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Abstract
The COVID-19 pandemic has put a lot of pressure on all the world’s health systems and public health leaders who have often found themselves unprepared to handle an emergency of this magnitude. This study aims to bring together published evidence on the qualities required to leaders to deal with a public health issue like the COVID-19 pandemic. This scoping literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. A search of relevant articles was performed in the PubMed, Scopus and Web of Science databases. A total of 2499 records were screened, and 45 articles were included, from which 93 characteristics of effective leadership were extrapolated and grouped into 6 clusters. The qualities most frequently reported in the articles were human traits and emotional intelligence (46.7%) and communication skills such as transparency and reliability (48.9%). Responsiveness and preparedness (40%), management skills (33.3%) and team working (35.6%) are considered by a significant percentage of the articles as necessary for the construction of rapid and effective measures in response to the emergency. A considerable proportion of articles also highlighted the need for leaders capable of making evidence-based decisions and driving innovation (31.1%). Although identifying leaders who possess all the skills described in this study appears complex, determining the key characteristics of effective public health leadership in a crisis, such as the COVID-19 pandemic, is useful not only in selecting future leaders but also in implementing training and education programmes for the public health workforce.
- COVID-19
- public health
- leadership assessment
- medical leadership
- management
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Introduction
The COVID-19 pandemic represents a major public health issue with a huge health, social and economic impact worldwide.1–3 After more than 3 years from the beginning of the pandemic, hundreds of millions confirmed cases and more than 6 million deaths have been reported worldwide.4
Indeed, the pandemic has undoubtedly generated enormous pressure on health systems, not only in terms of the scientific and logistical challenge of countering a new virus, but also in terms of allocation of resources and frequent disruption of essential services.5 This situation has created new barriers between the general population and the demand for healthcare, resulting in an intensification of health inequalities.2 6 Despite the lessons learnt from previous infectious diseases outbreaks,7 the COVID-19 pandemic demonstrated the lack of preparedness of healthcare systems, with significant implications for population health, economic growth of countries, social cohesion of communities and stability of governments and democracies.8 Moreover, shortage of investment in sectors such as healthcare, education and research has contributed to miscommunication, growing distrust in institutions and science, challenging public health decision-makers in implementing necessary measures to tackle the pandemic.9 10 Addressing these challenges requires strong evidence-driven public health leadership to coordinate an integrated policy response that can reduce the impact of the crisis and provide effective responses to increase resilience of health systems.11 In this context, keeping in mind Roger Gill’s quote ‘There is no one correct definition of leadership, or any one set of personal qualities or competencies that characterize leaders’,12 leadership is traditionally conceptualised through theoretical models that consider competence, behaviours and values. However, public health issues are complex, involve almost every sector of management and have consequences for every aspect of people’s lives, requiring public health leaders to engage multiple stakeholders in activities that are public and open to broad scrutiny and public debate.13 Models of health leadership need to consider the complexity of healthcare organisations, the intersectionality of challenges, and the need to involve and empower the population to give sustainability to the actions and the policies adopted. During the COVID-19 emergency, people who had to manage the pandemic both at a macro (political, governmental and institutional) and micro level (eg, in a hospital and local healthcare settings) faced several challenges, such as the limited or constantly changing nature of information, the need for rapid and problem-oriented responses, and fear and mistrust of the population.14 Therefore, leaders are required to direct, guide and establish the most appropriate strategies to make a difference between success and failure in the management of potentially catastrophic situations at all levels.
In this context, the aim of this review is to summarise evidence on the main leadership’s characteristics reported during the COVID-19 pandemic. Identifying capacities, values and traits of leaders can help institutions and educators to build programmes that ensure a workforce capable of strengthening the resilience and preparedness of healthcare systems and leading public health to address possible future threats.15
Methods
Search strategy
This scoping review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.16 A search of relevant articles was performed in the PubMed, Scopus and Web of Science databases using a query related to leadership skills and characteristics during the COVID-19 pandemic (online supplemental figure 1). The search was performed from January 2020 to February 2022. The resulting records were entered on the web application Rayyan-Intelligent Systematic Review,17 to be subsequently screened according to the inclusion/exclusion criteria. After the removal of duplicates, the selection of articles was made by reading titles and abstracts, and then full texts.
