POSITIONED at the forefront of the COVID-19 crisis, most health care systems are facing tremendous pressures as disruption is becoming the new norm and as many aspects of care delivery abruptly changed. While most disaster preparedness plans address pandemics, preparedness for such is “often overlooked or addressed in policy only.”1(p22) This holds true with COVID-19, as it created stressful situations for organizations, patients, families, and providers—especially nurses. Often, during stressful times, individuals look to leadership for direction and guidance. The “speed and scope” of COVID-19 demanded extraordinary leadership for most health care organizations,2 as nurses sought leaders who remained calm, candid, and optimistic to lead them through this unprecedented crisis.3,4 In fact, many believe that nurse leaders have a social responsibility to lead their followers through this challenging time.5
Crayne and Medeiros6 posited that the challenges leaders face may differ among circumstances and organizations, but an event such as the COVID-19 pandemic presented issues where universal application may be relevant. However, this was not the case. While similarities exist across organizations, there are differences in the environment in which the crisis occurred and the way leaders responded created different platforms for how organizations and individuals responded and adapted. Burrell and colleagues7 hypothesized that given the logistics of catastrophic events, leadership skills remain of utmost importance. These authors theorized that leaders needed to understand that various health care professionals may engage in similar activities but use different leadership styles to be effective depending upon the situation. This reflects in the work of Hersey and Blanchard,8 who suggested that leadership may be dependent upon the maturity level of the followers involved and that leadership styles changed over time as the maturity level of the follower increased.
Uhl-Bien and colleagues9,10 explored this paradigm in terms of Complexity Leadership Theory. Complexity leadership occurs because of adaptive challenges that exist and force leaders and their followers to identify new solutions, embrace innovation, and establish new norms and patterns of behavior. Uhl-Bien and colleagues9,10 postulated that adaptive challenges are not amenable to standard operating procedures but rather require exploration, new discoveries, and adjustments. Complexity leadership does not view leadership as a management function but focuses on the leader's ability to be collaborators who work together to enhance the overall organization to adapt to the current challenge. Thus, the researchers sought to explore current challenges of COVID-19 on health care delivery and leadership styles of nurse executives that were specific to the pandemic.
Given the nature of the question, the purpose of this descriptive qualitative study was to describe events through the “presentation of the fact of the case in everyday language.”11(p336) Sandelowski posited that a descriptive qualitative approach allows a “comprehensive summary of an event in the everyday terms of those events in which most people observing the same event would agree is accurate.”11(p337) It is theorized that a qualitative descriptive design recognizes the subjective nature of a phenomenon and the different experiences participants may have.12,13 Furthermore, qualitative descriptive studies allow researchers to stay closer to the stories of the participants than other qualitative methods where the broader meaning of a life experience is not a fixed entity but rather progresses with the context of the individual experience.14,15
Following approval from the institutional review board at Walden University and using purposive sampling, the researchers recruited nurse executives from across the United States to participate in the study via an introductory electronic message. Purposive sampling allowed the researchers to select participants who could speak to the aims of the article and who have knowledge of the phenomenon of interest.13 After a participant responded, the researchers provided additional information and scheduled a Web conference for the interview if the individual agreed. At the beginning of each interview, the researcher reviewed the informed consent and the participants elected whether to participate or not. Following 6 interviews, the researchers determined that saturation had been reached. Morse16 concluded that the number of participants in a qualitative study needed to reach saturation depends on a number of factors and may be accomplished with 6 to 10 interviews.
During 5 separate interviews, 6 nurse executives provided rich data. The researchers used a preformatted guide to assist in eliciting relevant information from the participants:
Given the current challenges of COVID-19 on health care delivery, what challenges are you facing? How would you describe your leadership experience and style? Can you describe an example of a nursing measure that was implemented during the COVID-19 crisis?
The individual may have been asked to expand on expressed ideas or clarify information he or she provided with prompts such as “Tell me more about that” or “What was that like for you?” Each interview averaged 1 hour. During the interviews, each researcher took notes to understand the nurse executive's descriptions. In addition, the use of videoconferencing provided an opportunity to witness the participant's facial expressions in order to reflect on emotions that may surface during the course of the interview. Before each interview concluded, the researchers reviewed the data to ensure the message was captured.
