Mass casualty incidents (MCIs) are defined as incidents leading to a surge of patients that overwhelm the local health care system.1 MCIs can be natural disasters, such as floods, earthquakes, or man-made events, including infrastructure disasters or terrorist attacks. The past few decades have witnessed an increase in several hazards, including the risk of natural disasters and terrorist attacks,Reference Ritchie, Rosado and Roser2, 3 as well as an increase in internal hospital disasters.Reference Klokman, Barten and Peters4 Combined internal and external events eventually affect the functioning of hospitals, with acute care departments being particularly vulnerable.Reference Klokman, Barten and Peters4 Disasters involving a large number of patients affect hospital functioning. Treatment of specific types of patients, such as radiographically contaminated or biologically contaminated patients, can cause disruption. Furthermore, the COVID-19 pandemic has demonstrated that large-scale infectious disease outbreaks pose a major burden on hospital functioning, with health care workers (HCWs) experiencing stress and moral injury, leading to increased burnout rates and staffing shortages.Reference Vizheh, Qorbani and Arzaghi5‒Reference Hesselink, Straten and Gallée7 Crises and disasters have the potential to further exacerbate this burden and its associated risks.
To address MCIs, hospitals are equipped with disaster management plans. Such plans almost exclusively rely on the availability of additional staff. However, is it reasonable for hospitals to expect their attendance in all disaster scenarios? Previous studies on the willingness to work (WTW) of emergency HCWs during a disaster revealed that there were no scenarios in which all HCWs were willing to work unconditionally.Reference Sultan, Løwe Sørensen and Carlström8‒Reference Chaffee10 Only a few studies have assessed the disaster preparedness of Dutch hospitals. Therefore, we aimed to investigate the WTW of Dutch emergency HCWs.
Methods
Study Design
A cross-sectional survey among ED and ICU HCWs in 5 Dutch hospitals.
Setting and Participants
ED and ICU nurses and physicians of 5 Dutch hospitals (VieCuri Medical Centre, Venlo; Laurentius Hospital, Roermond; Zuyderland Medical Centre, Heerlen; Zuyderland Medical Centre, Sittard-Geleen; and Adrz Hospital, Goes) were invited to participate in this study. Data were collected through an online survey. All ages and gender groups were included. HCWs were informed via departmental management, email, and posters. Information about the design and goal of the study was provided in the email, which contained the data weblink to the survey. Informed consent was obtained through survey introduction, where HCWs were informed that if they continued the survey, they agreed with study participation. Participants were informed that their participation was voluntary and that study withdrawal was possible before and while filling in the questionnaire (by not completing it). After the questionnaire was completed, all results were fully anonymous and could not be traced back to the individual.
Survey
The survey used, Fight or Flight, was developed by the Centre for Research and Education in Emergency Care (CREEC) at the University of Leuven, Belgium. The survey comprised a minimum of 52 items, potentially extending to a maximum of 134, distributed in 2 sections: a demographic section consisting of 9 questions, and a scenario section consisting of 11 disaster scenarios with 4 questions each (willingness to come to work, perceived knowledge of disaster scenario, perceived risk, and perceived danger of disaster scenario). When the first scenario question was answered with “willingness to work under certain conditions,” an additional 12 statements with working conditions were presented. Participants had to rate the importance of these statements in association with their willingness to work on a 10-point Likert scale. Knowledge of the scenario, perceived risk, and perceived danger was also rated on a 10-point Likert scale.
The original survey was adjusted to fit the current time frame and situation in the Netherlands. Changes included replacing the Mexican fever and SARS pandemic outbreak scenarios with a renewed SARS-CoV-2 surge and a mass shooting scenario. Two versions of the survey were used—one for nurses and one for physicians—which only included differences in the demographic sections. See online Supplement 1 for an example of the survey.
