Workplace Challenges and Support Needs Experienced by Nurse Leaders in Home and Community Care During the COVID-19 Pandemic: A Qualitative Study

Abstract

The COVID-19 pandemic had unprecedented impacts on the wellbeing of home care workers. Responsive leadership is a key facilitator for positive perceptions of work and reduced turnover intentions. Yet, the impact of the pandemic on nurse leaders working in home and community care remains to be explored. To describe the workplace experiences of point-of-care nurse leaders in the home and community care sector in Ontario, Canada during the COVID-19 pandemic. Semi-structured interviews were conducted with 8 nurse leaders in home care and analyzed thematically. Four overarching themes developed: (1) Inspired to lead—participants sought leadership roles to amplify their impact on client care, provider experience and the healthcare system. (2) Pandemic leadership challenges—leaders struggled to adapt to new pandemic-related workload demands, including unprecedented needs for staff well-being support. (3) Strategies to improve well-being—the personal toll of the pandemic was mitigated for some by maintaining personal boundaries and by strong support from peers and senior leaders. (4) Lessons learned—leaders expressed pride in their pandemic responses and professional growth through this time. They identified opportunities for stronger workplace structures to support them to excel in their roles. These experiences highlight the opportunity to better support nurse leaders in home and community care settings by creating work structures which promote healthy workplace boundaries, enable connections, and facilitate peer-to-peer information sharing. Such structures can support nurse leaders to thrive in their roles and continue to act as vital sources of support to their teams.

Keywords

home care nurse leaders COVID-19 occupational health workplace support

What do we already know about this topic?

Although previous research has demonstrated that nurse leaders in the home and community care sector played a key role in supporting home care workers to rebound from burnout during the COVID-19 pandemic, their own experiences from this period are under-researched.

How does your research contribute to the field?

This study describes the experiences of point-of-care nurse leaders in the Canadian home and community care settings working throughout the COVID-19 pandemic. A topic that has received limited focus in this context. We explore how their work experiences impacted their wellbeing, support needs, and professional commitment. We offer strategies to create work structures that would improve leadership support within home care organizations. When nurse leaders can thrive at work, they can be present and supportive to their teams.

What are your research’s implications toward theory, practice, or policy?

The findings of this study suggest that to cultivate supportive work environments in the home and community care sector, organizations should consider policy and practice solutions that address the structures of work that precipitate unmanageable administrative workloads and enable connections with peers and leaders.

Introduction

Internationally, the COVID-19 pandemic introduced new challenges and exacerbated many existing stressors faced by home and community care (HCC) workers.^1
-4 Most obvious among pandemic effects on HCC workers’ mental wellbeing was daily anxiety due to the risk of contracting or spreading COVID-19.^5
-9 In Canada, an unprecedented shortage of workers also contributed to stress and burnout from the physical and psychological demands of providing essential client care.^6,8,9 Cumulatively, these challenges contributed to HCC workers facing unsustainable levels of occupational stress,^6
-10 threatening their capacity to continue providing essential care to meet increased demand for healthcare at home.^11,12

The presence of strong leadership and support from workplaces has been a bright spot for many home care workers.^6,8 In particular, compassionate and responsive point-of-care nurse leaders have been identified as an important contributor to home care workers’ ability to rebound and recuperate from their COVID-19 experiences.^6,8 In a study exploring the pandemic work experiences of home care personal support workers (PSWs), point-of-care nurse leaders were identified as critical workplace supports, helping workers to feel valued, safe and supported through difficult periods.⁶ Multiple studies have found that strong, relational leadership can bolster staff morale^13
-16 while decreasing staff burnout¹⁷ and turnover intentions.¹⁸ Collectively, these findings suggest that point-of-care nurse leaders are well positioned to influence workplace culture and retention.

Point-of-care nurse leaders in HCC settings have extensive responsibilities for managing the provision of home care services in private dwellings, and the operations and management of large clinical teams including PSWs, care aids, and community nurses who work independently in the community.¹⁸ In their supervisory capacity, these nurse leaders are accountable for onboarding, coaching, training, and performance management while concurrently assuming responsibilities related to monitoring and assessing client safety and clinical care.^18
-20 During the COVID-19 pandemic, these responsibilities expanded to include deploying resources such as Personal Protective Equipment (PPE) to staff and clients, and supporting the rapid implementation of virtual models of care.²¹

Despite the acknowledged shift in their responsibilities, there is a paucity of evidence about how this has impacted the experiences of point-of-care nurse leaders in HCC. In other practice settings (eg, hospitals and retirement homes), nurse leaders reported difficulties managing the impact of the COVID-19 pandemic on their roles.²² Hospital-based nurse leaders have described overwhelming workloads, long work hours, abrupt changes to their practice scope and role, and managing staff shortages as contributing to their experience of burnout.^23
-26 Their pandemic experiences have also contributed to intentions to leave their role,²⁷ which is particularly worrying in the context of the ongoing health human resources crisis.

