Leadership in Times of Crisis

The emergence of covid-19 has created the need for nurse leaders to respond rapidly and decisively to the demands and challenges of a pandemic within a context of increased staff shortages and limited resources. This article aims to highlight the importance of decision making and emotional intelligence, suggests key leadership skills and strategies that nurses can use to underpin effective leadership in a crisis. We also address two key questions: 1. What do leaders in a crisis need to do that differs from any other time? 2. How do we know what effective leadership looks like in a crisis?


Introduction
The term 'crisis' is widely used to describe a period of intense difficulty, suffering or danger.At the macro level the term has been used in relation to global climate change and economics, for example the global financial crisis of 2007-2008.At the national or meso level we have seen the term 'UK nursing crisis' used to describe the ongoing nursing recruitment and retention challenges in the NHS and at the micro or community level, crises may relate to physical and mental health, finances and relationships.At the time of writing, we are in the midst of a global pandemic, , which has created intense difficulty, suffering and danger globally, nationally and within communities, families and for individuals.Nurses are currently at the core of the response to the demands of the crisis which requires us to focus on all four themes of the Code: prioritise people, practise effectively, preserve safety and promote professionalism and trust (NMC 2018).
We had not heard of Covid-19, which is a newly discovered coronavirus, until January 2020.From observing countries further ahead of us in the pandemic, we knew the virus was highly contagious with particular groups of people at high risk of mortality.However, this is a novel virus about which many questions remain unanswered.In a period of weeks, against a backdrop of chronic nursing shortages, nurse leaders have been required to transform services to increase critical care capacity.They have, and are continuing to achieve this within a context of increased staff sickness and absence due to quarantine measures, a changing workforce including returners and student nurses who have opted to become members of the workforce, a shortage of equipment and a workforce who are tired and anxious.Nurse leaders are having to be highly responsive, adaptive and resilient and, in turn, they need their workforce to demonstrate the same characteristics.
This article aims to highlight key leadership skills and strategies that nurses can use to underpin effective leadership in a crisis.This links clearly with aspects of the Code; ensuring quality of care, dealing with risk, supporting staff and providing leadership to ensure wellbeing (NMC 2018).
After reading this article and completing the time out activities, you should be able to: • Outline communication strategies that can support crisis leadership • Describe key leadership styles and approaches that can be applied to crisis leadership • Consider the main contexts where situational leadership and compassionate leadership is of use • Describe the characteristics of a suggested framework for crisis leadership • Outline the importance of emotional intelligence in supporting the workforce.

Time Out 1
Spend 5 minutes thinking about three reasons why leadership in a crisis may demand different approaches and skills to everyday leadership.

The Covid-19 response and crisis leadership
Change is widely held to be one of the few constants within healthcare (Jones and Bennett 2018).However, the response to Covid-19 has required health services to transition, with unprecedented speed, in order to create increased intensive care capacity.It is not only the pace of change that is challenging, the context in which change is required is particularly complex.Because Covid-19 is a pandemic, there is a global shortage of equipment, meaning that countries are unable to support each other as they would if the outbreak was a regional epidemic.There is also an international shortage of nurses (WHO 2020), meaning that countries such as the UK have had to introduce a Covid-19 temporary register of nurses and midwives who left the register up to five years ago (NMC 2020a) who will be re-introduced into the health service alongside student nurses who have been invited to join the workforce.These members of staff are making a vital contribution to the Covid-19 response but leading new teams, with varying levels of expertise, is particularly challenging.Furthermore, the work environment is currently very stressful.Internationally, the psychological impact of nursing patients with Covid-19 has been highlighted by the International Council of Nurses (ICN 2020).Stressors include exposure to intense levels of human suffering, long shifts, a lack of equipment in some areas, fatigue related to wearing Personal Protective Equipment (PPE) and fears of contracting the infection.In the UK, there is much concern within the nursing profession regarding shortages of PPE (NMC 2020b).
Nurse leadership, therefore, currently needs to be even more visible than in usual circumstances.Mayfield and Mayfield's (2018) research-based leadership communication model is particularly helpful in highlighting the importance of team motivation and the need for leaders to demonstrate: • direction-giving (dispelling ambiguity and transparently sharing work expectations) • meaning-making (giving significance and cultural guidance to the work) • empathy (demonstrating others' experiences, perspectives and feelings).
Mayfield and Mayfield (2018) demonstrate a positive relationship between the use of these facets of motivational language and performance as well as other outcomes such as job satisfaction, willingness to express voice, decreased staff turn-over and reduced absenteeism.However, leaders tend to use direction-giving too much and under-use meaning-making and empathy.

