key: cord-0729486-qkel7b64
authors: Vázquez‐Calatayud, Mónica; Regaira‐Martínez, Elena; Rumeu‐Casares, Carmen; Paloma‐Mora, Beatriz; Esain, Ainhoa; Oroviogoicoechea, Cristina
title: Experiences of frontline nurse managers during the COVID‐19: A qualitative study
date: 2021-10-24
journal: J Nurs Manag
DOI: 10.1111/jonm.13488
sha: 9e802bf749a865dd407ac56b6a819a7fdd0deb0c
doc_id: 729486
cord_uid: qkel7b64

AIM: To explore experiences of frontline nurse managers during COVID‐19. BACKGROUND: The COVID‐19 pandemic has complicated care provision and healthcare management around the world. Nurse managers have had to face the challenge of managing a crisis with precarious resources. Little research has been published about the experiences of nurse managers during the COVID‐19 pandemic. METHODS: A qualitative descriptive study of 10 frontline nurse managers at a highly specialized university hospital in Spain was carried out. Semi‐structured interviews were conducted between June and September 2020. The Consolidated Criteria for Reporting Qualitative Research checklist was used for reporting. RESULTS: Six themes emerged: constant adaptation to change, participation in decision‐making, management of uncertainty, prioritization of the biopsychosocial well‐being of the staff, preservation of humanized care and ‘one for all’. CONCLUSIONS: This study provides evidence for the experiences of nurse managers during the COVID‐19 pandemic. In addition, analysing these experiences has helped identify some of the key competencies that these nurses must have to respond to a crisis and in their dual role as patient and nurse mediators. IMPLICATIONS FOR NURSING MANAGEMENT: Knowing about the experiences of frontline nurse managers during the pandemic can facilitate planning and preparing nurse managers for future health disasters, including subsequent waves of COVID‐19.

The COVID-19 pandemic has complicated the provision of care and the management of healthcare worldwide (Tort-Nasarre et al., 2021) , placing nurses at the forefront of the response to the demands of the crisis (James & Bennett, 2020) . Despite this, a lack of available nurses to respond to the urgent need to care for COVID-19 patients and their families has been observed worldwide (Al Thobaity & Alshammari, 2020) . Nurse managers have had to face the challenge and threat of managing the crisis with precarious health supplies and resources, a changing workforce and exhausted staff who must cope with fear, uncertainty and the helplessness of not being able to assure humanized care for patients with COVID-19 and their families (Hofmeyer & Taylor, 2021; Xiang et al., 2020) . This contributes to the need to design new protocols and continuously reorganize services based on the changing information about SARS-CoV-2, which has led to many frontline nurse managers being overwhelmed (Bookey-Bassett et al., 2020) .

Despite the relevant role of nurse managers during the pandemic, little is known about their experiences (White, 2021) . This qualitative study contributes to the knowledge on the unique experiences of frontline nurse managers during the pandemic, which can help plan and prepare nurse managers for future health disasters, including subsequent waves of COVID-19.

The COVID-19 pandemic has caused a worldwide health and social crisis that has directly impacted the healthcare system (World Health Organization [WHO] , 2021). In our country, the first case was confirmed on 31 January 2020. Since then, the virus has spread rapidly, and the country has been severely affected. The government enacted a national lockdown on 14 March 2020, which is gradually becoming the 'new normal' (Ministerio de Sanidad, Gobierno de España, 2021) .

During this time, the role of nurse managers facing the pandemic has been briefly discussed in the grey literature. Published editorials have provided recommendations for effective leadership during the pandemic and suggest the requirement for courageous leaders with sound knowledge (Rosser et al., 2020; Shingler-Nace, 2020) . Only one study published on nurse managers' experiences during the pandemic with a qualitative approach has been identified to date, although the study did not focus only on frontline nurse managers and was carried out in another context (White, 2021) . According to this phenomenological study, the new role of nurse managers during the pandemic focuses on the emotional well-being of their staff and continual communication (White, 2021) . However, little research regarding the experiences of nurse managers during the COVID-19 pandemic has been published. Notably, future studies in hospital contexts should be developed (Bookey-Bassett et al., 2020; Lake, 2020; White, 2021) .

Furthermore, health organizations call for training programmes that prepare nurse managers to respond effectively in such situations (Cariaso-Sugay et al., 2021; Hodge et al., 2017) .

Understanding the experiences of frontline nurse managers during the COVID-19 pandemic is key to designing training programmes and organizational strategies that facilitate better management of future situations with similar epidemiological and clinical characteristics (Rosser et al., 2020) .

The aim of this study was to explore the experiences of frontline nurse managers during the COVID-19 pandemic.

