Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12100 Correlation between the 4Cs and motivation to become volunteers among nursing students Yakobus Siswadi, Bima Adi Saputra, Kinanthi Lebdawicaksaputri Faculty of Nursing, Universitas Pelita Harapan, Jakarta, Indonesia Abstract During the COVID-19 pandemic, there was a surge in public enthusiasm for volunteering, including among nursing students from the Faculty of Nursing at Universitas Pelita Harapan (UPH). The UPH nursing faculty has a foundational framework known as competence, compassion, commitment, and character (4Cs), which serves as the basis for shaping each student’s personality. This study aimed to explore how the 4Cs foundational framework moti- vates students to become COVID-19 volunteers. Using a quantita- tive descriptive design with a cross-sectional approach to data col- lection, the study focused on UPH nursing students who volun- teered for COVID-19 relief efforts, with a sample size of 100 respondents. Data analysis was conducted using Somers Δ. The findings revealed that the majority of respondents exhibited ade- quate motivation to volunteer, with 60% falling into this category, while 22% showed a high level of motivation. Notably, the factors of commitment (p=0.004) and character (p=0.009) demonstrated a strong correlation with encouraging nursing students to volunteer. Conversely, competence and compassion did not show a signifi- cant correlation with students’ motivation to volunteer. Among the four driving factors, only commitment and character were statisti- cally related to students’ motivation to become volunteers. Introduction The COVID-19 pandemic in Indonesia affected all aspects of life.1,2 One of the biggest effects was in healthcare because of the increasing number of cases in a very short time and the spread across various regions.3 Based on data from the COVID-19 han- dling task force as of October 9, 2020, the confirmed cases in Indonesia were 320,564; positive cases were 64,924 (20.3%); recovery cases were 244,060 (76.1%); and deaths were 11,374 (3.6%). The cases were spread across 34 provinces, with the high- est number of cases in Jakarta with 83,372 cases (26.0%), fol- lowed by East Java at 46,095 (14.4%); and the least cases in Bangka Belitung at 440 (0.1%).4 Moreover, according to the World Health Organization, in April 2020, more than 22,000 health workers worldwide were infected with COVID-19.5 Based on Media Indonesia, from March to August 2020, there were 295 healthcare workers who were exposed, and 89 of them died. The Indonesian Doctors Association stated that as of September 13, 2020, 115 doctors had died due to COVID-19.6 The increasing number of cases is not equal to the number of available healthcare facilities and workers.7 To meet the need, the government took steps by opening an emergency hospital and inviting community participation to be directly involved in deal- ing with the COVID-19 pandemic by volunteering.8,9 Public enthusiasm for volunteering is very high, as evidenced in three days (March 25-28, 2020), when as many as 5816 people, includ- ing 4008 (68.9%) non-medical people and 1808 (31.1%) medical personnel have registered themselves as COVID-19 volunteers.10 According to data from the Indonesian Ministry of Health, as of September 4, 2020, there were 16,247 volunteers from health pro- fessionals within the Nusantara Sehat project, which spread all over Indonesia to deal with COVID-19.11 Driving factors for people to become volunteers are altruism and self-interest. The concern altruism is to help others, mean- while, the need for self-interest or self-serving is to gain experi- ence or learn new things.12,13 Other researchers categorized extrin- sic (egoistic) as gaining new working experience or meeting the Correspondence: Bima Adi Saputra, Faculty of Nursing, Universitas Pelita Harapan, Jakarta, Indonesia. E-mail: bima.saputra@uph.edu Key words: factor, nursing student, volunteer motivation. Contributions: YS, resources, supervision, conceptualization, data cura- tion, validation, visualization, writing - original draft, review and editing; BAS, conceptualization, formal analysis, methodology, validation, and writing - original draft, review and editing; KL, validation, and writing - original draft, review and editing. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: this research has received eth- ical approval from Mochtar Riady Institute for Nanotechnology Ethics Committee 001/MRIN-EC/ECL/I/2021. During the study, the researchers paid attention to the ethical principles of information to con- sent, respect for human rights, beneficence, and non-maleficence. Informed consent: written informed consent was obtained for anonymized respondent information to be published in this article. Funding: this research was supported by a research grant from LPPM UPH with contract number 497/LPPM-UPH/XI/2020. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: the authors are thankful to LPPM Universitas Pelita Harapan for their valuable insights and contributions to this study. Received: 16 November 2023. Accepted: 16 May 2024. Early access: 21 June 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12100 doi:10.4081/hls.2024.12100 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2024;12:12100] [page 543] Non -co mmerc ial us e o nly class requirement and intrinsic (altruistic) as the will to help others to create a better community.14 Medical students play an important part in responding to participation in the COVID-19 diseases.12 Volunteering is related to the level of spirituality: the lower the spirituality, the higher the burnout level.15 Calling plays a signifi- cant role in volunteering: someone who is motivated by calling will be able to focus on bigger group goals and not financial needs, ego, or individual career.16,17 The Faculty of Nursing Universitas Pelita Harapan (UPH) supports government programs by opening volunteer opportunities for students. The debriefing and explana- tion about volunteers have been disseminated to all students, including service areas, health protocol procedures, and benefits obtained. Students who are willing and involved as volunteers are low because there are only 162 students (14.7%).10 This low partic- ipation rate in volunteering seems not to be reflected in the imple- mentation of the foundational framework, which consists of the competence, compassion, commitment, and character (4Cs). These frameworks prepare and equip all students to serve God by serving others. If public participation is low, it will cause a personnel short- age, which leads to extra work, fatigue, and finally a reduction in the quality of service. The objective of this study was to investigate how the 4Cs foundational framework influences students’ motiva- tion to participate as volunteers during the COVID-19 pandemic. Materials and Methods Research design This quantitative correlational research employed a cross-sec- tional approach in exploring and describing the factors driving nursing students to become COVID-19 volunteers at a specific point in time. The study was explained to elucidate the relationship between the 4Cs of respondents, and their motivation to engage as COVID-19 volunteers. Study participants The sample for this study comprised nursing students who vol- unteered for COVID-19 initiatives. The sampling method employed probability sampling, specifically total sampling, with a total of 100 respondents. Variable, instrument, and data collection Independent variables consist of competence, compassion, commitment, and character. The dependent variable was the respondents’ motivation to become COVID-19 volunteers. The questionnaire in this study consisted of the Self-Compassion Scale to measure the compassion of volunteers, the Brief Calling Scale to measure commitment, the Intrinsic Spiritual Scale to measure character, and the Achievement Index to measure competence. Meanwhile, the Volunteer Motivation Inventory instrument is used for measuring volunteers’ motivation. The validity and reliability tests of the instrument were carried out on 31 volunteers from UPH nursing students. Based on the validity and reliability tests, all the question items were declared valid with an r-table value >0.355 and a significance level of 5%. Meanwhile, for the reliability test, Cronbach’s α values were obtained for each instrument: the Self-Compassion Scale (0.781), the Brief Calling Scale (0.677), the Intrinsic Spiritual Scale (0.909), and the Volunteer Motivation Inventory (0.913). Because the values of Cronbach’s α > the values of the r-table, the whole instrument is declared reliable. Data was collected by distributing online questionnaires using Google Forms to nursing students who volunteered during the COVID-19 pandemic. Data analysis The Somers-d (or Somers Δ) statistic test was used to see the relationship between independent and dependent variables. Ethical clearance This research has received ethical approval from the Mochtar Riady Institute for Nanotechnology Ethics Committee 001/MRIN- Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 544] [Healthcare in Low-resource Settings 2024;12:12100] Table 1. Description of volunteers’ motivation and driving factors of competency, compassion, commitment, and character of the respon- dents. Variable Frequency Percentage (%) Volunteer Very low 1 1 Low 17 17 Moderate 60 60 High 22 22 Competency Low 1 1 Moderate 75 75 High 24 24 Compassion Low 29 29 Moderate 55 55 High 16 16 Commitment Very low 1 1 Low 25 25 Moderate 56 56 High 18 18 Character Very low 4 4 Low 9 9 Moderate 71 71 High 16 16 Total 100 Non -co mmerc ial us e o nly EC/ECL/I/2021. During the study, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. Results This study was conducted at a private university in Tangerang, Indonesia. The demographic characteristics of the respondents in this study show that of the 100 respondents, 78% were women, and the mean age was 20.57 (standard deviation=1.827, minimum 18 to maximum 23). Table 1 indicates that the majority of respondents exhibited moderate motivation to volunteer, with 60 respondents (60%) falling into this category, while 22 respondents (22%) showed high motivation. In terms of competency as a driving factor, 75 respon- dents (75%) were classified as having good competency. Similarly, with compassion, commitment, and character as driving factors, the majority of respondents fell into the moderate category, with 55 respondents (55%), 56 respondents (56%), and 71 respondents (71%), respectively. Table 2 presents the relationship between volunteer motivation and the factors of competency, compassion, commitment, and character. In the results of statistical tests using Somers Δ and γ, it was found that only two factors have significant values of <0.05, namely the commitment factor (0.004) and the character factor (0.009), which indicates that there was a significant relationship between these factors on the motivation of nursing students to become COVID-19 volunteers. Discussion Based on the results of this study, it was found that most respondents had moderate motivation. This may be due to the fact that the respondents are in their late teens (18-23 years old). This finding is in line with the previous study, in which the researchers found that younger volunteers tended to be more motivated by career functions than older volunteers.18 Young people are involved in volunteering in terms of benefits, needs, and reasons.19 In other words, students are more likely to have good motivation because of their desire to gain experience so that they can develop and progress.20 This is also in line with the self-determination the- ory, which has the basic assumption that individuals naturally and actively orient themselves toward growth and self-organization.21 In this study, the commitment and character factors in students had a strong relationship in motivating nursing students to become healthcare volunteers during the COVID-19 pandemic. The com- mitment factor has a strong value in driving motivation in nursing students to become volunteers. In this study, the commitment was measured using the Brief Calling Scale. It focuses on two aspects, such as the presence of calling and the search for calling.22 The commitment of nursing students can be in the form of awareness of their calling to serve and help so they can contribute to others. This is in accordance with the value of commitment taught to nurs- ing students, namely how students can demonstrate commitment to serve through service to others. In the foundational framework of the Faculty of Nursing at UPH, commitment means ministering to others with an attitude of service in response to God’s grace. Commitment, satisfaction, and motivation are important character- istics for a person to become a volunteer.18 Calling on medical stu- dents to become volunteers during the COVID-19 pandemic is a liaison for medical students’ behavior to become volunteers during the COVID-19 pandemic.20,23 Another strong factor that drives nursing students as respon- dents to volunteer is character. The respondents in this study were educated to be able to have a godly character in words, actions, and attitudes; specifically, what is meant by this godly character is that every word, deed, and attitude is always centered on Christ. Belief in God is a strong predictor of volunteer involvement, influencing individual attitudes, whether voluntary or involuntary, towards service as a volunteer.24,25 Spirituality plays an important role in one’s coping mechanisms when suffering or witnessing others suf- fer.26 A person’s beliefs or religion can influence someone to become a volunteer. These beliefs will influence a person’s values Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:12100] [page 