key: cord-1039729-5fwqogql
authors: Gibbons, Emily; Stein, Cory; Springer, Jennifer; Roemhild, Emily; Meadows, Emily; Dowling, Jamie
title: Knowledge, Attitudes, and Beliefs of Pediatric Healthcare Workers: Understanding the Response to COVID-19
date: 2022-04-06
journal: J Pediatr Health Care
DOI: 10.1016/j.pedhc.2022.04.002
sha: 212329eccb19299dd3ea3fc94b00985f8aae26ed
doc_id: 1039729
cord_uid: 5fwqogql

Introduction : This research aims to assess knowledge, attitudes, and beliefs of PHCW regarding COVID-19. Methods : Data collected using an electronic survey sent to PHCW. Results : Age was not likely to influence willingness to care for patients with COVID-19. Males were more likely to be willing to care for patients than female. Nurse practitioners were more likely to be willing to care for patients with COVID-19 than physicians. Availability of proper PPE, COVID-19 knowledge, and training did not influence willingness to care for COVID-19 patients. Healthcare workers with a higher risk of COVID-19-related sickness, and who received most of their COVID-19 information from social media, were less likely to be willing to care for COVID positive patients. As perception of hospital preparedness increased, reluctance to care for COVID-19 positive patients decreased. Discussion : Hospital preparedness and social media exposure play a significant role in willingness to care for patients with COVID-19.

The COVID-19 pandemic has altered our way of life for the unforeseeable future. As we learn more about transmission and prevention of the disease, healthcare workers have arguably been the most impacted. Caring for those sickened by COVID-19 has placed a strain on the healthcare workers, who are on the front lines combating the disease and treating those infected. There is fear that treating infected patients increases the healthcare worker's risk of infection and may alter the worker's willingness to participate in providing care to this population. Understanding the attitudes of healthcare workers regarding COVID-infected patients will allow for better education and protection of these workers and help to reduce occupational-related transmission risk. Additionally, studying healthcare workers' attitudes related to the caring for victims of the pandemic can help assess if workers are ready and willing to provide the appropriate care. For the purpose of this research, healthcare workers will refer to those who provide pediatric healthcare to pediatric patients in the hospital setting; for this study, that included nursing staff, hospital management, respiratory therapy, radiology, child life, physicians, and social workers.

To better understand this, a look into how healthcare attitudes changed during previous pandemics can help to approach the unknown during the COVID-19 outbreak. Literature addressing attitudes among healthcare workers during the following pandemics was reviewed:

HIV, influenza A/H1N1, and SARS. Research found that the attitudes of the healthcare workers improved as they treated more HIV patients and gained experience with the disease. Once a healthcare worker had cared for an HIV patient, their attitudes became much more favorable (Berkowitz & Nuttal, 1996) . SARS is most like COVID-19 since both are spread through airborne transmission. Most workers believed that washing hands often, wearing N-95 masks, and using negative pressure isolation rooms was highly effective in helping to prevent spread.

Yet, the need for reminders to wash hands as well as to use personal protective equipment has increased since the practical use of these often-steered people away due to time consumption and discomfort (Parker & Goldman, 2006; Imai, Takahashi, Hasegawa, Lim, & Koh, 2005) .

Healthcare workers dealing with H1N1 and SARS most prevalent concerns were infection of family and friends along with the health consequences of contracting the disease. Research at that time found that there were high levels of psychological distress including a moderate to high degree of anxiety among workers treating these diseases (Gouila et al., 2010) . For all three pandemics, there was a fear and anxiety of acquiring these diseases through their patients, but this did not stop the workers from caring for these affected populations (Goulia et al., 2010; Berkowitz & Nuttal, 1996; Parker & Goldman, 2006) . However, the attitudes were improved if the healthcare workers believed there was less perceived risk of infection through occupational exposure (Berkowitz & Nuttal, 1996) . As more research emerged and a better understanding developed, attitudes of healthcare workers began to improve, leading to more open-minded and empathetic care for patients (Kok, Guvenc, & Kaplan, 2018; Albano, Matuozzo, Marinelli, & Di Giuseppe, 2014; Person, Sy, Holton, Govert, & Liang, 2004) . It is important to consider the attitudes of healthcare workers because of the direct impact attitudes have on behaviorsif healthcare workers have a positive attitude regarding their job, patient, employer, etc., they could be more likely to provide quality care (as suggested in the cited studies above: Kok, Guvenc, & Kaplan, 2018; Albano, Matuozzo, Marinelli, & Di Giuseppe, 2014; Person, Sy, Holton, Govert, & Liang, 2004) . Extrapolating from the ideas of these previous studies, the goal of this study is to assess pediatric healthcare workers' (PHCW) knowledge, attitudes, and beliefs about COVID-19.

