The Work Experience of Newly Recruited Male Nurses during COVID-19:A Qualitative Study.

PURPOSE: This study was to investigate the work experience of newly recruited male nurses during the COVID-19 pandemic.
METHODS: With a phenomenological approach, this qualitative study was adopted semi-structured interviews by phone or video calls. A total of 9 male nurses newly recruited for the COVID-19 wards in Chinese hospitals were interviewed for this study. And Colaizzi's method was applied for evaluation in the data analysis.
RESULTS: Based on our findings, three themes were extracted. Firstly, the newly recruited male nurses showed negative emotions at the beginning of COVID-19 epidemic, which was caused by changesin working conditions and content, but also prompted the nurses to change the way of coping with the crisis. Secondly, they gradually mastered the working skills and psychological training tocope with COVID-19, and developed a positive attitude towards life and a high sense of professional responsibility. Finally, we learned about their needs to respond to public health emergencies such as the COVID-19 pandemic.
CONCLUSION: COVID-19 is a disaster for all of humanity. The newly recruited male nurses are an important force in emergency rescue. Although they suffered from short-term negative emotions, they quickly adapted to the crisis. In order to better prepare for future emergencies, the disaster response capacity of newly recruited male nurses needs to be further improved. In addition, newly recruited male nurses have a strong demand for timely and personalized career development guidance.

Introduction

According to the World Health Organization (WHO), the coronavirus disease 2019 (COVID-19) has been identified as a disease caused by a novel coronavirus [1,2], and the first case was reported in Wuhan, China on December 12, 2019 [3]. As of May 1, 2021, there were 150,989,419 confirmed cases of COVID-19 worldwide, including 3,173,576 deaths [4]. And male nurses were considered essential for the care and treatment of COVID-19 patients in response to such a serious public health event. In the face of emergencies, male nurses had strong adaptability and antipressure ability [5], strong physical quality, decisive character, and can undertake heavy physical work to relieve patients' tension and anxiety [6,7]. These qualities could make male nurses indispensable in the healthcare workplace, especially when dealing with medical emergencies [8].

In the early stage of clinical work, these new male nurses were full of curiosity and had a strong thirst for knowledge when they encountered new knowledge or problems at work. In addition, they had strong plasticity and adaptability and often showed high enthusiasm for their work [5]. However, in Asian culture, due to insufficient training, lack of clinical experience, weak safety awareness, and social prejudice [9,10], they were often vulnerable to physical and mental trauma [11, 12, 13].

The COVID-19 pandemic with high rates of infection, which leads to heavy work, has put pressure on inexperienced nurses in particular. And nurses, as a line of defense for healthcare, should be considered as people who also need support and attention. Previous studies on male nurses' response to public emergencies were mostly quantitative studies [14,15], which often failed to reflect the psychological experience of new male nurses in the outbreak of infectious diseases.

There have been quantitative studies examining nurses' response to public crisis events. However, most of them were evaluation studies designed to investigate the effects of educational interventions in simulated environments on crisis event prevention, response, and post-disaster management. While these studies may be helpful in identifying key factors in crisis response, they could not provide detailed information about the nurses' experience [16]. As recently observed, quantitative studies often failed to assess the perspectives, intentions, and role awareness of nurses in response to the COVID-19 pandemic [17]. At the same time, the influence of environment, law, and organizational culture on nurses' crisis response ability could not be fully clarified [18]. And qualitative research was considered necessary to advance the understanding of care and public health emergencies. As a commonly used qualitative research method, Colaizzi's phenomenological approach mainly focuses on the experience and feelings of participants and finds common patterns among the research subjects rather than individual characteristics. Therefore, it ensures the authenticity of participants' experience and follows scientific standards, which has been verified in various qualitative nursing studies [19].

In this study, Researchers aimed to understand the work experience of newly recruited male nurses during the COVID-19 pandemic through a well-designed interview and to further reveal the problems and challenges they might encounter in the process of their work. In addition, the identified experience could broaden the information available in the current literature on how nurses respond to public crisis events [20]. Therefore, by exploring the real experience of male nurses in coping with COVID-19, as well as the challenges and problems they faced, this study could provide information for further improving the comprehensive nursing management strategy and enhancing the ability of male nurses to cope with public health emergencies such as COVID-19.

