Registered Nurses' Perceptions After a Patient with Ebola Virus Disease Is Admitted to Their Hospital

Abstract

Emerging diseases affect the nursing workforce, but little is known about the willingness of registered nurses (RNs) to work during outbreaks (eg, Ebola virus disease, COVID-19). The objective of our study was to examine the perceptions and attitudes of RNs in the United States regarding their duty to care and willingness to work after a patient infected with the Ebola virus was admitted to their hospital. We performed a quantitative, descriptive study using social media to recruit critical care RNs to complete an online survey. A total of 72 RNs completed the survey. While only 20 respondents reported providing direct care, more than half (n = 38) reported that family members asked them not to work with patients infected with the Ebola virus. A majority of respondents (n = 63) agreed that healthcare workers have a duty to help sick people despite high risks to themselves or their families; however, 59 agreed that family responsibilities would take priority. Respondents were less likely to work if their partners (n = 11) or children (n = 7) were ill but more likely to work if colleagues were infected (n = 48) or dying (n = 40). Shunning was experienced by 32 respondents, and 25 knew of others who were shunned. We observed several factors that affect RNs' willingness to provide care when patients are admitted, including moral conflict between their duty to treat sick people and their duty to protect their family. As part of infectious disease emergency planning, health policy managers should consider these complex factors, which may modulate effective patient care. While this study was limited to RNs in the United States during an Ebola virus disease outbreak, the results signal a need for similar research on other emerging infections such as COVID-19.

Introduction

Since the 1918 “Spanish flu” pandemic, public health professionals have repeatedly faced novel and reemerging pathogens.¹ While some types of influenza occur annually, the United States has dealt with the emergence of several pathogens in the past few decades: HIV in 1981, SARS-CoV in 2003, MERS-CoV in 2012, and Ebola virus in 2014.^2-4 The most recent novel threat to public health is SARS-CoV-2 in 2019. The effects of fear and stigma on the ability of healthcare professionals to care for the infected, and possibly infected, has received little attention, with scant literature addressing the duty of registered nurses (RNs) to care despite real or perceived risks to personal safety. This article focuses on patients infected with the Ebola virus and the RNs who treated them, but the lessons regarding barriers to care described here are broadly applicable to the management of other emergent viral outbreaks, epidemics, and pandemics.

In 2013, the Bureau of Labor Statistics reported that the United States has over 2.6 million RNs. These nurses adapt and apply their knowledge, skills, and experience to meet the evolving demands of patient-centered care. Many would agree that personal safety is an expectation, and the risk for injury or illness is an intrinsic part of the profession.^2,5 According to the American Nurses Association's code of ethics,⁶ RNs have the moral duty to care for all patients. Concurrently, they have a moral obligation to protect their own integrity and wellbeing. On occasion, these divergent values may result in ethical conflict. RNs have the professional right to refuse any assignment that involves serious risk to self, especially as inadequate staffing can result in increased adverse events and early burnout.⁷ The professional duty to treat, as opposed to personal safety and freedom, is a challenging issue complicated by societal and familial obligations. This issue is further complicated by the knowledge that SARS, H1N1 influenza, Ebola virus disease (EVD), and the current COVID-19 outbreaks/pandemics have disproportionately affected healthcare workers.^2,8,9 Any emerging disease has the potential to disrupt a society and its healthcare system, evidenced particularly by the current disruptions associated with the COVID-19 pandemic. Already, the unprecedented actions to prevent the spread of SARS-CoV-2 are fueling societal fear and anxiety.¹⁰ Regardless of etiology, patients with emergent infections will continue to present for treatment.¹¹ Consequently, RNs will also continue to encounter conflicts between duty to care, family, moral obligations, and societal pressures.

