Introduction

In the early period of the COVID-19 pandemic, healthcare managers found themselves in the eye of a storm. They struggled with a lack of information when assessing health risks and prioritizing the treatment of patients while at the same time literally searching for safety equipment, such as disinfectants, disposable coats, and masks; managing personnel shifts, quarantines, and sickness; and creating COVID-19 departments with their own rules and procedures. Although healthcare organizations have institutionalized ways of handling emergencies, the scale and quality of the crisis caused by the pandemic caught them by surprise. “We had no training in handling this,” read a 2021 report from one university hospital in Norway. It upended routines and standards and disrupted daily patterns of interactions.

The dislocation of the guidelines about “the right way” to conduct business left those in charge of managing processes around life-and-death situations entering uncharted waters. The situation led to paralysis and psychological distress, and even trauma (Hossain & Clatty, 2021; Tedeschi & Calhoun, 1996). In this vein, the emerging literature on COVID-19 describes the experiences of healthcare managers as moral injury, that is, a violation of the engaged’s moral and ethical codes (Williamson et al., 2020).

Our study is empirically grounded in the experiences of eleven mid-level managers navigating through the initial months of the COVID-19 pandemic in two Norwegian hospitals. The managers wrote down their experiences in diaries and were later interviewed in focus groups. In this study, we explore how, despite the insecurity and despair of the situation (Bellazzi et al., 2020), the healthcare workers were actively searching for the right ways to handle the critical and ethically complex situation. They were not only “morally injured,” but they also actively responded to ethical issues, experiencing the “excruciating difficulty of being moral” (Bauman, 1993, p. 248). That is, they made decisions in a situation of high moral intensity (Jones, 1991). There was an imperative to act there and then, with an awareness that the decisions being made would affect people in the actors’ emotional and physical proximity, that is, co-workers, subordinates, patients, and their families. This led to the following question: how did the middle managers cope with such an overwhelming responsibility, and what can we learn about ethical decision making from their experiences?

Organizational and management theories offer several frameworks that illuminate ethical decision making. Rationalist approaches suggest that individuals use deliberate and extensive moral reasoning to respond to ethical issues, such as weighing evidence and applying abstract moral principles (Fritzsche & Becker, 1984; Hunt & Vitell, 1986). Proponents of interpretive approaches argue that moral reasoning involves moving between adhering to principles and values (e.g., Kant, 1788) and learning what is ethical in context (e.g., MacIntyre, 2007). This process of moving back and forth between the abstract and the contextualized may happen through processes labeled “value work” (Gehman et al., 2013). In this process, values are constantly revoked, negotiated, and transformed into practice, and they, therefore, provide guidance for what might be right and wrong actions (Askeland et al., 2020). Values enable actors to make sense of challenging situations and find ways to manage organizations in the midst of uncertainty (Christianson & Barton, 2021).

In our analysis of middle managers’ responses toward the crisis, we assume that individually held and collectively shared values provide the context for moral intuitions—immediate reactions that contain an affective valence (Sonenshein, 2007; Zajonc, 1980). Further, we argue that individuals engage in a specific type of value work, that is value inquiry (Espedal & Carlsen, 2021b) while performing reflection-in-action and collective reflection-on-action (Schön, 1991). Drawing on classical pragmatist theories, we suggest that practitioners perform value inquiry-in-action and -on-action and frame this process as moral agency development (MacIntyre, 1999; Nielsen, 2006; Wilcox, 2012), that is, a process of learning and moral competence-building in communication with others (Dewey, 1938; Mead, 1934). Communities facilitate moral agency development by engaging in value inquiry (Espedal & Carlsen, 2021b) shaped in a deliberative dialog, as a “collective, inter-subjective, and interpretive process for establishing shared meaning and reconciling multiple ethical viewpoints” (Reinecke & Ansari, 2015, pp. 867–868). Communities’ engagement in dialog re-establishes and strengthens the social bond. This bond is a major support for moral agency development and for navigating uncertainty for both managers and regular employees.

We found that while co** with uncertainty and urgency, middle managers performed value work within three partially overlap** steps. First, in a situation in which the upper level of leaders was engaged in crisis management, handling the acute situation of the hospital and, thus, unavailable to middle managers, the middle managers took steps to understand the social order of the situation. They engaged in a process of value inquiry, triggered by a moral reflex, an automatic, pre-reflective response to the situation. They asked questions of what matters, what should be done then and there. Second, the managers involved the community in a process of value calibration, collective reflection over what matters, what was already done, and what should be done. The significance of this phase lies not as much in discovering the right practices, and hence, building legitimacy for action, as in the enactment of mutual care and the re-establishment of social bonds, hel** those involved to reconcile with uncertainty and equip leaders with self-confidence. The third step involved taking action with the increased awareness of values and the ability to explain and justify them. Drawing on reflective practice framework (Schön, 1991; Yanow & Tsoukas, 2009), we label the steps, respectively: value inquiry-in-action, value inquiry-on-action, and reflective enactment of value. Through collectively embedded value inquiry, the managers developed moral agency and strengthened relationships of mutual trust and support.

