Predicting the Willingness of Nurses to Work with COVID-19 Patients: The Impact of Knowledge and Attitude

Aim: This study aims to assess the impact of nurses’ knowledge and attitude toward Coronavirus Disease 2019 (COVID-19) as a predictor for 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 and midwives working in Hamad Medical Corporation;the principle 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. Two main factors were found to be significant predictors for nurses’ willingness;knowledge level and the expected remuneration that is associated with the level of exposure to risk. The findings of this study may help nursing leaders design educational programs and remuneration models that may help boost nurses’ willingness to work with high-risk patient groups, especially during crisis situations.


Introduction
In December 2019, a novel coronavirus that causes coronavirus disease 2019  was rst detected in Wuhan-China (Imai, 2020;WHO, 2020). Similar to other previous respiratory coronavirus infections (e.g., SARS-CoV and MERS-CoV), patients presented with fever, dry cough, shortness of breathing, and lung in ltration in the most severe cases (Gralinski & Menachery, 2020). There is still no de nitive cure and global pharmaceutical companies are rushing towards a vaccine.
Since the initial detection of the virus, more than 7.6 million cases of Covid-19 have been con rmed worldwide. Qatar reported its rst case on 27 February 2020. As of this writing (June 21, 2020), Qatar ranks fourth in the Eastern Mediterranean region having a total of 86,488 con rmed cases with 98 total deaths. In Qatar, nursing is the largest and the most diverse professional workforce within the healthcare system. Therefore, their role in de ning 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, the majority of them are still willing to work and accept it as an obligation and part of their job despite the risks. (Al-Hunaishi, Hoe, & Chinna, 2019;Liu et al., 2020;McMullan, Brown, & O'Sullivan, 2016) The primary factor that can impact the willingness of nurses is the hospital's preparedness plans that consider the safety of their staff members (McMullan et al., 2016). Al-Hunashi et al. (2019) suggested improving self-e cacy through training can increase willingness to participate in a disaster, like a upandemic (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 a signi cant majority of 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, Koh, Lo, Lim, & Guo, 2007) Another study has investigated the relationship between hospital nurses' attitudes towards SARS infection control measures and their professional care obligation. The ndings showed that proper infection control measures were signi cant predictors of the nurses' ful lling of their professional care obligation. (Tzeng, 2004) On the other hand, the knowledge and attitude of nurses and other healthcare providers is expected to largely in uence the degree of adherence to the proper use of personal protective measures and ultimately will be re ected 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 nurses were getting COVID-19 related information from the World Health Organization (WHO) o cial reports and the Ministry of Health (55%), social media (48%), and traditional media (42%). However, the overall knowledge score was not signi cantly different according to age, education level, and work experience. The researchers suggested that providing more information might lead to better control of infectious diseases like COVID-19. (Ebrahimi & Nemati, 2020) Another two studies were done in China (Liu et al., 2020) 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 o cial corporate email where it was accompanied with a research information sheet explaining the expectations. Data was collected by the co-investigators, then it was coded and double checked by the PI (the PI was the link between data and code list); The data was stored in the protected computer by Hamad Medical Corporation (HMC) in accordance with the corporate's policies and guidelines.

Online survey
This cross-sectional study was conducted in Hamad Medical Corporation (HMC) in June 2020. The 35item self-administered survey was adapted from Shi et. al. [7]. The original version was a 33-item, Likertstyle questionnaire which included different levels of questions about the knowledge and attitudes toward COVID-19 among medical staff in psychiatric hospitals in China. Permission to use the tool was granted and obtained by the principal investigator.
The survey link was circulated to all the nursing services at HMC; approximately 11000 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 o cial training they had received with relation to COVID-19. They were also asked to evaluate their level of knowledge and con dence 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 analyzed for descriptive and inferential statistics at a con dence 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

Participants' characteristics
A total of 377 questionnaires were collected and included in the nal analysis out of 580; the response rate was 65%. The mean age of participants was 35.53 ± 6.32 years. Of them, 61.5 are females. (Table 1). 88.1% of the participants expressed their willingness to work with COVID-19 patients compared to 11.9% who were unwilling.

The reliability analysis
As the reliability of Shi et. al.
[7] study was not reported. In this study, the scale was evaluated for reliability and internal consistency and revealed satisfactory results (α ranged between 0.61 and 0.74). (Sekaran & Bougie, 2016)

COVID-19 related knowledge
More than half of the respondents (53%) reported their overall level of knowledge related to COVID-19 as "competent". The sources of their knowledge included the internet, medical journals, television, and newspapers) and hospital training.

Predictors of nurses' willingness
A total of 332 participants (88.1%) showed their willingness to work with COVID-19 patients. Logistic regression showed 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 .874). 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 of patients with . No signi cant difference was found between demographics and staff willingness to care for patients with COVID-19 (Table 3).