The study was conducted between November 9 th , 2020 through January 4 th , 2021 at a children's Hospital in Toledo, Ohio. COVID-19 cases were on the rise during this period and PHCWs were beginning to have greater interactions with COVID-19 positive patients. The survey was taken either before or right as the vaccine had become available to healthcare workers, so vaccination was not included within the questions. A 34-item survey was created and disseminated via the online service SurveyMonkey. The survey was designed specifically for PHCWs to gauge their knowledge, attitudes, and beliefs about COVID-19.

The survey questions were chosen based on a review of the literature involving HIV, influenza A/H1N1, and SARS outbreaks as well as the ideas of the authors. Seventeen questions were multiple choice, six questions were yes/no statements, three questions were yes/no/not sure statements, one question was a simple true/false statement, five questions were scored on a 5point Likert scale from strongly disagree (1) to strongly agree (5) or not effective (1) to extremely effective (5), and two questions were scored using a 10-point Likert scale from no stress (0) to extreme stress (10) or not at all infectious (0) to extremely infectious (10). The items were divided into five domains: demographics, knowledge of COVID-19, attitudes regarding COVID-19, behaviors, and beliefs.

IRB approval was obtained and was found to be exempt.

An email was sent to the nursing and departmental directors to ask for permission to send the survey out to their personnel. All contacted departments agreed to participation. The surveys were distributed electronically via email with weekly reminder emails sent by nursing and departmental directors. A description of the survey and informed consent were included in the email. Personnel in nursing (general nurses and nursing aides), hospital management, respiratory therapy, radiology, child life, general pediatric floors and pediatric subspecialties (physicians/faculty, which consists of medical doctors who have an academic title of faculty, and nurse practitioners), and social work were questioned. This combined population was grouped as pediatric healthcare workers (PHCWs). Overall, 610 PHCWs were sent the email and 256 healthcare workers responded, providing a 42% response rate. Deidentified surveys were collected online. Participation in these surveys was voluntary, but encouraged by nursing and department directors. There was a statement provided at the end of the survey that directed participants to contact their primary care physician or employee assistance program if they experienced emotional distress while participating in the study.

All study hypotheses were evaluated using SPSS version 25. The present study was designed to examine multiple hypotheses falling under four aims. The first aim of the present study was to examine demographic factors that may influence healthcare workers' willingness to care for COVID-19 positive patients. Three hypotheses fall under this aim, denoted 1.1, 1.2, and 1.3.

Hypothesis 1.1 states that healthcare workers' willingness to care for COVID-19 patients differs by occupational role. Hypothesis 1.2 states that healthcare workers' willingness to care for COVID-19 patients differs by healthcare worker age. Hypothesis 1.3 states that healthcare workers' willingness to care for COVID-19 patients differs by healthcare worker gender.

Hypotheses 1.1 and 1.2 were examined via between-subjects ANOVA tests with post-hoc analyses to examine significant group differences. Hypothesis 1.3 was examined using a t-test to compare the means between male and female healthcare workers on willingness to care for COVID-19 patients.

The second aim of the present study examined the role of healthcare worker perceptions of training and preparedness on willingness to care for COVID-19 positive patients. Two hypotheses fell under this hypothesis, denoted 2.1 and 2.2. Hypothesis 2.1 states that being provided proper PPE will influence healthcare workers' willingness to care for a COVID-19 patient. This hypothesis was evaluated using an independent samples t-test. Hypothesis 2.2 states that receiving training on caring for patient with COVID-19 will influence healthcare workers' willingness to care for a COVID-19 patient. Hypothesis 2.2 was also evaluated by conducting an independent samples t-test.

The third aim of the present study was to examine the influence of healthcare workers' knowledge and attitudes in their willingness to care for COVID-19 positive patients. Two hypotheses fall under the third aim, denoted 3.1 and 3.2. Hypothesis 3.1 states that healthcare worker knowledge of COVID-19 will impact their willingness to care for COVID-19 positive patients. Hypothesis 3.2 states that healthcare workers' perceptions of their institution's preparedness would correlate with healthcare workers' stress levels due to COVID-19.

