Abstract
Purpose
This study aims to explore the management learning during a long-term crisis like a pandemic. The paper addresses both what health-care managers have learnt during the COVID-19 pandemic and how the management learning is characterized.
Design/methodology/approach
The paper is based on a qualitative case study carried out during the COVID-19 pandemic at two different public hospitals in Sweden. The study, conducted with semi-structured interviews, applies a combination of within-case analysis and cross-case comparison. The data were analyzed using thematic deductive analysis with the themes, i.e. sensemaking, decision-making and meaning-making.
Findings
The COVID-19 pandemic was characterized by uncertainty and a need for continuous learning among the managers at the case hospitals. The learning process that arose was circular in nature, wherein trust played a crucial role in facilitating the flow of information and enabling the managers to get a good sense of the situation. This, in turn, allowed the managers to make decisions meaningful for the organization, which improved the trust for the managers. This circular process was iterated with higher frequency than usual and was a prerequisite for the managers’ learning. The practical implications are that a combined management with hierarchical and distributed management that uses the normal decision routes seems to be the most successful management method in a prolonged crisis as a pandemic.
Practical implications
The gained knowledge can benefit hospital organizations, be used in crisis education and to develop regional contingency plans for pandemics.
Originality/value
This study has explored learning during the COVID-19 pandemic and found a circular process, “the management learning wheel,” which supports management learning in prolonged crises.
Keywords
Citation
Rosenbäck, R. and Svensson, A. (2024), "Management learning in public healthcare during pandemics", The Learning Organization, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/TLO-01-2023-0002
Publisher
:Emerald Publishing Limited
Copyright © 2024, Ritva Rosenbäck and Ann Svensson.
License
Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode
Introduction
The COVID-19 pandemic presented an unprecedented challenge to health-care managers (Hølge-Hazelton et al., 2021). The pandemic placed emergent and extraordinary constraints on health-care services because of increased demand combined with limited capacity (Leite, Lindsay, & Kumar, 2020). The crisis created a high degree of uncertainty among health-care managers and a sense of decision-making urgency (Cater & Beal, 2014). Health-care managers are expected to understand, be resilient and to plan and coordinate resources in crises as well as in normal situations (Glenn, Chaumont, & Dintrans, 2020; Hans, Houdenhoven, & Hulshof, 2012). However, most research on management of surge capacity in disasters concerns short-term disaster with multiple instances that effect several public sectors and develop fast (Bonnett et al., 2007; Davis, Zobel, Khansa, & Glick, 2017; Hick, DeVries, Fink-Kocken, Braun, & Marchetti, 2012; Kaji, Koenig, & Bey, 2006). That means that the capacity needs to rise quickly to a high level, but the surge demand last just for a few hours or days. During the pandemic, the health care was struggling to provide care to patients infected by the COVID-19 virus and at the same time, to some degree, provide normal health care to other patients during a longer period. The surge capacity created to handle COVID-19 patients used capacity intended for other patients, while attempting to find a balance and maintain efficiency in the total capacity at the hospitals. The need for decisive, hierarchical management has been identified as important in crisis situations (Kapucu & Van Wart, 2008). However in a crisis, there is also a need for progressive and distributed management that incorporates perspectives of multiple stakeholders (Glenn et al., 2020). Moreover, it is important that the management endures over time (Rosenbäck & Svensson, 2021).
Boin, Hart, Stern, & Sundelius (2005) developed a framework for analyzing crisis management, consisting of five core tasks of management during crises: sensemaking, decision-making, meaning-making, crisis termination and learning. Tenkasi and Boland (1993) related sensemaking and meaning-making to learning and organizational change. Sinha and Ola (2021) described the importance of continuous learning during a crisis and the need for learning to recover after a crisis. When learning occurs in organizations, experiences about certain events are built up in knowledge structures. The point of departure for learning is the lived and living experience of everyday life, according to Brandi and Elkjaer (2011). In the aftermath of the health-care crisis, caused by the pandemic, it is important to understand what experiences were considered meaningful to make decisions and learn for the future. Therefore, this paper attempts to understand management learning and how the crisis management developed during a long-term pandemic. The paper addresses both the way health-care managers learnt and how they changed their management practice and learning during the pandemic.
The remainder of the paper is structured as described in the following. The literature overview is outlined in the next section, followed by the research methodological approach. Then, the findings from the cases are described, and the following section discusses the results of the study. The paper is finally concluded, and implications for future research are raised.