Theorizing Moral Agency in a Crisis Situation

While the pandemic situation was extreme, spontaneous reactions, thinking, and taking decisions in the midst of action are not uncommon in organizations. Organizational life consists of flows of interactions and improvisational responses, “reflecting in the midst of action, without interrupting what one is already doing, and resha** it at the same time” (Yanow & Tsoukas, 2009, p. 1340). Over the years, numerous studies of managerial work have indicated the little time managers have for reflection, due to both time pressure and a multiplicity of subjects, problems, and persons that require attention. Exploration of decision making in natural settings, especially those where action needs to happen quickly, like firefighting, hospital emergency services, or military operations (Klein, 2017; Salas & Klein, 2001; Weick, 2002), directs attention toward the role of intuition and reflection-in-action and, more generally, toward implicit cognition, including the role of emotional, embodied, and socially embedded aspects of cognition (Creed et al., 2020a, 2020b; Hargrave et al., 2020).

This interest is reflected in ethical sensemaking literature that reaches out to moral imagination (Sonenshein, 2007) and affective aspects (Reinecke & Ansari, 2015) to explain processes of responding to ethical issues in organizations. These attempts do not imply that rationalist models assuming extensive individual and collective moral reasoning should be shunted aside; rather, they suggest that implicit cognition including affect and intuition may have more merit under specific situational circumstances’ high levels of equivocality and uncertainty and time pressure (Sonenshein, 2007). To push theorizing on implicit cognition in ethical sensemaking, we reach to theoretical frameworks rooted in Dewey’s (1938) concept of inquiry, Schön’s (1991) concept of the reflective practitioner, and Mead’s (1934) concept of self as a process developed through self-reflection and in conversation with others. They assume constant movement from habitual, routinized, pre-reflective responses to stimuli to reflective, focused responses happening in conversation with the self as a member of a community, be it a community of practice (Schön) or a community as a social group of which an individual is a member (Mead). By exploring the active attitudes individuals have toward the world, these frameworks see individuals as important determiners of their lives rather than the pure product of conditioning (Stryker, 2008), as socially embedded and yet building personal autonomy though an inquiring attitude (Dewey, 1938).

Applying these frameworks to the process of responding to ethical issues enables us to understand managerial experiences of navigating through the COVID-19 pandemics in hospitals as a process of learning, building a skill of performing value reflection-in-action and value reflection-on-action. In the process, the individual develops moral agency, while at the same time being “carried” by a community in a reciprocal process of relationship building.

Develo** Practice and Develo** Self

Both Mead and Schön’s frameworks assume that people, that is, humans with minds and selves, adapt existing meanings and behaviors to deal with unforeseen contingencies in the social process (Stryker, 2008). The existing meanings and behaviors are imprinted into a person through a continuous process of social interactions and create a background for automatic, pre-reflective, “generalized habitual responses” (McVeigh, 2020, p. 501). Recent interpretations of Mead’s work underscore the embodied, even biological character of these socially acquired perceptions. Mead saw them as dispositions, instincts based on experiences of past actions. Dispositions deliver impulses that direct but do not determine action. Engagement in action is grounded in an embodied feeling rather than in consciously knowing why or how the action comes about (McVeigh, 2020). Habitual responses bear a family resemblance to Polanyi’s (1966) “tacit practice,” knowledge that practitioners have that is more than what they can delineate at any point in time (Yanow & Tsoukas, 2009). This is in line with considerations present in the practice research tradition that assume that “practice provides its members with ‘background’—an inarticulate (although, in principle, articulable) understanding of what they do that is implicit in their acts and precedes their ability to articulate descriptions of those acts” (Yanow & Tsoukas, 2009, p. 1349).

For Schön, reflection taking place in the midst of action is experimental in character, as well as sequential. Professionals engage in reflection after experiencing a surprise, a disturbance that produces an affective state of mattering. As a result, this focuses awareness and attention (Dreyfus & Dreyfus, 2005; Yanow & Tsoukas, 2009). Practitioner adopts an inquiring attitude, which, dependent on the experienced severity of the surprise, may engage her in a more or less active examination of habitual response and search for a more adequate way to cope with a situation. The switch between the habitual and the intentional triggers learning. For Mead, this switch is the beginning of self-development, where cognitive capabilities (the mind) are activated to creatively overcome an obstacle blocking the automatic stimulus–response mechanism (McVeigh, 2020). For both Schön and Mead, the process is equal with making the self an object of reflection. Reflective practitioner makes one’s thinking transparent, and own self permeable, which entails “setting aside one’s ego, as one may not have all the knowledge (or answers) necessary to comprehend a situation” (Yanow & Tsoukas, 2009, p. 1359). The later interpretations of Schön’s work indicate that reflection-in-action and reflection-on-action entail evaluative, implicitly cognitive elements of what should be part of the competent practice (Yanow & Tsoukas, 2009).

