Nurse managers' challenges and opportunities in the COVID‐19 pandemic crisis: A qualitative descriptive study

Abstract

Aim

The study was conducted to understand the experiences of nurse managers with regard to the difficulties and opportunities they encountered during the pandemic.

Background

Although many studies have been carried out to understand how nurses were affected in the COVID‐19 pandemic, there are few studies that treat the experiences of nurse managers.

Methods

In this qualitative descriptive study with 19 nurse managers working in pandemic management at a university hospital in Turkey during the first three waves of the pandemic, data were collected between April and July 2021 using the semi‐structured interview method. Content analysis was performed to analyse the data.

Results

Six themes were identified with respect to the experiences of nurse managers during the pandemic. These themes were initial reactions to the crisis, ineffective crisis management, excessive workload, the moral burden in decision‐making, support of colleagues and other multidisciplinary team and nurse manager empowerment.

Conclusions

The nurse managers had difficulties in their managerial roles during the pandemic. However, they also viewed the crisis as an opportunity because they were able to note the deficiencies in management at all levels of the hospital and their leadership and decision‐making roles took on more importance.

Implications for nursing management

Nurse managers may use the results of this study to be prepared for the continuing COVID‐19 pandemic and any other emergency circumstances that they may have to face in the future.

1. INTRODUCTION

The COVID‐19 pandemic, with more than 499 million cases and 6.2 million deaths so far, continues to wreak devastating consequences on health care workers, health care systems, the world population and economies (WHO, 2022). Important issues that had been prevalent in the period before the pandemic, such as the shortage of six million nurses around the world, burnout among nurses in the labour force and the increase in the number of nurses wishing to retire, gained more priority with the start of the COVID‐19 pandemic (ICN, 2021).

To date, many quantitative and qualitative studies have been conducted to understand the emotional reactions and experiences of nurses in the pandemic (Goh et al., 2021; Legido‐Quigley et al., 2020; Mao et al., 2020; Middleton et al., 2021; Moore, 2020; Zheng et al., 2020). On the other hand, there are few studies revealing the experiences of nurse managers during the pandemic. Nurse managers faced many difficulties during the pandemic, experiencing anxiety over not being able to provide the care that patients need, coping with uncertainties, managing inadequate resources and a constantly changing workforce and dealing with tired employees (Hofmeyer & Taylor, 2020; Xiang et al., 2020). Among the main problems that emerged, especially at the beginning of the pandemic, were nurses' being at risk of becoming infected due to the shortage of personal protective equipment (PPE), having to draw up new work schedules daily as a result of nurses dropping out of the work force due to infection or contact with infection and the inability to provide competent nurses for each shift (Baykal et al., 2020; Mao et al., 2020). Nurse managers experienced high levels of stress and anxiety in their efforts to manage these critical situations (Gab Allah, 2021; Middleton et al., 2021). Although MERS‐CoV had not taken on as wide a prevalence as the COVID‐19 pandemic, the issues that came to the fore during that epidemic were the lack of organizational preparation, the low morale among nurses and their high level of anxiety and the difficulties in obtaining psychosocial support (Al Knawy et al., 2019).

While the COVID‐19 pandemic proved to be an intensively challenging struggle, it also brought with it some positive outcomes. Nurses adopted an attitude of collaboration and support in their common goal of providing patients with the best health care possible during the pandemic (Vázquez‐Calatayud et al., 2021). It has also been noted that nurse managers became more visible during the COVID‐19 pandemic than ever before (Kagan et al., 2021); it was seen that they effectively participated in organizational decision‐making on different levels and gained the recognition of their colleagues (White, 2021). Especially when compared to the period prior to the pandemic, it can be seen that there were important changes experienced in the processes of problem‐solving and decision‐making and that these were perceived by the nurses as opportunities for professional development (Abu Mansour & Abu Shosha, 2021; White, 2021).

