The role of safety leadership
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in nursing management during
the pandemic:
A qualitative study in Indonesia
By Prof. Dr. Ratna Sitorus, S.Kp., M.App.Sc. and Lusianah Lusianah, S.Kp., M.Kep
ndonesia is one of the
I countries that was severely
impacted by COVID-19.
The first confirmed case of
COVID-19 in Indonesia was
announced at the beginning of
March 2020. A total of 6,719,327
cases of COVID-19 have been
reported as of December 30, 2022,
including 160,574 deaths.1
Hospitals had an important
role in countering the surging
number of COVID-19 cases. They
were expected to save patients’
lives and deliver high-quality
service despite struggling with
a lack of healthcare personnel
and supplies. The lack of per-
sonal protective equipment (PPE)
such as masks and hazmat suits,
mechanical ventilators, and med-
ications, along with uncertainty
about when this pandemic
would come to an end, were crit-
ical concerns. Such conditions
have forced hospitals to adjust
their operating procedures to
preserve regular healthcare ser-
vices and promptly respond to
the increased demand for care for
patients with COVID-19.2,3
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Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
The complexity of healthcare
service delivery during the pan-
demic challenged hospital lead-
ers to innovate practice. The
objective was to identify a new
approach to delivering safe, high-
quality care amid strict limita-
tions, excessive demand, and
high risk of COVID-19 infection.4
Providers hoped that this new
approach would prevent further
harm to healthcare professionals
caused by the pandemic. There
were 2,087 deaths of healthcare
professionals in Indonesia,
including 751 physicians, 670
nurses, 398 midwives, 46 den-
tists, 51 lab workers, and 171
other health practitioners as of
August 21, 2022. This mortality
was the highest in Asia and third
highest in the world.5
Leaders at all levels of the hos-
pital management system have a
significant role and responsibility
to build a culture of safety dur-
ing a pandemic. In particular,
head nurses have a strategic role
as a mediator between the orga-
nization and clinical practice.
During the pandemic, head
Nursing Management • May 2023 1
nurses as first-line managers
needed adequate managerial
competence to reduce staff and
patient anxiety by ensuring
an efficient ward operation, orga-
nizing relevant resources, and
empowering staff.6,7 They
ensured that high-quality care
and safety on the floor were
delivered according to organiza-
tional directions.8,9 Performance
of leadership roles was affected
by head nurses’ behavior toward
other staff; any perceived lack of
respect caused performance fail-
ure. Conversely, being support-
ive, affectionate, compassionate,
and empathetic encouraged soli-
darity and willingness of the staff
to ease each other’s burden dur-
ing the arduous pandemic.
Many nurse managers are
self-taught in their leadership
and managerial role and have
never received proper training
on safety leadership.10 With edu-
cation comes improved prioriti-
zation. When safety becomes a
leader’s priority, they are more
likely to prevent risk from
becoming an actual problem,
 The role of safety leadership in nursing management
evaluate patient safety, and
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analyze which actions should
be continued or improved.11
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Accordingly, this study aimed to
assess the safety-related leader-
ship behavior of head nurses in
inpatient facilities during the
pandemic in accordance with
Watson’s human caring theory.
Methods
Setting and participants
This was a qualitative study con-
ducted from 2020 to 2021 involv-
ing 17 participants from 2 public
hospitals: 13 head nurses, 2 chair-
men of the Committee for Quality
Improvement of Patient safety,
and 2 coordinators of the Sub-
committee for Patient Safety at
Regional General Hospitals in
Jakarta. Participants were selected
according to inclusion criteria
using a purposive sampling
method. The number of samples
was determined through data sat-
uration (no new information was
gleaned from the interview).12
Due to pandemic restrictions,
data were gathered through an
in-depth interview via an online
meeting platform. The objectives
of this study were explained by
the second author before obtain-
ing consent from all of the study
participants. Research questions
guiding this study include the
following:
• What was the role of the
head nurse as a caring safety
leader to ensure the safety of
patients and staff?
• What challenges existed
while performing the role?
Data collection and analysis
Each participant had a single 40-
to 60-minute interview in Indo-
nesian. The interview was sched-
uled at a time and date chosen
2 May 2023 • Nursing Management
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
by the participant and video and
audio were recorded with their
consent. The participants were
referred to by number, in the
order in which they were inter-
viewed. Questions posed by the
interviewer included the demo-
graphic data of the participants,
the application of safety leader-
ship by a head nurse in a ward
setting, and expectations and
obstacles during the process
based on the theory of human
caring by Jean Watson.
