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The year 2020 will be remembered as the year of the most significant global pandemic since the Spanish influenza. As Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) gradually encompasses the globe, it leaves a trail of destruction in its wake. Hundreds of thousands of direct lives lost, millions of persons affected with the disease, potentially with long-term health consequences, disruption to global travel and trade, and dislocation of communities and individual lives. At an international, national and community level, leaders across all sectors have been required to respond to both direct and indirect effects of this crisis, with little time for preparation, and in a constantly changing environment.
For leaders, this significant uncertainty exacerbates the challenges associated with decision making and requires a rapidly adaptive response not usually associated with leadership in more ‘business-as-usual’ times.1 Leadership examples and frameworks during crises exist from the military and emergency management sectors. However, a key challenge of a pandemic is that an effective management of the situation requires large-scale human behaviour change. When adoption is insufficient, collective benefits are not guaranteed. A global pandemic is therefore a ‘litmus test of trust in a health system’ (p.214). 2
The importance of trust
Trust is an individual’s expectation or belief, often in circumstances of vulnerability, that the actions or motives of another person are honest, fair and based on integrity (follow sound ethical principles).3 Trust can be at a system, organisational or individual level. It can be inspired by confidence from past behaviours, however, it is also dynamic, being developed de novo from individual or organisational relationships.
Trust allows a person with less knowledge, power or ability to process complex information, to rely on another individual or institution to make decisions aligned with their well-being. Thus, trust has historically been a cornerstone of clinical care and clinician–patient relationships, and healthcare systems and providers have traditionally been highly trusted. However, where once the public received their health information primarily from health professionals, social media has allowed broad sharing of information via peers, which may be viewed as equally credible, posing a modern challenge for leaders.4 The so-called COVID-19 ‘infodemic’ on social media has disrupted the key tasks of crisis leadership.5 Nevertheless, in a pandemic, scientific and public health experts remain more trusted by the public than non-health leaders.6
The Trust–Confidence–Cooperation framework of risk management, developed by Earle, Sitgrist and Gutscher states that the community must have trust and confidence in its leadership for it to cooperate with restrictive public health measures.7 Pandemic responses and the related social and economic upheaval are huge change-management exercises, and there will inevitably be resistance to change.8 Herein lies the issue of trust. ‘So many aspects of successful leadership, warfighting, and command and control are built around the framework of trust that, without it, we would meet with persistent failure’ (p.30).9 However, public trust in governments, leaders and businesses has been declining over recent decades. Without trust in the leading organisations, support for policy implementation is difficult to achieve, particularly where short-term sacrifices are demanded but long-term gains are less clear.
Trust is a key foundation of relationship-oriented leadership frameworks including situational leadership,10 authentic leadership and servant leadership; with transformational leadership also relying on leader and follower value congruence.11 In this paper, we will explore leadership during uncertainty through the lens of situational leadership, that is, through both a focus on leadership actions that can create trust in a crisis and the importance of leadership relationships and human connectedness with followers that can sustain trust.
Creating trust through action
Preparedness and planning
The last two decades have provided glimpses into what the world is now experiencing. These include H5N1 avian influenza in 1997 in Hong Kong; SARS in 2002–2003 in Hong Kong and Singapore; the 2009 influenza pandemic, also in Asia; and the Middle East respiratory syndrome coronavirus in 2014–2015 in Saudi Arabia. Countries that experienced significant impact related to these previous outbreaks, particularly in Asia, have in general responded more promptly to COVID-19 and have had broader community compliance than other nations for whom this is a new experience.12 13
Without specific or large-scale pandemic experience however, leadership can still be prepared and proactive. Pandemic planning can learn much from these previous exposures, including the benefits and risks associated with particular management and containment strategies. Emergency management and armed forces sectors stress the importance of regular organisational, sector, and cross-sector-level simulated exercises for building capability for crisis event management.12 Investment in public health, such as through the establishment of independent or government-managed national centres of public health or disease control, infectious disease physicians and disease outbreak response systems, provides a critical mass of available expertise.
