Emotional leadership in health care: A dire need illuminated by pivotal resource cuts

Abstract

Emotional leadership in health care emphasises the significance of a leader's ability to be empathically attuned and responsive to colleagues' feelings and needs and should be increasingly recognised as a crucial component of well-performing clinical teams. Emotional leadership in health care is a novel paradigm and speaks to the evergrowing need to address mental health, psychological and emotional safety and moral distress in medicine's complex and fast-changing environment. This article explores the concept of emotional leadership, its potential relevance to healthcare professionals, its impact on healthcare workers' well-being and its role in fostering a healthy learning environment.

Headnote

KEYWORDS:

medical culture, psychological safety, leadership

PUBLISHED:

29 May 2025

Significance:

Emotional leadership in health care emphasises the significance of a leader's ability to be empathically attuned and responsive to colleagues' feelings and needs and should be increasingly recognised as a crucial component of well-performing clinical teams. Emotional leadership in health care is a novel paradigm and speaks to the evergrowing need to address mental health, psychological and emotional safety and moral distress in medicine's complex and fast-changing environment. This article explores the concept of emotional leadership, its potential relevance to healthcare professionals, its impact on healthcare workers' well-being and its role in fostering a healthy learning environment.

The feeling of being emotionally unsafe is the ultimate killjoy.1

Introduction

Innovation often emerges from a dire need illuminated by a pivotal event.2 Those in leadership positions in health care in South Africa are facing difficult and challenging times, with significant implications for how they will lead going forward. Healthcare leaders in the public sector - from hospital managers and heads of departments and divisions to consultants - are now more than ever having to lead within a context of 'having to do more with less' and 'needing creative thinking' or 'thinking out of the box'. The current South African National Health budget cuts 2024/2025 and cuts to South African healthcare projects funded by the US Agency for International Development (USAID) and the US President's Emergency Plan for AIDS Relief (PEPFAR)3 have severely compromised public health efforts in the country and are undoubtedly already taking their toll on our clinicians, with concerns being raised about moral distress.4 Leaders in health care are very much aware that the termination of this funding will leave the most vulnerable of South Africa's population at risk. The work done day in and day out by healthcare workers in the public health sector is integral to the lives of millions of South Africans in the face of significant challenges.5 Public sector healthcare workers are at the very heart of the frontline services relied upon by South Africans, especially the most vulnerable in our society5 However, there is a cost to healthcare workers for bearing this burden. According to the Medical Protection Society survey released in October 2023, more than a third (35%) of healthcare practitioners in South Africa say their mental well-being is worse now than during the COVID-19 pandemic; 59% said the staff shortages plaguing the South African health system were having an impact on their mental well-being; and 39% of those surveyed said that the impact of burnout and exhaustion on patient safety was impacting their mental well-being.6 Other studies have indicated that over 70% of young doctors working in primary care have burnout from the cumulative effects of mental and emotional stress, have high workloads in substandard facilities and, now due to national health budget cuts, they are facing unemployment and diminishing training opportunities.7 Working and learning in the healthcare sector is frequently characterised by exposure to high-stress environments, where professionals face emotional and physical challenges.8 Factors such as long hours, high patient volumes, and the emotional weight of patient care contribute to a demanding workplace with high levels of anxiety and burnout.8 A vital task of leaders in health care is not only to deal with the logistical and practical implications of the budget cuts and diminishing resources, but also to support a chronically stressed and distressed workforce.

Emotional leadership could be part of the solution to supporting healthcare workers within our distressing context of shrinking resources. This Commentary explores the role of emotional leadership in promoting healthcare workers' well-being and enhancing patient care, underscoring the need for healthcare organisations to integrate a leader's ability to be empathically attuned and responsive to colleagues' feelings and needs into their leadership frameworks.21 do not assert that the burden of healthcare wellness reform rests on the shoulders of individual clinicians or healthcare leaders. System and institutional level changes are critical and essential but outside the scope of this article.2