The management practice and learning in crisis: theory
A learning organization is an organization where learning takes place in tight connection with work and where organizational aspects related to learning exist (Örtenblad, 2018). Organizational learning can be understood as a process of managing experiences and is related to the opportunity for people to share information and knowledge from their practical experiences at work, with other people inside or outside of the organization (Wang & Ahmed, 2003). Tuggle (2016) claimed that there is a positive correlation between learning capability and organizational performance. More knowledge sharing can take place in organizations that are less centralized and formalized. A crisis is characterized by a problematic situation and calls for decisions made based on joint collaborative reflections among managers, as an action approach (Argyris & Schön, 1996). Management learning is needed in times of crises, to learn and adapt to challenges, while still pursuing the core activities (Best & Williams, 2021). As a crisis implies learning, the managers are forced to learn, required by the context. To effectively adapt to a crisis, managers need to foster new ways of thinking. Therefore, the capacity to learn in a crisis is central, and an emergent nature of learning is often required. The ways learning in crises are experienced is shaped by the unknown and unknowable (Antonacopoulou & Sheaffer, 2014).
The relationship between learning and crisis, especially related to the uncertainties in management of health care, needs to be further explored (Boin & Lodge, 2021). This paper takes a social perspective on management practice and learning. In this perspective, the managers are the learning unit, as they are performing social activities. Moreover, the social perspective considers learning context dependent (Örtenblad, 2018).
Sensemaking in crisis learning
Sensemaking in a crisis involves collecting and processing information that helps crisis managers detect an emergent crisis and understand the significance of what is going on during the crisis. This is relevant in a variety of sectors, also in health care (Boin, Hart, Stern, & Sundelius, 2016; Lalonde, 2007). Sensemaking is a process that allows people to make retrospective sense of what happens. It is very difficult to predict and detect an emerging crisis. If managers can detect a crisis early on, they can deploy essential resources faster. However, crises often take managers by surprise. An escalating crisis is hard to recognize, as the signals that something is developing into a crisis often are vague and contradictory. In the sensemaking process, the managers attempt to understand what is happening. They want to take effective measures to deal with the emergent crisis, to protect society from harm. In this process, the managers must assess the urgency of the crisis, how threatening it is and consider how to act in the coming period (which could be hours or days). The managers must make sense of the coming crisis and what it is about and implement methods to diminish the threat. Indications of an emerging crisis can stem from many sources and be of different scales. In any case, the managers must sense the characteristics of the coming crisis based on those indications and other available information. Maitlis and Christianson (2014) concluded in their literature review that sensemaking is especially important when the uncertainty is high in an emergency, in, for example, a crisis. The external communication to society must be clear, as there could be many competing voices in a crisis, with their own positions and interests, providing alternative information (Boin et al., 2016).
Decision-making in crisis learning
Decision-making involves critically assessing strategic dilemmas and arranging for implementation of decisions made (Boin et al., 2016). When a crisis occurs, managers are often confronted by problems and needs of such dimensions that the scarce resources available need to be prioritized (Weick, 2007; Weick & Sutcliffe, 2011). Managers must weigh different aspects such as policies, political issues, organizational frameworks and ethical perspectives. They also need to make trade-offs between risks and opportunities, even when situations remain unclear and volatile. Sometimes it might also be necessary to make decisions that are not established in a contingency plan. The time to reflect upon, anchor and gain acceptance for such decisions is often limited. Moreover, the decisions must be implemented, often within a diffuse network of actors, requiring both horizontal and vertical coordination. Coordination is imperative to be able to communicate and avoid conflicts between the actors involved. Different professional logic and organizational routines need to be identified and aligned, as motivation is intrinsic, personalized and individualized. Hence, managers in health care need to create an environment for their employees to obtain positive energy (Conrad, Ghosh, & Isaacson, 2015; Rosenbäck, Lantz, & Rosén, 2022). There is an apparent risk of power games in such situations, and people may question who is in charge. Different actors may push for different decisions within an organization based on their different approaches and methodologies. Several processes and players could complicate decision-making situations for the health-care managers. To implement decisions and make the actors involved work in accordance with the decisions in times of crises is a challenging task. Thus, the managers need to establish a thorough understanding in the organization in the decision-making process.
Meaning-making in crisis learning
According to Tenkasi and Boland (1993), meaning-making as well as changes in meaning structures are found in the stream of organizational actions. Meaning-making processes are embodied in narratives and their structures and constitute essential elements of managers’ actions. Storytelling is thus used to socially construct meaning in an organization, and it is an important part of the management practice. It could offer a situational narrative that is convincing, helpful and inspiring to stakeholders such as personnel and citizens (Boin et al., 2016). Managers must provide an account of what is going on, and what needs to be done, to reduce uncertainty in a crisis. The managers must get others to accept their conception of the situation. They also need to assign meaning to their decisions, so that others can understand the efforts that were made. If the managers fail at getting others to understand that their decisions and actions make sense, their decisions may not be fully respected. Other actors who succeed better at getting their messages across may come to dominate the meaning-making process, thereby decreasing the managers’ ability to make decisions and maneuver the situation. Hence, it is imperative that managers in health care can describe what the crisis is about, what is at stake, what can be done and how to proceed through the crisis. It is also important that the managers are truthful, that their story is correct and that they show empathy and confidence when presenting their narratives and responses (Boin et al., 2016). It seems like knowledgeable and competent managers who could use this to the collective could gain power to decide.