A qualitative descriptive study was carried out. This design allows the study of people's experiences around a phenomenon (Polit & Beck, 2017) .

Ten nurse managers were selected by purposeful sampling, thus ensuring a notable degree of experience with the investigated phenomenon (Polit & Beck, 2017) . The inclusion criteria were front-line nurse managers from different units/services of a highly specialized university hospital in Spain who voluntarily participated and signed the consent form. No exclusion criteria were applied. The sample size was considered sufficient when the addition of new subjects did not reveal novel aspects of the studied phenomenon, and sufficient material was available to offer deep descriptions and interpretations (Polit & Beck, 2017) . The characteristics of the sample are presented in Table 1 .

Semi-structured interviews were conducted between June and September 2020. The interviews were audio-recorded for later transcription, and each interview lasted approximately 40 min. The interviews began with an open question and then addressed the areas of interest: change and unit management, influencing factors and suggestions for improvement ( Table 2 ). Aspects that complemented the data obtained through the interview, such as tone of voice, gestures and body posture, were recorded in the field notes to better understand and contextualize the experience of each nurse manager.

A systematic analysis of the transcripts was conducted by applying the methods proposed by Burnard (1996) . The initial phases of the analysis included comprehensive readings of the data and the development of a system of categories to describe the units of meaning identified in relation to the phenomenon studied. This system of categories was revised and refined based on the identification of common patterns. Accordingly, categories were ordered and regrouped into broader topics to explain the experiences of frontline nurse managers during the COVID-19 pandemic.

The procedures used to ensure the rigour of the study were selected based on the criteria proposed by Riege (2003) (see Table 3 ). In addition, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting (Tong et al., 2007) . The researchers considered their own reflexivity, being aware and reflexively self-critical of how their possible assumptions and biases could influence the process and the results (Riege, 2003) . The research team consisted of female nurses in senior positions with PhD (MVC and CO) and master's degree qualifications (the rest), broad and diverse healthcare experience, experience in academia (MVC and CO) and experience with qualitative research methods (MVC, CO and ERM).

Specifically, face-to-face interviews were conducted by two of the researchers (CO and ERM) who did not have a direct relationship with the interviewees. MVC, CO and ERM, who had experience in qualitative research, carried out the analysis and interpretation of the data.

All research team members were involved in drafting the manuscript and revising it critically for important intellectual content.

The participants were contacted via electronic mail and received verbal and written information emphasizing their free participation, confidentiality, data anonymity and the use of their data for scientific purposes. The first author encoded the identities of the participants as 'NM', with the number assigned to the interviewed nurse manager, and no other members of the team had access to identifying nurse T A B L E 1 Sociodemographic data of the participants (N = 10) 

Six themes were identified as follows: (1) 1. Constant adaptation to change 1.1 Urgent and constant reorganization of the service I have to organize protocols and procedures from one day to the next, even within hours. It was a constant change We were quickly looking for alternatives to many resources that were not available It was very changeable; it changed every day. We even changed the protocol every hour, everything had to be reorganized

The staff changed every so often, so it was difficult to manage them Another major challenge was managing the ever-changing staff

I found changing the way I proceeded every day because there was so much contradictory information We have sometimes lacked communication in changing circumstances Many times, in the most chaotic moments, different information has been received

It has been a time of important and quick decisions without consensus with many people Some decisions are made without considering the repercussions 3. Managing uncertainty Convey calm; like there was calm inside the chaos or uncertainty and fear We made a great effort to convey peace and tranquillity … in the midst of the uncertainty that existed You have to show that you feel secure, even though you have doubts inside you

My priority with the staff was to make sure that they did not lack anything We have prioritized making staff feel supported and backed up To be there, to be present, morning and evening with the staff

Do not forget about the person, being able to meet all the needs of the patient with care that is a little different from usual I have been able to accompany people who were dying to their last breath, who were alone, and keeping their families informed 6. 'One for all' 6.1. Teamwork These moments have truly united the team. They have worked phenomenally as a team; they have laughed and cried together As a team, we were going to direct, to organize as one, in sync, together

When I had needs or doubts … I always have a team that answered me at the moment and came and explained things to us These themes and their respective subthemes from which they evolved appear in Table 4 with examples of supporting verbatim phrases.

The pandemic situation abruptly brought on by COVID-19 required urgent and constant changes in the organization of services in terms of managing processes and staff, which required diligence and flexibility.

When you are in the situation, you are so involved (…) in work, in organising (…). 

Nurse managers perceived difficulties with the flow of information that they received regarding the guidelines to be followed during the pandemic crisis, both vertically and horizontally.

