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    Steve Brewer
    Steve Brewer, MBA, CMPE, FACHE
    Anyone working in healthcare in recent years knows how difficult it has been trying to constantly adapt and navigate through the COVID-19 pandemic. These challenges included many personal and professional struggles made worse by evolving and often controversial strategies for mitigating the public health emergency. Thankfully, there is some optimism that we have turned a corner and are on the cusp of getting back to a sense of normalcy.

    However, navigating what was “normal” before COVID-19 was not easy. For years healthcare has experienced high rates of reported burnout, feelings of exhaustion, and disengagement among physicians, nurses, and other healthcare workers.1,2,3 Coupled with growing concerns for employee well-being, healthcare leaders grappled with how to best meet the increasing expectations for delivering on the Triple Aim of quality care, positive patient experiences and affordable costs. These challenges may have been made even greater stemming from residual feelings of fatigue as we continue to recover from the COVID-19 pandemic.

    Rejuvenating our organizations may feel like another daunting task for today’s leaders. Given the fast-paced and complex dynamics of healthcare, the core principles and behaviors of adaptive leadership can provide a practical framework for navigating significant changes while enabling a positive culture that helps engage, empower and energize providers and staff.

    What is adaptive leadership?

    Healthcare executives may be more familiar with the models of servant or transformational leadership. These models are often used to describe positive traits that reinforce the values of serving others while working to transform healthcare to meet developing needs of patients and communities. Both models promote the notions of being connected to individuals, appealing to shared values, and envisioning uplifting futures.4

    Adaptive leadership shares these noble sentiments. In addition, and perhaps more germane to navigating the healthcare landscape, adaptive leadership includes an emphasis on understanding the complexities of helping people to accept significant change and being successful in facing new and turbulent truths.5 The adaptive model has been emerging since the early 1990s. At that time, leadership scholars Ronald Heifetz, Alexander Grashow, and Marty Linsky outlined a model designed to mobilize people in facing tough challenges and learning to thrive in new realities.6

    Core principles and key behaviors of adaptive leadership

    Peter Northouse provides a comprehensive overview of six core principles and behaviors adaptive leaders use to understand complex situations, engage people and achieve success.7

    1. Getting on the balcony

    The first principle is referred to as getting on the balcony and serves as the foundation of the adaptive model. Using the metaphor of being on a balcony and seeing the big picture, this principle entails leaders taking a step back to survey their circumstances. By getting on the balcony, leaders can assess the situation, see how different individuals and groups are responding to challenges, and formulate purposeful strategies to address issues.

    Assessing the big picture helps to avoid a common pitfall of seeing success in one area but overlooking issues in another. For instance, implementing EHRs has created significant opportunities for efficiency and streamlined operations; however, they can also be a major factor in physician burnout related to frustrations with increased workloads and feeling constantly connected and unable to recharge. Watching the EHR efficiencies develop while being aware of the early signs of other unintended consequences is a good example of how the adaptive model can be applied in monitoring important yet disruptive changes. 

    2. Identifying adaptive challenges

    The second principle of adaptive leadership is the ability to identify adaptive challenges. This entails seeing issues, diagnosing situations, understanding root causes of resistance, and addressing barriers to achieving goals.

    A key factor of this principle is the ability to quickly differentiate between technical problems and the less-obvious yet often more complex adaptive challenges. As the term implies, technical problems are more straightforward and can be addressed with known solutions. For clinicians this may include evidence-based treatments with well-known patient outcomes. Adaptive challenges are much less straightforward and often include considerations for individual and group perceptions, beliefs and values. This is similar to the concept of patient-centered care that takes into account individual values and perspectives in planning a course of treatment.  

    Northouse’s tips for successful engagement on adaptive challenges include:
    • Taking steps to avoid a disconnect between actions and words
    • Understanding conflicting values
    • Having candid conversations
    • Managing the human tendency for task avoidance in the presence of low motivation.8
    The healthcare environment is rich with opportunity for applying this principle given its many competing issues, complex ethical situations, deeply rooted beliefs, and diverse cultural norms, all of which can cause strife and lead to overly stressed clinicians and other healthcare workers.

    3. Regulating distress

    It is natural for people to gravitate toward the familiar. Changes can prompt high levels of uncertainty and distress, especially when accompanied by a loss of control or empowerment.9 How people respond to change depends on many factors, and what prompts feelings of being overwhelmed and distressed can be different for individuals and groups.10 Adaptive leaders recognize this fact and work to regulate the amount of distress and avoid unnecessary tensions and maladaptive behaviors.

