Experiences Of Nurses And Midwives During
The Ebola Outbreak In Liberia, West Africa
CHAPTER ONE : INTRODUCTION
Research Problem
The recent Ebola outbreak in the West African region resulted in
many deaths plus devastating health and socioeconomic upheaval. In recent
history other regions of the world have been subjected to disease outbreaks
such as human immunodeficiency virus/acquired immune deficiency
syndrome (HIV/AIDS), influenza, and severe acute respiratory syndrome
(SARS). As a result there is some awareness of the potential of experiencing
disease outbreaks in any part of the world. Health care workers (HCWs) are
central to the restoration and maintenance of optimum public health,
especially in situations such as disease outbreaks (Barnett et al., 2012). The
principles for HCWs’ training and preparedness have been studied to assure
their competent handling of these difficult situations. Studies have
demonstrated that the adequate training and preparedness of HCWs,
including nurses, is key to the survival of the population in the event of a
disease outbreak. Typically, HCWs are equipped with skills for surveillance,
communication, reporting, and containment of disease outbreaks (Chiu,
Polivka, & Stanley, 2011; Qureshi et.al, 2004).
The willingness of HCWs to respond in situations of uncertainty and
insecurity, along with their perceptions and attitudes towards their roles
during disease outbreaks, influences their availability and positive response
to the need for containment of the disease (Barnett et al., 2012; Devnani,
2012). Influenza epidemics have received attention by scholars and
researchers have identified that HCWs were willing to respond or care for
the victims during influenza virus epidemics (Balicer et al, 2010; Barnett et
al. 2009; Baster, Edwards, & Schulte, 2009). Studies have indicated
differences in the rate of willingness of health workers to care for patients
who are victims of virulent and life threatening epidemics, pandemics, and
infectious diseases. Barnett et al. (2012) and Basta, Edwards, and Schulte
(2009) describe the determinants of HCWs higher willingness to respond to
include type of disease outbreak (e.g., less virulent diseases associated with
higher willingness), and that lower threat perceptions of health care workers
are associated with higher efficacy assertion (meaning higher assertion to
being competent to handle the situation) by health care workers. In other
words, the less virulent a disease outbreak, the lower the threat perception of
the disease outbreak, and the higher the assertion of competence to handle
the situation. This in turn promotes a higher willingness of health care
workers to respond or care for patients during disease outbreaks. During the
peak of a disease outbreak, frontline health care workers who must be in
very close contact with victims of the outbreak, especially virulent diseases
that are of high risk to HCWs, were found to have a high rate of
unwillingness to respond
(Barnett et al., 2012; Baster, Edwards, & Schulte, 2009).
Despite what is known about HCW willingness to care in other
disease outbreaks, research on the willingness of HCWs to care for victims
of Ebola has not yet received much attention. The inner experiences of
HCWs combating Ebola in a region that has never experienced such an
epidemic is not yet understood. It is both timely and vital that a study
describing the experience of health care workers and their willingness to
care for patients during the Ebola disease outbreak be conducted. It is also
important to identify those factors that influenced HCWs to care for patients
during the Ebola outbreak.
It should be noted that during the Ebola outbreak in Liberia and West
Africa as a whole, not only was there a need to care for patients who had
contracted the Ebola virus, but there were other patient populations who
needed other health care services. Pregnant women, women in labor for
child birth, and postpartum women, children, and other adults with diverse
conditions not related to Ebola were constantly in need of health care
services.
Coping with a new disease with high mortality within the region,
including development of treatment protocols, was a concern in the region.
The resources needed including experts and health care workers, who were
experienced in treating patients with Ebola, were not readily available. The
cause of this adequacy in Liberia (one of the countries in the region) was that
the country had recently emerged from 14 years of civil war which lead to
lower availability of health resources and dysfunctional health care systems
(Buseh, Stevens, Bromberg, & Kelber, 2015). In addition, Ebola virus
disease symptoms are not easily differentiated from other endemic diseases
like malaria, gastroenteritis, or cholera (World Health Organization [WHO],
2015). The symptoms of Ebola virus disease are indistinct from other
infectious diseases and fatal. This led to increased anxiety levels of health
care workers, such that every patient who sought care or health care services
for other health conditions were treated as suspected cases (Hayter, 2015).
Furthermore, WHO (2015) released a statement on the Ebola outbreak in
Liberia in which they stated that Liberia had reported the highest number of
deaths in the largest, longest, and most complex outbreak since Ebola first
emerged in 1976 in the
Democratic Republic of Congo. At the peak of the epidemic, which occurred
between
August and September 2014, the country was reporting from 300 to 400 new
cases every week. During those two months, according to WHO (2015), the
capital city Monrovia was the setting for some of the most tragic scenes
from West Africa’s outbreak. Gates were locked at treatment centers that
were overflowing with patients, patients were dying on the hospital
premises, and bodies were sometimes not collected for days. Flights in and
out of the country were cancelled, and supplies of fuel and food ran low.
Public facilities such as schools, businesses, border crossings, markets, and
most health facilities were closed. The nation was in fear and uncertainty
about the future―for families, for communities, and for the country and its
economy. The situation devolved until treatment beds for Ebola patients
were exhausted and were no longer available anywhere in the country. This
led to the abandonment of infectious cases and corpses remaining in homes
and communities. Physicians and nurses continued to play a key role in the
management and treatment of patients, even when supplies of personal
protective equipment and training on its safe use were inadequate.
Altogether 375 health care workers were infected and 189 lost their lives
(WHO, 2015).
The International Council of Nurses (ICN), in a 2015 press
conference, alluded to the problem the Ebola outbreak posed to HCWs
within the West African Region and the entire health systems of the
countries affected by Ebola. The ICN (2015) noted that Ebola infections
were contracted by health care workers, resulting in devastating effects on
the health system, including closure of hospitals, depletion of the much-
needed health care workforce, and distrust in the health system. According
to the ICN (2015), Ebola exacerbated the pre-existing shortage of health care
workers, high rates of attrition, uneven distribution of workers, poor
employment conditions, and gaps in occupational health and safety in the
three countries most affected within the West African region:
Guinea, Liberia, and Sierra Leone. The ICN reported that health care
workers were 21-32 times more likely to be infected with Ebola than were
adults in the general population. In the affected countries, nurses accounted
for more than 50% of all health care workers infected, physicians and
medical students account for 12%, and laboratory workers accounted for
7%. The ICN (2015) recommended that in light of the numbers of nurses
who lost their lives, there is need to strengthen safety policies, and provide
adequate protection and appropriate training. In addition, the ICN, issued a
declaration which called on governments to create safe working
environments for health care workers as a prerequisite to the provision of
care to Ebola patients; it also called for adequate training and education,
availability of protective equipment, as well as nurses taking an active role
in policy making regarding the prevention of infection and patient care.
With the high risk to nurses associated with caring for infected
patients, there is a need to explore the experiences of nurses and midwives
during the Ebola outbreak in Liberia, to gain their perspective on the safety
issues, which social processes influenced the situation, and what other
measures apart from safety assurance would be needed to develop a more
realistic policy that will meet the needs of nurses and other health care
workers. There is also the need for a holistic and comprehensive approach to
understand what HCWs, specifically nurses and midwives went through
during the epidemic while caring for Ebola and non-Ebola patients. It is
important to explore the social process involved in nurses’ and midwives’
decision making about rendering or not rendering care to patients during the
Ebola outbreak. We need to understand why those nurses and midwives
who continued to care for patients did so, and the decision making of those
who chose not to work during the Ebola outbreak. We also need to explore
how nurses’ and midwives’ willingness to care for patients during the Ebola
outbreak influenced the care for patients who had contracted Ebola virus, as
well as other patients with other life threatening conditions.
Purpose of the Study
The purpose of this study was to explore the experiences of nurses and
midwives, including the decision making process involved in caring for
patients during the Ebola outbreak in Liberia, West Africa.
Specific Aims of the Study
The specific aims of this study were to:
i. Describe, analyze, and interpret the experiences of nurses and
midwives during the Ebola outbreak in Liberia.
ii. Explore the personal, institutional, and government influences of
the work decision process used by nurses and midwives during the
Ebola outbreak in
Liberia.
Definitions of Terminology
The operational terms used in this study are subjective values and in
the context of this study are defined as follows:
Experiences: the process of personally observing, encountering,
and/or carrying out patient nursing care and/or midwifery care
activities over a course of time.
Midwives: certified and registered health care personnel who
have at least three years training in midwifery. In addition to
their certification, some
have a bachelor’s degree in nursing. Midwives work in the obstetrics and
gynecology units, labor and delivery wards, and postnatal
clinics.
Nurses: are certified and registered health personnel who have
completed at least three years training in a nursing program at
the diploma level. In addition to their nursing diploma, some
have also earned a bachelor’s degree in nursing. Nurses are in
almost all care units or wards in the hospital.
Work decision: are the influences and outcomes of choices
made by the nurses and midwives to decide whether or not to
continue caring for patients during the Ebola outbreak.
Significance of the Study
This study provides a description and interpretation of the experiences
of nurses and midwives who in the face of grave danger chose not to
continue to care or who continued to care for both Ebola and non-Ebola
patients during the Ebola outbreak. The study showcases the contributions
and reasons for the work decisions of nurses and midwives during the Ebola
outbreak. The outcome of the analysis describes and interprets the
experiences of nurses and midwives, the characteristics of the nurse-patient
relationship, and the characteristics of the nurse-nurse relationship during the
Ebola outbreak. The outcome of the analysis also provides a conceptual
model that explains the personal, institutional, and governmental influences
involved in the process of nurses and midwives deciding whether or not to
continue providing care. The findings are informative for practice, policy
decisions, education, and curriculum development of nurses and midwives
on Ebola nursing care. The findings may also lead to further research on
Ebola outbreak management in the studied location and other locations with
similar contextual or socio-cultural conditions.
Significance for Practice
The stories of the nurses and midwives offer understanding into their
experiences in the midst of life-threatening circumstances during the Ebola
outbreak. From the perspectives of the nurses and midwives who were
involved in the care of patients during the Ebola virus disease outbreak,
other nurses, midwives, and HCWs may gain insight into the personal,
institutional, professional, and government influences on their attitudes and
practice. This understanding might be useful for those who will face similar
circumstances in the future. These findings have implications for practice
protocols regarding the personal preparedness activities, nurse-patient
relationship, nurse-nurse relationship, and protective measures of nurses and
midwives in the event of an Ebola outbreak in Liberia, West Africa, and
other resource-challenged areas of the world.
Significance for Education
Educational programs for nurses, midwives, and other health care
workers could include the derived conceptual model from this study in the
curricula. This could be done by including content, concepts from this study
in the epidemiological, disaster management, health promotion, and ethics
courses that would be taught to the students.
Significance for Policy
Nursing boards, nursing administrators, hospital administrators, and
Ministries of Health could use the findings and strategies recommended
from the study in the planning, implementation, and evaluation of Ebola
response policies. It could also inform the responsibilities of principals
towards nurses, midwives, HCWs, their families, and patients. Highlighted
guidelines and strategies to promote nurses’ and midwives’ experiences and
work decisions during Ebola outbreak could inform policy development and
implementation of appropriate Ebola prevention, treatment, and containment
methods.
Significance for Theory
This study identifies concepts that provide the description of
experiences of nurses and midwives during the Ebola virus outbreak in
Liberia. Data analysis resulted in a conceptual model of the work decision
process of nurses and midwives on caring choices for patients during the
Ebola outbreak in Liberia. The conceptual model provides a premise for
further development of theory.
Significance for Future Research
The development of a conceptual model provides a premise for further
research through which the development of a substantive theory and a
formal theory could be achieved. In addition, at any level of theory
development, the model could be tested using quantitative approaches in
Liberia and other countries within the West African Region. Intervention
studies on adequate strategies identified in the data that could be applied to
nursing practice to enhance practice and decision process during Ebola
outbreaks could be conducted
Researcher Perspective and Assumptions
The researcher is a registered nurse and registered midwife, living in
Liberia. The researcher had her training in an undergraduate generic nursing
program in Nigeria, a neighboring West African country, which equipped
her for nursing, midwifery, and community health nursing practice. In
addition she was exposed to further training in a master’s program for nurse
educators, with a focus on nursing the growing family in an off-campus
satellite program of a university in the United States. The researcher lives
and works as a nurse educator and nursing clinical consultant in Liberia,
and was living in Liberia during the Ebola outbreak; as a result, the
researcher brought her insider perspective of one who is familiar with the
social structure, cultural norms, political climate, and nursing professional
obligations in Liberia.
The assumptions from integrating of the symbolic interactionism
tradition, constructivist stance, and pragmatist world view were combined
with the researcher’s background. These assumptions will be described in
the methods chapter, along with how they fit the research design used in this
study.
Summary
This chapter has addressed the research problem including the need
for the study, which calls for the use of a holistic and comprehensive design
to explain what nurses and midwives experienced during the Ebola epidemic
in Liberia while trying to meet the needs of Ebola and non-Ebola patients. In
this chapter, we describe the need to explore the influences involved in the
decision making regarding nurses’ and midwives’ willingness to care for
patients and the explanation of nurses’ and midwives’ perceptions and
attitudes towards rendering care during the Ebola outbreak. The purpose and
specific aims of the study were presented and key terms defined. Experience
and work decisions were discussed. The significance of the study and the
researcher’s background, perspective, and assumptions were also identified.
Overview of the Remaining Chapters
Chapter two includes a critical review of quantitative and qualitative
studies conducted on disease outbreaks and health care workers’ responses
and attitude towards them. Sensitizing frameworks for this study are also
described in chapter two. Chapter three addresses the research design and
methods for this study, and also includes the sampling plan and setting for
this study, the method of data collection, the process and procedure for
collection of data, and the method of data analysis used. Chapter four
includes the description of the findings from the data analysis. A
publishable manuscript that contains the findings from data analysis is
embedded in chapter four. Measures used to ensure trustworthiness were
also addressed in chapter four. Chapter five provides the discussion of the
findings and highlights the strengths and limitations of the study. The
application of the findings to nursing practice, theory, policy, and future
research are also discussed in chapter five. Appendices at the end of this
report include the interview guide, human subjects’ approval, consent form,
letter of support, and a sample of transcribed data analyzed in the study.
CHAPTER TWO
CRITICAL REVIEW OF RELEVANT LITERATURE
Introduction to Chapter
This chapter examines the state of science on the willingness of health
care workers to provide care during a highly contagious disease outbreak. It
also highlights Ebola, its history, its recent effects on the countries directly
involved and on the world view about the disease, future expectations as
regards to its transmission, treatment, and containment, and current nursing
implications. There are a limited number of studies specific to Ebola and the
responses to care and attitudes of nurses and midwives. Consequently, I
broadened the scope of literature review to glean from the science that exists
in other disease outbreaks and the responses and attitudes of HCWs toward
providing care.
Ebola: The New Trial for the West African Health System
The World Health Organization [WHO] (2015) described that Ebola
viral disease (EVD) can be up to 90% fatal in humans. Humans contract the
virus from wild animals and then transmit the virus to other humans through
physical contact. Symptoms begin to manifest within 2 to 10 days after
contact with the virus. People are only contagious during the symptomatic
period. Early supportive care with rehydration and symptomatic treatment is
critical to survival since there is currently no standard pharmacologic
treatment to destroy the virus (WHO, 2015, “key facts,” para. 1).
History and Origin of the Ebola Virus Disease
Ebola virus disease or EVD, as we currently know it, first appeared in
1976 in two concurrent outbreaks in Eastern Africa: one in Nzara, Sudan,
and the other in Yambuku, Democratic Republic of Congo (WHO, 2015).
The latter occurred in a village near the Ebola River, from which the ailment
takes its name. The recent outbreak in West Africa, where the first cases
were identified in March 2014, is the largest and most difficult Ebola
outbreak since the virus was discovered. According to the WHO (2015),
there have been more cases and deaths recorded in this outbreak than all
others combined. It spread between neighboring countries, starting in
Guinea, then to Sierra Leone and Liberia, and eventually to Nigeria, the US,
Senegal, and Mali. The most severely affected countries were Guinea,
Liberia, and Sierra Leone. These countries have very weak health systems,
lack human and infrastructural resources, and have only recently emerged
from long periods of war and instability. The outbreak in the West African
Region became a public health emergency that claimed worldwide concern
under international health regulations (WHO, 2015, “Background,” para. 3).
According to Borio et. al. (2002) EVD is caused by a virus called
Filoviridae, one of the viruses included in the family of hemorrhagic fever
viruses which cause severe illness in humans including fevers and bleeding
tendencies. These viruses were described in Borio et al.’s (2002) report and
the WHO (n.d) to include Arenaviridae, which causes Lassa fever and New
World hemorrhagic fever. Bunyaviridae causes Crimean-Congo
hemorrhagic fever, Rift Valley fever, and Hantan hemorrhagic fevers with
renal syndrome. Filoviridae causes Ebola virus disease and Marburg virus
disease. Finally, there is Flaviviridae, which causes yellow fever, dengue,
Omsk hemorrhagic fever, and
Kyasanur forest disease.
Transmission of Ebola Virus Disease
It is thought that fruit bats are a natural Ebola virus host. Ebola is
introduced into the human population through close contact with the blood,
secretions, organs or other bodily fluids of infected animals such as
chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines
found ill or dead or in the rain forest (Borio et. al., 2002). Human-to-human
transmission of Ebola occurs by means of direct contact, such as when
broken skin or mucous membranes come into contact with the blood,
secretions, or body fluids of infected people, and with surfaces and materials
(e.g. bed clothing) contaminated with these fluids. Infected humans are
infectious as long as their blood contains the virus, even after they die from
the disease (WHO, 2015).
