Article Text

Building towards organisational resilience and complexity leadership: a case study of impacts and changes in a Dutch blood establishment during COVID-19
  1. Praiseldy K Langi Sasongko1,2,
  2. Mart Janssen2,
  3. Martine de Bruijne3
  1. 1Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
  2. 2Department of Donor Medicine Research, Sanquin Research, Amsterdam, Netherlands
  3. 3Public and Occupational Health, Quality of Care, Amsterdam UMC Locatie VUmc, Amsterdam, Netherlands
  1. Correspondence to Dr Praiseldy K Langi Sasongko, Public and Occupational Health, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, Netherlands; p.k.langisasongko{at}


Objectives This study examined how one large blood-related establishment coped and adapted during the first 1.5 years of the pandemic by evaluating the impacts and changes on its resources, communication, collaborations, and monitoring and feedback. Furthermore, we explored whether elements of complexity leadership emerged during this time.

Design Duchek’s organisational resilience framework was primarily used. We followed a three-step sequential approach: (1) a document analysis of over 150 intranet, internet and internal reports; (2) 31 semistructured interviews with employees and (3) four feedback sessions.

Setting Sanquin is known as the Dutch national blood bank and a large multidivisional expertise organisation in the Netherlands.

Results Sanquin coped well. Respondents accepted the crisis and catalysed many collaborations to implement solutions, which were communicated to the public. There were many positive aspects related to internal collaborations, yet challenges remained related to its historical siloed structure and culture. Sanquin adapted partially. Many respondents experienced the organisation becoming more connected and flexible during the pandemic. However, Sanquin was not permanently changed due to significant leadership changes and organisational restructuring occurring simultaneously. Respondents reflected on lessons learnt, including the need for continual collaboration and improvements in Sanquin’s culture. An important driver in the successful coping was management’s enabling attitude and the adaptations occurring within and through the collaborative groups.

Conclusions Sanquin improved its organisational resilience by exhibiting elements of adaptive spaces, enabling leadership and (temporary) emergence from complexity leadership. This illuminates how the organisation could continue benefiting from complexity leadership for non-crises and for future uncertainties.

  • COVID-19
  • management
  • leadership assessment
  • medical leadership

Data availability statement

No data are available. The qualitative data are not publicly available due to the identifying nature of the transcripts and lack of consent from participants to publicly share this data.

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:

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  • Healthcare organisations had to find a way to cope and adapt during the turbulence of COVID-19. Studies have highlighted the need for ‘organisational resilience’ and illuminated ‘complexity leadership.’


  • This study ties both organisational resilience and complexity leadership by first assessing the specific ways a Dutch multi-expertise blood organisation coped and adapted. Findings show how the pandemic created an opportunity window for elements of complexity leadership to emerge and make the organisation successful during this time.


  • Implementing complexity leadership in an organisation may be worthwhile in building organisational resilience for times of crises and non-crises.


The COVID-19 pandemic is a ‘wild card’, a volatile disruptive event that severely affects the human condition and is beyond the scope of human control.1 It can also be considered a ‘creeping crisis’ which occurs after a long incubation period and continues ‘simmering’ after the acute phase is over so that there ‘a seemingly permanent, epochal character, generating regular outbursts without reaching closure’.2 It is complex, due to the rich interconnectivity of things interacting and changing one another in unexpected and irreversible ways.3

Like a magnifying glass, the pandemic exposed the vulnerabilities of the healthcare sector and the need for resilience.4 Resilience is a multi-capability to anticipate, cope and adapt before, during and after crises. It comprises a multistep process that builds on a set of an organisation’s inward capabilities and routines.5 Two of these steps are coping (accepting the situation and developing solutions) and adaptation (reflecting, learning and changing).5 While the need for resilience within healthcare is not new,6 there is a resurgent call for healthcare organisations and systems to become resilient during these uncertain times.7 8