It is important for healthcare leaders to acknowledge that burnout and moral distress happen to healthcare workers who care.9 The term 'moral distress' originated in the field of health care and was conceptualised as a psychological and emotional response experienced by healthcare professionals when they believe they know the morally right course of action but are unable to act accordingly due to various constraints such as institutional policies, hierarchical structures, legal and ethical dilemmas, resource constraints or conflicting values within a healthcare setting.10 Funding cuts leading to services being delayed or abandoned will result in healthcare workers feeling a sense of betrayal towards the communities they serve. This moral distress is compounded by witnessing preventable health issues persist or worsen without the means to intervene effectively. What adds to clinicians' experience of moral distress is that the opportunity to develop connections with patients, to create a therapeutic alliance that is collectively oriented towards their healing, is significantly limited by resource constraints. This is not the way of medicine: to be this exhausted, this distressed, coping only by offering a detached version of ourselves. Our way of being in the world and interacting with others impacts the development and well-being of those colleagues junior to us.

Hierarchy in the field of medicine can act against the best interests of clinicians and destroy a collaborative healthcare culture. We should be vigilant of the impact that resource constraints will have on the mental health of junior colleagues and health science students, particularly those in the clinical years who will be anxious about the way diminishing medical officer and registrar posts will limit their future career options in South Africa. A scoping review of mental health needs and challenges among medical students within South African universities published in May 2024 highlighted serious concerns about mental health, particularly in studies which included clinical students.11 Unfortunately, despite its evidence-based nature, the field of medicine continues to struggle with providing psychologically safe environments for its staff and students.2 When teams are psychologically safe, they have a shared belief that they can take interpersonal risks such as speaking up, asking questions, and sharing.6 A lack of psychological safety destroys the open and collaborative culture that produces good patient care and drives talented individuals out of medicine.12 The hierarchical culture of medicine exacerbates feelings of low confidence and internalised insecurity, particularly for underrepresented groups and women.13 Medical culture stigmatises uncertainty, perceives vulnerability as failure, and shames the need for support.14 To date, the majority of interventions aimed at increasing clinician support have been implemented in response to pathology rather than as a proactive means to facilitate thriving and joy at work.2

There is little doubt that we are facing tough times in public and teaching healthcare facilities in South Africa. Leadership style is certainly not going to solve the legion of problems that are faced in health care, but it can contribute towards supporting colleagues through these difficult times. Leaders will frequently be in a position of having to deliver news to colleagues that causes distress to themselves and their colleagues. Many of those who lead will be left feeling powerless, hopeless and stuck in 'lose-lose' situations. Emotional leadership does not provide solutions for how to make decisions on where or how resources should be cut, but rather provides a framework for being empathic while doing so. By actively listening to others, considering their perspectives, and acknowledging their distressing emotions and experiences, emotional leaders can have an honest dialogue and provide more constructive resolution of difficult circumstances.15 Colleagues respond to communication based on how their leaders feel about them.15 Colleagues can sense how leaders experience them - whether that be as an object or a person.15 Tough feedback is more effective when leaders see the colleagues they are giving feedback to as people who are distressed because their ability to heal and care is being constrained.

Emotional leadership begins with seeing colleagues as people, not as problems to be solved, and with developing a culture that invites, incentivises, and supports colleagues to see each other as people.15 Emotional leadership in health care is a novel paradigm and speaks to the ever-growing need to address healthcare worker well-being, psychological safety and moral distress in medicine's complex and fast-changing environment. Effective emotional leaders in our multicultural healthcare context would need to develop an understanding that the 'appropriate' ways of colleagues' expressing emotion are not neutral, they are social constructs. What is appropriate emotional expression in one context, or for one social group, might be inappropriate in another. Emotional leadership can also enhance the teaching and learning experience in academic hospitals, ultimately leading to better-prepared healthcare professionals. It is well documented that a leader's ability to communicate clearly and to empathically16 act on behalf of the people they serve17 and mentor and develop others18 are critical factors in good leadership. In medicine, these skills are often not explicitly developed, thereby limiting leadership effectiveness and the performance of colleagues.19 Leaders who use higher levels of emotional management are able to improve the levels of their team's performance, and are better at managing conflict, emotions and their consequences for team performance.20 Higher levels of inspiration and communication of vision by leaders are directly associated with lower levels of bullying by team members.20 In nursing management, emotional leadership helps promote positive changes, improves organisational effectiveness, and increases clinical team engagement and satisfaction.21 Loughran's 2021 article emphasises the importance of understanding oneself as a leader, particularly in the realm of emotional leadership.22 The study explores how leaders can leverage their own emotions and self-awareness to create positive and effective learning environments. It highlights the significance of emotional awareness in building strong relationships, managing conflicts, and fostering a collaborative culture.22 Emotional leadership also enhances motivation, which has a positive impact on job performance.23

