For the Good of the People: an interpretive analysis of Chinese volunteerism in the critical matter of care at the start of the pandemic

ABSTRACT

Purpose

China employed a unique volunteerism system where health care providers outside of Hubei Province, the epicentre, travelled to reverse the devastation wrought by coronavirus disease 2019 (COVID-19) at its global onset. The aim is to study the unique circumstances of Chinese volunteerism in the context of continuing pandemic threats, specifically exploring the experiences of 20 Chinese nurse and physician volunteers fighting COVID-19 during the outbreak.

Methods

Interviews were done through video calling.

Results

Using content analysis with a hermeneutic perspective, emerging patterns showed the ways in which China’s particular manifestation of volunteerism teaches us how to engage global threats of this nature. The overarching lesson, For the Good of the People, was manifested in several dynamic and overlapping themes: 1) Reaching for Professional Standards Even in Crisis; 2) Constantly Caring Through Failures and Successes; and 3) Holding Fast to the Common Good. The devastation was met by the resilience of volunteers, who overcame profound challenges managing patient care.

Conclusions

Volunteerism required sacrifice and tremendous support in the form of training and administrative direction, family support, and peer collaboration. Volunteers’ physical and psychosocial wellbeing was a priority. Recognizing the representative themes can help societies plan for continuing and future events.

KEYWORDS:

• COVID-19
• volunteerism
• China
• qualitative research
• professional relationships
• delivery of health care

Introduction

Chinese volunteerism in the context of the focusing event, the coronavirus disease 2019 (COVID-19) outbreak in China, is a unique top-down system (B. Li et al., 2019). Those in command and control communicated to local agencies and hospitals to quickly mobilize nurse and physician volunteers from hospitals to travel with little notice to where they were needed in Hubei Province in Central China, the epicentre, containing Wuhan City (Lee et al., 2020). Like volunteerism immediately after the 9/11 attack on the Twin Towers in New York City in 2001, Chinese volunteerism during COVID-19 is seen as a therapeutic community response by persons taking on risks that they would not normally encounter (Miao et al., 2021; Steffen & Fothergill, 2009).

Volunteerism, by its nature, is part of a collective effort, where volunteers respect fellow volunteers, have different motivations, have a deep connection, and all have something to contribute, without anticipated reward (Steffen & Fothergill, 2009). Formal volunteer groups have organization, trust, and networks (Putnam et al., 1993). They see themselves empowered to participate in their community’s healing and recovery process (Fothergill, 2003). In the case of the volunteers who answered the call to national service in China, many had agreed to go to the COVID-19 epicentre without any assurance they would return. They were willing to give their lives to the cause (Y. Li & Li, 2017).

Volunteerism has been described as planned helping (Clary & Synder, 1999). Due to the nature of the COVID-19 crisis, this planned idea differs from the experience of volunteers going to the epicentre. First, the period of deliberation that usually goes into making the decision was short, not allowing much time to think. Second, they had no idea whether the experience would meet their personal needs or goals. Whether the Chinese volunteer experience might increase their understanding of a world outside of their own, enhance their careers, or strengthen social relationships was not known. Finally, the time frame for volunteering would be determined for them and that information was not necessarily known by administrators. Chinese volunteers providing care at the epicentre, therefore, represented a unique form of volunteerism.

It is the case that volunteerism often depends on the person, the situation, and the interaction of the volunteer with the environment (Clary & Synder, 1999). In the case at the epicentre, this idea can be expanded in the current study to the volunteer, the interaction among volunteers providing direct crisis patient care, and their interacting with an ever-changing environment, creating actual evolving health care circumstances. Only one study on 10 Chinese nurse volunteers was found in the literature (He et al., 2021) and it was written from a lessons learned perspective. The current study is novel because it examines dynamic interactions from an epicentre volunteerism perspective.

The overall aim is to study the unique circumstances of Chinese volunteerism in the context of continuing pandemic threats, specifically exploring the experiences of 20 Chinese nurse and physician volunteers fighting COVID-19 during the outbreak. By using first-hand knowledge of the situation at the epicentre and understanding volunteers’ unique experiences, health care managers and citizens may better understand how to plan for and support those needed in ongoing and future crises. Volunteers who experienced dramatic changes and lived through the time of the early COVID-19 crisis provide a barometer for crisis planning and management. Further, there are international effects when a pandemic starts in one country and spreads worldwide. It is important to understand the national experience in the case of the COVID-19 pandemic, since the results of the beginning outbreak affect the world. Likewise, the actions of the nation at the epicentre are lessons for global communities for the future.