Power in learning
Several scholars seem to agree on that differences in power between managers and others are obstacles to extended learning (Bunderson and Reagans, 2011). However, high power managers, who have knowledge and competence, will increase their influence in the organization (Willer, 2009). When the organization is decentralized the organization’s attention to differences in employees’ knowledge and experience increases and will improve the collective learning (Bunderson & Sutcliffe, 2002). Moreover, Bunderson and Sutcliffe (2002) suggested that a safe environment tolerates risk, especially when risk taking is needed in, for example, a crisis.
Research method
Research approaches
This paper is based on a qualitative and comparative case study conducted about a year after the start of the COVID-19 pandemic at two public hospitals in Sweden. A qualitative approach is often used in studies of management practice and learning in organizations (Flyvbjerg, 2006; Myers & Newman, 2007; Reich, Rooney, & Hopwood, 2017). The case study produces context-dependent knowledge and experiences and attempts to understand complex issues in real life (Flyvbjerg, 2006).
This case study is an investigation of two cases, used to observe the phenomena in their natural settings at two public hospitals. The cases are selected based on the different geographical contexts in which these health-care organizations operate. One hospital is a middle-sized emergency hospital located in an urban area in which COVID-19 spread early. The other hospital is a large university hospital located in a rural area in which COVID-19 spread late. Hence, the cases can be considered as “critical cases” (Flyvbjerg, 2006). The study involves a combination of a within-case analysis and a cross-case comparison, as this is considered a strong means of drawing inferences from case studies (George & Bennett, 2005). Thus, the rich data collected in the two cases are used to shed light on aspects of managers’ practice and learning during the pandemic but are also used as a basis for comparisons, to be able to find various perspectives on the same phenomenon (Flyvbjerg, 2006). The comparison of the cases focuses on analyzing and explaining the differences and explaining the phenomena in both broader and deeper details (Ragin, 1989).
Case descriptions
Like many public hospitals in Sweden, both case hospitals had contingency plans for crises based on the North Atlantic Treaty Organization (NATO) standard, with instructions for starting a regional command center (RCC) at the regional headquarters and local command centers (LCC) at the hospitals, and rules for how to communicate and make decisions (NATO, 2022).
Case A.
Case A is a middle-sized hospital with about 1,300 employees, located in a large urban region in Sweden, where several hospitals with different orientations are located. The case hospital is an emergency hospital but without infection department and with few intensive care unit (ICU) beds. The infection rate of COVID-19 in the catchment area of this hospital was high, sometimes the highest in the country. The hospital was about to implement the new NATO standard when the pandemic started and completed it quickly in the beginning of the pandemic to get the plan in place.
Case B.
Case B is a regional hospital with about 6,000 employees, located in a rural region in which the COVID-19 infection rate was lower, and the virus spread later, than in Case A. The year before the COVID-19 pandemic started, some reorganizations had been made in the region, in which regional departments with department managers who manage all specialty units of the same kind at the three hospitals in the region, had been created. The contingency plan had not been updated to match the new organization when the pandemic started.
Data collection
We have identified organizational actions related to management practice and learning by collecting data from narratives of managers as the basis for understanding processes of sensemaking, decision-making and meaning-making. Staff capacity building, treatment development and infection prevention were the main subjects in the interviews. The interview sessions started in March 2021, one year after the onset of the pandemic, and were completed after about three months. A total of 27 interviewees were conducted at the first hospital (Case A). Several members of the hospital management group were interviewed, namely, the chief executive officer, the chief medical officer and the managers of operations, human resources, communication, education and care. Others involved in crisis management, as unit managers of the ED, inpatient care and ICU, were also interviewed, as well as service managers handling logistics and maintenance. Two interviews (with unit managers) were conducted in groups of two.
Fourteen interviews were conducted at the second hospital (Case B). The interviewees worked at a higher organizational level compared to Case A, because of the regional position of the second hospital. Interviews were conducted with the regional care hygiene manager, the physician of infection prediction and control, the crisis manager of the (RCC), the regional chief physician and the regional director of health care. Members of the hospital management group were also interviewed, namely, the hospital manager, the managers of operations of internal medicine, infection and emergency and the manager of communication and human resources. In line with Case A, the interviewees were from three management levels; however, the higher management layers included fewer managers, and therefore the number of interviews were lower.
The interviews were semi-structured, which means the interviewees were allowed to talk freely, and the interviewer refrained from introducing words from the theory, to avoid affecting the interviewees (Flick, 2014; Gioia, Corley, & Hamilton, 2012). One researcher moderated the interviews, and an observing researcher listened and used an interview guide to control that all information was collected, as needed. The observing researcher also added a few questions, when needed. The moderator can be characterized as an “involved researcher,” as she has knowledge and experience as a manager and consultant within this field of research. All interviews were conducted via a videoconference tool, lasted for just over an hour and were recorded and transcribed verbatim.