Time Out 2
Reflect on how you communicate by considering the three points above.Do you give one aspect more thought and time than others and how can you ensure you demonstrate all three in equal measures?
In the current Covid-19 crisis, it is quite likely that you have a plethora of directions to give your team, but you are much more likely to reach your objectives if you explain to all members of staff the meaning of your proposed actions in the context of the four themes of the Code: prioritise people, practise effectively, preserve safety and promote professionalism and trust (NMC 2018).This is what Mayfield and Mayfield (2018) refer to as meaning-making.In addition, by demonstrating an understanding of the stressors associated with working with Covid-19 patients and an appreciation of how members of the team may be feeling, you will demonstrate empathy and are more likely to motivate the team.
In addition to motivating your team, it is essential that decision-making is transparent in crisis leadership.Heifetz (1990) identifies three types of decision: • Type 1: the problem is clearly defined and the solution is known.
• Type 2: the problem is clearly defined but the solution is unknown.
• Type 3: the problem is unknown and the solution is unknown.
In times of crisis, nurse leaders will be involved in finding solutions to each of these types of decisions.
In table 1 the approach to decision making is identified as suggested by Heifetz (1990).

Decision type
Approach to decision making Type 1 -the problem is clearly defined, and the solution is known Likely to require little consultation in order to formulate a plan.Type 2 -the problem is clearly defined but the solution is unknown There is a general understanding and agreement concerning the problem but there are several possible solutions.Involve all those affected in the decision-making process.Colleagues' voices need to be heard in exploring the pros and cons of each potential solution, enabling proposition of solutions from all to prevent the perception of favouritism.Type 3 -the problem is unknown, and the solution is unknown This requires further consultation and assistance is required in defining the problem as well as developing solutions.Involving multidisciplinary colleagues to find the root cause and the risks ensures a comprehensive understanding of the issues.
At the beginning of the pandemic a common Type 1 decision related to the need to up-skill staff; the problem was easily defined and the solution, for example, accessing clinical skills training for staff, may have been a familiar and relatively simple solution.
An example of a Type 2 decision may have related to the limited number of critical care beds available to treat Covid-19 patients.A number of possible solutions existed but through collective agreement the decision was made to suspend elective surgery and other planned treatments, to build additional care facilities and to implement public health recommendations aimed to reduce the speed of viral spread.
At the time of writing a number of Type 3 decisions and solutions are being explored, for example planning how the United Kingdom can safely come out of lockdown.Nurses should be actively involved in such decision making.
In 'Wicked problems and clumsy solutions: the role of leadership', Grint (2008) advocates differentiating between different types of problems, and associating these with Management, Leadership and Command.He argues that a Tame Problem is complicated but is likely to have occurred previously and involves low levels of uncertainty.It can, therefore, be resolved through unilinear actions and requires a managerial approach to resolving the issue.A Wicked Problem is complex, the relationship between cause and effect is unclear and such problems are often intractable.Wicked Problems also lack an answer on the part of the leader, meaning that leadership and collective engagement is key to addressing the problem.The leader's role with a Wicked Problem is concerned with asking the right questions rather than providing answers.Grint (2008) also identifies a Critical Problem or a 'crisis' which allows minimal time for decision making and action.Such problems are often associated with authoritarianism or Command.He argues that in a crisis there is virtually no uncertainty about what needs to be done and a Commander is required to take the decisive action and provide the answer to the problem.In crises such as the 7 th July terrorist attack in London, this approach may be required.However, in a global pandemic such as Covid-19, there has been no rehearsals and there are no clear-cut solutions.Instead, innovation and team working are key to providing novel solutions to a novel situation.We would, therefore, assert that nurse leadership in a crisis situation will comprise all three problems and will, therefore, require all three responses.

