DISSERTATION SUBMISSION FOR ROBERT KENNEDY COLLEGE MBA, LEADERSHIP &

SUSTAINABILITY

Leading Collaboratively:
A Study of a Model of Health Care Leadership
**********
7/1/2012
Masters of Business Administration, Leadership and Sustainability

In presenting this dissertation for assessment, I declare that it is a final copy including any last revisions. I also
declare that it is entirely the result of my own work other than where sources are explicitly acknowledged and
referenced within the body of the text. This dissertation has not been previously submitted for any degree at this
or any other institution.
So declared by **********, July 1, 2012
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.
Table of Contents
Introduction 3

Literature Review 7

Research Methodology 19

Results and Findings 26

Discussion 37

Bibliography 40

Appendix 1: Informed Consent 47

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Tables
The Spirit of Collaboration 13

The 5 C’s of Culture Change 16

Research Findings 30

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 1. 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,
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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,
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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
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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.

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 2. 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

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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.

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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.

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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.

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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

11
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).”
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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

Embracing
Empowering
Embracing the
"right" kind of Involving
Empowering
members members to Mobilizing
Involving and
enable supporting all
participation Mobilizing
members members to
make things
happen

(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.

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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

14
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
15
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

Comprehension Understanding the problem

Compassion Spirituality and commitment

Collaboration Teaming between subcultures and providers

Coordination System processes, infrastructure and ideation

Convergence Leadership of local culture with spread and dissemination of new norms in a rapid way

(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
16
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
17
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.

18
 3. 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

19
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

20
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

21
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

22
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

23
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

24
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.

25
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

26
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.
27
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.”

28
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
29
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

Theme Occurrence Topic

Collaboration 2 Innovative.
2 Collective intelligence.
Co-create roles, relationships,
1 behaviours.
1 Balance of disorientation & new
1 learning.
1 Complex.
1 Holistic.
Leadership Personal Mastery. Self-
7 knowledge.
6 Command and control.
5 Emotional intelligence.
5 Relationship management.
4 Accountable.
4 Personal transformation.
4 Organizational transformation.
Sense & actualize emerging
4 future.

30
 3 Stewardship.
3 Responsible.
3 Authenticity.
Leadership 3 Encouraging.
3 Orchestrating conflict.
3 Resonance. Dissonance.
3 Change.
3 Commitment & openness.
2 Tough question, not answers.
2 Coach, mentor, guide.
2 Lead by example.
2 Wisdom.
1 Adaptive.
1 Servant.
1 Values-based.
Integration 5 Redesign systems.
3 Alignment.
2 Cooperative.
2 Cross-functional & vertical.
Authentic – knowing, being, and
2 doing.
Empowered, accountable, &
1 responsible work force.
1 Opposite of fragmentation.
1 Transformed.
1 Local.
Community 4 Learning organizations.
Flexible, innovative, dynamic &
2 successful organization.
2 Openness.
2 No silos.
2 Coordinated whole.
1 Trust.
1 Common cause.
Governance 7 Silo vs. greater public good.
7 Patient/Customer-centred.
5 Collaborative.
4 Old paradigm of competing.
3 Provincial.
3 Local.
3 Value-for-money.
3 Accountability.
2 Stewardship.
2 Internal.
2 Risk adverse.
2 Risk taking.
1 Skill-based.
31
 1 Impact quality & safety.
Fragmentation 1 Isolated
1 Manageable complex tasks
1 Reassemble to see big picture.
1 Broken mirror.
1 Separate unrelated forces

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
32
 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.”

33
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-

34
 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)”

35
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)."

36
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.”

37
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

38
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.

39
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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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