key: cord-1041407-m6axi18k
authors: Leigh, Laurasona; Taylor, Colleen; Glassman, Tavis; Thompson, Amy; Sheu, Jiunn-Jye
title: A Cross-Sectional Examination on the Factors Related to Emergency Nurses’ Motivation to Protect Themselves against an Ebola Infection
date: 2020-05-06
journal: J Emerg Nurs
DOI: 10.1016/j.jen.2020.05.002
sha: 4b6c121367723023ac757265b4b0f40bce5c8bf0
doc_id: 1041407
cord_uid: m6axi18k

Abstract Introduction The 2014-2016 West African Ebola outbreak impacted the United States. Due to the sporadic occurrence of the Ebola infection, there is insufficient research regarding how the United States emergency nurses provide care to patients potentially infected with the Ebola virus and the nurses’ motivation to protect themselves when providing care to these patients. This study was aimed to investigate the predictors of emergency room nurse’s protection motivation. Method A cross-sectional design was employed in the study. A survey developed based on a modified Protection Motivation Theory was administered to randomly selected emergency room nurses who are members of the Emergency Nurses Association. Descriptive statistics, nonparametric Kruskal-Wallis H-Test (as well as post hoc Dunn-Bonferroni test), Spearman Rho correlation, and Stepwise Multiple Linear regression were conducted for data analysis. Result Protection motivation was found in two components: proactive and passive protection motivation. The regression analysis indicated that response efficacy (β=.27, p<.001) and self-efficacy (β=.17, p<.01) significantly predict emergency nurses’ proactive protection motivation, while perceived vulnerability (β=.26, p<.001), response cost (β=.19, p=.001) and knowledge (β=-.15, p<.01) significantly predict emergency nurses’ passive protection motivation. Conclusion Results indicate the need for interventions to improve emergency nurses’ response efficacy, self-efficacy, and knowledge, while simultaneously reducing the nurses’ perceived vulnerability and response cost. Such interventions would be expected to proactively motivate nurses to protect themselves when providing care to patients that exhibit the signs and symptoms of an Ebola infection and reduce their passive protection motivation.

Contribution to Emergency Nursing Practice: 49

• Only approximately 40% of emergency nurses felt prepared to provide care to patients 50 potentially infected with Ebola, even though on average 6.6 hours of training on 51

controlling an Ebola infection was reported and 84% of emergency nurses cited that their 52 place of employment provided accommodations, i.e. adequate patient placement for 53 individuals potentially infected by the virus. 54

• Response efficacy and self-efficacy positively predicted emergency nurses' proactive 55 protection motivation to provide care to potential patients of an Ebola infection. 56

Emergency care leaders are encouraged to provide continuous educational trainings and 57 simulations that will increase emergency room nurse's capacity, skills, resources, and 58 confidence, which might improve their ability to perform the recommended response. 59

• Perceived vulnerability, response cost and knowledge have an impact on emergency 60 room nurse's passive protection motivation. Emergency care leaders are encouraged to 61 provide continuous trainings on the pathophysiology of the Ebola infection and the use of 62 relevant protective equipment to make nurses feel less vulnerable. In the meantime, 63

health system administrators are encouraged to reduce nurse's response cost associated 64 with ensuring job security, and providing family and/or childcare support, professional 65 practice insurance coverage, and paid leave for incidents due to Ebola infection and other 66 emerging and highly communicable diseases, especially those that are associated with 67 significant morbidity and mortality. The sporadic occurrence of this infection has resulted in limited research on the care of 121 potential patients with an Ebola infection within countries such as the United States, since the 122 country has had a very low prevalence rate during past outbreaks. 4 Additionally, there is 123 insufficient research concerning how healthcare professionals treat patients potentially infected 124

with an Ebola infection. In most healthcare settings, the emergency room is the first point of 125 entry and nurses have an increased risk of exposure to the virus, especially nurses who often 126 come in direct and prolonged contact with patients while providing care. According to the 127 Centers for Disease Control and Prevention (CDC), nurses often experience blood and body fluid 128 exposure and have an annual exposure prevalence rate ranging from <10% to 44%. 5 129 Furthermore, during the 2014 to 2016 Ebola outbreak, two of the four United States Ebola-130 infected cases were healthcare professionals who were exposed while providing care to an 131 imported case from West Africa. 6 The purpose of this study was to use a modified Protection 132

Motivation Theory (PMT) to explore United States emergency nurses' motivation to protect 133 themselves against patients with an Ebola infection they may encounter at work and to identify 134 its associated factors and predictors. 135

