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Work stress and perceived organisational support on young Korean nurses’ care for COVID-19 patients

      ABSTRACT

      Background

      Since the outbreak of COVID-19 worldwide, frontline nurses have faced tremendous stress. Younger nurses in their early-to-mid careers can be more exposed to burnout and work stress, and perceived organisational support can influence the quality of nursing care for vulnerable patients.

      Aim

      To identify the impact of younger nurses’ work stress and perceived organisational support on their willingness to care for COVID-19 patients.

      Methods

      The cross-sectional secondary data analysis included 211 hospital nurses (<35 years) in South Korea with a mean age of 24.60 years (SD=1.90). Multiple logistic regression analysis was used to identify the factors influencing willingness to care.

      Findings

      Supplying personal protective equipment, training in the use of personal protective equipment, lower work stress, and positive perceptions of organisational support significantly increased early-career nurses’ willingness to care. For mid-career nurses, being male and higher work stress significantly increased their willingness to care.

      Discussion

      Support, including COVID-19-related education or training, should be provided to reduce work stress arising from being exposed to infection or while providing care to critically ill patients, especially among early-career nurses. Support from nurse managers, senior staff, and colleagues could help younger nurses cope better with the challenges of COVID-19, thus increasing their willingness to care.

      Conclusion

      Perceived organisational support may facilitate early-career nurses’ organisational commitment. Healthy work environments can relieve early-to-mid-career nurses’ work stress, thus facilitating patient-centred care.

      Keywords

      Summary of relevance
      Problem or issue
      Little is known about the impact of younger nurses’ work stress and perceived organisational support on their willingness to care for COVID-19 patients.
      What is already known
      Nurses at the frontline of caring for COVID-19 patients likely have higher work stress than doctors and other hospital staff. Perceived organisational support can reduce mental and physical fatigue among nurses.
      What this paper adds
      Higher work stress among younger Korean nurses disrupted their involvement in patient care during the COVID-19 pandemic. Support from nurse managers and experienced colleagues could help early-career nurses cope with challenges, increasing their willingness to care.

      1. Introduction

      Similar to many countries, the Korean healthcare system has experienced challenges during the COVID-19 pandemic (
      • Heo K.
      • Jeong K.
      • Lee D.
      • Seo Y.
      A critical juncture in universal healthcare: Insights from South Korea's COVID-19 experience for the United Kingdom to consider.
      ), with a significant impact on healthcare institutions, requiring more frontline healthcare providers and increased work capacity (
      • Liu Q.
      • Luo D.
      • Haase J.E.
      • Guo Q.
      • Wang X.Q.
      • Liu S.
      • et al.
      The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study.
      ). As burdens on overextended healthcare systems intensified and the pandemic prolonged, healthcare providers increasingly struggled because of high intensity demands and mental health issues, including depression and burnout (
      • Kakemam E.
      • Chegini Z.
      • Rouhi A.
      • Ahmadi F.
      • Majidi S.
      Burnout and its relationship to self-reported quality of patient care and adverse events during COVID-19: a cross-sectional online survey among nurses.
      ;
      • Lee H.Y.
      • Jang M.H.
      • Jeong Y.M.
      • Sok S.R.
      • Kim A.S.
      Mediating effects of anger expression in the relationship of work stress with burnout among hospital nurses depending on career experience.
      ;
      • Wang H.
      • Liu Y.
      • Hu K.
      • Zhang M.
      • Du M.
      • Huang H.
      • Yue X.
      Healthcare workers’ stress when caring for COVID-19 patients: an altruistic perspective.
      ).
      Among frontline health professionals, nurses have the highest contact with patients (
      • Wu B.
      • Zhao Y.
      • Xu D.
      • Wang Y.
      • Niu N.
      • Zhang M.
      • et al.
      Factors associated with nurses’ willingness to participate in care of patients with COVID-19: a survey in China.
      ). Unfortunately, nurse shortages and staffing shortfalls exist worldwide, largely owing to aging populations (
      • Uthaman T.
      • Chua T.L.
      • Ang S.Y.
      Older nurses: a literature review on challenges, factors in early retirement and workforce retention.
      ). This problem is also prevalent in South Korea despite an increased number of newly graduated nurses (

      Hospital Nurses Association. (2020). 2019 survey on hospital nurse staffing. Hospital Nurses Association. Available from: https://khna.or.kr/home/pds/utilities.php 31, July, 2022

