key: cord-0809049-n1hrnx58 authors: Li, Jiaying; Li, Pingdong; Chen, Jieya; Ruan, Liang; Zeng, Qiuxuan; Gong, Yucui title: Intention to response, emergency preparedness and intention to leave among nurses during COVID‐19 date: 2020-08-01 journal: Nurs Open DOI: 10.1002/nop2.576 sha: 2c664fac8a1320f206f5085cbbfff1d5ee0a930d doc_id: 809049 cord_uid: n1hrnx58 AIM: To comprehensively assess the current level and identify associated factors of intention to response and emergency preparedness of clinical nurses during COVID‐19 outbreak. DESIGN: A cross‐sectional study was designed. METHODS: Demographic and characteristic questionnaire, intention to response scale, emergency preparedness scale and a self‐designed questionnaire related to effects of events and intention to leave were used in this study. RESULTS: The mean scores of intention to response and emergency preparedness were 82.00 (SD = 18.17) and 64.99 (SD = 12.94), respectively. Moral consideration, engaged in COVID‐19 protection training, had working experience in SARS, and the other eight factors were explained 34.6% of the total model variance in intention to response model (F = 80.05, p < .001). While, the level of IR, whether the pace of work was affected and above three same factors were explained 21.5% of the total model variance (F = 91.05, p < .001). Pathway analysis revealed that moral consideration, intention to leave and impacts on work and life mediate the relationship between EP and IR. public disease control. Otherwise, nurses' practising certificate would be revoked (State Council of the PRC, 2008) . When there was a contradiction between the compulsory obligation and self-willingness, nurses were forced to work or were revoked their nurses' practice certificate. Working unwillingly will lead to decreasing the quality of care and increasing intention to leave, which will affect the workforce combating infectious disease in the short-term and aggravate the long-standing shortage of nurses (Kim, Yoo, Yoo, Kwon, & Hwang, 2006) . To meet the inevitable demands for combating public health events, it is necessary for managers to have a better understanding of the level of nurses' intention to response (IR) and associated factors. That will benefit the lay down of promoting training, rules and regulations. Previous studies had demonstrated varying healthcare workers' willing response rates to public health emergencies, ranging between 25%-80% (Alexander & Wynia, 2003; Lenaghan, Smith, & Gangahar, 2006; Ko et al., 2004; Qureshi et al., 2005) . Factors founded to be associated with nurses' intention to response were insufficient knowledge and skills, fear of being infected, overworking, a sense of responsibility, perceived self-efficacy, financial compensation, gender, age and academic degrees. (Cheong et al., 2007; Daugherty, Perl, Lewis, Andrew, & Rand, 2009; Ehrenstein, Hanses, & Salzberger, 2006; Martin, 2011; Qureshi et al., 2005; Wong, Wong,, Kung, Cheung, & Griffiths, 2010; Yonge, Rosychuk, Bailey, Lake, & Marrie, 2007; Cone & Cummings, 2006; Ives et al., 2009; Martinese, Keijzers, Grant, & Lind, 2009 ). Response rate and ability are crucial factors to maintain the nursing workforce during emergency events (Martin, 2011) . However, a handful of studies had described the current level and identified associated factors of IR of nurses by scales or instruments. Grimes and Mendias (2010) had assessed IR level and primarily pointed out several associated factors in their study with moderate sample size. By far, there was no research in developing countries or countries have the similar workforce-related laws in China. Research with larger sample size is also expected to be conducted to make the results more reliable. Adapted DeJoy's behavioural-diagnostic model was used to explain individuals' behaviour of IR. It comprised two components, which were individual factors (demographic, job-related and health status variables; influenza vaccination history/intentions; respiratory protection practices/intentions; perception of risk/fear/concern; pandemic-related variables) and organizational factors (workplace safety climate; organizational trust and shared values; respiratory protection programme; employer pandemic planning) (Gershon et al., 2010) . Some studies pointed out families factors (Smith, Morgans, Qureshi, Burkle, & Archer, 2009; Veenema et al., 2008) , cultural perspective factors (Kim et al., 2006) and care taking commitment (Adams & Berry, 2012; Grimes & Mendias, 2010) were also potential factors beyond the model but affected nurses' willingness to respond, which indicated that more unknown associated factors need to be identified to refine this model. Limited studies had assessed nurses' IR comprehensively used scales or other instruments with good reliability and validity. Furthermore, more potential-associated factors should be identified to refine the current model. Therefore, we aimed to give hospital managers a better understanding of nurses' willingness to provide care, so as to have a better arrangement of the workforce during infectious disease emergency events. The specific objectives of this study were to: (a) assess the current level of nurses' intention to response and also identify more potential factors facilitate or hinder nurses' intention to response; (b) describe the current level of emergency preparedness among nurses and analysis factors affecting nurses' emergency preparedness; and (c) examine the moderation by key variables on the relationship between EP and IR. Based on previous studies, Connor (2014a) pointed out that knowledge and perceptions of efficacy were crucial components