Pandemic Places Stress on Health Care Systems and Staff in Surprising and Complex Ways
By Alex McEllistrem-Evenson
When asked about the challenges she faces as a practitioner dealing with the H1N1 pandemic, Dr. Minto Porter, a general pediatrician in St. Cloud, Minnesota, remarks that “the biggest is the public’s perception of it. The media creates a lot of anxiety in parents, sometimes to the level of hysteria. It’s been difficult in making sure that patients are getting the facts.”
This should come as little surprise to anyone who has followed H1N1 coverage in national news media for the past six months, even casually. Since last June, when the World Health Organization Director-General Dr. Margaret Chan declared that “the world is now at the start of the 2009 influenza pandemic,” Novel H1N1 influenza (“H1N1” or “swine flu”) has been the subject of significant media attention, both domestic and abroad. Reports of deaths, vaccination shortages, and possible negative side-effects of the vaccination have been prominent.
Little attention, however, has been paid by the media to the certain challenges and controversies faced by health care providers, clinicians, administrators, and other members of the health workforce who must, by necessity, deal with this pandemic on the front lines.
There are health concerns that arise any time health care providers have to deal with viral infections on a broad scale, and controversies about mandatory employee vaccinations and required time off have surfaced in many facilities. There are more subtle issues as well, which only emerge when talking directly to practitioners and administrators. In that regard, increased employee stress levels, broader needs for employer-sponsored daycare services, and ethical concerns which ask administrators in some areas to weigh employee safety against budget constraints are just a few of the ways that the H1N1 pandemic has trickled down through our health care system thus far.
Stress Levels High
As a virus which has, according to Porter, “been very widespread among children,” H1N1 has raised unique issues.
“We’re stressed to the limit as far as staff,” Porter continues. Departments of pediatric medicine are among the busiest in terms of H1N1-related calls and concerns. “We’ve really worked late hours; much more than we typically see this time of year. We’re definitely working extra.”
Simply dealing with call volume becomes a challenge. An administrative staff member at the Mayo Clinic in Rochester, Minnesota reports that “the first day we opened the appointment lines for H1N1, we received 200,000 calls before noon.” According to Marilyn Jungbluth, who manages six clinics in the Twin Cities metropolitan area (four of which are urgent care), “there are people calling all the time who want [the vaccination]. That’s been our biggest challenge” so far.
“We’ve been on the lottery system,” adds Jungbluth, “so all of a sudden we’ll get a hundred doses, and have to go on the recommendations [from the Centers for Disease Control and Prevention, or CDC] about who to start with,” despite the fact that many patients in non-priority groups continue to call for availability.
Explaining these recommendations to concerned patients –anxious parents in particular – is another unique factor contributing to employee stress. “We’ve been trying to follow the CDC recommendations very closely and those things are being modified,” states Porter. “That has been difficult for staff to explain to families.”
As a result, some of the members of the health workforce under the highest levels of stress are those who answer the phone. “Our phone triage nurses have had to deal with a lot of upset parents who are trying to secure the vaccine for their children,” Porter elaborates.
From a management perspective, many health care facilities face additional concerns securing the vaccine for their employees providing direct patient care. Dr. Stephen Ostroff, Director of the Bureau of Epidemiology in the Pennsylvania Department of Health, reflects that “we remain very challenged getting the workforce vaccinated,” both in Pennsylvania and nationwide, “because of the current limited availability of the vaccine as well as reticence and reluctance of many workers to be vaccinated.”
While vaccine shortages pose problems in numerous ways, this is an issue which is well-publicized elsewhere and largely beyond the control of individual health care providers. The latter concern, however, regarding employees who are reluctant to receive the vaccine and/or who refuse it outright, may come as a surprise.
Porter confirms Ostroff’s commentary, reflecting on her own experiences in her facilities: “each year, the flu vaccine refusal rate amongst the staff is a point of controversy. The H1N1 is no exception. I think because staff knew they may be asked to stay home from work for up to one week if they or their children contracted a flu-like illness, the rate of staff vaccination was much higher. Our hospital has come about as close as legally possible in requiring staff to receive both vaccines.”
