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Research report

Preparing for swine flu: 10 questions that all nurses need to ask themselves

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An outline of 10 points nurses should consider when assessing whether they are prepared to deal with the challenges of a swine flu pandemic


SusanRobinson, A&E FCEM, FRCS (Ed), FRCP, is clinical director; Holly Sutherland, RGN, is emergency planning lead; DanielSpooner, BA, DipHE, RN, is lead emergency nurse practitioner; all at emergency department, Addenbrooke’s Hospital, Cambridge.



Robinson, S. et al (2009) Preparing for swine flu: 10 questions that all nurses need to ask themselves. Nursing Times; 105: 34, Early online publication.

Human swine influenza is spreading rapidly and it is timely to reflect on how well we as individuals are prepared for swine flu.

Being prepared includes nurses not only being confident they have a mask that fits but also being practised at putting on and removing personal protective equipment safely.

It also includes being familiar with the latest guidance from the Department of Health, having an understanding of the processes in their workplace and an appreciation of some of the ethical challenges if numbers of affected patients overwhelm the health system’s resources.

This article suggests staff ask themselves 10 questions to assess their level of preparedness.

Keywords: Influenza pandemic, Swine flu, Infection control, Preparedness

  • This article has been double-blind peer reviewed.



In December 2007 we visited Hong Kong to discuss with colleagues in emergency medicine and intensive care the lessons they had learnt from the SARS epidemic.

We learnt a number of important points. Most were related to changes in process such as screening and isolation, staff training and managing some of the practical and ethical issues such an event can result in.

However, the most important thing we were told was that living through an epidemic or pandemic would be one of the worst experiences of our professional lives. We were informed that the only thing those in charge of A&E departments could do to mitigate this was to ensure they have prepared their staff and department to the best of their ability.

These words remained with us and on our return we initiated fit-testing for staff in A&E and changed our processes at the front door so we were able to identify infectious patients before they entered the waiting room.

We wrote a paper aimed at those leading A&E departments, outlining their responsibilities for preparing staff. With the onset of the pandemic, this paper was fast-tracked and published electronically (Robinson et al, 2009). We have been able to incorporate much of what we learnt on that trip into our trust procedures and continue to refer back to what we saw and learnt as we manage the current situation.

However, only an individual staff member will know if they are truly prepared for this pandemic and so we have now changed our focus and begun to ask our staff these 10 questions so they can assess their own preparedness (see Box 1).

In our original paper, written some time before the start of this current pandemic, we outlined 10 points we believed those leading A&E departments should consider in preparing for pandemic influenza (Robinson et al, 2009). Since then the World Health Organization has declared a pandemic and the UK has moved from containment to the treatment phase.

Human swine flu (H1N1v) is spreading rapidly and is now beginning to have a significant impact on both primary and acute care. It seems timely to reflect on our preparations and ask how well we as individuals are prepared for the increasing number of patients with swine flu.

Protective equipment

Health and Safety Executive (2008) guidance recommended masks are fit-tested, before using them, to ensure they fit the wearer. At this stage all frontline staff should have been fit-tested for either a disposable FFP3 mask or a non-disposable mask.

As the numbers of patients needing admission begin to exceed the resources of each hospital, it is likely staff groups other than those in A&E departments, isolation areas and critical care units will have to care for patients with swine flu. Those on the hospital pandemic committee now need to ensure these practitioners have or are being fit- tested.

Staff are advised to wear personal protective equipment (PPE) in addition to masks when caring for patients with suspected or confirmed swine flu.

It should not be assumed that all staff know how to put on and remove PPE without contaminating themselves or others. If the decision has been taken to use non-disposable masks, staff need to know how to clean and care for these.

Appropriate training and an assessment of competence will help instil confidence. Staff will need to call on this confidence when coming to work will mean the certainty of exposure to a potentially lethal virus. In addition, this provides the organisation with the assurance their staff have been appropriately trained.

Box1. 10 questions to ask yourself

  1. Have I been fit-tested for a mask?
  2. Am I confident in putting on and taking off my PPE without contaminating myself?
  3. Am I aware of the latest guidance on managing patients with swine flu?
  4. If not, do I know where to find it?
  5. Do I know how infected patients are managed in the hospital?
  6. Have I discussed with my family possible arrangements for child or elderly care during a pandemic?
  7. Do I have key skills that could be re-deployed elsewhere?
  8. What would my training requirements be if I were to be re-deployed?
  9. What information would I want to know from my hospital manager during a pandemic?
  10. Have I considered and discussed the ethical dilemmas I may be required to deal with during this pandemic?


