key: cord-0982688-wg33s4ve
authors: Gan, Xiaoqing; Shi, Zeya; Ying Chair, Sek; Cao, Xi; Wang, Qun
title: Willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 epidemic: A cross‐sectional study
date: 2020-05-24
journal: J Adv Nurs
DOI: 10.1111/jan.14434
sha: a73441cfc81178ee74cf60d4f69ee398ae219bda
doc_id: 982688
cord_uid: wg33s4ve

AIMS: To investigate the willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 and to explore the associated factors. DESIGN: A cross‐sectional survey. METHODS: Clinical nurses were conveniently recruited by an online link in three provinces out of Hubei, including Hunan (Central south), Chongqing (Southwest) and Xinjiang (Northwest) during 4‐10 February 2020. A structured questionnaire was distributed by an online investigation system. Information on sociodemographic characteristics, willingness, possible influencing factors (previous experience, health status, training conditions, perceptions on volunteering to practice in Hubei, family attitude and insurance) were collected. Binary logistic regression was conducted to explore the association of different factors with the willingness decision of nurses. RESULTS: A total of 11,183 nurses participated in this survey and a high proportion of them were willing to volunteer to practice in Hubei combating the epidemic. Nurses who were likely to volunteer had the following characteristics: younger, unmarried, members of the Communist Party of China, with senior professional qualification, working in critical care departments, with support from their families, with adequate training and learning, with good health status and low levels of anxiety. The regression model could explain 31.1% of the variances of the willingness decision of nurses. CONCLUSIONS: A high proportion of nurses in China were willing to practice in Hubei during the coronavirus disease 2019 epidemic. Adequate training and psychological support would facilitate nurses to volunteer during the outbreak of an infectious disease. IMPACT: The study identified a high proportion of nurses in China were willing to to practice in Hubei combating the coronavirus disease 2019 epidemic. The findings will provide valuable references for nurses and decision makers to formulate better plans for increasing nursing workforce during such kind of public health crisis.

An on-going outbreak of a respiratory disease caused by the 2019 novel coronavirus 

Health Organization [WHO] , 2020). This new virus has a similar genome sequence with the Severe Acute Respiratory Syndrome-Associated Coronavirus (SARS-CoV) but is less pathogenic than the SARS-CoV and the Middle East Respiratory Syndrome coronavirus (MERS-CoV) (Chen, 2020) . The COVID-19 has a strong capability of human-to-human transmission, resulting in its rapid spread throughout China and later outside the country (Cao et al., 2020) . Until February 24, 2020, the number of confirmed cases in Mainland China had grown to 77,658, including 2,663 deaths and 47,672 under medical treatment; among these cases, 64,786 diagnosed patients and 2,563 deaths occurred in Hubei, the epicentre of the outbreak (National Health Commission of the People's Republic of China [NHC] , 2020a). In response to the COVID-19 outbreak, China has activated various emergency responses, such as holiday extensions, building specialty hospitals, the lockdown of Wuhan, a nationwide quarantine policy and sending a huge number of healthcare professionals from other parts of the country to help Hubei (Foreign Policy, 2020 , NHC, 2020b .

Nurses, the professionals with the most contact with patients, play an essential role in fighting against disease outbreaks. In addition to initiating nursing procedures, the outbreak of an epidemic imposes frontline nurses with additional roles, such as screening and recognizing potential cases, helping with isolation, implementing a quarantine and monitoring cases (Stirling, 2017) . Therefore, a substantial increase of nursing workforce is demanded to assume these responsibilities. The nurse-to-population ratio in Hubei is 2.65 per 1,000 people (National Bureau of Statistics, 2019), lower than the average level in Mainland China (3.14) (CNKI, 2020) and much lower than that in Japan (11.5) and the USA (8.6) (The World Bank, 2019). The 47,672 patients with COVID-19 require intensive treatment and care (NHC, 2020a) , thus imposing additional burden to the inadequate nursing workforce there.

Caring for this large number of patients places substantial stress on local nurses and may lead to their burnout.

