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Situational Leadership Theory

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

situational theory of leadership case study

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

situational theory of leadership case study

Verywell / Nez Riaz

Situational Leadership II

Elements of situational leadership theory, frequently asked questions.

Situational leadership theory suggests that no single leadership style is best. Instead, it depends on which type of leadership and strategies are best suited to the task.

According to this theory, the most effective leaders are those that are able to adapt their style to the situation and look at cues such as the type of task, the nature of the group, and other factors that might contribute to getting the job done.

Situational leadership theory is often referred to as the Hersey-Blanchard Situational Leadership Theory, after its developers, Dr. Paul Hersey, author of "The Situational Leader," and Kenneth Blanchard, author of "One-Minute Manager."

Leadership Styles

Hersey and Blanchard suggested that there are four primary leadership styles:

  • Telling (S1) : In this leadership style, the leader tells people what to do and how to do it.
  • Selling (S2) : This style involves more back-and-forth between leaders and followers. Leaders "sell" their ideas and message to get group members to buy into the process.
  • Participating (S3) : In this approach, the leader offers less direction and allows members of the group to take a more active role in coming up with ideas and making decisions.
  • Delegating (S4) : This style is characterized by a less involved, hands-off approach to leadership . Group members tend to make most of the decisions and take most of the responsibility for what happens.

Maturity Levels

The right style of leadership depends greatly on the maturity level (i.e., the level of knowledge and competence) of the individuals or group.

Hersey and Blanchard's theory identifies four different levels of maturity, including:

  • M1 : Group members lack the knowledge, skills, and willingness to complete the task.
  • M2 : Group members are willing and enthusiastic, but lack the ability.
  • M3 : Group members have the skills and capability to complete the task, but are unwilling to take responsibility.
  • M4 : Group members are highly skilled and willing to complete the task.

Matching Styles and Levels

Leadership styles may be matched with maturity levels. The Hersey-Blanchard model suggests that the following leadership styles are the most appropriate for these maturity levels:

  • Low Maturity (M1)—Telling (S1)
  • Medium Maturity (M2)—Selling (S2)
  • Medium Maturity (M3)—Participating (S3)
  • High Maturity (M4)—Delegating (S4)

How It Works

A more "telling" style may be necessary at the beginning of a project when followers lack the responsibility or knowledge to work on their own. As subordinates become more experienced and knowledgeable, however, the leader may want to shift into a more delegating approach.

This situational model of leadership focuses on flexibility so that leaders are able to adapt according to the needs of their followers and the demands of the situation.

The situational approach to leadership also avoids the pitfalls of the single-style approach by recognizing that there are many different ways of dealing with a problem and that leaders need to be able to assess a situation and the maturity levels of subordinates in order to determine what approach will be the most effective at any given moment.

Situational theories , therefore, give greater consideration to the complexity of dynamic social situations and the many individuals acting in different roles who will ultimately contribute to the outcome.

The Situational Leadership II (or SLII model) was developed by Kenneth Blanchard and builds on Blanchard and Hersey's original theory. According to the revised version of the theory, effective leaders must base their behavior on the developmental level of group members for specific tasks.

Competence and Commitment

The developmental level is determined by each individual's level of competence and commitment. These levels include:

  • Enthusiastic beginner (D1) : High commitment, low competence
  • Disillusioned learner (D2) : Some competence, but setbacks have led to low commitment
  • Capable but cautious performer (D3) : Competence is growing, but the level of commitment varies
  • Self-reliant achiever (D4) : High competence and commitment

SLII Leadership Styles

SLII also suggests that effective leadership is dependent on two key behaviors: supporting and directing. Directing behaviors include giving specific directions and instructions and attempting to control the behavior of group members. Supporting behaviors include actions such as encouraging subordinates, listening, and offering recognition and feedback.

The theory identifies four situational leadership styles:

  • Directing (S1) : High on directing behaviors, low on supporting behaviors
  • Coaching (S2) : High on both directing and supporting behaviors
  • Supporting (S3) : Low on directing behavior and high on supporting behaviors
  • Delegating (S4) : Low on both directing and supporting behaviors

The main point of SLII theory is that not one of these four leadership styles is best. Instead, an effective leader will match their behavior to the developmental skill of each subordinate for the task at hand.

Experts suggest that there are four key contextual factors that leaders must be aware of when making an assessment of the situation.

Consider the Relationship

Leaders need to consider the relationship between the leaders and the members of the group. Social and interpersonal factors can play a role in determining which approach is best.

For example, a group that lacks efficiency and productivity might benefit from a style that emphasizes order, rules, and clearly defined roles. A productive group of highly skilled workers, on the other hand, might benefit from a more democratic style that allows group members to work independently and have input in organizational decisions.

Consider the Task

The leader needs to consider the task itself. Tasks can range from simple to complex, but the leader needs to have a clear idea of exactly what the task entails in order to determine if it has been successfully and competently accomplished.

Consider the Level of Authority

The level of authority the leader has over group members should also be considered. Some leaders have power conferred by the position itself, such as the capacity to fire, hire, reward, or reprimand subordinates. Other leaders gain power through relationships with employees, often by gaining respect from them, offering support to them, and helping them feel included in the decision-making process .

Consider the Level of Maturity

As the Hersey-Blanchard model suggests, leaders need to consider the level of maturity of each individual group member. The maturity level is a measure of an individual's ability to complete a task, as well as their willingness to complete the task. Assigning a job to a member who is willing but lacks the ability is a recipe for failure.

Being able to pinpoint each employee's level of maturity allows the leader to choose the best leadership approach to help employees accomplish their goals.

An example of situational leadership would be a leader adapting their approach based on the needs of their team members. One team member might be less experienced and require more oversight, while another might be more knowledgable and capable of working independently.

In order to lead effectively, the three skills needed to utilize situational leadership are diagnosis, flexibility, and communication. Leaders must be able to evaluate the situation, adapt as needed, and communicate their expectations with members of the group.

Important elements of situational leadership theory are the styles of leadership that are used, the developmental level of team members, the adaptability of the leader, communication with group members, and the attainment of the group's goals.

  • DuBrin AJ. Leadership: Research, Findings, Practice, and Skills. Mason, OH: South-Western, Cengage Learning; 2013.
  • Gill R. Theory and Practice of Leadership. London: Sage Publications; 2011.
  • Hersey P, Blanchard KH.  Management of Organizational Behavior — Utilizing Human Resources . New Jersey/Prentice Hall; 1969.
  • Hersey P, Blanchard KH. Life Cycle Theory of Leadership. Training and Development Journal.  1969;23(5):26–34.
  • Nevarez C, Wood JL, Penrose R. Leadership Theory and the Community College: Applying Theory to Practice. Sterling, Virginia: Stylus Publishing; 2013.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Implementing the Situational Leadership Theory in Project Management

June 11, 2023 - 10 min read

Wrike Team

In the ever-evolving world of project management , effective leadership is a crucial factor in achieving the success of any endeavor. One leadership theory that has gained traction in recent years is the Situational Leadership Theory. This theory recognizes that different situations require different leadership styles and that effective leaders are those who can adapt their approach to suit the needs of their team. In this article, we will explore the basics of Situational Leadership Theory, its importance in project management, steps to implement this theory, real-world case studies, and challenges associated with its implementation.

