Supporting Reassigned Hospital Staff During the COVID-19 Pandemic in the Montreal Region: What Does it say About Leadership Styles?

Introduction

Health care facilities are at the forefront of crisis response, being the first point of contact for triage, detection, and treatment of populations (Denis et al., 2021). In hospitals and other health care organizations, the daily routines of health human resources (HHR) were thus significantly impacted by COVID-19 – which in turn affected their capacity to cope with a crisis. In addition, to contain COVID-19 outbreaks, several governments issued orders to allow hospitals to send their staff to most-affected services and facilities, an organizational phenomenon hereinafter referred to as “reassignment”. This decision entailed profound changes for the reassigned staff, with significant consequences for their wellbeing at work (Khajuria et al., 2021).

Previous studies have shown that, during a crisis, leaders play a central, crucial role to support staff's wellbeing at work and resilience (Grint, 2020; Obrien et al., 2021). Leadership has been defined as “the relationship between the individual/s who lead and those who take the choice to follow, while it refers to the behavior of directing and coordinating the activities of a team or group of people towards a common goal” (Sfantou et al., 2017, p. 1). Based on this definition, several leadership styles co-exist, and among them, some have specific features which may help organizations navigate through crises. A limited number of studies have investigated the relationships between leadership styles of health care organizations and/or managers, and the organizations’ or managers’ preparedness or response adequacy towards HHR. While several studies quantitatively and qualitatively described the reassignment experience (Juan et al., 2022; Kennedy et al., 2022), there is to our knowledge no literature reflecting on the phenomenon of reassignment in relation to leadership styles in the context of the response to the COVID-19 crisis.

Leadership styles can be classified into two categories, namely leader-centered styles, and follower-centered styles. According to Maslennikova, “leader-centered styles achieve organizational success through the self-realization and self-projection of the leader” (Maslennikova, 2007, p. 1). Common leader-centered styles include transactional leadership, authoritative leadership, and laissez-faire leadership. These styles are more often found in organizations that have top-down, hierarchical governance structures. Leaders considered ‘laissez-faire’ are often depicted as lacking involvement during critical organizational junctures (Eagly et al., 2003). Authoritarian leaders are task-oriented figures that provide their followers with clear expectations of what needs to be accomplished, and how it should be accomplished (Lewin et al., 1939). Transactional leaders promote followers’ compliance to a rewards and punishments system, which keeps followers motivated for the short-term (Bass, 1985). This type of leadership is said to be effective in emergency situations because they “share a concern for the resolution of immediate needs” (Tomkins & Simpson, 2015, p. 1020). Follower-centered styles reflect leadership styles that recognize and promote employees as valuable organizational assets, deserving careful attention (Maslennikova, 2007). Organizations that allow for follower-centered styles to express have horizontal governance structures. The most common follower-centered style is transformational leadership. Transformational leaders empower, inspire, and motivate followers to innovate and create change in organizations through a collective vision and greater ownership of their work (Bass, 1985). Transformational leaders generally are empathetic leaders. Unlike transactional leadership, transformational leadership reached beyond the immediate needs (e.g., in times of crisis) and often involves lengthy temporal trajectories to achieve long-term inspirational goals (Tomkins & Simpson, 2015). Other follower-centered styles include inclusive leadership and servant leadership. Inclusive leadership refers to a set of leader efforts to invite and appreciate group members’ contribution, while enhancing their feeling of being part of the group (belongingness) (Nembhard & Edmondson, 2006). This leadership style has been explored in the context of the pandemic, thereby showing the influence of inclusive leadership style in reducing the psychological distress of nurses during the COVID-19 crisis in Wuhan (Zhao et al., 2020). The goal of servant leaders is to serve their followers; they interact with them to achieve authority rather than power (Allen et al., 2016). Servant leaders focus on staff wellbeing. Lastly, by suggesting to rise above the leader-follower dichotomy, Tomkins & Simpson's definition of caring leadership goes beyond merely kind or compassionate leaders by re-emphasizing human agency and the consciousness of staff (Tomkins & Simpson, 2015). Caring leaders can navigate complex organizational decision-making with flexibility and adaptability – which we might also consider assets of organizational resilience.

