Healthcare Leadership Problems Faced During and After COVID-19: A Continuum

Every person in every corner of the world has been affected by the COVID-19 pandemic. By March 15, 2021, one year after the World Health Organization (WHO) declared the disease to be a pandemic, more than 120.7 million people had been infected by COVID-19 (Table 1)(1) (Figure 1).(2) Healthcare professionals are on the frontlines, fighting to curb the spread of the coronavirus and provide treatment, guidance and counseling, care, and other forms of medical support to those infected.

Figure 1. Global coronavirus cases by March 15, 2020. BBC News.(2)

Physicians, registered nurses, and other healthcare professionals have used their skills, knowledge, talent, and abilities to showcase their commitment, thoughtfulness, and hard work during these challenging times.(2) The healthcare system’s landscape can be described as volatile, uncertain, complex, and ambiguous.

Leadership in the nursing profession has been a big concern and a significant problem worldwide due to the prevailing COVID-19 pandemic, which has affected nurses’ service delivery and their satisfaction in their workplaces.(3) People tend to evaluate their work experiences in terms of liking or disliking their jobs and the organization in which they work. COVID-19 enhanced feelings of dissatisfaction. For instance, when leaders fail to provide adequate personal protective equipment (PPE) to keep employees safe, those employees are likely to be dissatisfied with their jobs. The nursing industry has been critically influenced by social information processing, and work conditions.(4) Increasingly, the opinions of an employee’s immediate supervisor have much more impact on their performance than general procedures or policies, as was the case before the pandemic.

A significant leadership problem has been the incomplete understanding of crisis decision-making processes and behaviors among practitioners, which has led to flawed results.(5) Flawed decision-making, in turn, has exposed healthcare institutions to excessive harm involving people, finances, reputation, assets, and other interests. Furthermore, the exponential increase in the frequency and intensity of coronavirus crises has been accompanied by heightened organizational expectations that practitioners will be able to effectively manage these situations. Some researchers have suggested that a limited understanding of organizational crisis decision-making has prevented practitioners from reducing harm from COVID-19, and they have called for novel leadership research as a means of yielding new insights.(6)

Characteristics of the COVID-19 Pandemic

The coronavirus pandemic has posed a significant threat to leadership in the healthcare sector. The pandemic’s geographic distribution indicates that more radical improvements are required to implement COVID-19 guidelines and control measures. The healthcare sector has been tracking the virus since the beginning of 2020 and has seen it undergo many changes and mutations. The South African and UK variants have become a significant concern due to their resistance to some developed vaccines.(7) The variants have further worsened an already bad situation because they have been more infectious and more transmissible (Figure 2).(8)

Figure 2. Emergence of SARS-CoV-2 B.1.1.7 Lineage — U.S., December 29, 2020(8)

As the crises continue to unfold, leadership remains in turmoil, with diverse expectations from organizational stakeholders.(9) Specialized practices and disaster recovery management systems have become more common. The industry leadership intends for such systems to help diminish the effects of crises and other unanticipated events on organizational obligations. Although such systems help guide the industry and organizational response to COVID-19, they have not eliminated the crises.(10) Even though contingency planning has become more expected from the healthcare leadership, insights into crisis decision-making are needed.

The current COVID mutations have created more leadership challenges due to the inaccessibility of vaccines; increases in the number of patients, leading to overextension of medical services; inadequate medical supplies, including PPE; poor remuneration of staff; low rates of promotion; and even staff shortages. Healthcare leadership is expected to develop innovative ways to address these shortcomings.(11) These challenges have influenced nurses both positively and negatively as they respond to the COVID-19 strategic recovery plan and care approach.

Scorecard Approach

The scorecard approach focuses on improving the performance of nurses in four main areas:

• Financial analysis: return on investment, profitability and income;

• Customer analysis: customer retention and service;

• Internal analysis: the realization of strategic goals; and

• Learning and growth: satisfaction and retention.

The pandemic has forced organizations into an adaptive capacity to focus on matching relevant regulatory mechanisms to varying environmental levels of disorder, organizational recognition, and COVID-19 purpose control.(12) Extra flexibility could be obtained by expanding a scorecard approach. This keeps the focus on an organization’s crucial strategic plans and, furthermore, circumvents the inherent danger of management knowledge overload.

