# 2138
Note: This is the Third of a multi-part series on the HHS's recent report on the home health care industry during a pandemic. Here are links to Part 1 and Part 2.
The recently released HHS document - Home Health Care During An Influenza Pandemic : Issues and Resources - covers a good many issues important to the Home Health Care sector, but none so important as anticipated employee absenteeism during a pandemic.
While this report is home health care provider centric, much of what is contained in it would apply to any health care delivery system, including hospitals, EMS, and long-term care facilities.
This is a subject I've covered numerous times, following the ongoing poll on allnurses.com (see here, here, here, and here) over HCW (health care workers) willingness to work during a pandemic.
While the polling question asked is whether nurses would work `during a severe pandemic with a shortage of PPE's', it is quite obvious from the responses that many nurses would be reluctant to work even with protective gear.
There are now more than 320 comments, and over 1100 respondents to this poll. As you will see, the results of the allnurses poll (currently 47% willing to work in a pandemic) closely match the results of polling referenced in this HHS document.
The HHS document looks at three different causes of employee absenteeism during a pandemic.
- Employees sickened and unable to work
- Employees unable to work
- Employees unwilling to work in a pandemic
The first category, employees sickened and unable to work, is addressed this way:
An obvious factor in the ability of the workforce to work during a pandemic is infection. A significant share of the home health care workforce likely will become infected with the influenza virus and be unable to report to work.
Estimates based on past pandemics suggest that at least 25 percent of the workforce overall will become infected.20 Today these estimates likely would be mitigated in the event of a pandemic by government use of antivirals.
As I pointed out in Part 2 of this series, the suggestion that infection rates among HCWs would be reduced by government use of antivirals is a curious statement.
The stated policy, so far, has been to use government stockpiled antivirals for treatment only, not for prophylaxis.
Since no one can know, in advance, what the attack rate would be of the next pandemic it is impossible to accurately judge the percentage of HCW's that would be affected by the virus.
The 25% number provided could be reasonable, or it could be far afield.
The second category, employees unable to work, anticipates that during a pandemic there may significant obstacles preventing many HCWs from being able to report to work.
School and daycare closures, a shutdown of public transportation, and even fuel shortages are mentioned as possible factors.
(The excerpts provided are reparagraphed for easier reading, and the highlights are mine)
The survey presented participants with a series of disaster scenarios. More than 80 percent of respondents indicated they would be able to report to work in the event of a mass casualty incident.
(The scenario presented was that of an explosion in Yankee Stadium with 2,000 seriously injured people transported to hospitals.) (See Figure 1).19
In contrast, less than two-thirds (63.5 percent) of survey respondents indicated that they would be able to report to work in the event of an infectious disease outbreak such as SARS.19 Similar �able to report� response rates were given for smallpox (68.6 percent) and radiation (63.8 percent) scenarios.19
Figure 1. Health Care Workers� Ability to Report to Work, by Disaster Scenario
N = 6,428 health care workers in 47 facilities
Source: Qureshi K, Gershon RRM, Sherman MF, Straub T, Gebbie E, McCollum M, Erwin MJ, Morse SS. Health care workers� ability and willingness to report to duty during catastrophic disasters. Journal of Urban Health. 2005;82(3):378�388.
The survey indicated that the two most significant structural barriers to workers� ability to report to work in a catastrophic emergency situation were transportation issues (33.4 percent) and child care (29.1 percent).19
The report goes on to list some of the steps agencies can take to try to remove barriers preventing employees from being able to work:
- Community planning groups may need to formulate contingency plans for providing health care providers, including home care providers, transportation during an emergency.
- The home health care agency should be aware of how many of its employees use public transportation and should share those numbers with local planners.
- In addition, the agency may want to make arrangements for the transport of its own workers. For example, agencies could consider approaching local schools to see if, in the event of a pandemic severe enough for school closures, school buses might be redeployed to transport home health care workers to their jobs while schools are closed.
- On the other hand, if schools and daycare centers are closed or children need to stay home because of influenza infection, either case could result in some home health care workers needing to stay home with children.
- Another issue related to workers� ability to work is the possibility that some may be employed by other health care facilities as well. The other employer may have a need for them during a pandemic that conflicts with that of the home health care agency.
Willingness to work during a pandemic is another issue altogether. Health care workers would not only be risking their own health, and lives, to treat patients they could potentially bring the infection home to their families.
Willingness of Health Care Workers to Report to Work During a Pandemic
Research indicates a distinct difference between the concepts of ability to work and willingness to work, with the first referring to a worker's capability and the latter referring to a worker's attitudes and intentions regarding reporting to work.19
Surveys indicate that a significant number of health care workers may be unwilling to report to work during an infectious disease-related emergency.
The New York City survey cited above indicated that less than half (48 percent) of the workers would be willing to report to work during an infectious disease outbreak (see Figure 2).19
The most commonly cited reasons that workers gave for not being willing to respond to an emergency included fear and concern for their own and their families' health and well-being (31.1 percent and 47.1 percent respectively).19
Figure 2. New York City Health Care Workers� Willingness to Report to Work, by Scenario
N = 6,428 health care workers in 47 facilities.
Source: Qureshi K, Gershon RRM, Sherman MF, Straub T, Gebbie E, McCollum M, Erwin MJ, Morse SS. Health care workers� ability and willingness to report to duty during catastrophic disasters. Journal of Urban Health. 2005;82(3):378�388.
Individuals are willing to put themselves at risk. We see it in every disaster and emergency. What they're not willing to do is carry that risk back home to their families.
Joseph Cappiello, M.A.
The Joint Commission
Other studies are cited, all providing similar results. Those interested should definitely read the entire document.
Measures that home care agencies can take to increase workers' willingness to report to work include:
- Ensuring that workers have appropriate personal protective equipment and providing training on its appropriate use, including fit testing. Knowing how and when to use such equipment may lessen some of the workers' concerns, thus increasing their willingness to report to work in a public health emergency.23
- Helping employees identify backup informal child-care and adult-care arrangements in the event of school and day care center closures.10
- Providing psychological support during a pandemic, including incorporating psychological support of health care workers into pandemic planning, reinforcing to workers their value and importance to the community; possibly extending resources to cover workers' families, and offering psychological resources to workers for an extended time after the pandemic subsides.24
Not listed at this point is the recent recommendation that employers of High and Very High risk employees (mostly health care workers and first responders) provide outbreak prophylaxis for the duration of a pandemic wave. I'm unsure why this was excluded in this summary since it is mentioned elsewhere in the document.
The results of these surveys show that many HCWs harbor deep concerns over working during a pandemic. Based on these results, a 50% (or greater) reduction of the workforce would not be unexpected.
Agencies, and health care facilities, need to take a serious look at how they can restore faith among their employees that their health and safety, and that of their families, will be the primary concern during a pandemic.
After the debacle of the SARS experience in Canada, where nurses weren't told early on just how infectious the disease really was, and sometimes weren't provided the most efficient PPEs, there remains a climate of mistrust regarding infectious diseases among many HCWs.
Openly, and aggressively, planning for a pandemic is one way to alleviate some of these concerns. Actively encouraging employee input and participation in these plans is essential to build trust. Pandemic planning should not take place behind closed doors.
The issues addressed in Home Health Care During An Influenza Pandemic : Issues and Resources go far beyond what I've covered in these three blogs. The document deserves a thorough reading by all health care providers.
