Leading under uncertainty: a qualitative case study of crisis leadership in Canada's health system

Prolonged public crises challenge leaders to make high-stakes decisions under conditions of uncertainty while sustaining organisational performance and public trust. Understanding how leaders navigate these complex demands is essential for strengthening health system preparedness and resilience.

The goal was to explore and unpack lived leadership experiences during a public crisis situation and to unpack how contextual factors shape their behaviours under uncertainty and prolonged disruption.

This study was conducted in Canada during the middle phases of the COVID-19 pandemic (October 2020-March 2021). Canada's healthcare system operates within a federal-provincial framework, with public health responsibilities spanning national, provincial and local levels. 16 senior leaders with provincial or national responsibilities across healthcare delivery, government, academia and research participated in the study. Purposive sampling was used to achieve variation across organtional and geographic regions. A qualitative case study design was employed, with semistructured interviews serving as the primary data collection method and thematic analysis used to analyse the data. The analysis was informed by Sriharan et al's Crisis Leadership Framework and reported in accordance with the Standards for Reporting Qualitative Research.

Videoconference interviews (40-50 min) explored leadership challenges, decision-making under uncertainty, communication, and contextual enablers and constraints. Transcripts were analysed using Braun and Clarke's six-phase approach with triangulation and reflexive documentation to enhance rigour.

Leaders described multifaceted roles that spanned clinical, administrative and advisory functions. Six leadership domains emerged from the analysis: adaptive leadership, learning-oriented leadership, systems thinking, psychological stewardship, implementation agility and strategic communication. Leadership enactment was shaped by structural integration and centralisation, which enabled real-time situational awareness and coordinated resource deployment. Rapid cycle decision-making was supported by emergency legislative flexibility, multidisciplinary evidence synthesis structures and peer learning networks. Constraints included systemic fragmentation, bureaucratic inertia, data sharing limitations and sustained workforce fatigue, all of which influenced leaders' ability to enact these domains under pressure.

Effective crisis leadership depended less on static competencies and more on dynamic enactment shaped by structural, operational and relational mechanisms. The findings extend the crisis leadership framework towards Dynamic Capability Leadership for Learning Health Systems, positioning leadership as a strategic capacity to sense emerging challenges, seize opportunities through rapid and accountable decision pathways and transform processes to sustain performance under uncertainty. These capabilities were enacted through adaptive and learning-oriented leadership, implementation agility, systems thinking, psychological stewardship and strategic communication, all amplified by structural integration and evidence-synthesis infrastructures. Overall, the findings highlight crisis leadership as a system property shaped by context, coordination and the ability to translate evolving knowledge into timely action.