Research for Evidence Based Practice

R E S E A R C H

Laurasona L Health Servic Rockville, M

Colleen Tayl of Nursing, U

Tavis Glassm and Human

Amy Thomp Population H Toledo, Tole

Jiunn-Jye She College of He

814 JO

A CROSS-SECTIONAL EXAMINATION OF THE

FACTORS RELATED TO EMERGENCY NURSES’

MOTIVATION TO PROTECT THEMSELVES AGAINST

AN EBOLA INFECTION

Authors: Laurasona Leigh, PhD, MPH, Colleen Taylor, PhD, RN, FNP-BC, Tavis Glassman, PhD, MSEd, MPH, CCPH, MCHES, Amy Thompson, PhD, CHES, and Jiunn-Jye Sheu, PhD, MSPH, MCHES, Rockville, MD, and Toledo, OH

Graphical Abstract of Emergency Nurses' Motivation to Protect Themselves Against an Ebola Infection

Proactive (+)

Protection motivation

Passive (-)

(-) indicates a negative association

Response efficacy (+)

Self-efficacy (+)

Perceived vulnerability (+)

Response cost (+)

Knowledge (-)

Note: (+) indicates a positive association and

eigh is a Public Health Advisor, Substance Abuse and Mental es Administration, Department of Health and Human Services, D.

or is an Assistant Professor and FNP Track Coordinator, College niversity of Toledo, Toledo, OH.

an is a Professor, School of Population Health, College of Health Services, University of Toledo, Toledo, OH.

son is Vice Provost for Faculty Affairs and a Professor, School of ealth, College of Health and Human Services, University of do, OH.

u is a Fulbright Specialist and a Professor, School of PopulationHealth, alth and Human Services, University of Toledo, Toledo, OH.

For correspondence, write: Jiunn-Jye Sheu, PhD, MSPH, MCHES, Health Education PhD and Public Health BS Programs, School of Population Health, College of Health and Human Services, University of Toledo, 2801 W. Bancroft Street, MS#119, Toledo, OH 43606-3390; E-mail: [email protected].

J Emerg Nurs 2020;46:814-26. Available online 6 May 2020 0099-1767

Copyright � 2020 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2020.05.002

URNAL OF EMERGENCY NURSING VOLUME 46 � ISSUE 6 November 2020

Leigh et al/RESEARCH

Earn Up to 8.0 Hours. See page 941.

Contribution to Emergency Nursing Practice

� The current literature on protection motivation indicates only approximately 40% of emergency nurses felt pre- pared to provide care to patients potentially infected with Ebola virus.

� This article contributes to the understanding of protec- tion motivation. Our study found that response efficacy and self-efficacy predicted emergency nurses’ proactive protection motivation and perceived vulnerability, response cost, and knowledge predicted their passive protection motivation.

� Key implications for emergency nursing practice found in this article are: health system administrators are encouraged to provide continual education that will in- crease emergency nurses’ capacity, skills, resources, understanding of pathophysiology, and use of protective equipment; to ensure job security; and to provide family and/or childcare support, professional practice insur- ance coverage, and paid leave for incidents owing to Ebola infection.

Abstract

Introduction: The 2014-2016 West African Ebola outbreak impacted the United States. Owing to the sporadic occurrence of the Ebola infection, there is insufficient research regarding how US emergency nurses provide care to patients potentially infected with the Ebola virus and the nurses’ motivation to pro- tect themselves when providing care to these patients. This study aimed to investigate the predictors of emergency nurses’ protection motivation.

Methods: A cross-sectional design was employed. A survey developed based on a modified Protection Motivation Theory was administered to randomly selected members of the Emergency Nurses Association. Descriptive statistics, nonparametric Kruskal-Wallis H test (as well as post hoc Dunn-Bonferroni test), Spearman rho correlation, and stepwise multiple linear regression were conducted for data analysis.

Results: Protection motivation was found in 2 components: proactive and passive protection motivation. Regression anal- ysis indicated that response efficacy (b ¼ 0.27, P < 0.001) and self-efficacy (b¼ 0.17, P< 0.01) significantly predict emer- gency nurses’ proactive protection motivation, whereas perceived vulnerability (b ¼ 0.26, P < 0.001), response cost

November 2020 VOLUME 46 � ISSUE 6

(b ¼ 0.19, P ¼ 0.001), and knowledge (b ¼ �0.15, P < 0.01) significantly predict emergency nurses’ passive protection motivation.

Discussion: The results indicate the need for interventions to improve emergency nurses’ response efficacy, self-efficacy, and knowledge, while simultaneously reducing the nurses’ perceived vulnerability and response cost. Such interventions would be expected to proactively motivate nurses to protect themselves when providing care to patients who exhibit the signs and symptoms of an Ebola infection and reduce their pas- sive protection motivation.

Key words: Ebola virus infection; Emergency nurses; Protection motivation theory; Response efficacy

Introduction

Since the Ebola virus was discovered in the Democratic Re- public of the Congo and the Republic of Sudan, it has caused at least 14 outbreaks around the world between 1976 and 2006, devastating towns, villages, and cities, espe- cially in the Eastern and Central African regions.1,2 During the 2014 outbreak, countries outside of the African region, such as the United States, were unexpectedly affected either by potential patients with the Ebola infection entering the country or by patients who were transferred for advanced medical care. The Ebola virus is still a potential threat because the World Health Organization recently reported 2,266 deaths from 3,456 total cases in the Democratic Re- public of the Congo.3