The interviews were combined with a collection of secondary data consisting of internal documents, texts from various internet sources, newspaper articles in which the hospitals were mentioned, as well as statistics from the hospitals’ own databases. The use of mixed methods, with multiple methods of data collection and combination of data types, contributed to the picture of the two case hospitals. The interviewees were later provided with significant feedback in the form of a lecture, to make sure the gathered information was correctly understood (Walsham, 2006).
Analysis method
The two cases were analyzed separately as single cases and compared in a cross-case analysis. A deductive, thematic analysis was used (Braun & Clarke, 2006), where the themes of sensemaking, decision-making and meaning-making were used according to the crisis management framework of Boin et al. (2005). In each of the themes, the excerpts were sorted in the areas of capacity building, treatment development and infection prevention and crisis management to find the results in each area. Examples of the excerpts are found in the result.
All data analysis was done separately and iteratively by the two researchers, using NVIVO12 in a circular coding process and in total three coding cycles. A critical analysis and reflection of interpretations was conducted, before going back and analyzing the data again. The analysis also included looking beyond the data, to consider wider implications of the findings. This procedure was conducted to enhance the rigor of the research (Carroll & Swatman, 2000). The researchers continued to discuss the interpretations of data and codes during the writing process.
Ethical considerations
The study was carried out in accordance with the World Medical Association Declaration of Helsinki (World Medical Association, 2013). The interviewees received both written and oral information about the purpose of the study, the procedure, how the results would be presented, that their participation was on voluntary basis and that they could withdraw at any time. The interviewees signed a written consent form to participate in the study and sent it back to the first author, in advance of the interviews. Data were transcribed without mentioning any names, and throughout the analysis process, the data were confidentially handled. However, in this study no sensitive personal data were collected, and as such, an application of approval to the Swedish Ethics Review Authority should not be conducted, according to the Swedish law.
Findings
The cases come with different narratives. Different surroundings and infection pressure meant that the managements needed to make (and made) different decisions. The findings focus on the crisis management during the first three waves of the pandemic and include both similarities and differences between the cases.
Sensemaking
In the unknown context of the pandemic, managers at both cases tried to detect and understand the pandemic but struggled to make sense of the situation. Information about the pandemic partly came from colleagues in international networks, but mostly from the reality at the hospitals where the patients were admitted. In both cases, the physicians and nurses were best positioned to sense the situation, estimate the need for capacity, choose treatment method and prevent infection. In both cases, managers at lower levels developed a sense of the situation and transferred it to managers at higher levels, with different degrees of success.
To combat the shortage of knowledge, the managers assigned physicians to find information about the latest treatment knowledge, which was then directly applied. The infection physicians used the network of the Swedish interest organization for specialist physicians to spread the latest knowledge, for example, through webinars.
Case A.
The ICU management received information from their Italian colleagues that the COVID-19 virus had come to Europe and that the need for inpatient capacity and especially ICU capacity was enormous (Cecconi, Pesenti, & Grasselli, 2020). This was the starting point in estimating the capacity needed to take care of the COVID-19 patients. The ICU management team successfully spread this sense of urgency to the managing director. The hospital management meant that the regional management did not develop the same sense of urgency, especially not in the beginning of the COVID-19 pandemic, probably because the regional management did not have access to the same information, or because they evaluated it differently, according to the chief physician:
It was obvious that we had other information than they had. (Chief physician)
In the beginning, estimates regarding the future capacity required to handle the COVID-19 patients were unavailable. After the first infection wave, the management team created a special forecasting team to address this sensed lack of essential information. The forecasts made during later waves were based on the knowledge gained during the first wave. However, a complicated network of decisions, for example, decisions about the amount of help obtained from a bigger hospital nearby, the national occupational health decision forbidding pregnant women to work with COVID-19 patients, and a regional political decision to increase elective surgery, affected the balance and made it hard to get a good sense of the needs at the hospital:
Later, the queues got critical and then it was more and more imperative care, and then the university hospital didn’t cope […] now you must manage by yourself more or less. (Managing director)
The hospital had several outbreaks of infection, most of which seemed to be caused by colleagues or family members. This information, and the understanding of it, provided a sense of how the virus spread and taught the staff to protect themselves from the infection. Managers started to use digital meetings to a higher extent than before, and they also limited the number of staff allowed in the canteens, to make sure they could keep their distance.
Case B.
