Leading primary care under the weight of COVID-19: how leadership was enacted in six australian general practices during 2020

Our data show variation in leaders’ ability to motivate and encourage workers to support necessary organisational change. Early responses emerged in varied ways within CHC, W, E and CBD. Decisive and early top-down decision-making at E and CBD motivated workers to some degree; whereas CHC and W were more collaborative. SE2 and SE1 leaders responded more slowly to the pandemic, yet over time, staff both demanded and assumed active leadership roles, motivating others. Board members in W transferred the role of primary decision-makers to individual team leaders ‘on the ground’, demonstrating the leaders’ ability to motivate others.

We’ve been, yeah, a lot more agile, a lot more focused on just making quick improvements to deal with … So I think that will change for the long term really. We’ve proven to ourselves that we can achieve some pretty massive things in a very quick timeframe, so why not keep that ball rolling? (W GP2)

By contrast, SE2’s leadership structure (key decisions made by remote corporate leadership) contributed to practice members feeling lost and unmotivated – this was partially alleviated by the creation of a local leadership group.

There has been a lack of clear leadership within the medical team. Indeed, there is a distinct lack of team spirit, leadership and cohesion within the organisation. (SE2 GP)

Across the range of management styles (unilateral to collaborative) all practices made changes to structures to motivate practice staff to participate in adapting to the pandemic. This highlights that early unilateral leadership styles were effective in implementing COVID-specific managerial/practice changes, but at the expense of wider team cohesiveness.

As is traditional in primary care, most practices had a hierarchical structure: PO being lead decision-makers, followed by lead PM and/or lead GPs, with nurses and administrative staff below (McInnes et al. 2015). This frequently contributed to experiences of power imbalance and lack of psychological safety. CHC and W’s more collaborative approach helped counteract this, whereas SE2 and SE1 became more balanced over time.

The GPs within SE1 challenged this traditional hierarchy, raising concerns early by writing a joint letter to PO on the practice’s approach to the pandemic. This informal leadership altered the POs’ approach, creating greater transparency and inclusion among GPs, through regular meetings where they could participate in decision-making. Interestingly, initially the dynamic continued to exclude non-GP members from collaboration, which reinforced GP dominance, leaving several cohorts feeling undervalued.

It would just be nice to be included in some of the decision-making. And everyone wants their voice heard, don’t they? (SE1 de-identified)

Although pre-pandemic, nurses within one practice experienced feelings of psychological safety, relationships with the GPs fractured during the pandemic. This was attributed to the PO/lead GP being the power centre, primarily engaging with GP clinicians in meetings and increasing GP collaboration at the expense of other staff members.

I think everyone should be doing what they are best at. And doctors are best at treating people and making these decisions, clinical decisions. This is [a] clinical problem. (de-identified PO)

Nurses at another practice expressed similar feelings, whereby privileging of communication between GPs reinforced the traditional leadership hierarchy.

It just makes me feel like – not a second-class citizen pretty much, but that doctors are the most important ones in his/her [PO] eyes, and the nurses – well, he/she just doesn’t think about it enough to have addressed my concerns in any way. So that’s frustrating. (de-identified practice nurse)

Although organisational hierarchy is generally critiqued for reducing mutual respect among the workforce (Rogers et al. 2020), data from the CHC showed that in times of urgent and unplanned change, their hierarchy (which was not GP-dominated) minimised power conflicts and feelings of vulnerability amongst staff.

This one is very different to a regular general practice in that we have the GPs working but you have the governing body across the top… And in the case of a pandemic… actually sometimes hierarchy is useful then because they can make rules that everyone else has to follow. (CHC CII)

These examples show the degree to which communication structures were intricately implicated in power hierarchies. Communication was strong within disciplines, but challenging or not emphasised between disciplines. Practices where leadership improved communication between disciplines saw less fracturing of relationships.

Across practices, leaders recognised the importance of communication through establishing new methods to address evolving needs. However, implementation was variable, and at times inconsistent.