      ). The number of active nurses in South Korea is extremely low compared with other Organisation for Economic Co-operation and Development countries (
      • Lee E.
      Why newly graduated nurses in South Korea leave their first job in a short time? A survival analysis.
      ). As there are not enough nurses to provide care for patients, the ratio of nurses to patients is skewed (
      • Kang Y.
      • Shin K.R.
      COVID-19: Korean nurses’ experiences and ongoing tasks for the pandemic's second wave.
      ), and COVID-19 has doubled the required number of nurses (
      • Heo K.
      • Jeong K.
      • Lee D.
      • Seo Y.
      A critical juncture in universal healthcare: Insights from South Korea's COVID-19 experience for the United Kingdom to consider.
      ). Thus, the retention of nurses has become increasingly crucial in South Korea (
      • Loerzel V.
      • Rice M.
      • Warshawsky N.
      • Kinser P.A.
      • Matthews E.E.
      Areas of satisfaction and challenges to success of mid-career nurse scientists in academia.
      ;
      • Modaresnezhad M.
      • Andrews M.C.
      • Mesmer-Magnus J.
      • Viswesvaran C.
      • Deshpande S.
      Anxiety, job satisfaction, supervisor support and turnover intentions of mid-career nurses: a structural equation model analysis.
      ).
      Work stress is a result of the conflict between work requirements or patients’ needs and workers’ abilities; it can cause decreased mental health and increased turnover intention or actual turnover among workers (
      • Adekanmbi F.P.
      • Ukpere W.
      Work stress, perceived organizational support, demographics, and burnout of registered nurses in Nigeria.
      ;
      • Kuo F.L.
      • Yang P.H.
      • Hsu H.T.
      • Su C.Y.
      • Chen C.H.
      • et al.
      Survey on perceived work stress and its influencing factors among hospital staff during the COVID-19 pandemic in Taiwan.
      ). Nurses who care for COVID-19 patients can experience serious distress, anxiety, and depression (
      • Wang H.
      • Liu Y.
      • Hu K.
      • Zhang M.
      • Du M.
      • Huang H.
      • Yue X.
      Healthcare workers’ stress when caring for COVID-19 patients: an altruistic perspective.
      ). Work-related stress during the COVID-19 pandemic predicts anxiety, depression, and burnout among healthcare providers (
      • Lee H.Y.
      • Jang M.H.
      • Jeong Y.M.
      • Sok S.R.
      • Kim A.S.
      Mediating effects of anger expression in the relationship of work stress with burnout among hospital nurses depending on career experience.
      ). Therefore, nurses’ work stress during the pandemic should be evaluated from the perspective of occupational health. Studies confirm a relationship between work stress, social support, and more work experience among nurses (
      • Adekanmbi F.P.
      • Ukpere W.
      Work stress, perceived organizational support, demographics, and burnout of registered nurses in Nigeria.
      ;
      • Lee H.Y.
      • Jang M.H.
      • Jeong Y.M.
      • Sok S.R.
      • Kim A.S.
      Mediating effects of anger expression in the relationship of work stress with burnout among hospital nurses depending on career experience.
      ). Perceived organisational support refers to employees’ perception that organisations acknowledge their contributions (
      • Robaee N.
      • Atashzadeh-Shoorideh F.
      • Ashktorab T.
      • Baghestani A.
      • Barkhordari-Sharifabad M.
      Perceived organizational support and moral distress among nurses.
      ). When employees perceive organisational support, they are more committed to their duties and organisations; moreover, their turnover intention decreases (
      • Sarfraz M.
      • Qun W.
      • Sarwar A.
      • Abdullah M.I.
      • Imran M.K.
      • Shafique I.
      Mitigating effect of perceived organizational support on stress in the presence of workplace ostracism in the Pakistani nursing sector.
      ). Perceived organisational support can reduce workplace stressors and improve care for vulnerable patients, especially those with COVID-19 (
      • Zhang N.
      • Xu D.
      • Li J.
      • Gong Z.
      Effect of perceived organizational support on fatigue of Chinese nurses during the COVID-19 pandemic: resilience as a mediator.
      ).
      Compared to older nurses, younger nurses have less role clarity and poorer clinical decision-making confidence (
      • Salminen H.
      • Miettinen M.
      The role of perceived development opportunities on affective organizational commitment of older and younger nurses.
      ). Early-career nurses—including newly graduated nurses—often feel inadequately prepared for their roles, increasing work stress and discouraging professional role adaptation (
      • Brook J.
      • Aitken L.
      • Webb R.
      • MacLaren J.
      • Salmon D.
      Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: a systematic review.
      ). Organisational support is crucial in the implementation of sustainable nurse retention strategies and the promotion of quality patient care (
      • Van der Heijden B.
      • Brown Mahoney C.
      • Xu Y.
      Impact of job demands and resources on nurses’ burnout and occupational turnover intention towards an age-moderated mediation model for the nursing profession.
      ). When caring for patients with COVID-19 in critical conditions, nurses need professional knowledge and skills of the highest level (
      • Gan X.
      • Shi Z.
      • Chair S.Y.
      • Cao X.
      • Wang Q.
      Willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 epidemic: a cross-sectional study.
      ). However, the uncertain nature of the virus and inadequate protection, such as shortages of personal protective equipment (PPE), may complicate COVID-19 care (
      • Gan X.
      • Shi Z.
      • Chair S.Y.
      • Cao X.
      • Wang Q.
      Willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 epidemic: a cross-sectional study.
      ;
      • Wu B.
      • Zhao Y.
      • Xu D.
      • Wang Y.
      • Niu N.
      • Zhang M.
      • et al.
      Factors associated with nurses’ willingness to participate in care of patients with COVID-19: a survey in China.
      ).
      Therefore, work stress and perceived organisational support are likely to have affected younger nurses’ care of vulnerable patients during the COVID-19 pandemic. However, topics such as work-related and organisational factors associated with organisational commitment and avoiding nursing shortages—especially in terms of nurses’ work experience—have been inadequately explored, both in South Korea and globally. Therefore, the current study identifies the impact of work stress and perceived organisational support on the willingness to care for COVID-19 patients among early- and mid-career registered nurses.

