Distributed leadership in health care teams: Constellation role distribution and leadership practices.

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JulyYSeptember & 2016

Distributed leadership in health care teams: Constellation role distribution and leadership practices Samia Chreim Kate MacNaughton Background and Purpose: Recent literature has been critical of research that adopts a narrow focus on single leaders and on leadership attributes and has called for attention to leadership that is distributed among individuals and to practices in which leaders engage. We conducted a study of health care teams where we attended to role distribution among leadership constellation members and to loose or tight coupling practices between leaders and the remainder of the team. This focus provides insights into how leadership can be practiced and structured to enhance team functioning. Methodology: A qualitative, multicase study of four teams was conducted. Data collection involved 44 interviews with almost all the members of the teams and 18 team meeting observations. Thematic analysis was conducted by the two authors. Findings: Leadership constellations can give rise to leadership role overlaps and gaps that may create ambiguity within teams, ambiguity is diminished if the leaders can agree on which leader assumes ultimate authority in an area, the presence of more leaders does not necessarily entail more comprehensive fulfillment of team needs, and teams’ needs for tight or loose leadership practices are influenced by contextual factors that we elaborate. Practice Implications: (a) It is important to recognize areas of overlap and gaps in leadership roles and to provide clarity about role boundaries to avoid ambiguity. Role mapping exercises and open discussions should be considered. (b) Attempting to spread formal leadership responsibilities informally among individuals is not always a workable strategy for addressing team needs. (c) Organizations need to examine critically the allocation of resources to leadership activities.

Introduction Leadership can play a crucial role and is an extensively studied topic in a variety of health care contexts. Gilmartin Key words: distributed leadership, interprofessional teams, leadership-as-practice, leadership constellation roles, qualitative research Samia Chreim, PhD, is Professor, Telfer School of Management, University of Ottawa, Ontario, Canada. E-mail: [email protected]. Kate MacNaughton, MSc, is Research Associate, Telfer School of Management, University of Ottawa, Ontario, Canada. This research received approval from the appropriate institutional review boards for human subjects research. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000073 Health Care Manage Rev, 2016, 41(3), 200Y212 Copyright B 2016 Wolters Kluwer Health, Inc. All rights reserved.

and D’Aunno’s (2007) synthesis of leadership in health care literature showed that leadership has a significant relationship with work satisfaction, turnover, and performance. Despite the abundance of leadership studies, recent contributions call for research into newer and important areas of inquiry (Chreim, 2015; Currie & Lockett, 2011; Denis, Langley, & Sergi, 2012). One area is distributed leadership, which involves conjoint action by individualsVpotentially at different hierarchical levelsVsharing leadership roles and practices (Bolden, 2011; Denis et al., 2012; Gronn, 2002; Spillane, Halverson, & Diamond, 2001). Currie and Lockett (2011) state that, despite the importance of distributed leadership in health care, there is insufficient consideration of how it is practiced on the ground. Distributed leadership is highly prevalent and is practiced at different levels in health care including the institutional, organizational, and team levels. For example, Chreim, Williams, Janz, and Dastmalchian (2010) studied an institutional-level integrative project that involved multiple health care organizations

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Leadership Practices and Role Distribution

and found that representatives from these organizations formed the project leadership team and that together they were able to mobilize authority, knowledge, and resources to implement the integration. Denis, Langley, and Rouleau (2010) studied three health care organizations undergoing change and found that leadership depended ‘‘critically on a constellation of co-leaders’’ who played complementary roles (p. 73). At the team level, Leach, Myrtle, Weaver, and Dasu (2009), who studied surgical teams, pointed out that ‘‘leadership shifts to a person with the needed expertise or ability to address the priority or problem of the moment’’ (p. 39), whether it be a surgeon, a nurse, or another practitioner. These examples illustrate that leadership may be distributed across two or more individuals and that this occurs in various contexts and at different levels in health care. Researchers indicate that distributed leadership offers several advantages such as pooling of knowledge and resources (Chreim et al., 2010), getting different views before making decisions (Gronn, 2002), and sharing the burden of management (Denis, Lamothe, & Langley, 2001). However, distributed leadership is, paradoxically, potentially problematic for the same reasons that it is beneficial. Sharing of leadership activities can create ambiguity about the roles of members of the constellation and between the constellation and the members that the constellation is expected to lead. Furthermore, not all constellations are successful, and authors have called for research that looks at the ineffective aspects of plural leadership (Chreim, 2015; Denis et al., 2012). This would provide opportunities to learn how to better structure leadership roles. Along with this recommendation, recent developments in leadership literature include a focus on practices of leaders (Crevani, Lindgren, & Packendorff, 2010; Denis et al., 2010; Spillane et al., 2001). This emphasis encourages researchers to go beyond a study of leadership traits and formally defined roles that may not give expression to what leaders actually do. The thrust of the leadership-as-practice literature has been to examine the activities, tasks, actions, and interactions of multiple leaders as they practice their roles (Chreim, 2015; Crevani et al., 2010; Denis et al., 2010; Spillane et al., 2001). Practice-based studies emphasize interpretations and interactions of organizational participants and highlight the social constructionist basis and emergent nature of leadership (Bolden, Petrov, & Gosling, 2008; Carroll, Levy, & Richmond, 2008; Crevani et al., 2010; Raelin, 2011). The notion of distributed leadership finds resonance with practice-based studies (Denis et al., 2010). Given the importance and prevalence of distributed leadership in health care settings (Chreim et al., 2010; Currie & Lockett, 2011; Denis et al., 2001, 2010) and the dearth of studies that delve into the social dynamics of role distribution and practices within leadership constellations in health care, we focus on this area of research. We rely on distributed leadership and leadership-as-practice literature and adopt an interpretive perspective that places emphasis on how

interactants view and experience leadership. The objectives we pursue are to explore (a) how role boundaries within leadership constellations are interpreted and practiced by members of the constellations and (b) how leadership practices interact with team dynamics. Attention to these elements provides insights into how leadership can be practiced and structured to enhance team functioning. To achieve the objectives, we conducted a qualitative multicase study of four teams operating in the area of community mental health.

