Skip to main content
NCBI home page
Wiley - PMC COVID-19 Collection logoLink to Wiley - PMC COVID-19 Collection
. 2020 Nov 18;29(3):421–431. doi: 10.1111/jonm.13181

Surviving an infectious disease outbreak: How does nurse calling influence performance during the COVID‐19 fight?

Yan Zhou RN 1, Eric Adom Asante 2, Yiyu Zhuang RN 1, Jie Wang 3, Yue Zhu 4, Lihua Shen RN 1,✉
PMCID: PMC7675343  PMID: 33058323

Abstract

Aim

To assess the performance of front‐line nurses, who believed they were living out their calling, during the coronavirus disease 2019 (COVID‐19) pandemic.

Background

Although as a profession nursing generally requires high levels of performance, the disruption arising from an infectious disease outbreak increases the work stress and decreases the performance of front‐line nurses. How this situation can be improved has yet to be thoroughly examined.

Method

We used a snowball sampling technique to recruit 339 nurses who were originally from outside Hubei but volunteered to join medical teams going to Hubei to tackle COVID‐19.

Results

Drawing on the theory of work as a calling, we found that living a calling had a positive effect on front‐line nurses’ performance through the clinical and relational care they provided. Perceived supervisor support strengthened these mediated relationships.

Conclusion

Our findings indicate that despite the constraints associated with pandemics, front‐line nurses who are living a calling are able to provide better clinical and relational care to infected patients, which in turn improves their performance.

Implications for Nursing Management

The findings of this study suggest that hospitals can introduce career educational interventions to enhance nurses’ ability to discern and live out their calling to improve their performance.

Keywords: caring, COVID‐19, living a calling, nursing performance, perceived supervisor support

1. INTRODUCTION

Infectious disease outbreaks have recently become more common worldwide (Lam et al., 2018), such as the outbreaks of the Ebola virus disease (Chertow et al., 2014), severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (Lam et al., 2018). The World Health Organization has confirmed a new pathogen, SARS‐CoV‐2, which causes a novel pneumonia called coronavirus disease 2019 (COVID‐19; Mo et al., 2020). Medical personnel are in great demand during infectious disease outbreaks. Given that nurses constitute the largest human resource component in health care organisations, their services are often those in greatest demand in such situations (Al‐Ahmadi, 2009; Baack & Alfred, 2013).

Nursing performance is defined as nurses’ level of effectiveness in meeting their employers’ goal of providing excellent patient care (Brady & Cummings, 2010). A high‐performing nurse pays attention to patients’ physical and mental needs, masters technological skills, communicates effectively with colleagues, patients and patients’ family members, and handles multiple tasks properly (Cho & Han, 2018; Pai et al., 2017). As nursing performance is vital to quality patient care and safety, researchers have shown great interest in how to improve nursing performance (Amarat et al., 2019; Terzioglu et al., 2016). Unfortunately, as infectious disease outbreaks are unplanned, they are impossible or very difficult to prepare for. Several studies have articulated the enormous challenges such outbreaks bring (Fauci & Morens, 2012; Lam et al., 2018), such as the heavy workload on nursing staff (Alghamdi, 2016), the necessity for nurses to acquire the knowledge and skills required to handle new diseases (Liu & Liehr, 2009) and the elevated risk of infection for front‐line nurses (Shih et al., 2009).

How do we maintain or even improve nursing performance in such critical situations? Recent management research has shown that employees who perceive their jobs as a calling are resilient in the face of adversity (Praskova et al., 2014; Thompson & Bunderson, 2019). As such, we draw on work as calling theory (WCT; Duffy et al., 2018) and argue that front‐line nurses who perceive themselves as living a calling through their nursing jobs are likely to demonstrate increased levels of nursing performance during the COVID‐19 outbreak. A calling is defined as work that a person believes is inseparable from his/her life and that provides fulfilment (Wrzesniewski et al., 1997). Living a calling involves being engaged in activities or work that meet this calling (Duffy & Autin, 2013). Nurses who believe they are living a calling are likely to exhibit greater work effort and caring ability towards their patients (Praskova et al., 2014). Such nurses may view their profession as their responsibility to public service rather than a mere job (Koh et al., 2012). They may also be more willing to comply with infection control protocols (Qureshi et al., 2013) and less likely to compromise on their professional nursing values and integrity (Lam et al., 2018; Schluter et al., 2008). These characteristics are very important to the performance of front‐line nurses in times of adversity, such as infectious disease outbreaks.

We further argue that front‐line nurses who believe that they are living a calling through their work demonstrate high levels of nursing performance, that this positive effect is mediated by their clinical and relational caring abilities (Cossette et al., 2006) and that these indirect effects are conditional on the level of perceived supervisor support (PSS) that they receive (Eisenberger et al., 2002). Thus, front‐line nurses who are living their calling are likely to exert more effort and show higher persistence when faced with the difficulties of COVID‐19 (Thompson & Bunderson, 2019). Living a calling also makes front‐line nurses conscious of their duties, leading to high clinical and relational care (Al‐Hamdan et al., 2017) and subsequently to higher nursing performance. Lastly, we argue that the indirect effect of living a calling on nursing performance is influenced by the extent to which leaders value subordinates’ contributions (i.e. PSS; cf. Eisenberger et al., 2002). A high level of PSS makes nurses more obligated to their work, thereby improving nursing performance. Considering that infectious disease outbreaks have become prevalent worldwide, it is important to examine the factors that can ensure that nursing performance remains high even in such trying times. Thus, examining the effect of living a calling on the nursing performance of front‐line nurses fighting against COVID‐19 and the underlying mechanism and boundary condition is both relevant and timely.

By examining these relationships, we make two main contributions to the nursing management literature. First, we extend the theoretical perspective of WCT (Duffy et al., 2018) from the fields of organisational behaviour and counselling psychology to nursing management by examining a unique group of nurses: those who took part in the fight against COVID‐19. Second, we propose that living a calling through work is a precursor for improved nursing performance during critical situations, such as infectious disease outbreaks. It can determine nurses’ level of preparedness when responding to an epidemic event and is therefore significant (Lam et al., 2018). Our theoretical model is shown in Figure 1.