Supplemental material
Inclusion/exclusion criteria
Eligible articles were any type of publication that outlined one or more characteristics of public health leadership during the COVID-19 pandemic, such as communication abilities, soft skills, ethics and values, management skills, training and work experience. We included articles concerning local healthcare settings, specifically hospital directorate and medical and nursing management of wards, or public health management at a national or international level. We considered articles published between the beginning of the healthcare emergency in January 2020 and February 2022. We considered only articles written in English or Italian. We excluded all articles that did not explicitly address the COVID-19 pandemic or with a different setting (eg, veterinarian, schools, enterprise). Moreover, we excluded articles that did not identify any leadership characteristics, intended as communication abilities, soft skills, ethics and values, management skills, training and work experience (wrong outcome).
Selection process and data extraction
Each record was assessed by title and abstract by two independent reviewers (VFC and FD’A). Any disagreement between reviewers, whether necessary, was discussed and solved with a third reviewer (TO).
The full-text assessment was performed in the same manner, thereby identifying the final list of eligible articles. Data extraction was performed by two reviewers (TO and AVG), and every disagreement was resolved by discussion with a third reviewer (LV). The data from the eligible studies were extracted in a predefined Excel sheet, defined by the following columns regarding information extracted from the studies: authors’ name, publication year, study country, study design, type of publication, study setting and main findings. Three reviewers (TO, AVG, LV) analysed and clustered elements that emerged from the analysis by using an iterative process rooted in grounded theory to compare and develop emergent themes.18 Thus, characteristics emerged as relevant and the number of times each characteristic was discussed was clustered in six macro groups: human traits, behaviour and emotional intelligence; management skills and decision-making; team working, collaboration and empowerment; responsiveness and preparedness; communication skills and stakeholder engagement; evidence-based approach and innovation. Finally, the entire research team discussed the clustering results to identify and resolve any disagreements.
Results
The overall research in the three databases yielded a total of 2449 articles. After duplicates removal, 1471 articles were screened based on the title and abstract. In total, 132 full-text articles were selected. Following the inclusion and exclusion criteria, the screening resulted in the final inclusion of 45 articles. Details about the study selection process are shown in figure 1. Of these, 7 were literature reviews (15.6%), 16 were research articles (35.6%) and 22 were classified as ‘other’ (48.8%), including editorials, commentaries, opinion pieces and reports.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram.
Data were recruited from a variety of countries, with the USA being the most represented, although about 30% of the articles are not placed in any specific geographical setting but produce general considerations.
More than 57.8% of the articles (n=26) addressed public health management setting, at national or government level, while 19 (42.2%) hospital setting, involving physicians (11.1%), nurses (11.1%), healthcare directorate and management (20%) (table 1).
General characteristics of the included studies
Leadership characteristics and clustering
We identified 93 characteristics (a characteristic can be expressed several times in different studies, for a total of 170 citations) that we clustered into six main groups: human traits, behaviour and emotional intelligence; management skills and decision-making; team working, collaboration and empowerment; responsiveness and preparedness; communication skills and stakeholder engagement; evidence-based approach and innovation.
Among the groups, in three cases (management skills and decision-making; team working, collaboration and empowerment; evidence-based approach and innovation), we found both positive and negative aspects related to the leaders’ characteristics. The groups identified are shown in table 2, while table 3 specifically reports the nomenclature and the frequency of each item found.
Number of articles reporting leadership characteristics by categories
Aspects of leadership mentioned in articles by categories
Characteristics attributable to the first group, ‘human traits, behaviour and emotional intelligence’, were identified in 21 articles (46.7%), 8 of which were research articles,19–26 11 opinion pieces27–37 and 2 reviews.38 39 In particular, empathy and ‘honesty and truthfulness in relationships’ were the two most cited characteristics (six and three times, respectively), followed by compassion, emotional intelligence and psychological safety, attention to psychological well-being, emotional effectiveness, equity and values, sense-making and sense-giving (all cited two times). Other characteristics emerged only once from the analysis (table 3).
