DISCUSSION

The survey described in this study was conducted during the initial phase of the COVID-19 outbreak in South Korea when there were 28 confirmed cases in the country and 3 patients were admitted to this hospital. The study revealed that approximately 60% of hospital workers were willing to accept their work duties, which is similar to previous results reported on the willingness of hospital workers to work during an infectious disease outbreak.^{Reference Koh, Lim and Chia7-Reference Gershon, Magda and Qureshi10} However, 8.1% of respondents thought about quitting their jobs due to the risk of COVID-19 infection, which is lower than that reported in a previous study, where 25.9% had considered leaving their jobs.^{Reference Shiao, Koh and Lo12} The results could be explained by the survey conducted in the initial phases of the COVID-19 outbreak and respondents’ perceived susceptibility of infection as low. However, we also found that respondents who considered quitting their job in the early stages of the outbreak also existed. Thus, the analysis of intention to work will be important for the preemptive response in the outbreak of infectious disease, and further studies are needed to monitor changes in hospital employees’ willingness to work and their consideration of quitting their jobs as the intensity of the outbreak changes.

The results of our study showed that, although the proportion of respondents who considered quitting their jobs was higher among nurses and first-line workers than other employees, there was no difference in the willingness to work based on task participation. This could be associated with the nature of hospital workers’ roles and perceived obligation to respond to an emergency situation.^{Reference Irvin, Cindrich, Patterson and Southall13,Reference Damery, Draper and Wilson14} A previous study reported similar results showing that health care workers’ perceived responsibility was associated with the willingness to work during an infectious disease outbreak.^{Reference Cone and Cummings15}

The multivariate regression analyses indicated that respondents who had little control over their anxiety were unwilling to accept their tasks, while factors such as “feeling more stress” and “having a hard time controlling fear” were positively associated with the consideration of quitting their jobs during the outbreak. This is in a similar context of a previous study, which reported that health care workers felt that they had little control of anxiety due to uncertainty and lack of information during the initial phase of the outbreak,^{Reference Charney, Rebmann and Flood5,Reference Chong, Wang and Hsieh9,Reference Maunder, Hunter and Vincent16} resulting in more stress. Some variables were adjusted for other variables, leading to statistically non-significant results in our analyses. For instance, “perceived job risk” could have been replaced by “possibility of death” for consideration of quitting their jobs. This could be explained by the notion that the former factor focuses on risk of infection, whereas the latter focuses on the risk of a fatal consequence. Similarly, anxiety of self would be more important for consideration of quitting their jobs and willingness to accept their work than perceived stigma and worry for others.^{Reference Tzeng and Yin17} This could be interpreted as personal fear having more impact than concern for their relationship with other people.

It is worth noting in our study that the evaluation of the hospital response was significantly related to the intention to work. Multivariate regression analyses showed that respondents who positively assessed their hospital’s response were more willing to accept their work and have less consideration of quitting during the COVID-19 outbreak. This indicates that the role of the hospital, such as communication with employees, response to safety, and care of staff, is quite important during an infectious disease outbreak. Several previous studies have reported that health care workers recognize hospital response and support as important factors. The intention to work and willingness to work increase when hospitals provide personal protective equipment (PPE)^{Reference Martin18-Reference Seale, Leask, Po and MacIntyre20} and accurate information appropriately.^{Reference Gershon, Magda and Qureshi10,Reference Garrett, Park and Redlener21}

Several recommendations arise from this study that may prevent a negative attitude toward the work intention of hospital employees during the initial phase of an infectious disease outbreak. First, the response of the hospital should be emphasized. Hospitals need to supervise and monitor the safety of employees by providing appropriate PPE and mental health support during an outbreak. Previous studies have reported that fear and anxiety are associated with a willingness to work,^{Reference Wong, Kung and Cheung8,Reference Tzeng and Yin22} and the provision of infection control measures would positively affect the work intention of hospital workers.^{Reference Irvin, Cindrich, Patterson and Southall13,Reference Martin18,Reference Mackler, Wilkerson and Cinti19,Reference Garrett, Park and Redlener21} In particular, hospitals need to consider the types of tasks that workers conduct during emergency situations. The results of our study showed that perceptions of stress, anxiety, and fear of infection in first-line workers are higher than those of other workers during the COVID-19 outbreak. Thus, frontline workers should receive priority for support from the hospital, not only with provisions for infection control measures, but also intervention for psychological health (eg, psychological brochures, psychotherapy, and counseling),^{Reference Kang, Ma and Chen23} which would be helpful for alleviating an unwillingness to work. Providing sufficient training and education is another important factor that affects the work intention of hospital employees. Continuous education and training should be provided to adequately deal with public health emergencies in the future.^{Reference Liu, Luo and Haase24,Reference Shi, Wang and Yang25} The sharing of pandemic preparedness planning, information, and communication between the employer and employees is important not only for increasing the willingness to work,^{Reference Garrett, Park and Redlener21} but also for improving the trust in employers.^{Reference Gershon, Magda and Qureshi10,Reference Ives, Greenfield and Parry26} A reciprocal relationship between the employer and employee should also be constructed.

It is also necessary for organizations to ensure the safety of hospital workers’ families. In previous studies, the intention to work was highly associated with the safety of health care workers’ families.^{Reference Seale, Leask, Po and MacIntyre20,Reference Garrett, Park and Redlener21,Reference Qureshi, Gershon and Sherman27,Reference Nickell, Crighton and Tracy28} Hospital employees working during an outbreak are often concerned about their families due to possibility of infection, which becomes a major barrier for the willingness to work. The willingness to work has been shown to increase when PPE is made available for workers’ families.^{Reference Garrett, Park and Redlener21} Thus, support for employees’ families would be effective for mitigating the concern of workers. Finally, compensation plays a key role in maintaining a sufficient health care workforce during the COVID-19 outbreak. Health care personnel reported that a positive incentive to keep working during the pandemic was related to special compensation, such as increased wages, additional vacation, and recognition,^{Reference Shiao, Koh and Lo12,Reference Khalid, Khalid and Qabajah29} whereas the intention to work did not increase when they were threatened by employers of losing their license.^{Reference Martin18} Therefore, hospitals and governments should develop and implement guidelines and policies to incentivize hospital personnel to remain working during infectious disease outbreaks.

Our study had several limitations. First, we only reported on the work intention of hospital employees during the early stages of the COVID-19 outbreak. The severity of the situation in South Korea was relatively less serious than other areas of the world, which indicates that there is a possibility that the perceived threat and job attitude of health care workers were underestimated. Second, the survey was not conducted with structured questionnaires, which made it impossible to compare the results to previous studies. There were a few scales that were substituted with several variables using single items. In addition, the variables of health care workers’ perception of the provision of infection control measures were absent, such as N-95 masks, gowns, and gloves, which were frequently used in previous studies. Third, the respondents of our study were limited to a single tertiary hospital, which makes it difficult to compare to health care workers in other settings, such as primary health care. In addition, the number of respondents who were physicians was limited, so it was difficult to compare the results with other occupations. Finally, due to the exploratory nature of this study, theoretical models were absent. The purpose of our study was to determine the perception and attitude of hospital employees, rather than testing theoretical hypotheses. Therefore, it is difficult to postulate a systematic explanation for the result of this study.