Understanding the Basics of Situational Leadership Theory

Developed by entrepreneur Paul Hersey and writer Kenneth Blanchard, the Situational Leadership Theory is based on the premise that there is no one-size-fits-all approach to leadership. Instead, it emphasizes the importance of adjusting leadership behaviors based on the maturity level of the team members and the specific task at hand. Leaders who can effectively diagnose the development level of their team members and apply the appropriate leadership style are more likely to achieve positive outcomes.

The Four Leadership Styles in Situational Leadership Theory

Based on the staff's development level, leaders can adopt one of four leadership styles: directing, coaching, supporting, or delegating. Each style is tailored to the specific needs of the team members, ensuring that their growth and success are maximized.

  • Directing: Appropriate when team members are low on both competence and commitment. In such situations, leaders take a more hands-on approach, providing explicit instructions and closely monitoring progress. 
  • Coaching: Suitable when team members have low competence but high commitment. In this style, leaders focus on both task accomplishment and personal development. They provide guidance and support, offering constructive feedback and helping team members enhance their skills. 
  • Supporting: Perfect for team members with high competence but low commitment. In this style, leaders facilitate and empower the team, providing support and encouragement. 
  • Delegating: For team members who have high competence and high commitment. In this style, leaders allow the team to take ownership and make decisions autonomously. 

The Importance of Situational Leadership in Project Management

Effective project management relies on leaders who can maximize team performance, facilitate effective communication, and promote flexibility and adaptability. 

Enhancing Team Performance

By adapting leadership styles based on the development level of team members, project managers can provide the necessary guidance and support for individuals to reach their full potential. This approach boosts team performance by tailoring leadership behaviors to the specific needs of each team member.

Let's consider a project manager who has a team consisting of both experienced professionals and new recruits. The experienced professionals may require less direction and guidance, as they have a high level of competence and commitment. On the other hand, the new recruits may need more support and clear instructions to build their skills and confidence. By using situational leadership, the project manager can adjust their leadership style accordingly, providing the appropriate level of guidance to each team member. This not only helps the new recruits develop their skills but also allows the experienced professionals to work autonomously, leading to improved overall team performance.

Facilitating Effective Communication

Communication is paramount in project management. Situational Leadership Theory encourages leaders to adjust their communication style to align with the competence and commitment of team members. By doing so, leaders can see to it that messages are conveyed effectively and understood by all team members, resulting in improved collaboration and productivity.

Consider a project manager who is leading a team with members from different cultural backgrounds. Each team member may have different communication preferences and styles. Some may prefer direct and concise communication, while others may prefer more detailed and contextualized information. By using situational leadership, the project manager can adapt their communication style to meet the needs of each team member, so that information is effectively transmitted and understood by all. This fosters a positive and inclusive team environment, where everyone feels heard and valued, leading to enhanced team collaboration and ultimately, project success.

Promoting Flexibility and Adaptability

Projects often encounter unexpected challenges and changes. Leaders who embrace Situational Leadership Theory are better equipped to adapt their approach and guide their team through turbulent times. This flexibility ensures that projects remain on track and objectives are met, ultimately leading to project success.

Imagine a project manager who is leading a team working on a complex software development project. Midway through the project, a critical software bug is discovered, requiring immediate attention and a change in the project plan. A project manager who practices situational leadership can quickly assess the situation, gather input from team members, and adapt the project plan accordingly. They may assign additional resources to fix the bug, rearrange priorities, or modify timelines to accommodate the change. By being flexible and adaptable, the project manager can effectively navigate through unexpected challenges, so that the project remains on track and objectives are met.

Steps to Implement Situational Leadership Theory in Project Management

Below are several key steps:

Assessing the Team's Competence and Commitment

To effectively apply Situational Leadership Theory, project managers need to assess the competence and commitment levels of their team members. This assessment can be done through various methods, such as individual interviews, skills assessments, and feedback sessions.

During individual interviews, project managers can have one-on-one conversations with team members to understand their strengths, weaknesses, and areas for improvement. They can conduct skills assessments to objectively measure the technical abilities of team members via tests, simulations, or practical exercises. Lastly, feedback sessions provide an opportunity for project managers to gather insights from team members about their level of commitment and motivation, through open discussions, surveys, or anonymous feedback forms.

Identifying the Appropriate Leadership Style

Once the team's competence and commitment levels have been evaluated, project managers can determine the most suitable leadership style for each team member. The goal is to match the leadership style to the development level of the individual, so that the team member receives the necessary guidance and support to succeed. There are four main leadership styles in Situational Leadership Theory: directing, coaching, supporting, and delegating. They are described above, in the section titled The Four Leadership Styles in Situational Leadership Theory .

Applying the Chosen Leadership Style

After identifying the appropriate leadership style, project managers must implement it effectively. This involves communicating expectations, providing resources and support, and monitoring progress. Regular feedback and coaching sessions can also help team members develop and grow.

When applying the chosen leadership style, project managers need to clearly communicate their expectations to team members. This includes defining project goals, outlining roles and responsibilities, and setting performance standards. Managers must also provide the necessary resources and support to enable team members to succeed. This can include providing access to training and development opportunities, allocating sufficient time and budget for project tasks, and offering guidance and assistance when needed. Lastly, project managers should regularly monitor the progress of team members and provide feedback to help them improve. This can be done through performance evaluations, progress reports, or informal check-ins. 

Case Studies of Situational Leadership in Project Management

Here are two case studies that illustrate the inclusion of situational leadership in project management.

Case Study 1: Tech Industry

In a technology company, a project manager utilized Situational Leadership Theory to manage a team of software developers. By identifying the competence and commitment levels of each team member, the project manager was able to adjust their leadership style accordingly. This resulted in increased collaboration, improved technical skills, and higher motivation among team members, leading to the successful completion of the project within the specified time frame.

Case Study 2: Construction Industry

In a construction project, a project manager applied Situational Leadership Theory to effectively guide a diverse team of skilled laborers. By recognizing the development level of each individual and adapting the leadership style accordingly, the project manager made sure that all team members understood their roles and responsibilities. This created a positive working environment, increased productivity, and minimized rework, resulting in the timely completion of the project and high client satisfaction.

Challenges and Solutions in Implementing Situational Leadership

Here are several obstacles in implementing situational leadership, along with tactics to overcome them.

Common Obstacles in Applying Situational Leadership

Implementing Situational Leadership Theory may encounter a few challenges. Some team members may resist changes to their preferred leadership style, or there may be a lack of understanding or awareness about the theory. Additionally, time constraints and resource limitations can pose obstacles to the effective implementation of Situational Leadership Theory in project management.

Effective Strategies to Overcome Challenges

To overcome these challenges, project managers can invest in training and development programs for both leaders and team members, promoting a shared understanding of Situational Leadership Theory. Clear communication and regular feedback can help address resistance and build trust among team members. Additionally, project managers can allocate sufficient time and resources to confirm that the theory is implemented effectively and seamlessly.

Ultimately, implementing the Situational Leadership Theory in project management can greatly enhance team performance, facilitate effective communication, and promote flexibility and adaptability. By understanding the basics of this theory, recognizing its importance, and following the steps to implementation, project managers can create a supportive and productive environment that drives project success. While challenges may arise, with effective strategies, these challenges can be overcome, and the benefits of Situational Leadership Theory can be realized.