Data Collection and Analysis
Data collection took place from November 28, 2022, until March 5, 2023. The surveys were distributed and data were collected via Castor EDC (Amsterdam, the Netherlands), a cloud-based secured platform for electronic data collection. All participants received a participant ID when their email address was uploaded to Castor. The email addresses could not be traced back to the researchers. Nonresponders received a maximum of 3 emailed reminders. A general survey link and QR codes were distributed via email and fliers to increase the response rate.
Statistics
Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics for Windows, v26.0, IBM Corp., 2019, Armonk, NY) was used for data analysis. Data was presented descriptively as means and standard deviations (SDs) for normally distributed continuous data, as medians and interquartile ranges (IQRs) for not normally distributed continuous data, and as frequencies and percentages for categorical data. χ 2 tests were used for categorical demographic data. Fisher’s exact tests were used for continuous demographic data and ordinal data.
The homogeneity of the items in the subscales of the Fight or Flight survey was analyzed by calculating Cronbach’s alpha via the Statistical Package for the Social Sciences (SPSS) version 20 (IBM, Texas, USA) in a previously performed study.Reference Sultan, Løwe Sørensen and Carlström8 Cronbach’s alpha was 0.927, which is a satisfactory value.
Ethical Approval
A non-WMO declaration was granted by the medical ethical review board of Maastricht University Medical Centre (study ID 2022-3417).
Results
A total of 647 HCWs were invited to participate in the study. Of the 322 (50%) HCWs who completed the survey, 16 did not fit the job description and were subsequently excluded. Overall, 306 participants were included in the analysis.
Most respondents were female (67.3%), and nurses represented 71.6% of the participants. For 7 (3.2%) respondents, the main department was unknown. A total of 85.3% of the respondents were in a relationship, and 56.2% had children. Approximately one-third of the physicians (32.2%) and 15.5% of the nurses had received any form of past disaster management training. Topic-specific disaster training, such as disaster management, dealing with epidemics/pandemics, chemical incidents, nuclear incidents, or mass casualty incidents, varied between 6.9% and 29.9% for physicians and between 5.5% and 18.7% for nurses (Table 1).
Demographic Data (N = 306)
* P < 0.05 statistically significant.
There was no disaster scenario in which all emergency HCWs were WTW unconditionally. HCWs were most likely to come to work during an influenza epidemic (69.0%), a SARS-CoV-2 pandemic (63.7%), or a natural disaster (53.3%). They were least likely to come during an Ebola or hemorrhagic fever (HF) outbreak (31.4%), a nuclear incident (35.9%), or a dirty bomb (37.9%) (Figure 1).
Willingness to work according to disaster scenario (N = 306).
An influenza epidemic and a renewed SARS-CoV-2 pandemic were scenarios in which the lowest number of HCWs required working conditions (27.5% and 30.7%, respectively). For all other scenarios, approximately half of all HCWs required working conditions (ranging from 42.2% during a natural disaster to 52.3% during an Ebola or HF outbreak). In the case of a dirty bomb, a nuclear incident, or an Ebola or HF outbreak, the rates of HCWs who were unwilling to work or had serious doubts about coming to work were highest (18.3%, 18.0%, and 16.3%, respectively). An influenza epidemic was the only disaster scenario in which no HCWs were unwilling to work.
Physicians were more WTW unconditionally during all disaster scenarios. The greatest differences were observed in the scenarios of the SARS-CoV-2 pandemic (physicians vs. nurses, 80.5% vs. 57.1%, P ≤ 0.001) and chemical incidents (physicians vs. nurses, 62.1% vs. 39.3%, P = 0.003). Nurses were more likely to set certain conditions to work than physicians were, ranging from 30.6% during an influenza epidemic to 51.6% during an outbreak of Ebola or HF. During the scenario of a dirty bomb, the highest number of nurses expressed doubt or unwillingness to work (20.1%); for physicians, this occurred during dirty bombs and nuclear incidents (both 13.8%) (Table 2).
Willingness to work according to profession
* P < 0.05 statistically significant.