      2. Methods

      2.1 Study design and participants

      This secondary analysis used data were obtained using convenience sampling, between August and October 2020, from 232 nurses (
      • Heo Y
      • Lee M
      • Jang S.J.
      Intentions of frontline nurses regarding COVID‐19 patient care: A cross‐sectional study in Korea.
      ) working in seven COVID-19 hospitals, as designated by the Korea Disease Control and Prevention Agency. The parent study (
      • Heo Y
      • Lee M
      • Jang S.J.
      Intentions of frontline nurses regarding COVID‐19 patient care: A cross‐sectional study in Korea.
      )’s inclusion and exclusion criteria were as below: “nurses with prior experience in providing care for patients confirmed or suspected to have COVID-19 were considered, while nurse managers who did not directly provide patient care and nurses with a clinical career of fewer than 6 months were excluded from the study”. In this current study, data on 211 younger (≤35 years old) nurses (

      World Health Organization. (2021). State of the world's nursing report—2020: investing in education, jobs and leadership. Available from: https://www.who.int/publications/i/item/9789240003279 31, July, 2022

      ) were included for analysis, and that on 21 nurses (>35 years old) were excluded.
      Nurses with <3 years of experience were classified as early-career nurses, while those with 3–10 years’ experience were classified as mid-career nurses. The required sample size for logistic regression analysis was 97, which was calculated using G*Power version 3.1.9.2 by assuming two-tailed analyses, with a significance level of .05, statistical power of .90, effect size odds ratio=2.2 (
      • Goshin L.S.
      • Sissoko D.R.G.
      • Stringer K.L.
      • Sufrin C.
      • Byrnes L.
      Stigma and US nurses’ intentions to provide the standard of maternal care to incarcerated women.
      ), X para σ=1, and Pr (Y=1ΙX=1) H0=.7. Thus, the sample size of 211 participants (early-career nurses, n=99; mid-career nurses, n=112) was deemed sufficient.

      2.2 Measures

      A questionnaire survey was administered to collect respondents’ demographic (i.e., age, marital/relationship status, and educational attainment) and work-related characteristics (i.e., total clinical experience, current working unit, COVID-19 infection control education, training related to PPE, and sufficient PPE supply).

      2.2.1 Work stress

      In the parent study, to measure nurses’ work stress, the Korean version of the Perceived Stress Scale was used, which has been validated for Korean hospital workers (
      • Lee J.H.
      • Shin C.M.
      • Ko Y.H.
      • Im J.H.
      • Cho S.H.
      • Kim S.H.
      • et al.
      The reliability and validity studies of the Korean version of the Perceived Stress Scale.
      ). This 10-item tool uses a five-point scale (0 = not at all to 4 = very much so), with scores ranging from 0 to 40. High scores indicate high levels of perceived stress. Cronbach's α for the Korean version (
      • Lee J.H.
      • Shin C.M.
      • Ko Y.H.
      • Im J.H.
      • Cho S.H.
      • Kim S.H.
      • et al.
      The reliability and validity studies of the Korean version of the Perceived Stress Scale.
      ) was .82 (.83∼.89), and in this study it was .80 (.72∼.81).