The sporadic occurrence of this infection in countries such as the United States has resulted in limited research on the care of potential patients with the Ebola infection, because it has had a very low prevalence rate during past outbreaks.4 In addition, there is insufficient research concerning how health care professionals treat patients potentially infected with the Ebola infection. In most health care settings, the emergency department is the first point of entry, and nurses have an increased risk of expo- sure to the virus, especially nurses who often come in direct and prolonged contact with patients while providing care. According to the Centers for Disease Control and Prevention (CDC), nurses often experience blood and body fluid exposure and have an annual expo- sure prevalence rate ranging from less than 10% to 44%.5

Furthermore, during the 2014-2016 Ebola outbreak, 2 of the 4 US Ebola-infected cases were health care

WWW.JENONLINE.ORG 815

Threat Appraisal

Perceived Severity

Perceived

Vulnerability

Protection

Motivation

Fear

Coping Appraisal

Response

Efficacy

Self-Efficacy

Response Cost

Knowledge

Outcome

Expectations

FIGURE

Modified protection motivation theory. Outcome expectation and knowledge constructs were added as a modification to the protection motivation theory.

RESEARCH/Leigh et al

professionals who were exposed while providing care to an imported case from West Africa.6 The purpose of this study was to use a modified Protection Motivation Theory (PMT) to explore US emergency nurses’ motiva- tion to protect themselves against patients with an Ebola infection whom they may encounter at work and to iden- tify its associated factors and predictors.

PROTECTION MOTIVATION THEORY

PMT focuses on the cognitive meditational processes, which involve maladaptive and adaptive responses. Both responses can be processed as the threat appraisal and coping appraisal.7 In this study, the modified PMT model (Figure) was used to investigate a social cognitive account of protective behavior in an attempt to provide clarity on the area of fear appeals and explain attitude and behavior change through matching cognitive pro- cesses that people use to evaluate threats and select coping alternatives.8,9

Protection motivation is an intermediate variable that functions to arouse, sustain, and direct protective health behavior within individuals. Similar to the intention to perform a behavior, it has a positive and negative linear

816 JOURNAL OF EMERGENCY NURSING

function. This includes whether the threat was considered severe (perceived severity), one’s perception of one’s vulner- ability (perceived vulnerability), effectiveness of the recom- mended response (response efficacy), and the confidence an individual has in their ability to perform the recommended response (self-efficacy). The negative function is the cost of conducting the recommended response (response cost).10

The constructs, perceived vulnerability and perceived severity are part of the threat appraisal, which results in fear. This means that the more an individual feels vulnerable and takes the threat seriously, the more their fear increases, which leads to a greater threat appraisal.8

To enhance the study, 2 additional constructs, knowledge and outcome expectation, were included to strengthen the predictability. The knowledge construct is found in other health behavior theories such as the In- tegrated Behavioral Model (IBM). Within the IBM, the intention to perform a behavior is considered the most important determinant of a behavior; however, knowl- edge is needed to carry out the behavior.11 The outcome expectation construct is found in the Social Cognitive Theory. Within this theory, the expected outcome is the belief that multiple consequences might result from the behaviors a person chooses to perform.12

VOLUME 46 � ISSUE 6 November 2020

Leigh et al/RESEARCH

Thus, for this study, it was hypothesized that each of the emergency nurses’ psychological variables (ie, self-efficacy, response efficacy, response cost, knowledge, outcome expec- tation, perceived vulnerability, perceived severity, fear, and protection motivation) are significantly correlated with, and predictive of, their motivation to protect themselves against an Ebola infection. In summary, this study used a modified PMT model to examine the emergency nurses’ motivation to protect themselves and determine their apprehension to provide care to potential patients who may have an Ebola infection, and their related factors.

Methods

A cross-sectional research design was used to examine emer- gency nurses’ motivation to protect themselves when providing care to a potential patient with an Ebola infection during a single point in time.13 The research protocol was approved by the Emergency Nurses Association (ENA), the Institute for Emergency Nursing Research director, and the University of Toledo Institutional Review Board (#200929).

SOURCE POPULATION AND SAMPLE SIZE JUSTIFICA- TION

In 2015, the United States had approximately 33,573 ENA members.14 A power analysis using G*Power (Heinrich Heine University, Düsseldorf, Germany) was conducted and a sample size of 436 was estimated to achieve a satisfac- tory statistical power. Multiple linear regression was selected as the statistical test for sample size estimation, and a projected power of 0.95, type I error of 0.05, and a conser- vative effect size of 0.03 were entered into the estimation.15

SURVEY INSTRUMENT

A systematic literature review was conducted to determine the journal articles that have used PMT as the theoretical backbone in conjunction with examining an infectious dis- ease (unpublished data).7,16 On the basis of the review, the survey items were developed using previous articles on Ebola and other infectious diseases,17-20 then refined with the assistance of a focus group. A focus group (n ¼ 10)21 was conducted to gather primary qualitative data from 10 emer- gency nurses working at a university teaching hospital. On the basis of the focus group discussion, the survey questions were modified to remove or include additional questions.

