Abstract

Background:  Fiscal concerns within the government of Ontario and many parts of the world have compelled health care organizations to re-evaluate leadership, among other things. Leaders in health care are traditionally in a hierarchical bureaucracy. Quality of care continues to decline in spite of dramatically increasing budgets and innovative strategies. The leadership structure of the system today, gives the results that are seen today. For the system to evolve and improve, the structure of leadership needs to evolve and improve.

Purpose:  This dissertation investigated a more integrated approach for creating a culture of collaborative leadership throughout the organization that encourages all the strategic aims of the organization including, cost efficiency and improved quality by creating an empowered, accountable and sustainable work force.

Methodology:  A phenomenological study of workers within the health care system was undertaken utilizing email responses to questions for data collection. The results were tabulated by theme and topic for discussion.

Findings:  The data showed that personal transformation and self-knowledge were important aspects of collaborative leadership.  A review of the command-and-control leaders, who operate in silos, rather than for the public good, highlighted the difficulty in implementing change in health care organizations. Collaborative leadership is seeping into the system by early adopters and is seem as a viable path for sustained change.

Discussions:  This study suggested that health care organizations are in the process of shifting from fragmented structures and processes to systems that function collaboratively to achieve the outcomes that the organization is seeking. Collaborative leadership at all levels of the organization was seen to be the future of patient-centred health care.

Introduction

The Canadian health care system, once a jewel in the crown of its culture is losing its luster.  It is in a state of disrepair. Organized as essentially a universal system that the government administers and everyone has access to, the system has been in decline for many years, both economically and in quality (Drummond, 2012). As Chief Justice Beverly McLachin of the Supreme Court of Canada opined, “access to a waiting list is not access to health care (Christensen, Grossman, & Hwang, 2009, p. xvi).” In a 2010 Common Wealth Report, Canada ranked sixth out of the seven countries studied in efficiency of the system and seventh in quality of care (Davis, Schoen, & Stremikis, 2010).  There have been many attempts to repair the system. Merging of hospitals to decrease duplicity and keep staffing shortages in check seems to have only increased the scale of the problem. The health care industry has slowly looked to other industries to improve performance and quality. Various cost-reduction, strategic change management, and quality improvement methods have been employed (Sherman, 2006) (Blumenthal & Kilo, 1998) (Serrano, 2006). The command and control systems employed by hospitals to enact some of these changes worked while the medical hierarchy stayed in place. (Lynch & Somerville, 1996) Bureaucracy, self-interest, red tape, and ‘that’s not how it’s done around here’ mentality saw only small percentage of those changes stick. They failed to translate into sustainable results leaving mixed benefits and many unanswered questions (Vest & Gamm, 2009). Several prominent business thinkers suggest that the business model for health care needs to change (Drummond, 2012) (Christensen, Grossman, & Hwang, 2009) (Porter & Teisberg, 2006). Traditionally, workers look to leaders with hope and high expectations of change. Health care delivery is too complex, too personal, and too quick to change to be left to the top-down, command-and-control, micromanagement style of leadership (Porter & Teisberg, 2006). For the business model to change, the leadership style needs to change.

This dissertation investigates a more integrated approach for creating a culture of collaborative leadership throughout the organization that encourages all the strategic aims of the organization including, cost efficiency and improved quality by creating an empowered, accountable and sustainable work force.

Much of the current research looks at increasing the value or quality of health care (Porter, 2010) (Christensen, Grossman, & Hwang, 2009).  Patient-centred care is a catch phrase for a change needed to take place in health care (Ball, 2010).  Creating value for the patient is paramount. The providers of the health care—hospitals, clinics, doctors and nurses—are the central actors of the system and the place where most of the value is delivered. The way that the patients are cared for will determine the success or failure of the system (Porter & Teisberg, 2006). As value improves, the patients and all stakeholders can benefit (Porter, 2010). Also, care can only take place on an individual basis. There is no system in caring (Letiche, 2008). If the quality of the care is directly related to the individual care that the patient receives, the people responsible for that care determine the quality of it. That practice depends on the individual’s willingness to be accountable for the well-being of the organization and the patient by operating in service of it rather than in control of it (Block P. , 1993).

Health care is complex. Control is difficult in a complex system. The organization of the system is complex, as is the delivery (Porter, 2010). Complexity science theory has been used as a model for health care organizations and delivery. A complex adaptive system is the basis of the theory.  Complex suggests that there are a large number of connections between wide varieties of individuals.  Adaptive implies the ability to learn from experience and adapt to change.  System is the box that contains the interdependent things (Zimmerman, Lindberg, & Plsek, 2008). In a complex adaptive system, individuals are free to act in unpredictable ways, and those actions are interconnected to networks of others that can change the context for other individuals (Plsek & Greenhalgh, 2001).  “Traditional views of health care managerial theory have been focused on organizational control and the goal of the management system was to ensure that the organization and its workers did what they were supposed to do.” (McDaniel & Driebe, 2001, p. 24) If health care problems are viewed as complicated, instead of complex, solutions assume a high degree of certainty in outcome.  However, health care problems are complex.  Uncertain outcomes are understood (Glouberman & Zimmerman, 2002). This uncertainty is one of the principles that underlie the complexity theory.

Instability and uncertainty cause workers to turn to internalized rules, standards and beliefs to decide on action (Plsek & Greenhalgh, 2001). As medicine becomes more complex, more input is needed to direct the appropriate care for each patient.  This jumble of complexity leads to starts and stops for strategic planning and change management.  One thing is certain. The patient’s stories and progress is an important part of any care and decision-making authority needs to be brought down to the level closest to the patient (Golden & Martin, 2004). Leadership, designed under the guise of complexity theory, understands that good practices will naturally evolve as the leader acknowledges and respects the efforts of others to innovate. “The leader’s role is to create systems that disseminate rich information about better practice, allowing others to adapt those practices in ways that are most meaningful to them.” (Plsek & Wilson, 2001, p. 748)

That is a different mindset for health care. Historically, the health care industry has embraced a command-and-control leadership model.  In essence, there are two hierarchical pyramids in the system.  There is the administrative hierarchy where health care administrators operate as transactional leaders that manage the business: financial analysis and administration, operational management, human resources, and quality improvement (Nembhard, Alexander, Hoff, & Ramanujam, 2009). There is also a patient care hierarchy that involves those directly related to patient care: doctors, nurses and aides.  The front line health care workers are at the bottom of both pyramids (Block & Manning, 2007). The divisions within each level of hierarchy, as well as by departments and units, create barriers that affect patient safety and outcomes (Amalberti, Auroy, Berwick, & Barach, 2005).  The quality of care that the patient receives and the results of that care are the top concerns of consumers in the health care industry (Drummond, 2012).

The health care industry is being forced into a disruptive change whose aim is to create a new system that keeps the patients and their families at the centre (Christensen, Grossman, & Hwang, 2009). This requires a new kind of leader and leadership.  Players in the industry need a collaborative mindset (Ball, 2010).

The old leadership model for health care is not working. The industry seems to have lagged behind the business world in adopting the insights from the latest in management research (Nembhard, Alexander, Hoff, & Ramanujam, 2009).  Six Sigma, Lean and Balanced Scorecard process improvement strategies have been adapted to various health care settings. For example, Lean Management principles look at each step in a process to ensure that all are needed and provide value.  Any wasted or unnecessary steps are eliminated (Womack, Byrne, Flume, Kaplan, & Toussaint, 2005). All of these change management tools require accountability and ownership throughout the organization.  Workers at all levels require leadership skills to initiate and maintain skillful, consistent and committed implementation of innovative improvements. The role of senior leaders and managers is to manage the process of learning so that those improvements can emerge creating a subtle balance between control and learning, and stability and change (Ziv, 2002).  Senior leaders are in a position to encourage collaboration between units and departments where priorities can be identified and quality improved (Luther, 2012). Ultimately, the success of any of these measures needs to be determined by patient satisfaction, and patient satisfaction with health, not just with care (Porter & Teisberg, 2006).

Ownership and the alignment of values between the organization and the individual are considered vital to employee engagement. The individual needs to consider that he has the ability to be a leader without consideration for position in the hierarchy.  Individual or self-leadership is not a replacement for executive leadership, but an important adjunct. Self-leadership is about the influence that individuals exert over themselves to be self-motivated and direct their behavior to achieve the desirable outcome.  Self-leadership involves self-assessment, self-reward, and self-discipline behaviors, such as identifying goals, applying rewards, and practicing desired behaviors. It utilizes natural reward strategies enjoying and valuing one’s work. Lastly, it encourages individuals to direct their thoughts in constructive, positive ways. “In sum, the use of self-leadership strategies facilitates a perception of control and responsibility which positively affects performance outcomes (Prussia, Anderson, & Manz, 1998, p. 524).”

The purpose of the present study is to discover whether collaborative self-leadership is a cause or an effect of an integrated community that would encourage grassroots innovation in the complex health care environment.