To control this outbreak and to relieve the healthcare workforce shortage at the frontlines,

This article is protected by copyright. All rights reserved physicians, nurses and other healthcare professionals have been recruited to practice in Hubei combating this epidemic. Till 17 March 2020, over 42,600 healthcare professionals from different hospitals all over the country, including 28,600 nurses, were sent to Hubei to fight against COVID-19 epidemic (NHC, 2020c) . These healthcare professionals that were sent to Hubei were organized by local health commissions (the government department). Therefore, there is a need to understand the willingness of nurses to practice in Hubei and the factors associated with their willingness.

Engaging healthcare professionals to serve during infectious disease outbreaks remains a difficult management topic. Previous studies reported a high proportion of absenteeism in Hong Kong (76.9%) (Wong et al., 2010) , Taiwan (43%) (Lee et al., 2005) , Australia (33%) (Stuart and Gillespie, 2007) and Germany (28%) (Ehrenstein et al., 2006) during the influenza pandemic, outbreaks of SARS and other infectious diseases. A survey in UK reported that only 1.7% of healthcare professionals volunteered to work in West Africa for the Ebola epidemic (Turtle et al., 2015) .

The willingness of healthcare professionals to serve at the frontline of an outbreak is influenced by various factors. It may also vary from epidemic to epidemic and from region to region. Psychological stress, previous experience with an epidemic, safety concerns on being infected, social support and the attitudes of the families were associated with willingness of healthcare professionals to serve in the frontline (Khalid et al., 2016 , Oh et al., 2017 , Turtle et al., 2015 . Specifically, the common facilitators for healthcare professionals being volunteers include receiving training, availability of effective treatments (Turtle et al., 2015) , perceived professional obligation, support from the hospital administration, financial compensation (Khalid et al., 2016) , adequate protective equipment, reasonable staffing and family support (Lee et al., 2005) . Insufficient information, worry of being infected and the concerns of their families are the most cited reasons for nurses to not help in the frontline (Turtle et al., 2015) .

With the strong transmission of COVID-19 and the rapid increasing number of patients, Accepted Article an escalating demand for nursing workforce exists in Hubei, the epicentre of this outbreak.

Nurses' willingness to help fighting against COVID-19 is a critical issue in the nursing management. Therefore, the current study was conducted to identify the willingness of Chinese nurses to practice in Hubei combating COVID-19 and to explore the associated factors. Findings from this study will provide valuable references for decision makers to formulate better plans for increasing nursing workforce during such kind of public health crisis.

2. THE STUDY:

The study aimed to investigate the willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 and to explore the associated factors.

This study was a cross-sectional study. Given the strong capability of human-to-human transmission of the COVID-19, close contact and mass gatherings should be limited (WHO, 2020) . Considering the wide use of social media in China, e.g. WeChat and QQ, an online survey approach was adopted, taking advantage of high efficiency and low cost.

The online survey was conducted in the rising stage of this epidemic from 4-10 February 2020 shortly before the peak. 

This article is protected by copyright. All rights reserved three province-level administrative divisions are located in different areas (North and South, Central and West) in China, with diverse ethnic compositions, populations, gross domestic product levels, cultural backgrounds and medical resources. Moreover, Hunan and Chongqing are both adjacent to Hubei, while Xinjiang is over 3000 kilometers northwest of Hubei. Recruiting participants from the three areas would provide a full picture of nurses with various characteristics, especially with the differences in geographic location and distance from the epicentre of the outbreak.

Registered nurses working in clinical practice were invited.

According to the most updated statistics, the total number of registered nurses was 184,000, 95,100 and 72,300 in Hunan, Chongqing and Xinjiang, respectively (National Bureau of Statistics, 2019). A convenient sample of at least 1% of the total number of nurses in each province was expected in the current study (Sun and Xu, 2014) . Accordingly, at least 3,514 nurses were required, including 1,840, 951 and 723 in Hunan, Chongqing and Xinjiang, respectively.

Based on findings of previous studies (Khalid et al., 2016 , Lee et al., 2005 , Oh et al., 2017 , Turtle et al., 2015 and a pilot test, a structured questionnaire was developed to investigate Nurses' Willingness of volunteering to practice in Hubei and the Influencing Factors (NWIF). The NWIF included 27 items, covering the sociodemographic characteristics (10 items), willingness of volunteering to help Hubei (1 item) and influencing factors (16 items).

The sociodemographic characteristics included age, gender, education, political party membership, professional qualification, working department, marital status, number of

This article is protected by copyright. All rights reserved children, living conditions and locations.

