Survey Study of the Knowledge, Attitudes, and Expected Behaviors of Critical Care Clinicians Regarding an Influenza Pandemic
Objective. Intensive care units (ICUs) are potential high‐risk areas for the transmission of respiratory viruses such as influenza. An influenza pandemic is expected to result in a dramatic surge of critically ill patients, and ICU healthcare workers (HCW) are likely to be at high risk of infection.
Objective. To characterize the knowledge, attitudes, and expected behaviors of ICU HCWs concerning the risk of and response to an influenza pandemic.
Design, participants, and setting. A survey was distributed to 292 HCWs (ie, internal medicine house staff, pulmonary and critical care fellows and faculty members, nurses, and respiratory care professionals) at 2 hospitals in Baltimore, Maryland.
Results. Of the 292 HCWs, 256 (88%) completed the survey. Just over one‐half of the respondents believed there is at least a 45% chance of an influenza pandemic within the next 5 years. However, only 41% reported knowing how to protect themselves during an outbreak. Despite this common belief that a pandemic is likely in the near future, 59% of those surveyed reported only minimal knowledge of the risks of and protective strategies for an influenza pandemic, and 20% reported being unlikely to report to work during a pandemic or being unsure about whether they would do so. The odds of reporting to work varied on the basis of race and responsibility for child care.
Conclusions. ICU HCWs reported having minimal knowledge concerning the risk of and response to an influenza pandemic, even though more that one‐half of HCWs expect that a pandemic will occur in the near future. This finding in a high‐risk setting is of concern, given that lack of knowledge among HCWs may result in increased nosocomial transmission to HCWs and patients. Interventions to improve knowledge of pandemics and understanding of risks among ICU HCWs are essential.
Received March 23, 2009; accepted July 7, 2009; electronically published October 29, 2009.
Before the outbreak of 2009 H1N1 influenza, the probability of an influenza pandemic was much debated in the popular and scientific press. Just last year, former Health and Human Services Secretary Michael Leavitt stated, “We don’t know when, and we don’t know how bad it will be. But we know it will happen sooner or later.”1(p2) Despite the fact that 2009 H1N1 influenza is upon us, many unknowns still remain. Efforts have been made to estimate the numbers of patients who may require hospitalization or critical care in the event of a pandemic, on the basis of historical models. Such models, although imperfect, have suggested that, even during a moderate pandemic like that of 1957 or 1968, nearly a million individuals are likely to require inpatient care and tens of thousands may require critical care support over the course of several months.2
A limited number of studies have examined the attitudes of healthcare workers (HCWs) toward reporting to work during a pandemic. The probability of responding has been found to vary according to the type of job a given respondent has, and an HCW's perception of the importance of his or her role in the response.3‐5 Despite both the prediction of large numbers of critically ill patients during a pandemic and the concern that risk of secondary transmission of respiratory viruses may be particularly high in intensive care units (ICU),6‐11 no study to date has characterized the knowledge, attitudes, and expected behaviors of ICU HCWs concerning the risk of and response to an influenza pandemic.
The purpose of our survey study was to assess ICU HCWs' knowledge, attitudes, and expected behaviors in the event of an influenza pandemic. Self‐reported data about knowledge of and expected response to an influenza pandemic may be incomplete. However, such an investigation provides a framework for understanding ICU HCWs perceptions about a pandemic and provides a pivotal starting point from which to formulate improved preparedness strategies.
Materials and Methods
Setting
Our study was conducted at 2 hospitals in Baltimore, Maryland: the Johns Hopkins Hospital, a 945‐bed tertiary care academic medical center, and the Johns Hopkins Bayview Medical Center, a 310‐bed community teaching hospital. Each hospital has a hospital epidemiology and infection control program that requires HCWs to follow both standard and transmission‐based isolation precautions consistent with the Centers for Disease Control and Prevention guidelines.12 Both hospitals are staffed by the same university‐based faculty and fellows, but the house staff, nurses, and respiratory care professionals are primarily affiliated with the individual institutions. All staff members are expected to participate in appropriate, relevant continuing medical educational programs that inform them of emerging recommendations and standards of care for their patients. Both hospitals are part of the Johns Hopkins Medical Institutions, but disaster planning and infection control are supervised separately by each institution.