The sudden impact of COVID-19 has crippled organizations and these entities have failed to reach intended goals or to accrue the benefit that the organization had aimed to achieve. New mutations of the virus may lead to waves of high infection, straining the existing healthcare system, whose human resources currently are depleted. Most care institutions have encountered myriad challenges in the process of implementing leadership strategies aimed toward curbing the spread of COVID-19 and in providing quality of care that is within acceptable standards.(13) Even well-thought-out strategies have failed to achieve the intended result due to poor implementation processes.

The decision-making process is seen to have become the responsibility of a few medical practitioners within government emergency agencies and public health systems. Research indicates that this assumption is mistaken, however, because since the outbreak and consequent spread of COVID-19, the ability to manage crises has fast become a standard expectation within any organization.(4) Research also suggests the frequency of COVID-19 crises is increasing steadily due to the unpredictable and complex nature of the disease and environments. In terms of scale, a 2018 World Bank report found that losses caused by pandemics alone account for $555 billion in economic losses each year, demonstrating that the negative consequences of the COVID-19 crises will be enormous.

Research-derived insights in response to the increasing need for crisis decision-making, understanding, and expertise, have been limited.(14) Recent data indicate that an increase in the frequency and number of COVID-19 infections might act as a catalyst for more radical changes in the sector, even as these numbers seem likely to overwhelm the healthcare system.(11) Itagi and Aithal’s study(11) on the expected behaviors of leaders after the pandemic found that organizational crisis decision-making in the context of COVID-19 leadership has not been the subject of research or theoretical development. The emergence of new coronavirus variants that may have different characteristics calls for more creativity on the part of leadership to improve crisis decision-making, but theoretical development and empirical testing are scarce.

Roles of the Healthcare System in the Pandemic

Decision-making defines the healthcare system’s connections to environmental influences; involves the healthcare sector, depending on resources of the industry’s functioning parts and putting control on the management movements; and is essential to the long-term well-being of healthcare practitioners. The healthcare system’s role in controlling the pandemic’s spread involves a range of efforts that relate to diagnosis, treatment, and enforcement of a response action against COVID-19.(10) The healthcare system is responsible for developing diagnostic and serologic tests, supporting the advance of vaccines for COVID-19 prevention, and ensuring that workers in the healthcare sector have the medical products and protective equipment they need (Figure 3).

Figure 3. The Role of Family Physicians in a Pandemic(15)

The speed of decision-making currently required enforces the role of healthcare systems in approving the use of new products. The FDA is responsible for ensuring that careful, deliberate processes and good science are adopted in decision-making while reviewing new products for use in the treatment and prevention of COVID-19.(15) Thus, the healthcare system helps support the commitment to COVID-19 recovery and provides accurate information to the public to improve uptake of the approved vaccines. The healthcare system also sorts the overwhelming quantity of data and information on COVID-19 to provide answers to patient questions and treatment recommendations.(12) These care systems play an essential role in supporting the practice of medicine, care providers, and even patients. Thus, healthcare systems present transformational leadership and a vision for what the sector will share with others. Agencies in this system regulate the quality, effectiveness, and safety of medical products, which is crucial in combating COVID-19. The healthcare system also oversees the aspects of training employees, providing motivating rewards, socialization, and regulations within the institution.(16)

The system also looks into the development of effective and safe medical countermeasures. The countermeasures ensure that frontline healthcare workers have the support they need, be it regulatory advice, technical assistance, or even guidance intended to advance vaccines; therapies; and tests development. It also works to strengthen the scientific response against the coronavirus, specifically the values, norms, beliefs, and assumptions as well as characteristics, organizational culture, and every other feature of the community that are likely to result in higher chances of attaining mass protection against the deadly coronavirus.(17) The healthcare system also looks into the promotion of organizational personnel in management, which is paramount to the attribute of job satisfaction and would lead to increased job satisfaction among practicing nurses. The system works hard to support industry collaboration, building public–private partnerships and creating open communication channels.(18) Such an approach stimulates practitioners in the industry to remain creative, reevaluate old values and beliefs, and consistently seek logical solutions to pressing issues.

Effects on the Healthcare Workplace

COVID-19 has had a profound impact on practitioners’ mental health in the workplace, increasing the risk of burnout. Since lockdown measures began, practitioners have experienced loss of employment and hopelessness. Even though conditions are slowly improving, levels of worry and anxiety in the workplace remain high. People are resistant to change, and, therefore, management intending to implement their strategic recovery plan has been forced to respond to that resistance and identify the overall challenges the plan might bring to the organization instead of criticizing the resistance.(13) Challenges that have been identified in the workplace include doubt on the part of stakeholders regarding weaknesses and failure brought about by COVID-19, lack of effective change leaders, and inadequate change culture in the organization.