Conceptual Overview Recent Trends in Leadership Research A large section of the literature on leadership has examined leadership behaviors and styles (such as transformational and transactional leadership) that may facilitate or inhibit team functioning (Burke et al., 2006). Individual leaders in ‘‘heroic’’ models have been proposed as keys to leadership success (Fulop, 2012). Presently, there is a shift in focus from units of single leadership to networks or teams of leaders (Denis et al., 2012; Fulop, 2012). For example, a health care team might have one or more administrative and clinical leaders who coordinate their work to support team functioning. Researchers have used such terms as ‘‘distributed,’’ ‘‘collaborative,’’ ‘‘collective,’’ ‘‘plural,’’ and ‘‘shared’’ leadership to refer to the presence of multiple leaders. A common element in these terms is ‘‘the idea that leadership is not a monopoly or responsibility of just one person’’ and the view that there is a ‘‘need for a more collective and systemic understanding of leadership as a social processI’’ (Bolden, 2011, p. 252). A review of the literature identifies different approaches in conceptualizing plural leadership and how it is manifested on teams (Denis et al., 2012). Some approaches focus on leadership that is concentrated at the top, and others consider how leadership emanates from different team members. The latter attends to both formal and informal leaders. Formal leaders have designated roles, whereas informal leaders tend to emerge from within the team. In other words, the distribution of clinical and administrative responsibilities across individuals in the leadership constellation may not stem entirely from a formal description of the division of labor but come about with the influence of circumstances such as team requirements. Another distinction (in addition to that made between formal and informal leadership responsibilities) addressed in the literature is between management and leadership. For example, Kotter (1995) states that management relates to keeping the current system operating, whereas leadership involves creating change. This is a limited view of leadership, which ties it to change. Other authors such as Yukl (1989) and Chreim (2015) have found the distinction between ‘‘leadership’’ and ‘‘management’’ unproductive and


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have instead used the two terms interchangeably. Alvesson and Sveningsson (2003) indicate that the definition of leadership should be based not only on theory but also on what members of organizations designate as leadership. In this article, we adopt the views expressed by Yukl, Chreim, and Alvesson and Sveningsson. Concurrent with the increased focus on the distribution of leadership roles (as interpreted by organizational participants), competency-based views have come under consideration. Distinctions have been made between competency and practice perspectives of leadership. Carroll et al. (2008) state that the competency perspective attends to measurable, technical elements of leadership and that ‘‘competency thinking, due to the difficulty of transposing context, tends to represent individual actors as acting and performing in isolation to others and context’’ (p. 365). These and other authors (Chreim, 2015; Crevani et al., 2010; Raelin, 2011) emphasize the importance of adopting a practice perspective that attends to the collective, relational, contextually situated, and socially constructed elements of leadership. We believe that the competency perspective tells only part of the story of leadership and that it needs to be complemented with attention to leadership practices. In this study, we move away from measuring competencies in favor of examining who is viewed as a leader by participants, how leadership roles are enacted, and how interpretations of leadership practices are influenced by the context.

Leadership Constellations Distributed leadership arrangements found on teams can be referred to by captions such as configurations (Chreim, 2015; Gronn, 2009) or constellations (Denis et al., 2001; Hodgson, Levinson, & Zaleznik, 1965). Gronn (2009) defines a leadership configuration as ‘‘a pattern or an arrangement of practice’’ (p. 383). Denis et al. (2001) use the term leadership role constellation to refer to a collective leadership group and state that ‘‘(t)his notion implies not only multiple actors, but also a certain division of roles among them’’ (p. 811). We use the term leadership constellation to include a limited number of people who jointly exert leadership roles, who may occupy different hierarchical levels (Denis et al., 2012; Gronn, 2002), and who are designated as leaders by the team members in our study (Alvesson & Sveningsson, 2003). This is consistent with our social constructionist approach that favors the interpretations of research participants. Role distribution and demarcation within leadership constellations. Ideally, in a leadership constellation, roles would be distributed in such a way as to allow adequate coverage of the activity domains of a team (Denis et al., 2001). Covering activity domains involves ensuring that a variety of leadership functions (Morgeson, DeRue, & Karam, 2010) are fulfilled to meet team needs. Morgeson et al. (2010) reviewed the literature on shared leadership and concluded


