Defining and Developing Leadership in Healthcare Emergency Management

The word ‘leadership’ is used liberally. We see it used in reference to managers, directors, and decision-makers, and its meaning is frequently “person in charge” or “person responsible.” In healthcare emergency management – and particularly when a disaster occurs that has tested a community’s response system – scrutiny of the response begins with evaluating the leadership of the affected community. Any perceived leadership strengths or weaknesses will be immediately and severely criticized in the media. Action documentation will use ‘leadership’ in the sense of the word described above; rarely, however, do we see language consistently associated with this kind of leadership in healthcare emergency management and more often than not we see contradictions in how the term is defined[i].

But we know it when we experience it.

Fortunately leadership theory provides definitions of leadership and allows us to identify behavioral characteristics—associated with task effectiveness—to aid our use of the term[ii]. Many of these characteristics transcend fields, cultures, gender, organizational structure, and national boundaries. This allows emergency healthcare management professionals to examine leadership, via observation of individual leadership style, as we would in other industries, e.g., banking, oil exploration, mining.

How is leadership defined?

At least two important leadership styles have been examined in detail and for both, relationships to effectiveness have been measured. One style has the characteristics of motivating others by using visionary, inspirational, and intellectually stimulating approaches, and paying high attention to individual differences among people[iii]. This is called transformational (formerly charismatic) leadership. These leaders assume that people will follow a person who inspires them, that a person with vision and passion can achieve great things, and that the way to get things done is by injecting enthusiasm and energy[iv]. A transformational leader goes beyond his or her self-interest for the good of the organization or group.

A second style of leadership assumes that people are motivated by reward and avoidance of punishment, that social systems work best with a clear chain of command, that when people have agreed to do a job, a part of the deal is that they cede all authority to their manager, and that the prime purpose of a subordinate is to do what his or her manager tells him or her to do[v]. This is called transactional leadership and these leaders have the characteristics of defining contracts and identifying mistakes in others.

When considering the relationship of leadership style to processes and outcomes, the transformational leader tends to emphasize ends over means (on achieving the desired outcome over the process of getting there); the transactional leader tends to emphasize means over ends (on maintaining a process over the actual outcome itself). Higher degrees of effectiveness have been associated with transformational leadership; however, a combination of the two have been found to have a relationship to effectiveness, and may be seen as complementary constructs that are both related to group success[vi]. In emergency management, the structure of Incident Command Systems is an example of a transactional process, but getting representatives to actually participate in the training may call upon the transformational leadership skills of emergency managers.

What is leadership in healthcare emergency management?

The common and most important element of disaster response is people: people coming together to help those in need. Doing so effectively is a function of maximizing resources and capabilities to provide the greatest good for the greatest number of victims. But examining leadership in healthcare emergency management is a complex issue given the unique behavioral characteristics that will exist in the phases of mitigation, preparedness, response and recovery. Known leadership behaviors must be considered in the context of all phases of emergency management. This makes developing leadership skills that much more difficult, but imperative nonetheless

Are healthcare emergency management leaders born or can they be developed?

Yes. And yes. Things we know: organizational environments influence how leadership style is developed (e.g., bureaucratic, public or private sector, military); some individuals have a propensity for leadership responsibilities and highly visible roles, while others prefer to quietly lead by providing guidance, resources, and fostering engagement often times from a level below the high-level decision makers.

Can leaders be developed over time by disaster declaration experience? Does the number of years engaged as an emergency manager in preparedness programs influence the development of leadership at the local level? Does education or professional background matter? One study examined these and many more questions in the immediate post Katrina-Rita period and found that some associations do exist, but that factors such as education and gender were not predictive of leadership styleⁱ (i.e. there was no difference between a man or a woman or either one of their educational levels that predicted a certain type of leader). These relationships were examined in the context of a regionally coordinated hospital system and whether the leadership style predicted a more cohesive response system. More studies examining these relationships and the factors that foster the development of healthcare emergency management leaders are needed.

Given the US federal initiatives to increase national healthcare preparedness capabilities that stem from the local level, fostering the development of leadership skills is an important component of doing so. As national and statewide systems and their respective funding sources evolve, state and local programs will require effective leaders, not only to implement effective programs, but to sustain them as well. Fostering healthcare emergency management leadership skills at all levels, therefore, is paramount to developing leaders that can adapt to the inevitable changes in priority planning areas. 

Author: Erin Downey MPH, ScD, Senior Health Systems Analyst

[i] Downey, E., Beyt, B., & Rice, J. (2006). The relationship of transformational leadership to organizational performance of hospital based disaster coordinators using the Multi-Factor Leadership Questionnaire.

[ii] Bass, B. M. (1997). Does the transactional-transformational leadership paradigm transcend organizational and national boundaries? American Psychologist, 52, 130-139.

[iii] Yammarino, F. J., & Bass, B. M., (1990). Long-term forecasting of transformational leadership and its effects among naval officers: Some preliminary findings. In K. E. Clark & M. B. Clark (Eds.), Measures of leadership. pp. 151-169. West Orange, NY: Leadership Liberty of America. [iv] Burns, J. M. (1978). Leadership. New York: Harper & Row.

[v] Bass, B. M. (1990). From transactional to transformational leadership: Learning to share the vision. Organizational Dynamics, (Winter): 19-31.

[vi] Avolio, B. J., & Bass, B. M. (1995). Individual consideration viewed at multiple levels of analysis: A multi-level framework for examining the diffusion of transformational leadership. Leadership Quarterly, 6, 199-218.