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JICA
20,3 The role of leadership in learning
and knowledge for integration
Paul Williams
164 Cardiff School of Management, Cardiff Metropolitan University, Cardiff, UK

Abstract
Purpose The purpose of this paper is to explore the role and approach to leadership for learning
and knowledge management within integrated care arenas.
Design/methodology/approach Following a critical review of the relevant literature, the paper
analyses the findings from case study research in South Wales which generated evidence from
in-depth qualitative interviews with a diverse set of health and social care managers and professionals.
Findings The paper argues that the leadership role for learning and knowledge management needs
to focus on four main areas promoting common purpose, developing a collaborative culture,
facilitating multi-disciplinary teamwork, and developing learning and knowledge management
strategies. The most effective leadership approach to undertake these roles is predominantly
collaborative and dispersed but may need to be flexible to reflect the hierarchical imperatives of
performance and accountability.
Research limitations/implications The research study is limited to a small case study and more
in-depth examples involving different integrated services are necessary to begin to accumulate more
knowledge in this area of study.
Practical implications There a number of implications that flow from this paper for policy and
practice both in terms of leadership development and training, and for the design of planned strategies
for learning and knowledge management.
Originality/value The paper addresses an undeveloped area of research and has value to both
theory and practice. It frames the challenge of integration as one of learning and knowledge
management and argues that this has significant implications for the role of, and approach to,
leadership.
Keywords Leadership, Learning, Knowledge management, Strategy, Health services sector, Social care,
Strategic planning
Paper type Research paper

Journal of Integrated Care
Vol. 20 No. 3, 2012
pp. 164-174
q Emerald Group Publishing Limited
1476-9018
DOI 10.1108/14769011211237500
Introduction
The case for devising and delivering integrated health and social care solutions for
vulnerable user is compelling. It is based on the need to secure efficiency in the use of
scarce resources especially at a time of severe financial restraint; on the need to tackle
complex and interrelated issues through the avoidance of duplication and promotion of
improved co-ordination and collaboration between diverse interests and agencies; and,
finally, as a response to the imperative of involving service users and communities in
their care through inclusive and participatory processes. Although the balance of these
motivations can lead to various forms of integration (Kodner and Spreeuwenberg, 2002),
a common thread to them all is that they rely on different professional groups and
organizations learning together what services are appropriate, and how best they can be
delivered. The full potential of integration is enhanced through the diversified
capabilities and knowledge resources provided by the different parties. Knowledge
needs to co-produced and shared by professional groups to ensure that integrated
solutions can be devised to achieve the most effective and appropriate outcomes for
service users. Learning and knowledge management processes are highly complex, and The role
are the subject of a range of both structural and agential determinants (Child, 2003). A of leadership
number of factors are influential in promoting effective interventions, but others act as
barriers, reducing progress towards integration.
This paper focuses on the role and importance of leadership in promoting learning
and K/M within integrated settings. Following a brief overview of some of the key
theoretical perspectives on these related phenomena; it draws on new empirical 165
research from a case study in South Wales to explore leadership approaches and their
roles. The paper concludes with a discussion of some emerging themes together their
implications for policy and practice especially in relation to the design of planned
strategies for learning and knowledge management.

Insights from the literature on learning and knowledge management

Learning and knowledge management are interrelated, complex, dynamic, multi-level
and contested phenomena. They are manifested in different forms and types which
make it difficult to follow and unravel the relationships between different levels and
processes. Structural perspectives emphasise the importance of organizational
and institutional forms, systems of communication, capacities, resource frameworks
and strategic planning. Alternatively, interpretive and cognitive stances highlight the
potential influences of culture, framing and communities of practice in enacting and
mediating learning and knowledge management processes. Social and relational factors
are important in learning and knowledge management. For instance, tacit knowledge
transfer relies on transparent and trusting relationships, and understanding the power
and ownership dimensions of knowledge are critical when different groups come
together to share or co-create knowledge. Agency in the form of leaders, managers and
boundary spanning actors is important in championing, brokering and enabling
effective learning and knowledge management policies and strategies.