In a pandemic, which creates a great burden for all health systems, in Turkey, as in other countries, nurse managers constitute a professional group that assumes the greatest responsibility. The ratio to the population of 2.4 nurses per 1000 population (OECD, 2021) and the number of approximately 15 million cases as of April 2022 (WHO, 2022) are indications of the difficulties nurse managers faced during the pandemic in Turkey. As of April 2022, the percentage of fully vaccinated people in the Turkish population was 62.56%. In Germany, where the size of the population is similar to Turkey, this percentage is 75.79% (Ritchie et al., 2020). In countries like Turkey, where doctors and nurses are in shortage in proportion to the population and vaccination rates are behind other countries with similar sized populations, there is a need for studies that explore the experiences of nurse managers during the pandemic. Using this as our starting point, we aimed to understand the experiences of nurse managers and to describe the difficulties as well as the opportunities they encountered during the first three waves of the pandemic. We believe that the results of our study will contribute to the processes of planning and decision‐making in other extraordinary circumstances such as the current pandemic.

2. METHODS

2.1. Study design

A qualitative descriptive study was conducted to understand the experiences of nurse managers with regard to the difficulties and opportunities they encountered during the COVID‐19 pandemic. The Consolidated Criteria for Reporting Qualitative Research (COREQ) list, containing the standards applied to the characteristics of the researchers, their roles in the study, the design of the study and to the data analysis, was used as a guide in the planning and reporting of this study (Tong et al., 2007) (Supporting Information S1).

2.2. Setting and participants

Twenty nurse managers responsible for pandemic management in a university hospital with a large hospital bed capacity in the third largest city in Turkey were contacted using the purposive sampling method. The hospital was a facility at which a significant number of patients sought treatment and care during the period of the pandemic. Of the 20 nurse managers, 19 agreed to participate in the study. The participants were charge nurses in the pandemic clinics, nurse supervisors in the pandemic clinics, assistant nursing directors and the hospital's nursing director. The mean age of the nurse managers participating in the study was 43 (ages 37–52); a large majority had bachelor's degrees. The nurse managers' professional experience ranged from 11–28 years (mean: 21), and the time spent as managers in pandemic clinics varied between 1 and 18 months (Table 1).

TABLE 1.

Sociodemographic data of the participants (n = 19)

Participant code	Position	Age (years)	Education level	Length of service in nursing	Length of service as nurse manager	Length of service in administrative position in units during the pandemic
P1	ND	41	Master's degree	21 years	2 years	18 months
P2	AND	41	Master's degree	20 years	2 years	18 months
P3	AND	41	Master's degree	15 years	2 years	18 months
P4	AND	50	Bachelor's degree	25 years	2 years	18 months
P5	NS	40	Bachelor's degree	20 years	3 years	18 months
P6	NS	40	Bachelor's degree	20 years	1 year	12 months
P7	NS	37	Master's degree	14 years	3 years	12 months
P8	NS	34	Bachelor's degree	11 years	9 months	5 months
P9	CN	43	Bachelor's degree	20 years	1 year	18 months
P10	CN	52	Bachelor's degree	28 years	20 years	3.5 months
P11	CN	42	Bachelor's degree	24 years	4 years	18 months
P12	QAN	45	Master's degree	23 years	15 years	12 months
P13	CN	46	Bachelor's degree	26 years	21 years	2 months
P14	CN	48	Bachelor's degree	27 years	17 years	1 months
P15	CN	45	Bachelor's degree	24 years	17 years	12 months
P16	CN	45	Bachelor's degree	23 years	15 years	18 months
P17	CN	37	Bachelor's degree	17 years	9 months	18 months
P18	CN	48	Bachelor's degree	25 years	4 years	12 months
P19	CN	46	Bachelor's degree	23 years	1 years	18 months

Abbreviations: AND, assistant nursing director; CN, charge nurse; ND, nursing director; NS, nurse supervisor; QAN, quality assurance nurse.

The hospital where the study was conducted is a research and practice hospital in the third largest city in Turkey. This hospital was selected for the study because of its long history of a good nursing care and its being an institution where experienced and highly qualified nurses have worked.

2.3. Data collection

The individual in‐depth interviews were conducted between April and July 2021. This period was the time when Turkey was experiencing the third wave of the COVID‐19 pandemic; a complete lockdown was announced on 29 April 2021. The researchers developed an interview guide for interview questions that focused on the challenges and opportunities experienced during the pandemic. A pilot interview was conducted with an individual who had initially been assigned as a nurse supervisor to pandemic units for a short period and was currently working as a charge nurse at a pediatric hospital. The interview guide was revised as needed. The nurse who took part in the pilot discussions was not included among the participants.

