Willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 epidemic: A cross‐sectional study

Abstract 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) was 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 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.


| INTRODUC TI ON
An ongoing outbreak of a respiratory disease caused by the 2019 novel coronavirus   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, Hacher, & Harmston, 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, 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 (National Health Commission of the People's Republic of China, 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.

| Background
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 & Gillespie, 2007) and Germany (28%) (Ehrenstein, Hanses, & Salzberger, 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, Khalid, Qabajah, Barnard, & Qushmaq, 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, 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.

| Aims
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.

K E Y W O R D S
COVID-19, epidemic, infectious disease, nurses, staffing, willingness

| 2 Design
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, for example, WeChat and QQ, an online survey approach was adopted, taking advantage of high efficiency and low cost.

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

| Participants
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 & Xu, 2014). Accordingly, at least 3,514 nurses were required, including 1,840, 951 and 723 in Hunan, Chongqing and Xinjiang, respectively.

Study instrument
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 children, living conditions, and locations.

| Procedures
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.

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

| Data Analysis
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. Chisquare 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 analysed as the dependent variable ('willing' =1, 'not willing' = 0). Possible associated factors were explored in the 'enter' method. Odds ratio (OR) and the 95% confidence intervals (CI) were computed. A p value less than .05 was set as statistical significance.

| Validity and reliability
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.

| RE SULTS
A total of 11,283 responses were received, among which 100 responded 'No' in the consent question. Finally, 11,183 responses were analysed, 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 1-week online survey fully met the minimum sample size requirement, indicating the feasibility and high efficiency of this approach.

| Demographic characters
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 (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 5 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), for example, 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 hr 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.

| Willingness and characteristics
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 < .05) with the willingness of nurses to practice in Hubei (Table 2).

| Perceptions of nurses towards volunteering to help Hubei
'To realize personal value' (56.5%) ranked No.1 in nurses' perception of the greatest benefit for being a volunteer to practice in TA B L E 1 The characteristics of the nurses (N = 11,183)

| Factors associated with the willingness of nurses
The binary logistic regression analysis findings were summarized in  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.

| Willingness of nurses to volunteer to help Hubei
Our study revealed that a large proportion of nurses (83.4%) were willing to practice in Hubei, which was much higher than that in Similar with other studies in Asia (Lee et al., 2005, Oh et al., 2015, family support is 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 hr 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  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.

| Factors associated with the willingness decision of nurses
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

TA B L E 3 (Continued)
China, with senior professional qualification, working in critical care 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.

| Limitations
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.

| CON CLUS ION
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.