University of Southern California Dissertations and Theses

Unpredicted but not unexpected: developing prepared health and human services crisis leaders

(USC Thesis Other)

Unpredicted but not unexpected: developing prepared health and human services crisis leaders

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Unpredicted but Not Unexpected:
Developing Prepared Health and Human Services Crisis Leaders
by
Michele Elizabeth Blake
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2024

© Copyright by Michele Elizabeth Blake 2024
All Rights Reserved

The Committee for Michele Elizabeth Blake certifies the approval of this Dissertation
Kimberly Hirabayashi
Maria G. Ott
Alison Keller Muraszewski, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
This study explores organizational influences on administrative preparedness in public health
crisis management, focusing on Health and Human Services (HHS) leaders within the executive
leadership teams of rural counties of California. Guided by a central research question, the study
seeks to understand: 1) What are the knowledge, motivational, and organizational needs and
strengths of California rural county HHS leaders that influence public health crisis management?
Utilizing Clark and Estes' (2008) conceptual framework, it examines the knowledge, motivation,
and organizational (KMO) factors influencing the performance of these leaders during public
health crises. Through semi-structured interviews with members within the leadership spectrum
of HHS in rural California, the study gains insights into the role of KMO factors in empowering
leaders to prepare for and manage public health crises effectively. Findings from the study reveal
that while HHS leaders in these rural counties demonstrate high knowledge and motivational
assets, they also confront notable organizational needs. The lack of organizational support in
crucial areas like resource allocation, training, and communication impede their crisis response
capabilities. Based on these findings, the study outlines three key recommendations to improve
the administrative preparedness of these leaders. These recommendations, integrated within
Lewin's three-step change model, provide a structured approach to enhance crisis management
strategies effectively. The research contributes valuable, actionable strategies to the body of
knowledge on public health crisis management, especially tailored to the unique contexts of rural
settings. By addressing current needs and focusing on these pivotal areas, the study aims to
significantly enhance the immediate and long-term preparedness and response capabilities of
HHS leaders in rural California.

v
Dedication
To Gannon and Mila for the incredible support and love you have shown me throughout my
doctorate journey. As your mom, it has been my privilege to watch you grow and thrive, and
your unwavering encouragement and understanding have been a source of strength for me during
this challenging process. As I have worked toward accomplishing my dream, I have often
thought about the legacy I want to leave you. I hope my work will inspire you to pursue your
passions and always believe in yourselves. Finally, I want you to know that you are my greatest
accomplishment and that nothing in this world could ever be more important to me than the love
we share. Thank you for consistently being my supporters, confidants, and inspiration! I am so
proud of the beautiful people you are becoming, and I am honored to be your mom.
To my parents, who continuously provide steadfast love and encouragement, thank you. You
were the people who believed in me from the very beginning, who taught me how to get through
this tough world. You have always been supportive during the ups and downs. You have always
motivated by constantly and plainly showing your belief in my capabilities. I am eternally
grateful for the bedrock of strength and love you have provided.
To Derek, my partner and staunch advocate, your belief in me and your praise for my
achievements have been the foundation of my tenacity.
Finally, to Fosse, the best companion one could ask for: Thanks!

vi
Acknowledgements
I deeply appreciate my committee chair, Dr. Allison Keller Muraszewski. I have been
depending on your advice for strength during this journey and I appreciate the role this has
played in my personal growth as a scholar and influence on the study. Your guidance,
encouraging and kind words continue to inspire me. I also appreciate the distinguished members
of my dissertation committee, Dr. Kimberly Hirabayashi and Dr. Maria G. Ott, whose brilliant
minds and specialized knowledge have greatly impacted my academic journey. I appreciate your
suggestions and teachings and have valued and carefully applied each with attention and careful
review.
Another exceptional group of people I must thank is my professors. Your tremendous
wisdom, extensive expertise, and invaluable knowledge have been crucial support to me. The
timely guidance and advice have had monumental influence on my educational journey that has
left a permanent mark on my personal development.
To Erica, Jennifer, Julie, and Pam, your consistent check-ins, endless cheer, and
unwavering support through the years have been a source of immense strength. You constantly
inspire and remind me of my purpose and potential.
A special note of gratitude goes to my Cohort 21 classmates. Your companionship on this
journey has been something to treasure for the rest of my life. I cannot fully explain how great an
experience it was and how this influenced my personal growth. To my study and support group,
Chris, Dayna, Henry, Jamie, and Waleed, your motivation and camaraderie have been my
stronghold. The friendship and solidarity we have developed will last a lifetime. FIGHT ON!
To all who have been part of this journey, your contributions have become an integral
part of my research and life. Thank you for being part of this significant chapter of my life.

vii
Table of Contents
Abstract.......................................................................................................................................... iv
Dedication....................................................................................................................................... v
Acknowledgements........................................................................................................................ vi
Table of Contents.......................................................................................................................... vii
List of Tables .................................................................................................................................. x
List of Figures................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Introduction to the Study.......................................................................................... 1
Context and Background of the Problem............................................................................ 2
Organizational Goal............................................................................................................ 3
Description of Stakeholder Groups..................................................................................... 4
Stakeholder Group for the Study ........................................................................................ 7
Stakeholder Performance Goal ........................................................................................... 7
Purpose of the Study and Research Question ..................................................................... 8
Importance of the Study...................................................................................................... 8
Overview of Theoretical Framework and Methodology .................................................... 9
Definition of Key Terms................................................................................................... 11
Organization of the Study ................................................................................................. 12
Chapter Two: Review of the Literature ........................................................................................ 13
Health and Human Services (HHS) Historical Context.................................................... 13
Crisis Management ........................................................................................................... 19
Crisis Leadership Skills and Competencies...................................................................... 24

viii
Crisis in Health and Human Services (HHS).................................................................... 31
Clark and Estes (2008) Gap Analysis Framework............................................................ 37
Stakeholder Knowledge, Motivation, and Organizational Influences.............................. 38
Conceptual Framework..................................................................................................... 62
Summary........................................................................................................................... 63
Chapter Three: Methodology........................................................................................................ 65
Research Question ............................................................................................................ 65
Overview of Methodology................................................................................................ 66
Data Collection, Instrumentation and Analysis Plan ........................................................ 66
The Researcher.................................................................................................................. 71
Ethics ............................................................................................................................... 72
Chapter Four: Findings................................................................................................................. 74
Participating Stakeholders ................................................................................................ 75
Results for Knowledge Influences.................................................................................... 76
Discussion for Knowledge Influences.............................................................................. 85
Results for Motivation Influences..................................................................................... 85
Discussion for Motivation Influences............................................................................... 90
Results for Organizational Influences............................................................................... 91
Discussion for Organizational Influences....................................................................... 106
Summary......................................................................................................................... 107
Chapter Five: Recommendations and Discussion....................................................................... 109
Discussion of Findings.................................................................................................... 109
Recommendations for Practice ....................................................................................... 114

ix
Integrated Recommendations.......................................................................................... 118
Limitations and Delimitations......................................................................................... 132
Recommendations for Future Research .......................................................................... 134
Conclusion ...................................................................................................................... 135
References................................................................................................................................... 138
Appendix A: Interview Protocol................................................................................................. 177
Appendix B: Information Sheet for Exempt Research ............................................................... 181
Appendix C: Stakeholder Demographics Table ......................................................................... 183

x
List of Tables
Table 1: Organizational Mission, Organizational Performance Goal, and Stakeholder Goal .... 8
Table 2: Crisis Leadership Competencies................................................................................. 31
Table 3: Knowledge Influences ................................................................................................ 44
Table 4: Motivation Influences................................................................................................. 48
Table 5: Organizational Influences........................................................................................... 61
Table 6: Data Sources ............................................................................................................... 66
Table 7: Assumed Knowledge Influences................................................................................. 76
Table 8: Assumed Motivation Influences................................................................................. 86
Table 9: Assumed Organizational Influences........................................................................... 91
Table 10: Summary of KMO Needs, Influences, and Evaluation Results…………………….108
Table 11: Implementation of Lewin's Three-Step Change Model…………………………….131

xi
List of Figures
Figure 1: Resilience Framework for Public Health Emergency Preparedness........................... 6
Figure 2: Clark and Estes' Gap Analysis Framework ............................................................... 10
Figure 3: Continual Approach to Crisis Management in Local Government ........................... 23
Figure 4: The Dimensions of Meta-Leadership ........................................................................ 53
Figure 5: Conceptual Framework ............................................................................................. 63
Figure 6: Lewin's Three-Step Model ...................................................................................... 121

xii
List of Abbreviations
CalHHS California Health and Human Services Agency
CDC Centers for Disease Control and Prevention
CAHAN California Health Alert Network
CERC Crisis and Emergency Risk Communication
DOF Department of Finance
ELT Executive Leadership Team
FEMA Federal Emergency Management Agency
HEW Health, Education, and Welfare
HRSA Health Resources and Services Administration
HHS Health and Human Services
ICS Incident Command System
KMO Knowledge, Motivation, and Organization
NIMS National Incident Management System
NPLI National Preparedness Leadership Initiative
RCRC Rural County Representatives of California
WHO World Health Organization

1
Chapter One: Introduction to the Study
Organizational factors significantly influence the administrative preparedness of Health
and Human Services (HHS) leaders in California rural counties, along with their capacity to
effectively address public health crises. Despite their imminence, growth, and increasing
complexity, public health crises are not mitigated sufficiently with local strategies (Anand et al.,
2023; Park et al., 2022). Research suggests that government organizational leaders who neglect
essential crisis management in the hierarchical government structure risk overloading varying
capacities, resources, and planning proficiencies (Christensen et al., 2018; Park et al., 2022).
Moreover, rural county government leaders face the double disparity of worsening population
health outcomes and modest organizational investments compared to nonrural organizations,
rooted in structural, economic, and social spending differentials (Leider et al., 2020).
Subsequently, government organizations enact siloed command-and-control policies and resist
change (Kapucu & Hu, 2022; Sriharan et al., 2022). Such decisions restrain the integration of the
innovative and adaptive administrative preparedness processes necessary to successfully
navigate public health crisis challenges (Janssen & van der Voort, 2020; Kapucu & Hu, 2022;
McConnell & Drennan, 2006).
The absence of organizational support for effective government leaders during public
health crises generates uncertainty and hurdles for employees and the community (Sharfstein,
2023), further impacting the organizations’ resilience, reputation, and culture (Coombs, 2022;
Sriharan et al., 2022). Failure to successfully manage public health crises produces negative
emotions that exacerbate harmful employee and community behaviors, eroding trust, health, and
safety as well as increasing mortality (Boin & ’t Hart, 2003; Sturmberg et al., 2022).
Furthermore, the socio-economic costs of public health crises are far-reaching and stress the

2
economy, with the COVID-19 pandemic costing California taxpayers at least $12.3 billion (State
of California Department of Finance [DOF], 2021).
Within organizations, increasing focus on administrative preparedness to effectively
address public health crises among California rural county HHS leaders is critical to mitigate the
loss of organizational trust, health, safety, capital, and life. In addition, research shows that
during a public health crisis, marginalized and vulnerable community members are at greater risk
than are other community members (Bullock et al., 2020; Dhanani & Franz, 2020), underscoring
the need to strengthen the administrative preparedness of crisis management among California
rural county HHS leaders to disrupt systemic inequities, disparities, and bias.
Context and Background of the Problem
California Health and Human Services' (CalHHS) mission is to improve all Californians'
health, wellbeing, and quality of life. California is divided into 58 counties, each of which
operates county-level HHS organizations responsible for delivering diverse services to residents,
including public health, behavioral health, and social services. Each county reflects unique
challenges and needs within California and further divides into urban and rural areas. This study
examined rural county HHS organizations throughout the state of California.
1
The organizational context of California rural county HHS operates in a complex and
ever-changing landscape wherein various stakeholders and factors influence the delivery of HHS
to rural communities. A significant obstacle for California's rural HHS is the limited availability
of resources, such as funding, staffing, and infrastructure, which can affect rural communities'
access and quality of care (Shi & Singh, 2021). Despite these disparities, rural county HHS in
1
Information derived from websites and documents not cited to protect anonymity.

3
California remains dedicated to delivering culturally sensitive and accessible care of the highest
quality to the communities being served, especially during public health crises.
Such crises are frequent and inescapable incidents within California rural county HHS
organizations. The need for efficient administrative preparedness to address public health crises
effectively has been highlighted by recent events such as the COVID-19 pandemic, outbreaks of
vaccine-preventable diseases such as measles, mumps, and rubella, mental health emergencies
such as increased rates of depression and anxiety, social injustice and racism in public health,
and natural disasters such as wildfires displacing essential services. To achieve heightened
administrative preparedness, California rural county HHS leaders must be empowered by robust
organizational support to anticipate events that can hinder their mission to improve the health
and wellbeing of individuals, families, and communities through the provision of comprehensive
HHS.
Organizational Goal
The organizational goal of California rural county HHS is to increase and maximize
administrative preparedness to address public health crises effectively and prevent harm to the
health and wellbeing of the community by developing prepared HHS rural county leaders who
possess the full range of competencies required for efficient crisis management. The
organizational goal is to develop prepared HHS rural county leaders' crisis management
competency to increase administrative preparedness to address public health crises effectively
and avoid adverse effects on the health and wellbeing of the community; notably, however, this
goal is pertinent only to this research and does not reflect an official objective of the HHS
organization in California's rural counties. Goal achievement requires the implementation of a
comprehensive and integrated approach to respond to public health crises, develop policies and

4
procedures to facilitate effective crisis management, and provide training and resources for HHS
leaders to better understand the challenges of a public health crisis. By increasing administrative
preparedness, California rural county HHS responds more efficiently to public health crises
while minimizing their impact and better protecting the health and wellbeing of the community.
To achieve its organizational goal, the California rural county HHS organization must
prioritize and appropriately value the development of an effective crisis management system.
Figure 1 depicts an empirically derived and theoretically informed framework that identifies 11
interacting elements (Khan et al., 2018, p. 12) required in administrative preparedness to address
crisis management while adequately supporting the long-term resilience of rural communities.
California rural county HHS should consider framework elements in Figure 1, such as
communication, collaborative networks, practice and expertise, community engagement,
capacity, and learning and evaluation, to meet the organizational goal.
Description of Stakeholder Groups
Achieving the organizational goal requires collaboration and active support from several
key stakeholder groups. Each group not only contributes to but also benefits from the goal.
Considering Bronfenbrenner's (1977) ecological theory, the first stakeholder group comprises
rural county HHS government frontline employees who function at the foundational tier of the
governmental hierarchy, perform essential daily tasks to maintain operational reliability and can
influence administration preparedness to address public health crises effectively. As per
California Government Code, Title 1, Section 3100 (Public Officers and Employees et al.,
1943/1972), all government employees, including these frontline employees, are declared
Disaster Service Workers, and may be called upon in any emergency to perform crisis
management functions. During public health crises, frontline employees are critical to directly

5
influence the health and wellbeing of residents in rural counties. Macro-level decisions can either
amplify or mitigate the effectiveness of services provided in the community and the risks faced
by these frontline disaster service workers (Timmis & Brüssow, 2020; Yarrow & Pagan, 2020).
The second stakeholder group is the rural county HHS supervisory unit leaders. Tasked
with overseeing the routine duties of frontline employees, these supervisory workers function at
the preliminary tier of leadership within the governmental hierarchy. Consequently, supervisory
unit leaders shape the work of frontline employees, and they are accountable for compliancy
with the team directives from upper management. Supervisory unit leaders pivotally facilitate
communication and oversee the attainment of organizational goals across all hierarchic levels,
including frontline employees.
The third stakeholder group is the executive leadership team (ELT), the upper
management team of HHS. The ELT is comprised of branch or deputy directors of social
services, public health services, and behavioral health services. The ELT is positioned to design
a governance structure that prescribes policies and procedures for the rural county HHS
organization. Moreover, the high-level management team instills compliance mechanisms and
enforces accountability (Dubnick, 2014). Most importantly, these stakeholders exercise
command, guiding the course of public health crises. Therefore, in the context of public health
crises, the ELT's role is primary as they guide the course of all crisis phases, ensuring the
delivery of vital services to the community while coordinating a complex web of operations.
This study focuses on the third stakeholder group, the ELT, as it investigates their critical
decision-making processes and strategic actions that directly impact the efficacy of public health
crisis management within rural county HHS organizations.

6
Figure 1
Resilience Framework for Public Health Emergency Preparedness
Note. From "Public Health Emergency Preparedness: A Framework to Promote Resilience," by Y.
Khan, T. O'Sullivan, A. Brown, S. Tracey, J. Gibson, M. Généreux, B. Henry, and B. Schwartz,
2018, BMC Public Health, 18:1344.

7
Stakeholder Group for the Study
Effectively addressing public health crises necessitates seamless collaboration and
alignment across stakeholders. Central to this coordination are HHS leaders, specifically the
ELT. The HHS leaders are a cornerstone, unifying diverse stakeholder groups and directing them
to achieve the organizational goal. For HHS leaders, establishing a clear vision and directional
strategy is fundamental, as the strategic articulation anchors accountability. It ensures that all
organizational resources are directed toward securing the objective.
Furthermore, as the executive leaders of HHS, the ELT commands decision-making
power, guiding stakeholders within the organizational framework. HHS leaders also create the
roadmaps by which organizations can achieve their organizational goals, with tremendous
potential for success or failure concerning administrative preparedness efforts to address public
health crises. Their role involves a strategic blend of leadership, policy direction, and managerial
oversight, significantly shaping the trajectory of crisis management.
This study focuses on the specific stakeholder group within the leadership spectrum of
the HHS leaders of a California rural county. Their strategic and operational decisions,
interdepartmental coordination, and management of frontline workers and supervisors have farreaching implications for the HHS organization and the communities they serve. Their role and
actions in crisis management offer valuable insights for understanding and enhancing
administrative preparedness in rural county HHS organizations.
Stakeholder Performance Goal
The stakeholder goal of California rural county HHS leaders is to improve administrative
preparedness competencies to effectively address public health crises, as seen in Table 1.

8
Table 1
Organizational Mission, Organizational Performance Goal, and Stakeholder Goal
Organizational Mission
The mission of California rural county health and human services (HHS) is to optimize the
health, wellbeing, and quality of life for all residents.
Organizational Performance Goal
The organizational performance goal is to develop prepared HHS rural county leaders'
competency within the crisis management system to support and increase administrative
preparedness to address public health crises effectively and avoid adverse effects on the health
and wellbeing of the community.
California Rural County HHS Leader Goal
The California rural county HHS leader goal is to enhance administrative preparedness
competencies within the crisis management system by prioritizing and championing initiatives
that prepare for and respond to public health crises.
Purpose of the Study and Research Question
The study aims to determine the organizational needs and strengths in administrative
preparedness among California rural county HHS leaders to effectively address public health
crises. The study utilizes a modified Clark and Estes' (2008) gap analytical framework to
examine the knowledge, motivation, and organizational factors influencing organizational
performance. The following question guides the study:
1. What are the knowledge, motivational, and organizational needs and strengths of
California rural county HHS leaders that influence public health crisis management?
Importance of the Study
Crisis management research demonstrates that prepared organizations and their leaders
plan, execute, and recover from a crisis better than organizations that need to prepare (Cloudman
& Hallahan, 2006; Coombs, 2022). Moreover, prepared organizations and leaders utilize lessons
from previous crises to better prepare for future crises (Coombs, 2022) and swiftly implement

9
useful mitigation measures to lessen health and economic consequences (Armstrong et al., 2021).
However, studies exploring effective HHS leaders’ administrative preparedness for crisis
management competencies are missing from the research (Sriharan et al., 2022). While
considerable published research provides public health crisis preparedness plans and evidencebased guidelines as best practices, few specifically focus on the administrative preparedness of
crisis management for leaders, and none focus on HHS leadership. As no two crises are the same,
research exploring factors related to understanding the temporal HHS leadership aspects of
administrative preparedness for crisis management could provide essential information to
improve public health crisis management. Understanding the problem will allow for better public
health crisis leadership development and prepare communities for the spectrum of crisis risk.
The focus on rural counties in California is significant as these areas often face unique
challenges in crisis management due to limited resources, geographic isolation, and a lack of
infrastructure compared to urban areas (Kutzin, 2013; Ranscombe, 2020). Additionally, rural
communities may have distinct cultural and social dynamics that impact crisis response and
recovery (Douthit et al., 2015; Bennett et al., 2019). By examining the administrative
preparedness of HHS leadership in these rural settings, this study aims to identify specific needs
and strategies that can enhance the effectiveness of crisis management in underserved and often
overlooked regions. This research could contribute to developing more tailored and effective
preparedness plans that address the distinct characteristics of rural communities, ultimately
improving public health outcomes and resilience in the face of crises.
Overview of Theoretical Framework and Methodology
Clark and Estes' (2008) modified gap analysis framework (Figure 2) is the theoretical
framework applied to approach the problem of practice. The framework provides a lens through

10
which to examine organizational performance gaps attributed to deficits in skills and barriers to
knowledge, motivation, and organization (KMO). The evaluation of key influences on
performance can reveal disparities between an organization's current overall performance and
their aspirations. In addition, this assessment supports the identification of practical solutions to
realize organizational performance goals. The framework is appropriate to address the problem
of practice because it will focus on California rural county HHS leaders' competencies in
addressing public health crises. Moreover, by exploring leadership factors, the framework will
determine the assets and underlying issues or causes in the local government context that
improve or impede administrative crisis performance. Crucially, it will also illuminate areas in
which the organization may better support leadership competency in crisis management.
Figure 2
Clark and Estes' Gap Analysis Framework
Note. This figure depicts the process of assessing an organization's current and projected
performance levels to identify gaps and develop strategies to address them.

11
Definition of Key Terms
In the study, the researcher frequently relies upon key terms, here defined from relevant
research to provide insight into their employment within the study. While individual terms may
have different interpretations or applications in other works based on context, the list emphasizes
those terms in the senses deemed relevant to this study.
• Administrative preparedness: The readiness of an organization, encompassing the
procedures, regulations, and resources necessary to prepare for and respond competently
to public health crises (Mwaungulu & Dwyer, 2019).
• Crisis: A pivotal moment requiring immediate and decisive action characterized by a
high degree of instability, uncertainty, and risk, with the potential to significantly impact
an individual, organization, community, or society (Boin et al., 2004).
• Crisis management: The processes and strategies that are used to mitigate or reduce the
adverse effects of a public health crisis to minimize the impact on public health and
safety (Dalcher, 2020). Extending beyond emergency preparedness, crisis management
now consists of four interconnected components: prevention, readiness, reactions, and
evaluation throughout all phases of a crisis (Coombs, 2022).
• Effectively address: The capability of rural HHS leaders in California to address a public
health crisis that reduces harm and optimizes outcomes for the population being served
(Kapucu et al., 2013; Richman et al., 2019).
• A public health crisis: A significant health emergency that threatens health and safety and
necessitates a prompt and synchronized response. Public health crises often stem from a
natural disaster, epidemic, or other health crisis and have long-lasting, extensive
consequences for the health and welfare of a community (Goniewicz et al., 2022).

12
• California rural county: A county in California characterized by low population density
and a limited range of economic and social services (Rural County Representatives of
California [RCRC], 2022). Moreover, rural county residents experience significant
healthcare disparities, resulting in higher rates of disease and death than those in urban
counties (Hauenstein et al., 2014).
Organization of the Study
Five chapters organize the study, and each section is arranged to provide a clear and
extensive outline of the research process. Chapter One introduces the problem of practice,
provides information about the organization and the stakeholder group under study, the purpose
of the study, the research methodology and modified gap analytical framework, and defined key
terms. Chapter Two examines relevant literature surrounding the problem of practice,
encompassing the knowledge, motivation, and organizational factors influencing California rural
HHS leaders' administrative preparedness to effectively address public health crises. Chapter
Three details the methodology for selecting participants, the data collection methods employed,
and the data analysis techniques applied in the study. Chapter Four presents and discusses the
research findings and data. Chapter Five highlights the study's findings and their significance,
and it provides suggestions for additional research.

13
Chapter Two: Review of the Literature
This research investigates the administrative preparedness of HHS leaders in California's
rural counties regarding crisis management within their organization. An organization's success
or failure in navigating a public health crisis depends on the competence of HHS leaders. The
study therefore focuses on high-level management leaders in California's rural organizations to
assess how crisis management knowledge, motivational factors, and organizational influences
contribute to their capacity to effectively address public health crises.
This chapter synopsizes the development of HHS, focusing on legislative acts that foster
the discipline of administrative preparedness, specifically in the context of public health crises. It
then assesses the administrative preparedness of leaders to address public health crises
effectively, as reported in the crisis management literature. The literature review covers the
understanding of crises, prominent practices in crisis management, and crisis leadership skills
and competencies. Furthermore, to gain a deeper understanding of the impact of current public
health crises on HHS organizations and their communities, this chapter examines crises with
immediate impacts on modern society, including the COVID-19 pandemic, the opioid epidemic,
climate-related hazards, and health disparities. The chapter concludes with the modified gap
analysis framework developed by Clark and Estes (2008) to evaluate what knowledge,
motivation, and organizational factors influence HHS leaders' capacity to address public health
crises effectively.
Health and Human Services (HHS) Historical Context
In 1953, President Eisenhower established the Department of Health, Education, and
Welfare (HEW) through the Reorganization Plan Number 1 of 1953 (U.S. Government, 1953).
HEW was formed to organize government agencies and advance the welfare of all Americans (A

14
Federal Department of Health et al., 1953; Folsom, 1963). Since that time, HEW has experienced
several organizational changes. In 1979, President Carter created an autonomous division of the
United States Department of Education (Stallings, 2002). The formation of the Department of
Education from HEW introduced the renaming of continuing HEW organizations, out of which
came the Department of Health and Human Services in 1980 (Salerno et al., 2009). This federal
HHS organization is responsible for various programs and initiatives, including public health and
social services (Salerno et al., 2009). Its massive budget of over $1 trillion (Department of
Health et al., 2022) reflects the importance of these programs and their impact on millions of
Americans (Salerno et al., 2009).
Beyond the federal HHS, many states have their own HHS agencies responsible for
administering healthcare and social service programs. One such agency is the California Health
and Human Services Agency (CalHHS), established in 2013 by Governor Jerry Brown. Prior to
the creation of CalHHS, California's HHS programs were spread across different departments
and agencies, impeding coordination and fragmentating services (California Health et al., n.d.).
CalHHS was created to address these issues by bringing together several departments and
agencies under one umbrella organization.
One of the key responsibilities of CalHHS is to ensure that California is prepared to
respond to public health crises, such as pandemics or natural disasters. Accordingly, CalHHS
collaborates closely with the California Department of Public Health and other state agencies to
establish regulations and processes to provide a swift and efficient response to any health crisis
in the state (California Health et al., n.d.).

15
Administrative Preparedness Legislation
In recent years, California has experienced several public health crises, including the
COVID-19 pandemic, wildfires, and droughts. These events have highlighted the importance of
administrative preparedness and led to new legislative policies to improve the state's ability to
respond to such crises. Effective administrative preparedness is the action organizations, and
their leaders take to identify and utilize strategies to enhance the efficiency of organizational
operations (Mwaungulu & Dwyer, 2019). Administrative preparedness aims to facilitate public
health crises through crisis management.
In 2019, to improve California's administrative preparedness for public health crises.
Governor Gavin Newsom enacted a package of bills. Among them were four bills addressing
climate hazards related to public health: AB 1279, SB 1020, SB 905, and SB 1137. The
legislation collectively established a statewide carbon-neutrality target for 2045, mandated a
3,200-foot setback for oil and gas wells and set milestones for clean electricity. In addition, it
imposed new regulations for carbon capture, storage, and utilization initiatives (Latham et al.,
2022). Among Newsom's bills was another essential piece of legislation, Assembly Bill 685
(COVID- et al., 2019), which mandates that employers supply written notice to employees who
may have been exposed to COVID-19 in the workplace and notify local health officials of any
outbreaks.
Aside from these legislative state policies, CalHHS has developed various programs and
initiatives to improve public health crisis management, administrative preparedness, and
response. One such program includes the California Health Alert Network (CAHAN), executed
in 2006. This statewide communication system improved the coordination and dissemination of
health alerts and emergency information among California public health agencies, healthcare

16
providers, and emergency responders. Indeed, CAHAN seeks to facilitate rapid communication
during crises, such as disease outbreaks, natural disasters, or bioterrorism incidents, to coordinate
response activities efficiently. However, disparities in the availability and quality of information
shared through the network and gaps in the response capacity of different jurisdictions,
particularly rural areas in California, have highlighted challenges and limitations of the
program's effectiveness.
Rural California
Numerous factors in rural California life can challenge organizations' attempts to address
public health crises: for example, inadequate access to healthcare services, environmental
conditions, socioeconomic circumstances, and cultural considerations. In addition, rural residents
face significantly limited access to healthcare services, with a sizeable proportion lacking access
to primary care, which can compromise health outcomes (Taylor, 2019). Additionally, California
rural areas often have fewer primary care providers per capita than urban areas (Bion, 2019),
further limiting healthcare access and delaying diagnoses and treatments, with poorer health
outcomes as a result. Environmental factors such as air pollution and water quality issues can
also contribute to health problems in rural areas where respiratory and cardiovascular diseases
and increased mortality rates have been reported (Fernandez-Bou et al., 2023; Goodridge &
Marciniuk, 2016; Kampa & Castanas, 2008). In addition, poverty rates in rural California are
higher than those in urban areas, with concurrently higher rates of chronic health conditions and
premature death (Taylor, 2019). Finally, limited access to healthy food in rural areas can worsen
these public health issues (Coleman-Jensen et al., 2017).
The issue of healthcare accessibility is an especially multifaceted and intricate health
challenge in rural regions. Cultural beliefs and practices may also impact health behaviors and

17
access to healthcare services in rural communities, leading to inadequate treatment of health
conditions, particularly mental health issues. Talbot et al. (2017) consider that stigma
surrounding mental health treatment may prevail in rural communities, lowering public reliance
on mental health services. An analysis by Coombs et al. (2022) reveals five principal themes:
friction among aspects of patients' rural identities and healthcare systems, cultural disparities,
fragmented communication, limitations of time and resources, and prioritization of profits over
the resolution of barriers demonstrating Western health systems lack cultural humility, marking
Western health institutions' lower empathy or respect for patients and dismissal of culture and
traditions as superstitions, leading to inadequate healthcare. The researchers concluded that
to enhance patient experiences and outcomes, monitoring every dimension of access is
imperative (Coombs et al., 2022).
Furthermore, Crocker's (2021) study on Mexican immigrants in the rural United States
found that their tendency to postpone seeking medical care until conditions worsen does not stem
from cultural beliefs about health but from their limited expectations and assumptions about the
advantages of preventive healthcare. Consequently, these immigrants rely heavily on affordable
and accessible lay modalities, such as home remedies or self-medication. Despite gaining access
to healthcare, the persistence of this practice can be explained by historical factors (Crocker,
2021). Therefore, to effectively promote public health in rural communities in California, a
comprehensive and distinct approach to care is imperative.
Distinct Approaches to Care in Rural California
Rural communities in California have benefited from several effective, comprehensive,
and distinct public healthcare approaches. One such approach is the utilization of telemedicine,
leveraging technology to provide healthcare services remotely. According to Kappel et al.

