First Line Managers' Experiences of Shaping Organisational and Relational Preconditions for Patient Safety in Swedish Intensive Care Units During the COVID-19 Pandemic: A Qualitative Study.

objectivesThe COVID-19 pandemic placed extraordinary demands on intensive care units (ICUs), posing significant challenges to patient safety and underscoring the critical role of healthcare managers. Although leadership has been widely studied during the pandemic, little is known about how first-line ICU managers experienced their work supporting staff and shaping organisational and relational preconditions for patient safety. This qualitative study aimed to address this gap by exploring first-line ICU managers' descriptions of their work during the pandemic.

methodsIndividual interviews were conducted with 15 first-line managers (nurses and physicians) who had operational responsibility for ICU staff, including nurses, physicians and assistant nurses, during the first wave of the COVID-19 pandemic (1 March-30 September 2020). Participants were recruited from five ICUs across three Swedish hospitals. Data were analysed using thematic analysis.

resultsThe first-line managers' experiences were described in three themes: Balancing resources, workload and the well-being of ICU staff; fostering a responsive and adaptive work environment; and building trust and collaboration. According to the first-line managers, they experienced conflicts between maintaining efficiency and ensuring preconditions for patient safety, often struggling to balance care with limited resources. They explained how flexibility, continuous learning and mutual trust contributed to an adaptable healthcare environment that enabled the identification of safety risks.

conclusionsThis study highlights the unique role of first-line managers in shaping organisational preconditions for patient safety in ICUs during the COVID-19 pandemic. Their leadership was enacted in real time, embedded in clinical care, shaped by ethical complexity, resource constraints and the need to support staff well-being. The findings reveal how adaptive leadership, characterised by flexibility, continuous learning and trust, enabled managers to respond effectively to rapidly changing conditions and maintain patient safety under pressure. IMPLICATIONS FOR NURSING MANAGEMENT: The results underscore the importance of equipping first-line managers with leadership competencies that promote adaptability, trust-building, and continuous learning, especially in high-pressure environments such as ICUs. By demonstrating how managers balanced staff well-being, resource constraints, and preconditions for patient safety, this study offers practical strategies to strengthen resilience in healthcare teams. These insights can inform leadership development programmes, organisational policies and system-level reforms aimed at enhancing patient safety and preparedness for future healthcare crises.