In 2014, 5 US hospitals treated patients infected with Ebola. The contagious nature of the disease, coupled with its high mortality rate and absence of effective treatment, intensified public anxiety.¹² Among healthcare workers, RNs were particularly affected as they are positioned at the epicenter of a confluence born of divergent perceptions and ethical responsibilities.² The stigma related to EVD is similar to that of HIV/AIDS during the 1980s.³ The emergence of HIV/AIDS spawned a tremendous sense of public fear and alarm in the United States.^13,14 As with HIV/AIDS, fear of EVD turned into hostility and stigma toward health teams in West Africa, leading to a shortage of healthcare workers tending to patients infected with the Ebola virus.^3,15 This shortage hindered efforts to contain the outbreak.¹⁶ The purpose of this quantitative descriptive study was to examine the perceptions and attitudes of RNs in the United States regarding their duty to care and willingness to work after patients infected with the Ebola virus were admitted to their hospitals.

Methods

Respondents

The target population for this study was critical care RNs in an emergency department and/or adult intensive care RNs while a patient infected with the Ebola virus was admitted to their hospital. We recruited respondents from the 5 hospitals in the United States where patients infected with the Ebola virus were treated. These hospitals were located in urban cities in the states of Georgia, Maryland, Nebraska, New York, and Texas. Three of the hospitals had previously established biocontainment units designed to care for highly infectious patients. Respondents may not have worked directly with patients infected with the Ebola virus, but given their departmental assignments, RNs may have known or provided care to colleagues who were tested for the disease but ultimately not infected. The remaining 2 were community-based hospitals without biocontainment units. The hospitals with biocontainment units had patients directly routed to them specifically for treatment.

During the fall 2014 outbreak of Ebola virus in the United States, the last infected patient was discharged in mid-November. We sent invitations to participate in the study in January and February 2015. Initial survey respondents were recruited by invitations distributed via various social media avenues such as Facebook and critical care electronic mailing lists. However, due to the specific target population, using social media alone to reach potential individual respondents was challenging. As such, we included in the invitation a request to forward the survey (ie, snowball sampling) to other potential respondents. Given the nature of the sampling methodology, the number of RNs who received an invitation link is unknown. However, 101 individuals met the inclusion criteria and chose to participate; of these, 72 provided complete data and were therefore included in the study. RNs not authorized to work in the emergency department or intensive care unit setting, and RNs who had not worked while Ebola-infected patients were admitted to the hospital, were also excluded.

Survey Instrument

We adapted a survey instrument from a nonvalidated but previously used instrument to query work habits during an influenza pandemic. Permission to adapt the survey tool, described in a study by Damery et al,¹⁷ was granted from the primary author. The authors developed the tool to examine sociodemographic and employment data, as well as duty to work, with regard to potential personal and familial conflicts in relation to a future influenza pandemic.

The modified survey instrument consisted of 5 sections, with 20 subsections, totaling 87 items. Eleven items elicited short answers, whereas the remaining 76 items required the respondent to choose from available dichotomous or Likert-type responses. The original survey was adapted to adjust for content validity. In the first and second sections, the only modification we made was the replacement of the term “pandemic influenza” with “Ebola” or “Ebola virus.” The first section captured a mixture of Likert-scale and dichotomous responses regarding the (1) beliefs and attitudes about the Ebola virus, (2) possible number of patients infected with the Ebola virus in the United States, (3) likelihood of becoming infected with the Ebola virus, and (4) availability of an Ebola vaccine. The second section consisted of statements used to collect Likert-scale and dichotomous responses regarding beliefs and attitudes about working while Ebola-infected patients were admitted. This section explored (1) infection of self or family members or (2) disruption in child or elder care that could influence the ability to report to work. Questions in this section also identified potential incentives such as vaccination for self or family, more flexible work hours, and hazard pay, all of which might influence a respondent's likelihood of reporting to work. Respondents indicated whether each of 14 incentives might make them “more likely” or “about the same” to work. The third section was designed to obtain responses to closed questions regarding demographic data. Most demographic information was nominal, whereas age was reported in ranges. We did not make any modifications to this section of the survey.