Prior to the interviews, the first researcher met the participants and explained the purpose of the study and the interview process. Both researchers were present during the interviews. The first researcher had taken graduate courses on qualitative research methods and was currently working as a nurse in the pediatric hospital. The second researcher is specialized in nursing management and had previously conducted qualitative research. When the nurse managers began to describe similar experiences, it was accepted that the data had reached a saturation point. However, since each manager worked at different management levels and in different units, the data collection process was completed by holding interviews with all of the participants so that the views of all of the nurse managers could be reflected. The interviews were conducted in a quiet environment where the participants would feel comfortable under pandemic conditions. A well‐ventilated room was used, and the researchers and participants wore masks during the interviews. The interviews were held in a building separate from the hospital, at the nursing school, which was unoccupied since the students were having classes online. The times of the interviews were scheduled according to the preferences of the participants. The interviews were recorded with a voice recorder. The average interview duration was 39 minutes.

2.4. Ethical considerations

The research was approved by the Dokuz Eylul University Non‐Clinical Research Ethics Committee (Prot.2021/09–33) and by the participating institution. All of the participants were informed about the purpose of the study and their verbal consent and written informed consent were received. They were also informed that they could choose to leave the study whenever they wished to and at any stage. The participants' names were hidden in the data records and the interviews were recorded anonymously. The participants were guaranteed that only two researchers would have access to the data, which would be securely stored for 10 years. The voice recordings and the interview notes that constituted the data were stored in personal computers that were password‐accessible only by the two researchers.

2.5. Data analysis

Conventional content analysis was used in the analysis of the data. In conventional content analysis, the statements of participants are transcribed verbatim, with no additional commentary made, taking care to remain as loyal to naturally rendered speech (Hsieh & Shannon, 2005). Encoding is used to identify the concepts behind the data and the relationships between them (Erlingsson & Brysiewicz, 2017). Both researchers analysed the data independently of each other. First, the researchers read through the interview transcripts multiple times to become familiar with the data, and the striking and meaningful themes and patterns among the descriptions given of the nurse managers' experiences during the COVID‐19 pandemic were identified. Units of meaning were assigned codes, from which sub‐themes were identified and then main themes from the relationships between them (Hsieh & Shannon, 2005; Sandelowski, 2010). At each stage of the analysis, the researchers came together to compare notes, aiming to attain consistency.

2.6. Rigour and trustworthiness of the study

Four criteria were used to ensure the rigour of the study, as follows: confirmability, credibility, dependability and transferability (Lincoln & Guba, 1986). To achieve confirmability of the data, a summary was made at the end of each interview to confirm findings and the participants were asked whether they wished to add or revise anything. The researchers met together after each interview to discuss the interview process. The main hospital in which the study was conducted consists of two hospital facilities, one for adults and the other for pediatric patients. The first researcher works as a nurse at the pediatric hospital. No pandemic unit had been opened at the pediatric hospital. Because of this, the nurse managers at the adults' hospital did not have any direct contact with the first researcher that would affect the research process. The second researcher is an educator at the school of nursing. To ensure the credibility of the data, the researchers transcribed the audio‐recorded interviews verbatim two days after the interview. The researchers read and reviewed the interview transcripts multiple times and returned to them frequently during the analysis. To confirm the dependability of the data, how the interviews were conducted, how the data were recorded, how the results were combined and interpreted were clearly described. To enhance the transferability of the study findings, the study method and sample characteristics, the study environment and process were explained in the study report.

3. FINDINGS

The nurse managers' experiences with respect to the challenges and opportunities they encountered during the COVID‐19 pandemic were identified under six main themes: (1) initial reactions to the crisis, (2) ineffective crisis management, (3) excessive workload, (4) the moral burden in decision‐making, (5) support of colleagues and other multidisciplinary team and (6) nurse manager empowerment. The 18 sub‐themes are shown in Figure 1. The codes derived from the data as well as the sub‐themes and themes were thus determined, such that for example, the concepts of ‘feeling like going into a war zone, the epidemic will remain in the Far East, a chaotic atmosphere, an event too difficult to cope with’ that were assigned codes led to the sub‐themes of ‘shock/disbelief, emotional reactions (fear, sadness, anxiety, inability to cope)’ and to the main theme of ‘initial reactions to the crisis’.

