Nurses’ willingness to work with COVID‐19 patients: The role of knowledge and attitude

Abstract Aim This study aims to assess the role of nurses’ knowledge and attitude in relation to their willingness to work with patients diagnosed with COVID‐19 in Qatar. Design A cross‐sectional study. Methods A self‐administered, 35‐item online survey was circulated to the Registered Nurses working in Hamad Medical Corporation, the principal healthcare provider in Qatar. Results A total of 580 attempts to complete the survey. Of them, 377 completed surveys with a response rate of 65%. Logistic regression was used to predict nurses’ willingness to work with patients with COVID‐19. Nurses’ knowledge level and monetary compensation that is associated with the work‐environment risk category were found to have a significant positive relationship with the nurses’ willingness to care for patients with COVID‐19 (p < .05). The findings of this study may help nursing leaders design educational programmes and remuneration models that may help boost nurses’ willingness to work with high‐risk patient groups, especially during a pandemic.

workforce in the healthcare system. Therefore, their role in defining the care and services is very instrumental. In Hamad Medical Corporation (HMC)-the principal healthcare provider in Qatar, more than 11,000 nurses and midwives working across different HMC hospitals, clinics, home care and residential services. In different studies, nurses are fearful of acquiring or being infected by a highly contagious virus. However, most are still willing to work and accept it as an obligation and part of their job despite the risks (Al-Hunaishi et al., 2019;Liu et al., 2020;McMullan et al., 2016).
The primary factor that can have an impact on the willingness of nurses is the hospital's preparedness plans that consider the safety of their staff members (McMullan et al., 2016). Al-Hunaishi et al.
suggested improving self-efficacy through training can increase willingness to participate in a disaster, such as a flu-pandemic (Al-Hunaishi et al., 2019).
In 2004, research on the SARS epidemic has provided a preliminary understanding of some of the challenges related to looking after patients with SARS. Shiao et al. reported most Taiwanese nurses believed that they should be looking after SARS patients (87.8%) and only (25.9%) were intended to leave nursing due to the perceived personal risk (mostly due to lack of PPEs) (Shiao et al., 2007). Another study has investigated the relationship between hospital nurses' attitudes towards SARS infection control measures and their professional care obligation. The findings showed that proper infection control measures were significant predictors of the nurses' fulfilling of their professional care obligation (Tzeng, 2004).
On the other hand, the knowledge and attitude of nurses and other healthcare providers are expected to largely influence the degree of adherence to the proper use of personal protective measures and ultimately will be reflected on clinical outcomes for patients with COVID-19.
Several studies were conducted on the awareness, knowledge, attitude and practices of nurses during the COVID-19 pandemic. In Iran, Nemati et al. measured the awareness level among nurses. More than half of nurses (56.5%) had almost good knowledge about COVID-19 related information (e.g. sources, transmission, signs and symptoms, prognosis, treatment and mortality rate). Mainly, most of the nurses were getting COVID-19-related information from the World Health Organization (WHO) official reports and the Ministry of Health (55%), social media (48%) and traditional media (42%). However, the overall knowledge score was not significantly different according to age, education level and work experience. The researchers suggested that providing more information might lead to better control of infectious diseases such as COVID-19 (Nemati et al., 2020).
Another two studies were done in China  and India (Ip et al., 2015), where both of them targeted the public rather than nurses or healthcare providers. Overall, they found a moderate to adequate awareness related to transmission, symptoms and preventive measures for COVID-19 infection. Therefore, it is crucial to explore the impact of knowledge and attitudes on the willingness of nurses and other healthcare providers during the COVID-19 pandemic.

| Ethical approval
The study was approved by the Medical Research Center (MRC-05-065) and in full conformance with principles of the "Declaration of Helsinki" for Good Clinical Practice (GCP). The online survey link was sent to all participants via their official corporate email, where it was accompanied by a research information sheet explaining the expectations. The co-investigators collected the data; then, it was coded and double-checked by the PI (the PI was the link between data and code list); the data were stored in the protected computer by Hamad Medical Corporation (HMC) in accordance with the corporate's policies and guidelines. Permission to use the tool was granted and obtained by the principal investigator.

| Online survey
The survey link was circulated to all the nursing services at HMC; approximately 11,000 nurses via the corporate nursing e-mail group. We assigned a two-week period for completing the survey. During this period, we counted how many persons clicked the link. The response rate (65%) was calculated based on the number of completed surveys (377) divided by the number of staff who opened the link (580). The survey includes the participants' demographics: gender, age, marital status, living status, hospital, unit, job title, level of education and COVID-19 risk category.
The participants were asked to report the source of information and any relevant official training they had received in relation to COVID-19. They were also asked to evaluate their level of knowledge and confidence in protecting themselves and others while working with COVID-19 patients. The options were categorized into a 5-point Likert scale (completely disagree, disagree, neither agree nor disagree, agree and completely agree). Lastly, the participants were requested to express their willingness to take care of patients with the COVID-19 if/when they have the opportunity.

| Statistical analysis
Data were analysed for descriptive and inferential statistics at a confidence level of 95% using SPSS v25. The scale reliability was evaluated for internal consistency and revealed satisfactory reliability (α above 0.6). Logistic regression was used to identify the predictors for nurses' willingness to work with patients with COVID-19.