In group 2, ‘management skill and decision-making’, we identified 15 articles (33.3%) containing features from this domain: 5 research articles,19 21 40–42 7 opinion pieces29 33 35 36 43–45 and 3 reviews.38 46 47 Elements that have emerged most frequently are decision-making (eight times), organisation and planning (both three times), adherence to rules, influencing policies, prepare (twice each). Moreover, in this group, three characteristics emerged as negatively associated with public health leadership: ‘inconsistent policy position’, ‘management at federal level’ and ‘unpredictable behaviour’.48 49
Sixteen articles (35.6%) were related to group 3, ‘team working, collaboration and empowerment’, of which eight research articles,19 20 22 24 26 42 50 51 six opinion pieces34 36 37 52–54 and two reviews.38 55 Notable characteristics are collaboration, which emerged predominantly five times, accountability, empowerment and team building (three times each), and shared decision-making/leadership (twice). Lack of coordination was underlined once as a negative aspect,49 while autocratic leadership was still presented as a deductive factor.56
Eighteen studies (40%) were included in group 4, ‘responsiveness and ‘preparedness’ (10 research articles,19–21 24 40–42 50 51 57 5 opinion pieces32 34 35 44 51 and 3 reviews38 46 47). ‘Adapt according to the situation’ was the most cited characteristic (seven times), followed by resilience (four times), act fast, creating strategies, ‘integrative and systematic thinking skills’ (three times), and pragmatism (twice).
The characteristics of the fifth group, ‘communication skills and stakeholder engagement’, were reported in 7 research articles,19–22 24 26 42 13 opinion pieces27 29–31 35–37 43 45 52 58–60 and 2 reviews38 61 (48.9%). About this topic, elements that emerged with greater frequency are clear communication, (10 times), transparency (6 times), advocacy, risk and crisis communication (2 times each).
Finally, group 6, ‘evidence-based approach and communication’ aspects have been found in 14 articles (31.1%), of which 5 research articles,19 20 25 62 63 7 opinion pieces27 32 35 36 44 53 60 and 2 reviews.46 47 ‘Evidence-based decision-making’ (six times) and technological skills (two times) are the most represented characteristics. Finally, one opinion piece48 highlighted ‘mistrust of science’ as a negative feature.
Finally, we found a different distribution of the characteristics according to the healthcare setting and type of professionalism (table 4). In particular, characteristics related to communication and team working, human traits and management capabilities were reported in articles dealing with medical professionalism, while no articles focused on the importance of the evidence-based approach. The importance of team working was reported also in articles dealing with nursing professionalism, as well as evidence-based approaches. In the articles dealing with the healthcare directorate, we found many leadership characteristics, such as human traits, preparedness and communicative elements. Finally, in the public health management setting, we mainly found leadership characteristics such as communication, team working and those related to human traits.
Distribution of leadership characteristics according to the healthcare setting and type of professionalism
Discussion
In this scoping review we summarised the main leadership’s characteristics that emerged during the COVID-19 pandemic, addressing both governmental and international as well as local settings. In detail, we identified six macro groups referring to several aspects of leadership that are reported as fundamental in order to be a good leader, capable of managing a public health emergency. Elements emerged from this analysis outline a varied profile, ranging in different characteristics and capacity areas. Human traits, behaviour and emotional intelligence emerged as really necessary to create and transmit trust and confidence, both at an institutional level (and therefore to citizens) and in the work team. In particular, empathy, compassion, attention to well-being and honesty are reaffirmed as key characteristics for ensuring credibility and trust,64–66 allowing the implementation of actions and measures, specifically during the pandemic, without causing doubt, perplexity and, in extreme cases, anger from the population. These points are closely linked to communication skills. Our study, in fact, shows that clear communication and transparency are the most cited characteristics in the description of the communication skills of a good leader during the pandemic. Indeed, the ability to communicate information in a clear, empathetic and evidence-based manner is critical to enable people to understand and accept measures being taken.67 68 The same could be highlighted at a micro level, like for example in hospital setting, where clear and transparent communication within the team and towards patients is fundamental for effective project development and goals’ achievement.69 70 A clear example of wrong communication and misinformation is about the COVID-19 vaccine campaign, where, based on assumptions and not on data, the administration of the AstraZeneca vaccine was stopped claiming associations between vaccination and increased risk of death.71 The suspension of this vaccine generated great panic among citizens, increasing doubts, fear and vaccine hesitancy,72 causing a slowdown of the campaign.
