Distributed leadership as a tool for integrated health services

Abstract

Introduction: Because of increasing life expectancy and more elderly people living with multimorbidity, municipal healthcare organizations are searching for new ways of combining human and non-human resources to provide integrated care. Distributed leadership theories conceptualize leadershipas a relational process where leadership can be enacted by anyone with the expertise or skills necessary to achieve the group's goals. With the promise of bringing together experts in solving complex problems, theories of distributed leadership are based on the premise that people outside of traditional leadership positions possess influence. Previous research findings indicate that distributed leadership can contribute to a culture of quality in health care by improving decision-making, performance, and organizational learning. However, research also suggest that the potential of distributed leadership is limited, as professional identities and regulations increase the likelihood of traditional or concentrated leadership. The contribution of the thesis work consists of three articles using data collected from semi-structured interviews with general practitioners (GPs) and patients to explore a different perspective of distributed leadership in integrated care in a municipal setting.

Methodology: The research project “Leadership and technology for an integrated health service” was a multiple case study conducted in a semi-urban municipality in Western Norway (2019-2020). The case study consisted of twenty groups of three people who are in regular contact: the patient, the patient’s GP, and a home care nurse. Qualitative analysis of semi- structured interviews carried out with patients and GPs are used to answer the following research questions:

Article 1: What type of leadership actions do GPs adopt in the collaboration with other healthcare professionals and the patient in order to provide integrated care? Do these leadership actions contribute to distributed leadership? Can the collaboration between GPs, patients and other professionals be characterized as distributed leadership?

Article 2: How is the collaboration between patients and GPs experienced by patients? Does the collaboration between patients and GPs contribute to distributed leadership and enhance the patients’ experience of integrated care?

Article 3: What are the ethical challenges for GPs taking part in distributed leadership processes in integrated care? How do they manage them?

Findings: Article 1 explores the leadership actions of GPs participating in integrated care. Are their collective work patterns considered distributed leadership? Do they contribute to integrated care? The results show that GPs contributed to distributed leadership when working in partnership with other health care personnel and patients to provide integrated care. GPs contribute to integrated care by facilitating cooperation with hospitals and other healthcare providers, creating continuity, and working to achieve a holistic focus in service provision. In addition, GPs secure internal coherence in collective work practices by monitoring and following up on work processes to ensure implementation and quality in healthcare provision. GPs achieve this primarily by participating in collective work processes that appear rule-based and preplanned, or what is known as institutionalized practices in distributed leadership. Less frequently, GPs are more involved in spontaneous collaborations characterized by physical meetings and relationship building. Findings show that spontaneous collaboration likely redirects the attention of healthcare workers from the macro-context of organizational structures and medical culture to the micro-context and work process of creating a patient experience of integrated care.

Article 2 explores the experience of patients receiving integrated care. Findings show that these patients find it difficult to influence the collective process of care provision. The findings show that patients’ lack of access to the collective work process is problematic if healthcare organizations aim to obtain the patient’s perspective on the experience of integrated care. The second article also shows that the location of leadership is shifting and dependent on the patient’s condition and situation; patients’ leadership beliefs frequently attribute leadership and responsibility to physical meetings with healthcare providers and the healthcare provider initiating medical treatments or healthcare service. Furthermore, the study identifies that a strong separation of responsibility and division of work leads healthcare workers to restrict their commitment to a limited set of services.

Article 3 explores the experience of GPs and the ethical work they do when moving from the traditional face-to-face encounter with patients to collective work processes in the provision of integrated care. The findings demonstrate that GPs participate in knowledge transfer to support and build patient autonomy and that GPs aspire for their patients to be autonomous and self-managing as far and as long as possible. However, GPs vary in their approach to this task and in their attitudes to patient participation and involvement in healthcare provision. In general, GPs consider that they have an obligation for non-maleficence and to avoid harming their patients. Furthermore, findings show that GPs who are practicing the principle of distributive justice and take professional pride in solving problems single-handedly may limit their own or other healthcare providers’ contribution to collective work processes and distributed leadership in integrated care. The findings also show that GPs experience ethical pluralism when involved in the collective provision of healthcare services. When GPs consult a patient face-to-face, they are more likely to practice pragmatic clinical ethics. In contrast, in collective work practices, healthcare workers are more likely to adopt a universal clinical ethic.

Discussion: This research thesis explores and identifies how the distributed leadership configurations in integrated care are influenced by the actions of healthcare workers, their work practices, tools, macro-contextual factors, the ethical work of GPs and patients' leadership beliefs. Findings from Article 1 demonstrate that most distributed leadership practices are guided and steered by referencing frames of organizational macrostructures and medical culture. Article 3 provides further exploration and discussion of the medical culture and ethical work performed by GPs participating in the provision of integrated care. Similarly, Article 2 demonstrates that patients hold leadership beliefs that contribute to the factors affecting the distributed leadership configurations that emerge from the analysis of the data collected. It is most evident when GPs cultivate closer relationships and collaboration with patients and home care nurses that the collaborative provision of integrated care becomes more attentive to the micro-context of the relevant patient case and able to identify better solutions to hard-to-solve problems.

The discussion section of the thesis focuses on the potential contribution of distributed leadership in relation to continuity, coordination, and comprehensive service offerings in integrated care. Regarding the referencing frames of organizational macrostructures and medical culture identified in the study, the thesis discusses whether the primary bottlenecks for distributed leadership in integrated care are underdeveloped or underused digital tools and meeting spaces, or the organizational structures, culture and psychological mindsets influencing the collaborative work between healthcare professionals and patients.

While further development of digital tools may strengthen patient participation, the achievement of spontaneous collaboration may require real-time digital communication, patient coordinators, or meeting spaces to strengthen patient access and influence in integrated care. However, the standardized collective work patterns, or institutionalized practices, identified from the study imply that the collective work patterns are governed by referencing frames of organizational macrostructures and medical culture which shape the content and limit the flexibility of the distributed practice observed in the municipality. The informal and formal rules that contribute to the division of labor and a harmonious working climate observed in the municipality hinder the flow of knowledge, skills, power, and responsibility across organizational borders. Similarly, the research findings show that the patients' leadership beliefs and adherence to social norms limit their attempts to influence collective work processes in integrated care.

Equating the leadership beliefs of patients and the different ethical frameworks of healthcare workers to psychological mindsets, the discussion section concludes that the digital tools and physical meeting spaces used, their ability to capture and represent the context, and the psychological mindset employed in distributed leadership in integrated care are interrelated. Achieving synergistic effects of distributed leadership in integrated care will require researchers to identify methods that can merge the tools, resources and psychological mindsets used with the context and the situation without group composition or professional belongings undermining the distributed leadership practices that emerge.