Hypothesis 3.1 was evaluated by conducting a linear regression to ascertain if knowledge predicted willingness to care and hypothesis 3.2 was evaluated by conducting a correlation analysis.

The fourth aim of the present study was to examine factors that influence healthcare workers' willingness to care for a COVID-19 positive patient. Three hypotheses fall under this aim, formed by social media will impact their willingness to care for a COVID-19 positive patient.

Hypothesis 4.2 states that having taken care of or being exposed to a patient with COVID will be correlated with making changes to home-life scenarios. Both 4.1 and 4.2 were examined using correlation and linear regression analyses if significant. Hypothesis 4.3 states that being personally diagnosed or knowing someone close who was diagnosed with COVID-19 will be related to making changes to home-life. This hypothesis was examined through conducting a chi square analysis.

The fifth aim of the present study was to examine perceptions of "self-risk" and hospital preparedness in willingness to care for COVID-19 patients. Two hypotheses fall under this aim, denoted 5.1 and 5.2. Hypothesis 5.1 stated that healthcare workers' beliefs of "self-risk" would impact their willingness to care for a patient and hypothesis 5.2 stated that the healthcare workers' perception of hospital preparedness would impact their willingness. Both hypotheses were evaluated by conducting correlation and linear regression analyses. Under aim 3, hypothesis 3.1 stated that knowledge of COVID-19 would impact healthcare workers' willingness to care for COVID-19 positive patients. Our hypothesis was not supported as knowledge of COVID-19 did not predict healthcare workers' willingness to care for COVID-impacted healthcare workers' decisions to not work with a COVID-19 patient if given the option.

This relationship was also not significant, F(1,227)=.682, p=.410. Hypothesis 3.2 stated that healthcare workers' perceptions of institutional preparedness would be associated with their stress levels due to COVID-19. Our hypothesis was supported as there was a significant negative correlation between perceptions of institutional preparedness and stress levels, r=-.25, p<.001.

Further, the results suggest that the higher the perceptions of institutional preparedness, the lower the stress levels.

For aim 4, we hypothesized (4.1) that healthcare workers' beliefs of COVID-19 formed by social media would impact their willingness to care for a COVID-19 positive patient. Our hypothesis was supported such that there was a significant positive relationship between beliefs of COVID-19 formed by social media and one's willingness to care for a COVID-19 positive patient, r=.16, p=.042. Thus, those who believed that social media formed their beliefs around COVID-19 were more unwilling to care for a COVID-19 patient. Participant sex F(4,153)=.52, p=.719, age F(4,154)=2.31, p=.061, and healthcare worker role F(3,158)=1.66, p=.177 did not significantly or differentially change how healthcare workers perceived social media influencing their beliefs and views of COVID-19. Thus, no study parameters measured had an affect on the influence of social media on COVID-19 beliefs. Additionally, beliefs of COVID-19 formed by social media significantly predicted healthcare worker's willingness to care for a COVID-19 positive patient, F(1,157)=4.22, p=.042. Additionally, healthcare workers' whose beliefs about COVID-19 were formed by social media were also more likely to not care for a COVID-19 patient if they had the option, r=.21, p=.008. Similarly, beliefs of COVID-19 formed by social media significantly predicted a healthcare worker's decision to not care for a COVID-19 patient if they had the option, F(1,157)=7.30, p=.008. Hypothesis 4.2 stated that having taken care of or being exposed to a patient with COVID will be correlated with making changes to home-life scenarios. Our hypothesis was not supported as there was not a significant correlation between the two variables, r=.03, p=.663. Hypothesis 4.3 stated that being personally diagnosed or knowing someone close who was diagnosed with COVID-19 will be related to making changes to homelife. A chi-square test was conducted due to the categorical nature of the predictor variable. Our hypothesis was not supported, χ 2 (16, n=223)= 14.36, p=.572.