Enhance your project management skills by effectively implementing the situational leadership theory with Wrike. Start a free trial and lead your team with adaptability and sensitivity. Note: This article was created with the assistance of an AI engine. It has been reviewed and revised by our team of experts to ensure accuracy and quality.

Wrike Team

Occasionally we write blog posts where multiple people contribute. Since our idea of having a gladiator arena where contributors would fight to the death to win total authorship wasn’t approved by HR, this was the compromise.

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Encouraging open and transparent conversations: Create a safe space for team members to share their ideas, ask questions, and share feedback via regular team meetings, check-ins, and one-on-one sessions. When employees feel comfortable sharing their thoughts and concerns, it leads to better collaboration, problem-solving, and decision-making. Scheduling regular team meetings and check-ins: Weekly, bi-weekly, or monthly team meetings are beneficial for promoting team cohesion, discussing project progress, and identifying potential roadblocks in advance. Check-ins can be done individually to discuss specific concerns and serve as a discussion forum to ask questions and get clarification on any tasks or responsibilities. Using visual aids to enhance communication: Charts, graphs, and diagrams simplify complex information and can perfectly illustrate project timelines, progress, and milestones. 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PMO teams can improve collaboration by: Fostering a collaborative team culture: Promote teamwork, create a sense of shared purpose, and acknowledge each team member's contribution and expertise. When team members feel valued and respected, they are more likely to work together seamlessly, resulting in a more productive and efficient team. Utilizing collaboration tools and techniques: Try Trello, Wrike, or Kanban boards, as these tools help teams to stay on the same page, track progress, and collaborate effectively. Encouraging cross-functional teamwork: Encouraging team members from different departments or areas of expertise to work together on projects can tap into a broader range of skills and expertise. This helps to improve collaboration and leads to better problem-solving and decision-making. When team members from different backgrounds come together, they bring unique perspectives and ideas that can lead to innovative solutions. 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How will changes be monitored and evaluated? Establish a Change Control Board A change control board is responsible for assessing change requests and verifying that they align with the project's overall goals and objectives. The board should be made up of key stakeholders, including project managers, business analysts, and subject matter experts. It should also meet regularly to review change requests and make decisions about whether to approve or reject them. When establishing a change control board, consider the following: Who should be on the board? How often should the board meet? What criteria will be used to evaluate change requests? What is the process for communicating decisions to stakeholders? Communicate Changes Effectively Effective communication allows you to manage change successfully. Create a communication plan to share information about changes with everyone affected by them. 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Measure and Analyze Team Performance Regularly measuring and analyzing team performance is necessary for identifying areas of improvement and ensuring that project outcomes align with overall business goals and objectives. Here are some ways to measure and analyze team performance: Establish key performance indicators (KPIs): KPIs let PMO teams measure progress toward specific project goals and objectives. Select KPIs that align with your project's priorities and overall business objectives.  Use performance dashboards: Be able to visualize and track team performance data over time. You will be able to notice trends, make data-driven decisions, and communicate progress to stakeholders.  Analyze team performance data: Use data analytics tools and software to analyze team performance data, identify areas of improvement, and develop strategies to address them. 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Application of situational leadership to the national voluntary public health accreditation process.

situational theory of leadership case study

  • College of Public Health, University of Kentucky, Lexington, KY, USA

Successful navigation through the accreditation process developed by the Public Health Accreditation Board (PHAB) requires strong and effective leadership. Situational leadership, a contingency theory of leadership, frequently taught in the public health classroom, has utility for leading a public health agency through this process. As a public health agency pursues accreditation, staff members progress from being uncertain and unfamiliar with the process to being knowledgeable and confident in their ability to fulfill the accreditation requirements. Situational leadership provides a framework that allows leaders to match their leadership styles to the needs of agency personnel. In this paper, the application of situational leadership to accreditation is demonstrated by tracking the process at a progressive Kentucky county public health agency that served as a PHAB beta test site.


The mission of public health, as identified by the 1988 Institute of Medicine (IOM) report, The Future of Public Health , is “assuring conditions in which people can be healthy” ( 1 ). A strong infrastructure is central to the mission of public health, since it supports the delivery of key public health services. The critical role infrastructure plays in assuring public health is underscored in a 2003 IOM follow up report that identified strengthening governmental public health institutions as an essential area of action for the twenty-first century. The 2003 report highlighted the key role that leadership plays in maintaining a strong public health system through the development of a competent public health workforce. It also identified the importance of leadership in such specific recommendations as making “leadership training, support, and development” a high priority for all governmental public health agencies, schools of public health, and the other entities within the public health system ( 2 ).

Successful leadership is contingent upon developing a clear mission and executing a vision to guide progress ( 3 ). Various frameworks have been developed to guide public health leaders in developing a mission and vision, including the three Core Functions of Public Health and the 10 Essential Public Health Services (EPHS) ( 4 ). While these frameworks are useful, they are macro-contextual, and may be disconnected from the day to day operations of a public health agency. The accreditation standards and measures developed by The Public Health Accreditation Board (PHAB) provide specific benchmarks to be utilized by agencies as a framework to guide their activities. While PHAB’s standards and measures can be used to guide organizational leadership, the changes associated with accreditation require strong leadership and an immediate short-term strategic plan and long-term vision based on effectiveness, efficiency, and sustainability.

Academic public health programs, as part of their curricula, educate students in leadership theories and models, and often include skill training at both the masters and doctoral levels. Students of public health rarely are provided the opportunity to practice the leadership skills developed in the classroom or to test leadership theories in real world situations prior to degree completion. This article discusses one opportunity to transfer leadership theory and practice from the classroom to the practice setting. In this instance, practice based field experience provided a public health doctoral student the opportunity to utilize concepts learned in the classroom in a practice setting, and develop a case study, based on initial and follow up interviews with public health agency personnel, focused on leadership in the context of preparing for participation in a Beta Test of the PHAB pilot standards and measures.

Situational Leadership

Situational leadership theory suggests that leaders should adapt their leadership styles based on the readiness, current skills, and developmental level of team members ( 5 ). It provides the leader with the flexibility to assess the situation and adopt a leadership style that best fits the needs of the follower. It is particularly well suited to leading public health agencies through the accreditation process as will be demonstrated.

Utilizing Situational Leadership requires leaders to be aware of the perceptions of their followers. What leaders say they do is one thing; what followers say they want and how well their leaders meet their expectations is another ( 6 ). Given the novelty of accreditation, and the potential anxiety engendered during the different phases of the process, public health leaders need to be aware of and adapt their leadership styles to match the readiness, current skills, and developmental status of the team members engaged in accreditation, allowing the agency to successfully navigate this intricate process.

Situational leadership is based on two behavioral categories: task behavior and relational behavior. Task behavior is “the extent to which the leader engages in spelling out the duties and responsibilities of an individual or group” ( 7 ). Relational behavior is “the extent to which the leader engages in two-way or multi-way communication if there is more than one person” ( 7 ). Thus, situational leadership provides a balance between (1) guidance and direction (task behavior), (2) socio-emotional support (relational behavior), and (3) the readiness level followers exhibit for a specific task ( 5 ). The leadership styles of situational leadership include:

1. Style 1 (S1) “Directing” characterized by “high task and low relationship” behaviors;

2. Style 2 (S2) “Coaching” characterized by “high task and high relationship” behaviors;

3. Style 3 (S3) “Participating” characterized by “high relationship and low task” behaviors;

4. Style 4 (S4) “Delegating” characterized by “low relationship and low task” behavior ( 5 ) (see Figure 1 ).


Figure 1. Situational leadership and public health accreditation . Adapted from Ref. ( 5 ).

