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Healthcare Workers' Attitudes Toward Patients With Ebola Virus Disease In The United States

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Background. We assessed healthcare workers' (HCWs) attitudes toward care of patients with Ebola virus disease (EVD). Methods. We provided a self-administered questionnaire-based cross-sectional study of HCWs at 2 urban hospitals. Results. Of 428 HCWs surveyed, 25.1% believed it was ethical to refuse care to patients with EVD; 25.9% were unwilling to provide care to them. In a multivariate analysis, female gender (32.9% vs 11.9%; odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4–7.7), nursing profession (43.6% vs 12.8%; OR, 2.7; 95% CI, 1.4–5.2), ethical beliefs about refusing care to patients with EVD (39.1% vs 21.3%; OR, 3.71; 95% CI, 2.0–7.0), and increased concern about putting family, friends, and coworkers at risk (28.2% vs 0%; P = .003; OR, 11.1) were independent predictors of unwillingness to care for patients with EVD. Although beliefs about the ethics of refusing care were independently associated with willingness to care for patients with EVD, 21.3% of those who thought it was unethical to refuse care would be unwilling to care for patients with EVD. Healthcare workers in our study had concerns about potentially exposing their families and friends to EVD (90%), which was out of proportion to their degree of concern for personal risk (16.8%). Conclusion. Healthcare workers' willingness to care for patients with Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, although they were strongly influenced by those beliefs. Healthcare workers may be balancing ethical beliefs about patient care with beliefs about risks entailed in rendering care and consequent risks to their families. Providing a safe work environment and measures to reduce risks to family, perhaps by arranging child care or providing temporary quarters, may help alleviate HCW's concerns.
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Healthcare Workers’ Attitudes Toward Patients With Ebola Virus Disease In
The United States
Deepa Maheswari Narasimhulu
1
, Vernee Edwards
1
, Cynthia Chazotte
2
, Devika Bhatt
1
,
Jeremy Weedon
3
, and Howard Minkoff
1
1
Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, USA
2
Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College
of Medicine, Bronx, USA
3
Statistical Design and Analysis, Research Division, State University of New York,
Brooklyn, USA
Corresponding author: Deepa M Narasimhulu, MD 967, 48th Street, Brooklyn, NY 11219
Ph: 718-283-7973, Fax: 718-283-8468, Email: drdeepamaheswari@gmail.com
Alternate corresponding author: Vermee Edwards, MD, 967, 48th Street, Brooklyn, NY 11219
Ph: 718-283-7973, Fax: 718-283-8468, Email: vedwards@maimonidesmed.org
Article Summary: Healthcare worker’s willingness to care for Ebola patients did not precisely
mirror their beliefs about the ethics of refusing to provide care, they were strongly influenced by
concerns about potentially exposing families and friends to Ebola virus disease.
Open Forum Infectious Diseases Advance Access published December 21, 2015
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Abstract
Background. We assessed health care workers’ (HCWs’) attitudes toward care of patients with
Ebola-virus disease (EVD).
Methods . A self-administered questionnaire-based cross-sectional study of HCWs at two urban
hospitals.
Results. Of 428HCWs surveyed, 25.1% believed it was ethical to refuse care to EVD-patients;
25.9% were unwilling to provide care to them. In a multivariate analysis, female gender (32.9%
vs 11.9%, OR:3.2, 95%CI:1.4-7.7), nursing profession (43.6% vs 12.8%, OR:2.7, 95%CI:1.4-
5.2), ethical beliefs about refusing care to EVD-patients (39.1% vs 21.3%, OR:3.71, 95%CI:2.0-
7.0) and increased concern about putting family, friends and coworkers at risk (28.2% vs 0%,
P=0.003, OR:11.1) were independent predictors of unwillingness to care for EVD-patients.
Although beliefs about the ethics of refusing care were independently associated with
willingness to care for EVD-patients, 21.3% of those who thought it was unethical to refuse care
would be unwilling to care for EVD-patients. HCWs in our study had concerns about potentially
exposing their families and friends to EVD (90%), which was out of proportion to their degree of
concern for personal risk (16.8%).
Conclusion. HCWs’ willingness to care for Ebola patients did not precisely mirror their beliefs
about the ethics of refusing to provide care, although they were strongly influenced by those
beliefs. HCWs may be balancing ethical beliefs about patient care with beliefs about risks
entailed in rendering care, and consequent risks to their families. Providing a safe work
environment and measures to reduce risks to family, perhaps by arranging child care or
providing temporary quarters may help alleviate HCW’s concerns.
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Introduction:
The public’s reaction to the threat of Ebola virus mirrored that of the Human
immunodeficiency virus /Acquired immunodeficiency syndrome (HIV/AIDS) epidemic when it
first surfaced. Similar to Ebola virus, there were no effective management options when HIV
first emerged, and both diseases had poor prognoses. Since healthcare facilities provide care to
patients during any epidemic, healthcare workers (HCW) are at increased risk of contracting
infection, and not all healthcare workers have willingly accepted that obligation. In fact, during
the 1980s, there were many publicized examples of providers distancing themselves from AIDS
patients, leading the surgeon general to publically assail those who were refusing to provide care
and denouncing them as a ''fearful and irrational minority'' who were guilty of ''unprofessional
conduct.'' It was during that period that the highly sensitive issues of law, ethics, morality and
social cohesion came to the fore. In 1988, a seminal article was published reporting the degree to
which physicians felt that it would be ethical to deny care to patients with AIDS [1]. Slightly
more than a quarter of a century later, in the fall of 2014, the world’s attention turned to Ebola,
and a level of concern similar to that which had been seen in regard to AIDS in the pre-HAART
era could again be seen in the lay press [2-4]. Not as much attention has been paid to whether
physicians attitudes towards Ebola mirror those of physicians in the 1980s in regard to AIDS.