Symptoms of Ebola Virus Disease
The WHO (2015) describes the symptoms manifested by people infected
with
EVD as starting 2 to 21 days after infection, although they are not infectious
until symptoms begin to develop. Symptoms start with the sudden onset of
fever, fatigue, muscle pain, headache, and sore throat, followed by
vomiting, diarrhea, rash, symptoms of impaired kidney and liver function,
and in some cases, both internal and external bleeding (Symptoms of Ebola
virus disease, para.1). EVD is difficult to distinguish from other infectious
diseases; however, Ebola virus infection can be confirmed through
laboratory investigations. These investigations are listed by the WHO (2015)
to include antibody-capture enzyme-linked immunosorbent assay, antigen-
capture detection tests, serum neutralization test, reverse transcriptase
polymerase chain reaction assay, electron microscopy, and virus isolation by
cell culture. Samples from infected patients are an extreme biohazard risk
and laboratory testing should be conducted under highest biological
containment conditions (WHO, 2015 “Diagnosis,” para. 1).
Treatment and Vaccines
The treatment for EVD has not yet been developed. However, there is
a range of potential treatments including blood products administration,
immune therapies, drug therapies, and vaccines which are currently being
developed. Supportive care including rehydration with oral or intravenous
fluids and treatment of specific symptoms improves survival (WHO, 2015,
“Treatment and vaccines,” para. 1).
Risk of Transmission to Health Care Workers
In the event of epidemic occurrences, health care workers are on the
frontline in combating the disease, and have been infected while treating
patients with suspected or confirmed EVD. Infection occurs through close
contact with patients, especially when infection precautions are not strictly
practiced (WHO, 2015). The recent Ebola epidemic in West Africa found
health care workers, including nurses and physicians, as frontline
combatants while some also became victims of the disease. The situation in
West Africa was compounded by the lack of skilled HCWs with experience
in preventing and treating Ebola. Other challenges include the lack of
adequate protective equipment and environmental aspects that could limit
spread (e.g. lack of enough isolation wards in treatment centers and holding
centers) The result was that health care workers in the affected countries
cared for patients and their families in difficult conditions which in most
cases increased their risk of contracting Ebola. The situation warranted
courageous health care workers, who despite not having adequate
knowledge of the virus they were contending with, were asked to tackle the
gruesome challenges. These challenges ranged from severe workforce
shortage, dysfunctional health facilities, inadequate resources and
equipment, and colleagues becoming infected and dying daily (Buseh,
Stevens,
Bromberg, & Kelber, 2015).
Nursing Implications for the Management of EVD
The skills and protocols involved in nursing care for patients with EVD
are undergoing development; however, some articles and opinion papers
have begun to shed light on the subject. Lessons can be learned from nurses
who were involved in the care of
EVD-infected patients during the Ebola outbreak in West Africa and
returned to the U.S.
(Matlock, Gutierrez, Wallen, & Hastings, 2015). The lessons were
summarized by
Matlock, Gutierrez, Wallen, & Hastings ( 2015) into five points:
1. “It is possible to care for patients with EVD with much better clinical
results than have been experienced in the past because current care
techniques have improved.
2. Personal protective gear and equipment are essential to prevent
transmission to care providers or environmental contamination.
3. Procedures to care for EVD within isolation units are multifaceted and
require intensive training, practice, and observation as well as a chance
to experience working in full gear.
4. Repeated, redundant, and detailed communications to all in and around
a clinical situation of EVD is vital because the associated fear and
inaccuracies in the media exaggerate concerns about personal and
community risk.
5. Volunteerism is critical in the first response to this crisis” (p. 23).
Furthermore, there is the opinion that the need for strict isolation has
compromised nurses’ ability to touch and provide comfort and human
connection to EVD patients (Connor, 2015). According to Connor (2015),
touch is a primary way humans connect and an important part of the nurse-
patient relationship and may be one of the central aspects of caring between
nurses and patients (para. 2). Nurses touch patients to offer comfort, promote
healing, and demonstrate caring. They touch patients in a multitude of ways
at every encounter; when taking vital signs, bathing patients, moving
patients in bed, helping them leave the bed to walk or sit in a chair (para. 3).
The physical touch nurses offer patients, especially in the case of Ebola, tells
them they are not alone and reassures them that the nurse is not afraid to be
near them. Because skin-to-skin contact is not acceptable when treating
EVD patients, despite the layers of protective equipment, nurses need to find
a way to provide human touch that is intentional, deliberate, and meaningful
to offer comfort, connection, and care (Connor, 2015).
Finally, on the issue of nursing implications for EVD, is the need for
development of a curriculum that provides for a better understanding of the
knowledge, skills, and attitudes required to care for patients during public
health emergencies. For instance, faculty at Emory’s Nell Hodgson
Woodruff School of Nursing partnered with colleagues at the Centers for
Disease Control and Prevention (CDC) to develop and deliver a course
entitled, “Introduction to Complex Humanitarian Emergencies for Nurses.”
The course included instructive presentations and active learning exercises
to examine the provision and management of care and opportunities for
leadership. This could be replicated and contextualized in West Africa and
globally (Downes, 2015).
Description of Literature
Studies in the area of health care workers’ attitudes and behaviors
towards the recent Ebola epidemic were limited at the time of conducting
this literature search.
Therefore the decision was made to expand the search terms to disease
outbreaks, medical disaster, health disaster, and public health emergencies.
This provided research articles that articulated studies on the experiences,
concerns, and determinants of willingness of health care workers to respond
or not to respond during a disease outbreak or public health disaster. It was
reasoned that lessons from those studies could offer understanding of the
phenomenon in the context of the Ebola epidemic. The search terms used
were willingness, attitudes, behaviors, infectious disease, disease outbreak,
epidemics, health care workers, and nurses. The databases searched include
Pubmed, Ebscohost, Academic Search Premier, Cochrane, Psych Info,
Global Health, and WHO websites. The type of articles used included
quantitative, qualitative, and mixed method studies, systematic reviews,
WHO facts and reports, and opinion articles. The search parameters include
English language, dates ranging from 2000 to 2016, and full text articles.
The literature on the subject matter is discussed under the following
headings: Ethical considerations on care, concerns and confidence to care,
statistics on health workers’ willingness to care (WTC), determinants of
WTC, strategies to foster WTC, and experiences during Ebola outbreak.
Ethics on Care for Patients with EVD
The discussion on the ethical considerations of care focuses on the
nursing ethics of care. This is because the researcher’s profession is nursing;
however, we could assume the same thread or fairly similar considerations
run through all health care professionals. The International Council of
Nurses (2012) code of ethics has four elements that outline the standards of
ethical conduct, concerning nurses and people. One of these is that the
nurses’ primary professional responsibility is to people who require nursing
care, making it necessary for the nurse to share with society the
responsibility for initiating and supporting action to meet the health and
social needs of the public, especially vulnerable populations. A second
element requires nurses to maintain a standard of personal health for
themselves such that the ability to provide care is not compromised. The
American
Nurses Association (ANA, 2015) code of ethics for nurses also has a list of
provisions. The second provision indicates that the nurse’s key obligation is
the health care needs of the patient, whether an individual, family, group,
community, or population (p. 5). This provision explains that when conflicts
arise from opposite loyalties in the workplace, including conflicting
expectations from patients, families, other health care workers, health care
organizations, and health plans, the nurse must examine the conflicts arising
between their own personal and professional values, the values and interests
of others who are also responsible for patient care and health care decisions,
and perhaps even the values and interests of the patients themselves. The
nurse addresses such conflicts in ways that ensure patient safety and that
promote the patient’s best interests while preserving the nurse’s professional
integrity (pp. 5-7). The American Nurses Association fifth provision states
that the nurse is obligated to care for self as well as for others, including the
responsibility to promote health and safety, and maintain competence (p.
19). The ANA (2015) further explains that while nurses are obliged to
conduct nursing actions such as assessment, intervention, and promotion,
among others for the health and safety of their patients and society, they
also are obliged to use the same health maintenance and promotion strategies
that they teach and render, use health care services when needed, and refrain
from unnecessary risks to their health and safety in the process of carrying
out their professional and personal activities (pp. 19-25).
Several nurse administrators of the Rhode Island State Board of
Nursing, together with physicians holding administrative offices in Rhode
Island, wrote on their perspectives on the professional responsibilities for
treating patients with Ebola. Their aim was to answer the questions whether
health care providers could refuse to treat a patient with Ebola. The
administrators examined their perspectives against the ethical principle of
beneficence, which means health professionals are to do those things that
will be of benefit to their patients. They asserted that a health care provider
has an ethical and professional duty to address a patient’s needs, as long as
the patient’s diagnosis falls within the provider’s scope of practice. They
judged that refusing to address patient’s needs is not consistent with the
ethical principle of beneficence. Application of beneficence to the care of
patients with Ebola was based on the premise that the Ebola virus disease is
now understood; that is, the origin, mode of transmission, symptoms, and
means of mitigating the risk of contracting the virus during patient care (e.g.,
use of protective equipment) is now better understood by health care
professionals (Twardowski, McInnis, Cappuccino, McDonald, & Rhodes,
2014). These authors further stated that health care providers within their
scope of practice are to use this knowledge and their licenses given to them
by state licensing boards, which impose upon them obligations and
responsibilities to care for patients with Ebola. They categorically indicated
that in the state of Rhode Island, licensed health care professionals in active
practice are obliged to treat and/or care for patients with Ebola, while
minimizing the risk of Ebola transmission to self and others. Their advice to
health care providers on this matter was that health care providers must
reflect very carefully before declining to care for a patient, because concerns
about personal risk (which in the case of Ebola, can be readily alleviated in
their opinion) must be weighed against ethical and professional obligations
(Twardowski, McInnis, Cappuccino, McDonald, & Rhodes, 2014). Sokol
(2006), in a more permissive take on health care workers’ duty of care
during virulent epidemics, stated that more evaluation is needed before
stakeholders in health care come to a consensus on the matter. His rationale
was that the term “duty of care” was more legalistic, suggesting that the
notion was too vague and ethically dangerous to the welfare of health care
workers. Sokol reasoned further that the term gave the illusion of legitimate
moral justification for health care workers’ duty to care for patients despite
unclear provision for their safety. It could be a subtle instrument for
intimidating and pressuring health care workers into working in
circumstances that they consider morally, physiologically, or physically
unacceptable. By virtue of their profession, physicians and nurses have more
stringent obligations of beneficence than most other health care workers and
may be put in danger through the idea of the term, “duty of care.” In the
opinion of Sokol, the term has no fixed limits but is contingent on various
factors in the working environment’s normal risks to the health care worker.
He recommended that this term be clarified through empirical social science
research to illuminate the views and reasoning of physicians, nurses, patients
and the members of the public on the limits of the duty of care. He
recommended further that research should also uncover infection control
measures, staff training and involvement, the role of medical students and
volunteers, the triaging of incoming patients, and the logistics of treatment,
depending on the severity of the epidemic, as well as the lessons learned
from past epidemics.
Coleman (2008), a professor of law in the Center of Health and
Pharmaceutical Law & Policy, Georgetown University, added her opinion to
the discourse that no social contract requires health care workers (HCWs) to
care for patients despite potential health risks. Coleman stated HCWs should
not be compelled to work and risk exposure to life threatening disease based
on their status as licensed professionals. Volunteerism, as Coleman (2008)
stated should be promoted by policy makers to assure the availability of
skilled care during disease outbreaks, instead of taking punitive actions on
health care professionals who decline to work during epidemics.
Other opinions on the subject of ethics were presented in a reflective
article in which the author Reid (2005) stated that many policy makers made
unrealistic assumptions about the duty of care, the risks that health care
professionals faced during the severe acute respiratory syndrome (SARS)
outbreak, and their response of service in the face of these risks. According
to Reid (2005), duty of care does not arise from the particular virtues of
professionals, not on altruism and heroism, but is based on social
expectations that the response to an epidemic be consistent with our values
and our needs. This is in recognition of our shared vulnerability to disease
and death.
The Institute of Medicine (2012) in a conference held in Atlanta,
Georgia in the
U.S., delivered a systems framework for catastrophic disaster response
called the Crisis Standard of Care (CSC). The IOM suggested that entering a
standard of care mode during crisis situations is not optional, but is
compulsory, based on incipient situations. Under such emerging situations,
failing to make substantive adjustments to care operations―that is, not
adopting a CSC―is very likely to result in greater death, injury, or illness to
the population. It also suggests that the implications of the CSC to health
care providers entail difficult decisions on care options, and intense trade-
offs about personal choices to care. Health care workers may be asked to
perform expanded roles outside their specialty through waivers, and
additional responsibilities and/or procedures may be obliged on them.
An alternative view presented by Hodge, Hanfling, and Powell (2013)
addressed practical ways to ease the ethical and legal challenges underlying
standard of care during a crisis. These practical methods were proffered as
an alternative to the 2012 IOM recommendations on ethical norms for
HCWs during a crisis. Hodge et al. (2013) were of the opinion that the IOM-
recommended standard of care in crisis was impractical and coercive. The
researchers’ recommended alternative practices include incentives for
HCWs work attendance, incentives for higher risk work, and incentives to
return staff to work. These approaches also include providing preventive and
protective measures to foster HCWs willingness to work during infectious
disease outbreaks.
Results from a fairly large quantitative design electronic survey (N =
908) in the U.S. indicated that most medical center employees felt it was
unethical to abandon the workplace during an influenza pandemic. Sixty five
percent of the employees did not want to be coerced; they wanted to be able
to decide whether or not to work. Seventy nine percent would agree to
volunteer on the condition that some incentives and protective equipment
with training for its use be given. This study indicates that a high percentage
of medical center employees expressed a willingness to care for patients
during pandemic avian influenza, with conditions of personal safety and
training attached. The limitation of this study was that the researchers
reported a low response rate from participants. The response rate was not
given in statistical figures; however, this could lead to the possibility of bias.
It is possible that those who responded are inclined altruism. The low
response rate may have limited the ability of researchers to identify possible
confounding variables; for example, reported gender differences might be
due to over representation of one gender (Shabanowitz & Reardon, 2009).
In a smaller quantitative study conducted in the U.K. among hospital
staff (N = 406) with a responsive rate of 40%, the respondents (83%) of the
survey felt it would be unprofessional to leave work during a pandemic
influenza event. Most of the staff (79%) felt professionally obligated and
would voluntarily work during a pandemic despite high personal risk (Barr
et al., 2008). Another quantitative study (N = 644) aimed to assess the
ethical conflict between professional duties and fear of influenza
transmission to family members among health care professionals (HCPs)
(Ehrenstein, Hanses, & Salzberger, 2006). The respondents partook in a
cross-sectional survey. Of the participants, 28% agreed that it was
professionally acceptable for HCPs to abandon their workplace during a
pandemic so as to protect themselves and their families. However, 52%
indicated they would not choose family over work during a pandemic. Of the
sample, 58% did not believe that the decision to report to work during a
pandemic should be left to the individual HCP. This finding might suggest
that this percentage of respondents felt that HCPs should be required to work
regardless of their personal choice. The findings also showed that 77% did
not agree that HCPs should be dismissed from work for not reporting to
work during a pandemic. The study would have been strengthened had they
accounted for gender differences and/or professional differences in terms of
clinical or non-clinical HCPs. It would have been valuable to identify the
association between gender or clinical competence and perceptions of ethical
obligations to care (Ehrenstein et al., 2006).
A study in Taiwan was conducted using a survey of 172 nurses, with
the objective to investigate the relationship among hospital nurses’
professional care obligations, their attitudes towards SARS, infection control
measures, whether they had ever cared for patients with SARS, and their
current health status. The result showed that nurses were willing to provide
care for patients with SARS. The study also noted that nurses who were
willing to use the personal protective equipment (PPE) and take the vaccine,
combined with the fact that personnel were not required to be quarantined,
significantly predicted nurses’ fulfilling their obligations to care for SARS
patients during an epidemic (Tzeng, 2004).
By way of synthesis, it could be concluded that health care workers
generally agree that it is their professional obligation to care for patients
during an influenza pandemic, despite the risk for themselves and their
families. Therefore, we could assume that while it may be a moral obligation
for health care professionals to care for the sick, they are not obligated to
bear the risk of infection during a disease outbreak. It is the duty of policy
makers to put in place appropriate measures to ensure their safety and refrain
from punitive measures on HCWs who prefer to stay away from the
frontlines of combating epidemics. One way to understand the factors that
influence health care workers’ willingness to care for patients is to look at
the situation from the perspectives of the health care workers. This could
inform policy makers and health care administrators of ways to enhance
HCWs’ willingness to care for patients during an epidemic. It could also
guide educational program curricula and redesigns of in-service training to
improve health care workers’ perspectives on the subject through mentoring
and education.
Concerns and Confidence to Care during Disease Outbreaks
While health care workers, including nurses agree that HCWs are
obliged to report to duty in an epidemic, and that their safety is also
important, reports from several qualitative and quantitative studies have
identified a varied range of concerns that affect willingness of HCWs to
work during a disease outbreak. A review of the literature shows confidence
issues that also affect willingness to work during public health emergencies.
One qualitative study explored health care workers’ concerns in the isolation
ward during the 2009 influenza pandemic in Hong Kong. Ten healthcare
workers, including physicians, nurses and others, were interviewed. The
findings showed participants who worked in the isolation ward expressed
professionalism and willingness to work. Their concerns included
appreciation from employers, efficacy and side effects of vaccines, frequent
policy changes, unclear protocols for case management of infected patients,
poor facility layout, and duty role stress (Wong, Wong, Lee, Cheung, &
Griffiths, 2012). A limitation of this study is that it did not explore the duty
concerns of health care workers in other routine wards during the pandemic.
In a quantitative study, researchers compared the concerns of 326
HCWs about the general risks involved in caring for patients with influenza
in two community hospitals and one tertiary hospital. Using a survey, the
authors reported that the tertiary hospitals had a higher percentage
expressing concern that their jobs exposes them to the risk of contracting
avian influenza (78% from the tertiary hospital vs 67.5% from the
community hospitals). The report also indicated that 90% tertiary hospital
staff and 82% of staff from the community hospitals felt they were better
prepared (through infection control training received and protective
equipment provided) for an outbreak. Concerns expressed in this study fell
mainly into three categories: personal safety, psychological impact, and
family safety (Cheong et al., 2007). Another quantitative survey in Taiwan
by Hsu, Chen, Chang, and Chang (2006) identified the issues related to the
selfconfidence of public health nurses in their ability to function safely, and
the influence self-confidence had on their willingness to work during an
epidemic. Of the 312 nurses studied, 71.9% expressed a general lack of
confidence in handling the SARS epidemic.
