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Factors associated with nurses' willingness to participate in care of patients with COVID‐19: A survey in China

Abstract Aim The research aims to assess nurses’ willingness to participate in care of patients with coronavirus disease 2019 (COVID‐19) in China and to identify its associated factors. Background Along with the increasing number of infections, the world has paid widespread attention to COVID‐19. Methods This cross‐sectional study used a convenience sampling method that included a demographics questionnaire and the Nurses' Perceived Professional Benefits Questionnaire. The survey was distributed to 1,787 nurses from 36 hospitals in China. Results In total, 1,176 questionnaires were usable for this research. 92.79% of nurses were willing to participate in care of patients with COVID‐19. Intensive care unit (ICU) nurses were less willing to participate, while surgical nurses were more willing to participate. In addition, nurses with high positive professional perception scores were more willing to participate than those with low scores. Conclusion The vast majority of nurses were willing to participate in care of patients with COVID‐19 in China. Surgical nurses and nurses with positive professional perceptions are more likely to be willing to participate in treatment. Implications for nursing management To increase nurses’ willingness to participate in care of patients with COVID‐19, improving the sense of perceived professional benefits, offering salary and offering paid sick leave for nursing staff are effective ways. In addition, raising the awareness of infectious diseases and increased pre‐disaster training during infectious diseases is critical.

At present, there is no special effective treatment for this disease (Huang et al., 2020). Along with the increasing number of infections, supplying nurse aid to the hardest-hit areas is a task which brooks no delay. Unfortunately, infection between patients and health care workers has been confirmed. As of on 5 March, more than 3,000 medical workers have been infected with and 34 of them have died (Department of human resources., 2020), which aggravated the panic among health care workers.
Outbreaks of infectious diseases placed a heavy burden on health care workers and caused adverse health consequences in lacking of disaster preparedness (Patel et al., 2017). Although nurses had trained in trauma, wound care, infection control and perioperative care before, in the face of a public health event with a high risk of infection, most of them had inadequate recognition of its risk and preparedness for its prevention and control (Tzeng et al., 2016). Several studies (Jong et al., 2014;Kilmarx et al., 2014) pointed out that medical staffs were infected due to insufficient infection precautions or omission of personal protective equipment in the treatment of patients with Ebola. In addition, a survey of the SARS epidemic in Singapore in 2003 (Koh et al., 2005) showed that health care workers were neither aware nor ready to respond to the epidemic, resulting in the rapid spread of the epidemic and high mortality rates.
In face of acute infectious disaster, not all health care workers were willing to work in disasters, which further limited the disaster preparedness (Connor, 2014). One study (Irvin, Cindrich, Patterson, & Southall, 2008) showed that only 50% of health care workers were willing to participate in bird flu pandemic work in the United States.
In other word, the lack of willingness of medical staff to work in disasters could lead to severe shortages of nursing manpower.
The cognitive in infectious diseases and pre-disaster training would obviously affect the nurses' willingness to support epidemic-stricken areas (Patel et al., 2017). During the SARS, Australian medical staff apparently lacked knowledge about the transmission of infection owing to the insufficient education or training on the source of infection. Date showed that 89% of them suffer anxiety, and 85% thought medical work was accompanied with high risk, which some researches took to be associated with the pressure surge of medical staff who involved in SARS treatment (Kerrianne et al., 2010;Maunder et al., 2004). It is reported that medical staff developed mental problems during SARS (Chua et al., 2004;Robertson, Hershenfield, Grace, & Stewart, 2004). Adaptive responses to stress and effective preventative training may offer protective effects for health care worker in similar epidemic outbreaks. An Australian survey  revealed that the nurses' willingness to participate in disease increased as the medical skills or knowledge in disasters increased. During the epidemic, effective preventative training for nursing staff in advance is a vital measure to reduce the psychological pressure of nursing staff in treating patients with infectious diseases.
Well-prepared and trained health care workers who are willing to participate in care of patients with COVID-19 are the key to overcome COVID-19. Therefore, knowing and mastering the factors that influence nurses' willingness to participate in care of patients with COVID-19 will be beneficial for making more effective planning to overcome the next inevitable outbreak. Accordingly, this investigation aims to assess nurses' willingness to participate in care of patients with COVID-19 and to identify its associated factors, which can give evidence for nursing administrators to prompt nurses to take part in the public health emergencies.