Figure 1.

Figure 1

Open in a new tab

Conceptual model.Note. Age, sex and nursing tenure are included as demographic controls. Work meaning is included as a control mediator

2. THEORY AND HYPOTHESIS DEVELOPMENT

2.1. Living a calling and nursing performance

WCT (Duffy et al., 2018) conceptualizes a calling as involving three overlapping components: (a) 'a transcendent summons, experienced as originating beyond the self', (b) approaching 'a particular life role in a manner oriented toward demonstrating or deriving a sense of purpose or meaningfulness', and (c) holding 'other‐oriented values and goals as primary sources of motivation' (p. 425). The first component represents the extent to which a person perceives his/her calling to a particular job to have come from an external source, the second represents the extent to which the work is perceived as achieving a particular purpose and meaning in life (Dik & Duffy, 2009), and the third represents the extent to which such work is perceived as a direct or indirect contribution to the greater good of society.

Living a calling has a positive effect on task performance across several occupations. For instance, in a sample of teachers, Rawat and Nadavulakere (2015) found that living a calling influenced performance. Among the staff members of a church, Kim et al. (2018) also found that living a calling was positively related to performance. The positive effect of living a calling on performance has also been found in other samples, including NGO employees (Kim et al., 2018; Lee et al., 2018). These favourable consequences of living a calling have been attributed to the fact that it makes people self‐motivated and ready to exert effort to achieve good performance (Kim et al., 2018). Despite these important findings, the influence of living a calling has yet to be explored in the nursing literature. We argue that the extent to which health organisational goals in a pandemic are achieved depends on the effective services front‐line nurses provide to infected patients, which are largely influenced by their effort and persistence when facing difficulties (Thompson & Bunderson, 2019). Thus, front‐line nurses who believe their nursing work during the fight against COVID‐19 meets their calling (Duffy & Autin, 2013) are likely to demonstrate high levels of nursing performance.

H1: Living a calling has a positive effect on nursing performance.

2.2. The mediating role of clinical and relational care

Caring is at the core of the nursing profession, with nurses often described as professional caregivers (Simmons & Cavanaugh, 2000). Professional caregiving involves the deliberate goals and processes of professionals in providing assistance to others to support their well‐being and alleviate undue discomfort (Leininger, 1981). Cossette et al. (2006) identified the four caring dimensions of humanistic, relational, clinical and comforting care. We focus on clinical and relational care as the two dominant dimensions (Cossette et al., 2006) in analysing the mechanism through which living a calling influences front‐line nurses’ performance.

The clinical care given by nurses is the expertise required for clinical assessment and monitoring and for treatment and symptom management. Relational care involves nurses respecting patients’ perceptions and assisting them in coming to terms with their health situations (Watson, 2008). Although caring is always an important component of a nurse's job, it becomes particularly important during infectious disease outbreaks (Chung et al., 2005). In an epidemic situation, nurses who can offer high levels of clinical and relational care are likely to perform well in their jobs, as such situations often involve nurses being frequently assigned new roles that may be beyond the scope of their usual clinical practice (Gebbie & Qureshi, 2002). Liu and Liehr (2009) found that clinical knowledge of infectious diseases led to improved service delivery during the SARS outbreak. Similarly, nurses’ relational care behaviour has been found to improve communication with critically ill patients (Expósito et al., 2018), thereby helping to improve the services delivered. Front‐line nurses’ ability to accomplish work goals, meet job expectations and achieve organisational goals is affected by their ability to deliver clinical and relational care to infected patients (Al‐Hamdan et al., 2017). Being able to provide such clinical and relational care has a direct effect on infected patients’ experience and health outcomes and determines the nursing performance of front‐line nurses (Henderson & Prescott, 2020; Lee & Ko, 2010).

To effectively utilize their clinical and relational care abilities, nurses must first believe that the activities in which they are engaging fulfil a personal need or contribute to the greater good of society. Thus, we argue that living a calling can have a positive influence on nurses’ clinical and relational care abilities. Research suggests that those who believe they are living a calling have clarity about themselves and their career choices (Thompson & Bunderson, 2019). As such, nurses who are living a calling are continually aware of their career choices and are willing to seek knowledge when faced with novel situations, such as the COVID‐19 pandemic (Dobrow & Tosti‐Kharas, 2011). They may also exhibit the relational behaviour necessary for improved service delivery. Thus, we argue that clinical care and relational care are the mechanisms through which living a calling influences nursing performance.

H2: Clinical care mediates the positive relationship between living a calling and nursing performance.

H3: Relational care mediates the positive relationship between living a calling and nursing performance.

2.3. The moderating role of perceived supervisor support

As the nurse–patient ratio increases during an epidemic, front‐line nurses are frequently assigned new roles, duties and responsibilities with which they may not be familiar (Gebbie & Qureshi, 2002). They may also be required to make crucial decisions concerning infection control, triage and the treatment of infected patients. PSS is the extent to which a supervisor appears to value his/her subordinates’ contributions (Eisenberger et al., 2002). PSS may be important in determining how front‐line nurses conduct their clinical and relational care duties during an epidemic. Supervisors act as the agents of an organisation and are responsible for directing and evaluating subordinates’ performance (Shanock & Eisenberger, 2006). Research has shown that under high levels of PSS, employees feel obligated to help their organisation achieve its objectives and may engage in extra role behaviours, such as helping colleagues (Eisenberger et al., 2001).

We argue that under high levels of PSS, front‐line nurses will treat infected patients better, help other nurses when their workloads increase and assist colleagues with their duties. When PSS levels are high, nurses also perceive that their supervisors treat them favourably (Shanock & Eisenberger, 2006). This positive treatment is likely to have a trickle‐down effect on infected patients. However, under low levels of PSS, nurses perceive their treatment by supervisors as unfavourable. The associated perception of negative treatment may similarly be transferred to patients. Thus, under high levels of PSS, we expect the positive effect of living a calling on clinical and relational care to be stronger than when PSS levels are low.

