key: cord-0882940-r3bug80s
authors: Zhou, Yan; Asante, Eric Adom; Zhuang, Yiyu; Wang, Jie; Zhu, Yue; Shen, Lihua
title: Surviving an infectious disease outbreak: How does nurse calling influence performance during the COVID‐19 fight?
date: 2020-11-18
journal: J Nurs Manag
DOI: 10.1111/jonm.13181
sha: c16dc8e145de31cbcd425507e366ccf1068714a9
doc_id: 882940
cord_uid: r3bug80s

AIM: To assess the performance of front‐line nurses, who believed they were living out their calling, during the coronavirus disease 2019 (COVID‐19) pandemic. BACKGROUND: Although as a profession nursing generally requires high levels of performance, the disruption arising from an infectious disease outbreak increases the work stress and decreases the performance of front‐line nurses. How this situation can be improved has yet to be thoroughly examined. METHOD: We used a snowball sampling technique to recruit 339 nurses who were originally from outside Hubei but volunteered to join medical teams going to Hubei to tackle COVID‐19. RESULTS: Drawing on the theory of work as a calling, we found that living a calling had a positive effect on front‐line nurses’ performance through the clinical and relational care they provided. Perceived supervisor support strengthened these mediated relationships. CONCLUSION: Our findings indicate that despite the constraints associated with pandemics, front‐line nurses who are living a calling are able to provide better clinical and relational care to infected patients, which in turn improves their performance. IMPLICATIONS FOR NURSING MANAGEMENT: The findings of this study suggest that hospitals can introduce career educational interventions to enhance nurses’ ability to discern and live out their calling to improve their performance.

to patients' physical and mental needs, masters technological skills, communicates effectively with colleagues, patients and patients' family members, and handles multiple tasks properly (Cho & Han, 2018; Pai et al., 2017) . As nursing performance is vital to quality patient care and safety, researchers have shown great interest in how to improve nursing performance (Amarat et al., 2019; Terzioglu et al., 2016) . Unfortunately, as infectious disease outbreaks are unplanned, they are impossible or very difficult to prepare for. Several studies have articulated the enormous challenges such outbreaks bring (Fauci & Morens, 2012; Lam et al., 2018) , such as the heavy workload on nursing staff (Alghamdi, 2016) , the necessity for nurses to acquire the knowledge and skills required to handle new diseases (Liu & Liehr, 2009) and the elevated risk of infection for front-line nurses (Shih et al., 2009 ). How do we maintain or even improve nursing performance in such critical situations? Recent management research has shown that employees who perceive their jobs as a calling are resilient in the face of adversity (Praskova et al., 2014; Thompson & Bunderson, 2019) .

As such, we draw on work as calling theory (WCT; Duffy et al., 2018) and argue that front-line nurses who perceive themselves as living a calling through their nursing jobs are likely to demonstrate increased levels of nursing performance during the COVID-19 outbreak. A calling is defined as work that a person believes is inseparable from his/her life and that provides fulfilment (Wrzesniewski et al., 1997) .

Living a calling involves being engaged in activities or work that meet this calling (Duffy & Autin, 2013) . Nurses who believe they are living a calling are likely to exhibit greater work effort and caring ability towards their patients (Praskova et al., 2014) . Such nurses may view their profession as their responsibility to public service rather than a mere job (Koh et al., 2012) . They may also be more willing to comply with infection control protocols (Qureshi et al., 2013) and less likely to compromise on their professional nursing values and integrity (Lam et al., 2018; Schluter et al., 2008) . These characteristics are very important to the performance of front-line nurses in times of adversity, such as infectious disease outbreaks.

