Lessons Learned by Nurse Managers During the COVID-19 Pandemic: A Systematic Literature Review

1 BACKGROUND

 The unusual coronavirus disease that was detected in Wuhan China in December 2019 and radically spread radically, and quivered the global health sphere (World Health Organisation, 2020a). Due to the enormous spread of this  highly contagious virus, on 30^th January 2020, the World Health Organisation (WHO), declared  COVID-19 as a worldwide health emergency and consequently as a pandemic on the 11^th March 2020 (WHO, 2020b). Evidently, the dire effects of the COVID-19 pandemic included escalating deaths and morbidity, which subsequently directly affected health services and resources management (Nyasulu & Pandya 2020:4, WHO, 2020c). The compounding effect of the pandemic had a traumatic impact on the health care workers especially the nurses’ emotional and physical wellbeing. In this dire situation of enormous strain, caused by COVID-19 pandemic, nurses as the frontline workers were consequently emotionally and physically affected (Sheraton, Deo, Dutt et al., 2020). The post-traumatic stress was also exacerbated by lack of personal protective equipment, uncertainties regarding the spread of the infection (Sheraton et al., 2020). According to Rapisarda, et al. (2022), in the midst of the COVID-19 pandemic crises, the nurse managers were not unscathed by the aftermath of the disease.

In all aspect, the nurse managers are expected to be competent in ensuring the smooth running of the health care facility. The four broad generic managerial functions of the nurse manager include planning, organizing, leading and controlling (Patarru, Patarru, Yosepfus Weu, Secsaria Handini et al., 2019). Furthermore, some of the nurse managers’ crucial competencies include financial skills, decision-making, strategic and human resources management, organizational management and communication skills (González García, Pinto-Carral, Sanz Villorejo et al., 2020). All these core competencies of the nurse managers are aimed at ensuring patient and staff satisfaction, maintaining high standards and quality of care and aligning the unit's goals with the hospital's strategic goals. According to Tan, Yu and Luo et al. (2020), the nurse manager’s roles and competencies, became more prominent and evident in the emergence the novel COVID-19 pandemic.

The nurse managers had to ensure that the availability of nurses and resources to cater for huge number of critically ill patients during the COVID-19 pandemic. Evidently, nurse managers are responsible for supporting the nurses by developing policies and protocols in order to ensure a conducive working environment during the COVID-19 pandemic (Mo, Deng, Zhang et al., 2020, Catton 2020). In addition, protocols that changed all the time, lack of adequate communication and unclear guidelines may lead to confusion and be barriers for nurse managers when leading their teams as such problems can threaten the quality of care as well as the safety of healthcare workers (Rodrigues & Silva, 2020). With this kind of a background, it is clear that some lessons can be drawn from the nurse managers’ experiences regarding the COVID-19 pandemic.

Aim

This review aims to synthesize existing qualitative studies exploring the experiences of nurse managers during the COVID-19 pandemic. It sought to describe the nurse managers’ challenges, opportunities and lessons learned in managing the health facilities during the pandemic.

2. METHODS

2.1 Design

The literature review was grounded by the Joanna Briggs Institute (JBI) guidelines (Aromataris & Munn, 2017).The PRISMA systematic review reporting checklist (Moher, 2009) was used as a basis for reporting the review.

Search strategy

The two authors with the use of Preferred Reporting Items for systematic reviews and Meta-Analysis (PRISMA) (source) conducted the systematic review of the literature. In order to identify the relevant articles, the initial search was conducted with the application of the Boolean search strategy and databases included CINAHL, EBSCO Host databases, Google scholar, MEDLINE and recovered 315 articles. The search terms included: “Nurse Managers”, “Nurse Leaders”; “experiences”; “Lessons”; “Perceptions”; “Nursing management”; “COVID-19 pandemic”; “Corona virus disease pandemic”. The search was subsequently tapered by the application of the inclusion criteria that entailed articles written in English, peer reviewed, original articles, full text and published from December 2019 to March 2023. The period was purposefully chosen by the two authors to find relevant research articles which focussed on the nurse managers’ experiences during the era of Covid-19. The relevance of the identified articles were further determined by checking the title and the abstract. The complete article was retrieved and evaluated by the two reviewers grounded on the inclusion criteria as illustrated in Table 1. The search strategy was summarised using the PRISMA statement flow chart (Moher, Liberati, Tetzlaff & Altman 2009).The exclusion criteria pertained to studies that focussed on experiences or perceptions of other health service manager. In the process of this search strategy, the authors retrieved twenty articles.

Table 1: Inclusion and exclusion criteria

Critical appraisal

The studies which met the inclusion criteria were further evaluated by the two reviewers to establish methodological rigor. Subsequently, articles were read, authenticated, reaffirmed by the two reviewers to guarantee the rigor of the articles and ensure that they met the inclusion criteria. The critical appraisal skills programme checklist (CASP) was employed to critically appraise the studies (CASP, 2018). The credibility of the selected articles was grounded on the author(s), publication year and country, title, methods sample and data quality. The credibility of the studies was predominantly based on the criterion such as appropriateness of the research design and methodology and ethical considerations as illustrated in Table 2.

Data extraction

 The data from the qualitative data were extracted with the use of a standardised JBI qualitative assessment and review instrument (JBI-QARI). The two reviewers (SHK and KLM), independently conducted data extraction and discussed to reach a consensus .The data extracted included the demographic information of the population, the phenomena of interest, study methods and findings that were relevant to the research question.

Data analysis

 Thematic analysis was employed in this study because it offers a systematic approach to organise, analyse and present qualitative data collected from different sources of literature (Thomas & Harden 2008). Thematic analysis was used to categorise the experiences and support needs of newly qualified nurses, which were grouped together into meaningful themes. The analytical process involved the reading and re-reading of the studies before extracting relevant statements (Thomas & Harden 2008). The extracted content was reviewed iteratively against the emerging themes, which were inferred with constant recourse to the research question on experiences and support needs of newly graduated nurses. The analysis yielded 35 categories that were then grouped into four main themes (see Table 2).

3.2 Screening

During the screening process, duplicates of articles were removed at title and abstract level, leaving 215 articles. The research articles were further screened using the title and abstract that further abridged the total included articles to forty. With the intense application of the inclusion and exclusion criteria, twenty-one articles were eliminated, resulted in retaining nineteen articles.

3.3. Analysis and quality appraisal

The information extracted from each article included: authors; year of publication; country; study aim; methodology; data collection method and analysis, limitations and key findings (Table 1). All the relevant articles were combined; data resemblances noted, critiqued and produced the report in three headings. The Critical Appraisal Skill Program (CASP) qualitative checklist was applied to verify the rigor and quality of the selected studies (CASP UK, 2020).

 After the quality appraisal, twenty articles were included (Figure 1).

     Source: Page et al. (2021)

3.4 QUALITY

Table 1: Critical Appraisal Checklist for Qualitative studies included

Source: JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses (2017)

Key: Yes: Y; Cannot tell =CN; No=N

3.4 Ethics

The study did not require ethics approval because it was literature review. However all the articles reviewed are adequately cited.

Table 2: Articles that met the inclusion criteria N=19: March 2023 = 17300 articles

Results

Nineteen (n=19) research articles which met the inclusion criteria and published between October 2022 to April 2023. For the purpose of this study, all the reviewed articles used qualitative exploratory descriptive design. The reviewed articles reported studies conducted in the Brazil (n=2); Canada (n=1); Iceland (n=1); Indonesia (n=2); Iran (n=3); Jordan (n=1); Norway (n=1) ; Philippine (n=1); RSA (n=1); Spain (n=1) ; Switzerland (n=1); Turkey (n=1); USA (n=2); UK (n=1)

Two themes were revealed from the 19 articles, namely: 1) Challenges related to the COVID-19 pandemic; 2) Opportunities and lessons learned by the nurse managers in the COVID-19 pandemic. Eight out of the nineteen included articles revealed that the nurse managers experienced various challenges related to the COVID-19 pandemic (Apsay & Alalag 2022; Abu et al. 2022; Deldar, et al. 2021; Moyo, et al. 2022; Sugianto, et al. 2022; Freitas et al. 2021; Hølge-Hazelton et al., 2021; Ozmen & Arslan Yurumezoglu 2022; Sutejo et al., 2022). An overwhelming number of the studies (n=14) revealed several opportunities and lessons learned by the nurse managers in the Covid 19 pandemic (Hølge-Hazelton et al., 2021; Ozmen & Arslan Yurumezoglu 2022; Jónsdóttir et al., 2022; Abu et al., 2022;Sutejo et al. 2022;White 2021; Vázquez‐Calatayud, et al., 2022;Ree et al. 2022; Bianchi et al., 2021; Apsay, & Alalag, 2022; Poortaghi, et al., 2021; Mollahadi et al., 2021; Losty & Bailey 2021; Sugianto, et al., 2022). Table 3, below unpacks the results which emerged from the reviewed articles

Table 3: Themes, subthemes, categories and direct quotes emerged from studies included       

DISCUSSIONS

The aim of this systematic literature review is to synthesize existing qualitative studies exploring experiences of nurse managers during the COVID-19 pandemic. Two broad themes emerged from the nineteen reviewed articles. These themes are discussed in the subsequent section

4.1 Challenges related to the COVID-19 pandemic

In support of this theme, several subthemes emerged from the studies, namely: 1) Demanding situations; 2) Shortage of non-human resources; 3) Human resource related challenges. Several challenges experienced by the nurse managers were highlighted by eight studies namely: (Apsay & Alalag 2022; Abu et al., 2022; Deldar et al., 2021; Moyo, et al., 2022; Sugianto et al., 2022; Freitas et al., 2021; Hølge-Hazelton et al., 2021; Ozmen & Arslan Yurumezoglu 2022; Sutejo et al., 2022). This theme is encored by the three subthemes 1) Demanding situations; 2) Shortage of non-human resources 3) Human resource related challenges.

 4.1.1 Demanding situations

The nurse managers in these studies experienced the demanding situation because of the COVID-19 pandemic. The demanding situation was further described as psychosocial stress (Abu et al., 2022; Freitas et al., 2021; Apsay & Alalag 2022; Sutejo et al., 2022). Nurse Managers perceived Covid 19 pandemic as physically demanding (Abu Mansour & Abu Shosha, 2022; Freitas et al., 2021; Apsay, & Alalag, 2022). Simultaneously, there was the sense of unpreparedness of the hospital surge of Covid-19 patients (Apsay & Alalag, 2022; Hølge-Hazelton et al., 2021; Freitas et al., 2021; Sutejo et al., 2022). The COVID-19 pandemic had a huge impact on both the physical and psychological aspect of the health care workers. It is understandable that the nurse managers were equally affected as they had a responsibility to optimise systems and adequately manage the demanding situation in alleviating the impact of the pandemic.

• Shortage of human and non-human resources

Nurse Managers need adequate resources to ensure good work life and eminence patient care. However, this study identified that the nurse managers were challenged by dire shortage of resources during the COVID-19 pandemic. This subtheme also manifested with: lack of material/ resources in COVID-19 pandemic; increased workload; lack of knowledge regarding crisis management (Abu Mansour & Abu Shosha, 2022; Moyo et al., 2022; Apsay & Alalag, 2022; Sutejo et al., 2022; Freitas et al., 2021; Ozmen & Arslan Yurumezoglu, 2022; Sugianto, et al., 2022;  Deldar et al., 2021; Cunha et al., 2023). According to Rydenf¨alt, Persson, Erlingsd´ottir, Larsson, Johansson (2023) that nurse managers had to deal with more responsibilities that also increased the complexity of their work, shared similar sentiments. According to Blaugh and Searle (2020), it is crucial that nurse managers should also be trained to manage pandemics. Hoffmann and Battaglia (2020) echoed that nurses should be skilled in leadership so that they can effectively and efficiently manage emergencies

• Opportunities and lessons learned during Covid 19 pandemic

Majority of the studies unanimously highlighted that amidst the COVID-19 pandemic, the nurse managers encountered opportunities and at same time learned some lessons. This theme is resonated by the four subthemes, namely: 1) Copying mechanisms, 2) Benefits in implementing nursing management, 3) Effective strategies in dealing with the crisis, 4) Fundamental improvement in leadership style

4.2.1 Copying mechanisms

Nine out of nineteen articles identified that the copying mechanisms used by the nurse managers included the colleagues’ support and received proper training (Hølge-Hazelton et al., 2021, Ozmen & Arslan Yurumezoglu 2022, Jónsdóttir et al., 2022, Abu et al. 2022, Sutejo et al., 2022, White 2021,Vázquez‐Calatayud et al., 2022, Ree et al., 2022, Bianchi et al., 2021). It is apparent that the nurse managers experienced high work pressures in terms of managing resources, dealing with huge number of acutely ill patients and prompt decision-making. The knowledge gap regarding the COVID-19 pandemic is understandable since the pandemic was new .These factors obviously surmounted to a lot of emotional and physical stress. Notably, the nurse managers required support from colleagues, administrative staff and their family members (Aydogdu, 2023).

• Benefits of implementing nursing management during COVID-19

Nine out of nineteen research articles documented the benefits of implementing nursing management during the COVID-19 pandemic (Sutejo et al., 2022; Bianchi et al., 2021; Jónsdóttir et al., 2022; Vázquez‐Calatayud, et al., 2022; Abu Mansour, & Abu Shosha, 2022; Freitas et al.,  2021; Ree et al., 2022;Mollahadi et al., 2021; Jackson & Nowell 2021). The subthemes is further supported by the following categories, namely: 1) Job satisfaction and Recognition; 2) Opportunities for growth and maturity. It is apparent that the nurse managers acquired a lot of intrinsic motivation during the COVID-19 pandemic.  The source of this motivation could be related to the fact they were able to make complex decision at the same provide support all other staff members and ensured quality patient care amidst the COVID-19 pandemic. In that regard, this resulted in the challenging work and the recognition of the nurse managers. Factors such as Achievement; Recognition, work itself have been described as contributory to the job satisfaction and motivation of an employee (Ayalew, Workineh, Abate, Zeleke, Semachew, & Woldegiorgies, 2021; Khunou & Davhana-Maselesele, 2016; Keith, Warshawsky, Neff et al., 2021). Ample prospects were availed for the nurse managers to acquire more skills, and knowledge especially with the opportunities for growth and maturity (Jackson & Nowell, 2021).

• Effective strategies in dealing with the crisis

Majority of the studies (n=11) out of nineteen revealed  the nurse managers employed effective strategies in dealing with the crisis (Abu Mansour & Abu Shosha, 2022; Ree et al., 2022; Vázquez‐Calatayud et al., 2022; White 2021; Freitas et al., 2021;Poortaghi et al., 2021; Apsay & Alalag, 2022; Mollahadi et al., 2021; Jónsdóttir et al., 2022; Hølge-Hazelton et al., 2021; Ozmen & Arslan Yurumezoglu 2022; Sutejo et al., 2022; Bianchi et al., 2021). The strategies used by the nurse managers included: compensating for shortage of materials and human resources; strategies to prevent understaffing; Staff development and mentoring the new generation of nurses; innovative solutions. To avert the impact of the COVID-19 pandemic, nurse managers strategized by being proactive and thinking about possible scenarios and solutions (Ree et al., 2022). Because there was a high demand for nurses, managers had to develop contingency such as hiring temporary employees plan. Dealing with new challenges on a daily basis could be the reason for the nurse managers being proactive (Ree et al., 2022).

4.2.4 Fundamental improvement in leadership style

Most studies (n=8) revealed fundamental improvement in leadership style of the nurse managers during the COVID-19 pandemic (Bianchi et al., 2021; Hølge-Hazelton et al., 2021; Freitas et al., 2021; Losty & Bailey 2021; Sugianto, et al., 2022; Abu Mansour & Abu Shosha, 2022; Apsay & Alalag, 2022). This subtheme is supported by the following categories: participatory leadership style and collaboration.  Jónsdóttir et al. (2022) emphasized that it mutual respect and teamwork are fundamental during the crisis. The assertion is that collaboration would assist the staff members, to assist one another, share ideas and resources. In addition, the managers encouraged togetherness and collaboration within and across units and being available and present as managers to secure a good psychosocial work environment during the pandemic.

Author Contributions: Conceptualization, SHK and KLM; methodology, literature search and formal analysis SHK and KLM; writing, proof reading, editing SHK and KLM. Both authors have read and agreed to the published version of the manuscript

Funding: This research received no external funding.

Institutional Review Board Statement: The review got permission from the University College of Human Sciences Research Ethics Review Committee (CREC Reference #:

90383060_CREC_CHS_202).

Informed Consent Statement: Not applicable.

Data Availability Statement: Not applicable.

Acknowledgments: The authors acknowledge all authors of the studies used.

Conflicts of Interest: The authors declares no conflict of interest.