A Phenomenological Study on the Challenges Faced by Nebraska Hospitals During the COVID-19 Outbreak

Abstract

The coronavirus disease of 2019 (COVID-19) presented hospitals not only with significant clinical challenges but also with organizational obstacles, forcing hospitals to adapt their operations to ensure continuity of care. This study aims to explore the challenges that Nebraska hospitals encountered during COVID-19. To achieve this goal, the study draws on data collected through semi-structured interviews with the Chief Executive Officers (CEOs) and Chief Nurse Officers (CNOs) of eight hospitals in the state of Nebraska. These incident commanders held pivotal decision-making positions in their associated hospitals during the COVID-19 pandemic and its surge times. Data were analyzed using inductive thematic analysis, revealing nine key themes related to the challenges faced by hospital leaders. The main challenges included difficulties with hospital operational procedures, issues related to physical layout design, concerns over insufficient capacity to meet patient demand, disruptions in the supply chain affecting essential resources, challenges in managing hospital staff effectively, barriers in communication within and across departments, infrastructure deficiencies that impacted functionality, financial constraints, and complexities in organizational management. These themes are accompanied by their respective sub-themes and supporting quotes from interview transcripts within this paper. The insights from this study can inform healthcare leaders to develop more efficient operational frameworks to navigate public health crises.

1. Introduction

The COVID-19 pandemic confronted hospitals worldwide with both extreme clinical demands and serious organizational challenges. In response, hospitals had to modify their operational procedures to uphold regular service provision and address the new demands raised by the pandemic [1]. This study explores these operational difficulties in depth, with a focus on management-related implications during crisis response. To support a better understanding of the technical terms, phenomena, and abbreviations used throughout the study, a list of key definitions is provided below:

• Crisis. A crisis can be described as a situation that develops quickly and requires a response from an individual or organization to mitigate the consequences [2].
• Healthcare Leadership. Healthcare leaders are described as compassionate individuals with a clear vision for a healthy, well-functioning system. These individuals and teams understand the complexity of the systems they lead and manage [3].
• Healthcare Sector. The healthcare sector includes businesses and institutions that provide medical services, drugs, medical equipment, and insurance to the public. This includes hospitals, nursing and care homes, medical and dental practices, ambulance services, laboratories, and scientific and research facilities [4].
• Healthcare Professional. Healthcare professionals are described as individuals who maintain the health of humans by applying evidence-based approaches to care. In addition, they study, diagnose, treat, and prevent illness and injury while focusing on preventative and curative measures for the population they serve [5].
• Hospital Managers. Hospital managers work with the administrators of medical facilities to plan, coordinate, and supervise the health services provided at the hospital [6].
• Pandemic. A pandemic is defined as a disease occurring worldwide and affecting large numbers of people [7].
• Nebraska. Nebraska is one of the 50 states in the USA, located in the Midwestern region.

COVID-19 is a respiratory illness that stems from the novel coronavirus, characterized by its infectious nature [8], and has been rebranded as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [9]. The first reported case emerged in Wuhan, China, on 31 December 2019. On 11 February 2020, the World Health Organization (WHO) officially named the disease COVID-19 [10], and on 11 March 2020 it was formally declared a pandemic [11].

Since the onset of COVID-19 in early 2020, various detrimental impacts have been noted on the global economy, financial markets, supply chains, and human health [12,13,14]. Notably, the COVID-19 pandemic has placed healthcare systems and their facilities worldwide under immense pressure [15] and has presented significant clinical, organizational, and managerial challenges to hospitals [16]. Hospitals worldwide had to modify their operational procedures to sustain routine services while addressing the escalating demands brought on by the pandemic. This worldwide health crisis has compelled hospitals to manage an increasing influx of COVID-19 patients within limited resources, including supplies, medications, and staff [1]. In the United States, the pandemic has also significantly altered the landscape of healthcare delivery [17]. COVID-19 exerted extraordinary pressure on the US healthcare system, exposing significant gaps in resources and planning. The crisis started with a lack of sufficient personal protective equipment (PPE) and continued to highlight shortages in staffing, supplies, and available space [18]. The U.S. Department of Health and Human Services published a report in March 2021 discussing the challenges in responding to the COVID-19 pandemic in hospitals throughout the United States. The report was based on a pulse survey conducted from 22 to 26 February 2021, with hospital administrators from 320 hospitals across 45 States. Survey results showed that hospitals reported difficulties in balancing the complex and resource-intensive care needed for COVID-19 patients with efforts to resume routine hospital care, staffing shortages and its associated problems, challenges associated with vaccine distribution efforts, financial instabilities, and lower revenues. The report outlined some strategies aimed at tackling these challenges. It pinpointed specific areas where additional government support could be instrumental in aiding healthcare facilities as they persist in their response to the pandemic [19].

During the COVID-19 pandemic, the healthcare system in Nebraska also faced significant challenges. According to data from Johns Hopkins University, the highest number of COVID-19 cases and hospitalized affected patients in Nebraska were reported on 18 November 2020 (2812 cases) and 17 January 2022 (8112 cases). The peak in deaths then occurred on 3 December 2020 (31 deaths) and 28 September 2021 (408 deaths). These data span from April 2020 to March 2023, highlighting the periods of most significant strain on Nebraska’s healthcare system [20]. A study [21] examined how factors related to healthcare access during the first year of the pandemic influenced mortality rates and length of stay (LOS) in Nebraska. Its findings highlighted the significant impact of health inequities, demonstrating that patients facing such disparities experienced longer hospital stays and higher odds of mortality.