A public sector context

However, whilst the theory and practice of learning and knowledge management has
resulted in a significant accumulation of research and literature in a private sector
context, there is considerably less that is grounded in the public sector, especially in
relation to integration in health and social care. Exceptions to this are Bate and Roberts
(2002) who highlight the social and informal aspects of knowledge transfer in their
research on NHS collaboratives particularly the tacit forms, but also stress the need
to convert and codify tacit knowledge to increase its fluidity across boundaries. They
argue further that public sector collaboratives should focus less on knowledge transfer
and capture, and more on strategies for the co-creation of knowledge between
individuals and organizations, and consider that: the process of collaborating needs
to change, to become more equal, spontaneous, naturalistic and improvising, and less
routine, hierarchical, structural and orchestrated (Bate and Roberts, 2002, p. 660).
Also in the healthcare sector, Nicolini et al. (2008, p. 253) reflect on the implications
of the fragmented and distributed nature of knowledge, knowledge overload, the
effectiveness of tools and techniques for knowledge management, and the benefits of
networks and communities of practice in spreading knowledge, but also the non-spread
of knowledge: as individual professionals operate within mono-disciplinary
communities of practice. Inter-organizational clinical networks in the NHS are one
JICA of the few examples to have knowledge sharing and transfer as a core objective,
20,3 although Addicott et al. (2006, p. 93) discovered that knowledge exchange across
organizational sites and health care professions was very limited primarily because
knowledge management as an activity was marginal and there was distrust between
professionals in different health care organizations who retained individualistic
agendas, retarding interorganizational knowledge sharing. In a similar vein, Currie
166 and Suhomlinova (2006) found that institutional forces both fostered and inhibited
collaboration between different practitioner groups and this impacted on knowledge
sharing through different processes especially highlighting the cultural and political
dimensions of knowledge sharing in practice.