HCWs who had received previous disaster training were more likely to be WTW during all disaster scenarios. These differences were most pronounced in the disaster scenario bomb attacks (training vs. no training, 59.7% vs. 39.8%, P = 0.030) and nuclear incidents (training vs. no training, 51.6% vs. 32.0%, P = 0.010). There were no HCWs with previous disaster training who were unwilling to work during a natural disaster, bomb attack, influenza epidemic, SARS-CoV-2 pandemic, mass shooting, or chemical incident; for HCWs without previous disaster training, this was only the case for an influenza epidemic (Table 3).
Willingness to work according to disaster training
* P < 0.05 statistically significant.
ED HCWs were more WTW unconditionally in all disaster scenarios. Furthermore, ICU staff more often indicated that they were only WTW under certain conditions than did ED staff in all the scenarios. These rates were lowest for an influenza epidemic (35.4%) or a SARS-CoV-2 pandemic (38.8%). The greatest degree of doubt or unwillingness to come to work was observed in the Ebola/HF scenario (ED) and nuclear incident scenario (ICU) (online Supplemental 2).
When WTW was compared according to gender, significant differences were found for the bomb attack (male vs. female, 54.0% vs. 38.8%, P = 0.037), Ebola/HF (male vs. female, 39% vs. 27.7%, P = 0.017) and dirty bomb (male vs. female, 39% vs. 37.4%, P = 0.014) scenarios (online Supplemental 3).
Single HCWs demanded fewer working conditions, and there were fewer scenarios in which they would not show up at all. However, when WTW was compared according to relationship status, no significant differences were found (online Supplemental 4).
When comparing WTW according to having children, significant differences were observed for chemical incidents (children vs. no children, 39.0% vs. 54.5%, P = 0.022) and biological incidents (children vs. no children, 37.2% vs. 47.8%, P = 0.025) (online Supplemental 5).
Some of the respondents indicated that they were WTW under specific conditions. Having access to adequate PPE was the most important condition in every disaster scenario (median [interquartile range (IQR)]: 10 [8-10]). During a natural disaster, bombing, mass shooting, chemical incident, nuclear incident, or dirty bomb, knowing that family is safe and taken care of was another condition deemed important (10 [8-10]). For the Ebola or HF outbreak, smallpox outbreak, chemical incident, biological incident, and nuclear incident scenarios, being properly trained and remaining updated on the development of the situation were the second-most important conditions. Keeping updated on the situation was also important during an influenza epidemic, a SARS-CoV-2 pandemic, and a dirty bomb. Financial compensation was deemed important only in the case of an influenza epidemic (8 [6-10]) (Table 4).
Willingness to work under certain conditions*
Rated on a 10-point scale (10 = most important, 1 = least important).
* (a) If I know my family is safe and taken care of; (b) If I am sure good communication lines with my family are available; (c) If my boss comes to work as well; (d) If I am trained to handle the situation; (e) If I get regular updates on the evolution of the incident; (f) If I am sure I can get adequate PPE; (g) If I get financial compensation; (h) I can get antivirals for free.
Perceived knowledge was rated highest for an influenza epidemic (8 [7-8]) and SARS-CoV-2 pandemic (8 [8-9]). The lowest rates were reported for the scenarios of dirty bombs, biological incidents, nuclear incidents, and Ebola or HF outbreaks (3 [2-5], 4 [2-5], 4 [2-5], and 4 [3-5], respectively). The perceived risk was highest for an influenza epidemic (8 [7-9]) and a SARS-CoV-2 pandemic (7 [5-8]). This was lowest for Ebola or HF outbreaks and dirty bombs (both 3 [2-5]). Perceived danger was highest for a nuclear incident and dirty bomb (both 8 [7-9]), as well as for an Ebola or HF outbreak (8 [6-9]), and a mass shooting (8 [5-9]). Perceived danger was lowest for a natural disaster, an influenza epidemic, and a smallpox outbreak (5 [5-7] all) (online Supplemental 6).