PMT focuses on the cognitive meditational processes, which involves the maladaptive 137 and adaptive responses. Both responses can be processed as the threat appraisal and coping 138 appraisal. 7 In this study, the modified PMT model as shown in Figure 1 [insert Figure 1 ] was 139 used to investigate a social cognitive account of protective behavior in an attempt to provide 140 clarity on the area of fear appeals and explain attitude and behavior change through matching 141 cognitive processes people use to evaluate threats and select coping alternatives. 8,9 142 Protection motivation is an intermediate variable that functions to arouse, sustain and 143 direct protective health behavior within individuals. Similar to the intention to perform a 144 behavior, it has a positive and negative linear function. This includes whether the threat was 145 considered severe (perceived severity), one's perception of her/his vulnerability (perceived 146 vulnerability), effectiveness of the recommended response (response efficacy) and the 147 confidence an individual has in her/his ability to perform the recommended response (self-148 efficacy). The negative function is the cost of conducting the recommended response (response 149 cost). 10 The constructs perceived vulnerability and perceived severity are part of the threat 150 appraisal, which results in fear. This means the more an individual feels vulnerable and takes the 151 threat seriously their fear increases, which leads to a greater threat appraisal. 8 152

To enhance the study, two additional constructs, knowledge and outcome expectation, 153 were included to strengthen the predictability. Knowledge construct is found in other health 154 behavior theories such as the Integrated Behavioral Model (IBM). Within the IBM, intention to 155 perform a behavior is considered the most important determinant of a behavior, however 156 knowledge is needed to carry out the behavior. 11 The construct outcome expectation is found in 157 the Social Cognitive Theory. Within this theory, the expected outcome is the belief that multiple 158 consequences might result from the behaviors a person chooses to perform. 12 159

Thus, for this study, it was hypothesized that each of the emergency nurses' 160 psychological variables (i.e. self-efficacy, response efficacy, response cost, knowledge, outcome 161 expectations, perceived vulnerability, perceived severity, fear and protection motivation) are 162 significantly correlated with and predictive of their motivation to protect themselves against an 163

Ebola infection. In summary, this study used a modified PMT model to examine the emergency 164 room nurses' motivation to protect themselves and determine their apprehension to provide care 165 to potential patients who may have an Ebola infection, and their related factors. 166

A cross-sectional research design was used to examine emergency nurse's motivation to 168 protect themselves when providing care to a potential patient with an Ebola infection during a 169 single point in time. 13 The research protocol was approved by the Emergency Nurses 170

Association, Institute for Emergency Nursing Research (IENR) director and the University of 171 Toledo Institutional Review Board (#200929). 172

In 2015, the United States had approximately 33,573 Emergency Nurses Association 174 (ENA) members. 14 A power analysis using G*Power was conducted and a sample size of 436 175 was estimated to achieve a satisfactory statistical power. Multiple linear regression was selected 176 as the statistical test for sample size estimation and a projected power of .95, type I error of .05 177 and a conservative effect size of .03 were entered into the estimation. 15 178

A systematic literature review was conducted to determine the journal articles that have 180 used PMT as the theoretical backbone in conjugation with examining an infectious disease 181 (unpublished data). 7,16 Based on the review, the survey items were developed using prior articles 182 on Ebola and other infectious diseases, 17-20 then refined with the assistance of a focus group. The 183 focus group (n=10) 21 was conducted to gather primary qualitative data from ten emergency 184 nurses working at a university teaching hospital. Based on the focus group discussion, the survey 185 questions were modified to remove or include additional questions. 

The survey was administered online using Qualtrics. Upon obtaining permission from the 215

Review Board, a randomized mailing list of emergency nurses within the United States was 217 obtained from ENA. To reduce external validity threats and increase response rates, best 218 practices in survey research were used. 25 These include using the three-wave mailing process to 219 maximize response rates. A systematic review of electronic survey has shown that non-monetary 220 incentives, the use of a university letterhead and personalization of cover letters might increase 221 the response rate. 25 222

Descriptive statistics (frequencies, mean and standard deviations), nonparametric 224

Stepwise Multiple Linear regression were performed using Statistical Package for the Social 226 Sciences (SPSS). These methods were chosen due to their ability to identify associations more 227 conservatively without normality assumptions. The Bonferroni correction for multiple tests was 228 applied to adjust the significance levels of Kruskal-Wallis H tests and Spearman Rho correlation. 229

The significant variables were considered a priority in the Stepwise Multiple Linear regression. 230

Incomplete answer of a particular question was treated as missing data and was excluded from 231 the statistical analysis involving the particular question. No participant missed all questions. 232