that different sources of team leadership are best suited to performing different functions. For example, structuring and planning team tasks might fall to leaders who participate in the daily activities of the team, whereas providing resources might be the domain of leaders who fall outside the team’s daily activities (Morgeson et al., 2010). Complementarity in the skills and practices of different leaders is desirable (Denis et al., 2001) so that all pertinent activity domains are covered and team needs are met, but we know that leaders engage in practices that overlap (Gronn, 2002) or enact roles that leave some team needs unmet (Chreim, 2015). We are interested in the role boundaries within the constellation. Thus, our first research question is ‘‘How are role boundaries and demarcations within the constellation interpreted and practiced?’’ Leadership constellationYteam interactions. Another important element in understanding leadership in teams concerns the way in which the leadership constellation interacts with the team. There has been research on the relationships of leaders with their environment through the use of the concept of ‘‘coupling,’’ which denotes the support for the goals and initiatives of groups inside and outside an organization (Denis et al., 2001). Denis et al. (2001) presented three categories of coupling: between members of the leadership team, between team leaders and team members, and between team leaders and the organization’s external environment. We examine phenomena at the first two levels and shed light on the division of responsibilities between the leaders (as per our first research question above) as well as the interaction between the leadership group and the team as indicated below. Interactions between the team and the leadership constellation (the second aspect of coupling) are varied and complex. There is evidence that, although shared leadership is associated with reduced conflict, increased trust, consensus, and cohesion in groups (Bergman, Rentsch, Small, Davenport, & Bergman, 2012), a lack of clarity about leadership roles could lead team members to feel uncertain and be less engaged in teamwork and decision making (West et al., 2003). Nevertheless, it is unlikely that every team needs to interact with the leadership constellation to the same extent. For example, self-managing teams (Druskat & Wheeler, 2003; Johnson, Hollenbeck, DeRue, Barnes, & Jundt, 2013) may require less, or looser, leadership. On the other hand, some teams may need tighter leadership around establishing clear goals and work structuring (Morgeson et al., 2010), both of which may be important considerations in interprofessional teams where practitioners are interdependent and bring different work approaches to bear on client care. These contrasts raise the question of how leadership practices interact with team needs. In the context of the teams we studied, this question can be more precisely stated as ‘‘How do tight/loose leadership practices interact with (a) different forms of service provision by the members of the interprofessional team and (b)


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divergence in team members’ points of view regarding client care?’’

Methodology Our research followed a qualitative, multicase study approach. This article is part of a larger study on mental health care teams that use interprofessional collaborative approaches. The overall research program attended to a number of different themes. Understanding leadership on the teams was one of the objectives of the larger study, which did not specify narrowly the aspects of leadership that would be pertinent. Rather, the research questions we pursued in this article were defined after the initial data collection revealed the importance of role boundaries and tight/loose practices to an understanding of leadership dynamics on the teams. Our comparative approach allowed us to map how leadership and its impact were manifested in sites subject to different contextual factors, and our qualitative approach allowed us to delve in depth into the practices and social dynamics of leadership on the teams (Eisenhardt & Graebner, 2007; Yin, 2009).

The Cases The four cases we studied were interprofessional mental health teams that operated in community settings in Ontario, Canada. They represented a variety of health services and leadership arrangements. Table 1 provides summary information on the teams. All four sites employed a variety of occupational groups. All teams had been in operation for over 6 years at the time of the study, and all had a leadership constellation that consisted of a clinical director and a program manager, at the least. Two teams, Assertive Community Treatment Team 2 (ACT-2) and Mental Health Consultation Team (MHCT), had experienced recent changes in the top tier leadership, whereby the senior leaders had taken on their formal positions about a year before the time of the study. These two teams also had an additional layer of leadership below the senior level given that the senior constellation had a span of control consisting of six teams. Shared Care provided short-term primary care services, and team members were dispersed across various locations. Thus, it was not possible for the leadership constellation to be co-located with the team at all times. The long-standing leadership constellation that had been in place since team inception consisted of a clinical director and a program manager, both of whom spent less than 50% of their time on leadership activities related to the team. The professionals on the team operated in a semiautonomous way: Different professionals typically provided services to the client if and as needed. Their assessment and services were entered sequentially in the client record. Team members who shared clients met or conferred with each other when client issues requiring joint treatment efforts arose.

ACT-1 was co-located with its long-standing leadership constellation consisting of a clinical director and a program manager who spent most of their time with the team. ACT-1 and ACT-2 (described below) were both Assertive Community Treatment teams that provided services to clients with serious and persistent mental illness such as schizophrenia. Services by different professionals on these teams had to be highly integrated. Despite there being ACT Standards for teams, it is not uncommon for different ACT teams in the province to take different forms in terms of leadership practices and structures. Both ACT-2 and MHCT were affiliated with a mental health organization and were part of the Outpatient Program. They operated independently of each other but reported to the same top leadership constellation. Two individuals had assumed top leadership of the Outpatient Program about 1 year before the start of this study: a program clinical director and a program manager. Of importance is that these two individuals provided leadership to all six teams that were part of the Outpatient Program (only two of which we studied) and therefore had a much more extensive span of control than the leaders of Shared Care and ACT-1. The two leaders were not co-located with the teams. ACT-2 had an additional layer of leadership below the senior levelVa team lead whose formal role involved administrative matters. MHCT had a team psychiatrist who had been associated with the team since inception and who was referred to as ‘‘medical head’’ by most of the team members, although the formal senior leaders indicated that the title of ‘‘medical head’’ was a self-appointed title that was not formally recognized at the organization. The team psychiatrist provided formal leadership at the clinical client level of MHCT and met with the program clinical director on a weekly basis. MHCT’s mandate was to provide assessment of clients and not treatment services, and in principle, once an assessment was jointly agreed upon by team members who worked closely with each other, the client file was passed on to other organizations that would provide treatment. Figure 1 depicts the four teams’ leadership constellations.

