a Disaster Health Services Volunteer and an Instructor for the American Red Cross. Her clinical background includes critical care and emergency nursing; she is also an instructor in Basic Life Support and Advanced Cardiac Life Support. Dr. Adams holds a degree with a focus in Leadership from Andrews University (Michigan), an MS in Nursing from Andrews University, a BSN from Wright State University (Ohio), and an AS in Nursing from Kettering College (Ohio).
Devon Berry, PhD, RN
E-mail: devon.berry@wright.edu
Dr. Berry is the Director of Innovation and Community Partnerships in the Wright State University College of Nursing and Health. In addition to his work in academia, he also works as a research consultant for a mid-sized health network. In this role he regularly designs and implements research projects that create the data needed to support evidence-based practices.
Table 1. Summary of Previous Literature
| Reference | Population | Response rate and/or sample size | Scenario/Event | Report to Work |
| RNs completing bioterrorism training | N=313 | Infectious diseases | 8-20% extremely likely to report; 21-64% highly likely to report | |
| ED physicians, nurses, support staff | 82%, N=204 | Airplane crash | 98% likely to report | |
| Biological agent | 54% likely to report | |||
| Radioactive bomb | 85.3% likely to report | |||
| Public health employees | N=140 | Pandemic influenza | 48% not likely to report | |
| Public health nurses | N=50 | Emergency | 70% likely to report | |
| Hospital and ED employees | N=1711 | Fire, rescue, collapse, mass casualty | 87% willing to report | |
| Biological | 58% willing to report | |||
| Chemical | 58% willing to report | |||
| Radiation | 57% willing to report | |||
| Snowstorm | 83% willing to report | |||
| Flood | 81% willing to report | |||
| Earthquake | 79% willing to report | |||
| Hurricane | 78% willing to report | |||
| Tornado | 77% willing to report | |||
| Ice storm | 75% willing to report | |||
| Influenza | 72% willing to report | |||
| Healthcare workers | N=6428 | Small pox | 69% able to report | |
| Radiation | 64% able to report | |||
| SARS | 64% able to report | |||
| Snow storm | 49% able to report | |||
| Chemical | 68% willing to report | |||
| Small pox | 61% willing to report | |||
| Radiation | 57% willing to report | |||
| SARS | 48% willing to report |
| Type of Event | Scenario |
| Weather emergency | Winter mix of 1 inch of ice and snow in a 24-hour period where you live |
| Bioterrorism | Smallpox outbreak in Springfield. 200 patients admitted to 5 hospitals |
| Chemical terrorism | Chemical terrorism attack at Dayton International Airport with 500 victims brought to hospitals throughout the Dayton area |
| Weather emergency/environmental disaster | Tornadoes injure hundreds of people in Kettering, Dayton, and Oakwood. Flash flooding has been reported throughout the Dayton area and is expected to worsen |
| Mass casualty incident | Explosion at The Nutter Center in Beavercreek with 2000 seriously injured brought to hospitals in the Dayton area |
| Radiation terrorism | Radioactive bomb explodes at The Greenes in Beavercreek. Thousands of people flocking to ER’s in the Dayton area |
| Untreatable infectious disease outbreak | Outbreak of 15 cases of SARS in the facility in which you work |
| Treatable infectious disease outbreak | Outbreak of pandemic influenza in the Miami Valley area |