The biology and epidemiology of Ebola virus disease (EVD) have become increasingly
well understood. Once infection is established in humans, Ebola virus can be transmitted person-
to-person by direct contact of skin or mucous membranes with blood or body fluids of infected
patients, contaminated objects (e.g. needles), or the bodies of individuals who died with Ebola
virus disease. Of note, Ebola virus does not appear to spread by airborne route in the endemic
setting, and infected individuals are only capable of disease transmission after the development
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of symptoms. Despite this enhanced understanding, there are still concerns about the health risks
posed to contacts of patients infected with Ebola, including threats to health care workers
(HCWs). The infection of health care workers in Texas who provided care to the first Ebola
patient in the US fueled that concern [5, 6]. Of the four cases of Ebola diagnosed in the United
States, only two were acquired by transmission within the United States. Both cases were nurses
(Diagnosed on October 10
th
, 2014 and October 15
th
, 2014 respectively) who cared for the first
case of Ebola (Diagnosed on September 30
th
, 2014) in the United States, a man who had traveled
to Dallas, Texas from Liberia. The fourth and last case in the United States (Diagnosed October
23
rd
, 2014) was also a medical aid worker who had returned to New York City from Guinea,
after serving with Doctors Without Borders. In the wake of those cases a massive training
program, and the organization of a triage system among hospitals was undertaken in the United
States.
Despite (or perhaps, ironically, because of) those efforts, anxiety about the Ebola
epidemic may be prevalent among HCW. However, despite a rich literature regarding
physicians concerns about HIV written during the 1980s, only limited assessments of HCWs
attitudes towards Ebola have been published. One recent study was written before any cases
were reported in the U.S., and focused primarily on HCWs’ knowledge and exclusively on
pediatric providers [7]. Any hesitancy by HCWs in general to render care to patients with Ebola
would have both ethical and public health consequences. Therefore we assessed HCWs’ attitudes
toward the care of Ebola-virus infected patients. To do so we used an approach similar to one
that had been used in one of the key studies from the 1980s that assessed attitudes of health care
providers towards AIDS patients, and conducted surveys using self-administered questionnaires
at two hospitals; one that was a designated Ebola center and one that was not. The former
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hospital was also one of the sites of the earlier study by Link et al [1] on attitudes towards care of
AIDS patients.
Methods:
After approval by our Institutional Review Board (IRB), a self-administered,
questionnaire-based study was performed to assess HCWs’ willingness to care for Ebola
patients, their concerns about acquiring Ebola from their patients, and their ethical beliefs
regarding refusal to render care to such patients. The study was carried out at two sites in New
York City between December 2014 and April 2015. The survey was anonymous and consisted of
15 multiple choice questions that included information on demographics, occupation, willingness
to care for Ebola patients, and respondents perspective on the healthcare system’s level of
readiness. There were also questions asking if the respondents thought it was ethical to refuse
care to Ebola patients and to patients with HIV/AIDS. Finally there were two brief vignettes to
assess the participants’ willingness to intervene as healthcare providers, outside of the hospital,
to help individuals found bleeding on the street, one of whom wore a tee shirt that said “Proud to
be a Liberian.” We piloted the questionnaire on 10 subjects to make sure that it was
understandable and not burdensome in terms of time. No changes were necessary based on the
feedback and no surveys from the pilot were included in the analysis. The average time to
complete the survey during the pilot was four minutes. The questionnaire was administered by
two of the authors (DMN, DB) to healthcare providers (physicians, residents, medical students,
physician assistants, registered nurses and midwifes) who filled it out in private, and then
returned it to the authors. We recruited HCWs from various departments (Internal Medicine,
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Emergency Medicine, Obstetrics and Gynecology) practicing in varied settings (Emergency
rooms, Inpatient floors, Outpatient clinics, Labor floor).
The study was designed as a cross sectional study to be conducted at both hospitals
simultaneously, but due to local IRB clearance and administrative delays, recruitment at hospital
B occurred more frequently in the latter portion of the recruitment period. Since it is possible
that attitudes might have evolved over time, as concerns about the Ebola epidemic waned, we
considered time of administration of the survey as a confounder in the analysis.
We hypothesized that the proportion of HCWs who would be unwilling to care for Ebola
patients would be the same as the proportion of HCW unwilling to care for patients with
HIV/AIDS in the 1980’s (25%). Given a projected prevalence of 25%, for a 95% 2-sided
confidence interval around that estimate with a width of plus or minus 5 percentage points, the
required sample size was 289 participants. Since we also wanted to consider time as a
confounder we recruited in excess of this number.
Standard descriptive statistics were used to describe the data. Two-way frequency tables
were generated to gauge strength of association of Ebola care outcomes (ethical beliefs and
willingness to provide care for Ebola patients) with demographics and other predictors.
Associations of apparent interest in these tables were selected for further examination using
regression modeling: Multiple logistic regression was used to predict each (dichotomized) care
outcome in a separate model. Details on the variables used in each logistic regression model and
dichotomization of the variables are described in the tables. Likelihood ratio (LR) test p-values
for type III analyses and adjusted odds ratios (AORs) with confidence intervals (CIs) for
regression parameter estimates significant at p<0.05 are reported. McNemar tests were used to
compare prevalence of ethical beliefs on refusing care to EVD as compared to HIV patients, and
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to compare the extent to which HCWs were willing to help individuals found bleeding on the
street, one of whom wore a tee shirt that saidProud to be a Liberian”.
Results:
Of 514 HCWs approached for participation, 428 (83.3%) completed the survey; their
demographics are shown in Table 1. The mean age of the participants was 39.9 years (SD 12.1),
most were female (68.2%) and most lived with family (73.8%). Nurses comprised the largest
group surveyed (41.2%) followed by attending physicians (31.8%). The HCWs perspectives on
Ebola are shown in Table 2. One fourth of the participants (25.1%) believed that it was ethical to
refuse to care for Ebola patients, and a similar proportion (25.9%) were “somewhat” or “very
unwilling” to provide care for a patient with Ebola. For patients with HIV/AIDs, 12.6% of
participants thought it was ethical to refuse care, which was significantly less than the proportion
of participants who thought that it was ethical to refuse care to EVD patients (P<0.001).