Data were analyzed using
Colaizzi’s phenomenological
approach.13 All transcripts were
read several times by the second
author for comprehensiveness.
Then, significant statements were
extracted before meanings were
formulated. Finally, themes were
clustered and a description of
identified themes were reviewed
by both authors. Any disagree-
ments were managed by discus-
sion between authors or asking
opinions from experts.
The trustworthiness of this
qualitative research was assessed
using four constructs: credibility,
transferability, dependability,
and confirmability.14 This method
enhances confidence in study
results.15 Credibility was an inter-
nal validity enhanced by imple-
menting member checks, in
which some research partici-
pants were given an opportunity
to verify the accuracy of inter-
view transcriptions. The research
credibility was also ensured by
participant variety and pro-
longed engagement with the
data. Dependability was needed to
attain reliable data independent
of any influence from researchers
or other factors. To ensure that
the final report of the study
described precise understanding
regarding the meaning of phe-
nomena observed by partici-
pants, the authors conducted
member check and cross-case
validation.16,17
The authors also ascertained
the originality of participants’
understanding, experiences, and
expectations from the interview
records and data triangulation.18
They confirmed the data with the
participants and selected experts
to ensure conformability to increase
the objectivity of the obtained
data and information. They
assured the transferability of the
study by providing sufficient
description of the study, includ-
ing its context, methods, partici-
pants, and research design, to
allow those who are interested in
the study to apply it in other con-
ditions.19 The authors came to a
consensus with experts regarding
the study findings. This study
was also enriched with a litera-
ture review from national and
international publications to sup-
port and confirm the study results.
Results
Participant characteristics
Most of the participants had been
in managerial positions for more
than 3 years; 82% and 18% of
participants had bachelor’s and
master’s degrees, respectively.
Identified study themes
The significance of caring values
as the foundation of leadership
effectiveness during the pan-
demic was highlighted by this
study’s findings. The results of
the study indicated three themes
pertinent to leadership and safety
during the pandemic: 1) leading
from the heart, 2) building caring
relationships, and 3) conducting
transpersonal teaching and learn-
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 ing processes on patient safety.
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There were also two themes
related to obstacles to leadership
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and safety in the ward setting:
1) internal obstacles and 2) exter-
nal obstacles.
Theme 1. Leading from the heart
Participants stated that the pan-
demic had altered the healthcare
delivery system in the hospital.
High demand for quality care in
conjunction with a shortage of
staff, PPE, and high virulence of
COVID-19 influenced the level
of anxiety, fatigue, and workplace
stress. This theme is composed of
two subthemes: leading from the
heart and safety perception, and
risk perception and safety inci-
dent of patient and staff.
Subtheme 1.1. Leading from
the heart and safety perception.
Participants acknowledged that
they had to deal with staff who
experienced immense anxiety
and fear in delivering care for
patients. They also needed to
handle staff shortages due to the
number of health team members
who contracted COVID-19
although the hospital was over-
whelmed by patients. Kindness,
sincerity, and gratitude in any sit-
uation are the primary ways
head nurses allowed for the pro-
vision of quality care for the
patient and family as well as car-
ing for their staff. According to
one participant, “We need to be
grateful even in overwhelming
conditions.” (P9)
Healthcare service during the
pandemic was unpredictable. A
lack of inpatient capacity became
the main concern of some head
nurses, including those who
managed the ICUs: “You can see
inpatient wards changed as if it’s
an intensive care unit. This is
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because when patients trans-
ferred from the emergency unit,
they had already been in severe
health conditions.” (P15)
Such situations required the
head nurses to be patient, stay
calm, and be logical so that deci-
sions could be made deliberately
and accurately. One participant
noted that: “In my opinion, a
leader should have the ability to
manage nursing staff and their
colleagues. It’s more about hav-
ing a wise and mature way of
thinking, so we can stay cool and
be rational. We can’t be too hasty
in handling a situation.” (P9)
Subtheme 1.2. Risk perception
and safety incident of patient
and staff. Provision of safe, high-
quality care requires an under-
standing of safety risks within
healthcare settings. Leading from
the heart allows leaders to iden-
tify risks, maintain patient and
staff safety as their main priority,
and prevent injury: “A head nurse
should be able to define risk and
identify what kind of safety risks
trend in ward settings. So, their
leadership leads staff to reduce
risks.” (P8)
Theme 2. Building caring
relationships
The many shortages and limita-
tions that occurred during the
pandemic have strengthened the
relationship between head
nurses and staff. Many teams
have become closer and more
affectionate. This theme consists
of two subthemes: staff bonding
and trusted and helping rela-
tionships.