The fourth section consisted of self-developed material designed to query respondents about their actual experience when a patient infected with the Ebola virus was admitted to a hospital. The section included 16 statements to which respondents answered yes or no. The statements were designed to determine the level of direct patient care the participant provided to patients infected with the Ebola virus, and their experiences with (1) social shunning, (2) body temperature monitoring, (3) quarantine, and (4) other travel restrictions. The final section consisted of closed-ended questions regarding employment information (ie, full time/part time, years in the profession, specialty certifications, travel distance from work, mode of travel). We modified this section slightly to focus on RNs versus healthcare workers in general.

Data Analysis

We analyzed the collected survey data from 72 respondents using IBM SPSS Statistics version 22 (IBM Corp., Armonk, NY). For each of the demographic variables, we calculated descriptive statistics including frequencies, which we used for the main analyses to explore missing responses and out-of-range values. We reported the median age range for the respondents.

We analyzed 9 nominal items of respondents' perceptions relating to Ebola virus disease and 41 nominal items on ethical/duty to work beliefs. These items were individually analyzed and evaluated and reported as frequencies and valid percentages. We conducted normality testing using the Shapiro-Wilk test (α = .05) for the variable describing years worked in healthcare.

Results

Respondent Characteristics

A total of 72 individuals met the study's inclusion criteria, completed most of the survey, and were therefore included in the study. The majority (n = 53, 73%) of the respondents identified as female and the median age range was 31 to 40 years. The majority (n = 51, 71%) of respondents reported they were RNs working in an intensive care unit, and most (n = 63, 88%) respondents indicated full-time employment status (Table 1). The variable “years worked in healthcare” was not normally distributed (P < .05). Sixty-six respondents disclosed a median of 12 years of practice in healthcare, ranging from 1 to 22 years.

Table 1.

Respondent Characteristics (N = 72)

Characteristic	n (%)
Age
21 to 30	16 (22)
31 to 40	30 (42)
41 to 50	16 (22)
51 to 60	5 (7)
≥61	3 (4)
No answer provided	2 (3)
Sex
Female	53 (73)
Male	17 (24)
No answer provided	2 (3)
Living arrangements^a
Live with spouse/partner and children/grandchildren under the age of 16	31 (43)
Live with spouse/partner and children/grandchildren not under the age of 16	17 (24)
Single parent/grandparent and children under the age of 16	0 (0)
Single parent/grandparent and children no under the age of 16	3 (4)
Live alone	13 (18)
Share with friends	4 (6)
Share with parents/other relatives	3 (4)
Live with older adult dependents	7 (10)
Primary caregiver to older adult dependents	7 (10)
Nature of employment^a
RN specialty ICU	51 (71)
RN specialty ED	8 (11)
RN specialty both ED/ICU	5 (7)
Not a charge RN/supervisor	40 (56)
Charge RN/supervisor	29 (40)
Primary work unit ED	10 (14)
Primary work unit ICU	50 (69)
Full time	63 (88)
Part time	7 (10)
Night shift	35 (49)
Day shift	33 (46)

Respondents could provide more than 1 answer. The percentage given is out of the total number of respondents, not the total number of responses.

Abbreviations: ED, emergency department; ICU, intensive care unit; RN, registered nurse.

Ebola Beliefs

Most respondents (n = 60, 83%) reported that patients infected with the Ebola virus would continue to present, but the majority (n = 60, 83%) expected the incidence to be low. All (n = 71, 99%) respondents, except the 1 who did not answer the question, agreed that anyone infected with the Ebola virus would not recover from it (Table 2). Most respondents (n = 64, 89%) reported they believed all age groups had an equal risk for contracting Ebola. However, with regard to the risk of dying from EVD, respondents were closely split between those who believed older adults (n = 35, 49%) were most likely to succumb and those who believed all patients were at equal risk (n = 31, 43%) (Table 3).