      2.2.2 Perceived organisational support

      For measuring perceived organisational support, a social support tool (
      • Jeong C.H.
      A study on the effect emotional labor on the job stress and job burnout of social work civil servant of SMG.
      ) was used, with the cut-off score as the mean. This tool comprises nine items and three domains (co-worker, supervisor, and organisation in general). Construct validity results using confirmatory factor analysis were: χ2/df = 2.71, goodness of fit index = .89, root mean square error of approximation = .07, Tucker-Lewis index = .84, and comparative fit index = .92 (
      • Jeong C.H.
      A study on the effect emotional labor on the job stress and job burnout of social work civil servant of SMG.
      ). The items are graded on a 5-point scale (1=not at all to 5=very much so), with scores ranging from 9 to 45, with higher scores indicating higher perceived organisational support. Cronbach's α was .87 (.85∼.89) in
      • Jeong C.H.
      A study on the effect emotional labor on the job stress and job burnout of social work civil servant of SMG.
      and .80∼.84 in this study.

      2.2.3 Willingness to care for COVID-19 patients

      As in
      • Wu B.
      • Zhao Y.
      • Xu D.
      • Wang Y.
      • Niu N.
      • Zhang M.
      • et al.
      Factors associated with nurses’ willingness to participate in care of patients with COVID-19: a survey in China.
      , a single item was used to measure nurses’ willingness to care for COVID-19 patients: ‘I am willing to participate in providing care as the nurse in charge of COVID-19 patients’. Answers were graded on a 7-point rating scale (1=not at all to 7=very much so). A score of 1–4 points (not at all to moderate) indicated an ‘absence of willingness to care’, and a score of 5–7 points indicated a ‘willingness to care’.

      2.3 Data analysis

      All statistical analyses were conducted using IBM SPSS Statistics (version 26.0; Armonk, NY: IBM Corp). Demographic and work-related characteristics, work stress, perceived organisational support, and willingness to care were analysed using descriptive statistics. The Kolmogorov-Smirnov test was used to test for normality of distribution. Differences in willingness to care by demographic and work-related characteristics were analysed using independent t-tests, one-way analysis of variance, and chi-square tests. Logistic regression analysis was used to identify the factors influencing willingness to care. Participants were divided into early- and mid-career nurses. All variables tested in the univariate analysis were included in the regression analysis.

      2.4 Ethical considerations

      We obtained approval for secondary data analysis from the Institutional Review Board of Chung-Ang University (Approval number: 1041078-202104-HRSB-113-01). The parent study was approved by the Institutional Review Board of Eulji University (Approval number: EUN20-017). All participants provided informed consent in the parent study. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

      3. Results

      3.1 Participants’ demographic and work-related characteristics

      Table 1 presents the participants’ demographic and work-related characteristics and the differences in these characteristics between early- and mid-career nurse groups’ age, marital/relationship status, and total clinical experience. There was a significant difference in age, marital/relationship status, and total clinical experience between the two groups.
      Table 1Participants’ demographic and work-related characteristics (n=211).
      CharacteristicCategory< 3 years(n=99)≥ 3 years(n=112)t/For χ2p-value
      n (%)/M±SD
      Age (year)24.60±1.9028.32±2.363.73<.001
      GenderWomen80 (80.8)94 (83.9)0.35.552
      Men19 (19.2)18 (16.1)
      Marital/relationship statusNo97 (98.0)100 (89.3)6.41.011
      Yes2 (2.0)12 (10.7)
      Educational attainment< Bachelor's degree8 (8.1)27 (24.1)9.76.002
      Bachelor's degree or higher91 (91.9)85 (75.9)
      Total clinical experience1.43±0.695.71±2.344.27<.001
      Current working unitED41 (41.4)54 (48.2)2.04.564
      ICU26 (26.3)24 (21.4)
      General ward19 (19.2)24 (21.4)
      Dedicated COVID-19 ward13 (13.1)10 (9.0)
      COVID-19 infection control educationNo30 (30.3)38 (33.9)0.32.574
      Yes69 (69.7)74 (66.1)
      Training related to PPENo17 (17.2)16 (14.3)0.33.565
      Yes82 (82.8)96 (85.7)
      Sufficient PPE supplyNo40 (40.4)50 (44.6)0.38.534
      Yes59 (59.6)62 (55.4)
      Abbreviations: M, mean; SD, standard deviation; ED, emergency department; ICU, intensive care unit; PPE, personal protective equipment; COVID-19: coronavirus disease 2019.