Subtheme 2.1. Staff bonding.
A caring manager understands
the differences among their staff
and uses a flexible, individual-
ized approach suitable to each
Nursing Management • May 2023 3
person's character. As many
health personnel have experi-
enced fatigue and anxiety, a two-
way communication enhanced
by consistency, openness, and
getting and receiving feedback is
required to ensure the delivery of
high-quality and safe care. “Like
parents usually do to their kids,
frequent communication and dis-
cussion are the keys that need to
be done.” (P5)
Subtheme 2.2. Trusted and
helping relationship. A caring
relationship between head nurses
and their staff is trust-based. Trust
is built when the head nurse dis-
plays transparency, honesty, and
fairness. They are also account-
able to, respectful and apprecia-
tive of, and confident with their
staff, encouraging the develop-
ment of caring relationships in the
workplace. “So, the first thing I
keep telling my colleagues is
about the importance of being
honest. If someone in the team
behaves disgracefully, then the
whole team and the organization
will be affected.” (P11)
Most participants mentioned
that the pandemic has increased
the workload of the nurses and
the head nurses. Head nurses
often delivered care directly to
the patient, working together
with staff, team leaders, and
other health professionals:
“There was a situation where I
must get involved with the team
on the floor to deliver nursing
care, so I will help them when-
ever they need it.” (P1)
Theme 3. Conducting transpersonal
teaching and learning processes on
patient safety
The participants in this study
stated that one of the caring
implementations they achieved
 The role of safety leadership in nursing management
in the ward setting was conduct-
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ing self-capacity improvement
for the head nurses and staff.
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This theme is composed of three
subthemes: (1) sharing knowl-
edge and experience about
patient safety, (2) coaching and
conducting evaluation, and
(3) role modeling.
Subtheme 3.1. Sharing knowl-
edge and experience about
patient safety. Sharing knowl-
edge and experience in caring for
patients with COVID-19 were
done by the whole healthcare
team including nurses. “So, we
had regular meetings where
we’ve got sharing about new
information or knowledge from
nurses, doctors, or ad hoc teams,
depending on what was most
needed at that time.” (P15) Some
participants illustrated that dis-
cussion with relevant case stud-
ies. Discussing the root cause of
the problem was one of the
methods used to find a solution.
Subtheme 3.2. Coaching and
conducting evaluation. A head
nurse with a caring competency
commits to improving and
developing the competence of
their staff. As one participant
mentioned, “I tend to be more
focused on how to improve my
staff’s capacity in the ward
setting.”(P13)
Subtheme 3.3. Role modeling.
Becoming a role model is a part
of leadership: “We should’ve
tried to do it ourselves then we
can tell them how it feels based
on our own experience. The
thing is, we must give them an
example first.” (P2)
Another example of role mod-
eling involved the procedure of
patient safety in the hospital. “I
am quite concerned about this
Objective of Patient Safety (OPS).
4 May 2023 • Nursing Management
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
It’s like a breath for nursing,
meaning that every single care
for a patient must refer to the six
objectives of patient safety.” (P15)
Theme 4. Obstacles to leadership
safety implementation
Participants stated that some
obstacles emerged during the
implementation of their leader-
ship role. This theme included
two subthemes: 1) internal obsta-
cles and 2) external obstacles.
Subtheme 4.1. Internal obsta-
cles. Participants viewed a lack of
awareness and courage as internal
obstacles. “Because being a ward
manager, not only it is about how
to manage the ward, but also, we
need to care for the staff who are
involved in it. It’s not easy really
because we often don’t have
enough time to do it.” (P4) Fur-
ther, “We can see some of them
have submitted the report regu-
larly, but it’s not good enough
because others have never
reported any incidents, even
when it’s happened in their
ward.” (P17)
Subtheme 4.2. External obsta-
cles. Most of this study’s partici-
pants described that a lack of train-
ing programs about patient safety
and limited resources were the
biggest issues in leadership safety
implementation. “We’ve never
had any patient safety training
before, just knew about it by self-
teaching.” (P5) One participant
said, “We really wanted to apply
the new policy, but the building
needs lots of renovation to comply
with the safety standards.” (P8)
Discussion
This study provides current
information about the leadership
role of a head nurse during the
pandemic. The interviews gener-
ated three themes: leading from
the heart, building a caring rela-
tionship, and conducting the
teaching and learning processes
of patient safety. Leading from
the heart was performed with
sincerity and good intentions to
promote staff safety and wellness
and to be beneficial for others.20,21
Leaders who performed their
role from the heart seemed more
understanding of safety risks and
patient safety incidents. This sin-
cere receptivity is a form of com-
passion and caring for self and
others which, at the same time,
becomes a method to build rela-
tionships with staff and other
healthcare team members.