Methods

Study design

This is a qualitative exploratory descriptive study, conducted using semistructured interviews, based on phenomenological research methods and Colaizzi's seven-step method. The interview explored the experience of newly recruited male nurses during the COVID-19 pandemic. This study is consistent with the unified standard of qualitative survey [21].

Setting and participants

The study started in March and recruited nursing staff who participated in the fight against COVID-19 in tertiary hospitals in Wuhan and Zhengzhou from January to February 2020. These hospitals were chosen because of their commitment to treating patients with COVID-19. Voluntary participation in this study was carried out by the method of objective sampling. Demographic information included age, educational level, years of nursing experience, and marital status. In order to determine the number of nurses in the sample, data saturation was considered in the qualitative study. A total of 9 nurses were determined to be required to achieve data saturation. The average age of these 9 interviewees was 25 ± 2.0 years old, all of them had a bachelor's degree, and the average time of participating in anti-epidemic work was 17.5 ± 3.1 days.

Ethical consideration

When collecting and storing participant information, researchers paid close attention to confidentiality principles. Therefore, all personnel information was anonymized by using codes (N1, N2 …) during the transcription process. Transcribed text was then fed back to the participants for their approval. Audio recordings, videos, and other interview materials were stored on a password-protected computer. At the end of the study, all acquired data would be deleted. This study was approved by the Ethics Committee of Zhengzhou University (Approval no. 2020-18).

Data collection

Previous relevant reports were studied in this study to formulate an interview outline [22]. The questions were reviewed by a nursing team (including two professors and a research fellow) with expertise in qualitative methodology. In order to adjust the interview outline and complete the interview guidance, three male nurses were selected for pre-interview, followed by a comprehensive survey using the improved interview guidance. The final interview guide consisted of five open-ended questions to explore various aspects of the nurses' experiences in isolation wards: (a) What came to your mind when you learned that you would be working in the COVID-19 patient isolation ward? (b) What has been your previous experience in caring for COVID-19 patients? (c) In your opinion, what are the advantages and disadvantages of male nurses in fighting the epidemic? (d) How do you view your career after this experience? (e) As a newly recruited male nurse, what do you expect from hospital training?

The interview started after the participants were informed of the purpose and significance of the study. Since these interviewees were mostly college classmates or friends of the researcher, the two sides maintained a good trust relationship, which laid the foundation for the smooth conduct of the interview. The interviewer has a master's degree in nursing and experiences in qualitative interview and psychological counseling. Additionally, the interviewer has obtained a Third-Level Psychological Consultant Certificate issued by the Ministry of Human Resources and Social Security of China. Hence, the researcher was qualified to conduct this study independently.

Considering the government's initiative in reducing the risk of infection, the interviews were conducted via video communication (using WeChat program). All interviews were recorded with the consent of the interviewees. Information was recorded simultaneously during the one-on-one interview. Through WeChat video interview, interviewers could clearly see the interviewees' facial expressions and body movements during the interview. Interviewers mainly listened to what the participants were talking about while paying attention to their movements, facial expressions and body language. Each interview lasted about 20 to 40 minutes.

Data analysis

Colaizzi's seven-step analysis was used to analyze the interview data: (1) transcribing recorded interviews verbatim into text and reading the participants' descriptions multiple times; (2) extracting significant statements from each description; (3) formulating meanings from those significant statements; (4) organizing those formulated meanings into themes; (5) integrating the results of the data; analysis into a description of the phenomenon under study; (6) returning the results to the participants for validation; and (7) incorporating any new, relevant data into the fundamental structure of the phenomenon [23]. The interview recordings were transcribed within 24 hours after the interview. The transcripts had been carefully checked and reviewed. Previous study from Lincoln and Guba [24] suggested that member checking was essential to ensure the credibility of qualitative data. In this study, the researchers gave feedback on emerging explanations, then reached a consensus within the group, and finally formed written materials. Finally, the written materials were emailed to the interviewees for verification. In this study, the interviewees had no disagreement about the completeness and accuracy of the written materials. After a careful reading of the transcript, the key information was highlighted and then properly encoded and subject optimized (Table 1 ).

Table 1

Extrapolation of Themes from Qualitative Data, Illustrating How Relevant Phrases Are Condensed to Codes and Extrapolated to Themes.

