Leadership and practice in times of complexity and uncertainty

Never have our skills as professionals been tested as much as they have during 2020. The National Competency Standards for Dietitians in Australia clearly articulate professional practice as a key area underpinning the work of dietitians.1 The importance of our ability as professionals to practise safely and effectively but also show leadership has been heightened in the challenges presented this year. While complexity and uncertainty are not new concepts in health care, our abilities to manage and lead in times of increasing complexity and uncertainly have never been more important to examine. There is increasing recognition of the complexity of health care.2 Complexity has been espoused to relate to both the system in which health care is delivered, as well as the health problems presenting. The complexity of nutrition and dietetics spans all areas of practice and science, and remains a challenge for dietitians.3 Complexity refers to the component parts of a problem or intervention that, on their own or together, influence our understanding of the problem or the effect of the intervention.2 Competency standards are an example of a complex concept due to the fact that competence or the expected performance in the workplace is not just the ability to discretely demonstrate each of the individual performance indicators.4 Obesity and food insecurity are nutrition issues commonly described as complex where current responses and multiple strategies are required to have an impact on the problem.5, 6 Uncertainty is the emotion that individuals experience when they are not certain of what the future holds.7 Tolerance of uncertainty has been defined as “the set of negative and positive psychological responses—cognitive, emotional and behavioural—provoked by the conscious awareness of ignorance about particular aspects of the world.”8 The challenges presented to dietitians in practice such as technology, social media and changing nature of employment provides an example of uncertainty for the profession.9 There is no doubt, even before the events of this year, that our community is in a world of increasing complexity and uncertainty. In the face of complexity and uncertainty, dietitians need to be positioned to thrive, not just to survive. Professional leadership is a recognised key competency for dietitians.1 It is the distinguishing feature of Dietitians Australia's Advanced and Fellow credentials.10, 11 Distinct from management, our profession has defined leaders as those “who continue to grow personally and professionally while encouraging and mentoring emerging leaders…[and] who bring people together.”10 This is synonymous with a widely recognised definition of leadership as the process by which an individual takes responsibility for discovering the “potential in people or processes, and who has the courage to develop that potential.”12 This year, in my own work area of dietetics education I saw first-hand, the leadership of many of my colleagues as they transformed to online teaching and indeed different models of practical placement.13 Leadership is demonstrable in much of the research in recent editions of Nutrition & Dietetics. This includes Chapple and colleagues' guidelines for managing critically and acutely unwell adult patients hospitalised with COVID-1914 and Langston's study showing the vital role of dietitian leadership in multidisciplinary lifestyle interventions.15 Indeed, Porter et al. show tremendous leadership, putting aside individual interests and recognising that to maximise research efforts within our profession requires a focus on key priorities to funnel limited resources such that greater impacts can be realised, identifying five key themes for dietetics research.16 Without leadership, it is impossible to manage in complex and uncertain environments. A key component of leadership is taking initiative and developing solutions to problems.1 Examples of this are illustrated in this issue of the journal from dietitian leaders supporting patients with cystic fibrosis and diabetes,17 prescribing very low calorie diets for obese general elective surgery patients18 and identifying what constitutes meaningful relationships with clients.19 Embracing 'vulnerability' in leadership in solving problems is key to success. Vulnerability is about taking risk, being comfortable with an uncertain outcome.12 These authors have certainly showed vulnerability, taking risks without knowing the outcome. In health, low tolerance of uncertainty can lead to burn out and negatively affect patient outcomes.8 This is driven by fear, with health professionals wasting time and resources in their efforts to mitigate unknowns and determine outcomes. This results in resistance to change and worry for not getting it 'right'. Our training as scientists may have done us a disservice in managing uncertainty. The scientific philosophical paradigm that our profession is based on views knowledge as something that is objective or 'real', can be measured accurately and something that is separate from individuals and the social systems in which we live—it's 'black or white'.20 In reality, what is real is as much socially constructed as it is measurable or 'right.' Social constructionism offers an alternative view of knowledge that acknowledges multiple realities.21 Those of us who have higher acceptance of uncertainty, are comfortable with 'grey' and acknowledge that the world is socially constructed. Those with higher acceptance of uncertainty may be more likely to show “flexibility, adaptability and resilience and the ability to manage own emotions”1, another key skill for effective professional practice. Effective leaders must acknowledge that decisions and actions must be taken even when we cannot determine precisely what the outcome will be. “The perfectionist streak is alive and well in dietetics [and] becomes a barrier if individuals avoid participation out of fear of imperfection, failure or potential criticism.”22 These important words by Lynne Daniels in the 2001 Lecture in Honour still hold true today. In a world of complexity and uncertainty, perfectionism is not a useful quality. Dietitians must foster a growth-oriented mindset. A growth mindset is one whereby we see experiences, and especially failures, necessary for enhancing our capabilities.23 In viewing work, life and learning with a growth mindset you acknowledge that qualities can be developed. This results in seeking challenges and demonstrating resilience when faced with setbacks, which are fundamental to learning. On the contrary, fixed mindsets are associated with perfectionism. Those with fixed mindsets avoid change and challenge due to anxiety associated with showing inadequacies.24 Other qualities of effective leaders include “self-awareness, self-regulation, motivation, empathy and social skill”.25 In a state of uncertainty and complexity, the challenge for leaders is to find a balance between immediate priorities for action, future focussed adaptive strategy and vision.26 Strategic leadership has been identified as key to preparing dietitians for emerging areas of practice, such as eHealth.27 To advance as leaders, dietitians need to embrace our failures or lack of achievement of results as vitally important for learning, as only then will nutrition and dietetics truly advance as a profession. As a profession we need to consider how the events and future uncertainty and complexity that await us will reflect dietary behaviour, risk factors and determinants. While existing evidence on socio-economic differences, such as those identified by Costa in this issue, are likely to predict nutrition outcomes,28 the profession must be challenged to think creatively in the rapidly changing future that awaits us. Nutrition environments such as universities, as highlighted by Whatnall et al29 will no doubt be an important area for intervention, but it is likely that our existing approaches may need to be reconsidered, as settings, such as universities and workplaces, are likely to look very different into the future. While many of the key skills described above are reflected in our competency standards, like all areas of performance health professionals must embrace a continued process of experimentation, reflection and reimagining our practice with personal and professional development. Are individuals able to develop skills in managing uncertainty and indeed leadership? The evidence suggests this can be achieved if individuals are willing to embrace a growth mindset.23 Tolerance of uncertainty is amenable.8 Research suggests that exposure to diversity and cases without definitive answers or challenges to existing solutions, can develop our ability to manage uncertainty.7 How well are these approaches reflected in our education that prepares our graduates for the future or indeed continuing professional development? Perhaps this is why mentoring and communities of practice are effective workforce development approaches as they embrace diversity and explore multiple solutions to problems.30 Through the right forms of continuing personal and professional development health professionals can develop the capability to deal with complexity and uncertainty. The events of this year have shown the need for leadership such that the profession has the capabilities needed to effectively practise and lead through the unknown with complex problems. I ask you to reflect on your leadership this year: To what extent did you show courage or deal calmly with uncertainty? How comfortable are you with 'grey'? Have the challenges presented to you this year been a trigger to a fixed mindset whereby you have been defensive and resistant to change or doing anything differently? Have you increased your digital literacy, used telehealth31 or had to deliver education through new and innovative ways? Part of being a professional is committing to lifelong learning. Indeed if this is you, consider your commitment to yourself and your workplace and colleagues, such that you can develop and ensure that dietitians are equipped with the leadership skills required to embrace the challenges that will no doubt present to us into the future.