Reflections on Healthcare Leadership in KwaZulu-Natal, South Africa During the COVID-19 Pandemic: Implications for Crisis Leadership Development and Implementation

Serela S Ramklass School of Clinical Medicine, University of Kwazulu-Natal, Durban, South AfricaCorrespondence: Serela S Ramklass, Email Ramklasss@ukzn.ac.zaBackground: The COVID-19 pandemic created volatile, uncertain, complex, and ambiguous (VUCA) healthcare environments globally, exposing systemic vulnerabilities in leadership preparedness, interprofessional coordination, and staff psychological support as healthcare leaders faced unfamiliar demands, moral distress, and competing priorities.Objective: To explore the lived experiences of physiotherapy, nursing, and medical leaders during COVID-19 at public sector hospitals in the eThekwini District of KwaZulu-Natal, with particular attention to how they navigated systemic constraints, psychological strain, interprofessional fragmentation, and adaptive leadership demands under crisis conditions.Methods: Using interpretive phenomenology, 10 physiotherapy managers, 8 nurse operational managers, and 9 senior medical consultants from 7 public hospitals (district, regional, and tertiary) participated in focus group discussions. Transcripts were analysed using Otto Scharmer’s Theory U as an interpretive analytical framework to examine leadership adaptation and transformation under crisis conditions.Results: Five interrelated themes emerged: (1) crisis leadership unpreparedness revealing educational and systemic gaps; (2) leadership failures in staff support contributing to psychological strain and burnout-related experiences; (3) fragmented interprofessional leadership sidelining allied health professionals; (4) leadership transformation from institutional rigidity to frontline innovation; and (5) personal leadership emergence through crisis. While institutional leadership often failed, frontline leaders demonstrated adaptive, human-centred leadership practices, shifting from authoritative, transactional approaches to collaborative leadership. Individual-level transformation was evident in a subset of participants, while others demonstrated partial progression through adaptive leadership processes shaped by institutional context. The crisis catalysed significant personal leadership transformation, prompting healthcare professionals to reconstruct their professional identities and develop adaptive capabilities through experiential learning under pressure.Conclusion: Resilient leadership for VUCA healthcare environments requires empathetic engagement, interprofessional collaboration, crisis management training, and communication that values staff voices. Leadership development must move beyond transactional models toward human-centred, adaptive approaches that strengthen both systems and the people within them. Strengthening leadership decision-making through evidence-informed management practices, organisational learning, and inclusive governance can enhance crisis responsiveness and operational effectiveness. Evidence-based recommendations address curriculum reform, institutional support systems, interprofessional collaboration, and crisis preparedness for resource-constrained contexts. Leadership programmes must recognise and harness individual transformative capacity emerging during crises, while addressing structural and interprofessional barriers that constrain the long-term institutionalisation of adaptive leadership practices.Plain Language Summary: We spoke with 27 healthcare leaders—physiotherapists, nurses, and doctors—from seven public hospitals in the eThekwini District of KwaZulu-Natal. Through focus group discussions (FGDs), participants shared their leadership experiences during the COVID-19 pandemic, describing what worked, what did not, and how they adapted under extreme pressure.Five critical patterns emerged. First, health worker education had not prepared leaders for crisis management or for supporting teams experiencing trauma. Second, promised counselling services often did not materialise, leaving staff without adequate psychological support. Third, traditional hierarchies prevented collaboration—physiotherapists were excluded from key planning meetings despite their critical role in respiratory care and patient recovery. Fourth, while senior administrators often remained constrained by institutional rigidity, frontline leaders created innovative solutions and support systems when institutions failed them. Finally, the crisis transformed some individual leaders, pushing them to develop more collaborative, empathetic approaches that valued every team member.Healthcare leadership training must include crisis management, psychological support skills, and collaboration across professions. Institutions need functional support systems ready to activate during emergencies, not empty promises. Future preparedness requires moving beyond purely hierarchical models toward human-centred leadership approaches that protect both patients and healthcare workers during crises.While limited to a single district, this study provides evidence of under-valued leadership capacity among frontline healthcare leaders in public sector hospitals in the eThekwini District, KwaZulu-Natal, which may be relevant to similar healthcare settings elsewhere in South Africa. Systematic development of this capacity, rather than reliance on individual heroism, could strengthen healthcare resilience for future crises.