Sunday, December 08, 2019

HCWs Willingness To Work During A Pandemic

flushotsmall (3)
Me in 1976, giving Swine Flu Shots.


Forty-three years ago, when I was an impossibly young paramedic (see photo above), public health authorities were preparing for the feared return of an H1N1 pandemic after a handful of soldiers at Fort Dix, NJ had fallen ill with a novel flu virus the previous winter. 
H1N1 had last circulated in 1957, and we'd seen two pandemics (H2N2 in 1957 and H3N2 in 1968) in the previous 20 years.  Because of its similarity to the 1918 pandemic virus, public health authorities were preparing for the worst.
While that pandemic failed to materialize, those interested in the history of that pandemic scare - and my (very) minor role in helping my county to prepare for its arrival - may wish to read my 2009 essay Deja Flu, All Over Again.

One of the topics of conversation among the EMTs, nurses, doctors, and other health care workers at the time was whether everyone would continue to work once the pandemic arrived. 
While much of it may have been false bravado, I don't recall anyone actually admitting they wouldn't work, at least as long as they were physically able. 
But then, we all had more faith in the emergency vaccine than it probably deserved, and I don't think any of us knew at the time just how bad the 1918 pandemic had really been.
Today we have a much more vivid image of a severe pandemic, and the odds of having an effective vaccine at the start are pretty slim.  Even PPEs (masks, gowns, and gloves) are likely to be in short supply a few weeks into a pandemic.
Our track record for being ready to deal with even lesser outbreaks isn't particularly reassuring.
The limited (16-hospital) MERS outbreak in South Korea in 2015 (see Study: Burnout & PTSD Among Nurses Working During A Large MERS-CoV Outbreak - Korea, 2015) illustrates - at least partially - the pressures HCWs would be under during a pandemic.
Staff shortages - along with shortages of everything from PPEs, to IV supplies and meds, to hospital beds (see Supply Chain Of Fools (Revisited)) - will further exacerbate the stress, and the resultant fallout among HCWs.
In the epilogue video (below) from last year's Johns Hopkins Clade X Tabletop Pandemic Exercise, the butcher's bill read, in part: `. . . 20 months into the pandemic . . . half of all healthcare workers had either died, become disabled, or quit . . .'

All of which suggests the concerns of Health Care Workers over their safety during a severe pandemic are far from misplaced.

Over the years we've looked at a number of polls and studies of HCWs (Health Care Workers) on their willingness to work during a severe pandemic, and consistantly a lack of PPEs, or a vaccine for workers (and their families), and inadequate hospital staffing and security are frequently cited as deal breakers.

Six years ago, in Study: Willingness of Physicians To Work During A Severe Pandemic, we looked at a study  published in the Asia Pacific Family Medicine journal, that polled Canadian doctors to try to determine under what circumstances they would be unwilling to work during a pandemic.
Although limited by only a 22% response rate to the poll, under certain scenarios, fewer than half of the doctors who responded would be willing to report for work during a severe pandemic.
The numbers from that Canadian poll are not out of line with previous studies we’ve seen, including a 2010 report (See Study: Willingness Of HCWs To Work In A Pandemic) that polled 18,612 employees of the Johns Hopkins Hospital from January to March 2009, and found: 
Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so.
Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza
More recently, a study published 6 months ago in Prehospital and Disaster Care asked the question: 
Are Australian Pharmacists Willing to Work in a Disaster?
Elizabeth McCourt (a1), Kaitlyn Watson (a1), Judith Singleton (a1), Vivienne Tippett (a1) ...


Current literature suggests that a large percentage of the health workforce may be unwilling to work during a disaster. The willingness of pharmacists to work during a disaster is under-researched internationally and non-existent in Australia.


To determine if Australian pharmacists are willing to work in a disaster and the factors that affect the willingness to work.

A 13-question survey was developed from the current literature and released nationally through professional organizations and social media.