| Table 3. Description of Participants * | ||
| % (N) | % (N) | |
| Employment status Full time Part time PRN Other |
80.3 (1077) 12.2 (164) 4.3 (25) 1.9 (25) |
|
| Shift Day (8 or 12 hour) Evening (8 or 12 hour) Night (8 or 12 hour) Other |
71.3 (957) 6.8 (92) 9.5 (128) 11.8 (159)
|
|
| Type of position Clinical Non-clinical |
60.2 (817) 39.8 (534) |
|
| Age range (years) 18-29 30-39 40-49 50-59 60+ |
12.0 (161) 18.8 (252) 26.6 (357) 31.1 (417 10.2 (137) |
|
|
Responsible for children | Yes 49.8 (668) | No 46.6 (626) |
| Responsible for elders | 21.6 (290) | 76.7 (1029) |
| Responsible for pets/livestock | 70.1 (941) | 29.2 (392) |
| Spouse/partner expected to work in disaster | 31.1 (417) | 68.0 (912) |
| *Not all participants answered all questions, therefore percentages do not all add up to 100% | ||
Table 4. Healthcare Workers’ Ability to Report to Work During Disaster
| Scenario | Able | Not Able | Not Sure |
| Explosion with mass casualties Total Clinical Nonclinical | 90.0 (742) 92.5 (472) |
1 (13) 1.1 (9) 0.6 (3) |
8.1 (109) 9.0 (74) 6.9 (35) |
| Influenza pandemic Total Clinical Nonclinical |
87.9 (1179) 87.9 (724) 89.5 (454) |
2.3 (31) 2.3 (19) 2.0 (10) |
9.2 (124) 9.8 (81) 8.5 (43) |
| Winter weather Total Clinical Nonclinical |
86.6 (1162) 87.0 (719) 86.5 (441) |
2.8 (38) 2.4 (20) 3.3 (17) |
10.4 (139) 10.5 (87) 10.2 (52) |
| Smallpox epidemic Total Clinical Nonclinical |
85.8 (1151) 84.0 (693) 89.4 (456) |
2.2 (30) 2.4 (20) 1.8 (9) |
11.7 (157) 13.6 (112) 8.8 (45) |
| Chemical event Total Clinical Nonclinical |
85.2 (1144) 83.5 (689) 88.8 (453) |
2.0 (27) 2.5 (21) 1.0 (5) |
12.4 (167) 13.9 (115) 10.2 (52) |
| SARS outbreak Total Clinical Nonclinical |
82.3 (1105) 82.7 (682) 83.4 (422) |
3.1 (42) 3.5 (29) 2.2 (11) |
13.9 (187) 13.8 (114) 14.4 (73) |
| Radiologic event Total Clinical Nonclinical |
72.4 (972) 71.4 (589) 74.9 (381) |
5.8 (78) 6.3 (52) 4.9 (25) |
21.4 (287) 22.3 (184) 20.2 (103) |
| Tornado/flooding Total Clinical Nonclinical |
71.1 (954) 72.0 (593) 70.5 (359) |
5.4 (72) 5.6 (46) 4.9 (25) |
23.1 (310) 22.5 (185) 24.6 (125) |
Table 5. Healthcare Workers’ Willingness to Report to Work During Disaster
| Scenario | Willing | Not Willing | Not Sure |
| Explosion with mass casualties Total Clinical Nonclinical |
93.0 (1248) 92.4 (763) 95.5 (483) |
1.4 (19) 1.7 (14) 0.8 (4) |
5.1 (68) 5.9 (49) 3.8 (19) |
| Winter weather Total Clinical Nonclinical |
92.8 (1245) 93.1 (766) 94.7 (478) |
2.1 (28) 1.7 (14) 2.4 (12) |
4.3 (58) 5.2 (43) 3.0 (15) |
| Influenza pandemic Total Clinical Nonclinical |
85.1 (1142) 86.2 (711) 84.5 (430) |
4.2 (56) 4.0 (33) 4.1 (21) |
10.4 (139) 9.8 (81) 11.4 (58) |
| Chemical event Total Clinical Nonclinical |
80.9 (1068) 79.2 (654) 85.0 (430) |
5.0 (67) 6.1 (50) 3.2 (3.2) |
13.6 (182) 14.8 (122) 11.9 (60) |
| Tornado/flooding Total Clinical Nonclinical |
80.4 (1079) 82.1 (677) 78.9 (400) |
5.7 (76) 5.6 (46) 5.7 (29) |
13.8 (180) 12.4 (102) 15.4 (78) |
| Smallpox epidemic Total Clinical Nonclinical |
79.4 (1065) 77.1 (636) 84.8 (428) |
6.2 (83) 7.4 (61) 4.0 (20) |
13.8 (185) 15.5 (128) 11.3 (57) |
| SARS outbreak Total Clinical Nonclinical |
74.6 (1001) 74.5 (614) 75.7 (386) |
7.0 (94) 7.5 (62) 5.9 (30) |
18.0 (242) 18.0 (148) 18.4 (94) |
| Radiologic event Total Clinical Nonclinical |
69.1 (927) 67.4 (557) 72.6 (368) |
9.2 (124) 10.5 (87) 7.1 (36) |
21.2 (285) 22.0 (182) 20.3 (103) |
Table 6. Responsibility for Children and Healthcare Workers’ Ability to Report to Work During Disaster