18
(2022), telemedicine has expanded access to care for underserved populations by facilitating
remote consultations and diagnoses. Another approach is to use community health workers,
trained members of the community promoting health and disease prevention. Samuel-Hodge et
al. (2022) report that community health workers have improved health outcomes and reduced
healthcare costs in rural communities. Moreover, partnerships between local health departments,
healthcare providers, and community organizations have effectively addressed public health
crises in rural areas. A Rural Health Research Gateway (Rydberg et al., 2021) study found that
such collaborations have mitigated health disparities and improved healthcare accessibility in
rural communities. Finally, culturally sensitive healthcare delivery has proven effective in
promoting public health in rural areas. For example, Sherrill et al. (2005) discovered that cultural
competency in health care services improved healthcare access and outcomes for diverse
populations in rural communities. In sum, telemedicine, community health workers,
interorganizational collaboration, and cultural competency training are among the practical
approaches implemented to address public health challenges in rural California communities.
The Confluence of Administrative Preparedness and Rural California
The aforementioned public healthcare approaches can significantly impact administrative
preparedness for public health crises in rural communities. Telemedicine, for instance, can be
utilized during pandemics or disease outbreaks to provide remote consultations and diagnoses,
minimizing the transmission of infectious diseases. Similarly, community health workers can
crucially disseminate accurate information and promote healthy behaviors during public health
crises (Peretz et al., 2020; Samuel-Hodge et al., 2022). In general, interorganizational
collaboration can coordinate resources and expertise to address public health crises (Rydberg et
al., 2021), while cultural competency training and practices can ensure that healthcare providers

19
deliver culturally sensitive care during crises (Sherrill et al., 2005). These approaches can
seamlessly transition from routine public healthcare services to administrative preparedness
measures in times of public health crises in rural California.
Crisis Management
Organizational research has attended closely to the study of crises and crisis
management. Researchers have explored various aspects of crises, including their causes,
typology, management, and leadership, asserting that crises have become deeply rooted in
present society (Björck, 2016; Mitroff, 2000). Understanding crisis management is crucial in
today's organizations, as leaders are vital in effective crisis management. This dissertation
expands this continuing conversation by investigating how crises can be effectively managed, as
well as their implications for organizational success.
Crisis Definition and Typology
Abundant literature has been published on crises. Most scholars (Björck, 2016; Boin,
2005; Brinks & Ibert, 2020; Mitroff, 2004) concur that all crises feature perceived danger,
unpredictability, risk to crucial societal resources, and a pressing need for action. Hart et al.
(1993) further define a crisis as a severe peril to the core frameworks or basic tenants and beliefs
of a societal system that demands crucial decision-making in the face of time constraints and
great uncertainty. As these definitions underscore, crises occur swiftly and can impede an
organization's vision and goals, compelling it to take prompt measures to mitigate potential risks.
Despite the ample scholarly attention, understanding a crisis can be challenging.
Overusing the term "crisis" to describe various events can diminish the term's seriousness and
make it more commonplace (Freeden, 2017). As leaders must prepare to manage the unique
features of crises, Cook and Anderson (2019) assert, crises should be distinguished from routine

20
emergencies. According to Phelps (n.d.), the primary distinction between crisis and routine
emergency is that although both challenging circumstances require a response, a routine
emergency is often predictable, whereas a crisis is not.
Crisis management requires the understanding that different crises necessitate distinct
responses, and leaders must identify a crisis's type to respond to one effectively (Coombs, 1999).
Björck's (2016) study on crisis typology classifies crises by context and time. Hart et al. (1993)
classify crises based on context, such as social, political, post-disaster, economic, and
organizational crises. Alternatively, Coombs (2022) outlines the temporal dimension of crises
over three phases: "precrisis, crisis, and postcrisis" (p. 11-12). Frandsen and Johansen (2020)
further identify the three interconnected crisis subfields of political crisis management, corporate
crisis management, and public crisis management to reframe the crisis management phenomena,
demonstrating that classifying crises into these subfields can help develop effective crisis
management strategies to mitigate the impact of the crisis.
Literature is abundant on the topic of crises. Most scholars (Björck, 2016; Boin, 2005;
Brinks & Ibert, 2020; Mitroff, 2004) agree that a perceived sense of danger, unpredictability,
a potential threat to essential societal resources, and an urgent demand for action typify crises.
However, comprehending a crisis can prove challenging. Crises demand different responses
than do routine emergencies, as well as an understanding that the diverse types of crises call
for unique responses (Coombs, 1999).
Crisis Management: Prominent Practices
Crisis management has been given considerable focus in organizational research, with the
aim being to comprehend how organizations can prepare for crises, navigate them effectively,
and alleviate their negative impact (Bundy et al., 2017; Ciftci et al., 2017; Hunter & Lambert,

21
2016; Kahn et al., 2013). Coombs (2014) states that although crises remain a topic of ongoing
interest, the field of crisis management requires additional investigation, as numerous
interpretations exist for what constitutes effective crisis management. Traditional perspectives on
crisis management have faced criticism for depending on outdated administrative preparedness,
such as establishing distinct positions or teams to manage crises (Oscarsson & Danielsson,
2018). Moreover, Holzweiss and Walker (2018) demonstrate the need to better prepare
administrative leaders with training and resources, as highlighted by recent crisis events.
Therefore, emerging research has emphasized the importance of equipping all organizational
leaders with comprehensive crisis management skills (Oscarsson & Danielsson, 2018) rather
than relying solely on a designed coordinator or crisis team with expertise in crisis management.
Pearson and Clair (1998) reason that successful crisis management should occur across
all three phases of a crisis. In the precrisis phase, leaders must identify strategies to minimize
potential risks prior to the occurrence of a crisis. In times of crisis, effective crisis management
requires a leader to collaborate to reorganize clear roles; following the crisis, leaders must
reorganize individual and collective behaviors and emotions (Pearson & Clair, 1998). In
addition, effective crisis management considers the context of the crisis. Effective crisis
management depends on organizational actions and outcomes that inspire leaders who engage in
knowledge management, communicate information, and build crisis management strategies
(Dutton & Jackson, 1987; Wooten & James, 2008).
Holzweiss and Walker (2018) noted that the organizational structure significantly impacts
crisis management. Research has shown that teams are among the most effective tools for
developing pre-planning strategies and successfully managing crises (Brandebo, 2020; Castle,
2019; Frandsen & Johansen, 2020; Pearson & Clair, 1998). Castle (2019) recommends creating

22
teams of stakeholders with a broad range of skills from various departments to ensure a prompt
operational response and effective preparation for decision-making in the event of unprecedented
events.
Public administration is another topic of study in the expanding domain of crisis
management practice. Considering the substantial number of potential threats in the coming
decade, Turoff et al. (2013) articulate that prioritizing planning and foresight for crises is
essential to safeguard public safety. Moreover, Šimák and Míka (2008) declare that an
organization's survival rests on its preparedness, the efficiency of its crisis team, the effective
implementation of contingency plans, and the management of the situation in the aftermath of
the crisis. Therefore, public administration crisis management must ensure preparedness for any
potential crisis, employing ongoing crisis management efforts to stabilize the community during
crises. In Figure 3, Tej et al. (2014) demonstrate that adopting a continuous approach to crisis
management is crucial for local government and should be a fundamental part of its culture.
Finally, awareness is a critical precursor to crisis management preparation (Kapucu,
2008). Research is shifting from conventional crisis management, relying on a top-down
approach where the government undertook all crisis preparedness and response, toward the
encouragement of local preparedness and the promotion of community resilience (Said et al.,
2011). When encouraging local preparedness, the government organization must consider
preparedness barriers for marginalized community members, such as language difficulties, lack
of knowledge, financial adversities, apathy, or logical complications (Burke et al., 2012;
Fielding, 2012) that can impede more specific and practical crisis preparedness.

23
Figure 3
Continual Approach to Crisis Management in Local Government
Note. From "Crisis Awareness of the Municipal District Residents: Implication for Crisis
Management at the Local Government Level," by J. Tej, P. Živčák, V. Ali Taha, and M. Sirková,
2014, Kvalita Inovácia Prosperita, 18(2), 1–14.
Effective crisis management is challenging because administrative preparedness is often
given low priority, and crises' unpredictability challenges leaders (McConnell & Drennan, 2006).
Furthermore, crisis management increasingly involves vast and dynamic data that leaders must
examine to extract useful information, and this data may come from uncontrollable sources, such
that its credibility and trustworthiness must be determined (Benaben et al., 2016). Consequently,
concerning leadership development requirements, education in crisis management and crisis
leadership are often insufficient (Powley & Taylor, 2014), even though crisis management is a
critical function of organizational leaders.

24
Crisis Leadership Skills and Competencies
Scholars from multiple fields of study have widely recognized that leaders, through their
actions, strategies, decision-making, and effect on others, shape the future of their organizations
both during periods of normalcy and in times of crisis (Bolman & Deal, 2021; Collins, 2001;
Dirani et al., 2020; Heffner et al., 2011; Northouse, 2022). While the study of crisis management
is process-driven and tactical, aimed to prepare for and respond to crises (Wooten & James,
2008), crisis leadership is purposeful and emphasizes leaders as those at the center of crisis
management. Crisis leadership studies examine the behaviors and competencies, such as
knowledge, skills, and abilities required of leaders to manage crises effectively. Developing
influential crisis leaders is critical to crisis management (Schoenberg, 2005). Nevertheless, Al
Thani and Obeidat (2020) assert that effective leadership skills alone are insufficient to operate
in a crisis position of leadership. Provided that crisis leaders encounter obstacles varying from
those encountered during routine organizational operations, effective crisis leadership
necessitates rethinking leadership development curricula (Wicker, 2021).
Crisis Leadership Skills
Crisis leaders must possess unique expertise and skills exceeding those necessary for
routine tasks of organizational leadership (Muffet-Willett & Kruse, 2009). Research on crisis
management and crisis leadership has consistently emphasized numerous core competencies for
leaders during crises: for example, effective communication, collaboration, trust-building,
flexibility in decision-making, and emotional intelligence (Coombs, 2022; Dirani et al., 2020;
Hajncl & Vučenović, 2020; Johansen et al., 2012; Wicker, 2021). These skills are fundamental
during each phase of a crisis, and they help leaders adjust to new circumstances, transition
operations, and connect meaningfully with stakeholders, emphasizing the need for common

25
ground understanding during crises (Jacobsen, 2000). In this context, "common ground" can be
defined as the point at which all stakeholders participate in efficient communication,
collaborative efforts, and trust-building actions to mitigate a crisis (Jacobsen, 2000; Stuart &
Szeszeran, 2021); therefore, finding common ground is imperative for contemporary leaders.
Achieving common ground necessitates utilizing crisis leadership skills in a comprehensive
approach.
Communication
During times of crisis, leaders must communicate clearly and effectively with various
stakeholders (Coombs, 2022; Kim, 2018). Coombs (2022) asserts that effective communication
supports crisis leadership as they provide clear and concise information, manage expectations,
build trust, facilitate collaboration, and enable learning and improvement. In addition,
meaningful communication requires leaders to ensure all stakeholders, both internal and external
to the organization, feel heard and that leaders listen attentively. Mazzei et al. (2012) and Kim
(2018) highlight the benefit of effective crisis communication for employee engagement, while
inadequate internal communication during a crisis can have negative consequences. Similarly,
Bundy et al. (2017) and Adamu and Mohamad (2019) emphasize the importance of employees
perceiving leadership communication as honest, sincere, trustworthy, transparent, and open.
Furthermore, the research demonstrates that clear and transparent communication
develop essential common ground among group members, encouraging them to innovate,
operate as organizational representatives, and contribute to advanced problem-solving (Adamu &
Mohamad, 2019; Kouzes & Posner, 2010; Sellnow & Seeger, 2021). Additionally, crisis leaders
who during a crisis provide clear direction and support to external stakeholders (e.g., guidance
on staying safe and accessing resources), facilitate trust and mitigate adverse effects on the

26
organization's reputation (Fragouli, 2020; Sriharan et al., 2022). Finally, crisis leaders delivering
accurate and timely information to the community throughout all phases of a crisis provide
stakeholders with the information they need to understand the crisis, its impact, and the steps
being undertaken to address it, helping to reduce confusion and fear among stakeholders (Avery
& Park, 2019; Garcia, 2017).
Despite its importance, communication literature is overlooked in the government sector,
specifically information on the administrative preparedness of communication contexts focused
on the precrisis phase (Avery et al., 2010; Ha & Boynton, 2013; Park et al., 2022). For example,
in a study of crisis communication published in communications journals over the last two
decades, more than 65% of the literature focused on postcrisis topics (Ha & Boynton, 2013; Park
et al., 2022).
Collaboration
Collaboration is essential for crisis leaders to plan for and respond to crises successfully.
Emphasizing a collaborative organization's foundation, specifically trust, shared expertise, and
clear communication structures, enables all stakeholders to work together effectively towards
shared goals and common ground (Rawlings, 2000; Rosenthal, 1998). As a foundational
principle, trust allows stakeholders to act collaboratively with greater effectiveness by fostering a
sense of mutual reliance and understanding. Shared expertise ensures stakeholders can support
each other by providing their knowledge and skills as needed (Kahn et al., 2013).
Rawlings (2000) emphasizes that true collaboration is marked by a commitment to
transferring knowledge and information, establishing cross-functional cohesiveness, and
fostering a culture of context-specific rich, trusting dialogue. Such in-depth dialogue enables a
group to generate interconnected joint solutions that promote mutual accountability for shared

27
decisions and outcomes (Rawlings, 2000). Furthermore, before a crisis occurs, leadership's
behavior enables or limits collaborative success, as leaders structure a collaborative team before
a crisis occurs (Turoff et al., 2013). When applied effectively and timely, these principles
contribute to the success of collaborative organizations by fostering an environment of trust and
respect, enabling effective communication, and empowering members to contribute their unique
expertise toward enabling those impacted by the crisis to achieve their desired outcomes and find
a timely resolution (Fusch et al., 2018). As an essential crisis leadership skill, moreover, the
implementation of effective collaboration expedites decisions and minimizes bureaucratic
obstacles, making successful crisis resolution more likely (Dirani et al., 2020).
Trust-Building
Effective crisis leadership relies on trust, a personal skill that leaders can harness when
navigating crises. Trust is a critical crisis leadership skill for success in organizational settings,
where leaders must work collaboratively to achieve common goals (Curnin et al., 2015;
Hollenbeck et al., 2012; Steelman et al., 2014; Sutherland, 2017). Colquitt et al. (2007) revealed
that stakeholders’ willingness to trust others is more likely to exhibit superior task performance,
greater social responsibility behaviors, and lower levels of counterproductive behavior, all
essential during a crisis. Moreover, researchers have contended that the value of trust in the
relationship with the leader is demonstrated in observed actions and attributions of the leader,
such as humanity, courage, consistency, justice, and, judgment, and stakeholders form
perceptions of the leader's trust on these perceptions (Boin & 't Hart, 2003; Fragouli, 2020;
Gustafsson et al., 2021; Van Wart & Kapucu, 2011). When leaders secure trust, the stakeholders
connect with them and, in turn, desire to build common ground toward ideas and plans to address
crisis challenges. Researchers assert that the presence of trust can further facilitate the process of

28
discovering common ground and lead to a successful resolution of a crisis (Colquitt et al., 2012;
Curnin et al., 2015; Meyer et al., 2017; Steelman et al., 2014).
Flexibility in Decision-Making
Flexibility in decision-making is another essential skill of crisis leadership. Oscarsson
and Danielsson (2018) highlight improvisation, prioritization, and creating alternatives when
responding to current information and changing circumstances. In a crisis, added information
may emerge rapidly. Leaders must be flexible enough to revise decisions and strategies based on
the latest information while remaining flexible enough to adapt to changes and adjust plans and
strategies accordingly. Additionally, decision-making flexibility maintains stakeholder
engagement, including building trust and collaboration by demonstrating a willingness to adapt
to stakeholder needs and fostering a culture of innovation and common ground (Boin & 't Hart,
2003; Fusch et al., 2018). Decision-making flexibility enhances innovation and creative problemsolving among members of an organization, encouraging leaders to be open to innovative ideas
and approaches to foster a culture of innovation among stakeholders' leaders to effectively shape
and present the plan or concept from the beginning, enabling the crisis leader to respond (Dirani
et al., 2020). Finally, decisions must often be made quickly in a crisis, to prevent or mitigate
harm. Decision-making flexibility can enable crisis leaders to make timely and effective
decisions under pressure (Fusch et al., 2018).
Emotional Intelligence
As crises can be highly stressful and emotionally charged, emotional intelligence shapes
crisis leadership. According to Hajncl and Vučenović (2020), effective crisis leadership
necessitates that leaders have high emotional intelligence, allowing them to regulate their
emotional responses and the emotions of their team members. Emotional intelligence involves a

29
recognition that emotions can be contagious and that an individual's emotional state can impact a
group's mood by serving as a model for those emotions (Cherniss & Goleman, 2001). More
specifically, as stated by Dirani et al. (2020) and Wicker (2021), emotional intelligence is one's
ability to recognize, understand, and manage one's own emotions in addition to the emotions of
others. Studies indicate that emotionally intelligent leaders have been better able to empathize
with stakeholders impacted by crisis during that crisis. They can effectively assume the
perspectives of others, helping to build trust, connect with those affected, and establish common
ground (Cherniss & Goleman, 2001; Dirani et al., 2020; Hajncl & Vučenović, 2020; Wittmer &
Hopkins, 2022). Dirani et al. (2020), Cherniss and Goleman (2001), and Wittmer and Hopkins
(2022) add that emotionally intelligent crisis leaders can better manage their emotions, even
given extreme stress and uncertainty. Emotional intelligence enables them to stay focused and
calm amid disorder and to make rational decisions based on available information. Furthermore,
as Hajncl and Vučenović (2020) have suggested, leaders with emotional intelligence have
personal attributes (e.g., conscientiousness and willingness to learn from unfamiliar experiences)
that are essential for managing crises.
The research argues that emotional intelligence anchor effective crisis leadership,
equipping leaders with the tools necessary to successfully address the emotional and practical
obstacles arising during a crisis, foster trust and rapport with stakeholders affected by the crisis
and make informed decisions to minimize the impact of the crisis.
Synopsis – Crisis Leadership Skills
Crisis leaders are expected to perform under scrutiny from all sides and enhancing the
abovementioned leadership skills can assist in crisis management to minimize harm to the
organization and its stakeholders. However, leaders needing greater administrative preparedness

30
and crisis leadership skills can negatively impact their performance, the organization, and
stakeholders by becoming overly controlling, avoiding responsibility, and yielding to stress,
which can lead to a loss of control of the crisis (Brandebo, 2020). In addition to developing crisis
leadership skills, Brown (2018) recommends developing a crisis plan to ensure ongoing precrisis
planning with organizational commitment and assessment of resources and responsibilities.
Fragouli (2020) emphasizes the significance of precrisis planning, underscoring prevention
strategies and recognizing potential early symptoms of a crisis. To prepare leaders for crises,
Smith and Riley (2012) advise scenario-based exercises engaging analytical reasoning while
acquainting crisis leaders with multiple crisis events.
Crisis Leadership Competencies
Coombs et al. (2022) and Schwarz (2008) caution against the conceit that to lead various
crises requires matching crisis leadership skills, as the various crisis types span critical problems
in the areas of finance, technology, personnel, and human error, as well as specifically
organizational crises; it is therefore more helpful to focus on crisis leadership competencies.
Wooten and James (2008) identify leadership competencies as the capabilities, understanding, or
qualifications required of a crisis leader to effectively execute their responsibilities. Crisis
leadership competencies should encompass myriad activities, including effective
communication, management of multiple stakeholders, and maintenance of a healthy
organizational culture (Bolman & Deal, 2021; Schein, 2017). Although research on the
competencies required for successful crisis management may be inconclusive, one common
factor is the importance of exceptional leadership in effectively addressing a crisis. The research
conducted by EH and A Consulting (n.d.) analyzes the nine crisis leadership competencies
identified by the Centers for Disease Control and Prevention (CDC) as the most crucial for crisis

31
leaders to have during a crisis. Table 2 features the nine crisis leadership competencies and their
key crisis leadership skills.
Table 2
Crisis Leadership Competencies
Leadership Competency Key Crisis Leadership Skills
Communication
Active listening; clarity; empathy; adaptability;
emotional intelligence; feedback; transparency; concise
crisis message planning
Connectivity Collaboration; trust-building; emotional intelligence;
communication; flexibility in decision-making
Courage and Perseverance Flexibility in decision-making; resilience; confidence;
communication; adaptability; trust-building
Credibility Trust-building; emotional intelligence; integrity;
transparency; consistency; vision; accountability
Decisiveness Emotional intelligence; adaptability; communication;
flexibility in decision-making
Emotional Effectiveness Emotional intelligence; flexibility in decision-making;
trust-building; communication
Integrative Thinking
Creativity; flexibility in decision-making; systemsthinking; collaboration; trust-building; cultural
competence
Situational Awareness Emotional intelligence; communication; flexibility in
decision-making
Team Leadership Collaboration; trust-building; communication; flexibility
in decision-making
Crisis in Health and Human Services (HHS)
The Department of HHS has recognized various public health crises, including climate
hazards, pandemics, and behavioral health complications. Despite notable scientific
advancements and the dedication of the HHS workforce, systematic deficiencies impede its
capacity to safeguard and enhance health, promote health equity daily, and respond effectively to
public health crises (Commonwealth Fund Issues Report Entitled et al., 2022). The Centers for
Disease Control and Prevention (CDC) confirmed the first case of COVID-19 in California and
the third case in the United States on January 26, 2020 (Wheeler, 2020). In addition, the nation

32
faces an unparalleled opioid epidemic, with more than 130 deaths per day from opioid-related
drug overdoses (Health Resources and Services Administration [HRSA], 2020). Climate hazards
represent another public health crisis underway. Climate change is humanity's most significant
health danger, and health experts (World Health Organization [WHO], 2021) are already
working to address the health consequences of this ongoing crisis. According to Devakumar et
al. (2020), health disparities are preventable discrepancies in disease risk, harm, victimization, or
resource availability for acquiring overall health, such that these discrepancies are experienced
by groups in marginalized economic or social circumstances, physical regions, or ecosystems,
culminating in many communities declaring racism as the new public health crisis. Numerous
public health crisis incidents have impacted the health and wellbeing of our communities,
underscoring the importance of HHS leaders being administratively prepared to address public
health crises effectively.
Types of Crisis
Throughout its history, the HHS has faced several public health crises, such as the HIV
epidemic in the 1980s, the SARS outbreak in 2003, the 2009 H1N1 pandemic, and the 2014-
2016 Ebola crisis. Additionally, numerous climate hazards have resulted in public health crises
that HHS has had to manage. To achieve organizational success, HHS leaders must be prepared
to respond effectively to these crises. Overlooking the risks and uncertainties associated with
crises is not an option (Lowe et al., 2022; Spiegelhalter, 2015). Given the nature of crises that
HHS may encounter, its leaders must be adept at crisis management. Recent illustrations of such
crises include a global pandemic, an overdose crisis, climate hazards, and health inequities.

33
COVID-19
COVID-19 is caused by the SARS-CoV-2 virus, initially diagnosed in December of 2019
in Wuhan, China. On January 7th, 2020, Chinese authorities alerted the World Health
Organization (WHO) to several cases of pneumonia in Wuhan (Palacios Cruz et al., 2021). By
January 30th, 2020, WHO had declared a public health emergency of international concern in
response to COVID-19 (Palacios Cruz et al., 2021). As Palacios Cruz et al. (2021) noted, the
pandemic declaration occurred on March 11th, 2020, after the virus infected more than 118,000
people in over 100 countries.
COVID-19 changed the world. The number of deaths from COVID-19 in the United
States has exceeded 1 million, overtaking the total number of military lives lost in all wars since
the nation's founding, according to the Commonwealth Fund report titled "Issues Report Entitled
et al." (2022). The COVID-19 pandemic has immensely strained our public health and healthcare
systems, exposing long-standing weaknesses and vulnerabilities, and it has further highlighted
the failures of HHS to achieve its purpose to improve the health and wellbeing of all Americans
(Department of Health et al., n.d.). Additionally, COVID-19 has highlighted the plight of large
populations susceptible to chronic illnesses and health disparities. More recently, there has been
an extensive increase in deaths related to despair, such as suicide and fatal drug and alcohol
poisoning (Knapp et al., 2019).
The pandemic has impacted HHS leaders tasked with developing and executing strategies
to contain the virus's spread while maintaining essential HHS. Furthermore, these leaders have
faced the challenge of communicating effectively with stakeholders, such as providing accurate
information about the virus and the best mitigation actions to prevent it while countering
misinformation and addressing multiple concerns (Brownson et al., 2020). As the full impact of

34
COVID-19 becomes increasingly apparent, HHS leaders must prepare for an ongoing series of
challenges and transitions in the field.
Opioid Epidemic
The opioid epidemic is an ongoing public health crisis related to the overuse and abuse of
prescription and illicit opioids (HRSA, 2020). This crisis has significantly increased opioidrelated deaths and has profoundly impacted HHS and its leaders. Several factors have fueled the
opioid epidemic, including the availability of potent synthetic opioids like fentanyl and the illicit
use of opioids such as heroin (Balidemaj, 2021); this epidemic has affected all Americans, but
devastates low-income communities and rural areas particularly (Flaherty et al., 2018). The
result has been that the California Department of Public Health (2016) introduced a statewide
plan to address opioid misuse, abuse, and overdose. The statewide strategy has caused HHS
leaders to implement several strategies to reduce opioid misuse, including increasing access to
medication-assisted treatment programs, improving prescription drug monitoring programs,
implementing a novel hotline to treat patients (LeSaint et al., 2021), and expanding access to
naloxone (a drug that can reverse opioid overdose).
However, despite the statewide prevention strategies, opioid-related drug overdoses in
California continue to increase annually. For example, according to initial data from 2021,
California had 6,843 overdose deaths related to opioids, with 5,722 linked to fentanyl (Centers
for Disease Control and Prevention [CDC], 2022a). In the same year, there were 224 deaths
related to fentanyl overdoses among teenagers aged 15-19 in California. Consequently, HHS
leaders have begun to focus on addressing the root causes of the opioid epidemic, including
economic distress, mental health disorders, and social isolation (Balidemaj, 2021; Cassoobhoy et
al., 2022). In the years ahead, HHS leaders must navigate the complex public health crisis of the

35
opioid epidemic and address challenges around addiction treatment, access to care, and
community engagement (Balidemaj, 2021; Feder et al., 2019).
Climate Hazards
Climate hazards encompass the various environmental risks and challenges that result
from climate change, such as heat waves, floods, droughts, and wildfires. The hazards have
become a public health crisis because they threaten human health and wellbeing (WHO, 2021).
For instance, wildfires produce smoke and other air pollutants that can worsen respiratory
conditions such as asthma, chronic bronchitis, and emphysema. Such conditions can lead to
shortness of breath, coughing, wheezing, and other respiratory symptoms, particularly in
vulnerable populations such as youth, senior adults, and those with pre-existing medical
conditions. In addition to imposing direct medical complications from smoke exposure, wildfires
can exacerbate health disparities. For example, low-income communities and communities of
color are often disproportionately affected by wildfires, due to factors such as lack of access to
healthcare, housing, and other resources (Hamideh et al., 2022; Power, 2018; Raker, 2020;
WHO, 2021). Wildfires can also result in displacement, loss of property, and other negative
social and economic impacts, with the 2018 California wildfires alone causing $150 billion in
damages (Wang et al., 2020). Moreover, wildfires can damage infrastructure such as roads and
power lines, making it difficult for people to access medical care, food, and water. Hamideh et
al. (2022) indicate that wildfires can correspondingly impact mental health and wellbeing,
particularly for individuals who have lost their homes, resulting in anxiety, feelings of
hopelessness, post-traumatic stress disorder, and other behavioral disorders.
To effectively address the public health crisis of wildfires in California, in addition to the
multiple other climatic hazards, researchers encourage HHS leaders to examine the

36
interconnections of climate hazards' impacts and to invest in research into the health impacts of
climate hazards and to develop effective interventions to address them. Such interventions might
be targeted (e.g., conducting surveillance and tracking the incidence and prevalence of climaterelated health issues) or consist of advocating for policies to reduce greenhouse gas emissions
and investing in infrastructure and technologies resilient to climate hazards (Frumkin &
McMichael, 2008; Schwartz et al., 2006). Schwartz et al. (2006) encourage leaders to collaborate
with other stakeholders to develop a coordinated response to the public health crisis of climate
hazards, involving sharing data and resources and organizing response efforts to prioritize the
needs of affected communities. Addressing climate hazards as an HHS leader requires a
multifaceted approach involving research, planning, climate change mitigation, and adaptive
strategies.
Health Inequities
Health inequities are differences in health outcomes between distinct groups, particularly
those resulting from social, economic, and environmental factors (Centers for Disease Control
and Prevention [CDC], 2022b). Health inequities are a public health crisis because they lead to
unnecessary suffering, premature death, and economic loss (Devakumar et al., 2020). Health
inequities can also contribute to social and political unrest and undermine public trust in health
systems (Bathina et al., 2021; Galea & Abdalla, 2020). Addressing health inequities can require
several steps to address effectively for HHS leaders, including an acknowledgement that racism
is a public health crisis and that inequities result from systemic racism and other forms of
discrimination, alongside a recognition of how racism and discrimination have contributed to
health inequities and a commitment to addressing these root causes (Mendez et al., 2021).
Historically, health inequities have been viewed as individual or group-level problems rather

37
than as systemic issues requiring structural solutions, resulting in an emphasis on individual
behavior change rather than addressing the underlying structural factors that contribute to health
inequities (Bathina et al., 2021; Cassoobhoy et al., 2022; Devakumar et al., 2020; National
Library of Medicine, 2017).
Moreover, the National Library of Medicine (2017) demonstrates the need for more data
and research on health inequities, particularly among marginalized and underrepresented
populations, making it difficult to fully understand the scope and impact of health inequities and
develop effective interventions to address them. The lack of political will and leadership to
prioritize health equity at the national level has been compounded by a lack of resources and
funding to address health inequities (Bathina et al., 2021; Cassoobhoy et al., 2022; Devakumar et
al., 2020; Galea & Abdalla, 2020), and by civil unrest highlighted by the recent COVID-19
pandemic, which has aggravated long-standing structural inequalities. Addressing health
inequities for HHS leaders will require a long-term, comprehensive, and concerted effort and
commitment from multiple stakeholders to prioritize health equity and act to address the root
cause of health inequities to achieve optimal health and wellbeing for all.
Clark and Estes (2008) Gap Analysis Framework
This study adopts and applies a modified gap analysis framework proposed by Clark and
Estes (2008). This framework involves a systemic approach to identify organizational goals,
assess performance needs, and continuously implement solutions to improve performance. The
study focuses on the three primary domains of knowledge, motivation, and organizational
influences that may contribute to performance needs and strengths.
Through the lens of the modified gap analysis framework, the study aims to understand
how organizational leaders can improve their crisis management strategies and overall

38
performance during all phases of public health crises in HHS. This academic scrutiny
underscores the organization's potential assistance of its leaders in identifying and addressing
these gaps, fostering an environment conducive to increased efficacy and performance. The
study uses a qualitative research approach to identify needs and assets shaping the performance
of HHS leaders in rural counties in California. It starts by identifying stakeholder goals and
competencies, then establishes an integrated awareness of the factors that influence stakeholder
skills of knowledge, motivation, and organizational influences by reviewing both contextual and
standard crisis literature on learning and motivation.
Stakeholder Knowledge, Motivation, and Organizational Influences
The sequential presentation of Clark and Estes' (2008) gap analysis framework aims to
explore the influence of stakeholder knowledge, motivation, and organizational influences on
effective crisis management. The study critically reviews these concepts to identify the needs of
HHS leaders and their organizations in effectively addressing public health crises. By leveraging
stakeholder knowledge, motivation, and organizational influences, this study seeks to enhance
HHS leaders' administrative preparedness for crisis management within all crisis phases, aiming
to reduce the adverse effects of public health crises on the organization and its community.
Implicit in this approach is the affirmation of the organization's instrumental role in equipping its
leaders with the requisite resources and support to successfully navigate crises, enhancing the
resilience and adaptability of the organization in the face of public health crises.
Knowledge Influences
Clark and Estes (2008) suggest that possessing specific knowledge and skills is a critical
determinant of success or failure for organizations. Specific knowledge and skills are particularly
relevant for the HHS sector, where effective management of public health crises requires leaders

39
with specialized expertise. In addition, to achieve performance goals, it is essential to
comprehend the how, when, why, where, and who aspects of the situation, as emphasized by
Clark and Estes (2008). However, HHS leaders may be unaware of their knowledge needs or
hesitant to acknowledge them, hindering their ability to address the challenges created by a
public health crisis. Moreover, organizations are pivotal in acknowledging the importance of
specific skills and knowledge and facilitating their acquisition among staff.
Four types of knowledge, namely factual, conceptual, procedural, and metacognitive,
have been identified that are useful in understanding performance (Krathwohl, 2002; Mayer,
2010; Pintrich, 2002). Factual knowledge pertains to terminology and specific details; in
contrast, conceptual knowledge involves recognizing, categorizing, and classifying objects or
ideas based on shared characteristics and on comprehending the connections between different
concepts (Mayer, 2010). Finally, procedural knowledge pertains to subject-specific capabilities,
strategies, processes, and standards, while metacognitive knowledge pertains to domain
expertise, self-awareness, and conceptual understanding of cognitive tasks (Krathwohl, 2002;
Pintrich, 2002). Categorizing knowledge into these four types can support acquiring, teaching,
and evaluating necessary knowledge.
The existing academic research emphasizes two distinct knowledge factors for HHS
leaders to comprehend and manage public health crises efficiently: conceptual and metacognitive
or help-seeking. These knowledge factors can aid leaders in achieving efficient administrative
preparedness to effectively address public health crises.
Conceptual Knowledge: Public Health Principles and Competencies
California rural county HHS leaders require a range of conceptual knowledge to
effectively address public health crises during all phases. To effectively address public health

40
crises, these leaders must deeply understand relevant public health principles, including social
determinants of health and epidemiology, to formulate effective strategies that prevent crises
appropriately and address them promptly. Conceptual knowledge extends beyond understanding
public health principles, including vital public health competencies such as trust-building. An
integrated understanding of these principles and competencies helps HHS leaders to formulate
strategies proactively preventing and responding to crises efficiently and suitably enabling HHS
leaders to consider unforeseen crises, and to provide the critical thinking skills (Mitroff, 2004)
necessary to navigate these challenges.
By understanding the role of social determinants of health, HHS leaders can develop
more effective strategies to address the root causes of poor health outcomes and healthcare
disparities in their communities. These determinants comprise the diverse social, economic, and
environmental factors that shape individuals' health outcomes and access to healthcare services
(Ahnquist et al., 2012; Horwitz et al., 2020). These determinants include poverty, unemployment,
education, housing, and access to food. Equally integral to the successful application of
conceptual knowledge is the competency of trust-building, a personal skill leaders employ when
navigating crises (Curnin et al., 2015; Hollenbeck et al., 2012; Steelman et al., 2014; Sutherland,
2017). Leaders exhibiting higher levels of trust demonstrate superior task performance, more
significant social responsibility behaviors, and lower levels of counterproductive behavior, which
are essential during a crisis (Colquitt et al., 2007). Trust between leaders and stakeholders is built
upon the observable actions and attributions of leaders, such as displays of humanity, courage,
consistency, justice, and sound judgment (Boin & 't Hart, 2003; Fragouli, 2020; Gustafsson et al.,
2021; Van Wart & Kapucu, 2011). Thus, trust pivotally facilitates collective action and successful

41
crisis resolution (Colquitt et al., 2012; Curnin et al., 2015; Meyer et al., 2017; Steelman et al.,
2014).
Leaders must grasp these social determinants and incorporate trust-building strategies at
all stages of a public health crisis, from prevention to mitigation and response. Research
demonstrates that during a public health crisis, these social determinants can significantly impact
the spread and severity of the crisis and the affected populations' ability to access necessary
healthcare services (Dow-Fleisner et al., 2022; Laborde et al., 2021; Peretz et al., 2020; Shah et
al., 2020). Benfer et al. (2021) have revealed that impoverished populations were more
vulnerable to diseases like COVID-19 due to their inability to practice proper hygiene or
implement social distance measures. Similarly, Dow-Fleisner et al. (2022) have found that rural
populations with limited access to reliable internet and devices encountered more significant
challenges in receiving treatment and preventative care during the COVID-19 crisis. According
to Tipirneni et al. (2021), understanding social determinants of health has been crucial in
addressing pandemics, including the 1918 influenza and 2009 H1N1 public health crises; hence,
targeted outreach efforts to at-risk populations, such as marginalized communities, help to reduce
the spread of the disease and to improve access to necessary healthcare services. Consequently,
by understanding the implications of the social determinants of health on the spread and severity
of public health crises, HHS leaders can develop more effective crisis management strategies to
address those underlying factors contributing to the seriousness of public health crises. By
recognizing the implications of social determinants of health and prioritizing trust-building, HHS
leaders can develop more effective crisis management strategies to address the multifaceted
challenges inherent in public health crises.

42
In relation to trust-building competency, another important public health principle is the
concept of the epidemiologic triad, which recognizes that disease outbreaks occur due to the
interaction between the host, the agency, and the environment (Pandit & Akkara, 2020; Thisted,
2003). The host is the person or organism susceptible to the disease, including age, genetics,
immune system function, and underlying health conditions. The agent is the microbe or pathogen
causing the disease (e.g., a virus or bacteria). The environment comprises the external factors
influencing the transmission and severity of the disease (e.g., climate, living conditions, and
access to healthcare).
Conceptual knowledge of the epidemiologic triad helps leaders understand the dynamics
of the public health crisis and identify the most effective interventions for prevention and control.
For example, Keyes et al. (2021) found that if the host is found to be particularly vulnerable to
the disease, crisis leaders may prioritize interventions to protect this population (e.g., vaccination
programs or targeted outreach campaigns), and if the agent is found to be particularly virulent or
easily transmitted, crisis leaders may prioritize interventions that reduce exposure to the
pathogen (e.g., social distancing or personal protective equipment). Considering the interplay
between the host, agent, and environment and applying the competency of trust-building enable
crisis leaders to understand better what influences the outbreak and develop more effective
strategies for managing the crisis (Compton & Jones, 2019; Melms et al., 2021; Pandit &
Akkara, 2020), which can include targeted interventions that address specific components of the
triad as well as trusted and broader public health measures that aim to reduce transmission and
protect vulnerable populations.