Early in the pandemic, the manager of infection prevention received help from a nearby university with doing tentative forecasts, which were uncertain, but nevertheless provided a common goal. The uncertainties associated with forecasting must be known, and there was a need to explain that the forecasts should be interpreted with caution:
If you just tell those who receive the figures – this is the best we can do now. Maybe it’s not right, but it’s something to hold on to. (Manager of infection prevention)
During the first wave, the infection pressure was low, but the uncertainty and worry among the employees was high. Later, the infection pressure increased, but the worry decreased. The situation was never unmanageable, and the needed surge capacity never exceeded the first prognosis:
There during the spring, when everything started, we knew very little of everything, that was very stressful during the spring, to prepare for something we didn’t know what it was. (Health-care director)
Because of the later outbreak, Case B had received more information from other regions, and the sense of the situation was better when the first patients arrived. The manager of infection prevention sensed that the emergency level was lower in the beginning and recommended the health-care management to use the available capacity for elective care. Later in the pandemic, when the RCC had been established, a “Corona plan” was introduced that gathered information intended to understand the needs and estimate how much capacity could be used for elective care:
It’s always been a judgement; it’s been there all the time – that we call the Corona plan. (Regional contingency chief of staff)
On an operational level, the information flow improved with the introduction of a newly developed daily updated dashboard with key numbers of demand and capacity. With the dashboard in place, the employees could get an improved sense of the changing capacity requirements for COVID-19 patients:
These dashboards are so valuable. (Chief physician)
Early on, the manager of infection prevention predicted that information regarding personal protection, infection tests and protection of elderly would be urgently needed (which turned out to be right). This early and correct prediction of the situation was probably because of the manager’s long experience and access to information from a large international network. The manager shared his sense of the infection situation by providing information about the latest recommendations twice a week to the hospital, primary care and community managers.
Decision-making
Numerous decisions needed to be made during the pandemic, and the decision-making process developed in both cases. Because the managers at the case hospitals found the RCC to act too slow, they instead used the normal, and some newly developed, decision paths to be able to act faster. Decision-making meetings were held more frequently, sometimes daily or more often during the most difficult times. Different people attended the meetings depending on the type of problem at hand, and the need for knowledge and information, at both case hospitals. In the beginning, it was most urgent to solve problems related to materials and laboratory capacity, after which problems related to test equipment, pharmaceuticals and staff became more pressing. Later, the focus changed to resilient shifting of capacity between elective care and COVID-19 care, and to evening out the pressure among the employees to prevent exhaustion.
Case A.
The former chief physician thought that the decisions from the RCC came very late and complained about having to wait, without freedom to act. The RCC first decided that the COVID-19 patients would not be admitted to the case hospital, but only to the university hospital nearby. When patients were already admitted at all hospitals in the region, the RCC decided that all hospitals should take care of the patients. When the ICU departments at all hospitals were overfilled, the RCC instructed all hospitals to maximize their number of ICU beds and decided that an external ICU (which was never used) should be built:
Then the region panics and an order to maximize the number of ICU beds comes, after they have been restrictive over and over again, and the idea of catastrophe management is to maintain a freedom of action. (Former chief physician)
The managing director bravely took the lead, long before the RCC released any orders, and made clear and rapid decisions based on information from the reality in the organization. The ICU department manager meant that bravery and delegations of responsibility were important in being able to cope with the crisis:
For me, the key factor has been a brave manager […] Trust the organization and the wisdom in it, because it’s the organization that needs to solve the task in the end. (ICU department manager)
The managing director found that the professionals grew in their roles by accepting a lot of responsibility and making many good decisions by themselves. The respect and trust grew between the managing director and the other managers, which helped them make the best of the situation.
The LCC, which consisted of the ordinary management group and a few additional experts who changed over time, decided to shut down all elective care to increase the capacity for COVID-19 patients. The decision quickly gained acceptance and the regional real estate company offered help in rebuilding according to the needs, despite the lack of decision from the RCC. The LCCs at the hospitals in the region concluded that the RCC was malfunctioning, and a rather tough discussion broke out between the RCC and the LCCs, because the hospital managers wanted to use the normal management lines instead of the crisis management in the protracted crisis:
We started up the LCC and then it became protracted, but we were managed by the RCC during the whole first wave. After that, a rather blustery discussion broke out and a bit of a power struggle between the RCC and the normal hospital management occurred. (Managing director)
In the second wave of COVID-19 infection, the managing directors of the hospitals in the region seized power from the RCC, and an existing regional production management group (PMG), consisting of the hospital managing directors, took over the decision-making. At PMG meetings held daily, the managers informed each other about their possibilities and decided how the hospitals should help each other to balance the pressure between the hospitals in the region. The regional chief of staff was later invited to the meetings to receive information that the RCC could use to make nonhealth-care decisions.
When the pandemic continued wave after wave, as much capacity as possible needed to be used for elective care. After the first wave, the hospital management learnt to make fast decisions between the tops of the waves to increase elective care, and change over to COVID-19 patients again when a new wave rolled in:
We were not prepared for this type of crisis, but we had enough tools to start everything, and then we’ve used agile methodology. We did learn during the first wave, and in the second wave we found our way, or a better way, now in the third wave we try to do several things at once. Both handle the wave and all other healthcare. (Managing director)
Decisions regarding the treatment or movement of patients, for example, between care levels or hospitals, were taken by the physician in charge of the treatment. Physicians were considered best suited to make such decisions because they worked close to the patients and had access to the most information about the capacity, disease progression and possible treatments, and because they were obliged to make decisions independently:
I said to them: You are the one with the most information – do what you think is best. I appreciate that more than if you do nothing. (ICU manager)
Decisions aimed at reducing the infection spread among the employees, for example, in canteens and meeting rooms, were made at the beginning of the second wave and only after several outbreaks.
