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.

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.