43
Help-Seeking (Metacognitive): Knowing When to Seek Help
HHS leaders must live up to elevated expectations as they juggle the responsibilities of
building and maintaining relationships with stakeholders, making decisions that affect various
groups, and independently addressing pressing issues every day. Moreover, they must intimately
understand the effective practices, social-emotional and trauma-informed practices, and cultural
sensitivity (Ambrose et al., 2010; Donnelly & Linn, 2019; Lins et al., 2023). Despite the
extensive amount of time spent working, moreover, leaders must also care for themselves and
stay current with HHS trends and legislative changes to avoid burnout. Metacognitive knowledge
is crucial for HHS leaders to understand their mental processes, including their ability to regulate
and monitor their thinking (Pintrich, 2002; Rhodes, 2019). Gottfredson and Reina (2020) have
revealed that an improved assessment of a leader's processing enables them to make more
strategic decisions by predicting events and conditions more accurately. Furthermore, helpseeking is a critical component of metacognitive knowledge, involving the recognition of when
one needs assistance or guidance and the pursuit of resources to address problems and challenges
(Ambrose et al., 2010; Robinson Hickman & Knouse, 2020).
Public health crises can be complex and multifaceted, requiring diverse expertise and
resources. Collaborating with other experts and seeking help can enhance the likelihood of
success in developing and implementing effective solutions, as stated by Robinson Hickman and
Knouse (2020). However, some leaders may be reluctant to seek assistance during crises because
of stigma or fear of being perceived as weak or ineffective, despite evidence showing that helpseeking can improve outcomes and increase the effectiveness of crisis management efforts
(Donnelly & Linn, 2019; Naser et al., 2019). Leaders must also overcome barriers to helpseeking, such as stereotype threat, lack of resources, or lack of knowledge about available

44
resources (Ambrose et al., 2010; Elliott et al., 2018; Gottfredson & Reina, 2020). By
understanding the significance of seeking help, knowing when and where to seek it, and
overcoming barriers, leaders can manage crises more effectively and improve outcomes (Medina
et al., 2017). This knowledge allows leaders to safeguard the wellbeing of their stakeholders.
Seeking help to overcome administrative preparedness difficulties from more knowledgeable
individuals or resources is a crucial aspect of independent learning for leaders dealing with
public health crises. Furthermore, help-seeking behaviors increase problem-solving effectiveness
(Naser et al., 2019; Rhodes, 2019). Therefore, regardless of any concerns about appearing weak
or ineffective, leaders must prioritize seeking support and resources whenever necessary. Table 3
represents the assumed knowledge influence and knowledge types essential for HHS leaders in
California rural counties to effectively address public health crises.
Table 3
Knowledge Influences
Assumed Knowledge Influence Knowledge Type
HHS leaders need to comprehend public health
principles and competencies to effectively
address public health crises.
Conceptual
HHS leaders need to be aware of their strengths
and weaknesses and seek appropriate assistance
to effectively address public health crises.
Help-seeking (metacognitive)
Motivational Influences
Clark and Estes (2008) emphasize that analyzing motivational factors is a critical
component of gap analysis. Motivation is essential for achieving objectives and addressing issues
related to human capital, operations, and performance, with studies consistently demonstrating
that motivated stakeholders contribute to improved organizational productivity (Grossman &
Salas, 2011). Schunk et al. (2008) postulated that active choice, persistence, and mental exertion

45
are the three most important characteristics in assessing motivated behavior. Active choice refers
to stakeholders' willingness to initiate the first steps towards goal achievement, while persistence
reflects an individual's ability to persevere despite obstacles and resource constraints. Finally,
mental effort pertains to the intensity and rigor with which employees approach problem-solving,
decision-making, and goal attainment (Clark & Estes, 2008; Schunk et al., 2008). These
recognized motivational behaviors can impact an individual's commitment to their objectives, as
they are motivated by an intrinsic and extrinsic desire for success.
Motivational factors can significantly influence decision-making and problem-solving
abilities, critical components of successful crisis leadership (Clark & Estes, 2008). In addition,
throughout all stages of a public health crisis, HHS leaders and stakeholders' motivations are
influenced by personal beliefs and experiences that might not necessarily be correct (Clark &
Estes, 2008). With this recognition, this study explores the impact of two motivational factors,
self-efficacy, and expectancy-value, on HHS leaders' administrative preparedness to manage
public health crises effectively.
Self-Efficacy: Assured Leadership
Bandura (1977) described self-efficacy as a psychological concept that refers to a
person's confidence in their capacity to succeed in a specific task or setting. Elliott et al. (2018)
identify self-efficacy as a significant motivational factor, since it can encourage individuals to
work on tasks, to exhibit perseverance in the face of challenges, and to efficiently accomplish
their goals. Conversely, Kayes (2004) found that individuals lacking self-efficacy are more
inclined to avoid complex tasks, give up quickly, and develop unfavorable feelings such as
anxiety and depression. According to Bandura (1977), self-efficacy is a more accurate indicator
of conduct in the face of potential threats than is past performance and suggests that self-efficacy

46
beliefs influence motivation through their impact on cognitive, affective, and behavioral
processes. Moreover, researchers have correlated performance on new and stressful tasks and
self-efficacy gained through prior accomplishments (Bandura, 1977). Bandura (1977) also
suggests that efficacy expectations impact performance by boosting the persistence and intensity
of one's efforts. For example, individuals with prominent levels of self-efficacy are more likely
to establish challenging goals, engage in active problem-solving strategies, and persist in the face
of setbacks, all of which increase motivation and achievement.
Self-efficacy is a significant predictor of leadership effectiveness in the HHS sector,
including public health crisis management (Revere et al., 2011; Sultan et al., 2020). When
leaders believe strongly in their ability to accomplish tasks and have positive expectations of the
achievement of a desired outcome, they are more likely to exhibit increased effort, perseverance,
and resilience during periods of change (Aguinis & Kraiger, 2009; Kotter, 2012; Rueda, 2011).
For instance, Baluszek et al. (2023) found higher levels of self-efficacy among public health
leaders to be associated with better crisis response efforts during the COVID-19 pandemic. In
rural regions, where resources and infrastructure may be restricted, self-efficacy may dictate
HHS leaders' ability to address public health crises effectively. According to Lochmiller's (2021)
findings, self-efficacy significantly predicts how well rural superintendents will navigate local
control during public health crises. Furthermore, factors such as leadership style, tasks, and
organizational culture can influence the impact of self-efficacy on crisis preparedness and
response. Sriharan et al. (2022) found leaders to crucially manage crises particularly at the
intersection of tasks, people, and adaptive efficacy, where contextual factors such as politics,
structure, and culture can affect the efficacy of their leadership. In the context of pandemics,
traditional command and control leadership styles are ineffective, as leaders must interact with

47
tasks and people and apply adaptive and transformative leadership styles (Egbuonye et al., 2022;
Smithson, 2021; Sriharan et al., 2022).
Moreover, leaders of California rural county HHS must make prompt decisions under
critical time pressure (Bieńkowska et al., 2020). Effective administrative preparedness in the
management of public health crises demands strong leadership that can make quick and informed
decisions despite limited information, as Goniewicz et al. (2021) has emphasized. The ability of
an HHS leader to act swiftly despite insufficient information is an important quality in crisis
management, according to Kaiser (2020). Consequently, leaders must endure the immense
pressure to plan and respond to public health crises by making flexible and timely decisions with
both immediate and long-term consequences, requiring a high degree of self-efficacy
(Hirudayaraj & Sparkman, 2019). The research suggests that self-efficacy is an essential
motivational influence on rural county HHS leaders' administrative preparedness to address
public health crises effectively.
Expectancy-Value: Value in Crisis Preparedness and Response
HHS leaders in rural California counties can enhance their administrative preparedness
for public health crises by acknowledging the practical benefits of managing such situations and
presenting trust in their capacity to improve crisis leadership behaviors and results (Eccles &
Wigfield, 2002; Rueda, 2011). According to expectancy-value theory, an individual's motivation,
perseverance, and mental effort increase in direct proportion to how valuable and important they
consider the action or project to be (Eccles & Wigfield, 2002; Finn et al., 2023) and how
confident they are that they can influence the desired results (Bandura, 2000). The expectancyvalue theory considers a person's internal processes and cognitive expectancies of their
probability of success at a task more than does the self-efficacy theory, which is more centered

48
on a person's view of their competence. On the former theory, individuals are more inclined to be
motivated when they recognize a task as essential (utility value) and have confidence that they
can do it (self-efficacy) (Eccles & Wigfield, 2002; Finn et al., 2023; Rueda, 2011). Expectancy
outcomes depend on external factors that impact the likelihood of success (Eccles & Wigfield,
2002).
By increasing their knowledge of the benefits of effective crisis management, rural
county HHS leaders in California can generate expectancy-value motivating them to prioritize
administrative preparedness for public health crises. Eccles and Wigfield (2002) posit that
individuals are more motivated when they have high expectations of themselves and their ability
to complete tasks and assign considerable value to the task. Furthermore, Eccles and Wigfield
(2002) suggest that individuals are more driven to complete a task when they perceive it as
necessary, valuable, and connected to their self-image, suggesting that motivation and attainment
value increase when a task is associated with an individual's values and self-identity (Pintrich,
2003). In addition, Bastons et al. (2017) and Cherniss and Goleman (2001) highlight that
individuals are more likely to be further motivated to work on difficulties when aligned with
their beliefs or the concerns of other stakeholders, improving results. Table 4 illustrates the
presumed motivation influence and motivational type necessary for HHS leaders to effectively
address public health crises.
Table 4
Motivation Influences
Assumed Motivation Influence Motivation Type
HHS leaders need to feel confident in their
ability to effectively address public health
crises.
Self-efficacy
HHS leaders need to believe there is value in
effectively addressing public health crises.
Expectancy-value

49
Organizational Influences
According to Clark and Estes' (2008) gap analysis framework, knowledge, motivation,
and other organizational factors underpin achievement of performance goals and success. The
diagnosing of a performance gap must consider both individual knowledge and motivation
influences, as well as organizational influences. Even if individuals possess the necessary
knowledge and motivation, organizational barriers can hinder their ability to achieve
performance goals (Clark & Estes, 2008; Rueda, 2011). Therefore, the organizational setting is
crucial in providing California rural county HHS leaders with the necessary training,
communication skills, and resources to effectively prepare for and address public health crises.
Moreover, Clark and Estes (2008) have noted that organizations are intricate systems
with unique organizational cultures, which can be the primary factor in determining whether an
organization succeeds or fails. Researchers suggest that observable characteristics in the
workplace demonstrate the cultural atmosphere, even though organizational cultures are firmly
rooted in the organizational structure and may not always be apparent (Elliott, 2009; Schein,
2017). Research indicates that each organization possesses a unique culture that can impact its
responses during a crisis (Adamu et al., 2016). Nizamidou and Vouzas (2020) recommend that to
effectively manage diverse types of crises, organizations must regularly examine their
organizational culture to ensure successful crisis management. Bhaduri (2019) suggests that
organizational culture helps to determine an organization's response to a crisis and the extent to
which successful leadership can prevent or manage it. This section will concentrate on the
assumed organizational influences associated with strengthening administrative preparedness to
address public health crises effectively and prevent an adverse effect on the health and wellbeing

50
of the community by equipping HHS rural county leaders with support and increased
competency in crisis management.
Valuing and Promoting Comprehensive Training for Leaders: An Organizational Model
Training and exercise activities are vital in enhancing the organizational readiness (Khan
et al., 2018) of rural county HHS leaders to effectively manage public health crises. These
activities develop necessary competencies among leaders, enabling them to perform and lead
efficiently during a public health crisis. Defining preparation is a persistent challenge for HHS
leaders, despite the significance of upstream readiness; the challenge stems from a knowledge
gap in existing frameworks, which do not account for the complexity pertinent to health systems
and the public health crisis context (Khan et al., 2018). To excel in their roles, HHS leaders must
possess proficiency in crisis leadership abilities and cross-disciplinary cooperation throughout all
crisis phases of precrisis, crisis, and postcrisis, where the competencies should surpass
discipline-specific functional capabilities (Burkle, 2019; Richmond et al., 2021; Sriharan et al.,
2022).
California rural county HHS leaders commonly receive training in the Incident Command
System (ICS) and the National Incident Management System (NIMS), aimed to enhance the
knowledge and capabilities of leaders who manage public health crises (Buck et al., 2006;
Department of Homeland Security et al., 2021). Through ICS/NIMS training, HHS leaders gain
insight into the general strategy, techniques, and resource allocation, as well as the
comprehensive power and accountability required for all operational needs during a crisis.
However, according to McNulty et al.'s (2018) research, the customary ICS/NIMS training fails
to address the behavioral elements leaders should consider to effectively manage during crises.
For example, certain cognitive and perceptual elements and shared mindsets can undermine

51
operational structures and impair situational awareness, limiting leaders' performance (Bigley &
Roberts, 2001; Bundy et al., 2017). In line with Zimbardo and Leippe's (1991) statement that the
organizational context strongly affects behavior, Schoenberg (2005) suggested that the
environment regularly determines the leaders' responses. Moreover, McNulty et al. (2018) call
for increased adaptive capacity, highlighting the need for leaders to close the gap between the
ICS/NIMS operational implementation and how people react in times of crisis. Finally, when
focused on leaders and their needs, Schoenberg (2005) reveals the importance of essential
discussions on values, authenticity, trust, and leadership beyond providing one-time training on
the ICS/NIMS system. Further, HHS leaders must exhibit rationality and dynamic
appropriateness for the crisis (Bigley & Roberts, 2001). To address this issue, McNulty et al.
(2018) and Paulus et al. (2009) propose the integration of brain science into crisis leadership
training systems as a training approach to robust performance in crises and extremely stressful
events.
Training programs customized to address the neurological and psychological aspects of
crisis preparation and response could enhance the development of crisis leaders when aligned
with ICS/NIMS (McNulty et al., 2018). The National Preparedness Leadership Initiative (NPLI),
a joint initiative between the Harvard School of Public Health and the Harvard Kennedy School
of Government, aims to equip leaders with the necessary skills to navigate the complex and highstress environments of crises effectively (National Preparedness Leadership Initiative [NPLI],
2021). The NPLI designs training programs to supplement ICS/NIMS training and address the
divide between technical skills and the political, social, and organizational challenges that crisis
leaders often face, and these programs emphasize collaboration, communication, and strategic
thinking to prepare leaders from various organizations and sectors to work together effectively

52
during crises. The NPLI program curriculum derives from the meta-leadership framework
(Marcus et al., 2006), which consists of three key dimensions: (a) the person of the meta-leader;
(b) the situation; and (c) connectivity in and across the meta-leaders system of individuals and
entities essential for success (as depicted in Figure 4) (McNulty et al., 2018). Moreover, the
NPLI training explores emotional intelligence (Cherniss & Goleman, 2001; Hajncl & Vučenović,
2020; Wittmer & Hopkins, 2022), the Triple F survival response to threat, which are freeze,
flight, or fight (LeDoux, 2014; McNulty et al., 2018), and mindfulness practices (Frewen et al.,
2010; Kantor et al., 2020), all of which dictate the effectiveness of crisis leadership. Even with
the ICS/NIMS management system training in place, the human element of a crisis response
cannot be overlooked. To be effective, crisis leaders need to deeply understand themselves and
the interpersonal dynamics between all stakeholders. If trained adequately by their organizations,
leaders can manage emotions and prepare for crises, as Moran (2010) noted. Leaders' selfunderstanding can be cultivated by incorporating more comprehensive training in neurological
and psychological phenomena and techniques to manage their impact, viewing crisis events as
opportunities rather than threats, and becoming equipped to manage disruptions, as highlighted
by Wicker (2021).

53
Figure 4
The Dimensions of Meta-Leadership
Note. From "Meta-leadership and National Emergency Preparedness: A Model to Build
Government Connectivity," by L. Marcus, B. Dorn, and J. Henderson, 2006, Biosecurity and
Bioterrorism: Biodefense Strategy, Practice, and Science, 4(2), 128-134.
Richmond et al. (2021) advocate coordinated crisis preparedness training with multiple
federal, state, and local authorities, in addition to the commercial sector and nonprofit
organizations. Such coordination would establish an ideal setting for relationship building.
According to Hertelendy et al. (2021), the time has come to go beyond reference to other
organizations as "partners" and to understand that every stakeholder must excel in their area of
expertise while collaborating effectively with others at all levels of a profession. In complex
crises, it should be assumed that no one has all the answers, and everyone may help find
solutions, from preparation through recovery (Hertelendy et al., 2021). Strong interconnectivity
within coordinated and regular training can reveal unknown, unrecognized assets. Collectively,

54
rural county HHS leaders in California that receive crisis management training with enhanced
neurological and psychological training and train for all stages of crises regularly with various
stakeholders may enhance the transfer of training throughout an organization (Grossman &
Salas, 2011) to effectively address public health crises and apply the training knowledge into the
culture of the organization (Alexander et al., 2009).
Provide Necessary Resources: An Organizational Setting
According to Albrecht et al. (2018), the effectiveness of leadership in crisis management
depends on the organization providing essential resources, as resource allocation within an
organization can influence the leaders' cognition, emotional responses, and reactions to
momentous events. When leaders cannot acquire the required resources, they can be inundated
by competing priorities, pressing needs, and ambiguity, resulting in stress, as observed by Kaiser
(2020). Dirani et al. (2020) propose that leaders must be able to share leadership, possess the
necessary resources, provide them to stakeholders, and promote organizational resilience.
Organizations must distribute their resources appropriately to address public health crises
(Gifford et al., 2022). These resources are the sources of the aid and materials an organization
provides to individuals or groups to help them achieve an organizational goal (Albrecht et al.,
2018; Gifford et al., 2022).
During a crisis, the public expects government leaders to minimize impact and restore
normality while fostering collective learning from experience. Resource availability defines a
significant element of government's ability to effectively manage a crisis, especially locally,
where stakeholders directly interact with crisis leaders (Nilsson, 2010). Planning and establishing
protocols before a crisis can significantly improve crisis management, minimize risk, and prevent
inefficient use of resources (Burnett, 1998; Kash & Darling, 1998). Including knowledge, skills,

55
time, and support from executive leadership, resources are crucial in crisis management. The
threat appraisal model proposed by Jin and Cameron (2007) identifies situational demands and
organizational resources as critical factors. Budget deficits, limited personnel, and lack of
funding are among local governments' most pressing challenges (Aikins, 2021; Dulal, 2017).
Organizational resources, financial, staff, and temporal limitations are primary considerations in
crisis management, directly affecting organizational resilience. Organizations with adequate
resources for crisis management will have better crisis preparedness and be more resilient in
effectively managing crises; however, local government leaders' views on the crisis resilience of
local governments remain unknown (Ott, 2022; Somers, 2009).
Research studies have identified organizational size and type as significant factors in
crisis preparedness, with larger and for-profit organizations having better crisis management
capabilities because they have more internal resources than smaller, not-for-profit organizations
(Cloudman & Hallahan, 2006; Guth, 1995; Penrose, 2000). In contrast, Avery et al. (2016) found
no correlation between the size of local governments and their interpreted ability to manage
crises effectively, clearly showing the need for future investigations into how the size of local
governments and their available resources influence public health crisis preparedness and
resilience. Finally, in the context of crisis management for local government leaders, Park et al.
(2022) examined the availability of internal resources, including time, financial resources, and
staff.
Although all three categories of internal resources were considered necessary, their
perceived availability decreased significantly, meaning local government leaders believed they
lacked the necessary internal resources to effectively address crises. The lack of discrepancies
between the community's size and the government's structure indicates that local government

56
crisis leaders should be prepared to utilize the existing resources efficiently and innovatively
(Park et al., 2022). In addition, scarce resources may increase organizational and public
uncertainty, which is vital to crisis resilience (Park et al., 2022). In general, resource scarcity is
expected to accompany public health crises. Therefore, within the political frame, as described
by Bolman and Deal (2021), HHS leaders must be adept at advocacy and politically astute, and
must spend significant time networking, building power bases, and establishing coalitions to help
overcome limitations and effectively addressed public health crises.
Transitioning from the broader organizational context to the specific challenges faced by
rural counties, it is essential to recognize that these areas often require additional resources due
to unique factors such as geographical isolation, limited access to healthcare facilities, and a
higher prevalence of chronic conditions (Cox et al., 2023; Golembiewski et al., 2022). Rural
counties may also face challenges in attracting and retaining skilled healthcare professionals,
further exacerbating the resource gap (Cosgrave, 2020). Supporting the management of public
health crises in rural areas with resources enables HHS leaders to develop and implement crisis
response teams and plans to coordinate with community partners, communicate effectively with
stakeholders, and manage resources efficiently (Coombs, 2022; Kapucu et al., 2013). HHS
leaders with limited resources can prove unable to mitigate the severe consequences that can
impact the health and wellbeing of the communities they serve (Fink, 2014; Nizamidou &
Vouzas, 2020). The context of public health crises is constantly changing and unpredictable
(Burkle, 2019). As new challenges and risks arise, HHS leaders must regularly practice several
skills to improve their preparedness and ability to respond to public health crises. These include
continual planning, preparedness, and resource management (Coombs, 2022; Danforth et al.,
2010; Silverman et al., 2016; Walecka, 2021; Woitaszewski et al., 2020).

57
Planning and preparedness involve developing and maintaining crisis response plans that
are regularly reviewed, updated, and tested (Avery et al., 2010). Crisis response plans enable
HHS leaders to respond effectively to public health crises, including natural disasters, disease
outbreaks, and other emergencies (Calonge et al., 2020). These plans outline the actions HHS
agencies will take in the event of a crisis, including allocating resources, communicating with the
public and other agencies, and coordinating response efforts (Comes et al., 2022). However, the
crisis response plan must be regarded as an outline, not a roadmap, for managing crises
(Hitchcock et al., 2021). Multiple vital steps should be considered when implementing a crisis
response plan in HHS (Brownson et al., 2020; Coccia, 2022; Coombs, 2022; Horney et al., 2017;
Silverman et al., 2016).
First, the HHS leader must form a crisis management team of cross-functional
stakeholders within the organization to manage potential crises (Coombs, 2022). This team
should be considered a community of practice, consisting of individuals who share a common
interest, learn from one another, and apply their knowledge to solve problems. According to
Coombs (2022), this team should be more than just a list of people on a crisis management
document. The team should meet regularly to discuss crisis communication and management,
aiming to improve their practice continually. Surprisingly, the American Management
Association discovered that only 56% of organizations with crisis management plans had
established a designated crisis management team (Huffmire, 2005).
Next, the HHS leaders and their crisis management team should conduct a risk
assessment to identify the crises in their communities (Hassel & Cedergren, 2021). Based on this
assessment, they should develop an all-encompassing crisis response plan that outlines resource
allocation, communication, and coordination procedures with other agencies. Subsequently, the

58
crisis management plan should establish clear communication channels to ensure accurate
information is shared promptly and transparently. The communication channels can be used to
create an emergency hotline or website, develop messaging and public information materials,
establish a social media strategy with messages crafted to populate social media channels and
monitor social media for early detection threats, allowing for fast organizational resolution of
crises (Danforth et al., 2010; Diddi & Wei, 2022; Vignal Lambret & Barki, 2018).
Furthermore, HHS leaders and their crisis management team should receive regular
training on crisis response procedures and protocols to ensure they are prepared to respond
effectively to public health crises. Regular testing and review of the crisis response plans are also
essential, allowing leaders to identify areas for improvement and ensure that the plan is current
and effective. Research has shown that implementing a crisis response plan can help HHS
agencies respond effectively to public health crises and protect the health and wellbeing of the
communities they serve. For instance, a study by the CDC found implementing a crisis response
plan to be associated with a more efficient and effective response to a tuberculosis outbreak in a
rural county (Cole et al., 2022). Lastly, effective resource management systems ensure
personnel, equipment, and supplies are available and accessible when needed (Woitaszewski et
al., 2020). By practicing these factors, rural county HHS leaders can effectively enhance their
administrative preparedness to address public health crises (Coombs, 2022; Danforth et al.,
2010).
Prioritize and Promote Communication: An Organizational Model
Historically, the principal responsibility of HHS was to inform individuals about health
hazards and motivate them to make beneficial lifestyle modifications to minimize those risks.
However, HHS responsibilities now exceed simply informing the public about potential health

59
risks: Events such as the 1997 H5N1 outbreak and 9/11 demonstrated that HHS plays an
increasingly extensive role beyond simply informing the public about potential health hazards
(Brownson et al., 2020; Danforth et al., 2010; Quinn, 2008; Sriharan et al., 2022; Veil et al.,
2008). Instead, the function of HHS has expanded to include an unprecedented role as a first
responder, together with a diverse set of communication requirements necessitating clear
guidelines for stakeholders to deliver effective crisis management services, shifting their focus to
recognize crisis-based limitations make even more critical the messaging that urges people to act
to protect themselves (Sriharan et al., 2022; Veil et al., 2008).
In 2002, the CDC introduced the Crisis and Emergency Risk Communication (CERC)
framework in response to the increasing responsibilities of HHS (Centers for Disease Control
and Prevention [CDC], 2018; Veil et al., 2008). Using research in psychology, communication,
problem management, and past crisis response, the CDC's CERC provides an established
framework and strategies for stakeholders to communicate on behalf of an organization during a
public health crisis (CDC, 2018). The CERC framework comprises six principles: be first, be
right, be credible, express emphatic sentiment, encourage action, and demonstrate respect (CDC,
2018). In every crisis phase, these principles ensure that limited resources are managed
effectively and used to maximum effect (Coombs, 2022; Sriharan et al., 2022; Veil et al., 2008).
Communication must be especially effective when addressing public health crises.
California rural county HHS leaders require effective communication skills to provide clear
information to the public and other stakeholders, fostering a shared understanding delivered
promptly for a common purpose (Ansell & Boin, 2019; Coombs, 2022; Sharfstein, 2023).
Scholars have advised the organizational creation and, through exercise simulation, regular
utilization of a CERC plan to enhance effective communication (Coombs, 2022; Miller et al.,

60
2015). The CERC plan provides the organization with a framework that allows for the
predetermination of processes in the case of a crisis and aids in the creation of an organized and
efficient response effort, which is advantageous as crises are time-pressured events demanding a
rapid response (Coombs, 2022; Miller et al., 2015). Furthermore, the development of the
organizational CERC framework necessitates a collaborative effort from partnering stakeholders
to strengthen the framework's coherence, unified approaches, and prioritized tasks. In addition,
the advancement of connections, facilitation of information sharing, and increased mobilization
of resources across stakeholders proves essential to communicating timely information when
addressing a public health crisis (Coombs, 2022; Kim, 2018; Mazzei et al., 2012; Veil et al.,
2008).
An organization's strategy for addressing public health crises must address effective
communication, as it reduces uncertainty and ambiguity during a crisis (Coombs, 2022; Gifford
et al., 2022; Kim, 2018). Nevertheless, when communication fails, the implications for the
organization, the leader, and the community can be severe (Dubé et al., 2022; Kim, 2018; Veil et
al., 2008). Prominent causes of communication failure during a crisis include inconsistent
messaging and lack of transparency (Dubé et al., 2022; Kim, 2018). An organizational leader
who conceals information about a crisis and delivers inconsistent messages can generate mistrust
among stakeholders, harming the organization's reputation, reducing its credibility, or in the
worst-case scenario, leading to its demise (Veil et al., 2008). Yoon (2022) reveals a significant
discrepancy between South Korea and the United States. For example, in comparison to South
Korea, the United States has suffered a 52-fold rise in the number of infected patients and a 49-
fold increase in the number of deaths from COVID-19, which is attributed to the effectiveness of
South Korea's response to the crisis being its emphasis on information transparency and

61
consistent messaging building capacity and helping to prevent the virus's spread among the
population. Sharfstein (2023) highlights communication errors such as the CDC and the White
House sending contradictory statements, together undermining the credibility of all governmentproduced messages and thereby, eroding trust and increasing COVID-19 death tolls in the United
States.
The research mentioned above, alongside other studies (Dubé et al., 2022; Kim, 2018),
demonstrates the significance of using the CERC framework consistently to develop successful
social response systems to eliminate discrepancies in communication that can amplify the
severity of a crisis. In sum, an organization's crisis communication framework enables leaders to
effectively address public health crises, and if implemented poorly, may result in multiple losses.
Yet, organizational leaders can mitigate a crisis and preserve stakeholder trust if they face crises
transparently, empathically, and responsively. Table 5 presents the assumed organizational
factors and categories deemed essential for HHS leaders to address public health crises
effectively.
Table 5
Organizational Influences
Assumed Organizational Influence Organizational Category
The organization needs to value and promote
comprehensive training to HHS leaders to
effectively prepare for and respond to public
health crises.
Organizational model
The organization needs to provide HHS
leaders with resources to prepare for and
respond to public health crises.
Organizational setting
The organization needs to prioritize and
promote communication to effectively prepare
for and respond to public health crises.
Organizational model

62
Conceptual Framework
This study applied Clark and Estes' (2008) a modified gap analytical framework to
address the problem of practice. This framework enables the assessment of performance needs
within an organization caused by deficiencies skills or KMO barriers, allowing the identification
of discrepancies between actual and desired performance levels and viable solutions to meet
performance goals. The framework is particularly relevant for the examination of California rural
county HHS organizational factors that can foster or shape leadership competencies to address
public health crises. Figure 5 demonstrates the conceptual framework showing the
interconnected relationship and alignment of KMO influences that can enhance California rural
county HHS leaders’ capacity to address public health crises effectively.
A conceptual model grounds a research study, including the key concepts, thoughts, and
ideas guiding the study (Merriam & Tisdell, 2016). Clark and Estes' (2008) model evaluated the
three key KMO factors, highlighting ways the organization can cultivate HHS leaders'
effectiveness in addressing public health crises in California rural counties. First, organizations
can bolster the HHS leaders' acquisition of further conceptual and help-seeking knowledge
(Krathwohl, 2002; Rueda, 2011) to enhance administrative crisis management processes to
improve prevention, preparation, response, and revision (Coombs, 2022) concerning public
health crises. Second, there is an opportunity for HHS organizations to provide leaders with the
opportunity to gain crisis experience (Heath et al., 2018) that can enrich motivational factors
such as self-efficacy and expectancy-value (Bandura, 2000). Third, by providing comprehensive
administrative preparedness training, effective communication strategies, and essential resources,
organizations can strengthen their organization's overall culture (Schein, 2017) concerning public
health crisis management.

63
Figure 5
Conceptual Framework
Summary
HHS leaders in California rural counties have faced several unpredictable and complex
public health crises (e.g., COVID-19, opioid epidemic, climate hazards, and health inequities).

64
The role of HHS leaders has evolved in recent decades to first responders of public health crises,
requiring an enhanced skill set to address public health crises.
The literature review further examines the presumed knowledge, motivation, and
organizational influences necessary to effectively address public health crises. The knowledge
influences included conceptual and help-seeking knowledge of a leader's capability to understand
relevant health principles and competencies, the epidemiologic triad, and the formation of
management teams. The motivational factors focused on self-efficacy and expectancy-value,
demonstrating leaders' ability to make prompt decisions under time pressure and assign values to
essential crisis tasks. Organizational influences included organizational settings and culture, such
as training, resources, and communication, providing the tools required to prepare for and
respond to public health crises to build trust and prioritize the health and wellbeing of the
community they serve. Lastly, the modified gap analysis framework developed by Clark and
Estes (2008) was drawn upon to create a modified conceptual framework exploring the assumed
knowledge, motivation, and organizational factors that impact the goal of competent crisis
leadership during all stages of crisis management.

65
Chapter Three: Methodology
The purpose of this qualitative research study is to analyze the organizational factors
influencing the administrative preparedness of HHS leaders in rural California to address public
health crises effectively. The study aims to understand organizational factors influencing HHS
leaders' ability to increase organizational performance and mitigate measures to lessen
community health and economic consequences amid crises. The importance of adequately
supported and well-prepared HHS leaders is central to sustaining effective organizational
operations during a crisis. The analysis in this study focuses on the HHS leaders' knowledge,
motivational, and organizational influences supported by the organization that contributes to
leaders' successful administrative preparedness to address public health crises. This chapter
details the methodology used to conduct this research, including the research question, an
overview of the methodology, data collection methods, instrumentation, and data analysis.
Finally, the chapter outlines relevant ethical considerations and the role of the researcher in
conducting this study.
Research Question
The study utilizes Clark and Estes' (2008) modified gap analytical framework to examine
the assets of knowledge, motivation, and organizational support that facilitate effective
preparation and execution during public health crises while identifying and addressing
organizational barriers that can impede the utilization of these valuable assets. As such, the
following question guide the study:
1. What are the knowledge, motivational, and organizational needs and strengths of
California rural county HHS leaders that influence public health crisis management?

