A correlational cross-sectional design was utilized in this study.

The study was conducted using online surveys distributed to nurses working in Jordanian hospitals. Jordan has four types of hospitals; private hospitals represent 57% of total health services, governmental 28%, military hospitals 13%, and university-affiliated hospitals 2% [20]. The study targeted nurses working in all health sectors in Jordan.

Convenience sampling was used to include 347 nurses from different hospitals in Jordan. Nurses working in hospitals, able to read and write English, and willing to participate were included in the study. The sample size was calculated with the G power program. The F test was utilized using an Alpha level of 0.05, a medium effect size of 0.20, and a power of 0.8. The estimated required sample size was at least 280 nurses.

Data collection started after obtaining ethical approval. Data were collected using an electronic self-administered questionnaire using Google forms that included a description of the study purpose, data collection procedure, and rights of the participants, followed by the consent statement. Networking and snowballing techniques of sampling were used to reach the target population. All submitted questionnaires were automatically saved in the researcher's private Google drive. Data collection occurred between May 1, 2020, and June 1, 2020.

The questionnaire used in this study was developed by Shi, Wang [16]. The 33-item survey questionnaire was designed to assess the knowledge and attitudes of medical staff (including nurses) in Chinese psychiatric hospitals regarding COVID-19 based on the study of Daugherty, Perl [12]. The questionnaire assessed three main variables: knowledge, attitudes, and willingness.

The participants were asked to report their experience caring for COVID-19 patients and any relevant training they had received (two items). They were also required to report the level of knowledge (10 items) and attitude (four items) in their ability to protect themselves and their patients from exposure to COVID-19 at work on a 5-point Likert-scale for some of the items (completely agree, agree, neither agree nor disagree, disagree and completely disagree). Two items were used to report participants' willingness to treat or care for patients with COVID-19. Finally, the participants were asked to report their behaviors and management practices (eight items) in caring for patients infected with the COVID-19 virus. Seven items were used to assess nurses' demographic characteristics, including hospital type, age, educational level, gender, marital status, job title, and living status. Only one question was modified from the original survey, “Have you had the experience treating or caring for psychiatric patients with confirmed or suspected COVID-19?” in which “psychiatric” was omitted. The questionnaire was distributed in the English language. Two experts in the field assessed content validity to ensure its appropriateness to the Jordanian culture and the study purpose. The Cronbach alpha reliability of the instrument in the current study was 0.76.

Ethical approval was obtained from the Scientific and Research Committee at Al-Ahlyyia Amman University-Faculty of Nursing (9-2019/2020). The data collection took place through an electronic self-administered questionnaire, the institutions obtained no permissions. Participation was voluntary, and nurses were assured that their responses would be confidential. The anonymity of the participants was ensured throughout the study. Data were secured in a password-protected computer. Permission was obtained from the author to use and adapt the questionnaire used in this study.

Data were analyzed using the Statistical Package for Social Science (SPSS) version 23 [21]. Descriptive statistics (i.e., mean, percentage, and standard deviation) were calculated to describe demographic characteristics and nurses’ knowledge and attitudes regarding COVID-19. All Likert-scale responses were dichotomized into completely agree/agree, neither agree nor disagree, and disagree/completely disagree and expressed in proportions. Binary logistic regression was used to identify predictors of willingness to work with COVID-19-infected patients. All hypotheses were tested as two-sided at a significance level of P≤0.05 and 95% confidence intervals.

Almost 56% of the nurses reported having the experience of treating or caring for patients with confirmed or suspected COVID-19. Although 55% of the nurses had finished a training program about COVID-19, 71.8% expressed willingness to care for patients suffering from COVID-19. The most common reasons for being unwilling to care for these patients included concerns about transmitting the infection to family members 50 (52.6%), concerns about transmitting the infection to family members and themselves 36 (36.7%), and concerns about transmitting the infection to themselves 12 (12.2%).

Nurses reported receiving information about COVID-19 from various sources, including the internet 62 (17.9%), training programs organized by their hospitals 39 (11.2%), and other sources (including television and medical journals). The largest proportion of nurses, 108 (31.1%), considered surgical masks, N95 masks, gowns, gloves, goggles, face shields, and hand hygiene as the correct PPE to be used. About 31% of the nurses reported that they should wear eye protection and a clean, non-sterile, long-sleeved gown during care for patients with COVID-19 during the following situations: the entire treatment or nursing care, when performing aerosol-generating procedures associated with an increased risk of infection transmission, during activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions, and when performing aspirating or open suctioning of the lower respiratory tract, endotracheal intubation, CPR, and bronchoscopy. In addition, 138 (39.8%) of the nurses reported that they should wear a surgical mask or N95 mask during care for patients with COVID-19 during the entire treatment or nursing care if they are working within approximately 1 meter of a patient with COVID-19, and when the patient is on droplet precautions (Table 2).