Their confidence was significantly associated with perceived epidemic
severity (OR 0.58, CI: 0.31-0.99), daily epidemic updates (OR 2.26; CI:
1.28-3.98), and the number of cases in the community (OR 2.21; CI: 1.13-
4.31). A limitation of this study is that the researchers did not report the
relationship between the confidence of the nurse and the willingness to work
during the SARS epidemic.
The studies on concerns and confidence indicators suggest a varied
range of concerns held by health care workers, including nurses, which need
to be considered when planning for effective workforce presence during a
disease outbreak. These concerns, along with the level of confidence of the
HCWs, might have some influence on their willingness to work during a
pandemic.
Willingness to Care Body of Evidence
The studies of health care workers’ willingness to care for patients or
work during disease outbreaks reflects a wide variation when compared
within clinical and nonclinical groups of HCWs. The body of knowledge
from quantitative studies reflects dissimilarities in rates of willingness to
care for patients during disease outbreaks among locations categorized as
developed societies. No pattern was observed among the countries studied in
terms of willingness to care, type of epidemic, population studied (groups of
health care workers), or study location or setting.
A study by Barnett et al. (2009) utilized the Extended Parallel Process
Model (EPPM) to examine the adaptive behaviors in an event of unknown
risk. First proposed by Witte in the early 1990s, the EPPM represents a
combination and extension of previous psychosocial models of ‘‘fear
appeal’’ (as cited in Barnett et al., 2009, e. 6365). The EPPM proposes that
to be effective messages must be comprised of two parts: threat and efficacy.
Those who receive the message sequentially perform two appraisals, first the
threat, then efficacy. The first part of the message has to convincingly
transmit the presence of a threat, leading to concern on the part of the
message receiver(s). The second part of the message has to convincingly
transmit the existence of efficacious interventions/mitigations, especially
those that are self-efficacious (that is, can be performed by the message
receivers), leading to confidence. According to this model, the threat and
efficacy components must be accepted by the message receivers to achieve
the desired behavior or practice (at both individual and collective levels);
this is referred to as ‘‘danger control’’ in the EPPM. If the threat portion is
not accepted, the message is rejected. If the threat portion is accepted, but
the efficacy portion is not, the acceptance of the threat portion triggers fear,
which the message receivers attempt to manage -by rejecting the entire
message; such a reaction is referred to as ‘‘fear control’’ in the EPPM (as
cited in Barnett et al., 2009, e. 6366). Hence, Barnett et al. (2009) utilized
the EPPM to conduct a survey of local health department personnel in three
states in the US to examine the relative influences of perceived threat and
efficacy on public health workers’ response willingness to pandemic
influenza. A total of 1875 responses were generated. The results showed that
16% of health personnel were not willing to respond to a pandemic. The
results also indicated that local health department workers with perceptions
of high threat and efficacy had the highest rates of willingness to
respond―31.7 times higher than those with low threat and low efficacy
profiles. The strength of this study was that it showed that high threat and
efficacy profiles could predict high rates of willingness among health care
workers to respond during influenza pandemic. A limitation of the study is
that the association between threat and efficacy profiles and other personal
or institutional factors was not examined against the effect of willingness to
respond during influenza epidemic.
Balicer et al. (2010) conducted another study that examined scenario-
specific willingness of hospital workers using Witte’s EPPM as a
framework. An online survey was sent to 18,612 employees of the Johns
Hopkins Hospital; 3,426 employees responded. The results indicated that
more than one in four (28%) of the employees were not willing to respond to
an influenza pandemic scenario if asked but were not required to do so. Few
(10%) were willing to respond if required to do so, and 32% were unwilling
to respond in the event of more severe pandemic scenarios. The results also
indicated that hospital workers who were hesitant to work additional hours
when required were 17 times less likely to respond during a pandemic.
Hospital workers with high efficacy had 5.8 times higher declared rates of
willingness to respond to an influenza pandemic. A study strength was the
identified relationship between threat and efficacy profiles with high rates of
willingness to respond during a pandemic influenza. It also indicated a low
declared rate of willingness among health care workers to respond during an
influenza pandemic. A limitation of the study is the low response rate, which
may have introduced a selection bias; specifically, those who responded
might have included more of those who were hesitant to work.
In another large study, Basta et al. (2009) aimed to determine how
informed health department employees are about pandemic response and
how willing they are to report to work during a pandemic. An electronic
survey was administered to 4,746 health department workers; 2,414
responses were retrieved and analyzed. The findings show that willingness
to work ranged from 93.3% for the lowest risk scenario to 56.2% for the
highest risk scenarios. The scenarios included the stage of influenza
pandemic and type of job duties. The study indicated that about half of
health workers are unwilling to report for work during the peak of influenza
pandemic, when their services would be vital for control and mitigation of
the pandemic. The limitation of the study is that the authors did not
determine if the various job duties among the different types of HCWs in the
health department affected the rates of willingness to respond for the
different scenarios. In a recent national cross-sectional survey of 332
emergency nurses in the U.S., researchers aimed to identify the perceived
likelihood of emergency department nurses to report to work during an avian
influenza outbreak (Bell et al., 2014). Another objective was to determine
the options available for nurses who decided not to report to work during an
avian influenza outbreak. The researchers explored the predictors of work
attendance by nurses. The results indicated that 84% of nurses responding to
the survey would report to work. The analysis showed that the likelihood of
reporting to work varied by educational level, the information on avian
influenza available to nurses, and whether the nurses had family members
living with them. Among nurses who were not willing to report to work,
90% were willing to provide information, 82% would administer
vaccinations, and 74% would triage neighbors and friends from home. One-
third of the nurses had not attended a disaster preparedness drill but had
received personal protective equipment (PPEs); this accounted for 40% of
the variance in the likelihood of reporting to work. A strength of this study is
that it identified a high rate of willingness to work among emergency
department nurses. It also related the high rate of willingness to work with
the level of education, availability of information on avian influenza,
provision of PPE. The study findings also showed that emergency nurses
were more likely to work when they had few family members’ living with
them and these family members were fairly independent themselves, such as
in the case when they had no children living with them. A limitation of the
study is that it may not have evaluated many other factors that influence
willingness to work during an avian influenza outbreak (Bell et al., 2014).
A similar study was conducted in Australia among emergency pre-hospital
medical care providers; that is, emergency paramedics involved in first line
support, resuscitation, and transportation of patients with emergency
conditions. The researchers aimed to investigate the association between
knowledge and attitudes regarding avian influenza on the likely behavioral
response of workers including first-aid providers, surveillance reporters,
public health promoters, etc.; these individuals often come into contact with
patients’ air droplets, secretions, clothing, and materials that may be
contagious or a means of disease transmission (Tippett et al., 2010). A reply-
paid postal questionnaire was distributed to 2,929 potential participants, of
which 725 responses (24.7% response rate) were returned. The outcome
measures were knowledge, attitudes, and anticipated behaviors such as
preparedness to wear personal protective equipment, preparedness to change
role, willingness to work, and likelihood of refusing to work with colleagues
who were exposed to influenza (Tippett et al., 2010). Multiple regression
analyses indicated the independent predictors of each of the anticipated
behaviors while controlling for other variables. Results showed that 43% of
participants were unwilling to work during pandemic conditions (OR 1.41;
95% CI 1.0-1.9), one-quarter would refuse to work even with personal
protective equipment (PPE), and one-third would refuse to work with a
colleague exposed to influenza. The results also indicated that adequate
knowledge about infectious agents significantly increased the variables
willingness to work (OR 1.41; 95% CI 1.0-1.9), and willingness to change
role (OR 1.44; 95% CI 1.042.00). Furthermore, adequate knowledge about
infectious agents significantly decreased refusal to work with an exposed
colleague (OR 0.48; 95% CI 0.3-0.7) or potentially exposed colleague (OR
0.43; 95% CI 0.3-0.6). Results show that confidence in an employer’s
capacity to respond appropriately significantly increased employees’
willingness to work (OR 1.52; 95% CI1.1-2.1), willingness to wear PPE (OR
1.68; 95% CI 1.1-2.5), and significantly decreased the likelihood of refusing
to work with colleagues exposed to influenza (OR 0.59; 95% CI 0.4-0.9)
(Tippett et al., 2010). A strength of this study is that it described the factors
related to the willingness to work of emergency pre-hospital workers.
However, a low response rate and sample bias may have affected the
findings of the study.
A cross-sectional survey was conducted by Dickinson et al. (2013) to
investigate the willingness to work of family physicians in Alberta, Canada
during an influenza pandemic. A sample of 192 participants (response rate
of 22%) responded. The results showed that 50% of family physicians were
willing to work during difficult scenarios created by influenza epidemic, and
men were significantly more willing to continue working than women. The
strength of this study is that the researchers found that the rate of willingness
to work among family physicians was high, and male family physicians
reported higher rates of willingness. The limitation of the study is that the
low response rate might have created a selection bias in the findings; that is,
participants may have been primarily men and those who were willing to
work.
Other researchers in Singapore used a self-administered questionnaire
to study 1,859 public health workers who responded on their concerns,
perceived impact, and preparedness in an avian influenza pandemic (Wong,
Koh, Cheong, Lee, et al., 2008). The findings from this study indicated that
82.7% were concerned with the high risk of contracting avian influenza,
63.5% felt that people would avoid them, 54.1% felt people would avoid
them and their families, and the majority, 83.7%, felt that their workplace
was prepared for an outbreak. The results also showed that 71.9% of the
participants accepted the risk, although 25.5% felt that they should not
provide care for patients with avian influenza despite the risk, and 15% of
the participants considered resigning from their jobs because of the risk
involved. A strength of the study is that the researchers described a high rate
of willingness to care for patients with influenza during a pandemic among
health care workers in Singapore. It further describes the concerns,
perceived impact, and preparedness level. A limitation of the study is that it
did not associate these concerns, perceived impact, and preparedness level to
the rate of willingness to care among the health care workers. In other
words, how do the identified concerns, perceived impact, and preparedness
level predict the rate of willingness among health care workers?
Mitani et al. (2011) conducted a study to identify how many medical
staff would be willing to work during a pandemic and the working
conditions that medical staff would require so as to be willing to work
during a pandemic. A cross-sectional survey using questionnaires was sent
to five private hospitals in Japan. The questions focused on the attitude of
medical staff toward a pandemic, including whether they would work in the
hospital, treat people, and the types of considerations (such as provision of
PPE, improved compensation, access to vaccination, and so on) they
required in order to work. A total of 1,975 hospital staff responded with a
response rate of 67%. The participants consisted of physicians, nurses,
pharmacists, radiologists, physical therapists, occupational therapists,
clinical laboratory technologists, office clerks, and others. The researchers
found that 204 hospital staff (10%) would not go to the hospital during a
pandemic; 363 (18.8%) would perform their duties as usual unconditionally;
504 (26.1%) would work at the hospital but would not treat avian influenza;
80% would work if they were provided with PPE; 69% would work if they
received compensation; 58.2% would work if they were given anti-virus
medication, and 57.8% would work if they received a pre-pandemic
vaccination. This study indicated that during a pandemic health worker
staffing at all levels would suffer if safety measures were not put in place
and compensation was not offered. The researchers also described
comprehensive measures to ensure availability of health care workers during
a pandemic. The limitation of the study is that the researchers did not show
the differences or similarities in the rate of willingness to work among the
different types of health workers, which could be useful information during
a pandemic.
A study was conducted in China by Seale et al. (2012), to assess the
views and intended behavior of hospital health care workers on intentions
regarding work and quarantine during an influenza pandemic. A cross-
sectional survey of 1,909 participants (response rate of 99%) was conducted
at 24 hospitals in Beijing. The results indicated that 74% of participants
would work despite the risk of infection; 71% felt they had the necessary
knowledge to provide patient care, accepted the risk of exposure to the virus
and were willing to be quarantined if necessary. Through this study,
researchers were able to assess the attitudes and intentions to work in
hospital workers in Beijing. The limitation of the study is that it did not
indicate the attitude and intentions to work among the different types of
health care workers. It also did not consider the cultural implications of the
attitudes and intentions expressed, since in some countries workers do not
have the option of refusing to work.
Martinese et al. (2009) conducted a study in Australia to estimate the
expected staff absentee rates and work attitudes in two scenarios in a tertiary
hospital. These scenarios were a single admission of a patient with avian
influenza and multiple admissions of patients with human pandemic
influenza. A cross-sectional study was conducted of the 560 who responded.
For the first scenario, single admission of an avian flu patient, 13% indicated
they would not report to work and 25% would only work provided that
immunizations and/or antiviral medications were immediately available. If
these medications were not immediately available, 38% would not report to
work. In the second scenario, multiple admissions of patients with human
pandemic influenza, 36% would not attend work, 17% would attend work if
immunizations and/or antiviral medication were immediately available, but
53% would not attend work if vaccines or medication were not available.
The researchers also found that staff in the emergency department or acute
medical ward was more likely to work (OR 2.2 for scenario 1; OR 1.6 for
scenario 2). The strength of this study is that the researchers identified high
absenteeism would occur during an influenza epidemic if protective
measures were not provided. The limitation is that the researchers
established status of intentions to work of the hospital staff during a
pandemic based on hypothetical scenarios. An actual influenza pandemic
might show different results.
Another study conducted of 644 health care workers in Germany
assessed the ethical conflict between professional duties and the fear of
infecting family members with influenza (Ehrenstein et al., 2006). The
results showed that 28% of respondents agreed that it was acceptable for
health care workers to abandon their workplace during a pandemic to protect
their families; 52% said it was not acceptable, and 19% had no opinion. A
breakdown of the disagreeing respondents showed that physicians were
more likely to disagree (65%), followed by nurses (54%), and
administrators, (32%). Fiftyeight percent of respondents did not think the
decision to report to work during a pandemic should be left to individual
health care workers, and 77% did not feel that health care workers should be
dismissed for not reporting during a pandemic. The strength of this study is
that the researchers established that fewer German health care workers and
more administrators of the same hospital were in favor of continuing to treat
patients despite potential risks. The limitation of the study is that the
percentage representation of the various groups of health workers was not
clearly associated with the reported rates of declared willingness to work.
This study would have been stronger if it evaluated the
relationship/differences/similarities between the decision to report to work
and the category of health workers ―physicians, nurses and
administrators―in terms of their percentage in the sample size. This would
reduce error from selection bias; that is, having more physicians in the
sample could account for higher reported rates. Nurses had the lowest
response rate, depriving us of the perspective of key figures in health care
delivery which is unfortunate since their perspective as key figures in health
care delivery, is important.
Ma et al. (2011) surveyed the knowledge and attitudes about an
influenza pandemic among 695 health care workers from 21 intensive care
units (ICUs) in 17 Chinese provinces. Of the respondents, 51.2% reported
caring for patients with influenza and 83.3% expressed willingness to care
for patients with influenza. The study also showed that physicians and nurses
were more likely than other professionals (such as respiratory therapists,
student nurses, and nurse assistants) to care for influenza patients (OR 4.05
and 3.23; p = 0.002 and 0.007 respectively). The likelihood of health care
workers caring for patients in this situation is associated with knowledge
and training provided prior to patient care (OR 1.53, p = 0.044) and
confidence that they will be able to protect themselves and their families
(OR 2.109, p = 0.001). The strength of this study is that the researchers have
identified factors that influence health care workers’ willingness to work.
However, the researchers did not explain the proportion of physicians and
nurses to the other health care workers (that is respiratory therapists, student
nurses, and nurse assistants) in the ICU. It was unclear whether lower
proportions of other health care workers in the sample were due to their
response rate or that they were fewer in the ICU. This information might
reduce sample biases of physicians and nurses compared to these other
professionals.
A cross-sectional survey of 288 health care workers conducted by
Butsashvili et al. (2007) sought to determine the magnitude and factors
associated with absenteeism among hospital-based health care workers
during an influenza pandemic in Georgia, Eastern Europe. The findings
indicated that 23% of the health care workers stated they would not report to
work, and more female health care workers and nurses were more likely to
state discontinuation of work than males (RR = 2.95, 95%, CI: 1.13-7.7).
The results further indicated that 58% of health care workers, mostly those
younger than 35 years, were opposed to being isolated or quarantined after
exposure to suspected or confirmed cases of influenza. Of the respondents,
67% knew which strain of the virus was responsible for the epidemic. The
strength of this study is that the findings indicated the rate of absenteeism
among health care workers in Georgia, which is reflective of the magnitude
of reduction in the workforce in the event of an influenza pandemic; the
predictors were also highlighted. The limitation of the study is that it did not
highlight the proportion of women and nurses in the sample, possibly
indicating selection bias.
In a study byDamery et al. (2009), the factors associated with the
willingness to work during an influenza pandemic were investigated among
health care workers in the West Midlands in the United Kingdom. This study
surveyed 3,000 HCWs with a response rate of 34.4%. (n =1,032). The results
suggest unwillingness to report to duty might be as high as 85% at any point
during a pandemic in the UK, with potential absence concentrated among the
nurses and ancillary workers (porters, hotel services, mortuary attendants).
The findings of this study indicated that barriers such as the obligation to
care for a family member, or lack of transportation could cause HCWs to be
unwilling to work. The limitation of this study is that participants were
responding to a hypothetical situation, and may not reflect HCWs’
willingness were they to actually experience a pandemic.