FIGURE 1.

Themes and sub‐themes

The data collected in the study showed that the initial reaction of the nurse managers towards the pandemic was more in the nature of emotional responses exhibited in the face of a crisis. With the progression of the pandemic, the nurse managers found it increasingly difficult to fulfil their roles due to ineffective crisis management and the extreme workload. The difficulties caused the nurse managers to experience conflicts in decision‐making processes, and they began to perceive of decision‐making as a heavy moral burden. On the other hand, despite all the adversities, it was found that nurses displayed increased professional support and solidarity towards each other, acted as facilitators in interdisciplinary collaboration, which all caused nurse managers to become empowered in their roles.

3.1. Theme 1: Initial reactions to the crisis

The nurse managers stated that they were negatively affected and that they experienced intense emotions due to the worrisome news reported in different countries at the beginning of the pandemic. They experienced shock and disbelief, especially in the first stage of the pandemic, then fear, sadness and intense anxiety that exhausted their individual ability to cope.

3.1.1. Subtheme 1.1: Shock and disbelief

The nurse managers believed in the predictions that COVID‐19 would be limited to countries in the Far East and would not spread to Turkey. Consequently, they experienced chaos and shock with the announcement of the first case in Turkey.

We all said that the SARS virus had existed before, that this was a different type of SARS, and it would not reach us. We believed the explanations when they said it would never reach us. (P16)

… It was as if a state of emergency had been declared, as if we were in a war zone … I felt as if we were going to have a war. It was like we were in a movie, the whole world … (P10)

3.1.2. Subtheme 1.2: Emotional responses (fear, sadness and anxiety)

The nurse managers experienced a fear of contagion, of experiencing the loss of family members and loved ones during the pandemic, and of perhaps themselves becoming infected. They were also emotionally affected by way of the intense empathy they felt for the patients they cared for.

We are worried about the harm we may inflict on our family, relatives, and neighbors. We all prepared a small suitcase and said goodbye to our children and spouses at home, in case we could not go home again …. (P19)

Many times, I felt extremely sad about the patients. I call this disease “the disease of loneliness” because no one can come near you. Your loved ones are not with you. (P15)

3.1.3. Subtheme 1.3: Inability to cope

The nurse managers were plunged into a chaotic situation and unprepared at the beginning of the pandemic, which was very wearisome and made it difficult for them to cope.

When I think about my own psychological state and my experiences in that period, I know it was very difficult for me to cope. (P12)

I always cried when I came home. After all these years, this was something I could not cope with. (P19)

3.2. Theme 2: Ineffective crisis management

The nurse managers stated that resources were not managed well, especially at the beginning of the pandemic. They said that nurses and nurse managers were the ones to bear the crux of the burden of the pandemic and that managers of other disciplines were not able to deal with organizing work at the hospital.

3.2.1. Subtheme 2.1: Inability to manage resources effectively

Nurse managers stated that all employees (regardless of whether or not they were in contact with COVID‐19 patients) wanted to use PPE and therefore the existing equipment could not be used efficiently.

For example, 50 N95 masks were used up in three hours in the emergency department because everyone wore them. That was because no one knew much about the virus and did not know how it infects … (P4)

3.2.2. Subtheme 2.2: Inappropriate human resource management

The nurse managers said that adapting to pandemic units and providing care to pandemic patients was a severe challenge for new nurses and nurses who had no previous intensive care experience. They also stated that they had a very difficult time assigning nurses to pandemic units because of a nurse shortage.

Nurses who had only worked for 3–4 months, who had not even adapted to their own unit were assigned to the pandemic units. (P15)

We were all new to the pandemic, but there were also those who did not have intensive care experience. It was very difficult to teach them anything because they were so afraid. (P11)

3.2.3. Subtheme 2.3: Insufficient psychosocial support for nurses

The nurse managers stated that the nurses working in the pandemic units were demoralized and anxious, and that they had difficulty becoming motivated.

