Organizational factors associated with primary care nurses’ self-efficacy in pandemic response: a multilevel study in China

Abstract

Background

Building primary care nurses’ self-efficacy in the pandemic response has great potential to improve their well-being and work performance. We identified the organizational factors associated with their self-efficacy in pandemic response and propose potential management levers to guide primary care response for the pandemic.

Methods

We conducted a cross-sectional survey with 175 nurses working in 38 community health centres varying in size and ownership in Shanghai, Shenzhen, Tianjin, and Jinan. Guided by self-efficacy theory, 4 nurse-level factors and 2 organization-level factors were selected, and a linear regression model accounting for the cluster–robust standard errors was built to examine their association with primary care nurses’ self-efficacy in the pandemic response.

Results

Primary care nurses exhibited a high level of self-efficacy in responding to the pandemic (mean = 4.34, range: 0–5). For nurse-level factors, with a 1-point increase in job skill variety, job autonomy, work stress and perceived organizational support, primary care nurses’ pandemic response self-efficacy increased by 0.193 points, 0.127 points, 0.156 points, and 0.107 points, respectively. Concerning organization-level factors, each point of improvement in organizational structure, representing higher mechanical organizational structure, was associated with a 0.145-point increase in nurses’ self-efficacy.

Conclusions

Our study added the knowledge of organizational factors’ impact on the pandemic response self-efficacy among primary care nurses and identified the potential management levers for frontline primary care managers to build primary care nurses’ self-efficacy in the pandemic response.

Introduction

As an unprecedented global crisis, every country has been making great efforts to better respond to the coronavirus disease 2019 (COVID-19) pandemic during the past 3 years.¹ Global experiences show that high-performing response countries generally have a resilient and people-centred primary care system with a strong and well-supported health workforce.² Primary health care, as the frontline of the health system, is managing the major share of COVID-19-related care and will play the “first in and last out” role of managing the aftermath of the pandemic and the collateral damage caused by allocating resources to the COVID-19 response while inadvertently hindering access to various primary care service.^3,4 Primary care nurses, as the backbone of the primary care system, participate in processes of care with other primary care professionals (e.g. general practitioners and pharmacists) and are responsible for lots of specific responsibilities in the pandemic response, mainly including taking charge of vaccinations, monitoring community residents at risk, undertaking community testing, providing health education in infection control and risk management, as well as providing routine health services.^5,6 Despite acting as crisis management personnel, primary care nurses are not immune to the negative psychological consequences due to the high infection risk and heavy workload during the pandemic.⁷ A recent study reported that a considerable proportion of primary care nurses experience anxiety, depression, or stress, with a pooled prevalence rate of 39.6% during the pandemic.⁸

To guide further COVID-19 response and prepare for the next pandemic, there is an urgent need to find out potential approaches to maintain and improve primary care nurses’ well-being and work performance. Self-efficacy refers to “individuals’ beliefs about their capabilities to exercise control over their level of functioning and over events that affect lives”.⁹ Self-efficacy could motivate primary care nurses to persist longer when confronted with challenging tasks, eventually improving their well-being and maintaining the pandemic response’s sustainability.¹⁰ It has been proved to be the most proximal determinant of nurses’ competence, practice, and work performance in a variety of health care conditions, such as pediatric palliative care,¹¹ health management,¹² chronic conditions care,¹³ obstetric and newborn care,¹⁴ public health,¹⁵ and psychiatric care.¹⁶ However, there is a paucity of studies assessing nurses’ self-efficacy in responding to the pandemic in primary care. For the determinants of self-efficacy, earlier studies have linked several sociodemographic characteristics like working experience,¹¹ as well as personal psychological characteristics like technical practice,¹⁵ and role,¹⁶ with nurses’ self-efficacy, but with little knowledge of potentially modifiable factors in organizational domains, such as organizational structure and culture, variety and meaningfulness of tasks, and work-related social support.¹⁷

With China’s strict zero-COVID policy lifted in December 2022, community health centres (CHCs) are ramping up services (e.g. expanding vaccination, building more fever clinics, and promoting epidemic prevention knowledge) to ensure an effective and sustaining pandemic response. CHCs, as the main primary care provider in urban China, have 3 main categories of models, including government-owned and -managed CHCs, government-owned and hospital-managed CHCs, and privately owned and managed CHCs.¹⁸ They can provide primary care services, medical care services, and public health services by health care personnel consisting of general practitioners, public health doctors, registered nurses, pharmacists, laboratory technologists, and managerial and assistant staff.¹⁸ During this pandemic, primary care nurses in CHCs have to take increasing responsibility and face a heavy workload, as well as greater work intensification, which consequently influences their well-being and work performance. Hence, it is urgent to identify the modifiable organizational factors associated with primary care nurses’ self-efficacy in the COVID-19 response. This could help find out the feasible approach to build their self-efficacy and improve their well-being and work performance, which, in turn, enhances the capacity of emergency prevention, preparedness, and response, to deal with any future health emergencies. In this study, using data from 175 nurses employed in 38 CHCs in 4 large cities in China, we aimed to fill the gap in primary care nurses’ pandemic response self-efficacy and to examine the organizational factors associated with primary care nurses’ self-efficacy in the pandemic response from a management perspective and inform a better understanding of the influence of organizational domains on their self-efficacy. Our findings will help frontline primary care managers find out potential management levers to build primary care nurses’ self-efficacy in pandemic response and guide further primary care preparedness and response for the next health emergencies.

Methods

Data collection

We conducted a cross-sectional in-person survey of healthcare workers working in CHCs in China from November 2021 to May 2022. A convenience sample of 38 CHCs in Jinan (6 CHCs), Shenzhen (14 CHCs), Tianjin (8 CHCs), and Shanghai (10 CHCs) were surveyed based on the ownership and size of CHCs. For each CHC, nurses who were on duty were invited to complete the nurse questionnaire and the director of CHC completed the organizational survey. If the CHC had fewer than 5 nurses, all nurses were invited to complete the questionnaire. If the CHC had more than 5 nurses, at least 5 were invited.¹⁹ Data were collected using self-administered questionnaires, containing information, for example, sociodemographic characteristics, job characteristics, organizational characteristics, leadership, and quality of care. The completed questionnaires were returned directly to the researchers and were reviewed by the researcher on-site to ensure completeness. Finally, the data of 175 primary care nurses from 38 CHCs were collected, corresponding to a response rate of 100%.

Measures

Self-efficacy.

The self-efficacy of primary care nurses in the COVID-19 response was measured using one item with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree): “I have the confidence in making a contribution to the pandemic prevention and control.”

Guided by self-efficacy theory,²⁰ 2 organization-level factors (organizational structure and organizational culture) and 4 nurse-level factors (job skill variety, job autonomy, work stress, and perceived organizational support) were selected.

Measurements at organization level.

Organizational structure was measured using one item “The CHC emphasizes getting personnel to follow the formal procedures” with a 7-point scale (1 = strongly disagree, 7 = strongly agree).²¹ Organizational culture refers to a set of values, assumptions, and beliefs shared by members of an organization.²² The 20-item organizational culture survey based on Competing Values Framework was adopted to measure organizational culture.²³ The participants were asked to distribute 100 points between various organization descriptions, which were used to constitute 4 types of organization culture: group culture, developmental culture, hierarchical culture, and rational culture.²³ A binary variable, hierarchical culture (emphasizing rules and regulations) or non-hierarchical culture, was created to measure organizational culture.

Measurements at the nurse level.

Four individual-level variables were measured using items with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). (i) Job skill variety, depicted as the various activities involved in performing the work, was measured with an average score of 3 items, for example, “The job requires me to use different skills and abilities.” ²⁴ (ii) Job autonomy, referring to the degree to which the job offers individuals significant freedom, independence, and discretion for its implementation, was evaluated by one question “The job does not give me any opportunity for judgment independently and get the work done.” ²⁴ (iii) Work stress, the process by which workplace psychological experiences and demands produce both short-term and long-term impacts on mental and physical health,²⁵ was measured using the mean score of two statements: “The number of projects and or assignments I have is large.” and “The volume of work that must be accomplished in the assigned time is large.” ²⁶ (iv) Perceived organizational support, defined as the employees’ perception that the degree to which the organization they work for values their contribution and cares about their well-being, was measured using the mean score of six items, for example, “The organization cares about my well-being.”²⁷

Control variables.

Age, gender, education level, working experience at the nurse level, organizational size, organizational ownership, and accredited status at the organization level, were included as the covariates (see Table 1).

Statistical analysis

First, we leveraged descriptive statistics to report the basic characteristics of primary care nurses. We also tested the difference in self-efficacy between various characteristic values using variance analysis. Second, the Skewness/Kurtosis test was adopted to examine the distribution of our main predictors. The result has shown that the value of work stress and skill variety variables accorded with normal distribution, others were abnormal distribution. Accordingly, Spearman’s rank correlation was conducted to preliminary test the relationship between self-efficacy and main predictors. Third, due to 175 primary care nurses nested within 38 CHCs, we calculated the intraclass correlation coefficient for suitability of the hierarchical linear model and found that the most variance of primary care nurses’ self-efficacy can be explained within CHCs rather than between CHCs. Therefore, the hierarchical linear model was not necessary. We also did collinearity diagnostics analysis and found that the value of the variance inflation factor was all lower than 10, and the tolerance all ranged from 0 and 1, suggesting that there was no multicollinearity issue. Therefore, the linear regression model with cluster–robust standard errors was built to examine the relationship between organization-level and nurse-level factors and primary care nurses’ self-efficacy in pandemic response while controlling for basic characteristics. A value of P < 0.05 was considered significant. We did not impose imputation for the missing data (education and work stress each had a missing value) because the proportion of missing data was small (1.14% of the data).²⁸ Data analysis was performed using Stata 15.0.

Results

In our study, 175 primary care nurses from 38 CHCs were included in the analysis. Table 1 reports the basic characteristics of the participants. Most primary care nurses were female (98.29%) and had junior college/college degree (93.10%). The average age was 34.93 years, with an average working experience of 11 years. Meanwhile, more than half worked in government-managed (62.86%) and accredited (56.57%) CHCs. We further compared the self-efficacy score by various basic characteristics and all the differences were not statistically significant except the age.

Table 2 displays the means, standard deviations, and the correlation between organizational factors and primary care nurses’ self-efficacy in the pandemic response. Table 3 presents the mean value and standard deviation of primary care nurses’ self-efficacy grouped by hierarchical-oriented culture. Overall, primary care nurses exhibited a high level of self-efficacy in the pandemic response, with an average score of 4.34 out of 5. Only job skill variety and perceived organizational support as nurse-level predictors were positively correlated with primary care nurses’ self-efficacy. For the organization-level predictors, organizational structure was not found to be significantly correlated with primary care nurses’ self-efficacy. Also, no significant differences were found in self-efficacy between the CHCs with hierarchical-oriented culture or not.

Table 4 summarizes the result of the multivariate linear regression model for the association between organizational factors and primary care nurses’ self-efficacy in the pandemic response. After adjustment for covariates, we found some strong positive predictors of primary care nurses’ self-efficacy related to COVID-19 response. Specifically, at the nurse level, for every 1-point increase in job skill variety, job autonomy, work stress, and perceived organizational support, primary care nurses’ self-efficacy increased by 0.193 points (Coef. = 0.193, 95%CI = 0.049, 0.337), 0.127 points (Coef. = 0.127, 95%CI = 0.020, 0.234), 0.156 points (Coef. = 0.156, 95%CI = 0.048, 0.265), and 0.107 points (Coef. = 0.107, 95%CI = 0.001, 0.212) respectively. At the organization-level, each 1-point improvement in organizational structure was associated with a 0.145-point (Coef. = 0.145, 95%CI = 0.039, 0.251) increase in primary care nurses’ self-efficacy. Hierarchical-oriented culture (Coef. = 0.153, 95%CI = -0.123, 0.428) seemed to have a positive impact on primary care nurses’ self-efficacy, although this relationship was not statistically significant.

Discussion

This cross-sectional study enrolled 175 primary care nurses within 38 CHCs to identify the organizational factors predicting primary care nurses’ self-efficacy in the pandemic response in China. Overall, participants reported a relatively high level of self-efficacy in the pandemic response. A high level of job skill variety, job autonomy, work stress, perceived organizational support, as well as mechanical organizational structure, were linked to stronger primary care nurses’ self-efficacy related to the COVID-19 response. To our knowledge, this study provides the first empirical evidence of the association between organizational factors and primary care nurses’ self-efficacy in response to the pandemic, which may substantially guide further primary care response for the pandemic.

Our results demonstrated that a high level of job skill variety and autonomy were positively associated with primary care nurses’ self-efficacy in the pandemic response. Job characteristics theory postulates that skill variety and autonomy, as the core job dimensions, could trigger meaningfulness of the work and responsibility for work outcomes, which, in turn, lead to beneficial personal and work-related outcomes, which has been verified in previous studies related to nursing practitioners.^29,30 Equally, during the pandemic, primary care nurses not only provide regular care but also take charge of offering pandemic-related care for residents. As some of the pandemic-related tasks were new and there was no guideline or experience for them to learn, high job autonomy was likely to foster their feelings of personal responsibility for the pandemic response. Meanwhile, these changed work contents could motivate nurses to stretch their skills and abilities to overcome challenging tasks, which may prompt them to experience the meaningfulness of the job. Ultimately, the two positive psychological states acting as reinforcers were more likely to strengthen primary care nurses’ self-efficacy in the pandemic response.

Our findings suggested that work stress was positively related to primary care nurses’ COVID-19 response self-efficacy. Conversely, prior research has linked work stress with negative psychological responses among nursing professionals.³¹ This diverging result could be explained by the transactional stress theory, which suggests that the impact of stressful events on subsequent outcomes depends on the extent to which individuals evaluate the event meaningfully.³² Facing the critical situation of COVID-19, primary care nurses experience a strong sense of meaningfulness (e.g. responsibility, commitment, collective action), which could create a positive psychological response.^33,34 One study in China has verified that perceived work meaningfulness could function as the crucial buffer against the encroachment of COVID-19 on their work engagement and taking charge behaviors.³⁵ Thereby, primary care nurses voluntarily struggling to cope with COVID-19 in a professional role with great meaningfulness were more likely to report a high level of pandemic response self-efficacy.³⁶

We also found evidence to support that perceived organizational support was a positive predictor of primary care nurses’ self-efficacy in the pandemic response, which was consistent with the existing literature on the positive impact of perceived organizational support on nursing care.^30,37 For example, a study in the United States found that high perceived organizational support was associated with higher job satisfaction and a lower possibility of turnover among primary care nurses.³⁷ Based on the organizational support theory, perceived organizational support may prompt primary care nurses to perceive that they have sufficient resources and support to effectively perform the tasks associated with their role, lead them to generate a feeling of responsibility to value the organization, and fulfill their social and emotional needs through the caring, approval, and respect by their organizations.^27,38 This could facilitate primary care nurses to incorporate their organizational role into their social identity and make constructive efforts for the pandemic response with a high level of self-efficacy.

Our study demonstrated that mechanical organizational structure was a necessary condition for building primary care nurses’ COVID-19 response self-efficacy. The positive impact of mechanical organizational structure, a structure with a high level of hierarchy, has been reported in a previous study, which found that medical care institutions with clear role boundaries and responsibilities were linked with successful infection control.³⁹ As healthcare provision during the COVID-19 pandemic is characterized by rapid change, complexity, and uncertainty, the positive impact of hierarchical structure may be specific to this context. In China, medical institutions, including CHCs, are required by the Chinese government to strictly implement national technical guidelines for preventing and controlling COVID-19. Medical institutions follow the national guidelines and reinforce the operational norms of specific work content related to the COVID-19 response. Supported by the hierarchical system and structured guidelines, frontline healthcare workers were supported to rapidly shift their routine work content to pandemic-relevant activities. The organizational structure that supports the implementation of nationally structured guidelines could provide a clear sense of primary care nurses’ responsibilities and required actions, which could increase their self-efficacy in the pandemic response.

Our findings should be viewed in light of study limitations. First, given the cross-sectional design of this study, we only examined the association between organizational factors and primary care nurses’ self-efficacy in the pandemic response. A further longitudinal study would help us to examine the causal relationships. Second, this study was exploratory in nature, there remains a lack of a clear mechanism to explain how these organizational factors influence self-efficacy in pandemic response among primary care nurses. Further research should be conducted to discern the possible avenue. Third, in our study, the data on organizational structure and organizational culture were collected from the organizational managers, which might differ from that perceived by primary care nurses. Despite the limitations, our findings add to the important knowledge of which organizational factors may affect the primary care nurses’ self-efficacy in the pandemic response.

Conclusions

Our study informed our knowledge of organizational factors’ impact on the primary care nurses’ self-efficacy in the pandemic response and identified the key factors (including job skill variety and autonomy, work stress, perceived organizational support, and organizational structure) important to build primary care nurses’ self-efficacy in pandemic response. These findings could provide guidance (e.g. enhancing the skill training for personal ability development and emergency response, empowering practitioners, offering routine confidential mental health services, valuing the contributions of practitioners and care about their well-being, clarifying job responsibilities, and improving formal regulations) for primary care managers to foster a supportive organizational environment to build the self-efficacy of primary care nurses and ensure the effectiveness of pandemic preparedness and response in primary care.

Acknowledgments

The authors would like to thank all the coordinators and participants involved in this study.

Funding

This study was supported by the China National Natural Science Foundation grant number 72004179 and China Scholarship Council.

Conflict of interest

The authors declared that there is no conflict of interest.

Authors’ contributions

WW: study design, statistical analysis, and manuscript preparation and revision. RM: conception, data interpretation, and manuscript revision. TX: data collection, statistical analysis, data interpretation, and manuscript preparation.

Ethical approval

This study was approved by Xi’an Jiaotong University’s Ethics Committee (Approval No. 2020-1344). Written informed consents were obtained from all study respondents before data collection. All methods that we used adhered to the accepted guidelines for ethical reporting.

Data availability

Research data are not shared. The data will be shared on reasonable request with the corresponding author.

References