Strengths and Limitations
To our knowledge, a survey-based WTW study had not yet been performed among Dutch emergency HCWs. The strengths of our study include its multicenter design and specific focus on emergency health care, as these are a hospital’s first-line responses during a crisis or disaster.
The total estimated response rate was 49%, despite placing maximum effort on inclusion. Survey-based studies performed within the ED or ICU generally showed response rates varying from 21.8% to 51%,Reference Hesselink, Straten and Gallée7, Reference Oerlemans, Wollersheim and van Sluisveld11‒Reference Opgenorth, Stelfox and Gilfoyle15 which implies that the response to the present survey is satisfactory. Unfortunately, we were not able to assess nonresponse bias due to the anonymity of the study. However, survey studies with smaller sample sizes (< 500 participants) need a response rate of 20-25% to provide fairly confident estimates.Reference Fosnacht, Sarraf and Howe16 Higher response rates are known to cause only minimal—or even nonexistent—differences in estimated outcomes.Reference Fosnacht, Sarraf and Howe16
The survey was considered to be extensive by some participants, which may be the reason 85 participants started but did not complete it.
The use of a 10-point Likert scale can be seen as a limitation, with the difference between scoring a certain number being unclear. The “estimation of risk or danger” may have various interpretations. Does the risk or danger entail the respondent or environment?
In the web-based survey, hypothetical disaster scenarios were presented to the participants. They might not necessarily provide an accurate representation of the WTW during an actual emergency. Most of the previous research in this field has been based on hypothetical scenarios.
Discussion
This study assessed the willingness of Dutch emergency HCWs to work during crises or disasters. HCWs were most likely to respond unconditionally during an influenza epidemic, a SARS-CoV-2 surge, or a natural disaster. The scenarios of nuclear or biological incidents, dirty bombs, and Ebola or HF outbreaks were most often associated with doubt among HCWs. In the event of a disaster, emergency HCWs are more likely to respond to hospitals’ efforts to increase their surge capacity if they have access to adequate PPE. The assurance that family is safe and having adequate training are other important conditions. Low perceived knowledge of certain chemical–biological–radiographic–nuclear (CBRN) disaster scenarios was associated with a lower willingness to work.
Previous studies have also revealed that there is no disaster scenario in which all HCWs are willing to work unconditionally. WTW depends on the type of disaster.Reference Arbon, Cusack and Ranse9, Reference Chaffee10 A similar study performed in Saudi Arabia reported the highest WTW during a natural disaster (62%) and a seasonal influenza pandemic (53%).Reference Hesselink, Straten and Gallée7 The high willingness to respond to natural disasters also resonates with previous research.Reference Arbon, Cusack and Ranse9, Reference Chaffee10, Reference Brice, Gregg and Sawyer17 Influenza epidemics are a regular occurrence in the Netherlands, and the high WTW may be explained by the high perceived level of knowledge and experience, and therefore feelings of preparedness. The same may hold true for a new SARS-CoV-2 surge. The WTW during the COVID-19 pandemic was previously shown to be high among physicians and nurses worldwide.Reference Rafi, Hasan and Tasnia Azad18‒Reference Hoffmann Kusk, Laugesen and Germund Nielsen20 Important conditions that were set included higher salaries (78.5%), better working conditions (72.1%), sufficient PPE (54.3%), and further education/training (62%).Reference Hoffmann Kusk, Laugesen and Germund Nielsen20
Similar to our study, an Ebola outbreak emerged in Saudi Arabia and Belgium as one of the disasters for which respondents expressed the most serious doubts about coming to work.Reference Sultan, Løwe Sørensen and Carlström8, Reference Hendrickx, Van Turnhout and Mortelmans21 In contrast, a study performed in Nigeria, where a hypothetical Ebola virus outbreak was presented, revealed that the majority of staff were willing to work during an outbreak (73.1%).Reference Ibiok, Onyedinma and Agwu-Umahi22 This difference may be explained by the fact that Nigeria experienced the West African Ebola epidemic in 2014-2016 and is among the African countries with the highest number of Ebola cases;23 this suggests that the perceived knowledge and experience of certain disaster scenarios influence the WTW.
