When an infectious disease emerges in populations that have rarely if ever been exposed to the disease, those who work on the frontlines in local public health departments and hospitals require specific information to prevent outbreaks and protect themselves, their patients, and their communities. Although local public health departments and hospitals are linked in many ways to address infectious diseases, they often perform different work in preventing epidemics. Nurses, for example, often provide direct patient care, whereas local health departments’ roles in direct patient care or disease surveillance may vary. If systems are to respond quickly, efficiently, and accurately when new public health threats emerge, they must be able to provide the types of information that workers in each setting need.
In the United States in 2014, Ebola directly impacted health care providers and public health professionals. Among the 4 confirmed Ebola diagnoses in the United States, 3 were health care providers who provided direct care for Ebola patients.1 Health care workers who engaged in direct patient care of Ebola patients were at increased risk of Ebola exposure and contracting the disease; they needed information about Ebola to protect themselves, care for patients, and prevent its spread. Health care workers who did not provide direct patient care also needed relevant information to respond accurately and efficiently, develop guidelines and recommendations, gather and process biological samples, dispose of biohazardous waste, and serve the public. Yet the information that health professionals and health care providers wanted or needed may not have been immediately available.Reference Gesser-Edelsburg, Shir-Raz and Haiek2 If health organizations do not provide accurate, sufficient, timely information to their employees, they risk the health and well-being of their employees, patients, and the general public.
In critical situations like the potential spread of Ebola, a disease uncommon in the United States and likely unfamiliar within the health care system, health organizations’ employees may turn to informal social networks to obtain information. Social networks might compensate for discrepancies between the information employees want and actually obtain from formal organizational channels (ie, the conduits for instructions, training, and formal notifications).Reference Gulati, Mayo and Nohria3, Reference Zmud, Lind and Young4 Social media (eg, Facebook, Twitter) provides new opportunities for emerging infectious disease communication where health care organizations can disseminate information and correct misinformation, and health care workers can obtain information.Reference Avery5Reference Strekalova11
The aims of this study were to (1) understand types and amounts of Ebola-related information that employees in hospitals and local public health departments wanted and obtained through formal, informal, internal, and external organizational communication channels; (2) determine potential discrepancies between information wanted and obtained; and (3) investigate how organizational structures (formalization of explicit rules and regulations; centralization of decision-making) might affect information wanted and obtained through those communication channels.
This study is grounded in 3 bodies of research. First, social network research views interpersonal relationships among individuals as conduits for exchange between individuals.Reference Brass, Galaskiewicz and Greve12Reference Granovetter14 Relationships within a network can provide individuals with beneficial resources,Reference Brass, Galaskiewicz and Greve12 one of which is information. However, not all contacts are equally valuable in providing new information. Research suggests that contacts who interact among each other less often and do not share strong emotional connections provide less redundant information.Reference Granovetter14 Thus, it may be that employees of health organizations might obtain more diverse and complementary Ebola-related information from sources beyond their formal organizational channels, such as informal contacts within the same organization, other health organizations, state or federal agencies (eg, the Centers for Disease Control and Prevention), professional associations (eg, the American Nurses Association, American Public Health Association), or special interest groups (eg, Doctors Without Borders). Given these informal contacts, employees of health organizations do not necessarily have to rely solely on formal organizational channels to obtain desired information.
The literature on organizational structure also informs this study.Reference Hage and Aiken15, Reference Pugh, Hickson and Hinings16 Because organizational structures influence how information disseminates through organizations,Reference Pugh, Hickson and Hinings16 structural differences in health organizations are likely to influence Ebola-related information obtained by employees. Organizations with high formalization (ie, the extent to which organizations formally document explicit rules, instructions, and procedures) are more likely than those with low formalization to have explicit rules regarding communication in the workplace. Their employees might be less likely to obtain information from internal contacts informally than employees in organizations with low formalization.
