A crisis is “a serious threat to the basic structures or fundamental values and norms of the social system, which, under time pressure and highly uncertain circumstances, necessitates making critical decisions.” Public health crises include natural disasters such as earthquakes and hurricanes, biological terrorism, influenza pandemics, chemical releases, and radiological emergencies. Under circumstances of extreme stress, all leaders must meet challenges that include recognizing the crisis, making decisions rapidly despite limited and fragmented information, providing effective communications, and balancing centralization with delegation. Individuals leading public health responses to crises serve as crisis leaders.
Professions that involve leading emergency responses often include formal training in leadership. In the United States, leadership training is provided to senior leadership in wildland firefighting, whereas the military services teach leadership through progressive training, education, and experiences. , Public health leadership training, in contrast, focuses on managing organizations that provide traditional public health functions, including epidemiology and laboratory investigations, sanitation, and immunization. Although tabletop exercises have illustrated the importance of public health leadership, preparing public health officials to lead those responses has not received comparable attention.
This shortfall was illustrated in the Top Officials (TOPOFF) 2000, a congressionally mandated national exercise to assess the nation’s response to simultaneous terrorist threats and acts across several regions in the United States. One component was a simulated bioterrorism attack in Denver using plague. Observers noted failures in crisis leadership, including reliance on massive, interminable conference calls, inability to make critical decisions, and failure to avoid leader exhaustion. The subsequent 2001 anthrax attacks also showed that traditional public health decision-making processes were not adequate for complex, fast-moving emergencies. The U.S. Government Accountability Office (GAO) found that the Centers for Disease Control and Prevention (CDC), which led the public health response, was hampered because at that time the agency’s leadership lacked formal protocols for making timely crisis-management decisions (although the agency has since implemented a robust emergency-management infrastructure and exercise program). ,
Public health educators and practitioners have defined competencies for public health emergency leadership as familiarity with public health roles, command systems, and emergency response plans. , Current assessments of public health emergency leadership in exercises focus on completion of tasks (identify activities to be performed, interact with relevant officials, identify one’s authorities, gather necessary resources, assist special needs populations, etc.) and scientific competencies involving knowledge of threats and hazards, clinical care, and epidemiologic investigation. Although the Incident Command System (ICS) has been adapted for use in public health programs, ICS training curricula in public health settings typically focus on ICS organization and roles rather than leadership challenges faced by public health incident leaders.
The practice of leadership in public health emergencies can be informed by assessing crisis leadership attributes in other professions including aviation, military, police and fire services, nuclear power plant operations, and mining.
Simulator-based research of aircrew performance during aviation emergencies has shown that crew-leader personality affects crew performance, particularly in critical, high-workload situations. Crews led by successful crisis leaders made fewer errors and were more likely to successfully resolve the emergency. Aircrews led by captains with a constellation of traits nicknamed “the right stuff” (including self-confidence, striving for excellence, and interpersonal warmth) also reported less stress compared with crew members led by other personality types. ,
Crew Resource Management (CRM) originally was developed in aviation to reduce crew error and better use human resources among the flight deck crew. The traits identified in successful aircraft captains using CRM include decisiveness, the ability to maintain awareness of the situation, and willingness to receive input from other crew members. CRM has been successfully adapted to the medical setting and used in emergency departments, operating rooms, and by delivery staff. Adaptation of CRM principles and tactics to public health crisis leadership is possible through training and simulated exercises.
Military In Extremis Leaders
The concept of in extremis leadership was developed by Colonel Thomas Kolditz of the United States Military Academy (West Point) to describe leadership when team and leader face immediate risk of death or injury. In extremis leaders are found in military combat units and among police and firefighters. The danger in these professions attracts leaders motivated by challenge and a willingness to share their followers’ risk. Followers demand competence of in extremis leaders, but, in return, they develop trust in and loyalty to their leader and each other.
First Responder Incident Commanders
ICS leaders are termed incident commanders . Key attributes of incident commanders in police and firefighting are decisiveness and the ability to conduct accurate situational assessments and execute either predefined or new courses of action as appropriate. Incident commanders coordinate across organizational and disciplinary boundaries, delegate responsibility, set priorities, and manage their own stress levels to avoid performance degradation.
Nuclear Power Plant Emergency Team Leaders
A study of emergency response personnel at nuclear power plants in the United Kingdom identified key nontechnical skills for various response positions. Identified nontechnical skills among “decision makers” who set strategic-response goals included decision making, communication, situation awareness and anticipation, promoting effective teamwork, managing team stress, and displaying leadership that can be either directional or consultative depending on the situational need.
Underground Mine Fire Survivors
Among miners surviving underground fires, leaders tended to notice details and be alert to their environment, which are traits likely to facilitate survival. They were decisive yet open to input from others and were flexible and willing to change decisions as circumstances evolved. They had a calming effect on other miners and inspired confidence. Competence appears to be important, particularly in the emergence of ad hoc leaders in mining emergencies. In some emergencies, an individual who was not in authority before the disaster emerged as a leader after demonstrating competence by providing consultation to the predisaster authority figure.
Common attributes of crisis leaders
Table 37-1 summarizes the referenced behaviors and attributes of successful crisis leaders. The disciplines surveyed for this assessment vary widely in their professional demands, training, and practice environment. An aircraft captain may supervise a crew of only two or three on the flight deck, whereas the incident commander at a large fire may oversee hundreds. Military leaders and commanders of first response organizations receive formal training in incident leadership, whereas the ad hoc leader of trapped miners may have no prior leadership role in the mine.
|Decisive/confident||Competent||Aware of situation||Accepts information from others||Emotional awareness||Coordinates & communicates||Other |
(traits in these columns are not grouped by similarity)
|Aviation: the “right stuff” ,||Self-confidence||Displays interpersonal warmth & sensitivity||Preference for challenging tasks||Being active||Strives for excellence||Competitiveness|
|Aviation: crew resource management||Makes decisions systematically||Maintains situational awareness |
Regulates information flow
|Accepts crew input||Coordinates |
|In extremis leadership||Competent||Inspires and builds trust |
Inspires & displays loyalty
|Shares values-based lifestyle||Shares risk|
|Incident commanders||Makes decisions||Assesses situation (awareness & interpretation) |
|Assesses situation (awareness & interpretation)||Coordinates team |
|Nuclear power plant emergency response leaders||Decision making||Maintains awareness of situation and anticipates||Consultative leadership (“in slower paced situations”)||Promotes communication within & in/out of plant||Manage own and team’s stress|
|Leaders in mining disasters||Decisive but flexible||Competent, knowledgeable||Aware of environment||Accepts input from others||Inspires confidence and trust Calming|
|Proposed public health crisis leadership attributes||Decisive||Competent||Maintains situational awareness||Interprets data to provide a situational assessment||Displays warmth, sensitivity Inspires trust||Coordinates & communicates Meta-leadership|