Multidisciplinary First-Line Healthcare Leaders’ Roles and Experiences During the COVID-19 Pandemic in Ontario Canada

Background and purpose

Over the past three years, healthcare leaders from all health sectors have played an important role in guiding and supporting frontline healthcare workers through and beyond the COVID-19 pandemic. The pandemic challenged healthcare leaders to focus on constantly changing quality, safety, patient-family, and workforce issues (Aquila et al., 2020). The pandemic became a prolonged crisis and a new normal where the experiences and needs of first-line managers must be understood to improve practices (Morse & Warshawsky, 2021). Much of the research on nursing leadership during the pandemic has focused primarily on the leadership responses during early phases of the pandemic.

Many studies have focused on nurse leaders in senior leadership roles such as clinical nurse executives (Freysteinson et al., 2021; Hartney et al., 2022; Jeffs et al., 2020; Riddell et al., 2022). Fewer studies have examined the role of middle level healthcare managers (Bookey-Bassett et al., 2021). There is even less published on the experiences of multidisciplinary first-line leaders in non-nursing disciplines such as physiotherapists, occupational therapists, social workers, and pharmacists) and other first-line leaders whose role includes leadership responsibilities such as professional practice leaders (PPL), managers, and clinical educators. In addition, much of the existing research has been conducted in hospital settings with less known about the experiences of leaders working in the home or community setting (Lefebre et al., 2020). For example, recent studies have explored the experiences of frontline leaders who were working in one hospital system or institution (Cathro & Blackmon, 2021; Freysteinson et al., 2021; Holge-Hazelton et al., 2021a, 2021b, 2021c) with the exception of Hartney et al. (2022) who explored Canadian healthcare leaders’ experiences in different sectors such as hospitals, long-term care and academic centres. Only two studies were found that were specific to the experiences of first-line healthcare managers in the Canadian health care system (Bookey-Bassett et al., 2021; Jackson & Nowell, 2021). Much of the research on healthcare leaders’ experiences during COVID-19 has been in health care systems in Europe (Holge-Hazelton et al., 2021a, 2021b, 2021c; Jonsdottir et al., 2022; Nevala & Vuorela, 2022), the Middle East (Abu Mansour & Abu Shosha, 2022; Mollahadi et al., 2021) and the United States (Alvarez et al., 2022; Cathro & Blackmon, 2021; Freysteinson et al., 2021). Further, many studies focused on leader experiences during the first wave of the COVID-19 pandemic in 2020 and wave two, early 2021 (Holge-Hazelton et al., 2021c; Nevala & Vuorela, 2022). This study, conducted during wave three in Ontario, the spring and summer of 2021, aimed to explore how first-line multidisciplinary healthcare leaders’ experiences of leading practice and work environment changes evolved throughout the different phases of the pandemic. Understanding how leader roles have been affected on a multidisciplinary level may provide insight on how leaders from various healthcare sectors can be more adequately prepared for future pandemics. This study addresses the gaps in the existing literature by describing multidisciplinary first-line healthcare leaders’ roles and experiences across various health sectors during the COVID-19 pandemic in Ontario, Canada, and provides an understanding of the impact of the pandemic on first-line leader roles and competencies needed to lead during a pandemic. The research questions guiding the study were as follows:

How do first-line leaders experience leadership during the current COVID-19 crisis?

How did they enact their leadership?

Methods and procedures

Results

Nineteen first-line leaders participated in the interviews. Participants were diverse in the professions represented, roles, sectors, and geographical regions. Approximately 50% of the sample were in nursing leader roles. However, participants also included physio- therapists, occupational therapists, pharmacists, and paramedics. Participant roles were diverse and included professional practice leads, clinical educators, advance practice nurses, directors of care, first-line management and nurse practitioner roles as shown in Table 1. Participants worked in various health sectors such as acute care, rehabilitation, public health, community, long-term care, reactivation care, and mental health. Most participants (68%) were from urban centers with 32% of participants working in rural smaller towns and cities across Ontario.

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Table 1.

Participant roles and employment sector.