    Regulating distress entails many of the elements outlined by the Institute of Healthcare Improvement, including clearly explaining the why of needed change, giving workers a voice in what matters to them, allowing for a psychologically safe environment, staying present and supporting positive engagement, and stepping in early when tensions get too high.11,12 A good example of regulating distress in healthcare organizations is tempering the timing of new initiatives — consciously avoiding the rollout of too many changes at one time and making sure to follow through with current projects before initiating the next big move.

    4. Maintaining disciplined attention

    It is easy for people to shift their attentions during big changes. This is particularly true when adapting to change requires a different way of thinking and challenges personal beliefs or values.13 Adaptive leaders have the focus and fortitude to bring up sensitive topics to effectively address changing environments and shifting cultures.

    Examples of compassionate but disciplined attention can be seen in helping clinical staff understand the realities of increasingly challenged payment models and the need to adopt new ways of delivering care that is cost effective and safe. However, in keeping with the previous three principles, this should be balanced with the acknowledgment that too much attention to numbers gives the appearance of caring more about margins than patients and can feed a disconnect between administrators and clinicians.

    5. Give the work back to the people

    This principle considers that most people respond best when they can participate in decisions and are empowered to shape how their work gets done. Adaptive leaders can sense when to engage and provide direction, but also when to step back and let those closest to the work think through issues and implement solutions. This is especially true in healthcare with a high number of well-trained professionals who are accustomed to critical thinking and taking decisive action.14

    For example, telling physicians that they need to take extra steps in meeting a new quality goal may often be met with significant resistance and strife. Explaining the background, translating the importance, and asking for their advice on how to measure and achieve a quality goal is much more likely to elicit positive ideas and practical solutions. Effectively applying the first four principles of adaptive leadership lays a solid foundation for giving work back to those at the front lines and enabling them to flourish through empowerment and self-sufficiency. 

    6. Protect leadership voices from below

    On a basic level, this component deals with making sure leaders remain open to input from all levels of the organization. This includes those with minority views and conflicting perspectives. This can be a particularly tricky endeavor in the face of challenging times and when group consensus may not support differing views. Moreover, there may be a fine line between fostering acceptance of all perspective and the need to sometimes temper destructive dialogue. However, being open to different ways of approaching issues can lead to innovative solutions that would otherwise go undiscovered.

    This also helps to guard against groupthink, which can overshadow new ideas, compromise effective decision-making, and stifle creative solutions.15 A good example of enabling input from all levels in healthcare is using interdisciplinary teams with members from various departments coming together to share their views and provide ideas on how best to improve processes while meeting standards for quality, patient experience, costs and, perhaps most importantly, preserving a positive culture.

    Summary and parting perspectives

    Healthcare was filled with complex issues and conflicting goals before the pandemic, which required constant effort to manage continuous change. Now that we are hopefully starting to recover from the public health emergency, it is even more important that we work to refocus and rejuvenate people. While leaders may also feel fatigued, it is a good time to be reminded of proven models for staying connected with people and supporting positive changes.

    The contemporary models of servant, transformational, and adaptive leadership include the positive notions of engaging individuals, supporting teams, and empowering others to achieve goals. However, in assessing these and other popular leadership theories, the adaptive model may be particularly relevant and applicable given the pace and magnitude of change in healthcare. The principles and behaviors of adaptive leadership can assist to refocus efforts and engage, empower, and energize physicians, nurses, and the many other committed individuals in providing safe and effective care to their patients and communities.


    1. Moutier C. “Physician mental health: An evidence-based approach to change.” Journal of Medical Regulation, 2018, 104(2): 7–13. Available from:
    2. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, and Feeley D. “IHI framework for improving joy in work.” Institute for Healthcare Improvement. 2017. Available from:
    3. Swensen S, Shanafelt T. Mayo Clinic strategies to reduce burnout. Oxford University Press, 2020. Available from:
    4. Northouse PG. Leadership: Theory and practice, 8th edition. SAGE Publishing, 2019.
    5. Arthur-Mensah N, Zimmerman J. “Changing through turbulent times — why adaptive leadership matters.” The Journal of Student Leadership, 2017, 1(2), 1–13. Available from:
    6. McCollum B, Shea K. “Adaptive leadership: The Leader’s Advantage.” InterAgency Journal, 2018, 9(1), 99–111. Available from:
    7. Northouse.
    8. Ibid.
    9. Arthur-Mensah, Zimmerman.
    10. Scandura TA. Essentials of organizational behavior: An evidence-based approach, 3rd edition. SAGE Publishing, 2020.
    11. Perlo, et al.
    12. Swensen S, Michael P, McMullan C, Kabcenell A. High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. 2013. Institute for Healthcare Improvement. Available from:
    13. Northouse.
    14. Borkowski N. Organizational behavior in health care. Jones and Bartlett Learning, 2016.
    15. Scandura.
    Steve Brewer

    Written By

    Steve Brewer, MBA, CMPE, FACHE

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