Seale et al. (2009) conducted a cross-sectional survey to explore
health care workers’ knowledge, attitudes and intended behavior towards an
influenza pandemic in Sydney, Australia. Eight hundred and ninety four
participants representing four categories of health care workers: nurses
(47.5%), medical (26.0%), allied (15.3%), and ancillary (11.2%) were
surveyed. The participants responded to hypothetical scenarios of what their
intended behavior would be. The study found that most health care workers
perceived the seriousness of the situation (80.9%), but fewer than half could
state the definition of pandemic influenza (43.9%). Of the participants,
83.3% were willing to work. In a hypothetical scenario in which colleagues
became infected, most health care workers (79%) were willing to work. The
researchers found that non-clinical staff were more likely to be unsure of
their intention to work. Only 42% accepted the efficacy of an antiviral
medication to protect them, and 77% believed in the benefit of the vaccine.
This study finding indicates low level intention of health care workers to use
an antiviral medication and higher intention to comply with quarantine
measures. Forty five percent of respondents (n = 486) indicated they would
comply and further 28.4% stated they would comply though they would be
unhappy with cooperating with the quarantine measures. It further identifies
the proportion of different types of health care workers in the sample. The
sample included HCWs such as medical (staff specialists, registrars, medical
students etc.), nursing (registered nurses, nurse unit managers, and enrolled
nurses etc.), allied health personnel (physiotherapists, occupational
therapists, psychologists etc.) and ancillary staff (domestic services,
administration, computer specialists etc.). This could help readers examine
the category of health care workers that might contribute more to the overall
findings. The limitation of the study is that the report did not clarify which
of the four categories of health care workers belonged to the clinical and
non-clinical staff. This would help readers examine which of the groups
were unsure of their intentions.
A U.S. study sought to determine the ability and willingness of
essential workers (such as physicians, nurses, policemen, firemen, public
health workers, workers in correctional facilities etc.) to report to duty
during a serious pandemic. Personnel from six organizations in New York:
hospital workers, police department, emergency medical services personnel,
fire department, public health department, and correctional facility officers,
were invited to participate (Gershon et al., 2010). A total of 1,103
participants responded. The researchers found that while 80% of workers
indicated they would report for duty during a pandemic, only 65% reported
they would be willing to report for to duty. Only 49% were both able and
willing to report for duty (Gershon et al., 2010). The strength of this study is
that the researchers considered several groups of essential workers, thereby
offering an expanded picture of the willingness of highly needed
professionals to serve in their different capacities during a pandemic of any
type. The finding was that a shortage of essential workers might occur in a
pandemic. The limitation of the study is that the low rate of willingness
reported may have been affected by the proportion of essential workers who
might not have been able and willing to report to work, since the study did
not consider the categories of essential workers separately.
Another cross-sectional survey was conducted to identify pre-event
knowledge and attitudes to living and working in pandemic conditions
among emergency prehospital medical care providers. This was in relation
to a potential human influenza pandemic in Australia (Watt et al., 2010). Of
the 725 participants surveyed, 81% perceived high personal risk associated
with working during pandemic conditions. Generally, respondents
demonstrated poor knowledge about avian influenza and infection
transmission mode. Fewer than 5% of respondents perceived that they were
adequately educated or trained about avian influenza (Watt et al., 2010). The
strength of this study is that the researchers identified the level of influenza
knowledge among pre-hospital medical care providers about living and
working in a potential human influenza pandemic condition with a nationally
representative sample. The limitations of the study is that the report did not
indicate if the attitude of the participants (that is, their high level of anxiety
and high level of perceived high risk) was reflective of their willingness to
continue living and working in the region when an epidemic occurs,
although the title of the study suggested it might do so. Moreover, the
situation was hypothetical, and the results might not be replicated in a real
pandemic.
A study to identify factors affecting nurses’ ability and willingness to
work during pandemic flu was conducted in the U.S. with questionnaires
mailed to the participants. Of the 1,200 nurses receiving the survey, 725
responded (Martin, 2011). The findings showed that initially 90% of
participants would work during a pandemic flu, but their willingness to work
decreased as the availability of PPEs dwindled, the family or nurse were
perceived to be at risk, and when vaccines or treatment were not provided.
The findings also indicated that the ability of nurses to work during a
pandemic flu decreased when nurses fell ill, a loved one needed care at home
or transportation problems existed (Martin, 2011). The study’s strength is
that the researchers identified a high rate of willingness and ability to work
during pandemic flu. The limitation of the study is that racial, ethnic, gender,
and educational diversity among the nurses was minimal. This poses a
possibility of under-representation of the intentions of the group not
adequately represented. The intentions of the nurses indicated in the findings
may not represent their attitudes and behavior during an actual pandemic flu
event, as they had responded to a hypothetical occurrence of a pandemic flu.
Goodhue et al. (2012) conducted a U.S. national survey to examine
the factors associated with pediatric nurse practitioners reporting to work
during a disaster, whether natural (hurricane, earthquake) or man-made (war,
terrorism). More than 2,600 nurses responded to the survey (N=2,627). The
results showed that fewer than 10% of the pediatric nurses were willing to
work during a disaster. The results also showed that pediatric nurse
practitioners with a specified role in disaster management were three times
more likely to respond than were those without a specified role. Since the
authors studied nurses’ behavior during natural or man-made disasters and
not an infectious disease outbreak, the findings may not apply to epidemics.
The findings seemed to indicate that the nurses’ willingness to work could
depend on whether the disaster directly affected the nurses, their roles, or
their families.
Moving from studies on influenza and pandemics generally, there was
a study in Taiwan conducted to determine perception of risk of SARS
infection in nurses, and the proportion of nurses considering leaving their job
as well as factors related to nurses’ consideration of leaving their job due to
SARS outbreak (Shiao et al., 2007). The nurses (N = 907) responded to a
self-administered Likert scale questionnaire. Multiple logistic regression was
used to analyze data. The results showed that 71.9% of the participants
believed they were at great risk of exposure to SARS, while 49.9% felt the
situation would increase their workload, and 32.4% of participants thought
that people avoided them because of their job and the risk of transmission to
others,. The results also showed that 7.6% of the nurses considered not
caring for patients with SARS and were looking for another job or
considering resigning. The predictors of nurses’ consideration of leaving
their job were shorter tenure, increased work stress, perceived risk of fatality
from SARS, and effects on social relationships (Shiao et al., 2007). The
researchers were able to identify a high rate of willingness by nurses to care
for patients with SARS and were able to identify factors that led to their
considering resigning from their jobs during a SARS epidemic in Taiwan.
Finally, a study was conducted by Kiliç Akça et al. (2013) to
determine the attitudes of 143 emergency department nurses toward
Crimean Congo hemorrhagic fever (CCHF) in six cities in Turkey, where the
disease was frequently seen. The outcomes of the study were that 94.3% of
respondents said health care workers exposed to the virus stand the risk of
contracting the disease. Of the nurses who responded, 37.8% experienced
caring for patients with CCHF, while 12.8% were willing to care for patients
with CCHF. Also, 16.3 % of the respondents would rather refer a patient to a
colleague than treat them; however 83.7% were not willing to refer a patient
to a colleague. The strength of this study is that the researchers have
identified the level of knowledge and attitude of emergency nurses to CCHF,
while the limitation is that the study indicates attitude towards working
during CCHF only for emergency nurses in six cities in Turkey where the
disease is common. The findings may not be representative of other cities in
Turkey, therefore generalization may not be possible. It would be valuable to
know the rate of willingness for other categories of health workers, in
addition to nurses.
Determinants of Willingness to Care by Health Care Workers
Studies have indicated several factors that determine HCWs’
willingness to report for duty during disease outbreaks. These factors are
congruent to nearly all the locations where such studies have been carried
out. A study conducted in Maryland, U.S. that assessed HCWs’ willingness
to respond to pandemic influenza through the application of the Extended
Parallel Process Model (EPPM), identified that HCWs with perceptions of
high threat and efficacy (HCWs with high rates of concern and high
confidence profiles in the EPPM analysis) had high rates of willingness to
respond―31.7 times higher than those with low threat and efficacy ( HCWs
with fewer concerns and who felt less confident (Barnett et al., 2009). The
strength of this study is that it provides evidence that a high EPPM profile,
which indicates a high rate of concerns and high confidence, predicts
HCWs’ willingness to respond during pandemic influenza. A similar study
in the same city but different hospital also indicated that hospital workers
with high threat and efficacy rates have 5.8 times higher willingness rates
than those with low threat and efficacy rates (Balicer et al., 2010). The
limitation of these studies is that they may not explain the relationship
between high threat and efficacy in association with willingness to respond
to pandemic influenza in an actual pandemic event, since the survey was
conducted for a hypothetical situation. Another large scale electronic study
in the same country indicated that 93.3 % of HCWs were willing to report in
a low risk scenario, while 56. 2% were willing to respond in a high risk
scenario. This presented evidence that the severity and type of epidemic
predicts HCWs’ willingness to respond. The limitation of the study is that
the study did not capture the association between the skill attained and
preparedness level with the willingness to respond in different types of
scenarios (Basta et al., 2009). Similar studies have shown that willingness to
respond during a pandemic is influenced by HCWs’ efficacy, confidence
levels, level of education, continuous updates and information on the
disease, and also the type of pandemic (Arbon et al., 2013; Bar-Dayan et al.,
2011; Barnett et al., 2012; Bell et al., 2014; Errett et al., 2013; Melnikov,
Itzhaki, & Kagan, 2014; Watt et al., 2010).
When HCWs are assured of and provided with personal protective
equipment, vaccinations, and personal safety measures they tend to report
willingness to care for patients during a pandemic. However, the limitation
of the studies did not explore a relationship between HCWs’ efficacy, skills
and confidence level with assurance of safety, in relation with willingness to
care for patients in the event of a pandemic (BarDayan et al., 2011; Chaffee,
2009; Devnani, 2012; Ma et al., 2011; Martin, 2011; Martinese et al., 2009;
Ogedegbe, Nyirenda, Delmoro, Yamin, & Feldman, 2012; Qureshi,
Gershon, Yamada, & Li, 2013; H. Seale et al., 2009; Tippett et al., 2010;
Tzeng, 2004). One study included stigmatization from family, friends, and
society related to fears of contracting the disease from the health worker
(Wong, Koh, Cheong, Sundram, et al., 2008).
Other factors that determine the HCW willingness to care for patients
during disease outbreaks in both qualitative and quantitative studies include
gender (men reported higher rates of willingness to care during pandemics),
family responsibilities, having children and/or dependents, safety of family,
and availability of transportation
(Adams & Berry, 2012; Anikeeva, Braunack-Mayer, & Street, 2008; Burke,
Goodhue, Chokshi, & Upperman, 2011; Butsashvili et al., 2007; Chaffee,
2009; Cowden, Crane, Lezotte, Glover, & Nyquist, 2010; Dickinson et al.,
2013; Ives et al., 2009).
Preparedness and confidence on personal, colleague,
administration/leadership, institutional, and government levels are associated
with willingness of HCWs to care for patients during a disease outbreak (S.
B. Connor, 2014; Gershon et al., 2010; Goodhue et al., 2012; Imai et al.,
2010; Lim, Lim, & Vasu, 2013; Rutkow, Vernick, Thompson, Pirrallo, &
Barnett, 2014; E. L. Wong et al., 2010).
Increased compensation, rewards, and acknowledgment from
employers also emerged as a determinant of HCWs’ willingness to care for
patients during a pandemic (Damery et al., 2010; Mitani et al., 2011). A
qualitative study on nurses’ response to SARS reported that a collaborative
spirit among nurses enhanced their willingness to care for patients during the
outbreak. The limitation of the study was that it did not highlight the
relationship between the emergent themes to help explain how the factors
interacted to enhance willingness to care (Liu & Liehr, 2009).
A summary of factors that determine high rate of willingness to work
among health care workers as identified by the body of evidence is itemized
as follows:
1. Increased threat and efficacy profile or awareness: health care
workers have adequate knowledge of the risks presented by the
disease outbreak, there is adequate information and update
concerning the ongoing situation, and health care workers have
high competence in the skills necessary to handle the situation and
care for patients.
2. Increase educational level of health workers, training
opportunities, and prior experience in working with patients during
epidemics.
3. Assurance of personal safety through provision of personal
protective equipment, also the availability of vaccines for health
care workers.
4. Gender differences showed that men rated higher in willingness to
care during disease outbreaks.
5. Settled family responsibilities, reduced family obligations, and
assured safety for family, children, and dependents.
6. Availability of transportation also affected willingness to work.
7. The type and severity of the epidemic: health care workers’
knowledge and awareness of the type of disease and less severity
of the disease.
8. Adequate preparedness and confidence of health care workers on a
personal, collegial, administrative/leadership, institutional, and
governmental levels.
9. Provision of increased compensation, rewards, and
acknowledgements from the employers.
The manner by which these factors relate with one another and
consequently predict the willingness to care of health care workers has not
yet been given adequate attention in the literature.
Strategies to Foster Willingness to Care
In lieu of identified determinants of willingness to care for patients
during disease outbreaks or pandemics/epidemics, several strategies to foster
willingness to care emerged from the studies. Liu and Liehr (2009)
conducted a study which identified instructive messages to guide nursing
practice in future epidemics by examining the stories of Chinese nurses who
cared for severe acute respiratory syndrome (SARS) patients. The studies
used a descriptive exploratory qualitative design and employed a content
analysis method. The results cited structured support, meaningful disease-
related information and sensitivity to the importance of a collaborative spirit
among nurses as factors which enabled practice. The strength of this study is
that it provides insight to the strategies that could be utilized in fostering
willingness by nurses to care for SARS patients. The limitation is that the
study did not establish an explanation or a model that could integrate the
strategies based on how they interrelated to foster willingness to care by
nurses. Another study identified nurses’ suggestions of interventions to
support their ability to cope during public health emergencies. Interviews
were conducted with 33 nurses working in a bioterrorism hospital. The
nurses recommend adequate PPE education, drills, and training on infection
control and treatment protocols, adequate information and available clinical
experts, and available administrators on the ground to offer support. Other
recommendations include increased security to protect nurses; emotional and
physical support, enhanced communication with nurses’ families, and
commitment from institutions to care for ill or injured nurses. The limitation
of this study is that it did not identify the process of implementing the
strategies; moreover, it did not consider the influence of policy and
administrators in implementing the recommended strategies.
The strategies to foster willingness to care could be summarized to
include the provision of all identified factors so that health care workers
could be encouraged to care for patients during disease outbreaks.
Experiences with the Ebola Outbreak in West Africa
de Vries et al. (2016) conducted an ethnographic study with the aim of
identifying the extent to which the community became a resource for early
disease detection and to identify the problems encountered with community
health workers and social mobilization strategies in Uganda in the 2012
Ebola outbreak. The study involved a nonprobability sample of 13 interview
respondents. The findings indicated that the community offered insufficient
collaboration with health workers to detect early Ebola victims due to the
community’s disbelief in biomedical explanations that were at odds with
local or cultural understanding of the outbreak. The authors recommended
early response combined with local community resources and public health
education that contextualizes cultural knowledge to help the community
build trust in the formal health system. The strength of the study lies in its
ability to highlight the need for reconciliation between biomedical
explanations and local cultural explanations of the Ebola phenomenon. The
limitation is that the study does not identify how long this effort should
continue to produce the desired results.
The grounded theory approach was used to study 15 focus group
discussions conducted in 15 communities in Liberia (Abrmowitz et al.,
2015). The aim of the study was to identify strategies being undertaken and
recommendations for the communitybased response to Ebola. Community
leaders (N = 386) participated in the study. The findings indicated that
strategies should include prevention, treatment, response, and community
recovery. The need for a positive attitude towards survivors and
communitybased psychosocial support was also indicated by the findings.
The study showed that respondents shared information based on their
knowledge and experiences of Ebola, which may only be applicable to their
communities.
Kobayashi (2015) conducted a large survey in five counties in Liberia
with varying incidence of Ebola. The purpose of the study was to assess
Ebola-related knowledge, attitudes, and practices in the community. It
gathered 609 respondents and was conducted in English. The respondents
were asked whether they agreed or disagreed with 38 statements relating to
Ebola. Findings revealed that across all counties, respondents were not able
to correctly recognize Ebola symptoms or the transmission risk from
asymptomatic persons. Fear of Ebola patients and Ebola treatment units was
prevalent. The fear of cured patients might partially be explained by the fact
that community acceptance of survivors was not part of the initial set of
Ebola health messages in Liberia. The strength of the study is that the
findings could be used to inform health awareness and messaging
interventions, to address fears, misconceptions, and practices regarding
Ebola. The limitations of the study is that the selection of the communities in
the counties was non-random and the interview questions were closedended
(binary; agree or disagree) which limited the richness of information.
Dynes, Miller, Sam, Vandi, and Tomczyk (2015) conducted a study
involving five focus group discussions with a total of 34 participants who
were health workers and support staff, held at six primary health centers and
four focus group discussions with a total of 27 participants who were
pregnant and lactating women in Sierra Leone. The aim was to understand
the factors that might have contributed to the decline in the use of maternal
and newborn health services observed from May to July 2014. Using a
structured interview guide and content analysis techniques, the researchers
identified four themes: 1) health facility use experienced decline; 2) facility
use picked up after Ebola awareness and educational activities were
implemented; 3) the reasons for decreased use of health services was due to
fear of contracting Ebola at facilities; and 4) misconceptions about the role
of health care providers and international exports in Ebola containment.
Ideas for encouraging the use of health care facilities identified from data
analysis ranged from a continued cordial relationship between health
workers and patients, traditional birth attendants recommending use of
health care facilities to women, and distribution of food and clothing as
incentives for attending clinics. Finally, training and provision of protective
equipment to health workers alleviated fear and reduced the death of health
care workers; this then decreased the fears of the women. The study did not
consider the role of the family members and socioeconomic issues that
might have influenced the perception of risk for Ebola among the women
and health care workers.
Turle (2015) conducted a survey to understand the barriers and
enablers of UK health care workers who were considering working in West
Africa during the Ebola outbreak but had not yet volunteered. A sample of
3,109 people answered the survey. The results indicated that for those who
considered going, the most important factors that prevented them from
volunteering were fear of contracting Ebola and their partners’ concerns.