Finally, this study is informed by our work on health information wants (HIW), which emphasizes a bottom-up approach to understanding types and amounts of diverse information that individuals want.Reference Xie, Wang and Feldman17Reference Xie, Wang and Feldman19 In a conventional top-down approach, authorities decide what types and amounts of information people need to know, which may or may not be what people want to know.Reference Xie20 Although our HIW work originated in the patient–provider context (what patients want to know versus what health care providers think their patients need to know), it can be applied to other situations with similar power asymmetries. Employees of health organizations might want to know a broad range of Ebola-related information that their organizations might not think they need to know and thus do not provide. Our HIW work covers a broad range of health information, information about specific diseases, treatments, laboratory tests, self-care, complementary and alternative medicine (CAM; eg, information about when or where to get CAM), psychosocial aspects, and providers’ credentials. Our validated HIW QuestionnaireReference Xie, Wang and Feldman21 (HIWQ) can help reveal the broad range of health information wanted by a health organization’s employees, which may or may not be the same as that provided to them by means of formal organizational communication channels.
Research Questions
For this study, we posed several research questions (RQs). For hospitals and public health departments, separately, we asked:
RQ1: What types and how much of each type of Ebola-related information did health organization employees want to have?
RQ2: What types and how much of each type of Ebola-related information were health organization employees able to obtain from formal and informal communication channels within and outside of their organizations?
RQ3: What potential discrepancies might there be between information wanted and obtained overall, and between information wanted and obtained from different communication channels (formal vs informal, internal vs external)?
RQ4: What demographic and job factors (gender, age, percent of direct patient care, organizational tenure) might predict amounts and types of information wanted and obtained?
Next, across the 2 types of organizations, we asked the following:
RQ5: What similarities and/or differences might there be between information wanted and obtained by health organization employees in hospitals versus public health departments?
RQ6: How might organizational structural characteristics (ie, formalization of explicit rules and centralization of decision-making) affect information wanted and obtained by health organizations’ employees?
METHODS
This was a cross-sectional descriptive study. Participants were recruited by means of personal contacts, professional associations (eg, Texas Nurses Association, Texas Public Health Association), and other sources (eg, Texas Department of State Health Services). From June to November 2015, a total of 526 health workers in 9 hospitals and 13 public health departments in Texas participated (hospitals, n = 216; public health departments, n = 310). Participants received an instrument with 3 components: a demographic questionnaire, the HIWQ adapted to comprise Ebola-related items, and a questionnaire about the structures of participants’ organizations. Of the 526 participants, 254 (48%; from 7 hospitals, n = 133; from 12 public health departments, n = 121) responded completely to the questionnaires; data from those 254 participants were analyzed.
Participants completed the questionnaires independently. To accommodate the schedules and circumstances of the participating organizations, we collected data through hardcopy and/or online questionnaires, whichever each site preferred. Completion took approximately 15–20 minutes. Informed consent was obtained before data collection. This study was approved by the Institutional Review Boards of the authors’ institutions, the participants’ institutions, and the City of Austin.
Measures and Materials
The background questionnaire asked about participants’ demographic characteristics (age, gender) and professional/organizational background (unit/department, employment length, job title, percent of work time to provide direct patient care, in-/outpatient setting). We adapted the original validated 21-item HIWQ,Reference Xie, Wang and Feldman18 which covers 7 types of information, by adding items for specific Ebola-like conditions. The first 3 adapted HIWQ questions served as control variables: (a) How contagious do you think Ebola is? (b) How deadly do you think Ebola is? (c) How knowledgeable do you think you are about Ebola? Of the expanded HIWQ’s 25 questions, 5 addressed diagnosis; 5 prevention/treatment; 3 laboratory tests; 3 self-care; 3 CAM; 3 psychosocial aspects; and 3 health care providers. These 7 information dimensions were the same as those in the original HIWQ, except that the original “treatment” dimension was broadened to “prevention/treatment” to reflect Ebola. Participants indicated the amount of Ebola-related health information they had wanted about each type of information in the last year (1 = none; 2 = a little; 3 = some; 4 = most; and 5 = all).
