Factors Associated with the Willingness of Health Care Personnel to Work During an Influenza Public Health Emergency: An Integrative Review

Abstract

Introduction

The first decade of the 21^st century has witnessed three major influenza public health emergencies: (1) the severe acute respiratory syndrome of 2002-2003; (2) the avian flu of 2006; and (3) the 2009 H1N1 pandemic influenza. An effective public health response to an influenza public health emergency depends on the majority of uninfected health care personnel (HCP) continuing to report to work. The purposes of this study were to determine the state of the evidence concerning the willingness of HCP to work during an influenza public health emergency, to identify the gaps for future investigation, and to facilitate evidence-based influenza public health emergency planning.

Methods

A systemic literature review of relevant, peer-reviewed, quantitative, English language studies published from January 1, 2001 through June 30, 2010 was conducted. Search strategies included the Cochrane Library, PubMed, PubMed Central, EBSCO Psychological and Behavioral Sciences Collection, Google Scholar, ancestry searching of citations in relevant publications, and information from individuals with a known interest in the topic.

Results

Thirty-two studies met the inclusion criteria. Factors associated with a willingness to work during an influenza public health emergency include: being male, being a doctor or nurse, working in a clinical or emergency department, working full-time, prior influenza education and training, prior experience working during an influenza emergency, the perception of value in response, the belief in duty, the availability of personal protective equipment (PPE), and confidence in one's employer. Factors found to be associated with less willingness were: being female, being in a supportive staff position, working part-time, the peak phase of the influenza emergency, concern for family and loved ones, and personal obligations. Interventions that resulted in the greatest increase in the HCP's willingness to work were preferential access to Tamiflu for the HCP and his/her family, and the provision of a vaccine for the individual and his/her family.

Conclusions

Understanding the factors that contribute to the willingness of HCP to report to work during an influenza public health emergency is critical to emergency planning and preparedness. Information from this review can guide emergency policy makers, planners, and implementers in both understanding and influencing the willingness of HCP to work during an influenza public health emergency.

DevnaniM. Factors Associated with the Willingness of Health Care Personnel to Work During an Influenza Public Health Emergency: An Integrative Review. Prehosp Disaster Med. 2012;27(6):1-16.

Introduction

Periodically, novel influenza viruses emerge and spread rapidly through susceptible populations, resulting in worldwide epidemics or pandemics.¹ The first decade of the 21^st century has witnessed three major influenza emergencies: (1) the severe acute respiratory syndrome (SARS) of 2002-2003; (2) the avian flu of 2006; and (3) the 2009 H1N1 pandemic influenza.² During a public health emergency caused by influenza, competent health care personnel (HCP) are an essential component of the health system response. Pandemic plans often specify that in addition to patient care, HCP will be involved in health education, epidemiological surveillance, quarantine management, fever clinics, and other duties.³ Thus, an effective public health response to an influenza public health emergency depends on the majority of uninfected HCP continuing to report to work, despite the risks they might face in doing so.⁴

Often it is assumed that those providing health care services have a clear duty to work, even in the face of personal risk. This duty is enshrined in the professional codes of conduct that guide HCP performance.⁵ But an influenza emergency, as with any event involving contagion or contamination, has the potential to alter the willingness of HCP to report to work for a variety of reasons.⁶ A review of the current literature regarding the willingness of HCP to work during an influenza public health emergency can provide critical information for policy makers, planners, and HCP, and can identify gaps for further research.

The purpose of this integrative review was to analyze the current evidence concerning the willingness of HCP to work during an influenza public health emergency in the 21^st century, and to identify the factors associated with their intents.

Methods

The methodology for integrative review as described by Whittemore et al⁷ and Chaffee⁸ was adopted.

Identification of Existing Reviews

A search for existing literature reviews on this topic revealed no relevant study.