66
Overview of Methodology
This qualitative research study examines the administrative preparedness of California
rural county HHS leaders to address public health crises. The primary data collection strategy for
this study were interviews. Interviews were selected as the preferred data collection method to
support a detailed analysis of the research topic from the perspective of stakeholders within the
ELT of the California rural county HHS organization. When direct observation of actions,
thoughts, or interpretations of the world is not possible, Merriam and Tisdell (2016) suggest
using interviews as a data-gathering strategy. Qualitative interviews utilize open-ended questions
to impart participants' beliefs and points of view (Creswell & Creswell, 2018), which makes
them helpful in explaining complex phenomena, such as the administrative preparedness of HHS
leaders in rural California counties to respond to public health crises.
Table 6
Data Sources
Research Question Interviews
RQ1: What knowledge and skills do California rural county HHS leaders need
from the organization to influence public health crisis management? X
Data Collection, Instrumentation, and Analysis Plan
The study used a qualitative research approach incorporating a pragmatic paradigm with
an interview design and inductive research methods. Qualitative research attempts to explore and
understand the lived experiences of research participants in their natural settings to gather rich
data to make sense of a phenomenon (Creswell & Creswell, 2018). Moreover, qualitative
research is valuable when subjective and personal factors, such as the given problem of practice,

67
drive inductive analysis (Creswell & Creswell, 2018). Furthermore, the pragmatic paradigm
meaningfully guided the research in seeking valuable contributions (Saunders et al., 2019) to
close the organizational needs of HHS leaders that embrace crisis management to dismantle
inequities, increase community resilience, mitigate illness and injury, and save lives.
Method: Interviews
In qualitative research, conducting interviews becomes useful when it is not possible to
observe the behavior, feelings, or the interpretation of the world by others (Merriam & Tisdell,
2016). Merriam and Tisdell (2016) state that researchers must conduct interviews when studying
past events that cannot be replicated with identical conditions. In this research, interviews were a
necessary tool to gather and investigate previous public health crisis experiences as reported by
the California rural county HHS leaders. The fundamental reason to conduct interviews is to
collect extensive information on the participants' conceptual and help-seeking or metacognitive
knowledge, in addition to their self-efficacy and expectancy-value. Furthermore, the interviews
aim to evaluate the influence of organizational training, communication, and resources on the
administrative preparedness of the participants to address public health crises. By examining
these factors in conjunction with the participant's feelings, beliefs, and understanding (Merriam
& Tisdell, 2016) of leadership in public health crisis administrative preparedness, it is possible to
identify areas in which organizational support may be inadequate and to develop practical
implementation strategies. Consequently, interviews are critical to this study, as they provide
invaluable insights into the subject under investigation.
Participating Stakeholders
A purposeful sampling method was employed to choose 15 stakeholders from rural
counties in California, as the researcher wants to select participants that can provide rich

68
information relevant to the research topic (Merriam & Tisdell, 2016). The interviews involved
members of the ELT responsible for managing HHS, including branch or deputy directors of
social services, public health services, and behavioral health services. These HHS leaders set the
vision and direction, guiding all organizational stakeholders, and postulating decision-making
power. Moreover, HHS leaders create a roadmap for how the organization will achieve its
organizational goal, creating tremendous potential for success or failure concerning
administrative preparedness efforts to address public health crises. Finally, the stakeholders must
hold a leadership position in a California rural HHS county. Although the sample may not be
representative of all leaders in the state government sector of California's rural counties, it
provided an opportunity to gather valuable data from individuals who can influence the
organization and advance the research. By selecting the abovementioned participants, the
researcher will capitalize on the relevance and quality of the data collected from the selected
participants (Merriam & Tisdell, 2016).
Instrumentation
To gather rich data about the participant’s “thoughts, beliefs, knowledge, reasoning,
motivations, and feelings” (Johnson & Christensen, 2015, p. 233), semi-structured open-ended
interviews with each participant were employed. A guided list of questions was utilized during
the interviews to explore relevant topics. The questions were asked flexibly, without any
predetermined sequence, to encourage an open and informative discussion (Merriam & Tisdell,
2016). Appendix A contains a semi-structured open-ended interview protocol designed to explore
the administrative preparedness of crisis management among California's rural county HHS
leaders. The objective was to understand better relevant knowledge needs and assets and the
motivational and organizational factors that may influence leaders' readiness to address public

69
health crises. Participants were virtually interviewed in their usual work environment, providing
a familiar and comfortable setting. Probes and follow-up interviews were used as needed to elicit
in-depth insights into their thoughts and feelings (Creswell & Creswell, 2018; Johnson &
Christensen, 2015). Eligible participants in the study included California rural county HHS
leaders occupying an executive leadership role in a rural county HHS organization and with the
authorization to impact crisis management administrative preparedness policies and procedures.
The selected participants shared experiences and positions yielding deep and broad information
(Creswell & Creswell, 2018).
Data Collection Procedures
To recruit eligible participants for the interview process in this research study, the
researcher utilized publicly available email addresses to contact individual HHS leaders who
meet the sample criteria. Upon acceptance of the initiation, a mutually agreed-upon date and time
was scheduled for the interview. Before beginning the study, the researcher shared information
about the project with each participant, including details outlined in the Information Sheet for
Exempt Studies, to ensure they completely understood their rights. The virtual platform Zoom
was used to conduct the interviews. Each interview lasted 60 minutes, and the researcher
recorded each interview for later transcription while taking notes during the interviews. The
researcher completed the interviews of 15 selected participants over two months, from
September to October 2023.
Data Analysis
Merriam and Tisdell (2016) identify data analysis as the systematic examination and
interpretation of data to derive significant insight and knowledge. The data analysis in this study
commenced simultaneously with the interview process. Following the process suggested by

70
Creswell and Creswell (2018), the researcher documented the observations, reflections, and
preliminary findings concerning the gathered data, considering the research question and
conceptual framework to develop a rigorous and meaningful approach to the analysis of
qualitative data. After each interview, the researcher used a multi-phased method to categorize
and analyze the qualitative data. During the preliminary stage, the researcher transcribed each
interview. The subsequent phase of the examination used an a priori coding method, drawing
from the research question, the conceptual framework, and the researcher's extensive
engagement with the data, followed by in vivo coding to reveal additional themes that were not
identified as components of the knowledge, motivation, and organizational influences.
Utilizing a priori and in vivo coding techniques facilitated the recognition of recurring themes
and trends within the data obtained from all interview participants. In the final phase of analysis,
emergent themes were examined, and their association to knowledge, motivation, and
organizational influences concerning California county HHS leader's crisis management and
administrative preparedness to address public health crises was generated.
Credibility and Trustworthiness
Merriam and Tisdell (2016) maintain distinct dimensions to evaluate research credibility
and trustworthiness. Specifically, they reason that a rigorous research process ensuring the
validity and reliability of the study is necessary to achieve trustworthiness (Merriam & Tisdell,
2016). Researchers establish credibility through ethical research practices involving explicit
disclosure of the responsibility of the researcher and relationship with the study participants, a
clear justification of the significance of the study, an in-depth review of the research
methodology employed, and a convincing presentation of the findings (Merriam & Tisdell,
2016). To further promote the credibility and trustworthiness of the research study, the researcher

71
engaged in reflexivity, as Creswell and Creswell (2018) suggest, to encourage ongoing selfreflection throughout the research process. Finally, the researcher adopted a qualitative design,
using non-leading interview questions and verbatim transcripts to facilitate accurate coding and
generate comprehensive and descriptive data that reflects the participant's experience (Merriam
& Tisdell, 2016).
The Researcher
The primary agent of qualitative data collection, the researcher, must be aware of their
positionality to maintain objectivity throughout the research process (Creswell & Creswell, 2018;
Merriam & Tisdell, 2016) to establish research trustworthiness and mitigate potential bias. The
researcher has worked at HHS for over 20 years and has served as a public information officer
(PIO) for a rural county during multiple crises. In 2009, the researcher wrote the first CERC plan
for a rural county public health agency. Through this work, the researcher has come to
understand the vital goal of protecting the health and safety of the community each day,
especially during a crisis event. However, recognizing their role and professional experiences,
the researcher is aware that internal bias regarding issues under study may arise. Therefore, it is
essential to employ Merriam and Tisdell’s (2016) recommended strategies to remove personal
thoughts and beliefs about the study's administrative preparedness for crisis management.
To mitigate potential assumptions and biases, the researcher is implementing multiple
strategies to strengthen the study's credibility, consistency, and transferability. First, the
researcher engages in reflexivity to reflect on their understanding of the problem and the
participants’ lived experiences. Reflexivity allows the researcher to “reflect about their biases,
values, and personal background” (Creswell & Creswell, 2018, p. 269). Reflexivity entails
continual self-reflection, noting the participants' lived experiences and not the researcher's own.

72
Finally, the researcher approached the qualitative design and procedures to include non-leading
interview questions and to capture verbatim transcripts, to enhance accurate coding and provide
rich and holistic descriptive data (Creswell & Creswell, 2018; Merriam & Tisdell, 2016).
Ethics
Merriam and Tisdell (2016) state that qualitative research requires investigation that is
ethical, ensuring the study’s validity and reliability. Further, “it is ultimately up to the individual
researcher to proceed in as ethical a manner as possible” (Merriam & Tisdell, 2016, p. 260).
Therefore, this study incorporates several measures to address the researcher's role and ensure
adherence to ethical standards established for research.
The researcher adhered to the Institutional Review Board (IRB) guidelines of the
University of Southern California (USC), including "do no harm" and the securing of informed
consent, ensuring that all participation is voluntary and that all participants are aware of the study
and can appropriately balance the risks and benefits. The research participants also received an
information sheet detailing the study's objectives, participation conditions, and confidentiality
guidelines for exempt research. The university's independent review board approved the study to
ensure the participants' protection before the interviews occurred.
To record the interviews, the researcher obtained approval and took necessary
precautions to secure and store the data in a secured, inaccessible area, maintaining the
confidentiality and integrity of the information recorded throughout the research. The researcher
also designed the proposed study to eliminate unnecessary risks to the participants and ensure
confidentiality. However, risk for participants could not be entirely eliminated, since participants
were asked to describe their lived experiences concerning crisis prevention, preparation,
response, and revision. Although the study’s purpose is to explain the possible risks, asking

73
participants to “relive” an emotional event may trigger a trauma. To mitigate this risk, the
researcher applied trauma-informed practices and informed the participants that they could take a
break at any time. When a subject was too emotional, the participant could stop speaking about it
at any time.
Finally, the researcher considered ethical issues through continual self-reflection and
examination of these reflections to minimize any obstruction to the trustworthiness of the study
arising from personal biases or philosophical positions. According to Merriam and Tisdell
(2016), the most effective approach for researchers is to remain mindful of ethical considerations
that may impact their research and critically assess their philosophical beliefs regarding these
issues.

74
Chapter Four: Findings
The study aimed to examine the organizational factors influencing the administrative
preparedness of HHS leaders in California rural counties to address public health crises
effectively. This research, informed by the foundational knowledge in Chapter Two, adopts
Clark and Estes' (2008) modified gap analysis framework as its guiding lens. The framework
helps to identify the organizational elements that influence the knowledge and motivation of
rural county HHS leaders in California, focusing on overall organizational performance. Semistructured interviews with rural California county HHS leaders were used to collect qualitative
data for the study.
This chapter provides an in-depth analysis of the knowledge, motivational, and
organizational needs and strengths of California rural county HHS leaders that influence public
health crisis management. By examining stakeholder interviews and integrating insights from
existing literature, this study aimed to identify the key areas where these leaders require support
and the assets they already possess. The goal of this work is to support HHS rural county leaders
in prioritizing and championing the increase of administrative preparedness competencies within
the crisis management system to address public health crises effectively. The following research
question guided the study:
1. What are the knowledge, motivational, and organizational needs and strengths of
California rural county HHS leaders that influence public health crisis management?
In this chapter, the assumed KMO needs identified through the literature review are
evaluated based on the interview results to assess whether they represent a need or asset within
the context of rural California county HHS leaders. The presumed needs were validated as
significant when the majority of participants, at least eight or more, provided evidence

75
highlighting a lack of knowledge, motivational, or organizational support from their
organizations, which is essential for enhancing administrative preparedness skills within the
crisis management system to address public health crises effectively. Conversely, the postulated
requirements were recognized as assets when eight or more respondents demonstrated that they
already possessed the necessary capabilities or resources, indicating strength in their current
preparedness and response framework.
Participating Stakeholders
HHS leaders play a pivotal role in navigating public health crises, especially in the
unique landscape of rural California. These leaders guide the response to immediate threats and
shape the long-term strategies ensuring the health and wellbeing of their communities. Detailed
interviews using the interview protocol developed (Appendix A) were conducted as part of the
study to examine organizational factors that influence these leaders' administrative preparedness.
Fifteen HHS leaders from rural California counties were interviewed through the Zoom
platform as key stakeholders for this study. These stakeholders bring a wealth of experience in
terms of their tenure and crisis management exposure. A quick comparison reveals a mix of
leaders from various HHS sectors like public health, behavioral health, and social services. Their
tenure within their current roles in the HHS organization ranged from two months to over two
decades, providing a rich depth and breadth of insights. Their experiences with public health
crises were varied, with many mentioning the recent COVID-19 pandemic and others recounting
events such as fires, earthquakes, the opioid epidemic, and even specific incidents like the H1N1
outbreak or a community shooting. Regarding formal education, the stakeholders held various
qualifications, ranging from degrees in epidemiology, multicultural and gender studies,
psychology, organizational leadership, and business to licenses and certifications in public health

76
nursing, behavioral health, and accounting. Appendix C provides demographic information
regarding these stakeholders.
To protect confidentiality and secure identifying information, pseudonyms have been
assigned to stakeholders with the labels HHS-L1 through HHS-L15.
Results for Knowledge Influences
Assumed knowledge influences were evaluated to determine needs and assets for
California rural county HHS leaders, highlighting the importance of specialized knowledge in
navigating public health crises and the complex landscape of knowledge delineation. The study
investigated conceptual and help-seeking or metacognitive knowledge domains, outlined by
Krathwohl and Anderson (2001). The knowledge and skills influences were identified as a need
or asset based on the findings from the stakeholder's interviews. As discussed above, the
threshold for determining a need or asset was set at eight participants. Table 7 summarizes the
findings relevant to each knowledge influence, followed by an analysis of these findings.
Table 7
Assumed Knowledge Influences
Assumed Knowledge Influence Need Asset
HHS leaders need to comprehend public health principles
and competencies to effectively address public health
crises.
X
HHS leaders need to be aware of their strengths and
weaknesses and seek appropriate assistance to effectively
address public health crises.
X
HHS Leaders Need to Comprehend Public Health Principles and Competencies
The CDC identifies nine crisis leadership competencies as the most crucial for crisis
leaders to have during a crisis. The nine leadership competencies include communication,

77
connectivity, courage and perseverance, credibility, decisiveness, emotional effectiveness,
integrative thinking, situational awareness, and team leadership (see Table 2 of Chapter 2). In
evaluating the proficiency of HHS leaders in the nine crisis leadership competencies, all exhibit
an understanding and practice of the competencies. Each stakeholder, in their own role,
exemplifies and utilizes these competencies, demonstrating foundational comprehension and
application in areas such as communication, connectivity, courage, and more when asked about
essential knowledge and skills crucial for leading during a public health crisis.
Leaders of rural counties in California HHS eloquently conveyed the essence of effective
leadership in the communication, connectivity, credibility, emotional effectiveness, and
integrative thinking in the leadership competency domains. HHS-L1 noted the importance of
calmness in adversity by stating, "an ability to stay calm in high-stress situations" and
understanding the intrinsic value of relationship-building while identifying the people involved
or necessary during crises, mentioning the need for a "Good read on people: an ability to know
who needs to be at the table to solve problems. So, a good read on people, I think, is really
important." Articulating a clear mission and vision is also pivotal, as HHS-L11
acknowledged, "You have to be able to communicate mission, vision, and values...folks need to
know why it is important." Trust is further captured in HHS-L8 statements of "I would say
honesty, transparency so that people know what you're doing" and "knowledge of your topic,
your subject matter so that you are trusted that you know what you're talking about." HHS-L14
further emphasized the importance of viewing the bigger picture:
I really think we all need to come from a prevention lens…we need to get way more
upstream. I think. However, we can do that and keep that at the forefront in our strategic

78
planning…The other thing is having a big picture view of how it's all
interconnected…Everybody impacts other people, all systems impact other systems.
The domain of team leadership is also emphasized in the essence of collaboration and
teamwork, as evidenced by HHS-L3's statement that, "collaboration is really important...where
everyone brings their unique role and perspective to the table."
HHS-L4 further noted the value of being actively involved and accessible, stating:
I don't just sit in my little Ivory Tower office and have people, you know, do their thing.
I'm more than willing to jump in. I want to know how they're doing. I want to know what
they're doing. And I want to know how I can help.
Within the leadership domains, stakeholders address attributes like courage,
perseverance, and credibility. In addressing courage and perseverance, HHS-L1 shares, "so I
think a healthy sense of humor…," HHS-L6 adds, "You definitely have to be able to think
outside the box. You have to be able to compose yourself." HHS-L3 emphasizes the value of
"being a self-starter," and HHS-L8 underscores integrity with "I'm a do what you say you're
gonna do kind of person." Credibility is further highlighted by HHS-L7:
People are promoted through the ranks in organizations. You're promoted to supervisor
because you're technically competent in your job, but the stakes get higher, the higher
you go in an organization, there appear to be less checks and balances. The higher you
are in the hierarchy; you have to be the check and balance because there may not be one.
Moreover, the reliance on team dynamics within the team leadership domain during
crises is echoed in HHS-L12's statement, "I lean on my team...It's really about trusting them."
The emotional effectiveness and situational awareness leadership domains are marked by
adaptability, where the stakeholders underscore the need for agility in crises, with HHS-L3

79
stating, "…adaptability and the flexibility with emergency situations…you don't know what's
going to happen next…so, being able to be agile is really important." HHS-9 also prioritizes, "To
me, building relationships so that people feel comfortable sharing information and
communicating with one another is priority." The stakeholders add that the unpredictability and
complexities of a crisis are crucial points, with HHS-L13 highlighting:
There are people who like the excitement and sexiness of an emergency, when
really…you have to really calm down and look at the overall picture, and I think, having
the ability to do that, to look at the bigger picture of who's involved in what. You have to
look at everything that it affects - human beings and their lives. So, having good
relationships with other community entities and being able to see the bigger picture.
Remaining calm in the face of when everybody else is getting excited and to be able to
listen well. And of course, you have to play the political part as well, which is very
difficult sometimes. It is a delicate dance.
The final leadership domain explored integrative thinking, underscoring the balance
between standards and relationships. HHS-L11 emphasized the need to "navigate difficult
conversations…Set strong boundaries," and HHS-L10 remarked, "Each person brings to the
table a unique set of skills."
In addition to the leadership crisis competencies, foundational public health principles,
including social determinants of health and the epidemiologic triad, encompass community trust,
decision-making insight, and visionary leadership and play a pivotal role in navigating the
myriad challenges that crises present. The study investigated these principles aligned with the
crisis leadership competencies to understand the broader investigation of the conceptual
knowledge of HHS leaders in rural California counties. HHS-L1 noted, "I think that my skill set,

80
and I probably didn't know this going in, but I think my training as an epidemiologist has been
very helpful," illuminating the importance of subject-matter expertise as a cornerstone for
decision-making. When leaders can sift through data and draw meaningful conclusions, it instills
confidence in their teams. HHS-L1 also pointed out that the ability to "make decisions based off
of data as opposed to emotions..." underscores the decisiveness, objectivity and precision
required in crisis scenarios. However, crisis management requires a blend of both hard and soft
skills, as identified by HHS-L2, "you also need to have an understanding of the structure and the
kind of documentation requirements and things that are needed in an emergency." However, this
must be coupled with soft skills, such as remaining calm under pressure. Further articulating the
balance, HHS-L2 continued, "you need to have the ability to sort of keep an even keel. Keep
calm and not run around with your hair on fire."
Furthermore, leaders should be deeply cognizant of the social determinants of health and
the complexities they manifest during a crisis. HHS-L4 states, "absorb the information and really
disseminate it effectively, so that you're not creating chaos," a testament to the leader's
understanding of these determinants. Of the need to reach out to vulnerable populations, ensure
they are safe, and provide them with the necessary assistance, HHS-L1 remarked:
All of our programs are designed to support the most vulnerable people in our county...so
we are usually called on during an emergency to reach out to those people just
proactively and make sure that they are okay, and whether they need anything or any
assistance.
At the core of it all is trust-building. HHS-L8 recognizes that community members need
to feel valued: "People need to feel valued. It's like if they don't feel like you're just telling them

81
what to do, and you have no idea what they do. It just causes resentment with
them." Collaborative efforts and open communication amplify this trust.
These responses demonstrate that HHS leaders have a solid conceptual understanding of
public health principles and the competencies to address public health crises effectively.
Considering all 15 stakeholders expressed similar ideas, it is evident that there is a collective
understanding of the concepts. Therefore, this conceptual knowledge is considered an asset, and
the assumption of a need in this area is not substantiated.
HHS Leaders Need to Be Aware of Their Strengths and Weaknesses and Seek Appropriate
Assistance
Stakeholders were asked to provide insights from their practical crisis experiences to
examine how these experiences impact a leader's competency in crisis management and
efficiency under stress. The aim was to pinpoint critical readiness measures and assess and
enhance cognitive strengths and weaknesses to bolster informed and strategic decision-making
capacities. The majority of responses revealed presence of metacognitive and help-seeking
influences in addressing the challenges leaders face during public health crises. As shared by
stakeholders, it paints a poignant picture of the deep-seated impact of such crisis events on the
decision-making processes, emotional fortitude, and resilience of those at the helm. The
narratives shared point to the complex weave of trauma, adaptability, and the critical role of
relationships in shaping leadership competency.
HHS-L1 underscored the overwhelming nature of recent public health crises: "we have
had more than our fair share of emergencies the last couple of years." This sentiment echoes
throughout the experiences shared by various stakeholders, revealing the multidimensional
challenges they faced with HHS-L7, adding, "The hats leaders have to wear have definitely

82
doubled, tripled, quadrupled in the last, Oh, gosh! So, I would say, since H1N1. Response efforts
that HHS has now is more complex than ever before."
A core tenet of resilience, as HHS-L9 highlights, is the pivotal role of interpersonal
connections: "The number one factor in resiliency for both clients and staff is relationships."
Such relationships are instrumental in team building and harnessing the collective strength of
resources, enabling a more fortified response in times of adversity. HHS-L7 further emphasized,
"We really have to have ongoing partnerships, and we have to think proactively about the system
we're putting in place when we're not in the middle of a crisis and disaster."
However, readiness is more than just relationships. The importance of being prepared is a
sentiment echoed by HHS-L8, "If we're better prepared, we won't fly by the seat of our pants
again." This perspective is strengthened by the need to learn from past experiences and build
systematic interventions to avoid repetition of past mistakes as HHS-L2 reported, "Let's have this
in writing... to ensure that we don't make the mistakes next time that we made this time."
Additionally, leaders' metacognitive ability to measure when to lead and when to delegate is a
refined balance, with HHS-L9 affirming, "Sometimes you have to know when not to lead and to
hand off," underscoring the importance of recognizing and leveraging expertise within the team.
The trauma, stress, and subsequent loss of public health employees during crises also
came to the fore, with HHS-L4 sharing, "We lost a lot of very capable public health employees
just due to the stress." HHS-L12 added, "Leadership changed in a lot of counties after COVID.
The exit has been pretty big…I give credit to the leaders in the director position because it wasn't
easy… a lot of them retired after because of burnout." This trauma is not limited to external
events but is also internalized, manifesting as secondary trauma within the workforce, as
reported by HHS-L4: "We have a workforce that is totally traumatized... leading a resilient

83
workforce who inherits secondary trauma every single day is a different skill set." The profound
realization of this trauma necessitates a pivot in how leadership is approached, with an emphasis
on mentorship, resilience, and understanding.
Moreover, the reactions and expectations of the community are pivotal, which
necessitates the challenge of balancing public perception, as evident in HHS-L4's interview:
"Public health staff were either perceived as doing too much or not enough." HHS-L5 expressed
the struggle of being at the frontline, especially when faced with external resistance: "We were
up against that resistance right out the gate. We are not a trusted source in this very small rural
conservative county." Overcoming such hurdles stretches their capacities, as summarized
succinctly by HHS-L7: "it's hard…pretty quickly, we work beyond our capacity."
While it is vital to recognize the many struggles encountered, it is essential to understand
that these difficulties frequently facilitate self-reflection and personal development.
Through personal wellbeing approaches, all leaders interviewed realize development in their
capacity to bounce back from challenges and boost their ability to think about their own
thinking through self-care and critical thinking, which is important in turning challenges into
opportunities for success. The narratives of these stakeholders share a common idea that they
cannot act independently and are interconnected. HHS-L1 noted the profound influence of the
support system in their professional journey: "I think it improves my wellbeing because I feel
like I have more resources to draw on." HHS-L6 echoed this sentiment, aptly capturing the
essence of collective strength: "I can't imagine trying to respond kind of as an island, or without
having that support system in place."
Seeking guidance and mentorship, especially during tumultuous times, becomes
imperative. HHS-L2 articulates, "I look to my leaders, you know, to my director for support, and

84
when we had a health officer, our health officer was just truly the most amazing individual." The
value of experience and wisdom, especially in times of uncertainty, is palpable in these
narratives. Additionally, networking and having a reliable support system emerged as crucial,
and HHS-L3 articulated the significance of these networks:
I think establishing a network of support is super helpful. So having those people that you
can draw on for, you know, commiserating when you've made a mistake or people that
you feel that it's kind of a safe space for you to be honest with, I think is really important.
While crises are unavoidably accompanied by uncertainties, preparedness and a proactive
mindset can mitigate anxieties, as HHS-L10 expressed: "Then uncertainty goes away in
situations of crisis. Right? Or it doesn't entirely go away. But you know where you're going."
HHS-L1 poignantly described their personal buffer against workplace stresses:
I have a really good work-life balance. So, my job is not everything for me. That is sort
of apart from my job. I think I have a healthy work-life balance which makes it so that if
things go wrong in my job, it's not the end of the world, or it doesn't feel like the end of
the world.
This sentiment emphasizes the power of detachment and the therapeutic nature of
personal passions, as HHS-L13 shared:
I ride my horse, it is like one of those things. I think it's probably like meditation for
other people. It's one of those things where I am not thinking about anything else at all
and so to be able to turn off, I think, is really important.
The recurring emphasis on mindfulness and self-care practices stands out for the
stakeholders when reflecting on the power of such practices, which can function as a compass in
guiding effective problem-solving, as HHS-L2 remarked:

85
I think one thing that really helped me during COVID was my natural tendency to just
kind of stay calm…and I started an exercise program and started doing mindfulness
practices such as mindful breathing and meditation.
The data suggest that despite facing unprecedented challenges, particularly in the realm
of metacognitive or help-seeking strategies due to complexities such as trauma, all HHS leaders
leveraged their experiences as an asset to enhance their resilience by implementing strategies
focused on wellbeing and personal growth to navigate the intricacies of public health crises more
effectively. A well-defined crisis plan can stabilize and better position HHS leaders to navigate
complex public health crises (Medina et al, 2017).
Discussion for Knowledge Influences
The evaluation of the presumed knowledge needs and assets influencing HHS leaders in
rural counties of California revealed that conceptual and help-seeking or metacognitive
knowledge were assets in their ability to address public health crises. First, the stakeholders
engaged in understanding public health principles and competencies to address public health
crises effectively. Lastly, the HHS leaders confirmed that they can effectively implement
wellbeing strategies that help to navigate their strengths and weaknesses to address public health
crises effectively.
Results for Motivation Influences
Assumed motivational influences were evaluated to identify the needs and assets for
California rural county HHS leaders to address public health crises effectively. The study
investigated the assumed influences of self-efficacy and expectancy-value on HHS leaders'
administrative preparedness. These motivational influences were classified as either a need or
asset based on the findings from the stakeholder's interviews. Table 8 provides an organized

86
summary of the results of each motivational influence and then follows a thorough examination
and interpretation of these findings.
Table 8
Assumed Motivation Influences
Assumed Motivation Influence Need Asset
HHS leaders need to feel confident in their ability to
effectively address public health crises. X
HHS leaders need to believe there is value in effectively
addressing public health crises.
X
HHS Leaders Need to Feel Confident in Their Ability to Effectively Address Public Health
Crises
The self-efficacy of the HHS leaders in handling public health crises are evident from the
sentiments shared, anchored in their deep reservoirs of experience and expertise and the
unwavering support of their respective teams. Twelve stakeholders expressed confidence in
addressing a public health crisis. While some statements reflected an inherent sense of certainty,
others delved into the importance of collaboration and trust in team dynamics. HHS-L2
expressed, "I'm confident that I would have the knowledge that I need in order to make those
decisions...I feel very confident that I have experts on my team," illuminating not only their faith
in personal capability but also their reliance on collaborative effort. HHS-L1 added, "Being able
to make a decision quickly, with whatever information you have at hand is so important." Such
agility in decision-making can be vital, especially when lives are at stake. However, outward
confidence can sometimes be a shield to protect and inspire those looking up to the leader. HHSL1 continued, "Even if you're not feeling confident, I think you need to fake it because people

87
are looking to you to lead "while HHS-L15 stated, "I feel a hundred percent more confident than
I did last year," adding that with experience, confidence develops.
Exploring the complexities of decision-making, HHS-L4 shared their evolution in
confidence over time: " I'm very confident, maybe not so much 5, 6 years ago, 8 years ago, but I
think that again, you're always presented with situations daily to increase confidence in decision
making..." showcasing confidence in their journey and highlighting that self-efficacy is not static
but evolves with experience and exposure.
In leadership, the weight of responsibility often coexists with moments of doubt,
especially in the face of public health crises. HHS-L1 mentioned, "Even if you don't truly feel
confident, I think the ability to seem like you do is equally important," a testament to the
resilience and adaptability inherent in these leaders, highlighting the significance of projecting
strength, even in moments of uncertainty. Reiterating the value of teamwork and camaraderie in
fostering confidence, HHS-L6 affirmed, "[my team] makes me feel confident. Makes me feel
like I can handle things because I know I have a team to back me up," underlining the collective
strength that a supportive team imparts, further boosting an individual's self-assurance. HHS-L3
continues to demonstrate how supportive teams and relationships enhance the leader's selfefficacy, especially when facing public health crises, by leaning on the team: "99% of the time...
I am really fortunate, extremely fortunate, that my direct supervisor, my director here does not
judge, or discipline... When mistakes are made, she advises, and she troubleshoots." HHS-L6
further emphasizes the growth mindset, stating, "The confidence is learning from where we may
be making mistakes or what we did."
While many leaders displayed confidence, some were candid about the ebbs and flows of
their confidence during public health crises. HHS-L9 admitted, "I'm feeling a little wobbly in

88
areas in the past where I've been very clear on what I need to do," but added that "confidence
builds with experience," highlighting their growth trajectory. To emphasize levels of self-belief,
HHS-L10 stated, "I feel pretty confident. I mean it... Nine out of 10," while acknowledging the
ever-present scope for growth and learning. This balanced perspective provides insight into their
self-awareness and continuous pursuit of improvement. HHS-L12 professed, "it's a very solid, I
feel a very solid." Furthermore, HHS-1 reflected on the dichotomies of confidence, saying, "It's
the unknown that I don't feel all that confident about," capturing the challenges inherent in
navigating public health crises.
Interestingly, while some leaders projected confidence rooted in past experiences, others
demonstrated trust in their cognitive abilities despite not facing a crisis. HHS-L13 remarked, "I
haven't really been here yet for a crisis. But I do feel confident in my thought process," which
encapsulates this forward-looking and prepared mindset, and added, "maybe because I'm new…I
lean on others." HHS-L14 addresses when there is a leadership void, asserting, "If no one's
leaning in... I will lean in and put myself out there." Moreover, the unpredictability inherent in
public health crises and the natural feelings of uncertainty that arise were candidly expressed by
HHS-L8, "I don't know that anyone feels super confident." Such statements offer a glimpse into
the challenges of leadership in complex environments, including public health crises.
The findings confirm that the 12 HHS leaders from rural California counties possess the
self-efficacy (Bandura, 1977) to address public health crises effectively; therefore, the assumed
motivational influence is an asset.
HHS Leaders Need to Believe There Is Value in Effectively Addressing Public Health Crises
In the interview responses, 13 stakeholders demonstrated an understanding and
recognition of the importance of crisis management in ensuring public health safety. HHS-L1

89
emphasized the broad spectrum of HHS's role in preparing for and responding to public health
crises: "Public health plays a role in almost every disaster or emergency event...disasters that
perhaps on the face don't seem to have a public health component usually do." Reinforcing the
value of addressing public health crises, HHS-4 pointed out that they "do it every day in one
form or another." HHS-L11 embodied the essence of expectancy-value, stating, "It's your
responsibility to continue to grow as a leader... The only way you're gonna learn it is by doing
it." Motivation is not passive, as HHS-L2 shared, "I try to make time to attend...an online
training." The continuous learning mindset is further illustrated by HHS-L6's initiative-taking
stance to connect and draw insights from various sources, "connecting with other counties, or I'm
connecting with other agencies," or HHS-L10 shares utilizing resources like the "County
Behavioral Directors Association."
The dedication to proactive response is evident in HHS-L4's reference to "trying to
change and mold and shape the arc of the whole trajectory of someone's life," highlighting that
every decision is considered with its impact on the entire county and reflects a belief that efforts
yielded positive results. This view was further represented by HHS-L1:
Our organization's mission is to help the most vulnerable members of our community and
we often check in with them during times of crises. Then we coordinate with the
emergency operations center to respond. So, we were able to kind of preemptively call
everyone to figure out who was in trouble. We have housing vouchers that we could use
at hotels to be able to temporarily house people. We had county employees volunteering
to clear the snow off of people's roofs. We kind of retooled our senior nutrition program
to deliver meals to people that were homebound during the storm... It's really kind of

90
relooking at our existing programs and re-envisioning them to be able to support the
entire community during a disaster or an event.
Moreover, the value a leader places on their role is expressed through comprehensive
outreach methods with emphasis on cultural sensitivity and recognition for adaptability, as HHSL2 imparted:
We had all the kind of basic things in place already, like we had a sign language
interpreter whenever we would do media briefings and the things that we didn't have in
place were really partnerships with those informal leaders in the community that are
trusted by different segments of the population to, you know, get the word out to them
...to make sure that we weren't inadvertently doing something that was going to be
culturally insensitive or not appropriate for that community, we would actually bring
vaccines to their communities, and we started working closely with the leaders in those
communities to get the word out.
The finding reveals that 13 HHS leaders from rural California counties possess the
expectancy-value necessary for adeptly addressing public health crises, indicated that the
assumed motivational influence is an asset.
Discussion for Motivation Influences
Upon examination of the assumed motivational influences, it was evident that the
experienced stakeholders possessed significant assets. Specifically, the HHS leaders of rural
California counties demonstrated high self-efficacy and expectancy-values for motivational
behaviors in effectively addressing public health crises. The following section will present the
outcomes of the assumed organizational influences.

