Abstract
Nurses are the largest group of health care providers and, therefore, are often at the forefront of epidemics: responding, treating, educating, and coordinating care as needed. But what happens when nurses are afraid of contracting an illness and decide to leave the workplace? The fear due to Ebola was in part caused by conflicting information around the proper use of personal protective equipment and need for quarantine. The nursing response to as well as the role occupational health nurses can play in diffusing the fear of contracting contemporary infectious diseases are discussed.
Keywords
The Ebola virus disease (EVD) has been causing infection and death in humans for decades. Only now, due to globalization, are infected individuals in the United States causing anxiety in the general public and the health care workforce. Advances in technology have linked individuals in ways that will likely increase global connections in years to come. Similar to the Swine influenza, Ebola has taught a global lesson: What affects one has the potential to affect all.
The Ebola virus had been devastating West Africa for months when a Liberian man traveling from an infected region introduced the disease to the United States. The man later died from the virus but not before infecting two nurses who cared for him. Once the media became involved in this unfortunate situation, fear took hold throughout the country, posing a unique challenge for occupational health nurses.
Relevance of EVD to Occupational Health Nursing
Because a fundamental role of the occupational health nurse is to protect workers employed in a wide variety of industries who could potentially be affected by EVD, these nurses must be involved in planning for infectious disease outbreaks whether the disaster plan is for a workforce or the entire community. Occupational health nurses may be responsible for airline workers, health care providers, hospital linen service personnel, or funeral home employees. Therefore, occupational health nurses must be knowledgeable about emerging infectious diseases, using evidence-based principles to protect individual workers.
Background and Epidemiology
The Ebola virus belongs to the Filoviridae family of linear, negative sense, single-strand RNA viruses (Henderson & Campbell, 2015). Five Ebola virus species have been identified, four of which are known to cause disease in humans: Zaire, Sudan, Taï Forest, and Bundibugyo. The fifth species, Reston, has caused disease in nonhuman primates (Centers for Disease Control and Prevention [CDC], 2015). First described in Zaire in 1976, the EVD has made several small appearances with fewer than 500 cases per outbreak. In contrast, the Zaire Ebola virus epidemic presently devastating Western Africa has resulted in more than 10,000 confirmed deaths and has a case-fatality rate of approximately 70% (Henderson & Campbell, 2015).
It is thought that fruit bats of the Pteropodidae family are natural hosts; consequently, EVD was introduced to humans via close contact with the body fluids of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines (World Health Organization [WHO], 2015).
Human-to-human contagion occurs by direct contact with body fluids of infected individuals and with surfaces and materials (e.g., bedding and clothing) contaminated with these fluids. No evidence exists of sexual transmission of EVD, but it is advised that abstinence be maintained for several weeks post-infection or male and female condoms be used if necessary (CDC, 2015).
Symptoms of EVD include fever, fatigue, muscle pain, headache, and sore throat, followed by vomiting, diarrhea, rash, symptoms of impaired kidney and liver function, and, in some cases, both internal and external bleeding (e.g., oozing gums and bloody stools). Humans are not considered infectious until they develop symptoms which may appear anywhere from 2 to 21 days after exposure. Confirmation of EVD is made using several tests including antibody-capture enzyme-linked immunosorbent assay (ELISA), reverse transcriptase polymerase chain reaction (RT-PCR) assay, and virus isolation by cell culture. Treatment is supportive and depends on timing and the individual’s immune response (WHO, 2015). Individuals who recover from EVD develop antibodies that can persist for 10 years; however, it is not known if these individuals are completely immune to the virus or could become infected by another species of Ebola virus (CDC, 2015).
Two new Ebola vaccines have been found to protect monkeys against the Zaire strain of the virus responsible for the current outbreak; these vaccines require only one dose and have no apparent side effects. Created by Profectus BioSciences, the highly anticipated vaccine will not likely be approved before 2017; safety trials began this summer on healthy human volunteers (Grady, 2015).
Review of Relevant Literature
The introduction of an unknown is uncharted territory and may be met with a host of emotions. Fear can have negative consequences that result in a release of stress hormones; stress hormones can impair mental functioning and memory and diminish performance. These energy-draining emotions are costly and inefficient; they negatively affect the individual as well as those around them (Horton-Deutsch, 2015).
Nurses are often the caregivers who spend the most time with patients; therefore, they must be vigilant to ensure patient safety and comfort. Fear is sometimes the result of lack of knowledge as the news of Ebola in the United States spread quickly via the media. However, for the nursing community, lack of knowledge may not have been the only problem. In October 2014, when the first cases of EVD appeared outside of West Africa, an editorial criticizing the inconsistent respiratory protection guidelines for health care workers was published by the
Another factor that added to fear within the nursing community was the inconsistent use of quarantine. According to CDC, quarantine is used to separate and restrict the movement of individuals who have been exposed to a contagious disease to evaluate and assess their potential for disease development. It is a public health measure that limits the introduction of infectious diseases into the United States and prevents contagion (CDC, 2015). In the United States, conflicting policies led to a nurse, after returning from treating Ebola patients in West Africa, being quarantined in a tent next to a New Jersey hospital and later at her home, while other returning health care workers roamed unrestricted, including a physician in New York City who later tested positive for Ebola. Similarly, the U.S. ambassador to the United Nations returned from an Ebola-stricken country and was simply placed under public health monitoring; returning U.S. military troops were quarantined for 21 days (Koenig, 2015).