November 2020 VOLUME 46 � ISSUE 6

As part of instrument testing, face validity was estab- lished through the systematic literature review and the focus group.22,23 Content validity was established by a panel of infectious disease, public health, and research measurement experts. In addition, construct validity was examined through Principal Component Analysis (PCA) using the same study sample population. The PCA yielded 2 components in protection motivation: proactive protec- tion motivation and passive protection motivation (un- published data). Four items loaded as proactive protection motivation, which examined the emergency nurses’ motivation to actively identify and seek resources or prevent the spread of the Ebola virus by adhering to the rules and regulations set by their place of employment. One item loaded as passive protection motivation, which examined the emergency nurses’ motivation to stay inac- tive by being hands-off (such as avoiding going to work) when confronted with a situation where a patient might have the Ebola infection. Each of the remaining survey constructs, that is, self-efficacy, response efficacy, response cost, knowledge, outcome expectation, perceived vulnera- bility, perceived severity, and fear yielded only 1 compo- nent with the PCA. To test the reliability of the instrument, internal consistency and stability were evalu- ated using a convenience sample of emergency nurses (n ¼ 23) to conduct Cronbach’s alpha and Spearman rho correlation respectively. Cronbach’s alpha ranged between 0.46 and 0.97, with 6 of the 8 survey constructs having an alpha of 0.80 or greater, which were within the recommended range.24 Spearman rho correlation was conducted to assess the stability of responses in each construct at 2 different points in time by examining the statistical significance of the coefficient. Items that had a P value less than or equal to 0.05 were removed or modi- fied. The survey had 10 sections comprising items for each construct and demographic questions. The instrument included 6 items on perceived vulnerability, 7 items on perceived severity, 4 items on response efficacy, 5 items on self-efficacy, 7 items on fear, 5 items on response cost, 5 items on protection motivation, and 6 items on outcome expectation, with each item having 5-point, uni- directional response options. The knowledge portion of the survey had 6 multiple-choice and 7 true or false ques- tions. Last, the instrument had 16 demographic questions.

PROCEDURES

The survey was administered online using Qualtrics software (Qualtrics LLC, Provo, Utah). On obtaining permission from the ENA Institute for Emergency Nursing Research

WWW.JENONLINE.ORG 817

TABLE 1 Sample characteristics and bivariate Kruskal-Wallis H test x2 values (n [ 388)

Characteristics Psychological variables

Variables N % PM1 PM2 PV RE SE FE RC OE PS KN

Gender (df ¼ 2) 7.60 3.97 3.75 4.66 9.42 0.84 11.74* 1.43 4.39 1.40 Male 73 19.8 Female 293 79.6 Other 2 .5

Age (df ¼ 3) 11.76 29.04� 18.48� 3.97 10.00 5.31 18.41� 1.88 6.69 0.79 21–35 129 36.4 36–49 123 34.7 50–65 100 28.2 66þ 2 .6

Race (df ¼ 4) 1.74 9.12 5.61 3.60 8.01 2.99 3.44 7.80 6.00 7.99 African American

12 3.3

Caucasian 326 88.6 American Indian

4 1.1

Asian or Pacific Islander

7 1.9

2 or more races

19 5.2

Level of education (df ¼ 4) 1.16 6.46 8.32 5.81 3.20 3.39 3.42 3.87 1.35 6.84 Diploma 16 4.3 Associate degree

69 18.8

Bachelor’s degree

211 57.3

Master’s degree

60 16.3

Doctoral degree

12 3.3

continued

818 JO

U R N A L O F E M E R G E N C Y N U R SIN

G VO

LU M E 46

� ISSU

E 6

N o v e m b e r 2 0 2 0

R E S E A R C H /Leigh

etal

TABLE 1 Continued

Characteristics Psychological variables

Variables N % PM1 PM2 PV RE SE FE RC OE PS KN

Licensure (df ¼ 3) 11.35 3.53 7.23 4.38 3.19 3.06 6.39 2.62 9.50 0.13 LPN/LVN 7 1.9 Registered nurse

339 92.1

Clinical nurse specialist

9 2.4

Nurse practitioner

13 3.5

Employment setting (df ¼ 2) 12.29* 1.32 3.55 3.67 2.35 4.28 1.90 0.40 3.07 1.42 Urban 205 55.7 Suburban 112 30.4 Rural 51 13.9

Years of practicing emergency nursing (mean ¼ 11.2, SD ¼ 9.7 y) (df ¼ 1)

4.08 6.41 1.38 .72 0.02 0.25 <0.01 1.89 0.63 .12

<25 y 323 87.8 >_ 25 y 45 12.2

Hours per week providing direct care to patients in the ED (mean ¼ 29.4, SD ¼ 14.2 h) (df ¼ 1)

4.48 0.03 1.40 0.05 0.05 0.29 0.91 0.12 0.04 1.71

<36 h 139 38.1 >_ 36 h 226 61.9

Number of hours of training received on controlling Ebola infection (mean ¼ 6.6, SD¼ 12.2 h) (df¼ 1)

0.19 0.38 4.38 5.12 29.17� 18.48� 9.64* 2.55 4.89 1.02

<10 h 228 84.4 >_ 10 h 42 15.6

Number of hours of training received on controlling Ebola infection from place of employment (mean ¼ 5.9, SD ¼ 10.5 h) (df ¼ 1)

0.09 1.70 2.36 3.41 23.25� 14.17� 8.69* 0.26 4.76 1.86

<10 h 211 85.4 >_ 10 h 36 14.6

continued

N o vem

b er

2020 VO

LU M E 46

� ISSU

E 6

W W W .JE

N O N LIN

E .O

R G

819

Leigh etal/R

E S E A R C H

TABLE 1 Continued

Characteristics Psychological variables

Variables N % PM1 PM2 PV RE SE FE RC OE PS KN

Does your place of employment have any accommodation to give care to a possible patient with Ebola? (df ¼ 2)

14.56� 2.97 6.45 3.93 16.69� 2.19 1.88 0.22 4.33 8.38

No 38 10.4 Yes 307 83.7 Not sure 22 6.0

Does your place of employment have the necessary equipment to give care to a possible patient with Ebola? (df ¼ 2)

6.92 3.88 10.15 5.20 19.38� 5.31 3.24 0.05 0.89 5.69

No 33 9.0 Yes 289 78.7 Not sure 45 12.3

Do you feel prepared to give care to a possible patient with Ebola? (df ¼ 2)

1.01 13.79* 39.65� 9.11 75.17� 42.65� 16.49� 13.52* 15.63� 6.91

No 153 41.7 Yes 152 41.4 Not Sure 62 16.9

Percentages may not equal 100% owing to rounding off. Type I error was adjusted by the Bonferroni correction for multiple tests. PM1, proactive protection motivation; PM2, passive protection motivation; PV, perceived vulnerability; ED, emergency department; RE, response efficacy; SE, self-efficacy; FE, fear; RC, response cost; OE, outcome expectation; PS, perceived severity; KN, knowledge; LPN, Licensed Practical Nurse; LVN, Licensed Vocational Nurse. * P < 0.005. � P < 0.001. � P < 0.0001.

