Nurses' willingness to participate in public health emergency: A qualitative study in China

Along with the increasing of infections of COVID‐19, nurses are needed more in caring patients with COVID‐19. The aim of this study is to explore the real intention and influencing factors of the nurses' willingness to participate in public health emergency in facing the COVID‐19. A total of 10 nurses who volunteered to care patients with COVID‐19 were selected. Data were collected by semi‐structured interviews and analyzed by content analysis method based on the theory of planned behavior. Three main categories were attitude, subjective norms and perceived behavior control. Under the first category, two subcategories were included: nurses' personal and professional value expectation, patriotism. Two subcategories were yielded for the second category: support from family and friends, role model impact of important people. In addition, three subcategories were identified for the third category: physical condition, professional knowledge and skills, national measures and incentive policies. Nurses with high willingness have seven features: high value expectation, patriotism, generous family support, good physical condition, experienced professional knowledge and skills, awareness of national measures and incentive policies. Combined with our previous quantitative study, developing tailored training programs to improve nurses’ professional value expectation, knowledge and skills in coping with unwilling attitude and weak perceived behavior control are effective ways.

In the critical moments of unexpected disasters, medical staff always goes to the front line to participate in rescue. 6 As the backbone of the rescue team, nurses have been playing a critical role in maintaining close contact with patients, providing direct care, and even performing some invasive nursing procedures, all of which can put nurses at high risk for infection.
Due to the insufficient understanding of the causes, protective measures, and treatment regimens of public health emergencies like the COVID-19, it is easy to cause fear, anxiety and other physical and mental health distress among frontline healthcare professionals.
Researches had been indicated that some medical staff will refuse to participate in frontline work or even leave their jobs due to high risk of virus infection, threat of death and not yet psychologically prepared. 7,8 Our quantitative research found that surgical nurses and high positive professional perception nurses were more willing to participated in the care of COVID-19 patients. 9 Lee found the nation's capacity to respond to public health events was affected a lot by medical stuffs' willingness to involved in the treatment and care of infected patients, which can even determine the effectiveness of saving. 10 In addition to the investigation of nurses' willingness to take part in the care of COVID-19 patients, 9 we also need more comprehensive and further understanding of the underlying reasons and influencing factors of nurses willingness by qualitative research. 11 The theory of planned behavior (TPB) proposed by Ajzen in 1988, puts forward that the decision-making process of individual behavior is related to information processing and expectancy-value. 12 TPB has a good explanation and predictive power for predicting and analyzing behavioral willingness, 13 which mainly includes three variables: attitude, subjective norm, perceived behavior control, it is suitable for the situation where people think they cannot completely control their behavior 14 as might occur in nurses' willingness to care for COVID-19 patients. The TPB is based on the hypothesis that our human is always rational, use the existing information systematically, and consider the meaning of a behavior before engaging in it. The possibility of a person performing a behavior depends on the intensity of the intention. 15 This study uses TPB theory as conceptual framework, include a quality study design by using semi-structured interviews among 10 registered nurses who have been actively signing up for taking care of COVID-19 patients. This study aimed to intensively explore the intention and influence factors of nurses' willingness to participate in responding to public health emergencies like the COVID-19.

| METHODS
This study adopted phenomenological method which is one of the most widely research approaches used in nursing and other human science research areas. 16 Converse (2012) defined phenomenology as "a philosophical perspective that helps researchers explore and understand everyday experiences without presupposing knowledge of those experiences". 17 We conducted one-to-one interviews using a semi-structured interview outline from January to February 2020 in Jiangsu Cancer Hospital. A total of 15 nurses who were actively engaged with taking care of patients with COVID-19 were volunteered to take part in our research. Finally, 10 nurses were involved because the content reached a saturation level. Interview location were chosen by participants including conference room and nurse's lounge, interviews lasted 21 to 40 min. Researcher A, B and D (teacher of a nursing college) written the manuscript. In addition, critical revisions for important intellectual content were conducted by researcher A, D, I and J (nursing manager). All researchers were uniformly trained to ensured that the participants' experiences were described without bias.

| Participants
This study is part of a larger program of research using both quantitative 9 and qualitative methodologies to explore nurses' willingness to participate in taking care of COVID-19 patients. Purposive sampling was used to selected participants from volunteers who (a) has been employed as nurses in China, (b) have applied more than twice to take care of COVID-19 patients as frontline nurses, and (c) were willing to participate in the study to share their experiences and provide informed consent. The maximum variation sampling technique was used to recruit heterogeneous nurses to get the most widely information. 18 The individual participant characteristics for each interview are presented in Table 1. Seven of the participants were female, and three were male. Participants had worked between 3 and 37 years, and age between 26 and 55 years old. In particular, five interviewees have their family members who are healthcare professionals.

