Navigating Uncharted Waters; Five Key Leadership Activities to Keep Healthcare Leaders and Their Crew Afloat

We suggest five key continuous activities, the 5 ‘R’s’, that healthcare leaders can undertake right now to more effectively engage and support their constituents and themselves as they navigate the unrelenting volatility, uncertainty, complexity and ambiguity of the healthcare system. Based on the work of Heifetz, Grashow and Linsky on adaptive leadership we incorporate fundamentals of change leadership with practical suggestions.


Introduction
To summarise Darwin "it is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change". [4] Successful leaders in healthcare are those that are able to effectively, efficiently and continuously respond to the evolving demands of a system, similar to captains on a ship. This requires mobilizing everyone to participate in ongoing change i.e. to positively engage their peers and constituents in the work of the organization. This is no small feat given increasing system complexity, rapidly evolving knowledge and clinical practice and the continuous introduction of innovations at a pace never before experienced pre-COVID pandemic. These demands come with heightened scrutiny and levels of accountability for leaders, their constituents and their organizations. We suggest five key continuous activities, we call the 5 'R's' that healthcare leaders can undertake right now to more effectively engage and support their teams and themselves as they navigate the unrelenting volatility, uncertainty, complexity and ambiguity of the healthcare system. These are illustrated as a continuous cycle in Figure 1. We are well past a time when a leader could raise their baton and expect the marching band to move in unison behind them, yet often leadership continues to be conducted in this way -top down. We believe a new paradigm is required, one that conceives of leadership as an ongoing activity exercised continuously by everyone irrespective of their organizational position. In practical terms this needs existing leaders to develop a new and enhanced ability to see, effectively analyze, and strategically intervene to mobilize constructive and continuous change across and within organizations. [1] As Heifetz and Linsky note an adaptive leader will "use the turbulence of the present to build on and bring closure to the past. In the process, [adaptive leaders] change key rules of the game, reshape parts of the organization, and redefine the work people do." [2] Developing your ability to accurately determine key stakeholders' readiness and capacity to engage i.e. participate in ongoing change, is vital to encourage a thriving healthcare organization. This is an activity a leader can hone -their ability to honestly and accurately assess key stakeholders' openness and capacity to learn and adapt. You can begin by assessing where key stakeholders are in relation to a "productive range of (disequilibrium) tension" or being in "the zone". In this sense, being in the zone refers to individuals being first able to acknowledge the need for change and secondly able to manage the possibility of loss due to change. Consider that if an individual feels quite comfortable with the status quo they may be less motivated to change, or below the "threshold for [new] learning". Conversely if an individual has constantly been inundated with demands they may feel overwhelmed with no time or energy to engage beyond their daily responsibilities, truly at their "limit of tolerance". [3] This is a balancing act and leaders need to constantly monitor and adjust their actions and interventions in response to others' readiness. It is not a matter as some change models may suggest, of a linear process whereby one creates a sense of urgency, communicates and then celebrates wins. Consider using yourself as a barometer to gauge where others might be in terms of being in "the zone". Continuously monitoring how you and others are reacting to circumstances every day allows you to accurately respond and support them to keep everyone in or returning to the productive range of tension, both engaged and motivated.
The second activity involves developing an ability to recognise and respond to the difference between technical and adaptive challenges. Technical challenges are those problems for which we already have or know of existing solutions. These solutions may be complex, but they do solve the problem and they do so with knowledge that we have in hand. An example of a technical challenge is working through a budget based on a fixed total amount which ultimately has to add up to a fixed amount perhaps 100% or 0%. Adaptive challenges on the other hand require new learning, innovation and development of novel patterns of behaviour. Consider what is needed to have healthcare funding follow the patient rather than the provider.
In a time of scarce resources, to come up with an optimal solution that helps us achieve the results we want often means that we have to motivate changes in constituents' hearts (values, emotions, assumptions) and minds. Adaptive challenges cannot be resolved by expert knowledge and routine management approaches alone. The technical pieces may be necessary but they are insufficient for successful continuous adaptation. The conversations and the insights technical pieces stimulate will help with the adaptive work needed to engage individuals who may want to remain in their comfort zone.