Discussion
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 monetary compensation purposes. The organization announced that the nurses who provide direct care to patients with COVID-19 would have higher risk allowance than those who don't provide direct care for patients with COVID-19 e.g., nursing support and admin staff. Accordingly, this may implicitly indicate a relationship between the level of monetary gain and the risk that the nurse is willing to expose him/herself to.

Dezzani et al examined potential predictors of nurses' intentions to work during the 2009 in uenza A
(H1N1) pandemic where nurses were signi cantly more likely to work if certain incentives were offered (e.g., risk allowance, family protection, priority for vaccination/antiviral treatment). (Martin, Brown, & Reid, 2013) Another study revealed that the most in uential factors that motivated people to work were feeling that they were being protected by their country, local government, and hospital. (Imai, 2020) A possible explanation of this phenomenon is that the vast majority of the nurses who work in Qatar are expatriates and particularly from Asia (El-Jardali et al., 2013). Very importantly, nurses from different countries may have different value sets that in uence their motivation. For example, Asian nurses are mostly motivated by nancial rewards and it is the main reason that makes them leave their countries to pursue better commercial packages overseas. (Henderson & Tulloch, 2008) Nevertheless, an experiment was discovered that incentive compensation should reward speci c strategies (must be clear and known in advance) to improve communication and engage employees which ultimately leads to enhance leaders' efforts to improve teamwork in large organizations. (Lazear, 2018) Also, incentives can have adverse effects on individual motivation, especially when extrinsic motivation signi cantly displaces the intrinsic motivation of the subject. (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 "pro cient". The result is consistent with other studies (Huynh, Nguyen, Vo, & Pham, 2020;Nemati et al., 2020;Nepal et al., 2020;Saqlain et al., 2020;Zhou et al., 2020) where most healthcare workers reported having good knowledge about COVID-19. This high percentage of knowledge among nurses and midwives regarding COVID-19 is due to the immense volume of information that was made public by social media. The utilization of the internet has drastically increased over the years. It has been reported that the average hours spent on the internet by an individual is 6 hours 49 minutes a day, 2 hours and 16 minutes on social media and that is before the COVID-19 pandemic. ("Digital 2019: Global Internet Use Accelerates," 2020) According to The New York Times, internet tra c in America has drastically increased during the pandemic with people seeking more information on COVID-19. (Times, 2020) In China, one online medical service had exceeded 4.26 million consultations on COVID-19 from January 22 to February 25, which is a 278% increase. (Sun, Yu, Xie, & Pan, 2020) One of the strategies to stop the spread of the virus is knowledge and information; for this reason authorized governing body, like the WHO (World Health Organization), CDC (Communicable Disease Center) and MoPH (Ministry of Public Health Qatar), have been consistently uploading COVID-19 facts through their websites and different social media platforms. In Qatar, nurses and midwives receive daily updates from the System-Wide Incident Command Committee Chair (SWICC) through SMS and emails and are granted free access to online medical journals. 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, health care workers generally receive information about COVID-19 through formal lessons which resulted in greater selfcon dence.  Different hospitals in Qatar have initiated programs to prepare nurses for COVID-19; however, only 12 out of 377 (3%) of our respondents have completed hospital-based training programs. A probable reason for this is that those who are less exposed did not nd the urgency to attend such programs or that the training was con ned to nurses and midwives who are directly working with COVID-19 patients. Still, the respondents claimed to have good knowledge and high willingness (88.1%) to treat and care for patients with COVID-19 among nurses and midwives. This is also, in contrast to the study of Al Hunashi, et.al.
where training healthcare workers improve the willingness to participate in the pandemic crisis. [5] The perception of occupational exposure may lead to an unwillingness to go to work, especially when they witness their colleagues acquire the disease [5,8]. In Thailand, most healthcare professionals were not willing to accept new patients or take care of patients during the COVID-19 pandemic. (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 u 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;Holly Seale, Leask, Po, & MacIntyre, 2009;H Seale, MacIntyre, Booy, & Leask, 2008) Importantly, we found no signi cant difference between demographics and staff willingness to care for patients with COVID-19.

Limitations
There are two signi cant limitations in this study that could be addressed in future research-rst, the possibility of selection bias. Although we sent the invitation to over 11,000 nurses via the corporate email, the respondents were, directly and indirectly, working with COVID-19 patients. Second, the crosssectional 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.

Conclusion
In conclusion, knowledge and expected monetary compensation that is associated with the level of risk exposure impact the nurses' willingness to take care of patients with COVID-19. The ndings of this study could inform the policy makes HMC and in the healthcare sector in Qatar invest in training and improving staff's knowledge and to consider satisfactory remuneration systems to boost their willingness to work in a hazardous environment.

Declarations
Ethics approval and consent to participate The study was approved by the Medical Research Center (MRC) -Institutional Review Board (IRB) at Hamad Medical Corporation (MRC-05-065).

Availability of data and material
All data generated during this study is included in this published article.