The willingness was asked by the item 'would you like to be a volunteer for Hubei to combat the COVID-19 epidemic?'. A volunteer means the nurse would leave his or her original working hospital and hometown and practice in a hospital in Hubei to fight against COVID-19. All volunteers to Hubei were selected and organized by local health commissions.

When the job in Hubei is completed, the volunteers will return to their original working positions.

The possible influencing factors included the aspects of personal health (3 items), previous experience (4 items), training condition (3 items), personal perceptions (4 items), family attitude (1 item) and insurance (1 item). The perceived health status was measured by the question, 'How do you feel about your current health status?', with the choices of 'energetic and spirited, as stable as before, feel depressed, unhappy for a long time, sleep disorders and others'. The perceived stress and anxiety levels were measured by the visual analogy scales (VAS), with 0 indicating no stress/anxiety and 100 indicating the highest level of stress/anxiety. The related experience items included 'whether you have participated in a similar kind of public health crisis', 'whether your friends/colleagues have participated in a similar kind of public health crisis', 'whether you had close contact with COVID-19 patients', 'whether any colleague was isolated', 'whether you bought a specific insurance for this crisis'.

The training conditions included 'whether you have received training for COVID-19', 'your understanding about COVID-19-related knowledge' (with choices of 'very good/good/partly/not understanding') and 'how much time per day you spent on learning COVID-19-related knowledge'. The perceptions of nurses on the greatest benefits and worst outcomes of volunteering to help Hubei, the facilitators and barriers for the willingness decision were also asked. The attitudes of families towards being a volunteer was asked by one question, with the choices of 'strongly support, support, a bit not support and not support at all'. The information on whether bought insurance for oneself was also asked by one item with yes-or-no choices.

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The questionnaire was presented in the Wenjuanxing online investigation system (www.wjx.cn) with a unique link. The researchers sent the link and introduction of the study to possible nurse administrators of different hospitals in the study areas. The survey link was thereby disseminated to clinical nurses through WeChat groups and QQ groups. The participation of this study was voluntary as there was no penalty nor award offered. The nurses could click the link and launch the first page, which introduced the aims, study criteria and process of the survey. The contact information of the investigators was also provided. At the end of the first page, the question: 'do you agree to participate in this survey' was asked to acquire the consent of the nurses. Only the 'yes' option led to the next page for the questionnaires. One mobile IP could only submit the answers once, which prevented duplication. No identity information was collected. The participants were only identified by the sequence numbers generated by the Wenjuanxing system. The online survey was discontinued a week later when the sample size was satisfied.

The current study followed the Declaration of Helsinki. The study was approved by the Ethical Committee of Hunan Province People Hospital (No. 2020004).

The data were exported from the online investigation system. SPSS software was used for data analysis. The statistics of mean, standard deviation (SD), count and percentage were employed to describe the characteristics and responses of the participants. The characteristics of participants who were willing or not to volunteer were presented. Chi-square tests and t-tests were used to explore the differences among the proportions of willingness among nurses with different characteristics. Binary logistic regression was conducted to explore the association of different factors with the willingness decisions of nurses. The willingness of nurses was analyzed as the dependent variable ('willing' =1, 'not willing' = 0). Possible

This article is protected by copyright. All rights reserved associated factors were explored in the 'enter' method. Odds ratio (OR) and the 95% confidence intervals (CI) were computed. A p value less than 0.05 was set as statistical significance.

The NWIF was developed by the research team based on literature review (Khalid et al., 2016 , Lee et al., 2005 , Oh et al., 2017 , Turtle et al., 2015 . The content validity of the questionnaire was evaluated by an expert panel, including two clinical nurses, a nurse manager, a hospital administrator and two nursing professors. A pilot test was conducted among 50 nurses in a hospital in Hunan Province to examine the readability, clarity and coverage of the questionnaire. Revisions were made based on nurses' comments in the pilot test. The content validity index was 0.92 for NWIF. The reliability (Cronbach's a) of NWIF was 0.71 in the current survey.

A total of 11,283 responses were received, among which 100 responded 'No' in the consent question. Finally, 11,183 responses were analyzed, with a response rate of 99.1%.