| Outcome variable
The outcome variable in this study is the nurse's willingness to care for patients with COVID-19. The variable is binary where [yes = 0] reflects staff willingness to work with COVID-19 patients, while [No = 1] means that the staff is unwilling to work with COVID-19 patients. The statistical model was designed to predict unwillingness [No = 1].

| Participants' characteristics
A total of 377 questionnaires were collected and included in the final analysis out of 580; the response rate was 65%. The mean age of participants was 35.5 years (SD 6.3). Of them, 61.5% are females (Table 1).
88.1% of the participants expressed their willingness to work with COVID-19 patients compared with 11.9% who were unwilling.

| The reliability analysis
As the reliability of the tool was not reported by Shi et al., (2020) study. In this study, the scale was evaluated for reliability and internal consistency and revealed satisfactory results with α greater than 0.06 (Sekaran & Bougie, 2016). Nurses' knowledge 6-item subscale scored α 0.74 and nurses' attitude towards infection control precautions in COVID-19 facilities 5-item subscale scored α 0.61 (Table 2).
No item deletion was required. The remaining 24 items were including the participants' demographics.

| Predictors of nurses' willingness
A total of 332 participants (88.1%) showed their willingness to work with COVID-19 patients. Logistic regression showed (Table 3) that the level of knowledge and the risk category that the staff is exposed to are the key predictors for nurses' willingness to work with COVID-19 patients. Nurses with a higher level of knowledge were more willing to work with COVID-19 patients (OR 0.874, CI 0.766-0.996).
Interestingly, the risk category is a strong predictor for nurses' willingness. Nurses who reported ranked their level of risk exposure as low are less willing to take care of patients with COVID-19.
The analysis shows that people who categorized themselves as low risk are less willing to care for patients with COVID-19 (OR 8.322, CI 3.001-23.076). This was found to be associated with the financial compensation that the organization announced to pay for the nurses based on the work-environment risk category. By conducting Chi-square association analysis, we found no significant association between other demographics and nurses' willingness to care for patients with COVID-19.

| D ISCUSS I ON
The study reveals a very important aspect of nurses' willingness to manage high-risk patients. The nurses who reported low-risk category expressed less willingness to care for patients with COVID-19.
It is very important to indicate that this variable was adopted from the risk categorization that was used by the organization for mon-  (Ryan & Deci, 2000).
In this study, we found out that more than half of the respondents (53%) reported their overall level of knowledge related to COVID-19 as "competent" and 34.3% rated themselves as "proficient" (   Table 2 shows that most of the respondents in this study obtain information from the Internet (93%), medical journals (66%) and television (64%). This is also true in the study on the assessment of COVID-19 knowledge among nurses in Iran where most information was obtained from the Internet: 55% from the World Health Organization (WHO) and their Ministry of Health, 88% from social media and 42% from traditional media. In comparison to one study in Taiwan, healthcare workers generally receive information about COVID-19 through formal lessons which resulted in greater self-confidence .

TA B L E 3 Predictors of willingness to
Different hospitals in Qatar have initiated programmes to prepare nurses for COVID-19; however, only 12 out of 377 (3%) of our respondents have completed hospital-based training programmes.
A probable reason for this is that those who are less exposed did not find the urgency to attend such programmes or that the train-  (Apisarnthanarak et al., 2020).
Because of fear of acquiring the virus, nurses and midwives may hesitate to provide the usual care or they minimize their caring hours.
There have been studies on previous flu epidemics where an increase in absenteeism is noticeable among nurses and other health care workers, which may or may not be related to sickness (Considine et al., 2011;Ip et al., 2015;Seale et al., 2008Seale et al., , 2009. A systematic review and meta-analysis showed that confidence in safety, risk perception, prior training, general and role knowledge and confidence in skills were proven facilitators for willingness to work during an influenza pandemic (Aoyagi et al., 2015). Unlike most of the earlier-mentioned studies, no significant associations were found between demographics and staff willingness to care for patients with COVID-19.

| LI M ITATI O N S
There are two significant limitations in this study that could be addressed in future research-first, the possibility of selection bias.
Although we sent the invitation to over 11,000 nurses via the corporate e-mail, the respondents were, directly and indirectly, working with COVID-19 patients. Second, the cross-sectional nature of the study was limited, and self-reported questionnaires are dependent on the participants' honesty as well as the validity and reliability of the tool.

| CON CLUS ION
In conclusion, nurses' level of knowledge and work-environment risk category was found to play a significant role in predicting nurses' willingness to work with COVID-19 patients. The findings of this study could inform the policymakers in HMC and other healthcare institutions in Qatar to invest in training and improving staff's knowledge and to consider satisfactory remuneration systems to boost their willingness to work in a hazardous environment.

ACK N OWLED G EM ENTS
The publication of this article was funded by the Qatar National Library. The authors would like to acknowledge the nurses and midwives who participated in the study.

AUTH O R S ' CO NTR I B UTI O N S
AJN*, AAA*, ASM, RCV, MMA: Research design, Data collection, Statistical analysis, Literature search, Manuscript preparation.

CO M PE TI N G I NTER E S TS
The authors declare that they have no competing interests.

E TH I C A L A PPROVA L A N D CO N S E NT TO PA RTI CI PATE
The study was approved by the Medical Research Center (MRC) -Institutional Review Board (IRB) at Hamad Medical Corporation (MRC-05-065).

DATA AVA I L A B I L I T Y S TAT E M E N T
All data generated during this study are included in this published article.