Inclusion Criteria

1. 1. Research Design—Only original, quantitative designs (not qualitative designs) were included, as current methods of evidence synthesis tend to favor quantitative data only, and reviews generally do not include qualitative data.⁹

2. 2. Primary Study Participants—All health care personnel involved in the delivery of health care services were included; employment site was not a factor.

3. 3. Outcome Measure—Willingness to work in an influenza emergency/pandemic/epidemic or SARS epidemic or flu epidemic was measured. Variations of wording were accepted including “willingness to report to work,” “willingness to care for patients,” “willingness to work,” “willingness to respond,” “willingness to report,” “willingness to report to duty,” and “willingness to provide care.

4. 4. Type of Research Reports—Only peer-reviewed, published, quantitative studies were included.

5. 5. Language of Studies—Only studies written in English were included.

6. 6. Time Period—Studies published from January 1, 2001 through June 30, 2010, either electronically, ahead of print, or in print were included.

Search Strategy

Potential reports for inclusion in this review were identified through: (1) a review of the Cochrane Library (John Wiley & Sons Ltd, http://www.thecochranelibrary.com); (2) an electronic database search of PubMed (US National Library of Medicine, Bethesda, Maryland USA, www.ncbi.nlm.nih.gov/pubmed/); PubMed Central (US National Library of Medicine, Bethesda, Maryland USA, http://www.ncbi.nlm.nih.gov/pmc/); EBSCO Psychological and Behavioral Sciences Collection (EBSCO Publishing, Ipswich, Massachusetts USA, http://www.ebscohost.com/public/psychology-behavioral-sciences-collection); and Google Scholar (Google Inc., Mountain View, California USA, http://scholar.google.com/); (3) an ancestry search in which the references of each publication selected for inclusion were examined for additional relevant publications; and (4) discussions with individuals possessing a known interest in the topic. Search terms used for the electronic database searches were: “willingness,” “willingness to report,” “willingness to report, influenza,” “willingness to report, influenza pandemic” “willingness to work, influenza” “duty,” “duty to treat,” “influenza,” “flu,” “H1N1,” “influenza pandemic,” “willingness duty influenza,” “SARS,” “SARS duty,” “SARS willingness,” “influenza pandemic duty,” “influenza pandemic willingness,” and “willing.”

Screening

Research reports were screened using a three-stage process described by Gifford et al¹⁰ and Chaffee.⁸ First, the titles of articles identified through the searches were reviewed for potential relevance and either retained for additional review or discarded. Next, the abstracts of relevant articles were reviewed using the inclusion criteria, and they were then retained for further evaluation or discarded. Finally, full articles were reviewed using the inclusion criteria. The studies included in this review were evaluated further using a checklist of specific aspects of quality, reliability, and validity developed by Chaffee.⁸

Study Quality

Evaluating the quality of primary sources in the integrative review method, in which diverse primary sources are included, increases the complexity of the review.⁷ In an integrative review with diverse sampling sources, it may be appropriate to evaluate quality in a manner similar to historical research in which the authenticity, methodological quality, informational value, and representativeness of available primary sources are considered and discussed in the final report.¹¹ The reasons to suspend trust in research include technical problems brought to the reader's attention, conflicts of interest, carelessness, sampling inadequacy, lack of replication, poor scholarship, and lack of review by a refereed journal.¹² The studies included in this review did not appear to have any reasons to suspend trust in their findings, although a number did not report all of the study characteristics that are desirable.

Results

A total of 32 studies of health care personnel's willingness to work during an influenza public health emergency were identified and met all inclusion criteria for review. Key findings of these studies are listed in Table 1. The purposes, methods, and sample characteristics of these studies are listed in Table 2. Twenty-eight of the 32 studies evaluated only influenza as the independent variable, whereas four studies¹⁴ , ¹⁶ , ²⁰ , ³⁰ evaluated other variables as well.