H4: PSS strengthens the positive relationship between living a calling and clinical care.

H5: PSS strengthens the positive relationship between living a calling and relational care.

By linking the mediating effects of clinical and relational care (H2 and H3) to the moderating effects of PSS (H4 and H5), we propose the following moderated mediation effects:

H6: PSS moderates the positive relationship between living a calling and nursing performance through clinical care, such that the relationship is stronger when PSS is high.

H7: PSS moderates the positive relationship between living a calling and nursing performance through relational care, such that the relationship is stronger when PSS is high.

3. METHOD

3.1. Study design

This study was designed to examine the effect of living a calling on front‐line nurses’ performance during the fight against COVID‐19. The study was conducted in China among front‐line nurses who were involved in the fight against COVID‐19 in Hubei. We used a descriptive, cross‐sectional and survey design.

3.2. Participants

The author team used a snowball sampling technique to recruit nurses who were originally from outside Hubei but who had joined medical teams going to Hubei to tackle COVID‐19. Thus, they had all been on the medical front line and treated patients with COVID‐19. Their participation was voluntary, and their confidentiality was ensured. Approximately 400 nurses were invited to participate in this study, and ultimately, 345 surveys were received. Six surveys with incomplete data were removed, yielding an effective response rate of 84.75%.

3.3. Measures

The surveys were initially written in English and translated into Chinese, in accordance with Brislin’s (1986) back‐translation procedure. Specifically, all translators were blind to the study's hypotheses, and two bilingual individuals independently translated the survey from English into Chinese. These two individuals discussed and solved any conflicts between their translations; a third person then translated the survey back into English. For all of the measures, the participants were instructed to recall their work attitudes or performance during the COVID‐19 fight in Hubei.

3.3.1. Living a calling

Living a calling was measured using a 6‐item scale adapted from Duffy et al. (2012). The following instruction was used: 'During the COVID‐19 fight in Hubei…' An example item is, 'I was working in a job that closely aligns with my calling' (1 = strongly disagree to 7 = strongly agree; α = 0.91).

3.3.2. Clinical care

Clinical care was assessed using the 9‐item clinical care subdimension of the Caring Nurse‐Patient Interaction Scale (Cossette et al., 2006). The nurses were asked to complete the following sentence: 'When providing care for patients with COVID‐19 in Hubei…' An example item is, 'I knew how to operate specialized equipment (e.g. pumps, monitors)' (1 = strongly disagree to 7 = strongly agree; α = 0.94).

3.3.3. Relational care

Relational care was measured using the 7‐item relational care subdimension of the Caring Nurse‐Patient Interaction Scale (Cossette et al., 2006). The following instruction was used: 'When providing care for patients with COVID‐19 in Hubei…' An example item is, 'I helped patients to look for a certain equilibrium/balance in their lives' (1 = strongly disagree to 7 = strongly agree; α = 0.95).

3.3.4. PSS

PSS was assessed using a 9‐item measure adapted from Wayne et al. (1997). The nurses were asked to complete the following sentence: 'During the COVID‐19 fight in Hubei…' An example item is, 'My supervisor cared about my general satisfaction at work' (1 = strongly disagree to 7 = strongly agree; α = 0.98).

3.3.5. Nursing performance

Nursing performance was measured using a 7‐item measure adapted from Fitzpatrick et al. (1997). The following stem was used: 'Please evaluate your performance during the COVID‐19 fight in Hubei'. An example item is, 'Attention to patients’ activity in accordance with their current and potential health status' (1 = unsatisfactory to 5 = superior; α = 0.95).

3.3.6. Control variables

Previous research (Terzioglu et al., 2016; Walpita & Arambepola, 2020) has suggested that age, sex and nursing tenure are associated with nursing performance. As such, these factors were controlled for. Age and nursing tenure were measured in years, and sex was measured as female = 0 and male = 1. In addition, work meaning (Ghislieri et al., 2019) was controlled to avoid confounding the mediation results. Meaningful work was measured using a 10‐item scale (Steger et al., 2012) scored on a 7‐point Likert scale (1 = strongly disagree to 7 = strongly agree; α = 0.97).

3.4. Data collection

In early April 2020, data were collected through a Chinese online survey system. At this time, all of the nurses who had gone to Hubei from other provinces had finished their missions and were either quarantined in Hubei or their home cities. The survey information was sent to several head nurses who had led medical teams to Hubei, who forwarded it to all of the nurses on their teams using the most popular instant messenger smartphone application in China. The participants could access the survey using a web link or a Quick Response code. The purpose, anonymity and confidentiality of the online survey were first briefly introduced, and consent was obtained by asking the participants whether they agreed to participate. If the response was negative, the survey ended immediately. Although head nurses helped with sample recruitment, participation was voluntary, and the participants were at liberty to stop the survey at any time. Ethical approval for this study was obtained from the first author's institute.

3.5. Data analysis

We used the Statistical Package for Social Science (SPSS) version 25.0 software (IBM Corp., 2017) for descriptive, correlation and regression analysis. To test our hypotheses, we used the PROCESS macro software package (Hayes, 2013). The seven hypotheses were analysed using Model 7 of the PROCESS macro. This allowed us to examine our direct, mediation and moderation hypotheses in one model simultaneously.

4. RESULTS

The personal and work characteristics of the study participants are presented in Table 1. Their average age was 32.32 years, 76.70% were female, their average nursing experience was 9.27 years, and all had completed an associate degree or above.

Table 1.

Personal and work‐related characteristics

Variable Mean (SD) N (%)
Gender
Female 260 (76.70)
Male 79 (0.23.30)
Age 32.32 (7.25)
Tenure 9.27 (6.94)
Marital status
Unmarried 105 (31.00)
Married 234 (69.00)
Parenthood
Nonparent 125 (36.90)
Parent 214 (63.10)
Open in a new tab

N = 339.