| Scenario | Able | Not Able | Not Sure | Χ2 | df | p | Cramer’s V |
| Winter weather Responsible for Children Yes No |
86.2 (576) 88.0 (548) |
2.5 (17) 3.4 (21) |
11.2 (75) 8.7 (54) |
2.97 |
2 |
.226 |
.048 |
| Smallpox epidemic Responsible for Children Yes No |
83.0 (553) 89.7 (560) |
2.9 (19) 1.6 (10) |
14.1 (94) 8.7 (54) |
12.29 |
2 |
.002 |
.098 |
| Chemical event Responsible for Children Yes No |
81.9 (547) 89.5 (557) |
2.4 (17) 1.6 (10) |
15.6 (104) 8.8 (55) |
15.39 |
2 |
.000 |
.109 |
| Tornado/flooding Responsible for Children Yes No |
68.1 (455) 74.4 (461) |
6.1 (41) 4.8 (30) |
25.7 (172) 20.8 (129) |
6.11 |
2 |
.047 |
.069 |
| Explosion with mass casualties Responsible for Children Yes No |
88.5 (591) 93.7 (583) |
1.0 (7) 1.0 (6) |
10.5 (70) 5.3 (33) |
11.8 |
2 |
.003 |
.096 |
| Radiologic event Responsible for Children Yes No |
68.7 (458) 76.5 (476) |
7.3 (49) 4.7 (29) |
24.0 (160) 18.8 (117) |
10.59 |
2 |
.005 |
.091 |
| SARS outbreak Responsible for Children Yes No |
79.0 (527) 87.2 (540) |
4.0 (27) 2.3 (14) |
16.9 (113) 10.5 (65) |
15.45 |
2 |
.000 |
.110 |
| Influenza pandemic Responsible for Children Yes No |
85.9 (573) 91.4 (566) |
3.0 (20) 1.8 (11) |
11.1 (74) 6.8 (42) |
9.71 |
2 |
.008 |
.087 |
Table 7. Responsibility for Children and Healthcare Workers’ Willingness to Report to Work During Disaster
| Scenario | Willing | Not Willing | Not Sure | Χ2 | df | p | Cramer’s V |
| Winter weather Responsible for Children Yes No |
92.9 (615) 94.2 (585) |
2.3 (15) 2.1 (13) |
4.8 (32) 3.7 (23) |
1.06 |
2 |
.590 |
.029 |
| Smallpox epidemic Responsible for Children Yes No |
74.9 (499) 85.2 (528) |
8.6 (57) 4.2 (26) |
16.5 (110) 10.6 (66) |
21.78 |
2 |
.000 |
.130 |
| Chemical event Responsible for Children Yes No |
77.4 (515) 84.7 (527) |
5.9 (39) 4.3 (27) |
16.7 (111) 10.9 (68) |
11.23 |
2 |
.004 |
.093 |
| Tornado/flooding Responsible for Children Yes No |
77.3 (514) 84.1 (523) |
7.2 (48) 4.3 (27) |
15.5 (103) 11.6 (72) |
10.02 |
2 |
.007 |
.088 |
| Explosion with mass casualties Responsible for Children Yes No |
91.4 (608) 95.7 (595) |
1.7 (11) 1.3 (8) |
5.9 (46) 3.1 (19)
|
10.4 |
2 |
.006 |
.090 |
| Radiologic event Responsible for Children Yes No |
65.2 (434) 73.0 (454) |
11 (73) 7.9 (49)
|
23.9 (159) 19.1 (119) |
9.44 |
2 |
.009 |
.086 |
| SARS outbreak Responsible for Children Yes No |
69.5 (462) 80.0 (499) |
9.2 (61) 5.1 (32) |
21.4 (142) 14.9 (93) |
19.4 |
2 |
.000 |
.123 |
| Influenza pandemic Responsible for Children Yes No |
83.6 (557) 87.0 (542) |
5.4 (36) 3.2 (20) |
11.0 (73) 9.8 (61) |
4.42 |
2 |
.110 |
.059 |
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Acknowledgements
This study was made possible in part through an Alma and Robert D. Moreton Research Award (2009 – 2010). The authors wish to acknowledge Dr. Wyndy L. Wiitala, PhD, and Dr. Jacquelyn Pennings, PhD, for statistical planning and analysis; Pam Lamb, BSN, RN, CEN, Laura Correll, BSN, RN, Nancy Jones, MS, C, RN, Elizabeth Jobson, RN, Emily Treffinger, CNP, RN, and other members of The Kettering Health Network Nursing Research Council for survey revision, distribution, and collection; Brandi Palmer, MS, for facilitation of the project; Orpheulia Davis, BSN, RN, for assistance with the literature search; Cuong Nguyen, BBA, for data entry and management; and personnel of The Kettering Health Network for their participation in the study.