Jungbluth reports that “about eighty-five percent” of more than 100 employees under her management have received both vaccines, a number she is pleased with. “We have had a few refuse the vaccination. They fill out a form [which indicates they are] deciding not to” receive it.
In other areas of the country, employee vaccination rates have raised much larger controversies. According to a September press release by Richard F. Daines, M.D., the New York State Commissioner of Health, “On August 13th , the New York State Hospital Review and Planning Council adopted a regulation … making approved annual influenza vaccinations mandatory, unless medically contraindicated, for health care workers in hospitals.” This regulation applies to the H1N1 vaccine as well.
Resistance to the mandate was well publicized, and in October, state Supreme Court Justice Thomas J. McNamara placed a temporary restraining order on any entities attempting to enforce this mandate, predominantly on the grounds that the mandate might be an infringement of employee civil rights.
“Knowing that our privileged access to the new vaccine is earned not by our personal risk factors but by the special trust society places in us,” states Daines in the same press release, “how can we as health care workers maintain that our cooperation in protecting the most vulnerable members of society is nevertheless optional? Without mandated vaccinations, many ethically troubling situations may occur.”
These include scenarios in which “Institutions may find themselves short staffed and less than fully capable” and others in which “the staff-wide immunity levels needed to assure patient safety and optimal staffing” are not achieved, which is in Daines estimation “the very reasons for which health care workers received their priority [for the H1N1 vaccination] in the first place.”
Priority or not, Porter, reflecting on her experiences in Minnesota, clarifies that “we had a lot of difficulty securing appropriate vaccine for our physicians and staff members who were unable to receive the FluMist. About 25% of our physicians were unable to receive the mist due to age, pregnancy, or medical history such as asthma, immune-suppression, etc. Although there was a strong effort to get vaccine to health care workers as soon as possible, I believe that specific population was overlooked.”
Personal Protective Equipment
Additional ethical quandaries have emerged regarding the use of Personal Protective Equipment (PPE) among those having direct contact with patients. Porter recalls that “at the very beginning [of the H1N1 pandemic] we were wearing masks and goggles and gloves before we went to see a patient … now we’ve modified that based on what the CDC says is appropriate, and it’s interesting because some staff members are resistant to going with less PPE (personal protective equipment).”
The CDC clarifies that “PPE ranks lowest in the hierarchy of controls,” below more effective measures such as elimination of potential exposure and facility-based “engineering” controls. “While providing personnel with appropriate PPE and education in its use is important,” states the CDC, “PPE will not be effective if adherence is incomplete or when exposures to infectious patients or ill co-workers are unrecognized. In addition, PPE must be used and maintained properly, and must function properly, to be effective.” The CDC recommendations go on to establish priorities for respirator use when shortages exist.
“We have encountered staff members who have refused to see patients without full PPE,” continues Porter, “but we follow the CDC recommendations as closely as possible. As far as I understand it, the CDC has always said that a surgical mask is adequate, so we used them until the shortage [in Minnesota of PPE]. There are also simple ear loop masks, but those provide inadequate coverage.”
“Because we are working hard to protect staff from exposure,” states Porter, “there have been unforeseen shortages of PPE such as gowns, surgical masks, and gloves. This has been statewide. We have had to try to balance the limitations of the shortage with the need to protect our staff.”
Jungbluth’s clinics have yet to face any problems due to a PPE shortage. “We have fitted each of our employees with an N95 [respirator],” she states. “We also have adequate supplies of goggles and gloves.”
As with the issue of employee vaccination, facilities face issues of maintaining adequate supplies of PPE as well as proper usage – or, in some cases, any usage at all: “as the virus has become fairly widespread,” remarks Porter, “some staff began to feel that PPE was unnecessary. This was difficult as we often will see patients only a few hours after their birth.”
