Of n = 64 participants, n = 32 were male, n = 31 female, and n = 1 undisclosed. N = 14 were aged 21–30, n = 12 were aged 31–50, n = 23 were aged 41–50, and n = 14 were aged 51 and over. N = 48 classified themselves as being White British, n = 3 as White Irish, n = 1 as White Scottish, n = 3 as Asian, n = 1 as Black African, n = 3 as Indian, n = 4 as other, and n = 1 undisclosed. N = 5 participants were junior hospital doctors; n = 5 were consultants; n = 12 were nurses; n = 6 worked in professions allied to medicine; n = 16 were ancillary workers; n = 10 were general practitioners, n = 5 were community healthcare workers; and n = 5 were managers. The demographic and professional spread of participants was not sought to be representative of NHS workers in the UK, but sought to access a wide range of views and perspective across a wide range of HCWs working in different areas of the NHS.
The overall themes that emerged are summarised in Figure 1. The network depicted expresses the relationships between the key themes that arose across all focus groups and interviews. Themes interact in one of four ways: (1) Impacting upon (a change in one may cause a change in the other); (2) Motivation (3) Association; (4) Solution.
In this paper we discuss key issues that relate to the 'duty to work' and 'barriers to working'. Eight main themes emerged relating to these two issues. Selected quotations are used to illustrate each of these eight themes.
The Duty to Work
Overall, participants seemed to feel a strong sense of duty to work regardless of the circumstances and displayed a general willingness to work during an influenza pandemic. This sense of duty was found across all categories of workers, but was justified in a variety of ways that can be brought under three headings:
A professional ethic (prominent in 4/9 focus groups and 5/5 interviews)
Some participants felt the duty to work is a professional duty that entails an obligation to work even in difficult and dangerous circumstances, because that is what they signed up for when they joined their profession. This kind of view was expressed most forcefully by hospital doctors and GPs, some of whom felt that this duty, which was developed during their training, was one owed both to their profession and to their patients. There were mixed views among participants about how far this obligation extended across different healthcare roles. Some doctors, for example, felt that the professional obligation did not apply so much to ancillary staff or nurses, though others felt that it applied to everyone, (see below).
Sense of duty developed during training
JI: So...what would you see as a source of this obligation to work, why would you personally feel that obligation to carry on? [long pause] It's a very tough question, I know.
C4: I suspect it must be something to do with the training, inherent to how it is being imparted. Now that's what I feel, I don't know what drives it to come to work, I suppose if I can come to work when I'm fit and well without a pandemic around, I expect that if I'm fit and well and I'm expected to work, then if it's a pandemic I'll have to come and work.
Duty confined to doctors
JI: There's various ways of looking at healthcare workers duties and some people will argue that health workers have a duty to tend to the sick and do their job no matter what. Some people will extend that to just doctors, some to doctors and nurses, and some would extend to anybody including admin and secretarial staff. Would you feel that that kind of duty does exist and how far do you think it extends?
GP10: Doctors yes, nurses probably, reception staff
GP8: No.
GP10: That depends on the people you've got. I think most of ours would turn up.
JI: What's the difference?
GP10: I just think it's the ethic. I mean you get into this job basically to look after people and, rather than man a phone for eight hours a day...
Duty to work extends to all roles
JD2: I think it's an obligation for doctors, I think that's set out by the GMC isn't it? It's the duty of a doctor.
JD5: It should be extended, I don't know, it's just my own opinion, it should be extended to everybody who comes in contact with the patient. Not only doctors, nurses as well
JD2: Well the hospital wouldn't function if it was just the doctors putting in the extra hours because you need support from the nursing staff, even down to the cleaning.
A duty to help (prominent in 8/9 focus groups and 2/5 interviews)
Some participants across a range of jobs spoke about an obligation arising from a general 'duty to help'. Some, for example, claimed that being in a position to help another person was a sufficient motivator for helping them. Others expressed the view that if a person or a society is in need, that need gives everyone a moral incentive to take steps to meet that need. Notions of a duty to help were sometimes accompanied by references to the "Blitz/Dunkirk' spirit" of wartime Britain in the 1940s, and the belief that in the event of a social crisis we all have to pull together and do what we can for the common good. Here, the duty to help was constructed both as an individual and a social requirement to contribute to the common good, applying to us as persons and not only as HCWs. One key source of the duty to help for some HCWs was that they had specific skills that would make them particularly useful, and this seemed to make them feel they had a special responsibility where others might not, see below.
If you can help, you should help/The obligation to help those in need
A1/9: I am agency staff but I don't feel any different. If I'm of use then there's no point me sitting around redundant...when I can actually do something, It'd be more frustrating for me to be sat at home because I can't work even though I can contribute, it would just feel counter productive.
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A1/2: I kind of feel about it the same way as if I saw somebody get knocked over by a car, I'd go and help if I could.
A1/6: Yes, its human nature I think a lot of it.
A1/2: Yeah, that's the sort of way I feel about it. If there's something I could do, I would do it, you know. I think, I don't, I can't explain any more than that really, it's just that, you know
A1/5: And if you were in that situation you'd hope somebody would help you, you know
A1/2: Well exactly and I think it's the good of human kind really, that you wanna help if you can
Blitz/Dunkirk spirit
N1/5: We're British, Dunkirk spirit.
N1/3: Absolutely.
N1/5: And that has, bizarrely enough, that has been bandied around. You know that there are a lot of people that will just adopt this, well
N1/3: Spirit of the Blitz.
N1/5: Yeah, get on with it
Specific skills
CH4: I think it would depend on what help was required. If it was to administer medicines or injections, it's obvious which one would be needed more. If it was to sit there and just chat, support, wash then the nursing skills perhaps might be in use somewhere else so it's a really hard question to answer. I don't think you could just split it like that 'cause you'd need to know more wouldn't you? [everyone nods]
A simple work ethic and confederate loyalty (prominent in 6/9 focus groups and 3/5 interviews)
Many participants, in a variety of roles, felt that absenteeism if one was able to work (whatever one's employment, in or out of the health service) was generally wrong and not just wrong during a pandemic.
This simple work ethic (see below) may be related to or reinforced by, a complex sense of loyalty and obligation to workplace confederates, in this case colleagues and patients. This account tended to emerge from a belief that, as both colleagues and patients depend upon you doing your job, by refusing to work (when you are physically able) you are letting both your patients and your colleagues down in way that is morally unacceptable, for example
Work ethic
A2/8: I mean personally, it don't matter what job I've got, whatever job I sign up for I look into that field and carry it on and I get, try to get personal satisfaction out of it and part of this becomes a dedication of where I want to be and what I want to do and it's like I'm now, I'm in domestics now and that gets some of my attention so therefore it's spread into that. So I'd come in anyway if I was all right, I would come in and that just ends it. Like if you had to do it anywhere else, you know you tend to go in because you think, 'Well someone else might be ill'.
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JI: If you were fit and well during an Influenza pandemic, how likely do you think it is that you would work as normal?
C3: Yeah sure, it's part of the role.
JI: Yeah, so I mean can you expand on that by 'part of the role'.
C3: Well that is part of what you do isn't it? You don't just work when the sun's shining.
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HC3: You're not a nurse just when everything's okay, do you know what I mean? You're a nurse when things are not okay.
Not wanting to let patients or colleagues down
P4: I feel like that really I would be letting those patients down if I didn't come in because they're my raison d'être, that's why I'm here.
P1: It's not just your patients. It's your colleagues as well.
P5: Yeah.
P1: You're letting your team down as well as the patients.
P4: That's right.
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N2/4: I think that's the other thing. It's camaraderie. You get like a good little team on a ward and half the time if you do feel a little bit sort of a little bit sick you think 'oh well I've got to go in because they'll struggle without me'.
Barriers to working
Although all participants tended to feel they have a duty to work during an influenza pandemic, there were nonetheless a number of perceived barriers to so doing. These tended to fall into one of two categories:
• perceived barriers to ability (prominent in 9/9 focus groups and 5/5 interviews)
• perceived barriers to willingness (prominent in 9/9 focus groups and 5/5 interviews)
These categories, however, were not clear cut in all cases, and the lines were most blurred when it came to concerns about childcare and family obligation. Some participants who had children regarded staying at home to look after them as a necessity that affected their ability to work, rather than a choice (see below). Childcare is not, however, obviously distinguishable from a barrier to willingness; for instance, where parents choose to look after their children themselves rather than rely on available others to do so for them. Choice, of course, is itself a nebulous concept. Where there is no externally available or accessible childcare, and where children are too young to care for themselves, there is a barrier to ability. However, what counts as 'accessible' or 'too young' and whether the available childcare is regarded as an adequate or acceptable alternative may owe as much to personal choice or preference as to inescapable circumstance.
It seems likely that the 'childcare' barrier is age and gender related. Women with young children tended to regard it as an insurmountable obstacle, with men raising the issue less often. Whether this gender difference was due to the participants' need to present themselves to their peers as participating in typical gender roles is unclear, although the discrepancy observed is predictable, and consistent with what we might expect. The group in which it was least prominent was the GP group, which was comprised largely of older men. The discussion was most prominent in the nursing groups, where women with young children were in the majority. The apparent lack of concern about this issue in the GP group may reflect gendered norms in the home, the age of the participants which meant that they were unlikely to have young children, or that GPs were better placed to afford reliable, private childcare. Similarly, the junior doctors did not discuss this issue: it was raised in passing only once. When they were questioned about why it had not been discussed, the answer was simply that they did not have children so it was not an issue.
For some, the duty to family was expressed as the simple claim that 'family comes first' which was taken for granted as an unassailable moral premise. If a child or a family member needed them they would not come into work pandemic or no pandemic: duties to families were more important than any duty to work. This was not so much a matter of weighing up competing obligations (to work and to family) but rather represented a pre-defined moral hierarchy acting as a barrier to ability (see below). For others, childcare functioned as a barrier to willingness, where a choice puts family before work.
Some barriers to ability were fairly concrete like being ill oneself and problems with transport (including lack of fuel). Participants recognised that they could not work if incapacitated by illness, and also anticipated that in the event of an influenza pandemic transport infrastructures might be affected, making it difficult to travel to work. Some participants thought that during an influenza pandemic people might be reluctant to use public transport for fear of becoming infected, leading to more people travelling to work in private cars. These same participants anticipated that Trusts would not have the parking space to accommodate additional demand, creating a further barrier for people who would otherwise be willing and able to work (see below). Insurmountable barriers to ability, however, exist at the extreme end of a continuum; for example where a person is literally too ill to get out of bed or function safely, where the person is infectious and poses a demonstrable risk to others, or where there is no fuel at all and the distance to work is too great to cover on foot or cycle. Further along this continuum, HCWs will be exercising choice about how to prioritise the different demands on their time and resources, and the greater the scope for preference or choice to be exercised, the more like a barrier to willingness the perceived obstacle becomes.
Child-care as a barrier to ability
N2/1: Well I've got two small children, small children are probably more likely to get these things so, the ones at school, if the schools are closed there's no way I'd be able to come in because you can't [Laughs] You can't just leave your kids. They're obviously a priority.
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A1/5: you'd have other outside influences wouldn't you? If you had children, if the schools were closed down and you'd got no-one to look after your children you... what, what options would you have then? You know your first duty is to their care so you would have to think about them before you could come in. If you'd got nobody to look after your children or equally your elderly parents if all that starts.
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P2: I was gonna say where, in my case there's one adult to look after a number of children at home and I'm their sole means of support. And so to me they need that support every day you know whether the hospital needs mine or not, I'm not. You know that's the kind of a theoretical benefit to the hospital. You know 'cause I work in preventative health. So it's easy for me to say my kids need me every day, and it's gonna be a different decision for everybody isn't it?
Family comes first
N2/1: But it's not just people with children, it's people with old parents or you know it's home situations isn't it? It's family situations and family comes before anything.
Concrete barriers to ability
A1/2: I think there's a Government issue as well like, you know for example if I come on, I come to work on the train, if the trains were all down because there's no staff to run them or whatever and I have to come to work in my car, um where do I park, um, and then you, I mean the icing on the cake would be if you parked up, they just said park anywhere and then get a bloomin' ticket from Q-park
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JI: What kind of effect do you think that Pandemic Influenza would have your work place and on your job?
C1: I think I would see it in two ways, one is if I'm personally myself infected, and affected then it would have an implication from the point of view of my ability to work, and if it's going to be infectious then clearly there's going to be the issue of isolation. So if I'm infected and if I'm isolated then I wouldn't be able to work. If I'm not infected and I need to come to work it would pose a question in my mind whether I'm going to get infected if I come to work.
Negotiating risk and duty (prominent in 9/9 focus groups and 4/5 interviews)
Other individuals saw the duty to their family as one of many competing claims. Concern about taking the virus home and infecting one's family, for example, was not perceived as a barrier to ability when participants believed that they were in a position to negate or mitigate the risk by employing infection control measures, or minimising direct contact with family members by staying at the workplace or sleeping in the spare room. Some groups, however, particularly consultants and managers, felt that anyone who thought that absenteeism would reduce the risk to their family had failed to appreciate that 'pandemic' meant that the virus was endemic in the community (see below).
Negotiating risk and duty
GP5: So if it is that there is a substantial risk that you yourself may succumb which sort of people might not be too concerned about their own mortality but the young children and dependents might be more of a concern. Then you'd want to make sure that if you're gonna put yourself in the front line then it's something worth doing. So there's no point, there's no point and if you're gonna be there you ought to be very well co-ordinated nationally and so you know what you're doing. Get as much protection as you can.
JI: Would that, do you think, be a requirement of your going into work, or would you go in anyway?
GP5: I think most of us would go in, even me who's raising all these concerns, I think most of us would go in, but there's a little bit of me that says that I'd tell you on the day.
GP3: I think if it was gonna kill you, you know sort of people, you know sort of healthy people or you know in their sort of thirties or whatever like me supposedly, yeah it would be nice to think you were gonna have some sort of protection, some sort of pull them down type fancy mask and yeah I might sort of sleep in the shed rather than give it to my daughter, but yeah.
Understanding 'pandemic'
JI: So people have said 'Well it's not me I'm worried about, it's taking it home to my children'. I think given what you've said, that's not going to be a concern for you?
C2: Well I mean that seems ridiculous to me, I mean I just think the whole point about a pandemic is it affects the whole herd, the whole tribe and why should I worry about taking it home when they're more likely to catch it from school or shopping or, and I don't know whether that's right but that's the way I've always looked at it really...I think it's probably a false assumption that you're gonna keep them safe by not going to work.
The risk to self (prominent in 9/9 focus groups and 2/5 interviews)
Despite disagreement on what the risk was and how it could be managed, the risk to family members of working was important to everyone whereas the risk to self seemed to be of less concern. Even when one GP broke the consensus that seemed to be emerging from her group by suggesting that if the risk was great she would not work, she made only passing reference to her own safety and quickly justified her position with reference to the safety of her family (see below). However, participants' apparent ambivalence to personal risk was to some extent belied by regular discussion of personal protective equipment (PPE). Whilst participants were reluctant to say outright that personal risk concerned them, many stressed the importance of being provided with effective PPE (for example see below).
Risk to self
GP2: Okay, can I be honest? If there was an outbreak I don't think I'd come in...If I put my life and my family's life at risk it's easier to say you would come in but then when you see your colleagues dying I think it's a different thing if you're taking it back to your family because you love them don't you, and I don't think if there was an outbreak and I saw my colleagues really sick on death's door that I'd want to be coming into work and putting my husband and my family at risk. I just don't think I could do it.
The need for PPE
N2/4: I think as well being aware of um showing, you know, how they use those paper masks in theatre whether that would be an effective barrier against it or whether you'd need something sort of
N2/3: The proper equipment, rather than a cheaper alternative which they tend to do don't they as well? Proper equipment would be best
N2/6: Yeah, what protection are the staff that's coming to work going to have against catching it from the patients?
Reciprocity (prominent in 8/9 focus groups and 1/5 interviews)
The belief that the relationship between HCW and employer is not reciprocal was one of the most significant barriers to willingness. Specifically, participants did not believe that the efforts of HCWs would be reciprocated or rewarded. This was expressed in a variety of different ways, including an expectation that HCWs would get no thanks or recognition for their efforts, the worry that any PPE provided would be the 'cheaper alternative' (see above) and concern that workers would receive little guidance or decision-making support (e.g. with respect to how resources should be allocated, how treatment should be allocated, or whether decisions made would receive the backing of the Trust).
The majority of participants said they had been given neither information about pandemic influenza, nor been made aware of what would be expected of them during such a crisis, and this gave many the impression that their employing Trust did not care about them or take their needs seriously. Lack of information was a key theme across all groups, with the majority finding the lack of information and engagement a demotivator to work, while clear information, guidance and support seemed to be important motivators (see below). The obvious exception was the management group, which included public health doctors, who were concerned about giving staff too much information, as they did not know if current information was accurate. They reasoned that as it was so difficult to get information through to the workforce, it was a waste of resources to attempt to do so, and possibly counter-productive, if the information given turned out to be inaccurate. Their preference was to disseminate information if, when and as it was needed (for example below). This was in direct contrast to the views expressed by the majority of other groups, who wanted information immediately and to be involved in the planning effort. The GPs were most similar to the managers; most seemed confident that they could cope with the pandemic if and when it occurred, and believed that the necessary information and guidance would be sent to them as and when appropriate, and that their role was one of implementation.
The need for information
N1/1: It's giving people information as well, if you're more informed about something you're more likely to do it than if you get up and you're not told anything, why should I put myself at risk if I don't have all of the information?
The dangers of giving information
M6: I think one of the difficulties is that there was a lot of changes initially in the national guidance on what could be expected, and there was a reluctance to pass that information down and then have to review it, and you know that affects the creditability of the information they're receiving
M3: but it's still very difficult given that we don't know when or what to give information. And if you think about giving information down to that level, it so rarely gets down there that if you got it down there now and it was wrong you'd have very great difficulty changing it when you need it to be right. So it's not about keeping ignorant, it's about informing people when you know. And it would be, I think it would be very wrong to give detailed guidance when we don't know what we're or what, you know, what the dangers are. But we've got to have a system in place to give guidance in an authoritative manner when the time comes.
Both clinical and non-clinical participants were worried about being asked to perform a role they had not been trained for, and had concerns both about being a danger to patients and being subject to litigation if something went wrong. Participants tended to feel they would need more support than usual from their managers (to help them to make decisions, to fight their corner, and to give hands-on assistance). There was also a belief, however, that there would be less support during a pandemic. It was clear that many participants would be reluctant to take on extended roles without some assurance that they would be protected from litigation and without explicit guidance on how to negotiate the ethical dilemmas that the pandemic was likely to produce (see below).
Litigation worries
A2/8: One thing that crossed my mind, is if I'm called in to help, clinical-wise and I make a gaffe, and the relatives take me to court who's gonna protect me? And it'll make me decide whether I was gonna help or not really.
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N1/5: There isn't enough, from what the Critical Care Community, are saying coming out of the Department of Health to reassure them and there's a big fear amongst medical staff that you know, two years down the line they'll be litigated against because they rationed and denied services to people because there weren't enough beds or because they chose one patient over another. And these are genuine concerns that are being expressed by nursing staff alone.
Apprehension about ethical dilemmas
CH1: Well who would get the vaccination, how would you choose?
CH5: I guess the consultant makes the decision who gets it and who doesn't.
CH3: So selection, like Auschwitz isn't it?
CH1: I wouldn't like to be...
CH?: That would be awful wouldn't it
CH5: I wouldn't like to think they'd think it would be left up to me......as an administrator...
CH4: Who you prioritise and deny people as well
CH5: I would be very reluctant to go anywhere without proper guidelines, because that would stay on your conscience forever wouldn't it.
Need for reciprocal support
P6: It is, it is a different decision for everybody but I think, personally I would be... I'd feel obliged to come in anyway professionally but I would like to know that the Trust doesn't – how shall I put this? – I would like to know that the Trust can rely on me but at the same time I can rely on the Trust to make sure of my safety...Because I'd feel obliged to come in and I will come in but they've got to make sure that they go the full mile as well.
A further, connected, issue was that of the general erosion of morale and goodwill in the NHS as a whole. This was connected to the previously mentioned expectation that the HCWs' role during a pandemic would not be appreciated, recognised or rewarded. Some participants believed that NHS staff generally felt so under-valued and under-appreciated that some would be unlikely to report for work if they thought they were at personal risk. The majority seemed to feel that, in a crisis, their sense of obligation to their patients or colleagues would overcome their generally low morale, but anticipated that many of their colleagues would not feel the same way (see below).
Wanting to feel appreciated
A1/8: If they just show they're grateful for what you did. Say if a patient says to me, 'Oh you've kept my room spotless while I've been in here', it gives me a boost to think I've done something, but when you don't get no credit, then that's a knock back to you. That's when morale goes down.
A1/5: Is it a matter of esteem as well isn't it, you know?
A1/1: Come the end of the pandemic you've kept your bone marrow transplant ward isolated, clean and none of the patients have come down with the flu or whatever it is, and everything goes in the paper and you don't get a single mention that's gonna be soul destroying
Erosion of goodwill/morale
N2/4: I think for years now a lot of the NHS has run on goodwill of nurses and I think that bit by bit, especially the Trust where I come from...that's why I left there, the goodwill was eroded...
N2/1: They beat it out of you don't they? ...You're right. They do! They badger you and badger you until...I mean it's a caring profession. It's not a job you do for the money. It's a job you do because you want to do it but there is a limit...
Some people will not work
CH5: I mean I could probably split my staff in two camps, of the administration camp there's those I know would be there and they'd give their time and those that would say 'Sorry, no'. And that's just because of the people that they are and then the other obligations that they have.
