Nursing Leadership and COVID-19:

Abstract

The COVID-19 pandemic overwhelmed health care systems and exposed major gaps in preparedness and response plans. The crisis challenged nurse leaders to develop and implement novel care delivery plans while preventing disease transmission to patients and staff. COVID-19 required nurse leaders to make decisions in an environment of conflicting data and directives. The authors share essential nurse leader competencies vital to the development and support of thriving nurse leaders. As crises persist and future challenges arise, nurse leaders can leverage these essential competencies to successfully drive engagement, lead ahead of consensus, and define the shadows of limited, incomplete, and conflicting data.

Key Points.

• •Nurse leaders often make decisions in an environment of conflicting data and directives.
• •Nurse leaders must harness respect and goodwill while overcoming current challenges.
• •Nurse leaders must develop and mature the skills necessary to quickly identify and effectively respond to crises.

The coronavirus disease 2019 (COVID-19) pandemic overwhelmed health systems globally and compelled leaders to restructure health care operations and services to sustain the regular cadence of sick and injured patients and meet additional care requirements during critical surges of patients with COVID-19.¹ The pandemic response caused an unprecedented global upheaval of routine care and standard procedures. The disruptions included socially distanced work spaces, cancellation of elective surgeries and screening procedures, expansion of telehealth across outpatient services, restricting inpatient visitation privileges, implementation of universal personal protective equipment (PPE), expansion of patient care into previously vacant or nontraditional spaces, dissemination of new patient care techniques (e.g., proning), staffing temporary external locations, changing patient flow patterns, assigning staff to unfamiliar work centers or partner facilities, communicating differently with patients’ family members, and implementing new testing techniques.²

Although federal and state laws mandate that hospitals develop and implement emergency response plans regarding natural and man-made disasters, many hospitals and healthcare systems were woefully unprepared for the pandemic response. The domino effect of disease-infected patients and health care workers resulted in staffing, equipment (e.g., beds, ventilators, oxygen cylinders), and PPE shortages while also reducing access to care for noninfected patients.³

The pandemic also created an extraordinary period of responsive innovation and agility across health care and the nursing profession. Nursing proved a particularly valuable contributor to the multidisciplinary health care team during the pandemic crisis because infection control, team-based patient care, and health surveillance are roles ideally suited to the profession's strengths. Federal and state policymakers temporarily removed long-established barriers limiting registered nurse mobility and eased regulations to address staffing shortages and aid the pandemic response, including those governing full practice authority for advanced practice registered nurses (APRNs).⁴ Through professional initiative and answering the challenge of the pandemic, nursing leadership validated their role as thought leaders, operational innovators, and trusted partners of other engaged disciplines.⁵

Nurse leaders contributed to many original solutions that limited the spread of disease and aided the pandemic response.⁶ Nursing leadership delivered rapid changes across health systems and adapted strategic plans and operational contingencies to address changing local and national policies, emerging data trends, scientific discoveries, and surge capacity requirements.

Critical to the profession’s ability to improve clinical practices based on evidence, nursing leadership quickly adapted to the evolving crisis by analyzing evidence in real-time and monitoring for data trends. Further testing both epidemiological and organizational agility, continually shifting data and directives forced nurse leaders to make timely, calculated decisions affecting the health and safety of patients and staff, while seeking to define ambiguous themes and unknown variables across multiple sources of limited, incomplete, and conflicting data.