Sixty Australian pharmacists completed the survey. Most participants believed their pharmacy was an essential service for their community. Pharmacists reported they would be likely to report to work during a pandemic or biological disaster (73%) or natural disaster (78%).
The two major factors likely to prevent pharmacists from working in a disaster are family and safety concerns. Pharmacists perceived that their duty of care to their patients would make them likely to work during a disaster. Most pharmacists noted they would work even if they were expected to work outside their scope of practice, or if their place of work lacked electricity or was damaged.

Depending on the disaster, up to 27% of the pharmacy workforce may be unwilling to work in a disaster. Family and safety concerns were the primary barriers to pharmacists reporting to work in the aftermath of a disaster. Providing guidelines on how pharmacists can prepare their family for a disaster may assist in ensuring pharmacists are willing to work.
(Continue . . . )

This week, another study has been published, one that polls EMS workers on their willingness to work during a severe pandemic.

The full report is behind a paywall, and we aren't privy to the `pandemic scenario' presented, but once again a significant number of EMS workers indicated their unwillingness to work during a future pandemic.

Emergency Medical Services Personnel’s Pandemic Influenza Training Received and Willingness to Work During a Future Pandemic
T. Rebmann, RL Charney, TM Loux, JA Turner, YS Abbyad & M. Silvestros
Accepted author version posted online: 04 Dec 2019
Download citation


Identify determinants of emergency medical service (EMS) personnel’s willingness to work during an influenza pandemic.


Little is known about the willingness of EMS personnel to work during a future influenza pandemic or the extent to which they are receiving pandemic training.


EMS personnel were surveyed in July 2018 – Feb 2019 using a cross-sectional approach; the survey was available both electronically and on paper. Participants were provided a pandemic scenario and asked about their willingness to respond if requested or required; additional questions assessed their attitudes and beliefs and training received. Chi-square tests assessed differences in attitude/belief questions by willingness to work. Logistic regressions were used to identify significant predictors of response willingness when requested or required, controlling for gender and race.


433 individuals completed the survey (response rate = 82.9%). A quarter (26.8%, n = 116) received no pandemic training; 14.3% (n = 62) participated in a pandemic exercise. Significantly more EMS personnel were willing to work when required versus when only requested (88.2% vs 76.9%, X2 = 164.1, p  < .001).

Predictors of willingness to work when requested included believing it is their responsibility to work, believing their coworkers were likely to work, receiving prophylaxis for themselves and their family members, and feeling safe working during a pandemic.


Many emergency medical services personnel report lacking training or disaster exercises related to influenza pandemics, and a fair percentage are unwilling to work during a future event. This may limit healthcare surge capacity and could contribute to increased morbidity and mortality. Findings from this study indicate that prehospital staff’s attitudes and beliefs about pandemics influence their willingness to work. Pre-event training and planning should address these concerns.
        (Continue . . . .)

On top of the number of HCWs (and other essential workers) who will refuse to work during a pandemic, there will also be attrition of the workforce due to illness, death, or the understandable need to stay home to care for loved one. 
Those who work in the periphery of healthcare - housekeeping, hospital security, food service - are even less incentivised to work, given their pay scale.  
While one might blame the HCWs who are unwilling to put themselves (and by extension, their families) in harm's' way during a severe pandemic, in truth, hospitals, EMS agencies, and practically all levels of government have failed to seriously prepare for the next global health crisis (see WHO: Survey Of Pandemic Preparedness In Member States).

Our battle against the next severe pandemic will likely be either won or lost in hospitals all across the nation. And while there are a lot of potential points of failure (lack of beds or ventilators, lack of IVs or meds, etc.), if we don't have the nurses, techs, EMTs and their support staff willing and able to work, it's pretty much game over.
If we lose the ability to provide reasonable health care - not only to pandemic victims, but also to those with heart attacks, strokes, cancer, and trauma - the societal and economic impact of the next pandemic could be unfathomable.
All reasons why, we - along with the rest of the world - need to find the foresight, fortitude, money, and political will to do something substantial to prepare before the next crisis strips us of that opportunity completely.

For more on pandemic planning and preparedness, you may wish to revisit:

JHCHS Pandemic Table Top Exercise (EVENT 201) Videos Now Available Online
#NatlPrep : Because Pandemics Happen

Pandemic Planning For Business

The Pandemic Preparedness Messaging Dilemma