Table 5.

Open ended comments exemplifying each item of the organizational effectiveness scale by leadership role

Organizational effectiveness scale item	Study team interpretation of item meaning	Executives	Managers	Others
Protocols for filling staffing needs when current staff have fulfilled their assignments	Organizational policies and practices for filling staffing needs	“Financial priorities of the hospital destroying staffing models that took years to recover from.” “Having the authority to have made [decisions about] staffing and equipment needs at the time I requested to have prepared better and prevent staff and resources from being depleted.”	“Begging staff to work while verbally told them to care for themselves.” “Being forced to stretch staff to unsafe ratios and being told that they may be uncomfortable, but it is not unsafe.”	“No support in my position, always had to give in, and provide staffing when we were stretched so thin. Continues on with no end in sight.”
Pathways for requesting ethics consultation or advice	Organizational policies and practices for requesting ethics consultations	No relevant quotes	“Clear escalation pathways for ethical concerns in a crisis, plans for resources during a crisis, nursing leadership in ethics and organization decisions.”	“Routine screening of moral injury symptoms of staff and leaders.”
Policies for increasing the number of ICU beds	Organizational policies and practices for increasing the number of critical care beds	“We had a variety of responses to the covid pandemic - opened new units, repurposed non-patient care areas, implemented team nursing, etc.  I feel like we used a variety of methods that could be applied to future pandemics.”	No relevant quotes	No relevant quotes
Communication updates regarding system-based changes	Organizational policies and practices for communicating changes between supervisors and employees	“Better support of national agencies and government officials. Politics got in the way of connected and coordinated communication and policies. Through a lack of national and state leadership, people became more fearful and very divided.”	“How to make sure staff had the communication they needed about the rapid changes being made while they were redeployed and not in their department.”	“Better information from senior leadership team to middle management, so we can be prepared to speak to changes to front-line staff before it happens.”
Transparent  communication regarding policy/practice changes	Organizational inclusion of employee stakeholders in decision making and disclosure of how leaders arrive at policy changes	“…Simply sharing recommendations from the CDC was not enough to thoughtfully care for patients with severe COVID-19 pneumonia. There were countless times that network leaders would send a document with reformatted CDC recommendations and say “we provided you all the information you need” and several of us would have to get together to discuss how these recommendations would need to be implemented and any process nuances that would need to be considered.”	“Although it was rapidly changing…and there was an overall feeling of confusion, the organization I work for was extremely transparent in decision making, PPE procurement, [etc.] and solicited the feedback from frontline leaders on a regular basis.”	“Using the input of front-line staff in decision making even in crisis. Creating a process that includes a level of shared governance during crisis instead of reverting to autocratic leadership in the C-suite.”
Budget adjustments to increase resources for nursing workforce	Organizational practices and policies to increase spending for nursing workforce (ratios, bonuses, hazard pay etc.)	“We all hear constantly that we need to think of creative new staffing models…after decades of working as a profession to prove that primary nursing effects every aspect of quality and patient experience. It is a moral dilemma to even consider moving to another, less effective nursing model. I haven’t heard anyone talking about that and it breaks my heart.”	“Staffing shortage is so profound yet our census is up 1.5 x the budgeted amount. We are asked to do more with less, constantly. Even if we pooled all staff together, we still don’t have enough to cover patient care. What is missing is higher pay to be offered. We will pay travelers $100/hr. but not willing to give our nurses raises.”	“Nurses were experts at knowing what they needed and how to achieve it. The focus on corporate finances backfired on administrators who later had to pay as much as 5 time more to replace nurses who left.”
Processes for staff to call out without fear of retribution	Organizational practices and policies pertaining to protections for calling out for illness and wellness	“Staff taking full advantage of illness policies to take extended time off.” “Staff calling off/being out sick and unable to cover patients [vs] bringing them back… when was the right time?”	“It was literally becoming an expectation that we were on call 24/7. I needed time with family and time off. Leaders cannot be expected to work all day, all night, and all weekend in staffing in addition to managing nursing input unit operations.”	“I ended up very sick but was forced to go to work because I’m essential staff. Healthcare workers should not have had different guidelines. In fact, we should have had stricter guidelines. We were the ones consistently exposed and fearing for our lives; our families lives. It was so difficult and taxing.”
Items below were not included in the original scale but were important themes in the qualitative data
Perceived value of nursing leadership within the organization	Organizational policies and practices that confer value	“We have disproportionate leadership at the organization I work for. By this I mean the physicians are the voice that is heard and nursing is frequently overlooked.”	“Although it was rapidly changing, we were short on PPE, and there was an overall feeling of confusion the organization I work for was extremely transparent in decision making, PPE procurement and solicited the feedback from frontline leaders on a regular basis.”	“Nursing shared governance structures were shut down when they were most needed. Nurses at the bedside didn’t feel they had a voice and many left to traveler positions for the money, but probably more so as a means of feeling valued.”
Balancing finances with safety	Balancing the institutional budget without compromising patient or staff safety	“[I] Brought [my concerns] to attention of Corporate leadership but the finance leaders stopped any positive initiatives due to cost.”	“Our leaders are unethical and lack integrity. Focus is on finances, not patients or staff.”	“Mostly I am challenged by the inability of upper management to understand the financial impact to them from cutting resources such as education from staff. They don’t come to us knowing everything they NEED to know, and we give them less and less during orientation. We see how it affects outcomes, but they avoid seeing the actual cause. We are using Band-Aids and not fixing the problem.”
Inequity between healthcare worker roles	Sidelining nurses and their expertise over nursing affairs in lieu of other disciplines	“[There is a] growing practice to put top nurse executives in positions to report to MD executives, called Chief Clinical Officers…sends a terrible message to nurses about the value of their profession when there are two professions in Executive practice, but one (nursing) must “report” to the other (medicine). Indicates an age-old bias against Nursing that can be indicative of a lack of respect that will filter into other decisions— including ethical decisions.”	“I found it challenging to integrate the ideas of physician leaders who were able to primarily work remotely when making decisions for staff that were physically present. There was a deep sense of caring for safety but not by example of safe in-person practice.”	“Physician management and communication tips would be nice.  They [physicians] consistently tried to find a loophole to get their way when it clearly wasn’t safe for us.”