We further argue that front-line nurses who believe that they are living a calling through their work demonstrate high levels of nursing performance, that this positive effect is mediated by their clinical and relational caring abilities (Cossette et al., 2006) and that these indirect effects are conditional on the level of perceived supervisor support (PSS) that they receive (Eisenberger et al., 2002) . Thus, front-line nurses who are living their calling are likely to exert more effort and show higher persistence when faced with the difficulties of COVID-19 (Thompson & Bunderson, 2019) . Living a calling also makes front-line nurses conscious of their duties, leading to high clinical and relational care (Al-Hamdan et al., 2017 ) and subsequently to higher nursing performance. Lastly, we argue that the indirect effect of living a calling on nursing performance is influenced by the extent to which leaders value subordinates' contributions (i.e. PSS; cf. Eisenberger et al., 2002) . A high level of PSS makes nurses more obligated to their work, thereby improving nursing performance.

Considering that infectious disease outbreaks have become prevalent worldwide, it is important to examine the factors that can ensure that nursing performance remains high even in such trying times.

Thus, examining the effect of living a calling on the nursing performance of front-line nurses fighting against COVID-19 and the underlying mechanism and boundary condition is both relevant and timely.

By examining these relationships, we make two main contributions to the nursing management literature. First, we extend the theoretical perspective of WCT (Duffy et al., 2018) from the fields of organisational behaviour and counselling psychology to nursing management by examining a unique group of nurses: those who took part in the fight against COVID-19. Second, we propose that living a calling through work is a precursor for improved nursing performance during critical situations, such as infectious disease outbreaks. It can determine nurses' level of preparedness when responding to an epidemic event and is therefore significant (Lam et al., 2018 ). Our theoretical model is shown in Figure 1 . WCT (Duffy et al., 2018) conceptualizes a calling as involving three overlapping components: (a) 'a transcendent summons, experienced as originating beyond the self', (b) approaching 'a particular life role in a manner oriented toward demonstrating or deriving a sense of purpose or meaningfulness', and (c) holding 'other-oriented values and goals as primary sources of motivation' (p. 425). The first component represents the extent to which a person perceives his/her calling to a particular job to have come from an external source, the second represents the extent to which the work is perceived as achieving a particular purpose and meaning in life (Dik & Duffy, 2009) , and the third represents the extent to which such work is perceived as a direct or indirect contribution to the greater good of society.

Living a calling has a positive effect on task performance across several occupations. For instance, in a sample of teachers, Rawat and Nadavulakere (2015) found that living a calling influenced performance. Among the staff members of a church, Kim et al. (2018) also found that living a calling was positively related to performance. The positive effect of living a calling on performance has also been found in other samples, including NGO employees (Kim et al., 2018; Lee et al., 2018) . These favourable consequences of living a calling have been attributed to the fact that it makes people self-motivated and ready to exert effort to achieve good performance (Kim et al., 2018) .

Despite these important findings, the influence of living a calling has yet to be explored in the nursing literature. We argue that the extent to which health organisational goals in a pandemic are achieved depends on the effective services front-line nurses provide to infected patients, which are largely influenced by their effort and persistence when facing difficulties (Thompson & Bunderson, 2019) . Thus, frontline nurses who believe their nursing work during the fight against COVID-19 meets their calling (Duffy & Autin, 2013 ) are likely to demonstrate high levels of nursing performance. H1: Living a calling has a positive effect on nursing performance.

Caring is at the core of the nursing profession, with nurses often described as professional caregivers (Simmons & Cavanaugh, 2000) .

Professional caregiving involves the deliberate goals and processes of professionals in providing assistance to others to support their well-being and alleviate undue discomfort (Leininger, 1981) . Cossette et al. (2006) identified the four caring dimensions of humanistic, relational, clinical and comforting care. We focus on clinical and relational care as the two dominant dimensions (Cossette et al., 2006) in analysing the mechanism through which living a calling influences front-line nurses' performance.