Nurses had to stay away from their children; they stayed in hotels. It was a stressful period; stress caused them to have the most difficult time. We tried protecting them by taking precautions as much as possible. Actually, we could not do much else for them. (P8)

3.2.4. Subtheme 2.4: Unorganized non‐nurse senior managers

It was stated that the needed action in the first period of the pandemic was delayed because non‐nurse senior managers were at a distance from the areas of the hospital dedicated to the pandemic and could not view the crisis as an integrated whole, and also because of ongoing communication problems.

The senior medical and administrative managers outside of the nursing department were slow in making decisions. For example, we always had to wait for their approval when we needed to procure protective equipment, uniforms and get organized, and so we lost a lot of time this way. Another example of this was the fact that nurses had to wait at the clinics for long periods of time at changes of shift because the administrative managers who had the responsibility of organizing transportation for the nurses were not in coordination. (P13)

3.3. Theme 3: Excessive workload

The nurse managers assumed many new responsibilities that had emerged during the pandemic. Working hours were prolonged to ensure that these responsibilities were fulfilled.

3.3.1. Subtheme 3.1: Increase in nurse managers' areas of responsibility

Wherever they went, the nurse managers faced a variety of problems because the pandemic was in an unpredictable spiral. Moreover, nurse managers had to take care of all problems at every stage as more and more pandemic units were opened. They were also responsible for ensuring that nurses could reach the hospital safely during this period.

All the problems were forwarded to me. I had to solve them. Problems were not only related to patient care, but to everything, including the food and water needs of employees… (P15)

All the employee training sessions were broadcast on the automated system. But then we saw that a pandemic patient was being transferred by an attendant down the normal corridor and put into a normal elevator. Cleaning personnel were not wiping the areas that should have been wiped. We took on the responsibility for these jobs even if this wasn't normally our duty. (P5)

You had to make sure that all nurses came to the hospital and went home safely … (P19)

3.3.2. Subtheme 3.2: Extension of working hours

The nurse managers had to inform each new employee of their duties and constant changes had to be made in the employees' workplaces. The nurse managers had to provide patient care themselves whenever there was a staff vacancy due to a nurse's testing COVID‐positive or being required to be in isolation due to contact with the virus.

I worked longer hours to support the new nurses. (P18)

… I had just finished my supervisor's shift in the morning. When the entire team of the pediatric intensive care unit was placed in isolation, I had to work the night shift too on the same day. We also worked in the clinics; it was a work pace that lasted long hours. (P7)

3.4. Theme 4: The moral burden in decision‐making

The nurse managers said that they felt an intense moral burden in making decisions, especially during the first wave of the pandemic. In that period, when there was as yet no vaccine and definitive protective measures were not fully known, uncertainty and conflict were at an extreme, and the nurses felt as if their decisions could be putting their colleagues in danger.

3.4.1. Subtheme 4.1: Regret after making a decision

The nurse managers stated that making decisions during the pandemic was very different than making routine management decisions, and they regretted every decision they made. They feared that by assigning nurses to the pandemic clinics, they were putting them at risk and that this risk could cost them their lives. This made the nurse managers feel a deep remorse about their situation.

When I assigned them to the pandemic units, I felt like I was throwing them into the fire; it was if I were their mother. It was an extremely difficult day, so I will never forget it. (P2)

3.4.2. Subtheme 4.2: Considering management decisions to be unethical

The nurse managers said that they felt they were experiencing an ethical dilemma because of the adverse outcomes that could come about due to their decisions. Especially in the first wave of the pandemic, they constantly questioned themselves about how ethical their decisions were, given the possibility that their colleagues could contract the disease while providing care to patients and even lose their lives under the circumstances.

It was the hardest thing to say to them, “You need to take care of a pandemic patient,” while I myself was also scared. (P6)

I was crying when I assigned four nurses to the emergency room; I did not know what would happen to them, they may have gotten sick or died… (P2)

3.5. Theme 5: Support of colleagues and other multidisciplinary team

The nurse managers however also said that some factors helped them to manage the pandemic and facilitated the fulfilment of their duties. The facilitators making their work easier during the pandemic were the solidarity among colleagues, the opportunity to work with experienced, competent and capable nurses, and the support provided by other disciplines.

