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• To gain an understanding of nurse managers’ experiences of the COVID-19 pandemic
• To appreciate that fear, related to fear of infection and information overload, was a major issue for nurse managers during the pandemic
• To consider adopting already-established COVID-19 guidelines to support effective infection control procedures and communication in future pandemics
Background: Research shows that front-line nurses’ workload and stress levels increased during the coronavirus disease 2019 (COVID-19) pandemic, however, there is little research of these factors in relation to nurse managers. Previous research undertaken in Austria found that some nurse managers working in nursing homes undertook clinical as well as managerial functions during the pandemic, a double burden that could have increased their stress levels and have had adverse psychological, physical and social consequences.
Aim: To investigate the effects of the COVID-19 pandemic on nurse managers’ workload, perceptions of teamwork and stress levels, and the physical, psychological and social consequences of working during the pandemic.
Method: A cross-sectional design was used. Respondents (n=238) were sent an online questionnaire during the second wave of the pandemic (which in Austria was November 2020 to March 2021) containing questions on demographics and fear of infection, their current workload compared with pre-pandemic workload, their perceptions of the influence of the pandemic on teamwork, their levels of stress measured using the Perceived Stress Scale (PSS), and the physical, psychological and social consequences of working during the pandemic.
Results: Most respondents (95%) had to undertake more or much more work than usual during the pandemic, while just over half (52%) perceived that the influence of the pandemic on teamwork had been positive throughout or partially positive. Overall, the respondents’ level of stress was moderate, as measured by the PSS. Around 28% of respondents were afraid of infecting someone other than themselves, notably their families, employees and patients. Fear for themselves, their families and their patients or residents were commonly reported psychological consequences of working during the pandemic, while confusion due to information overload was the second most commonly reported psychological consequence.
Conclusion: Comparing results with previous research is difficult due to the lack of research of nurse managers’ experiences of the pandemic. Fear appears to have been a major issue for nurse managers during the pandemic, particularly in relation to infection and information overload. This emphasises the need for healthcare organisations to focus on the mental health and well-being of nurse managers, as well as front-line staff, during and after crisis situations such as a pandemic. Organisations may consider reworking and adopting already-established COVID-19 regulations, schedules and local guidelines, particularly in terms of communication and infection control, which could help to reduce nurse managers’ fear in future crisis situations.
Nursing Management. doi: 10.7748/nm.2024.e2121
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Hoedl M, Reiter L, Schuettengruber G et al (2024) Exploring the effects of the COVID-19 pandemic on nurse managers. Nursing Management. doi: 10.7748/nm.2024.e2121
Published online: 23 April 2024
Healthcare workers were recognised as a specific high-risk group with regards to the coronavirus disease 2019 (COVID-19) (Centers for Disease Control and Prevention 2020). Nurses and midwives make up the largest group of healthcare workers globally and have been recognised as ‘key players in crisis and post-crisis situations’ (World Health Organization 2016), such as the COVID-19 pandemic. This also includes nurse managers, who have a critical role in the delivery of daily nursing care during such crisis situations (Hancock et al 2021).
Nurse managers have a nursing and executive function, typically report to a senior nurse leader, are responsible for effective functioning of their practice area and often work clinically as well as in a managerial capacity (Agency for Healthcare Research and Quality 2012). Overall, nurse managers have significant responsibility for the delivery of safe and effective daily nursing care, the well-being of their staff and the care and safety of patients and their relatives. The provision of high-quality patient care is influenced by many factors including, for example, the health and well-being of nurses and the organisation of shift work and resources, such as personal protective equipment (Rosa et al 2018), particularly during challenging periods such as a pandemic.
Much research has been undertaken to investigate the level of stress in healthcare workers, including nurses, during the pandemic (Arnetz et al 2020, Kuo et al 2020, Mo et al 2020, Petzold et al 2020, Thompson 2020, Donnely 2021). However, the authors of this article found little research of its effects on nurse managers’ levels of stress. The authors identified some qualitative studies that explored nurse managers’ experiences of working during the pandemic (Jackson and Nowell 2021, Poortaghi et al 2021, White 2021, Vázquez-Calatayud et al 2022), and one quantitative study (Gab Allah 2021); however, these studies were mostly undertaken in hospital settings and tended to focus on the managerial aspects of the participants’ roles.
A qualitative study undertaken in nursing homes in Austria found that during the pandemic nurse managers had often taken on clinical tasks usually assigned to front-line nurses, as well as continuing with their managerial work (Hoedl et al 2022). The researchers reported that this double burden increased nurse managers’ stress levels and could have adverse psychological, physical and social consequences (Hoedl et al 2022). The authors of this article, therefore, decided to explore these effects on nurse managers working in a range of healthcare settings in Austria. The subsequent study, which is reported here, was undertaken during the second wave of the pandemic, which in Austria was November 2020 to March 2021.
To investigate the effects of the COVID-19 pandemic on nurse managers’ workload, perceptions of teamwork and stress levels, and the physical, psychological and social consequences of working during the pandemic.
The study used a cross-sectional design involving an online questionnaire.
Participants comprised nurse managers, including nursing directors, nursing managers, ward managers, quality managers and other nursing leaders, from a range of healthcare organisations across Austria, including acute hospitals, nursing homes and rehabilitation clinics. Due to the pandemic infection control measures in place at the time of the study, the researchers used their personal contacts, ‘snowball sampling’ (where initial participants are asked to help the researchers identify other participants) and advertising on social media platforms to recruit participants.
In Austria at the time of the study there were 870 nursing homes (Bundesministeriums Für Gesundheit 2019) and 93 acute hospitals (Statistics Austria 2020). To calculate potential sample size, the authors assumed that, on average, one nurse manager position existed per nursing home and at least three per hospital. Based on these assumptions, a potential sample size of 429 nurse managers was calculated using a web-based software programme.
An online questionnaire was developed by the authors. The questionnaire included questions on demographics, such as age, gender, workplace, position, length of experience and number of employees led by the respondent. In the demographics section, respondents were also asked two questions related to fear of infection: first they were asked if they were afraid of infecting someone else; if the answer was ‘yes’ they were asked if this fear related to their ‘families’, ‘employees’, ‘patients/residents’, ‘relatives of patients/residents’, ‘others’.
• The study showed that nurse managers’ workload increased during the pandemic. However, comparison with other work is difficult due to the lack of research involving this specific group and the use of different concepts of workload and measuring instruments. Therefore, the authors recommend the development of a standardised set of outcomes for future research on this topic to facilitate international comparison of data
• Nurse managers perceived the pandemic as an opportunity for enhanced teamwork and collaboration. Therefore, leadership models that focus on developing effective teamwork are warranted
• Some nurse managers reported a high level of stress. Healthcare organisations can help to reduce nurse managers’ stress by establishing staff-centred work schedules and clear communication guidelines
• Healthcare organisations could rework and adopt established COVID-19 regulations, schedules and local guidelines to support effective communication and infection control procedures in future pandemics, which may help to reduce nurse managers’ feelings of fear
Respondents’ level of stress was measured using the German version of the Perceived Stress Scale (PSS) (Cohen et al 1983), a ten-item questionnaire designed to evaluate the degree to which an individual has perceived life as unpredictable, uncontrollable and overloading over the previous month. Respondents score each item on a scale of 0-4 (0=never, 1=almost never, 2= sometimes, 3=fairly often, 4=very often). Total scores range from 0-40, with higher scores indicating higher perceived stress level. The PSS has been used in previous research related to nurses’ burden and COVID-19 (Hoedl et al 2021).
Respondents were asked to compare their current workload (that is, during the second wave of the pandemic) with their pre-pandemic workload and to describe their perception of the pandemic’s influence on teamwork based on a set list of statements (Table 1). They were also asked to choose from a set list of psychological, physical and social consequences of working during the pandemic (Figure 1) that they recognised in themselves during this wave of the pandemic. This list was developed by the authors based on a literature review of the possible consequences of a crisis, such as a pandemic, for nurses and other healthcare workers (Brown et al 2016, Emond et al 2016, Li et al 2018, Inter-Agency Standing Committee 2020, Mo et al 2020, Ning et al 2020, Ong et al 2020, Petzold et al 2020, Zhang et al 2020). Respondents were asked to indicate yes or no for each consequence and could choose multiple consequences.
Those who agreed to take part in the study were emailed a link to the questionnaire, which remained live from 30 November 2020 until 2 March 2021.
Data analysis was undertaken using IBM Statistical Package for the Social Sciences 26. The data were analysed by the authors using descriptive statistics, reporting the mean and standard deviation (SD) for metric and frequencies, and using absolute numbers for categorical variables. The Cronbach’s alpha of the PSS for the study sample was 0.897.
The study was undertaken in agreement with the Declaration of Helsinki (www.wma.net/what-we-do/medical-ethics/declaration-of-helsinki/) and the Medical University of Graz (2024) Standards of Good Scientific Practice guidelines.
Respondents were informed about the study on the first page of the online questionnaire; to complete the first question they had to click on: ‘Yes, I want to participate.’ The survey was anonymous and no personal or IP address data were collected or stored, in compliance with the European General Data Protection Regulations (European Commission 2024). The ethical committee of the Medical University of Graz approved the study. The authors followed the strengthening the reporting of observational studies in epidemiology (STROBE) guideline (STROBE 2024).
In total, 321 (75%) of the estimated sample size of 429 nurse managers completed the online questionnaire. During analysis of the responses, the authors noted that 19 respondents did not lead employees or did not have a management function to their role, while data were missing for 64 respondents. These were therefore not included in the final analysis, leaving a total sample size of 238 nurse managers (55% of the estimated sample size).
Respondents’ characteristics are shown in Table 2.
Most respondents were female, worked in a hospital and were ward managers; their mean age in years was 47.2. Of the 238 respondents, 44 held two or more positions. Almost half (50%, n=118) of respondents led 21-50 employees, while 18% (n=44) led 51-100 employees.
In relation to the questions on fear of infection in the demographics section of the questionnaire, 28% (n=67) of respondents said they were afraid of infecting someone else; of those 67 respondents, 81% (n=54) were afraid of infecting their families, 66% (n=44) were afraid of infecting their employees and 63% (n=42) were afraid of infecting their patients/residents.
Most respondents (95%, n=226) reported having to undertake more or much more work than usual during the pandemic (Table 1). Just over half (52%, n=124) the respondents perceived that the influence of the pandemic on teamwork had been positive throughout or partially positive; however, 22% (n=52) perceived that the pandemic had a partially or entirely negative influence on teamwork (Table 1).
With regards to the PSS, 34% (n=80) of respondents reported a low level of stress, 56% (n=133) reported a moderate level of stress and 11% (n=25) reported a high level of stress. Respondents’ mean perceived stress level as measured using the PSS was 17·4 (SD 7.0), which indicates moderate stress.
Figure 1 shows the physical, psychological and social consequences of working during the COVID-19 pandemic on respondents. Respondents could choose more than one consequence in each section. With regards to physical consequences, almost three-quarters (74%, n=175) of respondents reported tiredness or exhaustion, around half (50%, n=120) reported sleeping problems, while 45% (n=107) reported headaches and 44% (n=104) reported concentration disorders.
In the psychological consequences section, 88% (n=209) reported experiencing more stress, while 78% (n=186) experienced confusion due to information overload. In addition, respondents experienced fear for their patients or residents (46%, n=110), their own family (50%, n=120) and their employees (51%, n=122). On the other hand, 61% (n=146) reported they had more time for self-reflection, 34% (n=80) reported having more self-esteem, while 27% (n=65) had more motivation.
In terms of social consequences, 90% (n=214) of respondents reported having fewer social contacts, while 14% (n=33) reported feeling lonely. However, 11% (n=27) reported having more intensive and closer social contacts as a consequence of the pandemic.
This study investigated the effects of the COVID-19 pandemic on nurse managers in Austria in relation to workload, perceptions of teamwork and level of stress, and the physical, psychological and social consequences of working during the second wave of the pandemic. To the authors’ knowledge this is the first study to focus on these factors in relation to nurse managers’ experiences of the pandemic.
Almost all respondents reported having a heavier workload during the second wave of the pandemic compared with their pre-pandemic workload. This suggests that it was not only front-line nurses’ workload that increased during the pandemic, as evidenced in previous studies such as Lucchini et al (2020), Shan et al (2021) and Lorente et al (2021).
Comparing the results of the present study with previous research is challenging, given the paucity of literature on this aspect of nurse managers’ experience of the pandemic. However, Shan et al (2021), who included nurses with management positions (n=57/446) in their analysis of the mental workload of front-line nurses during the pandemic, found that having a management position was linked with high mental workload. In addition, a Spanish study that investigated nurses’ (n=421) stressors and psychological distress during the pandemic found a moderate work overload among participants (Lorente et al 2021). Although Lorente et al (2021) did not include details of nursing roles, participants had an average work experience of more than 12 years, so it is possible that some held management positions.
Other challenges with comparing the results of this study with previous research relate to different concepts of workload and different measures. For example, Shan et al (2021) explored mental workload, while Lorente et al (2021) examined work overload. In the present study, respondents were asked to compare their current workload with their pre-pandemic workload, whereas Shan et al (2021) used the Chinese version of the National Aeronautics and Space Administration Task Load Index and Lorente et al (2021) used the Spanish version of the Nursing Stress Scale.
More than half of the nurse managers in the present study perceived that the influence of the pandemic on teamwork was positive throughout or partially positive. This is reflected in other studies. For example, a Spanish study that investigated the experiences of front-line nurse managers (n=10) during the pandemic reported a feeling of ‘one for all’ in terms of their experience of teamwork, and described how the crisis provided an opportunity for teamwork and collaboration between all patient care services (Vázquez-Calatayud et al 2022).
Teamwork and collaboration are requirements for strategic nursing leadership (Rosser et al 2020), therefore the authors would argue that the pandemic created an opportunity for nurse managers to strengthen their leadership skills; in turn, this strengthening of leadership skills can support delivery of quality patient care (Kowalski et al 2020).
Most respondents in the present study (89%, n=213) reported experiencing low or moderate levels of stress, while a small proportion (11%, n=25) reported a high level of stress. A Canadian study of the effect of the early phase of the pandemic on the mental health of critical care nurses (n=109) found that, overall, 54% experienced stress with 22% experiencing severe or extremely severe stress (Crowe et al 2021). The comparatively low levels of stress reported in the present study could be due to the period of data collection, which was the second wave of the pandemic, by which time respondents may have become more used to the situation. However, it is also important to acknowledge that participants in Crowe et al’s (2021) study were not nurse managers.
In the psychological consequences section of the questionnaire, around half the respondents selected ‘yes’ to statements regarding fear for their employees, their own families and their patients or residents (Figure 1). Fear was also evident in the responses to the questions on fear of infection in the demographics section of the questionnaire. These findings are reflected in Crowe et al’s (2021) study, in which participants reported feelings of anxiety linked to fear of infection for themselves, their patients and their families. Fear of infection was also the highest scoring stressor in Lorente et al’s (2021) study.
The second most frequently chosen psychological consequence in the present study was confusion due to information overload. It could be argued that this confusion also instigates fear. For example, Crowe et al (2021) reported that nurses’ anxiety and fears were linked to overwhelming and unclear communication, while White et al (2021), who investigated front-line US nurses’ (n=152) experiences of working in care homes during the pandemic, including those with management responsibilities (n=60), found that receiving contradictory information led to feelings of fear in participants.
It appears that fear in various contexts, including infection and communication of information, was a major issue for nurse managers as well as front-line nurses during the pandemic. This emphasises the need for healthcare organisations to focus on the mental health and well-being of all staff, including nurse managers, during and after crisis situations such as a pandemic.
In addition, healthcare organisations could consider reworking and adopting already-established COVID-19 regulations, schedules and local guidelines to support clear communication and infection control procedures in future pandemics. This may assist in reducing feelings of fear in nurse managers.
The study did not achieve the representative sample size of 429 nurse managers. However, the questionnaire was accessible for more than two months and reminders were sent to the relevant institutions. In addition, the authors attempted to increase the number of participants from less easily accessible settings, such as nursing homes, by using personal contacts.
The snowball technique was used as a recruitment tool due to pandemic-related infection control restrictions. However, this could have resulted in selection bias. In addition, the cross-sectional design could be regarded as a limitation since it does not allow for causal relationships.
There is a lack of research of nurse managers’ experiences during the pandemic in terms of workload, teamwork, stress levels and the physical, psychological and social consequences of working during the crisis. This study found that nurse managers’ workload increased compared with pre-pandemic workload; however, relatively low numbers of respondents reported high levels of stress.
The study also found that nurse managers experienced fear with regards to infection and information overload. This suggests there is a need for healthcare organisations to focus on the mental health and well-being of nurse managers, as well as front-line staff. Healthcare organisations may also consider adopting established COVID-19 regulations, schedules and local guidelines, particularly in relation to infection control and communication, to help reduce nurse managers’ fear in future crisis situations.
03 October 2024 / Vol 31 issue 5
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