Managing the pandemic

Staff need to be aware of the latest guidance from the Department of Health and Health Protection Agency. Keeping up to date with this is not easy given the amount of information being published. One person should be nominated within the department to do this and, if necessary, to simplify it for local use.

Hospitals should ensure a central site is developed on their intranet from which staff can locate up-to-date information.

Identifying infectious patients

Every febrile patient entering A&E or other assessment area could be infectious and each hospital must, by now, have a system for identifying these potentially infectious patients and isolating them from other patients and staff. This needs to be done at the ‘front door’ so that infectious patients do not wait in the reception areas throughout the hospital.

It is also important to remind practitioners that not all those who present with a fever necessarily have swine flu; those responsible for assessing these patients must not overlook other potentially serious infectious diseases.

All staff need to know the processes for managing these patients within their department and the hospital, and how these processes may change as the pandemic progresses. Ideally they should practise the system for transferring these patients from A&E or medical assessment unit to admitting wards. Information outlining these points should be readily available on hospital intranet sites in an easy-to-understand format. This is essential as it needs to be easily understood by all employees including domestic and support staff.

Workforce considerations

This is the time for senior nurses to calculate the percentage of their staff who are likely to be available for work during a pandemic. Others may have responsibilities for elderly relatives or vulnerable adults. They need to discuss with their families how they might make alternative arrangements for child or elderly care.

A large number of staff in Hong Kong did not return home for three months to avoid risk to their families. They either stayed in hospital accommodation or rented lodgings; staff need to consider whether this is a possible option. If so, managers need to estimate how much accommodation might be available on site or close to the hospital. Maximising the number of staff available to work is important, so staff members need to be consulted over what would facilitate their ability to work.

The work of a hospital is likely to change during a pandemic so a number of practitioners may need to be re-assigned to other areas of the hospital. Now is the time for senior nurses to identify which staff groups are most suitable to work in another department when, and if, their usual department stops work.

Core skills required by redeployed staff working in A&E or other areas need to be defined and a training and orientation programme for them should be developed and implemented.

Communicating with staff

Daily updates for staff were published in Hong Kong hospitals during the SARS epidemic. It is likely staff in the UK would also value consistent, up-to-date information. Such information could include the numbers of patients admitted with flu in the last 24 hours, the progress of sick colleagues or available supplies of PPE. The involvement of the communications department is crucial if this information is to be accurate, consistent and reliably published across the whole organisation.

Ethical considerations are particularly relevant to a pandemic situation where it is likely staff will have to cope with increased numbers of critically ill patients with limited facilities. It is possible there will be a significant number of patients, many of whom may be children, who will suffer potentially avoidable deaths because the ventilatory support or critical care they need is not available.

There are no easy answers to such ethical dilemmas; all we can do is consider the possible difficult choices we face and discuss them openly with colleagues.


The rapid escalation in the number of patients affected by the recent H1N1 virus has highlighted the need for hospitals to be able to activate plans promptly to cope with the surge in patients and increased demands on their service.

Although this particular strain has (so far) been relatively mild in comparison to previous pandemics, this is not the time for complacency. Hospitals should be focusing not only on processes for dealing with the pandemic but also on preparing staff.

Ensuring they are well informed and educated about this pandemic will enable staff to feel confident and secure in the role they will need to play during this time.

At this stage perhaps one of the most important and challenging aspects the nursing community needs to address is that working patterns, service delivery and maintaining patient care are likely to be subject to great change, at short notice, to cope with the pandemic.

Staff need to ask themselves the 10 questions set out in Box 1. Only when they have answered ‘yes’ to all of them can they be sure they are as prepared as possible.



We would like to thank our colleagues in Hong Kong for sharing their experiences with us. These were: Professor Colin Graham, Professor Tim Rainer, Stones Wong, Professor Charles Gomersall, Professor Gavin Joynt and Professor Nelson Lee of The Prince of Wales Hospital and Dr Albert Lit of The Princess Margaret Hospital. We would also like to thank Jim Wardrope, former president of the College of Emergency Medicine, for encouraging us to publish our original findings from Hong Kong.


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