Staff Management Policies
Staff with children often face additional barriers and exposure risks, a challenge which is easy to overlook in preparing for and coping with a pandemic.
“H1N1 is unique,” states Porter, “in that pregnant women are at an increased risk for complications if infected. We have had to take special steps to remove pregnant physicians, nurses, and ancillary staff from responsibilities which pose a risk for infection. This is a precaution we have not encountered before.” These measures place a greater strain on remaining staff to take on additional responsibilities and greater patient loads.
As patient load increases, many facilities have increased their hours or offered special after-hours clinics to care for those with flu-like symptoms. Porter remarks that these additional hours “make it difficult for our ancillary staff with children to find daycare. Often, their children have been ill with the H1N1 virus so typical daycare measures have not always been available. This has also placed a financial strain on a lot of our nurses or other staff.”
The Mayo Clinic offers a benefit to employees called “Children’s R&R,” which provides on-site child care staffed by nurses for employees’ kids when they are too sick to go to day care or school but can’t stay home. Administrative staff members report, however, that “this season they won’t take a child with H1N1 symptoms, which affects employees’ time off. They could have potentially worked that day, but are now required to go home to care for their children.”
Mandatory sick leave periods have been another point of controversy. “It’s been difficult for us to accommodate that,” states Porter. “Initially when the [CDC] recommendations came out, staff had to be away from work for a week after their fevers started, and that put a strain on our clinic practice and our daily flow when we’re short nurses and X-ray technicians and things like that.” Recommendations have since been reduced: “Workers who have symptoms of influenza-like illness are recommended to stay home … until at least 24 hours after their fever has resolved,” states official CDC documents.
Jungbluth reports that, in general, H1N1 has had a relatively mild impact on her staff. Of more than 100 employees who provide direct patient care, “we’ve only had two people who have had H1N1,” she remarks. “Really, I’m very surprised at how few people I’ve had out.”
Morale and Retention
Most experts at this point seem to agree that, in general, health workforce and health care facilities were adequately prepared for the H1N1 pandemic – at least, as much as was possible given various funding levels, and vaccination shortages notwithstanding.
“I know that we are definitely on the cutting edge [in Minnesota] for being prepared for a sort of a mass casualty or emergency with high numbers of patients,” states Porter, “but in the end we all have to be flexible and be able to make accommodations depending on particular circumstances.”
Ostroff agrees, citing avian flu and 9/11 as raising pandemic preparedness in public consciousness. “A lot of this training targeted to the health care workforce was highly relevant to the pandemic, even though we ended up talking about a different virus,” he states. “The overall level of severity of this pandemic was considerably milder than was addressed in most of the training courses that were put on for bird flu.”
It is apparent that the pandemic has served as a kind of broad-scope systematic stress test for many facets of health workforce, revealing areas where policies and procedures require clarification, improvement, revision, and in some areas, creation. Staff morale, however, may face the most long-term consequences from pandemic-related stressors.
Retention is widely recognized as a major point of concern in health workforce studies; the costs involved in recruiting and training new employees are significant. Even though the types of work-related stress which stem from the H1N1 pandemic are likely to be short term, it has the potential to lead health professionals to change careers or employers due to stressors or perceptions of poor treatment.
In this light, the facilities which prove most adept at helping their staff cope with job-related stress and which make an effort to recognize the kinds of sacrifices their employees make are likely to have the best outcomes in terms of retention. Treating employees’ personal lives and situations with compassion is crucial in this regard, and situations like this may call for more formal measures: employee assistance programs, flexible daycare options, or similar services to help employees cope with stress and personal needs more effectively.
Speaking as a practitioner dealing with a pandemic on the front lines, Porter remarks that emergency situations are, by nature, unpredictable. “You have to be fluid and ready to adapt,” she states. It would seem that this commentary applies to administrators and facility managers, in terms of adapting to the personal and professional needs of their employees which change and emerge as well.