Only 44.1% of participants felt that their hospital was well equipped to take care of
patients with Ebola. 16.8% of HCWs worried “quite oftenor “all the time” about contracting
Ebola from a patient, and 21.3% felt that concern about acquiring Ebola as a result of patient
care had added to their stress level “quite a bit” or “a lot.” If they had provided care to a patient
with Ebola, 90.8% of participants would be “somewhat” or “very concerned” about putting their
family, friends and coworkers at risk of Ebola even if they (the HCW) were asymptomatic.
43.9% of participants would help a young boy found bleeding on the street despite not having
any protective equipment, but only 30% would help a man in a similar situation if he were
wearing a tee shirt that said “Proud to be a Liberian.This difference was statistically significant
(P< 0.001).
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In a multivariate analysis, female gender (32.9% vs 11.9%, OR:3.2, 95%CI:1.4-7.7),
nursing profession (43.6% vs 12.8%, OR:2.7, 95%CI:1.4-5.2), ethical beliefs about refusing care
to EVD patients (39.1% vs 21.3%, OR:3.71, 95%CI:2.0-7.0) and increased concern about putting
family, friends and coworkers at risk (28.2% vs 0%, P=0.003, OR:11.1) were independent
predictors of unwillingness to care for Ebola patients (Table 3). Although beliefs about the ethics
of refusing care were independently associated with willingness to care for Ebola patients, 41.9%
of those who thought it was ethical to refuse care would still be willing to care for Ebola patients
while 21.3% of those who thought it was unethical to refuse care would be unwilling to do so
(Figure 1). We did not find any variables that independently predicted beliefs about whether it is
ethical to refuse to care for Ebola patients (Table 4).
Female gender (60.9% vs 44.8%, OR:1.6, 95%CI: 1.012.6) and increased concern about
contracting Ebola (76.1% vs 52%, OR 2.7, 95 CI:1.4-5) were also independently associated with
unwillingness to help a bleeding young boy without protective equipment, while concern about
putting family, friends and coworkers at risk (71.9% vs 50%, OR:2.2, 95%CI:1.08-4.5) was the
only predictor independently associated with unwillingness to help a man in a similar situation
when he was wearing a tee shirt that saidProud to be a Liberian.
Discussion:
With a record number of health care workers affected in the 2014 Ebola epidemic in
West Africa, and the failure of personal protective equipment in Dallas leading to EVD in a
healthcare worker, there has been increased concern among HCWs in the US about their
personal safety while treating Ebola patients. Indeed when the first Ebola patient in New York
was admitted to Bellevue hospital, an extra-ordinary number of its staff called out sick; one of
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the nurses went so far as to pretend she had a stroke [8, 9]. We have found, in a survey of 428
HCWs in large urban hospitals, that one fourth of HCWs were unwilling to care for Ebola
patients, and a similar proportion believed that it was ethical to refuse to care for EVD patients.
This is comparable to what was seen with HIV in the 1980s in the study by Link et al, in which
25% of HCWs would not continue to care for AIDS patients if given a choice and 24% believed
that it was ethical to refuse care to patients with HIV/AIDS. Almost three decades later, with
increased knowledge and improved prognosis for HIV patients after the advent of HAART, only
12.6% of HCWs in our study believed that it was ethical to refuse care to patients with
HIV/AIDS. As knowledge of the pathophysiology and epidemiology of EVD and its
implications for healthcare providers become more widely disseminated, it is hoped that a similar
evolution may take place for EVD.
Our findings are in concert with and extend those reported by Highsmith et al who found,
in a survey of 245 pediatric HCWs at a single institute, that only 80% of participants were
willing to examine EVD patients, and 64-79% were willing to perform procedures on them [7].
That survey was conducted before the first documented case of EVD was reported in the United
States and the factors that influenced the pediatricians unwillingness to care for EVD patients
were not explored. The study focused mainly on HCWs’ knowledge of Ebola transmission and
epidemiology, and found that the knowledge scores were poor (56%).
A question that arises in light of those findings and ours is, what are physicians’
obligations to society to care for patients with Ebola virus disease, and, pari passu, what are
society’s obligations to physicians? The question of whether there is a duty to treat even when
providing care puts the HCW at risk has been addressed by professional organizations whose
guidelines suggest that while there is a professional obligation, it is not absolute [10]. The
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American Medical Association Code of Ethics states that “Because of their commitment to care
for the sick and injured, individual physicians have an obligation to provide urgent medical care
during disasters. This ethical obligation holds even in the face of greater than usual risks to their
own safety, health or life. The physician workforce, however, is not an unlimited resource;
therefore, when participating in disaster responses, physicians should balance immediate benefits
to individual patients with ability to care for patients in the future [11].” It could be argued that
society also has an obligation to provide a safe work environment, and to make arrangements to
adequately care for and compensate healthcare workers who become infected in the course of
duty. Less than half of the participants in our study believed that their institution was well
equipped to take care of Ebola patients. HCWs’ concerns about acquiring Ebola are exacerbated
by concerns regarding their options if they were to get infected while treating an Ebola patient
and if, for example, they wanted to get short-term life insurance [12].
We found that while beliefs about the ethics of refusing care were independently
associated with willingness to care for Ebola patients, 41.9% of those who thought it was ethical
to refuse care would still be willing to care for Ebola patients while 21.3% of those who thought
it was unethical to refuse care would be unwilling to care for Ebola patients (Figure). In other
words, beliefs about the “right thing to dodo not always determine what people are willing to
do. Less knowledge about the disease is one possible explanation of why nurses were more likely
to be unwilling to care for Ebola patients than physicians. In a survey of pediatric HCWs
performed before the first case of Ebola was diagnosed in the U.S, knowledge scores about
Ebola were higher among those willing to care for patients with Ebola, and physicians scored
higher than non-physicians [7]. In regard to HCWs reticence to render assistance outside the
hospital, it is possible that it reflects more than just fears about Ebola since concerns about other
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infection such as HIV and HCV, particularly when personal protective equipment is not
available, are certainly reasonable. However we did see an even greater reticence when the
individual needing assistance wore a tee-shirt identifying himself as Liberian, suggesting both
that profiling may be at play, and, given that his infection status was unknown, that a person
need not be infected with Ebola to receive lesser care because of it.