This study is grounded in transformational leadership theory. According to this theory, leadership's effects and impacts are typically revealed and represented through the eyes of an organization's staff (Bass, 1985). Staff's perceptions of leadership's actions thus provide evidence of leadership effectiveness. Assessing the latter requires a detailed understanding of how leaders’ decisions were made and how those decisions’ implementation and effects were perceived by staff. Several studies described the effects of transformational leadership sub-categories, such as compassionate managerial leadership (Oruh et al., 2021) and/or adaptative leadership (Laur et al., 2021) on health care organizations’ crisis response. Among these studies, none conceptualized leadership styles in the context of specific health care organizations. Wibowo and Paramita found positive associations between empathetic leadership and COVID nurses’ resilience in Indonesia (Wibowo & Paramita, 2021). However, this work was not carried out at the organizational level and hence did not account for specific organizational decisions. To fill the research gap, our study investigated how two contrasted hospitals in Quebec supported HHR during the first and second waves of the pandemic (i.e., March-June 2020, and September 2020 to February 2021). Quebec was the Canadian province that experienced the highest COVID-19 death rate during the first two waves of the pandemic (Canada, 2020). Quebec's experience is significant because, in addition to an inadequate geographic distribution of HHR (Ministère de la Santé et des Services sociaux, 2022), the second most-populated Canadian province has had recurring challenges in retaining HHR. Reasons for lack of retention include the impacts of previous health system reforms, and a recurring lack of flexibility for accommodating family/work balance (Dubois, 2020). Bill 10 is a key element to understanding hospital (re)organization in Quebec. It primarily relied on administrative institutional integration and centralization of power at the macro-political (provincial) level. Table 1 below outlines the contents of Bill 10 and its influence on how reassignment decisions were made and how it impacted organizations and HHR.

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Table 1.

Bill 10, the reorganization of health and social services, and their influence on reassignment decision-making during the COVID-19 crisis.

Socio-political levels	Contents of Bill 10 and its implications for health and social services reorganization	Direct and indirect influence of Bill 10 on reassignment decision-making, implementation, and impacts, during COVID-19
Macro-level (provincial level)	Bill 10 induced more centralized decision-making, by abolishing regional health authorities, by instituting a direct report of CI(U)SSS to the minister, by replacing democratic processes for electing institutional boards of directors with government-appointed boards. For example, instead of being appointed by executive boards and through democratic processes, chief executive officers (CEOs) of CI(U)SSS became in 2015 directly appointed by the ministry of health, thus granting the latter significant leverage over the organization of CI(U)SSS.	March-April 2020 – issuance of ministerial orders and communiqués instituting staff reassignment: Order number 2020-007 of the MSSS dated March 21, 2020, which sees the modification of collective agreements and the possibility of reassignment of employees in the health network; Order number 2020-019 dated April 10, 2020, which gives the possibility of reassigning personnel from the education network to the health and social services network.
Meso-level (organizational level)	Bill 10 created 22 integrated health and social services networks (CISSS) (e.g., our case C2), nine of which designated “university integrated health and social services networks” (CIUSSS) and seven non-integrated hospitals (e.g., our case C1). The CI(U)SSS are responsible for service delivery and some degree of planning, thereby responding to population health needs in their respective territory. This reorganization translated into the de facto, streamlining of several health and social facilities, merged into large CI(U)SSS. Renewed focus on hospitals and clinical care, at the expense of long-term care services.	In all CI(U)SSS and non-integrated hospitals, training sessions were offered to staff, to increase their competence in intensive care. Some hospitals also offered basic training in geriatrics, with the goal of sending these newly trained hospital staff to long-term care settings. In the whole health and social services network, reassignment policies were initially voluntary; financial incentives were offered to those reassigned. In CI(U)SSS located in the most COVID-affected areas of Quebec, the application of ministerial orders quickly prompted mandatory reassignment, which was not the case for non-integrated (autonomous) hospitals (e.g., C1).
Micro-level (individual/team- level)	More than 20% middle managers were cut as a result of Bill 10, which meant less communications with clinical teams under their responsibility in the various organizations part of CI(U)SSS. This issue widened the distance between clinical teams and executive teams – which in turn impacted psychological distress at work, and resulted in increased absenteeism for clinical staff. Staff shortages (for both clinical and administrative staff) in CI(U)SSS thus predated the pandemic, including in long-term care settings under the purview of CI(U)SSS.	In March-April 2020, many employees working in long-term care settings became infected with COVID-19; their absence led to a massive abandonment of residents, leaving facilities even more vulnerable to COVID-19 clusters. CI(U)SSS staff – who were already vulnerable because of the impacts of Bill 10, and particularly those who were reassigned, were likely to experience: workplace anxiety – especially those who were reassigned to long-term care facilities; fear of being infected with COVID-19; professional exhaustion; loss of professional meaning.