In situational leadership, readiness is defined as “the extent to which a follower demonstrates the ability and willingness to accomplish a specific task” ( 5 ). The major components of readiness are ability defined as “the knowledge, experience, and skill that an individual or a group brings to a particular task or activity,” and willingness is defined as “the extent to which an individual or a group has the confidence, commitment, and motivation to accomplish a specific task” ( 5 ). As seen in Figure 1 , follower readiness is a continuum from low to high as followers develop ability and willingness. Leaders match their leadership style to the readiness level of their followers as follows:

1. Level 1 (R1) occurs when the follower is “unable and unwilling” to perform the task and lacks confidence, motivation, and commitment;

2. Level 2 (R2) occurs when the follower is “unable but willing” to perform the task and requires some guidance;

3. Level 3 (R3) occurs when the follower is “able but unwilling” to complete the task, possibly because of insecurity; and

4. Level 4 (R4) occurs when the follower is “willing and able” to accomplish the task with confidence ( 5 ) (see Figure 1 ).

Situational Leadership and Public Health Accreditation: A Local Health Agency Case Study

While accreditation is not a new concept in the American health sector [initiatives such as The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have been a part of the health care system for decades], it is a new phenomenon in public health practice in the United States. Informal discussions concerning the accreditation of public health agencies have occurred for some time; however, accreditation received a significant boost from The Future of the Public’s Health in the Twenty-First Century , which stated that “despite the controversies concerning accreditation, greater accountability is needed on the part of state and local health agencies with regard to the performance of the core public health functions of assessment, assurance, and policy development and the EPHS” ( 8 ). This report led to the creation of the Exploring Accreditation project in 2004, the creation of PHAB in 2007, and ultimately the release of PHAB’s standards and measures for voluntary national accreditation in 2011.

Accreditation is a useful tool for improving the quality of services provided to the public by setting standards and evaluating performance against those standards, and has been shown to be associated with higher performing health systems. In a working paper for the Robert Wood Johnson Foundation (RWJF), Mays demonstrated that clinical quality measures for care of myocardial infarctions were lower and mortality rates higher in hospitals not participating in JCAHO accreditation when compared to JCAHO accredited healthcare facilities ( 9 ). It may be postulated that accreditation of public health agencies will have a similar effect. PHAB states that its program is intended to develop and maintain “a high-performing governmental public health system that will make us the healthiest nation.” Thus, PHAB “is dedicated to promote, improve, and protect the health of the public by advancing the quality and performance of state, local, tribal, and territorial public health departments in the United States” ( 10 ).

The PHAB accreditation process has seven steps; Pre-application, Application, Documentation Selection and Submission, Site Visit, Accreditation Decision, Reports, and Reaccreditation; and was developed after extensive review and revision, including a beta test of the process, which included 30 state, tribal, and local public health agencies ( 10 , 11 ). Following an interview with the director of a local public health agency regarding the agency’s experience as a beta test site, the authors noted that the agency’s accreditation experience closely matched the four situational leadership styles in relationship to the stages of follower readiness displayed in Figure 1 . As a result, a follow up interview was completed to confirm these findings, and to further discuss the application of situational leadership to the accreditation process.

The agency was well prepared for accreditation given its previous commitment to continuous quality improvement, as evidenced by its application to be a beta test site. In addition, the agency director was a member of the Kentucky Department of Public Health Quality Improvement Team prior to accepting her current position ( 12 ). This agency is also committed to performance measurement and management, having completed in 2008 a local public health system performance assessment that demonstrated a relatively high (69%) score in the overall performance of the EPHS ( 12 ).

During the initial interview with the agency director, it was apparent that leadership was viewed as a key element to accreditation success. Fostering complete organizational commitment to the process was of particular importance, including high commitment from contract and part time employes, as well as members of the local board of health.

Early in the accreditation process, particularly during the pre-application and application stages, and partially during document submission, the agency staff was relatively unfamiliar with the accreditation process (R1 follower readiness level as depicted in Figure 1 ), necessitating that the agency director engage in leader directed activities, primarily those shown in the S1 area in Figure 1 . Such actions involved informing the agency staff of the requirements and processes of accreditation and directing them through the process with high task behaviors answering the question: what is public health accreditation? She utilized a directing style of leadership dealing with questions such as who, what, when, where, and how.

As agency staff members developed an understanding of the value of accreditation and gained some confidence through identifying their roles in the process and the documents necessary for review, they transitioned to an R2 stage of follower readiness as depicted in Figure 1 , resulting in the director continuing highly directive behavior while adding high relationship behavior as well. A coaching, persuading, and/or explaining leadership style (S2 quadrant of the diagram) became important. While the leadership style was still high task, moving from direction to explanation occurred in order to answer the question, “Why is accreditation important to our agency?”.

By the time the agency was ready for document submission its personnel had sufficient confidence to transition fully to the R2 stage of readiness. There were still gaps in knowledge and ability related to the accreditation process, thus necessitating a continuation of the S2 leadership style, including coaching, explaining, and continuously persuading public health agency staff members of the value of accreditation and the importance of each individual’s role in the agency’s effort.

By the time the agency reached the PHAB’s beta test site visit phase, it had reached an R3 stage of readiness as depicted in Figure 1 . As a result, leadership style was based on high relationship, low task behaviors characterized by quadrant S3. These follower-directed behaviors revolved primarily around encouraging and championing the efforts of a highly participatory agency staff, with agency leaders assuming the role of problem solvers instead of being more highly task oriented.

By the conclusion of the PHAB beta test experience, when mock accreditation feedback was provided, the agency staff members had developed to an R4 stage of readiness. The agency staff was able, willing, and confident with respect to accreditation. As a result, the leader’s style had shifted to a low task and low relational behavior approach as described by quadrant S4. The director successfully delegated the accreditation coordination task to an accreditation coordinator, thus serving as an engaged mentor.

The PHAB beta test experience allowed the agency to further develop its quality improvement, performance measurement, and management infrastructure. The agency had successfully completed the three prerequisites of PHAB accreditation by developing a community health assessment, a community health improvement plan, and a refined strategic plan with clear mission and vision statements that were ready to be adopted. In addition, a 12 member accreditation team had been formed, being led by the full time accreditation coordinator.

As a result of the commitment and intense preparation exhibited by the staff, on February 28, 2013, the agency was awarded 5-year accreditation status by PHAB. 1 Accreditation of the agency was a direct result of the leadership exhibited by the agency’s senior leadership. The accreditation result was based on the development of a high-performing team founded on full collaboration between staff members and leaders. The use of a situational leadership approach contributed to team development. Conflict resolution was more readily accomplished by the leaders’ understanding of the needs of the staff members and the leaders’ ability to utilize an appropriate leadership style to meet the staff members’ needs. Due to the nature of the PHAB accrediting process, no ethical issues were raised by staff members during the beta test experience.