820 JO

U R N A L O F E M E R G E N C Y N U R SIN

G VO

LU M E 46

� ISSU

E 6

N o v e m b e r 2 0 2 0

R E S E A R C H /Leigh

etal

Leigh et al/RESEARCH

and the University of Toledo Institutional Review Board, a randomized mailing list of emergency nurses within the United States was obtained from the ENA. To reduce external validity threats and increase response rates, best prac- tices in survey research were used.25 These included using the 3-wave mailing process to maximize response rates. A system- atic review of electronic surveys has shown that nonmonetary incentives, the use of a university letterhead, and personaliza- tion of cover letters might increase the response rate.25

DATA ANALYSIS

Descriptive statistics (frequencies, mean, and SD), nonpara- metric Kruskal-Wallis H test (which generates x2 values, as well as post hocDunn-Bonferroni test which generates t values), Spearman rho correlation, and stepwise multiple linear regres- sion were performed using SPSS version 26 (International Busi- ness Machines Corporation, Armonk, NY). These methods were chosen owing to their ability to identify associations more conservatively without normality assumptions. The Bonferroni correction for multiple tests was applied to adjust the significance levels of Kruskal-Wallis H tests and Spearman rho correlation. The significant variables were considered a pri- ority in the stepwise multiple linear regression. An incomplete answer to a particular question was treated as missing data and was excluded from the statistical analysis involving the particular question. No participant missed all the questions.

Results

SAMPLE CHARACTERISTICS

Of the randomly selected participants, 388 emergency nurses completed the online survey. Most of the participants were Caucasian (88.6%), female (79.6%), between the ages of 21 years and 35 years (36.4%), and registered nurses (92.1%) working in an urban setting (55.7%).Most of the participants had a bachelor’s degree (57.3%) and on average had practiced emergency nursing for 11.2 years (SD¼ 9.7 years), with 29.4 hours per week (SD ¼ 14.2 hours) of direct care to patients. Of the emergency nurses who responded, 85.4% indicated that they received less than 10 hours of training at their place of employment on controlling an Ebola infection.

BIVARIATE ANALYSIS

The bivariate analyses for each of the demographic charac- teristics and each investigated PMT construct are docu- mented in Table 1. The assumptions of the

November 2020 VOLUME 46 � ISSUE 6

nonparametric Kruskal-Wallis H test were met, which illus- trated a statistically significant difference between the gen- ders. Post hoc Dunn-Bonferroni tests indicated that male respondents had significantly higher self-efficacy (t ¼ 2.85, P < 0.005), whereas the female nurses had signifi- cantly higher response cost (t ¼ 2.81, P ¼ 0.005). Among the age groups, there was a statistically significant difference with regard to the emergency nurses’ passive protection motivation (x2(3) ¼ 29.04, P < 0.0001), perceived vulner- ability (x2(3) ¼ 18.48, P < 0.001), and response cost (x2(3)¼18.41, P< 0.001). Post hoc Dunn-Bonferroni tests indicated that participants aged 50 years to 65 years, when compared with those who were aged 21 years to 35 years and 36 years to 49 years, had significantly lower passive protec- tion motivation (t ¼ 4.89 and 4.26 respectively, both P < 0.0001). Furthermore, participants aged 50 years to 65 years perceived themselves to be less vulnerable to the infec- tion than those aged 21 years to 35 years (t ¼ 3.76, P < 0.001). In addition, compared with those aged 36 years to 49 years (t ¼ 3.88, P < 0.001) and 21 years to 35 years (t ¼ 2.41, P < 0.05), participants aged 50 years to 65 years believed that the response cost associated with protecting themselves from the infection was relatively lower.

The total training hours on controlling an Ebola infec- tion and the hours received from their place of employment illustrated statistically significant differences in the partici- pants’ self-efficacy (x2(1) ¼ 29.17, P < 0.0001 and x2(1) ¼ 23.25, P < 0.0001, respectively), fear (x2(1) ¼ 18.48, P < 0.0001 and x2(1) ¼ 14.17, P < 0.001, respectively), and response cost (x2(1) ¼ 9.64, P < 0.005 and x2(1) ¼ 8.69, P < 0.005, respectively). Emergency nurses who received more than 10 hours of training on controlling an Ebola infec- tion, either from their place of employment or from else- where, had significantly higher self-efficacy, less fear, and lower response cost in managing an Ebola infection than those who had fewer than 10 hours of training. These results demonstrate to health care administrators that providing more than 10 hours of training in infection control for emer- gency nurses will make them better prepared and confident.

Emergency nurses who felt prepared (as opposed to those who felt unprepared) to provide care to potential pa- tients with an Ebola infection had significantly lower passive protection motivation (t ¼ �3.33, P < 0.001), lower perceived vulnerability (t ¼ �6.30, P < 0.0001), higher response efficacy (t ¼ 3.01, P < 0.001), higher self- efficacy (t ¼ 8.67, P < 0.0001), less fear (t ¼ �6.30, P < 0.0001), lower response cost (t¼�3.80, P< 0.001), lower outcome expectation (t ¼ �3.65, P < 0.001), and lower perceived severity (t ¼ �2.90, P < 0.005).