For this study, we adapted the HIWQ separately for hospitals and public health departments, with slightly different wording for each. We reviewed multiple iterations and made revisions to ensure the survey questions’ clarity. The adapted HIWQ was also reviewed by outside experts (nurse researchers with public health expertise in another state) and administrators and/or staff of each site for context appropriateness. Using their feedback, we revised the questionnaire further.
To answer our research questions about information obtained from various channels (both in person and electronically), we added items about the amount of information obtained from formal and informal communication channels within and outside of the organization. To compare information wanted versus obtained from these 4 channels combined, we added items about the overall amount of information obtained from the 4 communication channels. Participants received specific definitions of the 4 channels and were instructed to refer to them as they completed the survey. An excerpt from the Ebola-specific HIWQ is presented in Figure 1. Full version of the adapted HIWQ can be obtained from the first author.
FIGURE 1 An Excerpt of the 25-Item Ebola-Specific HIW Questionnaire.
The third questionnaire asked participants about their perceptions of their organizations’ structures, including formalization (5 items adapted from Pugh et al.Reference Pugh, Hickson and Hinings16)Reference Schminke, Cropanzano and Rupp22 and 2 subdimensions of centralization of decision-making: employee participation in decision-making (4 items adapted from Hage and AikenReference Hage and Aiken15) and hierarchy of authority (5 items adapted from Hage and AikenReference Hage and Aiken15).Reference Schminke, Cropanzano and Rupp22 Sample items included: “My organization has a large number of written rules and policies” (formalization; 1 = very inaccurate; 7 = very accurate); “How frequently do employees usually participate in the decision about the adoption of new programs?” (employee participation in decision-making; 1 = never; 7 = always); and “There can be little action here until a supervisor approves a decision” (hierarchy of authority; 1 = strongly disagree; 7 = strongly agree).
Statistical Analyses
Chi-square and t tests were used to compare the demographic characteristics (gender, age, organizational tenure, direct patient care) of participants who completed the full instrument with the characteristics of those who did not. Only 1 statistically significant difference was found: More females completed the full instrument than did not, χ2 = 8.81, P < .01.
To answer RQs 1 and 2, we calculated descriptive statistics (means, standard deviations; see Table 2 for each type of Ebola-related information that health organization employees (1) wanted; (2) obtained from formal, informal, internal, and external communication channels; and (3) obtained overall from all 4 channels, across all sampled organizations in each type of organization (hospitals; public health departments).
To answer RQs 3 and 4, we conducted mixed design analyses of variance (ANOVAs) for hospitals and public health departments, respectively. Participants’ responses to the HIW items were the dependent variable. There were 2 within-person factors: (a) type of information, on 7 dimensions; and (b) information wanted versus obtained, on 6 dimensions including information (1) wanted, (2) obtained from formal, internal communication channels (3) obtained from informal, internal channels, (4) obtained from formal, outside channels, (5) obtained from informal, outside channels, and (6) obtained overall from all 4 channels. The ANOVAs included 10 between-person covariates: the control variables (perceived contagiousness of Ebola, perceived deadliness of Ebola, knowledge about Ebola, perceived formalization, employee participation in decision-making, and hierarchy of authority in the organization), gender, age, percentage of direct patient care, and organizational tenure. We also conducted regression analyses to examine the effects of these 10 between-person covariates on each type of information wanted, obtained overall from all 4 channels, and obtained from 4 channels separately.