This was caused by lack of information. In contrast, among those who were
not considering going or who had decided against it, family considerations
and partner concerns were the most important factors. The strength of the
study is that attitudes towards volunteerism during the Ebola outbreak of
foreign health workers were identified. The limitation of the study is that a
convenience sample was used, which is unlikely to be representative of all
UK health workers.
The political climate was also an issue in the Ebola outbreak
experiences in 20142015 in West Africa and globally. Stratton (2014)
reminded his readers that when a traveler from West Africa to the U.S. in
summer 2014 died of Ebola infection in Dallas, Texas, the risk of the virus
became a reality to an entire nation. Although the U.S. had years of
preparation for emergency and bioterrorism events, according to Stratton
(2014), the country had to deal with the failures of the health experts and
political leaders in containing the fast-spreading Ebola outbreak. The blame
was placed on the health experts because as Stratton indicated the health
experts did not adequately educate the public and the leaders. The political
leaders also were blamed for not taking seriously the rapid and
uncontrollable spread of the Ebola virus in West Africa.
The responses to the Ebola phenomenon were considered from the
nurses’ perspective, from the perspective of the media, and from the
religious perspective in the literature. Sagar (2015), in an opinion paper,
affirms the crucial role nursing plays in maintaining health and preventing
diseases, relating the Ebola outbreak to the nursing shortage in
underdeveloped countries. She recommended that nurses be involved in
decisions regarding Ebola virus in care settings and on all policy making
levels. McGillis and Kashin (2015) conducted a study to examine how the
media portrayed nurses and their roles during the 2014-2015 Ebola outbreak
in West Africa. Content analysis of 125 relevant articles indicated that there
was a gap in the preparedness for global health events and a lack of public
awareness of nurses’ roles. This study draws attention to the need for
accurate portrayals of nurses and the nursing profession during the Ebola
outbreak to avoid the potential of damaging the image of the nursing
profession.
Marshall and Smith (2015) stated in an opinion article that the
national governments of the three West African countries affected by the
Ebola outbreak and international aid organization were late in appreciating
the vital roles played by religious organizations in addressing Ebola and
supporting the health systems. According to the authors, religious
institutions provided health services and social support throughout the Ebola
crisis. Moreover, religious beliefs and practices influence the approaches
used to care for the sick, forms of stigma, and gender roles. Marshal and
Smith (2015) also identified three lessons they gathered from the Ebola
outbreak in West Africa: first, that strengthening the health system’s
knowledge of religious demography, institutions, and associations would
promote more effective engagement of faith communities; second, public
health institutions need more organized and multidisciplinary community
involvement approaches; third, the religious dimensions of behavior change,
for example in regards to burials, showcase the importance of community
proficiency and the need to draw on it more purposefully and thoroughly.
The authors also reported that the World
Health Organization’s (WHO) Safe and Dignified Burial protocol was vital
in containing the disease and providing opportunity for community trust.
This WHO protocol for safe burial of corpses infected with Ebola
collaborated with the faith communities in a robust communication network
to change the funeral practices during the outbreak. This significantly
reduced the rate of transmission. Other articles allude to the notion that the
spiritual, social, and cultural dimensions of health are crucial to care (Olivier
et al., 2015; Summerskill & Horton, 2015; Tomkins et al., 2015). These
articles further suggest that faith-based health care services may provide
avenues to reform faith and spirituality as part of the response to the
complexity of health care delivery.
Sensitizing Frameworks
Grounded theory studies are aimed at theory generation. As such, the
use of theory to drive GTM research studies may be out of context. The
GTM holds that scientific inquiry is subjective and based on the views of
those experiencing the situation together with the researchers who are
studying it. The GTM is inductive in nature and is set to discover patterns
and trends, and is used mainly for the description and understanding of a
situation or phenomenon (Meleis, 2012). However, some believe that the
researcher comes approaches each project with prior knowledge and
opinions. It is therefore safer to be reflexive and rely on sensitizing
frameworks. The frameworks used in this study are the Jean Watson Theory
of Human Caring, the Rosemarie Parse Theory of Human Becoming, and
Amitai Etzioni’s Decision-making Model.
Theory of Human Caring
According to Jean Watson, the very act of caring for others is
considered caring for the self. The theory describes human caring as healing
practices conducted with a focus on the relationship between the care giver
and care receiver. The theory of human caring postulates that the care giver
views the care receiver as whole human being (i.e. as a combination of the
physical, mental, social, spiritual aspects of being, etc.), and at the same time
developing a healing environment. The theory defines caring as techniques
used for healing which combine the art of nursing to promote the quality of
life, desired patient outcomes, and successful health systems (Watson,
2009). The act of caring in nursing, according to Watson (2009), is the
nurse’s professional obligation, which places the human-to-human
relationship as central to care activities. In early editions of her studies on
caring, Watson (2003) indicated that caring as a professional activity
ethically involves the subjective rendering of love and openness to patients
by nurses, who in return received the same responses of love and openness
from patients. Furthermore, the theory describes caring as a scientific
activity in which the nurses systematically assess, advocate, intervene,
educate, and research the health needs of their patients (Watson &
Smith, 2002). The ingredients to human caring by nurses Watson (2002)
summarized are intentionality and transpersonal consciousness.
Intentionality involves cognitively planning care activities that involve love,
service-orientation, honor and respect for human dignity, and creating a
trusting, hopeful relationship between nurse and patient. Transpersonal
consciousness is the awareness of the needs of another individual as well as
personal needs. The nurse finds a balance between meeting his or her
personal needs and meeting the health care needs of the patient.
These concepts of the theory of human caring were used to sensitize
the understanding the experiences of nurses and midwives during the Ebola
outbreak in Liberia. These concepts were used to understand the situation
from the perspective of nurses and midwives. The moral aspect and values
pertaining to the commitment of the nurses and midwives to protect and
enhance human dignity was explored. The concepts were sensitizing in the
exploration of the nurses’ openness to their patients’ needs and the symbolic
meaning of the events and decisions made by the nurses and midwives either
to care or not to care for patients, in light of the risks involved. The concepts
sensitized the exploration of the nurses and midwives understanding of self
in relation to the healing and dying process of the patients.
The Theory of Human Becoming
Rosemarie Parse’s “Human Becoming” theory is comprised of three
principles: meaning, rhythmicity, and transcendence. The principle of
meaning indicates that individuals co-participate in creating their reality
through the experience of living their values (Parse, 1999). The second
principle of rhythmicity indicates that individuals live by relating to opposite
experiences of others in rhythmical patterns and suggest flexibility while
relating to the ideals of others. The third principle, transcendence, indicates
that individuals move from present moments to become visible-invisible,
and develop multiple meanings to the continuous change occurring in the
emerging now (that is, their current situation) (Parse, 1999).
Parse’s theory describes how nurses, midwives, and other health
professionals live the art of human becoming in true presence with unfolding
meaning, shifting rhythms, and inspiring transcendence. In simple terms, the
nurse, midwife, and other HCWs creatively enter the world of the patient,
put themselves in the shoes of the patient, discover the new meaning of the
situation, and shift the mind towards hope for a peaceful and reassuring
process of healing or death (International Consortium of Parse Scholars,
2015).
The human becoming theory was sensitizing by using the framework
to understand how the nurses and midwives became actors in the situation of
the patients, to understand them and then provide appropriate care
interventions. It sensitizes the exploration of taking up “fatal risks” to enter
the unpredictable world of patients with rhythm, creativity, or freedom; to do
for the patients what the nurses and midwives would want others to do for
them. The nurse and midwives may offer meaning to the situation of the
Ebola outbreak to pervade the survival of humanity, then may creatively
seek to take appropriate actions to alter the current situation. If this happens,
the nurses and midwives would transcend self and peak into the situation of
the patients. The result might be to decide to treat their patients as they
themselves would want to be treated.
Etzioni’s Decision-Making Model
The decision-making model by Amitai Etzioni (1992), states that most
choices are made on the basis of emotional involvements and value
commitments. The model was developed from the assumption that emotions
are forces that play a vital role in reasoning. Emotions can help the decision
maker to consider issues other than logic. This includes the primacy of ends
over means, the selection of ethical means over others, mobilizing the self
and enhancing efficiency. The model was also developed from the
assumption that values contain affective elements, which give values the
motivational force needed. The way a person makes a decision involves the
emotion elicited by the situation, combined with the value attached to the
outcome of possible choices. The choice made will reflect the desired
outcome that will elicit the best emotions and attached value. For instance,
people will make choices that will alleviate fear and choices that will remove
suffering from themselves and others. Nurses can use this model to
understand why and how decisions are made that have clinical, professional,
and health desired outcomes for them and their patients.
Summary
The body of knowledge has identified varied rates of willingness to
care among HCWs. The variation is observed across the different locations
of study, type of epidemic, and category of health workers. The epidemics
covered in the literature search were influenza, SARS, and CCHF. It was
observed that the findings of the various studies and articles examined were
inconsistent in identifying the rate at which HCWs, including nurses,
reported their willingness to care in the face of risks and availability of
protection. Some studies found that HCWs with higher threat and efficacy
profiles, higher education and skills, and confidence levels reported higher
rates of willingness to care for patients during disease outbreaks. Others
identified that HCWs reported lower rates of willingness to care despite
strategies implemented to provide training, reduce risks, and provide
protection. Some literature showed that when preparedness and competence
was assured on a personal, institutional, governmental level, it fostered
willingness of HCWs to care for patients during a disease outbreak. Several
other factors that determine willingness to care for patients during disease
outbreaks also were identified. Other research findings focused on strategies
to enhance willingness among HCWs to care for patients during epidemics.
The literature reviewed highlighted recommendations by frontline nurses
and health care workers involved in caring for patients during epidemics.
The gaps identified in the literature show that a model for understanding or
implementing these strategies has not yet been identified. The inconsistency
and variations observed in the willingness to care for patients during
epidemics may reflect differences in the factors that predict willingness to
care by HCWs, and how these factors influence willingness to care. There
might be processes, contexts, and relationships between determinants of
willingness to care that need to be understood. A model that will adequately
describe the relationship between the influences and strategies to enhance
willingness to care needs to be explored. Moreover, more studies have been
conducted on this subject in the U.S. than other countries. Studies done in
Africa and conducted among nurses and midwives need more attention.
Also, studies on Ebola on willingness to care or the work decision process
whether or not to care for patients during an epidemic or outbreak have not
been given sufficient attention.
CHAPTER THREE
METHODS
Introduction to Chapter
This chapter identifies the research questions of the study, as well as a
description of the grounded theory method (GTM) and the fit of the method
to the study. It also includes the philosophical perspective supporting the
GTM, identifies the sample selection criteria; describes the research setting,
recruitment strategy, data collection method and analysis; and discusses
ethical considerations and strategies to ensure rigor, trustworthiness, and
credibility.
Research Questions
The following questions from the perspectives of nurses and midwives
were answered through this study:
i. What are the experiences of nurses and midwives during the Ebola
outbreak in
Liberia?
ii. What are the personal, institutional, and government influences of
the work decision process used by nurses and midwives during the
Ebola outbreak in
Liberia?
Research Design: Grounded Theory Method Grounded
theory is a form of qualitative research which allows for the identification
of concepts and the development of theoretical explanations; thus offering
new insights into a variety of experiences and phenomena (Morse et al.,
2009). There are several approaches to a grounded theory study. The
grounded theory method was developed in 1967 by Barney Glaser and
Anselm Strauss while they were at the University of California at San
Francisco, they developed the method from techniques used in their
research. As sociologists, Glaser and Strauss wrote about social processes
and conducted fieldwork with the goal of developing theory from the data.
They had different career paths, with Strauss remaining in academia and
Glaser moving on to research and consultation (Morse et al., 2009). These
differences in career direction resulted in differences in their individual
grounded theory approaches to data analysis. Strauss worked with Juliet
Corbin, his student and observer for 16 years, helping explicate his method
of analysis. Together they wrote the book Basics of Qualitative
Research Analysis in 1990. After Strauss’ death, Corbin finalized the second
edition in 1998, and has most recently written the fourth edition (Charmaz,
2014). Other students worked with both Glaser and Strauss and developed
ideas from both authors. One such student, Kathy Charmaz, developed the
constructivist grounded theory in 2006, which has also continued to evolve
over the years (Morse et al., 2009).
The Corbin and Strauss method has grown from a method of
verification with an emphasis on technical procedures to a more flexible
model which follows interpretive theory. According to the Corbin and
Strauss (2015) method, concepts are developed from data collected during
the research process and not chosen from prior research studies. This feature
is what grounds the developed theory and gives the method its name. In
grounded theory, data collection and research analysis occur concurrently in
an ongoing cycle throughout the research study. Initial data are collected, the
researcher does a preliminary analysis of the data, and the findings derived
from the preliminary analysis form the basis for subsequent data collection.
Data may be collected through interviews, observations, recorded materials
in videos, journals, diaries, drawings, internal documents, memos, internet
postings, and historical records. All data are analyzed through a process of
constant comparison. Data are broken down into units and then compared for
similarities and differences. Open coding is conducted. Codes that refer to
similar concepts are grouped together under the same heading. Further
analysis is done to group concepts together to form categories. Each
category is then developed in terms of its properties and dimensions, and
eventually all the categories are integrated around a core category. At this
stage, a flexible choice of coding concepts for context or process is
suggested. Coding for context specifies that coding locates and explains the
actioninteraction of participants within a background of conditions for the
actions, interactions, and outcomes categories (Corbin & Strauss, 2015, p.
153). As a result, concepts are linked together to enhance the results derived
from the theory. Two analytical tools may be used: paradigm or
conditional/consequential matrix. The paradigm is an analytical tool that
assists the researcher code around a category (Corbin & Strauss, 2015, pp.
156-160), requiring the use of a set of questions applied to data to help
researchers categorize concepts and establish linkages. This is accomplished
through the three features of the paradigm tool: condition (this answers the
questions when, why, and how come); actioninteraction (these are the actual
responses people or groups make to the events or problematic situations that
occur in their lives); and consequences (these are the anticipated or actual
outcomes of action and interaction). The other tool is the
conditional/consequential matrix, an analytical tool that helps researchers
identify the range of possible conditions affecting any situation and the
range of consequences that result from the action-interaction of participants
(Corbin & Strauss, 2015, pp. 160-165).
The other form of coding conducted within the Corbin and Strauss method is
coding for process, used during the analysis of the action-interaction phase.
Process is the rhythm as well as the evolving and repetitive methods of
action-interaction, including the suspensions and interruptions that occur
when individuals act and interact to reach a goal or solve a problem (Corbin
& Strauss, 2015, p. 172). Process coding identifies the adaptive changes in
action-interaction which occur in response to changes in conditions. The
core category and other categories provide the structure of the theory. The
properties and dimensions of each category provide details to the structure
by reflecting the linkages and connections within the structure (Corbin &
Strauss, 2015).
Charmaz (2014) method takes the “constructivist” turn, that is
provides a perspective that nullifies the notion of a neutral observer and
value-free researcher. The constructivist perspective sees research as a
construction, not a discovery, and encourages researchers’ to reflect upon
their actions and decisions. Because the researcher is involved in the
construction and interpretation of data, the method begins with data
collection, which is similar to the data collection method described by
Corbin above. This is followed by initial coding using line-by-line, word-by-
word, and/or incident-byincident coding, leading to emergent concepts.
These initial codes are then separated, sorted, and synthesized into focused
codes that are merged into categories. The categories are then integrated
around a core category, thus forming the structure of a theory (pp. 1214).
The difference between the Corbin and Strauss (2015) and the
Charmaz (2014) method can be found in their method of data analysis, at the
point of the coding process. The Corbin and Strauss (2015) method of data
analysis involves open coding for emergent concepts, leading to axial coding
for properties and dimensions of categories. It also involves coding for
context and process, as explained earlier. On the other hand, the Charmaz
(2014) method involves initial line-by-line, word-by-word, and incident-
byincident coding. Focused codes then are developed and kept simple,
direct, analytic, and emergent.
These grounded theory procedures enable researchers to examine
topics and related behaviors from different perspectives, thereby developing
comprehensive explanations. The procedures can be used to gain new
understanding of old problems, as well as to study new and emerging areas
of need for research. The procedures can be used to discover the beliefs and
meanings that underlie action, to study the motivation as well as non-
motivational aspects of behavior, and to illustrate how logic and emotion
combine to affect how people react to events or handle problems through
action and interaction. The procedures have been verified as culturally
sensitive and applicable to individuals as well as to organizations and
societies. The procedures are used for description, conceptual ordering, and
the development of substantive and formal theories (Charmaz, 2014; Corbin
& Strauss, 2015).
The aim of this study was to understand the experience and work
decision process from the perspective of nurses and midwives during the
Ebola outbreak. The goal of the study was to develop a comprehensive
description of the experiences of nurses and midwives during the outbreak,
and what caused them to be either willing or not willing to care for patients,
with or without Ebola, during the outbreak. This called for an understanding
of how logic, emotion, culture, and other factors combine to influence how
nurses and midwives responded to the Ebola outbreak in order to understand
their willingness to continue or not continue caring for patients. These
explanations were coconstructed by the participants and the researcher. The
study resulted in the identification of a conceptual model which represents
the description of the nurses’ and midwives’ experiences and work decision
process involved in either rendering or not rendering care to patients during
the Ebola outbreak in Liberia. As such, the grounded theory approach fits
this study.
This study used both the Corbin and Strauss (2015) and the Charmaz
(2014) methods. The process used to combine these methods and details of
how this was accomplished are indicated below.