Situational leadership theory and skills learned in the classroom were effective in understanding the leadership required to effectively guide a public health agency through the process of preparing for PHAB accreditation. This theory of leadership is an appropriate approach for leading the accreditation process due to its flexibility as a follower driven model of leadership. Given the novelty and the complexity of the accreditation process, a highly functioning team is required and situational leadership provides a framework for public health agency leaders to successfully guide their teams through the process. Use of situational leadership will ensure that public health agencies successfully develop an ongoing quality improvement and performance standards plan throughout the accreditation process. Thus, a classroom leadership theory was found to be useful as an approach to being faithful to public health’s mission to “assure conditions in which people can be healthy” ( 1 ).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

  • ^ http://www.phaboard.org/news-room/accredited-health-departments

1. Institute of Medicine Committee on the Study for the Future of Public Health. The Future of Public Health . Washington, DC: National Academy Press (1988).

2. Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century . Washington, DC: National Academies Press (2003).

3. Jaques E. Requisite Organization: A Total System for Effective Managerial Organization and Managerial Leadership for the 21st Century . Arlington, VA: Cason Hall (1998).

4. The Core Public Health Functions Steering Committee. 10 Essential Public Health Services. (1994). Available from: http://www.cdc.gov/nphpsp/essentialservices.html

5. Hersey P, Blanchard KH, Johnson DE. Management of Organizationl Behavior – Leading Human Resources. 9th ed. Upper Saddle River, NJ: Pearson Prentice Hall (2008).

6. Kouzes JM, Posner BZ. Follower-oriented leadership. In: Goethals GR, Sorenson GJ, Burns JM, editors. Encyclopedia of Leadership . Thousand Oaks, CA: Sage Publications (2004). p. 494–8.

7. Hersey P. The Situational Leader – The Other 59 Minutes . New York: Warner Books (1984).

8. Mays GP. Can accreditation work in public health? Lessons from other service industries. Working Paper Prepared for the Robert Wood Johnson Foundation ; 2004 Nov 30. New Jersey: Princeton (2004).

9. Public Health Accreditation Board. Public Health Board Guide to National Accreditation Public Health Accreditation Board – Version 1.0 . Alexandria, VA: PHAB (2011). Available from: http://dl.dropbox.com/u/12758866/PHAB%20Guide%20to%20National%20Public% 20Health%20Department%20Accreditation%20Version%201.0.pdf.

10. Public Health Accreditation Board. Evaluation of the Public Health Accreditation Board Beta Test . Alexandria, VA: PHAB (2011). Available from: http://www.phaboard.org/wp-content/uploads/EvaluationofthePHABBetaTestBriefReportAugust2011.pdf

11. Rabarison K. Conversation with Health Director . Frankfort, KY: Franklin County Health Department (2011).

12. Franklin County Health Department. Local Public Health System Performance Assessment – Report of Results . Frankfort, KY: Franklin County Health Department (2008). Available from: http://www.fchd.org/Portals/60/NPHPSP%20results%20.pdf

Keywords: situational leadership, public health accreditation, accreditation, leadership, student training

Citation: Rabarison K, Ingram RC and Holsinger JW Jr (2013) Application of situational leadership to the national voluntary public health accreditation process. Front. Public Health 1 :26. doi: 10.3389/fpubh.2013.00026

Received: 05 June 2013; Accepted: 31 July 2013; Published online: 12 August 2013.

Reviewed by:

Copyright: © 2013 Rabarison, Ingram and Holsinger. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: James W. Holsinger Jr, College of Public Health, University of Kentucky, 111 Washington Avenue, Lexington, KY 40536-0003, USA e-mail: jwh@uky.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Situational leadership emphasizes adapting one's leadership style to fit the specific needs of the situation and the followers involved. Nelson Mandela, the anti-apartheid revolutionary and former President of South Africa, exemplified this theory in his leadership journey. During his long struggle against apartheid, Mandela adjusted his leadership approach depending on the circumstances.


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1. transformational leadership: steve jobs at apple inc., 2. situational leadership: nelson mandela's leadership during apartheid, 3. servant leadership: herb kelleher at southwest airlines, 4. authentic leadership: oprah winfrey's media empire, 5. contingency theory: general dwight d. eisenhower during world war ii.

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A Methodology study of Hersey and Blanchard Situational Leadership Theory

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This study provides a discussion of the survey data collected and summarizes the results of the data analysis. It identifies the research questions with respective hypotheses and analytical techniques used. The Center for Leadership Studies Inc. performed a statistical analysis using the 360-Degree Leadership Style Feedback, Composite Profile and the Style/Readiness Matrix software.

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  • v.7(12); 2018 Dec

Complex Leadership in Healthcare: A Scoping Review

Zakaria belrhiti.

1 National School of Public Health, Rabat, Morocco.

2 Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium.

3 Vrije Universiteit Brussel, Brussels, Belgium.

Ariadna Nebot Giralt

Bruno marchal, associated data.

Background: Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how ‘CL’ has been applied in healthcare settings.

Methods: We followed the methodological steps proposed by (Arksey and O’Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016.

Results: Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective.

Conclusion: Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.

Nowadays, health systems are acknowledged to be complex systems, and often, they are described as messy and unpredictable. Consequently, there is a growing awareness among scholars, academics, practitioners, and policy-makers of the need to adopt a complexity perspective in health policy and system research. 1 - 3 Less attention has been paid to the consequences of the complex nature of the health system for management and leadership.

During the 1960s, theory on leadership moved away from the trait and personality theories towards theories that recognised the importance of leadership styles and behaviours. 4 Contingency leadership, developed by Fiedler 5 holds that managers have a preferred style of leading, which ranges from task-orientated to relation-orientated styles. Since all leadership styles suit some situations better than others, leaders are more effective in some situations than in others. The resulting situational favourableness to the leader is influenced by, for instance, the nature of the task at hand, the type of staff and the position of the leader in the group. Other authors differentiated between structuring and supportive styles or the structuring and the considering style (see Parry and Bryman 6 for more details). Situational leadership 7 is related to contingency leadership. In this view, there is no universalistic ‘best leadership’ approach. Effective leaders adapt their leadership style to the nature of the task, the staff’s capacity and experience with the task and the environment. The approach to leadership in these schools is transactional, ultimately aiming at aligning staff to the organisational goals through task definition, performance assessment, ‘reinforcement’ of positive behaviour and ‘punishment’ of negative behaviour. 8

During the 1980s, the transformational leadership school emerged, according to which effective leaders stimulate their personnel’s awareness of the value of their work and thus trigger the individual’s internal motivation, thereby focusing their attention on organisational goals (and not only personal goals). 8 - 10 In practice, transformational leaders do so by being a role model, communicating a clear vision and inspiring staff. This school was based on research of leaders who developed breakthroughs in the US industry, which found that such leaders were charismatic and visionary. 11 However, the limitations of transformational leadership were quickly identified in terms of the dark side of charisma and toxic or destructive leadership. 12 , 13 Since around 2000, complex leadership (CL) has been applied in healthcare management and healthcare organization theory fields. 14

In this paper, leadership is regarded as a behaviour or set of behaviours that emerges from the interaction among individuals and groups in organizations occurring throughout the whole organisation, and not a role or function formally assigned to an individual (See Plowman and Duchon, 15 Uhl Bien et al, 16 and Marion and Uhl-Bien 17 ). CL scholars like Uhl-Bien and Marion 16 , 17 argue that leadership in complex situations or organisations requires adopting a complexity lens. They call for a transformational, collaborative, reflective and relationship-based leadership style. However, in the field of healthcare, relatively little attention is given to how leaders would best deal with complexity. 18 , 19 Notable exceptions include Plsek et al 20 and Kernick. 21

In order to investigate how CL in healthcare has been defined, theorised and conceptualised, we carried out a scoping review of CL in healthcare. We present an overview of how CL is discussed in the health literature. We discuss the currently used definitions of CL, the seminal authors and the extent to which CL competencies or practices are discussed in the literature. We end by identifying research gaps and suggest a research agenda.