The clinical care given by nurses is the expertise required for clinical assessment and monitoring and for treatment and symptom management. Relational care involves nurses respecting patients' perceptions and assisting them in coming to terms with their health situations (Watson, 2008) . Although caring is always an important component of a nurse's job, it becomes particularly important during infectious disease outbreaks (Chung et al., 2005) . In an epidemic situation, nurses who can offer high levels of clinical and relational care are likely to perform well in their jobs, as such situations often involve nurses being frequently assigned new roles that may be beyond the scope of their usual clinical practice (Gebbie & Qureshi, 2002) . Liu and Liehr (2009) found that clinical knowledge of infectious diseases led to improved service delivery during the SARS outbreak. Similarly, nurses' relational care behaviour has been found to improve communication with critically ill patients (Expósito et al., 2018) , thereby helping to improve the services delivered. Front-line nurses' ability to accomplish work goals, meet job expectations and achieve organisational goals is affected by their ability to deliver clinical and relational care to infected patients (Al-Hamdan et al., 2017) . Being able to provide such clinical and relational care has a direct effect on infected patients' experience and health outcomes and determines the nursing performance of frontline nurses (Henderson & Prescott, 2020; Lee & Ko, 2010) .

To effectively utilize their clinical and relational care abilities, nurses must first believe that the activities in which they are engaging fulfil a personal need or contribute to the greater good of society. Thus, we argue that living a calling can have a positive influence on nurses' clinical and relational care abilities. Research suggests that those who believe they are living a calling have clarity about themselves and their career choices (Thompson & Bunderson, 2019) . As such, nurses who are living a calling are continually aware of their career choices and are willing to seek knowledge when faced with novel situations, such as the COVID-19 pandemic (Dobrow & Tosti-Kharas, 2011) . They may also exhibit the relational behaviour necessary for improved service delivery. Thus, we argue that clinical care and relational care are the mechanisms through which living a calling influences nursing performance.

H2: Clinical care mediates the positive relationship between living a calling and nursing performance.

H3: Relational care mediates the positive relationship between living a calling and nursing performance.

As the nurse-patient ratio increases during an epidemic, front-line nurses are frequently assigned new roles, duties and responsibilities with which they may not be familiar (Gebbie & Qureshi, 2002) . They may also be required to make crucial decisions concerning infection control, triage and the treatment of infected patients. PSS is the extent to which a supervisor appears to value his/her subordinates' contributions (Eisenberger et al., 2002) . PSS may be important in determining how front-line nurses conduct their clinical and relational care duties during an epidemic. Supervisors act as the agents of an organisation and are responsible for directing and evaluating subordinates' performance (Shanock & Eisenberger, 2006) . Research has shown that under high levels of PSS, employees feel obligated to help their organisation achieve its objectives and may engage in extra role behaviours, such as helping colleagues (Eisenberger et al., 2001) .

We argue that under high levels of PSS, front-line nurses will treat infected patients better, help other nurses when their workloads increase and assist colleagues with their duties. When PSS levels are high, nurses also perceive that their supervisors treat them favourably (Shanock & Eisenberger, 2006) . This positive treatment is likely 

This study was designed to examine the effect of living a calling on front-line nurses' performance during the fight against COVID-19.

The study was conducted in China among front-line nurses who were involved in the fight against COVID-19 in Hubei. We used a descriptive, cross-sectional and survey design.

The author team used a snowball sampling technique to recruit nurses who were originally from outside Hubei but who had joined medical teams going to Hubei to tackle COVID-19. Thus, they had all been on the medical front line and treated patients with COVID-19.

Their participation was voluntary, and their confidentiality was ensured. Approximately 400 nurses were invited to participate in this study, and ultimately, 345 surveys were received. Six surveys with incomplete data were removed, yielding an effective response rate of 84.75%.

The surveys were initially written in English and translated into Chinese, in accordance with Brislin's (1986) 

Living a calling was measured using a 6-item scale adapted from Duffy et al. (2012) . The following instruction was used: 'During the COVID-19 fight in Hubei…' An example item is, 'I was working in a job that closely aligns with my calling' (1 = strongly disagree to 7 = strongly agree; α = 0.91).

Clinical care was assessed using the 9-item clinical care subdimension of the Caring Nurse-Patient Interaction Scale (Cossette et al., 2006) .