Table 2.

Respondent Perceptions About Ebola Virus Disease (N = 72)

Perception	No n (%)	Yes n (%)	Unsure n (%)
Patients infected with the Ebola virus will continue to present in the United States	8 (11)	60 (83)	4 (6)
There will be an effective vaccine that can protect you against the Ebola	20 (28)	27 (38)	25 (35)
Everyone who catches the Ebola virus will recover from it^a	71 (99)	0 (0)	0 (0)
If there is an effective vaccine, you will have access to it	7 (10)	54 (75)	11 (15)
You will have access to personal protective equipment that will prevent you from catching Ebola^a	10 (14)	50 (70)	11 (15)

One respondent did not answer this question. The calculated percentage is out of the total number of respondents possible (N = 72).

Table 3.

Respondent Perceptions About the Incidence of Ebola Virus Disease (N = 72)

Perception	n (%)
Most at risk to catch EBV
Children	3 (4)
Fit healthy adults	2 (3)
Older adults	3 (4)
All at equal risk	64 (89)
Most at risk to die from EBV
Children	5 (7)
Fit healthy adults	1 (1)
Older adults	35 (49)
All at equal risk	31 (43)

Abbreviation: EBV, Ebola virus disease.

Of the 69 respondents who partially or fully completed the section about EVD-related experiences, only 20 (29%) reported providing direct care, but more than half (n = 38, 55%) of respondents were asked by family members not to work with patients infected with the Ebola virus. Almost half (n = 32, 46%) reported experiencing shunning as the result of a person infected with the Ebola virus being treated at their hospital, while a similar number (n = 36, 52%) reported fear of public reaction toward either them or their family members (Table 4).

Table 4.

Respondent Ebola Virus Disease-Related Experiences (N = 69)^a

Experience	n (%)
Provided direct care to a person infected with the Ebola virus in the hospital	20 (29)
Worked in the ICU that treated a person infected with the Ebola virus, but did not provide direct care	16 (23)
Asked to provide direct patient care to a person infected with the Ebola virus, but declined	1 (1)
Worked in a different ICU to permit other staff to volunteer to provide care to a person infected with the Ebola virus	18 (26)
Required to self-monitor temperature	27 (39)
Temperature was monitored by the health department	20 (29)
Restricted from places where the public gathers for 21 days after providing direct care to a person infected with the Ebola virus	18 (26)
Provided direct care to a colleague who became ill with Ebola virus as a result of their job duties	14 (20)
Placed on the TSA “no fly list” as a result of providing direct or indirect care to a person infected with the Ebola virus	16 (23)
Experienced shunning as a result of a person infected with the Ebola virus being treated at my hospital	32 (46)
Asked by family not to work with a person infected with the Ebola virus	38 (55)
Afraid of public reaction toward self or family	36 (52)
Did not personally experience social shunning, but know RNs that did	25 (36)
Not placed under official quarantine, but chose to self-isolate to protect others from possible infection (n = 68)	8 (12)
Stayed at accommodations provided by the hospital as not to take the infection home	6 (9)
Familial shunning (n = 44)	5 (7)
Social shunning (n = 44)	5 (7)
Public shunning (n = 44)	18 (26)

Only 69 of the 72 respondents completed this section of the survey. The percentages for all of the items in this table are calculated using 69 as the denominator. Although 4 items had lower response rates compared to the other items (their specific response number is next to each item), their calculated percentage is out of the 69 respondents who completed all or most of this survey section.

Abbreviations: ICU, intensive care unit; RN, registered nurse; TSA, Transportation Security Administration.

