With the rising morbidity and mortality associated with H1N1 influenza infection, contingency plans are needed since there is an increase in demand on the healthcare workforce in both hospitals and community settings. Absenteeism of HCWs, whether due to fear about work or due to being infected with H1N1 influenza, is one of the major concerns at the time of a pandemic . Studies that aim at improving our understanding of the characteristics and factors that may contribute to HCWs' decision to work or working conditions that may affect their willingness to work during a pandemic are important as they provide a deeper understanding of how to address HCWs needs and keep then engaged in the healthcare system.
Our study found a large proportion of community nurses being unwilling to work during the current influenza pandemic (76.9%) and the figure is much higher than those reported from nurses who work in the hospitals in Hong Kong (16%)  and from other countries (28-50%) [6, 7, 19]. Our findings are, however, consistent with findings from other studies conducted in the United Kingdom  which showed that community HCWs including nurses had the lowest reported likelihood of working during an influenza pandemic among all employment categories. The reasons for the higher unwillingness to work during H1N1 pandemic among HCWs in the community are unknown. We may only postulate that the inaccessibility of a protective working environment or facility, for example, isolation rooms with negative pressure may be the concern for HCWs working in patients' homes and further in-depth qualitative studies may be needed to address this issue.
Additional findings from our study showed that community nurses who had inadequate training in infection control were less likely to express a willingness to continue to work. Similar to findings from previous studies conducted in both hospitals and community settings, the major reasons for being unwilling to work during pandemic or outbreak were the risk of infection to self or family and psychological stress [10, 16]. The findings demonstrated that stress levels were significantly associated with higher levels of fear of the risk of infection to one's own and/or family health and potential negative impact of H1N1 influenza on nurses' daily living activities and quality of life. Lack of knowledge, ambiguity regarding one's exact tasks, and questionable ability in performing one's role as rick communicator were all significantly associated with a higher perceived personal risk and a two-to ten fold decrease in willingness to report to duty (new suggested one). Special attention should be paid to this group of more junior community nurses who need more training and guidance in dealing with an emerging infectious disease especially in the community setting. Currently infection control training has focused on infection control in the hospital settings, and our findings suggest that regular clinical training should be enhanced for HCWs working in the community in order to increase confidence among all HCWs including nurses in taking care of patients with influenza and reducing the occupational related psychological stress . The findings also showed that the majority of community nurses felt dissatisfied with the arrangements or management of the suspected H1N1 influenza cases (mean score: 71/100) and that unwillingness to work was significantly associated with the reported dissatisfaction. This may suggest that there is a lack of communication between hospital-based management and community HCWs but further studies are needed to explore reasons for dissatisfaction. Experience of SARS highlighted the need for effective communication and HCWs need full access to information as it becomes available .
To the best of our knowledge, this is the first study to explore the willingness of community nurses to work during an influenza pandemic and our findings suggest that this is an important issue for policy makers and healthcare organizations especially for those who participate in the provision of community care. Our strength includes an acceptable response rate of 66.6% which is higher than the last survey exploring hospital staff's working attitudes towards influenza pandemic in 2006 in Hong Kong (39%) (CUHK9). The response rate of other western studies covering similar topics was varied ranged from 34% to 79% (H1N1 2, H1N1 3, 3). Therefore, the SAR territory wide representative covers of all nurses working in the community nursing services in Hong Kong.
There were some limitations to this study. First, the marital status and family background of community nurses were not included. Though previous studies showed that HCWs with children were not significantly more likely to be absent, support for child care was reported to be one of the reasons related to the unwillingness to work during influenza pandemic. This may be related to school closure policies rather than hospital management. Nevertheless, this reason was not reported by our participants. Furthermore, we have only reported on the responses to a pandemic among general community nurses employed by the Hospital Authority and, nurses who work in private general practice or with elderly or mentally ill in community centres were not included in our sample. In addition, this was only a cross-sectional study and temporal relationships between unwillingness to work and its associated factors could not be confirmed.