Discipline	Professional Practice Leader	Clinical Educator	Advanced Practice Nurse	Director of Care (LTC)	First Line Manager	Nurse Practitioner	Total
Nursing	—	2	1	1	6	1	11
Physiotherapy	3	—	—	—	1	—	4
Pharmacy	1	—	—	—	—	—	1
Occupational Therapy	2	—	—	—	—	—	2
Paramedic	—	—	—	—	1	—	1
Employment Sector
Acute Care	3	1	1	—	4	1	10
Rehabilitation	3	—	—	—	—	—	3
Public Health	—	—	—	—	1	—	1
Community	—	—	—	—	1	—	1
Long-term Care	—	—	—	1	—	—	1
Reactivation Care	—	—	—	—	2	—	2
Mental Health Care	—	1	—	—	—	—	1

Multidisciplinary leaders enacted and adapted their leadership roles throughout the crisis of the pandemic in ways that reflected both transformational and complexity leadership theories. The results section begins with a description of deductive findings from these theoretical perspectives. The inductive findings are then described with key themes addressing research questions 2, 3 and 4.

Impact of COVID-19 on first-line leader roles

Leaders described several ways in which their roles were impacted by the pandemic. A major theme was dealing with change . Leaders experienced changes in their roles and responsibilities, often taking on multiple roles. For example, leaders described having to change the services being provided and having some services shut down or stopped for periods of time during the pandemic. Leaders reported how the pandemic impacted their own workload such as longer work hours to support staff and having to negotiate patient flow and care issues with senior leadership to best meet patient care needs. Constantly changing rules, practices and policies also meant leaders had to manage and communicate changes to their staff on what seemed to be a daily basis. Other participants described some aspects of their roles that had not changed during the pandemic, noting they still had to do all the pre-COVID work such as deal with staffing recruitment and education issues and maintain budgets plus additional responsibilities depending on the phase of the pandemic. Participant quotes representing these themes and sub-themes related to the impact of the pandemic on their role are presented in Table 2.

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Table 2.

Sub-themes related to the impact of the pandemic on leader roles.

Sub-theme	Supporting Quotes
Change in responsibilities	So, I carry professional practice frontline nursing management um, at times I’m the infection control nurse, At times I am the nurse educator.” (P5, RN/FLM). “…we have a community paramedic program as well, so mid pandemic because of my nursing background I was pulled into that job, instead of the normal QA. So, I started a brand-new job in the middle of it, …” (P9, Paramedic, FLM)
Change in service provision	“…we might have had to change something entirely in a period of a shutdown or a complete reversal of how we usually operate and then we got back into a period of restart, reopen.” (P13, PT/FLM) “…there's been a lot of innovative thinking moving towards more virtual visits, like for our pre-admission clinic, there's more virtual visits and more telephone visits. There's been changes that have been good, and I think they're good things that have come out of it.” (P8, RN/FLM)
Workload	“I know other leaders would just leave on time, but that is just not the way I lead. I had more work to do because of my commitment…” (P4, RN/FLM) “I have things to do that I don't get done at work. So the reason why I don't get my work done at work is because I'm in Zoom meetings every moment of every day. And they book you right up to the very end of your last Zoom meeting because they know you're not going anywhere.” (P17, RN/FLM)
Negotiating	So, I negotiated with senior leadership more on certain things trying to keep things that I knew that they felt was important just not giving it the larger role that they probably wanted.” (P5, RN/FLM) “…you're dealing with the stress of frontline staff … but at the same time you're also working with senior leaders and you're working with your own boss saying, ‘No, we need to implement something, families need this. They are telling us, they need this, we have to do something for them’.” (P11, Pharmacist/PPL)
Rules	“Trying to follow the rules when they change, and if you haven't read the right email that day, you might have missed the change.” (P3, RN/FLM) “It was a slippery slope of meeting what the community needed at that moment, or the client needed at that moment, more than what the organization needed. And you would actually go against some of the rules.” (P3, RN/FLM)

Discussion

This paper presents the experiences of a sample of first-line leaders from nursing and a small number of other health professions during COVID-19 within one province in Canada. Specifically, this study gives voice to perspectives previously not considered, namely the experience of various Canadian healthcare professionals from different disciplines in first-line leadership roles in all sectors, through the lenses of transformational and complexity leadership. A more nuanced understanding of leading in a crisis was possible by applying two theoretical models to the data collection and analysis processes. Transformational leadership helped to identify strategies that were used to enhance the leader-staff relationship during the crisis while complexity theory offered an understanding of how leaders acted to address operational demands at a systems level during the crisis. This duality in responsibilities is present in most formal first-line leadership roles.