In a study of attitudes towards patients with HIV, published a quarter century ago, the
authors called for greater education about HIV [1]. Our data suggest that concerns voiced about
HIV are not sui generis, and that each generation may have to confront their own fears about the
risks inherent in the practice of medicine. Some teaching therefore may need to go beyond the
unique biology, and infection control necessities associated with a given infectious agent, and
instead focus on the broader issue of the ethical responsibilities, and limits thereupon, of
physicians in the face of epidemics. There also is a need for institutions to demonstrate concerns
about their employees, and take steps to minimize risks. If the word “Ebola” was substituted for
the word AIDS” then a quote from a1980s article [1] would have direct resonance today; “It is
important for hospital and residency program administrators to realize that concerns about
personal risk may continue to prevail among health workers caring for AIDS patients, and that
these concerns not only have a significant impact upon their personal and professional lives, but
may detract from the medical care available to AIDS patients at a time when increasing medical
resources will be required.”
HCWs in our study were particularly concerned about potentially exposing their families
and friends to EVD (90%), and this was out of proportion to their degree of concern for personal
risk (16.8%). In fact, concern about exposing family and friends had the highest odds ratio (11.1)
among the predictors of unwillingness to care for Ebola patients. Female HCWs, who may be
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more likely to be primary care providers for their family, were also more likely to be unwilling to
care for Ebola patients. While the CDC recommends that pregnant HCWs not care for patients
with EVD, there are no recommendations for female HCW who may be breast feeding or caring
for infants or young children at home. HCWs may feel themselves torn between their ethical
beliefs and duty towards their patients on one hand, and moral obligations and responsibility to
their family on the other. It is therefore in the public interest to find the means to make it possible
for HCW to care for patients without abandoning their responsibility to their families, perhaps by
providing workers with child care assistance, and providing temporary living quarters to reduce
the risk of disease transmission to family members as well as insurance to protect them and their
families should they become ill.
Our study has limitations. The survey was conducted in two hospitals in New York City
and our findings may not be applicable to American HCWs in general. However, to our
knowledge, this was the first study focused on Ebola perspectives of HCW after documented
transmission of Ebola within the US. While we did not find any variables that independently
predicted beliefs about whether it is ethical to refuse to care for Ebola patients, we did not collect
information on all potentially important predictors including factors such as religious beliefs and
the psychological profile of the participants. While the study on HIV by Link et al [1] is similar
to our study on Ebola in many respects, there are some important differences. Our study included
a range of healthcare workers while the study on HIV included only physicians. Our decision to
include non-physician Healthcare workers was based on the fact that both health care workers
who acquired Ebola within the United States were nurses who cared for the first Ebola patient in
Dallas. In addition, the pre-HAART HIV/AIDS era impacted the United States to a much greater
degree than Ebola in terms of the number of patients seeking treatment and the number of
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facilities offering treatment. Our study also has several strengths; apart from the fact that we
focused on a unique and relevant public health concern, we recruited HCW from various
departments practicing in varied settings. We also recruited HCWs representative of the different
components of the healthcare workforce including attending physicians, resident physicians, and
nurses.
In sum, we have found that the response of HCWs to Ebola in the 21
st
century is similar
to that of HCWs in the 1980s to HIV/AIDS. The attitude of HCW towards HIV/AIDS has
evolved in the last three decades and a similar evolution may take place with EVD. HCWs’
willingness to care for Ebola patients did not precisely mirror their beliefs regarding whether it
would be ethical to refuse to care for those patients, although they were linked. HCWs seem to
be balancing their ethical beliefs about patient care with their beliefs about the risks entailed in
rendering that care and consequent risks to their families.
Funding: This work was supported by a research grant from the US National Institutes of Health
(Howard Minkoff: NIH AIU0131834).
Conflict of interest: The authors report no conflict of interest.
Acknowledgements: The study was supported by a research grant from the US National
Institutes of Health (Howard Minkoff: NIH AIU0131834).
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References:
1. Link RN, Feingold AR, Charap MH, Freeman K, Shelov SP. Concerns of medical and
pediatric house officers about acquiring AIDS from their patients. Am J Public Health. 1988
Apr;78(4):455-9.
2. Wagner M. 'A plague like no other': Americans panic over first U.S.-diagnosed Ebola patient.
Daily News. Available at http://www.nydailynews.com/life-style/health/americans-panic-u-s-
diagnosed-ebola-patient-article-1.1959147 Published October 1, 2014. Accessed June 5,
2015.
3. Petri A. Ebola? Here? Panic! Panic more! The Washington post. Available at
http://www.washingtonpost.com/blogs/compost/wp/2014/10/02/ebola-here-panic-panic-
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Huffington Post. Available at http://www.huffingtonpost.com/2014/10/21/ebola-panic-
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5. Yan H. American nurse with protective gear gets Ebola - how could this happen? CNN.
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happen/index.html Published October 14, 2014. Accessed June 5, 2015.
6. Texas Nurse Says Hospital Should Be 'Ashamed' of Ebola Response. ABC News. Available
at http://abcnews.go.com/Health/texas-nurse-hospital-ashamed-ebola-
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Among Pediatric Providers Before the First Diagnosed Case in the United States. Pediatr
Infect Dis J. 2015 May 26.
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8. Schram J, Celona L. Bellevue staffers call in “sick” after Ebola arrives. New York Post.
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9. Fox News. Hospital staffers reportedly take sick day rather than treat New York’s first Ebola
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Tables:
Table 1: Demographics
Demographics
No. (%)
Age
39.9 (12.1)
a
Gender
Male
135 (31.8)
Female
289 (68.2)
Current status
Attending physician
133 (31.8)
Resident physician
93 (22.2)
Nurse
172 (41.2)
Others
20 (4.8)
Department
Internal medicine
121(29)
Obstetrics and Gynecology
168 (40.3)
Emergency Medicine
128 (30.7)
Living situation
Not living with family
112 (26.2)
With family- no children
106 (24.8)
With family- with children
209 (49)
Time of survey
Initial surveys: Till the end of 2014
162 (37.8)
Later surveys: After the beginning of 2015
266 (62.2)
Hospital
Hospital A
283 (66.1)
Hospital B
145 (33.9)
a
Mean (SD)
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Table 2: Healthcare workers perspectives on EVD
Healthcare workers perspectives on Ebola
No. (%)
Think that the healthcare system in your hospital well equipped to deal with Ebola
174 (44.1)
How often have you worried about contracting Ebola from a patient?
