Caring for emerging or contagious diseases often provokes angst for health-care workers (HCWs). Hesitation to provide care has been documented in HCWs caring for patients with HIV,1 severe acute respiratory syndrome (SARS)2 and H1N1 influenza. The issue of perceived personal risk for HCWs has resurfaced with the current West African Ebola virus disease (EVD) epidemic.3 We examined the knowledge and attitudes about EVD among HCWs in a U.S. pediatric hospital mostly before the first U.S. case of EVD occurred to determine if they felt they could safely and willingly provide care to suspected Ebola patients.
A questionnaire was developed regarding knowledge of Ebola transmission, epidemiology4 and therapy, as well as providers’ comfort (5-point Likert scale), willingness to offer a suspected Ebola patient care within their scope of practice, and demographic data. It was administered anonymously to a convenience sample of HCWs in the emergency department (ED), intensive care unit (ICU) and general floors of a quaternary-care children’s hospital in Houston, Texas between September 11, 2014 and October 2, 2014. ICU and ED HCWs were specifically targeted, as these 2 units were the main areas where suspected EVD patients would be seen. Questions left blank were considered incorrect for the knowledge-based questions. The questionnaire was distributed before any hospital-wide EVD educational or training activities; all were completed before the 2 Dallas HCWs were infected with EVD. The authors distributed and collected questionnaires in person largely during group meetings, and then provided explanations of the correct answers for the knowledge-based portion. Institutional review board approval was obtained. Demographics, individual questions and summary scores of sections were calculated as percentages, means and interquartile ranges.
Two hundred and forty-five HCWs participated (see Table, Supplemental Digital Content 1, http://links.lww.com/INF/C140); 91% completed the questionnaire before the first U.S.-diagnosed Ebola patient (September 9, 2014).5 Knowledge regarding Ebola transmission and epidemiology is summarized in Table, (Supplemental Digital Content 2, http://links.lww.com/INF/C141). Knowledge scores were uniformly poor, particularly for mortality rate, the incubation period, lack of airborne transmission, and in which secretions and excretions the virus can be found. The overall mean knowledge score was 56%, and physicians scored significantly higher than non-physicians (61% vs. 50%, P = 0.001). There was also a significant difference between ED and ICU physicians in terms of knowledge of EVD transmission (72% vs. 55%, P = 0.01); there were no differences in knowledge between ED and ICU nurses (50.3% vs. 50.8%, P = 0.9). Knowledge scores were not statistically significantly associated with age (P = 0.08), gender (P = 0.34), years of experience at the hospital (P = 0.47), pregnancy status (P = 0.34) or living with children (P = 0.56).
Only 16% of all HCWs felt they had received sufficient information and training to safely care for an EVD patient. Despite this and their poor knowledge scores, 86% of respondents felt they would be safe at work and claimed a high degree of willingness to care for and perform procedures on EVD-suspect patients (64–79%). In contrast, significantly fewer physicians (62% vs. 86%; P < 0.001) and nurses (63% vs. 86%; P < 0.001) felt their colleagues would be as safe at work as they would be (Table 1). Although most HCWs thought that they would be safe (86%), 38% felt they might infect a family member and 49% felt their family would avoid them if they cared for a patient with EVD.
Knowledge scores tended to be higher among HCWs who felt safer and secure as well as those willing to care for patients. Respondents who felt they received sufficient information to provide care had higher knowledge scores than those who did not (69% vs. 53%, P = 0.001). Knowledge scores tended to be higher among those who were willing to care for patients, and respondents who were willing to come to work had significantly higher knowledge scores than those not willing (57% vs. 42%, P = 0.03).
Although most participants completed the survey before the media announcement of the first US-diagnosed case, the survey occurred 7 months after the initial recognition of the West African EVD epidemic6 and more than a month after the World Health Organization declared it a “public health emergency” of international concern. Houston is a large, diverse city with a large West African population, so it would be expected that HCWs would be aware of the possibility of caring for a patient with EVD. Since this survey, the hospital has been designated as 1 of the 6 designated pediatric hospitals for Ebola care.
The overall knowledge base for HCWs was poor. Although most providers knew that EVD was spread by blood and saliva, fewer HCWs realized that viral shedding occurred in other secretions and excretions, which could result in HCWs taking inadequate infection control precautions while caring for an EVD patient. In contrast, almost one-third of physicians and one-half of nurses wrongly thought there is airborne transmission of Ebola virus. Media images of HCWs in West Africa wearing N95 masks may promote this misconception. Most HCWs underestimated the length of the incubation period and did not know that patients are not infectious before they develop symptoms. The former could have led to HCWs not performing screening by wrongly assuming patients were beyond their incubation period, whereas the latter could have resulted in HCWs unnecessarily isolating patients because of concerns of asymptomatic viral shedding.
The survey results also illustrate issues with providers’ perceptions of safety and willingness to provide care to a patient with potential EVD, many of which are intimately tied to their knowledge base. For instance, the ED physicians, who were more likely to encounter patients before a travel history was obtained, had the best knowledge levels. However, they were less willing to perform invasive resuscitative procedures, perhaps indicating that they may have better understood the transmission risks. In contrast, ICU providers were more willing to provide care but had lower knowledge scores.
The results demonstrate several examples of cognitive dissonance related to HCW personal safety. First, HCWs felt they, and to a lesser degree their colleagues, would be able to safely care for a patient, despite having a self-admitted EVD knowledge and training deficit and a strong and accurate sense of lack of institutional preparedness. Second, this sense of personal safety was inconsistent with the prevalent HCW fears of potentially exposing their families to EVD, or being avoided by their family if they cared for an EVD patient.
It is now obvious that US-based HCWs and their institutions were poorly prepared to care for patients with EVD. At the time of this survey, our hospital had begun to develop epidemiology and symptom screening algorithms and rudimentary plans to care for a patient who might have had EVD. These plans included identification and collection of appropriate personal protection equipment, but little attention had been paid to education and training of HCWs. This survey suggests that HCWs might have had a false sense of security during patient care but also had significant personal and emotional concerns that were not addressed. As was illustrated by the SARS epidemic, knowledge is not a singular strategy to help providers be and feel safe and willing to provide care. Adjunctive efforts that proved helpful for HCWs caring for SARS patients included organizational emphasis on infection control precautions, incentivizing HCWs to comply with policies and provision of personal support to HCWs and their families. The latter included offering staff temporary housing to avoid fears of bringing SARS into their homes.7 Surveys of nurses who cared for SARS patients found that exhaustion and anger among nurses (because of risk of infection and subsequent quarantines) could be mitigated by perceptions of organizational support and trust in equipment and infection control initiatives.8 As new infectious disease threats occur for HCWs, comprehensive strategies for education and training, personal safety and emotional support must be undertaken.
This study had limitations. The survey tool was not validated. To protect the respondents, the survey was anonymous; nonrespondents were not tracked. As surveys were anonymous, we could not determine the impact of later educational interventions on individual knowledge. Qualitative interviewers were not done. It is possible that true/false questions may have overestimated knowledge by participants guessing correctly. It is not possible to compare results to other hospitals or to the general population’s knowledge.
Our study provides a unique insight into HCWs’ perceptions of EVD before the first case was diagnosed in the US. It demonstrates the cognitive dissonance that can occur when HCWs want to fulfill their duty to treat despite poor knowledge of a very real personal threat. Despite HCW’s lack of knowledge about EVD, their perception that the hospital was unprepared and their concerns about interacting with their families after caring for a patient with EVD, our HCWs wanted to believe they would be safe and were largely willing to care for patients, including performing invasive procedures. Although this dedication is admirable, health care institutions must ensure that the perceptions of their HCWs are accurate and their safety is ensured.
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