Time Out 3
Check your understanding of how leadership is distinct from command and management.
Andrew St George (2012), who wrote about leadership in the Royal Navy, describes command as institutional authority, based on hierarchical position.In the current Covid-19 crisis our Chief Nursing Officers for the devolved nations have represented the profession in strategic national planning for the crisis and senior nurses within health boards and trusts have adopted the command role at times.Management is concerned with the allocation and control of available resources to achieve objectives.In the current context, management has been vital in scaling up and transforming services, for example in ensuring the availability of staff, PPE, medicines and ventilation facilities.Leadership is visionary and inspires others to achieve a desired outcome.It requires qualities such as professional judgement, intelligence and knowledge as well as personal qualities such as integrity, empathy, willpower, courage and confidence.In addition to achieving the objectives of the current crisis, effective nurse leadership is pivotal to creating a positive legacy and long-term impact for the nursing profession.

Time Out 4
Access the Nightingale Frontline: NHS Leadership Support Service.Following the session, reflect on your learning and how you can further develop your leadership skills to support your colleagues.https://florence-nightingale-foundation.org.uk/nightingale-frontline-nhs-leadership-support-service/

People, performance and purpose
Within the leadership literature, much is written about styles of leadership; examples are provided in Table 2.There is a tendency at times to have an affinity with a particular leadership style, rather than considering the most suitable approach for the context and intended outcome.Rather than adopting your preferred style of leadership consider the following which may be more pertinent in the current crisis: • What is the aim?
• What are the desired outcomes?• How will I communicate these to the team?
• What approach should be applied to influence the team and ensure all team members work to their strengths?
• What resources are needed to support the team achieve these?
• At what point will I review my approach and measure effectiveness?
An effective leader should understand the interdependence of the three core themes of the above questions; people, performance and purpose (Porter-O'Grady and Malloch 2018).These also link to professional standards within the Code (NMC 2018).In times of crisis, this interdependence is even more obvious as decision making for all three areas becomes critical.An effective leader will need to understand the detail of all three themes to make these decisions, supported by the best available clinical evidence.However, it is recognised that in a situation such as Covid-19 teams of staff may be constantly changing due to staff sickness and redeployment and outcomes may need reconsideration due to the high demand and reduced capacity to manage.
Ensuring the purpose is clearly communicated however is important, to ensure safe patient care.Using a visual reminder can maintain the team focus as well as reassure staff that leadership is present and clear.

Situational and Compassionate Leadership
Many of the leadership styles set out in Table 2 have common characteristics, although they vary in terms of direction and authority.In the current crisis, it is helpful to consider two styles which are aligned to nursing's professional and ethical values, evidence-based decision making and personal experience, while supporting the extraordinary demands leaders are currently facing: Compassionate and Situational leadership.
Situational leadership Hersey et al (1996) identify four leadership styles (see Table 3) that vary in the amount of direction and support the leader provides and how much involvement the follower has in decision-making regarding how work should be completed.The theory proposes that the readiness level (see Table 4) of an individual should be matched with the appropriate leadership style.R1 will require a directional style (I), R2 will be best met by a coaching style (II), R3 requires support (III) and R4 is best served through delegation (IV).R4: Able and willing, competent and confident or motivated (high readiness).
Situational leadership requires self-awareness and emotional intelligence; the individual is aware of their personal leadership skills while being aware also of the context.Aligning the approach to leadership with the demands and needs of the context allows the leader to respond as required.For example, in a crisis, rapid decision making, and a highly directional style may be needed to affect a positive outcome in a rapidly changing situation.Once that outcome has been achieved, the responsive leader is then able to recede if this approach is no longer needed.Analysing the situation and responding appropriately is a skill which demonstrates high levels of emotional intelligence; adapting to the needs which are most urgent and knowing what characteristics to display and when, to ensure patients receive safe and effective care.