The Nebraska Health Care Workforce Collaborative highlighted Nebraska’s ongoing nursing shortage in its Workforce Shortage Report (2023), indicating that 73 out of Nebraska’s 93 counties have fewer registered nurses (RNs) per patient than the national average, and nine counties lack RNs altogether.

Nebraska’s 93 counties have fewer registered nurses (RNs) per patient than the national average, and nine counties lack RNs altogether. Contributing factors were outlined as an aging population, an aging nursing workforce, and a lack of resources for nursing education and training. The COVID-19 pandemic further worsened this situation and placed immense strain on hospitals from March 2020, as 973 nurses left their roles in 2022. In Critical Access Hospitals, 51% of nurses with less than one year of experience left their positions. Burnout and emotional stress have been identified as key factors driving workforce shortages [22].

The College of Public Health at the University of Nebraska Medical Center (UNMC) surveyed 106 Community Health Workers (CHWs) between July and September 2022, asking about various aspects of their work, including the impact of the COVID-19 pandemic. The findings showed that 20% of CHWs lost or quit their jobs during the pandemic, while the proportion providing maternal and child health services dropped from over 40% to 35%. Additionally, 17% felt their work was not respected, and 20% reported that their racial, ethnic, or cultural background influenced their role. Over 90% lacked a dedicated workspace, and nearly 80% cited vaccine hesitancy as a serious issue in their communities [23].

While research and reports present statistical data on workforce shortages, healthcare access, and the broader impact of the pandemic, they do not fully capture the day-to-day realities hospital personnel faced during crisis time. Exploring their firsthand experiences can provide deeper insight into the specific challenges they encountered during this critical period. This study aims to provide in-depth insight into the challenges and obstacles hospital leaders in Nebraska confronted during the COVID-19 pandemic, to inform future crisis preparedness and hospital response strategies.

It is worth mentioning that this research was designed to explore various aspects of the COVID-19 pandemic in Nebraska hospitals, and this paper presents findings related specifically to the challenges and obstacles hospital leaders faced. The interviews conducted with hospital CEOs covered a broad range of topics, including their roles during the pandemic and the decisions they made, changes in policies and protocols, hospital operations, doctors’ and nurses’ workflows, and staffing during surge periods, as well as the impact of policy adjustments on these aspects. Additionally, the interviewees discussed modifications made to their hospital’s physical layout to better accommodate the demands of the pandemic. This paper focuses on the experiences of hospital leaders and their staff, highlighting their difficulties. The findings of this study hold significant implications for the healthcare sector, offering valuable insights that can help hospitals and healthcare administrators make better-informed decisions when preparing for future pandemics. By understanding the specific challenges that hospital leaders faced during COVID-19, they can develop more effective strategies for managing resources, improving workflows, enhancing communication protocols, providing better staff support and training, and refining crisis preparedness frameworks to ensure a more resilient healthcare system in future public health emergencies.

2. Literature Review

The researchers conducted a review of journal articles to explore the approaches and extent to which researchers have investigated the experiences of healthcare workers involved with the COVID-19 pandemic across different contexts. Major databases and journals searched included PubMed, Google Scholar, ELSEVIER, SAGE journals, BMJ journals (British Medical Journals), and AJIC (American Journal of Infection Control). A combination of keywords and their variations were used, including but not limited to ‘Hospital’, ‘challenges’, ‘COVID-19’, ‘decision’, and ‘experiences’; irrelevant entries were excluded based on their lack of focus on hospital operations or leadership decision-making. For instance, studies focused exclusively on virology, outpatient care, or pediatric COVID-19 cases without discussing hospital management were excluded. A total of 27 peer-reviewed publications were included for full-text review and data extraction in this section.

The review revealed that many studies have focused on staff-related issues among healthcare workers caring for individuals with COVID-19 during the pandemic. For example, several studies examined the psychosocial experiences, concerns, and perceptions of healthcare workers who care for COVID-19 patients [24,25,26,27,28,29,30]. Some others explored factors affecting health workers’ well-being during the pandemic [31,32]. Additionally, some studies investigated broader challenges in healthcare systems. For instance, Yusefi et al. [33] examined human resource challenges in Iran’s medical science universities and healthcare centers during the pandemic. Butler et al. [34] conducted a qualitative study describing the perspectives and experiences of clinicians involved in planning for resource limitations and patient care during the pandemic.

Another group of studies addressed the experiences and challenges faced by COVID-19 patients during hospitalization or treatment time [35,36,37,38].

Some studies examined effective leadership practices for healthcare workers and hospital managers during the COVID-19 pandemic. For example, Adeyemo et al. [39] conducted a qualitative study using semi-structured interviews with 45 healthcare workers to identify effective leadership practices that supported them in their roles during the COVID-19 pandemic. Abdi et al. [1] explored the critical leadership skills essential for hospital managers, particularly in crisis management. Hou et al. [8] investigated emergency department preparedness strategies during the COVID-19 pandemic. Hick et al. [18] reviewed some of the key gaps in planning and provided recommendations to help hospitals respond effectively and equitably in crisis conditions.

Research also investigated the challenges healthcare professionals, hospitals, and health centers faced during the COVID-19 pandemic. A qualitative study was conducted across four hospitals in Iran to examine the challenges and strategies involved in hospital responses during the COVID-19 pandemic. In-depth, semi-structured interviews were conducted with 32 participants, including healthcare managers, nurses, and medical doctors. The collected data underwent qualitative content analysis, identifying four key categories: capacity expansion, management affairs, diagnostic services, and therapeutic services [40].