Emotional labour is frequently the unsung and unseen job of caring for and supporting others, but it is also critical to create a feeling of safety and connection, meaning and belonging within our institutions.24 Working with people, especially when they are suffering, is likely to involve a significant amount of emotional labour.25 This means that emotional leaders are expected to deliver "humane" personal care and display the expression of positive emotions, and empathy towards colleagues.25 We need to create more value around emotional leadership. This may start with the simple recognition that emotional labour is in fact valuable work. We should actually value "caring-for-others orientated traits" and treat this kind of leadership as something that requires time, effort and skill. Giving value to the skills of emotional leadership by including it in job descriptions and as a more formal aspect of annual performance evaluation and by finding more creative ways to reward it, could help to spread its burden more evenly amongst colleagues rather than letting it fall to the duty of a few. It is time that emotional leadership is recognised, trained and integrated into formal leadership portfolios. Emotional leadership requires a larger platform holding the space for the mental health and well-being of healthcare professionals.

Understanding emotional leadership

Emotional leadership involves several key components, including self-awareness, empathy, social skills, communication skills and investment in relationships. Leaders who exhibit these traits could create a supportive, emotionally safe environment that promotes open communication, trust, team collaboration and a supportive learning environment that can promote colleagues' engagement.

1. Self-awareness: Leaders' emotional displays have a larger impact on the perceptions of leaders than the content of the leaders' messages.26 Leaders should recognise their own emotional states and how these emotions affect their decision-making and interactions with others. Self-aware leaders can manage their reactions in stressful situations, modelling emotional regulation for their teams. Clinical teachers who practice self-awareness can better understand their own emotions and how these emotions impact their teaching. Recognising one's emotional triggers allows for more thoughtful responses to colleague's needs and concerns13, fostering a psychologically safe learning environment. Self-awareness is also intrinsically linked with authentic leadership, which has been associated with a range of positive outcomes, such as colleagues' performance, engagement, satisfaction, empowerment, trust in the leader and better relationship quality with the leader.13

2. Empathy: Empathy is shown to be an important variable that is central to emotional leadership.26 The ability to be open to understanding and authentically curious to learn about the feelings of others is crucial in health care.27 Empathetic leaders can connect with their colleagues and patients on a deeper level, fostering a culture of compassion and support.27 Identifying and responding to colleagues' needs, especially their emotional needs, is critical for successful leadership.13 Empathetic clinical educators can connect with junior colleagues and students on a personal level, understanding the challenges they face during their training. This connection can lead to a more supportive and nurturing educational environment, where students feel valued and understood.28 Moreover, fostering empathy in educators will translate into better patient care, as students learn the importance of understanding patients' emotional and psychological needs.28

3. Social skills: A key leadership function is to manage the emotions of colleagues, especially with regard to feelings of frustration.26 By identifying emotional leadership as an essential dimension of leadership, leaders can develop a better understanding of how emotional skills can enhance management communications in decision-making conflicts.29 Effective emotional leaders possess strong interpersonal skills that allow them to navigate complex social dynamics within healthcare settings.30 This includes conflict resolution, effective communication30, and the ability to inspire and motivate others. Leaders who can convey information clearly and compassionately are better equipped to address colleagues' concerns and foster an open dialogue. Delivering difficult content to colleagues requires skill and reflection on the way the content is delivered, but these are skills that can be learnt. Colleagues want to feel listened to, validated and understood by their leaders, and they want to understand what leaders are trying to communicate.13 Communications from leaders ought to show that colleagues are valued and have dignity13 Respectful communication can heighten colleagues' perceptions of the hospital as a just and fair workplace.13