Businesses and organizations have needed to offer occupational health services and support structures to their staff to cushion them against the effects of the novel coronavirus.(19) However, some positive changes also have come about in the workplace. The concept of working from home has revolutionized the working environment, as leaders increasingly consider adopting an agile and flexible working platform where many people can perform their daily duties from the comfort of their homes. Indicators show that workplace culture and size have a considerable effect on organizational factors. The findings also show that an organization’s current management style influences nurses’ job satisfaction and retention.(12) Face-to-face conversations remain a critical part of our social norms, even with social distancing measures. The coronavirus pandemic has reduced the cost of maintaining a physical business presence and avoided the unexpected major problems presenting during a change in management.

With people working further apart, however, poor coordination is one of the challenges associated with change plans after COVID-19 including competing activities. Organizations are required to formulate strategic plans that abide by government policy and take into account limited resources, the turbulence of the environment, and high competition among healthcare facilities and practitioners.(20)

Management of the organization often prescribes the way that organization commands and functions. Companies commonly are formed hierarchically, with various sections and faculties, each capable of a particular task, such as personnel resources administrators, production, or retailing. Many layers of management command their operation. Although this is still the most broadly used organizational arrangement, the coronavirus outbreak forced workplaces to incline toward a flat edifice where work is accomplished in teams of professionals rather than solidified departments.(16) The approach has made the system more extensible and dynamic by encouraging workers and excluding the middle management layers. Eventually, when life returns to normalcy, more employees are likely to embrace the concept of flexible work, such as working from home.

Leadership Problems

Training and Development

Little consensus exists concerning the boundaries of training and development applicable to COVID-19 crisis decision-making. This implies challenges to organizational training and development segments, because, in the absence of a recognized framework, potential exists for the loss of credibility and legitimacy.(21)

The first subcategory of interest within the decision-making domain involves the reflection of the presence of outcome uncertainty involving gains and losses in organizational training and development. Leaders in the healthcare sector need to assess, develop, and fine-tune training and development incentives to improve existing personal and professional skills and retain a proficient workforce.(22),(23) Most training initiatives have long relied on the traditional clinical interview, but the emergence of COVID-19 has changed the dynamic and led to taking a more hands-off approach to enforce changes in the sector, including attending seminars. The new approach involves more personalized patient care, open staff and patient communication, and alternatives to current industry practices.(8)

The renewed strategic planning process entails setting the comprehensive objective, goals, and mission for the particular enterprise and scrutinizing the macroenvironment affecting the enterprise, such as microresources, pandemic effects, and various strategic alternatives that must be considered. Factors affecting an enterprise’s consequent implementation are caused by the various styles in which diverse groups interpret and understand that strategy personality.(5)

Communication

Communication in the healthcare sector is intended to ensure effective, timely, and appropriate delivery of patient services and plays a part in achieving desirable performance targets.(10) The absence of a strategic plan for the implementation of communication has greatly affected health facilities’ operations across the country; hence the lack of effective and reliable healthcare services in private and public hospitals.(23) Healthcare leaders have had to provide guidance and direction on the role of communication in organizational roles, functions, and responsibilities, and to revise and devise strategies that everyone can quickly follow. Decisions made by a leader affect the sector’s performance. Communication thus takes center stage in building a collaborative environment where strategies can be deliberated upon, and everyone gets involved in helping to overcome challenges. (Figure 4) (24)

Figure 4. Communication Impact(24)

The outcomes of the process of communication will motivate practitioners in service delivery and care. Transformational leaders undergo what is known as “flow,” a subjective experience of total involvement with life.(14) A transformational leader must be aware of the importance of communication in dealing with the COVID-19 crisis with experience of their followers’ practice and performance. The organizational crisis decision-making frame thus significantly bounds this study within a broad decision-making research domain. The organizational crisis decision-making concept is framed on hierarchical communication embedded within the frames of general decision-making and risky decision-making.(18) The frame suggests COVID-19 should be approached iteratively, beginning with broad parameters focused on general decision-making, narrowing the focus to risky decision-making, and then focusing on organizational crisis decision-making.