Individual inquiry on action entails collective elements in implicit and explicit ways. In the first, implicit case, the collective is present in a form of collectively established distinctions and standards of excellence against which an individual assesses his own practice (Yanow & Tsoukas, 2009). Collective elements penetrate inquiry through representations, that is, individuals’ awareness of mental models of how others see a situation (Petty & Wegener, 1998; Sonenshein, 2007). Finally, collective dimension of individual inquiry emerges in an internal dialog triggered by awareness of how others see “me” in the situation and how “I” can respond to this. This “I”- “me” dialog that is a dialog between an active individual responding to the situation (“I”) and individual seeing itself through the eyes of others (“me”), lies at the center of Mead’s concept of self as a process. In the second case, the case of an explicit collectives’ presence in the inquiry, the individual actively negotiates meanings and actions with other practice members.

Develo** Moral Agency and Value Work

Schön and Mead describe the process of individual growth, the development of a competent practitioner, and an autonomous and agentic member of society. Their individuals participate in a social world as sovereign and conscious agents, adopting social norms and being able to question them, a conceptualization that lends a fruitful frame to considerations of moral dimensions. Although pragmatist perspectives have been utilized for this purpose already (MacIntyre, 2007; Nielsen, 2006), Schön and Mead remain at the margins of these discussions. We bring them to the center to underscore the dynamics of the moral development that happens in organizations when individuals respond to ethical issues.

The literature on ethical decision making and specifically on sensemaking offers similar explorations by applying low-effort and high-effort systems of cognition (Petty & Wegener, 1998; Street et al., 2001), as well as proposing a distinction between habitual sensemaking and morally imaginative sensemaking in managing ethical issues (Hargrave et al., 2020). What matters for ethical sensemaking literature and the moral intuition concept in particular is that reflective practice development implies that constructing interpretations in rapidly moving situations and acting on them in the moment becomes a skill that can be learned and improved (Crossan & Sorrenti, 2002; Weick, 2002; Yanow & Tsoukas, 2009), a skill that characterizes a reflective practitioner (Schön, 1991).

We propose to conceptualize ethical decision making in such processual and developmental terms to explore how managers develop the skill of value reflection and, therefore, how they develop moral agency in an individual and collective process of responding to ethical issues at work. To build an explicit moral component into reflection processes, we reach to the value work concept. Work on values includes responding to social needs to establish a foundation of moral commonwealth and building healthy communities (Selznick, 1992). As such, values work has been identified as ongoing performances situated in everyday practice that articulate and accomplish what are normatively right and wrong, good and bad, responses to organizational needs (Gehman et al., 2013). While some of these performances enact and communicate values, some of them acquire it through processes of value inquiry, including actors’ thought-action repertoires as they respond to unique demands, improvise, and make judgments by asking critical, self-reflecting question such as “is what we do reaching out to the needs of the people involved?” (Espedal & Carlsen, 2021b) It involves questions on how to build shared worlds of sedimented repertoires and aspirations, that is, a shared world of concerns (Creed et al., 2020a, 2020b) and an intentionality in relation to connecting values to actions (Aadland, 2010). In this sense, values work includes maintenance of values not viewed as dogma, fixed and stable principles guiding action, but as performances exploring the contextual meaning of values. A reflection on the intentions and actions involved can lead to a form of value awareness and ethical sensemaking (Aadland, 2010; Espedal & Carlsen, 2021a). In bewildering situations, awareness of values can potentially provide guidance, telling people what right and wrong actions are (Askeland et al., 2020; Gehman et al., 2013).

In this paper, we view the process of increasing value awareness and increasing the ability of value enactment as moral agency development. We adopt the following understanding of moral agency as typically manifested by either ethical action or inaction, which may be preceded by a moral struggle on the part of agents (MacIntyre, 1999; Wilcox, 2012), and ask the following question: how did hospitals’ middle managers develop moral agency in the process of responding to the COVID-19 crisis?

Research Setting and Method

On February 26, 2020, the first coronavirus infection was registered in Norway. Less than one month later, on March 12, 2020, the whole country was locked down. National rules were established on maintaining a social distance of one and two meters, washing hands, and restricting gatherings to only five people in the same place at the same time. People were asked to avoid traveling and public transport. Schools and kindergartens were closed, as well as gyms, churches, and cultural institutions. Healthcare personnel were immediately in a new role, searching for answers to the situation, determining what might be right and wrong actions. How should they handle higher workloads, psychological distress, and shortages of quality personal and protective equipment while having little or no time for reflection (HelseVest, 2020)?

