Management of the COVID-19 pandemic: challenges, practices, and organizational support

The COVID-19 pandemic started in Wuhan, China, in December 2019 and has spread intensely around the world since then, despite quarantine and containment measures [1].Sometimes crises are beyond human control and usually lead to death and affect people's lives in different ways. The crisis is a complex phenomenon that requires multi-directional corrective actions and, above all, preventive measures. There is no best way out of the crisis. Based on the facts of an absence of preparedness plans in hospitals, nursing managers face difficulties in managing the crisis during the outbreak of COVID-19, so studying the reality is the main target [2].

According to the World Health Organization (WHO), on April 13, 2019, more than 1.7 million people were infected, and nearly 85,000 people lost their lives. In addition, as of September 26, 2020, about 213 countries all around the world have been affected by this disease, resulting in 32,700,000 confirmed cases and more than 993,000 deaths.

In Egypt, the first positive case of COVID-19 was confirmed on February 14, 2020 [3]. Then there was a rise in the total number of cases and deaths. In parallel, there was a growing rise in the number of infected nurses and physicians [4]. In October 2020, Egypt was the 46^th country in the entire world and the 8^th Arab country affected by this virus. The number of cases has reached more than 106,707, and the number of deaths has reached more than 6,211. Moreover, this statistic is changing every day.

The COVID-19 pandemic is an extraordinary international health “war” in which the arena is the hospitals and our fighters are the health workers on the front lines. COVID-19 has presented nurses with unprecedented professional, social, and psychological challenges [5, 6]. Therefore, proper preparation of nurses is essential, as they are the greatest providers of health information and services for people [7]. The responsibility of this preparation falls on the nursing managers. Managers must be prepared to respond to the effects of this pandemic on themselves and their staff. Even with advances in healthcare and virus control technology, real success is not possible without effective leadership.

Nursing managers in health organizations currently face huge challenges related to dealing with pandemic operations. Therefore, managing the coronavirus crisis requires successful and proven scientific practices implemented through effective institutional work. Effective institutional work refers to the complete disappearance of vision and personal effort; the existence of institutions and entities that integrate with one another according to an interlocking system and a clear vision; the existence of methodologies and scientific foundations; the presence of a working group of people competent in the three levels of crisis management (strategic, executive, and operational); coordination among institutions, the optimal use of resources through a professional operating system that applies best practices; and the presence of many capabilities and local enablers that can be managed and built quickly and efficiently [8].

The scenarios for facing each pandemic wave need greater preparation and considerable experience in identifying the challenges, scientific practices, and organizational support. Since the beginning of the pandemic, the Egyptian Ministry of Health (MOH) has been using hotlines and sponsored advertisements on Facebook to teach people about the disease as a way to use such powerful tools to its advantage [9].

Also, leaders and nursing managers can provide specific support to their healthcare organizations and develop programs to cope with the coronavirus pandemic. This study can guide nursing managers in this regard [10, 11]. A coordinated global response is needed to prepare healthcare systems to face these challenges [12]. The World Bank emphasizes that global readiness for pandemics is crucial for global security and should be considered part of a program for strengthening healthcare systems [13]. Therefore, the researchers in this study sought to explore nursing managers’ experiences of the challenges, practices, and organizational support during the management of the COVID-19 pandemic. The study's findings would be useful to public health administrators and policymakers in determining how to manage crisis waves effectively.

Built on the outcomes of the interviews with nursing managers, the following three main themes and eight subthemes were related to “challenges,” “practices,” and “organizational support.” Challenges include development of a COVID-19 crisis management plan; shortage of nursing staff; and psychological problems. Practices included changes in work schedules for nursing staff, the exchange process (deal between university hospitals), hospital preparation, and training and education. Organizational support includes support at the organizational level and support at the individual level (Tables 1, 2, and 3).

This study was conducted through interviews with a total of 35 female nursing managers with a mean age of 41.36 ± 6.66 years and a mean work experience of 19.10 ± 5.57 years, including five nursing directors, five assistant nursing directors, 10 supervisors, and 15 head nurses, aiming to explore the challenges, practices, and organizational support dealt with by nursing managers in the management of the COVID-19 pandemic.

In this study, in Table 1, managers reported that the biggest challenge they faced at the start of the pandemic was the development of a plan to deal with the COVID-19 pandemic. According to those interviewed in his study, there might have been no plan that helped deal with the COVID-19 pandemic had been in place, but hospitals are usually required to have a crisis management or emergency response plan. The study conducted by Mathew et al., [22] found that lack of pandemic preparedness plan was one of the challenges faced by frontline health and social care workers during COVID-19 pandemic.

So as revealed from the interviews all activities related to the preparation were internally initiated. An Ad hoc committee was formed at the university hospitals level, composed of different department managers from nursing, medical, pharmacy, laboratories, engineering, physicians with different specialists, and infection control, assigned with the tasks and responsibilities to establish a preparedness plan for confronting the COVID-19 pandemic. These coordinated activities, what made the plan evolve in time. In many countries, strong coordination techniques were needed, as the fragmentation of health services resulted in inadequate responses and timely interventions to health emergencies [23].

The second biggest challenge facing nursing managers in this study was the shortage of nursing staff and figuring out how to work with 30% of hospital personnel. The research study by Matthew et al., [22] found several challenges faced by health and social care workers on the front lines during the COVID-19 pandemic, staff shortages, lack of personal protective equipment (PPE), and anxiety and fear among professionals. According to the result of the interviewees, the main reason for this shortage was absenteeism and fear of infection due to the lack of a clear plan and strategies for deal with the COVID-19 pandemic [24]. The WHO [25] recommends that staff shortages should be anticipated due to absenteeism and increased demand for services, and a plan should be put in place to address this shortage.

Regarding absenteeism, fear of infection was the main cause that make nurses use their vacation for absence. In addition, curfew makes transportation difficult especially in the night and in the remote villages, resulting in increase absenteeism in the night shift, putting nursing managers in a challenge. According to Adamczyk et al., [26] restrictions on movement and travel one of the challenges of the pandemic, In this study, nursing managers have been obliged to change the work schedules of the nursing staff to adapt to the curfew in Egypt (5:00 PM to 6:00 AM). The study by Partzick et al., [27] in Germany revealed that the COVID-19 pandemic has rapidly changed the working conditions of nurses and their working lives.

This change was imperative because, without the nurses, adequate care could not be provided to patients. In regular workplaces, the usual three-shift system (day, evening, and night) was revised to two shifts (9 h. a day and 15 h. a night), 7 AM–4 PM and 4 PM–7 AM. However, in isolation facilities, the changes in the work schedule involved implementing a four-shift day, with work for 6 h per shift and each nurse working two alternate shifts, and full accommodation provided (Table 2). This finding came in line with the policies applied in the region to overcome nurses’ shortage, as about 17 countries increased working hours and vacation time, in addition to implementing full-time work hours [28].

Moreover, to deal with the crisis, new and creative ideas were needed to solve the upcoming challenges innovatively. So, creativity and innovative solutions were needed to develop new working procedures and practices [29]. One of the most important and creative practices that were used to overcome shortages during the COVID-19 pandemic crisis was the exchange process (a deal between the university hospitals). The deal provides for taking young nurses who do not have spouses or children to work in isolated places, in return for giving elderly nurses, nurses who support their families, nurses who have children, and nurses who have chronic diseases the opportunity to work in regular workplaces (Table 2).

The third challenge facing nursing managers during the pandemic was psychological problems such as panic, fear, anxiety, and depression facing staff nurses. In many reported studies, staff nurses’ doubts regarding practices for carefulness with COVID-19 patients caused anxiety and fear. Furthermore, studies conducted in many countries related to caring for COVID-19 patients reported negative psychological consequences, such as anxiety, sadness, and stress, for nurses [30‐33]. According to the study conducted in Egypt on health care workers (HCW) exposed to COVID -19, an extensive number of them had symptoms of anxiety, insomnia, depression, and stress [34]. Another study conducted on nurses in Egypt reveals that about three-quarters (75.2%) of nurses working in fever hospitals had high-stress levels versus 60.5% of nurses working in general hospitals [35].

From another prospective, the findings of a recent quantitative study on frontline nurses’ experiences showed that fear and unwillingness were mitigated through increased knowledge about the virus [36]. According to Adamczyk et al., [26] uncertainty about the future and there was a lot of contradictory information in the media caused a sense of confusion and heightened the feeling of anxiety. Dealing with the situation was not facilitated by the phenomenon of global misinformation, called by some experts as the “infodemic”, which may be defined as an overabundance of information that makes it difficult for people to find trustworthy sources and reliable guidance [37].

Both nursing managers and nursing staff also faced psychological problems. The COVID-19 outbreak causes panic emotions among nurses, and a lack of preparation to deal with these emotions puts them under great tension. However, nursing managers in our study, having a strong presence in their departments, being a good role models the staff, and acting as both leaders and administrator, have the authority to generate a more positive impact on their staff during this pandemic [38].

A study conducted by Gao et al. [39] found that a close relationship between nursing managers and their staff nurses was a vital factor in increasing motivation. However, perspectives on the significance of the psychological well-being of nurses during the COVID-19 pandemic should be emphasized [40]. Emotional motivation to relieve nurses from the stress they experience at work was demanded.

In addition to the role, that hospital preparations plays in fighting a COVID-19 pandemic, through equipping the hospital with a rapid-response team who are prepared to deal with suspected and positive cases, allocating rooms to sort the cases and others to isolate positive cases, and equipping ambulances and the morgue.

Furthermore, the role played by the infection control team at the level of all the studied hospitals is not neglected. From the researchers’ viewpoints, the infection control team was the backbones of each hospital which its team act as the Liaison between the Supreme Council of Universities and hospital managers, according to the WHO [5], in the face of an unknown disease, sharing and collaboration are the best means of finding solutions. According recent policy paper developed by Ghannam & Sebae [41] itemized amongst its commendations the need for improved infection control in health services in their attempt to study the effect of the pandemic on the new health insurance system that is being piloted in Egypt. The infection control team prepares reports about suspected cases and infected cases and the whole plan relato ted their role, a tripartite committee was created to monitor PPE disbursement [42]. PPE is one of the most important requirements for fighting an infectious pandemic like COVID-19. This is in addition to providing temperature detection reagents.

Furthermore, education and training play an important role in preparing nursing and medical staff to proficiently face this pandemic. According to the study conducted to assess the nurses' knowledge, concerns, perceived impact, and preparedness toward the COVID-19 pandemic, around half (51.2%) of the studied nurses said that the main sources of knowledge were from the Ministry of Health and World Health Organization's websites and formal pages [43]. It should be provided to all nursing and medical teams and healthcare workers. According to Chimenya [44], hospitals should conduct training and education sessions to bridge the knowledge gap and educate workers about their fear of infection.

In line with the overall findings of the practices presented in this study, several protective and preventive policies were emerged to overcome the negative effect of the pandemic, these policies included: management and communication, training and education, wellbeing drop-in sessions, peer support, team support, availability of personal protective equipment, and proper planning [45].

The third theme that will be discussed in this study is organizational support (Table 3). Organizational support is carried out at two levels, one of which is at the organizational level to determine the paths and places of isolation in each hospital and to allocate the isolation hospital at Assiut University to serve the university’s faculty and staff members, and which has been divided into three zones according to the condition of the patients (green, yellow, and red).

Another at the individual level was the evidence of communication and collaboration between nursing and medical management teams during the COVID-19 pandemic. Nurses and physicians need to know the importance of communication in healthcare [46]. Nurses and physicians collaborate in providing care to patients during hospitalization; regarding Hossny [47, 48], when nurses and physicians have the increased opportunity to work in a civil environment, they will collaborate more. Also, the establishment of information and communication channels was required during crisis management. Communication and collaboration in this study were demonstrated by the creation of WhatsApp groups and open phones for in-charge personnel 24 h a day for both medical and nursing teams.

Other ways of organizational support provided include material support, for instance, the Supreme Council of Universities provided disinfectants (antiseptics) and preventive supplies to all university hospitals, The university also provided transportation and full accommodation, financial rewards, transferring of signature in the isolation facilities, free swabs for all employees, and the granting of exceptional leaves to workers in isolation and those with chronic conditions, as well as the exemption from signature for infected staff, were implemented.

According to Hossny, [49] it is the responsibility of hospital managers to develop the weaker services inside their hospitals. This helps ourselves and our institutions prepare for this complex and fast economy, which is essential for support. Accordingly, many procedures related to obtaining signatures and facilities performed in the healthcare setting make work during the pandemic easier. Regarding signatures, all nursing managers reported that granting exceptional leave to workers in isolation and those with chronic diseases, as well as an exemption for infected staff from signing, was implemented. Regarding facilities, Open University cities for medical staff who want to stay in isolation and the provision of buses for nurses to facilitate transportation were established.

Nursing managers have gained much experience in crisis management throughout the COVID-19 pandemic. Nursing managers faced many challenges in the management of the COVID-19 pandemic. These challenges include developing a crisis preparedness plan, shortage of nursing staff, and psychological problems. Useful practices include adapting schedules, equipping and preparing hospitals, and training and education. In addition, organizational support is carried out at two levels, one of which is at organizational level to determine the paths and places of isolation in each hospital and to allocate the isolation hospital. Another at the individual level include establishing communication and cooperation, and material support such as providing disinfectants, financial rewards, and transferring the signature to the isolation facilities.