| Data collection
Under the guidance of phenomenological methods of qualitative research, we conducted interview by the guided of interviews outline.
Two clinical nurses were interviewed before the formal research interview; this process was set up to push researchers familiar with the research process and to improve the analysis of the research.
The interview outline is drawn up by the whole research team around the theme of willingness to participate in public health emergencies. An interview guide was used starting with question such as,

| Ethical considerations
Ethical approval was granted by the Institutional Review Board of Jiangsu Cancer Hospital in China (NO. 2019/007). Before the interview started, the participates were introduced the research objectives, methods, the basic steps of the interview, confidentiality principles and their right to withdraw at any time, then signed the consent form. Codes were used to protect anonymity and confidentiality. There were no dual role conflicts between the researchers and the participants.

| Data analysis
The collation and analysis of the data were carried out at the same time. 19 According to the four steps (①Reading the written materials of the interview repeatedly, grasp the experience description text intuitively and gain a sense of the whole; ②Refining the meaning unit from a professional perspective, focusing on the phenomenon under study; ③Transforming the daily language of the research phenomenon into professional language, focusing on the research object; ④Integrate the meaning unit after language conversion into a coherent description.) proposed by Giorgi 20, the data collation and analysis were completed through coding, classifying, explaining the essence and meaning of the phenomenon, and refining themes and elements. The recordings were transcribed verbatim within 24h after each interview, and the transcription of each interview and the interview notes were coded in sequence according to N1, N2… N10. During the interview and transcription process, the researchers constantly discussed the problems and solutions in the interview with the research team. To minimize researchers' bias during analysis, two researchers independently analyzed the data and refined the theme. When they had different opinions, the research team checked the original materials and determined the final theme through group discussion. Themes were identified deductively guided by TPB that contents three variables of behavior attitude, subjective norms, and perceived behavior control and cognitive basis. 12   Therefore, I'd like to support too. My wife is a nurse too.
We both apply to support the frontline." (N7)

| Physical condition
Taking care of COVID-19 patients is very stressful to nurses. The interviewees thought that physical condition was an important factor that influenced their willingness to go to the frontline. At the same time, the interviewees all stated that personal characteristics will affect their willingness to participate in public health emergency, and those with compassion, kindness, and dedication are more willing to participate.
"Personal sympathy will also affect people whether to apply or not." (N1) "People who sign up to support the frontline are like me, very caring and compassionate." (N2)

| Professional knowledge and skills
There is no experience for medical staffs to learn in taking care of

| Physical condition, professional knowledge and skills, national measures and incentive policies could predict support willingness and behavior
Perceived behavior control in the TPB refers to a person's expectancy that performance of the behavior is easy or difficult, which is affected by two factors, control beliefs and perceived power. 32 The interviewees' perceived behavior control in this study was mainly reflected in three aspects, the first one was good physical condition to tolerate the frontline work. The second was professional knowledge and skills, such as intravenous treatment, intensive care, research capabilities.
The third was the national investment in preventing and controlling the epidemic, the safety guarantees and incentive policies. The reason for the above analysis was that COVID-19 is an acute respiratory infectious illness with rapid onset, strong infectivity and rapid course change, 33

| LIMITATIONS
As it was challenging to recruit nurses who did not want to participant in take care of COVID-19 patients, this study only included nurses who actively applied for public health emergencies support.
This limitation makes it impossible to obtain and analyze the obstacles of the low willingness to support. In addition, the fist-line nurses were busy with their job, as well as considered the telephone interviews may offer limited nonverbal communication, the first-line nurses were not included in the study sample as well. To probe greater understanding of nurses' willingness to participate in the public health emergency, future research should involve fist-line nurses.

| IMPLICATIONS FOR NURSING MANAGEMENT
To properly respond to public health emergencies, guarantee the firstline nurses' physical and psychological well-being, hospital management departments should pay more attention to create a supportive working atmosphere and develop benefit-finding education to cultivate medical stuffs' positive working attitudes, reduce workload to improve the physical and mental health of nurses. Nurse managers can carry out training on improving professional value expectation, professional knowledge and skills.

ACKNOWLEDGMENTS
The authors would like to thank the participants for their contribution and their support of the study. We gratefully acknowledge all medical staffs who apply for the frontline work from all of the China hospitals.

CONFLICT OF INTEREST
No conflict of interest has been declared by the authors.

ETHICS STATEMENT
The study was reviewed and approved by the Medical Ethics Committee of Cancer Hospital Affiliated with Nanjing Medical University (approval number: 2019007).