Quotations	Theme	Subtheme
• One person had to do several tasks at the same time. We were busy from morning till night, without rest. I really thought my work was futile and there might be no hope.	Ⅰ. Impact of the epidemic	Early negative experiences
• I will play my favorite online games after work, which can relieve me of stress and no longer think about the work experience.		Temporary response strategy
• I found being a nurse can save many lives in the first place, especially patient’s gratitude to me for treating them makes me proud of my profession and feels that everything is worth it.	Ⅱ. Gain experience and growth in the fight against the epidemic	Positive life perception
• I am proud to be able to come forward when our country and people are in distress. I feel that I have done a great thing. In this particular moment, I feel like a hero.		Improve professional recognition and enhance work responsibility
• Managers should strengthen the training of emergency rescue content so that we can respond to unexpected accidents in the future.	Ⅲ. Need for nurses in the epidemic	Need for more emergency knowledge training
• We don’t know the coping strategies...I think it would be easier if there are psychologists who can provide psychological counselling...		Need for psychosocial supports
• Everyone should abandon traditional ideas in the future, respect us in the hospital and not discriminate against male nurse.		Hope to get professional care

Findings

This study conceptualized the attitudes and perspectives of newly recruited male nurses in dealing with COVID-19 based on their work experience. Three themes and several subthemes emerged from the analysis, which are described as below in detail.

I. Impact of the epidemic

COVID-19 is a disaster that threatens people's health and safety, leaving people in fear. Newly recruited male nurses also have negative emotions in the early stages. In order to mitigate the detrimental effects, newly recruited male nurses have to adopt coping strategies to reduce the impact of negative experiences.

Early negative experiences

The COVID-19 outbreak was sudden and highly infectious, with a large number of people infected initially. Under the condition of insufficient medical staff and lack of medical resources, the newly hired male nurses need to wear protective gear to carry out a lot of treatment work. On the other hand, the newly recruited male nurses need to work longer hours in order to address the shortage of medical staff. The physical discomfort caused by the closed protective equipment and the extended work load therefore caused the nurses to have serious physical and psychological fatigue.

Hospital was crowded with early patients. We had to distinguish between the infected and the uninfected (patients) and adopt different treatment methods. One has to do several things at once. We were on the go from morning till night. (Nurse 4)

The overwhelming number of untreated patients in hospital has also increased the mental fatigue of newly recruited male nurses.

Sometimes at the end of a busy day, we could find that we had even more patients than when we took over. Faced with these circumstances and my mental exhaustion, I really thought my work was futile and probably hopeless. (Nurse 7)

In addition, witnessing how patients were infected, and in some cases the inevitable death, made newly recruited male nurses worry about their health and safety, as well as their families, increasing their psychological burden and fear of death.

The condition of a severely infected patient was both complicated and serious. Although as a nurse with expertise in respiratory diseases, I felt that my knowledge and experience were insufficient at this time. The rapid change of (patient)'s condition made me unable to determine whether I was doing the right thing and sometimes suspects that I really was not. (Nurse 3)

I saw news reports about thousands of medical staffs being infected, which made me worry about my health. At first, infected people were not treated successfully. I could adjust my emotions quickly, but many people die every day and the grief recurs without waiting for you to return. The rescue treatment was good but there was no good result. No mood to eat anything. (Nurse 5)

Temporary response strategy

In order to alleviate the negative experience caused by the clinical management of COVID-19, the newly recruited male nurses adopted an abstinence attitude, refused to pay attention to their own experiences and avoided expressing their feelings and emotions.

I will play my favorite online games after work, which can relieve my pressure and no longer think about my work experience. (Nurse 1)

Some psychological cues could help nurses strengthen their mental resilience and stress capacity.

I often tell myself that I am doing a great thing, so I will try to protect myself and save others. It is necessary and meaningful. (Nurse 7)

II. Gain experience and growth in the fight against the epidemic

With the great achievement in the fight against COVID-19, the newly recruited male nurses obtained a positive outlook on life. The healing and rehabilitation of patients also make them feel the greatness of professionalism, and at the same time improve their professional recognition and enhance their sense of responsibility.