Table 3 shows the results of the attitude and behavior of nurses toward the COVID-19 outbreak. About 91% of nurses reported that they had adequate knowledge about the COVID-19 pandemic, 95.1% were confident that they understood the risks of the COVID-19 pandemic on patients and medical staff, and 93.9% were confident that they understood how to protect themselves and their patients during COVID-19 pandemic. Most of the nurses, 326 (93.9%) considered that hand hygiene includes either washing hands with soap and water or the use of an alcohol-based hand rub, 204 (58.8%) reported washing their hands with an alcohol-based hand rub when they were visibly soiled, and 211 (60.8%) believed that the use of correct PPE eliminates the need for hand hygiene. Most of the nurses, 316 (91.1%) believed that the use of PPE will protect the medical staff from getting COVID-19, 275 (79.3%) of the nurses believed that the use of PPE will protect patients from getting COVID-19, 210 (60.5%) considered using recommended PPE when taking care for patients with COVID-19 inconvenient, and 246 (70.9%) believed that using recommended PPE interferes with patient treatment or nursing care. About 23% of the nurses considered that recommended PPE was not readily available in their hospitals. Almost half of the sample reported that their colleagues often forget to use recommended PPE when taking care of patients with COVID-19, and 148 (42.7%) reported that they forget to change PPE between patients when taking care of patients with COVID-19.

(Table 4) shows the results of the binary logistic regression analysis in two models. In the first model, the covariates of age, gender, level of education, living status, marital status, job title, type of hospital, and department were introduced to the regression. In this step, we found that older nurses had a 6% lower odds of willingness to provide care to patients with COVID-19 (AOR= 0.94, p = .038, 95% CI [0.849-0.997]), controlling for other covariates. Divorced nurses also showed 97% lower odds of willingness to provide care (AOR= 0.03, p = .046, 95% CI [0.001-0.939]) controlling for other covariates. On the other hand, nurses who were head of a department reported five times higher odds of willingness to provide care (AOR= 5.02, p = .049, 95% CI [1.006-25.067]), holding other covariates constant. Male and female nurses did not differ in their willingness to provide care.

In the second model, when the variables of interest were introduced to the regression, the age and marital status effect attenuated and became nonsignificant. Along with head of department (AOR= 6.92, p = .026, 95% CI (1.267-37.734)), another job title became significant predictor of the willingness; administrative nurses reported higher odds of willingness to provide care (AOR= 11.32, p = .047, 95% CI (1.035-123.766)), holding other covariates constant. Remarkably, 45% lower odds of willingness to provide care to patients with COVID-19 were among nurses who reported having experience in treating or providing care to patients with confirmed or suspected COVID-19 (AOR= 0.55, p = .034, 95% CI (321-.955)). Finally, nurses who worked in private hospitals had almost three times higher odds of willingness to provide care to patients with COVID-19 (AOR= 2.95, p = .047, 95% CI (1.016-8.585)). The two models of regression were statistically significant (p= 0.048, p= 0.002, respectively), and the overall second model fit (-2LL) was (361.8). Finally, the overall classification accuracy of the second model was (73.5).

Nurses’ managers should identify training priorities, provide training programs and information tailored to meet the needs of nurses during COVID-19 challenges and prepare them for any future pandemics. The training programs should be easily accessible, considering the hectic working environment during COVID-19. International collaboration to identify common training priorities, work on capacity-building solutions, speeding up development, adaptation, and dissemination means effective delivery of training and skills development (WHO, 2020d). Also, nurses’ managers should act as role models for other nurses in their knowledge, attitude, and willingness to care for COVID-19 patients. Health institution administrators should ensure that all the necessary supplies and PPE are readily available in all health institutions and have a plan of action when there is a shortage of supplies during financial hardship. This calls for international collaboration between medical suppliers and governments to work together to tackle the global shortage of PPE. Also, easily accessible, valid, and reliable information sources that are relevant to the context and healthcare settings may decrease the ambiguity and uncertainty of nurses in information related to COVID-19.

There were several limitations to this study. First, data collection was conducted using a self-reported questionnaire; therefore, there was a potential reporting bias. Further studies are needed to support these findings. Moreover, the used instrument has limited validity and reliability testing due to the emerging nature of the field where the underlying content is changing rapidly. Second, nurses’ knowledge, attitudes, and practice were based on the available information about the newly emerging strain of SAR-COV-2 that causes COVID-19 infection. The available information keeps updated frequently, which may be associated with ambiguous attitudes and behaviors among nurses and other healthcare professionals.