A thematic analysis approach provided the framework for data analysis. Sandelowski11 posited that thematic content analysis is the approach of choice in descriptive qualitative research as it allows the researcher to give a rich and detailed account of the data.13 During the analysis, the researchers read the oral descriptions to gain a general understanding of the text. Data were sorted using a line-by-line analysis, which allowed the researcher to identify significant statements and phrases that related to the study's objectives. These codes were then organized into similar phrases that allowed for the identification of patterns and themes. These themes allowed the researchers to focus on subsequent interviews. Upon completion of the 5 interviews, the researchers derived categories and common themes among the nurse executives.
To maintain the credibility of the data analysis, a second researcher reviewed the transcripts independently before the 2 researchers compared the codings, categories, and themes. Minor differences were identified, and the researchers collaboratively developed the interpretations of the findings. Once finalized, the common themes were reviewed with 2 of the 6 participants for confirmability. The core themes were then used to create a description of the nurse executives experience during COVID-19 and linked to the literature.13
Theme 1: Communication is paramount
As the pandemic developed, the need for clear, honest, and valid information was “obvious as information is the most effective prevention against the disease of panic.”17(p537) This certainly was the case as all 6 nurse executives shared how they first needed to identify the issue at hand and communicate it appropriately to staff, providers, patients, and families. Excerpts from the nurse executive included the following:
We needed to understand what COVID-19 was and how to respond to the quickly evolving situation. We developed 209 policies and procedures in less than 45 days. Our success rested upon effective and frequent communication. (Nurse Executive [NE] 01)
Our city was one of the hotspots in the country for COVID-19 and between 60% and 70% of our patients required an ICU level of care. This situation created an “all hands-on deck” situation that required good communication. (NE03)
We established a hotline for our community to call for questions and we established curbside testing centers at each campus. We communicated on all fronts and rose to the occasion. (NE03)
Our first challenge involved managing the frightening images portrayed by the media that did not initially materialize in our area. To address this, senior leaders at the system and local levels used various technologies to maximize communication with staff and patients. (NE04)
Effective and frequent communication is important in care delivery, especially those involving patients, families, and providers. However, during COVID-19, communication between these groups greatly suffered in an attempt to promote and maintain safe environments at a time when health care professions had a social responsibility to provide concise and valid information across different contexts.18 Research indicates that people are generally averse to uncertainty when communication is not clearly presented.19 For example, in most organizations, staff used technology to connect not only patient and families but also patients and providers. As one executive described,
Our organization is steeped in relationship-based care and with COVID-19, we went from being a family-centered care model to a no-visitor organization. By working closely with the information technology team, nurses established a “no touch Zoom” option for not only families but for staff and physicians, which allowed for multiple individuals to connect with the patient. (NE01)
Theme 2: Having a leadership presence
Interestingly, most can recognize leadership when it is experienced, but defining what leadership means can be a bit more challenging. Prentice's seminal definition of leadership, “the accomplishment of a goal through the direction of human assistants”20(p143) applies well, as the nurse executives understood the need for not only for leadership but allowing the staff to become leaders as well. As the nurse executives shared:
Our priorities focused on addressing the challenges of our staff while they were providing care to our patients and their families. It was like building a plane and flying it at the same time. (NE01)
Personally, I did have some apprehension that I would not be able to meet the staff's needs or give them the tools they needed to be successful. I learned to let the staff that I work with lead as well. (NE02)
I quickly recognized that my job was to get out of the way as COVID-19 provided staff the opportunity to create teams, to collaborate with members from other disciplines, and to create new roles to respond to what they needed. (NE02)
Part of being a leader was allowing the nurses to make decisions that affected THEIR WORK. I learned that I needed to LISTEN to my frontline and provide them with the support and trust during these difficult times. (NE03)
Our success in dealing with COVID-19 resulted from the flexibility of the nursing leadership in being leaders and being followers. (NE05)
Our team embraced the crisis as there is an expectation for us to be successful! The leaders' challenge was to create ways to maintain this spirit among our staff (NE06).