As part of the resilience process, complexity leadership is required. Complexity leadership theory (CLT) is a framework to understand how to enable the adaptability of people and organisations by assessing the social (and dynamic) interactions that occur within an organisation. As pressures occur, the system must change. There is an emphasis on ‘enabling’ leaders who foster adaptive spaces; adaptive spaces are where processes of conflict, connection and reintegration occur between those who have an ‘order’ response (operational leaders), and those who have an ‘adaptive’ response (entrepreneurial leaders). The role of complexity leaders is to keep the system from staying in order by enabling adaptive responses.3 9

Prior to the pandemic, we became interested in organisational resilience related to what a traditionally run Dutch blood bank needed to do or become to thrive into future uncertainties within transfusion medicine and healthcare at large. We found that ‘disruptive events’ formed an important but highly uncertain topic that would impact blood demand.10 Therefore, when this organisation (the Sanquin Blood Supply Foundation) quickly began various initiatives in response to the pandemic, it was an opportunity to link our prior results to the present circumstances and conduct a one-and-a-half-year observational study of the impact of this disruptive event on the organisation and its resulting organisational changes.

Therefore, our research aims were to:

  1. Examine how Sanquin coped and adapted during the pandemic as part of its organisational resilience process.

  2. Evaluate whether and how elements of complexity leadership emerged during that time.


Theoretical concepts and framework

Organisational resilience

Resilience is a meta-capability of an organisation, combining the abilities to anticipate potential threats and be prepared for, effectively cope with and adapt or learn from it. Duchek’s framework outlines three stages of resilience, of which we focused on the second and third stages as they were appropriate to the current stage of research and current state of pandemic at that time. The second stage of coping occurs during the disruptive event and requires (1) accepting the situation at hand and all its uncertainties and (2) developing and implementing solutions using social resources as part of cognitive and behavioural actions. The third stage of adaptation occurs after the disruptive event and involves (1) reflection and learning and (2) change.5 Underlying these stages are the main antecedent (knowledge base) and drivers (resource availability, social resources, and power and responsibility) that affect all or some (figure 1).

Figure 1

Duchek’s organisational resilience framework5 reproduced from a Creative Commons Attribution 4.0 Licence.

Setting the scene

In the Netherlands, Sanquin has been known primarily as the national blood bank, the sole entity legally tasked to collect blood and produce products under the Dutch Blood Supply Act. Under the Sanquin Foundation, there are two distinct but interconnected entities: a not-for-profit side (consisting of the blood bank, research and lab services, and corporate staff and services) and a for-profit side (consisting of Sanquinnovate and Diagnostics). Hence, Sanquin is a multi-divisional, multi-expertise organisation that singularly and collaboratively carries out its public and private duties.11


A three-step, consecutive qualitative approach was conducted:

  1. A document analysis of over 150 intranet, internet and internal Sanquin reports.

  2. Semi-structured interviews (n=31) with Sanquin employees.

  3. Four feedback sessions with Sanquin employees.

The document analysis was the first step. It began with assessing Intranet articles, posted by Sanquin’s Communications Department under the ‘coronavirus’ tag during March 2020–April 2021. This time frame was chosen to gain knowledge of the events that happened within the first year of the pandemic and of the employees who were active therein. Some of these posts had links to external (public) articles of Sanquin, which were also reviewed. Internal reports voluntarily shared from employees interviewed in step 2 gave further information regarding initiative(s) and its outcomes.

From June 2020 to August 2021, interviews were done using purposeful sampling from the key employees found in step 1. Inclusion criteria were that they were a Sanquin employee for at least a year, had been involved in a COVID-19 initiative and were willing to communicate in English. An interview guide was created in line with the research questions, and a semistructured method was chosen to allow for additional probing and follow-up questions as appropriates.12 All but one of the interviews occurred virtually or over the phone. Recording was done with consent and interview notes were kept for all. Respondents were free to recommend others to be interviewed. Interviews were done until saturation was reached.