For aim 5, hypothesis 5.1 stated that respondents' perceptions of "self-risk" would impact their willingness to care for a COVID-19 positive patient. Our hypothesis was supported such that respondents who perceived higher levels of "self-risk" were also more likely to feel reluctant in working with a COVID-19 patient, r=.22 p=.001. Further, perceptions of "self-risk" significantly predicted healthcare workers' willingness to treat a COVID-19 positive patient, F(1,219)=11.47, p=.001. Lastly, hypothesis 5.2 stated that healthcare workers' perceptions of hospital preparedness would impact their willingness to care for COVID-19 patients. Our hypothesis was supported as the results suggest that as healthcare workers' perceptions of hospital preparedness increased, their reluctance to treat a COVID-19 patient decreased, r=.17 p=.010. Further, healthcare workers' perception of hospital preparedness was a significant predictor of their willingness to care for COVID-19 patients, F(1,219)=6.71, p=.010.

One finding that the authors found particularly relevant to today's climate is the impact of social media on PHCW's perception of COVID-19 and how it affected their willingness to care for COVID-19 patients. The social media platforms investigated included Facebook, Instagram, Snapchat, and Twitter. Social media has become a large influence in shaping peoples' opinions on all topics. At the institution surveyed, the more information gained through social media about COVID-19 led to a decreased willingness to care for COVID-19 patients. This is significant because social media does not have a filter between true and false information, which can cause biased options and skew the mindset that people gain on various topics (Gralinski, Menachery, 2019; Karasneh, Al-Azzam, Muflih, Soudah, Hawamdeh, & Khader, 2021) .

Institutions can take note of the unique influence of social media and use it to their advantage by providing accurate information through their own social media platforms. Sharing correct information could still lead to negative outlooks on providing patient care, but at least the decisions would be more likely to be made based on accurate, unbiased information.

We found that respiratory therapists were significantly more likely to care for a COVID-19 patient than a physician/faculty, and nurse practitioners were also significantly more likely to care for COVID-19 patients than physicians/faculty. Willingness to care for a COVID-19 patient in person did not vary by age, but did vary by gender as male healthcare workers were more likely than female to care for a COVID-19 patient. Being provided proper PPE did not influence healthcare workers' willingness to care for a COVID-19 patient; similarly, receiving training on caring for patients with COVID also did not predict healthcare workers' willingness to care for a COVID-19 patient. Having knowledge of COVID-19 did not impact healthcare workers' willingness to care for COVID-19 patients. Healthcare worker perception of institutional preparedness was significantly negatively correlated with healthcare worker stress levels.

Healthcare workers who reported that social media formed their beliefs around COVID-19 were more unwilling to care for a COVID-19 patient than healthcare workers not impacted by social media coverage of COVID-19. There was no significant relationship between having to care for a COVID-19 patient and making changes to home-life scenarios and being personally diagnosed with COVID-19 or knowing someone close who was also did not impact healthcare worker decisions to make changes to home-life scenarios. Healthcare workers who had a higher level of perceived self-risk were more likely to be reluctant to care for COVID-19 patients; healthcare worker perceptions of hospital preparedness also impacted willingness to care for COVID-19

patients.

This study has two main limitations. Firstly, respondents completed the survey either right before or right as the vaccine had become available to healthcare workers. The timing of completing this survey likely impacted responses. This survey was distributed prior to the emergence of the Delta variant. In addition, the sample was taken from one hospital in one geographical area and therefore may not be representative of other healthcare workers across the country.

Future research could involve the inclusion of fear-based questions so that researchers could understand where the fear stemmed from, such as fear for themselves, for their families, or from potential spread of the virus to others could provide meaningful perspectives. Additionally, questions about burnout would be noteworthy since viewpoints may alter as the workers see the true effects of the virus on their patients.

These findings demonstrate that healthcare workers knowledge, attitude and beliefs about COVID-19 may have impacted stress levels as well as willingness to provide care for COVID-19 positive patients. Multifactorial perception of self-risk led to a decrease in willingness to care for patients with COVID-19. For future pandemics, institutional preparedness as well as positive use of social media in order to distribute accurate information may aid in decreasing healthcare worker stress as well increase willingness to provide patient care. Future research is necessary to determine which aspects of hospital preparedness would aid in decreasing healthcare workers stress and improving the number of workers willing to provide patient care. 

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The authors declare that they have no relevant or material financial interests that related to the research described in this paper.Key Words:COVID-19, pediatric health care workers (PHCW), infectious disease, community health This manuscript in part or full is not submitted or published anywhere else.Research activities were approved by an Institutional Review Board.All listed authors were involved in this research study throughout various stages and contributed to the completion of the manuscript.This study was not funded.All authors declare no financial or non-financial competing interests related to this study or its publication.