Demographics in research is an independent variable that describes the characteristics of a population being studied.9,10 In this case, staff nurses in Cebu Hospitals were the sample population and the demographics taken into account were age, sex, marital status, level of education, and length of working experience, which were relevant to our study. It is no surprise that nurses who spent a longer time serving were only the minority (2.92%). This is due to nursing migration that started in the late 1940s to address the shortage of the nursing workforce in the USA.11,12 Nursing migration is when nurses in the Philippines are being recruited by developed countries “to maintain acceptable staffing levels”.12 It was also mentioned that younger Filipino nurses were more likely to have greater intentions of migration than nurses who were 45 years old and above.13 Furthermore, a similar study also found out that more than half of Filipino nurses planned to leave the country in 6 months to 2 years.14 Workplace stress, low salary, heavy workloads, and lack of professional opportunities also influence nurse migration.13 This could explain why the majority of nurses being sampled in our study currently served in their institutions for only 1-3 years (64.96%).
Results in this study revealed that the common sources of information to COVID-19 included the internet (99.27%), social media (83.21%), government/health websites (83.21%) and television news (66.42%). In a similar study, social media (91.1%) and the websites of hospital/health ministry (82.6%) were the predominant sources of information regarding COVID-19 for healthcare workers in a hospital in Ho Chi Minh City.15 Likewise, the main sources of COVID-19 information for Pakistani nurses were the hospital/health ministry (85.89%) and social media (60.25%).16 However, social media and the internet are not only sources of information but also of misinformation and conspiracies. which represents a health risk.17,18 In addition, “information environment” influences our behaviors and response to COVID-19.17
Adequate knowledge on COVID-19 causative agent, its pathogenesis, transmission and management are all vital to combat this emerging infectious disease. In fact, the Philippine Department of Health (DOH) has launched several webinars and trainings on handling suspected and confirmed cases. It has created the DOH Emergency Operation Center (DOH EOC) for COVID-19, a command center in-charge of consolidating updates and information as the COVID-19 health event evolves. 19
It is apparent from Table 3.1 that respondents were most knowledgeable on items about COVID-19 causative agent, its transmission and pathogenesis (items 1 to 6), symptomatology (items 7 to 9), and preventive measures (items 10 and 11). This is to be expected since these domains were covered in nurses’ basic competency course training for hospital infection control and handling COVID-19 patients.20 On the other hand, majority are less knowledgeable on items referring to clinical and laboratory management (items 12 to 15). Patient clinical management including requisition of correct laboratory work-ups, medication prescription and recommending plan of treatment are tasks expectedly done by a registered physician and are not part and parcel of nurses’ job description.21
The respondents with a rate of 79.56% were generally knowledgeable regarding different COVID-19 related information with minority (20%) who were considered less knowledgeable overall. This overall knowledge level is relatively higher than the previous studies conducted in Uganda22 and Nepal23 at 69% and 76% respectively but lower than a study in Henan China where 89% of the respondents showed adequate knowledge pertaining to COVID-19.24 From the data gathered most respondents considered less knowledgeable were those with working experience of less than 2 years. Nurses who worked 3 years or more have a significantly higher score. This is in concordance with previous studies by Khan et al 25, Hou et al26, and Wen et al 27 showing that working experience is associated with KAP scores. The higher the number of years working as a staff nurse, the more knowledgeable and confident the healthcare worker is in dealing with public health emergencies.25-27
Patient outcomes and COVID 19 infection control and prevention is directly associated with the knowledge of nurses about the COVID-19 pandemic.28 Scarcity of knowledge about this infectious disease escalates the risk of contagion.23,27 To note, there is a higher risk among healthcare workers of contracting COVID-19 than the general populace.29 Some developed countries have reported considerable rate of infection among healthcare workers like the United States with an infection rate of 16%, Netherlands with 19.6%, Italy with 20%, and Spain with 26%.30,31 A study in Wuhan, China revealed that a lack of special training for nurses in emerging infectious diseases will ultimately lead to poor patient care.28 So to speak, it cannot be overemphasized that continuous knowledge update by appropriate trainings or courses are essential as the COVID-19 pandemic evolves.
The general attitude of the respondents was very favorable (4.45) to the different events that will help minimize the spread and contamination of the virus. This very favorable general attitude of the respondents were in agreement with previous studies conducted in China 32, Nigeria 33, Ethiopia 34, Iran 35, and Saudi Arabia 36. This finding however, is in contrast to studies in Nepal which showed a less optimistic attitude towards COVID-19 health events.23,37 Particularly, respondents were very keen in following health protocols mandated by the government knowing fully that there is a higher risk for health care workers to contracting COVID-19 and for fear of transmitting the infection to family members. Also, COVID-19 policies were strictly implemented by the Interagency Task Force for the Management of Emerging Infectious Diseases (IATF-EID), the agency in-charge for the overall management of COVID-19 preparedness and response in the Philippines.19 In addition, participants have a very favorable attitude towards acquiring complete vaccination doses and urging family members and friends to be vaccinated.