Underlying Assumptions of the Grounded Theory Method
As noted earlier, the grounded theory method (GTM) was developed by
Barney Glaser and Anselm Strauss in 1967 for the purpose of constructing a
theory grounded in data. The method evolved from their background in
quantitative research within the perspective of objectivity and empiricism
which was the principle of scientific studies at that time. Both Glaser and
Strauss had backgrounds in sociology and their work was heavily influenced
by the perspective of positivism. During their work together, Glaser and
Strauss developed a methodology which combined their backgrounds with
their different but complementary approaches to research (Morse et al.,
2009). The philosophical perspective which influenced their work was
pragmatism and symbolic interactionism (Charmaz, 2014; Corbin & Strauss,
2015). Two of their students, Juliet Corbin and Kathy Charmaz, have
developed the GTM to take up interpretive and constructivist approaches,
respectively. The grounded theory method is now influenced by several
philosophical perspectives, which include pragmatism, symbolic
interactionism, interpretive theory, and constructivism (Charmaz, 2014;
Corbin & Strauss, 2015).
Pragmatism was propounded by John Dewey and Charles Pierce, based
on the assumption that reality can be indeterminate and fluid. Therefore,
reality has several interpretations from different angles or perceptions of
those experiencing it. This perspective, as Charmaz (2014) puts it, suggests a
connection between facts and value, and that scientific truth is relative,
conditional, and can be assessed through empirical practice. Truth claims or
suggestion of facts should be judged in terms of how close they are to reality
when considered from the pragmatist perspective (p. 263). Pragmatists
believe that knowledge exists in the form of statements or theories which are
seen as instruments or tools, not as abiding truth. It is thought that either all
or any of our current tools may be surpassed in the future, an idea referred to
as fallibilism (Bryant, 2009,
“Varieties of pragmatic experience,” para. 4). Dewey believed there are no
fixed points for observing reality; therefore, there are no universal and
context-free claims to truth. He also claimed that all knowledge is
provisional, and should be judged in terms of its usefulness within a set of
confines. Dewey termed this as instrumentalism (Bryant, 2009,
“Varieties of pragmatic experience,” para. 3). As a result, knowledge is
created through the actions and interactions among self-reflective beings.
Therefore, meaning is not a state of the past or the present, but what
continues (Corbin & Strauss, 2015, p. 19).
Symbolic interactionism, as developed by Mead, sees human actions as
constructing self, situation, and society. This perspective indicates variations
in actions-interactions, and predicts outcomes of actions-interactions
according to the people who view them. Actions result in interactions based
on time, situation, culture, society, and meaning of self. Symbolic
interactionism consists of a theoretical framework of premises and concepts
used for viewing social realities that expands one’s views of meaning,
actions, and events in the studied worlds. It encourages learning about
people and places, times and troubles, actions and accomplishments the way
other human beings understand them. From this perspective, people are seen
as actively engaged in the everyday activities of their worlds and how they
go about these activities. This perspective produces an understanding of the
actions and events in people’s lives (Charmaz, 2014, p. 262).
Kathy Charmaz has further developed the constructivist perspective in
the GTM by viewing the researcher as a co-constructor of reality. This
perspective adopts the inductive, emergent, and open-ended approach of
Glaser and Strauss stated in their original work in 1967. The constructivist
view evolved in response to numerous criticisms raised about the earlier
version of grounded theory. The constructivist perspective highlights
flexibility and refutes the mechanical strategies involved in the early
grounded theory method. If we assume that social reality has multiple
interpretations, and is co-constructed, then the researcher’s position,
emotions, perspectives, and interactions have to be taken into account as an
innate part of constructed reality (Charmaz, 2014, pp. 12-14). Furthermore,
Charmaz (2014) explains that researchers themselves are affected by
studying humans, which should be considered when developing theories of
the constructed world. The researcher should address this by reflecting on
their actions and decisions during their work. The constructivist approach
nullifies the notion of a neutral observer and value-free expert, who comes
from an objectivist or positivist world view (p. 13). This means that the
researcher must examine, rather than erase or deny, how their emotions,
privileges, and preconceptions may shape their analysis, and examine how
their values shape the very facts they identify from data (p.13). Charmaz
(2014) chose the term “constructivist” to recognize the researcher’s
subjectivity and involvement in the construction and interpretation of data.
She also uses the term to point out the differences between her approach and
the social constructionism perspective of early GTM. In addition, grounded
theory invokes the concept of abduction from Pierce’s perspective, which
means a type of rationality that begins with further exploring data and after
analyzing it, seeking all possible explanations for the observed data, drawing
the most reasonable conclusions or interpretation. This idea is applied to the
concept of theoretical sensitivity in the grounded theory method (Bryant,
2009;
Charmaz, 2014).
Grounded theory method fits the pragmatist and symbolic interactionist
viewpoints, and is in line with the constructivists through its emphasis on
process and change. The aspects of present experiences give rise to new
interpretations and actions by the members of the studied world. Therefore,
researchers can study change in new ways while accounting for their values
and perspectives applied to the emerging reality. This is the result of
evolution from the pragmatist, symbolic interactionist stance to the
constructivist theory. Corbin and Strauss (2015) provided a summary which
they referred to as “the methodological implications of the assumptions of
grounded theory” (p. 28), stating that no single explanations can be applied
to events because the world is complex. Each event is unprecedented and
influenced by several factors. In other words, people give different meaning
to their actions and interactions during different situations. Researchers are
therefore urged to search for multiple perspectives on events that people
experience and build variation into a structure identified from data analysis
(Corbin & Strauss, 2015, p. 28). In addition, Corbin and Strauss added,
“human response must be located within the personal and larger social,
psychological, political, temporal, economic, and cultural context” (Corbin
& Strauss, 2015, p. 28). When the condition changes, humans take action
and interact in response; thus, it is important to identify the change in
condition during data analysis. Emotions influence the meanings given to
events experienced by people, and are considered part of the contextual
factors that influence the response to events through action and interaction
( Charmaz, 2014; Corbin & Strauss, 2015).
Corbin and Strauss (2015) described theoretical knowledge as “relevant
to time and place and should be updated to keep pace with change over
time” (p. 28). This idea is in line with the pragmatist perspective. They
continued by stating that “theory allows persons to gather information, give
meaning, and make sense of what is happening around them. Based on the
meaning, people are able to construct sensible plans of action for managing
problems and reaching desired goals” (p. 28). This statement reflects the
symbolic interactionist worldview. The description of the constructivist
stance was stated:
The researcher brings to the research process, philosophies, experience,
professional background, and interests. These factors influence the
choice of topic, approach to analysis, and where the emphasis is placed.
Therefore, the final theory constructed through grounded data is a
representation of both participant and researcher (p.28).
Different researchers could emphasize different aspects of the data to
construct different theories, thus providing another explanation of human
behavior. The benefit or result of the grounded theory studies then is that
knowledge is accumulated over time, and more theories are developed for
people seeking explanations of what is going on around them (Corbin &
Strauss, 2015, p. 28).
This study aimed to develop a comprehensive description of the
experiences of nurses and midwives during the Ebola outbreak and the
decision making process involved in their choice either to care or not to care
for patients with or without Ebola during the outbreak. The use of the GTM
uncovered nurses’ and midwives’ beliefs and meanings that underlie their
actions during the Ebola outbreak. The outcome of the analysis provides a
model of how logic, emotion, culture, and other factors combined to
influence how nurses and midwives responded to the Ebola outbreak, and
explain their work decisions either to continue or not continue caring for
patients. These explanations were co-constructed by the participants and the
researcher.
Sampling and Recruitment Criteria
A convenient non-random sample was recruited for this study. The
inclusion criteria should all be registered nurses or midwives, have a
minimum of one year working experience, were currently employed, and
might have worked or not worked at one of the three hospitals selected for
the study during the Ebola outbreak in Liberia. The exclusion criteria for this
study included nurses and midwives who did not provide direct patient care,
such as administrators or educators, and who were not permanent residents
or citizens of Liberia, such as international volunteers and experts with any
of the nongovernmental organizations in the country. The hospitals used for
this study were selected based on the following criteria: one private faith-
based hospital, one private faith-based hospital that receives funding from
the government, and the third, a government-managed hospital. Participants
who met the criteria were invited to participate in the study through the
recommendation of the nursing directors of the three hospitals; this is known
as the snowball sampling technique (Holloway & Wheeler, 2010). As
recruitment and analysis progressed, sampling was based on representation
of categories or concepts and further developed through the process of
theoretical sampling. Theoretical sampling is a data collection technique
whereby concepts derived from early data analysis are explored further by
collecting additional data on these derived concepts. The goal is to obtain
data that will exhaust all options for the development of the concepts derived
from the data on the basis of the properties and dimensions of the concepts.
Theoretical sampling is used to identify variations and linkages as the
concept is developed (Corbin & Strauss, 2015, p. 134). A total of 30
registered nurses and registered midwives were recruited from all three
hospitals; 10 nurses and midwives from each hospital. Concept saturation
was achieved after 25 interviews; an additional five interviews were
conducted to ascertain saturation.
Research Setting
Liberia is found in sub-Saharan Africa in the West African region. As
of 2012, Liberia had a population of 4,190,435. It is a low income country
with a life expectancy of approximately 60 years in 2011, compared to the
average of other countries in the region, which is 56 years (Health Finance
and Governance Project, 2013). Most adults are graduated from high school,
demonstrating a basic level education among citizens, including a general
understanding of health and related literature. Liberia spends an extremely
low percentage of its national budget on health, suggesting that not enough
resources are mobilized for health, that access to health care is insufficient,
and that the quality of services is poor (Health Finance and Governance
Project, 2013).
Liberia is divided into 15 counties. Each county is then divided into
districts, and each district is made up of several communities. The Liberian
National Health Policy provides for three levels of care in the health care
system: primary, secondary, and tertiary health care. Four health care sub-
systems are categorized under these three levels, and the County Health
Teams and implementing non-governmental organizations (NGO) partners
are responsible for staffing facilities based on each facility’s level in the
health system (Liberia Ministry of Health, 2011). The primary level health
care system is comprised of community level services, primary health care
clinics (level one), and primary health care clinics (level two). The
secondary level of health care comprises the district health system and
county health system. The district health system is the first provider of
secondary care, focusing on maternal and child health care, providing
general surgery, pediatrics, general medicine, and obstetrics and gynecologic
services. Tertiary level care in Liberia consists of two types of hospitals:
regional hospitals and the national hospital, John F. Kennedy Medical
Center, which functions as a specialized referral heath facility and teaching
hospital for physicians, nurses, and allied health professionals (Liberia
Ministry of Health, 2011).
Other hospitals are owned and operated by religious organizations and
private parties, providing care based on the level of the facility and the
category of health care in that county. For example, the SDA Cooper
Hospital is a secondary health care service provider operated by the Seventh-
day Adventist Church, with approximately 40 beds, including a laboratory
and eye clinic. Some hospitals owned by religious organizations also receive
government funding; these regional hospitals are better staffed and equipped
and provide tertiary care in the rural areas. The study participants were
recruited from secondary and tertiary care hospitals, since those facilities
were able to continue operations during the peak of the Ebola outbreak. Of
the three hospitals selected one hospital was operated by a religious
organization without government funding; one was operated by a religious
organization and received government funding, and one regional
government hospital that provided health care services during the Ebola
outbreak. Furthermore, the first hospital was faith-based, privately funded,
and continued with regular health care services; the second was also faith-
based, received both private and government funds, and served as an Ebola
Treatment Unit (ETU). The third hospital was government managed and
used as a holding center for suspected and confirmed Ebola cases due to the
overcrowded ETUs.
Method of Data Collection
Data were collected mainly through face-to-face interviews using a
semistructured interview guide (see Appendix B); demographic data were
collected using a demographic interview guide (See Appendix A).
Participants were allowed the flexibility to tell their stories in their own way,
with their responses to the questions directing the course of the interview.
Interviews were conducted at a convenient location for the participant (most
often in a quiet room in the hospital provided by the nursing directors), at a
time when they were off duty or during their break periods, and where there
were few disruptions and distractions. The interviews were tape-recorded
and transcribed.
Procedures
The participants were recruited based on the inclusion criteria earlier
identified, through purposeful and convenient sampling strategy. The
administrators of the hospitals were contacted and visited for approval and
support (see Appendix C for letters of support). In fact, the approval and
support provided by hospital administrators fostered the early identification
of interested participants. The administrators provided access to the
participants, and flyers were distributed to nurses and midwives prior to
making an appointment. Anyone who expressed interest in the study was
given a more detailed verbal description of the study and its significance,
and appointments were made when appropriate. As the interviews
progressed, subsequent participants were identified and interviewed through
the process of theoretical sampling. The participants read and signed the
informed consent document before the tape-recorded interviews were
conducted. The recorded interviews were then transcribed using identity
numbers to represent each participant to protect their identity. See Appendix
D for a sample of the transcribed data, which were stored in a password-
locked folder in a computer accessible only to the researcher. The
transcribed data were then analyzed, leading to the identification of
subsequent participants based on the identification of categories and the need
for concept development. After analysis was completed, the tape-recorded
interviews were destroyed.
Ethical Considerations
The Ethics Review Board of a Liberian university in Liberia which
has a Federal Wide Assurance (FWA) status approved this study. The
Institutional Review Board of the researcher’s university in the United States
deferred to the Liberian IRB. Appendix E in the appendices section contains
a copy of the Human Subjects approval. Every participant received a written
explanation of the study, and an informed consent (see Appendix F) signed
by each participant was obtained before each interview began. Participants
were told they could stop the interview at any point, and could refuse to
answer questions or talk about aspects of their experiences that were difficult
for them.
The interviews were recorded and the recordings destroyed after analysis
was completed.
The participants’ confidentiality and anonymity was assured through
the anonymous transcription of interviews. Instead, each participant
received an identity number that was known only to the researcher. In
addition, transcribed data was stored safely in a password-protected file, in a
password protected computer used only by the researcher. Any identifying
participant information was kept in a separate password protected file which
was only available to the researcher. The signed consent documents were
stored in a locked file cabinet at the researcher’s university office.
Permission for site entry was obtained from the hospital administrators.
Method of Data Analysis
Analysis of data progressed simultaneously with data collection, with
early discoveries from each data analysis used to guide subsequent
interviews with participants. Both the Charmaz (2014) and Corbin and
Strauss (2015) methods of analysis were used. The analysis began with line-
by-line coding, using gerunds in accordance with Charmaz’s approach:
coding started with a line-by-line examination of the transcribed data, with
codes ending in “ing” (gerunds) placed by each line of the transcription data,
e.g., “experiencing emotional pain.” Some codes were the exact responses
of the participants; such responses are referred to as “in vivo” codes
(Charmaz, 2014). Then, codes across various incidents described by the
participants were compared
(also using codes that end with ‘ing’ and “in vivo”). Similar codes were
then sorted, separated, and synthesized to form focused codes according to
Charmaz’s approach. These focused codes were then further analyzed
through sorting and synthesis to form categories and subcategories, and the
core category was identified. Axial coding using the Corbin and Strauss
method was conducted by identifying the properties and dimensions
of each category and their subcategories. Properties are the defining and
distinguishing characteristics of a category, and dimensions are the
variations within the properties or the range of defining characteristics of
categories and subcategories; these are identified by the researcher from data
analysis (Corbin & Strauss, 2015). Axial coding was used to reassemble the
categories and their subcategories to reflect the linkages between them until
saturation was achieved. The categories and subcategories were then
integrated around the core category. Further sorting and analysis using the
Corbin and Strauss method progressed until the structure, which showed the
links and relationships between the core category, the other categories, and
subcategories, was developed into a concept ordering or model. The
conceptual ordering or model assisted in representing the nurses’ and
midwives’ work decision process during the Ebola outbreak under different
conditions. Memo writing was used throughout the analysis to document
these comparisons, linkages, and answers to analytical questions (Corbin and
Strauss, 2015; Charmaz, 2014). A sample of the memos is placed in
Appendix G. Memos helped the researcher keep track of the analysis process
through the recording of new concepts to be explored, or interpretations of
concepts that were identified. The researcher’s values, emotions, and
perceptions were also written in a methodological journal (Corbin and
Strauss, 2015; Charmaz, 2014). Figure 1 demonstrates in summary form the
process of data analysis that was used.
Methods to Establish Rigor, Credibility and Trustworthiness
To establish credibility, the researcher ensured that the following
activities were conducted. The researcher became familiar with the research
setting by visiting the sites at least once before conducting interviews.
During the visits, the researcher interacted with the administrators, nurses,
and midwives to create rapport. The researcher ensured that data collected
were sufficient and rich enough to support the study findings. The range,
number, and depth of observations contained in the data were considered to
ensure methodological soundness and the steps and procedures of the
grounded theory method developed by Corbin and Strauss (2015) and
Charmaz (2014) were followed. Systematic comparisons between
observations, codes, and categories through data analysis were conducted
and recorded in memos. Audit trails, thick description, and researcher’s
reflexivity was accounted for in this report to provide ample evidence and
allow the readers to form an independent assessment of the study findings.
The audit trail, a clear description of the actions taken by the researcher
throughout the study period, was used to ensure confirmability and
credibility. The step-by-step procedures taken by the investigator are
accounted for in the study report (Crabtree, 2006). A thick description is
used in qualitative studies in which the researcher observes details of an
ongoing event and develops contextual and social meaning from the
observed actions, interactions, and behaviors of the research participants to
arrive at a contextual understanding (Dawson, 2013). This study used thick
description to ensure credibility. This includes portions of the data analyzed
for readers to assess the credibility of the findings. The research wrote
memos to keep track of the analysis process and aid in reporting findings.
Negative cases and alternative explanations known as variations in the
grounded theory method were examined and accounted for in the report
(Charmaz, 2014; Holloway & Wheeler, 2010).. Reflexivity is a practice
which systematically acknowledges the context of researcher and participant
knowledge construction, especially the effect of the researcher’s
perspectives and background at every step of the research process. This was
done through a methodological journal kept by the researcher. This is
recommended because the researcher’s experience and perspectives will
inevitably affect her subject matter, the angle of inquiry or methods
considered suitable, which findings are thought to be correct, and the
framing and report of conclusions (Crabtree, 2006).