3.5.1. Subtheme 5.1: Working with experienced and competent nurses with strong professional values

The nurse managers stated that working with experienced, competent, and dedicated nurses who had strong professional values and were committed to the profession facilitated their work during the pandemic.

We worked with highly experienced nurses… They worked with great dedication… You can only do this if you love nursing. (P2)

I'm thankful that this hospital has such nurses; it is so good that such strong and experienced nurses work here. (P3)

3.5.2. Subtheme 5.2: Support from colleagues and solidarity

The nurse managers always supported each other and made each other feel that they were in solidarity, which was a factor that facilitated their work during the pandemic.

Understanding each other was motivating and made things easier. We once again noticed what it was like to work as a team and realized our united strength. We are nurses, we can be nurses anywhere, we can do anything… (P7)

3.5.3. Subtheme 5.3: Support of senior nurse managers

The nurse managers stated that having the nursing director's team available to them at any time, knowing that they made frequent visits to the units and understood the nurses' problems made them feel that they were not alone.

The nursing director's team was with us in every matter. They found the appropriate equipment for me, and when I said there was a shortage of personnel, they resolved the problem. (P18)

3.5.4. Subtheme 5.4: Support from other disciplines

The nurse managers stated that cooperating with other disciplines, especially with physicians in various units, to find solutions for problems together facilitated their work during the pandemic.

The intensive care anesthesiologist facilitated all my work. He was in contact with associations worldwide, so he quickly gathered information about new developments and situations, about changes and world data. We organized the intensive care unit according to this information. (P5)

3.6. Theme 6: Nurse manager empowerment

The nurse managers stated that their decisions were being taken more into consideration during this period, that their areas of authority had expanded, and they had more access to senior management.

3.6.1. Subtheme 6.1: Improvements in problem‐solving and decision‐making skills

The nurse managers were used to solving a limited number of problems in their area of responsibility, but now they suddenly found themselves facing a wide range of issues that they had never encountered before.

Before the pandemic, we used to implement the decisions made by senior managers; now, the team's decisions gained more importance. (P16)

I'm very happy and feel very strong. I feel like I was able to be on top of my emotions during the pandemic. (P18)

3.6.2. Subtheme 6.2: Being required to be very quick in solving problems

The nurse managers had to make quick decisions to maintain existing health services and to protect the health of nurses in the pandemic.

One day, we found out that all the nurses of one department tested positive, so everyone was isolated and there were no nurses to work with… If a nurse got infected and there was a risk of infecting others, we had to isolate everyone and quickly create a new team. (P12)

3.6.3. Subtheme 6.3: Increasing autonomy, visibility and recognizability

The nurse managers improved their decision‐making skills and they felt more visible and more acknowledged in the hospital during the pandemic.

They told us, “You've gone through this process, you've managed it; you are the ones who are the real managers of this situation.” So, we were given more authority. They always told us we did a great job, and we felt more appreciated. (P19)

4. DISCUSSION

This study brings to light the difficulties as well as the opportunities that nurse managers faced during the first three waves of the COVID‐19 pandemic in Turkey, which is considered a developing country and remains low in the rankings of percentages of nursing staff among the OECD countries. Although the ratio of nurse‐to‐population is low, Turkey is a country that has provided quality nursing education at the bachelor's degree level for more than 60 years. The nurse managers in the study had either Bachelor's or Master's degrees and had long years of experience in the profession. The nurse managers' experiences were identified under six main themes: initial reactions to the crisis, ineffective crisis management, excessive workload, the moral burden in decision‐making, support of colleagues and other multidisciplinary team and nurse manager empowerment.

This study revealed that the nurse managers' initial responses to the pandemic crisis were emotional reactions. In particular, the risk of infecting their families and loved ones, and the fear of losing someone were the most terrifying concerns. It was reported in Hoffmann et al.'s study (Hoffmann et al., 2020) that the greatest danger perceived by health professionals during the pandemic was the risk of being infected with coronavirus and infecting their families. Qualitative studies conducted during the pandemic indicated that nurse managers were stressed and experienced negative emotions and that they felt devastated because of their inability to heal critically ill patients (Deldar et al., 2021; Holge‐Hazelton et al., 2021). The results of these studies show that the first reaction nurse managers gave in the face of the crisis was generally negative emotional responses. Differing from these studies, however, we found in our research that the nurse managers believed that the pandemic would not reach our country and would remain contained in the Far East. We note that while this is an interesting finding, it also stood as a barrier to approaching these extraordinary circumstances proactively.

During the pandemic, a lack of resources, the ineffective management of existing resources, the inability to meet the orientation and psychosocial needs of new nurses, and the attitudes of other senior managers towards the crisis were factors that challenged nurse managers. The results of our study indicated that nurse managers could not adequately provide nurses working in pandemic units with psychosocial support. Similarly, in several other studies, it is reported that it was difficult to motivate nurses and provide them with psychosocial support (Cathro & Blackmon, 2021; Hofmeyer & Taylor, 2020). Other studies show that nurse managers were asking nurses to reuse PPE due to supply problems, which was a point of stress for the nurses (Newby et al., 2020), causing them worry and anxiety (Holge‐Hazelton et al., 2021). In an experience‐sharing study on the subject, nurse managers had to assign novice nurses with no previous intensive care experience to intensive care units due to the rapidly increasing number of cases (Bambi et al., 2020). It has also been emphasized that nurse managers found it very difficult to establish a balance between assigning novice and experienced nurses when work schedules had to be prepared for each shift (Daly et al., 2020; Poortaghi et al., 2021). The results of studies show that procuring materials and human resources and managing these effectively were common issues. This indicates that under emergency circumstances such as a pandemic, nurse managers need to be able to assess alternatives effectively and have the skills to make good decisions. Differing from other studies, we found in our research that the problems stemming from the decision‐making and organizational activities of medical and administrative managers had an adverse effect on the fulfilment of the nurse managers' roles and functions. It is important that all senior managers of hospitals are able to synchronize their efforts in the processes of problem‐solving and decision‐making.

In our study, the nurse managers had assumed many new responsibilities emerging from the pandemic, extending working hours to meet the considerably increased workload. During this period, the nurse managers were especially responsible for managing the crisis as well as their staff's emotions, ensuring employee and patient safety, continuously sharing information and providing continuous education (Livornese & Vedder, 2017; Wang et al., 2021). The findings of our study as well as of others indicate that nurse managers make more efforts in securing the safety of the workplace and the care given through access to resources, ensuring that nurses have their psychosocial needs met, focusing on providing emotional support and protecting the physical and psychosocial health of nurses. Where our study differs from others is that we found that nurse managers took on extra responsibilities to find solutions for problems that did not directly fall into their scope of duties. This caused an increase in their workload and forced them to work longer hours than usual.

Our study showed that nurse managers felt a heavy burden of conscience and constantly experienced a moral burden arising from the consequences of their decisions. In Holge‐Hazelton et al.'s qualitative study (Holge‐Hazelton et al., 2021), nurse managers found it hard to assign their employees to pandemic clinics because they were not in a position to consider their preferences and needs. Role confusion, social, behavioural and mental trauma and stress caused by the COVID‐19 outbreak adversely affected decision‐making (McKenna, 2020). The results of the study showed that during the pandemic, the function of decision‐making, one of the most fundamental responsibilities of management, was a process that was particularly challenging for nurse managers. Our study revealed that the nurse managers experienced intensive anxiety and worry when they assigned nurses to the pandemic clinics and that they perceived these decisions as a heavy moral burden.

We found in our study that solidarity among colleagues, availability and support by senior nurse managers, as well as the supportive attitudes of colleagues in other disciplines were facilitators during the pandemic. Other qualitative studies have revealed that increased support from colleagues and solidarity, together with sharing responsibilities during the pandemic brought about positive outcomes (Holge‐Hazelton et al., 2021; Kagan et al., 2021; Vázquez‐Calatayud et al., 2021). Being able to cope with difficulties during the pandemic and receiving support from colleagues were reported to improve mutual respect and trust (Abu Mansour & Abu Shosha, 2021), which in turn reduced the fatigue caused by intensive working hours and mitigated the stress and anxiety of inexperienced nurses (Deldar et al., 2021). As other studies have revealed as well, the difficult circumstances brought about by the pandemic increased solidarity and support among colleagues, and this unity was perceived in effect as a way of coping.

We also found in our study that the problem‐solving and decision‐making skills of the nurse managers improved during the COVID‐19 pandemic and that they felt themselves to be more visible and more competent. It is similarly reported in other studies that nurse managers were satisfied with their managerial performance and proud of fulfilling challenging tasks during the pandemic (Kagan et al., 2021). They actively participated in organizational decision‐making processes and felt appreciated by their colleagues (White, 2021). Despite the challenges and stresses caused by COVID‐19, nurse managers stated that exposure to a new experience in the long run improved their problem‐solving, decision‐making and critical thinking skills, as well as their leadership competencies (Abu Mansour & Abu Shosha, 2021). Despite the adversities experienced in the pandemic, however, nurse managers were able to emerge from the situation stronger than before. They managed to develop and improve their problem‐solving and leadership skills, an important achievement that can be registered as a gain.

4.1. Study limitations

This study had a few important limitations. The first of these was that it was conducted in a hospital that worked under relatively better conditions and it was only the nurse managers working at this hospital who provided perspective on their experiences. Another limitation was that the participants worked at different levels of management, which may have affected their viewpoints. Lastly, since the study was carried out approximately 1 year after the start of the pandemic, there may be inconsistencies in the perceptions of nurse managers, especially in the first period of the pandemic.

5. CONCLUSIONS

Our study was conducted in a developing country where the nurse‐to‐population ratio is low; it reveals the difficulties and opportunities perceived by the nurse managers in the first three waves of the COVID‐19 pandemic. We found in this study that nurse managers had trouble with fulfilling their managerial roles during the COVID‐19 pandemic. Particularly, the negative emotional reactions that emerged with the start of the pandemic made crisis management difficult to carry out effectively, and consequently, the nurse managers were faced with an increased workload. At the same time, it can be said that one of the issues that was most challenging was the conflicts and moral burden that the nurse managers experienced in their decision‐making. Our study also showed that, whatever the burden of the pandemic, the situation also lent itself to becoming an incomparable opportunity for learning for the nurse managers. Solidarity among colleagues and collaborations with other disciplines were facilitating factors in this challenging period. The learning opportunities appearing before the nurse managers made them stronger. This is an important outcome that will be useful to consider in any potential future cases of emergency in terms of preparing for and achieving organizational improvements to deal with such a situation.

5.1. Implications for nursing management

The results of the study point to the necessity for quick and effective planning in procuring supplies and human resources for emergencies, creating psychosocial support mechanisms for employees and alerting nurse managers to the need for planning. The prerequisite for action is awareness of the difficulties and deficiencies of the current situation. Nurse managers should therefore be conscious of the knowledge and skills they may need in fulfilling their roles in cases of emergency.

Nurse managers should draw up a crisis plan to be periodically reviewed with the participation of all employees. In particular, international reports and recommendations on the pandemic should be followed closely, and plans updated accordingly. After a pandemic, nurse managers should adopt strategies that will afford them opportunities to maintain the greater autonomy, visibility and leadership that they achieved during the crisis.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

ETHICS STATEMENT

The research was approved by the Dokuz Eylul University Non‐Clinical Research Ethics Committee (Prot.2021/09–33; Approval Number: 6136‐GOA). Written informed consent was obtained from the participants before the interviews. The interviews were recorded anonymously. The participants were guaranteed that only two researchers would have access to the data, which would be securely stored for 10 years.

AUTHOR CONTRIBUTIONS

Concept: SO and HAY. Study design: SO and HAY. Supervision: HAY. Resources: SO and HAY. Materials: SO and HAY. Data collection and/or processing: SO and HAY. Data analysis and interpretation: SO and HAY. Literature search: SO and HAY. Writing the manuscript: SO and HAY. Critical review: SO and HAY.

Supporting information

Data S1. Suppporting Information

Ozmen, S. , & Arslan Yurumezoglu, H. (2022). Nurse managers' challenges and opportunities in the COVID‐19 pandemic crisis: A qualitative descriptive study. Journal of Nursing Management, 30(7), 2609–2619. 10.1111/jonm.13817

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.