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In response to a public health emergency

Senior clinical nurses can effectively contribute to the pandemic influenza public health response. Annie May reports.

On 24 April, 2009 the World Health Organisation advised of an outbreak of a new strain of flu – H1N1 Influenza 09, to become commonly known as swine flu.

The outbreak began in the Mexico state Veracruz, with evidence that there had been an ongoing epidemic for months before it was officially recognized as such. The Mexican government closed most of Mexico City’s public and private facilities in an attempt to contain the spread of the virus.

However, it continued to spread globally, and clinics in some areas were overwhelmed by infected people.

While in Australia the H1N1 pandemic of 2009 was milder than anticipated – according to Department of Health and Ageing figures there were 37,636 cases of pandemic (H1N1) influenza, including 191 associated deaths – public health systems were still required to surge to cope with the number of suspected pandemic cases and contacts involved and to maintain an effective response over the protracted ‘Contain’ phase.

Public health surge capacity described as the capacity to implement core public health activities. These activities include: liaising with treating clinicians about suspected and confirmed cases; confirming that suspected cases meet a case definition and determining their likely source of infection and contacts potentially placed at risk during their infectious period, advising on case isolation, quarantining of contacts, and initiating other appropriate public health action to mitigate further transmission.

Making the shift from individual and clinically-based disaster care to population-based care may prove a major challenge during public health infectious pandemics.

There are currently no clear guidelines on who should be utilised as public health surveillance surge capacity during a public health emergency. There are also no guidelines on how they should be trained.

One group that have been suggested as being ideal surge staff are senior clinical nurses sourced from areas defined as not clinically critical during the early containment phase of an influenza pandemic response, such as clinical consultants, nurse educators and nurse managers.

Testing this theory, researchers from NSW conducted a field exercise over four days in a regional area of the state that included presentation of suspected pandemic cases at 36 emergency departments, with 170 contacts identified. Fifty four senior nurses were deployed from their usual roles and rotated through operational public health surveillance teams over the four days of the exercise. The exercise was held at the end of 2008, before the 2009 pandemic.

The exercise aimed to test: the capacity of the regional area’s EDs to identify a person with suspected pandemic influenza, triage appropriately and complete case management; the use of surge workforce in the Public Health Unit and the processes to engage, roster, and support the identified surge staff; and the use of an on-line training package to prepare surge staff for the various roles.

Publishing their findings in the recent issue of the Australian Journal of Advanced Nursing, the authors said the exercise demonstrated that senior nurses were able to rapidly build on their existing skill base to function effectively in providing public health surveillance functions under the leadership of public health experts.

While at the beginning of the deployment period surge staff were reliant on experienced public health team leaders, as the day progressed they began competently taking responsibility for activities and functioning independently.

“Senior nurses are already experts in their field, and are thus able to rapidly prioritise tasks. While the nurses were placed in an unfamiliar work environment, their existing daily skills – including communicating with patients and families, undertaking assessments, decision making based on findings, dealing with medication and working in stressful environments – appeared to prepare them well for the deployment,” said the authors.

“The skills and confidence developed during the exercise were demonstrated during the 2009 first wave of the influenza A H1N1 (pH1N1) pandemic response when the same clinical nurse consultants, nurse educators and nurse managers performed as the public health surge workforce.”

In a questionnaire completed at the end of the exercise, participants indicated it was a positive experience and that they would be willing to perform these functions during a pandemic.
Perceived knowledge and familiarity with pandemic influenza increased following the exercise from 46 per cent to 93 per cent, as did participants’ self-reported ability to communicate with the public concerning an influenza pandemic (from 30 per cent to 86 per cent).

Confidence to perform duties and to work safely in their new environment also increased (from 46 per cent to 90 per cent and from 36 per cent to 86 per cent.

Access to the pre-exercise on-line training package was helpful, however the consensus was that more practical training was needed.

The package consisted of 13 modules including: an introduction to pandemic influenza; what is happening to prevent or control pandemic influenza; stress; infection control; surveillance; contact assessment and contact management.

The package took about four hours to complete and could be accessed via the internet or was available on CD.

Nurses taking part in the exercise recommended that improved role definition, possibly supported by role playing, would be helpful. Many reported limited available time to complete the online package prior to deployment due to their existing job responsibilities.

Another issue, said the authors, that has to be looked at is that while senior nurses may be asked to respond during an influenza pandemic, they also must be willing and able to report to work.

“For many, while they have the underlying skills needed, they are not experts in the area of communicable disease, reducing their confidence to deal with the situation. Research concerning the willingness to report to work indicates about 16 per cent of public health employees are not willing to report to work during an influenza pandemic in the United States of America and 33 per cent of front line health workers would not report to work in a similar study in Australia because of perceived increased risk to themselves or their families,” the authors said.

The field exercise appeared to change specific surge staff perceptions towards working during an influenza pandemic.

“The field exercise used in this study has shown that providing training and then putting the training into action is an appropriate strategy.

“While the training package requires some alteration it served as a good reference for the surge staff involved, but by itself appeared inadequate to effectively train surge staff alone.”

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