Perspectives on leadership
Although there is a vast, diverse and highly contested literature on leadership, little is
directly focussed on learning and knowledge management. The traditional literature
offers a number of seemingly plausible explanations and approaches. Theories based on
trait, style, contingency and new models (Parry and Bryman, 2006) might be
considered generally problematical in collaborative settings because of their focus on
heroic leaders evoking a leader-follower, unidirectional, top down and hierarchical
relationship, with a clear demarcation between the groups of individuals and functions.
However, LaPalombara (2003) still suggests that there is a role for the the right man or
woman being able to discharge effective leadership both in and between organizations,
emphasising the use of formal power in shaping and transferring organizational
learning through different structures, systems and people. Shared, dispersed or
distributed leadership models (Yukl, 2009; Pearce and Conger, 2003) arguably offer a
more promising approach for creating the right conditions for collective learning and
knowledge management because they reject the view that leadership is solely a top
management responsibility, and encourage a more emergent, bottom up approach, with
heightened individual learning skills (Fletcher and Kaufer, 2003) translated in practice
through social networks and cross-functional collaboration.
Hannah and Lester (2009) argue in favour of a multi-level, tight-loose approach to
leadership, with leaders setting the structure and conditions for knowledge creation.
Top leaders are cast, not in the role of hero but: as social architects and orchestrators
of emergent processes relevant to learning (Hannah and Lester, 2009, p. 35) and
catalyst and facilitator of network processes (van Wijk et al., 2005, p. 439). Sadler
(2003) too is equally sceptical of the traditional heroic and transformational leader in a
learning context, preferring the alternative of a learning leader who builds a learning
organization based on facilitating learning in others, acting as a role model,
encouraging learning through challenge and intellectual stimulation, institutionalising
learning through the provision of incentives and training (Salk and Simonin, 2005),
fostering a pro-learning culture which tolerates mistakes and encourages
cross-functional/disciplinary engagement, and develops learning transfer mechanisms.
Creating the right conditions through networks of diverse individuals can be
healthy for learning cultures (Schein, 1997), and the resultant conflict often arising in
the course of integration can be a positive experience if channelled constructively,
enriching the learning process (Child and Heavens, 2003) and generating novel ideas
(Nemanich and Vera, 2009). Also, participation in networks improves the potential for
knowledge transfer and acceptability. Child and Heavens (2003) consider that formal
leaders need to establish and sustain a learning culture with vertical and horizontal The role
communication channels across organizational boundaries. Effective organizational of leadership
learning requires clarity of intent, active management of the process, legitimation of
top management, the availability of resources and appropriate incentives (Child, 2003),
integration amongst different stakeholders, and systematic assessment of the
outcomes of learning.
In turn, these require leaders to evidence high quality conflict management and 167
interpersonal skills, to understand disparate corpuses of knowledge, and to build
trusting behaviours. Finger and Brand (1999, p. 151) assert: . . . through their
behaviour, their management style, their ways to reward (and to punish), but also
through their ability to coach, to mentor, to accept critique and alternatives, to question
dominant views, the leaders have a significant influence on individual and collective
learning. Finally, Jansen et al. (2009) suggest that different leadership approaches
are necessary for exploratory as opposed to exploitative learning. Exploratory learning
concerns the generation of new knowledge, insights and innovation; it involves more
risk, experimentation, new ideas and challenges the existing state; and, therefore,
is more consistent with transformational leadership. In contrast, exploitative learning
concerns an incremental improvement of existing skills, knowledge and systems; it is
about refinement, efficiency, extension of existing competencies and models,
reinforcing institutionalized learning, and consequently it is more in tune with
transactional approaches.
Completing this overview of leadership approaches, there are the more recent
contributions that emphasise collaborative approaches which take specific account of
the context. These highlight interdependency and connectivity in public management,
and reject the limitations of traditional approaches to leadership, particularly those
based on the primacy of hierarchy and heroic individuals (Lipman-Blumen, 1996;
Saint-Onge and Armstrong, 2004; Allen et al., 1998; Marion and Uhl-Bien, 2001).
Leadership in these models foreground the role of groups and communities rather than
individuals, the creation of structured learning environments, sharing ideas and
trusting relationships, and the role of formal leaders is shifted to: that of facilitators,
supporters, consultants, and sometimes teachers (Allen et al., 1998, p. 590).
The literature on leadership in multi-organizational, cross-sector environments
reflected in the work of Chrislip and Larson (1994), Linden (2002), Feyerherm (1994),
Luke (1998), Kanter (1997), Armistead et al. (2007), Bryson and Crosby (2005),
Alexander et al. (2001) and Huxham and Vangen (2005) emphasise the importance of
initiating and sustaining high quality inter-personal relationships between a diverse
set of stakeholders; building a common collaborative culture; combining diverse skills
and experiences in new ways to foster creativity and innovation, facilitating learning
and reflective practice; and dispersing leadership amongst individuals at all levels in
different organizations.

Case study research

In order to explore contemporary experiences of leadership for learning and knowledge
management within integrated care, a research project was undertaken in an area
of South Wales involving two integrated services one for assisting the recovery of
people suffering from mental illness, and the other providing reablement services to
prevent unnecessary hospital admissions, and to promote early discharges from
JICA hospital back into the community. The choice of this case study had a number of
20,3 advantages including, being located in an area that had established a culture of
partnership working between different agencies over a period of time reflected in both
structural arrangements and a network of inter-personal relationships, and where a
programme of whole-system re-engineering was being attempted to develop new
models of care and foster learning and innovation. An enabling strategic framework
168 was in place within which integration could prosper including the creation of a number
of joint appointments in key positions, the use of S.33 Health Act 1999 flexibilities to
provide pooled budgets, the creation of locality teams, and a rationalisation of
governance arrangements. The services involved in the case study were governed
jointly by the Local Health Board (responsible for commissioning and providing the
whole range of NHS services in that particular area Wales) and the local council
(responsible for social care), and were delivered from co-located facilities providing a
single point of contact for service users by multi-disciplinary teams led by an
integrated manager. In both cases, the process of integration was still dynamic and
emergent, building upon a lengthy period of change and development.
The research method involved was qualitative in nature and consisted of an
interrogation of relevant documentary material and a series of in-depth interviews with a
cross-section of managers and practitioners in each of the two services (20 in total). These
were supplemented by five additional interviews with actors holding strategic positions
in the two partnering organizations. The interviews typically lasted an hour, were based
on a topic guide covering a range of areas of enquiry, were taped, and subsequently
analysed using comprehending, synthesising, theorising and recontextualising
processes (Ritchie and Spencer, 1994) to identify key themes and mechanisms.