In the context of this reform, at the organizational level (meso-level), middle-management support structures for front-line workers within health care facilities were also streamlined. More than 20% middle managers were cut as a result of this reform, which meant less communication with clinical teams under their responsibility (Denis et al., 2021). According to various analysts, the bill's vision change was done at the expense of public health, long-term care services, and social services (Quesnel-Vallée & Carter, 2018). Indeed, Bill 10's application also translated into a renewed focus on hospitals, which are the bigger and most expensive components in the newly-created integrated networks (CISSS and CIUSSS). Within hospitals, a stronger centralization of power, and the cutting of middle managers, increased the distance between clinical teams and executive teams. At the individual level (micro-level), one plausible consequence of this issue is increasing psychological distress at work. In 2019, nearly 40% of HHR absenteeism in the health care sector was caused by mental health issues (Ministère de la Santé et des Services sociaux, 2019). A fragile HHR situation thus predated the health crisis; it contributed to worsening HHR shortages. Many HHR in long-term care settings became infected with COVID-19, and their absenteeism led to a massive abandonment of residents, leaving facilities even more vulnerable to COVID-19 clusters (Commissaire à la santé et au bien-être Québec, 2020). In fact, 62.6% of all COVID-19 deaths in Quebec in 2020 were identified in long-term care facilities (Institut National de Santé Publique du Québec, 2020). To make up for such HHR shortage and to contain COVID-19 outbreaks in long-term care facilities, many hospital staff were sent to those facilities, with significant consequences for their mental health (Cyr et al., 2021). Building upon their observational study findings, Cyr and colleagues invite scholars to investigate perceptions of organizational support tools. Drawing on the unique experience of HHR reassignment in Quebec, we decided to investigate the staff's perceptions of organizational support tools provided by high-level and mid-level managers from the ‘home’ hospitals.

Based on a comparative analysis of two hospitals in the Montreal Metropolitan Area, Quebec, this study sought to answer the following research question: What leadership styles are reflected through the hospitals’ support responses for hospital staff reassigned to long-term care services during the first and second pandemic waves in the Montreal region? To answer this question, we used a qualitative case study documenting hospital staff's experience with reassignment decisions and their perceptions of tools implemented to support staff that went to COVID-affected long-term care facilities (LTCFs).

Methods

Results

Discussion

Our study is amongst the few empirical research investigating relationships between leadership styles of health care organizations and organizations’ preparedness or response adequacy towards HHR in times of crisis. Based on our case study on two hospitals (C1 and C2), we documented features of diverse leadership styles revealed through the experience of support tools made available to HHR reassigned to long-term care settings in the context of the first and second waves of COVID-19.

