key: cord-0684873-w7m8x4an
authors: Schoberer, Daniela; Reiter, Lea; Thonhofer, Nina; Hoedl, Manuela
title: Occupational relationships and working duties of nursing management staff during the COVID‐19 pandemic: A qualitative analysis of survey responses
date: 2022-03-14
journal: J Adv Nurs
DOI: 10.1111/jan.15203
sha: aa80ebbb60a08233897a7e67d49857d3c465396d
doc_id: 684873
cord_uid: w7m8x4an

AIMS: To reflect on the situation of nurse managers, examining their professional relationships and additional working duties during the second COVID‐19 wave. DESIGN: Cross‐sectional online survey with open questions. METHODS: Nurse managers from different healthcare institutions, for example, hospitals and nursing homes, were included. Data collection took place from November 2020 to March 2021. Open questions were analysed with qualitative content analysis. RESULT: In total, 321 managers took part. With regard to professional relationships, four main themes were identified: cooperation, cohesion, communication and consequences. While cooperation and cohesion in the nursing and the interprofessional team were predominantly considered positive, communication was seen as challenging. Additional work duties arose in relation to fulfilling regulatory requirements, managing personnel and carrying out both organizational and informational tasks. Consequences of the pandemic were mentioned in two thematic categories (professional relations and additional work duties). Participants referred to a loss of image, a reduction in job satisfaction and mental stress. CONCLUSION: The regulation of certain tasks by the central authority, such as the enrolment of employees to manage the use of personal protective equipment, would make the managers' duties simpler. This would enable them to direct their attention towards their teams and provide necessary support in other parts of their profession. IMPACT: What problem did the study address? Nursing managers are important members of the nursing team and faced particular challenges during the pandemic. Nevertheless, their perspectives are rarely presented in research. What were the main findings? Overall, communication was perceived as good, and cohesion was strengthened during the pandemic. However, heavy burdens were placed on nursing managers due to the numerous additional tasks. On whom will the research have an impact? Facility managers and government representatives are called upon to provide supportive measures and clear information for nursing managers to relieve them from additional duties during the pandemic.

Internationally, the healthcare system faced and is still facing enormous challenges due to the COVID-19 pandemic. Numerous measures were taken in hospitals and nursing homes to protect vulnerable groups and to care for people suffering from COVID-19 (Alquézar-Arbé et al., 2020; Bauer et al., 2020) .

Even though nurses represent the majority of healthcare workers around the world (WHO, 2016) , the nursing staff shortage is a global problem. As an example, the number of nurses working in Austrian hospitals is lower than the average in the European Union (Bachner et al., 2019) . The International Council of Nurses estimates that up to 13 million of nurses are needed to fill the global nurse shortage gap (International Council of Nurses [ICN] , 2021). Even more troubling is the fact that staff shortage is a major consequence of the current COVID-19 pandemic (Rocard et al., 2021) . A recent report indicated that Austria would experience a nursing staff shortage of 76,000 persons by 2030 (Federal Ministry of Social Affairs, H., Care and Consumer Protection, 2019). Moreover, another study conducted on Austrian hospital nurses during the COVID-19 pandemic reported that 45% are thinking of leaving the profession, and 5% are currently planning or have already left the nursing profession (Gferer & Gferer, 2021) .

Overall, nurses were the group most frequently affected by COVID-19 during the pandemic (Gómez-Ochoa et al., 2021) . Several studies have been carried out to investigate the nurses' burdens and workloads during the pandemic (González-Gil et al., 2021; Kunz et al., 2021; Zerbini et al., 2020) . The results of these studies clearly show that the nurses' workloads increased, the patient-nurse ratio decreased and the nurses became emotionally exhausted. Nursing managers are key players in nursing teams and important stakeholders in healthcare organizations. However, they are infrequently represented in studies and are even an underrepresented group in the nursing profession (Hancock et al., 2021) .

During the pandemic, nurse managers were seen as important individuals who maintained the functions of the healthcare system. One important task carried out by nursing managers, and especially during crises, is to develop and ensure that effective communication is maintained (American Organization for Nursing Leadership, 2020) .

This allows frontline nurses to stay informed and maintains the quality of care and patient safety at a high level. Especially in crises, a breakdown of communication, information overload and lack of information lead to the feelings of helplessness and uncertainty among nursing staff (Browne & Braden, 2020) . During the COVID-19 pandemic, nursing managers were additionally confronted with changes in the deployment of staff and split team arrangements (Lim et al., 2020) . These changes may have had an impact on the interpersonal relationship between the nursing managers and the teams, as well as the relationships in the teams. Possible discrepancies (e.g. disagreements in the team) contribute negatively to the staff members' perceptions of their workload (Browne & Braden, 2020) . Therefore, this must be averted by managers at an early stage. Nurse managers need to strive to maintain positive staff relationships, as these relationships are associated with a higher level of job satisfaction (Bulińska-Stangrecka & Bagieńska, 2021) .

Another main task performed by nurse managers during the pandemic was to organize personal protective equipment (PPE) (Giorgi et al., 2020) . Since the COVID-19 pandemic began, the use of PPE has been viewed as the main strategy to minimize risk of workplace transmission when caring for suspected or affected COVID-19 cases (WHO, 2020b) . With regard to PPE, nurse managers fulfil two roles. Firstly, they have to ensure the availability of the PPE to maintain staff and patient safety (Agency for Healthcare Research and Quality, 2012) . Secondly, they have to ensure that their staff receives adequate training in donning/removing and disposing of the PPE (Agency for Healthcare Research and Quality, 2012) . By fulfilling both roles, managers can ensure that working requirements are fulfilled adequately (WHO, 2020a).

In addition, legal binding interventions were set to prevent the distribution of the virus and the collapse of the healthcare system (Federal Ministry for Social Affairs Health Care and Consumer Protection, 2020). For example, managers in nursing homes in Austria had to establish a plan that required nursing home staff to (1) wear mouth-nose protection and (2) get tested for COVID-19 every 3 days to be able to enter a nursing home (Federal Ministry for Social Affairs Health Care and Consumer Protection, 2020). As another important task during the pandemic, hospital and nursing home managers have to ensure that the legal rules regarding visitor management are followed. Overall, nursing managers were responsible for performing several additional tasks during the waves of the COVID-19 pandemic. Moreover, discussions with nursing home practitioners revealed that nursing home or ward managers often worked as both registered nurses and nursing directors in the respective nursing home. This happened due to a lack of nursing staff, resulting from COVID-19 infections. This double burden as well as all other additional tasks may have affected the occupational relationships and working duties.

The aim of this study was to reflect upon the situation of care management personnel from Austrian healthcare institutions during the second and third COVID-19 wave. More specifically, we asked two open-ended questions, focusing on the occupational relationships and duties at work.

• In which way is the COVID-19 pandemic influencing your relationship with your colleagues, your supervisors or other occupational groups?

• Which specific or additional working duties did you experience because of the COVID-19 pandemic?

We conducted a cross-sectional online survey with open questions, which were analysed with qualitative content analysis.

We invited nursing management staff (e.g. nursing directors, nursing managers, ward managers, quality managers) from different healthcare organizations (e.g. hospitals, nursing homes, rehabilitation clinics) to participate. Inclusion criteria were that the nursing managers had to work at the respective organization during the second and third COVID-19 waves.

In Austria, 870 nursing homes and 93 hospitals are registered (Federal Ministry of Social Affairs, 2015; Statistics Austria, 2020) .

Based on our experience in the field of nursing research in hospitals and nursing homes, we assumed one nursing manager per nursing home (N = 870) and at least three per hospital (N = 297), resulting in a total number of 1149 managers in nursing homes and hospitals. We calculated a sample size of 429 nursing managers (margin of error = .05; confidence level = 80%) using the Qualtrics Sample Size calculator (Qualtrics LLC, 2021).

Access to the online survey (open from November 2020 to March 2021) was distributed in various ways. We used different social media platforms such as Facebook, university websites and via snowball sampling with personal contacts to managers. We used LimeSurvey, a statistical survey web app to perform anonymous data collection. No personal data or IP addresses were collected and/or stored.

The online survey was used to collect demographic data and answers to both open-and closed-ended questions focusing on the second and third COVID-19 wave in Austria. The closed-ended questions were formulated with an instrument developed to measure the quantitative and qualitative workload as well as the organization and social environment of staff working with people with disabilities (Nickel & Kersten, 2017) . As an example, the quantitative workload was defined as too much or little work, and the social work environment was defined as, for example, atmosphere in the team (Koehler & Meyer, 2017) . The instrument is based on an occupational psychological extension of the transactional stress model (Nickel & Kersten, 2017) . The original instrument was tested. The construct validity showed that the four subscales could explain 55.2% of the variance, and Cronbach's alpha scores to measure internal consistency were 0.57-0.82 (Nickel & Kersten, 2017) . This questionnaire was also expanded for the use by home care staff, long-term care staff and hospital staff (Koehler & Meyer, 2017) . In addition, closedended questions were developed based on a review of the international literature and used to determine stress (Bauer et al., 2020; , occupational relationships (Wang et al., 2021) and working duties (Wang et al., 2021; WHO, 2020a) . 

To answer the open-ended research questions, the steps of qualitative content analysis by Schreier, 2012 (Schreier, 2012 were

followed. An inductive approach to the data analysis was used.

The coding frame for each of the two questions was developed using the progressively summarizing method (Mayering, 2014; Schreier, 2012) . This method includes paraphrasing contentbearing text passages, generalizing and drawing abstract concepts from this paraphrased text, reducing the text by deleting semantically identical paraphrased text passages and binding, construct- Finally, the text segments in the categories were summarized and supported with citations. The qualitative data analysis was carried out with MAXQDA 2020. MAXQDA is a software that can be used to analyse the qualitative content of unstructured data, such as the results of interviews with organization staff, to code these data and analyse them. MAXQDA includes several tools that can be applied to quantitatively analyse the data. To investigate the sample characteristics for each open-ended question, we used IBM SPSS Version 27 (IBM Corp. Released, 2020).

To ensure trustworthiness, we followed Lincoln and Guba's evaluative criteria (Lincoln & Guba, 1985) . Peer debriefing was carried out by discussing methods, procedures and results with colleagues, and researchers who were experienced in qualitative data analysis (DS, MH). To ensure the validity and confirmability of the coding frame, the coding frame draft was pilot tested by pairs of researchers. The clear definitions, anchor rules and signal words for the respective categories enabled a high level of intercoder reliability to be attained. The coding framework could be successfully applied to the remaining interviews. The codes were relatively evenly distributed across the subcategories, indicating that a high level of face validity had been achieved.

In total, 321 participants responded to the survey. Of these, 256 answered one or both of the non-mandatory open-ended questions. The majority of the participants in all groups were on average 47 years old, female and worked in hospitals. More than 50% of the participants in each group had worked as a ward manager for fewer than 5 years. Most of them were leading between 21 and 50 employees.

The analysis of the first research question, 'In which way is the COVID-19 pandemic influencing your relationship with your colleagues, your supervisors or other occupational groups?', revealed four themes: cooperation, cohesion, communication and consequences.

Please insert Figure 1 .

Most of the statements indicated that cohesion and cooperation were viewed positively during the COVID-19 pandemic (see Figure 1 ). Positive cooperation included the interdisciplinary and the interprofessional collaboration. One nursing manager described a 'very good cooperation with the nursing home director'.

Managers reported that the responsibility for some tasks was taken and that these tasks were carried out by members of several healthcare professions. In the team, people supported each other; survey respondents perceived the readiness to accept more responsibility and flexibility in the team as improved. Two persons TA B L E 1 Overall sample characteristics (total), plus stratified by participants who answered the open-ended questions (relationships, work load) Table 2 .

The consequences of the COVID-19 waves on the working relationships are discussed below.

Please insert Table 2 .

This question placed a focus on the specific or additional duties at work that the nursing managers experienced due to the COVID-19

pandemic. These were categorized into the following themes: regulatory working duties, personnel management, organizational tasks, informational tasks and consequences of the working duties. 