Never/ Once in a while
353 (83.2)
Quite often/ All the time
71 (16.8)
Has the concern of acquiring Ebola as a result of patient care added to your stress level?
Not at all/ Very little
333 (78.7)
Quite a bit/ A lot
90 (21.3)
If you had provided care to a patient with Ebola yesterday and you were currently
asymptomatic, how concerned would you be that you would put your family/ friends/
coworkers at risk of Ebola?
Not at all concerned
39 (9.2)
Somewhat/ Very concerned
387 (90.8)
How willing would you be to provide care for a patient with Ebola if the care required by
the patient is in your field of expertise?
Always/ somewhat willing to treat
240 (56.1)
Neutral
77 (18)
Somewhat/ very unwilling to treat
111 (25.9)
Think it is ethical to refuse to provide care for Ebola patients.
105 (25.1)
Think it is ethical to refuse to provide care for patients with HIV/AIDS.
53 (12.6)
Agree with a mandated quarantine of asymptomatic health care workers returning from
West Africa.
276 (66.7)
Agree with a mandated quarantine of asymptomatic health care workers caring for Ebola
patients in the US.
250 (59.8)
Will help a young boy lying on the street, unconscious & bleeding by compressing the
bleeding area with your bare hands (no protective equipment).
183 (43.9)
Will help a middle aged man wearing a T-shirt that saidproud to be a Liberian” lying on
the street, unconscious & bleeding by compressing the bleeding area with your bare
hands (no protective equipment).
124 (30)
EVD: Ebola virus disease, HIV/AIDS: Human immunodeficiency virus/ Acquired
immunodeficiency syndrome.
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Table 3: Multivariate analysis, Unwillingness to care for EVD versus demographics
No. (%)
P Value, AOR (95% CI)
Age
40.4 (11.2)
a
Gender
c
Female
95 (32.9)
P = 0.004, OR: 3.2 (1.4 - 7.7)
Male
16 (11.9)
Current status
c
Nurse
75 (43.6)
P = 0.002, OR: 2.7 (1.4 - 5.2)
Physicians (Attending and Resident physicians)
29 (12.8)
Department
Internal medicine
24 (19.8)
Obstetrics and Gynecology
51 (30.4)
Emergency Medicine
31 (24.2)
Living situation
c
Not with family
17 (15.2)
P = 0.064
With family- no children
23 (21.7)
With family- with children
71 (34)
Hospital equipped to deal with Ebola
c
Yes
30 (17.2)
P = 0.091
No
70 (31.7)
Worried about contracting Ebola
c
Never/ Once in a while
80 (22.7)
P = 0.860
Quite often/ All the time
28 (39.4)
Concern about putting family/ friends/ coworkers at risk
c
Somewhat/ Very concerned
109 (28.2)
P = 0.003, OR: 11.1
b
Not at all concerned
0 (0)
Ethical to refuse care for Ebola
c
Yes
41 (39.1)
P <0.001, OR: 3.7 (2.0 7.0)
No
67 (21.3)
Ethical to refuse care for HIV/AIDS
Yes
17 (32.1)
No
89 (24.3)
Time of survey
Initial: Till the end of 2014
47 (29)
Later: After the beginning of 2015
64 (24.1)
Hospital
Hospital A
81 (28.6)
Hospital B
30 (20.7)
a
Mean (SD).
b
CI not reported due to sampling zero.
c
Variables included in the logistic regression.
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Variables with more than two responses have been dichotomized as follows in the logistic
regression:
- Living situation: With children Vs Not with family/ With family- no children.
- Worried about contracting Ebola: Never/ Once in a while Vs Quite often/ All the time.
- Concern about putting family/ friends/ coworkers at risk: Somewhat/ Very concerned
Vs Not at all concerned.
The P values are provided for all variables used in the logistic regression, odds ratio and
confidence intervals are provided only when the P values were significant
EVD: Ebola virus disease, HIV/AIDS: Human immunodeficiency virus/ Acquired
immunodeficiency syndrome.
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Table 4: Multivariate analysis, Ethical to refuse care for EVD versus demographics
Ethical to refuse care for EVD
No. (%)
P Value
Age
38 (11.1)
a
Gender
Male
30 (22.4)
Female
75 (26.6)
Current status
c
Nurse
50 (29.9)
P = 0.994
Physicians (Attending and Resident physicians)
51 (22.9)
Department
Internal medicine
22 (18.6)
Obstetrics and Gynecology
42 (25.5)
Emergency Medicine
39 (30.7)
Living situation
Not with family
28 (26.2)
With family- no children
25 (24.3)
With family- with children
51 (24.8)
Hospital equipped to deal with Ebola
Yes
40 (23.3)
No
54 (25.1)
Worried about contracting Ebola
c
Never/ Once in a while
77 (22.2)
P = 0.541
Quite often/ All the time
27 (39.7)
Concern about putting family/ friends/ coworkers at risk
c
Not at all concerned
7 (18.4)
P = 0.957
Somewhat/ very concerned
97 (25.6)
Ethical to refuse care for HIV
c
Yes
26 (49.1)
P = 0.352
No
77 (21.5)
Time of survey
Initial: Till the end of 2014
42 (26.3)
Later: After the beginning of 2015
63 (24.3)
Hospital
Hospital A
75 (27.1)
Hospital B
30 (21.1)
a
Mean (SD)
c
Variables included in the logistic regression.
Variables with more than two responses have been dichotomized as follows in the logistic
regression:
- Worried about contracting Ebola: Never/ Once in a while Vs Quite often/ All the time.
- Concern about putting family/ friends/ coworkers at risk: Somewhat/ Very concerned
Vs Not at all concerned.
by guest on February 2, 2016http://ofid.oxfordjournals.org/Downloaded from
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21
The P values are provided for all variables used in the logistic regression.
EVD: Ebola virus disease, HIV/AIDS: Human immunodeficiency virus/ Acquired
immunodeficiency syndrome.
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Figure Legend:
Relationship between ethical beliefs on refusal to care for Ebola virus disease patients and
unwillingness to care for them.
by guest on February 2, 2016http://ofid.oxfordjournals.org/Downloaded from
... In the prior Ebola epidemic, we had reported that a quarter of healthcare workers were unwilling to care for patients with Ebola, and that they believed that it was ethical to refuse to do so. 5 Link and colleagues reported similar findings even earlier in regard to the AIDS epidemic. 6 Our aim was to explore healthcare workers' attitudes towards patients infected with COVID-19 in two urban health centers in New York during the early months of the pandemic when personal protective equipment was not always readily available. ...
... The survey was anonymous and consisted of 16 multiple-choice questions, and was similar to a prior survey that we administered during the Ebola epidemic. 5 The first five questions concerned demographics, including the participant's age, gender, occupation, department, and living situation. ...
... During the beginning of two prior epidemics, 25% of healthcare workers thought it was ethical to refuse care to patients with AIDS 6 , and 25.1 % thought it was ethical to refuse care to patients with Ebola. 5 In our prior report, when simultaneously evaluating attitudes for Ebola and HIV, we found fewer workers (12.6%) who thought it was ethical to refuse care to patients with AIDS 5 , suggesting worker's attitudes can change likely due to the greater amount of knowledge about transmission and the increasing availability of treatment over time. However, despite a lack of knowledge about, and treatment for, SARS-CoV-2 infection, workers in the pandemic's epicenter were willing to provide care. ...
Article
Full-text available
Background Early in the SARS-CoV-2 pandemic, before the routine availability and/or use of personal protective equipment, healthcare workers were understandably concerned. Our aim was to explore healthcare workers’ attitudes towards patients infected with SARS-CoV-2 at the time of the nation’s first surge in two highly affected hospitals in New York. Methods We performed a cross-sectional, self-administered survey study of healthcare workers. The survey consisted of 17 multiple-choice questions including demographic information, ethics and willingness to care for patients with SARS-CoV-2 infection. Subgroup analyses were performed using Fisher’s exact test. Results Of 340 healthcare workers approached, 338 (99.4%) consented to the survey; 163 (48.7%) were registered nurses and 160 (48.3%) lived with children. While 326 (97.3%) workers were concerned about putting their family/coworkers at risk of infection after caring for a patient with SARS-CoV-2, only 30 (8.9%) were unwilling to treat a patient with SARS-CoV-2 infection. Registered nurses were more likely than other healthcare workers to think it was ethical to refuse care for SARS-CoV-2 infected patients, worried more often about contracting infection, and felt that SARS-CoV-2 added to their stress level (p=.009, p=.018, p<.001, respectively). A similar contrast was seen when comparing workers who live with children with those that did not. Conclusion Levels of stress and concern were extremely high. In spite of that, the overwhelming majority of workers were willing to treat patients with SARS-CoV-2 infection. Registered nurses and healthcare workers who live with children were more likely to think it is ethical to refuse care for SARS-CoV-2 infected patients.
... We screened 2,653 articles for eligibility ( Figure 1). Thirty-five articles reporting on 33 studies were included: 19 quantitative [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29], 9 qualitative [30][31][32][33][34][35][36][37][38], and 7 mixed methods studies [39][40][41][42][43][44][45]. Twenty-seven articles focused on EVD preparations [11-13, 15-29, 31, 33, 35-37, 39-41, 43], six articles reported EVD preparations and data based on the admission of suspected/confirmed EVD patients [14,30,32,34,42,45], and two Downloaded from https://academic.oup.com/cid/advance-article-abstract/doi/10.1093/cid/ciz757/5549092 by University of Iowa Libraries/Serials Acquisitions user on 20 August 2019 articles focused on HCWs experiences after caring for EVD patients [38,44]. ...
... Six articles were completed in later phases of the EVD preparation (March−December 2015) [15,17,19,32,34,43]. The remaining fifteen articles encompassed approximately one year of assessment between 2014-2015 [23,30,40], included initial and later phases of the EVD preparation [20,24], or evaluated the "2014 Ebola outbreak" [27,35,38,44,45] without listing specific dates [11,14,22,25,26]. One study evaluated preparedness maintenance after the end of the 2014-2016 EVD outbreak [45]. ...
... Preparedness activities were varied and, except for three articles [21,22,24], vaguely described. Six articles did not provide information on the preparation phase [12,16,20,25,26,32]. The most frequent strategy was the performance of simulations and/or drills, including training on PPE (n=22) [11,[14][15][16]18 [11,21,22,24,34,39] and laboratory diagnostics (n=1) [41] were rarely reported. ...
Article
The 2014–2016 Ebola epidemic in West Africa provided an opportunity to improve our response to highly infectious diseases. We performed a systematic literature review in PubMed, Cochrane Library, CINAHL, EMBASE, and Web of Science of research articles that evaluated benefits and challenges of hospital Ebola preparation in developed countries. We excluded studies performed in non-developed countries, and those limited to primary care settings, the public health sector, and pediatric populations. Thirty-five articles were included. Preparedness activities were beneficial for identifying gaps in hospital readiness. Training improved health-care workers’ (HCW) infection control practices and personal protective equipment (PPE) use. The biggest challenge was related to PPE, followed by problems with hospital infrastructure and resources. HCWs feared managing Ebola patients, affecting their willingness to care for them. Standardizing protocols, PPE types, and frequency of training and providing financial support will improve future preparedness. It is unclear whether preparations resulted in sustained improvements. Prospero Registration. CRD42018090988.
... mortality. Patient avoidance and refusal to offer care owing to fear of contracting infection have been previously reported among healthcare workers during the eras of Human immunodeficiency virus/acquired immunodeficiency viral and Ebola viral diseases (EVD), respectively [6,7]. Here, we present three cases that were confused for COVID-19 in a tertiary hospital in Ondo State, Nigeria, and management challenges. ...