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Table 2.

Summary of key themes and sub-themes for each case.

	Case 1 (non-integrated)	Case 2 (CISSS-integrated)
Organization’s governance structure	Autonomous	Reporting to ministry; ministry-appointed board of directors
Reassignment decision	Voluntary	Voluntary, then compulsory
Tools for staff reassigned preparedness	Training in geriatrics and for managing grief and PTSD	training
Tools to support reassigned staff	Daily 1-1 check-in phone calls; training and sending of ‘COVID agents’; dedicated hotline; dedicated service with stable support staff; ‘battle buddies’; Facebook page for peer support	Team of psychosocial workers dedicated to reassigned staff; dedicated hotline; dedicated department but lack of management continuity; peer work
Tools for post-reassignment support	Debriefing; post-reassignment session upon reintegration in the hospital; training sessions for the managers of reassigned staff	Team of psychosocial workers dedicated to reassigned staff
Incentives and rewards	Bonuses; sending flowers	Bonuses; letters of recognition; social media recognition campaign
Perceived leadership style	‘Maternal leadership’ (e.g., health staff; approachability of female high-level managers)	Authoritarian leadership (communicating reassignment decisions with no discussion) Laissez-faire leadership (i.e., leadership virtually absent on the ground)
Leadership aspirations for the future	Moving towards caring leadership to enhance staff autonomy	Moving towards transformational, inclusive leadership

Source: Authors’ own work

At the start of the pandemic, both hospitals were facing pre-existing chronic HHR shortages. These shortages were reinforced by the pandemic crisis, because of the isolation and quarantine policies for any employee returning from travel and/or having contracted COVID-19 or being in contact with cases. Yet, C1 and C2 handled their HHR reassignment very differently. In one case (C1), the relatively low COVID-19 patient flows and a largely autonomous organizational structure, allowed for voluntary reassignment, which was not possible in CI(U)SSS-integrated hospitals like C2. As shown in Table 2, in C1, support systems included training in geriatrics and psychological distress management, regular telephone follow-ups with reassigned staff, battle buddies, and a debriefing and post-reassignment session upon reintegration in the hospital. In C2, reassigned nurses and other hospital staff had access to basic training, could be paired with someone of their occupation (pair working), and could call for assistance from a special psychosocial reinforcement team, or asked for advice via the use of a dedicated hotline. The design and handling of the reassignment system, as well as the different strategies to support reassigned staff, revealed C1 leadership's strong will to intervene and control the process in a compassionate or ‘caring’ fashion, which interviewees characterized as reflecting a certain “maternal leadership”, appeared to be conducive of a successful crisis response. There are important considerations, in addition to low caseloads (which notably allowed for more preparedness time), such as autonomous governance which enabled less dependence on Ministerial orders, more fluid decision-making, and the liberty to choose how to use their PPE stocks and how to allocate their HHR.

In C1, several characteristics of leadership described as “maternal” by interviewee respondents, allowed us to connect it to transformational leadership – particularly the “caring” feature. Similarly, Panton describes maternal leadership as “transformational leadership… with a pedagogy of caring” (Panton, 2016, p. 23). In our study, the maternal leadership style also shared commonalities with several subtypes of transformational leadership, such as the inclusive leadership style, in that it allowed for strengthening trust and the collective sense of belonging for HHR reassigned on the frontlines (Jambhekar, 2019). In addition, the “maternal” type seemed very close to compassionate managerial leadership, i.e., a leadership style that promotes organizational strategic goals (survival, sustainability) “while also addressing employees’ concerns (wellbeing, fear, uncertainty), through leadership compassion, benevolence, empathy, caring, engagement, reassurance and motivation” (Oruh et al., 2021, p. 1364). As in the case of the compassionate managerial leadership style, the support systems implemented by C1 leaders helped to alleviate stress experiences among HHR during and after reassignment, which in turn seemed to the hospital's resilience (Ridde et al., 2021).