Although all respondents partially or fully completed questions related to the likelihood of working during the admission of a patient with the Ebola virus, the response rates to each item varied greatly (Table 5). It is likely that the low response rate for some questions was due to the lack of an option for respondents to choose to report that the question was not applicable to them. The lowest number of responses (n = 55) was associated with the likelihood of working if one's children were ill. Of these responses, a majority (n = 42, 76%) reported that they were unlikely to work if their children fell ill. Similarly, a majority (n = 44, 66%) of 67 respondents reported being unlikely to work if their partner were ill. Of the 72 survey respondents, a majority reported that they were more likely to work if colleagues were infected (n = 48, 67%) or dying (n = 40, 56%).

Table 5.

Respondents' Likelihood of Working with Patients Infected with the Ebola Virus (N = 72)^a

Circumstance	Likely n (%)	Unlikely n (%)	Don't Know n (%)
Greater risk to self of becoming infected at work or falling ill (n = 70)	36 (50)	23 (32)	11 (15)
Greater than usual risk of infecting family	14 (19)	38 (53)	20 (28)
Asked to take on different or additional work/duties for which one has not been trained	22 (31)	39 (54)	11 (15)
Asked to work more hours	51 (71)	9 (13)	12 (17)
Schools/nurseries were closed or other childcare services were disrupted (n = 61)	40 (56)	14 (19)	7 (10)
Partner fell ill (n = 67)	11 (15)	44 (61)	12 (17)
Children fell ill (n = 55)	7 (10)	42 (58)	6 (8)
Asked to work at a different hospital/healthcare practice	36 (50)	27 (38)	9 (13)
There was a shortage of fuel, leading to disruption of transport (private or public) (n = 71)	28 (39)	20 (28)	23 (32)
Had to make decisions about who not to treat (n = 70)	41 (57)	15 (21)	14 (19)
Had to work with untrained volunteers or workers brought out of retirement	30 (42)	26 (36)	16 (22)
Colleagues were infected	48 (67)	16 (22)	8 (11)
Colleagues were dying	40 (56)	22 (31)	10 (14)

The percentages for all of the items in this table are calculated using 72 as the denominator. Although 6 items had lower response rates compared to the other items (their specific response number is next to each item), their calculated percentage is out of the 72 respondents who completed all or most of this survey section.

Only 70 respondents partially or fully completed questions related to the likelihood of working with specific incentives (Table 6). The lowest response rate (n = 41) was associated with the provision of childcare or eldercare, with a majority (n = 32, 78%) reporting they were more likely to work if childcare or eldercare were provided. Out of the 70 respondents who completed the section, most were more likely to work if living accommodations were provided (n = 61, 87%) or they were paid a higher salary appropriate to their level of duties during an outbreak (n = 61, 87%). Overall, respondents were more likely to work when incentives or policies had been identified.

Table 6.

Respondent Likelihood of Working with Incentives (N = 70)^a

Incentive/Policy	More Likely n (%)	About the Same n (%)
Allowed to work at the nearest hospital/healthcare practice (n = 69)	18 (26)	51 (73)
Provided with accommodation so not to take the infection home	61 (87)	9 (13)
Employer provided transport to work and home again	39 (56)	31 (44)
Childcare or eldercare was provided (n = 41)	32 (46)	9 (13)
Offered vaccination (if available) and/or offered treatment if fell ill	57 (81)	13 (19)
Family offered vaccination (if available) and/or offered treatment if they fell ill	59 (84)	11 (16)
Employer shared emergency plans regarding care responsibilities for a patient infected with the Ebola virus	59 (84)	11 (16)
Offered personal protective equipment when working with or around patients infected with the Ebola virus (n = 69)	58 (83)	11 (16)
Employer accepted liability for any mistakes	57 (81)	13 (19)
Allowed to work more flexible hours	55 (79)	15 (21)
Paid a top-up salary appropriate to the level of duties during an Ebola virus outbreak	61 (87)	9 (13)
Provided with life/disability insurance	58 (83)	12 (17)

Only 70 of the 72 respondents completed this section of the survey. The percentages for all of the items in this table are calculated using 70 as the denominator. Although 3 items had lower response rates compared to the other items (their specific response number is next to each item), their calculated percentage is out of the 70 respondents who completed all or most of this survey section.

