key: cord-0898502-9zaaclxb
authors: Lyman, Bret; Horton, Morgan K.; Oman, Alyssa
title: Organizational learning during COVID‐19: A qualitative study of nurses' experiences
date: 2021-09-01
journal: J Nurs Manag
DOI: 10.1111/jonm.13452
sha: 4e1ac75ca11532365863dae52e19e2f1c222b552
doc_id: 898502
cord_uid: 9zaaclxb

AIM: The aim of this study is to test the validity of the Organizational Learning in Hospitals model in the context of the COVID‐19 pandemic. BACKGROUND: Organizational learning is especially crucial in circumstances of intense, complex, enduring change, as with the COVID‐19 pandemic. Nurse managers need additional guidance for fostering organizational learning under such circumstances. The Organizational Learning in Hospitals model may be a helpful resource but requires additional validation. METHODS: Semi‐structured interviews were conducted to gather 19 nurses' first‐hand experiences of organizational learning during the COVID‐19 pandemic. Data were analysed using deductive thematic analysis. RESULTS: Nurses' experiences of organizational learning generally aligned with the tenets of the model. Specifically, effective organizational learning occurred when the contextual factors and mechanisms portrayed in the model converged. Model and contrary cases illustrate this phenomenon. CONCLUSIONS: This study validates and adds context to the model. It offers practical examples of the contextual factors and mechanisms of organizational learning. Leaders can use the model to guide their efforts to foster organizational learning. IMPLICATIONS FOR NURSING MANAGEMENT: This study reaffirms the importance of nurse leaders' central role in organizational learning. Nurse leaders can use the Organizational Learning in Hospitals model, and the practical examples provided, to foster organizational learning during challenging times.

In late 2019, a novel coronavirus struck Wuhan, China. The disease, later named COVID-19, was first identified in a cluster of patients with pneumonia and ultimately spread across the globe (McIntosh et al., 2021) . To slow the spread of disease, governments and public health officials urged people to social distance, wear face masks and only leave home when necessary (Centers for Disease Control and Prevention, 2020). Just as people made significant adjustments to their daily lives, healthcare workers needed to adapt their practices to meet the challenges presented by COVID-19. Frequent, rapid changes related to screening, testing, isolating, treating and immunizing for COVID-19 were necessary (Auerbach et al., 2020) . Healthcare organizations struggled to meet staffing demands and to provide front-line workers with adequate supplies and personal protective equipment (PPE; Loh et al., 2020) . Nurse leaders faced the particular challenge of directing practice changes while ensuring patients and staff were being taken care of (Cariaso-Sugay et al., 2021; Freysteinson et al., 2021; Losty & Bailey, 2021; Zhao et al., 2020) .

Throughout the global pandemic, effective organizational change has been crucial for providing the best patient care possible, keeping staff safe and mitigating the spread of disease. Organizational learning provides a helpful way to conceptualize such change. Organizational learning is a process of 'positive change in an organization's collective knowledge, cognition, and actions, which enhances the organization's ability to achieve its desired outcomes' (Lyman, Hammond, et al., 2019, p. 643) . Lyman, Jacobs, et al. (2019) However, additional research is necessary to explore whether the Organizational Learning in Hospitals remains valid in extreme circumstances, such as a global pandemic. Currently, there is only scant evidence regarding organizational learning in the context of complex, large-scale events, such as global pandemics (Sagy et al., 2018; Sharma et al., 2021 

This study was conducted using a deductive, qualitative descriptive approach. Qualitative, descriptive studies are commonly used in nursing and health care research to explore phenomena that are not well understood. When using a deductive approach, researchers purposefully select a theory or framework to guide the study. The analysis is, in part, focused on determining whether the data collected supports the chosen theory as is, indicates the theory should be modified or reveals something entirely unique (Kim et al., 2017) . In this case, the Organizational Learning in Hospitals model (Lyman, Jacobs, et al., 2019) guided the study's design and analysis, allowing the researchers to explore the model's validity in the context of a global pandemic. The model, generated through a realist review (Lyman, Jacobs, et al., 2019) and subsequently validated qualitatively (Lyman et al., 2020) , depicts how the convergence of six contextual factors and five mechanisms leads to organizational learning in hospitals. Ethical approval for this study was obtained through the researchers' university Institutional Review Board.

Participants were all registered nurses and licenced practical nurses providing direct patient care in an acute care or long-term care setting during the COVID-19 pandemic. Participants were recruited through network recruiting. This approach was chosen to diversify the geographic regions and facility types (e.g., acute care and long-term care)

represented in the sample. The researchers first invited several of their professional colleagues to participate and then asked those participants to refer their professional colleagues to participate as well.

The final sample included 19 participants, who worked in a total of 16 different facilities, located in eight different states across the United States (Table 1) , allowing the results to reflect a breadth of experiences.

Semi-structured interviews were used to gather information about the participants' experienced changes in the workplace during the COVID-19 pandemic. The authors developed an interview guide based on the Organizational Learning in Hospitals model . Participants were asked to describe how their organization prepared for the pandemic, how COVID-19 related practice changes occurred in their organization and the mechanisms and contextual factors present in those change processes. Interviews lasted up to 45 min. Participants received $20 Amazon.com gift cards.

The interviews were audio-recorded and transcribed verbatim. Data collection continued until saturation was achieved.

This study involved a deductive approach to thematic analysis, guided by the Organizational Learning in Hospitals model (Lyman, Jacobs, et al., 2019) . In concordance with the approach used by Lyman (Table 1) . Tables 2 and 3 Angela's hospital demonstrated substantial capability for preparing and responding to 

Jocelyn's experience is an example of difficult organizational learning.

In the residential treatment facility where Jocelyn had her experience, nearly all of the contextual factors and mechanisms associated with organizational learning were absent, before and during the pandemic.

Before the first case of COVID-19 was detected in the United States, Jocelyn's treatment facility started stocking up on personal protective equipment and screening staff for COVID-19 symptoms and potential exposures. As COVID-19 became a more imminent threat, the facility began requiring twice-daily vital sign monitoring for each of its 100 residents. This change was difficult to implement due to long-term staffing shortages and burnout among the nursing staff (inadequate infrastructure).

Jocelyn's facility, without input from the nurses or medical personnel. Jocelyn's facility did use deliberate learning in response to COVID-19. Nurses were provided training modules on proper hygiene, hand washing, social distancing and how to use personal protective equipment. Nurses also trained non-medical personnel to measure residents' vital signs, which did expand their capacity to screen residents for COVID-19 symptoms as frequently as necessary.

Although the nurses did communicate about their experiences implementing the changes, Jocelyn described them as gossip, rather than a purposeful attempt at collective reflection. Jocelyn was not able to identify any examples of how the facility had worked to sustain any of the changes that were made (retention).

Jocelyn's facility has long experienced rapid turnover at all levels of the organization, resulting in little shared experience for the team to draw on during a crisis. Because the leadership team had turned over so often, they did not have the rapport necessary to establish an effective working relationship with the staff. Although the staff had experienced a fair amount of turnover, several nurses on the team had been working at the facility for many years. These experienced nurses relied on their shared experiences to challenge the leadership team's efforts. Due to the facility's ongoing staffing needs, the experienced nurses felt the leadership team would be unwilling to administer disciplinary action against them.

Although nurses' experiences in acute care facilities were not directly compared to those in long-term care and residential facilities, Table 1 suggests the contextual factors and mechanisms associated with organizational learning were more prevalent in acute care facilities.

Regardless of which type of facility they worked in, all the nurses' experiences included both successes and challenges related to organizational learning. For example, one nurse's experience in an acute care facility included all of the mechanisms of organizational learning, but navigating change was still challenging because the team lacked motivation, critical infrastructure and shared experience. Another nurse's experience in a long term care facility was successful, even though motivation and opportunities for collective reflection were lacking.

She shared that these deficits were overcome through strong leadership, effective communication throughout the organization, clear expectations, adequate infrastructure and ample opportunities for deliberate learning, which allowed their team to respond effectively to COVID-19.

The primary purpose of this study was to test the Organizational tional Learning in Hospitals model appeared to be associated with organizational learning. Further, the absence of one or more contextual factors and/or mechanisms seemed to significantly impede the organizations' ability to learn. As a whole, these findings further validate the Organizational Learning in Hospitals model (Lyman, Jacobs, et al., 2019) , both generally and in the context of a pandemic.

The nurses' experiences also offered helpful insights into organizational learning during a pandemic that may be applicable to future crises. Although each contextual factor and mechanism is essential for organizational learning generally, some appeared to be particularly important for effective organizational learning within the specific context of a pandemic.

First, psychologically safe relationships were foundational to effective organizational learning in response to COVID-19. When psychological safety is present, nurses are not concerned about potential repercussions when sharing ideas and concerns (Edmondson, 1999) .

Psychologically safe relationships between administrators and staff helped the staff more readily adapt to a more top-down approach to leadership and to accept changes in clinical procedures, staffing models and resource allocation. Similarly, staff who felt psychologically safe tended to voice their concerns and share ideas in appropriate ways that productively influenced their organizations' COVID-19

responses. Psychologically safe relationships seemed to influence how frequently and how effectively team members interacted, collectively Third, adequate infrastructure was crucial for healthcare organizations to adapt to changes caused by the pandemic. Almost all nurses described an inadequate supply of personal protective equipment at some point during their experiences during the pandemic. Increased patient census and nurse turnover, coupled with numerous staff being exposed to or infected with COVID-19 also posed challenges. These issues were compounded in organizations experiencing inadequate staffing and staff burnout prior to the pandemic. Others Manzano García & Ayala Calvo, 2021; Wahlster et al., 2021) have also identified staff and equipment shortages as contributing to nurse burnout during the COVID-19 pandemic. with whom they had never previously worked. As a result, it was more difficult to ask for help, draw on each other's strengths and work collaboratively. In some cases, the shared experience of working through the COVID-19 pandemic brought a sense of unity and collective confidence to the staff. In other cases, nurses described their shared experiences as contentious and causing strain on team relationships. Thompson and Kusy (2021) also noted teams' mixed responses to working together through the COVID-19 pandemic (i.e., some became stronger, whereas others became less civil, more selfish and less effective), attributing those differences to the leader's effectiveness.

Although learning. This study adds credence to their suggestion that the Organizational Learning in Hospitals model may need revision to more accurately reflect the centrality of leadership (Lyman et al., 2020) .

Additionally, organizational learning appeared to occur most readily when the mechanisms occurred in a context conducive to organiza- 

Although differences between nurses' experiences across different types of healthcare facilities were not a specific focus of this study, it is worth noting long-term care and residential facilities may have experienced special challenges related to organizational learning. Even in the absence of a global pandemic, organizational learning in longterm facilities may be impeded by chronic issues related to inadequate staffing (Werner & Coe, 2021) , low staff retention (Kennedy et al., 2021) , stigma toward those working in aged care and its psychological impact on staff (Manchha et al., 2021) and few opportunities for front-line staff to engage in organizational learning 

The retrospective nature of this study made it possible to document organizational learning over time. However, a longitudinal design, documenting those changes in real-time, may have yielded richer descriptions of those changes. This study was informed by participants' personal narratives, rather than direct observation or numerically measured changes. Although such narratives are critical for understanding organizational learning, they can be subject to bias and imperfect memory. The Mountain West region was more heavily represented in the sample than other regions of the United States, particularly the long term care facilities, which may limit how well the results reflect organizational learning in other areas.

Although this study makes an important contribution to the literature, additional research is needed to more fully explore organizational learning during unique and challenging events, such as global pandemics. Future research may benefit from using longitudinal, mixed method designs and expanding the sample beyond front-line nurses.

Longitudinal research could offer better insights into how the presence of various factors and mechanisms of organizational learning prior to the event influence organizational learning during and after the event. Longitudinal designs could also provide a more detailed view of the dynamics among those factors and mechanisms. Mixed methods designs could be a valuable strategy to leverage the strengths of both qualitative and quantitative methods to create a more complete understanding of organizational learning and its effects. Expanding future samples beyond front-line nurses could add helpful perspectives (e.g., nurse managers, physicians, therapists and assistive personnel) and provide richer descriptions of the organizational learning process. Finally, future research could more intentionally explore organizational learning in long-term care and residential facilities to examine the validity of the Organizational Learning in Hospitals model (Lyman, Jacobs, et al., 2019) beyond acute care hospitals.

This study adds validity and context to the Organizational Learning in Hospitals model (Lyman, Jacobs, et al., 2019) , particularly in the con- 

The authors have no conflict of interest to disclose.

This study was funded by the Brigham Young University College of Nursing.

This study received ethical approval from the Brigham Young University Institutional Review Board. The approval number is E2020-253.

Data are available on request due to privacy/ethical restrictions.

https://orcid.org/0000-0003-1963-7880

Hospital ward adaptation during the COVID-19 pandemic: A national survey of academic medical centers

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

Public health response to the initiation and spread of pandemic COVID-19 in the United States

A large-scale survey on trauma, burnout, and posttraumatic growth among nurses during the COVID-19 pandemic

Psychological safety and learning behavior in work teams

The experience of nursing leadership in a crisis: A hermeneutic phenomenological study

Organizational factors associated with retention of direct care workers: A comparison of nursing homes and assisted living facilities

Characteristics of qualitative descriptive studies: A systematic review

Operational considerations and challenges of biochemistry laboratories during the COVID-19 outbreak: An IFCC global survey

Leading through chaos: Perspectives from nurse executives

Organizational learning and motivation in certified nurse aides: A qualitative study

Nurses' experiences of organisational learning: A qualitative descriptive study

Organizational learning in hospitals: A concept analysis

Organizational learning in hospitals: A realist review

Deeply discrediting: A systematic review examining the conceptualizations and consequences of the stigma of working in aged care

The threat of COVID-19 and its influence on nursing staff burnout

Severe staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic: Study examines staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19): Epidemiology, virology, and prevention. UpToDate

Thematic analysis

COVID-19 in nursing homes: Calming the perfect storm

Implementation of a rapid evidence assessment infrastructure during the coronavirus disease 2019 (COVID-19) pandemic to develop policies, clinical pathways, stimulate academic research, and create educational opportunities

Lessons learned from the 2009-2010 H1N1 outbreak for the management of the 2013 silent polio outbreak. BMC Infectious Diseases

Responses to COVID-19: The role of governance, healthcare infrastructure, and learning from past pandemics

Has the COVID pandemic strengthened or weakened health care teams? A field guide to healthy workforce best practices

Nurses' continuing professional development: A systematic literature review

The coronavirus disease 2019 pandemic's effect on critical care resources and health-care providers: A global survey

Strategies for Theory Construction in Nursing

Nursing home staffing levels did not change significantly during COVID-19

Caring for the caregiver during COVID-19 outbreak: Does inclusive leadership improve psychological safety and curb psychological distress? A cross-sectional study

Organizational learning during COVID-19: A qualitative study of nurses' experiences