Nurse leaders’ appraisal of work-organizational interventions during COVID-19: an interview study in German hospitals and long-term care facilities

BACKGROUND: The COVID-19 pandemic disrupted healthcare systems globally, requiring rapid organizational changes in inpatient care. Nurse leaders played a central role in adapting and implementing work-organizational interventions under challenging conditions. Understanding factors influencing intervention success is essential for building resilient healthcare systems. This study explored nurse leaders' perspectives on the success of work-organizational interventions during the COVID-19 pandemic in German hospitals and long-term care facilities. It examined which interventions were perceived as successful, key implementation facilitators and barriers, and how these related to perceived success. METHODS: This study employed an exploratory sequential mixed-methods design. A qualitative, retrospective study using semi-structured interviews was conducted, supplemented by quantitative organizational data. Fifty-three nurse leaders across strategic, middle, and operational management levels in hospitals and long-term care facilities in the German federal state of Saxony participated. Sampling ensured variation in care settings, ownership types, regions, and pandemic impact. Interviews were guided by a framework for evaluating organizational interventions, focusing on perceptions of intervention success, implementation processes, and context. Data was analyzed using qualitative content analysis. In the following, data was transformed into quantitative variables to examine frequencies and statistical associations of variables under investigation. RESULTS: Nurse leaders perceived 36 out of 51 interventions as successful, particularly those addressing infection control, staff scheduling, and teamwork or interprofessional cooperation. Perceived success was facilitated by effective collaboration, leadership support, and staff motivation. Barriers included staffing shortages, infrastructure issues, and psychological strain. Staff acceptance of interventions showed a statistically significant moderate association with perceived success, while internal initiation, nursing staff participation, active leadership role, systematic evaluation, management hierarchy level, and hospital setting were not statistically significant and showed weak or no association. CONCLUSIONS: Our results show that nursing staff acceptance is critical for successful intervention implementation during crises. Clear communication, participatory decision-making, and contextual flexibility enhance both acceptance and perceived success. These findings offer practical guidance for strengthening healthcare system resilience in ongoing and future crises.