91
Results for Organizational Influences
Assumed organizational influences were evaluated to determine needs and assets for
California rural county HHS leaders. Stakeholders were asked interview questions to determine
the training and resources provided to enhance administrative preparedness and the
communication strategies strengthened to effectively prepare for and address public health crises.
The organizational influences were identified as either needs or assets based on the findings from
the stakeholder's interviews. Table 9 summarizes the findings of each organizational influence,
followed by an analysis of these findings.
Table 9
Assumed Organizational Influences
Assumed Organizational Influence Need Asset
The organization needs to value and promote
comprehensive training to HHS leaders to effectively
prepare for and respond to public health crises.
(Organizational Model)
X
The organization needs to provide HHS leaders with
resources to prepare for and respond to public health crises.
(Organizational Setting)
X
The organization needs to prioritize and promote
communication to effectively prepare for and respond to
public health crises.
(Organizational Model)
X
The Organization Needs to Value and Promote Comprehensive Training to HHS Leaders
(Organizational Model)
Effectively addressing public health crises necessitates a comprehensive understanding of
the varied surroundings, detailed preparation, and steadfast dedication, particularly from

92
stakeholders that occupy these influential positions (Khan et al., 2018). Insights from HHS-L7
reveal a narrative of the challenges confronted and the training needs that persist:
I think the challenges for leaders is greater now more than ever because our world is
getting more and more complex. The requirements are greater, the stressors are greater,
the frequency of disasters with climate change is only going to grow. So, it is the new
norm, and you know, as a leader, you're probably thinking - I got it the worst.
Examining the experiences of the HHS leaders of rural counties in California revealed an
interesting paradox. It becomes evident that while all stakeholders have been provided some
form of ICS or NIMS training level by the organization, only four specify that they have
received more than the fundamental ICS/NIMS training, highlighting the common trend of
training focusing more on procedural formalities than on comprehensive content and practical
application, confirming the assumed influence as a need.
HHS-L12 underscores the discrepancy, "When it comes to emergency preparedness, I've
had some trainings. I actually haven't been to all the ICS trainings. But now some are required,
and it's like…can we just get grandfathered in because I know it." Yet, the transformative power
of comprehensive training is evident with HHS-L12 continuing, "The thing is, though when I do
sit through them, I'm like, I didn't realize this. The thing is that after the training, I'm like, Oh,
my gosh! That makes so much sense and wonder why don't actually do this in an emergency?"
The organizational support proves paramount, as HHS-L2 stated, "During COVID, we
had a CAO who very much prioritized emergency preparedness and response. I think that kind of
support was really important to have at the time." HHS-L2 continued, "It's a shame that it doesn't
exist anymore, because it just happened to be his personal viewpoint." HHS-L15 recalls their

93
CAO having the foresight to provide training and the urgency of preparedness in the face of the
public health crisis:
Maybe he knew it was coming, but he really recognizes the county. We are not as
prepared and he wanted to get everybody trained and then begin some more in-depth
training, and we didn't get to the in-depth training before we were in the thick of it.
The above statements emphasized that organizational support, therefore, lies at the nexus
of individual training and organizational commitment. As HHS-L11 declared, "in county
government especially, there's no time for that [training]. We just go…we do the work, and go
and go and go," capturing the commotion and activity and potential neglect of professional
development. Conversely, HHS-L13 remarked,
In an organization I worked for prior to local government, it was explicit that you grow as
a leader because it is part of our health as an organization. So, for the 10 years I was with
that organization, I was socialized with that idea that to grow the organization, time was
made and expected to grow as a leader.
HHS-L4 and HHS-L13 shared that while employed at a previous organization, both
attended disaster preparedness and leadership training from Federal Emergency Management
Agency (FEMA) in Alabama. HHS-L5 is the sole stakeholder interviewed who had received
comprehensive disaster and leadership training while employed at the rural county government.
Additional leadership training, outside of crisis preparedness and response, has been provided to
stakeholders by the organization. HHS-L6 shared that the organization "sent me to some
supervisor trainings at UC Davis," HHS-L13 organization also notes, "I was sent to UC Davis
leadership trainings…and a Harvard executive training."

94
HHS-L1 mentioned, "apart from just life experience, the ICS training and my
epidemiology background, I think that I don't have any really formal training that would qualify
to help me in public health crises," underlining the challenge of formalized training. Despite the
organization's mandatory ICS training advancement, as HHS-L1 added, "all levels of staff in the
county go through at least some ICS or NIMS training," the depth and relevance of training often
remain desired by stakeholders. HHS-L10 concisely expressed, "All of us have gone through that
ICS training structure, which is written in a foreign language, but it is actually English. It is the
most complex thing. But I'll have to say when it's actually implemented in practice, it works."
The data collected from the interviews did not provide evidence that the stakeholders
received comprehensive training to effectively prepare for and respond to public health crises. It
is essential for organizational support concerning training for stakeholders to evolve beyond
being a mandate with an aspiration to create robust, well-equipped leaders that do not just say, as
quoted by HHS-L13, "I have taken the required ICS training…to check the box," but who feel
empowered to best navigate and lead public health crises effectively.
The Organization Needs to Provide HHS Leaders with Resources (Organizational Setting)
As exemplified by the recent COVID-19 pandemic, stakeholders overwhelmingly agreed
that collaborations and strategic partnerships are indispensable resources the organization
provides to prepare for and respond to public health crises. Thirteen stakeholders discussed
collaborations that fostered a culture of innovation and creative problem-solving when internal
resource allocation was limited. As HHS-L1 astutely observed, "building the relationships
outside of a disaster" is pivotal not only during crises but even beyond. The stakeholder
emphasized the continuum of these relationships, noting that "building the relationships outside
of a disaster... Ensures the entire relationship isn't about 'that' crisis." HHS-L7 stated, "We

95
realized that we really have to have ongoing partnerships. And we have to think proactively
about the system we're putting in place when we're not in the middle of a crisis and disaster."
While some stakeholders acknowledged the efficacy of current collaboration, HHS-L3
lamented, "But our partnerships with our other government, our other county brothers and sisters
are not strong, and it has not ever been fostered from the CAO level that we should be a strong
county system. We're kind of these independent entities, each department. And I think that's
unfortunate." This perspective underscores the need for a more cohesive approach within county
systems to bolster collective efforts in public health crises. However, HHS-L1 was encouraged
through crises and strengthened collaborations, sharing, "We've never swapped duties like we
did during COVID-19, and I think... Just by having to learn new tasks and work together in a
different capacity really strengthened our agency in a lot of ways and broke down some of the
silos that we had," promoting coordination, adaptability, and creating a foundation of trust within
the organization. Such coordination, adaptability, and trust not only address the immediate
challenges but also foster resilience (Dirani et al, 2020). As voiced by HHS-L9, "I think for me,
it's built resilience. You learn from every event." Moreover, HHS-L14 added, "Partnerships,
partnerships with other county departments, and knowing who has staff and who's more willing
as a department head to give you their staff when you need them." When such collaborations
happen, leaders receive access to a greater pool of resources, including an expansion of
personnel, expertise, and support, by partnering with others from various departments.
Concurrently, HHS-L2 accentuated the leverage of community organizations,
stating, "The community organizations that we contract with to help us out with our regular dayto-day operations. Leveraging those partnerships during a public health emergency like COVID19, we were able to really efficiently get out there and provide resources and outreach to the

96
communities that we needed to." Further accentuating the role of community organizations,
HHS-L7 added, "We have a group who comes together, community organizations active in
disasters, and they are really our nonprofit partners who help to operationalize disaster response
and disaster recovery." The stakeholder also illustrated proactiveness, sharing insights about
meeting outside disaster periods to discuss "how we can streamline data collection and how we
can share data."
HHS-L3 shared the resource challenges that persist, "It's been really hard for our agency
partners to understand their role in emergencies...that piece of it is still not strong, because I don't
know why. I do know that it's been really, really, really hard." While resource limitations can be
a roadblock, particularly in rural counties, HHS-L6 affirms that as a leader, one must "be
creative and think outside the box," yet predicting needs amid crisis can be overwhelming as
HHS-L14 states, "I think the biggest challenge is just being able to predict what you're going to
need because you don't really know. You're kind of guessing." Optimistically, HHS-L15 shared,
"But the State Department of Social Services now has, like, a branch and some staff that we can
call on. So, there's like a regional liaison. He hosts meetings between our counties to talk about
shared resources or to learn from one another..." This instance demonstrates that when provided
with the right resources and support, HHS leaders can successfully address capacity limitations
in the rural HHS county while enhancing resource integration to foster significant societal shifts
(Park et al., 2022).
Beyond the strengthened collaborations to obtain tangible resource assets like "Vehicles,
radios for the elderly in vulnerable areas, and power generators," as stated by HHS-L14, nine
stakeholders supported the diverse range of resources required, which unveiled the underlying
need for funding, staffing, and advocacy strategies to effectively prepare for and respond to a

97
public health crisis. "Due to the pandemic, we were allocated short-term funding, which we used
for staff training, equipment purchases for the lab, and working remotely," HHS-L7 recounted,
portraying the dual accounts of prompt responses and enduring challenges. Resonating the
financial constraints and human resource barriers, HHS-L10 shared, "We have had to work with
limited staff and financial resources. We all wear different hats at the same time…because we
don't have the resources." The echo from HHS-L11 adds, "[the rural county] is traditionally very,
very leanly staffed throughout the entire county…and we don't receive any general fund
monies." The statement is mirrored by HHS-L3 when expressed, "When talking about resources,
we are kind of left to our own devices. Often, we don't get the support we need from other
entities. Even the county. We didn't get the staffing we needed for the COVID-19 response."
HHS-L8 stressed the common theme of restricted staffing, "…we have a very Conservative
board that does not want any additional staff. If they say no, you've got to be okay with that. The
policymakers don't want to see us grow government in any way."
HHS-L11 added to the staffing challenges, "Bare bones in terms of our staffing, and
there's just been a general philosophy into that accounting of, like the only good governments a
small government kind of thing." Meanwhile, HHS-2 highlighted resource variations, saying,
"…just hiring and filling position is really challenging for some positions period. We've had a lot
of turnovers. Just having consistent staff is really challenging as a resource. So that institutional
knowledge isn't gone and you're not retraining people constantly." HHS-L11 added an upstream
approach:
To advocate for more staffing and resources, we compared caseloads with other counties,
using data-driven methods and collaborated with fiscal staff to build a five-year plan,

98
showing a gradual addition of positions to ensure long-term sustainability where the goal
is to add positions without the cycle of hiring and laying off.
Highlighting the constant challenges stakeholders face, HHS-L3 explained, "Our
emergency preparedness staff are funded the same way as our tobacco program is. They're
funded to do a particular scope of work...all of our programs are like, and we can't do this
anymore." The stakeholder emphasized the complexity of managing tasks and crises: "then when
we're responding to fire or to measles or to tularemia or to whatever is happening, there is no
time to develop plans or to update those plans and incorporate new learning because we're
always responding." The stakeholder's response pressed the need for more robust funding as
stated, "If we're expected to both plan and respond, then we need funding for both of those
functions."
A further crucial perspective from HHS-L15 emphasized the burden on resources during
public health crises:
The County Welfare Directors Association has been pushing the State and really
advocating for dedicated funding, because it is not a little bit of work. To just maintain it
when you don't have a disaster, and then when you do, you know our agencies in
particular, like, when these things happen, the need for the community goes up and we
get spread super thin. So, I think the staff need is a challenge, and it's not resourced in
any way.
During the gathering and analysis of data concerning organizational resources, a noteworthy
theme emerged, emphasizing the mixed support of state-led initiatives in addressing public
health crises by seven stakeholders. HHS-L1 noted, "I think that it would be helpful to have the
State lead some of the effort because that would force those of us at a local level to prioritize

99
crisis." HHS-L1 further noted, "I think that [a state led initiative] would be easier to galvanize
around as opposed to us trying to generate that momentum internally within our own county."
HHS-L3 further supported the idea, "I do think that the State can have a stronger presence or
stronger laws in place that could help our community." However, HHS-L4 offered a cautionary
remark against reliance on mandates, "Without federal/state mandates in place, otherwise it's
always on a to-do list. It's never going to get done until there is a crisis. Even though it should be
done well before." HHS-L6 encouraged the State to provide rural governments funding to
strengthen local resources, "just more resources and funding provided to us instead of trying to
figure out a way to make sure preparedness gets done."
While HHS-L8 expressed state mandates as a driving factor to effectively address public
health crises, "if the State mandates emergency preparedness, then you know you'll have to do
this," HHS-L10 contrastingly emphasized the need for local flexibility, "Stop with all the
mandates. Stop!" HHS-L12 encouraged additional state funding to improve resources while
calling for flexibility and autonomy for local counties, "Trust us that we do know what we're
doing and trust that we know our community."
Stakeholders underscored collaborations, strategic partnerships, and resource allocation in
preparing for and responding to public health crises, yet several also identified needs in county
systems, indicating resource allocation is only partially addressed as funding, staffing, and
advocacy challenges highlighted resource inadequacy. Furthermore, mixed thoughts on state-led
initiatives surfaced, with some advocating for more substantial state involvement and others for
local flexibility.
Considering these collaborative efforts and challenges, the subsequent analysis delves into
the specific organizational resources, particularly crisis response plans and teams, which are

100
pivotal for HHS leaders in navigating public health crises. Upon closer examination of the
presumed impact of organizational resources, the findings reveal this influence to be a need as
HHS leaders need to know how to develop and implement comprehensive response plans and be
able to assess the risk and potential impact of public health crises. Stakeholders were asked to
impart measures or actions initiated to improve preparedness for public health crises. Only six
leaders referred to the existence of some form of crisis response plan, illuminating the conscious
awareness and strategic thought extended toward crisis preparedness. These plans, often central
components of the county's operational blueprint, are mandated requisites for federal disaster
assistance. However, the real-world applicability of such plans was questioned by HHS-L14:
We have continuity of operations plans or COOP that we are required and are really
facilitated by our CAO's office, and they were kind of not really useful, right? So, we
have these plans, and they sit on a shelf, or they sit in a computer. And they're not
necessarily practical for the real world. And so, we've really looked at those to revamp
them to be useful so that we can actually refer to them to use in a crisis.
The COVID-19 pandemic unveiled gaps in these plans and reinforced the importance of
having actionable, up-to-date strategies. HHS-L10 noted that "Everybody in the county
organization should be part of that plan," and HHS-L2 affirmed that "we realized that very few
of the people who participated in the plan were actually in the emergency response." HHS-L15
further noted, "our county plan was not up to date or as functional as it should be, so we had to
kind of figure out the plan while we were responding to everything." Reflecting on the
pandemic's aftermath, HHS-L2 continued:
When we did our after-action review from COVID, and we came up with our
improvement plan, we made some changes to our continuity of operations plan with

101
regard to our mission central functions...sort of a companion guide to go along with our
continuity of operations plan.
This statement resonates with the previously mentioned need for the operationalization of
plans, taking them off the shelf, and ensuring they are responsive to real-world challenges. HHSL8 candidly admitted, "Our plans basically were kind of an afterthought...we had developed a
resource guide but didn't practice it and didn't use it during the crises." Moreover, some HHS
leaders expressed concerns even when these countywide plans are in place and practiced. HHSL3 shared the following:
Tabletop exercises could assist in creating stronger leadership skills, but I wouldn't say
they currently do. They do make you kind of see a bigger picture, but when you do those
tabletop exercises, it is usually a lot of agencies, and we all get lost when you get the fire
or sheriff's involved because you, even though they have a huge part and it might be their
exercise, don't see what your role is or what your team can do to help...and it's hard to
speak up when you've got a lot of people in the room.
Such revelations underscore that countywide strategies and collaborations are undeniably
crucial. However, the unique challenges and responsibilities of HHS organizations necessitate
dedicated crisis response plans, catering to complex stakeholder interactions, addressing specific
health-related threats, and clarifying their role and contributions to inter-agency collaborations to
ensure efficient coordination and prevent potential overlaps or gaps, optimizing the response
during crises (Coombs, 2022). Nevertheless, a more granular inspection reveals a disparity in the
articulation and implementation of these plans. Only three stakeholders confirmed the existence
of a crisis response plan within their respective HHS organizations. HHSL-8 recognized that
although the HHS organization had a crisis response plan in place, the realities of the COVID-19

102
pandemic revealed its inadequacies and shared, "I'm working to get our plans updated to what we
actually did do. So that next time we can refer to that plan," underscoring the department's
commitment to learning from recent experiences and ensuring better preparedness for future
challenges.
Moreover, the findings reveal the absence of a recognized cross-functional crisis
management or response team among HHS leaders. This gap represents a potential vulnerability
in the existing organizational framework: Without such a team, the organization's ability to
cohesively respond to multifaceted crises could be compromised (Hassel & Cedergren, 2021).
Likewise, the absence of this integrated approach potentially limits the efficiency of resource
allocation, communication, and decisive action, which are vital during crises.
HHS-L7's observations on preparedness underscore the magnitude of the challenge:
I'm extremely strategic at plans and operationalizing things. Not everybody lives in that
space, so I will just share with you...I remember somebody saying to me that if we
prepare, we'll create panic and I was just blown away and I thought, you can't not prepare
because it is happening anyway. Do you really want to be caught off-guard? As a leader
you don't have a choice. You have to be willing to see the ugliest, most horrific
possibilities so that you can prepare for them because running around in crisis after the
fact is essentially shirking your responsibilities.
Furthermore, the complexities of crisis management require a blend of applied planning
and an understanding of leadership (Coombs, 2022; Danforth et al., 2010). HHS-L9 offered an
insightful perspective:
I think a good leader works through these crises by having not only the wisdom to build
systems, but also the wisdom to see where systems fail and rebuild systems because

103
nothing's ever gonna work right. The first time you're gonna have to rebuild and you're
gonna have to restructure. And I think if you want people to follow, you're gonna have to
admit that there's errors and give them a plan for how you gonna fix those problems so
they feel safe, confident, and comfortable, following through with you.
These insights gathered from stakeholders resonate with the findings discussed in
Chapter Two.
The existing literature emphasized the pivotal role of crisis response plans (Calonge et
al., 2020) and established a cross-functional crisis management team dedicated to confronting
public health crises (Coombs, 2022). However, feedback from HHS leaders in rural California
counties revealed a concerning need: 12 did not confirm the presence of structured crisis
response plans or specialized crisis management teams, as well as evaluate the potential risks and
impacts associated with public health crises.
The Organization Needs to Prioritize and Promote Communication (Organizational
Model)
Effective communication during crises is paramount, a sentiment strongly echoed by all
15 stakeholders. HHS-L1 firmly stated, "Well, like anything, I think communication is probably
the most important part of crisis preparation and response." The ramifications of not prioritizing
communication were evident during recent crises, as HHS-L1 continued, "I saw the effects of
poor communication during the COVID pandemic, from the highest levels of government down
to local communities." Indeed, the essence of effective communication extends beyond mere
transmission of information. "It's not just about sending a message," HHS-L2 noted. "It's about
the political appropriateness, the diplomatic nature, and the accuracy of that message." Further
amplifying the significance of effective communication, HHS-L5 emphasized, "I think that

104
effective communication during a disaster is what will make or break the response." HHS-L3
candidly shared, "So you characterize the significance of effective communication as you're
preparing for and managing public health crises…but we don't and we can do better."
These sentiments resonate with the more prominent belief that, without a plan,
communication during crises can quickly fall apart, as is evident in HHS-L4's statement, "I think
that there needs to be a more formalized communication plan." A recurrent theme in the
interviews was the challenge of maintaining consistent communication. As HHS-L5 revealed,
"The first thing that goes awry is communication. We didn't communicate with this person, or we
didn't communicate with, you know...so, it's always an ever-evolving situation." This thought is
further reinforced by HHS-L6, who stated, "Without clear communication, chaos ensues."
The challenge, however, continues beyond establishing clear communication channels. It
extends to prioritizing communication within the ever-changing landscape of public health
crises. HHS-L7 pondered the broader implications of communication methods:
Nobody is ever immune from doing better at communication...Because, you know,
communication is changing, is it just social media? Is it radio? Is it video? What's the best
way of actually getting our messages across? Part of being really good at language
inclusion means you're actually being better at engaging your community, and they're
more likely to actually show up to work with you on other issues. I mean, this is a
broader issue for us about respect and social inclusion.
HHS-L11 identified the importance of swift and transparent communication, "During
crises, it's essential to communicate more about decisions made, the current situation, and future
plans. Particularly in unexpected crises, it's crucial to tackle the crisis head-on and subsequently
inform stakeholders of the unfolding events and subsequent actions." HHS-L12 emphasized the

105
need for structure, as stated, "there are breaks in the communication if it is not in writing."
Surprisingly, when asked about the organizational CERC plan, only five stakeholders were aware
of its existence within the organization, and none had prioritized reviewing or practicing its
communication strategies, confirming that the assumed communication influence is a need.
HHS-L2 shared, "I know that we do have a CERC plan, and I know that in COVID we
found it to not be super useful. I think it's undergoing some revisions currently.... Once it's
finalized, then yes, we plan to exercise it regularly. We haven't started to do that yet, because
we're still working on revising it," underscoring the importance of an adaptable and current plan.
HHS-L12 admitted, "I believe we do, but we don't use or practice it. But we should,"
demonstrating the need between having a plan and its practical implementation. HHS-L3
emphasized, "Nobody really knows. The person that would have been responsible for the plan
worked in a vacuum, it's kind of a mess," signifying ambiguity around the plan and its utility.
HHS-L1 shared, "We don't practice enough out of that crisis communication plan…I'm not sure
that we've actually done anything specific out of that plan. I would say that that's probably an
area that we could improve." HHS-L6 noted, "Coming up with some clear communication.
Being able to connect and be able to network with those agencies outside of your own agency,"
resonated with HHS-L8 feedback, "I think that our communication was negatively received."
HHS-L4 mentioned the struggle to develop a robust communication plan, given the challenges of
time constraints and their multifaceted role. HHS-L5 summarized the importance of refining the
approach to communication: "We really needed to make a list of those people that we really
needed to communicate situations with... I think there has to be a better way to fine-tune that
communication component." HHS-L7 further reflected:

106
We're all in this together, creating a real sense of community... people need someone to
trust in times of darkness... You're the one who has to create the narrative of what this
scary, potentially scary world is, and make it seem okay, and that there's beauty in
navigating this together as one.
The role of communication, not just as a tool but as a vital lifeline in challenging times,
resonates deeply with all stakeholders. HHS-L2 remarked that crisis preparation is "not at the top
of the priority list of the people who are in those leadership positions." HHS-L3 admitted, "I'm
not sure how the overall organization perceives preparedness," even though the response seems
to be at the forefront. These insights affirm the profound importance of effective communication
in public health crises, emphasizing the organization's need to provide clear and prioritized
communication to HHS leaders to ensure they are adequately prepared and can respond
effectively to crises.
Discussion for Organizational Influences
The data analysis of organizational influences highlighted three confirmed requirements:
there is a distinct need for comprehensive training of HHS leaders to equip them effectively for
public health crises, and the emphasis on prioritizing and championing communication stands
out as another verified need for effective crisis response and preparation. The analysis also points
to an organizational need in furnishing HHS leaders with the necessary resources for crisis
management. Addressing these organizational aspects is crucial to bridging the disparity among
California rural county HHS leaders and enhancing their administrative readiness to address
public health crises.

107
Summary
This study proposed and evaluated seven influences on California rural county HHS
leaders to prepare for and respond to public health crises effectively. The analysis identified
whether each assumed influence was a need or an asset for these leaders. Table 10 provides a
detailed summary of the findings, highlighting the impact of knowledge, motivation, and
organizational factors on the administrative preparedness of stakeholders in efficiently managing
public health crises. The results underscore the need for additional organizational support to
enhance the readiness of rural county HHS leaders' readiness to navigate public health crises.

108
Table 10
Summary of KMO Needs, Sub-Category, and Evidence Results
Need Sub-Category Evidence Results
Knowledge
HHS leaders need to comprehend public
health principles and competencies to
effectively address public health crises.
Conceptual Asset
HHS leaders need to be aware of their
strengths and weaknesses and seek
appropriate assistance to effectively address
public health crises.
Help-Seeking
(Metacognitive)
Asset
Motivation
HHS leaders need to feel confident in their
ability to effectively address public health
crises.
Self-Efficacy Asset
HHS leaders need to believe there is value
in effectively addressing public health
crises.
Expectancy-Value Asset
Organizational
The organization needs to value and
promote comprehensive training to HHS
leaders to effectively prepare for and
respond to public health crises.
Organizational Model Need
The organization needs to provide HHS
leaders with resources to prepare for and
respond to public health crises.
Organizational Setting Need
The organization needs to prioritize and
promote communication to effectively
prepare for and respond to public health
crises.
Organizational Model Need

109
Chapter Five: Recommendations and Discussion
The study focused on factors within the HHS organizations in rural counties of California
that influence the leaders' ability to deal with administrative tasks and their preparedness during
public health crises. Interviews were conducted with 15 HHS leaders from California rural
counties, using the modified gap analysis framework developed by Clark and Estes (2008) to
examine the key elements critical to this research. Study findings were then used to guide the
development of strategic methods intended to improve the crisis management skills of HHS
leaders in rural counties in California and strengthen their administrative preparedness. The
study was based on a primary research question:
1. What are the knowledge, motivational, and organizational needs and strengths of
California rural county HHS leaders that influence public health crisis management?
This chapter analyzes the study's findings and offers recommendations to address the
identified needs arising from these findings.
Discussion of Findings
The examination of the data identified specific needs that reveal limitations in enhancing
the skills and competencies of rural county leaders in crisis management within the HHS
organization. These competencies are crucial for boosting administrative preparedness to
effectively manage public health crises and mitigate potential negative impacts on community
health and welfare. The insights from the interviewees' perspectives inform Chapter Five's
conclusions and action plans. This chapter commences with pragmatic suggestions to bridge the
identified needs in administrative preparedness concerning crisis management among HHS
leaders. It then proceeds to contextualize the findings within the existing body of literature,
providing evidence-based strategies to influence the organizational factors that support the

110
achievement of HHS leadership goals. No validated knowledge and motivational factors were
determined to be needed. Furthermore, this chapter integrates Kurt Lewin's three-step change
model—unfreezing, changing, and refreezing—to initiate, implement, and solidify the processes
(Burnes, 2020) that enhance HHS leaders' administrative preparedness in crisis management.
Chapter Five culminates by delineating the study's limitations and boundaries, proposing
avenues for subsequent inquiries, and concluding remarks on the research findings.
Discussion of Findings for the Research Question: Knowledge, Motivational, and
Organizational Needs and Strengths of California Rural County HHS Leaders
This study explored the knowledge, motivational, and organizational needs and strengths
of Health and Human Services (HHS) leaders in California's rural counties that influence their
ability to manage public health crises effectively. The findings indicate that while HHS leaders
possess foundational knowledge and intrinsic motivation, there is a significant need for enhanced
organizational support, particularly in training, resources, and communication, to prepare for and
respond to public health crises effectively.
The study revealed that HHS leaders in rural California counties possess a foundational
or conceptual understanding and practice of crucial public health competencies, particularly
communication, connectivity, and courage. This reveals the HHS leaders’ ability to provide
successful leadership during crises (Dirani et al., 2020; Van Wart & Kapucu, 2011; Wooten &
James, 2008). Moreover, the evaluation of HHS leaders' implementation of help-seeking
behaviors or metacognitive knowledge is identified as an asset. For instance, nine stakeholders
attested to their capacity to apply wellbeing strategies that capitalize on their advantages and
rectify their weaknesses in managing public health crises. The HHS leaders acknowledge the
need for more specific guidance because of the challenges they experience due to crises.

111
Consequently, despite showing self-awareness and initiative, the HHS leaders require more
structured support and direction toward successfully negotiating the complicated status of public
health crisis management. These findings resonate with Ambrose et al. (2010) and Donnelly and
Linn (2019) studies on the significance of metacognitive knowledge.
The analysis of motivational influences to address public health crises effectively, as
probed during interviews, indicated that HHS leaders demonstrate high self-efficacy and
recognize the importance of effectively addressing public health crises. These leaders already
demonstrate confidence in their decision-making, fostered through experience and team support.
They are acutely aware of the pivotal role that HHS plays in public health crises and understand
the significant impact of their decisions on community wellbeing (Kayes, 2004; Sultan et al.,
2020).
The study's examination of organizational influences underscored three confirmed needs:
comprehensive training, provision of necessary resources, and prioritization of communication
for crisis management. These findings align with the literature, which emphasizes the importance
of continuous planning, preparedness, and resource management in enhancing crisis response
effectiveness (Coombs, 2022; Danforth et al., 2010; Silverman et al., 2016; Walecka, 2021;
Woitaszewski et al., 2020). Addressing these organizational needs is crucial for bridging the
disparity among California rural county HHS leaders and enhancing their administrative
readiness to tackle public health crises.
Four out of 15 HHS leaders underwent disaster and leadership training. Effective crisis
management in HHS organizations necessitates comprehensive training that should extend
beyond procedural knowledge, touching on aspects such as practical crisis management
applications, including advanced ICS and NIMS training. The training should also encompass

112
specialized crisis leadership programs, an approach that may require organizations to provide the
resources required, such as staffing, funding, and strategic partnerships. According to de Tantillo
and Christopher (2021), in the NIMS framework, resource management involves the acquisition,
tracking, and mobilization of personnel, equipment, or supplies. Those who need additional
training should have access to opportunities to build skills and establish self-efficacy for remote
education. Such a training strategy should be supported by balancing immediate needs with longterm sustainability.
Consequently, the HHS leaders with the needed comprehensive training in crisis
management will record a higher success rate in responding to and managing a public health
crisis (Comes et al., 2022). This success is attributed to the effective coordination of team efforts,
judicious utilization of resources, and adapting to evolving crisis scenarios. This administrative
readiness equips the HHS leaders with the skills needed to address the immediate challenges of a
crisis while positioning them to lead with resilience and foresight, enhancing their organizations'
overall preparedness and response capacity.
The interviews additionally revealed a crucial need for the organization to support and
enhance effective communication. All HHS leaders emphasized the importance of effective
organizational communication. Despite this consensus, it was found that only five out of the 15
leaders interviewed were aware of the existence of a CERC plan within their organization.
Moreover, none had taken steps to prioritize the review or practice of its communication
strategies.
The findings from interviews with HHS leaders in rural California counties underscore
the critical need for organizational resources to prepare for and respond to public health crises
effectively. Stakeholders highlighted the indispensable role of collaborations and strategic

113
partnerships, particularly during the COVID-19 pandemic, in fostering a culture of innovation
and problem-solving when internal resources are limited (Dirani et al., 2020; Park et al., 2022).
However, challenges persist in creating cohesive interdepartmental and intergovernmental
relationships, with some leaders noting a need for more support from higher-level administration
for a unified county system. This lack of cohesion underscores the necessity for a more
integrated approach to bolster collective efforts in public health crises (Coombs, 2022).
The interviews also revealed a significant emphasis on the need to provide essential
resources for crisis management. The absence of structured crisis response plans and specialized
crisis management teams, as reported by 12 out of 15 leaders, highlights a need for
organizational preparedness. This need is particularly concerning in rural settings, where limited
healthcare infrastructure and workforce challenges exacerbate the impact of public health crises
(Gamm et al., 2010; National et al. Association, 2020).
Furthermore, the mixed support for state-led initiatives indicates a tension between the
desire for more substantial state involvement and local flexibility. This tension suggests that a
balanced approach, which provides rural governments with funding and resources while allowing
for local autonomy, may enhance public health crisis management in rural counties (Hassel &
Cedergren, 2021).
Finally, effective communication is crucial for reducing uncertainty and ambiguity during
crises (Coombs, 2022; Gifford et al., 2022; Kim, 2018). Failures in communication, such as
inconsistent messaging and lack of transparency, can have severe implications for the
organization, its leaders, and the community (Dubé et al., 2022; Kim, 2018; Veil et al., 2008).
Organizations must prioritize clear and practical communication guidelines (Brownson et al.,
2020; Danforth et al., 2010; Quinn, 2008; Sriharan et al., 2022; Veil et al., 2008). The CDC's

114
CERC framework, established in response to the evolving responsibilities of HHS, provides a
structured approach for HHS leaders to communicate effectively during public health crises
(CDC, 2018; Veil et al., 2008). By prioritizing and promoting the CERC framework principles,
the organization would ensure resources are used effectively, and messages are delivered
accurately, empathetically, and respectfully.
In conclusion, the findings from this study highlight the importance of organizational
support in providing HHS leaders in rural California counties with the necessary resources,
training, and communication tools to manage public health crises effectively. Addressing these
needs is crucial for enhancing the administrative readiness of HHS leaders and ensuring the
resilience of rural communities in the face of public health crises.
Recommendations for Practice
The study findings point towards some suggestions supporting the effectiveness of rural
California counties' HHS leaders. Below are three key recommendations, based on insights from
the interviews, designed to collectively address and resolve administrative preparedness needs to
prepare for and manage public health crises. The recommendations will close the crisis readiness
gaps, enabling HHS leaders to respond more adeptly to public health crises. This will reduce the
chances of adverse outcomes consequential to community health and wellbeing.
Recommendation 1: Develop a Comprehensive Crisis Management Capability
Enhancement Program
The fact that only three out of 15 HHS leaders in rural California counties have
established crisis response plans implies that there is an urgent need for improved crisis
management skills. To address this deficiency, a Comprehensive Crisis Management Capability
Enhancement Program specifically tailored to fill the organizational resource need identified in

115
the study should be implemented in the organization by the HHS leaders. The approach may
involve a few necessary processes such developing structured crisis response plans, emphasizing
the need for detailed frameworks covering risk assessment, resource allocation, and strategic
implementation. According to Clark and Estes (2008), this strategy supports the principles
highlighted, advocating training and education where there is a lack of related expertise, or when
the stakeholders have to anticipatory deal with future novel future challenges. Additionally,
Comes et al. (2022), emphasize the importance of practicing crisis response plans for effective
coordination with public agencies and the community, creating accountability (Dubnick, 2014)
for the HHS leaders to create the program for the organization.
To establish a structured crisis response plan, it will be necessary for the HHS leaders to
develop a comprehensive framework to craft detailed plans, including risk assessment, resource
allocation, and strategic implementation. Furthermore, HHS leaders will have the ability to form
specialized crisis management teams. These cross-functional teams, created and facilitated by the
HHS leaders, will have to develop and execute crisis response plans, while coordinating efforts
during public health crises. Additionally, the strategy should include workshops intended to
enhance wellbeing and resilience: workshops on self-care, stress management, and traumacoping mechanisms. Training sessions that foster self-awareness among HHS leaders should help
the HHS leaders recognize their strengths and weaknesses in crises, promote personal growth,
and help them become more effective in crisis management. The focus with this kind of
approach is to identify the resource organizational need, enabling the HHS leaders to effectively
address any complex situation whenever there is such need in public health crisis management.