Defining the Challenge

The COVID-19 pandemic quickly evolved into a once-in-a-lifetime global health challenge even as the United States grappled with social challenges such as unemployment, food insecurity, homelessness, xenophobia, health disparities, and higher rates of infection, hospitalization, and death for Black, Asian, Native American, and Hispanic persons.¹ As the nursing profession seeks to define these contemporary challenges and the many unknowns, empowered nurse leaders can leverage the nursing process, evidence-based practice, and professional experience knowing that those tools have always informed the profession’s ability to deliver positive change.⁷

A Foundation for Success

The nursing profession has historically represented a critical bridge between the science and the art of health care, and nurse leaders continue to deliver when challenges are the most daunting and the least defined. Through the first 2 decades of this new millennium, the nurse leader role has become even more vital as the frenetic pace of innovation and change challenges governments, health care systems, and communities.⁸

Nursing has a proud history of service during crises, including SARS, H1N1, MERS, Ebola, and Zika.⁹ Today’s challenges, including COVID-19, are no different, and nurse leaders remain uniquely positioned and equipped to lead ahead of the data, both now and in the future. The calling to care for all and relentlessly advocate for the most vulnerable continues to lighten the physical burden of illness for patients while bridging many divides within communities.

As identified by the American Nurses Association (ANA), foundational leadership competencies include flexibility and the capacity to adapt previously established plans to changing external pressures.¹⁰ Responsive nurse leaders must develop and mature the skills necessary to quickly identify and effectively respond to external forces threatening health care delivery in their communities. These threats may include health crises, political processes, and other catastrophic or emergent events.

Delivering on the Promise

Without regard for obstacle or challenge, the nursing profession would benefit from regular recommitment to professional and ethical standards that serve as foundational support for timely and effective decision-making.¹¹ Because leadership is fundamental to advancing the nursing profession,¹² nurse leaders have a professional obligation to develop their teams, readiness policies, and contingency procedures to support crisis and disaster readiness and management.

Huston¹³ identified 8 essential nurse leader competencies vital to developing prepared nurse leaders who can meet current challenges. Nurse leaders develop their people, guide their organizations, and build resilience through training, equipping, and preparing their teams for contingencies. Huston's 8 essential competencies are particularly relevant considering the current pandemic. Briefly, we expand on the competencies below and use COVID-19 to provide context for current and future pandemics, natural disasters, and terrorism.

Having a Global Perspective or Mindset Regarding Health Care and Professional Nursing Issues

A global perspective enhances the nurse leader’s ability to anticipate change and succeed as a healthcare champion. Nurse leaders with a global perspective were aware of the mounting evidence of a potential pandemic, and their organizations benefitted from an early shift to face the new challenge. A global perspective informs contingency planning, and these leaders were equipped to more effectively respond to shortages in PPE, respiratory adjuncts, ventilators, and staff.

A global mindset also empowers nurse leaders to acknowledge the diverse experiences and opinions of others alongside recognition of their own biases.¹³ Boldly pursuing alternative points of view creates a posture and environment conducive to success. Previously unreachable consensus and unrecognized opportunities become attainable through the integration of disparate interests and competing perspectives.¹⁴

As society grapples with a crisis of conscience around injustice and bias, nurse leaders are presented with a timely reminder to further enhance a posture of active support for diversity, inclusion, and social justice while addressing social determinates of health. Persaud¹⁵ identifies nurse leaders as standard-bearers for inclusion and diversity across organizations with an ethical obligation to build and support such environments.

Acquiring Technology Skills to Facilitate Mobility and Portability of Relationships, Interactions, and Operational Processes

Modern health care and nursing services are driven by perpetually evolving technology. Nurse leaders share unique perspectives and insights that can influence their organization’s acquisition, integration, and optimization of technology. System challenges, staffing contingencies, and environment of care considerations driven by COVID-19 have only accelerated the evolution of health care.

With the exponential growth of remote work and telehealth, nurse leaders are increasingly contributing to the business of health care through oversight of remote work policies, development of connectivity requirements, standardization of collaboration resources, and participation in patient privacy and data security governance.¹⁶ Selecting the right technology and validating existing infrastructure is seeing renewed emphasis as an integral component of the nurse leader role.