Similarly, the lack of transparency and objective communication of risk by several political leaders all over the world led to underestimation of the risk and made it impossible to control the spread of the infection in many countries, resulting in a high number of cases and deaths.73–75
Second, the results report as characteristics of a good leader, ‘management skill and decision-making’, closely related to ‘team working, collaboration and empowerment’. Another important theme is related to ‘responsiveness and preparedness’, with reference to the ability to plan and predict events in order to optimise resources available. Extending this vision to an international level, the definition of a clear chain of command and the centralisation of some decisions are a necessary prerogative for the correct management of an emergency.76 This is consistent with the vision of the dynamics that regulate the events during a pandemic as attributable to a system that we can define as ‘complex adaptive’,77–79 so it requires not only careful planning14 but also a considerable adaptability and resilience.
Leaders, by definition, never work alone, so it is essential that he or she is supported by a loyal and responsive working group, creating a constructive synergy. Of course, to achieve this type of relationship, it is important for leaders to provide inputs aimed at conveying a sense of empowerment to the group, promoting team-building dynamics that shift the structure of some decisions on a more shared level.80
Finally, another important aspect emerged from our study is the focal role of ‘evidence-based decision-making’ acquired during the COVID-19 pandemic. A leader’s activity in public health cannot be done without a robust system of scientific evidence to support decisions. This both to implement decisions that will positively impact the course of events and to fully justify the direction taken in a public health perspective.81 82
Regarding the distribution of leadership characteristics according to different settings, we noted a homogeneous distribution of qualities in specific settings. Indeed, both of the health directorate in local health authorities and hospitals and the public health management are representations, at macro and meso levels, of organisational and health planning settings, in which the leader is called to deal with multidisciplinary and varied inputs,83 thus requiring all the different categories highlighted by our study. Therefore, in these specific contexts, the clusters we have identified constitute paramount cross-cutting and key elements in the identification of the figure of a leader. Indeed, these are settings that can be traced to the complex system model, and as such require a systemic and inclusive approach of multiple elements,84 such as the one proposed in this work. Indeed, leaders operating in these areas should have a profile that reflects the multiplicity of challenges they face. This element suggests the importance of a cross-fertilisation of skills and capabilities between healthcare workers, including clinicians, surgeons, nurses and public health professionals. Thus, creating joint training programmes, taking into account the various characteristics we have identified, would improve professional capabilities and knowledge, fostering collaboration within complex systems at different levels.
Strengths and limitations
As far as we know, this is the first scoping review investigating characteristics of leadership during COVID-19 and succeeds in providing a comprehensive set of all the main qualities of a public health leader described in the literature. However, it is necessary to highlight the structural limits of some of the studies included in the analysis, as they lacked a standardised methodology in the process of identification and evaluation in terms of the characteristics and qualities regarding leadership in public health. Furthermore, in the search for articles, only articles in English and Italian were selected, which may have resulted in the omission of literature from some geographical areas. Given the limited number of studies in the literature aimed at measuring the effectiveness of a leader’s competencies in various contexts and the possible variables of interest, it is advisable to increase research aimed at finding methods to measure how leadership competencies actually influence the impact of public health measures and consequently the well-being of the population.