Well-being and Protection

Industry regulators argue that the emergence of COVID-19 has highlighted the need for improvement of medical practitioners’ working conditions and their welfare as a way to foster motivation. The approach is perceived as a way to reduce their work stress and raise their morale.(25)

The emergence of COVID-19 revealed healthcare workers’ critical situation and vulnerabilities that have been present for a long time. The pandemic sparked the need for organizations to improve the working conditions, safety, and welfare of their workers. Leaders in the healthcare sector have been prompted to ensure satisfaction in the workplace by increasing effectiveness, efficiency, and safety.(21) These situations have been projected to affect nurses, sometimes leading to demoralization, such as when circumstances or management forces nurses to work more than 10 hours a day. To counter the long work hours that resulted from staff shortages during the COVID-19 pandemic, the healthcare sector has provided an organizational structure and model that provides nurses with a formula for getting overtime pay and allowance.(20)

Healthcare leaders have the mandate to embrace the many changes in the healthcare system that are intended to positively impact the well-being of practitioners. The prevailing COVID-19 situation has forced them to develop and assess the best approach to meeting the needs and standards of patients and staff .(22) Thus, the situation has prompted leaders to routinely explore methodologies and models that help build partnerships in tackling healthcare challenges, self-development, promoting information awareness, research alternatives, staff training programs, and even recruitment.

Work–life Balance

The COVID-19 pandemic has shown us that generating a balanced organizational scorecard starts with a full critical appraisal and the precise connection of the organization’s important vision and purposes. This method is proven to create content that can be of tremendous value. To create a suitable work–life balance, healthcare institutions and other organizations have had to adopt a strategy practice that requires quality strategies for leveling action and behavior of workers towards administration, notably including efficient transmission systems and relevant supervision monitors.(5) This approach focuses on providing workers explicit control over their work through career growth and development and promoting satisfaction through work–life balance perks.

Through representation and description of the essential values of an organization, the COVID-19 scorecard presents operative “boundary” theories on work–life arrangements. Employing the COVID-19 scorecard aids in identifying preferences and harmonizing various stakeholders’ requirements, and intensifying strategic intelligence information and scholarship.(26)

Employee safety, quality service delivery, and compensation have been affected by the perceptions and implementation of strict professional conduct in the healthcare sector.(13) There are a very large number of care practitioners in the industry, and the number of staff continues to increase as hospitals transform in terms of innovation in medical research and nursing practice. The coronavirus pandemic has inclined healthcare leadership toward encouraging the participation of this vast number of care practitioners in national health policy planning on matters concerning medical services and work–life balance.(25)

Work–life balance focuses on efficiency and effectiveness in referral systems and equipment, with the intent of bringing out the best in each person and enhancing the quality of healthcare.(19) The COVID-19 emergency has necessitated nurses’ work in a variety of areas, each unit in the care facility, including the critical care unit, neonatal unit, radiology, and all others. The head of each nursing unit or structure is a trained registered nurse with at least three years of practice experience and a Master’s degree in the relevant field of study. The chief nurse gets reports from supervisors at the unit level and recommends, supports, and develops the team’s work–life balance to enhance ethical and professional nursing practice in delivering services to the public.(27)

Rewards and Recognition

The COVID-19 pandemic has created numerous leadership challenges in the healthcare sector. Leaders in the sector need to be at the frontline with healthcare workers to collaborate and enhance situational awareness. The previous approach to employee rewards and recognition was based on length of service, with scarce or frozen promotions along with increasing healthcare premiums. COVID-19 has taught leaders in the sector that rewards and recognition need to reflect the more elaborate individual industry efforts.(17) The healthcare system’s management style affects care practitioners’ overall job satisfaction, recognition, and retention. Multiple acute healthcare challenges have resulted from the COVID-19 pandemic necessitating the development of complex adaptive systems which promote self-awareness and the desire to survive.

COVID-19 has taught us about collective responsibility, whereby an incident that occurs in a unit is to be tackled by all nurses on duty at that particular time. This is patient-centered care adhering to procedure, practice, and ethical considerations. Employee rewards and recognition have gained more importance during the COVID-19 outbreak than they were given before.(22) Leaders in the healthcare sector have understood the importance of celebrating their staff and recognizing their efforts as a way to keep them engaged and connected. Recognition is now perceived as an essential organizational attribute, because it promotes a culture of excellence and nursing staff inclusion.