Data Collection and Analysis Data collection involved three approaches: interviews, team meeting observations, and document review. Table 2 shows the number of interviews and meeting observations. All members of the four teams (including the leaders) were invited to participate in interviews, and allVexcept one member in ACT-2Vparticipated, giving us 98% of our teams’ population. Interviews were semistructured and open ended to ensure that similar topics were addressed with all participants, but additional important topics brought up by interviewees were pursued (Patton, 2002). Interview topics included team history/mandate, nature of interprofessional collaboration, leadership roles and practices, relationships among the leaders, interactions between the


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Table 1

Descriptive characteristics of the four cases Number of team membersa

Team

Mandate

Shared Care

To provide mental health services at the primary level

ACT-1

To provide comprehensive, community-based treatment and support to individuals with serious and persistent mental illness To provide comprehensive, community-based treatment and support to individuals with serious and persistent mental illness

ACT-2

MHCT

To provide mental health assessment of clients; to provide consultation and education to other providers and the community

8

12

16

9

Leadership structure Clinical director and program manager -Both part time with the team -Neither is co-located with the team, which is dispersed across different locations Clinical director and program manager -Both full time with the team -Both co-located with the team

1. Program clinical director and program manager at the highest hierarchical level -Both part time with the team -Neither is co-located with the team 2. Team lead at the next hierarchical level -Full time with the team -Co-located with the team 1. Program clinical director and program manager at the highest hierarchical level -Both part time with the team -Neither is co-located with the team 2. Team psychiatrist at the next hierarchical level -Half time with the team -Half time co-located with the team

ACT-1 = Assertive Community Treatment Team 1; ACT-2 = Assertive Community Treatment Team 2; MHCT = Mental Health Consultation Team. a

Number includes team leaders.

leadership constellation and the other team members, and team strengths and weaknesses, among others. The first author conducted all the interviews, which were digitally recorded and transcribed verbatim. The first author also attended meetings spanning a period of 4 months for each of the teams, for a total of 18 meetings. These meetings involved discussions of client cases and/or of administrative matters; they allowed the observation of leadership practices. Notes were taken during meetings. Documents describing the teams’ mandate and operations were also reviewed for descriptive information. Data analysis involved several steps. Initial coding using Atlas.ti captured members’ accounts pertaining to different aspects of leadership and its context. Observation notes were read and analyzed by the two authors who identified leadershiprelated themes. These observations offered information on leadership practices and interactions and corroborated the themes identified in the interviews. Another step in the analysis consisted of mapping the leadership constellation on each of the four teams. Consistent with recommendations by Alvesson and Sveningsson (2003) and with our interpretive approach, we mapped the leadership structures based on participant accounts (Figure 1).

After this step, each of the co-authors worked separately in undertaking a fine-grained analysis of the data based on the two themes we were pursuing (role distribution and practices within the constellation and tight/loose leadership practices). We iterated between data and literature in our analysis (Miles, Huberman, & SaldaDa, 2014). Through our analyses and discussions, we identified a set of subthemes that included such notions as interpretations of role boundaries, leadership gaps, leadership overlaps, tight and loose leadership practices, and team needs for leadership. The co-authors worked together to elaborate the findings by creating tables, contrasting notes, and returning to the data as suggested by Hennink, Hutter, and Bailey (2011) when there were disagreements about the leadership dynamics.

Transparency We attended to the transparency and quality of this study throughout the research process. We obtained ethical approval from the applicable ethics boards and used consent forms for the observations and interviews. We removed identifying information to protect the anonymity of the participants and restricted access to the raw data


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Figure 1

Structure of leadership constellations

to the investigators to ensure confidentiality. We triangulated our data sources and iterated between the interview material and meeting notes as a means of improving the credibility of our findings (Miles et al., 2014). These cyclical patterns of data interpretation contributed to the rigor of our analysis. Furthermore, we sent the final report to research participants and solicited member checks (Creswell, 2013; Lincoln & Guba, 1985). On the basis of the feedback we received, we refined our analysis to more clearly reflect member views. Overall, we have endeavored to make our study design and data analysis procedures explicit to increase the transparency of this qualitative research (Hiles, 2008).

constellations were very similarly organized: Both had a clinical director and a program manager who liaised with each other and with the rest of the team. The ACT-2 and MHCT constellations were more complex because both had a program clinical director and a program manager who supervised several additional teams. ACT-2 also had an onsite team lead who had frequent contact with team members and with the program manager. In contrast, MHCT had an on-site team psychiatrist who provided regular supervision at the clinical client level and met regularly with the program clinical director. In what follows, we focus on how the role boundaries were interpreted by the members of the

Findings

Table 2

We present our findings in relation to the two research questions we pursued: leadership role distribution, boundaries, and practices within the constellation and tight/loose leadership practices in relation to the team.

Leadership Role Distribution and Practices In our analysis, we mapped the layout of the four leadership constellations (Figure 1). The Shared Care and ACT-1

Interviews and meeting observations Team

Interviews

Meeting observations

Shared Care ACT-1 ACT-2 MHCT Total

8 12 15 9 44

4 5 4 5 18


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leadership constellation, and in one case (MHCT), we drill down to the level of the other team members because they addressed a perceived ambiguity in the role boundaries of members of the constellation that the leaders themselves did not mention. On Shared Care, the roles were differentiated and complementary, and there were consistent interpretations of role boundaries. Both the clinical director and the program manager in separate interviews stated that the team administrative issues such as budgeting and scheduling vacations were the program manager’s responsibilities, whereas the clinical director took responsibility for clinical matters. In ACT-1, there were some overlapping responsibilities between the leaders, but there were clear understandings with regard to role boundaries; the leaders had similar interpretations of where the roles overlapped. I do some clinical supervision but I have this counter relationship with the [clinical director] who does more clinical supervisionI. When it comes to administrative pieces, so if there’s conflict between members on the team,IVthat she sees as my domain. However, I might use her as a consultantI. I tend to manage the scheduling, the budgetIstrategic planning. (Program manager, ACT-1) Administrative leadership is provided by [the program manager], but she consults me on stuff.... She’s the administrative leader and I’m the clinical leaderI. She provides clinical leadership too, but I take the lead on that, and so it’s kind of like a partnership. (Clinical director, ACT-1) The quotes show that the leaders of Shared Care and ACT-1 had consistent interpretations of where their roles intersected and diverged. The interactions we observed during team meetings substantiated this finding. On both teams, the program manager provided information about administrative issues such as budgets. In contrast, during client case reviews, the ACT-1 clinical director frequently moderated the discussion. Shared Care did not hold meetings to discuss patients; however, the clinical director played a dominant leadership role when the team raised challenges around managing patient referrals. The leaders on these two teams were in agreement about role distribution within the leadership constellation, implying clarity with respect to role boundaries. Where there was some overlap in roles and practices (ACT-1), the tendency was for one of the leaders to defer to the other as the ultimate leader in that particular domain. Similarly, on ACT-2 and MHCT, there were consistent interpretations of role boundaries between the program clinical director and the program manager, and here, there was no overlap between the two roles. As mentioned, both ACT-2 and MHCT were part of the same organization, and although they operated independently of each other, both reported to the same two senior leaders who headed the Outpatient Program.