Given the recognized shifts in workloads during the pandemic for nurse leaders and the concern this has presented in acute care settings suggests that insights into the impact of these changes amongst nurse leaders in the HCC sector are urgently needed. Qualitative inquiry offers an opportunity to develop contextual understanding of the experiences and support needs of point-of-care nurse leaders in this sector which is not only paramount to stabilizing this leadership workforce but also to enhancing support and security for their teams. This qualitative study thus explored the motivations, COVID-19 pandemic experiences, and emerging needs of point-of-care nurse leaders working in home and community care.

Method

Design

This exploratory, qualitative descriptive study²⁸ used semi-structured interviews and thematic analysis to describe the experiences and perspectives of point-of-care nurse leaders working during the COVID-19 pandemic at 1 home care service provider organization located in the Greater Toronto Area in Ontario, Canada. Qualitative description is a common methodology in nursing research and is useful for its flexible approach to achieving rich description of subjective perspectives.²⁸ All study procedures received institutional ethics approval from the University of Toronto. The reporting of this study is in accordance with COREQ guidelines.²⁹

Participants

Nurse leaders were recruited through purposive sampling at the study site in January 2023. A study information letter detailing the study purpose and goals was shared through organizational email listservs targeting approximately 27 point-of-care nurse leaders at the time of the study. Participants were eligible if they: (1) held either a registered practical nurse or registered nurse designation in Ontario; (2) were in a supervisory position overseeing home care workers (who, based on the practice setting, could be either nurses or personal support workers); and (3) were in their leadership role during the pandemic (March 2020 until the end of study recruitment in January 2023). Leaders who were in their role less than 3 months were excluded from the study.

Data Collection

Prospective participants contacted the research team for more information and, after screening for eligibility and providing written informed consent, were enrolled in the study. Participants were asked to indicate the date and time most convenient for them to conduct the interview. All interviews were conducted remotely via telephone or video conferencing (MS Teams) by a University of Toronto doctoral trainee (FB), skilled in qualitative methods who had lived experience as a nurse leader working in an institutional healthcare setting; the interviewer identifies as a woman and had no preexisting relationships with any participants. Interviews were audio recorded with permission and lasted between 40 and 75 min. Descriptive memos were recorded during and after each interview to capture the interviewer’s impressions and were used to aid in analysis and interpretation of data. A flexible interview guide (see Supplemental material S1) with open-ended questions was developed based on a review of literature surrounding the experiences of nurse leaders during the pandemic and the researchers’ previous study exploring the experiences of home care nurses during the COVID-19 pandemic.⁸ The interview guide was reviewed by colleagues in nurse leadership roles to confirm relevance and clarity of the questions. To begin, participants were reminded of the study’s goals and the procedures in place to protect their privacy. Next, participants were asked basic demographic questions, including age, ethnicity, gender identity, and tenure, before exploring participants’ leadership career motivations (Please share why you pursued a nurse leadership role. What do you enjoy most about your role?), the impact of the pandemic on their leadership responsibilities (Could you share with me what it has been like working as a nurse leader during the COVID-19 pandemic?), challenges that they experienced (Can you tell me about any challenges you faced or are facing working through the pandemic?), and participants’ attitudes toward their role as they transitioned out of the pandemic (How has working through a pandemic impacted your attitude toward your work?). Probing questions were incorporated to encourage participants to expand upon their responses. After 8 interviews, saturation was reached and data collection ended³⁰; no repeat interviews were conducted. Participants each received a $50 gift card to recognize their participation in the study.

