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Living through the covid-19 pandemic has been an unprecedented challenge for every human being on the planet. It shook the world, changed the way of life of the population, impacted the dynamics of society that, suddenly, found itself immersed in processes of social transformation of different levels.
The health area needed to restructure and join efforts to provide care to the population affected by the disease . In hospitals, as well as in other public institutions, there was a continuous effort to provide service with quality and effectivity required by the situation.
Health professionals needed to act masterfully on the front lines of the fight against the virus. Among them were hospital leaders, who acted with firmness and dedication in the daily struggle of managing hospitals. In this period, there was a mix of feelings, emotions, fears, frustrations and a range of new phenomena experienced by hospital leaders.
It was no easy task for leaders to run a hospital during this period. The latent doubt that guided this research went beyond the organizational difficulties of the leaders and prioritized their lived experiences in coping with the pandemic.
The aim of the research was to investigate the experiences lived by hospital leaders during the pandemic period caused by COVID-19 and the possible contributions arising from the leadership processes.

Method
To achieve the objective of this research, the method of integrative literature review proposed by Whittemore and Knafl was used, and it was carried out in 5 phases respectively: identification of the problem, data search, data evaluation, data analysis and presentation of results. Each phase is presented in the following sections.
Identification Of the Problem
The research problem was identified after a preliminary analysis of the literature on research related to hospital leadership in coping with COVID-19. After the initial readings, the guiding question emerged: How did leaders live the experiences of coping with COVID-19 in their hospital units? At this stage, a Prisma-p protocol (http://www.prisma-statement.org/) was built in which a path for integrative review was brought up.

Search For Data in The Literature
The searches were carried out following the strategy protocol built together with the library of a Brazilian Public University. The search strategies included three themes, they are COVID-19, lived experiences and hospital leaders. And they were adapted to the specificities of each database searched, which were PubMed, Embase, Scopus, Web of Science, PsycINFO, LILACS, SciELO, CINAHL.
Following the proposal of Whittemore and Knafl2, inclusion and exclusion criteria were defined. The inclusion criteria were i) articles on experiences lived by hospital leaders in coping with the COVID-19 pandemic; ii) no delimitation of time; iii) articles in Portuguese, English, and Spanish; iv) peer-reviewed articles; and v) any origin (location).
The exclusion criteria were: i) articles that do not include the COVID-19 pandemic; and ii) articles that do not report lived experiences of leaders in hospitals. The results captured from the searches in the aforementioned databases with the selected keywords and filters resulted in 1538 documents.

Data Assessment
The collected data were managed using the Endnote software. After the first phase of data processing and exclusion of the 774 duplicate studies, the Rayyan software was used to analyze the eligibility criteria. The titles, keywords and abstracts of the 764 studies selected after elimination of duplicates were read.
In reading the abstracts of the 764 selected articles, the inclusion and exclusion criteria were applied, resulting in 38 studies chosen for full reading. After reading the 38 studies, 18 articles remained included in this integrative review like demonstrated int the prism flow (figure 01) and the articles is in table 01.

Fig. 1
Tab.1
Tab.2

Presentation And Analysis of Results
The themes that emerged from the integrative review are described below.

Psychological Impacts: Stress, Mental Health and Burnout Syndrome
Among the studies analyzed, almost all of them have notes on stress, mental health and burnout syndrome during coping with COVID-19, as reported by White :1531.
I was tired all the time, really just exhausted. Managing during this time took its toll on my mental health. I wouldn’t say depressed, but I felt down. Physically I had body aches. I had zero energy. (nurse manager).
Dyson and Lamb :82 report the respondent's concern for the well-being of their team:
One of my major concerns throughout was staff wellbeing and I did what I could to support them; however, the possibility of having a safe space created to take time out seemed so implausible at the outset because of the incessant work-load. (interviewee).
Mental health issues are compounded among leaders by the need to provide support to the team, when the leaders themselves lived in a whirlwind stemming from enormous responsibilities7; . The difficulties were intense, as exposed by the investigation done by Freysteinson: :04.
[...] leaders lived an emotional roller coaster that rocked back and forth on a foundational horizon from certainty to uncertainty. There were feelings of being reckless, daring and living dangerously. There were times when the work was energizing, and there were times when there was fear that the number of patients with the virus might ‘explode, that one's staff members may die, and that one may carry this virus to one's family member’.
Among the leaders, stress, anguish and anxiety were also presented by the difficulty in leading teams in high turnover: "The leadership I usually practice has been set on hold. It is difficult to be leader for someone you don’t know, and you are alone on the post, and you get a new group of staff every fortnight. Suddenly my working week lasted 70 hours because I prioritized taking care of the staff. (WM-G) :1405.
In times of crisis, Nelson, Murdohch, and Norman report that prolonging working hours will inevitably lead to increased stress and burnout that can manifest itself by increased alcohol consumption, depression, job dissatisfaction, and decreased employee retention.
In the scope of leadership, these feelings combined with the shortage of professionals generated anguish and anxiety crises through the responsibility to maintain a minimum team for care.