Conclusions
The pandemic has highlighted the need for leaders highly prepared to manage public health emergency contexts. Of course, identifying a leader who possesses all the qualities we highlighted in our study could appear difficult or even impossible; however, for this reason, it is necessary and more urgent than ever to continue and increase investment in the preparation of those in charge of guiding people across difficult situations like the one we are experiencing with the COVID-19 pandemic. In this context, the training of professionals and leaders is a paramount action to address the challenges of the future in public health. In the area of communication, it would be appropriate to integrate training programmes specifically targeting communication skills into health professionals’ and decision-makers’ curricula at different organisational levels. We cannot assume that a single communication style fits all settings and situations in which a leader operates; however, by taking advantage of the available evidence,85 it is possible to identify the most appropriate educational tool for the development of effective communication skills. Similarly, the other elements that emerged from our study, such as adherence to an evidence-based approach in decision-making processes, emotional intelligence and team working abilities, should be included in the training programmes, in order to prepare leaders who interface with public health issues.
The development of research in the field of public health leadership can, starting from the characteristics we have identified, make use of quantitative and qualitative methods to investigate with increasing rigour the weight these attributes have in the management of critical public health issues. In this sense, future studies that can analyse more thoroughly the specific role in health crises of elements related to human traits, team working and communication skills are desirable, possibly proposing objective evaluations of how these factors have weighed in the management of the COVID-19 pandemic in different global settings. It would also be useful to investigate further the gaps in the literature referring to the lack of articles highlighting the importance of the evidence-based approach in a physicians' leadership setting and the crucial role of communication in nursing.
Finally, it is necessary to dwell on technological and digital skills, particularly related to the information sector and social media, as those deeply affecting the dynamics underlying the social response to health policies aimed at responding to a pandemic situation.86 The importance, today, in knowing how to use digital and information technology tools for the benefit of shared health is, in our view, critical in defining the characteristics that compete for a public health leader.
Thus, the value of our research lies in providing a comprehensive view of the attributes to look for in the figures we place at the top of our decision-making systems, promoting the value of leadership research and training to ensure we are prepared for future public health emergencies and emerging challenges affecting public health interventions.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Collaborators Public Health Leadership Coalition: Natasha Azzopardi Muscat, WHO Regional Office for Europe, Copenhagen, Denmark; Georges Benjamin, American Public Health Association, Washington, DC, USA; Bettina Borisch, Institute of Global Health, University of Geneva, Geneva, Switzerland, World Federation of Public Health Association, Geneva, Switzerland; Luis Eugenio de Souza, Health Collective Institute, Federal University of Bahia, Salvador, Brazil; Sharon Friel, Menzies Centre for Health Governance, School of Regulation and Global Governance, The Australian National University, Canberra, Australian Capital Territory, Australia; Alejandro Jadad, Centre for Global eHealth Innovation, University of Toronto, Toronto, Ontario, Canada; Jeff Smith, Australian Centre for Climate and Environmental Law, University of Sydney, Sydney, Australia; K Srinath Reddy, Public Health Foundation of India, New Delhi, India; Rüdiger Krech, Division of Universal Health Coverage and Healthier Populations, Department of Health Promotion, WHO, Geneva, Switzerland; Martin McKee, London School of Hygiene and Tropical Medicine, London, UK; Michael Moore, Public Health Association Australia, Curtin, Australian Capital Territory, Australia; Iveta Nagyova, European Public Health Association (EUPHA)-president, Utrecht, the Netherlands; Jean-Marie Okwo-Bele, Board of Trustees of the International Vaccine Institute; María del Rocío Sáenz Madrigal, School of Public Health, University of Costa Rica, San José, Mercedes, Costa Rica; Stefano Scarpetta, Director for Employment, Labour and Social Affairs at the OECD, Paris, France; Melissa Sweet, Croakey Health Media, Sydney School of Public Health, University of Sydney, Sydney, Australia; Sheila Tlou, Department of Nursing Education, University of Botswana, Gaborone, Botswana; Collin Tukuitonga, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Contributors All authors, including the collaborating group, contributed to the study conception and design. Material preparation and data collection were performed by TO, AVG, LV, VFC and FD'A. The data extraction was performed by TO and AVG, and every disagreement was resolved by LV. The first draft of the manuscript was written by TO, AVG, FC and ML. MRG and WR commented on the latest version of the manuscript and supervised the study. All authors, including the collaborating group, read and approved the final manuscript.
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.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.