Data Analysis

Descriptive statistics were applied to demographic data to enable reporting of participant characteristics. Audio-recordings of interviews were transcribed verbatim. Transcripts were de-identified and reviewed for quality assurance prior to analysis. Analysis was led by the first author who is a social worker trained in qualitative methods and was supported by the 2 analysts (NM, EM). Collaborative thematic analysis was guided by the team based DEPICT model developed by Flicker and Nixon³¹ which supports the inclusion of researchers at varying levels of experience. Analysis took place across 7 months and frequent group meetings held at each stage of analysis provided opportunities for analysts to reflect on data interpretation and to make decisions collaboratively. In the first step of analysis, all analysts read each transcript and corresponding memo notes independently, noting developing concepts, patterns and potential codes. Each analyst kept a reflexive journal while reviewing data to capture their thoughts, initial reactions and reflections on how their own potential biases may impact their interpretation of the data.³² Identified codes were organized into categories and sub-categories to create an initial codebook. This codebook was independently piloted by 2 analysts on 4 transcripts to test applicability and identify missing codes. After a group discussion to incorporate refinements, a final codebook was developed and used to code all transcripts line-by-line. Next, coded data was extracted, re-reviewed, and summarized into categories; exemplar participant quotes were identified for analytical review by the group. Broad themes were developed from these summaries, and a final series of discussions was held between all members of the study team until consensus was reached (Figure 1).

Figure 1.

Qualitative analysis process using the DEPICT model.

Trustworthiness

To support dependability of the study findings, 1 consistent interviewer with no pre-existing relationship with participants completed all interviews. Trustworthiness was established through prolonged engagement with the data and frequent, reflexive group discussions. Additionally, the research process was supported by a workplan and an audit trail maintained throughout the data collection and analysis.³³

Results

Eight participants were interviewed for the study. Participants’ self-reported demographics are available in Table 1; 75% of participants identified as women with an average age of 42. Participants had an average of 17 years of nursing experience, and an average tenure of 4 years in their current leadership role.

Table 1.

Self-reported participant characteristics (n = 8).

Characteristic	Sample
Age (years)
Mean (SD)	42 (12)
Range	30-67
Gender identity, n (%)
Woman	6 (75%)
Man	2 (25%)
Ethnicity, n (%)
Black/Caribbean	3 (38%)
East/Southeast Asian	2 (25%)
South Asian	1 (13%)
Mixed racial identity	1 (13%)
Not specified	1 (13%)
Leadership Role, n (%)
Supervisor	7 (88%)
Manager	1 (13%)
Years in nursing profession
Mean (SD)	17 (8)
Range	7-33
Years in home and community care
Mean (SD)	9 (6)
Range	2-18
Years in leadership role (current)
Mean (SD)	4 (2)
Range	2-9

The experiences of point-of-care nurse leaders working in the HCC sector during the COVID-19 pandemic have been described through 4 overarching themes: (1) inspired to lead; (2) pandemic leadership challenges; (3) strategies to improve well-being; and (4) lessons learned.

Theme 1: Inspired to Lead

In this theme, participants shared experiences and factors that steered them toward their nursing and leadership roles. They each shared influential personal experiences that inspired them to pursue a career in nursing and shaped their professional identity. Fundamentally, they were motivated by the intrinsic desire to aid and support vulnerable individuals as highlighted by the following participant:

I’ve wanted to be a nurse ever since I can remember in childhood. I’ve had ill family members and, you know, it gives me great pleasure and satisfaction to be able to help someone who’s not able to help themselves. [P02]

Participants also described pursuing leadership roles because of gaps and system-level challenges impacting healthcare workers, clients and caregivers, that they had observed when working at the point-of-care. They felt that their leadership roles offered opportunities to make meaningful contributions to improving health systems and care delivery.

I think my experience in community care really showed me a majority of the gaps or barriers in the healthcare system and the divide between the different sectors. So, the hospital doesn't know what's happening in the home. The [home care sector] doesn't know what happened in the hospital. The client has a bunch of numbers to call, and so it's really segregated. [P06]

Similarly, nurses appreciated that their formal leadership roles positioned them to advocate for better working conditions for home care workers and embraced the ability to represent the needs of their teams at leadership forums:

I think I am able to do more for the community. . .here, I am not just an advocate for the clients but for my staff, which is amazing. I become their voice which I am able to share [with] management. [P01]

Theme 2: Pandemic Leadership Challenges

Within this theme, nurse leaders described the leadership challenges they experienced during the pandemic which encompasses the subthemes (a) new workload demands; (b) supporting staff wellbeing; and (c) personal toll, which relates the impact of these challenges on their personal wellbeing. Throughout the crisis phases of the COVID-19 pandemic, leaders juggled new and competing priorities while maintaining their regular leadership responsibilities and commitments. Through this phase, they needed to play a greater role in helping staff to adapt to the changing context for care—including changing IPAC guidance, the need to remain up-to-date in their COVID-19 infection risk screening of clients, and drastically increased needs for staff support related to shifting to virtual forms of communication, fear of infection, family health challenges, unintended consequences of pandemic public health measures, and the resulting increase in disconnect and mental health challenges.