Ravaghi et al. [41] explored the experiences of EMR hospitals (hospitals that use Electronic Medical Records to manage patient information digitally) in combating COVID-19, analyzing their challenges and interventions to inform improvements in pandemic preparedness, response, policy, and practice. This thematic analysis revealed significant themes regarding the challenges and interventions experienced by hospitals in hospital readiness domains such as preparedness, leadership, operational support, logistics, supply management, communications and information, human resources, the continuity of essential services and surge capacity, rapid identification and diagnosis, isolation and case management, and infection, prevention, and control.

Razu et al. [42] conducted qualitative research among healthcare professionals in various hospitals and clinics in Khulna and Dhaka, Bangladesh, from May to August 2020. They conducted 15 in-depth telephone interviews using a snowball sampling technique. The data were analyzed, revealing seven key themes. Participants reported experiencing a higher workload, psychological distress, a shortage of quality personal protective equipment (PPE), social exclusion and stigmatization, lack of incentives, and inadequate coordination and proper management during their service.

Hossny et al. [43] explored the challenges, practices, and organizational support encountered by nursing managers in managing the COVID-19 pandemic. A qualitative content analysis study evaluated 35 nursing managers from five university hospitals through semi-structured interviews. Three main themes emerged: challenges include the development of a COVID-19 crisis management plan, a shortage of nursing staff, and psychological problems.

Another study sought to better understand healthcare providers’ challenges in caring for adult patients during the COVID-19 pandemic. A descriptive, qualitative study was conducted via semi-structured interviews with a purposeful sample of 23 healthcare providers.

Another descriptive qualitative study was conducted via semi-structured interviews with healthcare providers to better understand their challenges during the COVID-19 pandemic. A total of 23 participants were recruited through snowball sampling and an information systems-supported process (e-recruiting). Thematic analysis revealed four themes: (1) managing isolation, fear, and increased anxiety; (2) adapting to changes in healthcare practice and policy; (3) addressing the emotional and physical needs of patients and their families; and (4) navigating evolving workplace safety [44].

Sengupta et al. [45] explored the challenges faced by healthcare providers during the COVID-19 pandemic in Kolkata, India. Using a sample size of 20, they employed pile sorting to generate clusters of challenges. The findings were categorized into two main groups: workplace and societal/community challenges, each containing specific issues. Workplace challenges included resource availability, financial constraints, perceived managerial inefficiency, inconsistent guidelines, and occupational stress. Societal and community challenges encompassed fear of disease, social adaptability, and difficulties related to essential services.

Peiffer-Smadja et al. [46] investigated the challenges of organizing a hospital to respond to the COVID-19 outbreak in France. The study focused on Bichat-Claude Bernard, a 1000-bed university hospital in Paris, part of Europe’s most extensive hospital system. The researchers identified key challenges, including managing suspected and confirmed COVID-19 patients, logistical considerations, healthcare worker support, and maintaining usual care, research, and teaching activities.

3. Materials and Methods

This study adopts a phenomenological research method to qualitatively analyze the experiences of hospital leaders discussed in interviews. According to Bogdon & Biklen [47], qualitative research could be considered an umbrella containing a range of approaches to comprehend participants’ perspectives. Matua defines the purpose of qualitative research as understanding people’s everyday life experiences and reducing them to the central meaning or the essence of the experience [48,49]. Given that the study aims to delve into the experiences of hospital leaders during the COVID-19 pandemic, a qualitative methodology emerges as the most suitable primary approach. Creswell and Poth explain phenomenology as a qualitative research approach that seeks to understand and describe the essence of lived experiences. Its objective includes exploring the common meaning of experiences to uncover patterns [50]. When studying the lived experiences of individuals who have undergone the same phenomenon, phenomenology is an ideal approach [50,51]. This methodological choice allows for a deep understanding of the subjective meaning behind their experiences, enabling the researcher to uncover insights into the difficulties and challenges they encountered.

3.1. Sample Selection

A list was compiled containing information on 35 hospitals across Nebraska, including 16 general acute-care hospitals (these hospitals are equipped and staffed to provide short-term, inpatient medical and surgical care for various conditions and illnesses.), 17 critical access hospitals (CAHs are small, rural hospitals designated by the Centers for Medicare & Medicaid Services (CMS) to ensure access to healthcare in underserved areas.), and 2 children’s hospitals. This list featured details, including the hospital name, type, location, level of trauma care provided, geographical coordinates, website link, and contact information (email and phone number) for the hospital’s chief executive officer (CEO), if available, along with a general hospital contact number. The recruitment process included reaching out to hospitals by phone to request contact information for the CEO or by directly contacting the CEO via telephone and email. In certain instances, the conversation was continued with the chief nursing officer (CNO). During the communications, hospital leaders were provided with details about the study, including its objectives and potential benefits for the healthcare community. Following the initial contact, the hospital leaders were given a few days to consider their participation and respond, with the option to request further information about the research project if needed (such as interview questions). Once they expressed interest in participating in the interview, a suitable date and time were arranged.

Table 1. Interviewed hospitals: type, trauma level, and bed capacity.

Hospitals	Type	Trauma Level
Hospital 1	Critical Access Hospital	Level IV Trauma
Hospital 2	Critical Access Hospital	Level IV Trauma
Hospital 3	General Acute Hospital	Level I Trauma
Hospital 4	Critical Access Hospital	Level IV Trauma
Hospital 5	Critical Access Hospital	Level IV Trauma
Hospital 6	General Acute Hospital	Level III trauma
Hospital 7	General Acute Hospital	Level II Trauma
Hospital 8	General Acute Hospital	Level IV Trauma

presents information about the hospitals included in the study, detailing their type and trauma level. To maintain confidentiality, the hospitals are identified as Hospital 1 through Hospital 8.