As of the time of this writing, the Philippines has reached about 1.25 million recorded cases of COVID-19, ranking second to Indonesia with about 1.8 million recorded cases amongst countries in Southeast Asia with the highest number of COVID-19 cases. 38 Majority of the respondents had rated lowest on the attitude domain asking if they thought that the COVID-19 situation in the country will smoothen. The researchers believe that this is due to the rising number of active cases in the country, despite having a stringent and one of the longest lockdowns in the world. This finding is similar to a previous study in Nepal which revealed that only 50.5% of the respondents were confident that they could win the battle against COVID-19.37 In contrast to studies in China 32 and Nigeria 33, participants held a very optimistic attitude towards COVID-19 situation in their country. Confidence to work at the front lines was also rated low by most of the respondents. Being a developing nation, resources are scarce. Our front liners are underpaid.39 They battle against fear and anxiety while doing their duty.40 Apart from this, they are also burdened with so much pressure from work, stress, insomnia, denial, anger, and fear.41 In a similar study in Nepal, health care workers were also less confident in regards to working during this pandemic due to anxiety and fear. 37
In general, the respondents perceived their extent of practice regarding COVID-19 prevention measures to be Always (4.65) with handwashing the most frequent form of practice (4.91). Proper hand hygiene plays a vital role in preventing disease transmission. Many infections and conditions are spread by not washing hands with soap and clean, running water.42 A U.S. adult internet survey revealed that the proportion of U.S. adults who remember to wash their hands in certain circumstances is greater during the COVID-19 pandemic than before.43 This is supported by previous studies which revealed that during this pandemic majority of health care workers perform proper hand hygiene to prevent spread of infection.23,24,44 Our results showed that the respondents of this study have appropriate hand hygiene practices. This finding is of no marvel since the DOH strictly mandates observance of health protocols in all private and public hospitals in the country. It cannot be overemphasized in this write up that proper hand hygiene is the single most cost-effective measure to deter disease transmission.45,46 Furthermore, our data showed that respondents were also careful in observing other health protocols such as wearing of masks upon leaving home and during shifts, proper donning and doffing of PPEs when handling confirmed COVID-19 cases, following hospital infection control measures, avoiding social and large crowd gatherings, and getting tested and participating in contact tracing activities when exposed to confirmed cases.
In comparison, the item on “I have been trained on how to handle COVID-19 patients” was only rated with 3.96. This public health catastrophe befell upon humanity without warning. Little is known about this infectious disease and there is a lack of comprehensive knowledge of the causative agent of this disease, its mechanism of action and clinical symptomatology. In the early phases of the outbreak, Philippines had limited resources and even faced shortage of basic medical supplies such as masks and protective equipment, which hindered the efforts to implement standard protective measures. Not all nurses and other health care workers had the privilege to undergo special training in infectious diseases prior to the pandemic. This finding is consistent with a study in Nepal which revealed that only a few were trained to handle COVID-19 cases (17.5% out 103 respondents).37 Currently, more training sessions have been organized by the WHO, DOH, and private institutions to increase awareness and preparedness.
Generally, the respondents were very willing (4.52) to provide services for the COVID-19- inflicted patients. These findings concur with previous studies conducted in China 47, Australia 48, and Bangladesh 49, where the willingness of nurses to work during this pandemic is significantly high. These findings were also similar to previous studies conducted in China 50, Australia 51, Japan 52, USA 53, and Taiwan 54 during the H1N1 influenza pandemic indicating that healthcare workers were willing to extend and render their services to patients in that emergent outbreak. Aside from adhering to infection control measures promulgated by the hospital, the data from Table 6 showed that respondents were also very willing to do essential monitoring and follow-up care to COVID-19 patients by carrying out physicians’ orders, taking vital signs, maintaining respiratory functions, administering medications, and the like. They were also very willing to help doctors in educating patients about their condition and offer emotional support to patients and their families. Factors affecting their willingness to provide care were not assessed and will not be discussed in this paper.
On the other hand, there was a lower score in regards to the extent of willingness when respondents were asked about undertaking the drawbacks as a nurse during the pandemic that is, working extended shifts in the hospital and continuing to work despite increasing workload. Health workers had already been experiencing extended shift fatigue even before the pandemic hit.55 This has been intensified by the current COVID-19 situation. 39 On top of occupational exposure to the virus, nurses also experience workplace stress and anxiety due to heavy workload and low salary.13,41 Nurses who experience emotional burnout often evade taxing situations.56 Most ICU nurses experience stress and burnout due to long working hours, frequent night shifts and difficult-to-manage patients.57 These might be some of the reasons why most of our respondents are less willing to work for extended shifts and have considered other less demanding jobs during this pandemic. Moreover, studies by Al-Hunaishi et al 58, Ip et al 59, Liu et al 60, and McMullan et al 61 revealed that the perception of occupational exposure may lead to an unwillingness to go to work, especially when seeing their colleagues acquire the disease. Previous studies also showed a linear correlation of willingness to work and monetary incentives, that is, most are motivated by financial rewards.62, 63
Table 7 provides the extent (coefficient) and the significance (p-value) of the bivariate relationship of interest. It can be shown that there was no significant correlation between knowledge and practice with the level of willingness (p-value >0.05). In contrast, Nashwan et al, showed a positive correlation between the level of knowledge and willingness of nurses to work during the pandemic meaning, the higher the level of knowledge of nurses about COVID-19, the more willing they were to work with confirmed COVID-19 patients. 64 In addition, there was no significant correlation between practice and the willingness to care. However, attitude recorded a p-value of 0.00 (less than 0.05) which necessarily translates that there is sufficient statistical evidence in this study to claim that the kind of attitude the respondents had affect significantly their willingness to provide care to covid-19 patients. In fact, the positive coefficient is indicative that as the attitude of the respondents became more favorable, the willingness to care also increased. Wu et al in their study also showed that a favorable attitude correlates directly with willingness to work during this pandemic. 65