Introduction
Christchurch City, New Zealand has an urban population of approximately 400,000 people. On Tuesday, February 22, 2011, at 12:51 pm local time, a 6.3 magnitude earthquake struck this city. Peak ground accelerations were among the highest recorded from this type of earthquake.Reference Reyners 1 A combination of high peak ground acceleration, the time of the day, and the collapse of the buildings resulted in injury and loss of life. During the earthquake, Christchurch Hospital (Christchurch, New Zealand) was subjected to severe shaking, and as a result, sustained damage that severely strained the hospital's ability to function at regular capacity.Reference Ardagh, Richardson and Robinson 2
The first victim arrived in the intensive care unit (ICU) within one hour of the earthquake. Within 24 hours of the earthquake, the ICU team transferred 14 patients to other cities in New Zealand. During this period, 18 patients who were injured in the earthquake were admitted to the ICU from the emergency department and operating rooms.Reference Ardagh, Richardson and Robinson 2 Medical, nursing, and supporting staff in the unit had to cope with multiple complex challenges, such as an influx of patients with complex injuries, communication issues, and coordination of transfers with numerous hospitals across New Zealand, and they had to provide support to dying patients and their families.
Over recent years, interest has grown within management and organizational studies in alternative models of leadership in which leadership is not limited to the formally appointed leader. Particular interest has been directed to models of shared leadership.Reference Rosengren, Bondas and Nordholm 3 In an ICU setting, a shared leadership approach is used to identify strategies for solving problems and to provide answers to complex clinical and organizational challenges. In general, a shared leadership approach comprises two principal components: formal and informal leadership.Reference Pielstick 4 The main characteristics of a formal leadership role include decision-making responsibility, influence, and authority. Informal leaders, on the other hand, have influence and informal authority without possessing any formal title. Shared leadership is an on-going and fluid process which requires continuous evaluation within different contexts, including disasters.
As a rule, an effective crisis response takes into account the need for balancing both formal and informal leadership roles when disaster hits. Informal leadership has been recognized as an important factor in crisis management. 5 Large-scale disasters from the late 1970s onwards have given rise to much of the available research on crisis leadership. These disasters include: Tylenol's (McNeil PPC Inc; Fort Washington, Pennsylvania USA) cyanide poisoning, the 2001 Twin Towers terrorist attacks (New York, New York USA), Hurricane Katrina (USA; 2005), and the Haiti earthquake (2010). These events established crisis leadership as a new and rapidly developing field. Yet, because of its recent development, the study of leadership is highly fragmented. Few data-based studies exist, and much of what has been written are merely attempts by researchers to synthesize anecdotal information.Reference Jones 6
One of the most challenging critical situations which might require new forms of leadership, such as shared leadership, is a disruption of hospital systems during a city-wide crisis that produces mass casualties, and this can quickly overwhelm hospital emergency resources. Little has been published about crisis management and models of leadership in acute clinical settings in times of natural disaster.Reference Nates 7
There is a paucity of research on crisis management and different models of leadership in areas such as the ICU.Reference Nates 7 The main purpose of this study was to provide a comprehensive overview of crisis leadership from the perspective of multi-level interactions between staff members in the acute clinical environment during the process of the crisis management.
Methods
The research was qualitative in nature and employed a social constructivist methodological approach. The setting for the study was the Department of Intensive Care at Christchurch Hospital, New Zealand.
Study Participants
Participants were recruited into the study through purposive sampling. Participants were recruited who were employed in the ICU of Christchurch Hospital at the time of the earthquake, who were on duty during, and immediately after, the earthquake, and who remained employed at the ICU during the recovery period of three months (Table 1). Invitations to participate in the research were sent to potential participants via work emails. The invitations to participate included a copy of the research proposal, as well as the participant information and consent forms. Invitations were sent to 14 people, and they were asked to respond directly to the researcher. Ten people agreed to participate.
Table 1 Participants’ Data
Abbreviation: ICU, intensive care unit.
Data Collection
A semi-structured, audio-taped, personal interview method was chosen as a single data collection method for this study. At the time of their interviews, all the participants in the study were employed in different capacities by the Department of Intensive Care of Christchurch Hospital. The interviews were conducted in locations of convenience to the participants where privacy was able to be carefully maintained. Prior to commencing the interview, some time was spent ensuring the participants felt comfortable and confident in the process. The interviews varied in length from 30 minutes to 40 minutes, dependent on the length of participants’ response to questions and the number of examples they were able to provide. Interviews were digitally recorded with the participants’ knowledge and consent. Interviews utilized an open-ended questions approach. To achieve the level of depth and detail sought in semi-structured interviewing, the researcher worked out main questions, and further exploration and probing ensured that participants elaborated on their experiences. This process assured that all important themes were discovered in the interviews. The interview guide used in this study is presented in Appendix 1. Good data saturation was reached with collected interview response material.