Furthermore, the results showed that the level of licen- sure is associated with the emergency nurses’ proactive

WWW.JENONLINE.ORG 821

TABLE 2 Spearman rho correlation matrix showing the bivariate correlations among the modified protection motivation theory constructs

Variable PM1 PM2 PV RE SE FE RC OE PS KN

PM1 1 PM2 �0.02 1 PV �0.03 0.34� 1 RE 0.26� �0.05 �0.26� 1 SE 0.18� �0.09 �0.28� 0.38� 1 FE 0.08 0.24� 0.39� �0.10 �0.29� 1 RC 0.03 0.30� 0.26� �0.04 �0.15* 0.57� 1 OE 0.16* 0.18� 0.24� 0.03 �0.07 0.50� 0.41� 1 PS 0.17� 0.05 0.09 0.04 �0.02 0.49� 0.32� 0.36� 1 KN 0.03 �0.18� �0.01 0.12 0.03 �0.00 0.01 0.08 0.09 1

Type I error was adjusted by the Bonferroni correction for multiple tests. PM1, proactive protection motivation; PM2, passive protection motivation; PV, perceived vulnerability; RE, response efficacy; SE, self-efficacy; FE, fear; RC, response cost; OE, outcome expectation; PS, perceived severity; KN, knowledge. * P < 0.005. � P < 0.001. � P < 0.0001.

RESEARCH/Leigh et al

protection motivation (x2(3) ¼ 11.35, P < 0.05) and their perceived severity of the infection (x2(3) ¼ 9.50, P < 0.05). Further analysis exploring the differences by licensure found that, when compared with registered nurses and clin- ical nurse specialists, licensed practical nurses/licensed voca- tional nurses had significantly lower proactive protection motivation (t ¼ �3.08, P < 0.005 and t ¼ �2.65, P < 0.01, respectively) and perceived severity (t ¼ �3.06, P < 0.005 and t ¼ �2.35, P < 0.05, respectively).

The Spearman rho correlation matrix in Table 2 dis- plays the computed coefficients for each psychological vari- able when associated with the outcome variables. Proactive

TABLE 3 Stepwise multiple linear regression results showing predictors of motivation

Outcome variables Predictors B

Proactive protection motivation (Constant) 15 Response efficacy 0 Self-efficacy 0

Passive protection motivation (Constant) 1 Perceived vulnerability 0 Response cost 0 Knowledge � 0

R2, coefficient of determination; F, F statistic; B, unstandardized regression coefficient.

822 JOURNAL OF EMERGENCY NURSING

protection motivation was highly and positively correlated with response efficacy (r ¼ 0.26, P < 0.0001), self- efficacy (r ¼ 0.18, P < 0.0001), outcome expectation (r ¼ 0.16, P < 0.005), and perceived severity (r ¼ 0.17, P < 0.001).

The second outcome variable, passive protection moti- vation, was highly and positively correlated with perceived vulnerability (r ¼ 0.34, P < 0.0001), fear (r ¼ 0.24, P < 0.0001), response cost (r ¼ 0.30, P < 0.0001), and outcome expectation (r ¼ 0.18, P < 0.001). In addition, knowledge (r ¼ �0.18, P < 0.001) was highly and nega- tively correlated with passive protection motivation.

proactive protection motivation and passive protection

SE Beta t Sig. F R2

.32 0.59 26.11 <0.001 24.03 0.14

.16 0.04 0.27 4.49 <0.001

.06 0.02 0.17 2.78 0.006

.31 0.46 2.85 0.005 17.67 0.16

.08 0.02 0.26 4.66 <0.001

.05 0.02 0.19 3.34 0.001

.11 0.04 �0.15 �2.80 0.006

VOLUME 46 � ISSUE 6 November 2020

Leigh et al/RESEARCH

MULTIVARIATE ANALYSIS

Stepwise multiple linear regression was conducted for each outcome variable (proactive protection motivation and pas- sive protection motivation) to estimate their predictors and their proportion of variance. All the psychological explanatory variables were entered into the regressionmodel, and the step- wise procedure selected and removed the predictors on the basis of their significance levels. Response efficacy (b ¼ 0.27, P < 0.001) and self-efficacy (b ¼ 0.17, P < 0.01) were significant predictors of proactive protection motivation and accounted for 14% of the variance. Perceived vulnera- bility (b ¼ 0.26, P < 0.001), response cost (b ¼ 0.19, P¼ 0.001), and knowledge (b¼�0.15, P< 0.01) were sig- nificant predictors of passive protection motivation and accounted for 16% of the variance as illustrated in Table 3.

Discussion

The results from the study revealed a statistically significant relationship between the outcome variables and the modi- fied PMT variables, which rejects the null hypotheses that the psychological variables do not correlate with protection motivation and that there are no significant predictors of the nurses’ motivation to protect themselves against potential patients with the Ebola infection. The outcome variable, protection motivation, was divided into proactive protec- tion motivation and passive protection motivation on the basis of the PCA. Although the bivariate analyses showed multiple paired associations, multiple linear regression was able to further identify statistically significant predictors af- ter controlling other explanatory variables.