Leadership roles
The evidence from the research study suggests that effective leadership for learning
and knowledge management needs to encompass a number of key roles promoting
common purpose, establishing a collaborative culture, encouraging working in groups
and teams, and facilitating learning and knowledge management strategies. Each of
these is considered in more detail as follows.
1. Promoting common purpose. A key leadership role involves helping to develop
and negotiate shared purpose in the form of new service models that override narrow
organizational, sectional and professional interests. Shared models encapsulate the
essence of integrated services, underpinned by appropriate values and principles. They
offer an overarching framework that transcend different models of professional working
typically based on variations in medical and social models of health. They can be used as
a mechanism to focus effort in times of conflict and disagreement particularly about the
primacy of user interests, and a device for guiding new developments and for evaluating
outcomes. The integrated managers in both services within the case study commented
that they constantly looked for opportunities to re-enforce shared purpose. The new
model in the recovery service for people with mental illnesses was premised on
delivering a personalised service within the community with high levels of user
involvement, and this was a radical departure from the previously paternalistic,
group-focused service model that delivered services in a traditional residential setting as
explained by one interviewee in the following way: the old model was a holding service
not service user centred easier for staff and not challenging fine from a health
point of view because it was about stabilisation but did not explore a persons full The role
potential and quality of life it was risk averse. of leadership
2. Establishing a collaborative culture. The reablement services examined in the case
study involved a wide range of professional groups occupational therapists,
physiotherapists, nurses, social care workers, speech and language therapists and
dieticians working together to design and deliver integrated services. In this context,
a primary role of leadership was to build and sustain a culture that appreciated 169
interdependency, reciprocity and collaboration. Key values such co-operation, trust,
openness, fairness and teamwork needed to be instilled into the fabric of the services,
and those that worked within it. Leaders at all levels had a responsibility, not only to
champion those values in their own conduct, but also to promote them to all staff.
3. Encouraging working in groups and teams. Multi-disciplinary teamwork provides
the foundation for integrated working. They facilitate involvement, communication,
information-sharing, and allow for: a rich discussion between different professional
groups. They provide the vehicles for developing integrated health and social care
packages, and the arenas where experiential learning is built into the delivery and
substance of care packages. It is where learning about and with each other occurs, and
where knowledge is pooled in pursuit of effective service user outcomes. Ownership is
engendered through regular inter-personal relationships and informed deliberation.
Interviewees in the case study argued that teams provided the setting for: sharing
skills and knowledge, and people are more enriched by having their minds opened up
to different ways of thinking; conducive to gaining knowledge about other
professionals; of providing synergy leading to greater potential for innovation; and of
reducing professional jealousies and preciousness. The value of teams lies in their
ability to provide support, distribute information, offer communication, and develop
trust through social relationships. The members of one team reflected that their team
provided: lots of skills support from one another and the necessary black humour;
we work together really well; we communicate directly through conversations;
we are clear in our roles; we trust each other professionally; pulling together,
helping each other, if you dont know something, someone else will.
Team settings are especially useful conduits for the translation of tacit forms of
knowledge between team members. Tacit knowledge is notoriously difficult to codify
and communicate, and is inherently sticky because of its non-verbal, context-specific
and personally bounded nature. The professional practices of many members of
integrated services involve a considerable proportion of tacit knowledge, hence the
importance of learning vehicles that might promote its transfer. Carlisle (2002) suggests
that this could be affected through the adoption of a pragmatic view of knowledge
which recognises its situated and local dimension in the context of professional practice.
However, this is not unproblematic because of the diverse professional identities
involved and the difficulties of embedding new, collectively generated knowledge. An
important leadership role is to encourage and support teamwork and distribute
leadership functions to it, often helping to create team spirit and ownership. These can
be positive in the main but leaders have to guard against groupthink and the
intransigence caused by insularity. Certainly, heterogeneous groups offer a potentially
healthier learning environment because of the diversity of group members experiences
and capabilities. Sometimes the resultant conflict that emerges from such diversity, if
channelled constructively, can enrich the learning process.
JICA 4. Facilitating learning and knowledge management strategies. Negotiating common
20,3 purpose, building a collaborative culture and promoting multi-disciplinary teamwork
underpin a strategic approach to learning and knowledge management within
integrated settings. However, the leadership role needs to move forward from these
building blocks to develop a coherent set of strategies and interventions. A critical
decision concerns whether learning and knowledge management should be treated as
170 the product of an ad hoc, emergent and opportunistic approach, or whether it should be
the subject of an explicit and planned strategy.
In the research study, the evidence was that the former approach prevailed. Much of
the learning occurred in an experiential, on-the-job fashion in response to diverse
service user needs; a good proportion of this was the product of both formal and
informal processes of working within co-located and multi-disciplinary teams (referred
to by one interviewee as the corridor-conversations); and, the influences for learning
and knowledge management tended to be generated locally rather than be informed by
a wider system of policy and practice. Health professionals were more keyed into
communities of practice (Wenger, 1998) which allowed them to network with
colleagues across a wider domain. There was limited evidence that learning about
integration from the services involved was being captured and transferred, and the
absence of unified IT systems was problematical. On the positive side, examples of
learning and knowledge management were manifested at individual and group levels
in the form of training and development, supervision and appraisal, networking,
shadowing and job rotation and communities of practice. One health professional
commented that: shadowing is the key to understanding my fellow professionals
roles and perspectives. However, there was a sense that the general approach was
mainly reactive, unco-ordinated and not evaluated in terms of its impact.

Leadership approaches
The implications of these main roles for leadership approaches within integrated arenas
involving different professional groups from different backgrounds and with
accountabilities to different organizations, is that models based on authoritative,
directive and controlling leadership styles are inappropriate. In contrast, shared and
distributive approaches that reflect dispersed power relations, disparate sources of
knowledge and expertise, and the importance of teamwork, are likely to be more
productive. Especially in relation to learning and knowledge management, leadership
approaches need to place an emphasis on mutual learning, reflective practice and
innovation.
The leadership approaches adopted by the formal leaders in the research study were
characterised by their informality, inclusiveness and sensitivity to the roles and
contributions of diverse members of staff. One manager was variously described by
her staff as relaxed and approachable; always available to talk; supportive; invites
new ideas and gives good feedback; encourages open debate. One interviewee drew
attention to the enabling culture that allowed staff to generate and introduce new ideas
and ways of working with only limited checks and balances: all we have to do is run it
past the manager and do it; another considered that leadership needed to be: based
around people management; helping people to articulate their needs; to be creative and
allow constructive challenge; to be a patient-champion; and to be a coach and mentor to
their staff; and another referred to: the ability to manage difficult conversations;
an ability to communicate with a whole range of people; choosing who to network with The role
and why; needing to share leadership with others who have more relevant knowledge; of leadership
having the ability to enable others rather than provide the answers.
Other perspectives on leadership focused on the need for transparency, teamwork
and the promotion of high levels of communication and feedback upwards/downwards
and across the organization. A number of interviewees drew attention to the need for
formal leaders to be credible in terms of their knowledge of both health and social care. 171
This was demonstrated by one manager who trained as a professional nurse but also
had experience of working for a local authority social services department; and
another, who had an occupational therapy background but also social care experience.
However, despite the merits of a predominantly collaborative and dispersed
approach to leadership, leaders needed to balance this with the inevitable demands of a
formal hierarchy with its prescribed lines of reporting and accountability. This created
the dilemma referred to by Child and Heavens (2003) of simultaneously dispersing
authority and acting hierarchically the tight-loose approach advocated by Hannah
and Lester (2009). Strong leadership was required in some circumstances to achieve
the necessary change to take forward integration, to tackle issues of performance, and
to build learning cultures.