... They gave excuses such as inadequate provisions made by the hospital management for the isolation and care of suspected cases among others. A similar report was documented in a study in the United States of America, where less than half of the participants believed that their institution was well equipped to take care of patients with Ebola [7]. Filippo Anelli, President of Italy's National Federation Order of Surgeons and Dentists, was quoted as saying, "Our doctors have been sent to war unarmed; it is reasonable to assume that these events would have been largely avoidable if health workers had been correctly informed and equipped with sufficient personal protective equipment which instead continues to be in short supply" [11]. ...
... This study is significant in that it has verified the effect of public sympathy in examining the government's response to infectious diseases. Many studies related to infectious disease management and its response have focused on the attitudes and perceptions of medical professionals rather than public awareness and sympathy [96][97][98]. In contrast, this study has verified the importance of public awareness and sympathy in future infectious disease management response by confirming the effect of public awareness and sympathy on infectious disease response behavior. ...
Article
Full-text available
Since the outbreak of the novel coronavirus disease (COVID-19), the government has provided infection-control guidelines to prevent the spread of the virus. The authors of this study examined the structure (causal relationship) of factors that influence public behavior toward COVID-19 and verified the effect of public empathy with infection-control guidelines in each structure. Data were collected using a self-administered questionnaire survey from 211 Korean adults. The results showed that (1) the perceived susceptibility and severity of economic damage had a positive effect on infection-prevention attitudes and infection-prevention attitudes had a positive effect on infection-prevention behaviors; (2) the perceived severity of economic damage had a positive effect on infection-prevention attitudes; and (3) public empathy with infection-control guidelines positively moderated the effect of the perceived severity of economic damage on infection-prevention behaviors and that of perceived susceptibility on infection-prevention attitudes. Accordingly, the authors of this study present the following three suggestions to prevent the spread of an infectious disease: engage in risk communication focused on a potential virus infection and cooperation, make multifaceted efforts to increase public empathy with infection-control guidelines, and implement measures to alleviate or reduce economic damage to the public in a viral pandemic.
... The present study identified gender, COVID-19-related education and education level as predictors of nursing intentions towards patients with COVID-19. Male nurses had significantly higher nursing intentions than did their female counterparts, consistent with previous reports regarding emerging infectious diseases (Lee & Kang, 2020) and Ebola (Narasimhulu et al., 2016). However, a previous study of frontline nurses providing care for COVID-19 patients (Eddieson Pasay-an, 2020) found that female nurses showed slightly higher nursing intentions, encompassing aversion to germs and concerns about infectibility compared with male nurses, although the difference was not statistically significant. ...
Article
Aim This cross‐sectional study, conducted from August to September 2020, examined nurses’ stress, self‐efficacy, and nursing intentions when caring for COVID‐19 patients and identified the predictors of nursing intentions during the pandemic. Background The COVID‐19 outbreak has increased nurses' role expectations and imposed a heavy social responsibility. In particular, frontline nurses are under significant stress when caring for patients during a novel epidemic because of the lack of accurate information. Methods A total of 232 nurses with experience in providing care for suspected or confirmed COVID‐19 patients from seven large hospitals in three cities in Korea completed the Perceived Stress Scale, Self‐Efficacy Scale, and Predictive Nursing Intention Scale. Results Multiple regression confirmed that completing COVID‐19‐related education and self‐efficacy were significant predictors of nursing intentions during the current pandemic; the regression model explained 22.0% of the variance in nursing intentions. Conclusion Stress did not affect frontline nurses' nursing intentions toward COVID‐19 patient care, but completing COVID‐19‐related education and higher self‐efficacy predicted improved nursing intentions. Implications for Nursing Management Nurse leaders should recognize that to improve nursing intentions during a novel infection outbreak, infection‐related education should be provided and strategies to improve self‐efficacy should be implemented.
... However, some studies suggest the contrary, as the increased risk of infection may cause some health workers to decline (6), with the result that the response faces the risk of workforce shortages especially when the scale of the outbreak is massive and patient volume increased, as is the case of the COVID-19 pandemic (7). In a survey of 428 New York health care workers on their willingness to care for Ebola viral disease (EVD) patients, 25.1% and 25.9% of respondents respectively believed it was ethical to refuse care and indicated unwillingness to provide care (8). In Ghana, only 27.8% of health workers interviewed on their perceived preparedness to manage COVID -19 considered themselves prepared (9). ...
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Full-text available
Objectives: The study aimed to investigate health workers' knowledge, self-preparedness and willingness to volunteer for outbreak response and perceived institutional readiness to manage confirmed or suspected cases of COVID-19. Methods: A cross-sectional study was carried out among 300 consenting healthcare workers in a COVID-19 treatment facility in Edo state, Nigeria. Data were collected between April and May 2020 using self-administered questionnaires. Analysis was done using Statistical Package for Social Sciences, with Chi-square test and logistic regression applied with a 95% confidence interval. All ethical considerations were met. Results: One hundred and seventeen (39.0%) respondents were willing to volunteer in the response, with respondents who were confident in their ability to suspect a case, communicate risk effectively and who believed the facility should be a treatment centre being 3.55, 2.07 and 2.30 times more likely to volunteer respectively (P< 0.001, P = 0.04 and P = 0.02 respectively). Two hundred and seven (69.0%) respondents felt the facility was ready to manage confirmed cases. Management commitment 255 (85.0%) was the factor acknowledged as most indicative that the facility was ready to handle cases, with availabiltiy of personal protective wears as the least mentioned 166 (55.3%). Conclusion: Many health workers who should be in the frontline were unwilling to volunteer to manage cases, though perceived facility readiness was high. Health managers should take steps to address identified barriers and provide conducive work environments.
... The most experienced clinicians available should make this assessment at triage; ▪ Non-maleficence: COVID-19 health services must keep to a minimum the risk of nosocomial SARS-CoV-2 infection for clinical and support staff. Proposed COVID-19 treatment services should not be pursued if this risk could (i) present staff with a dilemma between caring for patients and preserving their health, particularly when abstaining from care provision would result in loss of income or stigma [11]; (ii) cause unacceptable absenteeism, mortality or long-term disability among healthcare workers, particularly where such losses would leave serious, long-term gaps in non-COVID-19 health service delivery [12,13]; and/or (iii) propagate transmission within healthcare settings (e.g. to non-COVID-19 patients) to an extent likely to negate the clinical benefits of treatment. ▪ Justiceefficiency: Against finite resources, COVID-19 treatment services must be carefully balanced to not excessively withdraw resources from potentially more cost-effective interventions [14] to mitigate both the direct effects of the epidemic (such as nonpharmaceutical prevention) and its indirect effects due to disruption of essential routine health services; ▪ Justiceequity of resource allocation: If COVID-19 treatment service capacity is not sufficient to meet demand, it should be offered equitably, with priority attributed to patients who would be most likely to benefit from treatment or palliation. ...