The lingering effects of the pandemic affect all countries. The United States (US) and the United Kingdom (UK), for example, have recently announced that they, like China, are implementing long-term counselling programs for health care providers (Organisation for Economic Co-operation and Development, 2022; Tri-Council for Nursing, 2022; Türközer & Öngür, 2020; Vostanis & Bell, 2020). This is an important next step that requires the mobilization of vast resources. Additionally, times are still uncertain regarding the trajectory of COVID-19. This study provides important insight about care issues because, currently, parts of the world continue to be under intermittent lockdown conditions or mandates due to outbreaks.

Materials and methods

Study design and sampling

A qualitative descriptive approach (Sandelowski, 2000) and content analysis (Creswell, 2013) with a hermeneutic perspective (Dibley et al., 2020) were used. That is, the study design, a classic qualitative descriptive approach, was initiated using semi-structured interview questions, but the responses were often extended storied accounts that required a more interpretive approach as data was analysed. The authors had experience in hermeneutic analysis and found the compelling storied accounts suitable for hermeneutical analysis. Therefore, as categorical themes emerged in the data and included experiential descriptions, the authors used hermeneutic perspectives to analyse and explicate the findings. The consolidated criteria for reporting qualitative research (COREQ) checklist was followed when the study was reported (Tong et al., 2007). Inclusion criteria were nurses or physicians ≥18 years of age; signed up as volunteers, travelled, had direct contact with patients with COVID-19 in Hubei Province; and volunteered to participate in the study. An exclusion criterion was lack of internet access. Ethical approvals were obtained from Institutional Review Boards at a US university and a Chinese hospital. Convenience sampling was used. Two researchers contacted potential participants from a list of volunteer names using a phone call to invite them to participate. Those wanting to be part of the study gave verbal informed consent. Twenty individuals volunteered to participate in the study. Participants were given pseudonyms to maintain confidentiality.

Data collection

Two female nurses outside and one female nurse volunteer inside Hubei Province conducted in-depth, semi-structured interviews (February 20 to March 19, 2020). The interview guide included questions about demographic and clinical characteristics, family members, motivations to volunteer, risk of volunteering, experience at the epicentre, and lessons from the volunteering experience. Participants were interviewed at their hotel rooms in Hubei Province, and only participants and researchers were present. Interviews were obtained through video calling and only the audio portion was recorded. Interviews ranged from 20 to 90 minutes. The sequence of the interviews by volunteer groups is captured in the Table 1. Data were collected until enough information was obtained to fully provide rich representations of experiences.

Table 1. Sequence of interviews by group (N = 20).

Volunteer group and time in Hubei Province	Number of interviewees	Pseudonyms of interviewees
First group January 25, 2020 - March 17, 2020	4	Pan, Nan, Shin, Ting
Second group February 9, 2020 - March 29, 2020	5	Chin, Yuan, Zheng, Min, Ban
Third group February 13, 2020 - March 23, 2020	10	Chung, Pong, Jung, Gion, Lenn, Shij, Yang, Sheng, Xiao, Jia
Fourth group February 21, 2020 -April 7, 2020	1	Den

Data analysis

Interviews were deidentified, transcribed verbatim, translated into English, and coded by two English-speaking and one bilingual Chinese qualitative researcher. Analysts read each transcript and wrote independent narratives summarizing findings. After summarizing and discussing the first four transcripts, working themes were identified from the data and a coding dictionary established. Subsequent transcripts were coded by individual analysts, discussed, and categorized by consensus. Finally, following numerous discussions, hermeneutic perspectives were generated by engaging comprehensive philosophical ideas relative to the common human experience expressed in all the accounts (Dibley et al., 2020).

Trustworthiness

The credibility of findings was established by using prolonged involvement with the data. To increase dependability, a limited literature review was conducted at the beginning of the study to avoid bias in the data collection and analysis process. Additionally, the researcher coded all the data until the findings were consistent over time. To increase transferability, the researcher provided a clear and detailed description of the researcher’s role, sampling process, data collection methods, and data analysis methods. To enhance confirmability, 20 interviews were coded independently by three researchers. In cases of disagreement, explanation and clarification were used to reach a final decision (Guba, 1981).