Case B.
In the beginning, when indications of a crisis appeared, a regional coordination group started working with one of the first potential problems that emerged, namely, the lack of material. When more information was available, and the crisis was a fact, the RCC was established. The organization had recently been changed and did not match the organization described in the contingency plan. The level of education about the plan and the experience of using it was low. General knowledge regarding how to work in a crisis was also lacking:
During the first wave, a lot of deficiencies became obvious […] Too few of us were educated and experienced [about the contingency plan]. (Regional contingency chief of staff)
The smaller hospitals in the region decided to establish LCCs, but the case hospital never did. Instead, the health-care director actively decided to manage through the normal regional health-care management group (RHMG), which was used as a regional health-care committee besides the RCC, as it was considered faster and more decisive:
The usual contingency plan is not customized to pandemics, it is customized to take care of accidents of short duration […] we worked in a committee from the contingency management group, you could say. (Health-care director)
A chief physician with contingency responsibilities was surprised about RHMG’s decision to work in a regional health-care committee outside of the established crisis management routes. During these power games between the RCC and the health-care management, a group of department managers started having their own meetings and making the practical decisions needed for building surge capacity. More participants were added to the meetings during the pandemic, because people wished to be included or because competence was needed. Because it was a self-started group, they had little mandate to decide over other departments at the hospital, and they were criticized and looked upon with suspicion by the RHMG:
We were some department managers who really established guidelines by ourselves […] We got very much criticism from the management group and were told not to talk loudly […] They thought we had started our own group, which worked against the healthcare management, which we didn’t think at all. (Department manager of internal medicine)
The most severe criticism from the RCC against the RHMG was that the decisions were few, and it was unclear who had taken them, because of inadequate documentation routines. The group of department managers was also unsure of who had taken the decisions:
I have noticed that I’ve become a little bit unsure of where the decisions really came from. (Department manager of infection)
After the LCC started, between the first and second infection wave, the documentation about the decisions improved regarding clarity and traceability, leaving the RCC more satisfied. One of the managers in the RHMG became the chief of the LCC and said that the RHMG learnt a lot and that the new organization became clearer. The RHMG, however, maintained that it was better to manage health care the usual way, because of the long duration of the crisis, and they continued to manage outside of the RCC and the LCC. Because the chief of the LCC had multiple positions, it was somewhat unclear where different decisions should be made. The department managers group eventually shut down and was incorporated into the LCC, after the group recognized that the newly established LCC functioned well and could make fast decisions.
The manager of infection prevention was employed at the regional level and had an assignment to work toward the communities as well. The manager, who early on had a knowledgeable sense of what was urgent, took his own decisions, by, for example, starting up external lab capacity and steering it toward workers at elderly care homes to reduce the spread of infection among the elderlies, which later became a considerable problem all over Sweden. The manager of infection prevention also recommended using safer personal protective equipment (PPE) at the hospital and decided to limit the number of people in canteens and meeting rooms already in the first infection wave. These decisions were made and communicated directly in the health-care organization’s network, without involving the RCC, which was possible because trust had been built for the manager beforehand:
Who has the power to decide? Here, we had a lot of informal power, because we’ve been loyal and always worked to make the region function overall. Yes, then you have trust in the back pocket when you have a crisis. (Manager of infection prevention, Case B).
Meaning-making
The managers needed to make the employees feel that they did something meaningful to increase the capacity at the units that needed support. In the beginning, most professionals felt that it was meaningful to help as many patients as possible and considered it their duty to do their best, despite the risk associated with the unknown disease. However, as the COVID-19 pandemic continued for a long time, the energy and dedication decreased, and it became harder for the managers to ensure that the employees maintained a feeling of meaningfulness. The managers at both cases considered it highly meaningful to protect their employees from the infection and increase the knowledge about treatments.
In both cases, the operational organizations sensed the emergency before the RCC, as described before. Because the RCC was slow at communicating and did not spread new information, both organizations concluded that it was meaningless to listen to it. The managers considered it much more meaningful to make fast decisions and take actions aimed at building in-house capacity, finding treatments, and protecting the employees.
Case A.
