key: cord-0734335-v1d347oo authors: Jackson, Jennifer; Nowell, Lorelli title: ‘The office of disaster management’ nurse managers' experiences during COVID‐19: A qualitative interview study using thematic analysis date: 2021-08-12 journal: J Nurs Manag DOI: 10.1111/jonm.13422 sha: 8b04b1ae8065397a0d183c4e447d3cd268e60f1b doc_id: 734335 cord_uid: v1d347oo AIM: The purpose of this study was to understand the experiences of nurse managers during the COVID‐19 pandemic. BACKGROUND: There is a growing body of knowledge about the experiences of clinical nurses during COVID‐19. However, there is less evidence about the experiences of nurse managers during the pandemic. METHODS: Eight nurse managers, from acute care and outpatient settings, completed semistructured interviews about how their roles had changed during the pandemic, how they felt about these changes, and what had gone well or been difficult. Each participant was interviewed once, for 20–60 min. We used thematic analysis methods to analyse the interview transcripts. FINDINGS: Nurse managers had to coordinate care in a context of uncertainty and guidance that changed frequently. Participants found that their roles and responsibilities either expanded to include more duties, or they were asked to take on a completely new role, with no orientation or training. Nurse managers were expected to provide support to their staff and patients, but did not necessarily receive support themselves. Participants were expected to plan simultaneously for care during the pandemic and for a return to normal working conditions. These factors contributed to challenging and difficult participant experiences of managing during COVID‐19. CONCLUSION: Nurse managers' experiences during COVID‐19 are influenced by changes to their roles and the support they received. Nurse managers continue to support high‐quality care despite working a difficult context. IMPLICATIONS FOR NURSING MANAGEMENT: Where possible, nurse managers can be supported to extend their roles or receive additional education and support if they are required to take on new responsibilities. Nurse managers require support in order to be a resource for their staff. In the first phase of this larger study (Nowell et al., 2020) we recruited participants by sending an invitation to complete a survey through email lists, social media and word of mouth (Palinkas et al., 2015) . Participants were recruited for this second qualitative phase through the survey, by inviting participants to leave their email addresses if they were willing to complete an interview. Nineteen nurse managers provided their email addresses on the survey. Each was emailed an invitation for an interview at their convenience, with one follow-up email reminder. We opted not to send additional reminders, as we recognized some potential participants may not have had capacity to participate during the pandemic. Eight participants responded and chose to complete interviews. Though the sample size was small, samples of this size have been determined appropriate by Guest (2006) for studies using thematic analysis. Semistructured interviews were conducted in July-September 2020 by a PhD prepared registered nurse with qualitative expertise. The interviews were completed over Zoom and Skype, which are rigourous ways to engage with participants (Iacono et al., 2016; Janghorban et al., 2014; Oates, 2015) . Participants were not required to have their video on during the call, and the recordings of the interviews were audio only. The interview guide included questions on how participants' roles had changed during the pandemic, how they felt about these changes and what had gone well or been difficult. Prompts were used to explore participants' comments further during the interviews. Each participant was interviewed once, for 20-60 min. We applied a pragmatic approach (Weaver & Olson, 2006) to the data analysis in this study, aiming to fill a gap in the existing knowledge about nurses' COVID-19 experiences. We used thematic analysis methods to identify common themes among nurses managers' diverse experiences (Braun & Clarke, 2019) . Thematic analysis is a flexible qualitative analysis method that supports researchers to explore perspectives among participants (Nowell et al., 2017) . Each interview was read, and then coding began with sentencelength phrases in the text. These codes were grouped together to create themes and were adjusted after each interview. After coding three interviews, the coding shifted to longer phrases of several sentences. An effort was made to move from descriptive codes to interpretive codes, to identify the broader connections among participants' experiences. After each interview was coded, the coding matrix was reviewed to identify the salient elements in the participants' experiences. We used several rigour enhancing strategies during the current study. The interviews were transcribed verbatim by a professional transcriber and verified for accuracy (Morse & Field, 1995) . The interview transcripts were organized in the data management software, NVivo v. 12 Plus. The sampling strategy supported credibility (Morse et al., 2002) , as the participants had been screened using their survey responses. Reflexive memos and written reflections were created alongside the coding process, to help make sense of participant experiences (Guba & Lincoln, 1994; Morse, 2015; Nowell et al., 2017) . The process of reviewing themes, reflecting on codes and well-organized records also supported the rigour of this study (Nowell et al., 2017) . Ethical approval for all phases of this study was obtained from the university research ethics board, protocol number REB20-0633 on 29 April 2020. Eight nurse managers participated in this study. Their demographic information is presented in Table 1 . All of the study participants were female. The majority of participants were from Canada (87.5%) and had a master's in nursing degree (62.5%). The participants managed diverse areas that included medical-surgical areas, palliative care and outpatient services. During COVID-19, several participants were asked to manage additional areas, while others were redeployed to completely new management roles. The participants were responsible for supporting patient care, maintaining staffing, managing budgets and ensuring operations continued. There were several themes identified in participants' experiences, listed in Table 2 . COVID-19 was the dominant contextual factor for participants, who reported that they had to work in a context of uncertainty and in challenging political climates. Participants' work changed, either by expanding their roles and responsibilities, or by changing to new management roles altogether. While working in these roles, nurse managers managed transitions and maintained care quality. Nurse managers also needed support themselves, to continue working in a stressful context. These findings are discussed in more detail in the following sections. The context for the participants was based on responding to This participant's role was to organize a response to staff cases of COVID-19 and struggled with the lack of planning for managing isolation and testing protocols. The participant who managed the staff cases of COVID-19 was redeployed from acute care management and was not from an occupational health background. Participants had to create new working procedures from scratch, such as a staffing management plan when large numbers of nurses were unavailable. As staff came in contact with potential COVID-19 positive patients, they were required to isolate, which resulted redeployment and staff shortages. Participants reported that personal protective equipment (PPE) was a significant concern, and much of their work included managing shortages of PPE and trying to protect their nursing staff. This participant reported that different clinical areas had different PPE guidelines, which raised concern about staff safety. Participants had a variety of experiences during the pandemic, which were influenced by the changes in their roles, their level of support and the transitions they needed to manage. Support was critical for nurse managers, which included clear communication, guidelines and helpful team members. Participants reported that they had to be a source of support for their nurses and patients, which required substantial emotional labour. Some participants reported negative consequences from a lack of support and recognition of their work. For example, one participant reported working 12-h days, 7 days a week while redeployed, only to be reassigned back to her role with no handover. So, there wasn't much appreciation, like, I do not need a thank you or a big party, but it was just kind of like, okay, so we did all of this, and you are asked us to come here and you did not thank us, it does not really make sense. We just did not really feel appreciated (M2). The lack of appreciation was hurtful after this participant had worked extra hours to support the nurses she was managing. Participants also stated that COVID-19 revealed people, and managers benefitted from strong team members, but also had to compensate for those that were disengaged. I think COVID definitely, to me, it exposed a lot of people, and how people react during like times of crisis. This participant was buoyed by the support of her colleagues, but also had to overcome gaps that were created by other colleagues who were less helpful. The presence or absence of support for participants was critical in their ability to provide support for their colleagues. Participants stated that COVID-19 was generally stressful and participants were fearful for themselves and their colleagues. This participant explained how she was candid with her staff about her feelings: 'Being able to share with staff and say, I'm scared too. That's what they did not need to hear, but they sure wanted to know that they were not in this alone (M7)'. Even though this participant was in a different role than a clinical nurse, she was worried about the outcomes for her colleagues, patients and community. Uncertainty and high workload contributed to the pandemic being a stressful experience. Participants also struggled with the emo- The purpose of this study was to understand the experiences of nurse managers during the COVID-19 pandemic. Overall, the experience of COVID-19 for nurse managers was stressful and was influenced by a nurse manager's context, the changes to their role and the availability of support. Nurse managers had to manage transitions in care, and in stages of the pandemic, and provided quality healthcare through problem solving. These findings are similar to an account from a nurse manager who worked during SARS (Lau & Chan, 2005) , indicating there may be similarities between nurse managers' experiences during pandemics. Nurse managers in our study had to coordinate and plan a response to COVID-19, while navigating a volatile political climate. While nurses often have to navigate politics in their work (McMillan & Perron, 2020) , nurses are generally unprepared to manage during disaster conditions (Labrague et al., 2018) . For nurse managers, chronic stress is known to impact decision making during challenging situations (Shirey et al., 2013) , which has implications for an organizational response to a pandemic. Extra stress may be created through budget decreases and other cuts to resourcing (Traynor, 2017) . It is important that possibilities like COVID-19 are considered in future healthcare planning so that nurse managers can respond effectively during pandemic or disaster conditions. In our study, nurse managers reported their roles expanded or changed completely in response to COVID-19. Nurse manager roles are known to be ill-specified, leading to a lack of role clarity (McCallin & Frankson, 2010) . These findings align with seminal research on nurse manager roles, which can change through "diffusion" or direct extension (Murphy, 1970, p. 381) . Generally, women's job roles are broader and less defined than men's (Ellemers, 2014) , which could contribute to the broad expectations for nurse managers (in a stereotypically female profession). Managing capacity is a central part of the role of a nurse manager during COVID-19 (Wu et al., 2020) . It may help to specifically designate staffing and resource management responsibilities to nurse managers with experiences in those areas. The findings of the current study indicate that expanding nurse managers' roles during a crisis is a more manageable plan than having managers change to taking on completely new responsibilities. Our findings indicate that nurse managers required a systems level view of the impact of COVID-19 across the spectrum of care, to ensure safe patient transitions and adequate resource for staff. Managing patient transitions is an underappreciated element of nursing work (Allen, 2014) . To avoid negative consequences, it is important that nurse managers have access to adequate resources and staffing (Lake & Friese, 2006) . In turn, nurse managers can support patient transitions across a care continuum. There were similarities to the findings for this population, and the experiences of clinical nurses during COVID-19. Nurse managers are asked to recognize the pressure on clinical nurses and provide support (Labrague & Santos, 2020; Mo et al., 2020) . However, nurse managers also need support themselves (McCallin & Frankson, 2010 There is an opportunity for organizations to reach out to nurse managers to inform responses to future pandemics. The participants in this study created strategies to maintain patient care quality and these strategies would be useful to capture for organizational development. Organizational learning is a key part of responding to serious incidents, but is challenging to implement across an organization (Sujan, 2015) . Organizational support is critical to learn from patient safety incidents (Anderson & Kodate, 2015) . Senior leaders are encouraged to engage with nurse managers to learn from the pandemic and inform future operations. This study is limited by a smaller sample size, of mostly white women, limited to Canada and the USA. The findings of the study should be applied with caution, as the experiences of people of colour, and those in other geographic areas were not represented in this study. We were limited to sampling nurse managers who responded to our initial PANDEMIC study survey. Participants selfselected, potentially limiting the representation of nurse managers perspectives. Comparison with more nurse managers from other backgrounds would strengthen the research, as would exploring the perspectives from a larger sample of nurse managers over time. Our study is also limited by the fact that we only spoke with participants once and did not have an opportunity to validate findings with the participants. 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The authors declare no conflicts of interest.