Applying the principles of adaptive leadership to person‐centred care for people with complex care needs: Considerations for care providers, patients, caregivers and organizations

Abstract Background Health systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs. Objective To reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level. Findings The defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery. Conclusions Advancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.


| What are person-centred care and adaptive leadership? How are these two concepts related?
Person-centred care is a partnership between patients and their care providers through which the specific needs, preferences and expectations of patients and their caregivers (family and friends who provide care) are continually sought out, respected and considered in care planning, in the execution of care, and adaptation of care over time. [16][17][18] Patient (or person)-centred care, as a concept, can be traced back to the works of Carl Rogers 19 and Michael Balint. 20 Rogers, a psychologist, coined the related term client-centred therapy, while Balint, a psychoanalyst, coined the term patient-centred medicine. Both concepts articulate the person as more than the sum of their physical health conditions. 21 Despite a growing interest in person-centred care over the past 2 decades, rhetoric about person-centred care has often moved ahead of practice because care systems remain rooted in a traditional model where expert care providers react to disease-related issues that passive patients present. 22,23 Based on their expertise, care providers offer care options to people who then consent to these interventions or approaches. However, increasingly, people's care needs are focused on chronic conditions, which require a significant and active care role for patients and caregivers, particularly in the self-management and monitoring of conditions between health system visits. 24,25 Chronic on-going illnesses may be straightforward to treat and manage on their own, but become complex when they occur in combination (multimorbidity), or produce complex symptoms impacting physical and cognitive abilities or social factors (caregiver strain, diminished finances, unmet housing needs, etc).
Such complex chronic illnesses are often challenging to treat and require time, trial and error, and on-going management by a team of care providers including patients and their caregivers. 26,27 Effective management of chronic illness, particularly when multiple conditions co-exist, requires a person-centred approach: an understanding of both the conditions that people present with and their social context (networks, social supports, financial health, housing, nutritional needs, capacity to support their day-to-day activities) 26,28,29 ; that directly influence people's abilities to access care, successfully self-manage and achieve optimal health outcomes. 30,31 Most importantly, person-centred care considers the views and preferences of patients and caregivers as the most critical inputs into care plans. 32,33 Strong and on-going relationships between care providers, patients and caregivers are a fundamental component of person-centred care. While some care providers (particularly, those in primary care medicine, nursing, geriatrics, social work, occupational therapy and physical therapy) provide care that considers both health and social care needs, the care experiences of patients, particularly within K E Y W O R D S adaptive leadership, chronic disease management, health services, Person-centred care, quality improvement acute care-oriented settings, often remain fragmented and focused on specific problems, not the overall health of individuals.
A number of authors have developed frameworks which seek to operationalize person-centred care as a set of 'action items' or 'activities' that can be carried out by care providers, including but not limited to assessing patient and caregiver priorities, being honest and transparent, allowing more time during clinical appointments, and providing a point person for patients and families to follow-up with when questions arise. 2,3,14,34,35 However, implementing person-centred care relies not only on individual skills, but also on supportive leadership that creates a practice environment enabling and sustaining these behaviours.
Individuals occupying leadership positions in health care need to help to shift organizational norms and encourage staff and care providers in evolving their relationships with patients and caregivers. Such shifts in mindsets and relationships require adaptive leadership skills, that is a leadership mindset that assists people in tackling tough challenges and thriving in complex and challenging environments. 36 Adaptive leadership enables organizational leaders and staff to develop competencies for supporting patient-centred care: the knowledge, skills and behaviours critical to facilitate new actions and supports. While other leadership approaches, such as transformational leadership, situational leadership, distributed leadership 37 and person-centred leadership, 38 may also enable major shifts in behaviours, roles and relationships, we focus here on adaptive leadership, whose core ideas seem most closely aligned to the changes necessary to move person-centred care from mechanistic to meaningful.
Adaptive leadership is a framework developed over thirty years ago by Ron Heifetz and Martin Linsky at Harvard. 36 Heifitz and Linsky identified a critical issue that undermined leaders' efforts to introduce transformational change: the failure to recognize adaptive problems and approach them differently from technical problems. 39 A technical problem can be managed with technological fixes or programmatic solutions. A technical problem in health care could be the introduction of new methods for repairing a broken hip or replacing a faulty heart valve. These problems can be challenging and complex, but build on the experience and underlying knowledge of the care providers involved. An adaptive challenge is different in that it may have many inputs and require changes in the ways of thinking and doing that cannot be solved by improving technical expertise alone. These solutions must start with an examination of current priorities, assumptions, habits and loyalties. Technical solutions can be complicated, but adaptive challenges are more difficult since there are rarely clear immediate solutions. Instead, the approaches to adaptive challenges rely on thoughtful reflections on what to preserve from past practices, what to discard, and how to create new approaches that build from the best of the past. 39 Heifetz et al 39 emphasize that a common mistake for leaders (specifically care providers, as illustrated in our example below) is applying technical solutions to adaptive challenges. For example, a care provider designing a self-care regimen for a patient with complex care needs may fail unless they consider the social factors that influence illness management (such as a patient's ability to purchase medications, arrange transportation to get to appointments and secure meals and nutritional support). A technical solution, like a prescription, will not yield the intended results unless these other adaptive challenges are considered. Through trial and error, patients, caregivers and care providers can learn how to address these adaptive challenges over time by testing some approaches, seeing what works and making adjustments along the way. Organizational leaders also have to differentiate between technical solutions and adaptive challenges. For example, while there may be straightforward approaches for some challenges (eg hiring more staff) adaptive challenges (eg addressing low satisfaction and poor experiences among patients and families) may require examining provider, patient and caregiver behaviours,  Table 1, we define each of these concepts and describe how they translate to person-centred care at the clinical care level.
To enable adaptive change, care providers, patients and caregivers should engage in the types of adaptive conversations described in Table 1, which promote the potential for shared leadership and decision-making as opposed to a conventional command and control approach.  [45][46][47][48] In addition to the adaptive leadership skills needed by care providers to guide patients and caregivers through change, care providers face their own adaptive challenges. Care providers may face challenges in stepping outside their roles as experts to work in teams, across care boundaries and to be vulnerable in accepting the discomfort and ambiguity felt by patients and caregivers. Incentives, workplace expectations of efficiency and using evidence-guided recommendations may create barriers to exercising person-centred care and adaptive leadership, leading care providers to feel like they are constantly reconciling competing pressures. Care providers may also experience roadblocks when they lack access to needed resources due to stringent eligibility criteria, funding limitations and other policy barriers. 43 Individual providers can find the tensions of balancing their efforts to provide person-centred care and growing workplace pressure difficult to reconcile on their own.