4. Relationship management: Leaders' influences on emotional processing have a large impact on performance.26 Emotional leadership contrasts with traditional authoritative approaches in medicine, which may neglect the emotional needs of colleagues and patients alike. Emotional leadership encourages a more holistic view of health care, integrating emotional and psychological aspects into clinical practice. Connecting with colleagues can improve meaning in our work. Using our talents to make a difference in the lives of others is at the essence of medicine and makes joy in medicine possible.31 Emotional leaders prioritise creating a sense of community within the hospital environment, promoting collaboration and teamwork across the traditional medical hierarchy24 This supportive network can enhance learning and helps individuals to develop vital interpersonal skills necessary for their future careers. Emotional leadership can manifest as supportive behaviours, including instrumental support (helping colleagues to overcome the stressor they are facing) and emotional support (helping colleagues to manage their emotions around the stressor).32

Potential outcomes of emotional leadership for healthcare workers' and students' well-being

1. Reducing burnout and promoting resilience: Leaders who prioritise colleagues' and students' well-being can implement strategies that mitigate burnout, such as using mental health resources and peer support programmes.33 When leaders are attuned to their team's emotional states and stressors, they can better address the factors contributing to burnout.34 By modelling the promotion of empathic connection amongst colleagues, leaders can encourage resilience among healthcare workers.35 Resilient employees are better prepared to adapt to changes and recover from setbacks, which ultimately benefits the entire organisation.

2. Enhancing job satisfaction: Joy in medicine, or the lack thereof, is a popular topic of discussion, even more so since the COVID-19 pandemic.36 Strategies like being kind, expressing gratitude, and using effective communication skills can establish greater connection with colleagues and patients, and, in turn, result in a more joyful work environment.36 Creating space for interconnectedness with patients and colleagues can rekindle feelings of joy in medicine.36 Emotional leadership can foster a positive workplace culture where colleagues feel valued, seen and heard. This sense of belonging can enhance job satisfaction34, leading to lower burnout rates and fewer mental health problems.24 Leaders who are empathically attuned and responsive to colleagues' feelings and needs are more likely to inspire loyalty and cohesion among their teams. When colleagues are engaged and experiencing joy at work, they are more likely to contribute to overall organisational success.

3. Fostering a culture of support: Emotional leaders can cultivate a culture in which seeking help is encouraged rather than stigmatised.33 This leads to an environment where employees feel safe to express their struggles and seek support, whether through mental health resources or peer networks. Such a culture not only improves individual well-being but also enhances team cohesion and collaboration.33

Potential outcomes of emotional leadership for patient care

1. Improving patient-provider relationships: Leaders who cultivate empathy and active listening skills can encourage their teams to adopt similar practices. This results in stronger patient-provider relationships, fostering trust and improving communication, which are crucial for effective care. Strong relationships between patients and providers lead to improved trust, increased patient satisfaction and adherence to treatment plans.27

2. Enhancing patient outcomes: Emotionally engaged healthcare teams deliver higher quality care. When healthcare professionals feel supported and understood, they are more likely to engage fully with their patients, leading to better clinical outcomes.27 Emotional leadership can thus be viewed as a catalyst for improving patient safety and satisfaction.34

Conclusion

Leaders in health care will need to be courageous to create a culture which challenges the long-standing premise of what medical culture should be like, to create a culture in which colleagues feel safe and supported.37 The emotional leader's obligation is to assess the environment and build opportunities for colleagues to work with less anxiety and less fear37 as they master more difficult situations in our current environment of national healthcare budget cuts in South Africa. High-performing teams result from a culture that promotes genuine care amongst colleagues.2 Creating such a culture happens through intentional emotional leadership that places an environment of caring, friendship, belonging and solidarity as top priorities.38 Making medicine about people starts with each of us. One person at a time and one step at a time is how we change the culture of medicine.

Declarations

I have no competing interests to declare. I have no Al or LLM use to declare.