To answer RQ5, we conducted another mixed design ANOVA, which added organization type (hospitals, public health departments) to the earlier ANOVA model. To answer RQ6, we first aggregated individual-level perceptions of the organizations’ structures (perceived formalization and 2 subdimensions of centralization of decision-making: employee participation in decision-making and hierarchy of authority) to the organization level. The aggregated scores of employee participation in decision-making and hierarchy of authority were highly correlated, r = −.73, P < .01, so we reverse-coded employee participation in decision-making and combined these 2 ratings as 1 composite score to indicate centralization of decision-making in organizations. We then conducted multilevel analysis to test the effects of the organization-level aggregated organizational structural characteristics (ie, formalization and centralization of decision-making) on information wanted and obtained. We controlled for individual-level predictors (age, gender, organizational tenure, percent of direct patient care, perceived contagious nature of Ebola, perceived deadliness of Ebola, and knowledge about Ebola) in these analyses.
RESULTS
Participant Characteristics
The respondents employed in hospitals (n = 133) were predominantly female (86.50%), newer in their employment (mean organizational tenure = 6 years), engaged in direct patient care (mean percentage of time spent in direct patient care = 72.62%), and working as staff nurses (72.5%). Respondents from public health departments (n = 121) included more males (58.70%), and fewer providers of direct patient care (mean percentage of time spent in direct patient care = 25.18%), with the majority in management/administrative (44.5%) or specialist (48.7%) positions (Table 1).
TABLE 1 Participant Characteristics
Psychometrics
The revised HIWQ has high face and content validity as supported by feedback from subject matter experts who reviewed iterations of the instrument. It also demonstrated excellent internal reliability among the items. Cronbach’s alpha for each subscale (range, .88-.98) is reported in Table 2.
TABLE 2 Cronbach’s Alpha Coefficient, Means, and SDs of Each Type of Information
Response scale anchors: 1 = none, 2 = a little, 3 = some, 4 = Most, 5 = all.
Information Wanted
Both hospital and public health department employees wanted at least “a little” (rounded up to 2) of all 7 types of information. They wanted information about diagnosis and treatment most (Table 2).
Information Obtained
Both hospital and public health department employees obtained at least “a little” of all 7 types of information from formal and informal communication channels within and outside of the organization (Table 2).
Information Wanted Versus Obtained
Among hospital employees, there was a significant interaction between type of information and information wanted versus obtained, F(30, 3660) = 2.15, P < .01. Post-hoc analyses with Bonferroni correction showed that information wanted was significantly less than that obtained for self-care but more than that obtained for the other 6 types, which was consistent for information obtained from all channels combined as well as from internal or external, formal or informal channels (estimates of differences and standard errors are available from the authors).
Among public health department employees, there was no significant interaction between type of information and information wanted versus obtained, F(30, 3300) = .70, P > .05. Post-hoc analyses showed that information wanted was significantly more than information obtained from all channels combined (difference = .64, SE = .09, P < .01), from internal formal channels (difference = .76, SE = .09, P < .01), from internal informal channels (difference = .90, SE = .09, P < .01), from external formal channels (difference = .75, SE = .09, P < .01), and from external informal channels (difference = .87, SE = .09, P < .01), for all 7 types of information.
Demographic and Job Factors
Among hospital employees, age, gender, percentage of direct patient care, and organizational tenure had no significant main effect on participants’ ratings. However, there were significant 2-way interactions between age and type of information, F(6, 732) = 3.10, P < .01; gender and information wanted versus obtained, F(5, 610) = 2.38, P < .05; percent of direct patient care and type of information, F(6, 732) = 3.43, P < .01; and organizational tenure and type of information, F(6, 732) = 2.41, P < .05. There was a significant 3-way interaction among gender, type of information, and information wanted versus obtained, F(30, 3660) = 2.15, P < .01. We, therefore, conducted regression analyses to examine the effects of the covariates on each type of information wanted and obtained (see Table 3 for predictors with significant effects).
TABLE 3 Summary of Regression Results
We listed the predictors that had significant effects in each cell. Gender is coded as female vs. male. Direct refers to percentage of work time devoted to direct patient care. “−” denotes a negative effect, and “+” denotes a positive effect.
