Crisis leadership and power dynamics in Portuguese hospitals: organisational learning from COVID-19

This paper aims to examine how power struggles, competing leadership logics and governance failures shaped organisational learning and crisis response in Portuguese public hospitals during the COVID-19 pandemic. By analysing tensions between managerial, clinical and political actors, this study explores how fragmented authority and informal leadership networks conditioned hospitals' adaptive capacity under sustained systemic pressure.

This study draws on 41 semi-structured interviews with hospital managers, clinical leaders and frontline coordinators across three major public hospitals, complemented by documentary analysis of contingency plans, internal communications and official reports. A deductive thematic analysis was conducted, supported by systematic triangulation, inter-coder validation and critical incident reconstruction.

Three interrelated patterns emerged: strained relationships between hospital management and central and regional authorities undermined coordination and trust; informal leadership networks developed within clinical departments to address operational bottlenecks, frequently bypassing formal hierarchies; and political interference intensified power rivalries, reducing coherence, transparency and institutional learning. Although these dynamics often constrained organisational learning, they also enabled pockets of rapid local adaptation driven by autonomous clinical leadership.

This study is limited by its focus on three large hospitals in Northern Portugal, which restricts generalisation to other regions or smaller institutions. The qualitative design, although suitable for exploring governance dynamics, captures perceptions that may be influenced by hindsight bias and the exceptional pressures of the pandemic. The absence of quantitative performance indicators limits the ability to assess the measurable effects of governance tensions. Future research should incorporate mixed methods, include diverse organisational contexts and examine longitudinal integration of informal practices into formal governance and learning systems.

Hospitals require governance arrangements that recognise and integrate informal leadership and frontline expertise during crises. Strengthening transparent communication channels, formalising multi-level coordination mechanisms and embedding learning processes within crisis governance frameworks are critical for enhancing resilience and leadership effectiveness.

This study highlights how governance tensions during the COVID-19 pandemic affected not only hospital functioning but also the broader social experience of healthcare. Unclear authority structures and delayed decisions contributed to public uncertainty, reduced confidence in health institutions and inconsistent communication with patients. Conversely, the emergence of informal leadership networks helped sustain essential services, mitigating the social impact of system fragmentation. Strengthening crisis governance, ensuring transparent decision-making and valuing frontline expertise can improve public trust and equity in access to care during future emergencies. These insights support more socially resilient and trustworthy health systems.

This study advances current understandings of crisis leadership and power dynamics in healthcare by demonstrating how national governance cultures interact with organisational learning processes and informal leadership practices during systemic shocks. Drawing on comparative and multi-level qualitative evidence from Portugal, it offers actionable insights to inform future hospital governance reforms.