Work as a Frontline Volunteer During the COVID-19 Outbreak in Hubei, China: A Qualitative Inquiry of Male Nurses

ABSTRACT Background During the coronavirus (COVID-19) outbreak in 2019, an increased large number of male nurses volunteered for frontline assignment. Their excellent performance suggests that male nurses have several advantages over female nurses. However, research into the activities of Chinese male nurses engaged in frontline work during the COVID-19 pandemic remains limited. Purpose This study was designed to summarize the reflections of male nurses on their experiences while volunteering for frontline COVID-19 duty in Hubei, China. Methods An interpretative qualitative descriptive study was conducted from May to July 2020 on male nurses who had volunteered for frontline COVID-19 duty in Hubei. Twelve male nurses were selected using a purposive sampling method. Data were collected using semistructured interviews, transcribed verbatim, and analyzed using thematic analysis. Results Four main themes and 11 subthemes were identified, including (a) changing the way of thinking at work (four subthemes), (b) clarity regarding career development (three subthemes), (c) change in life philosophy (two subthemes), and (d) personal growth (two subthemes). Conclusions The experience of volunteering during the COVID-19 public health emergency influenced the male nurses positively in terms of improved organizational, management, and decision-making skills as well as improved performance. The beneficial attributes of male nurses should be taken into consideration when developing management policies related to nursing personnel.


Introduction
In general, male nurses are well suited to care and treat patients during public health crises because they have strong physical characteristics and can undertake heavy physical work in difficult conditions (Shin & Lim, 2021;Zhang & Tu, 2020). However, male nurses often experience conflicts stemming from the historical lack of men in nursing, the lack of related mentorship programs, inadequate support from female colleagues, and low acceptance from a society unfamiliar with men working as nurses (Arif & Khokhar, 2017;Kronsberg et al., 2018;Rabie et al., 2020). These conflicts can impair the professional identity of male nurses.
During the COVID-19 pandemic, the excellent performance of volunteer male nurses was appreciated by both patients and society. Recent published studies reflect a growing interest in exploring the experiences of nurses during the COVID-19 pandemic (Liu et al., 2020;Shahoei et al., 2022;Zhou et al., 2021). Moreover, the advantages of male nurses in terms of physiology, psychology, personal protection ability, comprehensive emergency management ability, team organization ability, and instrument and equipment management ability over female nurses in public health emergencies have also been recognized (Göktepe & Sarıköse, 2022;Saleh et al., 2020;Zhang & Tu, 2020). However, despite the above, the experiences of male nurses performing volunteer frontline duties remain unexplored.
Therefore, this study was designed to explore the reflections of male nurses on their experiences volunteering for frontline COVID-19 duty. The findings of this study are expected to contribute to policymaking regarding the management of nursing personnel.

Study Design
This qualitative descriptive study collected data using face-toface, WeChat (a messaging app that includes voice-call features), and telephone interviews. The methodology included interpretive descriptive (Creswell, 2007;Shosha, 2012) and thematic (Braun & Clarke, 2006) analyses of the collected data.

Procedures
In this study, all of the authors were trained in qualitative research, and the following procedures were conducted. First, the researchers recruited participants with extensive experience (i.e., over 5 years of work experience) using a purposive sampling approach and explicit inclusion criteria. Moreover, to facilitate in-depth communication between the researchers and the participants, the participants were acquainted with the researchers. Second, in-depth interviews were conducted and the final recordings were validated by the participants. Third, after each interview was finished, the data were carefully verified by repeatedly listening to the interview recordings using peer review to ensure the accuracy of transcription. Finally, the principal investigator and one researcher coded the transcripts independently and compared individual codes and code clusters. In case of disagreement, the researchers debriefed, sought consultation with another researcher, and discussed the issues until consensus was reached.

Research Team
All of the researchers had qualitative research experience. The face-to-face interviews with the participants were conducted by Researcher A, whereas the interviews via WeChat and telephone calls were conducted by Researcher B or Researcher C. Researchers A, B, and C collected and analyzed the data to extract the themes. Researchers D and E then confirmed the identified themes and evaluated the interpretation and consistency of the themes. The entire process was guided by Researchers E and F who were, respectively, a nursing manager and a professor with experience in qualitative research.