Data Analysis
This study employed a thematic analysis approach. Upon the completion of interviews, all audio-taped data were transcribed into word format. Three data sets had been created and they had been categorized under the titles of formal, informal, and shared leadership. Thematic analysis was employed to reveal recurring themes from each data set. This involved obtaining an overview of the material and identifying patterns and major ideas emerging from the interviews. Several steps were taken to identify and construct themes. After the initial coding, codes were merged into larger units organizing those that were similar in meaning content. At the end, a number of themes were identified within three data sets which had been organized into thematic networks. These thematic networks were described subsequently and explored to identify and achieve full interpretation of formed patterns. Some were apparent immediately and others were discovered upon further analysis. Each theme was given a label descriptive of its content and this was reviewed several times in an effort to minimize assumptions about the event. Good data saturation was reached with collected interview response material.
Ethical Considerations
Ethical approval was obtained through the University of Otago (Dunedin, New Zealand) Ethics Committee. The study was supported by the Canterbury District Health Board research office (Christchurch, New Zealand) and endorsed by both the General Manager and the Director of Nursing of Christchurch Hospital. Participants were told that their names would be kept confidential, that they would get a chance to review and add additional information to the interview, and that, at any point, they could elect not to be a participant in the study. Each participant was assigned a unique pseudonym to protect their identity. The participants were provided with an opportunity for more detailed elaboration and discussion of the study with the researcher prior to seeking their written informed consent.
Results
Formal Leadership: Decision Making
Most of the staff, medical and nursing alike, indicated that the ability to make decisions under pressure was one of the most valuable contributing traits observed in the formal leaders in the ICU.
To me, a good person there, is the person who can lead by picking up the right options out of a very narrow range. You have not got time to think about options, but still a lot of things quickly run through your brain (Participant No. 4; Charge ICU Technologist).
According to the participants in this study, formal leaders in the ICU managed to lead staff towards crisis resolution by a robust and timely decision-making process.
Formal Leadership: Ability to Remain Calm
One participant, a senior staff nurse in the ICU, recalled the behaviors of one of the nurse managers:
I can picture one person in mind because that person, to me, was outstanding because he was on duty on the day shift of the quake and I think he was remarkable, remarkable in leadership, he could stay calm, he made a handover which was very quick, he was like everybody else, like very shocked from what happened, but it felt to me like we are safe he knows what's going on, and that was a day shift, handing over to us (Participant No. 5; Senior Staff Nurse).
Participants indicated that they viewed the ability to manage emotions during crisis as a key formal leadership skill which contributed to a sense of safety and control.
Formal Leadership: Effective Communication
Several participants emphasized the importance of communication in an evolving critical situation:
I think that when nurses were upset, there was a support because all of us had a shared experience, so there were tears from time to time when aftershocks came, but it was all right, it was like OK and was either go to the support worker or do you need to go home or that sort of things. I felt supported, I felt that it was a good place to be and our managers did a good job (Participant No. 2; Senior Staff Nurse).
Informal Leadership: Motivation to Lead
Factors contributing to individuals’ emergence as leaders in groups have been the focus of research over the past century.Reference Bass and Bass 8 One participant in this study could remember how impressed he was by the levels of motivation demonstrated by non-clinical staff:
I think I stepped up because it was partially stress, and then we are basically kind people and quite often, we are not pushed to do anything more than we do, just minimum required and all of a sudden… I think that we all got touched by personal stuff, we had something more to give, we are all human being after all, I don't know… I was confident that I could do it (Participant No. 5; Senior Staff Nurse).
Informal Leadership: Autonomy
When applied in a health-related field, autonomy usually includes attributes such as ability, capacity, and competence.Reference Ballou 9 The level of autonomy and self-reliance, as demonstrated by informal leaders in this study, was evident:
I think people tried very hard to function without bothering seniors with small stuff…like you tried not to bother people with stuff that you knew, I saw all the senior nurses doing that, making decisions, practical decisions, becoming much more autonomous, which was probably the most striking part because, as we know, we look at the very paced and quiet unit in say, peaceful times, well managed accordingly to a certain inner pace with some spikes of activity, but still generally very safe… (Participant No. 2; Senior Staff Nurse).