545] Table 2. Relationship of driving factors of competency, compassion, commitment, and character for nursing students to become healthcare volunteers during the COVID-19 pandemic. Variable Volunteer Value Approx. sig Very low Low Moderate High Total Competency Low 0 0 1 0 1 -0.002 0.968 Moderate 0 13 46 16 75 High 1 4 13 6 24 Compassion Low 1 8 15 5 29 0.164 0.063 Moderate 0 8 34 13 55 High 0 1 11 4 16 Commitment Very low 1 0 0 0 1 0.459 0.004 Low 0 8 13 4 25 Moderate 0 8 38 10 56 High 0 1 9 8 18 Character Very low 1 0 3 0 4 0.461 0.009 Low 0 4 5 0 9 Moderate 0 11 44 26 71 High 0 2 8 6 16 Non -co mmerc ial us e o nly and motives in viewing good relationships between people.27,28 Based on this explanation, it can be concluded that the respondents in this study were trained to continue to have a divine character with a passion for serving others. This allows divine character to have a strong relationship to the respondents’ motivation to become volunteers during the COVID-19 pandemic. In this study, competency and compassion factors are not the motivating factors for nursing students to become volunteers. This can be due to several things, including the characteristics of the respondents. In this case, the nursing students who become respon- dents are quite diverse. The competency factor of nursing students who become respondents can be related to their level of skills, and education, including the academic stage and the nurse’s profes- sional education stage. Lack of training and knowledge has become a barrier to volunteering.29 Compassion is something that cannot be separated from the nursing process because the subject of nursing is humans, so by having good compassion, nurses will have good morals and a sense of humanity.30 The significant fac- tors that can predict compassion in students are humanity and mindfulness in nursing students.31 Low self-compassion could con- tribute to worsening the response to participating in volunteer work.32 The limitation of this study is that the researchers only focused on the 4Cs foundational framework. These aspects may evolve throughout the student’s academic journey, and future research might benefit from examining them post-graduation. Conclusions In the wake of the COVID-19 pandemic, community health faces significant threats, and the healthcare system grapples with considerable challenges. Nursing students have the opportunity to actively contribute to pandemic response efforts by volunteering, thus bolstering the resilience of the healthcare system. The study revealed that, among the four driving factors, only commitment and character significantly correlate with motivation to volunteer. Therefore, it is crucial for faculties to support and cultivate stu- dents’ commitment and character. Incorporating activities such as self-reflection into learning sessions can help nurture these quali- ties in students. Further research could explore additional factors influencing nursing students’ decisions to volunteer. References 1. Djalante R, Lassa J, Setiamarga D, et al. Review and analysis of current responses to COVID-19 in Indonesia: period of January to March 2020. Prog Disaster Sci 2020;6:100091. 2. Mistry SK, Ali AM, Yadav UN, et al. COVID-19 related anxi- ety and its associated factors: a cross-sectional study on older adults in Bangladesh. BMC Psychiatry 2022;22:737. 3. Nurlinawati I, Sumiarsih M, Andarwati P, et al. Determinants of risk factors for COVID-19 transmission in densely populat- ed areas: Insights from the first wave of the pandemic. Electron J Gen Med 2023;20:em531. 4. Satgas COVID-19. Peta Sebaran COVID-19. 2021. Available from: https://covid19.go.id/peta-sebaran 5. WHO. Coronavirus disease 2019 (COVID-19): situation report, 82. Available from: https://iris.who.int/bitstream/han- d l e / 1 0 6 6 5 / 3 3 1 7 8 0 / n C o V s i t r e p 1 1 A p r 2 0 2 0 - eng.pdf?sequence=1&isAllowed=y. 6. CNN Indonesia. 295 tenaga kesehatan jatim terjangkit corona, 23 meninggal. Available from: https://www.cnnindonesia. com/nasional/20200714142414-20-524496/295-tenaga-kese- hatan-jatim-positif-corona-23-meninggal. [Material in Indonesian]. 7. Efendi F, Aurizki GE, Auwalin I, McKenna L. The need for speed: a qualitative study on nurse recruitment and manage- ment amidst the COVID-19 pandemic in Indonesia. J Multidiscip Healthc 2022;15:1809-17. 8. Lazarus G, Findyartini A, Putera AM, et al. Willingness to vol- unteer and readiness to practice of undergraduate medical stu- dents during the COVID-19 pandemic: a cross-sectional sur- vey in Indonesia. BMC Med Educ 2021;21:138. 