      3.2 Comparison of major variables between early- and mid-career nurses

      Table 2 shows comparisons between early- and mid-career nurses in terms of the major variables. Mean scores were used to distinguish between the two groups for perceived organisational support and work stress. The level of perceived organisational support differed between the two groups, with 66.7% (n=66) of early-career and 87.5% (n=98) of mid-career nurses reporting low perceived organisational support (p<.001). However, there were no significant differences concerning work stress and willingness to care for COVID-19 patients.
      Table 2Comparison of major variables between early- and mid-career nurses.
      CharacteristicCategory< 3 years(n=99)≥ 3 years(n=112)χ2p-value
      n (%)
      Work stress
      cut off value: mean
      High39 (39.4)59 (52.7)3.73.072
      Low60 (60.6)53 (47.3)
      Perceived organisational support
      cut off value: mean
      High33 (33.3)14 (12.5)13.17<.001
      Low66 (66.7)98 (87.5)
      Willingness to care for COVID-19 patientsNo46 (46.5)50 (44.6)0.07.791
      Yes53 (53.5)62 (55.4)
      Abbreviations: M, mean; SD, standard deviation; COVID-19: coronavirus disease of 2019.
      a cut off value: mean

      3.3 Willingness to care according to demographic and work-related characteristics

      Table 3 shows comparisons between early- and mid-career nurses’ willingness to care according to demographic and work-related characteristics. Early-career nurses showed differences in willingness to care based on their training related to PPE, sufficient PPE supply, work stress, and perceived organisational support. Among the participants who expressed willingness to care, 90.6% (n=48) had received PPE training, and 71.7% (n=38) had received sufficient PPE supply. Mid-career nurses showed differences in willingness to care depending on their marital/relationship status.
      Table 3Willingness to care according to demographic and work-related characteristics of early- and mid-career nurses (n=211).
      CharacteristicCategoryWillingness to care for COVID-19 patients
      < 3 years (n=99)≥ 3 years (n=112)
      No (n=46)n (%)Yes (n=53)n (%)χ2p-valueNo (n=50)n (%)Yes (n=62)n (%)χ2p-value
      GenderWomen41 (89.1)39 (73.6)3.84.05045 (90.0)49 (79.0)2.47.116
      Men5 (10.9)14 (26.4)5 (10.0)13 (21.0)
      Marital/relationship statusNo45 (97.8)52 (98.1)0.01.91948 (96.0)52 (83.9)4.26.039
      Yes1 (2.2)1 (1.9)2 (4.0)10 (16.1)
      Educational attainmentCollege4 (8.7)4 (7.5)0.04.83415 (30.0)12 (19.4)1.71.190
      University or higher42 (91.3)49 (92.5)35 (70.0)50 (80.6)
      Current working unitED20 (43.5)21 (39.6)4.04.25727 (54.0)27 (43.5)3.18.364
      ICU14 (30.4)12 (22.6)10 (20.0)14 (22.6)
      General ward5 (10.9)14 (26.4)11 (22.0)13 (21.0)
      Dedicated COVID-19 ward7 (15.2)6 (11.4)2 (4.0)8 (12.9)
      COVID-19 infection control educationNo14 (30.4)16 (30.2)<0.01.97919 (38.0)19 (30.6)0.67.414
      Yes32 (69.6)37 (69.8)31 (62.0)43 (69.4)
      Training related to PPENo12 (26.1)5 (9.4)4.80.0288 (16.0)8 (12.9)0.22.642
      Yes34 (73.9)48 (90.6)42 (84.0)54 (87.1)
      Sufficient PPE supplyNo25 (54.3)15 (28.3)6.94.00825 (50.0)25 (40.3)1.05.306
      Yes21 (45.7)38 (71.7)25 (50.0)37 (59.7)
      Work stress
      cut off value: mean
      High23 (50.0)16 (30.2)4.05.06323 (46.0)36 (58.1)1.62.254
      Low23 (50.0)37 (69.8)27 (54.0)26 (41.9)
      Perceived organisational support
      cut off value: mean
      High9 (19.6)24 (45.3)7.33.0103 (6.0)11 (17.7)3.49.085
      Low37 (80.4)29 (54.7)47 (94.0)51 (82.3)
      Abbreviations: ED, emergency department; ICU, intensive care unit; PPE, protective personal equipment; COVID-19: coronavirus disease of 2019.
      a cut off value: mean