Informal Leadership: Emotional Leadership
Some interviewees described how emotionally difficult the situation was:
I think the worst bit was to know that your family too was [affected]… I could not find my daughter, she has been in town, so seeing all these people come in… it was quite traumatic, you are trying sort of not to fiddle around other people just… I could not find her (Participant No. 3; Associate Charge Nurse Manager).
Many staff in the ICU provided emotional support when it was needed and participants indicated that informal leadership played an important role in that process.
Informal Leadership: Crisis as Opportunity
Successful performance in a crisis situation and demonstration of informal leadership skills can turn crisis into opportunity for those who step up, and this was expressed by several senior staff members:
You can identify some that we will keep watching to promote to senior roles, give them those extension roles, because they actually got that ability. They can join the flight team and they will be fine, they are quite self-sufficient, they prioritize their care really well, and they prioritize stuff that happening on the unit. They don't need to be told, and [the] quake, in some sense, helped us to mark those staff (Participant No.1; Nurse Manager).
Numerous participants indicated that, for them, recognition of efforts and development opportunities were among the most highly valued forms of reward.
Shared Leadership within Formal Medical and Nursing Leadership Groups
Team leadership in the ICU could be described as a complex set of functional and adaptive behaviors, whereby formal leadership of medical and nursing groups alike constantly attempt to understand and interpret challenges facing the ICU team, make and effectively communicate decisions, and manage activities and needs of team members.Reference Reader, Flin and Cuthbertson 10
One of the key formal leaders in the ICU reflected on the interactions within a formal medical leadership group:
I think you actually need two types of leaders in this sort of circumstances. You need a clinical leader who is in charge of clinical practice so you can coordinate the big picture in terms of which patient goes where, and you need a second leader who is actually caring for patients on the ground so you definitely need more personnel in leadership positions (Participant No.6; ICU Consultant).
The designation of who is leading in certain critical situations changes according to how the situation develops, and it migrates to the person with expertise relevant to the problem/decision combination at hand.Reference St. Pierre, Buerschaper and Simon 11
In the situation immediately after the earthquake, a formal leadership structure within the senior nursing staff made a quick adaptation to the new environment:
One of the associate charge nurse managers was exceptionally supportive of me, of my decision making that I was doing, and she was there and in the background always supporting the staff, and her and I both do that role. One of the educators took over from one of the staff who went home, and the other educator I placed with pediatric group because I thought that the senior nurse needs to be involved with that group to support nurses (Participant No. 9; Associate Charge Nurse Manager).
A concept of shared leadership, especially among formal leaders, often runs contrary to a widespread and established notion that explicit leadership by the most senior team member is paramount to manage complex crises.Reference St. Pierre, Buerschaper and Simon 11
Shared Leadership between Formal and Informal Leaders in the Intensive Care Unit
Shared leadership is highly practical in an acute health care setting, as the nature of the health care environment requires much collaboration, and quality of patient care often depends on how well diverse teams work together.Reference Kocolowski 12 The events of the earthquake created a complex set of interactions between formal and informal leaders in the ICU, which eventually led to the establishment of a shared leadership structure between those two groups:
People certainly were confident to carry on in an autonomous way… What it created, I think, the whole thing of formal and informal was the very high degree of trust. People could trust each other in many situations like… transfers, setting up stuff for the flight teams, things like that (Participant No. 4; ICU Technologist).
Discussion
The participants in this study discussed and identified decision making, ability to remain calm, and effective communication as being the core, formal leadership skills and behaviors that, in their opinion, led to the successful management and resolution of the crisis. These findings are in line with other emerging studies on formal leadership skills. In the literature, formal crisis leaders have been defined based on who they are versus what they know. They make quick decisions when they are faced with ambiguity, stress, and complexity. They demonstrate a high level of control and distinguish themselves as effective communicators.Reference Wooten and James 13
Most of the staff interviewed emphasized the importance of the ability of formal leaders to remain calm and composed while facing multiple challenges. This ability contributed to a general sense of control and relative safety. Uncertainty in a crisis situation was one of the main reported psychological challenges, and, while remaining calm under severe stress, formal leaders acted as role models, allowing staff to feel more secure and safe. All the participants involved in the study spoke of the critical importance of the ability of formal leaders to exercise effective communication and make sound decisions under extreme pressure. To lead in a crisis, one must communicate both internally and externally. Communication in crisis, however, is not an end in itself. Its purpose is to build a team and enhance successful task performance in critical situations.
The Christchurch Earthquake highlighted the leadership capabilities of many of the ICU staff. Emergent and informal leaders surfaced and operated in many different ways. Most of the participants emphasized that informal leadership in the ICU contributed to the overall management of the crisis by exercising self-reliance, autonomy, and by providing emotional support.
In the context of the ICU, autonomy and self-reliance refer to the ability to act according to one's knowledge and judgment, providing clinical care on the less-regulated and more-independent levels. This research attempted to explore the concept of crisis as opportunity. By stepping up and performing at a higher level, some staff demonstrated strong performance qualities and leadership capabilities. A number of participants indicated that it did not go unnoticed. Stepping up in the crisis created a range of opportunities for selected staff where they could continue to explore their leadership potential in a structured and supported environment. Informal leaders need to know that their positive attitude and creative contribution are of great value to the team.
The results from this study show that during a crisis, the team in the ICU adopted a shared leadership approach which comprised two main elements. The first element was sharing of leadership within the formal leadership group, which include both medical and nursing sub groups. The second element was sharing of leadership between formal and informal leaders in the unit. If people are to work together genuinely, they need to engage fully in the realities of problem solving and decision making in leadership tasks and be empowered to act with a certain degree of authority. Most of the participants in this study indicated that sharing leadership tasks assisted in creating a coordinated unit-wide response and provided a good framework for decision making and overall management of the crisis. It reduced task overload and increased team performance.
Limitations
The main limitation of this study was the ability to generalize its findings and practice implications outside of the study setting due to the small sample size and single location of the study. However, information gained through this study contributes to what little is known about crisis leadership in an acute clinical setting, so in this respect, this research met its objective.
Four out of 14 participants declined the invitation to take part in this study. Therefore, use of purposive sampling yielded the response rate of 71%. Interviews provided a rich data source, and data saturation was achieved. Upon completing 10 interviews, it became clear that certain topics, group of topics, and emotions became repetitive and conducting more interviews would add little value to the research.
Therefore, it could be concluded that the findings are reflective of the perceptions of participants in the study area at the time the research was undertaken and the potential impact of missing participants is minimal.
Although a large amount of qualitative data were generated from open-ended questions, an alternative method to collect data, such as focus group interviews, may have obtained richer qualitative data and allowed for clarification of responses, where deemed appropriate.
However, the main focus of this study was to establish a baseline in mapping and evaluating main patterns in crisis response within an acute clinical environment and chosen interview method deemed to be an appropriate tool in conducting this study.
Conclusions
The capabilities of formal leaders all contributed to the overall management of a crisis. Informal leaders are a very cohesive group of motivated people who can make a substantial contribution and improve overall team performance in a crisis. While in many ways the research on shared leadership in crisis is still in its early stages of development, there are some clear benefits from adopting this leadership approach in the management of complex crises.
This study may be useful to the development of competency-based training programs for formal leaders, process improvements in fostering and supporting informal leaders, and it makes important contributions to a growing body of research of shared and collective leadership in a crisis.
Acknowledgements
The author wishes to thank all participants in the study, who shared their thoughts and experiences and made this research possible. Special thanks to the senior staff of the Department of Intensive Care, Christchurch Hospital, for all their assistance with recruitment.
Appendix 1. The Interview Questions.
Abbreviation: ICU, intensive care unit.
Introductory question: On Tuesday, February 22, 2011, what were your job-related responsibilities? What was the situation on the unit on the same day prior to the quake?
1. How did formal leadership contribute to crisis management in the ICU during the disaster response?
Probe questions: Describe your actions immediately after the quake happened? Over the first 72 hours? What was your role in the crisis response? At the unit level? At the hospital level?
2. What leadership behaviors and skills were valued in formal leaders?
Probe questions: How would you define crisis leadership? What skills and behaviors are important for formal leader during the crisis? What skills did you have prior to the event? What behaviors/skills did you develop as a result?
3. How did informal leadership contribute to crisis management in the ICU during the quake response?
Probe questions: How would you define an informal leadership? Did it exist in the unit prior to the event? Did you recognize informal leadership during the crisis response? Describe the individuals who you considered assumed a role of informal leader? What was the contribution of the informal leaders?
4. What prompted staff to step up as the informal leaders?
Probe questions: Was it a stress response? Motivation? Something else?
5. In what way did formal and informal leaders interact?
Probe questions: Have you noticed any patterns of communication and interaction within formal and informal leadership groups? Between both groups?