As a last step, the results from steps 1 and 2 were analysed and shown back to respondents during four feedback sessions in January 2022 with differing the number of participants (n=1, 50, 7, 75). Two of these sessions (sessions 1 and 3) included only prior respondents while the other sessions included both prior and new respondents, which occurred during mandatory presentations for the research division. In all sessions, the first author presented the anonymised findings and invited open feedback from the audience.


Interviews were transcribed verbatim if they had been recorded; if they were not, the meeting notes were analysed instead. Qualitative software (MAXQDA 20202, VERBI Software) was used to conduct first-cycle coding using a predetermined coding scheme based on the research aims as described by Saldaña.12 Author PKLS and two external researchers assessed three transcripts independently, came together to discuss coding differences to the point of consensus and adjusted the coding framework. PKLS continued coding the remaining transcripts and then applied second-cycle coding, combining categories under emergent themes.12 To validate findings, the document and interviews were used to cross-examine one another. Furthermore, the feedback sessions were intended for respondents to see the anonymised results thus far, correct them if necessary and allow for their insights and interpretations. Interview summaries and transcripts were discussed regularly with the authors of this paper.

Patient and public involvement

Patients were not involved in any process of this study.



From the document analysis, 165 documents were reviewed: 150 which came from the Intranet and 15 which came from internal reports shared by the respondents.

Thirty-one employees were interviewed: 70% of them had worked between 11 and 45 years at Sanquin, representing the major divisions within the organisation.


The elements of acceptance, developing and implementing solutions, and the underlying drivers of social and resource availability are described below.

Acceptance and momentum

From the document analysis and interviews, the most prominent theme was that respondents not only accepted the scenario but were compelled into unifying action as exemplified by this quote: "And now, in the COVID-19 crisis, everybody had the opportunity to do a contribution. It created a common sense [of direction] of ‘Let’s do it. We can do a lot of important work, so let’s move forward, and let’s make it happen’[…]The magnitude of COVID-19 crisis created a platform we needed " (Corporate staff1, 20 years). Even in the face of difficult circumstances (words like ‘pressure,’ ‘intense’ and ‘urgency’ were used), respondents stated that they focused on having ‘common or clear goal.’ This acceptance and commitment led them to developing and implementing solutions, which came in the form of collaborations, modified communication methods and monitoring and feedback.


The topic of collaborations was the most prominent theme found in the interviews and the document analysis. Approximately 30 internal and external initiatives were found, ranging from internal safety measures to national efforts like PCR testing and donor antibody monitoring and many international research projects. Respondents shared how some collaborations were pre-existing, but others were new, and collaborations were markedly increased through COVID-19. One key aspect at the beginning of the pandemic was the organic, bottom-up nature of the research collaborations. Overall, respondents stated how unique it was that employees quickly sought each other across the organisation: "I collaborated with people that in the years before, [I] would never have collaborated with." (Researcher7, 15 years).

One document reviewed the quality of these collaborations, from those that were ‘more difficult’ to ‘excellent’ (the majority were good excellent; only one was deemed unsuccessful). From interviews, respondents shared how research collaborations were particularly rewarding, with quick data acquisition and many publications. Both the document analysis and interviews emphasised how joint collaborations with the Dutch government were of particular importance and success. Both the document analysis and interviews concurred that Sanquin’s multiexpertise knowledge base was the cornerstone as to why so many endeavours could successfully occur.

However, while there were many positive aspects, challenges remained (online supplemental table 1). Respondents shared how many of these challenges were rooted in the pre-existing structural and cultural organisational elements that came to the forefront as different departments worked together. Overall, while there was a clear, common goal and coordination, some groups still struggled with lack of governance and leadership issues, which caused delay and confusion.

Supplemental material

Communication methods

Both the document analysis and interviews revealed how because most employees worked from home, communication patterns and venues were modified and increased. For internal purposes, respondents explained how this resulted in more frequent use of existing communication means while creating new ways of communication, such as the Help Hotline which provided COVID-19 work advice from Sanquin physicians for employees at a response rate of within 2 hours. Respondents explained how the pandemic’s uncertainty forced the organisation to continue communicating and ‘communicate more’ on both microlevels and macrolevels.

