Orchestrating leadership communication during hospital incident command activation: A grounded theory study

Abstract

Hospitals can experience disruption to their operations, due to a variety of crisis events. To maintain operational functionality, they are required to implement a hospital incident command (HIC). This study explores the process from routine operations to a staff-based HIC, analyzing how leadership communication and dynamics emerge, evolve, and are negotiated during crisis transitions. The focus lies on interactions between roles, practices, training, and structures under high operational pressure. A qualitative single-site study was conducted applying a Grounded Theory methodology based on two consecutive HIC tabletop exercises following targeted training. Data comprised semi-structured post-exercise interviews with 19 HIC members from diverse professional backgrounds and triangulation with a series of collected observational materials (notes and protocols).The analysis indicates that the enactment of staff-oriented HIC structures varies along a spectrum of coordination: Explicit orchestration of leadership communication was associated with a shift toward more structured coordination, reflected in clearer role articulation, defined process boundaries, and separation of briefing and operational tasks. Where orchestration was less pronounced, coordination tended to rely on routine practices, accompanied by blurred responsibilities and more fragmented coordination patterns. The findings suggest that the mere presence of command structures, roles, procedures, and communication tools was often insufficient to establish coordinated staff work. Instead, their practical effectiveness appeared to depend on an interactional process, conceptualized here as orchestrating leadership communication. Moderation emerged as one important manifestation of this process, suggesting that HIC training should place greater emphasis not only on structures and procedures, but also on interactional practices.