The nurses were asked to complete the following sentence: 'When providing care for patients with COVID-19 in Hubei…' An example item is, 'I knew how to operate specialized equipment (e.g. pumps, monitors)' (1 = strongly disagree to 7 = strongly agree; α = 0.94).

Relational care was measured using the 7-item relational care subdimension of the Caring Nurse-Patient Interaction Scale (Cossette et al., 2006) . The following instruction was used: 'When providing care for patients with COVID-19 in Hubei…' An example item is, 'I helped patients to look for a certain equilibrium/balance in their lives' (1 = strongly disagree to 7 = strongly agree; α = 0.95).

PSS was assessed using a 9-item measure adapted from Wayne et al. (1997) . The nurses were asked to complete the following sentence: 'During the COVID-19 fight in Hubei…' An example item is, 'My supervisor cared about my general satisfaction at work' (1 = strongly disagree to 7 = strongly agree; α = 0.98).

Nursing performance was measured using a 7-item measure adapted from Fitzpatrick et al. (1997) . The following stem was used: 'Please evaluate your performance during the COVID-19 fight in Hubei'.

An example item is, 'Attention to patients' activity in accordance with their current and potential health status' (1 = unsatisfactory to 5 = superior; α = 0.95).

Previous research (Terzioglu et al., 2016; Walpita & Arambepola, 2020) has suggested that age, sex and nursing tenure are associated with nursing performance. As such, these factors were controlled for. Age and nursing tenure were measured in years, and sex was measured as female = 0 and male = 1. In addition, work meaning (Ghislieri et al., 2019) was controlled to avoid confounding the mediation results. Meaningful work was measured using a 10-item scale (Steger et al., 2012 ) scored on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree; α = 0.97).

In early April 2020, data were collected through a Chinese online survey system. At this time, all of the nurses who had gone to Hubei from other provinces had finished their missions and were either quarantined in Hubei or their home cities. The survey information was sent to several head nurses who had led medical teams to Hubei, who forwarded it to all of the nurses on their teams using the most popular instant messenger smartphone application in China. The participants could access the survey using a web link or a Quick Response code. The purpose, anonymity and confidentiality of the online survey were first briefly introduced, and consent was obtained by asking the participants whether they agreed to participate. If the response was negative, the survey ended immediately.

Although head nurses helped with sample recruitment, participation was voluntary, and the participants were at liberty to stop the survey at any time. Ethical approval for this study was obtained from the first author's institute.

We used the Statistical Package for Social Science (SPSS) version 25.0 software (IBM Corp., 2017) for descriptive, correlation and regression analysis. To test our hypotheses, we used the PROCESS macro software package (Hayes, 2013) . The seven hypotheses were analysed using Model 7 of the PROCESS macro. This allowed us to examine our direct, mediation and moderation hypotheses in one model simultaneously.

The personal and work characteristics of the study participants are presented in Table 1 . Their average age was 32.32 years, 76.70% were female, their average nursing experience was 9.27 years, and all had completed an associate degree or above.

The means, standard deviations, reliabilities and correlations of the variables are shown in Table 2 . Model 7 of the PROCESS macro (Hayes, 2013) was used for the substantive analyses. The results are presented in Table 3 . H1 proposes that living a calling has a positive effect on nursing performance. Results showed that living a calling was not significantly related to nursing performance (B = 0.05, p > .10). Thus, H1 was not supported. Results also revealed that living a calling was significantly related to clinical care (B = 0.60, p < .01) and relational care (B = 0.57, p < .01).

Clinical care (B = 0.16, p < .01) and relational care (B = 0.11, p < .01) were also significantly related to nursing performance. H2 and H3 state that clinical care and relational care each mediate the positive relationship between living a calling and nursing performance. As shown in Table 4 , clinical care (indirect effect = 0.10, The coding of the dummy variables is presented in Table 1 .

*p < .05; ** p < .01.

care (B = 0.11, p < .01) and relational care (B = 0.14, p < .01). Thus, H4 and H5 were supported. These interaction effects are plotted in Figure 2 at high and low values of PSS, defined as 1 standard deviation above and below the mean value, respectively (Cohen et al., 2003) .