The federal government has the authority, granted by the U.S. Constitution, to quarantine individuals; the task of implementing this authority is delegated to the CDC. Public health authorities often seek help from law enforcement officers to enforce a public health order. Viral hemorrhagic fevers (e.g., EVD), plague, cholera, smallpox, and yellow fever all require quarantine, so breaking a federal quarantine order is punishable by fines and imprisonment (CDC, 2015).
So, if the law is so clear on the reasons and concept of quarantine, why was the application of quarantine in this case seemingly unreasonable? Aside from the obvious violation of civil rights associated with unnecessary quarantine, health care workers could have been deterred from treating Ebola patients in their home countries and unwilling to travel to the source of the disease to assist in disease eradication (Koenig, 2015). Although many health care providers cope with potential or real threats to their health, lives, families, and careers daily, ambiguity and inconsistency surrounding the introduction of EVD to the United States led some health care workers to protect themselves and their families (Jackson, 2015). Unfortunately, some protection strategies were ineffective, and providers simply withdrew from practice (Jackson, Lowton, & Griffiths, 2014).
The American Nurses Association (ANA) states that nurses are obligated to offer nondiscriminatory and respectful care to all individuals; nevertheless, they do acknowledge the boundaries of acceptable personal risk that nurses are ethically expected to tolerate. They advise nurses to promptly voice concerns to and seek a resolution with their employers if they are at risk when providing care to any patient. According to ANA, nurses have the right to refuse an assignment if they do not feel adequately prepared or they do not have the necessary equipment to care for a patient (ANA, 2015).
Implications to Occupational Health Nursing
In an effort to address the fears and anxiety present in health care facilities and the community, the occupational health nurse must be strategic. First, to address the fundamentals of EBV transmission, the occupational health nurse must use appropriate infectious disease guidelines to ensure that all workers understand the disease, how it is transmitted, and the precautions necessary to protect themselves and others. The occupational health nurse must ensure that all workers have current knowledge, skills, and personal protective equipment to render their roles safely and effectively (Nickitas, 2014). Education should also extend to organization leadership so that evidence-based policies and procedures are developed and implemented (Koenig, 2015).
Next, the occupational health nurse must communicate CDC’s most recent guidelines, reminding employees that their recommendations are based on the best science at the moment and often evolve over time (Horton-Deutsch, 2015). Policies and procedures should ensure avoidance of legal ramifications of providing or refusing to provide care for EVD patients.
The occupational health nurse should also maintain open lines of communication, supporting effective interactions, teamwork, and staff resilience by controlling fear. Taking time to listen to staff concerns, including what is being said and what is not being said, is the essence of establishing a nursing relationship. Communicating without judgment fosters trust, and periodically confirming what is being heard ensures mutual understanding and respect. Occupational health nurses can offer additional support by acknowledging the stress and fear related to treating EVD patients. Offering stress-reduction programs focused on deep breathing or mindfulness can build physical, emotional, mental, and spiritual resilience to prepare for, recover from, and adapt to these emotions (Horton-Deutsch, 2015).
Finally, the occupational health nurse can act as a spokesperson, not only for the employees but also for the nursing profession. The nurse can present evidence-based information to employers and employees. For example, in the months following the EVD outbreak in the United States, the media reiterated “facts” that sustained fears regarding Ebola, including some negative ideas about the nursing profession. The ANA responded with elegance as President Cipriani dispelled myths and clarified what was known about Ebola via interviews on several national networks and multiple press releases. Nurses must be involved in health care issues to correct misinformation brought forward by the news media which can negatively affect the public’s trust in the nursing profession due to unfounded claims (Lamprecht, 2015).
Summary
With the introduction of EVD to the United States, society witnessed the full spectrum of emotions. Some were associated with fear, such as decisions to ignore scientific knowledge in favor of emotional overreaction and some were linked to heroism, such as the selfless volunteerism of some nurses to care for patients who might present with EVD (Cipriano, 2015). In the end, what is known is that nurses were present and were heard. As the largest group of health care providers, nurses must stay engaged to ensure appropriate attention to protection and education occurs for the good of the nation (Nickitas, 2014). Education must include not only protection from the threatening agent but also tools for equipping against strategies to cope with the psychological effects of confronting this deadly virus.
The Ebola epidemic has brought nurses into the national conversation about how to handle this public health threat (Nickitas, 2014). Because they were able to rise to the occasion, nurses are guaranteed a seat at the table the next time a dangerous epidemic strikes.