The means, standard deviations, reliabilities and correlations of the variables are shown in Table 2. Model 7 of the PROCESS macro (Hayes, 2013) was used for the substantive analyses. The results are presented in Table 3. H1 proposes that living a calling has a positive effect on nursing performance. Results showed that living a calling was not significantly related to nursing performance (B = 0.05, p > .10). Thus, H1 was not supported. Results also revealed that living a calling was significantly related to clinical care (B = 0.60, p < .01) and relational care (B = 0.57, p < .01). Clinical care (B = 0.16, p < .01) and relational care (B = 0.11, p < .01) were also significantly related to nursing performance. H2 and H3 state that clinical care and relational care each mediate the positive relationship between living a calling and nursing performance. As shown in Table 4, clinical care (indirect effect = 0.10, 95% bias‐corrected confidence interval [BC CI] = [.001, 0.208]) and relational care (indirect effect = 0.08, 95% BC CI = [0.018, 0.149]) both mediated the relationship between living a calling and nursing performance. The BC CIs were calculated with 5,000 bootstrap samples. Thus, H2 and H3 were supported.

Table 2.

Descriptive statistics, reliabilities and correlations

Range Mean SD 1 2 3 4 5 6 7 8 9
1. Age 18–60 32.32 7.25 1
2. Sex a 0–1 0.23 0.42 0.08 1
3. Nurse tenure 1–36 9.27 6.94 0.84** 0.00 1
4. Work meaning 1–7 6.24 0.94 0.11* 0.14* 0.06 0.97
Focal variables
5. Living a calling 1–7 6.48 0.70 0.08 0.00 0.08 0.66** 0.91
6. Clinical care 1–7 6.58 0.59 0.11 −0.07 0.16** 0.53** 0.75** 0.94
7. Relational care 1–7 6.42 0.75 0.14* 0.02 0.13* 0.62** 0.67** 0.79** 0.95
8. Perceived supervisor support 1–7 6.25 0.96 0.07 0.09 0.06 0.69** 0.69** 0.59** 0.62** 0.98
9. Nursing performance 1–5 4.65 0.47 0.14* 0.08 0.12* 0.72** 0.65** 0.64** 0.67** 0.62** 0.95
Open in a new tab

N = 339. Cronbach's alpha coefficients are shown in boldface on the diagonal.

a

Sex: 1 = male; 0 = female.

*

p < .05; ** p < .01.

Table 3.

Moderated mediation path model

Clinical care Relational care Work meaning Nursing performance
Control variables
Age −0.01* (0.01) 0.003 (0.01) 0.01 (0.01) 0.002 (0.004)
Sex −0.10* (0.05) −0.003 (0.07) 0.20* (0.08) 0.03 (0.04)
Nurse tenure 0.02** (0.01) 0.01 (0.01) −0.01 (0.01) 0.00 (0.004)
Independent variable
Living a calling 0.60** (0.05) 0.57** (0.06) 0.60** (0.08) 0.05 (0.04)
Mediators
Clinical care 0.16** (0.05)
Relational care 0.11** (0.04)
Work meaning 0.22** (0.02)
Moderating effects
Perceived supervisor support (PSS) 0.11** (0.03) 0.25** (0.05) 0.44** (0.05)
Living a calling X PSS 0.11** (0.04) 0.14** (0.04) 0.18** (0.06)
R 2 0.60 0.51 0.56 0.62
Open in a new tab

N = 339. Unstandardized regression coefficients are reported with standard errors in parentheses.

The coding of the dummy variables is presented in Table 1.

*

p < .05; ** p < .01.

Table 4.

Mediation and moderated mediation effects

Indirect effects (SE) 95% BC CI
Mediation effects
Living a calling → Clinical care → Nursing performance 0.10 (0.05) 0.001, 0.208
Living a calling → Relational care → Nursing performance 0.08 (0.03) 0.018, 0.149
Moderated mediation effects
Living a calling → Clinical care → Nursing performance
Moderated mediation index 0.02 (0.01) 0.001, 0.054
Perceived supervisor support (low) 0.08 (0.04) 0.001, 0.175
Perceived supervisor support (high) 0.11 (0.05) 0.005, 0.221
Living a calling → Relational care → Nursing performance
Moderated mediation index 0.02 (0.01) 0.001, 0.044
Perceived supervisor support (low) 0.05 (0.02) 0.012, 0.107
Perceived supervisor support (high) 0.07 (0.03) 0.020, 0.159
Open in a new tab

N = 339. Unstandardized regression coefficients are reported, with standard errors in parentheses. Bootstrap sample size = 5,000.

H4 proposes that PSS strengthens the positive relationship between living a calling and clinical care, H5 proposed that PSS would strengthen the positive relationship between living a calling and relational care. As shown in Table 3, statistically significant interactions were found between PSS and living a calling on clinical care (B = 0.11, p < .01) and relational care (B = 0.14, p < .01). Thus, H4 and H5 were supported. These interaction effects are plotted in Figure 2 at high and low values of PSS, defined as 1 standard deviation above and below the mean value, respectively (Cohen et al., 2003).

Figure 2.

Figure 2

Open in a new tab

(a) The interaction effect of living a calling and perceived supervisor support on clinical care. (b) The interaction effect of living a calling and perceived supervisor support on relational care

H6 proposes that PSS moderates the indirect relationship between living a calling and nursing performance through clinical care. As shown in Table 4, the index of moderated mediation (Hayes, 2015)—that is the product term of the interaction effect between PSS and living a calling on clinical care and the direct effect of clinical care on nursing performance—was statistically significant (index = 0.02, 95% BC CI = [.001, 0.054]). Thus, H6 was supported. H7 proposes that PSS moderates the indirect relationship between living a calling and nursing performance through relational care. The conditional indirect effect of living a calling on nursing performance through relational care was statistically significant (index = 0.02, 95% BC CI = [0.001, 0.044]). Thus, H7 was also supported.

5. DISCUSSION

In this study, we used a moderated mediation model to examine the effect of living a calling on nursing performance during the fight against COVID‐19 via clinical care and relational care. Using Model 7 of the SPSS PROCESS macro, the analyses revealed evidence that strongly supported our hypotheses. Living a calling had a positive indirect relationship with nursing performance through clinical and relational care. PSS moderated the direct relationships of living a calling on both clinical care and relational care, and the positive indirect effects of living a calling on nursing performance. These findings may have important implications for nurses.

First, our study provides theoretical clarification of and empirical evidence for understanding how and when living out a calling affects nursing performance during the fight against COVID‐19. Considering that nursing performance is vital to quality patient care and safety (Terzioglu et al., 2016), it is important to examine the factors that lead to high nursing performance. Although infectious disease outbreaks present enormous challenges (Fauci & Morens, 2012), our study found that front‐line nurses who live out their calling in their work performed effectively during such outbreaks. This extends the research on living a calling, which has focused mostly on stable environments (Cardador et al., 2011; Duffy et al., 2011; Yim & Fock, 2013).

In addition, our study extends the nomological network of living a calling by demonstrating its associations with nurses’ caring abilities. In particular, we demonstrate the associations between living a calling and clinical and relational care, which have not been previously hypothesized or shown. This finding is not surprising, because caring is central to the nursing profession (Simmons & Cavanaugh, 2000) and even more important during infectious disease outbreaks. Nurses with intense callings push themselves to provide clinical and relational care, which are two important caring abilities that determine their performance (Feo et al., 2020). Quality clinical care and relational care also improve patient satisfaction (Calong & Soriano, 2018).

Our finding that PSS strengthens the relationships between living a calling and clinical and relational care is also important. Front‐line nurses who believe they are living a calling in their nursing profession are likely to be engaged in activities such as clinical and relational care (Cardador et al., 2011; Duffy et al., 2011). We found the effect to be stronger when nurses perceive adequate support from their supervisors. When supervisors show that they care about and value their front‐line nurses, they initiate social exchange processes, which instil a sense of obligation among subordinates and motivate them to reciprocate (Goussinsky & Livne, 2016; Sarwar et al., 2020). In an outbreak situation, such an obligation to reciprocate may be expressed by exhibiting a high degree of clinical and relational care for infected patients (Lam et al., 2018). Thus, front‐line nurses who perceive favourable treatment from their supervisors (Shanock & Eisenberger, 2006) are likely to pass on the same treatment to their patients.

5.1. Implications for nursing management

As COVID‐19 has shown, infectious disease outbreaks can be intense and long‐lasting. As such, it is important for nurse managers to recruit individuals who believe they have a mission and calling to fulfil. Training such people to be nurses is easier, and when they are deployed, they will be willing to make sacrifices and work long hours to succeed, despite any obstacles they encounter. Therefore, surveys measuring calling values should be administered when nurses are being recruited. For front‐line nurses who are already employed, intervention programmes could be developed to enhance the meaning they attach to their nursing job to help them live their calling (Duffy & Dik, 2013). Career development workshops and career educational interventions could be established to enhance nurses’ ability to discern and live out their calling (Dik & Steger, 2008; Duffy & Dik, 2013) and to improve their performance. Studies have found that when employees are satisfied with their jobs (Thompson & Bunderson, 2019), have higher vocational self‐clarity (Dik & Duffy, 2009), and are free to make career choices (work volition; Dik & Duffy, 2009), they are able to live out their calling. As such, we suggest that by reducing nurses’ burnout (Jager et al., 2017), giving them autonomy and making them happy with their job, nurse managers can increase nurses’ ability to discern and live out their calling. Last, our results showed that leaders were essential in outbreak situations, as PSS enhanced the indirect relationship between living a calling and nursing performance through clinical and relational care. Therefore, supervisors should receive ongoing training so they can support nurses in trying times.

6. LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH

We used a cross‐sectional study design. Thus, we cannot draw any conclusions about a causal relationship between living a calling and nursing performance. In addition, the data collection process was based on self‐reporting. In future research, a longitudinal and multiple source design should be applied to test our model. Finally, although participation in the study was voluntary, head nurses were involved in the sample recruitment, raising concerns about convenient sampling. This should be addressed in future studies.

7. CONCLUSION

Infectious disease outbreaks have become prevalent worldwide in recent times. Although nursing requires high levels of performance, outbreaks such as COVID‐19 bring daunting challenges that can increase stress levels and decrease the performance of front‐line nurses. Drawing on WCT, we show that the front‐line nurses who perceive themselves as living a calling in their jobs exhibited superior nursing performance during the COVID‐19 outbreak through the mediating effects of clinical and relational care.

ETHICAL APPROVAL

The present study was approved by the Medical Ethics Committee at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University (approval number: Research 20200522–30).

ACKNOWLEDGEMENT

This research was supported in part by the research grant from the Department of Education of Zhejiang Province (grant number Y201738830) awarded to Yan Zhou, and the National Natural Science Foundation of China (grant number 71902092) awarded to Jie Wang.

Zhou Y, Adom Asante E, Zhuang Y, Wang J, Zhu Y, Shen L. Surviving an infectious disease outbreak: How does nurse calling influence performance during the COVID‐19 fight?. J Nurs Manag.2021;29:421–431. 10.1111/jonm.13181

REFERENCES

  1. Al‐Ahmadi, H. (2009). Factors affecting performance of hospital nurses in Riyadh Region, Saudi Arabia. International Journal of Health Care Quality Assurance, 22(1), 40–54. 10.1108/09526860910927943 [DOI] [PubMed] [Google Scholar]
  2. Alghamdi, M. G. (2016). Nursing workload: A concept analysis. Journal of Nursing Management, 24(4), 449–457. 10.1111/jonm.12354 [DOI] [PubMed] [Google Scholar]
  3. Al‐Hamdan, Z. , Oweidat, I. A. , Al‐Faouri, I. , & Codier, E. (2017). Correlating Emotional Intelligence and Job Performance Among Jordanian Hospitals’ Registered Nurses. Nursing Forum, 52(1), 12–20. 10.1111/nuf.12160 [DOI] [PubMed] [Google Scholar]
  4. Amarat, M. , Akbolat, M. , Ünal, Ö. , & Güneş Karakaya, B. (2019). The mediating role of work alienation in the effect of workplace loneliness on nurses’ performance. Journal of Nursing Management, 27(3), 553–559. 10.1111/jonm.12710 [DOI] [PubMed] [Google Scholar]
  5. Baack, S. , & Alfred, D. (2013). Nurses’ Preparedness and Perceived Competence in Managing Disasters. Journal of Nursing Scholarship, 45(3), n/a‐n/a. 10.1111/jnu.12029 [DOI] [PubMed] [Google Scholar]
  6. Brady, G. P. , & Cummings, G. G. (2010). The influence of nursing leadership on nurse performance: A systematic literature review. Journal of Nursing Management, 18(4), 425–439. 10.1111/j.1365-2834.2010.01100.x [DOI] [PubMed] [Google Scholar]
  7. Brislin, R. W. (1986). Translation and content analysis of oral and written materials. In Triandis H. C., & Berry J. W. (Eds.), Handbook of cross‐cultural psychology, Vol. 2 (pp. 389–444). Allyn & Bacon. [Google Scholar]
  8. Calong, K. C. , & Soriano, G. P. (2018). Caring behavior and patient satisfaction: Merging for satisfaction. International Journal of Caring Sciences, 11(2), 697. www.internationaljournalofcaringsciences.org [Google Scholar]
  9. Cardador, M. T. , Dane, E. , & Pratt, M. G. (2011). Linking calling orientations to organizational attachment via organizational instrumentality. Journal of Vocational Behavior, 79(2), 367–378. 10.1016/j.jvb.2011.03.009 [DOI] [Google Scholar]
  10. Chertow, D. S. , Kleine, C. , Edwards, J. K. , Scaini, R. , Giuliani, R. , & Sprecher, A. (2014). Ebola virus disease in West Africa — Clinical manifestations and management. New England Journal of Medicine, 371(22), 2054–2057. 10.1056/NEJMp1413084 [DOI] [PubMed] [Google Scholar]
  11. Cho, H. , & Han, K. (2018). Associations among nursing work environment and health‐promoting behaviors of nurses and nursing performance quality: A multilevel modeling approach. Journal of Nursing Scholarship, 50(4), 403–410. 10.1111/jnu.12390 [DOI] [PubMed] [Google Scholar]
  12. Chung, B. P. M. , Wong, T. K. S. , Suen, E. S. B. , & Chung, J. W. Y. (2005). SARS: Caring for patients in Hong Kong. Journal of Clinical Nursing, 14(4), 510–517. 10.1111/j.1365-2702.2004.01072.x [DOI] [PubMed] [Google Scholar]
  13. Cohen, J. , Cohen, P. , West, S. , & Aiken, L. (2003). Applied multiple regression/correlation analysis for the behavioral sciences. Taylor & Francis. [Google Scholar]
  14. Cossette, S. , Cote, J. K. , Pepin, J. , Ricard, N. , & D’Aoust, L.‐X. (2006). A dimensional structure of nurse‐patient interactions from a caring perspective: Refinement of the Caring Nurse‐Patient Interaction Scale (CNPI‐Short Scale). Journal of Advanced Nursing, 55(2), 198–214. 10.1111/j.1365-2648.2006.03895.x [DOI] [PubMed] [Google Scholar]
  15. Dik, B. J. , & Duffy, R. D. (2009). Calling and vocation at work: Definitions and Prospects for Research and Practice. The Counseling Psychologist, 37(3), 424–450. 10.1177/0011000008316430 [DOI] [Google Scholar]
  16. Dik, B. J. , & Steger, M. F. (2008). Randomized trial of a calling‐infused career workshop incorporating counselor self‐disclosure. Journal of Vocational Behavior, 73(2), 203–211. 10.1016/j.jvb.2008.04.001 [DOI] [Google Scholar]
  17. Dobrow, S. R. , & Tosti‐Kharas, J. (2011). Calling: The development of a scale measure. Personnel Psychology, 64(4), 1001–1049. 10.1111/j.1744-6570.2011.01234.x [DOI] [Google Scholar]
  18. Duffy, R. D. , Allan, B. A. , & Bott, E. M. (2012). Calling and life satisfaction among undergraduate students: Investigating mediators and moderators. Journal of Happiness Studies, 13(3), 469–479. 10.1007/s10902-011-9274-6 [DOI] [Google Scholar]
  19. Duffy, R. D. , & Autin, K. L. (2013). Disentangling the link between perceiving a calling and living a calling. Journal of Counseling Psychology, 60(2), 219–227. 10.1037/a0031934 [DOI] [PubMed] [Google Scholar]
  20. Duffy, R. D. , & Dik, B. J. (2013). Research on calling: What have we learned and where are we going? Journal of Vocational Behavior, 83(3), 428–436. 10.1016/j.jvb.2013.06.006 [DOI] [Google Scholar]
  21. Duffy, R. D. , Dik, B. J. , Douglass, R. P. , England, J. W. , & Velez, B. L. (2018). Work as a calling: A theoretical model. Journal of Counseling Psychology, 65(4), 423–439. 10.1037/cou0000276 [DOI] [PubMed] [Google Scholar]
  22. Duffy, R. D. , Dik, B. J. , & Steger, M. F. (2011). Calling and work‐related outcomes: Career commitment as a mediator. Journal of Vocational Behavior, 78(2), 210–218. 10.1016/j.jvb.2010.09.013 [DOI] [Google Scholar]
  23. Eisenberger, R. , Armeli, S. , Rexwinkel, B. , Lynch, P. D. , & Shanock, R. L. (2001). Reciprocation of perceived organizational support. Journal of Applied Psychology, 86(1), 42–51. 10.1037/0021-9010.86.1.42 [DOI] [PubMed] [Google Scholar]
  24. Eisenberger, R. , Stinglhamber, F. , Vandenberghe, C. , Sucharski, I. L. , & Shanock, R. L. (2002). Perceived supervisor support: Contributions to perceived organizational support and employee retention. Journal of Applied Psychology, 87(3), 565–573. 10.1037/0021-9010.87.3.565 [DOI] [PubMed] [Google Scholar]
  25. Expósito, J. S. , Costa, C. L. , Agea, J. L. D. , Izquierdo, M. D. C. , & Rodríguez, D. J. (2018). Ensuring relational competency in critical care: Importance of nursing students’ communication skills. Intensive and Critical Care Nursing, 44, 85–91. 10.1016/j.iccn.2017.08.010 [DOI] [PubMed] [Google Scholar]
  26. Fauci, A. S. , & Morens, D. M. (2012). The perpetual challenge of infectious diseases. New England Journal of Medicine, 366(5), 454–461. 10.1056/NEJMra1108296 [DOI] [PubMed] [Google Scholar]
  27. Feo, R. , Conroy, T. , Wiechula, R. , Rasmussen, P. , & Kitson, A. (2020). Instruments measuring behavioural aspects of the nurse–patient relationship: A scoping review. Journal of Clinical Nursing, 29(11–12), 1808–1821. 10.1111/jocn.14947 [DOI] [PubMed] [Google Scholar]
  28. Fitzpatrick, J. M. , While, A. E. , & Roberts, J. D. (1997). Measuring clinical nurse performance: Development of the King’s nurse performance scale. International Journal of Nursing Studies, 34(3), 222–230. 10.1016/s0020-7489(97)00009-6 [DOI] [PubMed] [Google Scholar]
  29. Gebbie, K. , & Qureshi, K. (2002). Emergency and disaster preparedness: Core competencies for nurses: What every nurse should but may not know. AJN the American Journal of Nursing, 102(1), 46–51. https://journals.lww.com/anesthesia-analgesia/00000446-200201000-00023.fulltext [DOI] [PubMed] [Google Scholar]
  30. Ghislieri, C. , Cortese, C. G. , Molino, M. , & Gatti, P. (2019). The relationships of meaningful work and narcissistic leadership with nurses’ job satisfaction. Journal of Nursing Management, 27(8), 1691–1699. 10.1111/jonm.12859 [DOI] [PubMed] [Google Scholar]
  31. Goussinsky, R. , & Livne, Y. (2016). Coping with interpersonal mistreatment: The role of emotion regulation strategies and supervisor support. Journal of Nursing Management, 24(8), 1109–1118. 10.1111/jonm.12415 [DOI] [PubMed] [Google Scholar]
  32. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression‐based approach. Guilford Press. [Google Scholar]
  33. Hayes, A. F. (2015). An index and test of linear moderated mediation. Multivariate Behavioral Research, 50(1), 1–22. 10.1080/00273171.2014.962683 [DOI] [PubMed] [Google Scholar]
  34. Henderson, A. , & Prescott, C. (2020). Re‐envisaging continuing professional development to improve patient outcomes. Nurse Education Today, 89, 104402. 10.1016/j.nedt.2020.104402 [DOI] [PubMed] [Google Scholar]
  35. IBM Corp . (2017). IBM SPSS Statistics for Windows (Version 25.0.).
  36. Jager, A. J. , Tutty, M. A. , & Kao, A. C. (2017). Association between physician burnout and identification with medicine as a calling. Mayo Clinic Proceedings, 92(3), 415–422. 10.1016/j.mayocp.2016.11.012 [DOI] [PubMed] [Google Scholar]
  37. Kim, S. S. , Shin, D. , Vough, H. C. , Hewlin, P. F. , & Vandenberghe, C. (2018). How do callings relate to job performance? The role of organizational commitment and ideological contract fulfillment. Human Relations, 71(10), 1319–1347. 10.1177/0018726717743310 [DOI] [Google Scholar]
  38. Koh, Y. , Hegney, D. , & Drury, V. (2012). Nurses’ perceptions of risk from emerging respiratory infectious diseases: A Singapore study. International Journal of Nursing Practice, 18(2), 195–204. 10.1111/j.1440-172X.2012.02018.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Lam, S. K. K. , Kwong, E. W. Y. , Hung, M. S. Y. , Pang, S. M. C. , & Chiang, V. C. L. (2018). Nurses’ preparedness for infectious disease outbreaks: A literature review and narrative synthesis of qualitative evidence. Journal of Clinical Nursing, 27(7‐8), e1244–e1255. 10.1111/jocn.14210 [DOI] [PubMed] [Google Scholar]
  40. Lee, A. Y. P. , Chen, I. H. , & Chang, P. C. (2018). Sense of calling in the workplace: The moderating effect of supportive organizational climate in Taiwanese organizations. Journal of Management & Organization, 24(1), 129. 10.1017/jmo.2016.16 [DOI] [Google Scholar]
  41. Lee, T. W. , & Ko, Y. K. (2010). Effects of self‐efficacy, affectivity and collective efficacy on nursing performance of hospital nurses. Journal of Advanced Nursing, 66(4), 839–848. 10.1111/j.1365-2648.2009.05244.x [DOI] [PubMed] [Google Scholar]
  42. Leininger, M. (1981). The phenomenon of caring: importance, research questions and theoretical considerations. In Leininger M. (Ed.), In caring, an essential human need: Proceedings of three conferences (Issue 2, pp. 3–17). Wayne State University Press. 10.1111/j.1547-5069.1994.tb00927.x [DOI] [Google Scholar]
  43. Liu, H. , & Liehr, P. (2009). Instructive messages from Chinese nurses’ stories of caring for SARS patients. Journal of Clinical Nursing, 18(20), 2880–2887. 10.1111/j.1365-2702.2009.02857.x [DOI] [PubMed] [Google Scholar]
  44. Mo, Y. , Deng, L. , Zhang, L. , Lang, Q. , Liao, C. , Wang, N. , Qin, M. , & Huang, H. (2020). Work stress among Chinese nurses to support Wuhan for fighting against the COVID‐19 epidemic. Journal of Nursing Management, 10.1111/jonm.13014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Pai, H. C. , Ko, H. L. , Eng, C. J. , & Yen, W. J. (2017). The mediating effect of self‐reflection and learning effectiveness on clinical nursing performance in nursing students: A follow‐up study. Journal of Professional Nursing, 33(4), 287–292. 10.1016/j.profnurs.2017.01.003 [DOI] [PubMed] [Google Scholar]
  46. Praskova, A. , Hood, M. , & Creed, P. A. (2014). Testing a calling model of psychological career success in Australian young adults: A longitudinal study. Journal of Vocational Behavior, 85(1), 125–135. 10.1016/j.jvb.2014.04.004 [DOI] [Google Scholar]
  47. Qureshi, K. , Gershon, R. , Yamada, S. , & Li, D. (2013). Factors related to essential workers’ ability and willingness to work and comply with personal infection control protocol during a large scale influenza pandemic in Hawaii WTC evacuation study view project substance use before and during pregnancy in Hawaii view project. Disaster and Emergency Medicine Journal, 2(1), 4–11. [Google Scholar]
  48. Rawat, A. , & Nadavulakere, S. (2015). Examining the outcomes of having a calling: Does context matter? Journal of Business and Psychology, 30(3), 499–512. 10.1007/s10869-014-9378-1 [DOI] [Google Scholar]
  49. Sarwar, A. , Naseer, S. , & Zhong, J. Y. (2020). Effects of bullying on job insecurity and deviant behaviors in nurses: Roles of resilience and support. Journal of Nursing Management, 28(2), 267–276. 10.1111/jonm.12917 [DOI] [PubMed] [Google Scholar]
  50. Schluter, J. , Winch, S. , Holzhauser, K. , & Henderson, A. (2008). Nurses' moral sensitivity and hospital ethical climate: A literature review. Nursing Ethics, 15(3), 304–321. 10.1177/0969733007088357 [DOI] [PubMed] [Google Scholar]
  51. Shanock, L. R. , & Eisenberger, R. (2006). When supervisors feel supported: Relationships with subordinates’ perceived supervisor support, perceived organizational support, and performance. Journal of Applied Psychology, 91(3), 689–695. 10.1037/0021-9010.91.3.689 [DOI] [PubMed] [Google Scholar]
  52. Shih, F.‐J. , Turale, S. , Lin, Y.‐S. , Gau, M.‐L. , Kao, C.‐C. , Yang, C.‐Y. , & Liao, Y.‐C. (2009). Surviving a life‐threatening crisis: Taiwan’s nurse leaders’ reflections and difficulties fighting the SARS epidemic. Journal of Clinical Nursing, 18(24), 3391–3400. 10.1111/j.1365-2702.2008.02521.x [DOI] [PubMed] [Google Scholar]
  53. Simmons, P. R. , & Cavanaugh, S. H. (2000). Relationships among student and graduate caring ability and professional school climate. Journal of Professional Nursing, 16(2), 76–83. 10.1016/S8755-7223(00)80019-8 [DOI] [PubMed] [Google Scholar]
  54. Steger, M. F. , Dik, B. J. , & Duffy, R. D. (2012). Measuring meaningful work: The Work and Meaning Inventory (WAMI). Journal of Career Assessment, 20(3), 322–337. 10.1177/1069072711436160 [DOI] [Google Scholar]
  55. Terzioglu, F. , Temel, S. , & Uslu Sahan, F. (2016). Factors affecting performance and productivity of nurses: Professional attitude, organisational justice, organisational culture and mobbing. Journal of Nursing Management, 24(6), 735–744. 10.1111/jonm.12377 [DOI] [PubMed] [Google Scholar]
  56. Thompson, J. A. , & Bunderson, J. S. (2019). Research on Work as a Calling…and How to Make It Matter. Annual Review of Organizational Psychology and Organizational Behavior, 6(1), 421–443. 10.1146/annurev-orgpsych-012218-015140 [DOI] [Google Scholar]
  57. Walpita, Y. N. , & Arambepola, C. (2020). High resilience leads to better work performance in nurses: Evidence from South Asia. Journal of Nursing Management, 28(2), 342–350. 10.1111/jonm.12930 [DOI] [PubMed] [Google Scholar]
  58. Watson, J. (2008). Nursing: The philosophy and science of caring (revised edition). In Caring in nursing classics: An essential resource (pp. 243–264). University Press of Colorado. [Google Scholar]
  59. Wayne, S. J. , Shore, L. M. , & Liden, R. C. (1997). Perceived organizational support and leader‐member exchange: A social exchange perspective. Academy of Management Journal, 40(1), 82–111. 10.5465/257021 [DOI] [Google Scholar]
  60. Wrzesniewski, A. , McCauley, C. , Rozin, P. , & Schwartz, B. (1997). Jobs, careers, and callings: People’s relations to their work. Journal of Research in Personality, 31(1), 21–33. 10.1006/jrpe.1997.2162 [DOI] [Google Scholar]
  61. Yim, F. , & Fock, H. (2013). Social responsibility climate as a double‐edged sword: How employee‐perceived social responsibility climate shapes the meaning of their voluntary work? Journal of Business Ethics, 114(4), 665–674. 10.1007/s10551-013-1712-4 [DOI] [Google Scholar]

Articles from Journal of Nursing Management are provided here courtesy of Wiley

RESOURCES