To counter the isolation induced by COVID-19, most practice leaders increased the frequency of clinical meetings compared with pre-pandemic (see Table 4), which assisted communication, including the transfer of COVID-19 related information. Two larger practices, CHC and W, quickly implemented weekly all-staff ‘Zoom’ meetings. Smaller practices established regular meetings, primarily involving the PO and GPs. As aforementioned, action by contractor GPs in SE1 resulted in major changes in practice leadership.

A group of us GPs … not including the two principals, came together and drafted a letter to the practice principals saying that we were concerned about how some of our practices were falling down in terms of both our safety – and our staff safety and all that of our patients, and we were very keen to address them in a more formal way because we felt that what had been done so far wasn’t working very well. (SE1 GP1)

Reflecting their highly individualised status as contractors in a corporate structure, SE2’s GPs very infrequently met, and relied on local leadership updates for clinical direction. By contrast, nurses had regular meetings.

WhatsApp was utilised variably at five practices; some initially for ‘informal’ conversation, with progression to it being a primary means of delivering updated COVID-19 information, decision-making and supporting practice change. WhatsApp effectively enhanced communication within SE1. Similar to the clinical meetings, WhatsApp groups in some practices only included GPs, and not PMs, nurses and receptionists.

Email was heavily relied upon, with reception staff from E noting that early in the pandemic, the PO communicated changes to practice policies up to three times a day. Remote leaders at SE2 similarly utilised email to distribute information; however, by the time it reached the local level, the advice was often outdated.

Despite more frequent formal communication and virtual interaction, CHC GPs noted that the lack of ‘corridor conversation’ was not effectively replaced by WhatsApp, describing this as a ‘huge collegiate loss’. The switch from rich (face-to-face) to lean (email, memos, What’sApp) communication was only partially effective, even with regular all-staff online meetings. Although needed in this instance, multiple new communication channels at times led to over-saturation of information, often at the expense of effectiveness.

Boundary spanning has three aspects: vertical spanning across levels and hierarchy; horizontal spanning across functions and expertise; and stakeholder spanning to organisations outside the practice (Crabtree et al. 2020). The degree to which leaders exhibited this attribute was inconsistent. Utilisation of vertical spanning by leaders was minimal across all practices; there was significant horizontal spanning at CHC, CBD, SE2 and W; and only CHC and W implemented stakeholder spanning.

Receptionists’ needing to rapidly modify their traditional work routines was a common example across practices of leaders implementing horizontal boundary spanning. Introducing temperature scanners and triaging patients meant reception had to work clinical equipment and identify ‘at risk’ patients – examples of horizontal spanning as these were previously considered beyond traditional administrative roles.

W’s leadership demonstrated stakeholder spanning, through implementing a government- funded respiratory clinic and externally led infection control clinical training. They demonstrated effective horizontal spanning through recruitment of ‘health assistants’; people with nursing, paramedic, retail, hospitality or even aviation backgrounds, whose job security had been impacted by COVID-19. The CHC reached outside the boundaries of the practice in liaising with key stakeholders – the State Government – and employing local community members as peer workers to implement a COVID-19 clinic for people in a public housing tower and other high-risk housing. Dental clinic staff were redeployed to this critical COVID-19 programme.

Across the practices, certain disciplines (reception in particular) took on new roles demonstrating mainly horizontal spanning, whereas the remainder of the heightened workload remained within disciplines. This represents a collective demonstration that horizontal spanning supported practice change.

Most practice leaders recognised the value of cultivating teamwork and nurturing cohesion within the team. The pandemic, however, challenged leaders’ abilities to foster heedful interrelations and group formation between members, due to the imposed work-from-home restrictions and shift to telehealth consultations. In our sample, cohesion within smaller practices was observed to a greater degree than larger practices (other than in the CHC), although there were some tensions between PO and workers, as illustrated by the GP letter to the SE1 PO (above). The leaders of two larger practices (CHC, W) tried to address these challenges by facilitating a strong local leadership team. Similarly, but later in the pandemic and with less impact, SE2 established a local leadership team to complement its existing and distant corporate leadership approach.

Early clinical challenges preoccupied leaders, and varying approaches to intrapractice communication highlighted their efforts to foster collectivity. Which disciplines were invited to clinical meetings was a contributing factor to wider feelings of practice cohesion.