Results

Seventeen nurses and three physicians who had undergone advanced training in infection control volunteered to participate in the study. They were 70% female, age 20 to 40 years (with 50% under age 30). The economy of Hubei Province was hit hard by the lock down. “When I arrived, lots of areas, not to mention small businesses, were suffering. In fact, residents’ lives were greatly impacted. This shocked me. Just like what was reported on television, there was no one on the streets, only some stray dogs were running.” (Shin) Upon arrival, volunteers evaluated the reality of the situation with their own eyes: “I went into the intensive care unit (ICU) to take a look” (Pan); “ … they have very few intensive care unit nurses” (Yuan). Lenn reflected: “At the beginning, the protective measures were probably not sufficient; some health care providers were infected. I felt so sorry. They were young.” To solve the ICU workforce shortage, health care volunteers who worked in other departments at home hospitals, such as a urology department, were deployed to ICUs in Hubei Province.

Initially, hospitals were unprepared for the crisis. Min said: “Before we came, there was nothing.” Clean, semi-contaminated, and contaminated areas were not separate. “Pressure” on the nurses was related to having to significantly alter hospital spaces to accommodate large numbers of COVID-19 patients quickly. “On the first day … we disassembled beds and re-arranged all rooms. Just like movers.” (Zheng)

Health care volunteers established a system of working processes in a short time. The processes were developed and posted on the WeChat group platform, a social media platform. Xiao said: “ … We added processes with more details that fit our real situation. The processes included handoffs during shift change, transfers and admissions, and sending patients for tests. While new diagnostic and treatment advances by physicians practicing Western medicine were made, physicians practicing Tradition Chinese medicine were on call and played an important supportive healing role during the crisis. Shifts for nurses were developed to fit the situation. A nurse volunteer recalled: “We have nursing shifts and disinfection shifts. Disinfect the ward and so on” (Zheng). Given the reality of the situation and seeing what was at stake, several nurses wondered when they would be able to return their home hospital. Pan said: “Right now, the time is uncertain. Our team leader said that we need to control the pandemic as soon as possible; then we can go home.” Following is a rendering of an overarching lesson and emergent themes.

For the good of the people: a way through crisis

The overarching lesson of these accounts can be described, “for the good of the people”. Chinese nurses and physicians expressed many heart-felt examples of their moral obligation to serve their country and a strong sense of responsibility for the greater good. They felt united with other Chinese, requiring self-sacrifice even to the point of the risk of death. Shin believed she should take on the responsibility at her [young] age and she desired life experience. She said: “I wanted to challenge myself.” Shin volunteered without hesitation even though her wedding had been planned. Ting prepared for death: “I left several papers for my husband: my family’s bank card password, insurance information, and the child’s arrangements.” The national pride is strong and the pandemic offered an opportunity to serve the people of the country. Throughout their stories, we have come to see the crises these volunteers experienced, along with the ways they survived, through the themes: 1) Reaching for Professional Standards Even in Crisis; 2) Constantly Caring Through Failures and Successes; and 3) Holding Fast to the Common Good.

Hermeneutic perspectives are rendered in this article as themes encompassed by the overarching pattern: For the Good of the People: A Way through Crisis. Exemplars of these themes are described in the following sections with additional exemplars noted in Table 2.

Table 2. Additional sample exemplars for each theme.

Theme	Additional exemplars
Reaching for Professional Standards Even in Crisis	Now, people on infection control shifts need to watch carefully. Cleaning hands must last at least 1 minute. Every step must be conducted properly. You are not allowed to rub your hands casually. Yes, if a person is working outside, he/she will be on an infection control shift and will work longer. When others put on protective suits outside, this person needs to check if the protective suits are put on properly and give others guidance. Now a camera is fixed. When people come out from the ward, a person will remind them when they do not take protective suits off properly. The person on infection control shift needs to spray alcohol on others’ bodies when they come out of the ward. The working time for infection control shift is a little bit longer, almost 8 hours. None of us brought a laptop. When we set processes for them, such as taking off and putting on protective suits or dividing the areas, if [we were] able to add videos or pictures, the processes will be more vivid and more understandable. However, we only have cell phones now. We will try to adjust later. We will integrate materials and make them more vivid. Well, before I came, the infection control department at our home hospital has been training about the knowledge of putting on and taking off protective suit. There were rotating teaching sessions on the 16th floor. Then, training at the home hospital is like such … Then like videos regarding putting on and taking off … how to make improvement during the process of putting on and taking off. It means [we can] reduce more contamination and do better protection. For this part, all the procedures have been revised. After the revision had been completed, just sent it to group chat and we practiced by ourselves. After that, everyone had to take an exam. After passing the exam, [we] are allowed to work in the hospital. There are people from infection control department who assess our practice in exam. It is like we strengthened infection control. Yes, we added processes with more details and made them close to our real situation. The processes included handover shifts, transfer admission, sending patients to do exams, and patient admission. The processes were developed and posted in chat group. We followed the processes. So, we improved the local processes. After [we arrived we] really established a set of systems for working process in a short time. In the daytime, what work will be conducted in each shift, and which scales will be used to evaluate severe patients, and then what will be conducted for severe patients during which shift? And then the night shift handover, and then during the night, all are important, and all need to be handed over efficiently. Now it is fully on track. We felt that our hospital was really running things according to standards. It means being careful and responsible.
Constantly Caring Through Failures and Successes	Well, everyone worked hard and supported healthcare professionals’ and police officers’ work. The local leaders are “very supportive”. Every day I feel that I’m so touched [by] leaders of the hospital, family members, and the volunteers from our team, the big team. Then, continuous caring, talking, and so on every day. I think really, even though we came out, we are, how to say it, cared about by so many people. Then, feel very happy after being cared about. The most touching thing was the head nurse of our department. We are volunteers, she treated us very well, equally well. The happiest was that everyone was fine. When you did patient rounds, everyone told you that they felt better. I did not have symptoms. Right? You had fulfilment. Patients saw that we came here and they might be full of confidence. Maybe they have confidence, because they feel someone will take care of them. They feel that someone got their back. I think there are many touching things including some services provided by staff here. I feel that they are really nice to me. Local doctors and nurses treat us well. They said that volunteers from [a hospital] came here to help us. When patients were discharged from the hospital, they would appreciate you. I was not familiar with the environment. For example, when I need to do nursing practice for a patient, I might have to look for some medical supplies. Just this, takes time. And the central oxygen supply there sometimes is unstable. For example, we may need to search for an oxygen tank and other equipment. Searching for equipment, … just running back and forth between our room and the next room.
Holding Fast to the Common Good	[I just] signed up, and I thought the country really needed us to go at that time. Then I do what I can do. And I think people should make some contributions to others in their lives. I will never encounter such thing in my life. [I have] the ability [to] make some contributions. I am very willing to do so. And if I had not come, when I think about it again, I would feel very regretful. We are brave. We dare to go to the frontline. Then, how to describe? We inherited the characteristics of the old generation, not afraid of difficulty, willing to contribute. When I heard that we can sign up, I really did not consider too much. I just want to come here and do what I can do. At that moment, I did not consider the possibility of being infected or the amount of risk. I just think that if I could come here, I would definitely fight for it. Therefore, I talked to my head nurse multiple times.

Reaching for professional standards even in crisis

Little was known about the nature of the COVID-19 virus. Volunteers were trained to take action to guard against contamination. Volunteers knew “we must not drop our guard” (Gion). Chin described a real threat: “When we arrived, local providers all ripped off their protective suits violently.” This unsafe situation was remedied by nurse volunteers. Additionally, health care volunteers also divided hospital areas into clean, semi-contaminated, and contaminated areas. Gion said: “Because of a supply shortage, each person had only one protective suit to wear per day.” When more suits became available, they were worn the prescribed 4 hours. The chance of infection was real for Xiao: “I feel the virus is pervasive. I take shallow breaths… (laughs) I do not dare to breathe too much air.” Sheng said: “Every time I put a protective suit on, I feel that it is not done properly. I feel there are some crevices in my suit. In fact, the suit is fine, it’s just [my perception that] it is not right.” Her solution was to tuck cotton balls under the protective glasses. Nan said: “Some gloves were too large or small … you need to use tape [to secure them to the suit]. Sometimes because the gloves were thin … we had to wear three layers.

Not all hospitals had showers. After work, Yuan felt unclean but, after intensive washing and disinfection, she felt better. She described an elaborate process she used after each shift:

We were sprayed with alcohol [at the hospital] … we took off our coats and left them outside the hotel … sprayed in front of the room door … disinfected and washed hands … took off our clothes and threw them directly into the wash basin that had bleach … took a shower for half an hour. Then we disinfected the eyes, nose, and mouth. (Yuan)

Den stated, “The risk of being infected is low if we do proper protective measures. It depends on us.” Ting adjusted to the situation: “I adapt very well after I am familiar with the environment.” (Ting) Participants overcame difficulties: “Regarding the fog and the heat in the protective suit, they are not a problem anymore; one just gets used to them gradually.” (Xiao) Shij commented: “I do not need help from others [to release the pressure]. I will solve my own problems.” (Shij)

These volunteers came into uncertain situations where their knowledge and professionalism were put to the test and creativity was required. Holding on to the touchpoints of what they knew as professionals grounded them and allowed for the building of procedures needed in critical moments. Their persistence in providing quality care was evident and described in the following theme.

Constantly caring through failures and successes

The volunteers described many stories of care during a time when patients were dying quickly and care provision was emotionally exhausting. Most of the volunteers worked on units in Hubei Province different from the units they worked on at home. A nurse who was a urology nurse at the home hospital said, “I really haven’t experienced life-or-death situations for a long time.” (Ban) Gion said: “I felt a little powerless when facing conditions like this,” and “felt that people were very small compared to the rapid spread of the virus.” Patients passed away unexpectedly fast. Dying alone in the hospital is a worst-case scenario for Chinese people generally. Pan reflected:

For patients, the development of the disease, from [being] sick to severely ill, is very fast. When seeing that the patient in Bed 11 had died and was moved away, a pair of red high heels remained under her bed; this actually touched me quite a lot. I thought that she came in wearing those red high heels, and then she just passed away. And then I kept thinking about it. (Pan)

The process of resuscitating patients was a traumatic psychological and physical stressor for health care providers, especially for those who seldom encountered patients’ deaths at home hospitals.

… And I could not bear to see this situation, feeling that, when I was rescuing that person, my heart, my nose was sore at that time … , I was about to cry. I was supposed to leave work at 9 am but I requested to leave work at 8:30am. I felt that my head was not very comfortable earlier that morning. I told the team leader at that time. I came out earlier. … because I used a lot of energy during the resuscitation, a lot of energy, I felt my body couldn’t bear it. [the protective suit] (Ban)

Health care volunteers expressed that they were pleased with the outpouring of hospitality and support they received. Den described:

We did not arrive with sufficient disinfectant, bed linen, or food. When volunteers mentioned that it was cold, quilts, heaters, and heating blankets were immediately provided. News online kept reporting that life in [city name] is so difficult. I was very touched that supplies were all provided immediately. Our food was prepared to match the tastes of our local cuisine. (Den)

Multiple strategies helped participants cope, diminished the harshness of the environment on self, diminished suffering, and allowed time to focus on the self or others. Den said: “The team leader is great. She makes me feel safe and peaceful.” Jia said: “The team here is like a big family.” Specific strategies included reading books, watching TV, doing meditation, and contacting family members. Chatting was a common strategy to communicate to their home hospital as well as with volunteers who arrived earlier. Nan and Shij reflected that thinking too much and being too emotional are not good strategies.

Opportunities and challenges were present side by side. The recovery and death of patients presented a range of feelings from hopelessness (“I cannot help them much” [Ting]) to feeling happy (“I felt we saved several families rather than a person” [Ting]). Ting was aware that the loss of one person affects many, as does saving one person. This sentiment echoes the collaborative and communal nature of the situation-one that affects a whole community. Xiao said: “The experience of volunteering gave health care providers lasting memories. Participating in the battle is unforgettable because it was my first big rescue … It will definitely inspire my future life…I can help more people. It makes me more aware of how to respond in a crisis.” Jia said: “Through this battle, I re-recognized the value of a health care professional.”

These acts of constant caring, persistence in providing care through hardship, also provided a sense of purpose and accomplishment for volunteers. This is important to remember in critical health care situations. Care provision is a grounding aspect of all health care provision, even in critical moments, and requires nurturing, support and explication.

Holding fast to the common good

The most striking finding in this analysis and the one that may provide the hope and inspiration we seek in common crisis, is that all these volunteers expressed a deep and assumed understanding that they are responsible for the common good. Pan, a critical care nurse reflected: “I have a great responsibility … Critical care nurses are needed on the frontline, so I signed up.” Nan, an ICU nurse, also said: “If we do not go, then who will go? No one can handle this situation except for health care providers.” Furthermore, nurses and physicians volunteered because it was the right thing to do. Ban, a nurse, said: “I have the skills after all. Isn’t it good to help and save others?” Pong, a physician, reflected: “I just think that people must do something meaningful during their lifetime.”

Most volunteers did not tell their families before signing up. Sheng said: “They miss us and want to have a video call every day.” Yuan’s family supported her and will care for her child if she dies: “When I came here, my family worried that I wouldn’t come back home. If I die, just continue to take care of my child the way you did before, when I was at work.” Shin said:

My parents told me that they cannot help [because they are not health care providers]. What they can do is taking good care of my sister and themselves at home. Then, my boyfriend told me that he will take good care of the cat and do his job well at home. We all contribute to our country by doing our own job well. (Shin)

Volunteers and their families understood that the good of all superseded individual needs. It was the duty of the young professionals to rise to the call of the nation.

Participants formed alliances for the greater good. Camaraderie was strong. Ban reflected: “The happiest time is when I met so many volunteers from our home hospital.” Den said: “To finish work on time, we help each other as needed.” To improve collaboration and medical care, Pong reflected: “These patients [infected care providers] and we are all in a chat group together. If they need anything, they will speak out.” Ban’s story emphasized collaboration, or care, on the part of leaders. The chief nurse, for instance, tells Ban that “she is the most important and she must come out of the protective suit when she is too uncomfortable.” (Ban)

Shin was working with others who inspired her. She felt as part of a team that worked together and this was exciting. The group working together provided a foundation for learning and growth, which is a part of the draw for Shin to volunteer. This sense of unity may ground Shin’s character and shape or account for her strong character. This sense of belonging was a very strong aspect of the experience and reflected the communal nature of the epidemic phenomenon. “Each time I enter the ward, I value the opportunity. I always want to learn something from colleagues or help them to improve. Going to work, we are very excited. I feel the sense of belonging.” (Shin). Thus, the good of the “other” or the good of all was manifest in the work groups themselves and this collegiality allowed the volunteers to manage the emotional and physical hardships of their situation.

These volunteers were able to transcend hardships for the common good, which they recognized would come back onto their own families. Ting says:

In our daily life, we are just very ordinary people; but when we encountered this, we are able to come here by overcoming fear. I think it is educationally meaningful, not only to our family, but also to our child. … [we are] educating him how to correctly establish his sense of social responsibility. People on social media from other countries recognized the Chinese health care providers’ call to service and communicated with them to support them, spurring them on. Nan reflects: “ … the wailing wall in Israel … someone wrote ‘Pray for the Chinese people’. I was quite moved when I read this message on the frontline fighting COVID. (Ting)”

This is an important theme because the commitment to doing for others or doing for the future was enough, in these instances, to overcome extreme difficulty. The support structures were in place and the common understanding among the Chinese people gave meaning to their experiences, keeping them going. This common purpose may be a necessary aspect of care during crisis that must be acknowledged and supported in similar events.

Discussion

The overall aim is to study the unique circumstances of Chinese volunteerism in the context of continuing pandemic threats, specifically exploring the experiences of 20 Chinese nurse and physician volunteers fighting COVID-19 during the outbreak. This discussion portrays characteristics of the volunteers, care that they received especially from leaders, and shifting patterns and processes, representing in the resulting themes in the ever-changing environment to meet the needs of the patients. The overarching lesson and themes call us to consider a number of insights that might otherwise be overlooked about these unique events.

Calling for health care volunteers to serve at the epicentre was a strategy to solve a major nurse workforce supply issue. According to the Global Nursing Workforce and the COVID-19 Pandemic, a document issued by the International Council of Nurses, one solution to critical nurse workforce supply issues is to increase flexible deployment of nurses (Buchan et al., 2022). China applied the nation-wide volunteering strategy, through which over 40,000 health care providers (70% nurses) answered the call to travel (The State Council The People’s Republic of China, 2020b). Volunteers in the current study were part of the team that successfully lightened the workload of local health care providers and helped suppress the COVID-19 surge at the epicentre between January 15 to 7 April 2020. Soon after, by 15 April 2020, all Chinese health care volunteers serving in Hubei Province had returned to their home hospitals (Xinhua Net, 2020).

Moral courage manifested itself through a national dedication to fighting COVID-19 for the good of the whole, the people of China. This term, moral courage, refers to an individual’s capacity to overcome fear and stand up for core values (Clary & Synder, 1999; Lachman, 2007). One volunteer alluded to this idea of moral courage when talking about ordinary people, health care volunteers, overcoming fear, and doing extraordinary things. Before heading to the epicentre, one health care volunteer made prescribed arrangements for her child in a matter-of-fact way in case the volunteer died. This calmness might be explained by the sense of peace individuals feel when they sacrifice for, what Lachman (Lachman, 2007) refers to as, a non-negotiable principle.