There are signs and signals to look for to help you assess if you have an adaptive challenge that needs to be addressed as you try to engage all stakeholders. These include: • identifying when more than people's preferences and routine behaviours need to change, instead working to understand how to appeal to people's hearts and minds as noted above; • when through a process of elimination, a technical approach has been unsuccessful; • when conflict persists as conflicts are the symptoms of a problem that has not been addressed; • When a situation devolves into a crisis.
Bear in mind that a common cause of leadership failure is treating an adaptive challenge with a technical fix. If any of the above signs or signals resonate with you it may be that you are missing or perhaps avoiding the adaptive challenge that complements the technical fix.
One of the more challenging activities is recognizing and then honestly acknowledging resistance or work avoidance. It is helpful to remember that what people will not tell you their behaviours will reveal. People failing or unwilling to engage in the work of change is a signal that they are outside the productive range of tension. Consider that when someone resists engaging with you i.e. with what you hope they might do, they are not just trying to ruin your day. Instead what you are asking them to engage with and how quickly you want them to become involved may be too much for them to tolerate. Avoid reacting in the heat of the moment and instead take a breath, stand back and observe, analyse and then refine your approach based on the information gathered from your observation(s). It is notable that resistance is an excellent indicator that you have in fact connected with someone, gaining their attention. Most importantly, it means you need to try a new approach.
Consider that no matter how it is coming across, passive or active resistance is only a signal, one that indicates that you are losing influence and are likely exceeding the amount of uncertainty and/or possible loss the person can tolerate. There are myriad ways resistance will manifest. Here is a short list to help you identify some of the more common behaviours grouped by theme; • Denial of the need to engage may include labelling something as 'flavour of the month'; o Displacing responsibility may have people attacking authority perhaps saying "they have no idea what it's like on the front line", "it's above my pay grade", "killing" the messenger or even scapegoating others e.g. "it's not our unit that's the issue they need to start with dept X first!".
o Distracting attention is a favourite of many who resist engaging by pretending to be busy or holding meetings which look like people are engaged yet only information is exchanged and no tangible engagement occurs.
o If someone intentionally picks a fight know that they are neither ready nor willing to engage. At this point it is imperative to take a step back and objectively review what you have observed. Based on your data refine your approach. Above all, avoid using the same approach twice.
We suggest that a core activity is the ongoing development and maintenance of relationships. A key skill needed to support robust relationships is communication. Consider the impact of poor inter-personal communication ranging from failure to complete projects to increased stress and low morale which together negatively impact patient, provider and organisational outcomes. [5] A straightforward approach to enhancing communication comes from the Harvard Negotiation Project. It is challenging to accept that there are only two things you can ever know for certain when communicating with someone else; your own intent and how the other person's comments have impacted you. With the best of intentions, we can never assume that our comments have been received as we hoped. Good intentions do not make bad impact unimportant or irrelevant. Equally, our assumptions about someone else's intentions are often wrong. To address these issues when in dialogue leaders can ask two questions. The first is "How does that feel (or land) with you?" when delivering a message. The second when the leader is receiving information, involves checking in with the other person by asking "This is how what you said felt or seemed to me. Is this what you meant?" Above all regularly take a step back and review the information or inputs you can gather about the environment, individuals and relationships. To do this well requires self awareness and the ability to metaphorically stop the action. A quick breath, short pause, even simply sitting back in your chair during a meeting or phone call can provide a moment to regroup and objectively evaluate how a situation is unfolding and what part you may be playing. Using this information, you can then re-engage, stepping back into the action and continuing or if the observations suggest it, trying something new. Building your own capacity to stay calm or to quickly recover when overwhelmed or triggered is critical to your successful exercise of leadership. Building this capacity in others is an act of outstanding leadership.

Conclusion
To successfully lead and manage a thriving healthcare organization in the face of unceasing and ever-changing demands at the micro, meso and macro levels requires continuous adaptation, a potentially exhausting endeavour. We suggest that developing an ongoing practice of the 5 'R's; assessing readiness to engage, recognizing challenges accurately, managing resistance appropriately, developing and maintaining relationships and continuously reviewing how things are going allows leaders to accurately and effectively support themselves, their constituents and their organizations.