Externally, the organisation shared many of its initiatives with the public. The document analysis proved how Sanquin’s initiatives were in the Dutch media spotlight on a weekly basis for consecutive months into the years. This boosted Sanquin’s reputation, as seen in this quote: "For the image of Sanquin, it’s been a blessing." (Corporate staff2, 13 years).

Monitoring and feedback

As these initiatives were done, monitoring and feedback occurred in unique and expedited ways. The interviews and the document analysis showed how there was a group called the Corona Steering Committee comprised individuals from many of the ongoing initiatives who met regularly to provide updates about their initiative to seek or offer help and feedback as needed. This group also included personnel who were not directly involved in various initiatives directly (e.g., finance, communications) but could provide their expertise and gain insights to bring back to their own departments. Interview respondents who were part of this committee stated how helpful it was.

Externally, one initiative remained in the Dutch spotlight through the years and was a type of external monitoring that accommodated public feedback. The ‘Finger on the Wrist’ study measured COVID-19 antibodies within the donor population over time. The results were released regularly and directly to the public, instead of being published through scientific publication. This was the first large Sanquin study of its kind to be communicated in such a manner which allowed citizens to forward potential explanations for data fluctuations to the principal investigator.


All the COVID-19 initiatives were supported by the organisation’s resource availability. The document analysis and interviews recorded how Sanquin received more financial resources during this time from the Ministry of Health and also acquired more external research grants. Furthermore, interview respondents explained that since most of the initiatives were done next to pre-pandemic functions, they experienced a shortage of time, supplies, skilled personnel and difficulties with outdated medical systems. These lacks forced employees to be creative in the interim, and all respondents reiterated the collective social strength throughout.


The elements of reflection, learning, change and the underlying driver of power and responsibility are analysed below.


From interviews, respondents reflected on how the organisation was impacted by the pandemic by comparing how it was prior to, and during, the pandemic (table 1). Some even called this comparison the ‘old’ versus the ‘new’ Sanquin as they saw a traditional, siloed and slow organisation become more connected, flexible and adaptive. For the majority, this was the first time they had experienced such shifts, and the consensus was that it was enriching and empowering. However, two respondents mentioned how they had experienced this activated spirit once before, namely during the HIV pandemic in the 1980s/1990s.

Table 1

Comparison of the organisation prior to and during the pandemic

However, while Sanquin was strongly impacted by the pandemic, it was not permanently changed. This was because there were significant leadership changes and organisational restructuring that were occurring simultaneously. These drivers were distinct from COVID-19 as they had begun before the pandemic, but through the interviews, it was found that some effects intertwined. These included how employees were overall more agreeable/cooperative in the processes of the restructuring and adjusting to new leadership ("A pandemic kind of helps in the sense that crises often help to get people to cooperate." Management1, 1 year). One respondent pointed out that COVID’s main effect on the organisation was to slow the process of separation. During feedback sessions, respondents agreed that the leadership changes and organisational restructuring were what was bringing significant and permanent organisational changes, not the pandemic.

Lessons learnt

Thus, interview respondents shared many lessons learnt, divided into themes of resources, culture/way of working, internal collaborations and communications, and external collaborations and communications (table 2). Many of these themes intertwined as the respondents pondered the elements of improving future collaborations and identified how to improve the culture/way of working both within collaborative groups but also within the organisation at large. These themes were mirrored within the document analysis, for example, as seen in the Corona Steering Committee’s compilation of lessons learnt in their final report. Such cumulative reports were submitted to management but respondents did not know or experience any permanent changes or implementations thereafter. Collaborations had dissolved or were near dissolving by the end of 1.5 years, with a few initiatives that remained in Sanquin’s organisational process. Therefore, interview respondents commented on how the organisation seemed to be shifting back to the ‘old’ Sanquin and suggested improvements (table 2).