In the case of a CBRN event, the WTW values are usually lower than those in other disaster scenarios. HCWs were less likely to respond to a CBRN event if they felt less prepared for such a scenario;Reference Chaffee10, Reference Brice, Gregg and Sawyer17, Reference Hendrickx, Van Turnhout and Mortelmans21, Reference O’Sullivan, Dow and Turner24, Reference Santinha, Forte and Gomes25 this can be attributed to a lack of formal education and awareness of radiation-related events.Reference Santinha, Forte and Gomes25 Exposure risk and lack of training in PPE increased anxiety among staff members, causing hesitancy among HCWs in treating radiographically exposed patients.Reference Sellers and Ranse27, Reference Thobaity, Plummer and Williams28 Adequate training in PPE application was found to be a core competency in a review of disaster nursing practices;29 this is in line with recommendations by the World Health Organization and the International Council of Nursing (ICN), who advocate for training and rehearsals of disaster scenarios and PPE use.Reference Aoyagi, Beck and Dingwall30
Most previous studies reported that female HCWs are less likely to work unconditionally than their male counterparts are, as seen in our study during bomb attack, Ebola/HF, and dirty bombs scenarios.Reference Oerlemans, Wollersheim and van Sluisveld11, Reference Brice, Gregg and Sawyer17, Reference Santinha, Forte and Gomes25, Reference Al-Hunaishi, Hoe and Chinna31, Reference Hill, Smith and Mills32 This difference was attributed to traditional role patterns in which women are more responsible for the care of their children. HCWs with more family responsibilities, especially small children and pets, show less WTW in an emergency context.Reference Chaffee10, Reference Brice, Gregg and Sawyer17, Reference Al-Hunaishi, Hoe and Chinna31, Reference Nickell, Crighton and Tracy33 This phenomenon was corroborated by the findings of our study.
Unwillingness to work in the case of an infectious disease outbreak was based mainly on the fear of contracting an infectious disease and spreading it to family members,Reference Arbon, Cusack and Ranse9, Reference Chaffee10, Reference Thobaity, Plummer and Williams28,34 perhaps explaining why single HCWs were more willing to work during such scenarios.
Safe shelter for family and kids is an important factor in the decision to come to work during a disaster,Reference Chaffee10, Reference Hendrickx, Van Turnhout and Mortelmans21 as is the ability to communicate with family members while at work.Reference Arbon, Cusack and Ranse9 In this study, knowing that family is safe and taken care of was most important in the case of a natural disaster, bombing, or mass shooting.
Conclusions
In this study, willingness to work depended on the type of disaster, profession, and department of the HCW. Access to adequate PPE was found to be the most important condition, followed by assurance that HCWs’ families are safe. HCWs with lower perceived knowledge about a certain CBRN disaster scenario were less likely to respond to work during a disaster. Hospitals should provide adequate education and training in different crises and disasters.
Supplementary material
To view supplementary material for this article, please visit http://doi.org/10.1017/dmp.2024.333.
Acknowledgments
All authors had an equal contribution in the creation of this concept article for conceptualization and writing of the manuscript. All authors read and approved the final manuscript.
Author Contribution
LM conceived and designed the original study and survey. LMJE and DGB set up the study as described in this article. FHMvO provided advice on the study design. LE, DGB, TJTB, MIG, GHPL, JM and ÖT undertook the recruitment of participants in each corresponding hospital. LE managed the data and performed data analysis. DGB and FHMvO supervised and aided in the data analysis. LE drafted the manuscript. All authors contributed substantially to its revision. DGB takes responsibility for the paper as a whole.
All authors attest to meeting the 4 ICMJE.org authorship criteria: 1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND 2) Drafting the work or revising it critically for important intellectual content; AND 3) Final approval of the version to be published; AND 4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Competing interest
The authors declare none.