In this study healthcare leaders demonstrated the four dimensions of transformational leadership reflecting the importance of the leader-staff relationships even during times of crisis such as the pandemic. Supporting and empowering staff through listening to their concerns, sharing information, keeping staff safe and being flexible was important. These findings are similar to other studies in which leaders have been recognized for their ability to build trusting relationships with staff (Freysteinson et al., 2021), navigate differently, and empower staff at the frontlines to continue to provide care throughout the pandemic (Bookey-Bassett et al., 2021; Lefebre et al., 2020). The results of this study further indicate the necessity for leaders to uphold principles of transformational leadership when dealing with crises.

In the quantitative phase of the study, transformational leadership was measured using the Multifactor Leadership Questionnaire (MLQ-5x-Short) (Avolio & Bass, 2004) where participants assessed their own leadership style before and during the pandemic (n  =  118). The scores for the total scale were higher pre-pandemic (mean 3.08, SD .34, range 0–4) than during the pandemic (mean 2.81, SD.51, range 0–4) and these differences were statistically significant (p  =  0.002). Therefore, transformational leadership was moderately high overall but fell somewhat as the COVID pandemic continued. For both time points, the highest ratings were for individualized consideration (mean 3.32, SD .44 and 3.06, SD .60 respectively) which is consistent with the qualitative findings where leaders noted the importance of supporting their staff and keeping them safe. The lowest scores were found for idealized influence (mean 2.76, SD .52 and 2.53, SD .63 respectively) which might be due to the demonstrating authenticity but also showing vulnerability as revealed by the leaders in Phase 2 of the study. Comparisons were made between how nursing (n  =  85) and non-nursing disciplines (n  =  31) expressed their leadership style and no statistically significant differences were found between these groups pre-COVID, but non-nursing leaders reported higher levels of transformational leadership than nursing leaders during the pandemic (mean 2.96 and 2.73 respectively, t  =  −2.17, p  =  0.02). The reasons for this difference need to be explored further and could be due to variations in role expectations, the number of direct reports or other factors that impact the ability to enact dimensions of transformational leadership.

Complexity theory elucidated the leaders’ ability to adapt to the pandemic conditions to lead staff and ensure the delivery of care during the pandemic. Leaders demonstrated entrepreneurial actions as they found solutions on the go. They created supportive conditions for the adaptive process by being fluid and flexible and supporting teamwork. There was little direct evidence of operational leadership where, according to complexity theory, leaders work to embed new ideas or solutions across the organization. The lack of movement into this third phase of adaptation may be due to the phase of the pandemic when data was collected or could be due to role expectations where system-level change is part of the mid or senior level leader and not the first-line leader. Given the complexity of the current healthcare system and the new crisis of the health human resources, a deeper understanding of complexity theory and its application could serve as a fruitful area for further development of leadership skills for first-line leaders.

Leaders in this study experienced a multitude of changes involving additional responsibilities, changing policies, changes to service delivery, and increased workload. These findings are similar to those of other studies where ambulatory care leaders described having to realign ambulatory care services to enable alternate or virtual care delivery (Alvarez et al., 2022). Some leaders in this study reported working longer hours in order to complete all that was required of them such as attending Zoom© meetings while still managing the day-to-day operations of their units and checking in with staff (Alvarez et al., 2022; Bookey-Bassett et al., 2021; Freysteinson et al., 2021). Leaders emphasized their role in negotiating and advocating with senior leadership for resources to support staff and maintain safe care delivery. This finding is similar to other studies that stated that advocacy is one of the key roles that leaders must balance (Cathro & Blackmon, 2021).

Leadership strategies used by leaders in this study align with those reported in the literature. For example, leaders appreciated the ability to work virtually from home as a strategy to balance their work and personal lives (Freysteinson et al., 2021). Self-care came across as both a strategy and as a recommendation for leading during pandemics. This finding illuminates the importance of self-care for managers and leaders during COVID-19 as identified in several studies representing leaders from different countries (Behget & Modi, 2021; Chipps et al., 2022). Supporting staff and protecting staff well-being requires that first-line leaders have time and support systems available to manage their own stress, mental health, and well-being (Behget & Modi, 2021). Peer support within and networking outside their organizations were also recognized as effective leadership strategies by the leaders in this study (Cherepanov, 2022).

Participant recommendations concur with findings from previous studies. Participants identified various skills and competencies necessary to lead during a pandemic. These included: developing skills in collaborative leadership, change management, critical thinking, resilience and flexibility, communication skills, conflict management skills, confidence building, and appreciation for other roles and professions. These findings align with those of previous studies identifying leader competencies for leading during crises such as pandemics and disasters (Asgari et al., 2021; Behget & Modi, 2021; Wymer et al., 2021). In addition, our findings support the importance of leadership development to prepare and support current and future leaders to lead interprofessional teams in and across all healthcare sectors. Recent studies acknowledge the importance of cross-training staff (Freysteinson et al., 2021) and disaster training for all staff (Asgari et al., 2021; Freysteinson et al., 2021). Further, the need for additional management and formal leadership training and mentoring within practice and academic settings is recommended to support leader development and the ability to lead during a crisis (Holge-Hazelton et al., 2021a, 2021b). Recommendations include incorporating disaster management programs into academic curricula (Asgari et al., 2021). Further, Behget and Modi (2021) recommend making self-care part of leadership development education.

Similar to a previous Canadian study, (Bookey-Bassett et al., 2021), participants in this study emphasized the importance of senior leadership visibility and in-person presence. Frontline leaders noted the importance of senior leadership taking time to be present with and listening to first-line staff as a source of support. Leaders are considered a resource for staff - visibility. should be seen as a priority for supportive work environments (Bergstedt & Wei, 2022). Leaders can support staff through increasing their presence and visibility by taking the time to round and meet with employees in small huddles (Freysteinson et al., 2021).

Organizations have a responsibility to ensure leaders and staff have the support they need to enable safe care delivery. For example, ensuring that staff receive the necessary training, adequate resources, and access to ongoing support services as needed (Alvarez et al., 2022).

Support for leaders may include peer support, as well as formal mental health resources (e.g., psychiatrists, psychologists). Leaders noted the need for better health human resource planning at both the organizational and provincial level and for clear policies for health care organizations to work more closely with the Ministry of Health. Evidence indicates that leaders play a key role in advocating for equitable access to services across health care systems and sectors (Asgari et al., 2021; Lefebre et al., 2020; Wymer et al., 2021).

Limitations and implications and future research

To further extend our understanding of first-line leaders in all disciplines and roles, it would be useful to conduct a secondary analysis of the data to compare multidisciplinary versus nursing leaders. This comparison may reveal useful similarities and differences that could guide leadership development specific to crisis situations. Although our recruitment strategy aimed to include representation from various sectors, we had few participants from the long-term care sector. It would be useful to repeat the study and include strategies to ensure adequate participation from across healthcare sectors as well as including other geographic areas beyond Ontario. A range of crisis situations could also be explored beyond the pandemic to determine if and how leadership experiences are impacted. These findings could also provide further insights about change management practices in crisis/pandemic situations.

Conclusion

Descriptions of first-line healthcare leaders’ roles and experiences during multiple waves of the COVID-19 pandemic have illuminated and validated the contributions of multidisciplinary leaders across various health sectors. Leadership behaviours exhibited during the crisis were representative of the key dimensions of transformational and complexity leadership theories. Explicit recommendations for leading during a crisis were obtained from the participants thereby providing additional insights into how first-line leadership roles can be effective under these extenuating circumstances. Engaging in self-care activities to manage the personal impact of the crisis, teamwork and collaborative leadership were highly recommended as was support from fellow first-line leaders and senior leaders. These theoretical views and leadership reflections can be used to inform leadership development programs designed to manage future crises for both academic and practice settings. Improved healthcare human resource planning by organizations and government would be beneficial so that redeployment of staff could be optimized to meet changing needs in a crisis. Multidisciplinary first-line healthcare leaders also saw the potential for enhanced collaboration between health care organizations and government to promote more equitable access to services across all sectors during crisis situations.