We adopted the guidance for scoping reviews provided by Arksey and O’Malley 22 and refined by Anderson et al, 23 Daudt et al, 24 and Levac et al. 23 We followed the steps described by Arksey and O’Malley 22 : (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results.

1. The Review Question

We defined the review questions as follows:

  • How is the notion of ‘CL’ in healthcare defined, theorised and conceptualised?
  • How has the concept of ‘CL’ been explored and operationalised in healthcare settings?
  • We specifically aimed at:
  • mapping key conceptual and operational definitions of CL
  • identifying seminal authors and works
  • identifying the underlying key complexity traditions (social versus mathematical complexity – see below)
  • identifying research gaps and priorities for further research

2. Identification of Relevant Studies

Search strategy and sources.

We searched four databases (Medline, Psychinfo, Wiley online library and Google Scholar). The search strategies and scope are presented in Table 1 . We identified additional sources through manual searching, citation tracking and snowballing from reference lists.

The scope of the study was adapted iteratively after discussion in the review team in order to balance between feasibility, time constraints and breadth of the scoping study.

3. Study Selection

Inclusion criteria.

We included published papers that explicitly mention ‘complex leadership’ or ‘complexity leadership’ in the publication title or abstract or that mention principles of complexity theory (complex adaptive system [CAS], adaptive leadership, enabling, emergence, non-linearity) in association with ‘leadership’ (See Supplementary file 1 ).

We defined the inclusion criteria as:

  • Publication type: peer reviewed articles, theses and book chapters
  • Phenomenon of interest: CL
  • Context: healthcare
  • Period of publication: between 2000 and 2016

Exclusion Criteria

We excluded the grey literature, commentaries, conference proceedings and book reviews. Papers discussing only other forms of leadership (transactional, transformational, engaging, distributed, shared or servant leadership) were excluded. All non-health papers are excluded from this review. Studies carried out in non-healthcare settings that might be of interest to other researchers are listed in Supplementary file 2 .

The Search Process

Our search and selection resulted in 37 papers ( Table 2 , Supplementary file 1 ). Figure 1 summarises the steps of the selection process according the PRISMA statement. 26 The three authors were involved in the screening process, which was led by the first author. The assessment of inter-rater reliability using the Cohen’s Kappa coefficient (K = 0.675) [ 1 ] showed a good agreement (according to Cooper et al 27 and Orwin & Vevea 28 ) on a random sample of 20% of records using the Random function in the Excel database ( Supplementary file 3 ). Disagreement on 7 references was resolved through discussion and full text screening by the three authors.

An external file that holds a picture, illustration, etc.
Object name is ijhpm-7-1073-g001.jpg

The PRISMA Flow Chart.

4. Charting the Data

From each paper included in the review, we extracted the data using the form presented in Box 1.

Box 1. Data Extraction Form

  • Author, date Publication country - origin
  • Research aim
  • Type of paper
  • Research tradition
  • Definition of complexity principles
  • Conceptual definition of CL
  • Main features and practical implication for leadership development
  • Underlying theories
  • Argument for using complexity theory in leadership
  • Arguments against using complexity theory in leadership
  • Research gaps and methodological development

Overview of the Papers

We first present an overview of the papers, addressing the question how CL is being used in the health literature. This review comprises 16 conceptual papers (13 articles and 3 book chapters), 14 empirical studies (4 PhD theses and 10 journal articles) and 7 advocacy papers ( Table 2 ). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK) (11 out of 14). Only three primary studies were carried out in low- and middle-income countries (India, Ghana, and South Africa) ( Figure 2 ). Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. We found that the majority of empirical studies adopted the case study design. 34 , 47 , 49 , 51 - 53 , 56 , 57

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Object name is ijhpm-7-1073-g002.jpg

Number, Type of Publications by Country of Origin.

We found that the concept of CL in healthcare is mostly taken up by researchers in the field of nursing (n = 16) (see Table 2 ).

Finally, researchers framed their research question according to different levels of analysis ( Supplementary file 4 ):

  • Micro-level (teams and individuals, care units): 18 papers
  • Meso-level (hospital, district): 13 papers
  • Macro-level (health system): 2 papers

Seminal Papers

In order to identify the seminal authors and papers, we assessed the number of citations in the reference list of the 37 papers included in our review. In addition, we also used Web of Science [ 2 ] and Google Scholar. The papers most referred to in this review are Uhl-Bien et al, 66 Uhl-Bien and Marion, 67 Plsek and Greenhalgh, 68 and Zimmerman et al 69 ( Table 3 ).

Abbreviation: NA, not available.

Definitions of Complex Leadership: Heterogeneous Definitions Reflect Different Perspectives

Our analysis shows that there are a number of definitions of CL being used in the literature. The main differences in definition relate to three characteristics: (1) the underlying complexity theories, (2) the definition of the scope (comprehensive or narrow), and (3) the claimed applicability (universal or situational) ( Table 4 , Supplementary files 5 and 6 ).

Abbreviations: CAS, complex adaptive system; CLT, Complex Leadership Theory.

The Underlying Complexity Theories

We used the ‘landscape of management’ framework of Snowden and Stanbridge 77 to classify the papers included in this review in terms of the complexity perspective they adhere to ( Figure 3 ).

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Mapping the Authors in the Landscape of Management Framework. 77

We found that most researchers subscribe to the mathematical complexity perspective. According to Snowden and Stanbridge, the mathematical complexity perspective asserts that the world is unordered and that human behaviour emerges from simple rules or minimum specification. In ordered systems, managers can determine the desired end state, assess the initial situation and consequently set out a series of actions to reach the desired end state. In unordered systems, one cannot do so because of the uncertainty related to how the end state can be attained. Instead, managers set out simple rules that guide the personnel regarding the desired end states and allow them to decide and implement actions locally. Trial and testing allows to learn in a systematic way and to optimise the activities. 77

Many other scholars we identified refer to the definition of CL by Uhl-Bien et al 66 (see for instance 39 , 41 , 42 , 44 , 46 , 49 , 56 - 58 , 62 , 64 , 65 ).