that have an impact on nurses' IR. Since EP has been regarded as an indicator that reflects the nurses' perceived familiarity with emergency preparedness and disaster response core competencies (Georgino, Kress, Alexander, & Beach, 2015) , it is expected that nurses with a higher EP indicate a higher level of intention to response. A range of ability-related factors has been confirmed associated with the willingness to a response, such as knowledgeable about the disease, able to recognize symptoms and treat appropriately (Connor, 2014a) . Potential factors that functioned from the ability to willingness demand being revealed. Since overworking (Cheong et al., 2007) and moral obligations (Yonge et al., 2010; Rosychuk et al., 2008) were proved to have an association with an intention to response, thus, we aimed to confirm the positive association between EP and IR. Besides, the moderation effect of moral consideration, degree of work and life being affected and intention to leave were also explored. The specific hypotheses are as follows: Hypothesis 1 There will be a positive association between EP and IR. Hypothesis 2 Intention to leave will mediate the relationship between EP and IR. Hypothesis 4 Degree of work and life being affected will mediate the relationship between EP and IR. A cross-sectional study was designed in our study. Respondents were recruited according to the following inclusion and exclusion criteria. Inclusion criteria were as follows: (a) nurses from hospitals in China; and (b) has the ability to read Chinese; Exclusion criteria were as follows: (a) according to the principle of voluntaries, the nurses who refused to participate in the survey were excluded; and (b) has no ability to read Chinese. For the calculation of sample size, it was recommended as 15 times pervariable in multiple linear regression according to Stevens (1992) . Therefore, desired sample size in this study was determined at more than 420. The questionnaire in this study contained a self-designed demographic and characteristic questionnaire based on literature review and key-person interview, Intention to Response instrument (IR), revised Emergency Preparedness Information Questionnaire (EPIQ) and a self-designed questionnaire related to effects of events and intention to leave. 10-items Intention to Response instrument (IR) is a self-reported questionnaire, which has good inter-item reliability with a Cronbach's α of 0.91 (Grimes & Mendias, 2010) . Continuous scores range from 0 (extremely unlikely to response) to 10 (extremely likely to response) for each item, and a total score range from 0-100. Higher scores of IR predict a higher level of IR. Original So Jump software (web link: https://www.wjx.cn) was used for design and distribution of the e-questionnaire. Data were collected from February 2020-March 2020. The submission of the e-questionnaire was allowed only if all the questions were completed. Therefore, the response rate was 100% in this study. This study was carried out by the ethical principles of the Declaration of Helsinki. The research protocol has been approved by the ethics committee of the First Affiliated Hospital of Guangzhou Medical University and the approval number is 2020 No.73. A total of 1,646 nurses have come from 27 provinces in China. Participants from Guangdong province accounted for the largest proportion, reaching 62.27%. The age of respondents was between 18-60 with an average age of 33.20 (8.43). Other demographic and characteristic details were given in Table 1 . Since Cronbach α values >0.9 indicating an excellent consistency (Zutshi et al., 2020) , the reliability of IR was also good with a Cronbach α of 0.96 in our study. Scores of IR among nurses ranged from 10-100, with an average score of 82.00 (18.17). Uni-variate analyses results demonstrated that education level (F = 6.67, p < .001), working seniority (F = 8.73, p < .001), had working experience in SARS (t = 7.77, p < .001), had protection training about COVID-19 (t = 9.51, p < .001), family members' job (t = 3.31, p = .001), moral consideration (F = 182.51, p < .001), whether the pace of work was affected (t = −7.24, p < .001), overwork (t = −5.61, p < .001), being treated differently by society (t = −8.96, p < .001), whether lifestyles were affected (t = −6.17, p < .001), whether income level was effect (t = −6.17, p < .001), TA B L E 1 Demographic and characteristic information of the respondents and differences in mean of IR and EP by characteristics of the nurses (n = 1,646) Category n % Note Computed by multiple stepwise linear regression analysis. Moral consideration (Totally moral consideration = 1, Many moral consideration = 2, A little moral consideration = 3, No moral consideration = 4), treated differently by the society (yes = 1, no = 2), had COVID-19 protection training (yes = 1, no = 2), had working experience in SARS (yes = 1, no = 2), overwork (yes = 1, no = 2), education level (associate degree = 1, bachelor degree = 2, master degree = 3, doctor degree = 4, post-doctor = 5), intention to leave (intention to leave due to COVID-19 = 1, intention to leave irrelevant to or no intention to leave = 2), support to set public nurse (yes = 1, no = 2), felt anxious and depressed (yes = 1, no = 2), department (other = 1, department of respiration = 2, emergency treatment = 3, ICU = 4), the pace of work was affected (yes = 1, no = 2). felt anxious and depressed (t = −9.27, p < .001), intention to leave (F = −6.15, p < .001), departments (F = 10.00, p < .001) had a significant different in the level of IR. More details were presented in Table 1 . For IR as the dependent