In this study, we investigate the experiences of eleven mid-level healthcare managers in two university hospitals in Norway working in the midst of the COVID-19 pandemic. The two university hospitals are located in the east and west parts of Norway. The hospital on the eastern side (E) is one of the country’s largest hospitals and operates as a local and acute hospital for large portions of the inhabitants of the capital of Norway, as well as a regional hospital for residents of the southeast region and the whole country. The hospital has 24,000 employees and a yearly budget of approximately NOK 25 billion. The university hospital in the west (W) serves the western part of Norway and has about 7,800 employees and a yearly budget of NOK 8 billion. During the data collection period, the two university hospitals were handling the COVID-19 situation on a yellow or red level, meaning all elective operations were shut down. The hospitals established new wards for coronavirus patients and had a massive reallocation of personnel to the wards.

Research Approach

We utilize an abductive approach (Golden-Biddle, 2020), moving back and forth between existing theories and empirical data from the field: personal diaries, focus group interviews, and organizational documents. For the purposes of this study, managers of different wards in the two hospitals were asked to write personal diaries during the pandemic. The participants were informed about the intended use of the data, that participation was voluntary, and that the confidentiality of the information shared would be protected. The research at each hospital was approved by the Norwegian Social Science Data Services. Six managers from the western hospital and five from the eastern hospital responded positively and wrote diaries from March to August 2020. The same managers were invited to focus group interviews 6 months later (December 2020–January 2021). Organizational documents and reports from both hospitals during the same period are included as data sources.

Data Collection

Diaries were chosen for data collection to capture the life worlds of the individuals and real-time experiences and personal reflections during the pandemic (Alaszewski, 2006; Milligan & Bartlett, 2019). Diaries were selected intentionally because of the limited time, the managers had for research interviews during the pandemic. Through the solicited diary method, the managers had the flexibility to choose when to write. The managers were given general guiding questions according to a template prepared in advance. The template included questions such as the following: What do you do differently now than earlier? What are the discussions and controversies you are taking part in? How do you reflect on what is important (values)? What dilemmas do you experience in your everyday life, and how do you deal with them? The managers were encouraged to write one page a week. The disadvantage of this method was the lack of opportunity to ask follow-up questions for elaboration on the entries.

The managers mostly ignored the template questions and the frequency the researchers proposed, instead writing personal reflections. As a result, we ended up with 60 pages of densely written text (each participant provided from 4 to 10 double-spaced pages) containing diverse types of descriptions, ranging from very short reflection notes to informative, report-like registers of happenings to detailed descriptions of specific situations and the emotions triggered by them. Although entries in the diaries were written chronologically, some of them were undated. The amount of data acquired from both sites was comparable (see Table 1 for comparison).

Table 1 Overview of manager ages, sexes, professions, hospital workplaces, titles, and responsibilities
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Ten of the managers were female, and one was male. They ranged in ages from 38 to 59 years old, though most of them were in their 40 s. Ten of the 11 were nurses and worked in positions such as Section (3) and ward leaders (6). One leader was a member of the hospital’s crisis team, and one worked as a leader for maintenance, responsible for infection control. Most of the managers (7) worked in wards and sections responsible for treating people with COVID-19, but two leaders worked in wards responsible for patients who had to be protected against the virus (e.g., cancer patients). Five of these wards were, before the pandemic, highly structured wards of observation and investigation for patients with different infections. However, it was necessary to reallocate patients to take care of the infected COVID-19 patients. Two of the managers led new wards established to treat COVID-19 patients.

In December 2020 and January 2021, the research participants were invited to two focus group interviews, in which all except one manager participated. The focus groups sessions were held at each hospital and led separately by the two last authors. The focus group interviews were conducted to extend the data and confront preliminary interpretations of the empirical material. The two authors followed a semi-structured interview guide similar to the questions in the diary guide. One of the sessions was attended by participants in person, and the other was conducted on Zoom due to COVID-19 restrictions. One focus group session was recorded and transcribed, but the recorder did not function in the other session. However, information was written down immediately afterward. Each focus group session lasted for about one hour, leaving the authors with 20 transcribed pages. Data from the diaries and interviews were supplemented with organizational documents, mainly evaluation reports by both hospitals, evaluating the preparedness and the coordination of the work at the hospitals (96 pages). The documents provided contextual information that was often of a factual character, like the chronology of events, titles and content of documents, and decisions issued by the hospital management and the state agencies managing the situation. The documents were read several times, and important aspects were highlighted.

Data Analysis

The data were analyzed in two rounds. First, the last two authors iteratively reviewed the empirical data along with relevant theories to analyze the role of values in a crisis situation. Second, the two first authors read the diaries and focus group interviews and coded them in Nvivo using interpretive codes (Miles & Huberman, 1994), such as “reflections,” “organizing,” “dilemmas,” “values,” “moral,” “agency,” and “actions,” as well as themes originating from Mead’s framework, such as “me,” and “I.” In line with Locke et al. (2016), the first two authors treated the coding as a provisional starting point rather than an endpoint, establishing a process of deriving further questions. The data analysis was inspired by a narrative approach, with a focus shifting from “what actually happened” to describing “how [people] made sense of what happened” (Riessman, 2008, p. 11).