New workload demands

Participants described increased administrative responsibilities related to COVID-19 contact tracing and reporting requirements implemented during this period. While recognizing that these time-sensitive tasks were critical in limiting community spread and protecting clients and staff, leaders found them to be lengthy and time consuming. Leaders found these challenging to balance with other competing priorities, such as responding to client care needs, addressing the consequences of acute staffing shortages, distributing PPE, and providing community-based training and education around the use of safety equipment. Participants felt absorbed by their new responsibilities and frequently worked longer hours to manage their workloads. One nurse leader associated an experience regarding the demands on their workload after a client or staff member had been identified as being COVID-positive:

[. . .] consistently getting calls about COVID-positive clients and COVID-positive staff in different areas, it took an enormous amount of time to do the follow-ups efficiently [. . .] you have to go back 48 hours, contact trace every client that they’ve seen, contact the funder, submit a contact tracing form to the best practice [team] and then you would have to book the staff off for 10 days, and provide them guidelines on how to return to work. And then, walking into everything [in the role] afterwards. [It was] extremely challenging. In every way. [P05]

Amidst the early-pandemic introduction of public health guidelines that prevented in-person gatherings, virtual methods of communication such as email and videoconferencing quickly became the primary methods of connecting with staff. The rapid shift to reliance on virtual communication was a source of frustration for those members of nurse leaders’ teams who were less comfortable with digital technologies and who had never previously needed to rely on them for work. These individuals required substantial support to be able to connect, much of it provided by their supervising nurse leaders.

So, working in isolation to communicate company policies, procedures, protocols were being done virtually. We really had to leverage virtual meetings, virtual communication, whether it be teleconferences or emails, and I felt that wasn't really an effective method of communication for my team. [P04]

Difficulty in maintaining a strong leadership presence and building meaningful relationships in a virtual environment across all staff members was also a challenge reported by participants who had assumed their positions shortly before or during the pandemic.

In terms of connection and developing those relationships, it was hard to kind of adjust to [working from home] when you're really working in a role that used to be fully face to face. So I think we all adjusted [to] the technology of Microsoft Teams and learning how to navigate those pieces. But that was a big barrier for team development and peers getting to collaborate with one another. It's not like a hospital or a long-term care home where you see your team every day. You're really an autonomous healthcare professional, kind of on your own. [P06]

Supporting staff wellbeing

Participants felt that an essential part of their leadership role was to be a supportive figure for their staff. They reported observing a rapid decline in team members’ mental health and wellbeing during the pandemic, requiring an unprecedented degree of emotional support. Despite feeling overstretched, participants prioritized providing emotional support for their staff by offering practical assistance and encouragement—including by making themselves available to support team members’ emotional support needs beyond their own regular working hours. They dedicated a substantial amount of their time to navigating delicate and complex conversations about fear of infection and transmission, work refusals, vaccine confidence, workload stress, client conflicts, and personal challenges that took a psychological toll on their staff. One nurse leader shared that they conducted wellness checks with staff who were off due to COVID-19 illness to ensure that they had groceries and other basic needs.

We would have conversations, sometimes at the end of a day, and staff would just be overwhelmed and mentally burnt out. . .sometimes they would call and just vent. [P02]

On the other hand, some leaders felt uncomfortable in providing the level of emotional support required during this period and found the experience draining as related by the following participant:

Providing the mental health support sometimes I find a bit draining [. . .] I have said that mental health in terms of an area of practice is not my strong suit. So, having to be called upon to provide that it does drain me, especially if it’s something that’s ongoing. I can do it to a certain extent, but I feel like it takes a lot out of me. [P07]

Personal toll

As a consequence of increased workload demands and perceived pressure to balance all of their responsibilities to clients, point-of-care staff and their employer, participants described themselves as experiencing symptoms of burnout.