Only 71 of the survey respondents completed the survey section addressing their alignment with value statements (Table 7). A majority (n = 63, 89%) of those respondents agreed that healthcare workers have a duty to tend to people who are sick despite high risks to themselves and their families. A majority (n = 59, 83%) also agreed, however, that family responsibilities take priority over work. All 71 respondents agreed that employers had a responsibility to provide personal protective equipment (PPE) if employees were working with patients infected with the Ebola virus. Almost all (n = 70, 99%) of these respondents agreed employers should offer vaccinations to workers, if available, and most (n = 55, 77%) believed infected healthcare workers should receive priority treatment over patients infected with the Ebola virus. Of the 70 respondents who responded to the item addressing personal finances, more than half (n = 42, 60%) reported an obligation to work due to personal financial circumstances.

Table 7.

Respondent Alignment with Value Statements (N = 71)^a

Statements	Agree n (%)	Disagree n (%)
Doctors and nurses have a duty to tend the sick even when there are high risks to themselves or their families	63 (89)	8 (11)
Healthcare workers should not be given any special priority during an Ebola outbreak and everyone should have equal access to treatment	16 (23)	55 (77)
Everyone working in the health service, not just doctors and nurses, has a duty to work during a health emergency, even if there are high risks involved	56 (79)	15 (21)
Healthcare workers should lose wages if they are unwilling to work with patients infected with the Ebola virus	11 (15)	60 (85)
People should do what their religious leaders advise or what their faith directs	31 (44)	40 (56)
Everyone should pull together during an Ebola outbreak	70 (99)	1 (1)
Healthcare workers should be allowed to refuse to work with or near patients infected with the Ebola virus	43 (61)	28 (39)
Professional bodies and unions should offer explicit guidance about the duty to work during an Ebola outbreak	46 (65)	25 (35)
People who refuse to work in a time of national crisis should be punished in some way	8 (11)	63 (89)
People who work through a national crisis should be rewarded in some way	61 (86)	10 (14)
My main responsibility is to myself and my family and my family will take priority over my work	59 (83)	12 (17)
I must work because I could not manage if I lost my wages (n = 70)^a	42 (59)	28 (39)
My employer has a responsibility to offer my family a vaccination if one becomes available	68 (96)	3 (4)
Healthcare workers should face discipline if unwilling to work with patients infected with the Ebola virus	11 (15)	60 (85)
My employer has a responsibility to offer me personal protective equipment	71 (100)	0 (0)
My employer has a responsibility to offer me a vaccination if one is available	70 (99)	1 (1)

Only 71 of the 72 respondents completed this section of the survey. The percentages for all of the items in this table are calculated using 71 as the denominator. Although 1 item had a lower response rate compared to the other items (its specific response number is next to that item), its calculated percentage is out of the 71 respondents who completed all or most of this survey section.

Discussion

In the survey of RNs, the duty to care despite personal and familial risk was prevalent, but not absolute. Family responsibilities were identified as a higher priority over work, with over half of respondents reporting that their families had asked them not to work with patients infected with the Ebola virus. Conversely, a high number of respondents reported a personal obligation to work due to financial concerns, which could compete with the drive to protect their families from infection. Competing values can also be seen with RNs being less willing to work if family members were ill or dying, but more willing to work if colleagues were ill or dying.

Personal financial circumstances compelled many to continue working. The likelihood of RNs working could also be incentivized. Most RNs reported being more likely to work in the majority of the circumstances identified in the survey, with the exception of being allowed to work at the nearest hospital. All respondents agreed that employers had a responsibility to provide PPE.