Article
Full-text available
The COVID-19 pandemic has the potential to cause high morbidity and mortality in crisis-affected populations. Delivering COVID-19 treatment services in crisis settings will likely entail complex trade-offs between offering services of clinical benefit and minimising risks of nosocomial infection, while allocating resources appropriately and safeguarding other essential services. This paper outlines considerations for humanitarian actors planning COVID-19 treatment services where vaccination is not yet widely available. We suggest key decision-making considerations: allocation of resources to COVID-19 treatment services and the design of clinical services should be based on community preferences, likely opportunity costs, and a clearly articulated package of care across different health system levels. Moreover, appropriate service planning requires information on the expected COVID-19 burden and the resilience of the health system. We explore COVID-19 treatment service options at the patient level (diagnosis, management, location and level of treatment) and measures to reduce nosocomial transmission (cohorting patients, protecting healthcare workers). Lastly, we propose key indicators for monitoring COVID-19 health services.
... This means that there is no treatment available for Corona Virus. In the last two pandemics like Ebola (2014) and HIV (1980) (Source: Narasimhulu et al., 2015) we may see similar reactions now from health professionalsthey may refuse to provide care to these infected patients. It should be noted that government officials can still work from home without shutting their offices to keep economy going. ...
Negative Results
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Covid19 Analysis in Canadian Healthcare Context: People need to self isolate for 14 days. If people feel that they are getting worse than they need to seek medical attention. Being in self-isolation may be a lot longer than 14 days because we still do not know exactly how Covid19 works.
... Our result is in concert with earlier studies (Balami et al. 2016;Kim and Choi 2016;Narasimhulu et al. 2016) that reported the fear of being infected as a hindrance to the willingness to treat patients with EVD. The fear of unwillingness to respond to 14 patients with EVD is mirrored to other severe infectious diseases in which health workers perished (Simonds and Sokol 2009;Taylor, Rutkow, and Barnett 2014). ...
Article
Full-text available
There is an association between the perceptions of and the attitudes to the willingness of nursing students to treat infectious diseases. However, this relationship between the perceptions, attitudes and willingness to treat rapidly spreading diseases with high fatality rates such as the Ebola virus is still evolving. The aim of this study was to explore and describe nursing students' perceptions of and attitudes to their willingness to treat Ebola patients in South Africa. Data were collected from 495 nursing students who voluntarily participated in a study on perceptions, attitudes and willingness to treat patients with the Ebola virus disease (EVD). A factor analysis was used to measure the association between nursing students' perceptions of and attitudes to their willingness to treat patients with EVD. The results showed that 44.8 per cent of the respondents expressed willingness to nurse patients with EVD. The willingness to care for patients with EVD was higher when family concerns and superstitious beliefs did not matter. Incentives and encouraging hospital settings were perceived to enhance a willingness to care for patients with EVD. The willingness to care for patients with EVD was less when a perceived fear of infection was high. To improve a willingness to care for patients with EVD, the identified perceptions and attitudes should be integrated in nurse training programmes. These factors may have a positive impact on the perceptions of and attitudes to caring for patients with EVD.
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Since the advent of 2019-Corona virus Disease (COVID-19) in Nigeria in February 2020, the number of confirmed cases has risen astronomically to over 61,307 cases within 8 months with more than 812 healthcare workers infected and some recorded deaths within their ranks. Infection prevention and control is a key component in ensuring safety of healthcare workers in the hospital as health- care-associated infection is one of the most common complications of healthcare management. Unbridled transmission of infection can lead to shortage of healthcare personnel, reduced system efficiency, increased morbidity and mortality among patients and in some instances, total collapse of healthcare delivery services. The Infection Prevention and Control Committee is a recognised group by the Centre for Disease Control and Prevention with their core programmes including drawing up activities, procedures and policies designed to achieve above-stated objectives before, during and after any disease outbreak, especially emerging and re-emerging ones such as the 2019 Coronavirus Disease. In this report, we highlight the roles played by the Infection Prevention and Control Committee of the University of Medical Sciences Teaching Hospital to prevent the spread of COVID-19 within and outside the hospital community and the lessons learned to date. Keywords: COVID-19; infection prevention; infection control; Nigeria.
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To assess the degree of house officers' concerns about acquiring AIDS (acquired immunodeficiency syndrome) from their patients, we surveyed 263 medical and pediatric interns and residents in four housestaff training programs affiliated with seven New York City hospitals with large AIDS patient populations; 258 questionnaires (98 per cent) were returned. Thirty-six per cent of medical and 17 per cent of pediatric house officers reported percutaneous exposures to needles contaminated with blood of AIDS patients. Forty-eight per cent of medical and 30 per cent of pediatric house officers reported a moderate to major concern about acquiring AIDS from their patients. Greater concern about personal risk was noted in those house officers who were earlier in their residency training, who reported having treated a greater number of AIDS patients, and who were in medicine rather than pediatrics programs. Twenty-five per cent of all respondents reported that they would not continue to care for AIDS patients if given a choice. The results demonstrate a substantial degree of concern about acquiring AIDS among house officers caring for AIDS patients and suggest the need for housestaff program administrators for formally address these concerns.
Article
The 2014 Ebola virus disease (EVD) outbreak triggered concerns about healthcare worker (HCW) readiness. 245 HCWs at a children's hospital were surveyed. Knowledge scores were lower for nurses than physicians (50/61%, p=0.001). Despite HCW's lacking EVD knowledge, their perceived lack of institutional preparedness, and their own lack of training, most HCWs wanted to believe that they would be safe and were willing to provide care.
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The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD. Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.
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