3.2. IRB and Ethical Considerations

Before initiating this research, approval was obtained from the University of Nebraska-Lincoln Institutional Review Board (IRB). Participants in this study were required to be at least 19 years old, in accordance with Nebraska State law, which recognizes 19 as the legal age of adulthood [52]. Participants were informed about the interview’s duration, the nature of the questions, and their right to withdraw from the study at any time (before, during, or after commencement) without any repercussions. Interviews were scheduled with leaders from eight Nebraska hospitals and conducted via Zoom.

3.3. Data Collection

The researchers outlined semi-structured interview questions and collected data by interviewing hospital CEOs and CNOs who voluntarily shared their experiences regarding the COVID-19 pandemic and its associated surges. Each interview session spanned approximately one to one-and-a-half hours per participant and was conducted via Zoom. These Zoom sessions were recorded with the interviewees’ consent using a voice recording tool and transcribed using YuJa platform tools available through the UNL website. Throughout the interviews, the researchers remained neutral in collecting the data, did not express personal judgments, beliefs, or understandings, and established good relationships with the participants. Each participant received a USD 50 compensation in the form of an electronic gift card. Reasonable steps were also taken to protect the privacy of study data. All data and records produced during the study were treated as confidential, adhering to IRB policies. Any information derived from research was reported in de-identified formats, and electronic data was securely stored on password-protected computers.

4. Results

The qualitative data gathered through interviews were transcribed and analyzed through inductive thematic analysis. This method sorts through large amounts of information to identify patterns and key themes highlighting hospital leaders’ challenges during crises. The authors conducted the analysis independently, and the data were peer-reviewed. The researchers identified and formulated the primary themes by analyzing significant statements.

4.1. Nebraska Hospitals’ Challenges During the COVID-19 Pandemic

Thematic analysis was performed on interview data, and a list was generated that encompassed the main challenges encountered by hospital incident commanders during the pandemic. This process involved categorizing and compiling the quotes extracted from eight interviews individually. Subsequently, a final list was formed, including insights from all interviews. The analysis identified nine key themes, highlighting a range of problems and challenges. Each of the nine key themes identified in the analysis is presented in the following sections, with a description of the relevant difficulties associated with each theme. The “H and Numbers” in parentheses indicate the hospital that mentioned the corresponding challenge during the interviews.

4.1.1. Theme 1: Hospital Operational Issues

• The interview data highlighted a wide range of operational challenges experienced by hospitals during the pandemic. As for the adaptation of policies and protocol, hospitals faced multiple challenges, including addressing political complexities (H2), addressing and adapting to daily policy changes, making frequent adjustments to protocols (H2, H4, H7), and continuously modifying procedures to adjust to new situations (H7).
• Providing patient care was another challenge, as hospitals managed an increased influx of patients with limited staff resources (H1). The challenges included employing less-than-ideal infection control practices due to a full patient capacity (H2), keeping patients for a long time in the hospital instead of transferring them (H2), and a significant reduction in care for non-COVID-19 patients due to changes to policies and protocols (H3), and directing patients to the appropriate departments to receive care (H4).
• Hospitals also struggled with rescheduling surgeries, particularly in dealing with the cancellations and rescheduling of elective procedures (H6). These disruptions created operational difficulties, making it harder to manage resources effectively (H7).
• Adjusting workflows to meet evolving demands was also a challenge, requiring staff to modify their routines and hospital operations constantly (H8).
• Additionally, cost-related pressures were a major concern, as high staff turnover significantly increased operational expenses (H1). Hospitals had to offer substantial salary increases and additional benefits to retain staff working extended hours and overtime (H4).

4.1.2. Theme 2: Physical Layout Challenges

• Another significant challenge was managing the existing physical layout to accommodate hospital operations during the pandemic. One major issue was the lack of anterooms, which created difficulties in PPE changeovers and resulted in cluttered hallways due to insufficient space for donning and doffing the PPE (H1, H5, H7). The absence of anterooms was also noted in critical areas such as the ICU (H6) and the emergency department (H7).
• The other challenge was the lack of isolation rooms, particularly in emergency departments, which have insufficient dedicated spaces to care for COVID-19 patients (H7) safely.
• Hospitals also faced layout-related problems, affecting overall hospital functionality and emergency department efficiency. In some hospitals, inadequate physical separation measures posed challenges in preventing infection spread (H1). Staff had to walk long distances between departments located on different floors (H1), hospitals had to repurpose spaces to avoid cross-contamination between infected and non-infected patients (H2), challenges appeared in fulfilling hospital administrative functions due to implementing social distancing policies (H2), and some hospitals struggle with logistical challenges for both staff and patients due to spatial limitations that became evident during the pandemic (H2, H4).
• In the emergency department, design flaws hindered operational efficiency. Some EDs could not convert rooms into negative-pressure zones, which limited infection control measures (H5). Other challenges included the lack of standardization for the ED rooms (H5, H7), the lack of distinct spaces for susceptible and insusceptible arriving patients (H6, H8), the absence of negative airflow or isolation room in the ED (H7), the lack of direct pathways from clean to dirty areas and lab space within the ER unit (H7), the incompatibility of the layout with fluctuating numbers of COVID-19 patients (H7), and the use of the same access points for both entrance and exit, which heightened the risk of contamination between patients, staff, and visitors (H7).