Infrastructure investment in isolation facilities, additional bed capacity, equipment, personal protective equipment and therapeutics provide needed resources for the response.14 Health sector surge workforce capacity can be created through relationships with workforce agencies, regulatory bodies and academic institutions. Planning also needs to address the unintended economic and personal consequences of the crises, including clear processes and procedures so that they can be implemented quickly and appropriately. However, not all scenarios can be anticipated or controlled, so comprehensive and regular risk assessments of the situation will still be needed, with leaders being willing to change their strategy rapidly and at any time.14
Supported with information and data
Leaders at times of significant uncertainty should constantly seek relevant information and intelligence regarding the crisis’s course and impact from reliable sources. This includes from health professionals, researchers, managers, industries and related sectors, but also from shared stories and experiences from international colleagues, networks and collaborative partners. Although intuition plays a role, leaders need to ultimately act in accordance with credible expertise and advice.
Surveillance systems including testing and contact tracing are crucial to understand the local scope and spread of a pandemic.15 Clinical data collection within the health system is equally important to understanding local requirements for health resources, patterns of disease and care and what interventions are providing the best outcomes. Examples from the Australian context include the Australian SPRINT-SARI (Short PeRiod IncideNce sTudy of Severe Acute Respiratory Infection) database collection of COVID-19 inpatient data across intensive care units16; other real-time aggregated case reports from international patient registries17; and the rapid development and continual evolution of treatment guidelines for COVID-19.18 It is vital that academics and governments publish their data as soon as possible, and many academic journals and media outlets are supporting this.19
International information sharing and global surveillance through research institutes such as John Hopkins University in the USA provide globally transparent, aggregated and real-time incidence and outcome data.20 Predictive data modelling can leverage this to provide leaders with a range of scenarios based on specific assumptions to help guide decision making. Informed leaders will consider all available intelligence and information, seek alternate perspectives and reflect on the various decision options available to them. There is increasing emerging evidence that rapid, comprehensive, national responses aligned with health guidelines have resulted in better health and economic outcomes and high levels of trust in the leadership, as has occurred in New Zealand.21 22
Adaptive and coordinated
In complex and unpredictable situations, leadership must be adaptive at all levels.23 Clinicians and researchers have constantly updated and adapted their definitions and understanding of the clinical course and management of COVID-19 in the face of emerging international data. Urgent requirements for population-level testing have led to the adaptation of alternative laboratories and settings to take on this huge task. COVID-19 tracing applications have been developed and used in many developed countries, with the aim of assisting manual contract tracing, although their effectiveness and privacy implications are still being debated.24
General practitioners are triaging persons with symptoms via telehealth, taking swabs from drive-through clinics, and manning super ‘fever clinics’. Pharmacists are collating and sharing pharmaceutical stock data with the government to assist in the management and rationing of the national supply. In Australia, non-urgent elective surgery and procedures, typically the mainstay of private hospitals, have been ceased as they prepare to share the medical load of COVID-19 patients with their public counterparts. Examples of adaptable governance structures include in Australia the creation of a new ‘National Cabinet’ with the Prime Minister and the Premiers and Chief Ministers of the constituent Australian states and territories. This has been a very effective body that meets regularly and has led to high levels of response coordination.
In order to build trust and the confidence of followers, leaders need to make decisions and provide a sense of control. Local command centres and other task-oriented leadership structures are critical in supporting intelligence gathering and timely decision making.25 However, leaders must remain connected with the communities that they lead throughout this process, to be informed by those at the coalface, as well as to receive feedback critical to decision making. New teams within existing structures may need to be created and conduits developed to allow two-way interaction with the frontline. Emergent and decentralised leadership should be encouraged, within an overall shared strategy.25
Leaders are responsible for the coordination of responses, including beyond the health sector across public, private sectors and non-government organisations. These collaborations may be hastily created, but form a crucial network of relationships, alliances and horizontal coordination mechanisms. The greater the communication and coordination, the more resilient the system is in the face of adversity. Leaders must engage the community through local groups to ensure there is local ownership, and that interventions are appropriate and acceptable. Communication is also critical for coordination and alignment with leadership planning and goals.26 As well as coordinating the response, leaders must also coordinate initiatives to support the well-being of their followers, including mental health support, organisational continuity planning, and staff and community welfare.