In the beginning of the pandemic, some employees were mandated to move to units in need of extra human resources. As the mandated relocations became criticized in the protracted pandemic, the management decided to make it voluntarily to move. Thus, they needed to increase the employees’ willingness to move by making it appear meaningful. The employees who had moved in the first wave were sometimes reluctant to move again because of the stress caused by their lack of knowledge about the tasks at the new units and the increased risk of infection. Moreover, they felt unable to contribute to meaningful work. For these reasons, negative stories about moving spread occasionally. The resident employees felt that the stressed and anxious relocated employees disturbed the work more than they helped and therefore tried to cope with all the work by themselves. The daily meetings fostered meaningfulness by creating a feeling of safety while managing the crisis, and the demand for help decreased thanks to the possibility to receive help fast. The reluctancy to move and provide help, and the hesitation to accept help, resulted in uneven pressure among the employees and increased exhaustion among the employees at the units with highest pressure:
We’ve had a lot of surgery nurses who have been at surgery and haven’t done anything […] During the same time the anesthetic nurses worked very hard at the Covid ICU. (Manager surgery unit)
The RCC initiated the building of an external ICU in the region but failed at creating any sense of meaningfulness among the employees to move there and start up a new organization. The employees at the ICU considered it more feasible and meaningful to increase the capacity at their own units, closer to other health-care services and colleagues, while supporting each other and using the own group’s cooperative knowledge.
Case B.
The RHMG decided to start up a new infection unit for the COVID-19 patients, with the intention that nurses and physicians from other parts of the hospital would move there voluntarily. However, this failed, possibly because the management underestimated the employees’ need to feel that it was meaningful to move. When the second infection wave started, the RHMG felt forced to mandate other departments to send a certain number of employees to the new infection unit:
Yes, very interesting, no one wants to be replaced and the voluntary [approach] doesn’t work. So, then we decided to mandate any way […] I think it’s just to decide, really. (Health-care director)
With the LCC in place in the second wave, the practitioners got more influence, and the managers got a better sense of the situation, which led to new decisions; the new infection department was shut down and an existing and well-functioning unit was assigned to take care of the COVID-19 patients. The unit managers needed to move some employees to the new unit, and because it was a better-known existing unit with established managers, and there was a stated end date of the relocation, they were more successful (compared to previous attempts at pursuing employees to move). The employees felt that it was more meaningful to take care of patients and help out at an existing unit, than taking time to start up a new unit, with an immature organization, at a new place.
The members of the department managers group felt that their work to get prepared for the COVID-19 patients was meaningful, but that the discussions and rivalry between the departments and the RHMG took a lot of energy, which reduced the feeling of meaningfulness. The mistrust between the management levels was so vast that one of the physicians in the department managers’ group was asked to resign from the managing position. This request was later withdrawn.
The manager of infection prevention considered it important that the employees felt safe and cared for by the management. Therefore, the manager sharpened the safety restrictions at the hospital, with the intention of increasing the feeling of safety and meaningfulness among the employees. As a result, the employees’ trust in the infection protection work increased:
We could say, okay safe before sorry. Then the staff, yes they understand that the managers care about the staff. So, if you communicated in a right way, it worked better […] I think it’s better to say – now we can’t use masks because we don’t have any, but if it would have been possible, we would have used masks. (Manager of infection prevention and control).
Discussion
There are differences as well as similarities between the two studied cases with regard to sensemaking, decision-making and meaning-making. The managers learned while struggling to make sense, make decisions and make meaning based on the contingency plans, information from networks and the reality at the hospitals. Management learning was essential throughout the pandemic; in the beginning when everything was unknown as well as later in the ever-changing situation (Sinha & Ola, 2021). The learning can be described as just-in-time, as it took place in parallel to the unfolding of events in real time.
The study shows that contingency plans for short-term accidents malfunction in pandemics and offer limited help to the hospitals’ management with managing a long-term crisis. Boin et al. (2016) and Tuggle (2016) claimed that the reality often differs from a beforehand made plan and that the opportunities for learning might be lost if the plan is followed too strictly. Power games at the case hospitals were often caused by different views of how strictly the beforehand made plan should be followed, which broke the trust between the RCC and the health-care organizations.
Capacity building
Surge capacity was built by internally moving health-care professionals from their ordinary units to the units in need of extra help (Rosenbäck et al., 2022; Rosenbäck & Svensson, 2021). To facilitate the building of surge capacity, the managers needed to increase the professionals’ willingness to move. The managers learnt that motivating employees to move by fostering a strong sense of meaningfulness was more effective than simply mandating that they move, which is in line with the research by Boin et al. (2016).
Negative storytelling among some of the relocated employees decreased the willingness to move. Research shows that a stronger sense of meaningfulness makes the narratives more positive (Boin et al., 2016; Conrad et al., 2015; Tenkasi & Boland, 1993), which can improve the situation. Managers in a pandemic therefore need to make decisions that foster meaningfulness among the employees and make them feel safe, both by reducing the infection risk and the worries associated with lack of knowledge about the tasks, for example, by providing fast and individualized education. Moreover, the managers need to ensure that the receiving units are welcoming and give the arriving newcomers meaningful tasks that match their competence. In the cases studied here, increasing the capacity internally was a more successful strategy than building capacity by using external resources, which could be explained by better cooperative learning in practice, as claimed by Argyris and Schön (1996).