Table 1 Key Findings in Reviewed Studies on Willingness of Health Care Personnel to Work During an Influenza Public Health Emergency

Abbreviations: CI, confidence interval; HCP, health care personnel; HCW, health care worker; ICU, intensive care unit; OR, odds ratio; PPE, personal protective equipment; SARS, severe acute respiratory syndrome.

Table 2 Purpose, Methods, and Sample Characteristics of Studies Reviewed

Abbreviations: HCP, health care personnel; HCW, health care worker; NHS, National Health System; RR, response rate; SARS, severe acute respiratory syndrome.

Thirteen (41%) of the studies were from the US, four (12.5%) were from Singapore, three (9%) each were from Australia, China, and Taiwan, two (6%) were from the UK, and one (3%) each were from Belgium, Germany, Canada, and Georgia.

The HCP included in the studies were physicians, nurses, administrators, medical and nursing students, paramedical workers, ancillary staff, emergency health care workers, home health aides, home attendants, and personal care workers. Twenty-one of the studies included more than two categories of HCP. Five studies included only nurses, two studies included only physicians, and two studies included only nurses and physicians. One study each included medical and nursing students only. Twenty-two studies reported the ethical clearance of their study.³-⁶ , ¹³,¹⁵,²⁰,²²-²⁷,²⁹,³¹-³³,³⁵-³⁷,³⁹-⁴⁰

Reliability

Two of the reports reviewed included evidence of reliability. Tzeng¹³ reported a Cronbach's α = 0.898 for all items in the health status questionnaire, and α = 0.657, 0.865, 0.922, and 0.899 for items of general health, physical health, psychological health, and social health, respectively. Tzeng and Yin¹⁹ reported a Cronbach's α = 0.899 for all items in the questionnaire, and α = 0.900, 0.827, 0.897, and 0.685 for items of physical health, psychological health, social health, and general health, respectively.

Validity

Evidence of the construct validity (ie, the confidence that the instrument used measured what it was expected to measure⁸ , ⁴¹) reported in the studies reviewed is listed in Table 3. Reports of face validity,⁸ , ⁴² content validity, construct validity, and/or criterion validity were sought specifically.

Table 3 Variables, Evidence of Reliability and Validity, and Quality Considerations of Reviewed Studies.

Abbreviation: SARS, severe acute respiratory syndrome.

Tippett et al reported that a panel of experts, including epidemiologists, infectious disease experts, and psychologists, assessed the face and content validity of the instrument used.³⁹ Tzeng reported that content validity was determined by two physicians and two nurse educators.¹³ Tzeng and Yin reported that content and expert validity evaluation was conducted by three scholars in sociology, psychology, and health care science.¹⁹ Barnett et al stated that the Johns Hopkins Public Health Infrastructure Response Survey Tool used in their study has been validated extensively in multiple national, cultural, and health care contexts, but no details were provided.⁴⁰

Garrett et al reported that the “Willingness to Work Score” tool used in their study has not been validated under real-world conditions.⁶ Shiao et al ensured the construct validity of the questionnaire used in their study, but no details were provided.²¹ Hogg et al reported pre-testing of their questionnaire by two focus groups.²⁰ Balicer et al reported that their findings fit well with their theoretical framework (indicating evidence of construct validity), but no details were provided.¹⁷ Basta et al used the instrument developed by Balicer et al.¹⁷ , ³²

No criterion-related validity was noted in any of the studies reviewed.

Evaluation of Instrument Development

New instruments were developed for use in 23 of the 32 studies included in this review. Evidence of psychometric evaluation sought included evidence of reliability and validity, stakeholders’ or focus groups’ interviews, multi-method study, and expert panel evaluation of survey items. No study described instrument development in detail.

Additional Factors Evaluated

Pre-testing

Eleven studies reported conducting a pre-test or pilot test. Four of these³,²¹ , ³⁰ , ³⁹ reported that the results of the pre-test led to instrument revision. Seven of the studies¹³ , ¹⁴ , ¹⁹ , ²⁰ , ²³ , ²⁴ , ²⁸ did not report the outcome of the pre-test or whether it was used to revise or refine the instrument or administration methods.