Among public health department employees, age, organizational tenure, and percentage of direct patient care had no significant main effect on participants’ ratings, but gender did, F(1, 110) = 5.68, P < .05. In addition, there were significant 2-way interactions between gender and type of information, F(6, 660) = 2.85, P < .05; organizational tenure and type of information, F(6, 660) = 2.33, P < .05; and gender and information wanted versus obtained, F(5, 550) = 3.14, P < .01 (see Table 3).
Hospitals Versus Public Health Departments
The preceding results varied across the 2 types of organizations (hospitals vs. public health departments). There was a significant 3-way interaction among organization type, information type, and information wanted versus obtained, F(30, 7260) = 3.65, P < .01. Specifically, employees in hospitals wanted more information about diagnosis (difference = .46, SE = .17, P < .01), treatment (difference = .57, SE = .20, P < .01), laboratory tests (difference = .79, SE = .24, P < .01), CAM (difference = .49, SE = .25, P < .05), and health care provider credentials (difference = .45, SE = .23, P < .05) than did employees in public health departments. As Table 2 shows, employees in hospitals obtained more information about diagnosis from internal formal communication channels (difference = .47, SE = .18, P < .05) than did those in public health departments; they did not differ on any of the other 6 types of information. Employees in hospitals and public health departments did not differ significantly on information obtained from internal informal, external formal, and external informal channels for any of the 7 types of information; neither did they differ significantly on information obtained overall from all channels combined about any of the 7 types of information.
Effect of Organizations’ Structural Characteristics
Considering the small sample size at the organization level (7 hospitals, 12 public health departments) and that both types of organizations were rated on the same set of structural characteristics, we combined the 2 types of organizations in the multilevel analyses. The sample size for the multilevel analyses was n = 252 at the individual level (2 participants did not indicate which organization they worked for and were thus excluded from these analyses); the sample size was n = 19 at the organization level. Multilevel analyses suggested that formalization was positively related to information about CAM obtained from external formal channels, γ = .35, P < .01; from external informal channels, γ = −.27, P < .05; and overall from all channels combined, γ = .31, P < .05. Centralization in decision-making was negatively related to information wanted regarding diagnosis, γ = −.22, P < .01; and negatively related to information obtained from internal formal channels regarding diagnosis, γ = −.25, P < .05. Formalization and centralization in decision-making had no significant effects on other information wanted or obtained dimensions.
DISCUSSION
Although Ebola did not become an epidemic or reach disaster proportions in the United States, widespread national concern about its emergence provided an opportunity to examine how hospitals and public health departments prepare employees to respond to emerging public health threats. The time-sensitive threat of Ebola enabled us to gain knowledge about information wanted and obtained by employees in 2 different types of health organizations, hospitals and public health departments. Our findings suggest the utility of having different communication channels for health organization employees to obtain information in crises. They also advance the use of our HIW framework, illustrating its use in the context of health organizations. Drawing on the literature about social networks, organizational structure, and health information seeking, we have been able to provide new knowledge about the information that health organization employees want and obtain from various communication channels. These findings also call for attention for health organizations to develop and disseminate high quality, relevant information, including through social media, to ensure the provision of timely and accurate information their employees want to have.Reference Gesser-Edelsburg, Shir-Raz and Walter8
The HIWQ was initially designed to examine patients’ preferences for different types of health information and decision-making autonomy. In this study, we modified it to study nurses and public health workers, who, in emergency situations like the threat of Ebola, are particularly vulnerable. The scientific rationale that motivated the initial development of the HIWQ is that individuals in a vulnerable position, such as patients or the general public, are not likely to have the information they want from authorities.Reference Gesser-Edelsburg, Shir-Raz and Walter8 Rather, they are given information that health care providers perceive them to need (typically to ensure compliance).