| How can adaptive leadership principles support person-centred care at the healthcare organizational level?
Organizational leaders play an important role in helping care pro-  Explicitly asking about fears and concerns, demonstrating compassion and empathy when communicating.

Courageous Conversation
Correcting unacceptable behaviours or respectfully calling out a discrepancy in others' behaviours.
Care providers being honest about the likelihood of a poor outcome due to a patient's behaviours. At the same time, patients and caregivers verbalizing their discomfort when they feel their preferences are not being considered. Patients and caregivers need to feel safe in speaking out without fear of reprisal.

Observing
Heifetz and Linsky 39 use the analogy of 'getting off the dance floor and onto the balcony'. From the balcony, you can see the broader context or the 'big picture' which can inform a greater understanding of issues and actions.
For care providers, it is about understanding the social context of patients and caregivers to identify factors that will influence their ability or willingness to manage their conditions. For patients and caregivers, it is about recognizing care providers' constraints in their ability to support them (such as a lack of time or resources, high patient demand, lack of evidence base of suitable treatments). Like any relationship, acknowledging the constraints of the other party is critical in creating a sustainable, respectful relationship and preventing burn-out.

Interpreting
Reading between the lines and not taking everything at face value. Heifetz et al 39 describes interpreting metaphorically as 'listening for the song beneath the words'.
Paying attention to body language, facial expressions and what is not being said. Such intentional listening requires patience, time, trust, probing and comfortable silence. Continuity of care between the care providers, patient and caregiver is required.

Intervening
Reflecting on the hypothesis of the problem. Any proposed 'intervention/solution' should be considered a 'trial' which may need to be adapted over time. The 'intervention' should be clearly connected to a shared purpose and take into account the resources available.
Trying a new treatment or care plan that reflects the shared goals of the provider(s), patient and caregivers with the caveat that things may need to be tweaked and changed over time (continually testing what works and what does not work). The new treatment/care plan needs to leverage available resources of the patient/caregiver (including their access to financial resources and caregiver capacity). It is important here that a balance be struck between giving a treatment or plan enough time to succeed versus pivoting to a new strategy too quickly. 40