Survey Participants and Protocol
During the influenza season in early 2007, a survey was distributed to pulmonary and critical care faculty and fellows, internal medicine house staff, registered nurses, and respiratory care professionals working in the medical ICUs and cardiac care units of the 2 study hospitals. The voluntary, anonymous survey was distributed to all HCWs during regularly scheduled staff and educational meetings. Instructions and a $5.00 gift card to a local coffee shop were attached to each survey.
Survey Instrument
The 29‐item survey assessed clinicians’ knowledge, attitudes, and behaviors related to an anticipated influenza pandemic as well as adherence to precautions for the prevention of healthcare‐associated influenza. Analyses of adherence have been recently published.13 Data on the characteristics of respondents, including age, sex, race, marital status, and job title, were also collected. Respondents were asked to estimate the probability of there being a pandemic in the next 1, 5, or 10 years and to indicate their sources of information regarding a possible influenza pandemic. Respondents were asked to report their level of knowledge about the risks of a pandemic and their level of confidence in their ability to protect themselves from exposure to influenza at work. Finally, HCWs were asked to estimate the likelihood that they would not come to work in the event of a pandemic and to determine which, if any, protective measures might influence that decision.
Attitudes and behaviors were examined according to degree of agreement with statements about pandemic influenza and potential control measures, using a 4‐point Likert scale (eg, not at all confident, somewhat confident, moderately confident, and very confident). Our study was approved by the institutional review board of Johns Hopkins Medicine.
Data Analysis
Statistical analysis was performed using the Fisher exact test to compare survey responses across all clinical professions as well as by age, sex, and race. Simple and multivariable logistic regression analyses were performed using respondents' characteristics, knowledge, and attitudes as predictor variables for the outcome of likelihood of not reporting to work. In multivariable regression, nurses were chosen as the reference category for clinical profession because of the significant amount of time they spend at the bedside of patients.
Likert‐scale responses were categorized as “agree” if the response was a 1 or 2 and as “do not agree” if the response was a 3 or 4. One percent of responses to questions regarding attitudes were recorded as missing values. The choice of predictors for use in the multivariable model was based on stepwise regression of respondent characteristics, reported importance of potential infection control measures, and confidence in the respondents knowledge and ability to protect him or herself, using both backward elimination (
) and forward inclusion (
). The model fit was assessed by use of Hosmer‐Lemeshow goodness‐of‐fit testing, and the number of predictors was evaluated to avoid overfitting the final regression model. Collinearity was evaluated using variance inflation factors.14 In all analyses, a P value of less than .05 was considered statistically significant. Analyses were performed using Stata statistical software version 9.2 (Intercooled Stata; StataCorp).
Results
Respondent Characteristics
The survey was distributed to 292 clinicians at the 2 study hospitals; of these 292 clinicians, 256 (88%) completed the survey (ie, 82 of 88 house staff members, 39 of 50 faculty members and fellows, 91 of 102 nurses, and 44 of 52 respiratory care professionals). The characteristics of respondents are described in Table 1. Although a small proportion of the faculty members of pulmonary and critical care medicine (PCCM) work at Johns Hopkins Bayview Medical Center, the majority are primarily assigned to clinical rotations at either Johns Hopkins Hospital or both hospitals. PCCM fellows are assigned at least 75% of their clinical duties at Johns Hopkins Hospital. For these reasons, PCCM faculty and fellows were assigned to Johns Hopkins Hospital for analysis.
Knowledge of the Risks of an Influenza Pandemic
Among respondents, the mean predicted probabilities of an influenza pandemic in the following 1, 5, and 10 years were 31%, 44%, and 54%, respectively. Despite this fact, fewer than one‐half of the respondents reported feeling confident about either the risks of a pandemic or how to protect themselves and their patients. This finding did not vary significantly across clinical groups (Table 2). Of the 256 HCWs, 136 (53%) reported only minimal knowledge of the risks of and protective strategies for an influenza pandemic (Table 2). Increased levels of knowledge were found to translate into significant differences between HCWs with regard to the degree of confidence regarding protection during an influenza pandemic; 27 (66%) of the 41 HCWs who reported having extensive knowledge about pandemic influenza also expressed confidence in their ability to protect themselves and their patients, and only 31 (23%) of the 136 HCWs who reported having minimal knowledge expressed the same confidence (
). There was no difference between hospitals in the proportion of HCWs who expressed confidence in knowing either the risks of an influenza pandemic (46% of HCWs at Johns Hopkins Hospital vs 52% of HCWs at Johns Hopkins Bayview Medical Center; 
) or how to protect themselves (41% of HCWs at Johns Hopkins Hospital vs 41% of HCWs at Johns Hopkins Bayview Medical Center; 
).
Factors Influencing Likelihood of Reporting to Work during a Pandemic
Overall, 21% of critical care HCWs reported that they were either unsure about whether they would come to work during a pandemic or were unlikely to do so. There were no differences between HCWs in their likelihood of reporting to work, based on job title, hospital affiliation, or the respondent’s degree of confidence in their knowledge of how to protect themselves (Table 3). Analysis of likelihood of reporting to work based on race revealed that a significantly larger proportion of African American respondents (31%) were unlikely to come to work than were whites (12%) and Asians (14%) (
). This difference was not explained either by differences in knowledge about risks or ability to protect oneself. Multivariable modeling for the odds of being unsure or unlikely to report to work during a pandemic revealed that only race and being a primary caregiver for children or adults were significant predictors (Table 4).
In an effort to better understand what protective measures might influence an HCW's decision to come to work during a pandemic, respondents were asked about the importance of vaccine, antiviral prophylaxis, or protective masks provided by the hospital for themselves and/or their families: 76% of respondents felt that the provision of a vaccine for themselves and their families would influence their decision, 70% reported that antiviral prophylaxis would be important; but only 50% indicated that the availability of protective masks for use at home would influence their decision to come to work. When comparing groups who were likely to report to work, not likely to report to work, or unsure, there were no significant differences in the proportion of respondents who thought these 3 protective measures would impact their likelihood of coming to work.
Discussion
A major concern with an influenza pandemic is that critical care HCWs will not work because they feel at risk, unprotected, or ill equipped.15 Our multiprofessional survey supports this contention and found major gaps in HCWs' knowledge of the risks of and protective strategies for an influenza pandemic, despite a relatively high expected probability of a pandemic in the next 1–10 years. Our survey, which had a high overall response rate of 88% and included clinicians practicing at 2 different healthcare institutions, revealed that, although the median expected probability of an influenza pandemic in the next 5–10 years is 45%–50%, approximately one‐half of all respondents lacked confidence in either their knowledge about the risks involved or their ability to protect themselves. Furthermore, despite the fact that those groups of HCWs reporting greater knowledge about an influenza pandemic appeared to believe that a pandemic is less likely than those with less knowledge, the groups with greater knowledge did not have greater confidence in their understanding of the risks involved or self‐protective strategies available.
Although previous studies have suggested that as few as 48% of HCWs may be willing to report to work in the event of an infectious disease outbreak,3 to our knowledge, no study has specifically assessed the willingness of critical care HCWs to respond. A study of public health workers by Balicer et al4 suggested that clinical staff would be more likely to report to work than nonclinical staff, but that study also suggested that as many as 50% of those surveyed would be unwilling to work. In light of these findings, our finding that only 21% of those surveyed were either unsure about whether they would report to work or were unlikely to do so could be considered reassuring.
However, we believe that our findings are a cause for particular concern. Estimates of the potential numbers of critically ill patients during an influenza pandemic are crude at best. Nevertheless, even conservative estimates suggest that demand for critical care services will rapidly outstrip current US critical care capacity. Given that workforce shortages are commonplace across the spectrum of critical care workers at baseline,16‐20 even a 20% decrease in the number of available HCWs would likely cripple ongoing clinical operations.
This problem will likely be further compounded by the finding that only one‐half of those surveyed reported confidence in their knowledge of the risks of an influenza pandemic, and even fewer indicated confidence in their ability to protect themselves. Data collected during the global outbreak of severe acute respiratory syndrome and from other experiences suggest that the risk of secondary transmission of respiratory viruses may be particularly high in the ICU.7‐11,21 Strikingly, however, those critical care HCWs in our study who reported high likelihood of reporting to work during a pandemic were no more likely to report confidence in their ability to protect themselves and their patients. This suggests that even those who are willing to work may be posing unnecessary risks to themselves and their patients. If as many as one‐half of those working in ICUs lack the knowledge to protect themselves, secondary infection of HCWs is likely to further threaten the stability of the critical care workforce during a pandemic.
Finally, to our knowledge, previous studies evaluating HCWs' willingness to report for work during a pandemic have not evaluated the influence of race on HCWs' attitudes.3‐5,22 Our data suggest that the odds of reporting to work are significantly lower for African American HCWs than for white HCWs. Previous studies have shown that African American patients are less likely than white patients to trust healthcare institutions and providers,23,24 and we speculate that our finding may reflect similar feelings of mistrust among African American HCWs regarding the ability of their employers to protect them in the event of a pandemic. This question was not specifically explored in our survey and warrants further investigation.
Although a high proportion of those surveyed completed and returned the measure (ie, 256 [88%] of 292 HCWs), the distribution of the survey was limited to HCWs who attended regularly scheduled business and educational meetings. Although it is likely that attendance at meetings was dictated more by work schedules than by systematic differences between those who attended the meetings and those who did not, nonresponse or selection bias cannot be ruled out. Furthermore, our study was conducted at only 2 hospitals (which share faculty and fellows), and our study only included medical and cardiac ICUs. The generalizability of our findings to nonteaching hospitals and surgical ICUs remains uncertain. An investigation using a multicenter survey that includes different types of ICUs is needed to further elucidate barriers to pandemic preparedness among critical care clinicians. Finally, our outcome of likelihood of reporting to work was measured by self‐report, which may have under‐ or overestimated true behavior, as previously discussed.
In summary, more than 20% of critical care HCWs are either unsure whether they will report to work during a pandemic or unlikely to do so. We observed significant gaps in knowledge about risks of an influenza pandemic and the measures needed to decrease risk of infection among all ICU HCWs, with only 40% expressing confidence in their knowledge of how to protect themselves. For the majority of respondents, the sources of knowledge about an influenza pandemic were largely the popular media, rather than the scientific literature or systematic education, with 60% of respondents reporting only minimal knowledge about the risks of an influenza pandemic and the appropriate self‐protective responses available. Critical care HCWs may be at substantial risk of developing and/or transmitting nosocomial influenza infection in the event of a pandemic. In order to have an appreciable impact on the safety of patients and the stability of the critical care workforce in the event of a pandemic, systematic efforts must be made to improve HCWs' understanding of pandemic influenza risks and protective strategies.
Acknowledgements
We thank all the staff members who participated in our survey, Dr Jonathan M. Zenilman, and Dr Peter B. Terry, who assisted with manuscript review and revision.
Financial support. This study was supported by the Johns Hopkins Center for Innovative Medicine, Mr Charles Salisbury, and the Salisbury Family Foundation.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
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