variable, the regression model was generated by multiple linear stepwise regression and was shown in Cronbach α of revised EPIQ was 0.900 in this research, which means an excellent consistency according to Zutshi et al. (2020) . EP scores were between 18-90, with an average score of 64.99 (12.94). As shown in Table 1 In EP model, demographics and characteristics information of participants were used as independent variables and EP as dependent variables. Table 2 shows moral consideration, had participated in COVID-19 protection training, had working experience in SARS, the level of IR, whether the pace of work was affected the level of nurses' emergency preparedness, which explained 21.5% of the total variance (F = 91.05, p < .001). The regression weight between EP and IR was 0.365 (p < .001), which confirmed the positive association by hypothesis 1. Three mediation diagrams for standardized estimates were contained in Figure 1 . In Figure 1a , EP significantly predicted IR (β = 0.20, p = .001). The direct effect of EP to moral consideration was −0.39 (p = .001), and the direct effect of moral consideration to IR was −0.41 (p = .001). Mediation by moral consideration on the relationship between EP and IR was 0.16 (p = .001), which supports our hypothesis 3. In Figure 1b and IC, impacts on work and life of COVID-19 and intention to leave also have slight effects on mediate the relationship between EP and IR with an indirect effect of 0.04 (p = .001) and F I G U R E 1 Mediation by key variables on the relationship between EP and IR. IR, intention to response; EP, emergency preparedness; MC, moral consideration; IWL of COVID-19: impacts on work and life of COVID-19. **p < .01. *p < .05 0.01(p = .006), respectively. Therefore, hypothesis 2 and hypothesis 4 were also been supported. Comparing to the previous study of Grimes and Mendias (2010) , the IR level of Chinese nurses with 82.00 (18.17) was much higher than that of nurses in the United States with 69.6 (21.1), which probably account for the different national system and the cultural difference. Chinese nurses had no right to refuse in any emergency event. Besides, the Chinese believe in the core values of "country first, then home" and "give up a family for everyone." However, the average EP score among nurses was 64. intention to response, which can be explained as respiratory protection practices by previously adapted DeJoy's behavioural-diagnostic model (Gershon et al., 2010) . In this model, overwork can be explained as a job-related variable, while department, felt anxious and fear also can be explained as the perceived risk. Besides, nurses who had a higher level of EP were likely to response because of the higher perceived behavioural control (Connor, 2014b; Grimes & Mendias, 2010; Ko et al., 2004 ). The factor of education level we identified was also in line with previous studies (Basta, Edwards, & Schulte, 2009; Martinese et al., 2009; Seale, Leask, Po, & MacIntyre, 2009 ). The nurse who did report a higher level of confidence was more likely involved in a disaster relief effort in the past (Baack & Alfred, 2013) , whereas who had an intention to leave was unlikely to respond due to the lack of professional obligation and duties (Giarratano, Orlando, & Savage, 2008; Qureshi, Gershon, & Conde, 2008) . Among three new associated factors, moral consideration as well as whether being treated differently by society was cultural and social perspective factors. Since the cultural perspective was pointed previously (Couig, 2012; Kim et al., 2006) , the intention to response and Canada (Mondy, Cardenas, & Avila, 2003; Philibin et al., 2010) . Nurses who support to set up PHNs have a higher level of awareness of its importance as well as emergency events. The EP among nurses in China was at a not high level that is in line with the results of Labrague, et al. (2018) . A highly qualified response not only depends on the willingness and ability, but also depended on readiness (McCabe, Barnett, Taylor, & Links, 2010) , although nurses' willingness to response was considerable in China. Unsatisfactory level of EP indicated that training need be taken for preparedness promotion and a better-qualified response. In our study, nurses who had protection training and working experience in SARS were likely to have a higher level of EP, which was consistent with the findings of previous studies (Baack & Alfred, 2013; Nilsson et al., 2016; Ning et al., 2014) . Besides, we found that moral consideration, IR and whether their pace of work was affected were also associated factors of EP. Therefore, we here suggested hospital managers pay more attention to the preparedness promotion among nurses who had less moral consideration, lower IR and less experience. What's more, the training we recommended was on the principle of not to affect the working pace. Since moral consideration greatly mediates the relationship between EP and IR, a reserve of plenty of nurses with well-trained and well-educated cannot completely address the shortage of nursing workforce in a future infectious disease outbreak. More potential variables associated with moral consideration should be noticed, such as social environment, professional commitment. Moreover, it is suggested that professional moral consideration should be emphasized in future nursing education and training, to ensure more able nurses have the willingness to respond in the future. Although our study has confirmed the current considerable level of intention to response among clinical nurses and thirteen factors associated with IR, several limitations are accounted for when interpreting the