Compassionate leadership
Compassionate leadership is defined as the combination of supportive leadership approaches with combined with four pillars of compassion: attending, understanding, empathising and helping (Atkins andParker 2012, West et al 2017).
The characteristics of compassionate leadership link intrinsically to nursing's professional values, allowing the development of a transparent, non-blaming and supportive culture which is important in this crisis when staff are experiencing a myriad of emotional and psychological stressors (James 2019).Taking a collective approach, where responsibility is shared, encourages innovation and learning (West et al 2017).While a time of crisis may not be associated with opportunities for innovation, it is clear that innovation is a key response to crisis from the examples shared on social media for example the nurse who has led the 'For the Love of Scrubs' campaign which has mobilised thousands of people in sewing uniforms for staff to use.In addition, care and support for nurses and their colleagues has been a noticeable change, as expressed in the 'Clap for our Carers' initiative.
The combination of professional, ethical and personal values combined with the skills of adapting to the needs of the situation offers a powerful approach to leadership in nursing at this time.Maintaining patient safety and care as a priority while also enabling a supportive, empathetic and collegiate culture is key.Compassionate leadership will enable nurses to cope with the stressors associated with Covid-19 (Bailey and West 2020).

Time out 6
Visit the web page below and spend 5 minutes reflecting on how you can become a compassionate leader. https://www.kingsfund.org.uk/blog/2020/03/Covid-19-crisis-compassionate-leadership

Emotional Intelligence
Emotional intelligence underpins situational and compassionate leadership.It is also pivotal to nurse leaders in safeguarding their own wellbeing as well as their colleagues' at a time of prolonged stress.
In response to the Francis report (Francis 2013), the NHS Leadership Model (NHS Leadership Academy 2013) acknowledges that personal qualities such as self-confidence, self-control and selfawareness, which are integral to emotional intelligence underpin effective leadership.
Emotional intelligence is concerned with the individual's ability to perceive, understand and express emotion.It relates to the individual's ability to both identify their own and others' emotions and to regulate and modify their mood (Goleman 1995).It comprises a group of five skills according to Goleman (1996): • Self-awareness: Knowing oneself • Self-regulation: Controlling or redirecting one's undesirable impulses and moods • Motivation: Relishing achievement for its own sake • Empathy: Understanding other people's emotional makeup • Social skill: Building rapport with others to move them in desired directions Cummings et al (2005) demonstrated that emotionally intelligent nursing leadership can inspire others through channelling emotions, passion and motivation towards the achievement of goals.Such leaders use emotions to mobilise teams, when coaching and in providing the team with a vision for change (Cummings et al 2005, Watson 2004).Furthermore, Slaski and Cartwright (2002) reported significantly lower stress and distress, higher morale, improved perceived quality of working life and significantly better health in managers who had high levels of emotional intelligence.

Key questions in crisis leadership
In considering what strengths are needed for effective leadership in a crisis we should also consider the following questions: 3. What do leaders in a crisis need to do that differs from any other time? 4. How do we know what effective leadership looks like in a crisis?
1. What do leaders in a crisis need to do that differs from any other time?
Knowledge and skills for leadership remain the same in any situation; it is the ability to adjust the way in which the different approaches and characteristics of leadership are applied that becomes important in a crisis, as well as being able to identify the most appropriate response to the need and situation.For many, the pressures of leading in a crisis such as Covid-19 will test the individual's resolve and ability to change and adapt to need.For example, circumstances may require a more rapid response to: • Accessing up to date evidence-based information • Swift and decisive decision-making • Access to the most skilled and appropriate staff • Ensuring effective communication is ongoing for all staff • Ensuring all patients receive appropriate and safe care • Supporting the wellbeing and health of colleagues and self In usual circumstances, a collaborative, multidisciplinary and ongoing discussion for decision making may take place within a healthcare organisation.While there is evidence that a collaborative approach to leadership, shared responsibility and decision making within a crisis is effective, it may need to be less even in its distributed value.For example, in the events following the earthquake in Christchurch, New Zealand, many staff in the critical care unit identified clear decision making by formal leaders under pressure as one of the most valued attributes of leadership (Zhuravsky 2015).
While preparation for leading in a crisis, such as terrorist attacks, have been ongoing in the UK over many years, a large-scale national crisis such as Covid-19 is a much wider and far-reaching challenge.Deitchman (2013) explored the common characteristics of crisis leadership within aviation, the military, mining and the nuclear power industry to develop a framework of leadership for Public Health.This has been adapted in figures 1 and 2, to consider the wider remit and implications of the current Covid-19 crisis which poses challenges for all areas of health and social care.Figure 1 outlines 'formal' leadership characteristics and figure 2 outlines 'informal' characteristics.'Formal' characteristics are associated with identified roles within the hierarchy and 'informal' with the characteristics associated with all levels of nursing.It is important to be aware that within the current context of this crisis many nurses who do not view themselves as 'formal' leaders may need to step into these more formal hierarchical roles due to staff shortages or redeployment.It is, therefore, essential to recognise the blurring of formal leadership roles and the need for all to be aware of the key competencies for effective leadership.Combining the formal and informal leadership characteristics may provide a useful framework and support both a Situational and Compassionate leadership approaches as it allows the blurring between directive decision making and supportive values-based characteristics.