Communication: necessity to establish an effective communication flow to support the decision-making by leaders
Developing methods to get communication flowing has become a differentiator in managing the crisis caused by the COVID-19 pandemic. According to White4, Dyson and Lamb5, Jeffs6, Freysteinson7, Shahil Fierce , Villalobos , Grubaugh and Bernard , and Riddell the need for continuous communication was due to uncertainty in the face of ever-changing protocols. The pressure was so imminent that one of the managers reported, "every time I was not at work I was still thinking about it”. (assistant manager). 6:1530
Despite the crucial importance of communication during the pandemic, studies have repeatedly pointed out the difficulty of establishing a good flow. Leaders had to deal with a large volume of communication in a highly unstable demand. In addition, there was the bad news that needed to be released: "Trying to establish a very strong sense of trust when you are delivering very difficult messages about the scarcity of resources was really tough. How do you look staff in the eye and say we only have two weeks’ supply of masks? (CNE003).8:13
With the need for social isolation, team meetings needed to become virtual, reducing person-to-person connection and making frontline leaders and employees learn to communicate virtually and effectively. :127.
It was identified that communication was experienced differently, and leaders who did not know how to deal with it had greater difficulties in coping with the crisis, “I experienced that my superiors went to information meetings with the hospital directors, but all that information was not passed on. Why don’t they involve the frontline leaders? (WM-H)”.10:1407
Leaders who were able to establish communication as a strong point of their strategy provided greater comfort to staff and patients and better outcomes in fighting the pandemic: " One of the things that we received a lot of really positive feedback for was that people said they really appreciated the rapid decision-making that meeting daily provided and people didn't feel they were having to wait.(Participant 014).17:06-07
Khalil and Schoenberg agree that one of the most important components of effective leadership during crises is communication. Among the strategies created to alleviate the communication problems that existed before the pandemic, was to provide an online communication service and provided technology, such as iPads, to assist communication.

Feelings: fear, disability, insecurity, anger and prejudice
In the midst of a crisis on a global scale, feelings of fear, incapacity, insecurity, anger, prejudice and discrimination have emerged. In addition, it was necessary to coordinate the need for immediate and broad actions for patient care combined with technical and budgetary difficulties.
Gut-wrenching fear-gripped leaders as they watched newscasts with images of hundreds of ambulances, overflowing hospitals, morgue trucks and mass graves to bury the dead. Many leaders found themselves ‘cooped up’ in front of a computer viewing these newsflashes intermittently as they opened COVID-19 units without a budget9:03.
Concomitantly, the feeling of anger emerged, which grew as the numbers of positive cases increased, as well as the denial of the disease outside the hospital walls.
[...] There are windows in our ICU that look over a soccer field. We could see people out there without masks on. Here we were being asked to sweep up the mess and put our people in jeopardy. They were playing games, and our nurses were cannon fodder in an invisible war (entervewee)9:04.
A paradox was established where health professionals, while being hailed as heroes, were suffering discrimination because they posed a threat of contamination. This was detected by the respondent of Shahil Feroz:11:11 "I know that in some cases health care workers do not tell their families and communities that they are working with COVID-19 patients. They fear that this will cause unnecessary panic and people may view them differently” (KII-19, Associate Professor). And as if all this wasn't enough, there was also the anger stemming from the pay cuts:
It is also interesting to note that, even at the beginning of the pandemic, there was not only the burden, fear, insecurity, and difficulty in dealing with human resources, but there were also cases of abandonment of those led by insecurity and unprepared leaders: "[...] The managers were sitting in protected places, in offices. To protect themselves. Yeah, they should protect themselves, but we shouldn’t! We were supposed to go out there and work.’ (Nurse aide, homecare) :09”.

Difficulties External to Coping with The Disease: preventing family members to be in the hospital, social isolation and Personal Protective Equipment (PPE)
From the narrative of those investigated, overload external to the action of coping with the disease, such as: distancing from family members, social isolation, and difficulties related to Personal Protective Equipment (PPE) also hindered the work of the leaders.
The removal of the companions from inside the hospitals caused sadness, not only to the patients, but to the workers who assisted them. In addition to sadness, guilt and even ethical conflicts haunted them.
The number of deaths on pandemic units was overwhelming, and although the public may have thought each patient died in the arms of a nurse or at least with a nurse, that was not the reality: some patients died alone. One leader aptly called the work on the frontlines ‘dirty work9:04.
Regarding social isolation, even though it is considered necessary for the healthcare system to have time, there are reports of difficulties for health professionals to live in this context:
One nurse expressed concerns as she had seen husbands turned away due to being potentially exposed to COVID-19 leaving mothers to labor on their own. In other instances, mothers were being asked to choose which relation would be present or if their birth attendant would be present instead of a family member. These difficult decisions left nurses with ethical dilemmas.11:130.
Another difficulty is associated with the acquisition and use of PPE. Initially, there was a lack of equipment in the market, however, a discussion arose about how, and which protective equipment was more efficient to protect professionals and promote care. In the reports presented by Roche18:05.there is a "Conflict of opinion among staff regarding necessity of PPE for all cases after hearing from media regarding PPE shortages elsewhere in the country, staff do not want to ‘waste’ PPE using it when caring for non-COVID-19 patients.”(pt 14).

