Are Nurses at Swedish Departments of Infectious Diseases Prepared to Care for Patients With African Viral Haemorrhagic Fever? - A Survey Study


 Background: The African viral haemorrhagic fevers have in recent years been causing large outbreaks with high mortality rates and elevated risks of global spread. These outbreaks puts the Departments of Infectious diseases, both national and international, on high demand when caring for this patient group, in a patient- and staff-safe manner. The aim of the study was to describe nurses perceived ability and knowledge about caring for patients with suspected or verified African viral haemorrhagic fever at Departments of Infectious diseases in Sweden. Method: A web survey was conducted to collect data. The results are presented through a descriptive design. Participants were registered nurses working in infectious diseases clinics; 216 survey results were registered. Results: Registered Nurses in Swedish Departments of Infectious diseases clinics witnessed about having limited knowledge about the African haemorrhagic fevers. They were also experiencing limited or very limited knowledge about some practical procedures, like drawing blood samples to confirm the infection. The majority of the participants had not been given theoretical education, nor had been given the opportunity to sufficiently practice using personal protective equipment at their place of work. The nurses witnessed about fear for their own safety while caring for this group of patients. Conclusion: The participants perceived about fear, both limited theoretical and practical knowledge and training about caring for patients with African haemorrhagic fever, even though they had worked with infectious diseases for several years. There is a need for implementation of measures to ensure the healthcare professionals' safety and to prevent them from being infected with potentially lethal infections. It also poses a risk for the patient in the absence of specific nursing care, which can lead to an increased critical disease state.

Globalization leads to natural gains in economics and social benefits, but also demand consciousness 64 and knowledge about its consequences [1]. In the infectious diseases healthcare, globalization is seen 65 in various ways. Tropical diseases find their way to previously unknown territory, like Sweden, in 66 ways through global traveling and immigration [2]. Climate change does also change the common 67 areas for tropical pathogens spread [2]. Recommended PPE should be provided by the employer, including responsibility for educating the 80 staff in using PPE [4]. 81

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Since the large Ebola outbreak in West Africa throughout the years of 2014 to 2016, which caused the 83 death of more than 10 000 people [5], countries have been forced to be more prepared and create a 84 structure on through how to cope with diseases whom are not that common but have high mortality 85 [6]. A large outbreak of Lassa fever has been ongoing in Nigeria since 2016 and several patients has 86 been cared for, both suspected and verified infection, in Swedish Departments of infectious diseases 87 through this outbreak [7]. WHO reports that among the group of Lassa fever infected patients are a 88 number of caregivers included [7]. 89 90 Currently, Europe is struck hard by the Covid-19 pandemic [8]. All over the world, healthcare 91 workers struggle to get hold of PPE and other necessaries to care for the patients. In Europe, Sweden 92 was one of the countries who hospitalized and cared for a lot of patients diagnosed with Covid-19 [8]. The study was conducted as a quantative study with a deductive approach. This was an opportunity to 114 see if there were trends in data collection and to describe the extent to which the various phenomena 115 occurred, for example routines and training opportunities. The web survey was chosen as method of 116 data collection. The method, which has the advantage to reach a larger population, is self-117 administered and the participants are also given the possibility to remain completely anonymous [12]. 118

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Participants 120 Eligible participants were all nurses employed within Departments of Infectious diseases in Sweden. 121 The inclusion criteria for the participants was that they were registered nurses (RN) and worked at the 122 Departments of Infectious diseases clinics, both in-and outpatient departments. In Sweden there are 123 28 Departments of Infectious diseases, 26 of them met the inclusion criteria, which was that there was 124 a possibility that a patient with haemorrhagic fever could be admitted to the ward. Two of them were 125 excluded, one because they were specialized in highly contagious diseases and one because they did 126 not care for this patient group at all. Of these 26 departments, 18 Departments of Infectious diseases 127 chose to participate. Eight departments chose to refrain from participating. In total 603 nurses were 128 asked to participate, this was the number of nurses working in those departments. Of these 603 nurses 129 there were 216 nurses that participated in the study. The study was conducted as a web survey. The data was collected between September 16 through 133 October 21 2019. The head of the departments of the included Departments of Infectious diseases 134 were contacted through email and were asked to forward the web survey by email to their employees. 135 The study project plan and the aim of the study were attached in the email. The heads of the 136 departments received reminders twice about participating in the study. They also received reminders 7 which they forwarded to the employees about answering the study. These reminders contained 138 information about that the respondents could ignore the reminders if they had already answered the 139 web survey. 140

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The web survey 142 The authors chose a web survey with closed-ended questions as the data collection method [12]. A 143 survey in the participants' native language, Swedish, felt necessary to get as high response rate as 144 possible. The authors could not find any pre-designed survey within the topic. Therefore, the web The result was analysed through descriptive statistics, which was appropriate when the authors 160 wanted to describe the participants' views on a particular situation. To describe the results of the 161 survey, the same software was used in which the survey was designed. The software used for this 162 study was esMaker [13]. By using esMaker, every single question has been processed and statistically 163 8 analysed. Demographic data is reported in nominal scale and descriptive data regarding age and work 164 experience are described according to quota scale. The issues that described a perceived level of 165 knowledge and security were analysed and reported according to ordinal scale [14]. Collected data has 166 been typed in as quantitative data in numerical form [12]. The study participants have been informed about the purpose of the study, their anonymity and that 180 they can choose to abandon the study or cancel it if they wish. The participants of the study answered 181 voluntarily, and the answers could not be linked to any specific individual. This is required to assure 182 the participants anonymity when participating in the study and also ensure that their data is held 183 confidential [12]. This has been done by using the esMaker survey program which does not register IP 184 addresses or e-mail addresses. EsMaker encodes the participants' respective survey responses and 185 indicates only the date and time the survey is completed. In this way, it has been impossible for the 186 authors to be able to identify the participants. This has also meant that a written consent was not 187 possible to obtain.