Table 2

Lessons learnt with illustrative quotes

Power and responsibility

From the interviews and document analysis, one significant aspect that occurred during the coping phase was top management’s attitude and support of the collaborations. As many unfurled organically, management was compelled to enable and equip them as much as possible, aiding with major steps such as ethical approval and funding: "We've tried to fund everything and to make all the initiatives make it to execution…But this was the culture at the management level: ‘Let’s make it happen.’" (Corporate Staff1, 20 years). In fact, several interview respondents stated that top management continued to support the growth of these initiatives giving so much freedom that respondents wished there had been more guidance from the top.

The document analyses highlighted specific persons who were either spearheading or involved within these initiatives; however, there was less emphasis on specific persons, but the groups they were part of, and how adaptation was occurring within and through these groups (i.e., new ideas, products, processes): "The way that different parts of the organization collaborated and participated in this one big project, that is unprecedented, I think. I was impressed by the speed and energy at which this was done." (Researcher5, 12 years).

However, 1.5 years later, in one feedback session, one respondent who is from the top management asked how to continue cultivating this organic collaborative spirit as it seemed to be disappearing.


This study examined how a multi-expertise blood-related organisation has coped and adapted during the first one-and-a-half years of the COVID-19 pandemic and whether complexity leadership elements emerged during that time.

Overall, Sanquin coped well. In line with Duchek’s model,5 excellent coping was attributed to the abilities of the organisation to accept, have monetary and social resources (although staff was limited, staff was willing) and implement solutions. In fact, the pandemic was an opportunity window for the organisation to showcase its expertise and benefit publicly and financially; hence, COVID-19 could be considered a ‘constructive crisis’13 for the organisation. As highlighted in the literature, the ability to accept and implement solutions requires bricolage, using existing resources towards new problems, and improvisation, the ability to act spontaneously and intuitively and ad hoc in an emergent manner.14–16

Furthermore, coping links to the next stage of resilience, adaptation, as ‘coping with crises builds the foundation for reflection, learning, and change’.5 Our study found that Sanquin partially adapted, with many lessons learnt, which included how the organisation became more collaborative with a stronger collective identity than it was prior to the pandemic. However, organic collaborations stopped or were near stopping a year and a half into the pandemic. Respondents were lamenting the return to ‘business as usual’ and even top management wondered how to continue this activated spirit. Arguably, the organisation had to revert to a place of more ‘normalcy,” as an organisation cannot be in a constant crisis mode, and the phase of the pandemic allowed for more stability.17 However, this ‘business as usual’ describes a return to the precrisis status, which respondents found wanting. Some healthcare studies describe how the pandemic created favourable conditions for improvisation and innovation7 8 18 19 and for some organisations, COVID-19 was a ‘catalyst for change’.20 For Sanquin, COVID-19’s effects to ‘catalyse change’ were less significant than the leadership changes and organisational restructuring that were occurring simultaneously. This result highlights Duchek’s framework, where power and responsibility are the driver for adaptation. Duchek describes the connection as such: ‘While crises can open ‘windows of opportunity’ for adaptation processes, crises alone do not automatically lead to learning and overall change. Organisations often generate new knowledge (‘lessons learnt’) but fail to translate this knowledge into new behaviours. In this context, power and responsibility play an important role (Duchek, p. 237, emphasis mine).5