Summary
The method by which this study was conducted has been identified
and explained in this chapter. The research questions answered by this study
were itemized. The description of the grounded theory research design was
elaborately discussed, highlighting both the Corbin and Strauss and Charmaz
approaches. This study used the combination of both methods in the analysis
of data. The methodology of the data analysis was explained. A total of 30
registered nurses and midwives from three selected hospitals, 10 from each
hospital, participated in this study. The research setting was the Liberian
health system. The structure, organization, and management of the Liberian
health system were described. Ethical approval was obtained from a Liberian
university’s Ethics Review Board which has FWA status; this approval was
accepted by the researcher’s university in the U.S. Participants’ consent,
confidentiality, and anonymity were assured. Data were collected through
face-to-face interviews using a semistructured interview guide. The
interviews were tape-recorded, transcribed, and stored safely. The data were
analyzed consecutively through line-by-line coding, focused coding, axial
coding, and conceptual ordering. This led to the identification of codes,
focused codes, categories, subcategories, the core category, and a conceptual
model, in that order. These procedures were used to gain an understanding
of the experiences and work decision process adopted by the nurses and
midwives. Memos were used throughout the data analysis and a
methodological journal was kept by the researcher to
support the rigor, credibility, and trustworthiness of the study.
CHAPTER FOUR
RESULTS
Introduction to Chapter
In this chapter the findings of the study are described, including the
study participants, the analysis, and an interpretation of the findings. The
findings are organized by categories and subcategories identified in the data
and are represented in a conceptual model which describes the work decision
process used by nurses and midwives during the Ebola outbreak in Liberia,
West Africa. An embedded manuscript is included in this chapter which
highlights the analysis and interpretation of the findings. The trustworthiness
of the findings is discussed and the chapter summary is presented.
Description of Sample
The participants in this study included 30 registered nurses and registered
midwives selected from three hospitals in the city of Monrovia, Liberia. Ten
registered nurses and midwives were selected from each of the three
hospitals. One hospital was a private faithbased institution which continued
with regular health care services during the outbreak. One was a private
faith-based hospital that also received funding from the government; during
the outbreak this hospital was used as an Ebola treatment unit (ETU). The
third hospital was government managed and used as a holding center for
suspected and confirmed Ebola cases due to the overcrowding of the ETUSs.
The study participants included one male registered nurse. They had an
average of nine years working experience. Most of the nurses and midwives
worked in the hospital during the Ebola outbreak (n = 27) with an average
monthly income of $23945.00
(Liberian dollars). Forty percent of the nurses and midwives had bachelor’s
degrees in nursing. Of those who worked during the outbreak, 13 (43.3%)
worked in the Ebola treatment Units (ETU). Table 1 below describes the
characteristics of the participants in the study.
Table 1. Participant Characteristics (N = 30).
Mean n %
Age (years) 38
Gender
Female
29 96.8
Male 1 3.2
Marital status
Single
11
36.7
Married 17 56.7
Other 2 6.6
Number of children or dependents 3
Registered nurse 28 93.3
Registered midwife 2 6.7
Years of working experience 9
Educational level
Diploma
10
33.3
Associate degree 8 26.7
Bachelor’s degree 12 40.0
Religious affiliation
Christianity
29
96.7
Describe oneself as spiritual
Yes
23
76.7
No 4 13.3
Worked during the Ebola outbreak
Yes
27
90.0
No 3 10.0
Worked in Ebola Treatment Unit
Yes
13
43.3
No 14 46.7
Monthly income (Liberian
Dollars) Before outbreak
$13968.50
During outbreak $23945.83
Adequacy of income
Before outbreak
Adequate
1
3.3
Less than adequate 28 93.3
During outbreak
Adequate
4
13.3
Less than adequate 20 66.7
Access to personal protective
equipment
Yes
24
80.0
No 1 3.3
Note. Categories that do not add up to n = 30 is a result of missing values
Analysis and Interpretation of Findings
The following is an embedded manuscript that reflects the
analysis and interpretation of the findings. It includes a description of
the experiences of nurses and midwives and contains the description
of the work decision process used by nurses and midwives during the
Ebola outbreak in Liberia, West Africa. Additional findings, which
include further detailed description of the subcategories for the
categories: family, professionalism and institutional influences, are
presented after the embedded manuscript. These additional findings
were not distinctly highlighted in the manuscript.
Abstract
The purpose of this study was to explore the experiences of nurses and
midwives, including the decision process involved in either rendering care or
not rendering care to patients during the Ebola outbreak in Liberia, West
Africa. Data were collected from 30 registered nurses and registered
midwives through face-to-face, semi-structured, taperecorded interviews.
This study combined both Corbin and Strauss (2015) and Charmaz (2014)
grounded theory methods of data collection and analysis, resulting in a
description of the experiences and a conceptual model that describes the
social process involved in the work decisions made by the study participants.
The core category identified in the data was “living in fear and terror.” The
work decisions of nurses and midwives were primarily influenced by family
responsibilities and demands. The findings of this study could be applied to
education, research, and working policies when planning for future disease
outbreaks in Liberia and other regions in the world.
Keywords: Ebola virus, nurses and midwives, decision making,
disaster nursing, willingness to work
Introduction
The recent Ebola outbreak in the West African region has resulted in
many deaths plus devastating health and socioeconomic upheaval. Health
care workers (HCWs) are central to the restoration and maintenance of
optimum public health, especially in situations such as disease outbreaks.
Health professionals are equipped with skills for surveillance,
communication, reporting, and containment of a disease outbreak (Barnett et
al., 2012). The willingness of HCWs to respond in situations of uncertainty
and insecurity, along with their perceptions and attitudes towards their roles
during disease outbreaks, influences their availability and response to the
need for disease containment
(Barnett et al., 2012). The determinants of HCWs’ willingness to respond to
disease outbreaks include type of disease, threat perceptions of health care
workers, and associated perception of efficacy (Barnett et al., 2012; Connor,
2014).
During the Ebola outbreak in Liberia and West Africa as a whole, in
addition to the need to care for patients who had contracted the Ebola virus,
other patient populations also needed health care services. Coping with a
new, high-mortality disease within the region, including development of
treatment protocols, was a concern throughout the region. The resources
needed, including experts and health care workers who were experienced in
treating patients with Ebola, were not readily available. In Liberia, this was a
result of the country emerging from 14 years of civil war that had led to
limited availability of health resources and dysfunctional health care systems
(Buseh, Stevens, Bromberg, & Kelber, 2015). In addition, Ebola virus
disease symptoms are indistinct from other endemic diseases like malaria,
gastroenteritis, or cholera (World Health
Organization [WHO], 2015, “Diagnosis,” para. 1). Ebola virus disease is
deadly. The WHO fact sheet reports the fatality rate of Ebola virus disease to
be 50% on the average and have recorded between 20%-90% in past
outbreaks (WHO, 2015). This led to increased anxiety levels in health care
workers, such that every patient who presented for treatment or services for
other health conditions was a suspected case (Hayter, 2015). Furthermore,
the WHO (2015) released a statement that Liberia had reported the highest
number of deaths in the largest, longest, and most complex outbreak since
Ebola first emerged in 1976 in the Democratic Republic of Congo. At the
peak of transmission in August and September 2014, the country was
reporting from 300 to 400 new cases every week. Public facilities in the
capital city, Monrovia, were under particular pressure once the government
declared a state of emergency. All residents were mandated to stay home and
public gatherings were strongly discouraged (WHO, 2015). Fear and
uncertainty about the future of families, communities, and the country,
including its economy, dominated the national mood. Health professionals
remained vital to the treatment of patients, even when supplies of personal
protective equipment and training in its safe use were inadequate.
Altogether, 375 health care workers were infected and 189 lost their lives
(WHO, 2015). According to the International Council of Nurses [ICN]
(2015),
Ebola intensified the existing inadequacies in the health system West Africa
countries of Guinea, Liberia, and Sierra Leone. These inadequacies ranged
from shortage of health care workers, high rates of attrition, uneven
distribution of health care workers, and poor working conditions to gaps in
occupational health and safety (such as availability of personal protective
equipment).
Some nurses cared for patients infected with Ebola at a hospital in the
U.S.; these patients apparently visited West Africa during the outbreak
before traveling to the U.S.
These nurses demonstrated the possibility of health care institutions and
health professionals to care for patients with Ebola Viral Disease (EVD)
with desired clinical results, while at the same time protecting the safety of
staff and other patients (Matlock, Gutierrez, Wallen, & Hastings, 2015).
Touch is considered a main source of direct physical connection and
an integral part of the nurse-patient relationship, however, skin-to-skin
contact is not suitable when caring for EVD patients. Regardless of the
layers of protective equipment, nurses needed to provide human and safe
touch that is intentional, deliberate, and meaningful in order to offer comfort,
connection, and care to their patients (Connor, 2015). Ethically, the
American Nurses Association (2015), in the fifth provision of the code of
ethics, indicates that while nurses are obliged to conduct nursing actions
such as assessment, intervention, and promotion, among others, for the
health and safety of their patients and society, nurses also are obliged to
apply to themselves the same health maintenance and promotion strategies ,
use health care services when needed, and refrain from unnecessary risks to
their health and safety while carrying out their professional and personal
activities (pp. 19-25 ).
There are a varied range of concerns held by health care workers,
including nurses, which need to be considered when planning for effective
workforce presence during a disease outbreak. These concerns might have
some influence on nurses’ willingness to work during a pandemic (Cheong
et al., 2007; Wong, Wong, Lee, Cheung, & Griffiths, 2012). These concerns
include appreciation from employers, efficacy and side effects of vaccines,
frequent policy changes, unclear protocols set for case management of
infected patients, poor facility layout, and duty role stress. Finally, there is
need for development of a curriculum that provides a better understanding
of the knowledge, skills, and aptitudes required to care for patients during
public health emergencies (Downes, 2015). The experiences of nurses
during the Ebola outbreak should be explored to gain insight into the safety
and social issues and enable the development of more realistic policies to
meet the needs of nurses and other health professionals.
The purpose of this study was to explore the experiences of nurses and
midwives, including the decision process involved in either rendering care or
not rendering care to patients during the Ebola outbreak in Liberia, West
Africa. This study provides a description of the experiences of nurses and
midwives who either continued to care for patients or who did not continue
to care for patients during the Ebola outbreak. The findings are informative
for practice, policy decisions, research, and education and curriculum
development for nurses and midwives in Ebola nursing care.
Method
A qualitative design which combined the grounded theory method
(GTM) of both Charmaz and Corbin and Strauss was used for this study to
identify concepts, develop theoretical explanations, and offer new insights
into the experience of patient care during an Ebola outbreak (Charmaz,
2014; Corbin & Strauss, 2015). The GTM acknowledges that the interaction
of the researcher and participants influence the nature of the data, and the
concepts and theory that emerges are the mutual creation of meaning (Morse
et al., 2009). In this study, the GTM was used to describe the experiences of
nurses and midwives and to develop a conceptual model of the work
decision process used by nurses and midwives during the Ebola outbreak.
The identification of the core category, subcategories, and the basic social
process through strategies such as theoretical sampling, theoretical
sensitivity, and constant comparison formed the basis of this analysis.
Ethical Considerations
The ethics review board of a Liberian university that had Federal
Wide Assurance (FWA) status approved the study. The researcher’s
university in the U.S. deferred to the
Liberian university’s FWA approval. Informed consent was signed by each
participant before the interview. Confidentiality and anonymity of the
participants was assured through the anonymous transcription of interviews
and by secure storage of the transcribed data. Permission for hospital entry
and recruitment was obtained from the hospital administrators.
Participants and Recruitment Criteria
A total of 30 registered nurses and midwives living in the country
during the outbreak and who had a minimum of one year working
experience were recruited into the study. Excluded from the study were
administrators and supervisors. These 30 registered nurses and midwives
(mean age: 38 years) were selected from three hospitals; 10 from each
hospital. One is a faith-based, privately funded hospital that continued to
provide regular health care services during the outbreak. The second hospital
is faith-based and co-funded privately and by the government. During the
outbreak, this hospital was used as an Ebola treatment unit (ETU). The third
hospital is government managed and was used as a holding center for
suspected and confirmed Ebola cases due to overcrowding in the ETUs..
Most participants were females (n = 29), with an average of nine years
working experience. Most nurses and midwives worked in the hospital
during the Ebola outbreak (n = 27) with an average monthly income of
$23945.00 (Liberian dollars). Forty percent of nurses and midwives had
bachelor’s degrees in nursing. Of those, who worked during the outbreak, 13
(43.3%) worked in the Ebola treatment units (ETU).
As data collection and analysis proceeded, sampling was based on
further development and representativeness of concepts using the process of
theoretical sampling (Corbin & Strauss, 2015). Concept saturation was
achieved after 25 interviews; however, an additional five interviews were
conducted to ensure saturation.
Method of Data Collection
Data were collected through face-to-face interviews, using a semi-
structured interview guide. Participants were encouraged to tell their stories
in their own way, with questions added to probe the participants’ responses
during the interview. The interviews were tape-recorded and transcribed.
After analysis was completed, the tape-recorded interviews were destroyed.
Method of Data Analysis
Data collection and analysis progressed concurrently, which set the
basis for subsequent interviews with participants. A combination of both the
Charmaz (2014) and
Corbin and Strauss (2015) methods of analysis was used. Charmaz’s
approach was used in the initial line-by-line examination of the transcribed
data in which codes were identified. The codes included words or phrases
ending with “ing” (known as gerunds) and codes consisting of the direct
responses of the participants (known as “in vivo”) were placed by each line
of the transcribed data. A comparison was conducted of the codes across
various incidents described by the participants also using codes that end with
“ing.”. This was followed by sorting, separating and synthesizing similar
codes to form focused codes, which were then sorted and analyzed to
identify the core category, other categories, and subcategories. Using the
Corbin and Strauss approach, the core category, other categories, and
subcategories were further analyzed by means of axial coding through the
identification of the properties and dimensions of each category until
saturation was achieved. Corbin and Strauss (2015) refer to this approach as
axial coding, the process of integrating categories and subcategories around
the core category. This process involves the identification of the properties
(which are descriptive and defining characteristics of categories) and
dimensions (which are variations within the properties of categories) (Corbin
& Strauss, 2015, p. 220). The integration of the categories and subcategories
progressed until the structure showing the conceptual order or model of
relationships between the core category, the other categories, and sub-
categories was achieved. Memo writing was used throughout the analysis to
document these comparisons, linkages, and answers to analytical questions
(Corbin and Strauss, 2015;
Charmaz, 2014).
Methods to Ensure Trustworthiness
To achieve credibility and confirmability, the first author attained
familiarity with the research setting by visiting the hospitals at least once
before conducting the interviews. While visiting, the first author interacted
with the administrators, nurses, and midwives to create rapport. Care was
taken to ensure that data collected was sufficient and rich enough to merit
the interpretation of the findings. Evidence has been provided through the
use of a comprehensive description to allow the readers to form an
independent assessment of the findings of this study. The first author
achieved reflexivity by keeping a methodological journal.
Findings
Analysis of data resulted in the identification of one core category,
seven categories, and 13 sub-categories. The description is as follows:
Core category: Living in Fear and Terror
The nurses and midwives reported feeling afraid and terrorized by the
possibility of contracting the disease through interaction with patients and
colleagues, and transmitting it to family members. The death of a patient or a
colleague with whom the nurse had previously been in close physical
contact, whether a suspected or confirmed case, caused anxiety for the nurse
as they reflected on the possibility of contracting the virus through
unsuspected exposure to the body fluids of the infected person.
It [Ebola outbreak] was a terrible experience for me. Where a disease,
when you come in contact with somebody by touching and as a
midwife, you have to do screening for patient. It was a terrible
experience that you coming in contact with patient where at the
beginning we never had personal protective equipment (PPE). And in
the delivery room; is a place where we have body fluids; so coming in
contact with patient, the first thing you are very afraid of who you are
coming in contact with. And then, what are you taking home for your
family? You are not so much particular about yourself but your
children and family members at home. So the Ebola outbreak was a
terrible, terrible experience.
The nurses and midwives reported that this led to fear about going to
work and losing zeal for their work. One of the nurses said, “You say, oh I
won’t come to work but then you … you go back the next morning. I just
had that fear to come to work and also lost the zeal to come to work.”
Knowledge, Skills, and Protective Equipment
Described in the next few sections are the subcategories of “Living in
Fear and Terror.” There was a lack of understanding at the beginning of the
outbreak about the virus and about infection protection and control. One of
the nurses said, “We had an experience about an unknown sickness that we
had not heard about or seen.” There was an initial lack of equipment which
posed a greater danger to health care workers and the patients they were in
contact with. When the outbreak began, the nurses did not know how to
wear and remove the personal protective equipment (PPE).. The PPE was
uncomfortable to wear because it generates and retains heat, causing heat
exhaustion for some participants. Nurses were determined to keep
themselves safe so they could care for the patients. When the PPE was not
available the nurses withdrew from work.
I answer here saying that yes we had some supply of PPE or so but it
was not much and so when we went out of it we had to withdraw. And
then we close down for about … I think a week or two and then we
came back on board.
Frequent hand washing with 0.05% chlorine water caused physical
discomfort for the nurses.
We were not use to wearing PPE and we just started using it so it was
difficult to cope with it. If you wear that PPE there’s lot of heat. If
you take off that PPE, you see that you sweat and lose enough fluid
and it was very uncomfortable wearing it. And sometimes you wear
the full PPE you see yourself suffocating. At the end of the day, you
face difficulty in breathing. And also the use of chlorine: in fact it was
more concentrated using 0.5, 0.05 [concentration of solution]. People
using chlorine and inhaling it and chlorine is like a chemical.
Sometimes you find your entire throat; the GI to be very dry and very
bitter.
High Risk Nursing
The nurses and midwives were constantly at high risk because they
were fighting the unknown and observed a high death rate of patients and
even their colleagues. With no clinical experience treating cases, they did
not know what kind of disease they were fighting. One of the nurses said,
“My experiences during the Ebola crisis was well challenging because for
one fact; we had not experienced Ebola in our country before. So when it
happened, we started to ask; what kind of illness is this?”