References

References

1. Tye J, Hanrahan K, Edmonds S, Hyatt D, Tye A. Courageous leadership for a culture of emotional safety. Nurs Manag (Springhouse). 2022;53(11 ):16-23. https://doi.org/10.1097/01.numa.0000891468.54597.90

2. Greenberg AL, Sullins VF, Donahue TR, Sundaram VM, Saldinger PF, Divino CM, et al. Emotional regulation in surgery: Fostering well-being, performance, and leadership. J Surg Res. 2022;277:A25-A35. https://doi.Org/10.1016/j.j ss.2022.02.032

3. Reardon S. Fear spreads that NIH will terminate grants involving South Africa. Science Insider. 2025 March 14. Available from: https://www.science.org/ content/article/fear-spreads-nih-will-terminate-grants-involving-south-africa

4. Hoare J, Matisonn H. From the burden of disease to the disease of burden. S Afr J Sci. 2024;120(11/12), Art. #18716. https://doi.org/10.17159/sajs. 2024/18716

5. Thaw R, Maree G. Western Cape on imposed budget cuts [webpage on the Internet]. c2024 [cited 2025 Feb 19]. Available from: https://www.gov.za/ news/media-statements/western-cape-imposed-budget-cuts-07-feb-2024

6. Hitzeroth V. Survey shines a light on mental wellbeing of doctors in South Africa [webpage on the Internet]. c2023 [cited 2025 Feb 19]. Available from: https://www.medicalprotection.org/southafrica/casebook-and-resources/me dicolegal-articles-and-features/view/survey-shines-a-light-on-mental-wellbe ing-of-doctors-in-south-africa

7. Nash J, Ross AJ, Naidoo M, Ras T, Brits H, Mathew S. Health budget cuts will be paid for by the most vulnerable. S Afr Fam Pract. 2024;66(1), a5934. http s://doi.org/10.4102/safp.v66i1.5934

8. Harrell M, Selvaraj SA, Edgar M. DANGER! Crisis health workers at risk. Int J Environ Res Public Health. 2020;17(15), Art. #5270. https://doi.Org/10.3 390/ijerph17155270

9. Penson RT, Dignan FL, Canellos GP, Picard CL, Lynch TJ. Burnout: Caring for the caregivers. Oncologist. 2000;5(5):425^t34. https://doi.org/10.1634/the oncologist.2000-0425

10. Fourie C. Moral distress and moral conflict in clinical ethics. Bioethics. 2015;29(2):91-97. https://doi.org/10.1111/bioe.12064

11. Winter ML, Olivia SG. A scoping review of mental health needs and challenges among medical students within South African universities. Int J Environ Res Public Health. 2024;21(5), Art. #593. https://doi.org/10.3390/ijerph21050 593

12. Power and bullying in research. Lancet. 2022;399(10326):695. https://doi.o rg/10.1016/s0140-6736(21 )02869-5

13. Fletcher KA, Friedman A, Wongworawat MD. Understanding emotional intelligence to enhance leadership and individualized well-being. Hand Clin. 2024;40(4):531 -542. https://doi.Org/10.1016/j.hcl.2024.06.003

14. Hoare J, Frenkel L. South Africa. Lancet Psychiatry. 2021 ;8(10):865. https:// doi.org/10.1016/s2215-0366(21 )00365-5

15. Mann S. Leadership and self-deception: Getting out of the box. Leadership Organ Dev J. 2010;31(7):666-667. https://doi.org/10.1108/01437731011 079709

16. De Vries RE, Bakker-Pieper A, Oostenveld W. Leadership = Communication? The relations of leaders' communication styles with leadership styles, knowledge sharing and leadershipoutcomes. J Bus Psychol. 2010;25(3):367-380. https://doi.Org/10.1007/sl 0869-009-9140-2

17. Van Dierendonck D. Servant leadership: A review and synthesis. J Manag. 2011;37(4):1228-1261. https://doi.Org/10.1177/0149206310380462

18. Gibson JW, Tesone DV, Buchalski RM. The leader as mentor. J Leadersh Organ Stud. 2000;7(3):56-67. https://doi.org/10.1177/107179190000700 304

19. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: Contributors, consequences and solutions. J Intern Med. 2018;283(6):516-529. https:// doi.org/10.1111/joim.12752

20. Ayoko OB, Callan VJ. Teams' reactions to conflict and teams' task and social outcomes: The moderating role of transformational and emotional leadership. Eur Manag J. 2010;28(3):220-235. https://doi.Org/10.1016/j.emj.2009.07. 001