Setting and Participants
The participants were clinical male nurses employed at various hospitals across Guangdong, China, who had served as frontliners in the Eleventh Medical Team as volunteers in the fight against COVID-19.
Purposive and snowball sampling methods were used to select male nurses who met the following inclusion criteria: (a) volunteered in Hubei for about 1 month and (b) were willing to participate in the study. The exclusion criteria included those who (a) had volunteered for less than the full volunteer period or (b) were unwilling to participate in the study. Interested potential participants were sent an invitation letter and form providing information on the purpose and method of the interviews via either messaging or WeChat. The maximum variation sampling technique was used to select nurses with different levels of expertise to ensure that a wide range of perspectives was obtained (Holloway & Wheeler, 2010). Twenty qualified participants were contacted, and eight declined to participate, mainly because of a lack of time and/or interest, resulting in 12 enrolled nurses, including ward nurses, specialist nurses, education nurses, infection control nurses, and nurse managers.

Data Collection
A training session was held for all of the researchers. The first draft of the interview guide was developed based on an extensive review of the literature on the effects of public health emergencies on nurses. Second, the research team members, including experts in qualitative studies, nursing, and management, reviewed the interview guide and provided feedback. Third, revisions to the interview guide were made based on the research team members' feedback. Finally, preliminary interviews were conducted with two participants to familiarize the researchers with the process and to identify any areas that required improvement. The final interview guide is presented in Table 1. The questions chosen aimed to elicit the motives and experiences of the participants and to further explore their reflections on performing volunteer frontline duties.
The interviews were conducted between May and July 2020, when data saturation was reached (i.e., no new topics were identified). To ensure maximum recall, the interviews were held immediately after the participants had completed their frontline assignment. The interviews were held either face-to-face or via WeChat or telephone calls at a place and time convenient for the participants. Consent was obtained from the participants to record the interviews. The participants were encouraged to speak freely, clearly, and independent of others' opinions. Each interview lasted 30-50 minutes. Additional telephone calls were made for clarification when needed.

Data Analysis
Data were analyzed using descriptive thematic analysis (Vázquez-Calatayud et al., 2022). Two of the researchers (A and B) analyzed the data independent of one another within 24 hours after the interviews. They listened carefully to the audio/video recordings several times, transcribed the collected data verbatim, and familiarized themselves thoroughly with the information. The transcripts were imported and analyzed thematically using NVivo 12, a qualitative data analysis software package (Braun & Clarke, 2006). The data were then categorized into meaning units and coded. Patterns and potential themes were then organized by relationships and associations. These themes were then reviewed, and a thematic map was generated. Next, themes were defined and named, and representative examples were selected. If there were disagreements, Researchers A and B debriefed, sought consultation with Researcher C, and discussed the issues until they reached a consensus.
To validate the feasibility of this research, Researchers D and E, who were not involved in the interview process but were experienced in qualitative data analysis, reviewed the initial analysis. Finally, all of the researchers verified the consistency of the coding and ensured that the results were meaningful. Clarifications were sought from all of the participants as necessary. All of the researchers took special care to ensure that their own experiences, thoughts, and opinions did not influence the analysis of the data (Lee et al., 2019).

Ethical Considerations
Ethical approval was obtained from the institutional ethics review board of the hospital (2020ZH0072), and the research conformed to the provisions of the Declaration of Helsinki (as revised in Brazil in 2013). All of the participants provided informed consent and were briefed on the study's purposes and methods, the voluntary nature of their participation, and their right to withdraw from the study at any time. The anonymity of the participants was maintained by using numerical substitutes for names (e.g., N1, N2) and removing any identifying information from their transcripts.

Results
The mean age of the participants and mean years of experience were 31 (SD = 3.18, range: 27-36) years and 7.75 (SD = 2.38, range: 5-11) years, respectively. Eight were married, and four were single. Their main roles included management of nursing personnel, sensory control supervision, sampling, and caring for patients with mild and severe diseases. The primary work responsibilities of the participants included care for patients with mild symptoms, pharynx swab collection, intensive care, administration and training, intensive care management, infection control, management information system, and administrative head nurse. Data extraction, induction, and in-depth analysis of the transcripts revealed 11 subthemes under four main themes, including (a) changing the way of thinking at work (four subthemes), (b) clarity regarding career development (three subthemes), (c) change in life philosophy (two subthemes), and (d) personal growth (two subthemes).