In the past … there’s been a little bit of lack of communication and a lack of cohesion, and I felt that maybe with this crisis, might bring us together … I think we’re agreeing more, … we’re all sort of on the same page, but there’s always going to be differences in opinions and differences in the way we think things should happen. (SE1 GP)

Notably, the desire for ongoing improvement in team building continued to be recognised;

So I think that’s definitely the biggest thing in that centre that needs to improve, is the team ethos amongst the doctors. They [central managers] probably need to be a bit incentivised and autonomous to do their own thing, and look at their local factors, and they need to build the team ethos to make sure that you can react as a team, sensibly and consistently. (SE2 CII)

Although practices infrequently met Crabtree’s definition of a ‘team with a collective mind’, workers at several practices (E, W, SE2, CHC) commented that they felt ‘closer as a team’ despite physical distancing, segregated lunch breaks and lack of social interaction.

[Emerging from pandemic] if anything, I think we have solidified and as a practice having been through that, I think everyone’s looked after each other and have got to the other side stronger from an interpersonal relationship point of view, yes. (W GP)

This theme is strongly related to theme 3, as the use of virtual communication media and meetings was important for building interconnectedness.

The pandemic motivated system change, providing opportunities for practice staff to take on new responsibilities. Mostly, the pandemic created the ‘need’ for workers to ‘step up’ as new leaders, with few instances of practice leaders fostering environments to support emergent leaders.

Several practices experienced leadership changes at the pandemic onset. The CHC PM left just before the pandemic, and very early on a nurse established a ‘COVID-19 response committee’, sourcing COVID-19 protocols. The CBD PM also left immediately prior to COVID-19, but by contrast, the PO eagerly took over this role with a specific ‘heroic’ perspective.

This is what we have been waiting for all of our lives. This is why we went to medicine. Yes, there is a risk, but we signed a contract when we entered medical school… (CBD PO)

Lack of local governance within SE2 placed a strain on the practice leadership team from early on. With the practice under early financial strain and no concrete plans from central leaders, one GP ‘agreed’ to step up into the clinical lead position, supporting the idea that leaders were ‘needed’ during this time, rather than ‘fostered’, as per Crabtree’s definition.

The transition of leadership from board members to local team leads at W was the main example of active fostering of emergent leaders.

A ‘learning organisation’ is one that is skilled at creating, acquiring and transferring knowledge, and modifying behaviour to reflect new knowledge and insights (Crabtree et al. 2020). In the learning process, organisations make cognitive, interpersonal and organisational adjustments that allow new routines to be successfully implemented (Edmondson 2003; Crabtree et al. 2020). All practices felt that they had changed how they did their work; however, transformation only occasionally met Crabtree’s definition.

Interpersonal growth between W’s staff brought the practice team ‘closer together’, and resulted in foreseeable permanent changes to clinical routines and structures.

And then on the leadership sense … I think that will continue on. That’s my feeling. And I think we’ve just made a decision that maybe our previous world was that we were just too slow and why were we too slow and look at what we can achieve in a short period of time. (W GP1)

Emergent leadership demonstrated by contractor GPs at SE1 illustrates how leadership behaviours, from levels other than the top of a hierarchical arrangement, are essential to reinforce continual reflection and learning within an organisation. Members of SE1 reflected changes to how leaders did things assisted practice success during the pandemic.

Although some practices demonstrated behaviours that encouraged the development of their practice into a learning organisation, others focused on the clinical demands of the pandemic, as seen by E and CBD. Whereas infrequent reference was made to being a learning organisation at CBD, some staff members viewed the PO’s leadership style as successful.

I felt like she [PO] … was really driving quick changes as they needed to happen, because she was driven by not only her clinical skills and her clinical knowledge about PPE [personal protective equipment] and infection, but she was also driven by the fact that she’s got a stake in the company, in the practice. (CBD CII)

Overall, practices were able to partially move towards being learning organisations – principally through rapid adaptation to emerging data and COVID-19 updates. This highlights that contributions from levels other than the top of the hierarchy are vital to organisational success, and that interpersonal growth strengthens changes.