Among the participants, 2,342 (20.9%) were from Hunan, accounting for 1.27% of local nurses; 5,758 (51.5%) were from Chongqing, accounting for 6.05% of local nurses; and 3,121 (27.6%) were from Xinjiang, accounting for 4.32% of local nurses. The one-week online survey fully met the minimum sample size requirement, indicating the feasibility and high efficiency of this approach.

The characteristics of the study participants were presented in Table 1 . Most participants in the current study were female nurses (96.7%), aged below 40 years (89.2%), with no political party membership (87.7%), with bachelor's degree or above (56.5%), married

This article is protected by copyright. All rights reserved (69.3%), with at least one child (61.5%) and living with their parents (53.1%). Most nurses had primary (73.8%) or middle (21.9%) levels of professional qualification and had more than five years of working experience (66.8%). In the current study, 21.6% of the nurses worked in high-risk departments for contacting with COVID-19 (NHC, 2020e), e.g. critical care departments (11.7%), emergency department (6.3%) and infectious disease departments (3.6%).

Most nurses had stable health as before (43.9%) or were energetic and spirited (18.5%).

The mean level of stress was 57.84 (SD = 23.11, range 0-100) in the VAS measurement. The mean anxiety level was 52.80 (SD = 23.78, range 0-100). Only 6.6% of the nurses experienced a similar kind of public health crisis and 8.0% of them had close contact with suspected or diagnosed patients. Most nurses received related training for the COVID-19 (98.0%), spent 1-3 hours per day learning related knowledge (47.55%) and had a good understanding of related knowledge (14.3% for very good, 60.3% for good). The attitudes of nurses' families were generally supportive, with 35.5% "strongly support" and 39.2% being "support". Only 22.4% of the nurses had bought insurance for themselves.

As to their willingness, 83.4% of the nurses were willing to volunteer to practice in Hubei in the epidemic. The chi-square tests and t-tests examined the association between characteristics of nurses and their willingness choices. Except for gender, age and education levels, all the other demographic characteristics (such as the location, professional qualification, working department, political party membership, marital status), personal health, previous experience, training condition and personal perceptions revealed significant associations (all p values < 0.05) with the willingness of nurses to practice in Hubei (Table 2) .

'To realize personal value' (56.5%) ranked No.1 in nurses' perception of the greatest benefit for being a volunteer to practice in Hubei, followed by 'to contribute to the society'

This article is protected by copyright. All rights reserved (27.1%) and 'to promote professional skills' (12.2%). Few nurses considered personal profits in decision making, e.g. chances for promotion (1.1%) or honorary certification (0.6%). As for the worst outcome of being a volunteer, the participants answered 'being infected' (51.6%) the most, followed by 'unable to take care of the family' (24.6%) and 'short supply of protective equipment' (13.3%). The top three facilitators for the willingness decision of nurses were 'the impact of role models' (33.6%), 'professional ability' (26.1%) and 'family support' (23.9%). The three key barriers included 'family disagreement' (45.6%), 'lack of protective equipment' (24.6%) and 'the rapid epidemic' (10.7%).

The binary logistic regression analysis findings were summarized in Table 3 

This article is protected by copyright. All rights reserved studies, the outbreaks of COVID-19 might impose additional stress on nurses (Oh et al., 2017) . Some nurses felt depressed (24.2%), unhappy (3.1%) or had sleep disorders (8.5%).

This finding was consistent with the results of the NNSC, where 86% of the nurses expressed the need for psychological support to release their stress from daily work (China Social Welfare Foundation, 2017) . This finding indicates that professional support should be provided to promote the psychological health of nurses not only when an infectious disease occurs, but also as a routine practice.

Our study revealed that a large proportion of nurses (83.4%) were willing to practice in Hubei, which was much higher than that in previous outbreaks of infectious diseases (Khalid another key facilitator in the current study. As high as 72.7% of the current participants reported the supportive attitude of their family towards them to be a volunteer. The regression analyses also confirmed that nurses with support from their families were more likely to make a willing decision.

In addition to Chinese-specific factors, professionalism also engaged the willingness of nurses to practice in Hubei. In the current study, 26.1% of the nurses regarded 'professional ability' as the key facilitator for their willingness decision. Moreover, the logistic regression findings indicated those who had senior professional qualification, received frequent training on COVID-19 and spent 1-3 hours per day learning about related knowledge were more likely to make a willing decision. Similar with the findings in previous studies (Khalid et al., 2016 , Lee et al., 2005 , Turtle et al., 2015 , professional knowledge and related training would increase the confidence of nurses and prepare them better to fight against the outbreak.