The authors organized the codes and the connected extracts as exemplified in Table 2. To give an overview of the data structure, such as citations on first-order and second-order themes and aggregated dimensions of analysis, the first-order citations represent individuals’ experiences. Second-order themes and categories (Gioia et al., 2013) emerged after reflection on the first-order citations, such as fear and anxiety, searching for help and guidance, control, and moral reflex. Following Mead (2010), we distinguished experiences of the intuitively reacting individual, experiences of “I” as an active individual responding to the situation and to others, and “me” as an individual seeing itself through the eyes of others. Hence, we reconstructed both mental models of how others see a situation and how they see the individual in the situation.

Table 2 Structure of the data analysis
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The aggregated analysis led to the discovery of a three-step moral agency development process evolving through community-embedded value inquiry. As such, the aggregated dimension of the process was (1) inquiring “I” and “me”—a pre-reflective automatic response based on intuition inquiring what matters for me, what should be done, who should do it, what others think I should do, (2) calibration in a dialog of “I,” “me,” and others (here, three groups of “significant others” emerged from the data—superior leaders, peers, and subordinates), and (3) taking a stance through action and justification of action, reconciling with the vulnerability and uncertainty. On the later stage of analysis, these dimensions were theorized as value inquiry-in-action, value inquiry-over-action and reflective enactment of value.

Findings: From Moral Reflex to Moral Agency

In this section, we illustrate the aggregated categories emerging from the empirical data. The categories reflect three partially overlap** steps of value inquiry that are performed in the face of uncertainty and crisis and that facilitate the process of moral agency development. In the first step, the individuals experienced the situation as uncertain and urgent. Value inquiry was dominated by value questions of what matters, what should be done, what is valuable to do, who should do it, and what the standards of the work should be. The urgency of the situation did not leave space for much reflection; hence, at this stage, values came to the surface as embodied reactions that we labeled “moral reflex,” a pre-conscious reaction reflecting deeply internalized values. In the second step, the individuals turned to others. In an attempt to regulate uncertainty, a collaborative dialog was organized to exchange information and to calibrate values to guide actions. Dialog triggered a collective and ethical sensemaking, reflecting on what is right and wrong and how to make sense of it. Moreover, the dialog re-established and strengthened the social bond that became a scaffold for navigating uncertainty for both managers and regular employees. In the third step, the managers developed a sense of self in the situation, that is, an increased confidence in acting upon ethical issues and in taking a stance by explaining and justifying the action. Through this process, they developed social relationships, moral agency, and legitimacy for future actions for the individuals and the group to act as moral agents.

Inquiring “I” and “Me”—What Do I See, What Do I Do, What Matters?

At the beginning of the pandemic, everything was in flux. The managers described the first period of the COVID-19 situation as a complex, enduring, frustrating situation. One manager wrote in a diary, “From that day [March 12], nothing was as we usually knew, not at home and not at work” (Manager 4, undated). Information was flowing from many directions, and there were no procedures or systems according to which decisions were supposed to be taken. People were “not sure on anything and confused about everything” (Manager 5, week 11). Despite this uncertainty very tangible actions needed to be taken, like deciding how to physically organize the treatment of infected and uninfected patients:

In 48 hours, our ward went from being a ward of investigation without infection problems to a pandemic ward for patients with COVID-19. Furthermore, in just a couple of days, we were reassigned to a ward for observation/treatment. We had to constantly change managers and premises of the work. (Manager 10, undated)

Embodied Emotions

The uncertainty of the situation included a lack of overview of how to treat patients, how to protect personnel, and how to find protective equipment, leading one manager to confess, “We cried with joy when we were allowed to ‘borrow’ five disposable coats after wearing them continuously for more than 24 h” (Manager 3, undated). The everyday work was broad, with ethical dilemmas, unclear leadership lines, and questions of who was in charge. It was described as a continuous battle on who should be tested and which patients should be allowed to have next-of-kin visiting. One manager noted, “It required a mental strain to go to work, and we were in constant fear of being infected ourselves” (Manager 2, undated).

Intuition

In this situation, the managers were explicit about their feelings of fear and vulnerability. They admitted that there was a lack of control and less knowledge on how to reach out to employees and, to some degree, patients. One manager said that at first, they were trying to find “adults” who could give directions for right and wrong actions (Focus group 1). When in doubt, they actively engaged with the habitual response toward emergency, that is, making oneself and others safe. In terms of reaching out to the value of making people safe, they operated based on intuition (Manager 1, April 4):

It was a new situation for us and the whole world. There was no time for reflecting on and prioritizing what was important. We just had to follow a “gut feeling.” We had to outline different scenarios and make the best out of [them], deal with what we thought was relevant, and make sense of it.

In this situation, the values became the point of reference in the chaos, a provisional orientation point or a compass for navigating uncharted waters. It revealed itself first through intuition and second through reflection-in-action, that is, the intentionality of actions triggered by a major disturbance of routines.