9. Nugraha D, Salamah S, Luke K, et al. Evaluation of health- related quality of life and mental health in 729 medical stu- dents in Indonesia during the COVID-19 pandemic. Med Sci Monit 2023;29:e938892. 10. Martin B, Kaminski-Ozturk N, O’Hara C, Smiley R. Examining the impact of the COVID-19 pandemic on burnout and stress among US nurses. J Nurs Regul 2023;14:4-12. 11. Kominfo. Fasilitas dan tenaga kesehatan berbagai daerah sudah disiapkan menangani pasien covid-19. Available from: https://www.kominfo.go.id/content/detail/29414/fasilitas-dan- tenaga-kesehatan-berbagai-daerah-sudah-disiapkan-menan- gani-pasien-covid-19/0/virus_corona 12. Tran QA, Nguyen HTT, Bui TV, et al. Factors associated with the intention to participate in coronavirus disease 2019 front- line prevention activities among nursing students in Vietnam: an application of the theory of planned behavior. Front Public Heal 2021;9:699079. 13. Perveen S, Laurence C, Mahmood MA. Indicator-activities to apply primary health care principles in national or large-scale community health worker programs in low-and middle-income countries: a Delphi exercise. BMC Public Health 2022;22:1599. 14. Claxton-Oldfield S, Jefferies J, Fawcett C, et al. Palliative care volunteers: why do they do it?. J Palliat Care 2004;20:78-84. 15. Scherer LL, Allen JA, Harp ER. Grin and bear it: an examina- tion of volunteers’ fit with their organization, burnout and spir- ituality. Burn Res 2016;3:1-10. 16. Faletehan AF, van Burg E, Thompson NA, Wempe J. Called to volunteer and stay longer: the significance of work calling for volunteering motivation and retention. Volunt Sect Rev 2021;12:235-55. 17. Alimansur M, Quyumi E. Prevention efforts with compliance to the prevention of transmission Of COVID-19 to COVID-19 volunteers. J Public Heal Res Community Heal Dev 2020;4:81-7. 18. Widjaja E. Motivation behind volunteerism. CMC Senior Theses; 2010. 19. Hamzah SR, Suandi T, Shah JA, et al. Understanding the rea- sons for Malaysian youth participation in volunteering activi- ties. Athens J Soc Sci 2016;3:39-52. 20. Shi Y, Zhang S e, Fan L, Sun T. What motivates medical stu- dents to engage in volunteer behavior during the COVID-19 outbreak? A large cross-sectional survey. Front Psychol 2021;11:569765. 21. Ryan RM, Deci EL. Self-determination theory and the facilita- tion of intrinsic motivation, social development, and well- being. Am Psychol 2000;55:68-78. 22. Dik BJ, Eldridge BM, Steger MF, Duffy RD. Development and validation of the calling and vocation questionnaire (CVQ) and Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [page 546] [Healthcare in Low-resource Settings 2024;12:12100] Non -co mmerc ial us e o nly brief calling scale (BCS). J Career Assess 2012;20:242-63. 23. Wulandari CP, Muthi’Ah AD, Aldhama SA, et al. Analyzing perceived academic stress among first year undergraduate stu- dents during online distance learning. AIP Conf Proc 2023;2536:040001. 24. Weiss Ozorak E. Commentary: culture, gender, faith. The social construction of the person-god relationship. Int J Psychol Relig 2003;13:249-57. 25. Nurtjahyani SD, Amin M, Handajani R. Identification of hep- atitis C virus genotypes in volunteer blood donors from blood transfusion center of Tuban, Indonesia. Malays J Microbiol 2020;16:29-33. 26. Callister LC, Bond AE, Matsumura G, Mangum S. Threading spirituality throughout nursing education. Holist Nurs Pract 2004;18:160-6. 27. Park JZ, Smith C. ‘To whom much has been given..’: religious capital and community voluntarism among churchgoing protestants. J Sci Study Relig 2000;39:272-86. 28. Smidt CE. Religion as social capital: producing the common good. Waco, TX, USA: Baylor University Press; 2003. 29. Tran V De, Pham DT, Dao TNP, et al. Willingness of health- care students in vietnam to volunteer during the covid-19 pan- demic. J Community Health 2022;47:108-17. 30. Su JJ, Masika GM, Paguio JT, Redding SR. Defining compas- sionate nursing care. Nurs Ethics 2020;27:480-93. 31. Susanti RD, Yudianto K, Mulyana AM, Amalia IN. A Systematic scoping review of motivations and barriers in COVID-19 volunteering among health students: the potential for future pandemic volunteers. J Multidiscip Healthc 2023;1671-81. 32. Gonzalez-Mendez R, Díaz M. Volunteers’ compassion fatigue, compassion satisfaction, and post-traumatic growth during the SARS-CoV-2 lockdown in Spain: self-compassion and self- determination as predictors. PLoS One 2021;16:e0256854. Transforming Healthcare in Low-Resource Settings: A Multidisciplinary Approach Towards Sustainable Solutions [Healthcare in Low-resource Settings 2024;12:12100] [page 547] Non -co mmerc ial us e o nly