As evidenced, these 6 nurse executives demonstrated their engagement with their followers. It was critical that they as leaders not only recognized their role in leading their staff but also had the leader presence to allow the staff to become leaders as well. Kerns defined leadership presence as “displaying a set of key behavioral practices to achieve desired impacts.”21(p92) However, as Sandberg22 posited, leadership is about making others better as a result of one's presence and making sure that the impact lasts in one's absence. Tahan23 further developed this idea of leadership presence in that it is not as tangible as one thinks; however, when it is absent, it is easily felt and recognized. The interesting perspective of leadership presence is that true leadership presence has a ripple effect by directly and indirectly influencing others regardless of the physical presence of the leader.21 Thus, in order to be successful during COVID-19, the nurse executives demonstrated strong leadership abilities that carried through to their staff, regardless of their physical presence, in order to provide the best care possible.
Theme 3: Mental toughness
The term “mental toughness” is often used to describe elite athletes, members of the military, first-responders, and police officers.24,25 The concept encompasses the ability “required to excel in a chosen field”24(p292) and is based on the idea of “an unshakable self-belief in one's unique qualities and abilities that make one better than one's opponents and the intrinsic motivation to succeed.”25(p483) In other words, mental toughness allows one to perform successfully under intense pressure. Throughout the interviews, it was evident that these nurse executives and their staff had the mental toughness to maximize care delivery as illustrated in the following extracts:
As the supply chain became challenged, one nurse developed a face shield that connected to her glasses using a magnet; it was amazing how innovative and flexible the nurses became when faced with uncertainty. (NE01)
Our nurses embraced the situation and rose to the occasion. For example, one of our RNs who was being interviewed by a major news network questioned herself, as a professional, if she were working enough and wanted to know what else she could do to give back. I was humbled by her professional commitment. (NE02)
The nurses maintained their dedication to the organization's mission and supported their community and their patients. As leaders, we worried about the psychological crisis that may ensue and how best to encourage the nurses to take a break. We found that they did not want to take a break. (NE02)
In one situation, a nurse repaired a toilet in a patient's room with the plumber outside of the room explaining to her what needed to be done. Our nurses became technicians, mechanics, and plumbers ... they simply did what they needed to do. (NE03)
In the process of interviewing these executives, the idea of mental toughness resonated as the participants described situations where nurses persisted in dire situations, maintained composure during challenging situations, and demonstrated the ability to recover quickly in order to function effectively. These nurse executive led their teams, patients, and families through challenging and, often, heartbreaking experiences. Evidence demonstrates that athletes who can adapt quickly and change direction when necessary tend to cope better with uncertainty and change; thus, they tend to succeed.25 This evidence suggests that these nurse executives and the nurses who follow them demonstrated mental toughness to deal with the adversity of the evolving pandemic.
Research has demonstrated that it takes 10 years of dedicated practice to become an expert in any given field.26 However, given the challenges of COVID-19, these nurse executives lacked the luxury of time to develop and enhance the necessary leadership skills needed to address the pandemic. This study is an attempt at understanding the challenges that nurse executives faced and what tenets were key in promoting positive patient and organizational outcomes. Interestingly, Bennis27 posited that one of the 2 primary threats to global stability would be a pandemic. However, given the findings of this study and despite negative consequences, this pandemic may be viewed as a catalyst in identifying concepts that are of benefit during a crisis. In analyzing these data, it is evident that these nurse executives and their organizations systematically approached their individual challenges in order to achieve positive patient and organizational outcomes through communication, leadership presence, and mental toughness.
At some time, all organizations have experienced a crisis that can be viewed as a threat to any organization.28 While communication is critical in any situation, it is imperative during a crisis in order to manage the crisis and return the organization back to normal operating procedures as quickly as possible. Communication was paramount in the case of COVID-19, however, as demonstrated by this study, many of the nurse executives needed to identify new and innovative ways to communicate with their patients, family, and staff. For example, one of the most common concerns centered around the need to connect patients and families. It is hypothesized that communication is imperative not only to convey a clear understanding of the status of the organization but also to support and protect all of those involved.28 In the case of patients and families, organizations moved quickly to identify solutions to connect loved ones through the use of technology, which, in many cases, expanded to connecting patients with providers, and providers and specialists from other clinical services or disciplines, in order to provide the most up-to-date information and care plans. Wu and colleagues19 concluded that effective and enhanced communication during a crisis empowers and restores a sense of control among providers.
As demonstrated, leadership presence represented a significant and necessary factor for success. In analyzing this tenet, one may relate leadership presence to “command presence,” a term used frequently in the military and with law enforcement. The core components of command presence include competence, composure, decisive, perpetual energy, and problem solver.29,30 The interesting perspective surrounding command presence is that it is the mere presence of the individual that “commands” appropriate behavior from followers.31 While these leaders discussed the importance of having “a presence” in terms of being present, the understanding extended into something greater in terms of the nurse executives having a presence independent of their “physical” presence. In other words, these leaders developed and demonstrated their leadership not only from their physical presence as a formal leader but also in their absence, which extends their command presence in their absence. This phenomenon is of great interest as it addresses the trust that exists between the leader and his or her followers.
The key components of mental toughness as defined by Clough and colleagues32 include confidence, commitment, control, and challenge, which have been consistently identified in qualitative studies. Similarly, Vince Lombardi, one of the greatest coaches and leaders in the history of American sports, described mental toughness as “many things and rather difficult to explain. Its qualities are sacrifice and self-denial ... it is a state of mind ... it is character in action.”33(p59) In applying these definitions to the themes identified from the interviews, the nurse executives from these organizations demonstrated mental toughness in their care delivery.
Mental toughness is often closely related to the concept of resiliency, which has been greatly studied in health care. However, Percy and colleagues differentiated the two in terms of “resilient people survive difficult situations and mentally tough people prosper in such situations.”25(p475) In this framework, one can see the mental toughness that the nurse executives demonstrated in order to not only address the challenges presented by COVID-19 but also learn from the challenges, perform to the best of their ability, and adapt for future challenges in order to maximum positive outcomes.
In maximizing the strengths of these concepts, these nurse executives have been successful in managing the COVID-19 crisis. Moreover, despite each of the organizations using different strategies to connect patients, families, and providers with the hope of enhancing and promoting patient outcomes, their leadership presence and mental toughness of staff allowed them to maintain composure and overcome obstacles. Having the composure in the face of stressful and distressing circumstances allowed the leaders to respond professionally and to enhance positive patient outcomes.
Kerrissey and Edmondson2 described the actions of Adam Silver, the National Basketball Association's commissioner, who on March 11, 2020, suspended the basketball's season well before state governments began restricting public gatherings. Much like Silver, these nurse leaders quickly identified and communicated the situation with openness and transparency to their staff and used their leadership presence combined with the nurses' mental toughness to jump-start the organization's ability to handle the COVID-19 crisis with great attentiveness and reserve. As a result, the nurse executives were able to leverage their leadership abilities against the chaotic and uncertain nature of the situation in order to maximize positive patient and organizational outcomes.
This study had several limitations. First, the participants were hand-selected by the researchers to participate in the interview. Although it is impossible to predict whether the findings would apply to other organizations, this represents an attempt to describe the current challenges of COVID-19 on health care delivery and leadership styles that were specific to the pandemic. Second, this study revealed previously unknown ideas about the reality of the individual's perceptions and experiences during the COVID-19 crisis. While these perceptions and experiences may provide useful information to develop and implement similar strategies, one must be cautious about the development of practices and policies based simply on the participant's perceptions. Third, while descriptive qualitative research produces findings that are “data-driven,” the findings are nevertheless considered to be interpretative.11 Finally, given that the responses were focused on the individual's organization, bias may exist in terms of what the individual reported during the interview.
As with any crisis, the work of the leaders and followers develops and evolves. Evidence from this study suggests that communication, leadership presence, and mental toughness assisted the nurse executives and their organizations to navigate the disruption caused by COVID-19. Leaders set the tone for excellence, but nurse managers and frontline clinical nurses embraced the challenge. As a result, these followers responded to their leader's presence by having the mental toughness to lead through chaotic and challenging times. By allowing the nurses to take ownership of their practice, to act on the behalf of the organization, to look at patient care as part of their role, these nurses kept inventing ways to provide the best care possible. And, in doing this, they were able to find a way to overcome obstacles while maintaining patient-centered care. In this light, these 3 concepts may have importance in executive leadership and executive leadership competencies.
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