Value Calibration in a Dialog—Reaching Out to Significant Others

There were three groups of significant others that emerged in the empirical data: superior leaders, peers, and subordinates. The middle managers experienced little help from top leaders, who were engaged in determining right and wrong policies and strategic decisions for the whole hospital. The professionals with knowledge of crisis treatment were involved in crisis teams, leaving the middle managers to handle the everyday challenges of the pandemic on their own.

Permeable Self in Dialog with Others

In the absence of the top leaders as guides, the middle managers found peers and subordinates to be adequate reflection partners, especially as the latter expressed a pressing need for dialog about how to apply values and ethical rules that they knew from the professional codes of ethics.Footnote 1 With colleagues, they reflected on and calibrated “what could be right and wrong actions” (Manager 10, undated). In the reflections, they embraced the vulnerability of the situation by allowing themselves to be visibly and publicly “not-knowing” (Yanow & Tsoukas, 2009, p. 1357). Making one’s inquiry public and inviting others to the inquiry required them to relinquish their sense of control over the situation and over others. In fact, it was a leap of faith in others:

Together, we discussed how to find solutions. When I did not know what to do…was desperate and doubtful, I showed emotions openly. I expected people not to take me seriously. However, it was experienced very [positively] and helped to find solutions. (Focus group 2)

Manager 10 noted these embodied responses were all about living and maintaining the values of the organization and the profession of nursing:

Caring, involvement, inclusion, security, honesty, respect, knowledge, and quality[,] [these are] all values I value…The pandemic situation challenged me to stick to these values.

Community Support

The crises triggered a need for both action-oriented and reasoned ethical sensemaking about what was happening and how to respond but also a need to be together and support each other, including support against others (like patients’ families). Said one manager, “There were many discussions about how to approach all the practical ethical dilemmas and deal with criticism and even aggression, e.g., in response to visiting restrictions” (Focus group 2).

The managers did not know what to do, but they acted together with others and with others in mind. Being present was among most crucial of these actions. When reflecting on the situation six months later, one of the managers stated, “It was important to be present…I had to be there to be talked to” (Focus group 1).

As such, the values were calibrated in relation to others. In the feelings of insecurity among the personnel, the managers recognized the positions of others. The values that surfaced in taking the attitudes of others were inclusion, honesty, respect, and working for quality. The values were objects of dialog but also a motivation for dialog. They were inseparable from actions and decisions, emerging through them, and creating relationships that helped to manage the uncertainty of the situation.

Taking a Stance—Increased Level of Value Awareness

The managers established spaces for the collective value inquiry in the midst of action and on action. They did this through openness to casual conversations, the provision of physical places for ad hoc exchanges of reflections (like bulletin boards in hospital corridors), and the organization of meetings. Those spaces gave an opportunity to decide on actions as well as to reflect more generally on what mattered and how to evaluate decisions. Throughout these encounters with others, the managers included voices into the internal dialog of “me” and “I,” and they developed increased awareness of their own values and increased confidence in acting upon those values. They arrived at a point at which they were able not only to “act on a gut feeling” but also to trust their own gut feelings and “trust their own values” (Focus group 2). They adjusted to the situation by enhancing the values of physical and psychological security and enacting this through building relationships of care in which individuals shared a set of concerns (Creed et al., 2020a, 2020b).

Community Support

Enactment of care reinforced and strengthened a social bond that became a safety net for the individuals acting in the midst of uncertainty. “You do not know, but you need to take a stance…and have a plan b, and maybe c in case that does not work” (Focus group 1). Another leader said, “It was actually very important to be honest about it and say that we live in very uncertain times, and we do our best based on the best available information” (Focus group 1).

Reconciling with Uncertainty

One manager described embracing uncertainty as a process of reconciliation, of accepting the situation to find a form of calm (Manager 1, March 12). The manager said that being present was a way of handling the situation. One leader described it this way: “To say that I do not know and still be there meant a lot for people. It made them more secure” (Focus group 2). Others said they worked on being role models, inspiring and motivating employees (Focus group 1).

Reinterpretation of Values

The managers used their inner value compasses as management tools to find directions for the meaning-making process. As such, the decisions were made in loyalty to the group, gained as a result of inclusion and relationships. When a decision was taken after a discussion, even if people did not agree, this showed they were backed up as leaders. When the leaders had many employees in quarantine and had to rebuild and structure new wards and wonder who they should trust, their work as managers was emphasized as building an honest relationship of mutual care.

Explicating the Role of Value Inquiry in the Process of Moral Agency Development

To finalize the findings, we found that the situation of uncertainty during the pandemic facilitated value work in the form of individual value reflection-in-action and collective and individual value reflection-on-action among middle level managers and their teams. Interruption of daily institutionalized rules and routines guiding practice triggered a moral reflex, that is an intuitive response rooted in internalized values that managers and regular employees used to constitute their professional identities. The moral reflex was filtered through a whole range of other social identities. In this pre-reflective moment of acting upon what matters, private and public fears were intertwined. The initial entry in the beginning of this article illustrates that vividly: “Who would believe that we going into 2020 should stay in line for alcohol … that we would cry with joy when allowed to borrow five disposable coats.” At the same time, there were private insecurities: “What if my mother gets COVID? She hadn’t survived it. What if my cancer-sick partner does not get his treatment?” (Manager 3, undated).