116
Recommendation 2: Resource Mobilization and Management Framework
The establishment of a Resource Mobilization and Management Framework addresses
the need for effective resource management in crises, being one of the most impactful
recommendations for HHS leaders in rural California counties. The suggestion directly responds
to study findings that point towards a need in resource availability and efficient utilization during
public health crises. Such a need is a massive concern, as the data analysis highlights. According
to Clark and Estes' (2008) conceptual framework, organizational resources, and support are
necessary for enhancing performance.
The recommendation involves two main parts: firstly, conducting a comprehensive
assessment of the resource needs for effective crisis management, including evaluating the
requirements for technology, personnel, and emergency supplies; secondly, developing a
systematic resource allocation and management approach to ensure these resources are readily
available and efficiently used during crises. The first stage in this implementation should always
be detailed resource inventory and needs analysis to identify current resources and determine
additional requirements accurately. The detailed resource inventory and needs analysis should be
performed by the specialized crisis management team, led and accountable by the HHS leaders.
Afterward, this can proceed to the organization providing training opportunities to the HHS
leaders and their crisis management team members on resource mobilization, utilization, and
management during crises is crucial; such training is vital because it should equip them with the
necessary skills to manage resources effectively, a key component in responding to and
managing public health crises.
The expected outcomes of this strategic recommendation will achieve four benefits: 1)
assured availability of resources during public health crises, 2) optimal utilization of resources,

117
3) enhanced preparedness of HHS leaders and their developed crisis management team, and 4)
improved response capabilities of HHS leaders and the crisis management team. Additionally,
through much better resource management, this suggestion will improve the overall crisis
management framework within rural California counties. As a result, the HHS leaders will be
better prepared to manage the complexities and challenges of public health crises.
Recommendation 3: Enhance Communication Infrastructure and Strategies
Based on the identified results, which highlight the vital need for improved crisis
communication among HHS leaders in rural California counties, a key recommendation emerges
to enhance communication infrastructure and strategies. The foundation for this recommendation
is supported by research emphasizing the critical role of clear and efficient communication
during public health crises within organizations and with external stakeholders (Coombs, 2022),
aligning with Clark and Estes' (2008) conceptual framework. It addresses the organizational
environment and skills needs through specific, targeted interventions, echoing Malloy's (2011)
advocacy for practitioner-led inquiry in fostering effective change.
Stakeholder insights affirm this recommendation, revealing a significant need in the
awareness and practical implementation of formalized communication plans. Specifically, only
five out of 15 interviewed stakeholders were aware of the existence of an organizational CERC
within their organization, and none had prioritized reviewing or practicing its communication
strategies.
The proposed recommendation involves the development of effective communication
protocols to facilitate swift and accurate information dissemination during crises by the HHS
leaders. The recommendation incorporates the optimization of both internal communication
within HHS and external communication with other agencies and the public. Aligned with

118
Malloy's (2011) insights, the process should involve enlisting the right people with the necessary
expertise and trust to develop the protocols. Crucially, comprehensive training modules focusing
on crisis communication skills should cover message crafting, media handling, and engaging
with diverse stakeholders, among other subjects, reflecting Malloy's (2011) emphasis on
providing dedicated time and professional development in inquiry practices.
The effectiveness of this recommendation will depend on the HHS leaders' collaboration
with communication experts, this should enable the implementation of appropriate
communication protocols and training content. Regular drills and simulations led by the HHS
leaders should be normalized in this case to reinforce the implemented communication protocols,
which should prepare HHS leaders and their stakeholders for real-world scenarios. Upon
effective implementation of this suggestion by the HHS leaders, the expected results include
improved coordination and information sharing during crises and enhanced public trust and
compliance for the organization; this is contributed by the clear and effective communication
from HHS leaders. This recommendation will address the identified need and foster better crisis
response capabilities among the HHS leaders and the organization. As a result, there will be an
overall improvement in the management of public health crises in rural California counties.
Integrated Recommendations
The HHS leaders play a crucial role as potential change agents within their communities
and organizations during crises. These leaders deserve all the knowledge and organizational help
they can get for better preparedness and to enhance their competency within the crisis
management system. Through appropriate support by organizations, HHS leaders can
successfully address public health crises and mitigate adverse effects on community health and
wellbeing. Research, including insights from Maccalla et al. (2021), underscores the role of

119
individuals as agents of change, with Kurt Lewin's three-step model of change providing a
foundational framework for this transformation. According to Burnes (2020), the foundational
theory emphasizes the power of collective agency in achieving group objectives as well as the
critical influence of self-efficacy in driving change.
The HHS leaders’ interview revealed a consistent theme of self-efficacy and expectancyvalues and affirms the HHS leaders’ belief in the capacity to bring about change. This finding
aligns with Bandura's (1977) focus on self-efficacy's role in cognitive, motivational, affective,
and decisional processes as well as descriptions of institutional change agents who understand
the impact of cultural norms and practices on structural inequities. Ensuring the HHS leaders are
well-prepared to drive change is fundamental and resonates with the findings of Heffner et al.
(2011) which found a correlation between employee attitudes and the sense of making a
difference with organizational outputs.
The current study proposes three integrated recommendations to capitalize on the
identified insights. Rooted in the principles discussed by Clark and Estes (2008), these
suggestions should facilitate an effective administrative preparedness during crises. These
researchers advocate for clear and compelling visions to support adopting and implementing
emerging skills and behaviors. Additionally, Rueda (2011) emphasizes the need for deliberate
and clear expectations to achieve organizational goals. According to Burnes (2020),
implementing these recommendations through Lewin's change model—presents unfreezing
current norms, implementing changes, and refreezing new practices—presents a multi-month
iterative process to close the identified needs. This approach helps address skill and resource
deficiencies as well as the opportunity for HHS leaders to embrace their roles as change agents.
As a result, the HHS leaders can significantly improve public health crisis management within

120
their organizations and can use this opportunity to advance a more resilient and responsive public
health infrastructure in rural California counties. Figure 6 demonstrates the iterative nature of
Lewin's three-step model.
Integrating the nine crisis leadership competencies (see Table 2 of Chapter 2) to become
more salient in the recommendations to enhance them further is crucial: 1) communication is
crucial for HHS leaders to convey clear and empathetic messages during crises; 2) connectivity
to emphasize the importance of building strong networks and partnerships for effective crisis
management; 3) courage and perseverance are essential for HHS leaders to demonstrate courage
and perseverance in the face of adversity; 4) credibility to inspire trust and confidence among
stakeholders; 5) decisiveness is crucial for HHS leaders to make timely and informed decisions
during crises; 6) emotional effectiveness for managing emotions and maintaining effective
relationships during challenging times; 7) integrative thinking to enable HHS leaders to think
holistically and integrate diverse perspectives for comprehensive crisis management; 8)
situational awareness is essential for HHS leaders to adapt to the evolving dynamics of a crisis;
and 9) team leadership is a key skill for leading teams effectively, especially in high-pressure
situations. These competencies are vital for HHS leaders to navigate the complexities of public
health crises effectively. By embedding these skills into the change program, HHS leaders can
enhance their preparedness and response capabilities, leading to more resilient and responsive
public health systems in rural California counties.

121
Figure 6
Lewin's Three-Step Model
Note. From "The Origins of Lewin's Three-Step Model of Change," by B. Burnes, 2020, The
Journal of Applied Behavioral Science, 56(1), 32-59.
Step 1: Unfreeze
In the first stage of Lewin's change model, unfreezing, the focus is on altering current
organizational processes, achieved by clearly communicating the nature of the change and its
importance. To HHS leaders’ perspective, it implies the understanding of the procedures needed
to effectively manage crises and identify the benefits of better administrative preparedness.
Much of this relates to the principles outlined by Burnes (2004) and expanding upon them with
insights from Cummings et al. (2016). According to these two studies, during this initial stage of
Lewin's three-step model, it is crucial to engage openly with any concerns or doubts stakeholders
raise. The objectives raised by stakeholders should be supported to heighten the focus on
developing administrative preparedness competencies within the crisis management system,
enabling more effective responses to public health crises.

122
In this unfreezing phase, HHS leaders are encouraged to recognize the needs in crisis
management, communication, and resource management to begin the journey of transforming
the crisis management approach, aligning with insights from Schein (2017), who avers that
organizational culture is created through shared experiences and learning and cannot be imposed,
making it essential to involve stakeholders, such as the developed crisis management team in this
transformation process actively. Cummings et al. (2016) underscore the importance of engaging
stakeholders in this process, facilitating a shift in perspective by openly addressing doubts and
fostering an environment that challenges the status quo. Lewin's concept highlights the need of
destabilizing the existing equilibrium to encourage the adoption of new behaviors and strategies
(Burnes, 2020).
In this phase, focused discussions and workshops are two key actions that would matter
most. Through workshops and discussions, the HHS leaders feel ready for any change.
Subsequently, using robust crisis response plans and enhancing communication and resource
management strategies can facilitate this approach. The emphasis aligns with the framework that
Khan et al. (2018) developed in identifying 11 interacting elements essential for administrative
preparedness in crisis management. These elements—including communication, collaborative
networks, practice and expertise, community engagement, capacity, and learning and
evaluation—are vital in supporting the sustained resilience of rural communities. Incorporating
these framework elements into the discussions and workshop can make the different in aiding the
HHS leaders to be aware of the needs in their current crisis management system. Subsequently,
the HHS leaders can also understand the comprehensive nature of the required changes.
According to Clark and Estes (2008), such a strategy can help build a consensus among the HHS

123
leaders by ensuring these leaders are mentally prepared and equipped to embrace new
methodologies.
According to Khaw et al. (2022), “A negative reaction towards change often generates a
strong resistance to change. This happens if change is perceived as harming.” (p. 19138).
Cummings et al. (2016) argue that change implementation is only effective if those involved
understand and accept the change. Therefore, this calls for the creation of an atmosphere in
which HHS leaders and the stakeholders perceive safety in terms of exploring innovative ideas
and approaches, all essential in the Unfreeze stage. This includes the HHS leaders providing
reassurance about the positive outcomes of change and addressing any fears or misconceptions
about the new processes. According to Pickett (2023), when the stakeholders are encouraged to
engage in discussions and exchange of information about a crisis management, it becomes a
cathartic experience, fostering a collective sense of competence in addressing crisis challenges.
According to De Silva et al. (2023), “To implement change agility successfully, it is important to
actively include stakeholders and address their concerns to reduce change resistance.” (p. 60).
Getting through this unfreezing stage can help the rural HHS leaders in several ways. As
far as effective implementation of comprehensive crisis management, the HHS leaders are able
to improve their communication, and identify better resource management strategies as proposed
by the Lewin's model. This step is therefore important when making sure the leaders are ready
for any change and become active participants in the transformation process. Such readiness is
vital in improving public health crisis management within the community.
In the unfreezing stage, HHS leaders begin by recognizing the need for change in crisis
management, communication, and resource management. This stage involves open discussions
and workshops to build consensus on developing administrative preparedness competencies

124
within the crisis management system. Key competencies such as communication, connectivity,
and team leadership are crucial here, as they foster a culture of openness and collaboration
essential for addressing concerns and resistance to change. Encouraging active listening, clarity,
and empathy (communication) and promoting trust-building and collaboration (connectivity and
team leadership) are vital in creating an environment conducive to change.
Step 2: Change
For the Change stage of Lewin's model, HHS leaders in rural California counties take
active steps to implement the new strategies. In this stage, there is also the need for processes
that enhance the leaders’ crisis management capabilities, marking the transition from theoretical
concepts to actions that exemplify a more effective means of managing crisis.
Comprehensive Crisis Management Capability Enhancement Program is crucial in this
second change stage; it a program that entails the rollout of structured crisis response plans and
the formation of specialized crisis management teams. The program’s focus is usually on
workshops, with the aim of building resilience among leaders through self-care, stress
management, and trauma-coping mechanisms. According to Heffner et al. (2011), this
comprehensive approach ensures leaders have essential procedural knowledge and the
metacognitive skills to manage crises effectively.
Furthermore, there is concerted effort to enhance communication strategies, including
developing new communication protocols and introducing training modules focusing on crisis
communication skills. According to a study conducted by Pincus (1986), effective supervisory
communication strongly correlates with job satisfaction and performance. Regular drills and
simulations are needed in this strategy to provide the leaders and their stakeholders with the
opportunities to practice and refine their communication skills in simulated crisis scenarios.

125
According to Kwok et al. (2019), emergency drills "provide an opportunity for the crisis
response teams to face the emergencies and practice crisis management skills or procedures in a
nearly real environment by replicating emergency events in the real system." (p. 712-713).
Alongside these initiatives, it would be crucial to establish a detailed Resource
Mobilization and Management Framework. This framework begins with a thorough resource
inventory and creates a systematic resource allocation and management approach. HHS leaders
are better equipped to manage and use resources during crises thanks to training sessions on
resource mobilization and management. These results corroborate those of other studies, like
Gupta et al. (2021), which highlight the importance of complete and accurate information,
unbiased environments, and welcoming and sympathetic environments.
In this phase, it is important to have stakeholder engagement. Such engagement is crucial
in ensuring a widespread understanding and support for the recent changes across the
organization. Training and development opportunities can reinforce it through capacity building.
This aligns with Kluger and DeNisi's (1998) research on timely, concrete, and goal-focused
feedback effectiveness. Furthermore, establishing a continuous monitoring and evaluation
system is critical to assessing the implemented strategies' effectiveness and making necessary
adjustments.
Successfully implementing this stage requires building capacity for the change. A few
ways to achieve this is through addressing resistance, celebrating early successes, and promoting
a culture that embraces change and innovation, vital for maintaining momentum. It is also
important to make sure all the policies are updated, and the procedures and documentation reflect
the new strategies, and these must be integrated into the organization culture and practices at the
oversight of the HHS leader.

126
Throughout Step 2: Change, gathering evidence is critical to demonstrating the
effectiveness of the changes, which includes collecting quantitative and qualitative data from
training evaluations, stakeholder feedback, improved crisis response outcomes, and records of
successful integration of new practices. Such evidence is then used to validate the change
process and form the foundation for accountability and ongoing improvement and adaptation.
With many excellent evidence-based programs available and the high self-efficacy
motivation and expectancy-value among HHS leaders, as discussed by Eccles and Wigfield
(2002), the likelihood of successful implementation is heightened if these leaders function as
change agents. HHS leaders can effectively protect their communities during crises and in times
of normalcy by putting more emphasis on their preparedness. HHS leaders’ role as change agents
instrumentally drive these improvements. Such developments highly depend on their ability to
leverage their high self-efficacy and expectancy-values to effect meaningful change and ensure
the wellbeing of their community.
During the change stage, HHS leaders take active steps to implement new strategies,
focusing on enhancing crisis management capabilities. This stage sees the rollout of structured
crisis response plans and the formation of specialized crisis management teams, emphasizing
competencies such as decisiveness, emotional effectiveness, and integrative thinking.
Decisiveness is critical for making informed decisions, emotional effectiveness for managing
stress and emotions, and integrative thinking for developing holistic solutions. Training modules
on crisis communication skills and regular drills and simulations help refine these competencies
in simulated crisis scenarios, ensuring leaders and their teams are well-prepared for real-world
challenges.

127
Step 3: Refreeze
During the third and last stage of Lewin's change model, known as Refreeze, HHS
leaders in rural counties in California focus on consolidating and sustaining the recently made
changes inside their crisis management systems. This phase is critical to ensuring that the most
recent improvements become long-lasting and thoroughly ingrained in their organizational
culture and practices. This last step is crucial for ensuring that procedures and tactics are
ingrained in culture and practice, which promotes long-term resilience and adaptation.
In this phase, HHS organizations and their leaders formally incorporate the new resource
management plans, communication guidelines, and crisis management techniques into their dayto-day operations. The organization's ability to successfully complete this phase will mostly rest
on its ability to update its standard operating procedures, rules, and procedures to reflect the
recently implemented strategies and guarantee consistency at all levels. Frequent training and
development refresher courses serve to reinforce newly acquired knowledge and techniques,
which can be particularly important for fostering lifelong learning and adaptability to changing
organizational standards.
Establishing the procedures for ongoing assessment and feedback is a crucial part of the
Refreeze phase. These procedures are necessary to support the continuing evaluation of the
modifications that have been put into place. These mechanisms also aid in the necessary
modifications that are required to continuously improve methods. It is equally crucial to cultivate
a culture that emphasizes resilience and adaptation. Recognizing and celebrating achievements
over the change journey can help maintain motivation and commitment among the HHS leaders
and the organization. According to White et al. (2021), "Recognizing and celebrating team
success boosts morale and helps link the program’s success with a more positive and communal

128
workplace culture, addressing a fundamental and universal human need to be acknowledged by
others and for efforts to be valued." (p. 9).
HHS organizations implement long-term monitoring and sustainability planning to assess
the sustainability and impact of the changes over time. This long-term perspective ensures that
the improvements in crisis management remain effective and relevant. Active engagement with
leaders and stakeholders is maintained to reinforce the importance of the new practices. HHS
leaders, who are highly motivated to be change agents due to their strong self-efficacy and
expectancy-values, are encouraged to serve as role models and champions for the changes,
fostering an environment supporting innovative approaches.
This is one of the stages that need documentation and knowledge sharing of the lessons
learned and best practices developed through the change process. Sharing the lessons beyond the
organizations contributes to broader learning and improvement in crisis management. According
to Moorman and Grover (2009), followers use attributions of leader integrity as a predictor for
future behavior. Similarly, Schein (2017) note that trust in leaders is based on perceived ethical
behavior.
The high motivation of HHS leaders, stemming from their self-efficacy and expectancyvalues, features in the success of this stage. Their willingness to function as change agents
enhances the likelihood of maintaining and sustaining these changes, aligning with Eccles and
Wigfield's (2002) suggestion that the more a person values a task and believes in its success, the
greater their motivation to pursue it. By prioritizing the enhancement of administrative
preparedness capacities, these leaders ensure the protection and wellbeing of their communities,
both in normal times and during crises. Their continued role as initiative-taking change agents

129
drives and sustains improvements, leveraging their capabilities to foster a more resilient and
responsive public health infrastructure in rural California counties.
In the refreezing stage, the focus is on consolidating and sustaining the changes made.
HHS leaders work to integrate new resource management plans, communication guidelines, and
crisis management techniques into their daily operations. Competencies such as credibility,
situational awareness, courage and perseverance become paramount. Credibility ensures that
leaders maintain trust and confidence among stakeholders, situational awareness allows them to
adapt to evolving crisis dynamics, and courage and perseverance enable them to face adversity
with resilience. Continuous training and development, along with ongoing assessment and
feedback, help reinforce these competencies, ensuring the long-term success of the changes
implemented.
Summary
In the integrated approach to public health crisis management, HHS leaders in rural
California counties are at a pivotal point, uniquely positioned to function as change agents within
their communities and organizations. Implementing Lewin's three-step change model—
Unfreeze, Change, Refreeze—provides a structured framework to enhance administrative
preparedness and overall competency within the crisis management system to support the
achievement of the California rural county HHS leader goal to prioritize and champion the
increase of administrative preparedness competencies within the crisis management system to
address public health crises effectively. The iterative process, illustrated in Table 11, outlines
each stage's key activities and durations, highlighting how rural California county HHS leaders,
with their high motivation and self-efficacy, can leverage their roles as change agents to drive
significant improvements in public health crisis management. The approach underscores the need

130
for continuous evaluation and adaptation, reflecting the dynamic nature of crisis management in
rural settings.
Throughout all three stages, the nine crisis leadership competencies are crucial in guiding
HHS leaders as they navigate the complexities of public health crisis management. By focusing
on these competencies, leaders can enhance their preparedness and response capabilities,
ultimately leading to more resilient and responsive public health systems in rural California
counties.

131
Table 11
Implementation of Lewin's Three-Step Change Model
Stage Duration Key Activities
Unfreeze Months 1-6 Awareness campaigns and workshops
Identifying and discussing needs in crisis
management
Fostering open dialogue on concerns
and resistance
Building consensus on the need for
change
Change Months 7-12 Rollout of the Comprehensive Crisis
Management Capability
Enhancement Program
Developing and implementing new
communication strategies
Establishing resource management
frameworks
Conducting training and development
programs
Regular drills and simulations
Refreeze Months 13-18 Formal integration of new practices into
daily operations
Updating policies and procedures
Continuous training and development
Long-term monitoring and evaluation
Ongoing stakeholder engagement
Note. This table demonstrates the implementation of Lewin's three-step change model in rural
HHS crisis management, highlighting the structured and iterative approach required for effective
organizational change.

132
Limitations and Delimitations
Each study is influenced to some extent by inherent bias or uncontrollable variables
beyond a researcher's control, and these limitations may impact study results (Price & Murnan,
2004). The present research acknowledges potential limitations, such as a small sample size,
social desirability bias, and potential researcher bias. According to Merriam and Tisdell (2016),
the limited sample size is a common limitation in qualitative research, relating to the number of
participants or cases in a study that might or might not be sufficient to provide a comprehensive
understanding of the phenomenon under investigation. Creswell and Creswell (2018) note that in
qualitative research, a small sample size may inhibit the generalizability of the findings, diminish
the study's trustworthiness, and bias or compromise the findings. Boddy (2016) consider limited
sample sizes to be a standard limitation in qualitative research and argues that it is not
necessarily a problem as long as a researcher is transparent about the study's limitations and
takes steps to address them. An example is purposive sampling, where participants are selected
for the study based on their relevance to the research question and their ability to provide rich
data by which to collect diverse data and develop in-depth knowledge.
Second, qualitative research often exhibits social desirability when participants might
conceal information instead of revealing their actual views or experiences, limiting research
findings. Therefore, Carian and Hill (2021) encourage qualitative researchers to center the
subjectivity of the participants and leverage the complete advantages of interviewing methods to
mitigate aversion to respond genuinely, which the researcher adopted, such as utilizing openended questions, conducting interviews in a safe and private environment, using probing
inquiries to determine authentic convictions of participants, and cultivating a rapport with
participants to foster their willingness to disclose truthfully their experiences (Gibbs, 2018).

133
Lastly, potential researcher bias can limit accurate data (Creswell & Creswell, 2018;
Merriam & Tisdell, 2016). To mitigate this limitation, the researcher relied on the Dissertation
Committee and other professors from the USC to review study protocols and practice reflexivity.
Secules et al. (2021) highlights the significance of the researcher's positionality in equity, so it is
important in understanding how the researcher's perspectives and experiences might have shaped
the research process and outcomes. This is particularly important in the unique context of rural
California's HHS organization. Furthermore, as Kezar (2000) has discussed, positionality theory
underscores the impact of background and power conditions on shaping perspectives, especially
in leadership research. The concept is important to this particular study especially because HHS
leadership is intricately linked to authority and power and demands an understanding of how
these factors influence perceptions and interpretations of leadership in crisis management.
According to Kezar (2000), diverse voices and perspectives help in understanding the HHS
leaders’ unique challenges and viewpoints in rural California, more so, in terms of administrative
readiness for public health crises.
One delimitation involves the intentional and organized boundaries purposely employed
in the research design by the researcher (Price & Murnan, 2004). Given the distinctive
characteristics and specific focus on examining leaders within the HHS organization in a rural
county of California, it is not practical to generalize the results to other organizational types,
including educational institutions, for-profit businesses, or non-profit entities. Efforts to compare
or implement the study's findings among comparable stakeholder participants across distinct
organizations may raise concerns. This is so particularly in situations where occupational titles or
hierarchical positions are similar. The research results might be subject to additional boundaries,
particularly as a result of the exclusive focus on one stakeholder group as the primary subject of

134
inquiry. Although other stakeholder groups may offer valuable information and perspectives,
such groups are generally outside the study’s coverage. Therefore, a further delimitation stems
from the decision to use a qualitative research design applying interviews as the primary data
collection technique instead of selecting a mixed-method or quantitative approach.
Recommendations for Future Research
Based on the findings and objectives of this study, several recommendations for future
research emerge. This study's recommendations aim to build upon the foundational insights
gained about administrative preparedness among California rural county HHS leaders on public
health crisis management. The study employs the Clark and Estes' (2008) modified gap
analytical framework and the ELT stakeholder group within the HHS. Future studies may extend
the stakeholder perspective beyond the ELT to include frontline workers and mid-level
managers. This expansion can offer a better understanding of crisis management across
organizational levels. Comparative studies between rural and urban HHS organizations could
provide more understanding of the distinct challenges as well as effective strategies tailored to
different settings. Implementation of longitudinal research in future studies could yield better
insights in tracking the performance of the employed crisis management strategies' long-term
effectiveness and sustainability. Another potential suggestion in future studies could be a specific
focus on identifiable public health crises (e.g., pandemics or natural disasters). Such specific
focus could offer a detailed view of the specialized knowledge and skills required. Additionally,
evaluating the impact of training programs intended to foster better procedural and metacognitive
knowledge among HHS leaders can be insightful in assessing their effectiveness during real
crises.

135
Future studies can quantitatively analyze organizational support factors, including
resource allocation and communication strategies to assess their impact on crisis management
efficacy. There is also the opportunity in examining cultural, societal, and contextual influences
on administrative preparedness and crisis management in rural settings. This approach can be
used to explore how these factors affect the implementation of a crisis management plan.
Technology has a role in crisis management, and this could be a potential research focus on how
digital tools can support communication, training, and resource management during crises.
Testing other theoretical models alongside Clark and Estes' (2008) framework could provide
different perspectives or validate this study's findings. There is a high reported self-efficacy and
expectancy-values among HHS leaders. As a result, research may focus on specialized leadership
development programs for crises in rural areas. These recommendations aim to address current
research needs, act as the foundation for future research on this concept and enhance the
understanding of crisis management in rural HHS.
Conclusion
This study ventures into the critical domain of administrative preparedness among HHS
leaders in rural California counties, aiming to adeptly unravel their capacity to navigate the
turbulent waters of public health crises. Anchored by the modified gap analysis framework
refined by Clark and Estes (2008), the research meticulously examines the interplay of
knowledge, motivation, and organizational dynamics that shape the efficacy of HHS leaders. The
focal point of this inquiry is to dissect the essential needs requisite for these leaders to excel in
crises and explore the asset underpinnings that bolster their crisis management efforts.
The narrative unfolds from the semi-structured interviews with 15 rural county HHS
leaders in California is one of resilience tempered with challenges. Armed with robust

136
knowledge, self-efficacy, and expectancy values, these leaders find themselves at a crossroads,
grappling with a need for the identified organizational influences to support administrative
preparedness concerning crisis management. This study highlights a glaring gap in
organizational support, particularly in resource allocation, training, and communication,
necessitating a targeted intervention to bolster the crisis management prowess of HHS leaders.
In an era marked by the escalating frequency of public health crises, the imperative for
HHS leaders to be well-prepared is unequivocal. The literature corroborates that prepared
organizations exhibit superior efficacy in crisis management (Cloudman & Hallahan, 2006;
Coombs, 2022). By spotlighting the unique challenges faced by HHS leaders in rural settings,
this study bridges a vital research gap and lays the groundwork for developing robust crisis
management strategies to fortify community resilience and elevate public health outcomes.
This study's findings have profound implications for policy and practice. These findings
offer valuable insights towards the understanding of how to develop targeted training programs
and resource allocation strategies that can help strengthen crisis management systems in rural
HHS organizations. This knowledge is fundamental as far as the current and future HHS leaders
are concerned, as it offers an idea of what needs to be done to equip them with the tools and
understanding to manage public health crises effectively.
In summary, this dissertation closely examines the current state of administrative
preparedness among rural HHS leaders in California and raises a call to action. The study
emphasizes the need for continuous improvement and adaptation in crisis management practices,
confirming that these leaders are well-prepared and armed with appropriate tools and knowledge
to protect and serve their communities in times of crisis. This research holds significant value for

137
public health crisis management, offering a pathway toward enhanced preparedness, response,
and resilience in rural health services.

138
References
A Federal Department of Health, Education, and Welfare. (1953). The Social Service Review
(Chicago), 27(2), 201-203. https://doi.oeg.10.1086/639178
Adamu, A. A., & Mohamad, B. (2019). A reliable and valid measurement scale for assessing
internal crisis communication. Journal of Communication Management, 23(2), 90-106.
https://doi.org/10.1108/JCOM-07-2018-0068
Adamu, A. A., Mohamad, B., & Rahman, N. (2016). Antecedents of internal crisis
communication and its consequences on employee performance. International Review of
Management and Marketing, 6(S7), 33-41.
Aguinis, H., & Kraiger, K. (2009). Benefits of training and development for individuals and
teams, organizations, and society. Annual Review of Psychology, 60(1), 451–474.
https://doi.org/10.1146/annurev.psych.60.110707.163505
Ahnquist, Wamala, S. P., & Lindstrom, M. (2012). Social determinants of health – A question of
social or economic capital? Interaction effects of socioeconomic factors on health
outcomes. Social Science & Medicine, 74(2012), 930–939.
https://doi.org/10.1016/j.socscimed.2011.11.026
Aikins. (2021). Effects of covid-19 related government budget shortfall on funding and provision
of essential public services. Çocuk Enfeksiyon Dergisi, 22(4), 112–126.
Al Thani, F. B. H., & Obeidat, A. M. (2020). The impact of strategic leadership on crisis
management. International Journal of Asian Social Science, 10(6), 307-326.
https://doi.org/10.18488/journal.1.2020.106.307.326

139
Albrecht, S., Breidahl, E., & Marty, A. (2018). Organizational resources, organizational
engagement climate, and employee engagement. Career Development International,
23(1), 67–85. https://doi.org/10.1108/CDI-04-2017-0064
Alexander, P.A., Schallert, D.L., & Reynolds, R. E. (2009). What Is learning anyway? A
topographical perspective considered. Educational Psychologist, 44(3), 176–192.
https://doi.org/10.1080/00461520903029006
Ambrose, S. A., Bridges, M. W., DiPietro, M., Lovett, M. C., & Norman, M. K. (2010). How
learning works. San Francisco: Jossey-Bass.
Anand, A., Buhagiar, K., Kozachenko, E., & Parameswar, N. (2023). Exploring the role of
knowledge management in contexts of crisis: a synthesis and way forward. International
Journal of Organizational Analysis (2005), 31(7), 2953–2978.
https://doi.org/10.1108/IJOA-02-2022-3156
Ansell, C. & Boin, A. (2019). Taming deep uncertainty: The potential of pragmatist principles for
understanding and improving strategic crisis management. Administration & Society,
51(7), 1079–1112. https://doi.org/10.1177/0095399717747655
Armstrong, D., Moore, J., Fraher, E. P., Frogner, B. K., Pittman, P., & Spetz, J. (2021). COVID19 and the health workforce. Medical Care Research and Review, 78(1), 4S–6S.
https://doi.org/httpsL//10.1177/1077558720969318
Avery, E. J., & Park, S. (2019). The influences of relationship quality with external partners and
required levels of approval of messaging on crisis preparedness. Public Relations
Journal, 45, 119-127. https://doi.org/10.1016/j.pubrev.2018.08.001

140
Avery, E. J., Lariscy, R. W., Kim, S., & Hocke, T. (2010). A quantitative review of crisis
communication research in public relations from 1991 to 2009. Public Relations Review,
36, 190-192. https://doi.org/10.1016/j.pubrev.2010.01.001
Avery, E. J.; Graham, M.; Park, S. (2016). Planning makes (closer to) perfect: Exploring United
States’ local government officials’ evaluations of crisis management. Journal of
Contingencies and Crisis Management,24(2), 73–81. https://doi.org/10.1111/1468-
5973.12109
Baluszek, J. B., Brønnick, K. K., & Wiig, S. (2023). The relations between resilience and selfefficacy among healthcare practitioners in context of the COVID-19 pandemic – a rapid
review. International Journal of Health Governance, Vol. ahead-of-print
https://doi.org/10.1108/IJHG-11-2022-0098
Bandura, A. (2000). Exercise of human agency through collective efficacy. Current Directions in
Psychological Science, 9(3), 75–78. https://doi.org/10.1111/1467-8721.00064
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological
Review, 84(2), 191-215.
Balidemaj, F. (2021). Public health strategies to combat opioid epidemic in the United States: A
systematic review. European Journal of Public Health, 31(Supplement_3).
https://doi.org/10.1093/eurpub/ckab165.226
Bastons, M., Mas, M., & Rey, C. (2017). Pro-stakeholders motivation: Uncovering a new source
of motivation for business companies Journal of Management & Organization,
23(5),621–632. https://doi.org/10.1017/jmo.2016.14

141
Bathina, K. C., ten Thij, M., Valdez, D., Rutter, L. A., & Bollen, J. (2021). Declining well-being
during the COVID-19 pandemic reveals US social inequities. PloS One, 16(7), e0254114.
https://doi.org/10.1371/journal.pone.0254114
Benaben, F., Lauras, M., Truptil, S., & Salatge, N. (2016). A metamodel for knowledge
management in crisis management. IEEE International Conference on System Sciences,
Proceedings, 126-135. https://doi.org/10.1111/1468-5973.12310
Benfer, Vlahov, D., Long, M. Y., Walker-Wells, E., Pottenger, J. L., Gonsalves, G., & Keene, D.
E. (2021). Eviction, health inequity, and the spread of COVID-19: Housing policy as a
primary pandemic mitigation strategy. Journal of Urban Health, 98(1), 1–12.
https://doi.org/10.1007/s11524-020-00502-1
Bennett, K. J., Borders, T. F., Holmes, G. M., Kozhimannil, K. B., & Ziller, E. (2019). What is
rural? Challenges and implications of definitions that inadequately encompass rural
people and places. Health Affairs, 38(12), 1985–1992.
https://doi.org/10.1377/hlthaff.2019.00910
Bhaduri, R. (2019). Leveraging culture and leadership in crisis management. European Journal
of Training and Development, 43(5/6), 534-549.
Bieńkowska, A., Tworek, K., & Zablocka-Kluczka, A. (2020). Organizational Reliability Model
Verification in the Crisis Escalation Phase Caused by the COVID-19 Pandemic.
Sustainability, 12(10), 4318. https://doi.org/10.3390/su12104318
Bigley, G. A., & Roberts, K. H. (2001). The incident command system: High-Reliability
organizing for complex and volatile task environments. Academy of Management
Journal, 44(6), 1281–1299. https://doi.org/10.2307/3069401

142
Bion, X. S. (2019). Health Affairs' Rural Health Issue Has Special Relevance to California.
California Health Care Foundation. https://www.chcf.org/blog/health-affairs-rural-healthissue-special-relevance-california
Björck, A. (2016). Crisis typologies revisited: An interdisciplinary approach. Central European
Business Review, 5(3), 25-37. https://doi.org/10.18267/j.cebr.156
Boddy, C. R. (2016). Sample size for qualitative research. Qualitative Market Research, 19(4),
426–432. https://doi.org/10.1108/QMR-06-2016-0053
Boin, A. (2005). Disaster research and future crises: Broadening the research agenda.
International Journal of Mass Emergencies and Disasters, 23(3), 199.
Boin, A., & ’t Hart, P. (2003). Public leadership in time of crisis: mission impossible? Public
Administration Review, 63(5), 544–553. https://doi.org/10.1111/1540-6210.00318
Boin, A., Kofman-Bos, C., & Overdijk, W. (2004). Crisis simulations: Exploring tomorrow's
vulnerabilities and threats. Simulation & Gaming, 35(3), 378-393.
https://doi.org/10.1177/1046878104266220
Bolman, L., & Deal, T. (2021). Reframing organizations: Artistry, choice and leadership. (7th
ed.). San Francisco, CA: Jossey-Bass.
Brandebo, M. F. (2020). Destructive leadership in crisis management. Leadership &
Organization Development Journal, 41(4), 567-580. https://doi.org/10.1108/LODJ-02-
2019-0089
Brinks, V. & Ibert, O. (2020). From corona virus to corona crisis: The value of an analytical and
geographical understanding of crisis. Tijdschrift voor Economische en Sociale Geografie,
111(3), 275-287.