Theme 1: Changing the Way of Thinking at Work
The participants reported a change in how they perceived their way of thinking at work that was attributable to their frontline duties. In the fight against COVID-19, the duties of the nurses were different from their daily, routine responsibilities; were challenging; and had to be completed rapidly. During this period, they gained broader experiences, different perspectives, and greater confidence in their skills, resulting in changes in their way of thinking and behavior. These changes were categorized into the four subthemes of (a) improvement in awareness regarding the prevention and control of infections, (b) development of management-based thinking, (c) realization of the importance of humanistic care, and (d) awareness of the importance of training to the development of independent specialist nursing talents. Improvement in awareness regarding the prevention and control of infections Some of the participants explained that, although they were previously aware of measures for the prevention and control of COVID-19, daily exposure to the infection during their frontline assignment made them pay more attention to these measures.
If you don't touch novel coronavirus, you don't understand it; if you don't participate in this fight, you don't feel the importance of prevention. Once you're been exposed, it seems like you're going to be more focused on it. (N7) Moreover, the participants gained a deeper understanding of the strategies used to prevent and control infections and epidemics as well as relevant standardized measures.
We will pay more attention to infection control and have a deeper understanding of this aspect [prevention and control awareness]. Moreover, some of our quarantine measures will be more standardized. (N10) Development of management-based thinking Some of the participants noted how their work on the front line as managers helped them learn to assess situations from a broader, management-based perspective. They were well organized during difficult moments and were required to work with new partners. Moreover, as men show advantages in team organization, they were required to quickly complete many challenging tasks as team leaders. However, although in the minority, the participants generally did not think about nurse management or the need to manage large numbers of female nurses. Therefore, many of the participants indicated that they had an inadequate understanding of team management and were not aware of appropriate management methods, but they learned and practiced various strategies during their volunteer period.
I had ideas for team building before, but took no action. Now I am acting. For example, I have developed a nursing research group, a nursing staff group, a ventilator management group, and so on. (N11) After the male nurses returned to their institutions after volunteering, they tried to think and work with a management-based perspective.
When dealing with problems, I will pay more attention to the overall situation. The overall situation and the big aspects will be considered before the small aspects. I think I have made a lot of progress in dealing with problems. (N8) Realization of the importance of humanistic care Several of the participants mentioned that they had learned the importance of providing humanistic care and wanted to improve in this aspect. At the time, patients were under high psychological pressure because of the lack of close companions and fear of the disease, and they needed more psychological support and humanistic care, which are rarely practiced by male nurses in their routine work. This was a huge challenge for the participants, and they learned a great deal during this period. Some of the participants recounted how they were required to improve their communication skills and address special needs when encountering depressed or uncooperative patients so that they could complete treatment and be discharged after recovery.
As a man, I think we should work hard on this [humanistic care]. Men may handle things a little faster. But, in terms of care, they should improve. This is one of my biggest suggestions. (N1) The participants also thought about the importance of adopting a humanistic attitude in their regular nursing work and suggested ways to improve.
I'm in the emergency department in our hospital, where humanistic concerns are somewhat ignored. Then I went there [to Hubei]. I am not good at communicating with people, but a lot of communication and composure was needed there. I realized that this [humanistic care] is really an important job. We should learn more about it and know more about the patients so we can get close to the real needs of patients. This is the direction we can strive to go in the future. (N5) Awareness of the importance of training for the development of independent nursing specialist talents Both from the perspective of the participants and their managers, the participants showed an awareness of the importance of specialist training. Most of the interviewees noted the following: (a) They were able to contribute to the management of the pandemic because they had certain beneficial qualities; (b) they realized experiencing certain limitations in their professional role, scientific knowledge, and team management; and (c) they appreciated continuous training as important for improving their professional and technical knowledge.
I will pay more attention to the trends in my specialty because our nursing staff must have professional and technical knowledge. Now, I am paying special attention to the training of our specialists. What I have been doing since I came back is improving myself and my team using a scenario simulation teaching method. (N10) After I came back, I focused on improving the individual abilities of my team, hoping they can work on their own. When I leave, each of them can finish the job as if I was there. (N11) Although we had many advantages over female nurses in many aspects when we were in Wuhan, it was actually difficult for us to learn many things because we lacked training during ordinary times. (N9)

Theme 2: Clarity Regarding Career Development
The second theme identified in this study was the realization by the participants of the impact of the pandemic on

Professional identity
The participants discussed their sense of professional responsibility based on the beneficial attributes associated with being a male nurse. When they were first deployed to their pandemic duties, they lacked sufficient knowledge about the pandemic and the situation. However, professional responsibility and realization of their strengths enabled them to complete their duties. Once they successfully completed their frontline assignment, their efforts were recognized by both patients and the public, which strengthened their personal identification with their profession.
I have a sense of professional responsibility. Male nurses actually have a lot of advantages. First, they are stronger than female nurses. Second, they are firm in making decisions. Third, they are bolder than female nurses. In some special departments such as the operating room and emergency department... male nurses are more suitable. (N1) Recognition by the public helped them feel more confident in and proud of their nursing work.
People used to think that nurses gave out medicine and injections, and now they say, "Oh! It can be like this!" People's impressions of us are quite different (now). (N6) In terms of being able to resist pressure and deal with emergencies, men have more advantages. Maybe male nurses are needed more in the environment there. This experience also strengthened my sense of responsibility to this profession. (N8)

Occupational benefits
After their frontline assignment, the male nurses were appreciated and honored by patients as well as the general public, which boosted their self-confidence and instilled a sense of professional achievement.
Through this event, the nursing profession caught the attention of the public, and public perceptions regarding our male nurses changed. (N3) It just feels like patients' attitudes toward us have become kinder and much better than before. (N5) They also obtained some unexpected professional benefits such as exemption from examinations and priority for professional promotion.
After fighting against the epidemic, there is more praise. So my career achievement and self-confidence have improved and I may have some opportunities for promotion. (N12)

Career planning
The participants explained how their pandemic duty enabled them to identify their shortcomings. Moreover, they worked toward taking appropriate steps to further advance their careers.
This has helped me with planning my professional position, how I want to develop, which is a little clearer than before. (N7) After coming back, I think I can equip myself with skills such as management ability. I think I can try different things and can also be competent. (N8) You should have your own profession. I really realized the importance of professional technology. In addition, I am also considering pursuing technical and management positions. (N10)

Theme 3: Change in Life Philosophy
The participants described how their frontline assignment had changed their life philosophy in terms of (a) life attitude and (b) life goals.

Life attitude
The participants indicated that their frontline work had helped them develop a more positive, patient, and tolerant attitude toward people and events. It is necessary to look at things with a longer perspective and deal with things with more patience. After all, having been there made me want to try my best to do a better job in the future and try to do everything better. (N8) My view of life has changed and I feel like I've become a little bit more patient, a little bit more openminded, and a little bit more tolerant of things. (N9)

Life goals
The participants reported that their pandemic work experience had helped them identify their life goals.
After experiencing this frontline assignment, I feel that what I am doing is not only a job, but I can also contribute to improving the health of human beings, which may be the meaning and goal of life that I have been seeking. (N5) I used to feel I was a small citizen and just did my own things. But after this [frontline assignment], I feel that no matter where I am, at the bottom or wherever, I can make a contribution and I want to do my part. (N7) Volunteer Duty of Male Nurses VOL. 31, NO. 4, AUGUST 2023 Theme 4: Personal Growth The fourth theme identified in this study was personal growth. Some of the participants noted that their frontline experience had helped them grow as individuals, mainly in terms of (a) improved personality and (b) positive behavioral change.

Improved personality
The participants reported that their frontline assignment changed their personality, making them tougher, calmer, and kinder.
This experience has made me more resilient [able to work under pressure], which means I will be calmer during emergencies in the future. At the same time, I feel more powerful inside. I feel that if people can push themselves, their potential can be realized. (N8) Once I had to go to work and had no time to eat, I asked the restaurant staff to leave a meal for me. However, they forgot and felt very embarrassed. They cooked noodles for me immediately. They still feel guilty even after a long time. It's not that someone is pushing them for anything, but it's obvious that they really love us. After staying in such an environment for a long time, I found that my attitude gradually changed and I am more friendly toward people and things. (N9)

Positive behavioral change
The participants described how their behavior toward others had changed, which involved improving their self-image and promoting active involvement in public education regarding the pandemic.
I will take the initiative to ask myself to do better, and I will try my best to overcome any little faults and inconveniences. Everyone regards us as heroes, so we should be better role models. (N5) The epidemic is not over yet, so we need to go out and share our stories, so that knowledge about the epidemic can be spread more widely, and positive education can reach more people. (N9)