Caring relationships are built
on trust, respect, openness, and
honesty among staff. A thorough
understanding of the unique
character of each staff member
enabled head nurses to develop
good collaboration with interpro-
fessional teams to accomplish
the goal of patient safety. As a
response to the heavy workload
carried by nursing staff, a caring
leader assists in delivering care
for patients. This promotes a
relational caring and attentive
presence of authentic leader-
ship.22 It transforms interactions
into a caring, healing relation-
ship, and the implementation of
relational caring requires positive
communication and reflective
learning.23-26
Trustworthy leaders will
enhance work bonding and
belonging and also work to
achieve common goals.27-29 This
shared objective can only be
accomplished by collaboration,
team commitment, and patience.
It's undeniable that care delivery
during a pandemic requires
patience, and a resilient leader
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 will motivate the team to stay
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positive.30,31
People’s demand and attention
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to high-quality care have
increased during the pandemic.
Therefore, coaching and supervi-
sion suitable to the needs of
healthcare service, staff, and the
team must be maintained by the
head nurse. To ensure the deliv-
ery of safe, quality care, caring
leaders stimulate themselves,
their staff, and the team to con-
tinue learning, learn from previ-
ous cases, and improve work
performance.32
Safety coaching provided in
safe mental, physical, social, and
spiritual environments increases
staff and team engagement in
behavioral change.33 Behavioral
change can be enhanced with an
evaluation by and feedback from
the safety leader. This feedback
promotes self-esteem and even-
tually will improve commitment
and belonging.34 Learning out-
comes can be used as a bench-
mark for future improvement
and decision-making.34
Learning culture emerged as
the main focus of the interviews.
Learning is informed by trust,
including two-way (reflective
and effective) communication
rather than “shaming” and
“blaming” language to describe
previous mistakes.35 According to
Watson, continuous monitoring
is the best form of interpersonal
process evaluation that requires
a deep understanding of staff
working conditions and a form
of therapeutic intervention for
healing and recovery.22,36
The most challenging factor to
implementing safety-focused
leadership was the limited work-
ing hours due to heavy work-
load. A similar result was
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reported by Selig, who men-
tioned that the ability to provide
adequate time needed for leader-
ship was precluded by opera-
tional duties in their own unit.37
Moreover, a lack of awareness to
report any safety incident was
caused by fear of losing credibil-
ity that could compromise their
personal career and income. A
culture that encourages open and
honest reports and emphasizes
learning without judgment must
be applied in daily nursing prac-
tice.
The obstacles to safety are influ-
enced by internal and external fac-
tors. Fear of being blamed for mis-
takes was one issue stated by par-
ticipants. Therefore, a patient
safety advocate or leader who
avoids a culture of blame will
diminish fear and encourage a cul-
ture of responsibility, constructive
feedback, and learning to improve
the current system. This is because
a caring leader is intuitive, sensi-
ble, and attentive regarding staff
and patient safety.38-40
Implications for nurse leaders
Overall, our findings and previ-
ous literature suggest the impor-
tance of leading with care and
supporting policies that focus on
developing safety leadership in
nursing managers. The applica-
tion of human caring theory to
leadership practice should be
emphasized in the form of struc-
tured and continuous training.
Ensuring safety for all
During the pandemic, leaders
had to adjust their own expecta-
tions and modify their work-
places to build healing relation-
ships among themselves, other
healthcare team members, and
the communities they served.
Nursing Management • May 2023 5
The caring leader will encourage
the formation of positive team
behavior and collaborative rela-
tionships to ensure safety is
addressed for all. NM
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Acknowledgement: We sincerely
thank the participants in this study who
shared their leadership experience
during the pandemic.
At Universitas Indonesia in Depok,
West Java, Indonesia, Ratna Sitorus
is a professor, Faculty of Nursing, and
Lusianah Lusianah is a PhD candidate,
Faculty of Nursing.
This article is part of a supplement
to Nursing Management sponsored
by the Faculty of Nursing, Universitas
Indonesia to publish the proceedings of
their 8th Biennial International Nursing
Conference “Global Challenges,
Innovation of Nursing Services and
Education in the Future.”
This work was supported by the Director-
ate Research and Development Univer-
sitas Indonesia (Hibah PUTI) (NKB-096/
UN2.RST/HKP.05.00/2022). The authors
have disclosed no additional financial
relationships related to this article.
DOI-10.1097/nmg.0000000000000007
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