Through a phenomenological study, this dissertation will explore the creation of a culture of leadership in a health care setting.  The research will incorporate literature reviews and semi-directive interviews to discover the experience of collaborative self-leadership in health care and its effect on strategic change leading to improved quality of patient care and/or efficiency.

Following this introduction, chapter 2 will present a literature review of leadership theories and practices within complex organizations, generally, and health care settings, specifically.  Leadership research is evolving to more closely match the reality of the organizations is it hoping to reflect. The limitations of quantitative studies are apparent in the review.

Chapter 3 will present the qualitative research methodology for the research including the data gathering methods and interview techniques. Phenomenological research is examined and its merits for organizational research. Critical management research is defined and expanded for use in this thesis.

Chapter 4 presents a narrative of the research, and the results.  The goal of the research is to discover how the culture of collaboration and its inherent leadership style are being used in the health care setting to meet strategic transformational goals. The goal of phenomenological research is to capture the meaning and experience of the phenomenon. A narrative approach is used to express that in this dissertation. The results of the research are expressed using thematic grouping and topic isolation. The themes and topics are illustrated by the participant’s discussion. The goal is to ensure that the data reflects the meaning of the experience.

The final chapter provides a critical management reflection on the qualitative research. Insights explained, critiques analyzed, and transformative redefinition discovered. The conclusions reached from the study of collaboration and integration in the complex health care delivery system will open up opportunities for further research.

• Literature Review

As with art and science, the study of leadership has evolved.  Standing on the shoulders of the wise scholars, the past of leadership is visible and as is, perhaps the future.

 “To attempt to build up theories of art, or to form a style, independently of the past, would be an act of supreme folly. It would be at once to reject the experiences and accumulated knowledge of thousands of years. On the contrary, we should regard as our inheritance all the successful labours of the past, not blindly following them, but employing them simply as guides to find the true path.” Owen Jones, The Grammar of Ornament (cited in, van der Merwe, 2012, pg. 1)

Literature about leaders abound. Historically, leadership emerged when the characteristics of a leader was examined within the context of a situation (Bass & Bass, 2008). Leaders such as Nelson Mandela and Jack Welch are seen as case studies for the study of leadership (Bradson & Perry, 2007).  As the study of leadership advanced so did the development of theories that incorporated more individual and situational variables (Bass & Bass, 2008).

Leadership can be seen as the problem and solution to the challenges being faced in all manner of organizations.  Increased complexity and the rapid pace of change that is seen in organizations have put more pressure on finding more creative leadership theories (Bradson & Perry, 2007).

The purpose of this literature review is to identify historical leadership practices in health care and isolate the challenges as they relate to a complex organization.  Leadership practices and behaviours need to evolve as health care systems become more complex and solutions to the system’s failings continue to falter.  Improvement in the quality of patient care and efficiencies of the system depends on the day-to-day decisions of doctors, nurses and staff (Ham, 2003). An extensive literature review was undertaken to study the effectiveness of leadership styles with a community with the intention of providing insight into how the concept of leadership has evolved and its role in an integrated community.

Literature searches were conducted through Google Scholar and the related databases, as well as the University of Cumbria off-campus library which included EBSCO Discovery Service, Web of Knowledge, PubMed, ScienceDirect, among others.  Books were accessed through the local library, Google Books or purchased. In some cases, a digital edition of a book was utilized for referencing.  The key areas of the search were leadership, leadership styles, collaborative leadership, integrated communities, vertical integration, integrated care, communities of practice, complexity science and complexity leadership theory. As much as possible, references were isolated to health care related text, research and literature.

Transactional and Transformational Leadership

Of relevance to the study of health care leadership is the identification of the predominant leadership styles in the organizations.  As in many industries, health care tends to follow a transactional leadership model (Nembhard, Alexander, Hoff, & Ramanujam, 2009).  Transactional leadership utilizes the carrot and stick philosophy of management (Bass & Bass, 2008). Followers are rewarded for meeting standards and doing their job.  They are reprimanded for failing to reach the objective (Bass & Bass, 2008). This failure, if not forgiven, can have far reaching effects on employee engagement and job satisfaction.

Transactional leaders in health care settings dictate procedures requiring cost-benefit analyses and objective criteria for action (Letiche, 2008). “Health care supposedly requires standardization, control, and radical new efforts to achieve efficiency (Letiche, 2008, p. 3).”

Theory has evolved.  Leaders need to acknowledge their followers, something that transformational leaders do (Bass & Bass, 2008).

Transformational leaders raise their followers’ level of involvement in the organization’s desired outcomes. They get followers to put the interests of the team or organization above their own. And they encourage thoughts of achievement rather than baser needs such as safety and security (Bass & Bass, 2008).

For decades, studies have examined the differences between transactional and transformational leadership (Bono & Judge, 2004) (Eagly, Johannessen-Schmidt, & van Engen, 2003). In 1995, Medley and Larochelle examined the relationship between transformational leadership and job satisfaction (Medley & Larochelle, 1995). This research study looked at the extent to which staff nurses distinguish between the transformational and transactional leadership behaviours exhibited by their head nurse, and the relationship between the leadership style and the staff nurses’ job satisfaction.

Through a Multifactor Leadership Questionnaire, the researchers found that staff nurses could distinguish between transactional and transformational leadership with the exception of contingent reward, which is generally understood to be a transactional leadership behavior (Bass & Bass, 2008). A variance of 85.1% could indicate that the nurses were unsure how to classify it.  The researchers acknowledged this possibly due to the lack of performance based rewards in the nursing profession.

The study also attempted to correlate job satisfaction with leadership style.  One significant conclusion to the study was that the nurses were neither satisfied nor dissatisfied with their jobs scoring 186.3, on average, out of a possible 308 on a job satisfaction rating scale.  With no significant job satisfaction, it might be difficult to extrapolate the results to show whether transformational leadership behaviours led to higher job satisfaction. This study suggests that is does by statistically significant results in two qualities associated with transformational leadership.

The researchers are careful not to generalize the results of the study, nor draw any firm conclusions. This study does acknowledge the need to research the effects of leadership on employee job satisfaction and retention. Significant nurse shortages mean that ensuring staff nurses stay on the job is critical to a sustainable health care system.

Related to job satisfaction, emotional exhaustion and burnout was studied to see if leadership style affected that.  Stordeur, D’hoore and Vandenberghe (2001) used the same leadership scale as Medley and Larochelle (1995) to determine the leadership style of the head nurse, as the staff nurses’ understood it.  The researchers discovered the same characteristics of leadership as the above study showing that the nurses could identify transformational qualities.  Similarly, they found that contingent reward was considered a transformational quality.  This study was designed to discover if the leadership style affected employee burnout, as related to emotional exhaustion.  Given the stressful nature of the environment and the tasks related to the job, a supportive leadership style was considered likely to decrease the nurses’ emotional exhaustion.  The researchers determined that charismatic leadership qualities including individualized consideration, intellectual stimulation and contingent reward does decrease the burnout among nurses.  Encouraging participation with two way communication generated a positive climate among the nursing team.  Leaders who seemed to micro-manage their staff, where they seemed to looking to prevent mistakes, tended to generate higher levels of emotional exhaustion.

This study was careful to state that emotional exhaustion was affected by many factors to a greater degree than leadership.  These included the physical demands of the job and the social stressors.  It is weakly suggested that transformational leadership could influence the emotional exhaustion of staff nurses because they provide a vision for the future and clarity of tasks and goals.

Transformational leadership does not seem to be the whole answer determining employee engagement and involvement which might encourage improvements in the quality of care and cost efficiencies.  The above study recognized its limitations in that it only investigated one aspect of job burnout to determine if leadership ameliorates it.

Studies have dug deeper into job satisfaction.  Nursing shortages, high workload, lack of social support (Stordeur, D’hoore, & Vandenberghe, 2001) have helped to push the issue of commitment and job satisfaction to the forefront. 

Lok and Crawford (1999) investigated leadership as it related to organizational commitment. They suggested that a supportive and innovative unit and organizational culture, as well as leadership style would positively correlate with commitment.  They discovered that both organizational and ward culture positively affected commitment to the organization.  The highest correlation with commitment was an innovative and supportive ward.   The researcher also found the opposite to be true.  A bureaucratic subculture negatively impacted commitment. 

This study showed a weak positive association with the leadership consideration variable.  In looking for the answer, leadership style again comes up short.  The environment and culture were strikingly more important to the level of organizational commitment.  The research studies presented show that leadership style is an important consideration for job satisfaction, emotional exhaustion and commitment.  However, there are many additional factors that positively influence the health care environment including ward subculture.

Leadership has also been investigated to determine if the quality of patient care was affected (Firth-Cozens & Mowbray, 2001). A sizeable number of studies were collected by Firth-Cozens and Mowbray to discover how leadership is perceived in a health care organization. Interestingly, they determined that transformational leadership might be in conflict with the processes that are used to achieve the hospital’s desired outcomes.  Performance monitoring clinical audits, accreditation, and centralized control of processes cause leaders to become more transactional in their style.  A blend of styles seems to be the best choice. It seems that leaders need to be a chameleon. The researchers found that, when asked, staff and leaders, themselves what was the model of an ideal leader.  It was discovered that a servant leader was most desirable.  The servant leader engaged others in partnerships, and encouraged creative thinking, and by lowering the staff’s stress by creating a sense of justice.  Levels of error were higher where leaders were arrogant, hostile or dictatorial.  The quality of care improved, as seen by the less number of errors, when the leader encouraged an environment of positivity and support.

Job stress also is a factor in quality of care. A team environment, a sense of community was an important predictor of job stress.  As illustrated in the previous study, a positive and well-functioning organizational culture and subculture helped to reduce the levels of stress in the environment.

Firth-Cozens and Mowbray (2001) conducted a meta-analysis and determined that one of the principal causes of job stress was the leader.  They extrapolated that good leadership created good team environments, lower stress, and better care.

What is considered good leadership is an area that continues to challenge researchers.  Although research has shown that behaviours exhibited by transformational leaders have a positive impact, Yukl (1999) illustrated that there were conceptual weaknesses in the theory that made it incomplete. The author explained that there is no study that determines what influence processes a transformational leader uses to affect followers’ attitudes, motivation and behavior.  Understanding how the leader works would make the theory stronger.

In most studies, a Multifactor Leadership Questionnaire (MLQ) is administered to subordinates to rate the behavior of their leader (Bass & Bass, 2008).  This questionnaire isolates the subordinates by examining his relationship with and opinions of the leader.  Group and organizational level processes for leadership influence are not highlighted.  Considering the leader is expected to be a visionary and offer strategic direction for groups and organizations, this is a wide gap in the research.  Additionally, as shown in a study above, there seems to be some cross contamination between a transactional leader and a transformational one.  Contingent reward behaviour was considered a transformational quality.  However, the studies investigating both styles of leadership found that followers considered it more of a transformational quality (Medley & Larochelle, 1995).

Yukl (1999) indicated that the MLQ and the definition of transformational leadership were missing several core behaviours:

“The core transformational behaviours at the dyadic level of analysis should probably include inspiring (infusing the work with meaning), developing (enhancing follower skills and self-confidence), and empowering (providing significant voice and discretion to followers)…At the group level of analysis, the core transformational behaviours should probably include facilitating agreement about objectives and strategies, facilitating mutual trust and cooperation, and building group identification and collective efficacy. At the organizational level of analysis, the core transformational behaviours should probably include articulating a vision and strategy for the organization, guiding and facilitating change, and promoting organizational learning (Yukl, 1999, p. 285p).”

Finally, transformational leadership has been studies in different organizations and industries, as well as different countries, the positive qualities and influence seems to translate well (Bass & Bass, 2008).  However, it has been proposed that some variables that might influence the positive aspects have not been studied, such as, in environments that are unstable, where there is an organic, cooperative structure, instead of a hierarchical one, and in an entrepreneurial culture.

The transformational leadership theory falls under the ‘heroic leadership’ banner. The effective performance of individuals, groups or organizations is suggested to be dependent upon the leadership of an individual with the right skills to find the right path and motivate everyone else to take it (Yukl, 1999).  Alternatively, leadership could be more collaborative.  This evolution of leadership in health care, as well as other industries, comes with the realization that organizations involving humans, or other living systems, tend not to like to follow regimented steps to achieve objectives.  Organizations are considered complex entities. And as such, groups of people are look to collaboration to make the system work.

Collaborative Leadership

Complex science has moved into the field of organizational management and leadership.  The study of complexity science is the study of patterns of relationships how they organize and are sustained, and how the outcomes emerge (Zimmerman, Lindberg, & Plsek, 2008). Leadership emerges from events.  It is the outcome of relationships rather than a skill, exchange or symbol (Lichtenstein, Uhl-Bien, Marion, Seers, Orton, & Schreiber, 2006). Complexity leadership transcends the individual and becomes a product of the relationship dynamics.  Leaders guide and influence the process.  Individuals can act as leaders, but that is not determined by bureaucracy, rather by skill and experience (Lichtenstein, Uhl-Bien, Marion, Seers, Orton, & Schreiber, 2006).

Leadership does not need to be performed by one individual, but by a set of people who are organized.

The idea of leadership as participatory, voluntary and egalitarian is taking hold in many complex environments that need to evolve to be sustainable. Collaboration becomes a principle-based system to lead, manage and work together.

“The implicit principles of hierarchy, power and authority, are replaced with the explicit principles of collaboration: ownership and alignment. Ownership is defined as, ‘The degree to which people believe or feel that a process, decision, or outcome is theirs.’ Alignment is defined as ‘The degree to which people see and understand the problem, goal, or process in the same way.’ (Conerly, Kelley, & Mitchell, 2008, p. 2)”

It is considered an advantage to achieve collaborative synergies (Vangen & Huxham, 2003). “Each person doesn’t benefit most when he does what’s in his own best interests. He benefits most when he does what’s in his own interest and the interests of the group (Conerly, Kelley, & Mitchell, 2008, p. 1).”

Collaborative leadership theory is in sharp contrast to classic leadership theory which illustrates behaviour and roles as vital to its application.  The collaborative structure and processes are the pivotal features that bring the theory into practice (Vangen & Huxham, 2003). Vangen and Huxham suggested that collaborative leaders were in fact facilitators who were concerned with building infrastructure and relationships that fostered cooperation.  Rather than focusing on behaviours, the researchers suggested that collaborative leadership involved a supportive role that embraced, empowered, involved and mobilized workers, as seen in the table below:

Table 1: The Spirit of Collaboration

 (Vangen & Huxham, 2003, p. S66)

Enacting collaborative activities through facilitation is not without its challenges.  In some instances, leaders become more directive attempting to influence the agenda and maneuver members towards the desired result (Vangen & Huxham, 2003). However, as organizations have become more complex, cross-functional collaborative has become an implicit value that drives results (Rawlings, 2000).  It is understood that a shift in mindset from silo to collectivity, from competition to cooperation, and from power grabbing to power sharing (Nickitas, 2012).

Alleyne and Jumaa (2007) studied evidence-based clinical nursing leadership and discovered that management and leadership approaches significantly influenced the nurses’ capacity for improving the quality of their services and that using group supervision with an executive co-coaching approach helped implement and sustain quality services (Alleyne & Jumaa, 2007). Executive co-coaching is a management tool that facilitates learning and personal development in line with the organizational strategies and goals.  The process suggests that whatever benefits the individual could also benefit the team and the organization (Alleyne & Jumaa, 2007). This tool allowed for clearly defined boundaries, but recognized the opportunity for participants to create and explore personal and professional development that enhanced the quality of the services that the nurses provided.

The collaborative leadership theory is not only about the relationships within the organization. It also concerns the culture and the environment that the organization exudes.

Collaborative Culture

Health care is searching an answer to enhance the safety and quality of care while controlling resources.  Organizational culture has been investigated as playing a role in the future health care model. Davies, Nutley, and Mannion (2000) suggested that “culture change needs to be wrought alongside structural reorganization and systems reform to bring about ‘a culture in which excellence can flourish.’ (Page 111)” The researchers found that defining a culture within an organization was a nebulous undertaking. Their working definition for culture was that it was an emergent property of the organization that encompassed the underlying assumptions, beliefs and values that were taken for granted, on an unconscious level.  These give rise to standards and goals that become the organization.  Part of the challenge related to cultural transformation that encourages quality of care improvement is defining what culture is and what would be a beneficial shift. There are aspects of the health care system that are functioning and changing them is not feasible or desirable.  Therefore, any strategy for culture change would need to find a balance between what is worth continuing want what needs to be reworked.  The authors considered cultural cohesion as valuable, although the subculture can be diverse and have conflicts, which might lead to important innovations. Organizational standards and goals lead to internalized values and beliefs throughout the organization, and vice versa. The National Health Service in the United Kingdom created a vision for organizational culture that included open and transparent across the levels and change leadership that is everyone’s business.

Creating a culture where everyone accepts leadership responsibility for tasks, their unit, and their organization is the subject of studies that consider organizational learning one of the corners of the foundation. Leaders at all levels of the system need to have a sense of shared purpose that builds effective relationships and strengthens the culture. Carroll and Edmondson (2002) suggested that health care organizations could improve quality by enhancing organizational learning which requires leadership at the top, middle and the informal networks at the bottom and creating interdependencies throughout the environment. The authors stated that “leadership must be distributed broadly if the organizations are to increase their capacity for learning and change and therefore to flourish in a complex and changing environment.” (pg. 54) Culture change could evolve as new ideas and technologies are introduced and the soft skills needed to effect the change can then become the new ideal.  The executive leaders need to create a safe environment to allow for change. The middle managers have a considerable burden in being asked to vitalize the vision for change and to support the staff in doing the work.  Then there are the informal network leaders who are community builders who support and hold the organization together.  With little or no formal authority, they turn weakness into strength by demonstrating strong commitment to action and progressive change when they act from personal conviction.  This is the leadership that will affect change and redesign the health care system.

Two studies were recently completed to test how leadership affects the environment and attitudes of individuals coping with change in a health care setting (Savic & Pagon, 2008) (Caldwell, Chatman, O’Reilly III, Ormiston, & Lapiz, 2008). Savic and Pagon undertook a study of Slovene hospitals to determine if organizational culture, teamwork and leadership models played a role in individual involvement in health care. Their results show that leadership played a key role in promoting employee engagement and implementing change.  The transformational leadership style was found to encourage individuals at all levels of the organization. In some instances, a transactional leadership style was valuable to move things along.  The authors speculated that possibly was due to an ingrained social hierarchy belief. The study found that, although the Slovene hospitals were not achieving this, they remarked that organizational culture, leadership and teamwork does encourage individual involvement in work processes and change implementation.

Caldwell et al. (2008) found similar results.  In a study of a large health care organization, physicians were surveyed to determine, among other things, if a leader’s actions and a groups’ general orientation toward change supported change that resulted in an improvement in patient satisfaction. The study was across four health care centres and involved 313 physicians in eight specialty departments. The first phase interviewed 38 leaders in the organization that was undergoing a dramatic shift in strategy to increase patient satisfaction. The second phase surveyed the physicians after the changes had been implemented. This mixed method study carried substantial weight in examining its variables and themes. The results showed that support for a new strategy and leaders’ actions can influence implementation. There were two broad conclusions from the study: intangible factors like support, norms and leaders’ actions can influence implementation, and the effects of social processes are interactive. Leadership had the most profound effect on creating a positive orientation to change.  The authors suggest that leaders need to create a groundswell of support for strategic changes in order to have a successful implementation. Organizational culture needed to encourage change. As with much of the research that involves a subjective measure, like patient satisfaction, as its outcome, there is a complex interplay of a number of factors. It is unclear what the real cause of the increase in patient satisfaction was. It was clear, however, that the implementation was successful.

Ascension Health, the largest Catholic and nonprofit health care system in the United States, presented itself as a case in point for developing a leadership framework for culture change (Rose, Thomas, Tersigni, Sexton, & Pryor, 2006). The centre developed a model of distributed influence what involved promoting the desired behaviour without the traditional command and control leadership. They approached challenges in their environment by employing the 5 C’s of Culture Change:

Table 2: The 5 C’s of Culture Change

(Rose, Thomas, Tersigni, Sexton, & Pryor, 2006)

Ascension defined their culture as the way things are done around here (Rose, Thomas, Tersigni, Sexton, & Pryor, 2006), given the organization’s unique shared beliefs and customs. Although, it is a work in progress, surveys of staff and caregivers to patients suggests that there is a positive safety climate and encouragement to express spirituality which fosters teamwork; that good teamwork is associated with better job satisfaction and more engagement; that communication is important accelerate change; and that dedication to the vision and patience is required to facilitate change (Rose, Thomas, Tersigni, Sexton, & Pryor, 2006).

Culture is one aspect of an environment that can facilitate change and improve quality of care through employee engagement and satisfaction.  A culture of collaboration has created a model of support called Communities of Practice.  “Communities of Practice is a phrase coined by researchers who studied the ways in which people naturally work and play together. In essence, communities of practice are groups of people who share similar goals and interests. In pursuit of these goals and interests, they employ common practices, work with the same tools and express themselves in a common language. Through such common activity, they come to hold similar beliefs and value systems (Wenger, 2000, p. web page).”

Communities of practice have the following characteristics: (a) emergent task missions that are not mandated by the organization; (b) voluntary membership; (c) emergent and dynamic leadership; (d) low interdependence on tasks; (e) emergent structure; (f) informal, social accountability; and (g) internally resourced (Kirkman, Cordery, Mathieu, & Rosen, 2011).

The need for a new business model in health care has caused practitioners to look to other types of organizations for solutions. Communities of practice from the knowledge management industry offer one opportunity. Lathlean and May (2002) explain how the University of Southampton, UK was experimenting with communities of practice in two arenas where the patients would be best served by an interagency multi-professional group.  They discovered that the keys to having a functioning and sustainable community of practice included carefully selective membership, strong commitment to the group, relevance to the issues needing resolved, enthusiasm for the mission, infrastructure for access to needed resources, variety of skills within the membership, and resources (Lathlean & Le May, 2002).

In communities of practice, as the community evolves, so does the leadership. There is often a coordinator who manages the community day-to-day.  Other forms of leadership also become part of the organization, including thought leaders, networkers, people who document practices and pioneers. These positions can be held by one, two or more individuals and can change over time (Wenger, 2000). The ability to adapt is integral to communities of practice. The leadership of the community also adapts over time to provide it with sustainability. 

Summary

Leadership theory has evolved over the years to suggest that it is not the leader that is important in managing complex environments and implementing strategic change, but the leadership skill set (Mumford, Campion, & Morgeson, 2007).  Understanding leadership as something that is transferrable, allows it be adopted by individuals throughout the organization.  The type of leadership needed depends on the situation at hand.  The organizational culture helps to create an environment where the best person for the leadership job is encouraged to pick up that role.  W. Edward Deming suggested that that 93% of all problems in organizations were due to poor design, and 7% of the time the problem was people related (Ball & Verlaan-Cole, 2006).

Leadership research has progressed from suggesting that the skills lie with the individual in a position of power to a skill set that can be applied at any level of the organization. The health care industry has been looking at a fit for leadership style that will encourage employee engagement and result in high quality patient care.  Transactional leadership is needed in operational system and financial systems to ensure the organization has the resources needed to fulfill its mandate (Bass & Bass, 2008). Managers who exhibit transformational leadership skills improve worker job satisfaction and reduce employee burnout (Stordeur, D’hoore, & Vandenberghe, 2001). There is still a piece missing.

Complexity science has become a management theory. As such, research is looking at the organizational structure and culture to create sustainable change and improve performance.  The structure and culture is a function of the relationships within the organization. Collaborative leadership looks at relationships within an organization and encourages ownership of the change. Creating a culture of collaboration is an important factor in ensuring strategic change is implemented and sustained. However, discovering collaboration in an organization cannot be achieved through scientific experimentation.  It is experienced. Communities of practice are an experiential collaborative community. Quantitative leadership research has not given the whole picture because it removed the experience of the people from the study.  Collaboration is about people working together is situations that are not predictable. The usefulness of the theory is in the experiences of the people.

This dissertation is looking at designing an integrated environment that encourages collaborative leadership re-energizing the system for transformation, taking a qualitative, experiential look at whether collaboration can work in a stoic hierarchical community like health care.

• Research Methodology

A fundamental feature of this dissertation is to examine the perceptions of individuals as seen through the collaborative leadership lens. It seeks to identify where, or if, collaborative leadership in an integrated community health care setting is working. Positive deviance theory suggests that we only need to find where it is working, distill it down to the essence and apply those skills to other situations, or other areas (Marsh, Schroeder, Dearden, Sternin, & Sternin, 2004).

Research is defined, by Merriam-Webster, as a “careful or diligent search, or  a studious inquiry or examination; especially : investigation or experimentation aimed at the discovery and interpretation of facts, revision of accepted theories or laws in the light of new facts, or practical application of such new or revised theories or laws.” (Merriam-Webster, 1999, p. web page) The science of it is systematic and controlled. Traditionally, the scientific approach to research was used to establish a theory and challenge then it in a hypothesis. The researcher undertook four steps to ensure duplicability and rigor.  The four steps included: 1. Define the problem, obstacle, idea or theory; 2. Develop speculative statements that related to two or more phenomena presented in the idea; 3. Hypothesize the relationship between the phenomena; 4. Observe, test and experiment with the hypothesis to determine if the relationship is statistically probable or merely chance (Antonakis, Schriesheim, Donovan, Gopalakrishna-Pillai, Pellegrini, & Rossomme, 2004).

Out of the scientific reasoning, two types of research methods emerged: quantitative and qualitative. Quantitative research is about objectivity, generalizability and numbers that are utilized to obtain information about the world (Simon, 2011). Qualitative research is a holistic approach in that it utilizes perceptions that could be different for each person and could change over time. Qualitative research methodologies have been criticized for lack of rigor. However, those judging need to understand that the outcomes expected are different (Simon, 2011).

Historically, leadership research has been quantitative. Scientific method was used to conduct experiments that verified theories. The complexity of leadership, its adaptability to situations and people lends itself to qualitative study also. Organizational science is transitioning now to non-experimental qualitative study (Alvesson & Deetz, 2000).

There are many weaknesses in the current batch of leadership research.  It has accumulated knowledge, a purpose of research. However, the degrees of success in illustrating an understanding of leadership are not very high. . “Development of general and abstract knowledge aiming to explain and predict social phenomena in law-like, causal fashion requires the production of a stable object which continues through time.” (Alvesson & Deetz, 2000, p. 52) Of the many thousands of studies conducted on leadership, many are contradictory or inconclusive. Leadership is as complex as the people who are in the leadership role and its very nature and definition carries with it ambiguity (Alvesson & Deetz, 2000).

With qualitative research, there is resurgence in the use of phenomenological research for management. Ehrich (2005)suggested that it could shed some light on the meanings of human experiences and could effectively be used in management research. It turns away from science and returns the experiences back to themselves. “Effects of investigating particular human experiences outside the confines of pre-existing theories and well established constructs can yield ‘startling new insights into the uniquely complex processes of…managing and leading.’” (Ehrich, 2005, p. 8) The outcome of any social science research should be an understanding of how to act and think in situations.  Hermeneutic phenomenology interprets experiences and offers an in depth and colourful account of phenomena.  It seeks to describe rather than explain (Lester, 1999).

Research Approach

This dissertation follows hermeneutic phenomenology and utilizes the method outlined in Doing Critical Management Research (Alvesson & Deetz, 2000). The central tenet of the methodology is that management research needs to be critical with discipline stemming from critical theory and post-modern work which is “questioning established social orders, dominating practices, ideologies, discourses, and institutions <and> ‘interpretive’ research that aims at understanding the micro-practices of everyday life.” (Alvesson & Deetz, 2000, p. 1)

The three tasks of critical management research are achieving insight, critique and transformative re-definition. Insight provides a hermeneutic understanding, critique deconstructs the structure of the experience, and transformative re-definition ensures that there is a development of practical, relevant management knowledge and understandings.

Insight is the production of knowledge. It is a way of seeing the knowledge. It takes the seemingly objective character of objects and events and interprets how they are formed and sustained. It is related to interpretation. In fact, it is integral to it and an outcome of it. Insight comes from successful interpretation. Successful interpretation, or insight, looks at something that is not obvious, makes sense of it and enriches the understanding of it. It adds something to what has been understood prior to the insight. Insight, itself, does not remove the event or object from the context. It reframes it around previously hidden knowledge, practices and concepts (Alvesson & Deetz, 2000).

It is not sufficient to describe the phenomena, the researcher must also criticize. Critique is the deconstruction of the knowledge. Critique understands that knowledge, relationships and structures are human-made constructions. It will take it apart to understand the structure.  Critique follows insight. Without deep local understanding, knowledge within context, it would be impossible to provide any legitimate and well-founded critique of any subject matter. Critique helps the researcher by providing better answers to questions that have been addressed where there is an understanding that the answers are insufficient. It also provides the basis for alternative interpretations and understandings that are subsequently presented in transformational re-definition (Alvesson & Deetz, 2000).

Transformative re-definition is a natural extension of insight and critique. When the tasks of getting insight in and producing critique about social phenomenon are complete, the next task is to use the new knowledge to redefine what we know about the phenomenon and how to use it in a real world context. “The transformative re-definition task demonstrates our commitment to more pragmatic aspects of critical thought, recognizing that insight and critique without support for social action leaves research detached and sterile.” (Alvesson & Deetz, 2000, p. 17) With the formation of new concepts and practices the research, researchers and participants enhance the understanding of organizational life.

This dissertation utilizes a narrative presentation style.  Through interviews and stories narrative research helps to understand the problem. The stories are collected from individuals and case studies and are interwoven to provide insight into the meaning of leadership. The stories are analyzed for their key elements and themes (Creswell, Hanson, Clark Plano, & Morales, 2007). It utilizes the oral descriptions of the leadership experience by participants as a means of reflecting upon the central question of the research which was: Can a more integrated approach for creating a culture of collaborative leadership throughout the organization that encourages all the strategic aims of the organization including, cost efficiency and improved quality by creating an empowered, accountable and sustainable work force?

This phenomenon is examined in research, and as such, a study of it could provide new insight and transformative re-definition.

Research is conducted with people rather than on them.  It becomes a co-operative inquiry as it is based on the researcher’s biases and previously held belief (Broussine, 2008). The interviewer is aware of how she contributes to the inquiry through the questions raised and responses made (Alvesson & Deetz, 2000).

This researcher studied and worked in the health care industry more than 25 years ago. More recently, she has been involved in leadership and strategic development with entrepreneurs in unrelated industries.  She acknowledges her bias in the innovative and dynamic business model development that has had to take place in the globalization of the free market. It seems that health care has not kept pace with this creative movement for managing organization and implementing transformational change. As part of the data collection and analysis procedures, every effort was made to bring objectivity to the process, including the phenomenological techniques of epoche and bracketing (Taylor, 2006). A reflexive methodology was also made part of the research methodology to increase the trustworthiness of the data (Lowe, 2012).

Since the phenomenon dictates the method and the participants, purposive sampling was selected as the most relevant kind of non-probability sampling that identifies research participants (Groenewald, 2004). Participants include workers and leaders within the health care setting, as well as consultants who would be able to provide a unique far-reaching perspective.

Ethical Issues

An informed consent was utilized to ensure that research remained ethical and protect the rights of the participants (Creswell, 2008). The informed consent ‘agreement’ stated that they were participating in research, the purpose of the research, the procedures involved, the risks and benefits, the voluntary nature of participation, the ability of the participant to withdraw from the interview at any time, the procedure used to protect confidentiality, and the names of who to contact should any questions arise (Creswell, 2008). The central research question was not identified for the participants to prevent insights where honesty and confidentiality reduces suspicion and promotes sincere responses (Groenewald, 2004).

Sample

In keeping with Creswell’s recommendation, interviews with up to ten people were selected (Groenewald, 2004). Data collection interviews with participants continued until no new perspectives were forthcoming.  The sample was purposive. Participants were selected by their involvement in health care leadership, their availability and desire to be involved in the research. Examples of questions asked of the participants included:

• What is your understanding of collaborative leadership and integrated community?
• Describe where collaborative leadership has been successfully or not applied encourage the strategic aims of the organization including, cost efficiency and improved quality by creating an empowered, accountable and sustainable work force.
• Describe an experience where collaborative leadership or integrated community was applied in a health care organization?

Data Collection Methods

There is a distinction between the research question and the interview questions.  Although, as a phenomenologist, the researcher does not direct the responses to the questions, she cannot be detached from her own presuppositions and the researcher does not pretend otherwise (Groenewald, 2004).

As the researcher has limited experience within the industry, bracketing was utilizes. The perspective of this researcher is mainly historical in nature. A researcher must bracket her own experiences and preconceptions and enter into the participant’s world using the self as the experiencing interpreter (Groenewald, 2004).  Curiosity regarding innovations in the health care leadership since removing herself from the industry assisted this researcher in this endeavour. As the researcher has no experience in the current practices in the industry, she was also able to engage epoche—meaning stay away from or abstain—to have an informal interview with the participant.

Groenewald (2004) quoted Kvale with regard to data collection during an interview in that an interview “is literally an inter-view, an interchange of views between two persons conversing about a theme of mutual interest” (2004, p. 13) where the researcher attempts to understand the subject’s world from their point of view, as it unfolds. The root of phenomenology is the intention to understand phenomena from the perspective of the person experiencing it.

A semi-structured interview was organized around the above set of pre-determined open-ended questions, with other questions emerging from the dialogue (DiCicco-Bloom & Crabtree, 2006). Interviews were conducted one-on-one allowing the subject to delve deeper into the subject matter revealing personal experiences and opinions. The interview was designed to be a personal encounter in which open, direct questions were used to elicit detailed narratives and stories (DiCicco-Bloom & Crabtree, 2006). During the interview, an attempt was made to collect qualitative documents including newspaper articles, official reports and personal documents. The researcher looked to capture all the useful information in order to stretch the imagination about possibilities for transformative re-definition (Creswell, 2008).

Interviews were conducted on the telephone. Several attempts were made to coordinates schedules of participants in order to conduct face-to-face interviews. In the interest of time, the researcher was unsuccessful. Some interviews were also conducted via email.

Meho (2006) examined the used of email as an interview device. One of the benefits of using asynchronous email interviewing is the cost savings.  There are no travel or telephone charges. It also reduces the cost of transcribing as the data is received in an electronic format and requires little editing before analysis. The researcher can interview more than one person at a time, outside of a focus group, because the interview questions can be sent simultaneously to several participants, regardless of geographic barriers.  The time frame for data collection could be a challenge as it may require considerable time for the participant to respond. Follow-up could be important in receiving timely replies. Although interviewing by e-mail requires access to the internet, it enables the researcher to reach a diverse and international group of participants. It also permits a degree of anonymity, perhaps allowing for more expressive and honest responses.  Without face-to-face meetings, individuals might be more forthcoming with their experiences and opinions. As with all forms of research involving humans, an informed consent can be obtained via email, either by electronic signature, scanning and sending a signature, or by replying affirmatively to a consent email. Although the data from email interviews has been considered not as rich as data from face-to-face or telephone interviews, since body language, eye contact or vocal tone cannot be observed, some bias or prejudice caused by race, gender, age, etc., can be eliminated. It was considered that email participants might not be eloquent writers. However, with the explosion of email correspondence, it is becoming less of an issue.  Several studies (Meho, 2006) have shown that quality of the responses in email interviews vs. face-to-face interviews is not much different.  The data quality in both instances depends on who is being interviewed, the clarity of the questions and the skill of the interviewer.

In this dissertation, several participants were contacted via email, consent obtained and the choice was given to the participant whether the interview was to take place over the telephone or via email. The informed consent email is included in the appendix as are the email questions.  The same questions were asked during a telephone interview.  Telephone interviews did allow for clarification questions to be asked that were not pre-ordained leading to a semi-structured format.

Data Analysis

Data analysis will combine the critical research management framework presented by Alvesson and Deetz (2000) and the analysis of qualitative research data as outlined in Creswell’s Research design: Quantitative, Qualitative and Mixed Method Approaches (2008). 

Following the data collection, it was organized for analysis by transcribing the interview, collating email responses, sorting and arranging data into different types.

A detailed analysis of the information was begun.  The process involved organizing the material into chunks of text so that meaning can be assigned. After the gist of the information is reviewed with notes made, each document was reviewed for what it is about looking for the underlining meaning. Once each piece of data was reviewed, a list of topics are clumped together being arranged into major topics, unique topics and others. The researcher tried to discern if there are any new categories were needed. The topics were grouped into descriptive categories by looking for similarities and relationships. The data was assembled by categories for preliminary analysis. The grouping process is used to generate descriptions for settings, people, categories or themes (Creswell, 2008).The descriptions can be used in the narrative. The themes and descriptions are reviewed and analyzed in a narrative format for insights. There might be a chronology to the events or subthemes that become apparent with close scrutiny. Themes are reviewed for lessons learned. These insights could be meaning from the researcher’s personal interpretation or meaning gleaned from literature or theories. There might be new questions that need to be asked. The themes and descriptions are then critiqued showing problems with the meanings. The construction of the themes could show faults in the organizational structure (Alvesson & Deetz, 2000).

The data is checked for validity throughout the process. Validity does not carry the same weight in qualitative research as with quantitative. In qualitative validity, the accuracy of the data is confirmed through thorough checking.  Because the interviews relate personal experiences, accuracy related to the researcher’s processes only.  Reliability of the data is confirmed by checking that the approach is consistent across different projects for researchers (Creswell, 2008). The bias of the researcher will also be clarified through open and honest narrative. Reflectivity is a core characteristic of critical research and good qualitative research is expected to contain how the findings were influenced by the researcher’s background and beliefs.

It is not expected that the themes will be generalizable across health care organization, particularly outside of Ontario. Cross-boundary similarities could indicate a need for further research to show the extrapolation of themes across the province.

4.  Results and Findings

Stories are powerful and engaging.  They explore the truth and nuances of experience in a real way and result in a dynamic understanding of phenomenon. In exploring phenomena for insight, what is talked about and what is expressed opens questions that lead to interpretation. The story creates an opportunity for reflection (Tsoukas & Hatch, 2001). The information collected over the course of the research is presented below in a narrative format. The participants were initially contacted by email. Several attempts to connect in person and over the phone failed to create an opportunity to meet.  An email exchange was initiated and the information collected. To supplement this, current headlines related to health care integration and collaboration was researched.

Behind every narrative there is a narrator. The narrator was also the initiator and as such did not sit passively by registering the comments of the raconteur. As reflected in the previous section, the researcher is removed from the health care industry and, therefore comes from a place of curiosity and discovery. Emails were exchanged asking for clarification and meaning to the participants. Detailed responses were given to simple questions.  The flow of the conversation was retained in the telling of the story below. The direction of the flow was designed by the researcher.  The participants are referred to as P1 and P2.

The purpose of the present study was to discover whether collaborative self-leadership is a cause or an effect of an integrated community that would encourage grassroots innovation in the complex health care environment. Participants responded to the following questions with a narrative of their own:

• What is your understanding of collaborative leadership and integrated community?
• How do you see collaborative leadership working in health care?
• How do you see integrated community in health care?
• What value do you see to collaborative leadership in health care?
• What value do you see to integrated community?
• Describe an experience where collaborative leadership or integrated community was applied in a health care organization?

Health care is in a state of disrepair. According to a consultant on health care governance and leadership, referred to hereafter as P1, the traditional “command and control” leadership style focusing on personal power and authority over others does not support an empowered, accountable and responsible workforce. He advocated that “people throughout the organization have the ability and the responsibility to lead.” The senior leaders themselves must stretch themselves to act as stewards, who coach and guide their staff towards the organization’s evolving vision. A shift in mindset, structure and leadership style that will bring about the necessary organizational transformation will come about as many people learn together and undergo personal transformation towards personal mastery.

P1 was contacted because of an article that he wrote in 2010 about the disruptive change that is necessary to ensure that Ontario has a sustainable health care system. In the article, he suggested that the health care system would implode starting in 2012. He was asked if what he had predicted had come to pass. He responded by email.

He admitted that, in the minds of senior health care leaders, the system has passed from one crisis to the next with hardly a blink. They are so focused on fire-fighting over each progressive twelve months that innovative strategic planning for the long term is far from their agenda.

One of their current fires is the Ministry of Health’s plan to shift funding to those services or organizations that provide value-for-money. This painful paradigm shift is waking more and more leaders to the idea that things really do have to change.

P1 stated “Everything about our health care services delivery system—how it is funded, how accountability will be practiced, how resources will be allocated, how performance will be measured and monitored for both managerial and governance purposes; how strategic priorities shift to quality, safety and the patient/client experience—are each at different stages of evolution as our health care delivery system begins to adjust to the new economic realities of 2012 – 2015.”

Evolutionary changes happen slowly, the current economic climate could require revolutionary change to internal and external environments.  The ministry is proposing a new integrated health model in its Action Plan.  This model uses primary care as its hub with access to care shifting from emergency rooms to community care.

P1 suggested that about thirty percent of health care organizations are on-board with health care reform. These are the innovators or early adopters.  He estimated that another thirty percent are on-the-fence and will wait-and-see what happens to the early adopters. There might be thirty percent who fully intend to resist the change by keeping their head down and faking compliance. The last ten percent just don’t get it.

P1 expanded on an example where the health care provider does get it. He suggested that the commonly held belief among change scholars that innovation takes place at the edges was true in that a small rural Local Health Integration Network (LHIN) was working with community and management stakeholders to design a system that met everyone’s needs, especially the patient, who also happens to be the owner, as a tax payer.

P1 attended a conference recently where the LHIN Board Chair explained that they were focusing on best practices and lessons learned about system governance, and that they were okay with making it up as they went along. Rather than assuming that the LHIN had all the answers, the managers designed “Care Connections Project” in order to create the future they wanted for their community.  The organization built a foundation of trust and collaboration. Every stakeholder has ownership of the local service delivery system—patients, managers, boards, and health care providers. Their focus is on how to improve services to the people. The leadership of the LHIN has taken their title to be part of their mandate: local and integrative and networked and health.  Through stewardship, the board and staff has caused everyone to pull together advancing common interests.  From the beginning, the LHIN has fought the silo mentality and collaborated for a common cause. There is a spirit of continuous improvement.

P1 suggested that several factors determined the success of collaborative transformation. In particular, the boards needed to examine their key strategic imperatives and outcomes. They needed to determine what system performance metrics and patient-centred metrics to hold all senior leaders accountable to, and how can the “governance boards across each local health care delivery system ensure that collaboration produces a more customer-focused, higher-quality and more cost-effective delivery system at the operational level.” P1 suggested that all stakeholders be asked to let go of their narrow perspectives and embrace a larger shared vision of a patient-centred or people-centred delivery system that meets the needs for all.

Within this small LHIN, health “system design” initiatives are emerging. The shift in system design is where every aspect of the system revolves around the patient, and where the patient-system partnership drives everything.

This is a powerful vision. Unfortunately, one of the initiators of the vision, the provincial government has caused some disruption of its own by contending that the independent boards of governance that are to hold the management accountable for this vision are dysfunctional. P1 does not share the government’s view and believes that transformation is possible if prudence is considered a valuable virtue. The government and some LHINs seem to have freaked out and are desperately seeking to control and regulate everything. That needs to change.

The ultimate success of a transformation strategy will be dependent on mobilizing to redesign and align each part of the system to the vision of “an efficient, effective, high quality, patient-focused and seamless health care system—at the local network level, at the organizational level, and at the customer level.”

The system needs collective and aligned leadership that liberates the system to transform itself from the bottom up in a self-organized fashion.

The second participant, P2, referenced several news stories and articles as examples of the style of leadership that she saw as important in health care.

P2 relayed an experience from axiomnews.com (Strutzenberger, 2012), Providence Care, a faith-based community care facility, has recognized that to be truly collaboration in its decision-making requires good conversations and authentic relationships. Managers and staff are able to let go of their own self-interest through initiatives such as World Café, open space technology, knowledge and pro-action cafés.

“It means you’re not just sitting and listening to what it takes to be a good leader, you’re practicing leadership conversation methodologies in a safe environment with colleagues,” says Lauri Priest, director of learning and leadership services for the Kingston-based health care provider, “The program is multi-dimensional and requires each participant to practice personal reflection, and commit to understanding yourself. How can you lead others if you cannot lead yourself?” (Strutzenberger, 2012, p. 1)

In another story forwarded by p2, the federal government is also taking initiative to bring a community integrated health care delivery system into reality. At the beginning of June, they announced funding for community-integrated hospice palliative care models across Canada. This initiative is expected to ensure hospice palliative care at the community level as an accessible part of the continuum of care.

In another LHIN, however, the command-and-control leadership style is still strongly held.  In an interview with a senior manager, P2, the situation was described quite differently from the previous LHIN discussion.  In a brief unstructured interview, P2 spoke of the extensive leadership development that was taking place at the LHIN level and at the provider level.  This organization utilized a system known as Leaders for Life (Pelletier, 2010). She forwarded the information and indicated that it was being employed at the mid to upper management level in the hospitals.  She explained that leadership development was a ‘hot’ topic.  When asked about collaborative leadership between the LHIN and local health providers, she relayed and incident from a meeting with a senior executive from a small rural hospital.  The senior executive was attempting to maintain the emergency room services in his organization. The provincial government had suggested that the area would be better served with a primary health clinic and emergencies would be accommodated at the closest urban centre. In charge of the resources, the LHIN informed that executive that its emergency doors would be closing without further discussion. The tone of P2 suggested that she was surprised that the senior executive would think that the LHIN would even consider supporting his request. Collaboration was not considered.

According to P1, collaboration and integration are essential components of a transformed health care delivery system. The two cannot be separated or put in priority implementation order. Through changes in mindset, personal transformation and letting go of ego, collaboration and integration are part of the patient-centred system desired.

The research for this study wielded small but consistent results. The researcher led the discussions with two individuals working in the health care industry. One individual was a consultant for multiple health care organizations as well as provincial bodies. The other individual works for the provincial government in a health care transformation capacity overseeing change processes in several organizations. The themes that evolved out of the discussion were collaboration, leadership, integration, and community. Because one of the participants was very involved in governance, that theme was prevalent in his discussions. The themes gave way to topics grouped under them. The themes and topics are presented below. The data was collected and the reference to the topic by each individual was noted. The occurrence indicated the number of times the topic was referenced by either individual.

Table 3: Research Findings

The data suggests that personal mastery and self-knowledge under the leadership theme, and silo vs. greater public good and patient/customer-centred under the governance theme were the most discussed points. These were followed by command-and-control, emotional intelligence, relationship management and collaboration.

The silo vs. greater public good topic revolved around the traditional hierarchical, medical model of leadership and the increasing bureaucracy that seems to be the government’s solution to the challenges facing health care. As the health care industry comes under more and more scrutiny (Drummond, 2012), the government is looking for answers. P1 asked, “Will our health system collapse under the new economic realities that Ontario must manage, or, will we now begin to undergo a series of disruptive innovations that will end up creating a “patient-centred” healthcare delivery system that is more effective, efficient and sustainable than our existing system? To be honest, it could go either way. I think it all depends on leadership – provincial, local and organizational leadership at the service delivery level of our health system.”

Patient-centred care is the hot topic around health care. Implementation of change looks to ensure that a patient-centred outcome is the focus (Porter & Teisberg, 2006). P1 suggested “…it is not about being Queen’s Park, or LHIN office-driven. It is not about being “provider-driven”. It is not about being management or board-driven. It is about being customer and patient/family-driven.” The participants were not sure that the current structure could create the environment that this outcome needs:

P1 stated:  “This toxic environment for both patients and staff is clearly not the enlightened vision for an empowered/bottom-up/facilitative/empathic/caring/patient-centred/evidence-based system that the healthcare reformers have been calling for at least the past ten to fifteen years. The truth is our current circumstances within the healthcare services sector are tough on both patients and our health care providers.”

He continued: “While frontline care providers and patients share a very similar perspective, the fact is professional healthcare service providers work in fragmented and misaligned systems, structures and processes that are actually designed to create these poor performance outcomes. This is why they say every system is perfectly designed to create the outcomes it produces. So, if we don’t like the outcomes in our existing healthcare delivery system, it needs to be designed to produce very different outcomes. Health system redesign from a patient perspective will also mean – according to extensive evidence – a much more efficient system, which is what we urgently need.”

This illustrates  the command-and-control style of leadership that is the experience of most health care workers, with a stewardship style that is well publicized as the next step above transformational leadership (Bass & Bass, 2008) (Blanchard, 2007) (Block P. , 1993). The participants spoke most frequently of the need for personal mastery within individuals in order to affect successful change. P1 believed that “the shift in leadership styles, mindset and structures requires a journey on the part of many people as they learn together and as they undergo personal transformation towards personal mastery.” With personal mastery comes self-knowledge: he continued, “the central attribute of a leader is the search for self-knowledge, at its deepest level: ‘Why am I here? What am I here to do on this earth?’ Generative leaders try to understand the direction where life is calling them to travel. If they have the courage to follow that destiny, then they can remain calm, steadfast, and open to inspiration—even in the face of ambiguity and turbulence. This, in turn, gives others hope and confidence.”

P1 suggested that emotional intelligence and its requisite relationship management as outlined by Daniel Goleman in Primal Leadership and Emotional Intelligence (Goleman, 2004) (Goleman, 2000). The skills associated with emotional intelligence help individuals to collaborate and work in an integrated community. “Understanding the powerful role of emotions in the workplace sets the best leaders apart from the rest—not just in tangibles such as better business results and the retention of talent, but also in the all-important intangibles, such as higher morale, motivation, and commitment.” This leadership style is also essential to a learning organization. Further, P1 expanded on the value of emotional intelligence: “Daniel Goleman’s books, Emotional Intelligence (Goleman, 2006) and Working with Emotional Intelligence (Goleman, 2000), has profoundly contributed to our understanding of the extent to which our emotions—our feelings—impact on our thinking. By slowing down the process, by practicing reflection, by thinking about our thinking and by striving to know ourselves and those around us better, we learn how we can become more integrated—as individuals and as a system of individuals.”

Integration and collaboration are almost twins in topics for discussion. To have integration, P1 stated, collaboration is required. “The information age shifts organizations from their fragmented structures and processes and redesigns them to function together collaboratively to achieve the outcomes that the organization is seeking. Instead of processes and structures being fragmented and disjointed, they are integrated and networked together.”

Integration and collaboration is the next evolution, or perhaps revolution, that can cause organizational transformation. P1 suggested that “boards need to explore what they need to do differently—if they applied the frameworks for collaborative and generative governance in their unique circumstances. Governance leaders, who are still trapped in the old paradigm of representing their silo, rather than representing the broader public interest, may actually be preventing the current delivery system from actually transforming.” Collaboration is needed at all levels of leadership—local, internal, and provincial.  Ontario has set up a governing body whose name seems to help with collaboration and integration: Local Integrated Health Network (LHIN). Unfortunately, P1 saw this originally as a way of building another silo. That is gradually changing. “Indeed, after eight years, local health service providers are beginning to ‘get connected’—so that local system partners can determine together, where they are going (vision)—and, how they are going to get there (strategy). However, because every LHIN is different, we have a variety of circumstances with which to deal. There are big differences in the levels of connectedness and trust that exist in each LHIN. But while the local health system transformation journey ahead will be different everywhere, there should be a standardized approach to roles.”

Integration requires system re-design. P1 stated: “LHINs that have discovered that the real leverage is in ‘system design’ are beginning to reap the benefits—in terms of people’s willingness to innovate and integrate health care at the service delivery level. Engaging in system design exercises unleashes energy and creativity. So there is a big difference between the role of the ‘system manager,’ and the role of ‘system designer.’ System designers are liberators. System managers are controllers (Emphasis his).”

And integration leads to transformation.

P1 stated: “On an organizational level, transformation involves re-designing work processes in various components of the organization so that work processes are streamlined and seamless, and services achieve their intended results.

During an organizational transformation journey the people at the top shift from being focused on the component parts of the organization to focusing on strategies which will integrate the organization cross-functionally and vertically.”

And transformation is what is needed, P1 expanded, to remove the “politically-driven, top-down, command-and-control, rules-based, fear-driven, insensitive to the needs of the patients/clients—and provider-focused” system that persists.

P1 stated: “This toxic environment for both patients and staff is clearly not the enlightened vision for an empowered/bottom-up/faciliative/empathic/caring/patient-centred/evidence-based system that the health care reformers have been call for at least the past ten to fifteen years. The truth is our current circumstances within the health care services sector are tough on both patients and our health care providers.

While frontline care providers and patients share a very similar perspective, the fact is, professional health care service providers work in fragmented and misaligned systems, structures and processes that are actually designed to create these poor performance outcomes. This is why they say ‘every system is perfectly designed to create the outcomes it produces.’ So, if we don’t like the outcomes in our existing health care delivery system, it needs to be designed to produce very different outcomes.”