Use of a Theoretical or Conceptual Framework

Theories predict the presence of new phenomena and generate hypotheses that can be translated into questions that can be answered through scientific study.⁸ , ⁴³ Not using theory to guide research can leave a gap in the scientific process. Five studies described the use of a conceptual or theoretical framework¹³ , ¹⁷ , ¹⁹ , ³³ , ⁴⁰ and Wong et al reported using a conceptual framework suggested by Patel et al.³⁶ , ⁴⁴

Sampling Strategy

Eight studies used random sampling (a sampling strategy that improves external validity)⁴ , ⁵,²⁴,²⁶,²⁷,³²,³⁹,⁴⁰ and 23 used a convenience sampling strategy. The sampling method was not stated in one study.²⁵

Statistical Power

Seale et al reported a power analysis.³⁷ Balicer et al noted that the sample size of their study limited power, but no power analysis was discussed. No other studies included a discussion of statistical power.¹⁷

Selection Associated with Non-response

Four studies evaluated non-response bias and found no significant difference; the variables included were age, gender, and job classification.⁶ , ³² , ³⁷ , ⁴⁰

Social Desirability Bias

Martinase et al and Barnett et al discussed the potential for social desirability bias in their studies.²⁹ , ³³

Missing Data Management

No studies reviewed included discussions of analysis or management of missing data in the research reports.

Data Synthesis

The following factors were found to be associated with the willingness of HCP to work during an influenza public health emergency:

Age

Seale et al reported that age ≤40 years was statistically associated with reporting to work during an influenza public health emergency,³⁷ whereas Shabanowitz and Reardon reported that the age group 20-34 years was more likely to abandon work during an influenza pandemic as compared with the other age groups.³¹

Gender

All studies that evaluated gender as a correlate to willingness to report to work during an influenza public health emergency reported that being female lowers the likelihood of a respondent's willingness. Damery et al found that females were significantly less likely to work during a pandemic than males,⁴ while Butsashvili et al reported that women were more likely to discontinue work during a pandemic compared with men.²⁴ Qureshi et al found that, compared with males, females had a significantly lower likelihood of willingness to report to duty during a catastrophic disaster for most types of events including influenza pandemic.¹⁶

Race

Daugherty et al analyzed the self-reported likelihood of reporting to work during an influenza public health emergency based on race, and found that a significantly larger proportion of African-American respondents (31%) were unlikely to come to work than were whites (12%), and Asians (14%).³⁵

Marital Status

Irvin et al found no statistically significant difference between married and single respondents’ willingness to report to work during an influenza public health emergency.²⁸

Type and Location of Health Facility

Emergency prehospital medical care providers based within metropolitan regions were less willing to work during an influenza public health emergency than were those employed outside of the metropolitan regions.³⁹ Cheong et al reported that health care workers in tertiary level hospitals were less willing to care for influenza- afflicted patients as compared to health care workers in community hospitals.²²

Category of Worker

Twelve studies evaluated the association between category of health care worker and willingness to respond during an influenza public health emergency; 11 studies found statistically significant differences in willingness among different categories of staff, whereas Martinese et al did not find any differences.²⁹ The majority of the 11 studies reported a higher willingness to report to work during an influenza epidemic among physicians and nurses than other health care personnel. Damery et al reported that doctors and general physicians (GPs) were most likely to continue working during an epidemic, despite the risk.⁴ Irvin et al reported that doctors were more likely to respond to work during an avian influenza pandemic than were nurses.²⁸ Qureshi et al found that physicians and emergency medical technicians were significantly more likely to be willing to report to work during various catastrophic events as compared with nurses, administrators, and support staff.¹⁶

Area of Work

Four studies found that HCP who were working or had worked in the clinical services department, emergency department, and/or with acute medical patients were more willing to report to work during influenza emergency as compared with HCP working in technical and/or non-clinical areas.¹⁷ , ²⁹ , ³² , ³³

Type of Employment

Staff who worked part-time were less likely to work during an influenza pandemic compared with full-time workers.⁴ , ²⁹

Duration of Employment

Shiao et al²¹ reported that nurses with longer work tenure were the least likely to consider leaving their jobs during a SARS outbreak, whereas Martinese et al²⁹ did not find any association between job duration and willingness to report to work.