      3.4 Logistic regression analysis for predictors of willingness to care

      Logistic regression analysis was performed to determine the influence of work stress and perceived organisational support on willingness to care among early-to-mid-career nurses (Table 4). To control for gender, marital/relationship status, educational attainment, current working unit, COVID-19 infection control education, training related to PPE, and sufficient PPE supply, all variables were input together with work stress and perceived organisational support.
      Table 4Factors influencing younger nurses’ willingness to care for COVID-19 patients (n=211).
      < 3 years (n=99)≥3 years (n=112)
      VariablesAOR2 (95% CI)p-valueVariablesAOR2 (95% CI)p-value
      Sufficient PPE supplyGender
      No1Women1
      Yes2.70 (1.01–7.24).049Men3.65 (1.06–12.54).040
      Training related to PPEWork stress
      No1Yes1
      Yes4.44 (1.18–16.67).027No0.40 (0.17–0.94).036
      Work stress
      cut off value: mean
      High1
      Low3.43 (1.26–9.39).016
      Perceived organisational support
      cut off value: mean
      Low1
      High5.02 (1.64–15.34).005
      χ2=26.83, p=.001-2 Log likelihood χ2=109.92, Cox & Snell R2=.24,Nagelkerke R2=.32Hosmer–Lemeshow χ2=8.75, p=.364χ2=20.91, p=.013-2 Log likelihood χ2=133.07, Cox & Snell R2=.17,Nagelkerke R2=.23Hosmer–Lemeshow χ2=9.14, p=.330
      Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; PPE, protective personal equipment; COVID-19: coronavirus disease of 2019.
      Note. Adjusted variables: gender, marital/relationship status, educational attainment, current working unit, COVID-19 infection control education, training related to PPE, sufficient PPE supply, work stress, and perceived organisational support.
      a cut off value: mean
      First, the logistic analysis of early-career nurses showed that the regression model was significant (χ2=26.83, p=.001). The variance inflation factor ranged within 1.03–1.26; as the value was <10.00, the results confirmed no multicollinearity between the independent variables. The analysis results showed that work stress and perceived organisational support influenced willingness to care among early-career nurses. Moreover, the most significant individual influence was high perceived organisational support (mean ≥31 points), which increased willingness to care by 5.02 times (95% confidence interval [CI]: 1.64–15.34), followed by training related to PPE (4.44 times; 95% CI: 1.18–16.67), low work stress (3.43 times; 95% CI: 1.26–9.39), and sufficient PPE supply (2.70 times; 95% CI: 1.01–7.24; Table 4).
      The regression model for willingness to care among mid-career nurses was also significant (χ2=20.91, p=.013). The variance inflation factor ranged within 1.03–1.26; as the value was <10.00, the results confirmed no multicollinearity. The Hosmer–Lemeshow test results showed that the regression model had a good fit (χ2=9.14, p=.330). While the effect of perceived organisational support was not significant, work stress influenced willingness to care; high work stress increased willingness to care by 2.52 times. Among mid-career nurses, being a man increased willingness to care by 3.65 times (95% CI: 1.06–12.54).