About half of the respondents experienced societal shunning and/or reported fear of public reaction; however, its effect on the likelihood to work was not explored. Other investigators have also observed that the presence of the Ebola virus in the United States was associated with social shunning, travel restrictions, and quarantine in a setting of public fear and distrust.¹⁸

While the specific types of stigma and public reactions were not explored in this study, other studies support that EVD-related stigmatization is more related to fear of contagion than moral conflict, similar to how it was with HIV. Exploration of stigma faced by health professionals who survived EVD in Guinea revealed that health workers' professional roles did not protect them from stigma even within their own healthcare facilities and families.¹⁹ During the 2003 SARS outbreak, a majority of healthcare workers reported experiencing stigma due to close contact with SARS patients or for meeting quarantine criteria.^20,21 The effects of healthcare workers experiencing stigma and public fear should not be overlooked. This experience could have a profound effect on both the individual and on the healthcare infrastructure at large. While it does not appear to be as prevalent, there are reports of healthcare workers being shunned and harassed during the COVID-19 pandemic.^20,22 As with EVD, this stigmatization appears to be more related to fear of contagion.^20,23

Over half of respondents were asked by family members not to work with patients infected with the Ebola virus, which is a reflection of competing ethical values. Damery et al¹⁷ identified similar opposing values with regard to a potential pandemic influenza. With COVID-19 pandemic, healthcare workers often work long hours with inadequate resources, including PPE.²⁴ At the same time, they accept the amplified risk of infection associated with close interaction with these patients. As with EVD, healthcare workers are vulnerable both to becoming infected and transmitting this disease to others. Actual infection is not the only factor, however, as anxiety over fear of transmission to loved ones can have compounding psychological effects as it did during SARS.²⁵

Notwithstanding the differing clinical outcomes, the initial presentations of EVD and COVID-19 have nonspecific symptoms similar to other common viral infections. With regard to Ebola and the knowledge that using PPE does not completely mitigate risk of infection, respondents overwhelmingly agreed there was an ethical duty to work, even when putting themselves and families at risk.

The concept that employers have a responsibility to provide adequate PPE for RNs working with patients infected with the Ebola virus is not as simple as it seems. In 2015, Fischer et al²⁶ identified PPE as a single part of a larger Ebola infection control strategy. Best practices for the proper use of PPE, including donning and doffing procedures, are as vitally important as the equipment.^26-28 Best practices can improve the exposure rate, but there may be a coinciding effect on willingness to work. In a qualitative analysis examining RN perceptions of EVD care in the United States, Speroni et al²⁹ identified lack of PPE best practices, lack of equipment, and failure to consistently follow protocols as common nurse-related concerns. However, development of best practices is hindered by the lack of sufficient data due to the nature of an emerging disease. During the EVD outbreak in the United States, the World Health Organization, the US Centers for Disease Control and Prevention, and the Public Health Agency of Canada issued changes to the guidelines for PPE use.^30-32 Lack of PPE, such as N95 respirators and gowns, and evolving guidelines have also been persistent issues during the COVID-19 pandemic.²⁵ Wang, Zhou, and Liu²³ identified the shortage of PPE in mainland China as a key risk for healthcare workers becoming infected with SARS-CoV-2. As we continue to face challenges created by limited PPE and changing guidelines, it is important to understand how this affects the willingness of healthcare workers to continue to expose themselves without proper protection.

Hospital administrators must understand that RNs expect employers to provide adequate PPE and infection prevention interventions.³³ Incentives that employers can offer to increase the likelihood of RNs being willing to work during the admission of patients infected with the Ebola virus include (1) accommodation to prevent taking the infection home, (2) dependent or eldercare, (3) hazard pay, (4) sharing of emergency plans for EVD, and (5) providing vaccination or treatment to family members. Providing dependent care would be especially important in the event of school closures. Hospital administrators also need to consider the factors that increase RNs' willingness to work in the setting of admissions for patients infected with the Ebola virus; in addition, emergency planning should include discussions about the ethical implications and consumer perception of providing treatment to these patients.