How do we know what effective leadership looks like in a crisis?
It is known that where leadership is ineffective, there are lapses of care standards and dysfunctional teams (Francis 2013).Identifying how effective leadership is outside of a crisis may include results of ongoing audits or evidence of cohesive team working and excellence in patient outcomes (Wong et al 2013).Measuring and identifying effective leadership within a crisis often focuses on data and results captured on a wider scale, from a macro perspective such as national or regional numbers of patients discharged from hospital and such data tend not to be nursing focused.While Covid-19 has had an immediate effect on the ability of nurses to care for patients due to variations in access to effective equipment and staffing levels, it is possible to learn from previous evidence and inquiry about leadership, nursing, patient outcomes and safety.Key examples for us to learn from include: • An organisational culture of safety and quality means high quality care should remain the aim (Leonard and Frenkel 2012) • Healthcare staff as a whole need to feel empowered to speak up if lapses in care are noted and the psychological care of staff is imperative (Francis 2013) • All levels of leadership need to remain connected to what is happening in the clinical environment and staff must be enabled to be transparent (Keough 2013) • Clarity of purpose and continuing to monitor patient safety remains a priority and a culture of blame is not acceptable (Berwick 2013) • Learning from comprehensive data collection and maintaining a consistent approach will support future approaches to crisis in public healthcare (Keough 2013).

Time Out 7
Considering the article and what you have learnt, spend 15 minutes considering the requirements of leadership as set out by the Code (NMC 2018 p 25) which specifies that in providing leadership nurses need to: • "Identify priorities, • Manage time, staff and resources effectively • Deal with risk to make sure that the quality of care or service you deliver is maintained and improved, • Put the needs of those receiving care or services first • Support staff you may be responsible for to follow the Code at all times.
• Ensure they have the knowledge, skills and competence for safe practice • understand how to raise any concerns linked to any circumstances where the Code has, or could be, broken" Identify how these requirements apply in crisis leadership practice?

Conclusion
This article has highlighted key leadership skills and strategies that nurses can use to underpin effective leadership in a crisis.Linking clearly with aspects of the Code (NMC 2018) and leadership theory and evidence, we have identified key considerations while acknowledging the exceptional challenges the current situation presents for nurse leaders.It is clear that this is a time of significant demand on resolve and strength for all levels of nurses and there are times when all will be required to take high impact and rapid decisions.We have presented a suggested framework for leadership characteristics to consider and we have emphasised the need for empathetic and compassionate approaches to leading colleagues and acknowledging your own and others' wellbeing needs.

Time out 8
Spend 10 minutes reflecting on what you have learned from reading this article and completing the time out activities.Think about the following: • What effect have the time out activities had on your practice?
• What have you observed as a result of completing them?
• How has your understanding of leadership in a crisis changed?

Time out 9
Now that you have completed the article you might like to write a reflective account as part of your revalidation.

Table 2 . Examples of Leadership Styles Examples of Leadership Styles Characteristics
An effective leader should always communicate the key aims to be achieved.This should be accompanied by transparency about the realities of the provision of care, what the next challenges are and provide clear direction.Teams need an identified leader and clarity of purpose to function well.Reflect on how you communicate your leadership to your team.Are they aware of who leads the team and how do they respond to you? Write down 3 ways you can ensure you communicate leadership characteristics to your team on a daily basis.