The seminal authors we identified can all be classified under the mathematical complexity perspective. They all refer explicitly to concepts of CASs theory. For example, Plsek and Wilson draw upon CAS terminology to explain certain aspects of CL:

“…effective organisation and delivery of healthcare does not need detailed targets and specifications, nor should it focus primarily on ‘controlling the process’ or ‘overcoming resistance.’ Rather, those who seek to change an organisation should harness the natural creativity and organising ability of its staff and stakeholders through such principles as generative relationships, minimum specification, the positive use of attractors for change, and a constructive approach to variation in areas of practice where there is only moderate certainty and agreement.” 31

The social complexity perspective acknowledges ‘un-order’ and emergence, but considers that this results from the uniqueness of human beings and that it cannot be reduced to simple rules. In this view, humans decide on the basis of social interactions and patterns of past experience. Researchers who adhere to this perspective emphasize the importance of conversation and socially constructed meanings. Authors refer, for instance, to complex responsive systems theory 71 and critical realism. 78 , 79 They focus on meanings and sense making. In this perspective, CL is regarded as a communication process that is socially constructed by the interaction of agents. 51 , 79 Viitala suggests the following definition of leadership:

“Leadership is seen here as a socially constructed product, which is at the same time institutionalised both in organisations and in a society and also continually being reproduced in everyday situations in communities. (…) The core of the issue is communication, influence and interaction between people and in this process both power and resistance play important role.” 53

Our analysis shows that only few authors adopt a social complexity perspective. Gilson, for instance, emphasise the role of leaders in terms of making sense of reality using a complexity lens. 51

We also noticed that a number of authors seem to combine both perspectives (mathematical and social complexity), for instance Porter-O’Grady 60 and Prashanth et al. 52 This is what Snowden and Stanbridge 77 labelled the contextual complexity perspective, arguing that people (ie, managers and researchers) are able to shift between the mathematical and social complexity perspective. Through such multi-ontology sense making, managers or researchers adopt different “ diagnostic techniques, different intervention devices and different forms of measurement depending on the ontological state .” 77

The Definition of the Scope

Definitions of CL can be considered to be comprehensive or narrow. Comprehensive definitions present a multilevel perspective of leadership that is situated at all hierarchical levels of an organisation (top, middle, and line management). The most comprehensive definition is proposed by Uhl-Bien et al, 16 who present a holistic view of leadership that comprises an administrative, enabling and adaptive dimension of leadership. Their complexity leadership theory (CLT) explores how order emerges from the interactions among agents. 16 , 67

“Adaptive leadership is an emergent, interactive dynamic that is the primary source by which adaptive outcomes are produced in a firm. Administrative leadership is the actions of individuals and groups in formal managerial roles who plan and coordinate organizational activities (the bureaucratic function). Enabling leadership serves to enable (catalyse) adaptive dynamics and help to manage the entanglement between administrative and adaptive leadership (by fostering enabling conditions and managing the innovation-to-organization interface). These roles are entangled within and across people and actions.” 16

Similarly, authors such as Weick 2007 80 consider that leadership can be located anywhere in the organisation (“constellation leadership”). This view emphasizes that diffused power is beneficial in complex organisations.

In contrast, authors who present a narrow definition of CL locate leadership at the operational level.

“Leadership emerges in day to day work as people interact with each other to do their jobs. Adaptive leadership is the work that practitioners do to mobilize and support patients to do the adaptive work. Adaptive leadership is fundamentally a non-linear, iterative, reciprocal interaction between the healthcare practitioner and the patient.” 43

Other authors use similar narrow definitions of CL 29 , 32 , 34 , 35 , 41 , 43 , 45 , 48 , 56 , 58 - 61 , 63 (see Figure 4 ).

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Position of the Papers Along the ‘Complexity Theories,’ ‘Scope,’ and ‘Applicability’ Axes.

Applicability: Universal Versus Situational Perspective

The definitions of CL can be categorised as universal or situational. Authors adhering to the universal perspective argue that CLT can or should be applied to any situation. 29 , 33 , 35 , 36 , 39 - 41 , 49 , 51 , 52 , 56

“There is need for leadership at all levels and in all professions in the complex worlds of NHS institutions.” 61

Their main argument is that healthcare organisations should be considered as CAS: they are characterised by non-linear dynamics, sensitivity to initial conditions, unpredictability of both social behaviours and contextual components, interconnectedness, interdependency and emergence. For these authors, it thus makes sense for leaders in the health system to always apply CL.

“Organizations embedded with various properties and mechanisms that contribute to collective adaptive capacities and tendencies are described as CASs.” 39

Other scholars suggest that CL should be used in only complex situations. 20 , 30 , 32 , 37 , 42 , 44 , 47 , 48 , 50 , 53 - 55 The latter are defined as situations or contexts in which the cause-effect relationships are unknown. In such case, leaders should stimulate self-management and support decentralised decision-making. Given that the situation is defined as complex because of the uncertainty related to the root causes of the problems, and thus of the solutions, leaders encourage testing solutions and continuous learning. They set boundaries but do not steer the process. 35 In this view, simple and complicated events do not require CL; transactional and transformational leadership will be more effective. This view implies that health managers should a priori assess the situation or context, categorize it as simple, complicated or complex, and accordingly apply the most appropriate leadership approach.

“A new type of leadership is needed within healthcare organizations, based on adaptive capacity, understanding the external environment and connecting with the internal organizational culture and thriving in situations where groups need to learn their way out of unpredictable problems.” 46

In Figure 4 , we present how the papers are located against the complexity, scope and applicability axes. It shows that while there is a homogeneous representation across narrow and comprehensive scope, and universal and situation perspective, most authors refer to mathematical complexity.

Complex Leadership Competencies

We found that only a few authors have described specific competencies or practices related to CL. According to Ford, 35 complex leaders should be able to:

foster network construction at the frontline, middle and top of the organization,

catalyse emergence from the bottom-up by identifying the knowledge centres within the organization and encouraging these centres to communicate with one another and engage in creative problem-solving, and

nurture systemic thinking.

According to Anderson and McDaniel, “ managers who focus on relationship building, loose coupling, complicating, diversifying, sense making, learning, improvising, and new ways of thinking about the future will be able to create new levers for positive movement in their organizations.” 29

We present in Table 5 a set of complexity leadership behaviours in healthcare.

This review shows that there are relatively little empirical applications of CL in healthcare settings. Virtually all empirical studies have been carried out in the North and focused on exploratory or explanatory research objectives, which reflects other reviews’ findings. 82 , 83

We found that there is a wide variation in definitions of CL, even if there are clearly seminal papers. We identified some common themes. First, leadership is increasingly seen as a process of process and less as a process centred on individuals. Second, CL is about fostering interactions and enabling conditions for the emergence of creative behaviours. 84 Third, CL is associated with positive outcomes such as contributing to learning organisations, creativity, innovation and adaptability. The heterogeneity of CL definitions explains the variety in CL research, but also raises questions related to the generalisability of the concept.

In summary, CL could be defined as a multilevel process throughout the whole organization, as opposed to an individual’s attribute. It is less focused on predicting and controlling the future and more about facilitating staff interaction. It emphasises roles of distributed leadership and learning adaptability. CL fits situations of complex healthcare issues (eg, patients centred care) where there is low certainty and agreement. It is a socially constructed process that includes communication, influence, interaction between individual agents on a day-to-day basis and considers the role of power and resistance. In such situations, leaders stimulate sense making and self-reflection among staff to help them develop new insights into how to deal with the issues at hand (eg, improving quality of care).

We found that most authors may be classified as adhering to the mathematical perspective on complexity, which reflects commentaries of Polack et al, 82 Burnes 85 and McKelvey, 86 who argue that there is an increased application of mathematical complexity in organisational studies in health.

The Use of Metaphors

In our review, we found very few empirical papers and these present explorative research rather than evidence on effectiveness of CL approaches. This, too, is consistent with findings from other reviews of complexity in health system research 18 , 87 and management and organisational studies. 82 , 85 It seems that at this stage, scholars on leadership mainly apply complexity in leadership on theoretical and metaphorical grounds rather than on the basis of empirical studies and evidence. We agree with Anderson et al 88 that there is a need for developing middle range theories on CL and testing them in empirical studies in a variety of settings.

Can Complex Adaptive System Concepts Be Transposed to Leadership?