Of the randomly selected participants, 388 emergency nurses completed the online 235 survey. Majority of the participants were Caucasians (88.6%), females (79.6%), between the 236 ages of 21 and 35 (36.4%), who are registered nurses (92.1%) that work in an urban setting 237 (55.7%). Most of the participants had a bachelor's degree (57.3%) and on average had practiced 238 emergency nursing for 11.2 years (SD=9.7 years), with 29.4 hours per week (SD=14.2 hours) of 239 direct care to patients. Of the emergency nurses that responded, 85.4% indicated that they 240 received less than 10 hours of training at their place of employment on controlling an Ebola 241 infection. 242

The bivariate analyses for each of the demographic characteristics and each investigated 244 PMT construct are documented in Table 1 p<.001) was highly and negatively correlated with passive protection motivation. 287

Stepwise multiple linear regression was conducted for each outcome variable (proactive 289 protection motivation and passive protection motivation) to estimate their predictors and their 290 proportion of variance. All the psychological explanatory variables were entered into the 291 regression model and the stepwise procedure selected and removed the predictors based on their 292 significance levels. Response efficacy (β=.27, p<.001) and self-efficacy (β=.17, p<.01) were 293 significant predictors for proactive protection motivation and account for 14.3% of variance. 294

Perceived vulnerability (β=.26, p<.001), response cost (β=.19, p=.001) and knowledge (β=-.15, 295 p<.01) were significant predictors for passive protection motivation and account for 15.6% of 296 variance as illustrated in Table 3 [insert Table 3 ]. 297

The results from the study revealed a statistically significant relationship between the 299 outcome variables and the modified PMT variables, which rejects the null hypotheses that the 300 psychological variables do not correlate with protection motivation as well as there being no 301 significant predictors for the nurses' motivation to protect themselves against potential patients 302

with an Ebola infection. The outcome variable, protection motivation, was divided into (1) 303 proactive protection motivation and (2) passive protection motivation based on PCA. While the 304 bivariate analyses showed multiple paired associations, the Multiple Linear Regression was able 305 to further identify statistically significant predictors after controlling other explanatory variables. 306

Based on the results from the multivariate analysis, response efficacy and self-efficacy 307 positively predicted emergency nurses' proactive protection motivation. Both response efficacy 308 and self-efficacy are part of the coping appraisal in PMT. Response efficacy assesses the belief 309 that the recommended coping response might be effective in reducing their threat and self-310 efficacy assesses the perceived ability to perform the recommended coping response. 8 Both 311 constructs influence the nurses' motivation to conduct the recommended coping response. The 312 regression coefficients from these two constructs indicate that higher self-efficacy and/or higher 313 response efficacy can lead to an increase in the nurses' proactive protection motivation. These 314 findings are consistent with previous studies that used PMT as their theoretical framework. 315

Coping strategies available for participants have a stronger effect on whether they will conduct 316 the protective behavior and high response efficacy strengthens their intention to protect 317 themselves and reinforces their belief that the protective behavior is effective. 7,8 318

For passive protection motivation, the regression analysis indicated that perceived 319 vulnerability positively, response cost positively and knowledge negatively predicted passive 320 protection motivation. Perceived vulnerability assesses the likelihood of contracting the disease, 321 response cost assesses the cost associated with performing the recommended protective behavior 322 and knowledge is the amount of information needed to carry out the behavior. 8,11 The more 323 vulnerable a nurse believes he/she is, the more likely they would exhibit passive protection 324 motivation behavior. Perceived vulnerability was the strongest predictor of passive protection 325 motivation. Vulnerability is associated with fear of the disease and believing that the individual 326 has a higher likelihood of contracting and being exposed to the disease. Previous researchers 327 have examined behavioral intention and vulnerability relating to the individual hearing about the 328 threat, assessing how dangerous the disease is and estimating their personal vulnerability before 329 determining whether to perform the protective behavior. 8 330

Added to perceived vulnerability, the cost associated with the preventive behavior and 331 less knowledge they have about the disease led to an increase in passive protection motivation. 332

Limited knowledge about the Ebola virus and the protective behaviors determine whether a nurse 333 will actively perform the protective behavior or possibly avoid their place of employment due to 334 potential patients they might encounter. According to the American Nurses Association survey 335 of RNs (n=7,353), health and safety at their work place were cited as influencing concerns on 336 whether nurses will continue working in the field and the type of nursing work they choose to 337 perform. 5 In addition, media messages and incorrect information can lead to heightened 338 perception of risk, which could increases fear and perceived vulnerability. The CDC reported 339 that high frequency of risk-elevating messages in news coverage can increase public concern and 340 perception and contribute to social amplification of risk, which leads to the spread of 341 misinformation. 26 Continuous re-education, training and demonstrations of preventive 342 recommendation and non-pharmacological interventions 6 will not only increase nurses' 343 confidence in providing care to potential patients but it might also reduce passive protection 344 motivation. 345