However, professional knowledge would also compel nurses to be greatly worried about the 'lack of protective equipment' and 'the rapid epidemic' in the COVID-19 epidemic.

The logistic regression indicated that compared with the 20-29-year group and the unmarried group, nurses who were over 40 years and married were less likely to make a willing choice. This result might be related to the key family roles in China. Married and older nurses might have greater family commitment towards caring for the parents and

This article is protected by copyright. All rights reserved children, leading to their unwillingness decision (Lee et al., 2005 ).

An interesting finding was that nurses from Chongqing were less likely to help Hubei, compared with those in Xinjiang. Given the adjacent location, convenient transportation and a huge number of migrant populations with Hubei, Chongqing was estimated to be another epicentre of the COVID-19 epidemic (Caixin Health, 2020). On January 27, 2020, Chongqing reported 132 COVID-19 patients, ranking No.1 amongst all the cities outside Hubei (Chongqing Health Commission, 2020) . The rapid growth of the epidemic in Chongqing might impose essential stress on local nurses, thus diminishing their willingness to serve in Hubei.

Another interesting phenomenon was identified in working departments. Nurses working in infectious diseases departments were less willing to practice in Hubei. Given the rapid spread of the COVID-19 throughout China, nurses of infectious diseases departments might have already been fully occupied with screening suspected patients and caring for infected patients locally. They might not have extra energy to help Hubei. By contrast, critical care nurses were more willing to be deployed to Hubei. As reported by the WHO (2020), the rate of severe cases caused by the COVID-19 was lower than SARS-CoV. The COVID-19-related occupation rate in critical care departments of the study provinces was much lower than that in Hubei. Given their outstanding professional ability, critical care nurses would be confident in joining the combat with COVID-19.

In the current study, health condition of nurses was significantly associated with their willingness decision, which was consistent with previous studies (Damery et al., 2009 , Lee et al., 2005 , Wong et al., 2010 . Nurses with good health (energetic and spirited, as stable as before) might be greatly confident with their personal immunity and were more likely to volunteer, whereas those with high levels of anxiety were less likely to make a willing decision.

The current study indicated that nurses with the following characteristics were more likely to volunteer to practice in Hubei: those who were younger, unmarried, member of the Communist Party of China, with senior professional qualification, working in critical care

This article is protected by copyright. All rights reserved departments, with support from the family, with adequate training and learning, with good health status and lower level of anxiety. Adequate training and psychological support might be feasible interventions to maintain the willingness of nurses to serve in the frontlines. The public acknowledgement of their professional contributions and support from their family might also help to engage nurses to volunteer.

The current study indicated the feasibility and high efficiency of an online survey among nurses in the outbreak of an infectious disease. There are also some limitations in this study.

Firstly, it was an online survey using convenient sampling. Secondly, the willingness, health status, stress and anxiety levels of nurses were measured by single questions. To facilitate the online survey and response rate, only multiple-choice questions were designed. In-depth reasons for the willingness choices of nurses were not explored. Future studies could employ the systematic sampling methods. Qualitative studies were also suggested to provide more comprehensive understanding about the willingness of nurses during the outbreak of an infectious disease.

The current study revealed that a high proportion of nurses in China were willing to practice in Hubei during the outbreak of COVID-19. Adequate training and psychological support would facilitate nurses to volunteer during the epidemic of an infectious disease. 

This article is protected by copyright. All rights reserved # presented as mean, standard deviation, and examined by independent t tests. 

Press conference on the latest 2019 novel coronavirus epidemic forecast by Hong Kong University

Estimating the effective reproduction number of the 2019-nCoV in China

Pathogenicity and transmissibility of 2019-nCoV-A quick overview and comparison with other emerging viruses

National Nurses Survey of China

Updates of COVID-19 epidemic in Chongqing till 27

Will the NHS continue to function in an influenza pandemic? a survey of healthcare workers in the West Midlands

Influenza pandemic and professional duty: family or patients first? A survey of hospital employees

The authors thank all the nurses that participated this investigation.

The authors declare no conflict of interest.

This study was supported by the grant from Shenzhen University (no. 2019126). The funding source had no influence on the study design, procedure, data analysis, or interpretations of the findings.

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