Discussion
The reflections of male nurses on volunteering for frontline COVID-19 duty in China were analyzed in this qualitative descriptive study. The findings showed that their volunteering experience changed their way of thinking at work, helped them formulate clear career development plans, changed their life philosophy, and promoted personal growth. The results also indicate that frontline assignment had considerably positive impacts, both professionally and personally, on the male nurses. Their experiences helped them improve their thinking and behavior at work. These changes may be expected to influence the future care they provide to patients as well as their pro-fessional work (Güzel & Döndü, 2022;Martins & Robazzi, 2009;Sundus & Younas, 2020). The male nurses in this study fostered behaviors intended to enhance their image and relationship with patients. Furthermore, the need for specialized training for technical improvement as well as continuing education to gain more knowledge was evident.
Their narratives revealed that volunteering helped the participants formulate a clear career development plan. This is consistent with the finding in a recent study on the lived experiences of 14 nurses in Iran (Bahramnezhad & Asgari, 2020) that the experience of dancing with death in the aftermath of COVID-19 made them think of ways to improve the public image of nurses and develop professionally. These findings suggest that public health emergencies are associated with rapid increases in the numbers of nurses who volunteer for frontline assignment, regardless of gender.
The dominance perspective theory is rooted in positive psychology, and it states that, for individuals to achieve their goals, it is necessary to focus on their inner strength and utilize superior resources (Han et al., 2020), seek and expand the resource advantages of the service object, and use their own resources to achieve their goals (Lyu et al., 2022;Roccato, 2014). Male nurses played several important roles during the pandemic. They gained greater appreciation of their value in adversity. Within nursing teams, male nurses attract much attention. In addition, their outstanding performance in Hubei led to hospital staff entrusting them with important responsibilities. They took on various responsibilities during the pandemic such as team leader, temporary head nurse, teaching group leader, and quality control commissioner. During their time on as frontline volunteers, the male nurses played leading roles and received wide attention and support from society for their courage in providing care during the pandemic.
In China, nursing education focuses more on theoretical knowledge and practical skills than on humanistic care training. However, humanistic care is important during a pandemic, as observed in Wuhan. Considering that men are generally less emotional, training in humanistic care is important for male nurses. Thus, the findings of this study also confirmed the necessity of humanistic care training and education.
A recent study on the work experience of newly recruited male nurses during COVID-19 (Zhou et al., 2021) found that the experience changed their attitudes toward COVID-19 and helped them develop a positive attitude toward life and a high sense of professional responsibility, which is consistent with the findings in this study. However, Zhou et al. found no impact on how the nurses thought about their work or about the importance of training to the development of specialist nursing talents. These differences may be attributed to differences in the study populations. Zhou et al. mainly focused on newly recruited male nurses, whereas this study mainly focused on male nurses with experience who were in management positions and thus more likely to consider problems more carefully.
Frontline nursing duty enabled the participants to gain clarity regarding their career trajectory, which is crucial to establishing a professional identity. The great dedication and selfless attitude shown by male nurses during the pandemic earned them recognition as heroes and improved the image of the nursing profession, which further helped establish their professional identity. In addition to career and professional growth, serving in frontline assignments also helped them achieve personal growth and boosted their confidence. This is consistent with the findings of Sheng et al. (2020).
Compared with other countries, China has a very low percentage of registered male nurses (Zhang & Tu, 2020). The implementation of strategies to recruit and train significant new numbers of male nurses would help address the shortage of labor and the existing gender imbalance in nursing. Possible strategies include generating public awareness regarding the importance of male nurses, improving their professional training and social status, and promoting a positive image of the male nursing community, which can be expected to have an overall beneficial effect on the nursing field.

Limitations
This study is affected by several important limitations. First, some of the interviews were conducted via telephone or WeChat, which limited the ability to assess nonverbal communication. Direct, face-to-face interviews may have added further granularity to the findings. Second, some of the potential participants declined to take part in the semistructured interviews. The reasons for refusing to participate should be identified in future investigations to provide additional data. Third, only male nurses were included in this study because of the substantial changes in their professional role and identity as a result of their frontline COVID-19 duties. However, all nurses performing frontline COVID-19 duties had extremely difficult experiences, and reflections on their experiences deserve to be explored qualitatively. Furthermore, as all of the participants were from Guangdong Province, regional differences may not be captured in the results. For deeper insights, future research should be conducted on a larger scale and involve participants drawn from a more widespread population base.

Conclusions
To summarize, the findings indicate that frontline COVID-19 assignment positively affects male nurses. When planning for the management of public health emergencies, hospital managers should take into consideration the specific potential of male nurses. In addition, the findings showed that frontline COVID-19 assignment helped the male nurses recognize their skills in the realms of organization, management, decision making, and performance. These findings are useful in understanding the issues facing the male nursing community and developing appropriate strategies to improve their conditions as well as perceptions of their work among the general public.

Relevance to Clinical Practice
The observations in this study found positive outcomes for the male nurses of volunteering for frontline COVID-19 assignment. The advantages of recruiting male nurses need to be recognized. Systematic and targeted training plans for responding to public health emergencies should be developed for male nurses, and appropriate opportunities should be provided to improve their career progress and professional identity. The findings also highlighted the importance of preparing for public health crises and the need to educate and train male nurses for related responsibilities. Personal, administrative, and institutional strategies are warranted to better utilize male nurses in public health emergencies.