The purview of the clinical director is the oversight of the clinical activities of all [Outpatient] teamsI. And then I have a counterpartV[the program manager]V with a different purview that’s more administrative and operational. (Program clinical director, ACT-2 and MHCT) As well as the differentiated roles of the clinical director and program manager, these two teams had an additional layer of leadership. The interaction between the two hierarchical levels of leadership was complex, and divergent views about the role boundaries at the lower hierarchical level were present on both teams. On ACT-2, the senior leaders’ views diverged from the team lead’s view in terms of what fell under the latter’s role. There’s no management authority [for the team lead position] but you can still be a leader and provide direction without having management authority on a team. (Program manager, ACT-2) One of the things that might need to happen [with the team lead role] is to definitely keep a focus on team dynamics but also keep a focus on the team activities, what’s being done by whomI. Leadership envisioning what are our operations looking like, and working closely with the program manager on that. (Program clinical director, ACT-2) [The team lead position] is still part of the union. It involves daily management in terms of assigning tasks, ensuring follow through on tasks and a conduit of information between the team and the program managerI. I don’t haveIauthority [to deal with somebody not showing up at work] but then I’m reporting on my colleagues to [the program manager]I. At times I wish I would have some kind of authority to say, ‘‘Well this is not okay,’’ and be more direct with people, but basically I don’t have any sort of ability to sanctionI. I think at times it’s stressful. (Team lead, ACT-2) These quotes indicate that the senior leaders expected the team lead to practice more authority in terms of operational matters, but the team lead viewed his level of authority as limiting his ability to go beyond reporting on his colleagues. He described the situation as stressful. Note that, in interviews, team members differentiated between the inadequacies of the role distribution and the competencies of the team lead: [The team lead] does a really good job of leading the team given the capacity that he’s able to. I just think that there are some things he’s not able to do given the job title. (Mental health counselor, ACT-2) In the case of MHCT, the program manager acknowledged that he provided ‘‘limited’’ leadership on the team because of an extensive workload, and the team psychiatrist


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elaborated on the difficulties of negotiating between remaining within her primary clinical leadership role and compensating for a lack of direct administrative oversight on the team. The psychiatrist provides a lot of leadershipI. At this point I have had a limited role on that team due to the demands of a new program with several teams and locations. (Program manager, MHCT) Is that my role as a physician clinical person to say ‘‘You [team member] are not really following the guidelines that we have,’’ or should I be getting the manager of the program in to deal with this on another level?I It’s hard for me to figure out where to go to the next step. (Team psychiatrist, MHCT) During team observations, we noticed that the psychiatrist, who was described by team members as a highly competent clinician, occasionally stepped into a managerial role in the absence of other managers. There was a vacant administrative leadership space on MHCT, and as the psychiatrist stated, she had to occasionally step into this space by necessity and not because these practices were appealing to her. She and a few other participants questioned whether she, whose major responsibility was clinical at the client level, should have been taking on administrative leadership tasks. The administrative leadership space was ambiguous and gave rise to divergent interpretations of role distribution. In addition, on MHCT, some members saw an overlap between the leadership roles of the program clinical director and the team psychiatrist. Although these two leaders did not speak about an overlap in their domains, team members indicated a perceived blurring of the boundaries between the two roles. If there’s an issue with a client, a difficult interaction with a family member, do we report it to [the team psychiatrist]? Do we go to [the program clinical director]?I It’s not always clear who to report it to. (Nurse, MHCT) The referral question was so interesting I thought [the program clinical director] needs to hear about this because it’s an unusual kind of referral. So I took that referral to her so that she would be aware of it and we worked out what to do about thisI. [The team psychiatrist felt] ‘‘as medical head, I needed to know.’’ (Social worker, MHCT) Although there was a clear understanding of the role distribution (distinction and/or overlap) between administrative and clinical leadership at the highest level for all four teams, ambiguity was present in the role boundaries at the next level, between leaders who shared responsibility for administrative areas as well as between leaders with major clinical responsibilities. The ambiguity occurred in ACT-2 and MHCT where the leadership constellation included individuals at different hierarchical levels. In both cases, the ambiguous leadership space occurred at the level

below the clinical director and program manager. On MHCT, there was perceived overlap in clinical responsibility. On this team as well, there appeared to be a void in the area of administrative leadership and divergent views about who should practice this oversight. Similarly, on ACT-2, there was undersupplied administrative leadership and different views about how this situation should be addressed. In the case of MHCT, the team psychiatrist stepped in to fill the administrative leadership vacancy despite her view that this was not part of her role. In the case of ACT-2, the team lead expressed the stress that accompanied the role of leading a team without the commensurate authority to practice the expected leadership role.

Tight and Loose Leadership Practices In this section, we show the findings in relation to our second research question, which aimed at understanding how different forms of practiced leadership (loose and tight) interacted with team dynamics (such as degree of service integration and agreement of members on team goals or service model). We categorized the leadershipYteam interactions for these four cases as tight or loose depending on the extent of oversight provided, which corresponds toVor is closely associated withVtime spent with and physical presence on the site of the team. This is distinct from the competence of the leaders, because highly competent leaders may have limited time to devoteVor may choose to devote little timeVto leadership activities. The terms ‘‘tight’’ and ‘‘loose’’ leadership should not be construed as evaluative of leadership capabilities because they do not refer to effective or ineffective leadership as we show below. The leadership exercised on Shared Care, ACT-2, and MHCT by the senior leaders was loose, whereas on ACT-1, it was tight. Loose leadership is characterized by less oversight and intermittent or no co-location of the leaders with the team, which was the case in Shared Care. Tight leadership entails accessibility and direct contact with the leaders as well as leader involvement in the daily activities and decisions by the team, which was the case in ACT-1 where the leaders attended team meetings every morning. Although Shared Care and ACT-1 exercised leadership differentlyV the first exemplified loose leadership, and the second exemplified tight leadershipVmembers of both teams spoke of their satisfaction with the leadership provided: [The clinical director]Iis an excellent leaderI. And [the program manager] similarly, is in an administrative leadership role, she again is very approachable and knowledgeableI. (Physician, Shared Care) We have a psychiatrist who is a clinical leaderIand she would meet with us and talk to us if she thought that somebody’s judgement was off a little bitI. And then the administrative stuff, that would be [the


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program manager]II think it’s excellentI. There’s a couple of leadersIbut I never feel like it’s too much. (Peer specialist, ACT-1)

and keeps a very positive attitude. The only sort of problem I have is availability. I think he’s stretched too thin. (Team lead, ACT-2)

Highly competent leaders may enact loose or tight leadership, and the findings show that loose and tight leadership may both be feasible models of interaction between leadership and their team. Importantly, the appropriate form of leadership is dependent on the context. On the basis of our findings, two aspects of the context appeared relevant here. The first was the extent to which the work of different practitioners on the team needed to be integrated. On ACT-1, there was a need for tight integration of services provided by different practitioners to minimize disruption for clients with serious mental illness. In our observations of ACT-1 team meetings, we noticed that discussions about client care could be extensive and could involve a variety of treatment approaches. Any decision about client care had to be endorsed and understood by all team members. Team leaders played an important role in integrating the views and in ensuring that members understood the role they needed to take in client care. In contrast, on Shared Care, there was less need for tight leadership; team members functioned semiautonomously, working sequentially at times with clients who were not severely ill. Team members involved in the care of a client met or conferred about the client if the coordination of treatment was required. The second aspect of the context was the extent to which the members of the team (including those in leadership positions) agreed on the work distribution on the team and on the goals or service model of the team. To the extent that members were in agreement on these elements, there was less need for tight leadership. This was the case in Shared Care where the leaders indicated that the other team members were in agreement about the work to be done and, as the program manager stated, did ‘‘their job extremely well’’ and thus required less oversight. A nurse on Shared Care explained further that ‘‘Everybody [on the team] comes with at least 20 years of experienceI. We’ve all been in management [and] don’t need a lot of management.’’ ACT-2 and MHCT both had loose models of senior leadershipYteam interaction given that senior leaders had six teams under their purview. As indicated, loose leadership is a practice that may be enacted independently of the competencies of the leaders. The quotations below describe the competencies and the work charge of the senior leaders on these two teams.

One of the problems is the [leaders’] job is enormous, like there’s six outpatient teamsI. These people are spread so thin that we don’t see them often enough. (Mental health counselor, MHCT)

The program clinical director is excellentI. She has a very good knowledge and background in the outpatient programI. She’s very well consideredIis very approachableIbut she doesn’t have the time to come and actually see how we’re working clinically. (Mental health counselor, ACT-2) I think the program managerIlikes to work in a collaborative way with people, he’s fair,Ilistens well

On ACT-2, some participants stated that the team could move closer toward a rehabilitation focus and that stronger input from the program clinical director in this regard would be beneficial. It was also mentioned that not all members of ACT-2 were pulling their weight in terms of the work that needed to be done and the need for more administrative leadership was expressed. The team lead stated that he believed ‘‘some people would behave differently if there was a manager on-site,’’ and this was echoed by other participants. The need for more administrative leadership was also expressed by members of MHCT because of divergent interpretations of the team’s service model. An earlier quote by the team psychiatrist indicated that she had to ask members to close files and to move on to other clients. MHCT’s service model involved providing diagnosis and not treatment services. Yet, some members had difficulty closing files and transferring clients to other clinics for fear that the clients ‘‘might fall through the cracks,’’ as specified by some members. Thus, members of the team engaged in divergent practices. The team psychiatrist stated ‘‘the team is suffering from not having an opportunity to talk about their concerns on a regular basis.’’ In brief, ACT-2 and MHCT members expressed dissatisfaction with loose leadership practices and pointed to the large charge of competent senior leaders as a reason for loose leadership. It is important to note that, at the end of the study period, a new manager was hired to provide frontline administrative leadership to ACT-2 and MHCT, and this was expected to close some of the gaps that were expressed by the members.

Discussion In this section, we position our findings in relation to extant literature and consider the limitations and research implications of our study.

Distributing Leadership Roles In our study, the interpretations of role demarcations within the leadership constellations ranged from consistent to divergent. Role boundaries were interpreted in a consistent way on Shared Care and ACT-1 but showed signs of divergence on ACT-2 and MHCT. On the latter two teams, divergence occurred in areas where leadership functions were only partially fulfilled and where leadership roles were perceived to overlap. The dynamics on the four teams we studied parallel the findings from Chreim’s (2015)


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research on leadership in teams. She described ‘‘leadership spaces’’ as potentially ambiguous and ‘‘undetermined spaces’’ that are structured through the practices of the leadership constellation members and the roles they adopt. According to this author, the leadership space can be structured through overlapping, complementary, or insufficient leadership practices by the different members of the constellation as they interact, and some arrangements work better than others in reducing ambiguity and meeting team needs. Studying various constellations allowed us to conclude that overlapping responsibilities can offer some benefits and that this situation does not inevitably create ambiguity. This echoes research on role boundaries on interprofessional teams, which showed that overlapping responsibilities can provide such benefits as easing the burden of members’ workloads (MacNaughton, Chreim, & Bourgeault, 2013). We found that, although overlap may entail challenges, it can also be beneficial, as in ACT-1 where one leader overlapped with another but remained in a supportive role to the primary role holder. This finding adds nuance to the notion of complementarity between leaders (Hodgson et al., 1965; Wholey et al., 2014) by showing that overlap in roles can be beneficial where there is a clearly understood chain of responsibility for dealing with issues. In addition, Gronn (2002) points to two advantages of overlap: First, it provides mutual reinforcement for leadership functions that need to be accomplished, and second, those whose roles overlap can cross-check each other’s work, implying better quality decisions. These benefits occur when there are consistent interpretations of role boundaries and overlap within the constellation. We would like to emphasize that overlaps and gaps in leadership are not necessarily indications of lack of competence on the part of the leaders. These situations may arise as leaders mutually adjust to each other. We believe that divergent interpretations are likely to be found in leadership constellations of limited tenure where leaders may be in the process of defining role boundaries and of building trust. Gronn (2002) indicates that concerted action and ‘‘intuitive understandings are known to emerge over time when two or more organization members rely on each other and develop a close working relationship’’ (p. 430) and that this mutual influence is highly dependent on trust. Similarly, Chreim et al. (2010) found that trust plays a major role in the exercise of distributed leadership. Furthermore, contrasting the findings from the four cases provides additional insights into the complexities of practicing distributed leadership. Distribution of leadership roles appears to be more complex with a higher number of leaders and with more hierarchical levels. For example, with more leaders, communication must become multidimensional (e.g. three-way instead of two-way) to create a shared understanding of role distributions. With more hierarchical levels of leadership, tasks that would otherwise have been

the sole purview of one leader (e.g., more immediate responsibilities and higher level decision making) may need to be split into multiple components. Recently, researchers have illustrated that single leaders are unlikely to be able to assume all leadership roles on a team and have proposed that the presence of more leaders may enable more leadership functions to be filled (Bergman et al., 2012). Yet, our study shows that having more leaders does not necessarily result in more comprehensive leadership practices for a team.

Leadership Practices We discerned the various enactments and interpretations of role boundaries, discussed in preceding paragraphs, through a focus on leadership practices and interactions. It is advantageous to employ a practice-based approach because it allows researchers to capture informal dynamics at work within leadership constellations and enhances understanding of how these dynamics diverge from stipulated structures (Gronn, 2002). In ACT-2 and MHCT, formal role definitions indicated that the program manager would fulfill the administrative leadership role. However, the big charge of this leader did not allow him to engage in practices commensurate with team needs. In the case of MHCT, the team psychiatrist, whose formal role did not include exercising administrative leadership, stepped into this leadership space and engaged in administrative practices. The focus on practices yields a more dynamic and comprehensive view of what leaders actually do (Crevani et al., 2010; Spillane et al., 2001) and how they interpret their own and their colleagues’ roles. Furthermore, the practice perspective goes beyond inventorying leaders’ competencies and shows the importance of attending to leadership enactment on the ground. In keeping with the leadership-as-practice perspective, we note that a leadership constellation is partly shaped by interactions. It is not an isolated individual forging a path but a network of reciprocal relationships that shapes the leadership constellation via the combined agency of various actors (Chreim, 2015). Practice-based articles discuss the constant development of leadership constellations (Crevani et al., 2010; Denis et al., 2010). In keeping with the focus on evolution of leadership on a team, it is important to note here that the senior leadership constellation in ACT-2 and MHCT had been in place for a short period when we collected our data and that it is possible that the divergent interpretations and ambiguity surrounding leadership roles were issues that would be resolved with time. Although we did not follow these teams longitudinally and cannot report on the teams’ progress (i.e., exacerbation or resolution of team leadership challenges), there is research showing that young teams often tend to overcome early challenges in working together. In fact, Kreindler, Dowd, Dana Star, and Gottschalk’s (2012) review of studies on interprofessional health care teams likened seemingly tenacious problems to growing pains that are likely to be resolved further along in


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the team’s evolution. We believe the same might apply to individuals coming together as part of a leadership constellation and that, as mentioned earlier, trust in interactions is an important element in helping resolve role boundary issues.

Tight and Loose Leadership We categorized the leadership constellations as either loosely (Shared Care, ACT-2, MHCT) or tightly (ACT-1) coupled with their team. Loose leadership on Shared Care and tight leadership on ACT-1 worked well for the respective team members. In contrast, loose leadership on ACT-2 and MHCT felt insufficient for many interviewees. Thus, different teams may have different requirements for coupling practices with their leaders. In comparing these findings in a contextualized manner, we can make observations about the degree of teamY leadership coupling practices. Research has shown that the context is a particularly important element in understanding the practice of leadership (Bolden et al., 2008; Gronn, 2002). Our results show that two contextual elements influence the ideal level of coupling between a team and its leadership constellation. The first is the degree of service integration. It is possible that teams with more integrated services require more oversight to function well. Another contextual element is whether the team members have agreement on goals/service model and on task distribution among members. Lack of agreement appears to require tighter leadership practices. Co-location of leadership with the team is an important consideration when the team needs tighter leadership because leaders may be more accessible and better positioned to fulfill certain functions (Morgeson et al., 2010). Our findings indicate that teams operating within the same sector (outpatient mental health care), but with different service models or team dynamics, may have different needs for teamYleadership coupling. More resources may need to be devoted to tightening the teamYleadership coupling on teams that provide integrated services and/or experience disagreements, whereas other teams may function well without the additional oversight. There may also be other factors that influence the need for teamYleadership coupling such as the nature of work (complex and highly variable vs. routine and unchanging) and the organizational and/or team culture that could be explored in future research.

Limitations, Contributions, and Transferability A limitation of our study is its cross-sectional nature, which did not allow us to observe the evolution of leadership on the teams we studied. We noted earlier that the senior members of the leadership constellation in ACT-2 and MHCT had taken their positions shortly before our study started. Thus, we were able to speak about the dynamics present in early stages of those constellations. A longitudinal study would have revealed how these dynamics would have evolved and whether ini-


tial divergent interpretations would have converged through interaction or would have become more entrenched. On the other hand, our study offers the benefit of comparing role distribution on newer and older leadership constellations. It also contributes to the literature on leadership in health care in several ways. It directs attention to the importance of studying role distribution and boundaries between leaders. Much of the literature is focused on single individuals, or on attributes and skills, and overlooks the interpretations of and the interactions among leaders. The article also argues that a focus on practices provides insight into how leadership is enacted and how leadership practices interact with team context in such a way as to meet team needs or leave these needs unmet. In addition, we provided evidence of leadership spaces characterized by overlaps and by gaps, after new developments in the literature. Thus, our study opens new lines of inquiry. An important consideration is whether the findings and implications from our study apply in contexts beyond our four teams. Although it is not possible for us to generalize at large on the basis of findings from case studies, we can speak about the transferability of our findings to other situations (Creswell, 2013; Holloway & Wheeler, 2010; Miles et al., 2014). Distributed leadership is a common phenomenon in health care settings at the macro level (e.g., health care consortia), organizational level (e.g., long-term care facilities, hospitals, primary health organizations), and more micro level (e.g., departments, teams). The research findings and implications are likely applicable in a variety of these contexts. For example, members of any leadership constellation may have complementary and/or overlapping responsibilities. The findings from our study about how leaders interpret role boundaries and how they practice their roles are informative of the dynamics that can be found in other leadership constellations. Similarly, our findings regarding the need for tight or loose leadership practices are likely to apply in a variety of situations. For example, professionals on palliative care teams often need to share knowledge and integrate client assessments and may thus require more coordination and tighter leadership. On the other hand, some models of health service delivery continue to operate under loose leadership, such as teams working in remote locations. These teams handle many day-to-day decisions without oversight from their off-site leaders.

Practice Implications In conclusion, we advanced the following insights related to leadership role distribution and practices in health care teams:

& Gaps and overlaps in leadership can be sources of ambi-

guity. Challenges in dividing leadership tasks among multiple leaders appear to be more common where such tasks are in the same area of leadership (i.e., leaders dividing administrative tasks or leaders responsible for clinical matters).


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& Overlaps in leadership do not always lead to ambi-

guity if the leaders have agreement on areas of overlap and on which leader assumes ultimate authority in a given area. & More leaders or more qualified leaders do not necessarily entail more leadership practices or more comprehensive fulfillment of team needs. As important as the leaders’ competencies is the correspondence between leadership practices enacted and team needs. & Spreading leadership responsibilities informally among a greater number of people may not address team needs. & Teams do not always need tight relationships with their leaders. Loose leadership may be adequate for teams where members provide services autonomously, and tight leadership may be beneficial for teams that provide highly integrated services or that experience disagreements. These results point to practice implications. The findings suggest the importance of addressing ambiguities caused by overlaps or gaps in leadership. Explicitly identifying gaps and poorly defined overlaps in leadership may be an initial step for constellationsVespecially those in early stages of development. This exercise may be helpful in clarifying or avoiding leadership role ambiguities and unnecessary duplications, safeguarding against leadership vacancies that result in the inability to meet team needs, and preventing team member confusion about which leader can best address a particular challenge or issue. Discussions and role mapping exercises for members of the leadership constellation would be helpful. Agreement among the constellation members on role distribution and boundaries would have to be communicated and discussed with team members. Open lines of communication between leadership and other team members would allow the determination of team needs and ways that these needs can be met. Furthermore, spreading leadership responsibilities informally among a greater number of people may butVas our study showsVdoes not always address team needs. Some individuals may feel more comfortable assuming leadership responsibilities for which they have formal authority. Finally, in our studies of health care organizations, we consistently come across leadersVsimilar to the senior leaders in ACT-2 and MHCTVwho are spread too thin. It is common to see program managers and clinical directors who spend a small fraction of their time on demanding leadership activities. It is important that these role allocations be considered critically (Reay, Goodrick, Casebeer, & Hinings, 2013). Decision makers need to consider more carefully if minimal time allocations meet the needs of the leaders, the teams, and ultimately, the clients being served. In conclusion, we hope that our study encourages more thorough consideration of the important issues of leadership constellations, role distribution, and leadership practices in health care contexts.

Acknowledgments

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