It is unlikely that nurse leaders will see a significant drawdown in these new responsibilities in a post-COVID-19 environment. Opportunities to empower patients, improve access to care, facilitate research, and optimize outcomes will continue to drive nurse leader engagement, relationships, and operational processes.¹⁷

Developing Expert Decision-Making Skills Rooted in Empirical Science

The pandemic has forced nurse leaders to recalibrate strategic plans and reorganize clinical operations without discrete data or a roadmap to guide those decisions. As the crises evolve, advanced decision-making expertise empowers and equips nurse leaders to develop and implement innovative solutions to address present requirements while establishing the framework for future success.¹⁸

Well-honed decision-making skills are most effectively developed in a supportive and change-welcoming environment defined by open communication and collaborative relationships.¹⁹ For many, the spectrum of current challenges have proven “career-defining” for the professional development of nurse leaders through professional acceptance as well-equipped and fully integrated peer collaborators across multidisciplinary organizations and agencies confronted by a poorly defined global crisis.²⁰

Creating Organizational Cultures That Permeate Health Care Quality and Safety

Many methods can help build a productive and inclusive professional culture, but successful nurse leaders never miss an opportunity to elevate their staff as patient advocates and quality champions. As COVID-19 continues to impact communities, nurse leaders can consult with professional and community partners to acquire, track, identify, isolate, evaluate, analyze, document, and pursue those variables and concerns shaping their local care environment.²¹ As respected collaborators across multidisciplinary teams, nurse leaders can contribute to enhanced quality and safety structures within their organizations.²²

Recognizing Opportunities to Appropriately Intervene in Political Processes

Nurse leaders are unique positioned to intervene and shape public discourse and healthcare policy on behalf of their patients and communities. As highly respected health care advocates, the most trusted profession, the largest health care profession, and the professional bridge between health care policy and health care delivery, no group is more equipped to appropriately intervene in political processes.²³ Nickitas²⁴ argues that nurse leaders cannot allow the current climate of political division to affect the profession’s response to COVID-19.

As the country reels from the COVID-19 pandemic, natural disasters, and social disruption that defined 2020 to 2021, nurse leaders must drive political awareness and policy development, addressing threats to healthcare professionals, patients, and communities.²⁴ Political education, active psychological engagement, and collective influence are known factors that enhance nursing influence on policy and politics.²⁵ Even in a pandemic environment, nurse leaders must own political advocacy in pursuit of good policy. Nurse leaders remain supremely qualified to identify gaps between current policy and health-related requirements through integrated knowledge of community resources, needs, and disparities.²⁶

Possessing Highly Developed Collaborative and Team-Building Skills

Highly collaborative, team-building nurse leaders establish healthy work environments built around standards and expectations for professional communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.²⁷ Engaged employees become active and contributing team members achieving shared values, common purpose, and cooperative work.¹³ Meyer²⁸ brilliantly highlights the nurse leader’s obligation to educate their staff that agreement and support are not codependent concepts. Huston¹³ also identifies the critical role of collaboration as empowering for leaders of highly educated, multidisciplinary professionals.

Balancing Leadership Authenticity and Performance Expectations

The ever-changing health care environment has made communication even more vital as nurse leaders seek to drive performance, enhance safety, impact quality, and deliver better outcomes. The dynamic nature of current challenges has further altered and stressed communication between nurse leaders and staff during a time when timely and effective engagement is most vital.

Authenticity is another tool that can serve as a bridge to success for nurse leadership establishing new expectations while seeking to limit the burden on their overtasked staff. The principles of authentic leadership include the unique characteristics of self-awareness, relationship transparency, and having an internalized moral perspective. Authenticity can be delivered by nurse leadership by focusing on one’s own development, knowing oneself, and demonstrating transparency in all relationships.²⁹ These efforts may serve to empower the individual staff member and enhance team performance as the nurse leader communicates genuine interest and care for their teams.²⁹

Envisioning and Proactively Adapting to a Health Care System Characterized by Rapid Change and Chaos

Today’s environment has reinforced the critical role of nurse leaders in assessing, developing, and enhancing their organization’s capacity for change. The unique demands of strategic leadership, operational excellence, and relationship management dictate a decisive yet agile approach that leans into and owns every challenge. In this way, nursing leadership models the nursing profession’s well-established capacity to sustain and thrive through chaos and change.³⁰