4.1.3. Theme 3: Capacity Concerns (Capacity at the Hospital Level: The Maximum Number of Patients a Hospital Can Manage)

• Capacity limitations also posed a significant challenge, impacting hospital operations during the pandemic. Many hospitals faced inadequate patient rooms, negative-pressure rooms (in both the hospital and emergency department), and isolation rooms for COVID-19 patient care (H1, H2, H3, H6, H7, H8).
• Insufficient beds were another major challenge, as hospitals frequently struggled with bed shortages in different units, including the ICU (H3, H7).

4.1.4. Theme 4: Supply Chain Issues

• Supply chain disruptions also emerged as a significant challenge for hospitals during the pandemic, as reflected in the interview findings. Hospitals experienced supply shortages, struggling to maintain an adequate stock of essential items, including PPE, lab supplies for COVID-19 testing, uniforms, and disposable gowns throughout the pandemic (H1, H3, H5, H6, H7, H8). They also struggled with uncertainties about ensuring adequate supply availability in the future due to the direct impact of COVID-19 on the supply chain (H6, H7).
• The financial burden also presented as the need to purchase supplies at significantly higher costs than their actual value (H1, H4).
• Hospitals also faced supply storage challenges, with some facilities lacking a designated permanent supply depot in key areas such as the emergency department (H5).

4.1.5. Theme 5: Staff Management Problems

• Hospitals faced numerous challenges related to their staff during the pandemic. All interviewees reported significant physical, emotional, and other difficulties encountered by their teams. These insights are categorized and detailed as follows:
• One of the first challenges for healthcare workers was learning the proper use of PPE. The people in charge struggled with teaching staff to use PPE and protective gear correctly and prevent exposing each other (H1, H5).
• Another major challenge hospitals faced was their staff’s physical and mental well-being. Some hospitals had difficulties ensuring physical and emotional protection for their staff as they continued caring for COVID-19 patients (H1, H3, H7). Staff were also concerned about their health as they were consistently exposed to COVID-19 during that time (H1). This constant exposure led to staff illnesses in several cases, forcing them to stay home and causing hospital staff shortages (H1).
• The financial burden on staff costs added further strain as hospitals struggled with limited budgets (H1). Due to staff shortages, some hospitals paid traveling staff three or four times more than regular pay (H7).
• Staff burnout was another pressing issue, with increasing dissatisfaction and exhaustion among staff resulting from prolonged, demanding work schedules (H1, H2).
• Staff shortage was another challenge several hospitals faced during this demanding time. Some hospitals lacked Registered Nurses (RNs) and healthcare professionals (H2, H3). They also experienced an increased need for additional staff to manage the rising number of patients and insufficient staff to align with bed capacity, lowering overall hospital capabilities. (H3). In some other hospitals, staff resigned from healthcare due to the high stress they endured and mandatory vaccination (H2, H7). Additionally, providing coverage for staff members who were ill or tested positive for COVID-19 was challenging (H4).
• Frequent staff turnover further complicated hospital operations. Hospitals faced challenges in cross-training and redeploying staff in departments that were closed or experienced decreased volume (H7). Additionally, relying on traveling staff led to operational disruptions and increased costs (H1).
• Other staffing-related challenges included difficulties in communication between staff, patients, and families (H3), time-consuming workflows (H3), and working overtime (H2).

4.1.6. Theme 6: Communication Challenges

• Managing effective communication between healthcare workers, patients, and other individuals was a significant challenge for healthcare systems. In some cases, a considerable amount of healthcare professionals’ effort was spent addressing individuals who denied the existence of COVID-19 and actively resisted healthcare measures, including vaccination (H1). Additionally, several hospitals struggled to effectively convey frequently changing treatment policies to the community (H4), ensure that everyone remained informed with the latest data (H6), and communicate the rationale behind lockdown measures to the public (H4).

4.1.7. Theme 7: Infrastructure Defects

• Infrastructure defects were another challenge for hospitals during the pandemic. Many hospitals identified the need for more air exchange in their air handling systems to improve ventilation and infection control (H1, H3). Several hospitals reported a lack of reverse airflow in their isolation, emergency, and inpatient rooms (H5).

4.1.8. Theme 8: Financial Constraints

• Hospitals experienced a substantial revenue decrease, mainly due to suspending and canceling elective surgeries (H6). They also faced a significant cost increase, particularly in supply expenses, salaries, and benefits (H4).

4.1.9. Theme 9: Organizational Management Matters

• Effective hospital management during the pandemic requires balancing multiple operational demands while adapting to evolving circumstances. Interviewees discussed management-related challenges as leaders coordinated staff, resources, and policies while responding to external pressures such as regulatory changes and supply chain disruptions (H1–H8).
• Table 2. Exemplary quotes supporting hospital problem domains and sub-themes.