In the process of moral agency development, the managers engaged in value inquiry and actively made themselves objects of observation, reflected upon their own emotions and vulnerabilities, and recognized the need to care for others and the need others have to be cared for. This self-inspection required making own thinking and feeling transparent and made individuals’ own not-knowing and anxiety observable to themselves and others. This permeability of self implies attention and responsiveness to unfolding processes, an opening of value inquiry (Yanow & Tsoukas, 2009).

As such, values inquiry includes letting go of control over the situation and/or over others while retaining control over oneself and one’s own inquiry process. Letting go of control over the situation enables regaining balance and control through social relationships and acquiring more or less temporary agreements about meaning and acting on the situation. The collectively agreed meaning and acting was further communicated to others: patients, their families, top leaders, and the general public (see Table 3).

Table 3 Responding to ethical issues as community-embedded moral agency development
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Each of the three steps of moral agency development involves conversations between three levels of explicit and implicit cognition. The first level is about experiencing the changing environment that the organism feels and to which it instinctively responses. It is what Mead calls “contact experience”, that is a physical contact between organism and object accompanied by a direct manipulation and handling of an object (Mcveigh, 2020, p. 503). In the case of our analysis, contact experience designates the direct, in-the-moment experiences of managers as they move through the process. The second level of explicit and implicit cognition focuses on a conscious examination of the initial responses of “I” to the contact experience, as well as engages in an internal dialog of “I” and “me”. The third level of implicit and explicit cognition is about active engagement with others. As Table 3 illustrates, all three levels of cognition are visible at each of the steps but in different proportions and with different roles.

While in the first step contact experience and individual responses dominate, in the second step it is the level of individual responses and the collective level on which the dialog enfolds. The third step engages mainly individuals as grown-up moral agents, yet they are supported by both the experience of reconciliation and social bonds and collective meaning-making (see Fig. 1). Reaching out to reflective practitioner framework for an inspiration, we can label the steps as value inquiry-in-action, value inquiry-on-action, reflective enactment of value.

Fig. 1
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The development of moral agency through a value inquiry process

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Discussion: The Development of Moral Agency in a Crisis Situation

We started this paper by asking how hospitals’ middle managers develop moral agency in a process of responding to a constrained pandemic situation rife with uncertainty and upended organizational circumstances. Leaning on Mead and Schön’s frameworks, we found a process of moral agency development comprising three steps of value inquiry: individual value inquiry-in-action (step 1); individual and collective value inquiry-over-action (step 2); reflective enactment of values (step 3). In response to these findings, we will in the following describe two sets of overall contributions from our study. These contributions describe how a notion of value inquiry, and value inquiry-in-action and over-action extends research on values work and moral agency and how this is part of an ethical sensemaking process in uncertain times.

Ethical Sensemaking

Our investigation opens a discussion about several assumptions made by ethical sensemaking literature. First, this literature clusters equivocality and uncertainty in an inseparable relationship. While equivocality involves multiple interpretations, and hence confusion about how to mediate among them, uncertainty is about a lack of access to a plausible interpretation and an inability to see how actions will affect future interpretations (Reinecke & Ansari, 2015; Sonenshein, 2007; Weick, 1995). Hence, “in either case individuals engage in ethical sensemaking because it is difficult to determine a course of action” (Sonenshein, 2007, p. 1028). We suggest that there is a major difference in experiencing not knowing what the possibilities are and not knowing which of the possibilities to choose (and based on what premises). Experiences of uncertainty are more likely to trigger a process of open inquiry because there are no firm positions about how to handle the ethical issue.

Second, sensemaking models suggest construction as a first phase and moral intuition as a second phase (Sonenshein, 2007). Without being dogmatic about order, and while recognizing the intertwined nature of the steps, we suggest that in handling uncertainty (and under time pressure), moral intuition is a primary reaction. It reaches rather to motivations than to experiences, and hence it is rooted in values. The person does not ask “what is it that I see?” (construction) but rather “what is it that I need to save?” or, in other words “what matters most?” The preliminary identification of a value through intuition further motivates the person to inquire and hence make herself transparent, publicly not knowing and publicly caring. We argue that this step is a moral one because it entails a setting aside of one’s ego and exposing oneself for the sake of what matters.

Third, our moral agency development model sees the collective as something much more than a repository of alternative mental models of how others see a situation, a repository that can be creatively engaged with in internal dialog (“I-me”) or in explicit collective deliberation. It is a group sharing of a world of concerns (Creed et al., 2020a, 2020b) in which subordinates trust leaders’ moral judgment because they recognize the honesty of a declaration of not-knowing-but-caring, as well as because they feel they are being seen and recognized. This relationally responsive trustworthiness (Almassi, 2022) is what provides a manager with the moral courage to act.