Flexibility and improvising are needed for health care providers to function in crisis (Hugelius & Adolfsson, 2019). In the current study, infected health care providers and health care volunteers were all in one WeChat group, where infected nurses and physicians could speak out about their ideas, an adaptation designed to enhance communication and collaboration (Clary & Synder, 1999). In addition, the power of caring when evoked during a crisis provides beneficial and needed support to help health care providers endure harsh environments (Hugelius & Adolfsson, 2019). One participant described the situation as feeling that the team was a family. Another participant felt that needs beyond basic needs were met in that the leader made it possible for the volunteers to receive food that resembled home cooking with flavours they were used to. Finally, an individual can grow as a person and a professional nurse after facing traumatic memories (Clary & Synder, 1999; Hugelius & Adolfsson, 2019). In the current study, volunteers felt that their future lives would be inspired by this experience, and they recognized the value of their profession.

Health care volunteers face various types of pressure at work. Major sources of pressure with discomfort identified in the literature during the pandemic were homesickness, uncertainty how long the current working status would last, concern about being infected, skin damage caused by prolonged wearing of protective equipment, and discomfort caused by protective equipment (Y. Zhang et al., 2020). The current study found that altering hospital spaces in a short time served as a unique source of pressure for health care volunteers. For example, nurse volunteers disassembled beds and re-arranged all rooms, “like movers”, to quickly alter hospital spaces. Additionally, some nurse volunteers were assigned to disinfection shifts that involved disinfecting entire hospital units; it was heavy physical work. On the whole, health care volunteers displayed what Organ et al (Organ et al., 2005). call organizational citizenship behaviour. This term in relation to the pandemic refers to a type of positive work behaviour that is above and beyond the usual nurses’ role, includes helping others out when they get behind, and on the whole promotes the efficient and effective functioning of the organization (Bachrach et al., 2007; Bateman & Organ, 1983; Organ et al., 2005; H. Zhang et al., 2020, 2021).

According to a middle-range theory (Foli, 2022) and in alignment with the most recent Chinese review about disaster nursing that could be found (S. M. Li et al., 2016) nurses experience psychological trauma due to the exhausting need to care for critically ill patients in disasters. The current study found that nurse volunteers bore overwhelming mental burdens in the form of stories and nursing procedures when facing the crisis. In the theme of constantly caring through failures and successes, for example, a glimpse at red high heels under a patient’s bed after the owner of the shoes died was embedded into the memory of a nurse volunteer. Given that no family members were allowed to be with the patient, there was not even anyone to whom to give these red heels, shoes that had obvious meaning to the wearer before circumstances overtook her. In addition, health care volunteers who served as first responders put themselves at risk for mental trauma from giving nursing care during the crisis (Foli, 2022). In the theme of constantly caring through failures and successes, a volunteer nurse depicted the traumatic psychological experience and the challenges she experienced resuscitating a COVID-19 patient in the protective suit.

The devastation was met by the resilience of volunteers, who overcame profound challenges to manage contagion; opportunities and challenges occurring simultaneously were handled and the process became easier once protocols and infrastructure, developed urgently, were in place. Resilience amid challenges was a major category in another study of local health care providers in Hubei Province (Liu et al., 2020). The volunteers displayed varying strategies and degrees of self-dependency to manage the tension, often without known endpoints to their service. They worked with one another, learned to protect themselves from contagion (Clary & Synder, 1999; Lazarus et al., 2021) and developed coping mechanisms to manage their personal responses (Clary & Synder, 1999). Two studies in health care volunteers at the epicentre found that greater resilience was beneficial and related to lower emotional exhaustion, lower negative affect such as fear, greater positive affect such as hopefulness (X. Zhang et al., 2021), and greater active coping behaviours (Lin et al., 2020). Developing effective, individualized resilience interventions in the pandemic is critical (Folkman & Tedlie, 2004) and further studies are warranted in this area.

Much can be learned from China’s handling of the volunteer situation during outbreaks in China. For volunteers coming back from Hubei Province, and for other frontline health care providers since then, China provides benefits and rewards such as double pay while volunteering; efficient treatment and accelerated reimbursement for medical care costs if infected with COVID-19; optimal staffing patterns; and mandatory on-site leave for those experiencing long-term heavy burdens or for those unable to work due to physical or psychological causes. This also includes friendlier policies regarding promotion, a free physical exam and a paid retreat to rest, and more paid vacation time. In addition, in regard to those frontline volunteers who sacrificed their lives to fight against COVID-19, a cash payment is given to their family and preferential treatment regarding school admission is given to their children (The State Council The People’s Republic of China, 2020a). Frontline health care providers could not return home in an effort to prevent infecting their family members. Therefore, it was a priority to ensure the elder family members were taken care of. A community volunteer would take the responsibility of caring for the elder family members, doing work including calling elders to check on them, delivering medications, and accompanying them to hospitals. The elders who had agreed to temporarily live at nursing homes were sent to nursing homes with excellent infection control standards (The State Council The People’s Republic of China, 2020b). Other countries might want to consider adopting or adapting these protocols for their own health care providers during the continued COVID crisis.

The Nineth Version of the COVID-19-Related Psychological Intervention Guidelines, which targeted Chinese health care providers, was issued in June 2022 (The State Council The People’s Republic of China, 2022). It is recommended that health care providers, especially those on the frontline, receive psychological evaluations. Those who were diagnosed with psychological disorders are referred to mental health hospitals for follow up. Psychologists evaluate health care providers’ mental health status, and online or face-to-face interventions are provided. Next, it is recommended that local public health departments build a database to record 1) psychological services available in the local area including mental health hospitals and other institutions that provide psychological services, 2) numbers of local psychiatrists, therapists, counsellors, and social workers, and 3) numbers of psychological service hotlines. Finally, it is recommended that frontline health care providers do not work day after day for long periods, but have rest days interspersed with work shifts to prevent compassion fatigue, burnout, and physical problems due to long-term work (The State Council The People’s Republic of China, 2022).

Conclusions

Volunteerism took a unique form in that it required health care providers from other places geographically in China to drop what they were doing and travel to try to reverse the devastation wrought by COVID-19 at the epicentre. Volunteers expected to take on the duties of providers who were exhausted or became hospitalized. What it would take in resources and sheer grit to promote health and healing at the epicentre was greatly underestimated. The Chinese people took a stand.

Volunteerism as an intervention had benefits in the current study and it occurred in the context of tremendous support in the form of hospital training and administrative direction, family support, and peer collaboration. Nurse managers monitored the volunteers’ physical and psychosocial wellbeing as a priority. Volunteers had moral courage and displayed organizational citizenship behaviour in the presence of high caseloads and heavy physical work when units were understaffed during uncertain times. They were able to adjust working behaviours to meet the demands of changing patient care situations. The balancing of opportunities and challenges simultaneously required enormous effort, flexibility, and resilience on the part of volunteers. The WeChat platform helped volunteers feel connected and it provided the latest information about protocols and procedures.

The current study is one of two articles (He et al., 2021) that focuses on dynamic interactions from an epicentre Chinese volunteerism perspective, an important contribution to the body of literature. The term, volunteer, in the qualitative literature has been used loosely and, except in one case (He et al., 2021) does not refer to the Chinese volunteerism system. Countries might benefit from considering the unique volunteerism system used in China, during disaster situations such as future pandemics.

Ethics statement

Ethical approvals were obtained from Institutional Review Boards at University of Missouri-St. Louis (approval number:275305) and Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine (approval number: 2020LWKY022).

Acknowledgments

We thank nurses and physicians who shared their experiences and stories.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset can be accessed using the link: https://figshare.com/articles/dataset/Transcript_Data/21586035

Additional information

Funding

This work was not supplied by any funding.

Notes on contributors

Fan Li

Fan Li is a PhD in Nursing. She is currently an Adjunct Professor at College of Nursing at the University of Missouri-St. Louis.

Chunyun Gu

Chunyun Gu is a nurse at the Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School.

Yanqun Hu

Yanqun Hu is a Masters-prepared nurse at Hainan General Hospital.

Roxanne Vandermause

Roxanne Vandermause is Dean and Professor of Nursing at the University of Missouri-St. Louis. She is well-known in the areas of health transition and recovery and hermeneutic phenomenology.

Anne F. Fish

Anne F. Fish is a Professor of Nursing and PhD Program Director at the University of Missouri-St. Louis. She is an expert in cross-cultural nursing care, collaboration, and research.

Zehui Zhou

Zehui Zhou is a Research Assistant in Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health.

Xiaodan Yuan

Xiaodan Yuan is a Masters-prepared nurse researcher at the Department of Health Education, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine.

Qianqian Zhou

Qianqian Zhou is a Masters-prepared nurse at the Nursing College in Huzhou University.

Junya Zhu

Junya Zhu is the Director of Yale-China Health Programs. She is an expert in patient experiences and outcomes, health care quality, patient safety, and health-related quality of life. She works closely with the Health Advisory Committee and partners in China to provide strategic leadership and program execution for Yale-China’s health program work.

Qingqing Lou

Qingqing Lou is the director of the Department of Health Education, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine.