temps 1994
Leadership Without Bosses:
Shared Leadership in the Creation
of a Health Network
by Chris Elliott
T his study reviews the leadership behaviour
during the planning stages of a health network
in province X" after the Minister of Health an-
nounced that health administration would be regional-
ized. The decision to form a health region, based on
the Timberwell" and Eaton* townsites, and the p l p -
ning for the resultant Richlands Health Network,
were the culmination of more than a year's events.
Four agencies were involved: the Timberwell and
Eaton hospitals, the Timberwell Health Unit and the
Timberwell Wrsing Home.
The chief executive officer of Timberwell Hospital
first suggested the network. He had presented the con-
cept of a "health campus" as the vision for such a net-
work in Community Health Campus: Draft**some six
months before the announcement of regionalization.
As events unfolded leadership appeared "as a com-
munal endeavourrri or "consensus or collegial leader-
ship."2 Certainly, what Van Fleet and Yukl described
as "where one person dominates, a conventional view
of leadership exists,112(p. 75)does not apply in this case.
The Minister of Health described the proposal for
regionalization as a "paradigm shift," and for many it
was a new way of thinking about health care.
38
Volume 7, No.
arious participants.
Participants needed to believe that two or more health
agencies working together need not mean the takeover
of the smaller and less-well funded by the bigger and
busier ones. Those involved were required to embark
on a planning process that involved considerations
broader than a focus on single, separately governed
and separately funded facilities.
Participants had to look past the traditional
bureaucracy nature of hospitals described by Wilson3
and the way that many people regard them in order to
involve the different health agencies in the negotia-
tions. Required was what Foster described as leader-
ship: "a communal endeavour wherein the direction of
the society is discussed and debated. Leadership, in
this respect, resides in actions and acts, not persons
and positions.111 (p. 18)
The planning of the health region as a communal en-
deavour resulted in a situation where the values,
beliefs and understandings of each of the participants
could be taken into account. To form a cohesive group
the participants needed to develop a "shared environ-
ment," encompassing the views they each had of their
world, their organization, the health system and their
place in it, and of leadership itself.
Healthcare M q e m e n t FORUM
Volume 7, No. 1
Figure 1: A Conceptual Framework: Leadershipas Language
\ (stylisticrepresentation)
I leadership process and stressed the importance of un-
SEMANTICS
(meanings)
Source: Developedfrom reference #15
Community Health Campus: Draft, which became
the vision statement for the health network, was repre-
sentative of much current thinkin about required or
desirable changes in health care.4qo In addition, the i n
tent of this document bore striking similarity to the
Minister of Healths vision for health care which in-
cluded the effective use of resources and access to a
spectrum of health services and a greater emphasis
on health promotion and disease prevention across
the province.
With the promotion of the vision of a health
campus as the basis for the proposed region there
occurred what Handy described as the ah ha effect
when a leader shapes a shared vision that gives a
point to the work of others. . .The vision must be dif-
r f 1 1 (pp.238-
ferent . . . [but] must make sense to others.
239) Levey wrote, New ideas are often discovered by
several people separately at the same time - they are
in the air in some sense. The shared environment is
also essential if a erson with a vision is to become a
leaderl2(pp. 136-17) and the pursuit of a vision implies
the implementation of change. As Kotter remarked,
Since the function of leadership is to produce change,
setting the direction of that change is fundamental to
leadership.13(p. The leaders in the current study
needed to establish a complementary role with other
participants in the way Kosowski and colleagues
described: by creating a shared sense of reality [where
a leader] plays a complementary role to the members
in the leadership process. . . . Members respond to
the leaders vision and unify their efforts in its
direction.r r 1 4 (p. 39)
FORUM Gestion des soins de sante
Spring/Printemps 1994
Concepts from the literature on leadership
One of the most interesting aspects of leadership is
the difficulty that has surfaced in reaching agreement
on a definition for the term, perhaps because, as the
literature indicates, context is an important issue.
Pondy used the analogy of language to describe the
derlying meanings and values. His metaphor was
used as the conceptual framework for the study. He
wrote, To practise, say, democratic leadership is to un-
derstand the set of meanings (values?)to be conveyed,
to give them primitive expression, to translate them
into stylistic representation, and ultimately to choose
sounds and actions to manifest them.15(p. 89) Figure 1
PHONETICS attempts to describe Pondys (1978) metaphor.
(observablebehaviour)
Pondy asserted that we need to look further than the
observable, surface, stylistic components15 (P. 90) of
leadership if we are to increase our understanding of
the leadership process. Leadership is of interest in busi-
ness, public administration, health, education and
politics. Political scientist Barbara Kellerman stated,
Knowing more about leadership will enable us to bet-
ter understand our past and resent and, hopefully, to
P
better manage the future.16 p. ) In what he termed a
critique of a tradition Greenfield criticized those
who consider leadership as though it occurs exclusive
of context when he stated, Adequate theories of
leadership should take into account the sources of con-
trol in organizations, and the dynamics of both inter-
nal and external forces which influence the operations
of the system.17(P. 57)
Research by Eblen into leadership in hospitals and
into the clerical, police, maintenance, parks and recrea-
tion, and engineering departments of city government
administration indicated that the needs of the in-
dividuals are essentially intertwined with their situa-
tional context. As an outcome of that study Eblen
commented, Leadership/ commitment relationships
seemed to fluctuate from situation to situation. . . . The
complexity of leadership style/social skills/commit-
ment relationship establishes the need for exploration
in this area.,118 (pp. 192-193)
Many of the most recent authors have stressed the
importance of taking culture and context into account
when considering leadership. Bolman and Deal wrote
that to ignore the culture of the organization in which
the leadership is operating is to run the risk of present-
ing a simplistic solution to a complex issue. They con-
cluded that such approaches neglect man of 421)
,,l?(p. the
most critical challenges that leaders face.
Schein, in apparent agreement, wrote that culture and
leadership, when one examines them closely, are two
sides of the same coin, and neither can really be
39
Springhrintemps 1994
understood by itself.20(p. 4, In commenting on a series
of good leadership studies over the last decade Bol-
man and Deal remarked that vision is the only charac-
teristic of effective leadership that is universal in these
reports.,119 (p. 411)
The expression of a vision that has its genesis in the
needs of the followers is at the heart of what Burns ad-
dressed when he differentiated between transforma-
tional and transactional leadership: The relations of
most leaders and followers are transactional - leaders
approach followers with an eye to exchanging one
thing for another: jobs for votes, or subsidies for cam-
paign contributions. . . . The transforming leader looks
for potential motives in followers, seeks to satisfy
higher needs and engages the full person of the fol-
lower.w21 (p. 4)
The lofty goals of transformational leadership com-
prise an important thread that runs through the litera-
ture of the 1980s and 1990s. [Elngaging the whole
person is reflected in or receives direct mention in re-
search or overviews of research by numerous writers.
Smyth used the term transformative in calling for
leadershi that stimulates dialogue and mutual learn-
h~g,~(p.#and Rosenbach and Taylor described trans-
s
formational leadership as involving grou members
joining in a shared vision for the future.2 (p. 152)
The essence of transformational leadership makes ex-
plicit the concept that leadership, culture and group
membership are intertwined. This has been described
by Foster as praxis which In this respect, stands for
the ability of all persons to engage in acts of leadership
which help in the transformation to a way of life which
incorporates participative principles; leadership, in
this regard, is both critical and a shared leadership. It
is shared because no one individual has the right
way. (p. 14) Traditionally, much of the leadership
literature has referred to the leader and has placed
an implicit connection between leadership and posi-
tion. This is being increasingly criticized. Sergiovanni
wrote that when professional socialization, purposing
and shared values, and collegiality are emphasized,
they become substitutes for leadership. This means
that direct leadership from administrators can be less
intense - indeed much more informal.1/24 (p. 96)
Stageq*of leaders hip
Organizational survival was an important motivator
in the preparation of Community Health Campus:
Draft and was also an important issue for those that be-
came involved in the health network, but the com-
munity health campus concept was also directed at
higher-level needs. The health campuses in the United
States on which the ideas presented in this document
were based proved to be successful because they
directed the delivery of health care at community
needs.
40
Volume 7,No. 1
The satisfaction of lower-level needs, such as or-
ganizational survival and job security, were described
by Sergiovanni as bartering, the first of five stages of
leadership. The others are building, bonding,
binding and banking. The second stage is leader-
ship by building [when] the focus is on arousing
human potential, satisfying higher-order needs, and
raising expectations of both leader and follower in a
manner that motivates both to higher levels of commit-
ment and p e r f ~ r m a n c e . (p.
~126)
~ The planning of the
Richlands Health Network also showed what
Sergiovanni described as leadership by bonding
[which] responds to such intrinsic needs as a desire for
purpose, meaning, and significance in what one
does.25(P.126)However, the degree to which they had
become sufficiently ingrained as to become assump-
tions, described by Schein2 as the core of a culture,
remained uncertain at the end of this study. The im-
plementation of the health network had not
progressed to the stage where the institutionalization
involved in the banking stage could have occurred.
Similar to that described above, Keenhert and
Lewis26suggested three stages in a construc-
tive/developmental analysis of leadership. These
authors suggested two stages involving transactional
leadership: imperial leadership, where the organiz-
ing process involves personal goals and agendas
directed at perceptions, immediate needs and feelings;
and interpersonal leadership, where interpersonal
connections and mutual obligations are the subject and
personal goals and agendas are the object of be-
haviour. The third stage is institutional or transfor-
mational leadership, where the leaders behaviour
depends on the basis of personal standards and value
systems and is directed at establishing interpersonal
connections and mutual obligations. Like the stages
suggested by Sergi~vanni?~ events in the current
study could be described using these stages.
The creation of shared meanings
So that real planning for a health region could occur
an organizational culture had to develop. Kreffing and
Frost referred to this as shared meanings - patterns of
beliefs, symbols, rituals, and myths that evolve across
time that function as the social glue.27(p. 155) For the
planning of the Richlands Health Network to be suc-
cessful it was essential for the participants to develop a
sense of ownership in the process.
The chief executive officer of Timberwell Hospital
suggested the creation of the health network and
proposed a collaborativeprocess for its planning. He
aimed for leadership that would mean the abolition
of privileged and elitist forms of leadership . . . and for
their replacement with a form of leadership that stimu-
lates dialogue and mutual learning.22(pp. 6-7) The de-
gree to which the needs of the various participants
Healthcare Management FORUM
Volume 7, No. 1
Figure 2: The Planning Process
C O L L E G I A L I T Y ,
were addressed would prove to be the determinants of
the extent to which the participants became a part of
the creation of a new organizational culture.
The emphasis in the planning of the Richlands
Health Network had been on people rather than struc-
tures, which contributed to the success of the planning
process. The Maxcy and Caldus suggestion that
leadership be reconstituted to reveal the pluralistic
meanings currently displayed by that concept; to recog-
nize that leadership may be shared and that leadership
in a democratic society requires followersbe treated as
ends in themselves, rather than meanstrz8(p. 26) ap-
pears to apply. The circumstances demanded an open-
ness and honesty in approach, referred to by Bennis as
being required when environmental encroachments
and turbulence,. . . the fragmentation of constituencies
. . . multiple advocacy, win-lose adversarial conflicts
between internal and external forces . . . has led to a
situation where our leaders are keepin their heads
below the grass, as L.B.J. once put it.,&p. 12)
A values base for the network
The health campus vision represented several values
that the other articipants were likely to support,
4
while having t e potential to satisfy their basic needs.
Essential values for what was to become the Richlands
Health Network were sharing and equal partnership
and the creation of the regional group as a collabora-
tive enterprise.
A climate was established that would allow each of
the other participants to modify the vision in response
to their own values and needs and their own view of
the world. The vision was moulded to fit the par-
ticipants and this process was made possible by the
context of collaboration and trust, two values the par-
ticipants were likely to support. This process of interac-
tion between the vision and the needs and values is
FORUM Gestion des soins de sant6
Springhrintemps 1994
SEMANTICS
VALUES
focus on community health needs
equal partnership
sharing of human, material, and financial
resources
NEEDS
organizationalsurvival
improvedhealth service delivery
* input into long-termcare planning
H O N E S T Y A N D T R U S T
illustrated in Figure 2. Other participants indicated
they had different basic needs and, although the needs
shown in Figure 2 do not apply to each participant, the
potential to be taken into consideration in the planning
process was provided.
As suggested by Pondy,15the syntax of leadership re-
lates to the vision, whereas the meanings and values re-
late to the semantics of the leadership.
Because the planning process that was established
was based on collegiality, honesty and trust, these
values became a part of the process and assisted in al-
lowing the participants different conceptions to be
taken into account and to contribute to the moulding
of the vision. However, the semantics of leadership in-
clude more than just the values and needs shown in
Figure 2. The individuals conceptions of the world
and their place in it, and their individual under-
standings about organizations were vital components
and influenced the participants behaviour. This be-
haviour can thus be understood as an expression of the
way each participants view of the world and of his or
her place in it interacted with the vision for the health
network and the common understandings they had
developed. Those that saw themselves as managers
contributed to the planning process as managers, and
those that considered themselves to be visionaries con-
tributed as visionaries.
Expressions of leadership
The individuals realities were constructed through
their values, beliefs, needs and wants, and the way
these were applied to their situations determined their
expectations of themselves and others. Perhaps what
is important in the way people express their leader-
ship is how they perceive themselves as leaders.
S e r g i ~ v a n nproposed
i~~ a hierarchy of five leadership
forces that school principals may use - technical
1
41
Spring/Printemps 1994
leadership, human leadership, educational leadership,
symbolic leadership and cultural leadership. In-
dividuals express their leadership in terms of the par-
ticular forces they believe are appropriate to use. These
forces, modified to relate to health administration, may
be applied to the current study.
The major difficulty with applying Sergiovannis
hierarchy of leadership forces to health administration
is the educational force when the principal [takes the
form of a] knowledgeable colleague or leader of
leaders who engages with teachers on an equal basis
on matters of teaching and learnin with the aim of
i$
improving educational practice]. tPP. 102-103)How-
ever, if we think of this middle level being aimed at im-
proving administrative practice, it proves useful.
Rebore wrote, Administration is the process of
managing human, financial, and mana erial resources
toward the fulfillment of a mission,r30fb.9)and Hodge
and Anthony3 referred to management involving
planning and controlling; organizing, staffing, and
directing; and decision-makingand influence. If ad-
ministrative leadership is considered to facilitate the
improvement of these activities, then it was displayed
in this study.
SergiovanniZ5described the bottom three levels of
his hierarchy of leadership forces as being necessary
for a competent school, but if excellence is to be
aspired to, the top two levels are also required. For the
bottom three levels the values and beliefs that make up
the school culture are implicit, whereas with the ex-
pression of the top two forces, the cultural values are
made explicit. Two of the participants in the study, in
particular, made the values expressed in the vision for
the health network explicit both verbally and by their
actions; and other participants expressed symbolic
leadership by their actions. No one person was
reported to be dominant in leading the planning
process. One participant talked about the leadership in
the organization. The leadership has been shared, he
said. This is leadership without bosses. There are no
bosses. Its shared leadership. In support, another par-
ticipant said, We dont have one leader. Thats been
our practice alfilong. Not one leader. We move meet-
ings and we move chairs. When asked about the
leadership in the organization, another participant
identified one participant as the most important leader
but three others as having made important contribu-
tions to the leadership and the success of the planning
process.
Conclusion
The planning for the health network was meaningful
for the participants because each became a part of the
process and contributed to the leadership. A key issue
was the participants expressed desire for leadership
rather than control. All participants sought to work
42
Volume 7,No.1
together as equal partners in the creation of a common
understanding that was premised on agreed-upon
values.
References and notes
1. Foster, W. 1986. The Reconstruction of Leadership,
Melbourne, Deakin University Press.
2. Van Fleet, D.D. and Yukl, G.A. 1989. A century of
leadership research. In Rosenbach, T.E. and Taylor,
T.E. (Eds.):Contemporary Issues in Leadership, 2nd
ed., Boulder, Colo., Westview.
3. Wilson, D. 1992.Paradigms and nursing manage-
ment analysis of current organizational structure in
a large hospital. Healthcare Management Forum 5(2):
4-9.
4. Armitage, J.D. and Bain, B. 1992.CEO selection
trends in the 1990s. Leadership in Health Services
May/June: 29-32.
5. Bezold, C. 1992. Five futures. Healthcare Forum
Journal:Leadership Strategies for Healthcare
May/June: 29-42.
6. Bridging the Gap in Healthcare. 1992. Ibid: insert.
7. Johnson, J. 1991. Proactive executives: prospering in
tough times. Hospitals: A Magazine for Health Care
Executives March: 22-27.
8. Moeller, A.D. and Johnson, K. 1992.Shifting the
paradigm for health care leadership. Frontiers of
Health Services Management 8(3):28-30.
9. Vladick, B.C. 1992. Health care leadership in the
public interest. Ibid: 3-26.
10. Wolford, C.R., Moeller, D., and Johnson, K.E. 1991.
Bridging the Leadership Gap in Health Care,
San Francisco, Healthcare Forum.
11.Handy, C. 1989. The language of leadership. In
Rosenbach, W.R. and Taylor, R.L. (Eds.):Contem-
porary Issues in Leadership, 2nd ed., Boulder, Colo.,
Westview.
12. Levey, S. 1989.The leadership muddle [El. Hospital
and Health Services Administration 34(2): 135-137.
13.Kotter, J.P. 1990. What leaders really do. Harvard
Business Review May-June: 103-111.
14. Kosowski, M.M., Grabbe, L., Grams, L., Lobb.,
M.O., Willoughby, D.F., Davis, S.P., and Sines, G.P.
1990. An interactive model of leadership. Nursing
Administration Quarterly 15(1):36-43.
15.Pondy, L. 1978. Leadership as a language game. In
McCall, M.W. and Lombardo, M.M. (Eds.):Leader-
ship: Where Else Can We Go?, Durham, NC, Duke
University Press.
16.Kellerman, B. (Ed.). 1984. Introductory Remarks.
Leadership:Multi-disciplimy Perspectives,
Englewood Cliffs, NJ,Prentice-Hall.
Healtheme Management FORUM
Volume 7, No. 1
17. Greenfield, T.B. 1968. Research on the behaviour of
educational leaders: Critique of a tradition. Alberta
Journal of Educational Research 15(1):55-76.
18. Eblen, A. 1987. Communication, leadership, and or-
ganizational commitment. Central States Speech
Journal 38(3-4): 181-193.
19. Bolman, L.G. and Deal, T.E. 1991.Refvaming
Organizations:Artistry, Choice, and Leadership,
San Francisco, Jossey-Bass.
20. Schein, E.H. 1985. Organization and Cultural Leader-
ship, San Francisco, Jossey-Bass.
21. Burns, J.M. 1978. Leadership, New York, Harper &
Row.
22. Smyth, W.J. 1986. Leadership and Pedagogy, Mel-
bourne, Deakin University Press.
23. Rosenbach, W.E. and Taylor, R.L. 1989. Style, sub-
stance and circumstance.In Rosenbach, W.E. and
Taylor, R.L. (Eds.):Contemporary Issues in Leadership,
2nd ed., Boulder, Colo., Westview.
24. Sergiovanni, T.J. 1992.Moral Leadership: Getting the
Most out of School Leadership, San Francisco,
Jossey-Bass.
25. Sergiovanni,T.J. 1991. The Principalship: A Reflective
Practice Perspective, Boston, Allyn & Bacon.
26. Keenhert, K.W. and Lewis, P. 1989.Transactional
and transformational leadership: a construc-
tive/developmental analysis. In Rosenbach, W.E.
and Taylor, R.L. (Eds.):Contemporary Issues in
Leadership, 2nd ed., Boulder, Colo., Westview.
FORUM Gestion des soins de sant6
SpringPrintemps 1994
27. Kreffing, L.A. and Frost, P.J. 1985. Untangling
webs, surfing waves, and wildcatting: a multiple-
metaphor perspective on managing organizational
culture. In Frost, P.J., Movre, L.F., Louis, M.R.,
Lundberg, C.C., and Martin, J.: Organizational
Culture, Beverley Hills, Sage.
28. Maxcy, S. and Caldus, S.J. April 1988. Moral im-
agination and the philosophy of school leadership.
Paper read before the American Educational Re-
search Association, New Orleans, La.
29. Bennis, W. 1989.Where have all the leaders gone?
In Rosenbach, T.E. and Taylor, R.L. (Eds.): Contem-
porary Issues in Leadership, 2nd ed., Boulder, Colo.,
Westview.
30. Rebore, R.W. 1991. Personnel Administration in
Education: A Management Approach, 3rd. ed.,
Englewood Cliffs, NJ, Prentice-Hall.
31. Hodge, B.J. and Anthony, W.P. 1991. Organizational
Theory: A Strategic Approach, 4th ed., Boston, Allyn
& Bacon.
* Fictitious names for purpose of confidentiality
** Confidential internal vision statement
This article reports the preliminaryfindings from research
conducted for a Doctor of Philosophy in Educational Ad-
ministration, University of Alberta.
Chris Elliott, BE, ME, is a school principalfvom
Australia.
43