Although the majority of the 2014-2016 EVD outbreak was confined to West Africa, a nurse technician in Spain and 2 RNs in the United States contracted the virus while caring for patients infected with the Ebola virus.³³ Each recovered without recurrence of the disease. However, an RN in Scotland who had been treated for the virus and discharged without a detectable viral load fell ill with EVD-related meningitis 9 months later.³⁴ These healthcare workers are unlikely to be the last to contract emerging infections while providing patient care. The complexity of the EVD outbreak, the infection of healthcare workers, and the subsequent stigma and restrictions on healthcare workers providing care for patients infected with the Ebola virus created a unique opportunity to examine willingness and duty to care for these complex patients.

Limitations and Recommendations for Further Research

This study had several limitations. The foremost limitation was the small sample size. At the time of the survey, only 5 hospitals in the United States had admitted patients infected with the Ebola virus for treatment. Restricting inclusion criteria to RNs working in an emergency department or intensive care unit of these hospitals further constrained an already small population. The study did not explore the willingness or likelihood to work in the setting of possible travel restrictions and quarantine. Decreased willingness to work due to fear of travel restriction, quarantine, or furlough without pay should be explored. Twenty-nine eligible respondents submitted only partially completed surveys—possibly because they felt the survey may have been too long, some questions did not apply to them, or they believed their responses would not be held in confidence, despite assurances. Additionally, the results cannot be generalized to RN perceptions in other countries, or generalized for other serious, novel, or potentially fatal emerging diseases. At the time of survey distribution, a vaccine approved by the US Federal Drug Administration was not available, and therefore the impact of vaccination on perceptions was not measured.

This study did not explore RN perceptions toward infection control measures beyond the responsibility of employers to provide PPE. There should be expanded exploration examining how infection prevention strategies may affect willingness to provide care.

In this study, we examined the likelihood of working with patients infected with the Ebola virus, but we did not explore the concept of duty to care or the moral obligation to care. According to the American Nurses Association's code of ethics, RNs have an obligation to provide care, unless said care would interfere with their concurrent obligation to maintain a state of personal wellbeing.⁶ There is no clear delineation to which obligation supersedes the other. While the code of ethics is a professional standard, there has been limited investigation into how individual RNs interpret these ethos as they apply to infectious diseases. In addition to the code of ethics, there is a need to explore RNs' knowledge and understanding of the rules, regulations, and standards of practice as they apply to the concept of duty to care.

Further research on the willingness of healthcare workers to work in the setting of other emerging diseases such as Middle East respiratory syndrome, avian influenza, and COVID-19 is needed. Research on healthcare workers exposed to EVD-infected patients should be expanded to all healthcare workers including those in nonclinical positions such as security and environmental care staff. The effects of social stigma, travel restrictions, quarantine, and potential loss of income on willingness to work with these and similar patients should be explored. The current outbreak of COVID-19 should also prompt research into the practical, social, and psychological effects on healthcare workers and their willingness to provide care in these situations.

Conclusion

In the United States, patients with highly infectious emerging diseases like EVD will continue to present for treatment. This study of the perceptions and attitudes of RNs revealed a prevalent belief in an ethical duty to work despite personal or familial risk. At the same time, the study found that RNs had a predominant ethical belief in prioritizing family responsibilities over work responsibilities. Previous studies related to pandemic influenza have also identified this moral conflict between duty to treat versus duty to family. Our study revealed that this complex issue is compounded by many different factors that can affect RNs' willingness to provide care when patients infected with the Ebola virus are admitted for treatment. Some employer-offered incentives can increase the likelihood of RNs working in the setting of admissions for patients infected with the Ebola virus. However, more research is needed to explore factors that affect the ability and willingness of healthcare workers to provide care during novel and reemerging viral outbreaks that are associated with public fear and stigma. Finally, emergency planning for emerging infections should include discussions about the ethical implications and consumer perceptions of providing treatment to these patients. Until these issues are addressed, in the setting of stigma, public fear, and threats to physical safety, healthcare workers may simply choose to stay home.

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