| Survey questionnaire
The questionnaire included a general situation questionnaire and the Nurses' Perceived Professional Benefits Questionnaire.
The general situation questionnaire assessed demographic information, such as age, gender, education, fertility, only child or not, the nature of the hospital, hospital level, department, professional title, working years and individual annual income. In addition, the willingness to participate in epidemic work was also assessed. Nurses' willingness to participating in care of patients with COVID-19 was measured using a single self-report question: 'Are you willing to par-

| Data analysis
Data analysis was performed using Social Sciences (SPSS) version 22.0. The statistical description of count data is expressed by frequency and composition ratio. The measurement data did not coincide with normal distribution; thereafter, the statistical description is expressed by interquartile range. In single factor analysis, the chisquare test was used to compare the scores of different dimensions, including gender, whether or not the only child, the nature of the hospital, age, education, professional title, fertility status, working years, hospital level and the department. Wilcoxon rank-sum test was used to compare each dimension scores of nurses' perceived professional benefits and the total score. For multiple factor analysis, binary logistic regression model was adopted to analyse the influencing factors of nurses' willingness to participate in the epidemic work. The difference embodied statistical significance when p < .05.

| Ethical consideration
Ethical approval was obtained from the Institutional Review Board of Jiangsu Cancer Hospital in China (no. 2019/007). As this study was conducted for a relatively short time, permission to conduct the study was not obtained from each of the 36 hospitals from which nurses were recruited. But this study was conducted with the support of the nursing directors from the rest of the selected hospitals.
A participant information sheet providing detailed explanation on the research study was attached to the questionnaire for their reference. All participants were informed about the study's purpose and procedures by the researchers. To maintain anonymity, participants were assured that participation was wholly voluntary, and were reminded not to write any form of identifiers on the questionnaire. They were assured that all information would be treated in strict confidence.

| Nurses' willingness to participate in care of patients with COVID-19
A total of 1787 nurses were invited to complete the survey voluntarily. Finally, there were 1776 that were usable for this research.

| Single factor associated with nurses' willingness to participate in care of patients with COVID-19
Single factor associated with nurses' willingness to participate in care of patients with COVID-19 is listed in Table

| Binary logistic regression of nurses' willingness to participate in care of patients with COVID-19
To conduct the binary logistic regression, nurses' willingness was used as its dependent variable. Each dimension's scores and the total score of the statistically significant factors according to the single factor analysis, including age, working years, professional titles, department and nurses' perceived professional benefits, were used as independent variables. As shown in Nurses with score between 31 and 35 on the positive professional perception dimension of the nurse's professional benefit were 3.804 times more willing to participate in epidemic work than nurses with score less than 20 (OR = 3.80, p < .05, 95% CI = 1.063-13.606).

| Nurses' willingness to participate in care of patients with COVID-19 was generally high except for 'older, frail, young and pregnant nurses'
In Areas for mitigation may include care and provision for dependent family members, protection for workers and improving working skills. Emphasizing the sense of importance and responsibility to nursing staffs may also be helpful in improving staff willingness during infectious diseases.

| Nurses' willingness to participate in care of patients with COVID-19 was not significantly related to demographic factors such as age, gender, professional title and working years
The survey showed that there was no significant correlation between nurses' willingness to participate in epidemic control and demographic factors such as age, gender, professional title and working years, which was consistent with the findings of Arbon, Cusack, et al.
(2013); . In addition, some studies showed that male respondents were more willing to work during the epi-

demic. A survey conducted by AI-Hunaishi et al. (2019) found that
young, male and well-educated medical workers were related to the willingness to work during the epidemic. Charney et al. (2015) reported that women were less likely than men to work and participate in epidemic work, especially women with children. The difference between those studied and our survey was that the respondents in these studies were all medical workers, while the survey respondents in this study were mainly nurses. In fact, male nurses are a minority in China, and the sample of Chinese male nurses in this study was small, which may result in the insignificant correlation.
Surveys conducted by Tzeng et al. (2016) and by Loke et al. (2013) showed that nurses with more clinical experience were more willing to engage in disaster relief work than those with less clinical experience.
According to previous single factor analysis, ages and working years had different impact on nurses' willingness to participate in care of patients with COVID-19. However, the binary logistic regression did not show essential differences. This difference may have been caused by cultural differences of various respondents. Therefore, it is better for nursing managers to make prudent decisions to deploy nurses based on realistic situations while referring to this research.