      4. Discussion

      This study analysed the influence of work stress and perceived organisational support on the willingness to care for COVID-19 patients in younger and less experienced Korean registered nurses. Logistic regression analysis among early-career nurses showed that lower work stress, higher perceived organisational support, and training related to PPE significantly increased the likelihood of willingness to care.
      Nurses have higher work stress levels than doctors and other hospital staff who treat COVID-19 patients (
      • Kuo F.L.
      • Yang P.H.
      • Hsu H.T.
      • Su C.Y.
      • Chen C.H.
      • et al.
      Survey on perceived work stress and its influencing factors among hospital staff during the COVID-19 pandemic in Taiwan.
      ). The main stressors for nurses were fear of social isolation, discomfort due to protective equipment, and the burden of patient care (
      • Kuo F.L.
      • Yang P.H.
      • Hsu H.T.
      • Su C.Y.
      • Chen C.H.
      • et al.
      Survey on perceived work stress and its influencing factors among hospital staff during the COVID-19 pandemic in Taiwan.
      ). Under such circumstances, early-career nurses may lack awareness or confidence about their roles (
      • Salminen H.
      • Miettinen M.
      The role of perceived development opportunities on affective organizational commitment of older and younger nurses.
      ). Moreover, they may experience work stress owing to a perceived lack of adequate preparation (
      • Brook J.
      • Aitken L.
      • Webb R.
      • MacLaren J.
      • Salmon D.
      Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: a systematic review.
      ). Higher work stress leads to increased burnout and turnover (
      • Fessell D.
      • Cherniss C.
      Coronavirus disease 2019 (COVID-19) and beyond: Micropractices for burnout prevention and emotional wellness.
      ), which can reduce the quality of patient care and safety (
      • Van der Heijden B.
      • Brown Mahoney C.
      • Xu Y.
      Impact of job demands and resources on nurses’ burnout and occupational turnover intention towards an age-moderated mediation model for the nursing profession.
      ). The present study found that willingness to care decreased as work stress increased, which is in line with the findings of previous studies. Therefore, appropriate measures to manage work stress among early-career nurses must be formulated.
      Perceived organisational support can reduce mental, physical, and emotional fatigue among nurses (
      • Zhang N.
      • Xu D.
      • Li J.
      • Gong Z.
      Effect of perceived organizational support on fatigue of Chinese nurses during the COVID-19 pandemic: resilience as a mediator.
      ) and is closely associated with work stress and burnout (
      • Adekanmbi F.P.
      • Ukpere W.
      Work stress, perceived organizational support, demographics, and burnout of registered nurses in Nigeria.
      ). Among newly graduated nurses, transitional support is the foundation of success (
      • Hussein R.
      • Everett B.
      • Ramjan L.M.
      • Hu W.
      • Salamonson Y.
      New graduate nurses’ experiences in a clinical specialty: a follow up study of newcomer perceptions of transitional support.
      ). Further, organisational support is crucial for early-career nurses to develop willingness to care for COVID-19 patients. Moreover, perceived organisational support has been found to be strongly associated with perceived stress in younger nurses (
      • Khrais H.
      • Higazee M.Z.A.
      • Khalil M.
      • Wahab S.D.A.
      Impact of organizational support on nursing job stressors: a comparative study.
      ). Therefore, support from nurse managers, senior staff, and colleagues could help early-career nurses cope with the challenges of COVID-19, thus increasing their willingness to care.
      In comparing early- and mid-career nurses, the results revealed differences in willingness to care among early-career nurses based on their training related to PPE and sufficient PPE supply. This may indicate that early-career nurses with limited experience lack confidence in their nursing competency (
      • Salminen H.
      • Miettinen M.
      The role of perceived development opportunities on affective organizational commitment of older and younger nurses.
      ). However, they may develop a greater willingness to care for COVID-19 patients upon receiving PPE training. While adequate training and learning influenced willingness to care among Chinese nurses (
      • Gan X.
      • Shi Z.
      • Chair S.Y.
      • Cao X.
      • Wang Q.
      Willingness of Chinese nurses to practice in Hubei combating the coronavirus disease 2019 epidemic: a cross-sectional study.
      ), the only predictor of willingness to care among Australian intensive care unit nurses was timely communication from managers (

      Lord, H., Loveday, C., Moxham, L., & Fernandez, R. (2021). Effective communication is key to intensive care nurses’ willingness to provide nursing care amidst the COVID-19 pandemic. Intensive and Critical Care Nursing, 62, Article 102946. https://doi.org/10.1016/j.iccn.2020.102946