Elements of servant leadership were also salient in the case of C1. Key attributes of servant leaders (Allen et al., 2016) that would bring them close to the “maternal” style, included leaders’ listening abilities (highlighted by several respondents), their inclination to promote teamwork and collective problem-solving, as well as their capacity to motivate by providing autonomy (e.g., promote a sense of initiative) and resources (e.g., PPE in LTCFs). Timely provision of adequate material resources (e.g., PPE) and implementation of mental health supports are in fact likely to increase staff self-efficacy and confidence (Wu et al., 2020). Regulatory bodies also recommended that hospital managers be trained to prevent and detect the onset of distressing symptoms in their staff, particularly for those reassigned to other care settings (INESSS, 2020). Again, the described experience of C1, which developed a training program for managers whose staff had been sent to LTCFs during the spring 2020 crisis, and for the staff themselves, was particularly illustrative. Some of the videos on how to cope with psychological distress and prevent post-traumatic stress disorder that they developed were transferred to other hospitals in Quebec. Beyond the individual resilience of health care personnel, these strategies could therefore strengthen organizational resilience (Behrens et al., 2022).

By contrast, leadership in C2 displayed more centralized and vertical decision-making, and much less proactive intervention, often coming up with support tools considered too basic, too little, or too late – especially in the context of HHR already being vulnerable. This reflects the impact of the 2015 reform; the pandemic creating multiple situations whereby leadership teams were caught between two sides (i.e., the ministry's orders and HHR wellbeing). Specifically, insufficient or late reactions were noted in C2, such as poor communication on the implementation of reassignment (managers vs. professionals, CISSS vs. unions), and the lack of consideration for employees’ mental health in general, or the lack of preparation for the “re-integration” process. The choice of passive interventions to support reassigned staff, mirroring a form of transactional leadership, may have been costly for C2. C2's reassigned staff strongly expressed the need for additional moral and psychological support from the institution. This is coherent with one of the key recommendations provided in a major report on health systems resilience across the globe, “health workers need support too” (Sagan et al., 2021, p. 93). In C2, staff specifically asked for more proactive support (i.e., offering support rather than giving it on demand). As a result, the difficult management of reassigned staff hindered the quality of the response to the pandemic crisis. It also had negative mid-term impacts on the hospital. Indeed, the transfer of professionals to completely different environments may have had significant impacts at the beginning, and then persisted through time. This led to several resignations, particularly in professions in short supply.

Our study also revealed a nuanced portrait of leadership styles. Indeed, while the key themes highlighted contrasted leadership styles between C1 and C2, they also showed diversified forms of leadership through the reassignment experience. For instance, both C1 and C2 included forms of transactional leadership (i.e., incentive and reward system – see Table 2). In C2, authoritarian leadership appeared to co-exist with forms of laissez-faire leadership on the ground. In C1, “maternal leadership” coincided with managers’ wish to move towards caring leadership in order to further staff autonomy. More broadly, our findings emphasized the complex nature of organizational leadership in the context of unpreceded circumstances (the COVID-19 crisis).