Positive life perception

There is no denying that newly recruited male nurses play an important role in the care of COVID-19 patients. The support and warmth they receive from society and family reassures them and in turn expresses gratitude to those who support them.

The whole society is praising us and supporting us. The whole country is our backing. We only need to treat patients wholeheartedly. (Nurse 6)

Improve professional recognition and enhance work responsibility

In the early days of the COVID-19 outbreak, there was a shortage of medical supplies, which quickly overwhelmed Wuhan's medical system. The rescue conditions in hospitals were rapidly exhausted, and nurses were faced with high workload and psychological pressure. In this case, the newly recruited male nurses had outstanding physical and psychological advantages in this rescue work.

After the outbreak of the epidemic, I found that being a nurse could save many lives in the first place. Especially, the gratitude of patients for my treatment made me proud of my profession and feel that everything was worthwhile. (Nurse 6)

I am proud to be able to come forward when our country and people are in distress. I feel that I have done a great thing. In this particular moment, I feel like a hero. (Nurse 8)

The newly recruited male nurses felt the appreciation and care from the whole society and were grateful for it.

We were from different departments. At the beginning, I was worried about getting along with everyone, but everyone was enthusiastic, helped each other at work, and cared for each other. I felt warm in the team, and everyone was working together to fight against the disease. (Nurse 3)

III. Need for nurses in the epidemic

Through the fight against COVID-19, newly recruited male nurses have found themselves lacking in professional knowledge and are eager for psychosocial support and professional guidance in their career development.

Need for more emergency knowledge training

Newly recruited male nurses find themselves lacking in treating COVID-19 patients and wish to improve their knowledge and skills in the future.

Managers should strengthen the training of emergency rescue content in order to respond to unexpected accidents in the future. (Nurse 2)

Improve my expertise and master more advanced professional operations. (Nurse 6)

Need for psychosocial support

The COVID-19 outbreak had led to a rapid increase in the number of infections, and new male nurses faced greater work pressure and psychological burden. Therefore, the way to alleviate this situation was to give them the material and psychological spiritual support they need from all walks of life.

We don't know how to deal with it … I think it would be easier if there are psychologists who can provide psychological counseling … We do need some kind of support from family members or social groups because we are facing high risks. (Nurse 2)

Hope to get professional care

During the COVID-19 pandemic, society discovered that nurses were prone to burnout from overloaded care. In times like this, however, newly recruited male nurses expressed that social support has been a powerful source of motivation.

Everyone should abandon the traditional ideas in the future, respect us in the hospital and do not discriminate against male nurses. (Nurse 4)

Discussion

Under the threat of the epidemic, people often feel afraid of their own health and helpless psychologically due to lack of knowledge, which only leads to the aggravation of negative emotions such as fear, exhaustion, and anxiety. COVID-19 is clearly a serious disease of international concern. It was more infectious than SARS, and more people were infected and killed than SARS [25,26]. Like others, newly recruited male nurses were concerned about their lives, health, and job safety in the face of a COVID-19 pandemic. Studies have shown [19] a sharp increase in the number of infections due to the COVID-19 outbreak, a 1.5-2 times increase in nurses' normal working hours and workload, and widespread fatigue. However, in the interview, it was found that the main reason for the fatigue of newly recruited male nurses was not the extension of working hours or the increase of workload, but the change in working conditions and content. Because this is a highly contagious disease, all treatment takes place in isolation wards. Frontline nurses without infectious disease expertise faced many challenges in adapting to a new work environment [27]. In addition, the management of COVID-19 patients needs to be both comprehensive and specific. Many newly recruited male nurses have little clinical experience in infectious intensive care [28]. When the health department is not prepared to deal with outbreaks of infectious diseases, there is an urgent shortage of medical staff. Therefore, there is an urgent need to train and educate newly recruited nurses. The rapid change in work content has also caused newly recruited male nurses to become more stressed and anxious on the job. We found that newly recruited male nurses showed significant anxiety during their first week on the job when they first entered the isolation ward. As working hours lengthen, most nurses experience an increase in fatigue and awareness of their own safety. Therefore, in the early stage of the epidemic, it is particularly important to carry out early psychological intervention for nurses. This could include immediate stress assessment and professional, continuous psychological interventions [29,30] to promote emotional relief and improve the mental health of nurses [31]. In addition, an early support system should be established for newly recruited male nurses working in isolation wards for a long time to ensure adequate supplies and reasonable staffing. Managers should also introduce flexible shift schedules and fixed allocations based on infections, illness, workload, and the number of nursing staff in order to provide a productive working environment for newly recruited male nurses. They should also ensure that nurses have enough time to recuperate to improve the quality of medical care [32].

Previous studies, such as those conducted during SARS, have found that infectious diseases have brought great pain to medical staff, affecting more nurses than doctors [33]. This is due to the nature of their work and their long-term close contact with infected patients. In addition, due to the shortage of staff, nurses also have to handle some of the daily work of the hospital. Therefore, it is interesting to see how nurses respond to the challenges of care and treatment during the COVID-19 outbreak. In the face of a variety of challenges, the newly recruited male nurses have shown great strength and resilience. They actively seek multiple support systems and self-regulation skills to relieve stress because they know that in order to save more lives and protect themselves, they need to take care of themselves and focus on their responsibilities. In terms of psychology, they often gave themselves positive psychological affirmation, defining fighting COVID-19 as a process that supports positive experiences and growth, which was consistent with Sun's findings [19]. Male nurses tend to adopt a certain abstinence attitude, refuse to pay close attention to their own experiences and further avoid expressing their feelings and emotions. For example, they will play online games, watch movies, and listen to music to adjust the unhappy mood at work. Similar to previous studies [19,34], some nurses record their emotions and cognition through electronic diaries or letters, and interact closely with the outside world to obtain social and family information and psychosocial support. Unlike previous research results, newly recruited male nurses did not mind paying attention to the news about COVID-19. They just do not want to recall their experiences in the ward but are still keen on social report on COVID-19. This may be because they come from different regions, hoping to get more information about their hometowns.

Like other medical staffs, male nurses had negative experiences in the early stage of the COVID-19 fight, but they were able to quickly adjust and adapt to working in the isolation zone and continued to develop positive emotions during their work. Overall, respondents were more optimistic and could feel their own peace of mind. They were proud to participate in the epidemic prevention and control work and were full of confidence and expectations for the future work. Newly recruited male nurses have several reasons to be particularly optimistic: (a) they are enthusiastic about their work and are willing to accept challenging things; (b) they believe that participating in the fight against the epidemic has given them a sense of self-worth and accomplishment; (c) team support, social care, and compliments from patients can alleviate their mental stress of patients and reduce the impact of some negative emotions; and (d) in terms of crisis management, men are more likely to choose to tackle impersonal problems that cause specific difficulties and are less likely to focus on emotional issues.Therefore, when dealing with stress, they rarely use emotion-centric coping methods [35].

COVID-19 has been a disaster, creating huge challenges for newly recruited male nurses. However, despite the stress of the epidemic, they had to use their medical and psychological knowledge to make psychological adjustments. At the same time, they were in emergency rescue and infectious disease prevention. The physical and mental recovery and control of the injured after the disaster also gave them good experience in responding to public health crises in the future. Based on our findings, we were able to determine that the majority of newly recruited male nurses grew psychologically and cognitively under stress. They actively reflected on their cognitive thinking and found positive forces, such as greater respect for health and life, increased professional identity and responsibility, and gratitude for social and family support, which was consistent with the findings of Shih et al. [36]. Notably, the newly recruited male nurses showed positive altruism and greater solidarity in the face of disaster. The sense of responsibility that comes with a career encouraged them to take an active part in related work, which improved their professionalism and self-esteem [37]. In addition, the collaborative work of nurses from different regions and positions also enabled newly recruited male nurses to participate in a multidisciplinary teamwork. Therefore, during the COVID-19 epidemic, actively guiding and inspiring newly recruited male nurses to realize their own growth, adjusting cognitive evaluation, guiding positive coping styles, and stimulating positive emotions might play a positive role in psychological adaptation and career development.

Our findings indicated that newly recruited male nurses responding to the COVID-19 pandemic need more training in emergency preparedness, psychosocial support, and specialized care. Respondents showed that although they had received training on disaster knowledge during their employment, they mainly focused on emergency drills such as earthquakes and fire. These trainings mainly include first aid techniques, trauma treatment and injury, disposal, and classification of the wounded [38]. However, in the prevention and control of infectious diseases, the newly hired male nurses are still inadequate, such as lack of experience in response. Based on these findings, newly hired male nurses should also play a more important role in the leadership, such as resource allocation, patient transport, and health support for survivors and vulnerable groups [39]. In the future, leaders should pay attention to the construction of the disaster relief team, improve the relevant rules and regulations, and ensure the team construction and talent reserve [40].

Previous studies have shown that [41] lack of psychosocial support is a significant risk factor for negative psychological experiences in all types of disasters. At the same time, positive emotions are related to the support of patients, family members, team members, government, and the whole society. Therefore, psychosocial support is also anessential resource for newly recruited male nurses to fight the epidemic. This study also identified that good psychological adaptability and sufficient social support could ensure that newly hired male nurses could quickly acquire the mental recovery ability under severe stress. Therefore, encouraging various social supports and strengthening the psychological treatment of nurses fighting COVID-19 in the initial phase of the COVID-19 response is critical to ensure the mental health of newly hired male nurses in the aftermath of disasters.

Although we found a further increase in the professional identity and responsibility of newly hired male nurses to participate in the COVID-19 outbreak, there were still many who were not involved in the treatment of COVID-19 patients and might require more professional guidance and care. Men were relatively underrepresented at different levels of employment in most countries, and male nurses were in a minority category [42]. Male nurses with less than 4 years of work experience have a higher turnover rate [43], which is not conducive to maintaining the diversity of the nursing team.

Male nurses tend to be enthusiastic at the beginning of their work and have high expectations for the development of their nursing career, but often their positions do not match their own conditions, which can only lead to major setbacks for male nurses [44]. The training of male nurses mainly includes professional training, continuing education, further training, promotion teaching, and scientific research [45]. During the interview, respondents mostly wish to receive more professional and scientific research training. According to the professional ability demand of male nurses, specialized training groups such as pressure ulcer care group and nutrition care group should be set up. Group training should be conducted once a week; furthermore, long-term planning arrangements should be made. Moreover, managers need to take full account of gender differences in the profession and make use of “person-job matching” [46], which could help them make full use of their own advantages and meet their career expectations according to their personal situation, professional ability, and personality characteristics of male nurses.

At present, nursing is still a highly gendered occupation. It is deeply influenced by traditional gender discrimination, regional development level, and other factors. In some regions, especially in developing countries, nursing recognition is low, nurses generally have a low social status, and men's participation in nursing is often disingenuously accepted [47]. Respondents believe that improving their social status is of far-reaching significance for future career development. Therefore, it is suggested that nursing managers and educators should carry out the concept of “gender neutrality” in nursing work, so as to promote the dedication of male nurses, establish the image of male nurses in society in the new era, and change the public prejudice against male nurses. At the same time, gender-sensitive nursing policy should be made consciously, so that gender-sensitive nursing policy should run through the whole education, practice, supervision, and leadership functions.

Although the newly recruited male nurses were well adapted to this incident, we could not ignore the physical and mental damage they suffered. We called on the family members and the community to provide full support and care to the male nurses in their prevention work. Psychologists should play a greater role in the diagnosis and treatment of male nurses who had completed rescue work.

Limitations

This study has limitations. Our study examined the working experiences of newly recruited male nurses working in major hospitals in several Chinese cities, including the previous epicenter Wuhan city. As a result, we still lack information about male nurses working in other countries and in different cultural contexts. Besides, our findings were based on data from participants who had shared educational experience at undergraduate institutions. Thus, it is necessary to expand the sample size and further study in combination with the investigation.

Conclusion

The COVID-19 outbreak has become a disaster that affects all of humanity. Compared with female nurses, male nurses were more adaptable to COVID-19 (able to make rapid psychological and cognitive adjustments to improve vocational skills and career planning level), but negative emotions were evident in the short term. Therefore, the integration of appropriate medical resources and social support and the establishment of supporting systems are crucial to alleviate the severe physical and mental stress of new male nurses in dealing with COVID-19 in its early stages. Based on these results, nursing managers should further strengthen the disaster rescue ability of newly recruited male nurses and make timely career development guidance to promote the career growth of new male nurses.

Conflict of interest

The authors declared no conflict of interest.