There were some limitations in this study. The random sample of emergency nurses are 347 members of ENA. The ENA members may not demographically represent all emergency nurses 348 in the United States, which presented a potential threat to the external validity of the findings. 349

However, it can be hypothesized that ENA members might be professionally dedicated and 350 experienced, and the current findings is a liberal estimate of the nurses' motivation to protect 351 themselves when providing care to potential patients with an Ebola infection. 352

Additionally, the timing of the Ebola outbreak might have influenced the nurse's 353 motivation towards engaging in protective practices while providing care to patients possibly 354

infected with the disease. The outbreak occurred over a year before the survey was distributed 355 and the nurses' heightened awareness of the disease might have reduced considerably, which 356 affected the response rate. The study response rate was 23% (388/1,686), which yielded a power 357 of 93%. The power analysis indicated a strong probability that the research might only commit a 358 small type II error. 359

Previous studies that surveyed emergency nurses and other healthcare professionals 360 achieved high and low response rates depending on the research topic and their specialty. Studies 361 that focus on stress, burnout and depression among nurses had a response rate of 84%, 27 362 substance abuse study had response rate of 69%, 28 research focused on exposure to various 363 common diseases had response rates between 66% to 83% 29 and work place injury research had 364 response rates between 67% and 75%, 30 while a violence surveillance study had a response rate 365 of 9.5%. 31 366

This study identified that perceived vulnerability, response cost and knowledge have an 368 impact on whether the nurses exhibit passive protection motivation behavior. Thus, it is 369 recommended that administrators provide continuous training and simulations for nurses. 370

Administrators need to provide continuous education about the disease, its method of 371 transmission and current CDC personal protective equipment (PPE) recommendations when 372 providing care to Ebola infected patients. Rebmann et al., identified that fewer than 15% of 373 healthcare personnel correctly don and doff a PPE needed to provide care to an Ebola patient, 374 while hand hygiene compliance was between 40% and 53% among triage nurses in an 375 emergency department. 6 Continuous training and education acquired by nurses would reduce 376 their perceived vulnerability towards the disease and increase their self-efficacy and response 377 efficacy towards the protective behavior such as using the recommended equipment and 378 guidelines. Such educational intervention also improved PPE compliance from 44% to 69%. 6 In 379 instances where the infectious agent is new such as with the current COVID-19 pandemic, nurses 380 can use prior education and training to direct their current protective behaviors. 381

Additionally, emergency care leaders need to have updated protective equipment such as 382 adequate respirators, disposable impermeable gown/coverall, disposable exam gloves with 383 extended cuffs, disposable boot covers and disposable apron available in their hospitals or 384 clinics. 32 The availability of PPEs has emerged as a major barrier to nurses and other health care 385 professionals, with regards to their self-efficacy and response efficacy towards their protective 386 behaviors in the current COVID-19 pandemic. Furthermore, administrators should be aware of 387 the influencing factors and barriers that prevent the use of PPE among nurses. A focus group 388 study indicated that emergency situations, availability of equipment, negative influence of 389 protective equipment on nurses, patient discomfort, being busy, implementing guidelines being 390 time consuming and physicians influence were cited as barriers that may influence a nurse's 391 compliance with standard precautions, even if they received continuous training. 33 Although 392 these factors were identified by participants in the focus group as barriers to the use of PPE 393 among nurses, these findings may not be supported for other communicable infectious diseases. 394

The transmission route, knowledge and outcome expectations as well as the mortality and 395 morbidity associated with an infectious disease may have an influence on nurses' proactive 396 protection motivation, which could limit their engagement in the recommended protective health 397 behaviors. More specifically, nurses' perceived severity and perceived vulnerability towards an 398 infectious disease may have a stronger impact than their response efficacy and self-efficacy, 399 which might enable them to be proactive in their motivation to engage in protective health 400

behaviors. During the current COVID-19 pandemic, multiple anecdotal evidence is emerging in 401 support of nurses being proactive in their motivation to engage in protective health behaviors. 402

Adequate accommodations such as having an available single patient room with a private 403 bathroom and providing dedicated medical equipment should be made accessible, while also 404 adhering to the hospitals environmental infection control guide. 34 Reducing the response cost 405 such as making the protective equipment readily available and up to date can limit the nurses' 406 passive protection motivation behavior. Finally, having a standard operating procedure (SOP) for 407 receiving patients with a potential Ebola infection is also recommended. 408

To our knowledge, this is the first study to examine emergency nurses' motivation to 

2. The type I error was adjusted by the Bonferroni correction for multiple tests:

* p<.005, ** p<.001, *** p<.0001 

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