Fourth, we suggest that constructing a plausible interpretation, which is part of ethical sensemaking processes, may be more about determining the right questions than about providing right answers, even if those answers are temporary. The managers were operating on automatic reactions, or what could be named intuitive judgment (Sonenshein, 2007), but they engaged with others not to explain and justify, but to explore how others feel and experience the moral meaning of the situation. Middle level managers calibrated values with other leaders, peers, and subordinates. Especially in relation to colleagues and subordinates, this included a creative reflection on the needs of the community.

Extending Value Work and Moral Agency

The situation of healthcare workers not only created severe psychological distress (Hossain & Clatty, 2021) but also an inquiry process exploring the right foundation for action in an indeterminate situation (Dewey, 1938). Scholars suggest that this active attitude of inquiry and action—that is, the process of agency development—is one of the ways by which individuals regulate uncertainty (Griffin & Grote, 2020). Our research flows from this line of argument while indicating that in certain types of situations, when the health, wellbeing and lives of others are clearly affected, agency development inevitably involves values and hence becomes a development of moral agency.

The value inquiry of the healthcare managers included an intuitive and conscious reflection of the situation. The work the managers were doing was right in the sense that it affirmed the basic importance of moral courage and motivation and revealed that values could matter, even in situations in which they were not spoken about or present (Kraatz et al., 2020). As a first step, the moral reflex was based on the values of the individuals and their professional occupations, forming the basis for moral agency. As such, the descriptions of the moral reflex as leading to moral agency expand the moral agency literature by identifying how values inform the basis of agency. The moral reflex manifests ethical actions as a point of departure to handle the moral struggles involved, comprising an endeavor of questioning what are right and wrong practices (Wilcox, 2012). This process included a process of reflection where the involved iterated between the steps of value inquiry-in-action, and value inquiry-on-action, as well as reflecting on what reflective engagement they had in values.

The inquiry involve a calibration of the values involved (step 2), building a bridge between moral agency and crisis management. Develo** a moral “tone” in a crisis, close to what Seeger and Ulmer (2001, p. 369) describe, is part of the reflection; however, the reflection does not only involve ethics of justice and ethics of care but also enhances various values, such as trust and care, safeguarding employees, supporting them, and working for reconciliation with the situation.

In the third step, the collective reflection of these values in an uncertain situation reaches out to a collective value work reflection on the difficulty of the COVID-19 situation, leading to a notion of what the new standards of action in this difficult crisis situation should be (Selznick, 1957/1983). As such, the third step builds a bridge between values work and ethical sensemaking. The value inquiry includes the lived uncertainty of the crisis situation, opening up for organizational value reflections and dialogs to find meaning and action. The process represents a collective reflection, termed by Nilsson (2015, p. 370) a “collaborative inquiry process.” A collaborative inquiry explores the paradoxes of a situation to organize for dialog and discover the capabilities of moral competence (Selznick, 1992, p. 36).

Future Studies

In extreme situations, collecting data can be a difficult endeavor. In this study, it was the managers who decided what information was provided in the diaries, leaving the researchers in the position of not being able to ask follow-up questions. The number of diaries in this study is not large; however, we discovered that the study disclosed patterns of working on moral agency through values during times of crisis. Even though there was little time for reflecting, the managers handled the difficult situation by reflecting on their ethicality and values, both individual and collective. Suggestions for further studies would be to include a larger number of managers, as well as observations of middle managers and their peers, possibly also verifying the essence of moral agency development and the development of moral values work at a stage when the crisis situation is more under control.

Conclusions

We have in this study investigated how healthcare managers developed moral agency in the challenging crisis situation of the COVID-19 pandemic. We discovered a dynamic process of ethical sensemaking, as well as how this involved a process of value inquiry. As part of ethical sensemaking, we found that the uncertainty of the crisis situation triggered the involved moral intuition as a primary reaction based in a moral reflex. This reaction resided in motivation to do something with the situation, as well as to take part in both internal dialogs and collective deliberations. The value inquiry led the involved not to focusing on right answers but to focusing on right questions, develo** moral agency as typically manifested by ethical actions—setting aside one’s own ego and exposing oneself for the sake of what matters. The inquiry included asking self-reflecting questions on how to deal with the situation to determine what matters, as well as how to calibrate values in relation to others to make sense of the situation and take stances to explain and justify actions.

As such, this research expands the literature on moral agency and ethical sensemaking by including a process of value inquiry. The process reveals two aspects critical for moral agency development: it happens through confrontation with uncertainty, and it is relational, as one manager highlighted: “The pandemic situation challenged me to stick to the values—both at work and in private[,] even though they were not quite clear.” The community-based needs of the people led the involved into a relational process of translating values into action through engaging in moral support, involving values such as safeguarding the situation, trust, and enacting compassion, also leading to a reconciliation with the situation.