At the vertical level, several nurse managers identified communication problems in their stories mainly for two reasons: (1) lack of impartial information at the right time and (2) 

The suddenness of COVID-19 generated many fears and considerable uncertainty among nursing professionals. Nurse managers became aware of the need to project a sense of calm, security, confidence and apparent control of the situation. They were aware of the importance of not expressing their doubts and uncertainties in their day-to-day work and not projecting their concerns and fears. 

One of the priorities that the nurse managers repeatedly expressed in the interviews was ensuring the biopsychosocial well-being of the staff in charge. They realized that their main objective was to ensure that nurses could work in the best possible physical conditions in terms of their rest and protection (material and training) to adequately care for patients with a minimal risk of contagion.

That the staff were comfortable working within the circumstances in which they lived (…), they had shifts so that they were well-rested when they came to work (…), that they had material, that they did not lack anything. (NM2)

Another important challenge was organising the groups of professionals. I made two groups in all the units so that they did not mix with each other and so that if there was a concern regarding infection in one, the other stayed, even though we worked with isolation protocols. (NM1)

Nurse managers also described how they formed teams such that they had a friendly work environment in which the professionals felt comfortable. At the same time, they tried to have staff with experience and knowledge to ensure the safety of care and a balance among the professionals themselves.

When the shift groups were made, groups were not made randomly but with certain characteristics. Those groups were always the same. In addition, it was done with a thought towards like-minded people (…), and I Similarly, an aspect of care that was highlighted was ensuring that the patient did not feel alone, trying to bring the family as close as possible and reinforcing behaviours that compensated the lack of closeness imposed by protective measures. Such measures included making calls or ensuring that the nurse had a greater presence in complicated situations.

I have been able to accompany people who were dying to their last breath, who were alone, and I felt good because I was able to do that for them (…). There was also the challenge of keeping their families informed so that they would not be lost, not knowing where the relatives were or how they were admitted. (NM2)

We asked them if they had been able to speak with their family; we would facilitate a call or make it ourselves and give the patient the phone. (NM10)

The crisis caused by COVID-19 became an opportunity for teamwork and collaboration among all the services that are part of patient care at the hospital.

V AZQUEZ-CALATAYUD ET AL.

Nurse managers reflected in their testimonies how during the first weeks of the health crisis, nursing teams were more united than ever, resulting in teamwork playing an important role not only in ensuring the quality of patient care and preserving the patients' safety but also in providing mutual support among nurses.

These moments have really united the team. They have worked phenomenally as a team; they have laughed,

This team spirit revealed the willingness of nursing professionals to become involved and offer their help with whatever was needed.

It has been very easy to manage all the changes that have been generated in staff members, shifts, rotations; that is, they have helped a lot; they have made it much easier to be able to make the protocols and change them continuously. (NM10) Support and unity were reflected not only among the nurses who performed their work at the bedside but also among the first-line nurse manager team.

The support (…), the team of three was very helpful because you feel supported, the decisions, the consultations … I think it is a priority that as a team, we were going to direct, to organise as one, in synch, together, to get by, because there were many difficult moments.

(NM6)On the other hand, nurse managers reflected on how the relationship with the medical team was based on communication and trust. Meetings were held daily to address each patient condition;

aspects of improvement were identified, and action plans were discussed and agreed upon. The crisis allowed the establishment of relationships and practices that were not usually carried out during patient care, which facilitated the provision of care and highlighted the focus on the patient.

We have worked a lot as a team with the COVID team, which included infectious disease physicians, 

This study generated knowledge about nurse managers' experiences in the face of the COVID-19 pandemic in a hospital in Spain. Specifically, the findings provide explanations of these experiences as constant adaptation to change, participation in organizational decisionmaking at different levels, management of the uncertainty of the situation, prioritization of the biopsychosocial well-being of staff and preservation of humanized care, as well as an opportunity for teamwork and multi-and interprofessional collaboration. Additionally, the analysis of these experiences helped identify some of the competencies that nurse managers consider key from their experience to respond to a crisis, their dual role as patient and nurse mediators and strategies that may be useful in future pandemics.

In this study, adaptation to change was identified as a key experience that allows nurse managers to respond to the pandemic, with the peculiarity that during crises, adaptation must be developed continuously and diligently. Nurse managers identified this experience as a competency that they had to develop 'live' and required knowledge, attitudes and skills in reorganizing the processes and staff of the units, seeking quick solutions, making complex operational decisions and devising communication strategies with the team (e.g. using mobile apps) to obtain and convey new information quickly. These latter skills had previously been identified as essential for improving crisis leadership in the health context (Bookey-Bassett et al., 2020; Deitchman, 2013; Veenema et al., 2017) . However, the literature indicates that organizations lack training programmes that prepare nurse managers to respond to a crisis (Baack & Alfred, 2013; Cariaso-Sugay et al., 2021; Hodge et al., 2017) . Some of the findings of this study suggest the importance of nurse managers' attitude; specifically, they suggest that nurse managers must nurture a proactive and visionary attitude that allows them to anticipate events, analyse problems that may arise and think about how to avoid or minimize such problems. In this sense, integrating methodologies such as simulations, role-playing and case studies (Deitchman, 2013) into training may be interesting, which may allow nurse managers to improve their responses to future pandemic outbreaks of the same nature.

Another essential experience they have had to deal with and for which they must be trained in the face of COVID-19 is managing uncertainty. Nurse managers should project a sense of calm, confidence and authority among the staff in charge. These findings are consistent with the principles defined by the American Organization ing this point in a situation as exceptional as a pandemic seems key.

Through such actions, nurses will be able to count on the necessary support to maintain their well-being and reduce the possible harm caused by the crisis (Cathro & Blackmon, 2021) .

Finally, the positive impact that working during the first wave of the pandemic had on the nurse managers of this study is notable; they felt support from superiors, peers and subordinates who worked 'one for all' in multi-and interprofessional collaboration with the common goal of providing the best patient care possible. This good relationship within and among teams can be attributed to the crucial moment that they experienced given that crises require professionals to assume interprofessional collaboration dynamics that are different from the usual dynamics (Reeves et al., 2010) , which is a key element in times of crisis (Rosser et al., 2020) .

As a limitation, this qualitative research gathers the experiences of nurse managers in a specific health context. Therefore, the findings pertain to the context in which the study took place and the perceptions of a limited number of participants. Although the sample can be considered small, it is sufficiently broad for a qualitative study because it ensured saturation of the data and redundancy in nurse managers'

contributions. However, this study does not intend to generalize the findings but rather to provide in-depth knowledge about the reality perceived by the nurse managers included in the study. In this sense, developing similar research in other contexts would be desirable to improve the understanding of the phenomenon.

This study provides evidence on the experiences of nurse managers dual role as patient-nursing staff mediators should be emphasized to provide an optimal response in a crisis. Lastly, these contributions must be further explored by carrying out new qualitative studies in other contexts.

Nurse managers can use these findings to improve organizational management policies during health catastrophes, including the impending waves of the COVID-19 pandemic, as well as future pandemic outbreaks of a similar nature. Similarly, the findings will serve as a basis for the design of educational strategies aiming to improve the key competencies that a nurse manager must learn to adequately respond to a crisis and ultimately improve the biopsychosocial wellbeing of staff and patient outcomes.

Nurses on the frontline against the COVID-19 pandemic: An integrative review

The role of the COVID-19 pandemic as a risk factor for suicide: What is its impact on the public mental health state today?

Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honour Society of Nursing

Safeguarding and inspiring: In-patient nurse managers' dual roles during COVID-19

Teaching the analysis of textual data: An experiential approach

Nurse leaders' knowledge and confidence managing disasters in the acute care setting

Fears and perception of the impact of COVID-19 on patients with lung cancer: A mono-institutional survey

Nurse leaders' experiences and learnings navigating through the chaos of a pandemic

Enhancing crisis leadership in public health emergencies

Nursing selfperceptions of emergency preparedness at a rural hospital

Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID-19

Effective nurse leadership in times of crisis

How effective response to COVID-19 relies on nursing research

Nursing research: Generating and assessing evidence for nursing practice

Interprofessional teamwork for health and social care

Validity and reliability tests in case study research: A literature review with "hands-on" applications for each research phase

The need for visible nursing leadership during COVID-19

COVID-19: When leadership calls

Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups

Frontline nurses' responses to organizational changes during the COVID-19 in Spain. A qualitative rapid ppraisal

Nurses' continuing professional development: A systematic literature review

Hospital administration and nursing leadership in disasters: An exploratory study using concept mapping

Compassionate leadership: How to support your team when fixing the problem seems impossible

A phenomenological study of nurse managers' and assistant nurse managers' experiences during the COVID-19 pandemic in the United States

Coronavirus disease 2019 (COVID-19) situation report 93

World medical association declaration of Helsinki: Ethical principles for medical research involving human subjects

Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The Lancet

Experiences of frontline nurse managers during the COVID-19: A qualitative study

We wish to express our gratitude to the nurse managers' participants who made this study possible.

The authors have no conflict of interest to declare. Elena Regaira-Martínez https://orcid.org/0000-0002-0892-5820