The current nursing leadership experience, defined by rapid change and chaos, has represented a uniquely powerful opportunity to “stress test” our infrastructures and systems in very real and practical ways.³¹ The nursing profession and nurse leaders were at the forefront of the pandemic through leadership of response teams, improving access to care through expanded telehealth, shaping new policies and procedures, and many other ways. In the face of disruptions to care, access, and utilization, nursing leadership remains a vital link in building and sustaining resilience through enhanced resources and support to health care teams.³²

Looking to the Future

Nursing leadership remains a lynchpin for effective multidisciplinary engagement with sustained commitment to patient and community advocacy. Nurse leaders across academia, clinical practice, and industry represent the best of a profoundly gifted and dynamic group, which is only increasing in size and influence. The continuous evolution of the profession and its powerful role in communities, nations, and the world is based in the diversity of the professionals, specializations, and unique roles that comprise its ranks.

The nursing profession represents a critical link between science and the art of healthcare. The calling to care for all and relentlessly advocate for the most vulnerable continues to lighten patients' physical burden while fostering greater respect, humility, and understanding. Nurse leaders must harness respect and goodwill in pursuit of those challenges that are without solutions and those questions that are without answers.

As nursing leadership develops strong, sustained, and mutually enriching relationships across teams, departments, and organizations, individual leaders will continue to serve as vital partners as communities seeking to heal division and mistrust. The nursing profession’s focus on service to others and the betterment of all will empower these efforts of renewal and rebuilding as the nursing profession and nursing leadership demonstrate their unique ability to deliver on trust.

Leveraging a heritage of resilience, innovation, and scientific inquiry, nursing leadership is uniquely equipped to guide organizations through tumultuous times. The multidisciplinary strength of the nursing profession has thrust nurse leaders into key roles across the full spectrum of our nation’s response to the current crises. Nursing leadership must own and build on the profession’s proud legacy of untiring and unwavering passion for caring and excellence in the service of others.

Conclusion

The nursing profession arose out of the recognition that humanity could do better and could be better. In that spirit, nursing leadership is equipped with the knowledge, experience, and skills to deliver when the data and the science are poorly defined. Nurse leaders have delivered excellence in health and caring for humanity many times in the past, and the profession will continue this proud legacy.

A unique blend of moral, ethical, and legal obligations serve to empower nursing leadership to elevate teams and transcend contemporary challenges. Today’s leadership environment includes compelling opportunities to drive innovation, enhance organizations, serve communities, and deliver on a remarkable history of resilience, integrity, and achievement while redesigning health care delivery systems in an image that is more equitable, adaptable, and resilient.

The guideposts from the past empower nursing leadership to define the shadows and pave a bold path for tomorrow’s nursing professionals. Individual nurse leaders will continue to find success in conquering contemporary challenges and building more resilient teams and systems while satisfying their professional obligations of service and caring. The profound connection that nursing leadership has built, and continues to build within their organizations and communities, will enhance the nursing profession’s future achievements, growth, influence, and impact for patients and communities.

Biography

Joshua A. Wymer, MSPM, MA, MSN, RN, CNOR, CSSM, RN-BC, NEA-BC, CPHIMS, FACHE is Chief Nursing Informatics Officer at the Naval Medical Center San Diego, in San Diego, California. He can be reached at joshua.a.wymer.mil@mail.mil. Christopher H. Stucky, PhD, RN, CNOR, CSSM, CNAMB, RN-BC, NEA-BC, is Deputy Chief of Research and Nurse Scientist at Center for Nursing Science and Clinical Inquiry, Womack Army Medical Center, in Fort Bragg, North Carolina. Marla J. De Jong, PhD, RN, CCNS, FAAN, is Dean, Professor, and Louis H. Peery Presidential Endowed Chair at the University of Utah College of Nursing in Salt Lake City, Utah.