143
Buck, D., Trainor, J. E., & Aguirre, B. E. (2006). A critical evaluation of the incident command
system and NIMS. Journal of Homeland Security and Emergency Management, 3(3), 1–
1. https://doi.org/10.2202/1547-7355.1252
Bullock, J. A., Haddow, G. D., & Coppola, D. P. (2020). Introduction to emergency management
(7th ed.). Butterworth-Heinemann.
Bundy, J., Pfarrer, M., Short, C., & Coombs, W. T. (2017). Crises and crisis management:
Integration, interpretation, and research development. Journal of Management, 43(6),
1661-1692. https://doi.org/10.1177/0149206316680030
Burke, S., Bethel, J. W. and Foreman Britt, A. (2012). Assessing disaster preparedness among
Latino migrant and seasonal farmworkers in eastern North Carolina. International
Journal of Environmental Research and Public Health, 9, 3115-3133.
https://doi.org/10.3390/ijerph9093115
Burkle, F. M. (2019). Challenges of global public health emergencies: Development of a healthcrisis management framework. The Tohoku Journal of Experimental Medicine, 249(1),
33-41. https://doi.org/10.1620/tjem.249.33
Burnes, B. (2004). Kurt Lewin and the planned approach to change: a re-appraisal. Journal of
Management Studies, 41(6), 977-1002.
Burnes, B. (2020). The origins of Lewin’s three-step model of change. The Journal of Applied
Behavioral Science, 56(1), 32–59. https://doi.org/10.1177/0021886319892685
Burnett. (1998). A strategic approach to managing crises. Public Relations Review, 24(4), 475–
488. https://doi.org/10.1016/S0363-8111(99)80112-X
Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American
Psychologist, 32(7), 513-531. https://doi.org/10.1037/0003-066x.32.7.513

144
Brown, C. H. (2018). The role of leadership in surviving a school shooting. Journal of Cases in
Educational Leadership, 21(2), 3-14. https://doi.org/10.1177/1555458917735357
Brownson, R. C., Burke, T. A., Colditz, G. A., & Samet, J. M. (2020). Reimaging public health
in the aftermath of a pandemic. American Journal of Public Health, 110(11), 1605-1610.
https://doi.org/10.2105/AJPH.2020.305861
California Department of Public Health. (2016). State of California strategies to address
prescription drug (opioid) misuse, abuse, and overdose epidemic in California.
https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/SACB/CDPH%20Document%20L
ibrary/Prescription%20Drug%20Overdose%20Program/CAOpioidPreventionStrategies4.
17.pdf
California Health & Human Services [CalHHS]. (n.d.). Historical background and statutory
authority. www.chhs.ca.gov/about
Calonge, N., Brown, L., & Downey, A. (2020). Evidence-based practice for public health
emergency preparedness and response: Recommendations from a national academies of
sciences, engineering, and medicine report. JAMA : the Journal of the American Medical
Association, 324(7), 629–630. https://doi.org/10.1001/jama.2020.12901
Carian, E. K., & Hill, J. D. (2021). Using frameworks of social desirability to teach subjectivity
in interviews. Teaching Sociology, 49(4), 381–393.
https://doi.org/10.1177/0092055X211017195
Cassoobhoy, Sardana, J. J., Benigas, S., Tips, J., & Kees, A. (2022). Building health equity:
Action steps from the American college of lifestyle medicine’s health disparities solutions
summit (HDSS) 2020. American Journal of Lifestyle Medicine, 16(1), 61–75.
https://doi.org/10.1177/15598276211052248

145
Castle, A. (2019). Crisis management in 21st century. Turan: Stratejik Arastirmalar
Merkezi;Kars, 11(42), 318-322. https://dx.doi.org/10.15189/1308-8041
Centers for Disease Control and Prevention [CDC]. (2022a). U.S. overdose deaths in 2021
increased half as much as in 2020 – but are still up 15%. U.S. Department of Health and
Human Services.
https://www.cdc.gov/nchs/pressroom/nchs_press_release/2022/202205.htm
Centers for Disease Control and Prevention [CDC]. (2022b). What is health equity? U.S.
Department of Health and Human Services.
https://www.cdc.gov/healthequity/whatis/index.html
Centers for Disease Control and Prevention [CDC]. (2018). CERC: Introduction. U.S.
Department of Health and Human Services.
https://emergency.cdc.gov/cerc/ppt/CERC_Introduction.pdf
Cherniss, C., & Goleman, D. (2001). The emotionally intelligent workplace: how to select for
measure, and improve emotional intelligence in individuals, groups, and organizations.
(1
st ed.). Jossey-Bass.
Christensen, T., Lægreid, P., & Rykkja, L. H. (2018). Organizing for societal security and crisis
management: Governance capacity and legitimacy. In Societal security and crisis
management (pp. 1–23). Springer International Publishing. https://doi.org/10.1007/978-3-
319-92303-1_1
Ciftci, G., Kucukaltan, D. & Mentes, S. A. (2017). Empirical analysis of crisis management
practices in tourism enterprises in terms of organizational learning. Business
&Management Studies: An International Journal, 5(1), 42-57.

146
Clark, R. E., & Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions. Charlotte, NC: Information Age Publishing.
Cloudman, R., & Hallahan, K. (2006). Crisis communications preparedness among U.S.
organizations: Activities and assessments by public relations practitioners. Public
Relations Review, 32(4), 367–376. https://doi.org/10.1016/j.pubrev.2006.09.005
Coccia. (2022). Preparedness of countries to face COVID-19 pandemic crisis: Strategic
positioning and factors supporting effective strategies of prevention of pandemic threats.
Environmental Research, 203, 111678–111678.
https://doi.org/10.1016/j.envres.2021.111678
Cole, B., Nilsen, D. M., Will, L., Etkind, S. C., Burgos, M., & Chorba, T. (2022). Essential
components of a public health tuberculosis prevention, control, and elimination program:
Recommendations of the advisory council for the elimination of tuberculosis and the
national tuberculosis controllers association. MMWR. Morbidity and Mortality Weekly
Report, 69(7). 1-27. https://dx.doi.org/10.15585/mmwr.rr6907a1
Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2017). Household food security in
the United States in 2016, ERR-237, U.S. Department of Agriculture, Economic
Research Service. Retrieved from:
https://www.ers.usda.gov/webdocs/publications/84973/err-237.pdf?v=42979
Collins, J. (2001). Good to great: Why some companies make the leap and others don’t. New
York, NY: Harper Collins.
Colquitt, J. A., LePine, J. A., Piccolo, R. F., Zapata, C. P., & Rich, B. L. (2012). Explaining the
justice–performance relationship: Trust as exchange deepener or trust as uncertainty
reducer? Journal of Applied Psychology, 97(1), 1–15. https://doi.org/10.1037/a0025208

147
Colquitt, J. A., Scott, B. A., & LePine, J. A. (2007). Trust, trustworthiness, and trust propensity:
A meta-analytic test of their unique relationships with risk taking and job performance.
Journal of Applied Psychology, 92(4), 909-927. https://doi.org/10.1037/0021-
9010.92.4.909
Comes, M., Alexander, D., Boin, A., Eckert, C., Elmqvist, T., Fochesato, M., Helbing, D.,
Latusek-Jurczak, D., Lauta, K., Meriläinen, E., Nikkari, S., Papadimitratos, P., Renn, O.,
Rios Insua, D., Rizza, C., & Zio, E. (2022). Strategic crisis management in the European
Union: Evidence review report. SAPEA . https://doi.org/10.26356/crisismanagement
Commonwealth Fund Issues Report Entitled 'Recommendations for Building a National Public
Health System That Addresses Ongoing and Future Health Crises, Advances Equity and
Earns Trust'. (2022, Aug 09). Targeted News Service. https://www-proquest
com.libproxy2.usc.edu/wire-feeds/commonwealth-fund-issues-reportentitled/docview/2700134656/se-2
Compton, & Jones, C. M. (2019). Epidemiology of the U.S. opioid crisis: The importance of the
vector. Annals of the New York Academy of Sciences, 1451(1), 130–143.
https://doi.org/10.1111/nyas.14209
Cook, R., & Anderson, R. (2019). Transitioning from incident to crisis management to continuity
of operations. Journal of Business Continuity & Emergency Planning, 14(1), 46-54.
Coombs, N. C, Campbell, D. G., & Caringi, J. (2022). A qualitative study of rural healthcare
providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC
Health Services Research, 22(1), 438–438. https://doi.org/10.1186/s12913-022-07829-2

148
Coombs, W. T. (1999). Information and compassion in crisis responses: A test of their effects.
Journal of Public Relations Research, 11(2), 125-142.
https://doi.org/10.1207/s1532754xjprr1102_02
Coombs, W. (2014). Applied crisis communication and crisis management. SAGE Publications,
Inc., https://doi.org/10.4135/9781544308531
Coombs, W. T. (2022). Ongoing crisis communication: Planning, managing, and responding
(Sixth ed.). SAGE Publications, Inc.
Cosgrave, C. (2020). The whole-of-person retention improvement framework: A guide for
addressing health workforce challenges in the rural context. International Journal of
Environmental Research and Public Health, 17(8), 2698-.
https://doi.org/10.3390/ijerph17082698
Cox, J., Clark, C., & Sanders, T. (2023). Rural Healthcare (Second edition). CRC Press.
https://doi.org/10.1201/9781003302438
COVID-19: Imminent Hazard to Employees: Exposure: Notification: Serious Violations, A.B.
685, 2019-2020 Reg. Sess. (Cal. 2019). (enacted).
https://leginfo.leislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200AB685
Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed
methods approaches (5th ed.). SAGE Publications, Inc.
Crocker, R. M. (2021). The Impact of Binational Barriers to Medical Care on the Care-Seeking
Practices of Mexican Immigrants. Qualitative Health Research, 31(6), 1043–1055.
https://doi.org/10.1177/1049732321992041
Cummings, S., Bridgman, T., & Brown, K. G. (2016). Unfreezing change as three steps:
Rethinking Kurt Lewin’s legacy for change management. Human Relations, 69(1), 33–

149
60. https://doi.org/10.1177/0018726715577707
Curnin, S., Owen, C., Paton, D., Trist, C., & Parsons, D. (2015). Role clarity, swift trust, and
multi-agency coordination. Journal of Contingencies and Crisis Management, 23(1), 29-
35. https://doi.org/10.1111/1468-5973.12072
Dalcher, D. (2020). Leadership in times of crisis: What’s the difference now? PM World
Journal, 9(5), 1-17.
Danforth, E., Doying, A., Merceron, G., & Kennedy, L. (2010). Applying social science and
public health methods to community-based pandemic planning. Journal of Business
Continuity & Emergency Planning, 4(4), 375–390.
De Silva, R., Perera, G. D. N., & Tharanganie, M. G. (2023). Change agility: A paradigm of
change acceptance for organization sustainability. Management Journal for Advanced
Research, 3(6), 51–69. https://doi.org/10.54741/mjar.3.6.6
de Tantillo, L., & Christopher, R. (2021). Implementing the national incident management
system at schools of nursing in response to COVID-19. Journal of Professional Nursing,
37(2), 255–260. https://doi.org/10.1016/j.profnurs.2020.12.013
Devakumar, Selvarajah, S., Shannon, G., Muraya, K., Lasoye, S., Corona, S., Paradies, Y.,
Abubakar, I., & Achiume, E. T. (2020). Racism, the public health crisis we can no longer
ignore. The Lancet (British Edition), 395(10242), e112–e113.
https://doi.org/10.1016/S0140-6736(20)31371-4
Dhanani, L. Y., & Franz, B. (2020). Unexpected public health consequences of COVID-19
pandemic: a national survey examining anti-Asian attitudes in the USA. International
Journal of Public Health, 65, 747–754. https://doi.org/10.1007/s00038-020-01440-0

150
Diddi, P., & Wei, L. (2022). Crisis management on social media: Effect of pre-crisis inoculation
strategy and midst-crisis organizational interactivity. Public Relations Review, 48(5),
102206–. https://doi.org/10.1016/j.pubrev.2022.102206
Dirani, K. M., Abadi, M., Alizadeh, A., Barhate B., Garza, R. C., Gunasekara, N., Ibrahim, G. &
Majzun, Z. (2020). Leadership competencies and the essential role of human resource
development in times of crisis: A response to covid-19 pandemic. Human Resource
Development International, 23(4), 380-394.
https://doi.org/10.1080/13678868.2020.1780078
Donnelly, & Linn, J. (2019). Preparing metacognitive educational leaders: How placing critical
thinking at the heart of our program is transforming our students. Journal of Higher
Education Theory and Practice, 19(2), 39–55. https://doi.org/10.33423/jhetp.v19i2.1442
Douthit, N., Kiv, S., Dwolatzky, T., & Biswas, S. (2015). Exposing some important barriers to
health care access in the rural USA. Public Health (London), 129(6), 611–620.
https://doi.org/10.1016/j.puhe.2015.04.001
Dow-Fleisner, S., Seaton, C. L., Li, E., Plamondon, K., Oelke, N., Kurtz, D., Jones, C., Pesut,
L.M. C., Hasan, K., & Rush, K. L. (2022). Internet access is a necessity: A latent class
analysis of COVID-19 related challenges and the role of technology use among rural
community residents. BMC Public Health, 22, 1-11. https://doiorg.libproxy1.usc.edu/10.1186/s12889-022-13254-1
Dubé, È., Labbé, F., Malo, B., & Pelletier, C. (2022). Public health communication during the
COVID-19 pandemic: Perspectives of communication specialists, healthcare
professionals, and community members in Quebec, Canada. Canadian Journal of Public
Health, 113(Suppl 1), 24–33. https://doi.org/10.17269/s41997-022-00697-7

151
Dubnick, M. (2014). The ontological challenge. In M. Bovens, R. E. Goodin, & T. Schillemans
(eds.), Oxford handbook of public accountability (pp. 649-654). Oxford: Oxford
University Press.
Dulal, H. B. (2017). Making cities resilient to climate change: identifying “win-win”
interventions. Local Environment, 22(1), 106–125.
https://doi.org/10.1080/13549839.2016.1168790
Dutton, J. E., & Jackson, S. E. (1987). Categorizing strategic issues: Links to organizational
action. Academy of Management Review, 12(1), 76-90.
https://doi.org/10.5465/amr.1987.4306483
Eccles, J. S., & Wigfield, A. (2002). Motivational beliefs, values, and goals. Annual Review of
Psychology, 53, 109–132. https://doi.org/10.1146/annurev.psych.53.100901.135153
Egbuonye, N., Sesterhenn, L., Goldman, B., Pikora, J., & Parmater, J. (2022). Bridging the gap
between transformative practices and traditional public health approaches. Journal of
Public Health Management and Practice, 28(Supplement 4), 151-158.
EH & A Consulting. (n.d.). Crisis Leadership Competency. Resources.
http://www.ehaconsulting.org/resource/
Elliott A., Dweck, C.S., Yeager D.S. (2018). Handbook of competence and motivation: theory
and application, (2nd edition), New York: Guilford Press.
Elliott, D. (2009). The failure of organizational learning from crisis - A matter of life and death?
Journal of Contingencies and Crisis Management, 17(3), 157–168.
https://doi.org/10.1111/j.1468-5973.2009.00576.x

152
Feder, K. A., Letourneau, E. J., & Brook, J. (2019). Children in the Opioid Epidemic: Addressing
the Next Generation's Public Health Crisis. Pediatrics, 143(1), e20181656.
https://doi.org/10.1542/peds.2018-1656
Fernandez-Bou, A., Rodríguez-Flores, J. M., Guzman, A., Ortiz-Partida, J., Classen-Rodriguez,
L. M., Sánchez-Pérez, P. A., Valero-Fandiño, J., Pells, C., Flores-Landeros, H.,
Sandoval-Solís, S., Characklis, G. W., Harmon, T. C., McCullough, M., & MedellínAzuara, J. (2023). Water, environment, and socioeconomic justice in California: A multibenefit cropland repurposing framework. Science of The Total Environment, 858,
159963. https://doi.org/10.1016/j.scitotenv.2022.159963
Fielding, J. L. (2012). Inequalities in exposure and awareness of flood risk in England and
Wales. Disasters, 36(3), 477−494. https://doi.org/10.111/j.1467-7717.2011.01270.x
Fink, L. (2014). Workers in Hard Times: A Long View of Economic Crises (Vol. 331). University
of Illinois Press. https://doi.org/10.5406/j.ctt7zw62c
Finn, B., Miele, D. B., & Wigfield, A. (2023). The impact of remembered success experiences on
expectancies, values, and perceived costs. Contemporary Educational Psychology, 72,
102143–. https://doi.org/10.1016/j.cedpsych.2022.102143
Flaherty, M. T., Stuby, P., & Kose, W. (2018). Addressing the opioid epidemic in rural America.
Psychiatric Services (Washington, D.C.), 69(10), 1114–1114.
https://doi.org/10.1176/appi.ps.691004
Folsom, M. B. (1963). Health, Education and Welfare: The First Decade. Current History (1941),
45(264), 87–118. https://doi.org/10.1525/curh.1963.45.264.87
Fragouli, E. (2020). Interaction of crisis leadership and corporate reputation. Journal of Business
and Retail Management Research, 15(1), 44-58.

153
Frandsen, F. & Johansen, W. (2020). Crisis Communication. Berlin, Boston: De Gruyter Mouton.
https://doi.org/10.1515/9783110554236
Freeden, M. (2017). Crisis? How is that a crisis?! Reflections on an overburdened word.
Contributions to the History of Concepts, 12(2), 12-28.
https://doi.org/10.3167/choc.2017.120202
Frewen, P. A., Dozois, D. J. A., Neufeld, R. W. J., Lane, R. D., Densmore, M., Stevens, T. K., &
Lanius, R. A. (2010). Individual differences in trait mindfulness predict dorsomedial
prefrontal and amygdala response during emotional imagery: An fMRI study. Personality
and Individual Differences, 49(5), 479–484. https://doi.org/10.1016/j.paid.2010.05.008
Frumkin, H., & McMichael, A. J. (2008). Climate Change and Public Health. Thinking,
Communicating, Acting. American Journal of Preventive Medicine, 35(5), 403–410.
https://doi.org/10.1016/j.amepre.2008.08.019
Fusch, P., Hall, J., & Fusch, G. (2018). Empowering internal stakeholders through the
dissemination of useful information: A review of crisis management concepts. Journal of
Social Change, 10(1), 145-158. https://doi.org/10.5590/JOSC.2018.10.1.12
Galea, S., & Abdalla, S. M. (2020). COVID-19 pandemic, unemployment, and civil unrest:
Underlying deep racial and socioeconomic divides. Journal of the American Medical
Association, 324(3), 227–228. https://doi.org/10.1001/jama.2020.11132
Garcia, H. F. (2017). Strategic choices for managing potential crises. Strategy & Leadership,
45(6), 34-40. https://doi.org/10.1108/SL-08-2017-0082
Gibbs, G.R., (2018). Analyzing qualitative data (Vol. 6). Sage.
Gifford, R., Fleuren, B., van de Baan, F., Ruwaard, D., Poesen, L., Zijlstra, F. R.., & Westra, D.
(2022). To uncertainty and beyond: Identifying the capabilities needed by hospitals to

154
function in dynamic environments. Medical Care Research and Review, 79(4), 549–561.
https://doi.org/10.1177/10775587211057416
Golembiewski, E. H., Gravholt, D. L., Roldan, V. D. T., Naranjo, E. P. L., Vallejo, S., Bautista,
A. G., Lavecchia, C. M., Patten, C. A., Allen, S. V., Jaladi, S., & Boehmer, K. R. (2022).
Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic
Review and Thematic Synthesis of Qualitative Studies. Annals of Family
Medicine, 20(3), 272–272. https://doi.org/10.1370/afm.2798
Goniewicz, K., Burkle, F.M., Hall, T., Goniewicz, M., & Khorram-Manesh, A. (2022). Global
public health leadership: The vital element in managing global health crises. Journal of
Global Health, 12. https://doi.org/10.1177/1073110519857322
Goniewicz, K., Carlström, E., Hertelendy, A. J., Burkle, F. M., Goniewicz, M., Lasota, D.,
Richmond, J. G., & Khorram-Manesh, A. (2021). Integrated healthcare and the dilemma
of public health emergencies. Sustainability (Basel, Switzerland), 13(8), 4517–.
https://doi.org/10.3390/su13084517
Goodridge, D., & Marciniuk, D. (2016). Rural and remote care: Overcoming the challenges of
distance. Chronic Respiratory Disease, 13(2), 192-203.
https://doi.org/10.1177/1479972316633414
Gottfredson, R. K., & Reina, C. S. (2020). Exploring why leaders do what they do: An
integrative review of the situation-trait approach and situation-encoding schemas. The
Leadership Quarterly, 31(1), 101373–. https://doi.org/10.1016/j.leaqua.2019.101373
Grossman, R., & Salas, E. (2011). The transfer of training: What really matters. International
Journal of Training and Development, 15(2), 103–119. https://doi.org/10.1111/j.1468-
2419.2011.00373.x

155
Gupta, N., Balcom, S., Gulliver, A., & Witherspoon, R. (2021). Systematic review of health
workforce surge capacity during COVID-19 and other viral pandemics. European
Journal of Public Health, 31(Supplement_3).
https://doi.org/10.1093/eurpub/ckab165.034
Gustafsson, S., Gillespie, N., Searle, R., Hailey, V. H., & Dietz, G. (2021). Preserving
Organizational Trust During Disruption. Organizational Studies, 42(9), 1409-1433.
Guth, D. W. (1995). Organizational crisis experience and public relations roles. Public Relations
Review, 21(2), 123–136. https://doi.org/10.1016/0363-8111(95)90003-9
Ha, J. H., & Boynton, L. (2013). Has crisis communication been studied using an
interdisciplinary approach? A 20-year content analysis. International Journal of Strategic
Communication, 8(1), 29-44. https://doi.org/10.1080/1553118X.2013.850694
Hajncl, L., & Vučenović, D. (2020). Effects of measures of emotional intelligence on the
relationship between emotional intelligence and transformational leadership.
Psihologijske Teme, 29(1), 119–134. https://doi.org/10.31820/pt.29.1.7
Hart, P., Rosenthal, U., & Kouzmin, A. (1993). Crisis decision making: The centralization thesis
revisited. Administration & Society, 25(1), 12-45.
https://doi.org/10.1177/009539979302500102
Hassel, H., & Cedergren, A. (2021). Integrating risk assessment and business impact assessment
in the public crisis management sector. International Journal of Disaster Risk Reduction,
56, 102136–. https://doi.org/10.1016/j.ijdrr.2021.102136
Hamideh, Sen, P., & Fischer, E. (2022). Wildfire impacts on education and healthcare: Paradise,
California, after the Camp Fire. Natural Hazards (Dordrecht), 111(1), 353–387.
https://doi.org/10.1007/s11069-021-05057-1

156
Hauenstein, E. J., Glick, D. F., Kane, C., Kulbok, P., Barbero, E., & Cox, K. (2014). A model to
develop nurse leaders for rural practice. Journal of Professional Nursing. 30(6), 463-473.
https://doi.org/10.1016/j.profnurs.2014.04.001
Health Resources and Services Administration [HRSA]. (2020, November). Opioid Crisis.
https://www.hrsa.gov/opioids
Heath, R. L., Lee, J., Palenchar, M. J., & Lemon, L. L. (2018). Risk communication emergency
response preparedness: contextual assessment of the protective action decision model.
Risk Analysis, 38(2), 333–344. https://doi.org/10.1111/risa.12845
Heffner, S., Kennedy, S., Brand, J., & Walsh, P. (2011). Develop your leaders, transform your
organization. Harvard Business School. Retrieved from www.harvardbusiness.org.
Hertelendy, A., McNulty, E. J., & Burkle, F., M. (2021). The new normal: A catalyst for
leadership adaptation in a tumultuous world – Let's stop applying 20th century solutions
to 21st century problems in emergency management. Journal of Emergency Management,
19(4), 323-325. https://doi.org/10.5055/jem.0628
Hirudayaraj, M. & Sparkman, T. (2019). Building leadership capacity: a framework for
disruptive events in tourism. Industrial and Commercial Training, 51(2), 114-124.
Hitchcock, L. A., Báez, J. C., Sage, M., Marquart, M., Lewis, K., & Smyth, N. J. (2021). Social
work educators’ opportunities during COVID-19: A roadmap for trauma-informed
teaching during crisis. Journal of Social Work Education, 57(1), 82–98.
https://doi.org/10.1080/10437797.2021.1935369
Hollenbeck, J. R., Beersma, B., & Schouten, M. E. (2012). Beyond team types and taxonomies:
A dimensional scaling conceptualization for team description. Academy of Management
Review, 37(1), 82-106. https://doi.org/10.5465/amr.2010.0181

157
Holzweiss, P. & Walker, D. (2018). Higher education crises: Training new professionals for crisis
management. College of Student Affairs Journal, 36(1), 124-135.
https://doi.org/10.1353/csj.2018.0008
Horney, J., Nguyen, M., Salvesen, D., Dwyer, C., Cooper, J., & Berke, P. (2017). Assessing the
quality of rural hazard mitigation plans in the southeastern United States. Journal of
Planning Education and Research, 37(1), 56–65.
https://doi.org/10.1177/0739456X16628605
Horwitz, Chang, C., Arcilla, H. N., & Knickman, J. R. (2020). Quantifying health systems’
investment in social determinants of health, by sector, 2017–19. Health Affairs, 39(2),
192–198. https://doi.org/10.1377/hlthaff.2019.01246
Huffmire, D. W. (2005). Why some companies emerge stronger and better from a crisis: 7
essential lessons for surviving disaster. Choice, 42(11), 2030.
Hunter, J. A., & Lambert, J. R. (2016). Do we feel safer today? The impact of smiling customer
service on airline safety perception post 9-11. Journal of Transportation Security, 9(1-2),
35-56. https://doi.org/10.1007/s12198-016-0165-2
Jacobsen, W. (2000). Why common ground thinking works. Educational Leadership, 57(4), 76-
80.
Janssen, M., & van der Voort, H. (2020). Agile and adaptive governance in crisis response:
Lessons from the COVID-19 pandemic. International Journal of Information
Management, 55, 102180. https://doi.org/https://doi.or/10.1016/j.ijinfomgt.2020.102180
Jin, Y., & Cameron, G. T. (2007). The effects of threat type and duration on public relations
practitioner’s cognitive, affective, and conative responses in crisis situations. Journal of
Public Relations Research, 19(3), 255–281. https://doi.org/10.1080/10627260701331762

158
Johansen, W., Aggerholm, H. K., & Frandsen, F. (2012). Entering new territory: A study of
internal crisis management and crisis communication in organizations. Public Relations
Review, 38(2), 270-279. https://doi.org/10.1016/j.pubrev.2011.11.008
Johnson, R. B., & Christensen, L. B. (2015). Educational research: Quantitative, qualitative,
and mixed approaches (5th ed.). Thousand Oaks: SAGE.
Kahn, W. A., Barton, M. A., & Fellows, S. (2013). Organizational crises and the disturbance of
relational systems. Academy of Management Review, 38(3), 377-396.
https://doi.org/10.5465/amr.2011.0363
Kaiser, R. (2020). Leading in an unprecedented global crisis: The heightened importance of
versatility. Consulting Psychology Journal: Practice and Research, 72(3), 135-154.
Kampa, M., & Castanas, E. (2008). Human health effects of air pollution. Environmental
Pollution, 151(2), 362-367. https://doi.org/10.1016/j.envpol.2007.06.012
Kantor, L., April, K. A., & Nilsson, W. (2020). The transformative leadership capacities of
mindfulness. Effective Executive, 23(3), 27–64.
Kappel, C., Rushton-Marovac, M., Leong, D., & Dent, S. (2022). Pursuing connectivity in
cardio-oncology care – The future of telemedicine and artificial intelligence in providing
equity and access to rural communities. Frontiers in Cardiovascular Medicine, 9,
927769. https://doi.org/10.3389/fcvm.2022.927769
Kapucu, N. (2008). Culture of preparedness: Household disaster preparedness. Disaster
Prevention and Management, 17(4), 526-535.
https://doi.org/10.1108/09653560810901773

159
Kapucu, N., Hawkins, C.V., & Rivera, F.I., (2013). Disaster preparedness and resilience for rural
communities. Risk, Hazards & Crisis in Public Policy, 4(4), 215-233.
https://doi.org/10.1002/rhc3.12043
Kapucu, N., & Hu, Q. (2022). An old puzzle and unprecedented challenges: Coordination in
response to the covid-19 pandemic in the us. Public Performance & Management
Review, 1–26. https://doi.org/10.1080/15309576.2022.2040039
Kash, T. J., & Darling, J. R. (1998). Crisis management: prevention, diagnosis and intervention.
Leadership & Organization Development Journal, 19(4), 179–186.
https://doi.org/10.1108/01437739810217151
Kayes, C. (2004). The 1996 Mount Everest climbing disaster: The breakdown of learning in
teams. Human Relations (New York), 57(10), 1263–1284.
https://doi.org/10.1177/0018726704048355
Keyes, K. M., Kandula, S., Olfson, M., Gould, M. S., Martínez-Alés, G., Rutherford, C., &
Shaman, J. (2021). Suicide and the agent–host–environment triad: Leveraging
surveillance sources to inform prevention. Psychological Medicine, 51(4), 529–537.
https://doi.org/10.1017/S003329172000536X
Kezar, A. (2000). Pluralistic leadership: Bringing diverse voices to the table. About Campus,
5(3), 6–11, 722–743.
Khan, Y., O'Sullivan, T., Brown, A., Tracey, S., Gibson, J., Généreux, M., Henry, B., &
Schwartz, B. (2018). Public health emergency preparedness: a framework to promote
resilience. BMC Public Health, 18(1344). 1-16. https://doi.org/10.1186/s12889-018-
6250-7
Khaw, K. W., Alnoor, A., AL-Abrrow, H., Tiberius, V., Ganesan, Y., & Atshan, N. A. (2023).

160
Reactions towards organizational change: A systematic literature review. Current
Psychology (New Brunswick, N.J.), 42(22), 19137–19160.
https://doi.org/10.1007/s12144-022-03070-6
Kim, Y. (2018). Enhancing employee communication behaviors for sensemaking and sense
giving in crisis situations. Journal of Communication Management, 22(4), 451-475.
https://doi.org/10.1108/JCOM-03-2018-0025
Kluger, A., & DeNisi, A. (1998). Feedback interventions: Toward the understanding of a
double-edged sword. Current Directions in Psychology, 7(3), 67–72.
Knapp, E. A., Bilal, U., Dean, L. T., Lazo, M., & Celentano, D. D. (2019). Economic insecurity
and deaths of despair in us counties. American Journal of Epidemiology, 188(12), 2131-
2139. https://doi.org/10.1093/aje/kwz103
Kotter, J. (2012). Leading change. Boston, MA: Harvard Business Review.
Kouzes, J. M., & Posner, B. Z. (2010). The truth about leadership: The no-fads, heart-of-thematter facts you need to know. John Wiley & Sons.
Krathwohl, D. R. (2002). A revision of bloom's taxonomy: An overview. Theory Into Practice,
41(4), 212–218. https://doi.org/10.1207/s15430421tip4104_2
Kutzin, J. (2013). Health financing for universal coverage and health system performance:
concepts and implications for policy. Bulletin of the World Health Organization, 91(8),
602–611. https://doi.org/10.2471/BLT.12.113985
Kwok, A. P. K., Yan, M. C., Chan, B. K. P., & Lau, H. (2019). Crisis management training using
discrete-event simulation and virtual reality techniques. Computers & Industrial
Engineering, 135, 711–722. https://doi.org/10.1016/j.cie.2019.06.035

161
Laborde, Martin, W., & Vos, R. (2021). Impacts of COVID‐19 on global poverty, food security,
and diets: Insights from global model scenario analysis. Agricultural Economics, 52(3),
375–390. https://doi.org/10.1111/agec.12624
LeDoux, J. E. (2014). Coming to terms with fear. Proceedings of the National Academy of
Sciences - PNAS, 111(8), 2871–2878. https://doi.org/10.1073/pnas.1400335111
Latham & Watkins Environment; Land & Resources Practice. (2022). California Legislature
Passes Four Aggressive Climate Bills and Authorizes Extension of Diablo Canyon
(Client Alert Commentary September 8, 2022, Number 3007).
Leider, J. P., Meit, M., Mac McCullough, J., Resnick, B., Dekker, D., Alfonso, Y., & Bishai, D.
(2020). The state of rural public health: enduring the needs in a new decade. American
Journal of Public Health, 110(9), 1283–1290. https://doi.org/10.2105/AJPH.2020.305728
LeSaint, K. T., Ho, R. Y., Heard, S. E., & Smollin, C. G. (2021). California poison control system
implementation of a novel hotline to treat patients with opioid use disorder. Journal of
medical toxicology: official journal of the American College of Medical Toxicology,
17(2), 190–196. https://doi.org/10.1007/s13181-020-00816-1
Lins, M. E., Pamplona, L., Lins, A. E., & Lyra, K. (2023). Metacognitive attitude for decision
making at a university hospital. International Transactions in Operational Research,
30(3), 1366–1386. https://doi.org/10.1111/itor.12975
Lochmiller, C. (2021). Rural superintendents’ responses to COVID-19: Navigating local control
during a public health crisis. Frontiers in Education (Lausanne), 6.
https://doi.org/10.3389/feduc.2021.617058
Lowe, T. C., Lee, L. M., Dineen Gillespie, K. K., Feig, C., Ferdinand, A. O., Mohapatra, S.,
Brett-Major, D. M., & Wynia, M. K. (2022). Uncertainty, scarcity and transparency:

162
Public health ethics and risk communication in a pandemic. Lancet Regional Health.
Americas, 16, 100374–100374. https://doi.org/10.1016/j.lana.2022.100374
Maccalla, N., Joseph, C., Purnell, D., & Zhong, S. (2021). Development of the self-efficacy as
faculty change agent for diversity scale. Journal of Higher Education Theory and
Practice, 21(3), 104-110.
Malloy, C. (2011). Moving beyond data: Practitioner-led inquiry fosters change. Phi Delta
Kappa International, 6(4), 1-20.
Marcus, L. J., Dorn, B. C., & Henderson, J. M. (2006). Meta-leadership and national emergency
preparedness: A model to build government connectivity. Biosecurity and Bioterrorism:
Biodefense Strategy, Practice, and Science, 4(2), 128-134.
https://doi.org/10.1089/bsp.2006.4.128
Mayer, R. (2010). Applying the science of learning to medical education: Applying the science
of learning. Medical Education, 44(6), 543–549.
Mazzei, A., Kim, J. N, & Dell'Oro, C. (2012). Strategic value of employee relationships and
communicative actions: Overcoming corporate crisis with quality internal
communication. International Journal of Strategic Communication, 6(1), 31-44.
https://doi.orb/10.1080/1553118x.2011.634869
McConnell, A., & Drennan, L. (2006). Mission impossible? Planning and preparing for crisis.
Journal of Contingencies and Crisis Management, 14(2), 59–70.
https://doi.org/10.1111/j.1468-5973.2006.00482.x
McNulty, E. J., Dorn, B. C., Serino, R., Goralnick, E., Grimes, J. O., Flynn, L. B., Pillay, S. S., &
Marcus, L. J. (2018). Integrating brain science into crisis leadership development.