I felt burnt out. I felt overwhelmed. I felt depressed at one point because the workload– the workload was so much. Besides doing your day-to-day tasks it would increase almost on a weekly basis. And . . . you had to work in isolation. So, the increased workload coupled with isolation, it was a bad mix. [P04]

Participants also acknowledged feeling unprepared to lead through a crisis and perceived support to be lacking for managing their own wellbeing; 1 participant [P07] used the analogy, “I felt like I was out in the middle of the ocean swimming without a life jacket,” to emphasize this experience. Others noted personal challenges in leading their teams with confidence throughout the pandemic.

It was exhausting. It felt never-ending. It was scary. Before the pandemic, when things would happen, you would feel confident about leading people, doing certain things. But when it's something brand-new that no one's ever experienced, your confidence slowly declines, and you know just as much as the people who you're leading. [P02]

Theme 3: Strategies to Improve Well-Being

In this theme, participants described the help-seeking and coping strategies they implemented to manage the personal impacts of pandemic hardships and improve their overall well-being. Two subthemes were identified: (a) workplace support and (b) setting boundaries.

Workplace support

Supportive behaviors demonstrated by senior nurse leaders were described by participants as essential to maintaining their ability to cope during the pandemic. Participants received and exchanged reliable information and guidance when touchpoints with senior nursing leaders (including practice colleagues, directors, and managers) were frequent and timely. This type of support gave them a sense of security and confidence managing uncertainty. Most participants had positive experiences when they reached out to other nurse leaders and peers for support.

I would say because I have a good manager, a good regional director, who was guiding me all the way, I was able to come out of it. The [professional practice lead] has been my pillar during the pandemic. They always made sure that everyone was abreast of what’s happening. [P01]

We connected as a team [. . .] just a casual get-together virtually, just to debrief, just to chat, just to communicate with our colleagues, other supervisors from other regions. And I think that was a way where we could destress together–in a healthy way. [P04]

However, this was not an experience shared by all. For 2 participants, insufficient leadership and collegial support deepened feelings of loneliness and frustration as captured by this participant:

Frustrated is another emotion that I felt quite strongly because it's like, "How, how do I get this information?" Nobody seems to know where this information is. "How do I do this?" So that not knowing and sometimes not knowing where to go for help [. . .] that made the experience even more frustrating. [P07]

Participants who experienced stronger workplace supports from both leaders and colleagues shared that this positively impacted their ability to cope with the challenges of providing leadership during the pandemic.

Setting boundaries

Setting healthy workplace boundaries and taking opportunities to disconnect were seen by nurse leaders as valuable self-care strategies to improve their physical and mental wellbeing. For example, some took breaks away from their workstation to add physical movement to their day, and others gave themselves permission to pause when they recognized that they were becoming overwhelmed.

What helped me was ensuring to make sure that I have clear boundaries on when work time is and when home time is. Because if not, they all run in together, it's too easy to burn out [. . .] there were days I had to just close my computer and walk away. [P02]

These personal strategies were deliberate, as participants felt it necessary to role model self-care as they encouraged their own staff to do the same.

I wanted to do it all, even working into extension, beyond the hours I should work. But I learned to say no, [and] give myself a tap on the back. I know I'm preaching self-care, work-life balance to my staff, I need to bring it over to myself, too. I need to, like, pump myself up at times. I need myself to be vulnerable. [P03]

Theme 4: Lessons Learned

In this theme, participants reflected on the insights they gained from their work through the crisis period of the pandemic and the lessons that gave them new perspectives on their leadership role and support needs. Two subthemes were identified: (a) personal and professional growth and (b) strengthening leadership support structures.

Personal and professional growth

Participants reiterated the deep commitment they felt to their role and to be a “better leader,” having witnessed the challenges affecting the wellbeing of their staff and clients. They acknowledged personal and professional growth from their pandemic experience and identified ways in which they could integrate their learnings from this time to improve their leadership practice. One nurse leader related this experience by recognizing their own personal strength and knowledge gained:

I think I became a stronger, better leader since the pandemic. I've learned a lot. Now I think I am able to not just motivate my staff, but I know how to specifically connect them with people within the organization that will help them get the help that they are needing. [P01]

Participants also felt professional pride in having risen to the occasion during the pandemic crisis. They attributed this to their dedication to supporting the healthcare system, and to the gratitude expressed by clients and staff who reaffirmed their value as leaders. Participants expressed greater appreciation of the contributions made by people in varying roles across the HCC sector; their greatest praise was for point-of-care home care workers who they believed deserved more “gratitude and compassion” for their efforts to keep clients safe in the community.