21. Jang SY Park CM, Yang EH. Factors related to emotional leadership in nurses manager: Systematic review and meta-analysis. J Korean Acad Nurs. 2024;54(2):119-138. https://doi.org/10.4040/jkan.24026

22. Loughran J. Understanding self as a leader: Emotional leadership and what it means for practice. J Educ Adm Hist. 2021 ;53(2):132-143. https://doi.Org/1 0.1080/00220620.2020.1805418

23. Ouakouak ML, Zaitouni MG, Arya B. Ethical leadership, emotional leadership, and quitting intentions in public organizations: Does employee motivation play a role? Leadership Organ Dev J. 2020;41 (2):257-279. https://doi.org/10.11 08/LODJ-05-2019-0206

24. Hoare J. The power of connected clinical teams: From loneliness to belonging. Philos Ethics Human Med. 2023;18(1), Art. #16. https://doi.Org/10.1186/s 13010-023-00143-7

25. Martinez-lnigo D, Totterdell P, Alcover CM, Holman D. Emotional labour and emotional exhaustion: Interpersonal and intrapersonal mechanisms. Work Stress. 2007;21 (1):30-47. https://doi.org/10.1080/02678370701234274

26. Humphrey RH. The many faces of emotional leadership. Leadersh Q. 2002;13(5):493-504. https://doi.org/10.1016/s1048-9843(02)00140-6

27. Moudatsou M, Stavropoulou A, Philalithis A, Koukouli S. The role of empathy in health and social care professionals. Healthcare. 2020;8(1), Art. #26. https://doi.org/10.3390/healthcare8010026

28. Dobie S. Viewpoint: Reflections on a well-traveled path: Self-awareness, mindful practice, and relationship-centered care as foundations for medical education. Acad Med. 2007;82(4):422-427. https://doi.org/10.1097/01.ac m.0000259374.52323.62

29. Jin Y Emotional leadership as a key dimension of public relations leadership: A national survey of public relations leaders. J Public Relat Res. 2010;22(2):159-181. https://doi.org/10.1080/10627261003601622

30. Frank LP, Despres K, Broome R, Sherman K. Emotional intelligence and wellbeing practices: A crucial aspect of crisis leadership in hospitals -Insights from hospital leadership during COVID-19. J Health Adm Educ. 2024;40(3):387-402.

31. Stepien K. Vulnerability and compassion: Sources of joy in medicine. Pediatrics. 2018;142(1 MeetingAbstract):96. https://doi.org/10.1542/peds .142.1ma1.96

32. Mathieu M, Eschleman KJ, Cheng D. Meta-analytic and multiwave comparison of emotional support and instrumental support in the workplace. J Occup Health Psychol. 2019;24(3):387^109. https://doi.org/10.1037/ocp0000135

33. Hoare J. Provision of mental health care to healthcare workers during COVID-19: A call for the practice of vulnerability. S Afr J Sci. 2022;118(5/6), Art. #13904. https://doi.org/10.17159/sajs.2022/13904

34. Jeffrey D. Empathy, sympathy and compassion in healthcare: Is there a problem? Is there a difference? Does it matter? J R Soc Med. 2016;109(12):446-452. https://doi.Org/10.1177/0141076816680120

35. Bender AE, Berg KA, Miller EK, Evans KE, Holmes MR. "Making sure we are all okay": Healthcare workers' strategies for emotional connectedness during the COVID-19 pandemic. Clin Soc Work J. 2021 ;49(4):445-455. https://doi. org/10.1007/sl 0615-020-00781 -w

36. SanftT, Winer E. Rekindling joy in medicine through thoughtful communication: A practical guide. Am Soc Clin Oncol Educ Book. 2023;43(43), e100034. http s://doi.org/10.1200/edbk_100034

37. Kerfoot K. The culture of courage. Nurs Econ. 1999;17(4):238-239.

38. Koka S. Leadership and love: Part 1. J Prosthodont Res. 2023;67(1):x-xi. https://doi.Org/10.2186/jpr.jpr_d_22_00286