Guidance and Counseling

The global COVID-19 outbreak has put enormous pressure on everyone, and even more on leaders in the healthcare industry. Healthcare system leadership needed practical strategies to provide guidance and counseling to care practitioners working in a stressful environment.(28) Care institutions increasingly expect a great deal from industry leaders and their management skills to guide efforts in COVID-19 recovery. Leaders in the nursing department need experience as practicing nurses, practical skills, and advanced training to develop better comprehension of the current situation in the sector. Having a single leadership style in the nursing profession has been a major worldwide problem that has dramatically affected nurses and other care practitioners’ service delivery. During the COVID-19 pandemic, guidance on emergency medical services (EMS) became crucial.(18) Healthcare leaders have provided direction on the importance of self-monitoring and delivering the necessary support to healthcare staff. They also have provided counsel on mental health and guided industry leadership in that area, which has been crucial in moving things forward.(18)

Policies and Procedures

COVID-19 has dramatically changed the norms in our society and organizational operations, including resource allocation, tactical and operational plans, power and politics, globalization forces, as well as policies and procedures. Industry regulations in the market economy have faced the challenge of resource allocation.(29) Policies and procedures have become even more important, following which industry regulators needed an incentive to stimulate the economic growth rate. Strategy policy implementation and its challenges in public corporations have been the primary incentive to stimulate the economy. Poor management of resources, poor leadership, lack of finances, limited IT capacity, and lack of participation by all employees are the significant challenges facing operations in many government institutions.(18) Policies thus play an essential role in streamlining corporate culture, which supports a strategic plan implementation. Therefore, the significant challenges in implementation of the strategic plan include hospital employee culture, resistance to change, lack of government support, and inadequate skills and competencies for specialized health services, all of which can be countered by adopting policy incentives.

Recommendations

Leadership Team Coordination

The coronavirus pandemic has taught us that organizational processes involve a set of logically ordered actions that lead to the desired result. It has been further suggested that modeling these processes fosters a comprehensive understanding of a set of actions.(20) Before the emergence of COVID-19, staff in public hospitals viewed the service rendered to their clients as a favor, not a right. This view hindered any change efforts in the hospitals that were geared toward improved performance in service provision and the stakeholders’ satisfaction. Policymakers in the health sector have adopted results from past studies to guide policy draft and ensure enforcement of a recruitment policy that can bring on board staff that has specific personality characteristics through competitive recruitment instead of relying on recruitment by referrals.(22) An incentive could help change employees’ attitudes in most public hospitals and ensure that their clients get value for their money.

The coronavirus pandemic is fast accelerating the shift to a hybrid working model requiring fundamental changes in team skills to succeed in the industry (Figure 5). The leadership trend in this new hybrid system requires a different set of skills that go beyond the traditional approach to management. The industry trend shows that successful leaders are those who can operate well under two different sets of conditions. First, there must be influential leaders in virtual coordination. Such leaders can drive information sharing, monitor progress, establish goals, and even remotely sustain connections with colleagues. Second, they also need to be effective at face-to-face collaborations when their teams come together periodically to discuss their progress.(28) Leaders who operate in this distinct mode foster dedication, acculturation, innovation, and deep learning.

Figure 5. COVID-19 Rapid Response Team Guidance(8)

Staff must be sensitized to increase their understanding of the post-pandemic future of teamwork focusing on decentralized and autonomous healthcare system divisions and the role that each staff member plays in the overall achievement of the organization’s strategic healthcare objectives. The study recommends that management invest more in teambuilding activities for their staff, which will help the staff understand that the activities they are required to carry out within their departments are geared toward helping the organization achieve its overall objectives. Failure by any of the staff to achieve their targets contributes to the overall shortfall in targets for the entire organization.(30) This study further recommends that all healthcare institution management emphasize the formulation of a clear vision to steer the change and then effectively communicate that vision to all employees and other stakeholders. Management must explain how, why, and when change is necessary, and also let the expected consequences be communicated openly to all if the change is to be effected and the benefits to be derived from the change. This will help all stakeholders walk together through the post-pandemic future of teamwork and be on the same page while managing strategic organizational change. It also will assist in dealing with the anxiety brought about by fear of the unknown in the post-pandemic era.

Management should set up staff training sessions to equip them with ways of implementing the strategic plan for full realization of the organization’s objective.

Ninety percent of existing firms and care institutions have not managed to implement changes of their strategies through practical approaches.(27) Most of the strategies set by these organizations fail because they require more resources and fail to accommodate the changing coronavirus environment. However, those organizations that prioritize the strategies and effectively implement them have been better positioned to identify and seize opportunities and offer unique products or services in the market, which eventually provides a competitive advantage to them.