I, as a person, became more resilient. And I have more respect for life and the work of people. Whether you are a cleaner or a PSW, I have greater respect for them. I value every one of them. Their work, their contribution means a lot to us. [P08]

Strengthening leadership support structures

As they reflected on the tremendous benefits that they had gained from strengthened connections with peers and leaders through the crisis phase of the pandemic, participants saw opportunities to create structures that would further improve leadership supports within the organization. They specifically identified a need for more peer support and mentorship. They valued opportunities to reflect on practice, share resources, and speak openly about their experiences with colleagues in similar positions to gain additional perspectives. This was particularly emphasized by less experienced nurse leaders who needed further guidance to navigate their roles as leaders in HCC.

Looking back, having a stronger supportive system at the beginning, like a mentor or a peer that you could reach out to would have been really helpful. [P06]

Participants also expressed a desire for more check-ins initiated by their own leaders and greater acknowledgment around their increased efforts, in preference to them needing to reach out for support:

As a supervisor, I feel like you are constantly pouring out. So, in terms of somebody ‘pouring in,’ there hasn’t been much support. . .I would want regular check-ins. [P07]

Through the hardships of the pandemic, these nurse leaders had learned more about their own leadership motivations and practices and identified opportunities to improve how they lead and support their teams.

Discussion

Nurse leaders are vital members of the home care workforce. Over 97% of publicly-funded home care services in Ontario, Canada are provided by nurses and personal support workers,³⁴ the vast majority of whom are supervised by nurse leaders. This study described motivations, experiences and emerging needs of home care nurse leaders in the context of the COVID-19 pandemic, revealing opportunities to enhance organizational leadership supports for and retention of these vital leaders. To the researchers’ knowledge, this is one of the first studies to explore the pandemic experiences of point-of-care nurse leaders working in the Ontario home care sector.

This study’s findings echo the experiences of nurse leaders globally with respect to increased job demands during the pandemic – including the uncertainty introduced by managing the impacts of a new and evolving virus, difficulty in keeping abreast of the latest information and guidance, occupational stress exacerbated by enhanced responsibility to protect staff, and mitigating the effects of staffing shortages.^{2,22
-26,35,36} Similar to Rydenfält et al’s² descriptions of the experiences of Swedish home care nurse managers, participants in the present study described challenges related to increased administration and competing workloads, mental strain, concern for staff wellbeing, and the rapid adoption of technology for communication.² However, Rydenfält et al² found that nurse managers decreased social support to their teams as a trade-off in response to workloads, whereas participants in the present study often extended their efforts to provide staff support, even at the expense of other personal and professional responsibilities.

Unlike some other studies which have found that difficult pandemic experiences negatively impacted nurse leaders’ willingness to remain in their roles,²⁷ participants in this study did not express intentions to leave their positions. They attributed their renewed commitment to their HCC nurse leadership roles to a combination of altruistic motivations, professional growth, and resilience related to the adoption of self-care practices. Despite this, some feelings of burnout and exhaustion were shared by all participants, reinforcing that individual-level strategies alone are not enough to sustain nurse leaders’ ability to cope in their roles through difficult periods—this is in line with conclusions that have also been noted in the literature.^37,38 Self-care practices such as mindfulness and setting boundaries between work and personal domains have been found to alleviate burnout for some healthcare workers. However, they can become less effective over time when individuals have chronic exposure to high work demands and insufficient resources with which to manage these.³⁹ This highlights the need for an integrated approach that incorporates both personal strategies and organization-led supports.^8,39
-41 In the home and community care sector, this approach is necessary to manage the challenges that lead point-of-care nurse leaders to experience burnout and is particularly vital during public health crises such as the COVID-19 pandemic.

To cultivate supportive workplace environments, organizational interventions should target aspects of work that diminish motivation and advance burnout.^8,41 These interventions can include policy solutions and resources to address the structures of work that precipitate unmanageable workloads and unrealistic job expectations.^24,41 For example, a study conducted by Miller and Hemberg²⁴ with public health nurse leaders recommended frequent evaluation of their workloads to identify opportunities for delegation of non-clinical administrative tasks. This would allow point-of-care nurse leaders to focus more clearly on elements of quality leadership that have been identified by participants in the present study as key factors motivating them to pursue roles as nursing leaders. Organizational interventions which streamline administrative workload and reduce demotivating elements of work could also improve a leader’s perception of job quality and reduce the risk of burnout.