Lessons for policy and practice

This paper argues that leadership for learning and knowledge management within
integration is a substantially under-researched area of policy and practice. This is a
matter of concern because integration is fundamentally about the challenges of different
organizations and professional groups coming together to learn what services are
appropriate and how best they can be delivered. Leadership is central to this challenge
but what form should it take and what roles are involved? The evidence presented from
both theory and the case study research suggest that a leadership approach that is
facilitative, inclusive and collaborative at both strategic and operational levels is critical
in allowing diverse stakeholders and interests to work effectively and efficiently
together. This sets the tone for learning, continuous improvement and innovation. The
fieldwork presented demonstrates that dispersed leadership approaches are the most
appropriate in this environment, particularly in the context of multi-disciplinary teams.
Formal leaders have a particular role in encouraging managers to develop collaborative
mind-sets to: facilitate the management of the complex relationships inherent in
networks and bridges the boundaries of knowledge between organizations,
professionals (Weber and Khademian, 2008, p. 344).
The conclusion from the case study was that, in general, an ad hoc, incremental and
unplanned approach was taken to learning and knowledge management. In reality,
these phenomena were often narrowly framed as simply matters of training and
development, rather than as central to the success of integration itself. Whilst there is a
role for spontaneous and unplanned individual and group learning, there is
considerable value in designing strategies for learning and knowledge management to
accompany, and be integral, to integrated service development. If a key leadership role
is to set the fertile conditions for learning and knowledge management to flourish
(Sadler, 2003), then there is a case for a more planned and structured approach.
Table I offers a framework to assist leaders and managers in the development of
such strategies. This is not intended to be prescriptive, but poses key questions that
JICA
Purpose What are the purposes of learning and knowledge management? How do they
20,3 contribute to the particular model and stage of integration?
Level At which levels does learning take place individual, group, organizational and
network? Are particular approaches needed at different levels? What barriers and
facilitators exist at each level? How does learning transfer between different levels?
Type What form of knowledge is involved tacit or explicit? What form of learning is
172 involved operational, double-loop or exploitative learning?
Processes and What are the mechanisms structures, carriers and processes for sharing and
modes transferring knowledge? What are the learning modes involved cognitive, cultural
or behavioural?
Context What structural and organizational factors are necessary help or hinder effective
learning and knowledge management strategies? Are management arrangements
networked or hierarchical? Are there unified information systems in place to support
learning cultures and knowledge exchange? What mechanisms exist to measure
interventions and strategies?
Culture Is there a collaborative culture in place to support and promote collaborative
learning and knowledge exchange?
Resources Are there resources available to support learning and knowledge management
activities?
Leadership and Do managers and practitioners possess the skills and competencies to promote
agency learning and knowledge management? Are there specific catalysts and champions of
Table I. learning and knowledge management? Are there mechanisms to incentivise learning
Framework for learning and knowledge management? Are communities of practice encouraged and is there
and knowledge cross-fertilization between them? Are there schemes that encourage learning from
management strategy integration elsewhere in the UK, and from other policy areas or sectors?

need to be addressed, the answers to which can be tailored to specific circumstances

and contexts. This paper has significant implications for leadership approaches within
integrated care which need to be reflected in future training and development
programmes. Leaders need to be more knowledgeable about learning and knowledge
management phenomena and approaches, and understand what contribution they can
make to securing effective interventions. Leadership for integration is not a simple
extension of leadership within single organizations the context and parameters are
materially different, and demand different skills and competencies. The future of
successful integration in health and social care needs to acknowledge this as a matter
of priority.

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Corresponding author
Paul Williams can be contacted at: pmwilliams@cardiffmet.ac.uk

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