  Theme	Quotations
  Sub-theme
  1. Hospital Operational Issues
  i. Adaptation of Policies and Protocols	“The biggest challenge was dealing with the politics surrounding the pandemic pretty much the entire time” (H2). “The information regarding diagnosis and treatment of the disease changed daily. So, we changed our protocols almost daily to keep up with the new knowledge” (H4). “I think one of the challenges for us as we looked at changing policies and procedures is CMS, CDC, the Joint Commission, and the FDA were not aligned. So we were constantly trying to read the regulations and the updates from respective organizations that we work with and hold us accountable for meeting certain standards. And it was very, very challenging because it was constantly changing” (H7).
  ii. Patient Care	“One significant challenge was, of course, getting people to the proper location to receive the best care for their illness” (H4).
  	“Policies change caused a significant reduction of care of non-COVID patients” (H3).
  iii. Scheduling Surgeries	“I think probably the biggest (operational change) was the cancellation of elective surgeries. That was a significant change in operations. It caused the delay of preventative and management of healthcare conditions for those patients who couldn’t have their surgeries” (H7). “I really would point back to having to cancel and then reschedule, you know, a bunch of elective surgeries and procedures as biggest challenges” (H6).
  iv. Hospital Workflow	“Health practitioners had to change the way they did things based on COVID protocols, the way they protected themselves, grouping their cases, wearing N95 masks all the time” (H8).
  v. Costs	“We saw a big increase in our salaries and benefits because of the staff that had to work long hours and overtime” (H4). “We did see a large turnover in staff, much like many other organizations. And with that turnover, we used traveling staff, and that obviously affected operations heavily with the increased cost” (H1).
  2. Physical Layout Challenges
  i. Lack of Anterooms	“Because the units are not built with those kinds of anterooms on the outside of the area. So, we actually did close some conference rooms. We converted them to PPE storage areas” (H7). “We didn’t have an anteroom or anything like that” (H5).
  ii. Lack of Isolation Rooms	“We didn’t have enough isolation rooms to care for the COVID patients. So, we had to convert physical units to isolation units” (H7).
  iii. Physical Layout Problems	“It would have been nice to have more physical separation” (H1). “Well, the one I just said, the negative pressure rooms were at the end of our patient hallway, so they had to travel past other patients to get to the negative pressure rooms and staff had to travel clear to the end of the hallway instead of having a negative pressure room close to the nurse’s station, which would have made it much more convenient for them. Also, those patient rooms and negative pressure rooms were a considerable distance from the emergency department. So that also caused there to be a need for more staff because of just the time that they had to travel back” (H4). “In our 27-bed ER, you may have a point in time where you have five respiratory patients. So, you may have another point in time where you have 22 respiratory patients. And so, the physical layout of the ER was problematic” (H7). “So, we have clearly a separate entrance for our ED. I would say the biggest issue is you have to come in. Clearly, there’s a waiting room there. So, there could be some exposure when you’re sitting in the waiting room” (H8).
  3. Capacity Concerns
  i. Inadequate Number of Rooms	“We definitely learned that we didn’t have enough negative pressure, um, in the facility” (H2). “We didn’t have enough isolation rooms to care for the COVID patients” (H7).
  ii. Inadequate Number of Beds	“Lack of bed capacity and staff to match the bed capacity was hindering” (H3) “The one other thing was that we had more ICU-level patients than we had ICU beds. So, we had to create additional ICU beds in non-ICU units” (H7). “Discussing two of the most significant challenges, having enough available beds to take care of, you know, the patients that needed it” (H8).
  4. Supply Chain Issues
  i. Supply Shortages	“You know, we didn’t know if we were going to be able to get more supplies or what we had. And then when that ran out, we were done” (H6). “Lack of standardized access to PPEs was hindering” (H3).
  ii. Financial Burdens	“The unavailability of some supplies also affected operations, and the fact that there have been times when we paid ten times as much for a box of gloves as we would have paid previously” (H1). “We saw a big increase in our supply costs” (H4).
  iii. Supply Storage	“We have supplies everywhere; we’re working on putting here some more permanent supply areas even in the ER” (H5)
  5. Staff Management Problems
  i. Proper Use of PPE	“There was a lot of education with staff on how to properly don and doff PPE” (H1). “I would say that was a challenge to teach everyone how to use it (PPE) right” (H5).
  ii. Staff Physical and Mental Health	“The most significant challenge during the pandemic was to keep staff as healthy as possible so that they could continue to take care of patients” (H3). “We had to make decisions around this, staffing, self-care for employees, making sure that they could handle stress, and they had resources for self-care” (H1).
  iii. Managing Staff Costs	“Some of those travel and salaries were three to four times what our full-time employees get paid” (H7). “I would say the most significant challenge definitely was cost. Besides traveler cost, we also paid premium bonuses to our nurses” (H1).
  iv. Staff Burnout	“We could definitely see an increased amount of dissatisfaction and burnout” (H1). “If politics never entered the pandemics, we could have managed it so much better, and I think that our staff wouldn’t have burned out” (H2).
  v. Staff Shortages	“The most significant challenge was the availability of healthcare professionals” (H3). “The stress that the staff experienced through the key volumes of the pandemic caused a lot of people to leave healthcare” (H7).
  vi. Challenges in Staff Turnover	“We did see a large turnover in staff, and with that turnover, we used traveling staff, and that obviously affected operations heavily with the increased cost” (H1). “We redeployed a lot of people whose departments had closed or whose volume had decreased” (H7).
  vii. Other Challenges	“We were on texts every single evening trying to stay up to date on stuff from a staffing standpoint, um, because it, it required more staff than normal because of the PPE and the different things” (H2). “The ICU nurses were under so much pressure because they would put on their positive air pressure respirators, and were in there for 12 and a half hours a day” (H7).
  6. Communication Challenges
  i. Communication Challenges	“Some of the challenges really were the defect that some people just did not believe that COVID was real. Some folks, when we had a vaccine available, were actively working against us giving vaccines” (H1). “I think it was the challenge trying to keep everybody on the same page and sort of managing all the different communications that came from the community, from the medical staff, from our hospital staff, and then keeping everyone informed as new data was made available” (H6).
  7. Infrastructure Defects
  i. Air Exchange	“We increased the capability of doing more air exchanges to do better filtering” (H1). “Lack of air handling in all facilities was hindering operations” (H3).
  ii. Reverse Airflow	“We had two reverse isolation rooms, but they weren’t set up appropriately” (H5). “ER was just one big space with no reverse airflow” (H5).
  8. Financial Constraints
  i. Revenue Decrease	“The first thing when we stopped doing elective surgeries, that’s a huge revenue source for our organization” (H6). “The biggest thing was cancellation of elective surgeries; and it was a significant financial impact to the organization because surgery is your biggest profit-making department in a hospital” (H7).
  ii. Cost Increase	“We saw a big decline in our revenue and a big increase in our supply costs and our salaries and benefits because of the staff that had to work long hours and overtime” (H4).
  9. Organizational Management Matters
  i. ManagementChallenges	“Managing all of those moving parts that are inside the organization as well as outside the organization was probably the biggest challenge” (H6).