On the basis of the results from the multivariate analysis, response efficacy and self-efficacy positively predicted emer- gency nurses’ proactive protection motivation. Both response efficacy and self-efficacy are part of the coping appraisal in the PMT. Response efficacy assesses the belief that the recom- mended coping response might be effective in reducing the threat, and self-efficacy assesses the perceived ability to perform the recommended coping response.8 Both constructs influence the nurses’ motivation to conduct the recommen- ded coping response. The regression coefficients from these 2 constructs indicate that higher self-efficacy and/or higher response efficacy can lead to an increase in the nurses’ proac- tive protectionmotivation. These findings are consistent with those of previous studies that used the PMT as their theoret- ical framework. Coping strategies available for participants have a stronger effect on whether they will conduct the pro- tective behavior, and high response efficacy strengthens their intention to protect themselves and reinforces their belief that the protective behavior is effective.7,8

November 2020 VOLUME 46 � ISSUE 6

For passive protection motivation, the regression anal- ysis indicated that perceived vulnerability positively, response cost positively, and knowledge negatively predicted passive protection motivation. Perceived vulnerability as- sesses the likelihood of contracting the disease, response cost assesses the cost associated with performing the recom- mended protective behavior, and knowledge is the amount of information needed to carry out the behavior.8,11 The more vulnerable the nurses believe they are, the more likely that they will exhibit passive protection motivation behavior. Perceived vulnerability was the strongest predictor of passive protection motivation. Vulnerability is associated with fear of the disease and in the belief that the individual has a higher likelihood of being exposed to and contracting the disease. Previous researchers have examined behavioral intention and vulnerability relating to the individual hearing about the threat, assessing how dangerous the disease is, and estimating their personal vulnerability before determining whether to perform the protective behavior.8

Added to perceived vulnerability, the cost associated with the protective behavior and the limited knowledge they had about the disease led to an increase in passive protection moti- vation. Limited knowledge about the Ebola virus and the pro- tective behaviors determine whether a nurse will actively perform the protective behavior or possibly avoid the place of employment owing to potential patients that they might encounter. According to the American Nurses Association sur- vey of registered nurses (n ¼ 7,353), health and safety at their workplace were cited as influencing concerns on whether nurses will continue working in the field and the type of nursing work they choose to perform.5 In addition,mediames- sages and incorrect information can lead to heightened percep- tion of risk, which could increase fear and perceived vulnerability. The CDC reported that the high frequency of risk-elevating messages in news coverage can increase public concern and perception and contribute to social amplification of risk, which leads to the spread of misinformation.26

Continual re-education, training, and demonstrations of pre- ventive recommendations and nonpharmacological interven- tions6 will not only increase nurses’ confidence in providing care to potential patients, they might also reduce passive pro- tection motivation.

Limitations

There are some limitations to this study. The random sam- ple of emergency nurses comprise ENA members. ENA members may not demographically represent all emergency nurses in the United States, which presents a potential threat to the external validity of the findings. However, it can be

WWW.JENONLINE.ORG 823

RESEARCH/Leigh et al

hypothesized that ENA members might be professionally dedicated and experienced, and the current findings repre- sent a liberal estimate of the nurses’ motivation to protect themselves when providing care to potential patients with the Ebola infection.

In addition, the timing of the Ebola outbreak might have influenced the nurses’ motivation toward engaging in protective practices while providing care to patients possibly infected with the disease. The outbreak occurred more than a year before the survey was distributed, and the nurses’ heightened awareness of the disease might have decreased considerably, affecting the response rate. The study response rate was 23% (388/1,686), which yielded a power of 93%. The power analysis indicated a strong probability that the research might only commit a small type II error.

Previous studies that surveyed emergency nurses and other health care professionals achieved high or low response rates depending on the research topic and their specialty. Studies that focused on stress, burnout, and depression among nurses had a response rate of 84%,27 substance abuse study had a response rate of 69%,28 research focused on exposure to various common diseases had response rates be- tween 66% and 83%,29 and workplace injury research had response rates between 67% and 75%,30 whereas a violence surveillance study had a response rate of 9.5%.31

Implications for Emergency Nurses

This study identified that perceived vulnerability, response cost, and knowledge have an impact on whether the nurses exhibit passive protection motivation behavior. Thus, it is recommended that administrators provide continual training and simulations for nurses. Administrators need to provide continual education regarding the disease, its method of trans- mission, and current CDC personal protective equipment (PPE) recommendations when providing care to Ebola- infected patients. Rebmann et al6 identified that fewer than 15% of health care personnel correctly don and doff the PPE needed to provide care to an Ebola patient, whereas hand hygiene compliance was between 40% and 53% among triage nurses in an emergency department. Continual training and education acquired by nurses would reduce their perceived vulnerability toward the disease and increase their self-efficacy and response efficacy toward the protective behavior, such as using the recommended equipment and guidelines. Such educational intervention also improved PPE compliance from 44% to 69%.6 In instances where the infectious agent is new, such as with the current coronavirus disease (COVID-19) pandemic, nurses can use prior education and training to direct their current protective behaviors.

824 JOURNAL OF EMERGENCY NURSING

In addition, emergency care leaders need to have updated protective equipment such as adequate respirators, disposable impermeable gowns/coveralls, disposable exami- nation gloves with extended cuffs, disposable boot covers, and disposable aprons available in their hospitals and clinics.32 The availability of PPE has emerged as a major bar- rier to nurses and other health care professionals, with regard to their self-efficacy and response efficacy toward their pro- tective behaviors in the current COVID-19 pandemic. Furthermore, administrators should be aware of the influ- encing factors and barriers that prevent the use of PPE among nurses. A focus group study indicated that emer- gency situations, availability of equipment, negative influ- ence of protective equipment on nurses, patient discomfort, being busy, implementing guidelines being time-consuming, and physicians’ influence were cited as barriers that may influence a nurse’s compliance with stan- dard precautions, even if they received continual training.33

Although these factors were identified by participants in the focus group as barriers to the use of PPE among nurses, these findings may not be supported for other communi- cable infectious diseases. The transmission route, knowl- edge, and outcome expectation as well as the mortality and morbidity associated with an infectious disease may have an influence on nurses’ proactive protection motiva- tion, which could limit their engagement in the recommen- ded protective health behaviors. More specifically, nurses’ perceived severity of and perceived vulnerability to an infec- tious disease may have a stronger impact than their response efficacy and self-efficacy, which might enable them to be proactive in their motivation to engage in protective health behaviors. During the current COVID-19 pandemic, mul- tiple anecdotal evidences are emerging in support of nurses being proactive in their motivation to engage in protective health behaviors.

Adequate accommodation, such as a single-patient room with a private bathroom, and dedicated medical equipment should be made available while also adhering to the hospital’s environmental infection control guide.34

Reducing the response cost, such as making the protective equipment readily available and up to date, can limit the nurses’ passive protection motivation behavior. Finally, hav- ing a standard operating procedure for receiving patients with a potential Ebola infection is also recommended.

Conclusions

To our knowledge, this is the first study to examine emer- gency nurses’motivation to engage in protective procedures to help prevent the transmission of the Ebola virus, based on

VOLUME 46 � ISSUE 6 November 2020

Leigh et al/RESEARCH

demographics (ie, gender, race, level of education, current licensure, age, employment setting, and years of emergency nursing) and psychological variables (ie, self-efficacy, response efficacy, response cost, knowledge, outcome expec- tation, perceived vulnerability, perceived severity, fear, and protection motivation) using a modified version of the PMT model. The lessons learned from this study, although about the Ebola virus infection, can be applied to the COVID-19 pandemic because their transmission routes are similar; therefore, nurses’ protection motivation can be reasonably projected.

Future research should focus on conducting a longitudinal study that examines how knowledge affects nurses’motivation to protect themselves from the Ebola virus or other infectious diseases. Transmission routes and ease of transmission, as well as the morbidity and mortality of the disease, should be exam- ined to explore if there is a relationship between these factors and nurses’ motivation to protect themselves from infectious diseases and if their protection motivation varies across dis- eases. The low variance found in the analysis did not indicate very strong predictors of protection motivation within the modified PMT model. However, the PMT has been used by previous researchers to examine the prevention of HIV and nurses’ motivation to care for HIV patients.8,10 Similar infectious-disease studies have used thePMTto explore nurses’ motivation for care; this suggests that the theory is appropriate for this study. The addition of other constructs to the original PMT model and modifying the survey items might be other suggestions that could indicate stronger predictors of protec- tion motivation.

This research did not measure the actual behavior of nurses but focused on their intended behavior. It is sug- gested that future research should examine the nurses’ actual behavior and the use of preventive recommendations and nonpharmacological interventions when providing care to infected patients in comparison with the nurses’ intended behavior. Legitimate reasons, such as fear and limited knowledge, also determine whether nurses conduct proac- tive protection motivation behavior or passive protection motivation behavior. Fear, possible response cost, and limited knowledge hinder, and possibly influence, nurses providing care to potential patients infected with Ebola. Ef- forts should be focused on providing support, continual training, and current resources and guidance that empower and encourage nurses to exhibit proactive protection moti- vation behavior.

Author Disclosures

Conflicts of interest: none to report.

November 2020 VOLUME 46 � ISSUE 6

REFERENCES 1. Legrand J, Grais RF, Boelle PY, Valleron AJ, Flahault A. Understanding

the dynamics of Ebola epidemics. Epidemiol Infect. 2007;135:610-621. https://doi.org/10.1017/S0950268806007217

2. Pourrut X, Kumulungui B, Wittmann T, et al. The natural history of Ebola virus in Africa. Microbes Infect. 2005;7:1005-1014. https:// doi.org/10.1016/j.micinf.2005.04.006

3. World Health Organization. Ebola in the Democratic Republic of the Congo: health emergency update. Accessed April 20, 2020. https:// www.who.int/emergencies/diseases/ebola/drc-2019

4. National Center for Infectious Diseases. Ebola Hemorrhagic Fever: Known Cases and Outbreaks of Ebola Hemorrhagic Fever in Chronological Order. Centers for Disease Control and Prevention; 2010:1-7.

5. Stone PW, Clarke SP, Cimiotti J, Correa-de-Araujo R. Nurses’ working conditions: implications for infectious disease. Emerg Infect Dis. 2004;10:1984-1989. https://doi.org/10.3201/eid1011.040253

6. Rebmann T, Carrico R. Consistent infection prevention: vital during routine and emerging infectious diseases care. Online J Issues Nurs. 2017;22:1. https://doi.org/10.3912/OJIN.Vol22No01Man01

7. Rippetoe PA, Rogers RW. Effects of components of protection- motivation theory on adaptive and maladaptive coping with a health threat. J Pers Soc Psychol. 1987;52:596-604. https://doi.org/10.1037// 0022-3514.52.3.596

8. Milne S, Sheeran P, Orbell S. Prediction and intervention in health- related behavior: a meta-analytic review of ProtectionMotivation Theory. J Appl Soc Psychol. 2000;30:106-143. https://doi.org/10.1111/j.1559- 1816.2000.tb02308.x

9. Floyd DL, Prentice-Dunn S, Rogers RW. A meta-analysis of research on Protection Motivation Theory. J Appl Soc Psychol. 2000;30:407-429. https://doi.org/10.1111/j.1559-1816.2000.tb02323.x

10. BoerH, Seydel E. Protectionmotivation theory. In: ConnerM,Norman P, eds. Predicting Health Behavior: Research and Practice With Social Cognitive Models. Open University Press; 1996:95-120.

11. Montano DE, Kasprzyk D. Theory of Reasoned Action, Theory of Planned Behavior and the Integrated Behavioral Model. In: Glanz K, Rimer BK, Viswanath K, eds.Health Behavior and Health Education: The- ory, Research, and Practice. Jossey-Bass; 2008:67-96.

12. McAlister AL, Perry CL, Parcel GS. How individuals, environments, and health behaviors interact: Social Cognitive Theory. In: Glanz K, Rimer BK, Viswanath K, eds.Health Behavior and Health Education: The- ory, Research, and Practice. Jossey-Bass; 2008:169-188.

13. Johnson B. Toward a new classification of nonexperimental quantitative research. Educ Res. 2001;30:3-13. https://doi.org/10.3102/ 0013189X030002003

14. Emergency Nurses Association. About Emergency Nurses Association. Accessed June 11, 2015. https://www.ena.org.

15. Kotrlik J, Williams H, Jabor K. Reporting and interpreting effect size in quantitative agricultural education research. J Agric Educ. 2011;52:132- 142. https://doi.org/10.5032/jae.2011.01132

16. Bell MA, Dake JA, Price JH, Jordan TR, Rega P. A national survey of emergency nurses and avian influenza threat. J Emerg Nurs. 2014;4:212-217. https://doi.org/10.1016/j.jen.2012.05.005

WWW.JENONLINE.ORG 825

RESEARCH/Leigh et al

17. Gupta N, Mehta N, Gupta P, Arora V, Setia P. Knowledge regarding Ebola hemorrhagic fever among private dental practitioners in Tricity, In- dia: a cross-sectional questionnaire study.Niger Med J. 2015;56:138-142. https://doi.org/10.4103/0300-1652.153405

18. Rubsamen N, Castell S, Horn J, et al. Ebola risk perception in Germany, 2014. Emerg Infect Dis. 2015;21:1012-1018. https://doi.org/10.3201/ eid2106.150013

19. Alqahtani AS, Wiley KE, Willaby HW, et al. Australian Hajj pilgrims’ knowledge, attitude and perception about Ebola, November 2014 to February 2015. Euro Surveill. 2015;20:21072. https://doi.org/10.2807/ 1560-7917.es2015.20.12.21072

20. Garvin JH, Gordon TF, Haignere C, Ducette JP. Development of a pub- lic health assessment tool to prevent Lyme disease: tool construction and validation. Perspect Health Inf Manag. 2005;2:11.

21. Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. 4th ed. SAGE Publications; 2008.

22. CookDA, Beckman TJ. Current concepts in validity and reliability for psy- chometric instruments: theory and application. Am J Med. 2006;119:166.e167-116. https://doi.org/10.1016/j.amjmed.2005.10.036

23. Patton MQ. Qualitative Research and Evaluation Methods. 3rd ed. Sage Publication Inc.; 2002.

24. Higgins PA, Straub AJ. Understanding the error of our ways; Mapping the concepts of validity and reliability. Nurs Outlook. 2006;54:23-29. https://doi.org/10.1016/j.outlook.2004.12.004

25. Edwards PJ, Roberts I, Clarke MJ, et al. Methods to increase response to postal and electronic questionnaires. Cochrane Database Syst Rev. 2009;3:MR000008. https://doi.org/10.1002/14651858.MR000008. pub4

26. Sell TK, Boddie C, McGinty EE, et al. Media messages and perception of risk for Ebola virus infection, United States. Emerg Infect Dis. 2017;23:108-111. https://doi.org/10.3201/eid2301.160589

826 JOURNAL OF EMERGENCY NURSING

27. Wunderlich GS, Sloan FA, Davis CK. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? National Academy Press; 1996.

28. Cares A, Pace E, Denious J, Crane LA. Substance use and mental illness among nurses: workplace warning signs and barriers to seeking assistance. Subst Abus. 2015;36:59-66. https://doi.org/10.1080/08897077.2014. 933725

29. Brtnikova M, Crane LA, Allison MA, Hurley LP, Beaty BL, Kempe A. A method for achieving high response rates in national surveys of U.S. primary care physicians. PLoS One. 2018;13:e0202755. https://doi.org/ 10.1371/journal.pone.0202755

30. Mark BA, Hughes LC, Belyea M, et al. Does safety climate moderate the influence of staffing adequacy and work conditions on nurse injuries? J Safety Res. 2007;38:431-446. https://doi.org/10.1016/j.jsr.2007.04.004

31. Emergency Nurses Association, Institute for Emergency Nursing Research. Emergency Department Violence Surveillance Study. ENA; 2011.

32. Centers for Disease Control and Prevention. Guidance on personal pro- tective equipment (PPE) to be used by healthcare workers duringmanage- ment of patients with confirmed Ebola or persons under investigation (PUIs) for Ebola who are clinically unstable or have bleeding, vomiting, or diarrhea in U.S. Hospitals, including procedures for donning and doff- ing PPE. Accessed January 25, 2020. https://www.cdc.gov/vhf/ebola/ healthcare-us/ppe/guidance.html

33. Efstathiou G, Papastavrou E, Raftopoulos V, Merkouris A. Factors influencing nurses’ compliance with standard precautions in order to avoid occupational exposure to microorganisms: a focus group study. BMC Nurs. 2011;10:1. https://doi.org/10.1186/1472-6955- 10-1

34. Centers for Disease Control and Prevention. Infection prevention and con- trol recommendations for hospitalized patients under investigation (PUIs) for Ebola virus disease (EVD) in U.S. hospitals. Accessed January 25, 2020. https://www.cdc.gov/vhf/ebola/clinicians/evd/infection-control.html

VOLUME 46 � ISSUE 6 November 2020