P1 was optimistic with the changes that he sees on small scales, like the rural LHIN story relayed above and “Saint Elizabeth Health Care, a major home care health service provider in Ontario and British Columbia, revised its vision two years ago to reflect its desire to honour the ‘Human Face of Heath Care.’ The innovative CEO of SEHC, Shirlee Sharkey reached outside the health care industry to the tools and processes originally developed for the Disney Corporation’s theme parks.”

Is collaborative leadership and integration the path to transformation for the health care industry in Canada?  Transactional leadership is limited. Transformational leadership is not enough (Bono & Judge, 2004). Collaboration is a way forward. Leadership at all levels will bring the exceptional quality of health care that is available to the level of the patient, where it is needed.

This study had strong emphasis on self-leadership for all individuals through personal and self-mastery. True leaders use their emotional intelligence to manage relationships and encourage resonance within the community. Leaders are responsible and hold themselves and others accountable to goals and vision of the organization.

The research conducted in this dissertation suggests that in order to create a value-based, patient-centred health care system, organizational transformation must take place. The prevailing command-and-control, self-interest leadership model displayed at the governance and provider level needs to give way to a collaborative, integrated design. As Director of Health System Transformation, Susan Plewes suggests: “We think our health system design process is working well because it truly is a collaborative effort based on our collective intelligence. So the ownership of our future local service delivery system is extensive. Patients, managers, boards and health care providers are all determined to build a better system for the people we serve. (Quoted by research participant)”

Patient-centred, evidence-based, communities of practice are theories in research that hope to help the health care industry implement change that will result in an improvement of quality and cost efficiencies (Alleyne & Jumaa, 2007) (Christensen, Grossman, & Hwang, 2009) (Porter & Teisberg, 2006). The literature is moving away from the traditional roles of leadership, such as transformational and transactional (Eagly, Johannessen-Schmidt, & van Engen, 2003), because they do not give the whole picture in the complex environment that is health care. This study follows the trend of leadership research which shows that leadership is not about a position, but about a set of skills that any individual can and should use to further the interests of the organization (Axelsson & Axelsson, 2009). Discussions revealed that health care in Ontario is struggling to implement the ideas that have been successful in other areas of the world (Caldwell, Chatman, O’Reilly III, Ormiston, & Lapiz, 2008). The research participants agreed that a culture of collaboration would encourage leadership that would focus on patient-centred care and remove the silo thinking that has been part of health care hierarchy for generations.

Leadership, collaboration, integration and community are the future of organizational transformation according the research participant. P1 sees changes starting at the local level illustrating the quote, “Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has (Mead, 2012).”

5.  Discussion

General Findings

The aim of this dissertation was to investigate leadership within the health care industry. It was designed to discover whether collaborative self-leadership is a cause or an effect of an integrated community that would encourage grassroots innovation in the complex health care environment. There was no shortage of leadership research in literature and the current climate in Ontario is such that the government is looking for answers (Drummond, 2012). Leadership is considered an important ingredient in the successful transformation of the health care delivery system (Amalberti, Auroy, Berwick, & Barach, 2005). In an attempt to understand the experience of collaborative self-leadership, a phenomenological study was undertaken.

There are many flavours of leadership. The study of leadership began with the examination of the characteristics of the leader in trait theories and evolved into behaviour theories (Robbins, Judge, & Campbell, 2010). These theories assigned the traits and behaviours to individuals in positions of power. The leader was considered someone with authority and responsibility. Fast forward to current understanding, leadership is now not considered dependent on a position, but on a set of skills and the attitude of the individual with the skills. Anyone, at any level of an organization, can exhibit the traits and behaviours of a leader.

The research for this dissertation reveled that collaboration and integration are two of the hallmarks of the value-based health care system that authorities envision (Porter & Teisberg, 2006). This conclusion was echoed in the interviews conducted for the study. Collaboration and relationship management were two of the most prevalent topics discussed in this study by participants. Silo vs. greater public good and command-and-control was discussed as aspects of the current system that are hindering progress. Patient/customer-centred metrics are the outcome the current research holds as paramount (Christensen, Grossman, & Hwang, 2009), which is a topic most discussed by participants.

P1 declared the essence of the findings of this dissertation: “The information age shifts organizations from their fragmented structures and processes and redesigns them to function together collaboratively to achieve the outcomes that the organization is seeking. Instead of processes and structures being fragmented and disjointed, they are integrated and networked together.”

The literature review and the research of this dissertation suggest that collaboration is part of a complex system because a complex adaptive system is about relationships (Lichtenstein, Uhl-Bien, Marion, Seers, Orton, & Schreiber, 2006). As the health care system moves towards patient-centred, evidenced-based care, an integrated community built on collaboration will create its own style of leadership (Block P. , 2009). In this small study, leadership evolves from a self-organizing culture. Collaboration is the cause of this evolution.

Recommendations

The research suggests that methods of successful implementation needs to investigated further under the guise of collaboration. It seems that the research participants agree with the research that shows that collaboration and integrated communities are the pathways to successful change (Axelsson & Axelsson, 2009).  Methods for personal transformation and self-knowledge need to be investigated to bring collaboration to the minds of community so that change can be sustained (Alleyne & Jumaa, 2007).

For leadership to be effective in a collaborative environment, cooperative skills need to be learned at all levels in an organization. Examples of these skills are the ability to create a safe environment for exploration and innovation—as well as making mistakes, the ability to listen rather than advocate, defend or give advice (Block P. , 2009), and the ability to ask  formidable questions. These are not skills that come naturally to bureaucratic leaders.  Positive deviance and appreciative inquiry are methods (Marsh, Schroeder, Dearden, Sternin, & Sternin, 2004) (Mohr & Watkins, 2002) that can guide leaders at the top of the hierarchy to encourage leadership skills to be expressed at the bottom of the hierarchy. Further exploration on those methods in collaborative environments is warranted.

Further research is recommended into how leadership evolves in a collaborative environment so that practices can be developed to speed the evolution.

Limitations

In the planning of this research, careful consideration was given to the type of study needed to ensure that the right information was collected. Because leadership is about individuals and their relationships, the researcher believed that one of the strengths of the study was the use of qualitative methodology. In the complex environment that has become the health care system; the experiences of the individuals were an important piece of the research. Also, the researcher has no recent experience with the leadership of the health care industry. Another strength of the study is that the researcher had minimal bias. She accepted the information presented in the literature review and by the participants at face value. Meaning was assigned by the presenter. At no time did the researcher offer up her opinion and questions were asked for information gathering and clarification. The participants in the research interviews are in the industry and are involved in leadership as different levels. The consultant overs leadership development and strategic visioning for health care providers and has been involved in industry governance for over thirty years. Reference was also made to news articles regarding a director of leadership development. The LHIN manager is involved with system transformation and interacts with senior health care leaders daily.

Counterbalancing these strengths were weaknesses. Because the researcher is not directly involved in the industry, third party introductions and open call messaging was undertaken to solicit opinions about the research topic. A couple of individuals offered up their time to assist with the research, but declined for different reasons: one suggested that she did not have the experience that she felt warranted involvement and the other declined to allow for recording of her conversation and was not open to an email interview. As a result, only one in depth interview and one informal interview was conducted. Although phenomenological study can involve a smaller cohort (Creswell, 2008), the data would be more robust with more participation. With the one participant, a semi-structured interview as undertaken. The interviewee has a large body of knowledge. More information could have been gleaned with more structure to the interview, which would have kept the individual focused on the research question. The second interview was unstructured discussion that led to experiential insights.

The in depth interview participant has very strong opinions regarding the changes that are needed in the health care delivery system. Because there was no other opinion to counterbalance his, the researcher was drawn into his view. Prevailing research and news stories supported his discussions. The large Drummond report produced by the Ontario government in February (Drummond, 2012) echoed his sentiments in many ways.

Although, no new conclusions came as a result of this research, it reinforced the work that is already underway in the Ontario health care provider network and noted that there is much work to be done to move the Canadian health care system back to its place as one of the best in the world.

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Appendix 1:

Informed consent

You are invited to participate in the study on the collaborative leadership in health care. This study is a qualitative research. The purpose of this study is to explore the experience of collaboration as it relates to leadership and culture in a health care setting. You are invited because your experiences and perspectives are the first hand data which are the fundamental building blocks of this study. In this study you will be interviewed via email or over the phone. The data collected from you will be analyzed qualitatively and then provide insight into the current experience of collaboration. Your participation and contribution to this study is highly appreciated.

The duration of this study is one semester, the spring semester of year 2012. There is no risk or discomfort associated with your participation. It doesn’t take much time or special effort on your part. The information you provide is confidential, and all the names of the participants in data will be removed. All the written and recorded data will be destroyed at the end of this research. The researcher in this study is *******, a master’s student at Robert Kennedy College. The research advisor is *********.

Your participation in this study is highly valued and voluntary. You may withdraw your participation any time during the process of this study by notifying the researcher.

Your reply to this email will confirm that you, having read and understood the information presented, decide to participate and contribute in this study. Thank you very much.

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