H6 proposes that PSS moderates the indirect relationship between living a calling and nursing performance through clinical care. As shown in Table 4 , the index of moderated mediation (Hayes, 2015) -that is the product term of the interaction effect be- (Terzioglu et al., 2016) , it is important to examine the factors that lead to high nursing performance. Although infectious disease outbreaks present enormous challenges (Fauci & Morens, 2012) , our study found that front-line nurses who live out their calling in their work performed effectively during such outbreaks. This extends the research on living a calling, which has focused mostly on stable environments (Cardador et al., 2011; Duffy et al., 2011; Yim & Fock, 2013) .

In addition, our study extends the nomological network of living a calling by demonstrating its associations with nurses' caring abilities. In particular, we demonstrate the associations between living a calling and clinical and relational care, which have not been previously hypothesized or shown. This finding is not surprising, because caring is central to the nursing profession (Simmons & Cavanaugh, 2000) and even more important during infectious disease outbreaks. Nurses with intense callings push themselves to provide clinical and relational care, which are two important caring abilities that determine their performance (Feo et al., 2020) . Quality clinical care and relational care also improve patient satisfaction (Calong & Soriano, 2018) .

Our finding that PSS strengthens the relationships between living a calling and clinical and relational care is also important. Front-line nurses who believe they are living a calling in their nursing profession are likely to be engaged in activities such as clinical and relational care (Cardador et al., 2011; Duffy et al., 2011) . We found the effect to be stronger when nurses perceive adequate support from their supervisors. When supervisors show that they care about and value their front-line nurses, they initiate social exchange processes, which instil a sense of obligation among subordinates and motivate them to reciprocate (Goussinsky & Livne, 2016; Sarwar et al., 2020) .

In an outbreak situation, such an obligation to reciprocate may be expressed by exhibiting a high degree of clinical and relational care 

for infected patients (Lam et al., 2018) . Thus, front-line nurses who perceive favourable treatment from their supervisors (Shanock & Eisenberger, 2006) are likely to pass on the same treatment to their patients.

As COVID-19 has shown, infectious disease outbreaks can be intense and long-lasting. As such, it is important for nurse managers to recruit individuals who believe they have a mission and calling to fulfil. Training such people to be nurses is easier, and when they are deployed, they will be willing to make sacrifices and work long hours to succeed, despite any obstacles they encounter. Therefore, surveys measuring calling values should be administered when nurses are being recruited. For front-line nurses who are already employed, intervention programmes could be developed to enhance the meaning they attach to their nursing job to help them live their calling (Duffy & Dik, 2013) . Career development workshops and career educational interventions could be established to enhance nurses' ability to discern and live out their calling (Dik & Steger, 2008; Duffy & Dik, 2013) and to improve their performance. Studies have found that when employees are satisfied with their jobs (Thompson & Bunderson, 2019) , have higher vocational self-clarity (Dik & Duffy, 2009) , and are free to make career choices (work volition; Dik & Duffy, 2009 ), they are able to live out their calling. As such, we suggest that by reducing nurses' burnout (Jager et al., 2017) , giving them autonomy and making them happy with their job, nurse managers can increase nurses' ability to discern and live out their calling. Last, F I G U R E 2 (a) The interaction effect of living a calling and perceived supervisor support on clinical care. (b) The interaction effect of living a calling and perceived supervisor support on relational care our results showed that leaders were essential in outbreak situations, as PSS enhanced the indirect relationship between living a calling and nursing performance through clinical and relational care. Therefore, supervisors should receive ongoing training so they can support nurses in trying times.

We used a cross-sectional study design. Thus, we cannot draw any conclusions about a causal relationship between living a calling and nursing performance. In addition, the data collection process was based on self-reporting. In future research, a longitudinal and multiple source design should be applied to test our model. Finally, although participation in the study was voluntary, head nurses were involved in the sample recruitment, raising concerns about convenient sampling. This should be addressed in future studies. 

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