Opportunities for interpersonal connection in the HCC sector are limited in comparison to hospital and long-term care settings; this study and others have highlighted the need to intentionally create sustainable structures to promote connections with both peers and senior leaders. According to Frangieh et al³⁸ senior nurse leaders have a crucial role in creating a culture that that allows point-of-care nurse leaders to thrive through modeling healthy leadership behaviors. It follows that workplace strategies must be designed to enable visibility of these behaviors—even in non-institutional contexts. In the current study, workplace social support that included collegiality and outreach from senior leaders was believed to alleviate psychosocial strain during the pandemic crisis and to mitigate the consequences of working in isolation. Indeed, when participants did not receive this direct support, they felt frustrated and alone. Point-of-care nurse leaders require ongoing mentorship from senior leaders, particularly when periods of crisis arise, so that they can build their leaderships skills and remain responsive to the needs of their teams without feeling the need to compromise their own wellbeing.^24,38,42
-44 Additionally, to facilitate peer support, building supportive practice communities which enable formal and informal peer support could provide opportunities for point-of-care nurse leaders in the home care setting to enhance their professional self-efficacy and workplace connections while enabling resource sharing and promoting cohesion across their teams.

The capacity to manage and support staff wellbeing was an important need emphasized by all participants in this study and a growing concern for healthcare workers across health sectors.⁴⁵ Workplace resources such as peer support and mentorship are important practices and structures that can support nurse leaders’ ability to respond to concerns related to employee mental health appropriately.^43,46 For home care organizations that are challenged by the current health human resources crisis, cultivating supportive and balanced work cultures that allow point-of-care nurse leaders to thrive and preserve the parts of their role that fuel their passions is essential, so that they may continue to act as vital sources of support to their teams.

Limitations and Strengths

The nurse leaders who volunteered to participate in this study were drawn from a single home care provider organization operating in urban and suburban contexts in southern Ontario, Canada. The leaders who chose to participate may have been those with the strongest feelings related to the research question; their experiences may differ from those of individuals who chose not to participate or who experienced the pandemic while working for other home care organizations or in different settings. Despite this, the dependability and confirmability³³ of the analysis and reporting strengthens the study’s findings which generally align well with existing published research regarding nurse leaders across multiple contexts.

Nurse leaders are of critical importance to the functioning of the home care sector, and it is vital that they feel well supported to remain and excel in their roles. Future research studies can be used to gain deeper insights into the types of workplace resources required to support nurses’ leadership practices in HCC and across different geographies. Further research can also build upon our findings to develop and evaluate interventions, such as those suggested by participants in this study, that build supportive work cultures.

Conclusion

This study adds perspectives from the home and community care sector to the developing body of literature describing the challenges experienced by point-of-care nurse leadership during the COVID-19 pandemic. Like nurse leaders in other sectors, those working in home care struggled to adapt to new workload demands introduced by the pandemic, including providing unprecedented levels of support for staff wellbeing and keeping abreast of frequently changing infection prevention and control information, guidance and directives. This took a personal toll on leaders which for some was mitigated by strong support from senior nurse leaders and from peers, complemented by personal strategies such as boundary-setting. These experiences highlight the opportunity to better support nurse leaders in home and community care by creating sustainable structures which promote healthy workplace boundaries, enable connections with peers and leaders, and facilitate both top-down and peer-to-peer information sharing. Such structures can support nurse leaders to thrive in their roles and continue to act as central sources of support to their teams. As the Canadian healthcare system continues to recover from the unprecedented workforce instability which characterized this pandemic period, intentionally designing work environments that sustain positive wellbeing is a necessary focus for the HCC sector.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251329794 – Supplemental material for Workplace Challenges and Support Needs Experienced by Nurse Leaders in Home and Community Care During the COVID-19 Pandemic: A Qualitative Study

Supplemental material, sj-docx-1-inq-10.1177_00469580251329794 for Workplace Challenges and Support Needs Experienced by Nurse Leaders in Home and Community Care During the COVID-19 Pandemic: A Qualitative Study by Sonia Nizzer, Nicole A. Moreira, Emmelie T. C. L. Mohammed, Frances Bruno, Sandra M. McKay, D. Linn Holness and Emily Catherine King in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors would like to extend thanks and gratitude to all participants who graciously made time to participate in this study.

ORCID iDs

Sonia Nizzer

Nicole A. Moreira

Sandra M. McKay

Statements and Declarations

Supplemental Material

Supplemental material for this article is available online.

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