findings. First, respondents were mostly from Guangdong province in China that can hardly completely represent all the clinical nurses in other provinces or other countries. We encouraged future research carried out at several sites in multiple countries. Second, IR and EP scales were self-reported scales, which may rely on the accuracy of participant responses. Third, we used a self-designed demographic and characteristic questionnaire for linear regression, which may bring limitations to identification of potential factors that affect IR or EP. We expected future researches could identify more associated factors based on the conceptual framework of IR and EP, so as to give managers a better understanding of what promotes or hinders the level of IR and EP among nurses. Notwithstanding the above limitations, this study proved a considerable level of intention to response among nurses accompanied by a moderate level of emergency preparedness. Our findings highlight the effects of social and moral factors on intention to response beyond the previous model. For nursing management, we recommended politic makers and managers to set up education courses or training projects related to emergency preparedness for a more qualified response to currently COVID-19 or future infectious disease outbreak emergency events. Who will show up? estimating ability and willingness of essential hospital personnel to report to work in response to a disaster Ready and willing? Physicians' sense of preparedness for bioterrorism Nurses' preparedness and perceived competence in managing disasters Assessing public health department employees' willingness to report to work during an influenza pandemic Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: A retrospective review of medical records Concerns and preparedness for an avian influenza pandemic: a comparison between community hospital and tertiary hospital healthcare workers Detriments of a self-sacrificing nursing culture on recruitment and retention: A qualitative descriptive study Hospital disaster staffing: if you call, will they come? When and why health care personnel respond to a disaster: The state of the science Factors associated with the intention of health care personnel to respond to a disaster Willingness, ability and intentions of health care workers to respond Survey study of the knowledge, attitudes and expected behaviors of critical care clinicians regarding an influenza pandemic Influenza pandemic and professional duty: Family or patients first? a survey of hospital employees Evaluation of an instrument to measure nurses' familiarity with emergency preparedness Emergency preparedness education for nurses Factors associated with the ability and willingness of essential workers to report to duty during a pandemic Perinatal nursing in uncertain times: The Katrina effect Nurses' intentions to respond to bioterrorism and other infectious disease emergencies Healthcare workers\" attitudes to working during pandemic influenza: A qualitative study Attitude, beliefs and intentions to care for SARS patients among Korean clinical nurses: An application of theory of planned behavior Applying theory of planned behavior to predict nurses' intention and volunteering to care for SARS patients in southern Taiwan Disaster preparedness among nurses: A systematic review of literature Emergency preparedness and bioterrorism: A survey of the Nebraska Medical Center staff and physicians Nurses' ability and willingness to work during pandemic flu How would Australian hospital staff react to an avian influenza admission, or an influenza pandemic? Ready, willing and able: A framework for improving the public health emergency preparedness system The role of an advanced practice public health nurse in bioterrorism preparedness Disaster nursing: Self-reported competence of nursing students and registered nurses, with focus on their readiness to manage violence, serious events and disasters Factors affecting emergency preparedness competency of public health inspectors: A cross-sectional study in northeastern China Severe acute respiratory syndrome The role of the public health nurse in a changing society Factors that influence medical reserve corps recruitment Health care workers' ability and willingness to report to duty during catastrophic disasters AIDS, Avian flu, SARS, MERS, Ebola, Zika… what next? Vaccine Willingness to volunteer during an influenza pandemic: perspectives from students and staff at a large Canadian university. Influenza and Other Respiratory Viruses Will they just pack up and leave?"-attitudes and intended behaviour of hospital health care workers during an influenza pandemic Paramedics' perceptions of risk and willingness to work during disasters State Council of the People's Republic of China Applied multivariate statistics for the social sciences Factors affecting hospital-based nurses' willingness to respond to a radiation emergency Emergency preparedness competencies: Assessing nurses' educational needs Will the community nurse continue to function during h1n1 influenza pandemic: a cross-sectional study of hong kong community nurses Nursing students' general knowledge and risk perception of pandemic influenza. The Canadian Nurse Willingness of university nursing students to volunteer during a pandemic The legal duty of care for nurses and other health professionals Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia Reducing patient burden and improving data quality with the new Cleveland clinic colorectal cancer quality of life questionnaire The authors thank the head nurses across the China to help distribute the questionnaire.