Despite the increasing need for effective decision-making during the COVID-19 crisis, the topic has received limited treatment among researchers and theorists. Although crisis management experts have expressed a need for novel ideas to advance decision-making, scholars have not answered the call by engaging in rigorous research and theoretical development on the subject. The account of healthcare decision-making during this coronavirus pandemic can be described as being full of dark stretches. Recent research does not suggest the landscape has changed dramatically—although decision models describe decision processes, they universally fail to adequately describe how the culmination of the decision process occurs.(24) Aspects such as the nature and mix of tasks dictate the team operation modes.

The research process recommends that leaders in the healthcare sector should adopt best practices in managing their employees to transform themselves into an effective and efficient service and avoid the issue of labor–management conflict. Preparatory measures are recommended to ensure that challenges faced in strategic plan implementation are mitigated, because ignorance of these challenges in critical strategy implementation leads to low industry performance.(29),(30) Additionally, management should set up staff training sessions to equip them with ways of implementing the strategic plan for full realization of the organization’s objective.

Ultimately, stakeholder recognition and involvement in the change process are mandatory for the success of strategic change in any organization. This gives the stakeholders a sense of ownership and the motivation to carry the process to successful completion.(31) It also instills a level of faith and confidence that management’s support of the change process in terms of resources, time, and effort is guaranteed; thus, the study recommends this to the current healthcare sector management. Stakeholder investigation also relates closely to the availability of resources. Funds allocated in the strategy’s planning must be adequate for proper planning and implementation.(7) The study emphasizes that the organizational culture’s stability promotes implementation of the strategies. Healthcare institutions and other organizations need to develop a culture that works with the strategy implementation process.

Conclusion

As the coronavirus pandemic has shown, crises are challenging to manage because they are unpredictable, unexpected, time constrained, and dynamic. Furthermore, each crisis presents unique circumstances, contexts, and potential impacts. The holistic view of organizational crisis decision-making in this study depicts how decision consequences interrelate with ongoing decision-making processes and behaviors. As a frame for classifying outcomes, this study invoked the model of crisis management, which applies to wide-ranging organizations, threats, and consequences. Complex decision-making in real-world situations can prompt people to adopt a holistic view of a situation, engaging in several simultaneous and interrelated cognitive activities that produce an understanding that is not found in each element on its own. Examples of dynamic and interacting elements that contribute to holistic cognition include focus and attention, developing mental models, managing uncertainties associated with COVID-19, and generating courses of action. Leaders in the healthcare sector need to embrace holistic measures to collectively build an effective response action. The holistic view of decision-making will involve problem detection, planning, situation assessment, and naturalistic decision-making. The literature suggests that the holistic nature of the organizational crisis decision-making phenomenon is fluid and consists of multiple aggregated decision-making actions and cognitions.

Both internal and external factors influence decisions. Internal factors include characteristics innate to the decision-maker, such as a leader’s self-concept, stress response, and experience. In contrast, external factors are those imposed upon the decision-maker and are related to environmental, organizational, and social forces. Examples of external factors that influence the response action against COVID-19 include time constraints, work rules, and limited information. Because both internal and external factors can alter and weaken the strategies formulated, it is crucial for all units of the organization to be harmonized toward the success of the strategy implementation process. The current organizational structure in the healthcare system needs to define each team’s role in strategy implementation, and that structure should conform to all changes in the strategy implementation. The study concluded that in formulating a strategy, the healthcare sector should aim to fulfill the vision of pandemic eradication, define how the strategies will be implemented, and ensure all involved members understand the strategies. The study furthermore concluded that communication methods such as training and seminars serve a vital function within the organization in the process of strategy implementation. A fixed communications system should exist in the organization to enhance strategy implementation. Vertical communication systems delay delivery of information that is supposed to reach middle and low-level staff.

Finally, from a practitioner standpoint, this study was intended to promote interest in practices and interventions designed to improve crisis decision-making. Although it is premature to identify the precise nature of COVID-19 interventions that would benefit practitioners in the long run, it is expected that existing interventions such as knowledge sharing, wearing protective clothing, social distancing, and covering the mouth while coughing might enhance the development of reflective practice, development of group member trust and cohesion, and increased exposure to various decision-making processes. Furthermore, these insights may be informative in enhancing common standards of practice that many organizations look to for future crisis preparedness guidance.

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