Indonesia is one of the 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 personal protective equipment (PPE) such as masks and hazmat suits, mechanical ventilators, and medications, along with uncertainty about when this pandemic would come to an end, were critical concerns. Such conditions have forced hospitals to adjust their operating procedures to preserve regular healthcare services and promptly respond to the increased demand for care for patients with COVID-19.2,3 The complexity of healthcare service delivery during the pandemic challenged hospital leaders to innovate practice. The objective was to identify a new approach to delivering safe, high-quality care amid strict limitations, 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 dentists, 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 hospital management system have a significant role and responsibility to build a culture of safety during a pandemic. In particular, head nurses have a strategic role as a mediator between the organization and clinical practice. During the pandemic, head nurses as first-line managers needed adequate managerial competence to reduce staff and patient anxiety by ensuring an efficient ward operation, organizing relevant resources, and empowering staff.6,7 They ensured that high-quality care and safety on the floor were delivered according to organizational directions.8,9 Performance of leadership roles was affected by head nurses' behavior toward other staff; any perceived lack of respect caused performance failure. Conversely, being supportive, affectionate, compassionate, and empathetic encouraged solidarity and willingness of the staff to ease each other's burden during 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 education comes improved prioritization. When safety becomes a leader's priority, they are more likely to prevent risk from becoming an actual problem, evaluate patient safety, and analyze which actions should be continued or improved.11 Accordingly, this study aimed to assess the safety-related leadership 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 conducted from 2020 to 2021 involving 17 participants from 2 public hospitals: 13 head nurses, 2 chairmen of the Committee for Quality Improvement of Patient safety, and 2 coordinators of the Subcommittee 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 saturation (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 obtaining 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 Indonesian. The interview was scheduled at a time and date chosen 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 interviewed. Questions posed by the interviewer included the demographic data of the participants, the application of safety leadership 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 disagreements were managed by discussion 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.15Credibility was an internal validity enhanced by implementing member checks, in which some research participants were given an opportunity to verify the accuracy of interview transcriptions. The research credibility was also ensured by participant variety and prolonged 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 phenomena observed by participants, 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, including its context, methods, participants, and research design, to allow those who are interested in the study to apply it in other conditions.19 The authors came to a consensus with experts regarding the study findings. This study was also enriched with a literature review from national and international publications to support 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 pandemic 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 learning processes on patient safety. There were also two themes related to obstacles to leadership and safety in the ward setting: 1) internal obstacles and 2) external obstacles. Theme 1. Leading from the heart Participants stated that the pandemic 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 incident 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 overwhelmed by patients. Kindness, sincerity, and gratitude in any situation are the primary ways head nurses allowed for the provision of quality care for the patient and family as well as caring 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 because when patients transferred 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 decisions 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 having 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 understanding of safety risks within healthcare settings. Leading from the heart allows leaders to identify 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 limitations 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 relationships. Subtheme 2.1. Staff bonding. A caring manager understands the differences among their staff and uses a flexible, individualized approach suitable to each person's character. As many health personnel have experienced 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 discussion 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 displays transparency, honesty, and fairness. They are also accountable to, respectful and appreciative of, and confident with their staff, encouraging the development 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 whenever 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 in the ward setting was conducting self-capacity improvement for the head nurses and staff. This theme is composed of three subthemes: (1) sharing knowledge and experience about patient safety, (2) coaching and conducting evaluation, and (3) role modeling. Subtheme 3.1. Sharing knowledge and experience about patient safety. Sharing knowledge 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 discussion with relevant case studies. 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 modeling involved the procedure of patient safety in the hospital. “I am quite concerned about this Objective of Patient Safety (OPS). 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 leadership role. This theme included two subthemes: 1) internal obstacles and 2) external obstacles. Subtheme 4.1. Internal obstacles. 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) Further, “We can see some of them have submitted the report regularly, 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 obstacles. Most of this study's participants described that a lack of training 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 generated three themes: leading from the heart, building a caring relationship, 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 sincere receptivity is a form of compassion and caring for self and others which, at the same time, becomes a method to build relationships 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 interprofessional 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 leadership.22 It transforms interactions into a caring, healing relationship, 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 will motivate the team to stay positive.30,31 People's demand and attention to high-quality care have increased during the pandemic. Therefore, coaching and supervision suitable to the needs of healthcare service, staff, and the team must be maintained by the head nurse. To ensure the delivery of safe, quality care, caring leaders stimulate themselves, their staff, and the team to continue learning, learn from previous 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 eventually will improve commitment and belonging.34 Learning outcomes can be used as a benchmark 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 working hours due to heavy workload. A similar result was reported by Selig, who mentioned that the ability to provide adequate time needed for leadership was precluded by operational duties in their own unit.37 Moreover, a lack of awareness to report any safety incident was caused by fear of losing credibility 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 practice. The obstacles to safety are influenced by internal and external factors. Fear of being blamed for mistakes was one issue stated by participants. Therefore, a patient safety advocate or leader who avoids a culture of blame will diminish fear and encourage a culture of responsibility, constructive feedback, and learning to improve the current system. This is because a caring leader is intuitive, sensible, and attentive regarding staff and patient safety.38-40 Implications for nurse leaders Overall, our findings and previous literature suggest the importance of leading with care and supporting policies that focus on developing safety leadership in nursing managers. The application of human caring theory to leadership practice should be emphasized in the form of structured and continuous training. Ensuring safety for all During the pandemic, leaders had to adjust their own expectations and modify their workplaces to build healing relationships among themselves, other healthcare team members, and the communities they served. The caring leader will encourage the formation of positive team behavior and collaborative relationships to ensure safety is addressed for all.