They also experienced mental stress, as they had to support other wards if needed. Some managers said that the continual struggle to maintain the motivation of the employees exhausted them. In addition, they had to deal with psychological aspects of their own and staff experiences, such as blame and self-doubts. A manager expressed her frustration with the way her staff were treated as follows: 'Our staff has to endure accusations, resentment, anger and disrespect and still is expected to be nice, because that's the only way to make a difference'.

Please insert Table 4 .

The aim of this study was to present the situation of care management personnel during the second and third COVID-19 wave with regard to its influence on occupational relationships as well as specific or additional working duties. Most of the study participants said that they were assigned additional duties at work due to the pandemic. This finding is reflected in several other studies. Changes that would normally take years had to happen over the period of a week, underlining the enormous efforts that needed to be invested by healthcare managers and staff (Salisbury, 2020) . Similarly, a Danish survey revealed that most nurse managers had to perform management duties and responsibilities that they had not before COVID-19 pandemic (Hølge-Hazelton et al., 2021) . Nurses in China experienced having to perform additional tasks under time pressure and with reduced resources as major stress-promoting factors (Zhan et al., 2020) . An Austrian survey with bedside nurses showed a statistically significant association between an increase in the number of working hours per week and the nurses' perceived stress level (M. . Members of other professions also suffered because they were burdened with additional, time-consuming tasks. According to a press release, a medical doctor at a university hospital in the United States complained about having to work too many shifts, that is, 36 h (Yong, 2021) .

However, Zhan et al. (2020) (Wang et al., 2021) .

These authors also noted that communication was one main strategy used to resolving problems between different occupational groups as well as between external stakeholders or higher-level management centres (Wang et al., 2021) . These findings are endorsed by the WHO, which considers the provision of the timely access to information and simpler communication of information to health- The majority of the participating nursing managers reported observing negative consequences of the pandemic with regard to the image of the field, their job satisfaction and mental stress. About mental stress, they had to deal with feelings of insecurity due to changes, the confrontation with COVID-19, blame and self-doubts.

Similarly, a study conducted with Swiss healthcare workers, most of whom held leading positions, showed that they experienced emotional distress as a consequence of the pandemic (Riguzzi & Gashi, 2021) . These findings indicate that not only nurses need to be supported but also managers, by offering financial incentives, greater appreciation of their work performance in society or by providing personnel support.

The open-ended questions were not the primary/only focus of conducting the online questionnaire survey. However, due to the many answers to these open-ended questions -some of which were very extensive with more than 200 words -we considered it useful to conduct a separate qualitative analysis and presentation of the results. The beginning calculated sample size could not be fully achieved. However, this was calculated with the assumption that at least one manager of each Austrian healthcare organization would participate. As the qualitative results deliver rich results, this limitation is marginal. In general, interpreting and coding texts from surveys is more difficult than analysing data obtained through interviews because the opportunity to ask questions does not exist.

In some interviews, single keywords were identified in the text responses. Those responses were challenging to interpret and could only be understood by examining all questionnaire responses, which was done very carefully in these cases. The data analysis was performed in the context of a seminar with master's students who were supervised by experienced researchers. Even though the students were at an early stage of their higher education, the analysis process was performed conscientiously and with many opportunities for discussion with peers and supervisors.

Nursing managers, who are key personnel in healthcare institutions, were burdened with numerous additional tasks during the pandemic. This led to mental stress and had a negative impact on their job satisfaction. To reduce these burdens and to keep people on the job, supportive measures and clear information from a centralized agency (e.g. government, facility management) are needed. Support possibilities for leaders might be, for example, more resources for contact tracing and staff testing, but also staff training programmes on the use of protective clothing. In addition, we identified a need for nurse managers to receive corresponding appreciation and financial rewards for their additional working duties, as they often needed to be available around the clock at their facility.

Parts of this study were analysed in a university course. Therefore, we sincerely thank Ms. Druml M., Ms. Jiménez García L, Ms.

Legenstein K., Ms. Schelnast A., Ms. Schinnerl S., Ms. Steinbauer T.,

Ms. Stoff L., Ms. Tuppinger H., Ms. Walter M. and Ms. Winter S.

No conflict of interest has been declared by the author(s).

The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15203.

Data available on request due to privacy/ethical restrictions. 

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