National Defense
The nurses likened the situation to that of war. The alertness, armory,
and support from other fighters that characterized a typical war situation
were needed in the fight against Ebola. As the national defense personnel
fighting a war, nurses had to use defense principles and tactics to win the
battle.
My experience during the Ebola period was just so fearful; the
hospital was like a war zone……well, we couldn’t just give up
because if we as nurses will just sit and say we are afraid, … just to
serve humanity to see that we battle this disease that came; this virus
that came so that it can leave our country.
Psycho-physical Symptoms
At times, after a patient or a colleague became infected or died as a
result of Ebola, the nurses out of fear started manifesting some of the signs
and symptoms; they also became sad and concerned for their survival.
Our mental tension was very, very high. Thinking that, we were not
safe anytime we could contract a disease from somebody. So many
days we felt sick; if you see the situation you just say “I finish get my
own!” Sometimes you go home you already having headache.
Sometimes you home you have fever of no origin. So we were afraid;
for me I was actually afraid, I was afraid. Every time I touch patient;
I just feel that maybe I can get my own any time I don’t know who is
who.
Family
Family is one of the categories identified from the data. This category
is characterized by concern for family safety, physical distancing,
discouragement from working, encouraging nurses to work, praying for
nurses’ safety, and providing emotional and psychological support. The
situation caused the nurses and midwives to fear for their safety and the
needs of their family. Nurses addressed this fear by bathing upon returning
home and prior to interaction with family members. It was difficult to endure
the physical distancing between spouse and children. The nurses saw this as
the responsible thing to
do to ensure safety despite their desire for closeness and affection with their
families. Family was identified as the primary reason for a nurse to stop
working during the outbreak. Those who did not work or stopped after a
period of working did so because family members discouraged them or
because of family responsibilities (e.g., pregnancy or to maintain marital
stability).
I stopped working because of the Ebola crisis especially when most
of my friends that we all like working together, graduated together
they contracted the virus and then they died during the process; really
my parents were like on me oh don’t work, don’t work and also my
former husband. He was like every time don’t go to work, don’t go to
work. Even at times, he use to make it out of confusion. Some days he
will say don’t go to work you don’t know who is who, don’t go to
work and it used to be like problem between he and myself always.
Those nurses and midwives, who stayed home and chose not work,
reported that they provided first aid treatment and health advice to their
neighbors and community members who sought their professional help
during the outbreak. Nurses who stayed at home reported being conscious
and cautious for their safety because they lacked protective equipment while
at home.
All through the Ebola time people was so afraid to treat people at
home but some patients use to come to me … like my relatives … I
see them I still use to continue that care…. In the case of emergency,
there will be lack of equipment or resources to conduct adequate and
accurate care. It is better that the patients report to the hospital where
there are specialized personnel and equipment readily available for
diverse cases.
Those who continued to work were concerned for their family safety
and affected by physical distancing between them and their family members.
When the nurse educated her family about the disease, it enhanced family
support, eased strain in the relationships, and boosted family dynamics,
allowing the nurse to continue working.
Because they felt that, I had the knowledge so I will protect myself
more than them. They had that confidence in me so every time I went
home they had hands around me. Even my family at the house, they
had hands around me. I was like telling them to take thing serious
they shouldn’t believe in the lies but they should wash their hands, so
for my family home it was ok. They were supportive, at certain from
the beginning it was hard but after going by they started being
supportive.
Professionalism
The nurses expressed passion for their profession, love for people, and
sympathy or empathy for sick people. Though the nurses needed income for
their livelihood, it was not the primary motivator. Nurses who worked did
not do so primarily for the financial benefits. Nurses expressed their logic
for continuing to work by weighing the options and the benefits to
themselves and their society.
So I was not looking at the financial aspect; I was looking at serving
humanity because that’s what I took oath for. So I was not looking at
any other thing whether from outside, whether pay or whatever. I took
oath to serve humanity so that was my motivation.
The nurses reasoned that their refusal to work would eventually lead to
genocide, that neither they nor their relatives would be spared; that would be
the retribution.
When we realized that people were dying and we were the ones to be
on the line to save them, so I had no other option but to go help
because it could be me or my relatives or someone out there that I
know.
The nurses appreciated the opportunity to gain additional clinical
experience, competence, and confidence. Those nurses who did not work felt
unfortunate that they could not join their colleagues in the fight against
Ebola as a result of their unique individual circumstances.
I was not doing nothing but yet then still they were paying us. They
were paying us but still I was really feeling bad because I was not
doing nothing and just see people dying and I can do nothing.
God and Safety
The nurses reported that they depended on God for safety. Some of
the participants regarded this as the primary resource for safety, despite the
availability of protective equipment. Some of the participants attested that
several nurses and HCWs were infected despite using protective gear. They
believed that the surety of protection was only possible through dependence
on God. The nurses reported that they prayed for their safety and for the
safety of their family and colleagues. Nurses reported that all three hospitals
conducted devotions at the beginning of every working day. This reflects the
spiritual dimension of the experience involving both personal and corporate
prayer.
Every morning before I go to work I will pray and present myself to
God because He [is] the only person that will protect me in the unit
and then when I get there I try to look after my patients. We also use
to pray before going in [treatment unit]. After dressing we hold hands
together, we pray before entering. During the assembly we had to pray
every morning; we had our general assembly before, they do
debriefing. We use to call it debriefing and during that debriefing, it’s
like time of worship. It can be easy in the morning; we can storm the
place with God. It was so interesting.
Stigmatization
People in society thought nurses were at risk of infection and could in
turn spread the virus to the public, leading to stigma.
Even in the community if they notice that you are working to this
institution they then stigmatize you. This is a crisis, this is a condition
that came in the country and we want it to go away, so how will this
go away if we are not there to help? When we go to help then people
stigmatize us, it was so frustrating… yes.
Stigmatization resulted in feelings of fear, frustration, and sadness.
The strained relationship between nurse and neighbors who had distanced
them was improved when neighbors saw that the nurse and their family were
applying measures to keep themselves
safe.
Institutional Influences
This category is characterized by the hospitals’ influences and
activities that affected the nurses’ experience. The actions and attitude of the
hospital administration were both motivational and non-motivational for the
work decisions of nurses and midwives. One of the nurses said “They
[hospital administration] contributed by making the materials available, that
[is] all. As I said the financial aspect was very, very low. No motivation
from the hospital, administration.”
The three hospitals closed down temporarily at different periods
during the peak of the Ebola outbreak. Each closed when the first staff cases
were diagnosed, treated, and died from Ebola. When hospitals closed
because of fear, unpreparedness, and possible high risk of transmission to
staff, nurses felt the opportunity to continue serving was closed.
The hospital was closed down like I said only the outpatient
department (OPD) section was functioning and they never had control
over the staff everybody choose to go anywhere. They really never
had control over the staff so they had no influence over anybody.
Where you choose to go and work fine you go and work after
everything people started coming back.
The nurses and midwives reported that training was provided by the
hospitals, which boosted their confidence and competence.
We were being prepared because even though we were not really
notified, like I said from the onset but we had a doctor who came
from Azerbaijan, she was here by then. When she [doctor] heard
about Ebola; because according to her she was in Zaire when Ebola
went in Zaire, she just did like one week brush up [training]. We had
sterile protective equipment, we had gloves both obstetric and
gynecological (OBGYN) and surgical gloves. I can really commend
the hospital administration; we were prepared by them; we had rain
boots and things here too to work with.
Government Efforts
Though the government followed through on their responsibility to
provide PPE, it failing to deliver on its promise to compensate the workers
with hazard allowance. Nurses indicated that government efforts were
centered on public health, thus it was perceived as neglecting the nurses and
other health workers by not providing incentives and benefits. One of the
nurses said, “We were not treated fine from the government, let’s be frank.
They didn’t even commend us for what we have done, it broke us down.”
Work Decision
The components of the experiences of nurses and midwives
influenced the choices made by the nurses: whether to work or not. Although
nurses and midwives were living in fear and terror, those who chose to work
did so for personal reasons such as obligation to professional oath, passion
for their jobs, sympathy for dying people, and spiritual duty. The primary
resources for their decisions were family support. Other influences were the
institutional and government efforts to provide protective equipment and
training for the nurses and midwives.
I continued to work to be able to help my people because it was too
pathetic to see such a condition. And also because I had passion for
the job….. Where you know that these people you’re working with
than to work outside of it; so I saw the logic because I knew I will still
work, I will not sit home. I saw the logic in it and I decided to work;
and that’s how I continued to work.
Those nurses who did not work described family demands and
disapproval. Some of the nurses were forced to work by hospital
administration. Later, they were glad that they had worked during the
outbreak because of the professional gains that they later enjoyed.
I was forced to work with the Ebola unit but too I refused and they
told me that if I don’t work, I was going to be sacked, and I had no
other place to work and I just had a three months old baby just from
maternity leave, so I had no option.
The same nurse later expressed:
I gain plenty things… Certificate! … people know me worldwide
because people can call me oh you are so, so, and so. We saw you on
TV you did this, you did this thank you very much. People will say oh
yes this is the girl that worked in the Ebola unit, thank you very much
you did well and most of the survivors always they are appreciative
any day they come here.
The subcategories of the work decision category are the outcomes (working
conditions) identified for working. These subcategories are described in the
following sections.
Nurse-patient Relationship
The nurses and midwives who decided to work experienced changing
dynamics in the nurse-patient relationship. They were in danger of
contracting the deadly virus through physical contact with infected body
fluids, posing a challenge to the usual nursepatient interactions. These
challenges included nurses carrying out procedures incorrectly or avoiding
certain procedures. Other challenges included treating patients harshly and
experiencing strain on the nurses’ touch role.
You see now it is terrible, the experiences I had now it is affecting my
patients now because we know that Ebola is more or like on and off
so the relationship we had with patients you find out now it is a gap.
We were not nursing patient the way we used to in a sense that when
a woman is laboring you have to help her; rub her back, go closer to
her, talk to her. Yes we can go there and talk but where you have to be
rubbing her back and other thing now we are really not doing it
because of Ebola situation so the only thing we do [is] talk to them.
Stay at a distance talk to them, encourage them, and rub them. I don’t
touch patient when I am not wearing gloves but before we used to.
Sometimes you will feel bad but it was the time such a condition, you
have to work within that time.
The nurses reported that the training and the provision of protective
materials boosted their confidence and competence and eased the strain in
the nurse-patient relationship.
Team Nursing
The nurses reported that the relationship among nurses also
experienced changes. This included support for each other, bonding,
working in twos, and being alert to each other’s needs:
Yes, take for instance if a nurse see you with a gloves and you forgot
because you forgot and you are human you are liable to forget: so if
your friend see you with gloves going to touch a chart; that anybody
could go touch with their bare hand they will stop you. . . . other
materials that you not supposed to use with the gloves and you want
to handle that material with gloves because your friend know you not
supposed to handle that material with gloves anyone could handle it
with their bare hand. Because they won’t know that someone handle it
with their gloves so at the end of the day they will alert you. They will
put you on the alert you will not even reach they will put you on your
guide. Reminding each other about how to keep being protected.
The nurses also reported experienced strain in their interactions with other
nurses:
It [physical interaction] was also hindered; because this times no
touching. Before the crisis you and your friends will shake hands, you all
hug, but this time around you’re only seeing each other, no touching. You
not coming in contact with your friend, you use to ask for your friends pen;
during Ebola even if they will to give you their pen you not willing to use it
because you afraid of your own friend. So that relationship was really
hindered. Lessons
The nurses reported that they learned from deciding to work. The
nurses advised students to take their training seriously, whether or not
conditions studied are familiar. Other lessons identified by the nurses were
the need for strict adherence to safety measures, to take seriously the
infection prevention control measures, and to continue to practice universal
precaution measures.
Can you imagine those days back I had a presentation on Ebola; and
nobody was even listening in the class. The place was noisy, it wasn’t
interesting, only at the end of the day we find ourselves here so as a
student you have to take everything serious because you don’t know
when you will find yourself into that thing, and that was just what
happened. I who even presented on it, I even forgot about it. The
lesson we can pass is to always take our universal precaution first.
Regardless of Ebola we should always remind ourselves that we
should protect ourselves because we don’t know when there will be
an outbreak of a communicable disease.
A summary of these categories and their subcategories are presented :
Categories Subcategories
Living in fear and terror (core
category)
Knowledge, skills, and
protective equipment
High risk nursing
National defense
Psycho-physical symptoms
Family Family education
Home based nursing
Professionalism Professional gain
Professional role strain
God and safety
Stigmatization
Institutional influences Hospital access
Ebola nursing care
Government efforts
Work decision
Nurse-patient relationship
Team nursing
Lessons
Linkages between Categories and Subcategories (The Work
Decision Process)
Data showed that nurses and midwives were living in fear and terror.
This affected them emotionally and psychologically. Six categories were
identified to influence their work decisions; however the key category was
identified as the family. Family responsibilities and demands were the main
reasons the nurses and midwives either chose to or chose not to work during
the Ebola outbreak. Other categories that influenced the nurses’ work
decision positively were professionalism and dependence on God for safety.
Institutional influences and government efforts were found to influence the
nurses’ work decisions both positively and negatively. Data showed that
stigmatization negatively influenced nurses’ work decisions, causing sadness
and frustration.. However, stigmatization however was not identified as a
reason for nurses and midwives to stop working during the outbreak. Nurses
and midwives who chose to work experienced changes in the nurse-patient
relationship and the nurse-nurse relationship. All nurses and midwives who
participated, whether they worked during the outbreak or not, shared the
lessons they gathered from their work decisions. A conceptual model
representing the linkages between the categories and subcategories identified
from data analysis is presented.
Discussion
The nurses and midwives were living and working in fear and terror
during the
Ebola outbreak in Liberia; Their families’ lives and their own lives were
endangered. Dickenson et al., (2013) described several concerns for HCWs
during a disease outbreak similar to those identified in this study, also
identifying the family as a concern for safety, psychological, emotional, and
social support (Dickinson et al., 2013). Other research reports support the
findings in this study; namely, that nurses and midwives who felt obligated
by the nursing profession continued caring for patients during the Ebola
outbreak (Twardowski, McInnis, Cappuccino, McDonald, & Rhodes, 2014).
The nurses and midwives experienced stigmatization by the public during
the outbreak. Some studies concur that health care workers engaging in the
education of their families and patients, together with institutional
influences, and government efforts eased the effect of stigmatization
(Abramowitz et al., 2015; Kobayashi, 2015). Stratton’s (2014) finding
supports the need for government efforts through policy development,
provision of safe working conditions, and funding of training and
educational programs in Ebola care.
The experiences of the nurse and midwives included change in the
dynamics of nurse-patient relationship and team nursing. Through training
and provision of protective equipment the nurses and midwives regained
their confidence. The nurses and midwives then created methods to touch
their patients while using the personal protective equipment and fully
conducted nursing procedures, improving the relationship between the
nurses and their patients. Results from another study concur with this finding
(Connor, 2015).The spiritual dimension of health care was identified as
crucial to enhancing nurses’ well-being. Other authors have also reported
that faith-based health care institutions and services are the vehicle used to
drive spiritual health care (Marshall & Smith, 2015). This study is
distinguished from other studies in that, the decision process involved in the
nurses’ and midwives’ choices either to render care or not to render care for
patients were made on the basis of emotional connections between nurses,
their families, and society. The decision process also was based on their
value system, including professionalism and spirituality. As a distinguishing
feature, the findings of this study highlight the spiritual dimension of the
nurses’ and midwives experiences. The findings also indicate the influence
of the spiritual resources of nurses and midwives on their decision to work.
Previous studies on health care workers’ willingness to work during disease
outbreaks have not captured the spiritual dimension. The Etzioni’s (1992)
decision-model suggests that most choices are made on the basis of
emotional involvements and value commitments. This study of the nurses’
and midwives’ decision process supports the Etzioni’s decision model.
Given that the experiences of these nurses and midwives are
significant in ensuring that they continue in their role during a disease
outbreak, the grounded theory approach provided the avenue for exploration
of their experiences and work decision process. The strength of this study is
that the findings were grounded in the perspectives of the nurses and
midwives.
A limitation of the study is that participants were mostly female,
thereby posing an under-representation of male nurses’ perspectives. The
participants were recruited from hospitals in one city in Liberia, which does
not represent the experiences of nurses in rural areas. The scope of this study
was limited to nursing and midwifery practice in the Liberian setting. The
study may not adequately represent the experiences of other
HCWs in Liberia or other settings.
Applicability of the Findings
Nurse administrators, hospital administrators and government leaders
could apply the insight gained from this study to amend working policies to
acknowledge nurses’ family concerns during disease outbreaks. Findings
could be applied by nurse educators in strengthening Ebola nursing care
training in nursing curricula and in continuous education for professional
nurses and midwives. The study findings support the need to ensure that the
provision of personal protective materials and inclusion of nurses’ family in
protection and compensation plans and policies be considered in times of
emergencies. Additionally, attention should be given to ethical
considerations, spiritual dimensions, and mental or psychological
implications of Ebola nursing care.
Conclusions
The Ebola outbreak in Liberia caused unimaginable devastation and
deaths. The role of HCWs in containing disease outbreaks cannot be
overemphasized. The nurses and midwives were living in fear and terror
during the Ebola outbreak in Liberia. The family was the key determinant
for their work decisions. When working on the ETUs, nurses experienced
challenges in the dynamics of the relationship with their patients and among
themselves. Training and provision of protective equipment will most likely
boost the confidence of nurses and midwives during an Ebola outbreak. The
emotional stress faced by nurses and other health care workers should be
considered by hospital administration and government leaders when making
policies on Ebola virus disease containment. The findings of this study could
be applied to educational and working policies when planning for future
disease outbreaks in Liberia and other regions of the world.