  outlines the key themes representing hospitals’ problem domains during COVID-19, along with their corresponding sub-themes. The table also presents exemplary quotes from the interviews categorized under each sub-theme, highlighting specific challenges. These quotes allow readers to assess the researchers’ interpretations and the grounding of themes in participants’ experiences.

5. Discussion

This study explored the challenges that hospital leaders in Nebraska faced during the COVID-19 pandemic, identifying nine significant areas of concern. These included difficulties in managing hospital operations, issues related to facility physical layout, constraints in accommodating capacity demand, disruptions in the supply chain, workforce-related struggles, breakdowns in effective communication, shortcomings in infrastructure, financial pressures, and broader organizational challenges. These findings are particularly valuable, as they reveal interconnected issues affecting strategic decision-making, resource allocation, and operational adaptability during crises.

While this analysis provides an overview of shared challenges experienced across all interviewed hospitals in Nebraska, given that roughly half of the hospitals were Critical Access Hospitals (CAHs) and the remainder were general acute-care hospitals, it is insightful to consider how each hospital type emphasized issues within the identified themes.

A key area of challenge was the operational management of hospitals during the pandemic. While financial constraints emerged as an issue for all, Critical Access Hospitals (CAHs) emphasized financial stressors more extensively, likely due to their limited budgetary flexibility. Both CAHs and general acute-care hospitals recognized significant struggles in adapting to evolving guidelines, protocols, and policy mandates; however, CAHs discussed more difficulties in navigating political complexities and coping with constantly changing policies. Both hospital groups experienced a reduction in patient care quality, yet CAHs faced more challenges in accepting the high number of patients and keeping them for a long time. The general acute hospitals highlighted canceling and rescheduling surgeries as significant operational disruptions in their facilities.

As for physical layout-related problems, issues such as struggling with inadequate anterooms and isolation rooms were discussed by both hospital groups. The CAHs reported more frequent problems related to physical separation inadequacies and inefficient internal travel routes, whereas general acute ones emphasized difficulties related to emergency department configurations, including non-standard rooms, inadequate negative pressure rooms, and inflexible ED layout arrangements.

When discussing capacity constraints, both groups noted insufficient patient rooms during patient surges, though general acute hospitals more frequently reached or exceeded capacity limits.

Supply chain disruptions, particularly shortages in personal protective equipment (PPE) and laboratory supplies, were noted by both groups, but predominantly highlighted by general acute-care hospitals. CAHs reported greater strain from increased supply costs due to their limited budgets.

Staff management problems were significant across all hospitals, with both CAHs and general acute-care hospitals experiencing mental and physical health concerns in staff members, staff burnout, turnover challenges, staff shortages, and inadequate staff budgeting. Similarly, communication challenges were common to both groups, though reported with greater emphasis by CAHs. Infrastructure-related concerns, such as inadequate air handling systems and a lack of reverse airflow, were reported by both hospital groups. Financial constraints, notably revenue declines due to canceled or rescheduled elective procedures, were emphasized more strongly by general acute hospitals. Finally, organizational management complexities were recognized across both hospital types.

These findings reflect broader systemic vulnerabilities in the structure and functioning of the U.S. healthcare system, particularly in times of crisis. Issues such as staffing shortages, supply chain disruptions, and capacity constraints are not isolated events but indicators of deeper structural limitations. For example, Critical Access Hospitals (CAHs), which are often under-resourced due to their rural location and funding constraints, were especially affected by increased costs and prolonged patient stays. Meanwhile, general acute-care hospitals faced workflow breakdowns tied to inflexible departmental layouts and elective procedure cancellations. The recurring difficulties in policy adaptation and communication further reveal a lack of cohesive emergency response frameworks and coordination channels across institutions. These challenges underscore the need for systemic preparedness strategies that go beyond individual hospital operations and address federal and state-level planning, equitable resource distribution, and workforce resilience.

The results of this study are aligned with previous research on hospital operations during public health crises. Consistent with other findings, hospital leaders in Nebraska reported significant difficulties in maintaining routine patient care while managing the surge of COVID-19 cases, often leading to disruptions in hospital operations [40,41,46]. Capacity constraints, particularly shortages of hospital beds and limited isolation spaces, have been recognized as pressing challenges in healthcare settings [40,41]. Similarly, staff shortages and burnout, driven by extended working hours and emotional distress, reflect the struggles reported in multiple healthcare contexts [41,42,43,44]. Supply chain disruptions also posed significant obstacles, with hospitals struggling to secure essential resources. Shortages of high-quality personal protective equipment (PPE) were documented [41,42], and concerns about resource availability were highlighted in studies such as that of Sengupta et al. [45]. Communication challenges and high-stress work environments during the pandemic have also been highlighted in previous studies [53,54].