      ). Thus, timely education and information delivery is crucial to increase nurses’ willingness to care. In particular, providing sufficient PPE to nurses caring for COVID-19 patients is key to ensuring the safety of patients and nurses, and nurse managers should be vigilant in this matter and in upskilling nurses (
      • Hofmeyer A.
      • Taylor R.
      Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID-19.
      ).
      Unlike early-career nurses, mid-career nurses showed a higher likelihood of willingness to care for COVID-19 patients when work stress was high than when it was low. However, perceived organisational support did not have an influence on their willingness to care for COVID-19 patients. As described above, several studies have confirmed the negative impact of high work stress on nursing and patient outcomes (
      • Fessell D.
      • Cherniss C.
      Coronavirus disease 2019 (COVID-19) and beyond: Micropractices for burnout prevention and emotional wellness.
      ;
      • Van der Heijden B.
      • Brown Mahoney C.
      • Xu Y.
      Impact of job demands and resources on nurses’ burnout and occupational turnover intention towards an age-moderated mediation model for the nursing profession.
      ). By contrast, the current results unexpectedly showed that willingness to care increased with higher work stress. While the causes of work stress among nurses were not analysed in detail, several factors may play a part—even during the COVID-19 pandemic (
      • Mo Y.
      • Deng L.
      • Zhang L.
      • Lang Q.
      • Liao C.
      • Wang N.
      • et al.
      Work stress among Chinese nurses to support Wuhan in fighting against COVID-19 epidemic.
      ). Moreover, for mid-career nurses, other factors, not directly associated with caring for COVID-19 patients, may have contributed to increased work stress. Therefore, additional studies with several work stress-related factors are needed to reexamine the relationship between work stress and willingness to care for COVID-19 patients among mid-career nurses.
      The results of the current study showed that perceived organisational support was a key factor in increasing willingness to care for COVID-19 patients among early-career nurses. However, perceived organisational support was not significant among mid-career nurses. This difference may be because, in the analysis of differences between the two groups, the percentage of participants with low perceived organisational support was significantly higher in the mid-career nurse group. As mid-career nurses had lower perceived organisational support, there was no significant association with their willingness to care for COVID-19 patients, unlike early-career nurses. However, lower perceived organisational support could cause higher perceived stress (
      • Khrais H.
      • Higazee M.Z.A.
      • Khalil M.
      • Wahab S.D.A.
      Impact of organizational support on nursing job stressors: a comparative study.
      ) and decreased intention to stay (
      • Adekanmbi F.P.
      • Ukpere W.
      Work stress, perceived organizational support, demographics, and burnout of registered nurses in Nigeria.
      ). Therefore, organisational and leadership roles are needed to promote a positive perception of organisational support among mid-career nurses.

      5. Implications

      The present study confirmed that work stress should be managed among early- and mid-career nurses to increase their willingness to care for COVID-19 patients and provide safer patient care; organisational support plays an important role in this endeavour. Thus, support—including COVID-19-related education or training—should be provided to reduce work stress arising from being exposed to infection or providing care to critical patients, especially among early-career nurses. Furthermore, sufficient PPE supply was essential in increasing nurses' willingness to care; therefore, nurse managers must ensure that nurses can access adequate PPE, support strategies, and resources to practice safely. A multidimensional analysis of the various factors influencing nurses’ work stress and perceived organisational support through follow-up studies could facilitate the development of specific strategies to foster a healthy and safe work environment.

      6. Limitations

      This study has several limitations. First, as a secondary data analysis study, a limited number of variables could be selected, measured, and controlled. Further studies are needed to identify the relationships between variables. Second, cross-sectional studies are limited in their ability to explain causality between the major variables. Longitudinal studies are needed to examine the influence of work stress and perceived organisational support on nurses—not only on their willingness to care but also on other long-term nursing outcomes, such as turnover intention. Third, there was potential recall bias as the data were collected using self-reports. Finally, measures of perceived organisational support are limited in their ability to assess actual levels of organisational support. Although a nurses’ perceptions of organisational support are important, organisational support should be assessed with standards that allow for objective comparison. This would enable analysing the influence of actual organisational support on nurses’ willingness to care and intention to stay. Despite these limitations, this study is meaningful because it classified participants into early- and mid-career nurses to identify the influence of work stress and perceived organisational support on their willingness to care for COVID-19 patients. The findings provide evidence for the establishment of effective measures for managing work stress and enhancing organisational support for nurses during crises such as the COVID-19 pandemic.

      7. Conclusions

      Work stress significantly decreased willingness to care for COVID-19 patients among early-career nurses, whereas perceived organisational support significantly increased willingness to care among them. Unexpectedly, work stress significantly increased willingness to care among mid-career nurses. Therefore, further research is needed to determine the relationship between work stress and willingness to care for COVID-19 patients. It is important to create work environments with work and psychological support from leaders and colleagues at the organisational level.

      Data availability statement

      The data presented in this study are available on request from the corresponding author and with permission of the Institutional Review Board of Chung-Ang University.

      Author contribution statement

      All authors have read and agreed to the published version of the manuscript.

      Funding statement

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Ethical approval

      We obtained approval for secondary data analysis from the Institutional Review Board of Chung-Ang University (Approval Number: 1041078-202104-HRSB-113-01 ). The parent study was approved by the Institutional Review Board at Eulji University (Approval Number: EUN20-017 ). All study participants provided informed consent in the parent study.

      Conflict of interest

      The authors have no conflict of interest to declare.

      Acknowledgements

      We thank the respondent nurses for their participation in this study.

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