Other Impacts and Contributions from The Leadership Process: practical gains and coping strategies.
Even during so many challenges, the feeling of intra and inter team support was evident in several situations and brought contributions from the confrontation of the crisis by the leaders. Leaders needed to seek help in adaptive systems facilitating a culture of mutual respect, learning, collaboration, and diversity16.
Belonging and commitment in the relationships between leaders and their teams is noticeable.9,14, , ,22,17
The experiences lived in the country by nurses who fulfilled their role within the administration in Ecuadorian public health institutions were favorably motivated by nursing professionals who denote belonging, commitment, responsibility, service and ability to lead with ethical bases and humanist sense15:13.
In addition, in the daily practice of care, small changes in the bureaucratic routine were identified, such as the issue of excessive paperwork:
[...]Leaders met with the technology department and found 83 no essential previously mandatory documentation fields for adult patients that could be hidden9:4-5.
The evolution of leadership was validated in the process of reducing bureaucracy, diversification and increased training, agility in decision-making, stimulating team spirit and an accurate perception about the mental health care needs of its workers.
The various forms of mental health care provided by managers to their team was another good practice identified. Continuing these measures, beyond the pandemic, can reduce burnout, decrease alienation from the profession, and improve employee retention. ,9, ,25,
Consistent and open communication between management and employees has emerged with the potential to alleviate persistent concerns, build trust, and accommodate the emotional and physical needs of professionals?.

Final Considerations
The objective of this research was to investigate the experiences lived by leaders during the pandemic period caused by COVID-19 and the possible contributions arising from the leadership process, based on an integrative review. It is important to emphasize that the focus of this research was to identify what leaders of hospital units experienced when facing the pandemic, rather than how they dealt with each emergent situation throughout the process.
Through thematic analysis, it was identified that the experiences lived by leaders were related to psychological impacts such as stress; mental health issues, burnout syndrome, communication problems related to the need for establishing a communication flow capable of supporting decision-making; feelings of fear, helplessness, insecurity, distress, and prejudice; and difficulties related to the separation from family, social isolation, and personal protective equipment (PPE) challenges.
These experiences, both related to psychological impacts and those arising from emerging feelings, placed an extra demand on leaders to provide care not only to patients but also to their teams, who were experiencing illness due to daily difficulties.
Communication problems compelled leaders to seek alternatives to alleviate the impact of the large volume of information by establishing a digital communication flow capable of meeting the needs of the altered routine and providing teams with necessary information for daily activities. Leaders who were able to solve their communication problems and establish a good flow provided higher quality patient care and more comfort to their teams.
To minimize the impacts of separation from family, social isolation, and difficulties with the acquisition and use of PPE, digital communication lines were made available using tablets between patients and their families, and psychological and psychiatric support was provided to the team to deal with the pain caused by workload overload and challenges faced.
In this pandemic crisis, research concludes that leadership proved to be essential in providing psychosocial support to professionals or making critical decisions regarding policies and procedures. Invested and consistent leaders were essential for team formation, communication, and mutual trust in the face of challenges. However, the management of stress and exhaustion of the leaders themselves needs to be considered.
In contrast, the efforts required to face the pandemic brought practical gains such as strengthening the sense of team due to the feeling of duty accomplished, improvement of training coupled with the establishment of continuous training, continuous psychological care provided to workers, acceleration of digital transformation resulting from virtual communication needs, and the formation of a support network for coping.
Nevertheless, there was reported the feeling of leading while trying to balance workload overload, paying attention to the team's needs, budget constraints, social isolation, and society's prejudice viewing healthcare professionals as a potential risk for COVID-19. Psychological support and the support network formed during the pandemic provided comfort to these leadership difficulties.
These conclusions highlight the need for strong leadership, adaptation, emotional support, and innovative strategies to face future challenges in healthcare, not only during pandemics but also in building a more resilient environment prepared for imminent crises. Additionally, prior planning for future pandemics, with clear protocols, provision of adequate PPE, and improvement in emergency training and response to infectious diseases, would enable a healthier and protected environment for healthcare professionals. Both organizational support and teamwork, interpersonal relationships, and professional appreciation are strategies that contribute to overcoming crises. The experiences of frontline healthcare professionals reveal serious psychological and emotional impacts. Social support, as well as their own personal strengths, enables these professionals to cope with suffering and recover. Investigating such impacts and providing targeted interventions are essential for the well-being of these workers.
The integrative review identified that there are several reports on how hospitals organized themselves to face the COVID-19 pandemic, but no document was found on the experiences lived by hospital top management during the COVID-19 pandemic. This raises the opportunity for new research that allows for a better understanding of the experiences of leaders in facing this pandemic.
Future research could explore the subjective experience of hospital leaders in times of crises and pandemics through qualitative phenomenological approaches. Such studies would reveal the lived experiences, unique challenges, strategies, lessons learned, and professional and personal impacts involved in managing hospitals in the face of unpredictable and rapidly changing circumstances.

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