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The research has followed the ethical considerations given for presenting a clinical research [17]. This 189 through informing about consent, choosing a relevant subject regarding the group of participants and 190 leading up to content that is useful for further studies and education. The largest group of answers was the ones of "agree" (35.6 %, n=77) followed by participants who 243 The demographic data that were collected from the participants did in some ways reflect the 301 demographics of Swedish nurses. The dividing of genders was accurate to the general nursing staff in 302 Sweden [18]. Concerning age, 40 % of the participants where younger than 30 years, which in the 303 general group of nurses in Sweden is 11 % [19]. This could mean that the participants had limited 304 years of working experience, but 32 % of the participants' reply practicing in the specialised field of 305 infectious diseases for at least 10 years. 67 % of the participants had been working in the field for 306 more than 3 years. The authors are concerned because of the fact that the nurses experienced limited 307 knowledge concerning several topics in the web survey, even though the nurses had worked with 308 infectious diseases for several years. 309

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The results of this study states that nurses that perceived having inadequate theoretical-and practical 311 practice felt insecure and had less knowledge about the haemorrhagic fevers. Almost half (45 %) of 312 the participants responded that they did not agree, nor disagree, on the claim that they had good 313 knowledge of the haemorrhagic fever. Similar results have previously been described, among others 314 The result showed that in some ways, the participants were not able to, even though they had 326 extensive working experience, live up to the standards put up by WHO and International Council of 327 Nurses (ICN) [4,22]. The majority of the nurses who participated in the survey did not receive 328 theoretical training on the haemorrhagic fever, nor did they practice PPE sufficiently to feel confident 329 in their work caring for patients. Several studies has shown that it is precisely the practical training 330 combined with increased theoretical knowledge that is the foundation for being able to safely care for 331 patients with high risk infection [10,24,25]. This has also been shown in other studies regarding 332 several other nursing fields [26][27][28][29]. As a practitioner having a specific knowledge regarding a 333 specific patient group leads to a higher clinical expectation and understanding of changes in the 334 patient's health [30]. It also means that the observation capacity is enhanced [30]. Since almost half of 335 the participants responded negatively to the claim that they have "... good knowledge about the 336 haemorrhagic fevers ..." it could mean that they have difficulty reaching a higher level of nursing 337 practice. That some experienced nurses could feel like being on a novice level can be related to 338 Benner who described different levels from novice to expert [28]. This could occur in a clinical 339 environment where the nursing of the patient is unfamiliar. For example, more than half of the 340 participants of this study answered negative to the statement that they were sure of how to screen 341 patients for African viral haemorrhagic fevers. These nurses could then be perceived as novice, even 342 though they had several years of experience working in the nursing field [31]. 343

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This study showed that more preparation is needed to take care of patients with infectious diseases in 345 order to feel safe in the situation as caregivers. The fact that participants experienced such insecurity 346 about caring for this patient group was not unexpected, it has been shown numerous times in other 347 studies [10,11,24]. It was shown that the nurses felt more secure through learning how to handle the 348 risks they were exposed to through practical experiences [24]. The WHO guidelines for PPE 349 regarding African viral haemorraghic fever clearly describe that the employer must provide both 350 information and education as well as materials [4]. WHO  showed that many governments and healthcare institutions were not prepared for the consequences of 377 a global spread of an infectious disease like this, neither guarantee the patients safety whilst caring for 378 these large numbers of patients infected [9]. The large demand on PPE, necessary treatments for 379 intensive care and biological tests created a shortage of these supplies and also illuminated challenges 380 in a pandemic situation [8]. The authors would have preferred to use a pre-designed validated survey, but since the study's 385 research area is to a level unexplored, there are no accepted measuring instruments [12]. For this 386 reason, the authors constructed questions that answered the purpose. The comprehensibility of the 387 web survey was evaluated by having an expert group read and answer the actual questionnaire. The 388 response options were designed, in addition to the demographic questions, with the response options 389 "Strongly disagree", "Disagree", "Undecided", "Agree" and "Strongly agree". This is according to the 390 Likert scale, which is a validated response scale where the participant indicates the degree to which 391 they agree with a statement. However, there is a risk when the same answer alternative repeats 392 throughout the survey that the participant's response becomes routine [12]. 393 Strengths throughout the study has been the use of an expert group, who could confirm that the survey 394 The participants perceived about fear, limited theoretical and practical knowledge and training about 400 caring for patients with African haemorrhagic fever, even though they had worked with infectious 401 diseases for several years. There is a need for implementation of measures, managemental and 402 educational interventions to ensure the healthcare professionals' safety and to prevent them from 403 being infected with possible lethal infections. It also poses a risk for the patient in the absence of 404 specific nursing care, which can lead to an increased critical disease state. Future studies are needed to 405 increase knowledge about the nursing care regarding these patients. There is also a need to study the 406 future level of implementation of practical and theoretical education in this nursing field.