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

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.

INTRODUCTION

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.

BACKGROUND

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).

METHODS

Aim

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

Design

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

Participants

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.

TABLE 1

Sociodemographic data of the participants (N = 10)

	Mean ± SD (years)	Range (years)
Age	47.5 ± 7.33	36–57
Professional experience
As a nurse	25.3 ± 8.3	9–36
As a nurse manager	5.4 ± 4.86	1–14
	n (%)
Gender
Female	100%
Male	0%
Education level
Bachelor's degree	20%
Master's degree	80%

Data collection

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.

TABLE 2

Thematic guide

Tell me about your experience as a supervisor during this period.

What have been the main challenges you have faced during the COVID‐19 pandemic in your unit/service? Why?

How have you faced these challenges? What has been your role as a supervisor in facing these challenges? What have been your priorities regarding staff? Regarding the team? Regarding patient care?

What barriers have you encountered in responding to the needs of your unit/service during this period? What facilitators have you encountered?

What strategies have you used to manage the crisis with the staff? With the team? With patients?

What has everything you have experienced meant to you? What are the main lessons you have learned during this period?

From your experience in these months, what are the key aspects in the management of a crisis like this one?

Before ending the interview, would you like to tell me anything else that I did not ask you about that is important to you?

Data analysis

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.

Rigour

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.

TABLE 3

Procedures used to enhance study rigour

Criteria	Procedures
Confirmability Logical and impartial interpretation of data	Detailed descriptions of the characteristics of the participants and the criteria for the inclusion and selection of participants Detailed and explicit descriptions of the research methods and procedures
Credibility Veracity of the results	Use of textual quotes from the transcripts to support the arguments Searches of the text for textual evidence to support the findings
Transferability Applicability of the results to similar contexts	Each individual's perceptions are unique; the meanings behind them are common
Trust Stability and consistency of the data	The interpretative results (narratives) have been confirmed by some of the participants

Ethical consideration

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 manager information. Informed consent was collected from those who agreed to participate, and an interview was scheduled. This research was approved by the Research Ethics Committee of the University of Navarre (Code 2020.126) and by the hospital's management team and was performed in accordance with the criteria of the Declaration of Helsinki (World Medical Association, 2013).

RESULTS

Six themes were identified as follows: (1) constant adaptation to change, (2) participation in decision‐making, (3) management of uncertainty, (4) prioritization of the biopsychosocial well‐being of staff, (5) preservation of humanized care and (6) ‘one for all’. These themes and their respective subthemes from which they evolved appear in Table 4 with examples of supporting verbatim phrases.

TABLE 4

Themes and subthemes extracted from the qualitative data and examples

Themes	Subthemes	Examples of coded phrases
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
	1.2 Complexity of staff management in a changing situation	The staff changed every so often, so it was difficult to manage them Another major challenge was managing the ever‐changing staff
	1.3 Communication problems in changing situations	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
2. Participation in decision‐making		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
4. Prioritization of the biopsychosocial well‐being of staff		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
5. Preservation of humanized care		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
	6.2. Collaboration	When you call, the doors open (…) the support is impressive When I had needs or doubts … I always have a team that answered me at the moment and came and explained things to us

Constant adaptation to change

Urgent and constant reorganization of the service

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 (…). They called: ‘Hey, you have to organise this’, and there you are; it cannot wait for the next day, right? Things changed from one day to the next, even within hours, the protocols changed, and the procedures; so it was, well, a constant, constant, constant change (…). (NM1)

Faced with a new and unknown situation, the nurse managers indicated that they were forced to seek alternatives to the problems that arose and to provide prompt solutions. This proactive search for quick solutions helped them to face and overcome a situation for which they often lacked both organizational and patient care guidelines.

(…) what were we going to do? If not, we were looking for alternatives to things: well, if there were no such thing … we would look for alternatives to many resources that were not available (…). We had to search for alternatives to the problems that came up and solve them quickly … because, well, you are never prepared; you always have things, you always have resources, alternatives. (NM6)

This proactive attitude of the nurse managers was present even before they had to face the pandemic. As the following quote illustrates, they began to plan and devise solutions for the organization of infrastructure and human and material resources after exploring and analysing situations in other regions.

Before the worst of the pandemic arrived, we already began to work on things; we tried to organise (…) with all the experience we had of what was happening, of what we were hearing from Madrid (…); we got ahead of many things (…), most importantly, especially staff, patient organisation, organisation of medical teams, equipment, training …. (NM6)

Complexity of staff management in a changing situation

The complexity of managing staff arose mainly because personnel requirements needed to be changed continuously to adapt to clinical activity and absenteeism due to COVID‐19; the response in many cases involved incorporating staff from other services.

What has happened to us is that the staff changed every so often, between some being infected and then having to replace them and then the number of patients increased, because we had to bring new people, so it was difficult to introduce new people (…). That has added more work, perhaps, for management because you did not have much time to teach a lot to another person …. (NM10)

On the other hand, activities required adjustment to the type of patients who were being treated in the units; therefore, management assumed the training of staff such that in a short time, nurses could learn to attend patients other than those for whom they were qualified to care.

We were going to have to care for critical patients when the staff here (…) are not used to attending intubated patients; they do not know how to handle them, so they have helped us (…), people from the surgical area who were trained with ventilators (…), but that is an added fear (…) because patient care is the most important thing we have to provide. (NM3)

Communication problems in changing situations

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) diverse information that was contradictory or came from different sources. As illustrated in the quote below, both types of internal communication problems led nurse managers to continuously change their practices and to feel uncertainty and insecurity regarding their decisions.

(…) I found myself changing the way I proceeded every day without knowing very well what I was basing myself on because there was so much contradictory information, and from very good sources in principle (…). It is that uncertainty and insecurity of ‘Am I doing it right? Am I not doing it right? Will this be a good decision? Will it not be good...?’ (NM7)

On the other hand, regarding communication with their teams, nurse managers reflected on how the changing situation forced them to quickly convey different messages and devise strategies, such as the use of informal channels, to ensure that staff were informed. Nurse managers tried to transmit information that was clear, concise and truthful at all times and to convey it quickly to all staff members.

Everything changed day by day, so we communicated by WhatsApp, which was the fastest …. People had not even assimilated one thing, when there were changes one after another (…). The information had to be given very concisely, very clearly. (NM6)

Participation in decision‐making

Decision‐making at different levels was another relevant issue during the pandemic that nurse managers emphasized. On the one hand, at the operational level, they were able to participate in the decisions that were made.

… our contributions have helped them, and they have listened to us (…); if we felt that something was not right, then we would go over it [occupational risks] again with them to change it … they did not make the protocols [for occupational risks] alone; they made them with us…. (NM2)

In this sense, one nurse manager stressed that after reflecting on what they did and how they did it, they were aware of the decisions that they had to make without consensus; due to the importance of these decisions, having a consensus would have been better.

Now, afterwards, I realise how many things we did in a few days and that we organised without considering anyone's decisions (…). Therefore, you can see that it has been a time of making important and quick decisions without many people agreeing on them (…) and saying, ‘My goodness, this is me; here I am deciding this, and I would have liked to have been able to agree with three or four others, right?’ (NM1)

On the other hand, some nurse managers perceived not feeling involved in certain decisions that were made at a more strategic level and seemed not entirely correct and could have hindered operational management.

Some decisions are made without considering …, without thinking about the repercussions they may have. I don't know, it's as if … if everyone can speak, everyone is involved, I think it would be better. (NM5)

This centralized decision‐making also hindered operational aspects given the need to make decisions in a changing situation and without prior knowledge on which to base those decisions. Some nurse managers reported not being able to make correct decisions and not having autonomy due to a lack of updated information about which guidelines to follow because they felt that these guidelines were not quite viable in practice.

You did not know what to rely on to reinforce these regulations. Everything was changing so fast that, in the end, you saw that you were not capable of making a correct decision because you did not really know what the real criterion was for making that decision (…). So, I lacked some autonomy because, in the end, you do many things according to your decision, but you still want to have slightly more general information …. (NM7)

Managing uncertainty

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.

You have to show you feel secure, even though you have doubts inside you, right? And this is so, but no matter how many times you try not to show your insecurity, in the end, you convey it. (NM9)

Convey calm; they have been telling me that everyone had the sense of everything being organised, like there was calm inside the chaos or uncertainty and fear. (NM6)

Nurse managers also highlighted how, despite the uncertainty of the situation, the ability to anticipate events played an important role in the management of that uncertainty. The managers tried to look beyond the current problem and anticipate problems that could occur to avoid them or minimize their impact.

Each day you came to work, it was something different (…). Therefore, for us, the most important thing was to get ahead of events, that is, that they never caught us unaware. (NM4)

Prioritization of the biopsychosocial well‐being of staff

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 think that was successful …. (NM6)

Therefore, making those groups and then also bringing in the people who came, if they were an experienced person in X [service], I put them in a group that lacked that (…). That's how we went about figuring out groups. (NM3)

In addition, nurse managers were always receptive to responding to individual needs, sharing experiences and ensuring that the professionals could balance work and family life.

My priority with the staff was to make sure they didn't lack anything; to listen to them in case someone didn't feel well enough to work; to talk to them to give them more days off if they needed it, or to replace them with other people, so that they would be well, calm, not overwhelmed; (…) we used to get together to share the good things, the bad things, their fears. They were calmer when they talked and said what they thought. (NM2)

Changing people shifts, extending working hours (…), they said, ‘It's that I have my parents, my children, but I work elsewhere’; what do we do? Of course, we are going to help you. We are going to do what we can together; we will arrange shifts. (NM6)

Preservation of humanized care

This issue alludes to the double challenge that supervisors faced to ensure the protection of patients/families and professionals without losing sight of the person as the focus of care. This second challenge was difficult due to the impossibility of knowing the patients personally.

I did not know the patients. I did not recognise their faces. I only knew them by name … Going through the unit and not being able to … and not having their families … that was really hard for me. (NM6)

In this sense, nurse managers highlighted their concern that the priority of nursing work should continue to be holistic care of the patient and to ensure that they could address all of the patient's needs and concerns and provide the support that they needed at all times during their hospitalization.

Do not forget about the person. It has been very hard, the truth, because we have not been able to care as perhaps we would have liked to care, but that has been the greatest challenge: being able to meet all the needs of the patient with care that is a little different from usual. (NM10)

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)

‘One for all’

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.

Teamwork

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, they cried together …. (NM2)

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, pneumologists … we met every day and talked patient by patient about how we saw it and how we could improve. (NM2)

Collaboration

Collaboration among all the teams involved in patient care allowed the nurse managers to feel supported and ensured that decisions were made in a more agile and effective manner.

We work at an institution where when you call, the doors open (…) but [it] also supports you with accompaniment (…). The support is impressive. (NM9)

And then, I can tell you that other services have had (…) a very good attitude (…). They have made everything easier. (NM10)

Similarly, nurse managers valued the interdependence among the multiple departments of the hospital. They identified that their collaboration ensured that the needs of different services were covered quickly and diligently in a way that allowed formal channels to be skipped to expedite decision‐making.

When I had needs or doubts … I have always had a team that answered me at the moment and came and explained things to us. (NM2)

There are many things for which, at certain times, the response is, ‘Send me an email; write it down’. Well, no; now it is enough to call to get an answer, which I think has made things easier. In general, we have been open to not requiring written notification of authorisation to do something …. We have also been able to skip the usual regulatory channels to respond. (NM7)

DISCUSSION

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 decision‐making 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 for Nursing Leadership for crisis management by nursing leaders and partially coincide with the results found in recent publications of the same nature (Bookey‐Bassett et al., 2020; Shingler‐Nace, 2020). The present study highlights the positive impact that leaders have on staff; by example, leaders encourage staff members to remain calm and modulate their attitudes and behaviours. These findings have interesting implications for teaching the management of uncertainty in a crisis situation and support the importance of training in emotional self‐management for nurse managers.

In addition, the study allowed an examination of the protective role of nurse managers during the pandemic. Their dual mediating role has been linked to the so‐called compassionate leadership in times of crisis, defined as ‘the combination of supportive leadership approaches and the four components of compassion: attending, understanding, empathising and helping’ (James & Bennett, 2020; Vogel & Flint, 2021). In this study, the characteristics of compassionate leadership have been reflected in the way in which a nurse manager relates to both patients and personnel during a pandemic. On the one hand, nurse managers have been the voice of patients during the crisis, prioritizing their needs at all times (Aquila et al., 2020). Recent studies corroborate this assertion (Bookey‐Bassett et al., 2020; Hofmeyer & Taylor, 2021). Patient isolation and the absence of the relatives necessitated the development of strategies, such as telephone communication or a greater nurse presence, to alleviate the patients' loneliness and retain the essence of the patient–nurse relationship.

In line with the findings of other authors (Catania et al., 2020; Cathro & Blackmon, 2021; Hofmeyer & Taylor, 2021; White, 2021), the nurse managers in this study faced the challenge of protecting their staff members at the biopsychosocial level during the pandemic. Specifically, the findings of this study indicate that nurse managers in a crisis should ensure both the physical and mental protection of staff members, such as facilitating an adequate work environment, attending to psychological needs and/or providing emotional support. Among the strategies used to provide such support, being present both physically and emotionally through listening stands out (Bookey‐Bassett et al., 2020). To this end, one practice that helps nurse managers to encourage and support their staff is, for instance, to create a space to frequently share fears and good and bad experiences, which results in feeling better and more confidently delivering care to patients. Hofmeyer and Taylor (2021) provide information, practice updates and resources to develop a personalized self‐care plan to alleviate anxiety and support renewal and resilience. This strategic action of nurse managers can positively impact nurses' well‐being and ability to provide safe and high‐quality care for patients with COVID‐19 (Hofmeyer & Taylor, 2021). Another interesting strategy used by nurse managers to support their staff, which was not found in the published literature, was the formation of related teams and the management of flexible shifts to ensure work–life balance. Because the balance between the two spheres is one of the priorities that nurses express for their professional development and proper performance under normal conditions (Vázquez‐Calatayud et al., 2021), emphasizing 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).

Limitations

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.

CONCLUSIONS

This study provides evidence on the experiences of nurse managers during the COVID‐19 pandemic. This knowledge can inform the design of educational and management strategies aimed at improving the management of the COVID‐19 crisis and future pandemic outbreaks of a similar nature. A first step could be the development of training strategies for nurse managers to promote continuous and diligent adaptation to change and to help them manage uncertainty through training in emotional self‐management and the promotion of a proactive and visionary attitude. Similarly, the importance of their 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.

IMPLICATIONS FOR NURSING MANAGEMENT

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 well‐being of staff and patient outcomes.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

ETHICS STATEMENT

This research was approved by the Research Ethics Committee of the Navarre University (Code 2020.126) and by the hospital's management team and was performed in accordance with the criteria of the Declaration of Helsinki (2013).