Based on the same rationale, we studied employees of health organizations, who are likely to be similarly vulnerable, that is, these employees might want a broad range of information, but employers or other professional agencies may not think that the employees need it or simply do not provide as much information as employees want. The HIWQ, with good validity and reliability, may be valuable for future research about other situations with similar power imbalances. Further supporting the need to look at information dissemination in power imbalance situation, our analyses suggest that how employees see the organizations’ structures in terms of formalization and centralization of decision-making can impact the types of Ebola-related information wanted and where it was obtained. In organizations with more formalized procedures of documenting policies and rules, employees obtain more information about CAM from external (formal and informal) channels. This pattern emerged likely because internal channels were more likely to be reserved for disseminating formally documented diagnosis and treatment procedures in organizations with many formal documentations. Interestingly, we also found that employees in organizations with highly centralized decision-making structure wanted and obtained less information from internal channels about diagnosis, which might have resulted from employees’ expectations that important decisions (eg, diagnosis regarding emergent, rare disease) would be a top-down process.
The novelty of significant and transient public health threats like Ebola requires information to be disseminated quickly and accurately to those in hospitals and local public health departments. The spread of this disease among direct patient care providers in Texas caused strong reactions from management and employees in health care organizations of all types (2 of the 3 confirmed Ebola diagnoses among health care providers were in Texas1). It is extremely important to understand the dissemination of information within and beyond health care organizations in such situations.
Limitations and Future Directions
This was a cross-sectional study from 1 state, reflecting only a snapshot of events that might not generalize to the nation overall. Future research would benefit from longitudinal studies of changes in health workers’ information wanted and obtained through different communication channels. Although we initially intended to use a representative sample of health organizations in Texas, we encountered much organizational resistance from potential sites. Despite many efforts and attempts, we were able to collect data only from a convenience sample; and of the participants we were able to reach, only 48% of them completed the questionnaires. Considering that those who were contacted and completed our questionnaires could be different from non-respondents in certain attributes (eg, demographic characteristics, attitudes toward research), our findings may not generalize to all health organizations in Texas. Future research should aim for a more representative sample. The gender effects reported in Table 3 should also be interpreted with caution, considering that (a) female participants were more likely to complete the survey instrument and (b) the majority of the participants in our sample were female (particularly in the hospital sample, 87% women). Differences between male and female participants in Ebola-related information wanted and obtained may not generalize to an organizational context where gender composition is more balanced or is dominated by males.
Furthermore, we lacked sufficient information about organizations’ size (ie, number of employees, number of beds for patients, and related size measures), so that we could not examine differences between larger public health departments or hospitals and smaller ones; this should be examined with larger, more representative samples. Larger systems that perform a greater volume of services in areas such as outbreak investigations and infectious disease control may be more effective at providing such services (and, presumably, in preparing their employees) than smaller organizations.Reference Mays, Smith and Ingram23 Finally, studies should examine how partnerships between public health departments and hospitals impact the dissemination of needed information to employees, because inter-organizational collaborations can improve the flow of information, reduce duplicative efforts across organizations, and help organizations adopt effective practices more quickly.Reference Mays and Scutchfield24
CONCLUSIONS
Hospital nurses received more self-care information than they wanted from every communication channel separately and combined. However, they received less information about all other types of information than they wanted from each communication channel separately and combined. Public health department employees wanted more information than they obtained from each communication channel separately and combined for all 7 types of information. Discrepancies existed between types of Ebola-related information wanted and obtained by hospital nurses and among employees in different types of public health organizations. In similar crises in the future, health organizations, government agencies, and professional associations should strive to provide a broad range of information, including but not limited to self-care information. Self-care information, about how to avoid contracting Ebola, for example, is critical in safeguarding employees’ own health and well-being; however, it alone may be insufficient for meeting employees’ preferences for a broad range of information.
Acknowledgments
We thank the staff and administrators of the organizations that participated in our study.
Funding
This material is based on work supported by the National Science Foundation under Grant 1521089 (Principal Investigator: Bo Xie) and Grant 1522557 (Principal Investigator: Le Zhou). Editorial support with manuscript development was provided by the Cain Center for Nursing Research and the Center for Transdisciplinary Collaborative Research in Self-management Science (P30, NR015335) at The University of Texas at Austin School of Nursing.