Education and Training

Five of the six studies that evaluated the association between education and training on the topic of influenza with willingness to work during an influenza public health emergency found a positive association,¹⁴ , ³¹ , ³⁶ , ³⁸ , ³⁹ whereas Basta et al reported that having attended pandemic influenza training in the past year was not significantly associated with willingness to report to work.³²

Past Experience with an Influenza Emergency

Tam et al reported that nurses who had previously worked during an influenza public health emergency were less likely to avoid influenza patients and to change their jobs.²³ Tzeng also found that nurses in the post-SARS group were more willing to provide care for patients with SARS than were those in the during-SARS group.¹³

Phase of Pandemic

Basta et al reported a decline in willingness to report to work with the progression of a pandemic from early phase to peak phase, and when face-to-face contact was required.³²

Value in Response

The perception of value of one's role in the overall response of an agency/department was positively associated with the HCP's willingness to work during an influenza emergency in five of the studies.¹⁷ , ²⁹ , ³⁰ , ³³ , ⁴⁰

Belief in Duty

Health care personnel who believed that they had a duty to treat were more likely to respond during an influenza public health emergency. Gullion reported that nurses’ willingness to respond was positively correlated with their agreement with the statement that “a nurse has an obligation to care for a patient.”¹⁴ The perception of a duty to work emerged as a strong predictor of potential work attendance in the study by Damery et al. Those agreeing with the statement that “all HCWs have a duty to work” were more likely to report to work than were those who disagreed.⁵ Similarly, those who agreed that “doctors and nurses have a duty to the sick” were over four times more likely to work than those who disagreed with that statement.

Infection Risk Perception

Fear of becoming infected with influenza was one of the major reasons for an unwillingness to report to duty during an epidemic, although the majority of HCP accepted a personal risk of influenza infection in the course of their work.²³ , ³⁶

Concern for Family and Loved Ones

Fourteen of the 32 reviewed studies evaluated this aspect, which emerged as a barrier to willingness to work in an influenza emergency. Basta et al reported that 72.6% of the respondents selected family health and safety as their greatest concern during peak of an influenza pandemic.³² Martinese et al reported that the existence of a pregnancy in the family was a predictor for absenteeism during a pandemic.²⁹ Damery et al found that HCP with family-caring responsibilities were less likely to report to work during an influenza pandemic compared with HCP without children or elderly dependents.⁴ Barnett et al noted a decline in willingness to work from 92-97% to 48% if there was a possibility for disease transmission to family members.⁴⁰ Garrett et al reported that concern for the safety of their family was the most significant barrier to hospital workers reporting to duty during an influenza pandemic; this concern for family safety was even more important than were personal safety concerns.⁶ Qureshi et al also noted that fear and concern for family were greater barriers to a willingness to report to duty than concern of self.¹⁶

Personal Obligations

Five studies reported that child care, elderly care, and pet care were significantly associated with willingness to report to work during an epidemic. Qureshi et al found child care (29.1%), personal health concerns (14.9%), elder care responsibilities (10.7%), pet care (7.8%), and second job obligations (2.5%) to be barriers to HCP's willingness to work during a disaster.¹⁶ Daugherty et al reported that being a primary caregiver for children or adults was a significant factor influencing the likelihood of reporting to work during a pandemic.³⁵ Damery et al found that workers who agreed that family responsibilities were important had a lower likelihood of working than those who disagreed with that concept.⁵ However, Irvin et al reported no statistically significant difference in the proportion of respondents with children <18 years old that would report to work as usual, compared with those without children who would report to work as usual.²⁸