The managers learnt how to continuously keep the balance between demand and capacity, as the capacity requirements for the COVID-19 patients varied with the infection waves. When the number of COVID-19 patients decreased, the managers efficiently used the free capacity to treat other patients, in line with Best and Williams (2021). Continuous learning builds resilience, which is important when using capacity in a crisis (Tuggle, 2016; Weick, 2007; Weick & Sutcliffe, 2011).
Treatment development and infection prevention
Health-care professionals all over the world cooperated at their hospitals and in professional networks to continuously increase the knowledge about COVID-19 patient treatments, while the disease and practical treatments evolved. In Sweden, the interest organizations for specialist physicians took the initiative to gather and rapidly spread the new knowledge, while national authorities such as the National Board of Health and Welfare, did not. The feeling of meaningfulness increased among the employees as the knowledge about how to treat the patients improved. Meanwhile, the managers who supported the learning gained trust.
The infection prevention strategies changed because of shortages of PPE, but also because of knowledge increase, changing infectivity of the virus and the onset of vaccinations. Managers who were able to follow the recommendations of infection prevention by solving shortages and/or supporting the purchase of new types of PPE gained trust in the organizations.
Crisis management
The contingency plan for accidents malfunctioned in the pandemic because information flows differently in accidents. In accidents, the information comes from a rescue leader, through the RCC, to the hospital. In a pandemic, however, the information is born at the hospitals, where the patients arrive. Both cases redeveloped the normal management decision routes by adapting them to the pandemic, which seems not to have been mentioned in the literature before.
The managements in both cases found that a combination of hierarchical and distributed management was preferable in the long-lasting crisis. Decisions taken higher up in the hierarchy, regarding, for example, how to understand information, how much surge capacity to build and how to divide responsibilities, needed to be clear and rapid. According to Kapucu and Van Wart (2008), high hierarchical decisiveness makes organizational decision making efficient. Higher-level decisions need to be meaningful and senseful and should be seen as a service to support the organization do the work. Other decisions, such as how and where to handle the patients, need to be delegated to professionals in the patient flow, who need to have support from the management. The importance of progressive and distributed management in a crisis is supported by Glenn et al. (2020). Tuggle (2016) meant that freedom to make decisions results in increased sharing of knowledge between organizations, and Antonacopoulou and Sheaffer (2014) meant that delegative management fosters new thinking. Moreover, an increase in collective learning, which is important in an ambiguous environment, is supported by a decentralized organization (Bunderson & Sutcliffe, 2002). Daily decision-making meetings contributed to creating the same sense of urgency in the entire organizations. Moreover, enhanced information sharing among employees and managers based on practical experience increased both the distributed decision-making and organizational learning, which is in line with Brandi and Elkjaer (2011) and Örtenblad (2018), and so-called combined management seemed to strengthen the feelings of meaningfulness and trust in the organizations.
This study clearly shows that managers need to be trustful to be able to affect the organization, which is in line with Boin et al. (2016). Moreover, the managers and staff must feel safe to experiment and make mistakes to be able to learn to manage new situations (Bunderson & Sutcliffe, 2002). However, it also shows that trust built beforehand can be helpful during a crisis, which is different from Boin et al. (2016), who says that trust need to be built in the crisis. We found broken trust and conclude that trust needs to be carefully protected from power games and unanchored decisions. Trust between managers at the operational level was built in collaboration during the crisis, in line with Argyris and Schön (1996). The storytelling in the organizations was either positive, in which case it supported learning through better information exchange and sensemaking, or negative, in which case it undermined trust for the managements in the organizations.
Conclusions
Learning makes it possible to handle a crisis more effectively, especially a crisis characterized by the unknown, such as a pandemic, compared to an accident where the patients’ injuries from violent forces are better known. Learning is supported by the mutually dependent aspects sensemaking, meaningful decision-making and trust, as visualized in the management learning wheel (Figure 1). Trusted managers play a key role in acquiring honest information and getting a good sense of the situation, which is necessary for making the right decisions, meaningful for the organization. Storytelling in organizations is either positive, thus supporting learning through better information exchange and sensemaking, or negative, thus undermining learning in the organization. Meaningful decisions contribute to building trust for the managers.
This study shows that the crisis management required in a short-term disaster or accident differs considerably from the management required in a prolonged crisis, like a pandemic. The flow of information is different in a pandemic than in an accident. Therefore, the regional managers had a less developed sense of the situation compared to the local managers. The practical implications provided by this study for health-care organizations is that an effective provision of health care in a long-lasting crisis requires a blended management with a combination of hierarchical and distributed management, which is different from the hierarchical management used in accidents and suggested in contingency plans. Moreover, the study suggests that normal decision flows, but higher decision frequency are preferable and more functional in pandemics. The management of health-care organizations also needs to be aware of and try to be prepared and manage power games and storytelling. The findings need to be further researched to be able to draw more general conclusions about management learning and practice in pandemics, and more research is needed to develop the knowledge about power games and storytelling.
Figures
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Kvale, S. (1994). InterViews: An introduction to qualitative research interviewing, New York, NY: Sage Publications.
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