Related to the previous point, our review shows that many authors draw concepts from CASs terminology. For instance, Forbes-Thompson et al 34 and Minas 32 argue that CL consists of setting simple rules that allow emergent behaviour to happen, the way flocks of birds adopt flight patterns. However, the papers often provide little justification for the fit of CAS concepts to the social world and thus it is not clear whether and exactly how these concepts can be applied to understanding leadership in healthcare organizations. This is similar to the use of CAS concepts in other disciplines. Scholars often take for granted the assumption that organisations can be assimilated in all their aspects to CAS. 14 , 89 Such analogy allows them to explain social change as an interaction between agents, groups, and institutions that are operating at different levels. However, Mowles 90 and other authors argued that complexity concepts derived from natural science may not automatically fit management 86 , 91 - 93 and social settings. The study of social complexity should be rooted in social theory relevant to organizations. 91 , 94 - 96 If not, there is a risk of scientific reductionism.

Situational or Universal Complex Leadership?

Our analysis also indicated that there is little consensus on when or in which situation CL should be applied. For one set of authors, the complex nature of health systems requires leaders always to apply a complexity perspective. Authors including Uhl-Bien et al, 16 Hanson and Ford 35 , 39 argue that in the current knowledge era, traditional leadership and management approaches are no longer sufficient to deal with the organisational and contextual complexity. Thus, it is argued, context plays a key role in shaping leadership 24 , 41 , 46 , 97 , 98 and because of the complex nature of health systems, leaders should always adopt a CL perspective.

Other authors advocate for a more situational approach, arguing that the leadership approach should be used only in complex settings. This approach fits well with sense-making frameworks, such as the Cynefin framework, 99 the ‘simple-complicated-complex’ frame of Stacey, 71 Glouberman and Zimmerman 100 or Stacey’s diagramme. 92 Here again, the empirical evidence is poorly developed.

Leadership Effectiveness

Our review showed that the relation between CL and organisational performance is little developed. A number of scholars argue that complex leaders foster interconnectedness, open communication, relationship building, and non-linear processes, and that this contributes to positive outcomes such as collaborative learning, innovation, perceived team performance, and organisational change. 16 , 57 , 62 , 67 , 74 , 101 , 102 These writers emphasize the need to pay closer attention to the quality and the nature of leadership processes in exploring leadership effectiveness.

Howard, Grady and Weberg examined the abilities needed to improve resilience and trust among healthcare teams. 49 , 56 , 63 Nursing researchers emphasized the need to explore the relationship between CL and specific health outcomes. 46 Others stress that CL is about interaction among agents. Authors like Marion and Uhl Bien 39 , 41 , 44 , 49 , 57 , 62 , 65 , 103 conceive leadership as rooted in the interaction between agents. Understanding these interactions or ‘the space between’ the actors is then a relevant means of investigating the mechanisms that enable processes of adaptation and creation. 66 , 74 , 104 - 107

Research Gaps

The papers we reviewed suggest some gaps in research, both in terms of substance and methods.

Content-wise, some authors call for exploring the nature of network dynamics associated with the transformation process, generation of innovation, emergence and diffusion, 108 shared leadership and organisational adaptability. 109 Authors like Clancy et al, 110 Weberg, 46 and Carter et al 111 call for less emphasis on computational modelling and simulation. We suggest that leadership scholars should empirically test CL theories in social settings rather than merely use complexity concepts as explanatory metaphors. Further attention should be paid to CL effectiveness on learning, innovation, adaptability and followers’ behaviours. We suggest also that scholars should pay attention to related concepts, such organisational learning and organisational culture theories to build detailed middle range theories.

In terms of research methodology, some stress the need for context-sensitive methods, which should enable identifying the context factors and mechanisms that explain leadership and patterns of behaviours in organisations. 84 , 112 They call for exploring how mechanisms, understood as patterns of social interaction, produce specific outcomes, thereby opening the black box of CL effectiveness. Research methods should take into account the multi-layered aspect of leadership and the dynamic interactions over time between context (eg, health policy) and organisational characteristics (power, intentions, codes, organisational culture, followers’ behaviour and expectations…). Others point to the need for rigorous methodologies to study patterns of leadership interaction over time. 32 , 74 , 113 , 114 Viitala 53 suggests using ethnography, longitudinal designs and embracing a social constructionist perspective. We would argue that other interesting methodological avenues include case based methodologies (including qualitative comparative analysis 115 , 116 ), the sociology and complexity science toolkit (SACS), 117 cluster analysis and social network analysis. In general, more empirical research, and particularly in low- and middle-income countries, would enable producing better insights into what constitutes CL and its relation to organisational effectiveness. It would also add contextual validity to concepts mainly developed in the North.

We acknowledge the limitations that are specific to the scoping methodology (for instance, the absence of quality appraisal, and the potential interpretation bias). 22 - 25 , 118 , 119 We also had to balance comprehensiveness with feasibility. Finally, our search strategy ( Table 1 ) may have overlooked some relevant studies. However, our primary objective was to explore the application of ‘CL’ in health and to contribute to shaping the research agenda and to these ends, the scoping review proved appropriate.

This review showed how the limited attention in the current literature to applications of CL in healthcare settings. While we identified a number of seminal papers, the definitions of CL are heterogeneous. We found that the majority of researchers seem to adhere to a mathematical complexity perspective. At this stage, there is very little empirical research, while we need a better understanding of the key characteristics of CL and how complex leaders contribute to better healthcare. Although complexity science has been extensively used elsewhere, it is still not much applied in health systems. Further research could focus on how a social complexity perspective could be applied to leadership in healthcare.


We would like to thank Mouloud Benabbou head librarian at the National School of Public Health and Dirk Schoonbaert head librarian at ITM and their teams for their help in the extraction of articles.

We would like to thank the editor and the anonymous reviewers for their insightful comments and Dr. Issam Bennis for reviewing an earlier version of the manuscript.

Ethical issues

Not applicable.

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

All authors participated in the design of the study and the review process. ZB led the review process and drafted the first manuscript. AN contributed to the selection process, the synthesis process and the revision of the manuscript. BM contributed to the study design, the synthesis process and the drafting of the manuscript. All authors read and approved the final manuscript.

Authors’ affiliations

1 National School of Public Health, Rabat, Morocco. 2 Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium. 3 Vrije Universiteit Brussel, Brussels, Belgium.

[1] Kappa Coefficient interrater reliability measures the agreement between two authors making simple inclusion/exclusion decisions) and scores as follows: 0.40 to 0.5: fair agreement; 0.60 to 0.7: good agreement, 0.75 and more: excellent agreement.

[2] Until recently, the Web of Science index did not include chapter books nor papers from the field of organisational studies.

Supplementary files

Supplementary file 1. List of Included Studies.

Supplementary file 2. Complex Leadership Studies in Non-healthcare Settings and Reasons for Exclusion.

Supplementary file 3. Measurement and Interpretation of Kappa Coefficient

Supplementary file 4. Research Question in Complex Leadership

Supplementary file 5. Scope, Epistemology, Theory and Conceptual Definitions of Complex Leadership.

Supplementary file 6. Categorization Criteria of Included Papers.

Citation: Belrhiti Z, Nebot Giralt A, Marchal B. Complex leadership in healthcare: a scoping review. Int J Health Policy Manag. 2018;7(12):1073–1084. doi:10.15171/ijhpm.2018.75


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