While these findings are consistent with prior research, they also reflect deeper, long-standing challenges within the U.S. healthcare system that were intensified during the pandemic. For instance, the financial instability caused by the cancellation of elective surgeries is connected to an ongoing shift toward outpatient care and the resulting decline in inpatient hospital revenue. Staff shortages, predated by the pandemic, have also been ongoing as the United States is experiencing a demographic and health transformation that will have profound implications for its healthcare system and society [55]. Additionally, other concerns such as implementing PPE methods and training healthcare workers [56,57], problems with donning and doffing PPE [58,59], lack of adequate patient care units [60], and the significant cost of preparedness activities [61] were raised during past outbreaks like Ebola. These patterns reveal the system’s existing vulnerabilities and highlight the need for more proactive and sustained preparedness planning.

These findings become even more meaningful when viewed within the context of Nebraska’s healthcare landscape. The state faced multiple pandemic surges that placed significant pressure on hospital infrastructure, particularly in rural regions. Longstanding workforce shortages, especially among nurses, were further exacerbated during this time, as noted in recent reports documenting high turnover and limited access to care in many counties. Critical Access Hospitals, which make up a large share of Nebraska’s hospital system, were especially affected due to limited staffing, financial constraints, and geographic isolation. The challenges reported in this study, such as care continuity, staff burnout, communication breakdowns, and layout limitations, reflect how broader systemic vulnerabilities were experienced within Nebraska’s healthcare system, particularly in rural and resource-limited hospital settings.

By providing a firsthand understanding of the challenges hospitals faced during the COVID-19 pandemic and its surge periods, this study highlights key areas that require attention and intervention. The identified themes emphasize the complex nature of crisis management in healthcare settings, reinforcing the need for targeted strategies and support systems. Based on the findings, several practical insights may support hospital preparedness in future crises. These include ensuring flexible infrastructure design to accommodate patient surges, developing cross-functional staff training to manage resource shortages, and establishing reliable internal communication frameworks for adapting workflows. Additionally, fostering coordination between hospital leadership and public health agencies can help ensure policies are implemented effectively and contextually. These strategies can strengthen hospital resilience in the face of rapidly evolving emergencies.

5.1. Study Limitations

One limitation of this study relates to the initial recruitment process. Of the 35 hospitals contacted, only eight leaders who played key decision-making roles during the pandemic agreed to participate in interviews, resulting in a response rate of approximately 23%. Some hospital leaders were constrained by their demanding schedules and were unable to allocate time for an interview. Moreover, some were hesitant to share facility-specific details, possibly due to concerns about confidentiality or institutional policies. Consequently, while the insights gained from the interviewed leaders are valuable, the study’s findings may not fully capture the perspectives of all types of hospitals within the Nebraska healthcare system. Additionally, the findings of this study could be further strengthened by incorporating the perspectives of other healthcare workers, such as nurses and healthcare practitioners who were directly involved in patient care during the pandemic.

5.2. Future Research Directions

Understanding key problem domains in critical situations like COVID-19 can help healthcare professionals gain deeper insight and guide future preparedness efforts. In support of this, leveraging advanced research methods and technologies, such as Augmented Reality (AR) and simulation modeling methods, can offer researchers valuable means to study the identified challenges within hospital environments and develop strategies for future preparedness. For example, Augmented Reality (AR) offers significant potential for evaluating healthcare environment design by enabling staff to interact with real and virtual components, identify spatial inefficiencies, implement design modifications, capture user insights, and provide immediate feedback [62]. Similarly, simulation modeling methods assist healthcare researchers in creating virtual representations of healthcare environments and testing multiple “what-if” scenarios. This allows for exploration of how changing variables such as layout features, staffing levels, and resource availability may impact hospital performance indicators and operational efficiency. For example, a recent study on vaccine supply chain strategies employed an advanced simulation platform integrated with heuristic algorithms to optimize vaccine storage, appointment scheduling, and distribution networks. This simulation-driven approach allowed for a detailed analysis of healthcare logistics and identified strategies to reduce vaccine wastage, thereby improving overall operational efficiency [63]. These methods would serve as powerful research approaches for informing future interventions, designing frameworks, and creating policy recommendations that ultimately benefit hospital leaders and healthcare systems. The findings of this study have also served as a foundation for follow-up research. For example, the hospital challenges discussed by interviewees in this study, the identified decision domains during crises, and physical layout considerations were further explored in a study by Abdolahzadeh et al. [64], presented at the I3CE 2024 conference. Building on these data, the researchers developed a conceptual framework for hospitals’ primary decision domains and physical layout management, aiming to enhance the accuracy of simulation modeling for investigating pandemic scenarios in healthcare settings (the conference proceedings are in press).

6. Conclusions

This study provided an in-depth, experience-based understanding of the challenges faced by hospital leaders in Nebraska during the COVID-19 pandemic, using a phenomenological approach. Through interviews with decision-makers across different hospital types, the study identified nine thematic areas of concern. These challenges were persistent throughout the pandemic and often intensified during surge periods, requiring leaders and staff to continually adapt workflows and resource strategies. Rather than pointing to a single source of difficulty, the findings underscore the complexity of crisis response in healthcare settings, where internal hospital policies, external regulatory guidance, and rapidly evolving scientific information all intersect. While participants expressed frustration with the pace and frequency of changes, the findings suggest that hospitals benefit most from clear, consistent, and context-sensitive guidance during emergencies. As healthcare systems prepare for future crises, policies should prioritize flexibility in surge capacity planning, investment in adaptable infrastructure, and communication channels that support real-time, collaborative decision-making between hospitals and public health agencies. This study’s insights contribute to a deeper understanding of frontline operational decision-making and can support more resilient and coordinated responses in future health emergencies.