Sustaining trust through connectedness
Responsibility and transparency
Crises require leaders to take responsibility and do this visibly. By being visible and responsible, they are showing accountability and sharing risks with their followers, an important sign of solidarity with the many health workers and others who face personal risks during the pandemic. By being responsible, they show and model personal vulnerability. Taking responsibility also means that leaders exhibit constancy and resilience, that they are in this for the long haul and can be relied on to continue to persevere on behalf of their followers.
For followers to trust their leaders, they need access to objective information and to be able to speak up and ask questions. Being open and transparent are two of the most important behaviours leaders can demonstrate to maintain the trust of their constituents. This includes being accessible, available, open and willing to answer questions, as well as providing credible up-to-date information for their followers to consider. It has rightly been said that the midst of the pandemic is not the time to identify detailed failings by leaders with the best of intentions,27 however, leaders also need to show honesty in admitting when they have made missteps and when there have been failures.28
Authenticity: ethical and values-based leadership
When leaders’ responses to crises are based on ethical and values-based principles, they provide a shared sense of purpose with their followers.22 Personal and professional values that support acting ethically in the face of adversity will then be the guiding framework that informs decision making. Frontline healthcare workers are particularly at risk, and all efforts must be made to prioritise their health so they feel valued and protected.29 Examples include ensuring that guidelines for their and their families’ protection are enacted, sufficient workforce is harnessed and workload and well-being are managed.
Beyond this, leaders should speak with candour and frankness about the uncertainties that exist. Strong empathic responses are important at times when many people’s lives are disrupted and families have lost loved ones. Responses that acknowledge and ‘apologise’ for the illness, the interruptions to care, and the specific work and relationship-related personal impacts of social restrictions show a deep connection with the community, as does personally thanking individuals and collectives for their effort and commitment to the task. A leader’s constituents will also be likely to forgive less favourable outcomes if they consider the criteria and tools used in the decision-making toward those outcomes have been reasonable.30
Authentic leadership encompasses honesty, concern and benevolence towards followers and their peers. A pandemic and its associated responses such as restrictions of mobility cause uncertainty and anxiety and have the potential to paralyse action and divide communities. Social trust may increase following natural disasters; however, distrust in governments and institutions may lead to disinformation and conspiracy theories and social unrest regarding perceived authoritarian control. In particular, stigma may be associated with infected persons, whether via individual non-compliant actions or not. Their privacy and dignity should be respected.
Both leaders and followers play an important role in creating and sustaining trusting relationships. Leaders must trust their followers, especially if they are to delegate responsibility or share decision making. This of itself requires leaders to take risks and display vulnerability.
Trust in leadership is needed for transformative, collective action in times of uncertainty, such as during a pandemic. For leaders to instil trust in their followers, they must take appropriate action via preparation and planning; seeking out information and intelligence; leading adaptation; and ensuring a coordinated response. However, to sustain trust, leadership requires taking ongoing responsibility and accountability, and remaining closely connected to those on whom their decisions impact. Developing and maintaining leader trust in circumstances such as a pandemic is a dynamic process, changing over time from pre-existing trust, to trust based on actions, to trust in the strength of the authentic relationship. As COVID-19 continues to play out over the globe, it is becoming clear that trust ultimately also requires leaders to offer hope, a credible vision of our lives for the future and guidance on how it can be achieved.
Patient consent for publication
Contributors SA conceived and drafted the article, and EL also materially contributed to the drafts. Both authors approved the final paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.