Availability of Personal Protective Equipment

When comparing groups who were likely to report to work with those who were not likely to report to work during an influenza epidemic, Daugherty found no significant differences in the proportion of respondents who thought protective measures would impact their likelihood of coming to work.³⁵ But findings from other studies indicate that personal protective equipment (PPE) was considered to be important by workers and the availability of PPE was associated with a willingness to work during an influenza emergency.¹³ , ²¹ , ²⁸ - ³⁰

Confidence in Employer

Tippett et al reported that an increased willingness of HCP to work during an influenza emergency was associated with high confidence in their employer.³⁹

Knowledge of the Pandemic Plan

Health care personnel who had read one of the pandemic influenza plans were more likely to be willing to respond during an emergency.³² The self-described likelihood of reporting to work during an influenza emergency was associated with the HCP's familiarity with one's role-specific response requirements.¹⁷ , ⁴⁰ Incomplete knowledge of the pandemic plan was associated with work avoidance.³,⁴⁰

Influenza and Other Types of Disasters

Qureshi et al compared the willingness to respond in different disaster settings and found that HCP were least willing to report to work during a SARS event as compared with disasters from other events such as a snow storm, environmental event, radiation, smallpox, or chemical event.¹⁶ Kaiser et al also reported that medical students were more likely to respond to a disaster from a natural cause than to an influenza pandemic.³⁰

Persuadability and Interventions

Damery et al examined the “persuadability” of those HCP who indicated a <100% likelihood of working during a pandemic by assessing their response to 12 proposed interventions or changes in work conditions.⁴ The findings indicate that that nearly 70% of the proposed interventions would persuade HCP to continue to work during a pandemic. The demographics of the groups that were most persuaded by the interventions included those in the 16-30 years age group; community HCP; HCP living in households without children; and HCP living with parents or relatives. Groups that were least persuaded by the proposed interventions were nurses and HCP living with friends. The most influential interventions were the provision of vaccination for oneself and one's family, followed by the provision of personal protective equipment, and having employers share emergency plans with their HCP.

Interventions that would provide incentives or employee safeguards also were recognized as being potentially beneficial. These interventions included having employers accept liability for any mistakes made; being able to work flexible hours; receiving a financial bonus commensurate with the level of extra duties an individual may be asked to perform; and the provision of life/disability insurance. Garrett found that the intervention with the greatest increase in the HCP's willingness to work was preferential access to Tamiflu for the HCP and his/her family.⁶ Daugherty et al reported that 76% of respondents felt that the provision of a vaccine for themselves and their families would influence their decision to come to work during an influenza emergency.³⁵ In the same study, 70% of the respondents reported that antiviral prophylaxis would be important, while only 50% indicated that the availability of protective masks for use at home would influence their decision.

Discussion

The majority of the studies on the willingness of HCP to work during an influenza public health emergency have been conducted in the United States. This is followed by studies from Singapore, Taiwan, and China, countries that were affected severely during the avian flu and SARS epidemics. Surprisingly, no study was found to be from Mexico, the epicenter of the 2009 influenza pandemic. Similarly, no studies from Latin America and Africa have been reported. The willingness of HCP to work during an influenza public health emergency has been scrutinized by multiple disciplines (medicine, public health, nursing, intensivists, anesthetists, emergency management). The inclusion of multinational and multidisciplinary health care team participants in future studies may help to establish global evidence.