Thus, through the lens of CLT, we realised that COVID-19’s impact on Sanquin was to change the dynamics of power relationships, shifting organisational structure and culture during this time. COVID-19 was the external pressure that put Sanquin’s system into disequilibrium, forcing the organisation to cope to find solutions.21 Here, the elements of adaptive process, adaptive spaces and enabling leadership occurred. The resulting collaborations were examples of adaptive spaces where Sanquin’s entrepreneurial (innovative) persons were forced to work together with operational (stability and efficiency) persons to achieve their aims. Within these spaces, respondents experienced how to conflict and connect well (defined as finding ways to bridge differences to create adaptive solutions, or linking up ideas, information, resources in beneficial ways or a beneficial new order.22 Overall, these spaces enthused respondents because it was the first time that many of them experienced its fruitfulness. Additionally, the strong support and wide freedom from top management were novel and significant as it gave room for these adaptive spaces to continue. Furthermore, enabling leadership occurred through the presence of key persons (not necessarily managerial) who led these collaborations and/or fostered the adaptive process by using skill and creativity to unite people together.22 Lastly, the adaptive process was completed when the solutions within the adaptive spaces became incorporated into the operating system in the form of new order21 (e.g., new processes, new blood product, digitalisation of the donor registration form). However, as found by our respondents, and described in CLT, after a certain time, the opportunity window for adaptation closes and it becomes more difficult for adaptive spaces to occur unless CLT elements are built into the system.21 22

With regard to leadership, the collective COVID-19 experiences have shown that for organisations to thrive in turbulent times, it is not and cannot be one person who is the sole driving force for survival and success, but an entire system composed of meaningful and effective interactions.7 8 22–26 Put simply, as CLT states, leadership is co-creation.21 Leadership studies from the pandemic period have similar overtones that leadership needs to be a sustainable, collaborative, changing mentality,20 27 28 focusing more on purpose and relationships than outputs and/or outcomes20 21 27 so that there is a shift away from ‘planned’ to ‘playful’ change.29 Complexity leaders are described as having attributes of deep conviction to take risks in creating adaptive spaces for others but humble enough so others can take the lead. They are willing to engage with tension and ambiguity and use it to propel forward action. They possess skillsets of brokering, connecting, facilitating and energising learning and growth. Complexity leaders share credit and work collaboratively as seeing people engaged and systems changing gives them deep fulfilment and fun.3 9 Uhl-Bien describes how healthcare systems, when faced with complexity, usually respond with traditional bureaucratic approaches. She advocates that instead of adding complexity leadership on top of traditional leadership, it is more effective to replace the latter with complexity leadership. This requires a multiprong approach that includes top management laying out the strategy, the willingness of operational, entrepreneurial and enabling leaders who support one another within the adaptive process, and a reduction in unproductive bureaucratic meetings or processes.22 This provides an opportunity for Sanquin to decide whether to implement CLT practices sparked during the pandemic for times of non-crises. Doing so would enable the organisation to become more adaptable, which is the heart of both resilience and CLT, and be a way forward with regard to future uncertainties regarding blood demand, transfusion medicine and healthcare at large.

To our knowledge, this is the first empirical study to assess the specific impacts on a Dutch blood establishment during the first 1.5 years of the pandemic. While it is limited to one setting, it portrays common challenges and opportunities faced in a crisis, thereby extending relevance to other healthcare organisations and, potentially, other healthcare crises.


Our results show how a traditional blood organisation was able to improve its resilience by displaying complexity leadership. Complexity leadership enabled the organisation to successfully cope during the pandemic, thereby illustrating its potential to continue to improve its resilience through a structural and cultural transformation.

Data availability statement

No data are available. The qualitative data are not publicly available due to the identifying nature of the transcripts and lack of consent from participants to publicly share this data.

Ethics statements

Patient consent for publication

Ethics approval

Sanquin’s Executive Board gave approval for this study, waiving it from needing further ethical approval by Sanquin’s Research Board, due to its lack of obtaining confidential data or personal contact with donors, patients or vulnerable groups. Respondents gave written and verbal informed consent to participate in the study before taking part.


We wholeheartedly thank all the participants in this study, not only for their responses but for their passionate and committed efforts during the pandemic. The authors also thank J. Schröder for his help in the analyses and F.K. Boersma for his insightful guidance.


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.


  • Contributors PKLS initiated the research idea, conducted the data collection, analysed the data and drafted and revised the paper. She is the guarantor. MJ and MdB supervised data collection and revised draft papers.

  • Funding This study was supported by an internal grant PPOC-L2245.

  • 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.