The COVID-19 pandemic further highlighted the importance of human work (Behrens et al., 2022) which is at the core of hospitals and health systems resilience. In April 2020, the Institut national d'excellence en santé et en services sociaux of Quebec published a rapid review of the literature that highlighted the main sources of psychological distress resulting from the COVID-19 pandemic for health human resources (INESSS, 2020). In addition to pandemic-related risks, the review noted that factors related to organizational environments may exacerbate psychological distress or mental health status among HHR. In fact, one of the key factors in the prevention of mental health problems in the context of COVID-19 included strong leadership within health care facilities (Wu et al., 2020). The current HHR situation in Quebec has significantly worsened since 2020, the pandemic accelerating an already difficult situation. Even though the pandemic is not over, we can suggest that, at least on the HHR front, Quebec's health system demonstrated a rather low resilience, since the situation only worsened for HHR since the beginning of 2020. Closed emergency rooms and postponed surgeries have been recurrent since 2021 because of workforce shortages, leaving institutions no choice but to implement “contingency plans” or crisis management solutions, and to hire more personnel through private placement agencies. A vicious circle seems to be in place, with a lack of resources leading to worsening working conditions and resulting in poorer retention (The Canadian Press, 2022). To address these challenges, Quebec's government announced a plan to rebuild its healthcare system, with HHR being one of its top priorities ( ICI.Radio-Canada.ca, n.d.). The ambition is to move “from understaffing to overstaffing”, e.g., by bringing in 1,000 nurses from abroad and recruiting 3,000 administrative officers (ibid.). In terms of staff retention, this plan provides for the implementation of self-scheduling, based on the success of several pilot projects in some places. Those measures may sound promising, but with the crucial question of managerial leadership styles remaining a blind spot for policy-makers, the ambitious plan might not yield the expected effects, particularly in terms of staff retention.

This study also offers insight into several recommendations to support the mental health and resilience of the health workforce. At the macro-political level, more consideration for adaptive and agile decision-making in hospitals in times of crisis should be given when designing new health system policies, a recommendation that is aligned with the global report on health systems resilience (Sagan et al., 2021). This could be conducive to the expression of a more diverse set of leadership styles with the goal of bringing hospital leaders closer to hospital staff's needs (e.g., more person-centered leadership styles, such as the servant leadership style). At the organizational level, systematizing the use of anticipatory planning tools (e.g., needs assessment) in hospitals would entail better organizational preparedness when facing a crisis (Dagenais et al., 2023; Gabet et al., 2023). Beyond times of crisis, given the importance of maintaining close links with teams on the front line, implementing a staff health service – another element that we can link to servant leadership – would certainly provide a sustainable and proactive response to HHR's support needs. If such service cannot be considered an option, e.g., for financial reasons, specific provisions for HHR supportive communication systems in hospitals should be anticipated in yearly budgets. More broadly, the generalization of graduate or practice-based teachings about leadership styles could be an interesting option to consider for hospital managers, at least to expose them to the diversity of leadership styles, to their value and limitations. Lastly, involving mid-level managers of health care facilities more actively in the collective identification and formulation of a ‘toolbox’ of solutions to support mental health at work, would be most valuable (Corbière et al., 2020).

This study has several limitations. Data collection was carried out in Summer and Fall of 2020 (i.e., after the first wave of COVID-19, and during the second wave), reflecting different pandemic timeframes, and changing perceptions for interview respondents, who were HHR themselves going through those changes. The fluctuating pandemic context also reflected a discontinuous and sometimes incoherent decision-making process in times of crisis, which was often difficult to reconstruct post hoc. For these reasons, our study findings ought to be interpreted in their respective time and space, which might challenge the possibilities of extending the findings to other settings.

Conclusions

As with previous studies, our study has demonstrated that many aspects of Quebec's pandemic response are related to the major political reform of 2015. By re-enforcing a top-down, highly centralized decision-making, this health systems reform shaped hospitals’ manifestation of certain leadership styles. C1, not being under direct control by the ministry (i.e., a non-integrated hospital) was not bound by the ministerial reassignment order. Executives in C1 were thus free to proactively design support systems and offer reassigned HHR timely and adequate psychosocial support tools. For leaders of C2, which belonged to a CISSS, lack of compliance with ministerial orders was not an option, even if that resulted in creating long-standing tensions within the hospital's HHR.

Our study also offered several insightful recommendations to support the mental health and resilience of the health workforce in times of crisis and beyond. As the retention of HHR becomes an even more priority issue for policy-makers, and since future crises will certainly unfold in the next few years, we also encourage the production and diffusion of more research in other Canadian provinces on wellbeing support tools at work for nurses and health care professionals.