| Surgical nurses were more willing than ICU nurses to participate in care of patients with COVID-19
According to this study, surgical nurses had a higher willingness to participate in care of patients with COVID-19 than internal Binary logistic regression model was adopted.

TA B L E 3 Factors influencing nurses'
willingness to participate in care of patients with COVID-19 medicine nurses, and ICU nurses had a lower willingness to participate than internal medicine nurses. A previous study (Danaci & Koc, 2020) showed that surgical nurses reported higher job satisfaction, lower job burnout and higher personalized nursing perception than nurses in other departments, which may result in surgical nurses being more willing to participate. When nurses experience emotional burnout, they often avoid stressful situations (Chen et al., 2020). Due to long working hours, frequent night shifts and difficult-to-manage patients, 80% of ICU nurses experience stress and burnout, and 38% of them plan to leave the ICU within the next year (Saravanabavan, Sivakumar, & Hisham, 2019). Tzeng et al. (2016) showed that nurses with emergency or intensive care experience performed better in emergencies, indicating that those nurses were more likely to be prepared an epidemic. However, this did not mean that they were more willing to participate in epidemic control. Another study

| Higher positive professional perception scores
were associated with higher willingness to participate in care of patients with COVID-19 Nurses' perceived professional benefits refer to the nurses' perception of the benefits of their work and the recognition that being a nurse can lead to growth (Fang, 2019

| CON CLUS ION
Nurses' willingness to participate in care of patients with COVID-19 plays a considerable role in ensuring the stability of the nursing team and in controlling the epidemic. Respondents in this survey were generally more willing to participate. Demographic factors such as age, gender, professional title and working years have no statistical significance to willingness; surgical nurses and nurses with higher positive professional perception scores were considerably more willing to participate in epidemic control. In future studies, we should explore the key issues in maintaining nurses' ability to respond to the epidemic. Therefore, we suggest that further research could examine nurses who are highly willing to participate in care of patients with COVID-19 based on qualitative research.

| LI M ITATI O N S
The research used convenience sampling rather than random sampling. Moreover, the chosen samples were concentrated in Jiangsu, Zhejiang and Anhui provinces, resulting in a lack of representation.
At the beginning of this investigation, nurses participated in care of patients with COVID-19 were not surveyed, which affected the accuracy of the results.

| IMPLI C ATI ON S FOR N UR S ING MANAG EMENT
Surgical nurses with higher job satisfaction and lower job burnout had a higher willingness to participate in care of patients with COVID-19 than other nurses. In addition, ICU nurses showed a lower willingness owing to high-risk inflection and a high-pressure job. To increase nurses' willingness to participate in care of patients with COVID-19, improving the sense of perceived professional benefits, offering salary and offering paid sick leave for nursing staff are effective ways.
In the face of a public health event with a high risk of infection, most health care workers had inadequate recognition of its risk and preparedness for its prevention and control. Therefore, raising the awareness of infectious diseases and increased pre-disaster training during infectious disease outbreaks is equally critical. This result suggests integrating disaster management to nurses' in the early stages of their educational curriculum. This could be achieved by adding early exposure of health care workers to relevant disaster experiences, which would further boost their willingness to participate in infectious diseases response.
Beyond that, owing to tremendous differences in historical background, social system and cultural tradition among countries, health care workers have different reactions to infectious diseases and nursing administrators need to make prudent decisions according to nurses' actual conditions when deploying nursing staff.

CO N FLI C T O F I NTE R E S T
The authors declare no conflict of interest.

E TH I C A L A PPROVA L
This study received approval from ethics committee of Jiangsu Cancer Hospital (number: 2019/007).