The seminal work by Tzeng in 2004 was important, as it included the development of a conceptual framework for study, and provided evidence of both reliability and validly.¹³ These factors contributed to the soundness of the study and its findings. Only three subsequent studies described the use of a conceptual framework. Tzeng found that nurses in the “post-SARS group” (ie, having had experience caring for SARS patients) indicated a greater willingness to provide care for patients with SARS than did those who were in the “during-SARS group.”¹³ Tam et al concurred with these findings and reported that nurses who had previously worked during an influenza public health emergency were less likely to avoid caring for patients with influenza.²³ Understanding the factors that might influence the HCP's willingness to report to work during an influenza epidemic is essential for preparedness planning. This review reveals various factors associated with a willingness to work during influenza emergency: being male, being a doctor or nurse, working in a clinical or emergency department, working full-time, prior influenza education and training, prior experience of working during an influenza emergency, the perception of value in response, the belief in duty, the availability of PPE, and confidence in one's employer. Factors found to be associated with less willingness were: being female, holding a supportive staff position, working part-time, the peak phase of the influenza emergency, concern for family and loved ones, and personal obligations. Being African-American was reported to be associated with a reduced willingness in one study,³⁵ but the association between race and willingness to work requires further research. Neither the marital status nor the seniority of the HCP was associated with willingness to work.²⁸ , ²⁹ Any association between age and HCP's willingness to work was not clear as study results were conflicting. Although age ≤40 years was associated with reporting to work during an influenza emergency in one study,³⁷ findings from another study indicated that HCP in the age group of 20-34 years were more likely to abandon work during an influenza pandemic as compared with the other age groups.³¹

With regard to professional discipline, two studies¹⁶ , ²⁸ found that doctors were more likely to report to work than were nurses. However, this difference was not evident in the study by Martinese et al.²⁹ Nurses also were found to be the least persuaded by various work-related changes or interventions.⁴

The concern for family and loved ones emerged as a barrier to the willingness to work, and even exceeded personal safety concerns according to two studies.⁶ , ¹⁶ This was corroborated by the findings that the provision of vaccination for family,⁴ , ³⁵ and preferential access to Tamiflu for family members were the most influential interventions to improve work willingness.⁶ Other interventions associated with improvement in willingness to work were: the provision of PPE, bonus salary, insurance, and flexible hours. This provides valuable information about beneficial interventions to be targeted towards those HCP who initially are less willing to work during an influenza emergency, and who may constitute a substantial portion of the workforce. Sharing the emergency plans and protective programs with employees before an event occurs also improves the confidence of workers in their employer.

In comparing the willingness of HCP to report to work in different disaster settings, it emerged that HCP were less willing to work during an influenza emergency than during a disaster from other natural events and other causes such as radiation, chickenpox, and chemical events. The reasons for this were not elucidated from these studies and require further investigation. However, this finding emphasizes the need for health care authorities to be more concerned about the absenteeism of HCP during influenza public health emergencies than during a disaster from any other event.

It is hoped that the results of this integrative review will strengthen the methods used in future studies of the willingness of HCP to work in influenza emergencies. Such studies could be strengthened by: (1) the inclusion of a clear sampling strategy; (2) evidence of reliability and validity; (3) the use of conceptual frameworks; and (4) descriptions of pre-testing procedures and results. Details of the data collection instrument development also are helpful for researchers considering replication of a study.

The actual behavior of HCP in real situations may or may not be the same as that reported in the studies reviewed, and thus, the findings require cautious interpretation. The rate of HCP absenteeism during an influenza epidemic could be much higher, or possibly lower. Nonetheless, this integrative review provides valuable information regarding the barriers to HCP willingness to work during an influenza public health emergency and the appropriate actions required to improve their response.

Limitations

Despite an extensive search, it is possible that one or more studies may have been missed as the topic pertains to multiple disciplines and studies could appear in a wide variety of publications. Studies in languages other than English also may exist.

Conclusions

Influenza public health emergencies have increased in frequency in the 21^st century and will continue to be a challenge to health care systems. This integrative review has revealed valuable information on the issue of the willingness of HCP to work during influenza public health emergencies, a crucial factor in providing an efficient and effective health care response. The findings documented in this review help us to understand and address the issue of willingness of HCP to report to work during influenza public health emergencies.