163
Journal of Leadership Studies (Hoboken, N.J.), 11(4), 7–20.
https://doi.org/10.1002/jls.21548
Medina, M. S., Castleberry, A. N., & Persky, A. M. (2017). Strategies for improving learner
metacognition in health professional education. American Journal of Pharmaceutical
Education, 81(4), 78A-78N. https://doi.org/10.5688/ajpe81478
Melms, Falk, E., Schieffer, B., Jerrentrup, A., Wagner, U., Matrood, S., Schaefer, J. R., Müller,
T., & Hirsch, M. (2021). Towards a COVID-19 symptom triad: The importance of
symptom constellations in the SARS-CoV-2 pandemic. PloS One, 16(11), e0258649–
e0258649. https://doi.org/10.1371/journal.pone.0258649
Mendez, S. J., Adodoadji, L., Toval, C., McNeil, M., & Sindhu, M. (2021). Racism as public
health crisis: Assessment and review of municipal declarations and resolutions across the
United States. Frontiers in Public Health, 9, 686807–686807.
https://doi.org/10.3389/fpubh.2021.686807
Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and methods
approaches (4th ed.). San Francisco: Jossey-Bass.
Meyer, F., Le Fevre, D. M., & Robinson, V. M. (2017). How leaders communicate their
vulnerability: Implications for trust building. International Journal of Educational
Management, 31(2), 221-235. https://doi.org/10.1108/IJEM-11-2015-0150
Miller, S., France, D., & Welsh, K. (2015). Development of crisis and emergency risk
communication (CERC) activities and an evaluation of their impact on learning:
Geoscience students’ perceptions. BELGEO (Leuven), 1(1).
https://doi.org/10.4000/belgeo.16386

164
Mitroff, I. I. (2000). Managing crises before they happen: What every executive and manager
needs to know about crisis management. AMACOM/American Management Association.
Mitroff, I. I. (2004). Crisis leadership: Planning for the unthinkable. Wiley.
Moorman, R., & Grover, S. (2009). Why does leader integrity matter to followers? An
uncertainty management-based explanation. International Journal of Leadership
Studies, 5(2). Retrieved from
https://www.regent.edu/acad/global/publications/ijls/new/vol5iss2/IJLS_vol5_iss2_moor
man_grover_leader_integrity.pdf
Moran, D. J. (2010). ACT for leadership: Using acceptance and commitment training to develop
crisis-resilient change managers. International Journal of Behavioral Consultation and
Therapy, 6(4), 341-355. https://doi.org/10.1037/h100915
Muffet-Willett, S. L., & Kruse, S. D. (2009). Crisis leadership: Past research and future
directions. Journal of Business Continuity & Emergency Planning, 3(3), 248–258.
Mwaungulu, G., & Dwyer, K. (2019). Responding to public health emergencies at the local
level: Administrative preparedness challenges, strategies, and resources. Journal of Law,
Medicine & Ethics, 47(S2), 72-75. https://doi.org/10.1177/1073110519857322
Naser, A. N., Khalifa, G., Abuelhassan, E., Nusari, M., & Isaac, O. (2019). Investigating the
impact of leadership and business continuity management on organizational crisis
performance. International Business Management, 13(7), 266–278.
https://doi.org/10.36478/ibm.2019.266.278
National Library of Medicine. (2017). The root causes of health inequity.
https://www.ncbi.nlm.nih.gov/books/NBK425845/

165
National Preparedness Leadership Initiative [NPLI] (2021). State of the program 2021. Retrieved
from https://npli.sph.harvard.edu/wp-content/uploads/sites/2644/2022/08/State-of-theProgram-2021-FINAL.pdf
Nilsson, J. (2010). What’s the problem? Local officials’ conceptions of weaknesses in their
municipalities’ crisis management capabilities: Local officials’ conceptions of crisis
management capabilities. Journal of Contingencies and Crisis Management, 18(2), 83–
95. https://doi.org/10.1111/j.1468-5973.2010.00607.x
Nizamidou C., & Vouzas, F. (2020). The contribution of preoccupation with failure to TQM,
crisis management and HR aiming to overcome crises. TQM Journal, 32(6), 1077–1098.
https://doi.org/10.1108/TQM-11-2019-0265
Northouse, P. (2022). Leadership: Theory and practice (9th ed.). Thousand Oaks, CA: Sage.
Oscarsson, O., & Danielsson, E. (2018). Unrecognized crisis management - Normalizing
everyday work. J Contingencies and Crisis Management. 26, 225-236.
https://doi.org/10.1111/1468-5973.12176
Ott, M. A. (2022). Unintended technology outcomes can pose challenges for local government
leaders: As we move out of crisis mode, we have the opportunity to carefully examine
how technology can help us achieve the best for our communities. Public Management,
104(3), 6–.
Palacios Cruz, M., Santos, E., Velázquez Cervantes, M. A., & León Juárez, M. (2021). COVID19, a worldwide public health emergency. Revista Clínica Espanola, 221, 55-61.
Pandit, N. & Akkara, A. (2020). Best weapon to fight COVID-19-like pandemic - Its host factors
of epidemiological triad. Journal of Integrated Health Sciences, 8(1), 52–53.
https://doi.org/10.4103/JIHS.JIHS_16_20

166
Park, S., Graham, M., & Foster, E. (2022). Improving local government resilience: Highlighting
the role of internal resources in crisis management. Sustainability, 14(6), 3214.
https://doi.org/10.3390/su14063214
Paulus, M. P., Potterat, E. G., Taylor, M. K., Van Orden, K. F., Bauman, J., Momen, N., Padilla,
G. A., & Swain, J. L. (2009). A neuroscience approach to optimizing brain resources for
human performance in extreme environments. Neuroscience and Biobehavioral Reviews,
33(7), 1080–1088. https://doi.org/10.1016/j.neubiorev.2009.05.003
Pearson, C. M, & Clair, J. A. (1998). Reframing crisis management. Academy of Management
Review, 23(1), 59-76. https://doi.org/10.2307/259099
Penrose, J. M. (2000). The role of perception in crisis planning. Public Relations Review, 26(2),
155–171. https://doi.org/10.1016/S0363-8111(00)00038-2
Peretz, P. J., Islam, N., & Matiz, L. A. (2020). Community health workers and covid-19 —
Addressing social determinants of health in times of crisis and beyond. The New England
Journal of Medicine, 383(19), e108–e108. https://doi.org/10.1056/NEJMp2022641
Phelps, R. (n.d.). Leadership at Times of Crisis [White Paper].
https://go.everbridge.com/leadership-at-times-of-crisis-assetpage.html?aliId=eyJpIjoiNVk4ZTNKeG9aNlowMlpCQyIsInQiOiJrWjg3eDF2U0hoem1
HNmdIUE9TclR3PT0ifQ%253D%253D
Pickett, A. D. (2023). Strengths, weaknesses, and catharsis: The role of information sharing in
public health after the COVID-19 response. Health security, 21(S1), S101–S104.
https://doi.org/10.1089/hs.2023.0034
Pincus, J. (1986). Communication satisfaction, job satisfaction and job performance. Human
Communications Research, 12(2), 395–419.

167
Pintrich, P. (2003). A motivational science perspective on the role of student motivation in
learning and teaching contexts. Journal of Educational Psychology, 95(4), 667–686.
https://doi.org/10.1037/0022-0663.95.4.667
Pintrich, P. R. (2002). The role of metacognitive knowledge in learning, teaching, and assessing.
Theory into Practice, 41(4), 219–225. https://doi.org/10.1207/s15430421tip4104_3
Power, N. (2018). Extreme teams: Toward a greater understanding of multiagency teamwork
during major emergencies and disasters. American Psychologist, 73(4), 478-490.
https://doi.org/10.1037/amp0000248
Powley, E., & Taylor, S. (2014). Pedagogical approaches to develop critical thinking and crisis
leadership. Journal of Management Education, 38(4), 560-585.
https://doi.org/10.1177/1052562913519081
Price, J. H., & Murnan, J. (2004). Research limitations and the necessity of reporting them.
American Journal of Health Education, 35(2), 66–67.
https://doi.org/10.1080/19325037.2004.10603611
Public Officers and Employees, California Government Code, 1 GOV §3100 et seq. (1943 & rev.
1972).
https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=3100.&l
awCode=GOV
Quinn, S. C. (2008). Crisis and emergency risk communication in a pandemic: A model for
building capacity and resilience of minority communities. Health Promotion Practice,
9(4), 18S–25S. https://doi.org/10.1177/1524839908324022

168
Raker, E. J. (2020). Natural hazards, disasters, and demographic change: The case of severe
tornadoes in the United States, 1980–2010. Demography, 57(2), 653–674.
https://doi.org/10.1007/s13524-020-00862-y
Ranscombe, P. (2020). Rural areas at risk during COVID-19 pandemic. The Lancet Infectious
Diseases, 20(5), 545–545. https://doi.org/10.1016/S1473-3099(20)30301-7
Rawlings, D. (2000). Collaborative leadership teams: Oxymoron or new paradigm? Educational
Publishing Foundation, 52(1), 36-48. https://doi.org/10.1037//1061-4087.52.1.36
Revere, D., Nelson, K., Thiede, H., Duchin, J., Stergachis, A., & Baseman, J. (2011). Public
health emergency preparedness and response communications with health care providers:
A literature review. BMC Public Health, 11(1), 337–337. https://doi.org/10.1186/1471-
2458-11-337
Rhodes. (2019). Metacognition. Teaching of Psychology, 46(2), 168–175.
https://doi.org/10.1177/0098628319834381
Richman, L., Pearson, J., Beasley, C., & Stanifer, J. (2019). Addressing health inequalities in
diverse, rural communities: An unmet need. SSM – Population Health, 7, 100398.
https://doi.org/10.106.j.ssmph.2019.100398
Richmond, J. G., Tochkin, J., & Hertelendy, A. J. (2021). Canadian health emergency
management professionals’ perspectives on the prevalence and effectiveness of disaster
preparedness activities in response to COVID-19. International Journal of Disaster Risk
Reduction, 60, 102325–102325. https://doi.org/10.1016/j.ijdrr.2021.102325
Robinson Hickman, G., & Knouse, L.E. (2020). When leaders face personal crisis: The human
side of leadership (1st ed.). Routledge.

169
Rosenthal, C. (1998). Determinants of collaborative leadership: Civic engagement, gender or
organizational norms? Political Research Quarterly, 51(4), 847–868.
https://doi.org/10.1177/106591299805100401
Rueda, R. (2011). The 3 dimensions of improving student performance. New York, NY:
Teachers College Press.
Rural County Representatives of California [RCRC]. (2022). 2022-2025 Strategic Plan
(Published January 1, 2022). [Strategic Plan]. https://indd.adobe.com/view/c67453efdfd9-43b7-b6f5-711bbd3e1dac
Rydberg, K., Tuttle, M., Tanem, J., Gilbertson, M., & Henning-Smith, C. (2021). Trends in
Network Development Planning Grantees, 2003-2020. [UMN Rural Health Research
Center Policy Brief]. https://rhrc.umn.edu/publication/trends-in-net-work-focus-areasamong-network-development-plan-ning-grantees-2003-2020/
Said, A. M., Ahmadun, F., Rodzi Mahmud, A. and Abas, F. (2011). Community preparedness for
tsunami disaster: A case study. Disaster Prevention and Management, 20(3), 266-280.
https://doi.org/10.1108/09653561111141718
Salerno, J. A., Schultz, A. M., & Schaeffer, L. D. (Eds.). (2009). HHS in the 21st Century:
Charting a new course for a healthier America. National Academies Press.
Samuel-Hodge, C. D., Gizlice, Z., Allgood, S. D., Bunton, A. J., Erskine, A., Leeman, J., &
Cykert, S. (2022). A hybrid implementation-effectiveness study of a community health
worker-delivered intervention to reduce cardiovascular disease risk in a rural,
underserved non-Hispanic Black population: The change study. American Journal of
Health Promotion, 36(6), 948-958. https://doi.org/10.1177/08901171221078272

170
Saunders, M. N., Lewis, P., & Thornhill, A. (2019). Research methods for business students (8th
ed.). Pearson.
Schwartz, B. S., Parker, C., Glass, T. A., & Hu, H. (2006). Global environmental change: What
can health care providers and the environmental health community do about it now?
Environmental Health Perspectives, 114(12), 1807–1812.
https://doi.org/10.1289/ehp.9313
Schein, E. H. (2017). Organizational culture and leadership (5th ed.). Wiley.
Schoenberg, A. (2005). Do crisis plans matter? A new perspective on leading during a crisis.
Public Relations Quarterly, 50(1), 2.
Schunk, D. M., Pintrich, P. R., & Meece, J. L. (2008). Motivation in education: Theory, research,
and applications. Upper Saddle River, NJ: Pearson Merrill/Prentice Hall.
Schwarz, A. (2008). Covariation-based causal attributions during organizational crises:
Suggestions for extending Situational Crisis Communication Theory (SCCT).
International Journal of Strategic Communication, 2(1), 31-53.
https://doi.org/10.1080/15531180701816601
Secules, S., McCall, C., Mejia, J. A., Beebe, C., Masters, A. S., L. Sánchez‐Peña, M., &
Svyantek, M. (2021). Positionality practices and dimensions of impact on equity
research: A collaborative inquiry and call to the community. Journal of Engineering
Education, 110(1), 19-43.
Somers, S. (2009). Measuring resilience potential: An adaptive strategy for organizational crisis
planning. Journal of Contingencies and Crisis Management, 17(1), 12–23.
https://doi.org/10.1111/j.1468-5973.2009.00558.x
Sellnow, T. L., & Seeger, M. W. (2021). Theorizing crisis communication. John Wiley & Sons.

171
Shah, G., Shankar, P., Schwind, J. & Sittaramane, V. (2020). The detrimental impact of the
COVID-19 crisis on health equity and social determinants of health. Journal of Public
Health Management and Practice, 26(4), 317-319.
https://doi.org/10.1097/PHH.0000000000001200
Sharfstein, J. M. (2023). The public health crisis survival guide: leadership and management in
trying times (Updated ed.). Oxford University Press.
Sherrill, W., Crew, L., Mayo, R. M., Mayo, W. F., Rogers, B. L., & Haynes, D. F. (2005).
Educational and health services innovation to improve care for rural Hispanic
communities in the US. Education for Health, 18(3), 356-367.
Shi, L., & Singh, D.A. (2021). Delivering health care in America: A systems approach (8th ed.).
Jones & Bartlett Learning.
Silverman, B., Chen, B., Brener, N., Kruger, J., Krishna, N., Renard, P., Romero-Steiner, S., &
Avchen, R. N. (2016). School district crisis preparedness, response, and recovery plans—
United States, 2012. MMWR. Morbidity and Mortality Weekly Report, 65(36), 949–953.
https://doi.org/10.15585/mmwr.mm6536a2
Šimák, L., & Míka, V. (2008). Traps of decision-making in crisis situations. Science & Military
Journal, 3(1), 57-.
Smith, L., & Riley, D. (2012). School leadership in times of crisis. School Leadership &
Management, 32(1), 57-71. https://doi.org/10.1080/13632434.2011.614941
Smithson, R. (2021). The compatibility of multiple leadership styles in responding to a complex
crisis: Leading a health service COVID-19 response. Journal of Health Organization and
Management, 36(4), 469–481. https://doi.org/10.1108/JHOM-07-2021-0263

172
Spiegelhalter, D. (2015). Making sense of uncertainty, risk and chance in public health.
Veterinary Record, 176(3), 65. https://doi.org/10.1136/vr.g7591
Sriharan, A., Hertelendy, A. J., Banazak-Hall, J., Fleig-Palmer, M. M., Mitchell, C., Nigam, A.,
Gutberg, J., Rapp, D. J., & Singer, S. J. (2022). Public health and health sector crisis
leadership during pandemics: a review of the medical and business literature. Medical
Care Research and Review, 79(4), 475–486. https://doi.org/10.1177/10775587211039201
Stallings, D. T. (2002). A brief history of the US Department of Education, 1979–2002. Phi Delta
Kappan, 83(9), 677-683.
State of California Department of Finance [DOF]. (2021). State of California Budget Change
Proposal Fiscal Year 2021-22 (Attachment II COVID-19 Direct Response Cost Estimate:
Total Expenditures by Fiscal Year).
https://esd.dof.ca.gov/Documents/bcp/2122_ORG0511_BCP4874.pdf
Steelman, T. A., McCaffrey, S. M., Knox Velez, A., & Briefel, J. A. (2014). What information do
people use, trust, and find useful during a disaster? Evidence from five large wildfires.
Nat Hazards. http://dx.doi.org/10.1007/s11069-014-1512-x
Stuart, J., & Szeszeran, N. (2021). Bullying in the military: A review of the research on
predictors and outcomes of bullying victimization and perpetration. Military Behavioral
Health, 9, 1-12. https://doi.org/10.1080/21635781.2020.1864527
Sturmberg, J. P., Tsasis, P., & Hoemeke, L. (2022). COVID-19 - an opportunity to redesign
health policy thinking. International Journal of Health Policy and Management, 11(4),
409–413. https://doi.org/10.34172/ijhpm.2020.132
Sultan, M., Sørensen, J. L., Carlström, E., Mortelmans, L., & Khorram-Manesh, A. (2020).
Emergency healthcare providers’ perceptions of preparedness and willingness to work

173
during disasters and public health emergencies. Healthcare (Basel), 8(4), 442–.
https://doi.org/10.3390/healthcare8040442
Sutherland, I. E. (2017). Learning and growing: Trust, leadership, and response to crisis. Journal
of Educational Administration, 55(1), 2-17. https://doi.org/10.1108/JEA-10-2015-0097
Talbot, J. A., Ziller, E. C., & Szlosek, D. A. (2017). Mental health first aid in rural communities:
Appropriateness and outcomes. The Journal of Rural Health, 33, 82-91.
https://doi.org/10.1111/jrh.12173
Taylor, M. M. (2019). Rural health disparities: Public health, policy, and planning approaches
(spingerbriefs in public health) (1st ed., 2019). Springer.
Tej, J., Živčák, P., Ali Taha, V., & Sirková, M. (2014). Crisis awareness of the municipal district
residents: Implication for crisis management at the local government level. Kvalita
Inovácia Prosperita, 18(2), 1–14. https://doi.org/10.12776/qip.v18i2.295
Thisted, R. A. (2003). Are there social determinants of health and disease? Perspectives in
Biology and Medicine, Suppl. Special Issue: "Social Determinants of Health and
Disease", 46(3), S65-73.
Timmis, K., & Brüssow, H. (2020). The covid-19 pandemic: Some lessons learned about crisis
preparedness and management, and the need for international benchmarking to reduce
deficits. Environmental Microbiology, 22(6), 1986-1996. https://doi.org/10.1111.1462-
2920.15029
Tipirneni, Renuka, M.D., M.Sc. (2021). A data-informed approach to targeting social
determinants of health as the root causes of COVID-19 disparities. American Journal of
Public Health, 111(4), 620-622.

174
Turoff, M., Hiltz, S. R., Bañuls, V. A., & Van Den Eede, G., (2013). Multiple perspectives on
planning for emergencies: An introduction to the special issue on planning and foresight
for emergency preparedness and management. Technological Forecasting & Social
Change, 80(9), 1647–1656. https://dx.doi.org/10.1016/j.techfore.2013.07.014
U.S. Department of Health & Human Services [HHS]. (2022). Fiscal Year 2023 Budget in Brief.
www.hhs.gov/budget
U.S. Department of Health & Human Services [HHS]. (n.d.). Introduction: About HHS.
https://www.hhs.gov/about/strategic-plan/2022-
2026/introduction/index.html#:~:text=The%20mission%20of%20the%20U.S.,public%20
health%2C%20and%20social%20services.
U.S. Department of Homeland Security [DHS], Federal Emergency Management Agency.
(2021). National incident management system. Retrieved from
https://www.fema.gov/sites/default/files/documents/nims-guideline-resourcemanagement-preparedness.pdf
U.S. Government. (1953). Reorganization Plan No. 1 of 1953, 67 § 631, U.S. Government
Printing Office, March 12, 1953.
Van Wart, M., & Kapucu, N. (2011). Crisis management competencies: The case of emergency
managers in the USA. Public Management Review, 13(4), 489-511.
https://doi.org/10.1081/14719037.2010.525034
Veil, S., Reynolds, B., Sellnow, T. L., & Seeger, M. W. (2008). CERC as a theoretical framework
for research and practice. Health Promotion Practice, 9(4), 26S–34S.
https://doi.org/10.1177/1524839908322113

175
Vignal Lambret, C., & Barki, E. (2018). Social media crisis management: Aligning corporate
response strategies with stakeholders’ emotions online. Journal of Contingencies and
Crisis Management, 26(2), 295–305. https://doi.org/10.1111/1468-5973.12198
Walecka, A. (2021). The role of relational capital in anti‐crisis measures undertaken by
companies—conclusions from a case study. Sustainability (Basel, Switzerland), 13(2), 1–
16. https://doi.org/10.3390/su13020780
Wang, D., Guan, D., Zhu, S., Kinnon, M., Geng, G., Zhang, Q., Zhang, H., Lei, T., Shao, S.,
Gong, P., & Davis, S. J. (2020). Economic footprint of California wildfires 2018. Nature
Sustainability, 4(3), 252-260. https://doi.org/10.1038/s41893-020-00646-7
Wheeler, I. (2020, February 4). Orange county coronavirus patient released, in good condition,
health officials say. Orange County Register.
https://www.ocregister.com/2020/02/04/risk-of-catching-coronavirus-in-so-cal-is-lowhealth-officals-say/
White, T. E., Wong, W. B., Janowiak, D., & Hilborne, L. H. (2021). Strategies for laboratory
professionals to drive laboratory stewardship. Practical Laboratory Medicine, 26,
e00249. https://doi.org/10.1016/j.plabm.2021.e00249
Wicker, C., (2021). Competency-based approach to developing leaders for crises. New Horizons
in Adult Education and Human Resources Development, 33(2), 52-59.
Wittmer, J. L., & Hopkins, M. M. (2022). Leading remotely in a time of crisis: Relationships
with emotional intelligence. Journal of Leadership & Organizational Studies, 29(2), 176-
189. https://doi.org/10.1177/15480518211053531
Woitaszewski, S. A., Savage, T. A., & Zaslofsky, A. F. (2020). From neutral to high gear: Critical
implementation drivers for PREPaRE school safety and crisis response in practice.

176
California School Psychologist, 24(3), 337–348. https://doi.org/10.1007/s40688-020-
00315-8
Wooten, L. P., & James, E. H. (2008). Linking crisis management and leadership competencies:
The role of human resource development. Advances in Developing Human Resources,
10(3), 352-379. https://doi.org/10.1177/1523422308316450
World Health Organization [WHO]. (2021, October 3). Climate change and health.
https://www.who.int/news-room/fact-sheets/detail/climate-change-and-health
Yarrow, E., & Pagan, V. (2020). Reflections on front-line medical work during covid-19 and the
embodiment of risk. Gender of Work Organ, 28(S1), 89-100.
Yoon, H. Y. (2022). Is crisis and emergency risk communication as effective as vaccination for
preventing virus diffusion? Measuring the impacts of failure in CERC with MERS‐CoV
outbreak in South Korea. Risk Analysis, 42(7), 1504–1523.
https://doi.org/10.1111/risa.13842
Zimbardo, P. G., & Leippe, M. R. (1991). The psychology of attitude change and social
influence. New York, NY: McGraw-Hill Book Company.

177
Appendix A: Interview Protocol
Introduction:
I value your willingness to participate in this interview. I expect the interview to last about an
hour. Does that time still suit you?
I am a doctorate student at USC and am conducting a study examining the administrative
preparedness of Health and Human Services (HHS) leaders in effectively addressing public
health crises in California's rural counties. My study aims to better understand the factors
contributing to effective public health crisis management. To achieve this, I am interviewing
several HHS leaders in various rural counties across California.
I will assign you a participant number for the study that will keep your identity confidential to
ensure your privacy. You can decline any interview questions, discontinue the study, or stop the
interview at any point. When reflecting on previous crisis response efforts, some questions may
trigger an emotional response. If you need to take a break at any point, you may do so.
For accurate data collection reporting, I plan to record our discussion and assure you that the
recording will be treated confidentially, only accessible to me, and disposed of as soon as it is no
longer required. Do you have any questions?
Demographics:
1. Please describe your position within the organization and duration of service as an HHS
leader.
2. Tell me about public health crises you have managed as an HHS leader.
Knowledge and Skills Influences:
3. What knowledge and skills do you consider to be essential qualities that have contributed
to your effective leadership during challenging public health crises?
• What makes those skills essential in the context of public health crisis leadership?
• In the absence of those skills, what potential challenges or limitations might a
leader experience in the context of crisis leadership?
4. Can you describe any education, training, or classes you have participated in to advance
your ability to prepare for and manage public health crises?

178
• What kind of education, training, or classes has your organization provided you to
prepare for and manage public health crises?
• To what extent did the knowledge and skills acquired from these education,
training, or classes influence your leadership approach during a crisis?
5. What steps have been taken by your HHS organization to prioritize public health crisis
preparedness and management?
• What makes those steps so important?
6. Can you provide examples of interventions or strategies your HHS organization has taken
to protect vulnerable populations during public health crises?
7. How do you stay current with the most recent findings and recommended practices in
public health crises?
• What actions, if there are any, does your organization take to encourage
integrating this knowledge into your work?
• Are there any challenges you face in staying up to date and/or integrating this
knowledge into practice?
8. When faced with complex challenges in public health crisis preparedness and
management, how do you determine what information or resources you need to seek
help?
9. Has there ever been a time when seeking help or collaborating with other experts
enhanced your ability to better prepare for and manage a public health crisis?
10. How did seeking help or collaboration impact your wellbeing, if at all?

179
Motivational Beliefs and Value Influences:
11. How confident do you feel in your ability to successfully prepare for public health crises
as an HHS leader?
12. How does your confidence in your abilities influence your decision-making during a
public health crisis?
• How do you handle situations where you realize you have made a wrong
decision?
13. What strategies or practices do you employ to maintain a positive mindset and resilience
while managing a public health crisis?
14. What do you perceive as the importance of addressing public health crises?
• How do you consider the expectations and concerns of other stakeholders when
determining the importance of addressing public health crises?
15. What resources does the organization provide you to prepare for a public health crisis?
16. Can you discuss any challenges you have faced in acquiring the resources you need for
public health crisis management?
• How have these challenges impacted your thinking, feelings, and reactions to the
crisis?
17. How do you advocate for and leverage available resources from the organization to
address the difficulties and demands of public health crises?
18. How would you characterize the significance of effective communication when preparing
for and managing public health crises?
• Can you provide examples of successful crisis communication strategies you have
previously used to address public health crises?

180
19. How does your organization ensure all voices are heard when preparing for or responding
to public health crises?
Conclusion:
20. Is there anything you would like to add concerning today's discussion that was not
previously covered?
I thank you for spending time with me today and sharing your knowledge. Your thoughts will be
crucial when determining the best strategies for addressing public health crises and establishing
administrative preparedness for Health and Human Services leaders in rural counties in
California.

181
Appendix B: Information Sheet for Exempt Research
University of Southern California
Rossier School of Education
STUDY INFORMATION SHEET FOR EXEMPT RESEARCH
STUDY TITLE: Unpredicted but not Unexpected: Developing Prepared Health and Human
Services Crisis Leaders
PRINCIPAL INVESTIGATOR:
Michele E Blake, Doctoral Candidate
FACULTY ADVISOR:
Alison Keller Muraszewski, EdD
As a rural county Health and Human Services organization leader, you are invited to participate
in a research study voluntarily. The present document explains details about the current study.
Inquiring about any aspects that may be ambiguous to you is advisable.
PURPOSE
This research aims to examine the organizational elements that impact the administrative
preparedness of Health and Human Services (HHS) leaders in rural counties of California
regarding their capacity to manage public health crises efficiently. You have been invited as a
participant because you are a rural California Health and Human Services organization leader.
PARTICIPANT INVOLVEMENT
As a participant, you will be requested to engage in an interview that centers on your experience,
thoughts, actions, perspectives, and understanding of public health crises and leadership across
all crisis phases. It is anticipated that the duration of the interview will be approximately 60
minutes. The interview will occur virtually, and all responses will be kept confidential. The
interview will be recorded through the Zoom platform and maintained securely.
PAYMENT/COMPENSATION FOR PARTICIPATION
There will be no compensation provided for your participation. There are no financial costs
associated with your participation, as the only investment required is the time dedicated to the
requested interview.
CONFIDENTIALITY
The University of Southern California Institutional Review Board (IRB) and the research team
members can access the research data. The Institutional Review Board (IRB) conducts a

182
comprehensive evaluation of research investigations to safeguard the rights and welfare of the
participants involved.
The dissemination of research findings through publication or conference presentations will not
involve utilizing any personally identifiable data.
The recorded interview will be securely stored on Zoom and restricted by a password, with
exclusive access granted to the researcher. The field notes, and transcripts will be securely stored
in a designated filing cabinet within a restricted and locked office, accessible solely by the
researcher. The transcripts shall be identified solely by a designated numerical identifier assigned
to each participant. Data will be disposed of upon completion of the research.
INVESTIGATOR CONTACT INFORMATION
For inquiries regarding this research, please contact Michele E Blake at [email and phone
number].
IRB CONTACT INFORMATION
In case of any questions regarding the rights of research participants, please contact the
Institutional Review Board of the University of Southern California at (323) 442-0114 or
irb@usc.edu

183
Appendix C: Stakeholder Demographics Table
Stakeholder Duration of
Service in
Current Role
Additional
Leadership Context
Formal Education Crises Managed
HHS-L1 3 years 15 years in
epidemiology
Epidemiology
background
Fires; weatherrelated events;
COVID-19
pandemic
HHS-L2 3 years 21 years in public
health; former
emergency
preparedness
manager for
organization
Bachelor's degree
in multicultural and
gender studies;
master's degree in
public health
Fires; storms;
COVID-19
pandemic
HHS-L3 2.5 years 18.5 years in public
health
Bachelor's degree
in psychology;
master's degree in
public health
Fires; COVID-19
pandemic
HHS-L4 1.5 years 20+ years in public
servant work
Master's degree in
organizational
leadership
Fires; COVID-19
pandemic
HHS-L5 16 years Working in public
health since 1999
Public health nurse
license
Fires; COVID-19
pandemic
HHS-L6 2 years Former supervisor
role since 2013
Bachelor's degree
in psychology
Fires; COVID-19
pandemic; Floods
HHS-L7 4 years 21 years with the
HHS organization
Business school
graduate;
progressed and
became an EMT
Fires; COVID-19
pandemic
HHS-L8 10 months 8 years in the HHS
organization
Office management
certification
COVID-19

184
HHS-L9 2 months Previously private
behavioral health
sector
Behavioral health
licensed clinician
Community
shooting
HHS-L10 1 year 10 years as director
in other California
counties; 30+ years
of total local
government service
Military
experience;
licensed marriage
and family therapist
(LMFT)
Fires; high-rise
flood; COVID-19
HHS-L11 3 years 12 years with local
HHS organization;
previously worked
10 years in the
private sector
Licensed marriage
and family therapist
(LMFT)
Fires; COVID-19
pandemic;
extreme heat and
cold
HHS-L12 5 years 23 years with the
HHS organization
Accounting
background; moved
up through the
hierarchy over the
years
Fires; COVID-19
pandemic; floods;
air quality; storms
HHS-L13 1 year Previously worked
within a school
district and local
hospital
Public health nurse
license
N/A
HHS-L14 2 years Child welfare
director for 10
years prior
Bachelor's degree
in child
development;
master's degree in
social work
Fires; COVID-19
pandemic;
earthquake; air
quality; storms
HHS-L15 1.5 years 16 years with
organization
Bachelor's degree
in social work;
master's degree in
social work; two
years in Peach
Corps
Flooding

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

An improvement study of leading a sustainable electric utility future through organizational change effectiveness

PDF

Corporate innovation labs: exploring the role of university research park innovation lab leaders

PDF

Women in information technology senior leadership: incremental progress and continuing challenges

PDF

A qualitative examination of the methods church leaders use to increase young adult attendance in Christian churches: an evaluation study

PDF

First-generation college students and persistence to a degree: an evaluation study

PDF

Gender role beliefs of male senior leaders in retail and the impact on women’s advancement

PDF

Organizational agility and agile development methods: an evaluation study

PDF

The first-time manager journey: a study to inform a smoother leadership transition

PDF

Advancing equity and inclusion in higher education: the role of the chief diversity officer and the institution in creating more diverse campus climates

PDF

Health care disparities and the influence of nurse leader cultural competency: an evaluation study

PDF

Mitigating low employee engagement through improved performance management: an evaluation study

PDF

Implementing organizational change in a medical school

PDF

The role of organizational leaders in creating sustainable diversity, equity, and inclusion initiatives in the workplace

PDF

Gender inequity in executive leadership of midsize and large organizations in Los Angeles County: overcoming barriers & building leaders

PDF

A strategy to thrive during a crisis for nonprofit organizations

PDF

The role of professional development and certification in technology worker turnover: An evaluation study

PDF

Deckplate leadership: a promising practice study of chief petty officer development

PDF

Creating the conditions for change readiness in higher education: an innovation study

PDF

Leave no leader behind (LNLB): leadership development for K-12 operations leaders

PDF

A faith-based nonprofit organization’s implementation of strategic planning: A qualitative study

Asset Metadata

Creator Blake, Michele Elizabeth (author)

Core Title Unpredicted but not unexpected: developing prepared health and human services crisis leaders

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-05

Publication Date 03/07/2024

Defense Date 02/20/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag administrative preparedness,California rural county,crisis,crisis management,OAI-PMH Harvest,public health crisis

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Keller Muraszewski, Alison (committee chair), Hirabayashi, Kimberly (committee member), Ott, Maria G. (committee member)

Creator Email blakemic@usc.edu,mblake@co.sutter.ca.us

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113848785

Unique identifier UC113848785

Identifier etd-BlakeMiche-12683.pdf (filename)

Legacy Identifier etd-BlakeMiche-12683

Document Type Dissertation

Format theses (aat)

Rights Blake, Michele Elizabeth

Internet Media Type application/pdf

Type texts

Source 20240311-usctheses-batch-1128 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu