Franco 2011

Leadership & Organization Development Journal
Organisational learning and leadership styles in healthcare organisations: An

exploratory case study
Mário Franco Joana Almeida
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To cite this document:
Mário Franco Joana Almeida, (2011),"Organisational learning and leadership styles in healthcare
organisations", Leadership & Organization Development Journal, Vol. 32 Iss 8 pp. 782 - 806
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LODJ
32,8 Organisational learning and
leadership styles in healthcare
organisations
782
An exploratory case study
Received October 2010
Revised February 2011
Mário Franco
Accepted February 2011 University of Beira Interior, Covilhã, Portugal, and
Joana Almeida
Unit of Integrated Continuous Care, Arrouquelas, Rio Maior, Portugal
Abstract
Purpose – This paper aims to understand the association between organisational learning and
leadership styles in the healthcare context.
Design/methodology/approach – A qualitative approach was applied in two continuous care
units in the same Portuguese healthcare organisation (single case study). Data were obtained from a
survey of 28 collaborators and an interview with its manager-leader/general director. Documental
analysis was also used.
Findings – The findings attested to the central role of organisational learning and leadership in
organisational performance/effectiveness within healthcare organisations. Different levels of performance
were identified in the organisation selected. The practical implications of findings are also discussed.
Research limitations/implications – The study of a single case has been analysed, with the
consequent disadvantage of not considering generalisation. For this reason, further research should be
carried out to detect structural and cultural differences in healthcare organisations. On the other hand,
most of the writing on organisational learning and leadership is conceptual, so this empirical study
was important.
Originality/value – Despite the vast quantity of studies in the domain of leadership and
organisational learning, very little work associates these two topics. Taking into account the relevance
of these research topics for healthcare organisations, the findings give additional support to the
argument that leadership plays an important role in instilling organisational learning in the healthcare
sector.
Keywords Leadership, Organisational learning, Performance, Health context, Portugal
Paper type Research paper
1. Introduction
The competitive pressures of the present environment (Rijal, 2010), the growing
dynamism and uncertainty of markets, the increasing rate of technological
development (namely in the field of information and communication) (Rebelo and
Gomes, 2008), and other political and social factors have called for the development of
Leadership & Organization new and effective organisational forms (Cacioppe, 1998; Gunasekaran, 2004).
Development Journal
Vol. 32 No. 8, 2011
pp. 782-806 This study was supported by a Research Unit (NECE), financed by the FCT – Science and
q Emerald Group Publishing Limited
0143-7739
Technology Foundation of Portugal. The authors thank the anonymous reviewers for their very
DOI 10.1108/01437731111183739 helpful comments that contributed to the development of this paper.
According to Dodgson (1993) and Amitay et al. (2005), these mutations of endogenous Organisational
and exogenous origins arise constantly in organisations and these are dynamic, almost learning
omnipresent processes which are frequently continuous.
These global transformations are particularly important in current health policy. As
noted by Ojha et al. (2002), over recent years, health organisations have undergone a
change of paradigm. In Portugal, health organisations face a continuous challenge to
successfully translate quality improvements into sustainable competitive edge. Like 783
people, these organisations should learn in order to adapt successfully to the
ever-changing situation. From this perspective, health organisations should be
prepared to respond to changes, and therefore, the basic requirement of any
organisation is its capacity to learn throughout its life. It is in this context that
researchers as well as practitioners have started to believe that organisations should
move away from adaptive learning to generative learning (Singh, 2010). Shukla (1997)
emphasises the importance of learning in organisations surrounded by a qualitatively
changed environment due to economic globalisation.
In fact, a tool that can facilitate an organisation’s process of adapting to changes in
the current competitive climate is “organisational learning”, which can be considered
as the precursor of change (Rousseau, 1997; Sher and Lee, 2004; Ipe, 2003; Amitay et al.,
2005; Rijal, 2010). In this study, a “learning organisation” is defined as an organisation
skilled at creating, acquiring and transferring knowledge and at modifying its
behaviour to reflect new knowledge and insights (Garvin, 1993). Organisational
learning has also been viewed as a process through which an organisation
continuously acquires new knowledge and adjusts itself to successfully adapt to
internal and external environmental changes and to maintain sustainability and
development (Chen, 2005). Thus, in this study organisational learning is considered as
long-term activities that build competitive advantages over time and require sustained
management attention, commitment and effort.
As noted by Stata (1989), learning is especially important for organisations in
knowledge-intensive industries such as the health sector where the rate at which an
organisation learns should be greater than the rate at which its general and
task/operating environment changes (Singh, 2010). This sector was chosen for our
study because improving organisational performance through learning has been a
critical factor for organisational survival due to the sector’s rapid technological
advances and highly competitive markets (Rijal, 2010). Thus, healthcare organisations
are an ideal context for this study, because they not only represent a
knowledge-intensive sector, but also provide particularly complex services.
Senge (1990) identified a different role for leaders of learning organisations.
Similarly, several authors (Johnson, 1998; Prewitt, 2003; Sandler, 2003; Rijal, 2010)
have emphasised the important role leadership plays in the development of the
learning organisation. Leaders can therefore have an influential role in providing the
organisation with a climate favourable to continuous learning, change, flexibility,
innovation and responses that are adjusted to mutations in the environment (Cacioppe,
1998; Amagoh, 2009). In this view, leadership refers to people’s ability, using minimum
coercion, to influence and motivate others to perform at a high level of commitment
(Bass, 1985, 1999). A learning organisation hence requires a leader who brings out the
best in others, leadership that is more adaptive and flexible (Rijal, 2010).
LODJ While there are several definitions of leadership, in essence leadership is an act of
32,8 motivating people to act by non-coercive means (Popper and Lipshitz, 1993). Here, we
defined leadership as a multi-dimensional process involving multiple members across
organisational levels in exerting influence on health promotion imperatives (Barrett
et al., 2005).
Despite the amount of interest in the topics of organisational learning and
784 leadership, at the moment there is a limited amounted of empirical research
(Easterby-Smith, 1997; Garvin, 2000; Popper and Lipshitz, 2000a). This situation is
found even more in the context of health organisations (Witt, 1993). Little has been
done to examine the relationship between leadership and organisational learning in the
health context. Day (2000) and Vassalou (2001) state that few authors have studied
practices in health organisations that facilitate construction and spread of knowledge.
Dowd (2000) also adds that the first studies about organisational learning in the sphere
of health were provided by the area of nursing.
To our knowledge, only Popper and Lipshitz (2000b) and Amitay et al. (2005) carried
out studies aiming to identify the mechanisms for organisational learning and
leadership styles in health organisations. Study of Portuguese health organisations is
similarly lacking. Our research question, therefore, is: How does leadership style affect
organisational learning? In order to address this subject, the main aim of this study is
to understand the phenomenon of organisational learning and leadership styles in a
Portuguese healthcare organisation called Naturidade, and which comprises two units
of continuous care. More specifically, this study aims to identify this organisation’s
leadership style and the foundations for the level of organisational learning
performance. For Amitay et al. (2005), additional aspects of leadership that are
conducive to organisational learning have yet to be analysed and empirically
investigated. Thus, this paper is innovative as it deals with the conjunction of
leadership and organisational learning in the health care sector.
The article is organised as follows. The next section gives a theoretical overview of
the main aspects of organisational learning and leadership and demonstrates that this
interface provides a useful framework to explain organisational performance in the
health context. Section 3, based on a qualitative approach, presents methodology and
data from a single Portuguese case in the health sector. Section 4 presents and
discusses findings, paying special attention to organisational learning and leadership
styles. Finally, section 5 concludes, puts forward suggestions for health leaders and
practitioners, and presents some limitations of the study.
2. Theoretical framework
2.1 Organisational learning and the learning organisation
Practitioners and managers know that competition and environmental turbulence due
to rapid and unexpected changes are inescapable features of a global world. In such a
scenario, developing new competences and capabilities has gained importance and this
places learning at the centre of the organisation. This has led to the development of
new organisational forms known as “organisational learning”.
In the nineties, a seminal work by Peter Senge (1990), The Fifth Discipline,
popularised the idea of organisational learning, the philosophy first expounded several
decades earlier by Kurt Lewin in the thirties, and again by Chris Argyris in the fifties.
However, the concept of organisational learning can be traced back even earlier, to Lev
Semenovich Vygotsky’s studies about child education in the 1s. In the 60s, Cangelosi Organisational
and Dill (1965) showed the need to study the interactions between individual and learning
organisational learning in order to identify environmental, organisational and human
characteristics which could influence learning potential, and to detect what allows
anticipation and identification of situations where learning takes place. In the 1980s,
the findings of Lucas (1988), Romer (1986) and de Geus (1988) drew the attention of the
business community to the importance of learning in a definitive manner. 785
Traditionally, organisational learning had been considered as a result only and not
a dynamic process (Lieberman, 1987). Now, numerous analyses have evinced its
complexity and multilateral character. Sher and Lee (2004), and Ipe (2003) point out
that the terms change, learning and adaptation being used indiscriminately to describe
the process by which organisations adjust themselves to their surroundings. Likewise,
Pedler et al. (1989) and Ipe (2003) assert that a learning organisation facilitates the
learning of all its members, and thereby continuously transforms itself.
Over the years, several authors have commented on the ambiguities and divergence
that afflict the literature on organisational learning and learning organisations (Popper
and Lipshitz, 2000b). However, the work of Senge (1990) determined the concepts’ great
popularity, since it showed organisations a practical way of applying and improving
learning. In fact, during this period, a new interrelated concept emerged: the concept of
the learning organisation, a new type of organisation that intentionally develops
strategies to promote learning.
There is no unified definition of organisational learning, but, for Senge (1990), a
learning organisation is a place where people continuously expand their capacity to
create the results they truly desire, where new and expansive patterns of thinking are
nurtured, where collective aspiration is set free, and where people are constantly
learning to see the whole together. These organisations are more adaptive and flexible,
and tap the learning of individuals to improve organisational performance and enhance
organisational learning (Rijal, 2010).
Consequently, an organisation that learns (i.e. a learning organisation) is a
particular type of organisation that has the capacity to change and adapt continuously.
The focus of analysis of organisational learning should be understood as the process
through which there is development of the knowledge that is the result of the
organisation’s interaction with its environment (Ducan and Weiss, 1979).
Organisational learning includes the proposal that organisations could learn through
employees’ learning and knowledge and sharing that knowledge, i.e. it includes the
idea that organisations learn and that learning could take place at an organisational
level (Rebelo and Gomes, 2008).
Combining university and research studies with the evolution of learning and
professionals’ experience, five components/pillars as the basis for organisational
learning are identified: vision, infrastructure, culture, learning dynamics, and training
investment (The Conference Board of Canada, 2009).
In a learning organisation, the organisation’s clarity of vision exists to the extent
that learning is part of that vision. The organisation’s vision plays important roles in
creating and sustaining a learning organisation (Vardiman et al., 2006). O’Connor and
Kotze (2008) add that a shared vision is important in organisations, as it aligns efforts
towards supplying creative energy.
LODJ According to Kolb (1984) and Pankakoski (1998), the share of information and
32,8 knowledge (infrastructure) consists of making knowledge accessible and
comprehensible to other people. The same author states that for this, there must be
exteriorisation, i.e. conversion of tacit knowledge in explicit knowledge. Salm and
Amboni (1997) are of the opinion that the ability to gather information and use that
same information to alter behaviour is the pillar of effectiveness in a learning
786 organisation. Therefore, information and knowledge should be made available in
suitable means for intensive use by all collaborators in the organisation.
Brown and Duguid (1991) and Cook and Yanow (1993) added also a cultural
perspective of organisational learning, emphasising the importance of people’s
interaction and their insertion in a particular and unique organisational environment
as the essence of organisational learning. Corporate culture influences all aspects of
organisational performance, including organisational learning. For Roberts (1970),

culture represents the shared values and norms that bind members of a society or
organisation together as a homogenous entity. Organisational culture shows itself in
ideologies and knowledge patterns (Schein, 1985, 1993). So culture is considered as the
basis of the learning organisation, since all individuals need to share organisational
values (López Salazar and Lopez Sánchez, 2001). Goh (1998) argues for the creation of a
culture based on the construction of knowledge and learning.
Claver et al. (2001) also say that individuals should help each other, share knowledge
and professional experience so as to create important synergies. In this connection,
various investigators believe that one of the most important characteristics of
organisations that learn is continuous learning (Barrett, 1995; Leitch et al. 1996). A
system of effective organisational learning challenges collaborators to think and act with
a wide perspective, to look for deep causes, patterns and interdependence. Consequently,
people must learn to think systematically about the impact of their decisions.
From another aspect, it is important to stress that a learning organisation has a
learning atmosphere based on freedom. Collaborators are not afraid to speak, errors are
accepted and failings are not punished (Barrett, 1995). These organisations, besides
optimising their own experience, examine the experience of others and use it for their
own benefit (Salm and Amboni, 1997). Pantoja and Borges-Andrade (2009) claim that
learning should be developed through actions focusing on the acquisition of
knowledge, skills and attitudes that can have diverse purposes, such as improved
work, preparing the professional for another activity, individuals’ adaptation to new
technology and the growth of individuals within the organisation.
2.2 Leadership
The rapid changes in the global world such as rapidly-evolving technologies, and
political and social factors have also called for the development of effective leadership
skills (Cacioppe, 1998). Consequently, leadership development programs have become
an increasing priority for government organisations.
The concept of leadership has generated lively interest, debate and occasional
confusion as management thought has evolved. Even today, it is not easy to define
leadership, and given the complexity of the subject, there is no general consensus about
delimitation of the field of analysis. According to Bass (1999), definition of leadership is
related to the purpose associated with the attempt to define it, and so presents a wide
range of possibilities. Leadership can be seen as a group process, an attribute of
personality, the art of inducing complaisance, an exercise of influence, a particular type Organisational
of action or behaviour, a form of persuasion, a power relationship, an instrument to learning
achieve goals, the result of an interaction, a differentiated role or initiation of a
structure (Bass, 1999, 2000; Zacharatos et al., 2000).
The concept of leadership is defined, according to Hersey and Blanchard (1979,
p. 1418), “as the process of influencing the activities of an individual or a group in
efforts toward goal accomplishment”. For Senge (1990), leadership is associated with 787
stimulants and incentives that motivate people to reach common objectives. Hersey
et al. (2001) state that the essence of leadership involves achieving objectives with and
through people. Weihrich and Koontz (1994) define leadership as the process of
influencing people so that they make an effort by their own will and enthusiasm
towards obtaining the group’s goals. According to Kotter (1990), without leadership,
the probability of mistakes occurring increases and the opportunities for success
become more and more reduced. For these same authors, and in this context, leadership
allows cooperation, diminishes conflicts, contributes to creativity and has an
integrating role, as it keeps people united even when not physically so. In this way,
leadership, together with stimulants and incentives, promotes people’s motivation
towards achieving common goals, having a relevant role in the processes of forming,
transmitting and changing organisational culture (Senge, 1990).
Critical to the success of any leadership development process is the ability to
encourage participants to reflect on learning experiences in order to promote the
transfer of knowledge and skills to work contexts. The concept of a leadership
development culture is similar to the idea of a learning organisation (Senge, 1990;
Vardiman et al., 2006). A learning organisation facilitates change, empowers
organisational members, encourages collaboration and sharing of information, creates
opportunities for learning, and promotes leadership development.
More recently, Alas et al. (2007) view leadership in terms of individual traits, leader
behaviour, interaction patterns, role relationships, follower perceptions, influence over
followers, influence on task goals, and influence on organisational culture. Vardiman
et al. (2006) and Yukl (2006) also describe leadership as a process of influence toward
the accomplishment of objectives. This view of leadership generally focuses on the
dyadic relationship between a leader and followers, but not on what conditions need to
be in place for effective leaders to emerge or to develop (Vardiman et al., 2006). As
already mentioned, this study used the definition presented by Barrett et al. (2005).
Among the situational theories of leadership, the situational leadership model of
Hersey and Blanchard (1969, 1979, 2001) is one of the best known, and despite
criticisms made of it (Graeff, 1997; Nahavandi, 1997; Papworth et al., 2009), brought
added value to the domain of leadership. This model is one of the most widely known
leadership approaches (Bass, 1990; Northouse, 2004; Vecchio, 1987; Yukl, 2006).
The model proposes dynamic and flexible leadership rather than static leadership
and includes two essential variables: the behaviour of the leader and the maturity of
collaborators. The leader’s behaviour is described according to the way task behaviour
is crossed with relationship behaviour. According to Hersey et al. (2001), task
behaviour refers to the leader’s directions: telling people what, when, where and how to
perform. The leader’s behaviour is characterised, therefore, by establishing
well-defined organising patterns, communication channels and ways of carrying
things out.
LODJ The same authors define relationship behaviour as the way adopted by leaders to
32,8 maintain personal relationships between themselves and the members of their group.
Regarding maturity, Hersey et al. (2001) define it as people’s capacity and will to
assume responsibility for directing their own behaviour. The same authors add that
the maturity variable should be considered in relation to a specific task. So this model
recognises it is necessary for leaders to adjust their style of behaviour to collaborators’
788 level of maturity.
Leadership styles considered in the model by Hersey and Blanchard (1969, 2001)
are: telling, selling, participating and delegating. Table I shows these leadership styles.
Briefly, in spite of the various typologies and styles of leadership (e.g. Barrett et al.,
2005) this study opted for the classic model by Hersey and Blanchard (1979). As Hersey
et al. (2001) state, in situational leadership “there is no one best way to influence
people,” i.e. different situations call for different types of leadership orientation and
action.
2.3 Organisational learning and leadership in health organisations

In this fast-changing era, Speechley (2005) believes that leadership capability
enhancement programs should focus on integrating the learning domains, i.e. cognitive,
psycho-motor and affective components of leaders’ persona. Amagoh (2009) argues
that a major goal of all leadership development programs is to increase leadership
effectiveness in guiding organisations through periods of uncertainty and change.
Effective leadership is often viewed as the foundation for organisational performance
and growth.
The literature on organisational learning across different organisations suggests
that leadership impacts the learning capabilities of the organisation in such a way that
learning organisations without visionary leadership is impossible (Singh, 2010).
Therefore, for this author, leadership plays an important role in helping an
organisation to become a learning organisation.
The roles of leaders in learning organisations have been described as those of
developers (Boydell and Leary, 1994), coaches (Ellinger et al., 1999; McGill and Slocum,
1998), facilitators (Macneil, 2001; Weaver and Farrel, 1997), and teachers (Cohen and
Task Relationship
Leadership style behaviour behaviour Description
Telling or directing High Low There is great orientation to the task or

productivity and little orientation to
interpersonal relationships
Selling or persuading High High In this style most of the direction is still
provided by the leader
Participating or problem- Low High There is little orientation to the task or
solving productivity and great orientation to
interpersonal relationships
Delegating or monitoring Low Low People have both ability and motivation
Table I. and little direction or support is needed
Situational leadership
styles Source: Adapted from Hersey and Blanchard (1969, 2001)
Tichy, 1998). Senge (1990, 2000) stated neatly that the role of leader in a learning Organisational
organisation is that of an architect, a teacher and a steward, for the express purpose of learning
clarifying mission, vision and values; specifying strategies, structures and politics;
creating efficient learning processes; and helping subordinates continuously develop
their mental model and system thinking. Leaders are needed to empower all members
of the learning organisation by developing a shared vision, providing resources,
delegating authority, celebrating successes, and most importantly, by being a learning 789
architect (Hitt, 1995).
The main task of leaders in learning organisations should be to encourage
knowledge sharing, support learning through mistakes, and create continuous team
learning (Macneil, 2001); to build relationships, create shared vision and strategy, and
empower people to enhance commitment to learning and reduce the need for
bureaucratic control (Boyle, 2002).

Popper and Lipshitz (2000c) emphasise that leaders can create organisational
structure and shape organisational culture, the result of influence through various
actions and service; thus leadership to actually affect organisational learning. Leadership
has also been found to improve the process and result of organisational learning
activities (Lam, 2002; Leithwood and Menzies, 1998). Most discussions on leadership in
the learning organisation are about creating an atmosphere of openness and
psychological safety which are regarded as critical factors for effective organisational
learning to occur (Argyris and Schon, 1996; Edmondson, 1999; Schein, 1993).
According to Kilpatrick (2009), the effectiveness of health organisations is affected by
the relationships formed by people, technology, resources and administration in
providing health care. Barrett et al. (2005) stress that these factors have a dominant role
in attaining organisational goals, allowing the health organisation to change the quality
of its healthcare. Azevedo (2002, p. 6) mentions that “understanding of the specificities of
health organisations [. . .] indicate the need for a management model based on permanent
negotiation and valuing the various internal groups, particularly the professional ones,
so representing a search for a more distributed type of leadership group”.
On the other hand, faced with the changes in the health system, organisational
learning can allow a higher level of performance in this type of complex organisation
(Bass, 2000). The accumulating evidence suggests that health organisations
functioning as learning organisations improve their effectiveness (Fullan, 2002;
Chapman and Harris, 2004).
Vassalou (2001) made a study aiming to identify the facilitating and hindering
elements of the learning process in hospitals in the UK and Greece. The study was
based on the model by Goh (1998) considering that the five fundamental principles of
organisational learning are: mission and vision, leadership, transfer of knowledge,
teamwork and co-operation, and an experimenting culture. That investigation
highlights two more building-blocks of the learning organisation: organisational
design and employee skills and competences.
The results of this study show a gap between the expectations of health
professionals and management, besides a different understanding of the importance of
organisational learning for the organisation as a whole. A learning organisation is in
essence a particular type of organisation that develops mechanisms to promote
productive learning (Popper and Lipshitz, 2000a), and so creation of a learning
organisation needs effort (Ortenblad, 2001). Vassalou (2001) also found that
LODJ organisational leaders did not have competences to develop organisational learning,
32,8 that organisations supported individual learning so as to correct mistakes and promote
acquisition of new competences, that experimentation was limited and the lack of time,
human resources and commitment prevented people from taking on risks to improve
processes.
The response to the challenges faced today by health organisations is only possible
790 through adoption of the roles of leadership by the various people in charge. It is
important to develop the competences and effectiveness of leadership at various levels,
defining mobilising goals, ensuring the clarity of objectives, building high performance
teams, concentrating on developing the best talents, creating a climate favourable to
innovation, stimulating permanent learning and creating a culture of merit always
based on the cohesion of teams and the quality of service provided (Kilpatrick, 2009).
Some authors (e.g. Ben-Horin Naot et al., 2004) found correlations between high-level
organisational learning and supportive leadership. Amitay et al. (2005) studied the
relationship between leadership style and organisational learning in 44 community
health clinics. They found that transformational leadership, which broadens and
elevates the interests and aspirations of employees, was associated with more intensive
organisational learning activity and with stronger learning facilitative culture than
transactional leadership.
In the context of a learning organisation, a leader should promote a climate in which
compromise and collaboration will be the norm (Senge, 2000). Therefore, leadership
emerges in the context of health organisations as a means to allow effectiveness of the
healthcare provided (Kilpatrick, 2009). For this same author, leadership in healthcare
organisations is both similar to and different from leadership in other organisations.
However, healthcare differs from most industries and many services industries in that
leadership must not only motivate, inspire and uplift employees, but should also seek
to motivate, inspire and uplift patients and their families.
At present, in Portuguese health units people are frequently appointed as team
managers, their qualifications being related to their specialisation or years of service.
This fact may effectively by positive and help personal development. However, the
person appointed as team manager does not always emerge as leader. Cameron and
Quinn (1999) say that leadership is crucial for the success of organisational models.
According to the literature review and the objectives defined for this study, the
following conceptual model of analysis is proposed (Figure 1).
Figure 1.
Conceptual model of
analysis
3. Methodology Organisational
3.1 Type of study learning
This study used the mixed method (qualitative and quantitative) of research, which is
an exploratory method. More precisely, this paper adopted a qualitative approach
(Eisenhardt, 1989, 2007; Yin, 1984; Patton, 1990) through the understanding that this is
most appropriate to investigate phenomena of an organisational nature. In this type of
approach, “investigators are more interested in the investigation process than simply 791
in the results or products arising from it” (Yin, 1984), i.e. the most important thing is to
understand the phenomenon.
As the particular form of this type of investigation, the case study approach was
chosen (Yin, 1984). Patton (1990) states that case studies aim to analyse results arising
from individual cases, which allows the generation of richer, more detailed and more
useful information about the phenomenon under observation. Yin (1984) and
Eisenhardt (1989) also claim that case studies are a knowledge base, they provide a
direction for future research, are an interactive and flexible project, use a holistic
approach to study real-life events and use multiple data-gathering sources (qualitative
and quantitative) and techniques. The case study was used to gain deep insights into a
contemporary and complex issue within its real-life context (Yin, 1984) and one case
was purposefully selected: a health organisation.
3.2 Case selection and characterisation

The context of analysis of this study is a health organisation: Naturidade. The selection
principles were: the organisation belongs to the Portuguese Network of Integrated
Continuous Care and is formed of two units: medium-stay and rehabilitation unit
(MSRU) and long-stay and maintenance unit (LSMU).
This organisation was chosen due to its ideal location, particularly concerning ease
of access for investigators, and as the health organisation is part of the National
Network of Integrated Continuous Care, an organisational model created in Portugal
(Law no. 101/2006 of 6 June), by the Ministries of Employment and Social Solidarity
and Health. This network is formed of a variety of public and private institutions that
provide continuous care and social support. Apart from these aspects, in selecting this
case/organisation, another criterion was the fact that the organisation is made up of a
multi-disciplinary team, which allows for more diversified data collection and a more
wide-ranging study, such as was intended with this investigation. The chosen
organisation is situated in the centre of Portugal and began operations on 16 June 2008.
In terms of size, this institution has a maximum limit of 30 beds in MSRU and 30 beds
in LSMU. As for staff, the organisation has a nursing and auxiliary staff totalling 63
collaborators.
3.3 Data selection and measurement

The fieldwork was conducted using several data collection methods (qualitative and
quantitative). Qualitative empirical data were gathered via in-depth interviews and
documental analysis, while quantitative data were obtained through a survey. As Yin
(1984) states, the adoption of various data sources is relevant, as it allows increased
validity of the construct and reliability of a case study. The same author adds that one
strength of case studies is the opportunity to use multiple data-gathering sources, i.e. to
use triangulation of data to obtain evidence.
LODJ To identify the leadership style and the components/pillars at the basis of
32,8 organisational learning, a semi-structured interview was held with the director of
Naturidade. The interview was held on 28 March 2010 and lasted about 45 minutes.
With the interviewee’s agreement, this was recorded. The interview protocol (Yin,
1984) was subjected to a pre-test so as to validate the vocabulary used in the
questions and ensure the latter allowed us to reach the intended objectives. To
792 identify leadership style, this protocol adapted some questions taken from the
questionnaire on description of leader effectiveness and adaptability (Hersey et al.,
2001).
This instrument is made up of 12 possible situations/items which a human
resources manager can be faced with. Each situation has four possible answers,
corresponding to different styles of leadership according to the leader’s interest in
personal relationships and task development. Therefore, according to Hersey et al.

(2001), people are asked to choose between four options (high task and low
relationship behaviour; high task and high relationship behaviour; high relationship
and low task behaviour; and low relationship and low task behaviour) the style they
think describes most closely their own behaviour in a given situation. This
instrument highlights predominance of one or another style in the person it is
applied to.
Concerning characterisation of the health organisation selected, documental
analysis was carried out. Yin (1984) states that documents play an explicit role in
any data collection exercise. The same author adds that documents have the
strengths of being stable (they can be referred to over and over again) and exact
(they contain names, references and details about an event). We therefore used
documents such as nursing staff, technical and auxiliary staff, protocol with the
Portuguese network of integrated continuous care and the internet site of the
organisation studied.
In the quantitative method, organisational learning was examined. Thus, to
measure this dimension, some surveys were considered:
.
the organisational learning diagnostic scale (OLDS) developed and standardised
by Pareek (2003);
.
organisational learning questionnaire constructed by Ellis and Globerson (1996)
and Ellis et al. (1999); and
.
learning organisation profile developed by Marquadt (1996).
However, in this study the “self-assessment survey” (The Conference Board of Canada,
2009) was used, because it was more adaptable to the Portuguese health context than
the other instruments. This tool measures organisational performance in five
dimensions/components: vision, infrastructure, culture, learning dynamics, and
training investment. In fact, these dimensions, based on solid research, make up the
critical elements characteristic of a learning organisation.
This scale/tool was administered to a random sample of 29 collaborators in the
multi-disciplinary teams of the two units in the organisation studied (MSRU and
LSMU) on 15 February 2010 with 28 questionnaires taken in on 22 March of the same
year. It should be noted that the population is formed of 63 collaborators, which
corresponds to a response rate of 44.4 per cent. Respondents rate their organisation for
each statement in each of the five components on a four-point Likert scale
(1 ¼ strongly disagree to 4 ¼ strongly agree). Then add up the total score and refer to Organisational
the assessment guide that follows to determine how their organisation rates concerning learning
its performance as a learning organisation. According to this tool we can achieve four
levels of organisational performance:
.
level 1 (basic level of performance);
.
level 2 (fundamental level of performance); 793
.
level 3 (strong level of performance); and
.
level 4 (high level of performance) – see Appendix.
3.4 Ethical procedures and data analysis

After selection of the data-gathering instruments, we proceeded to organisation and
analysis of the data. In this connection, the following procedures were undertaken:
.
Assessment of the possibility of carrying out the study in terms of accessibility
and framework. To do so, the general guidelines and objectives of the study were
presented to the Naturidade organisation, so that they could judge if this study
contributed to improving their organisational system.
.
The organisation was contacted personally for consultation of institutional
documents. After this contact, there was telephone contact to arrange the date of
the interview with the director.
.
The interview was held, and in parallel, the questionnaires were applied to the
collaborators. As data from the questionnaires were gathered, we transcribed the
interview from the recordings made. According to Carmo and Ferreira (1998, p.
218), “rigorous analysis of data is fundamental in any investigation and in the
case of a qualitative study, the investigator should analyse data as they are
collected”.
. In the qualitative method, content analysis technique for the interview and
document analysis was used. Weber (1985) and Patton (1990) define content
analysis as a technique of investigation that allows objective, systematic and
quantitative description of the content shown in communications, with the aim to
interpret it. Content analysis is a “distinctive approach to analysis” that seeks to
quantify the content of text in “a systematic and replicable manner” (Bryman,
2004, p. 181).
For the “self-assessment survey” (quantitative method), the data were treated with
two types of statistics, namely, descriptive analysis and the Pearson Chi-Squared
test. Firstly, separate tables interpret the scores for each individual component
considered in the “self-assessment survey” (see Appendix). Secondly, to identify
statistical differences between the two health care units studied (MSRU and LSMU),
the Pearson Chi-Square test was used. The data were analysed using SPSS 17.0
version.
To summarise, scientific validation was made of all the information treated through
the technique called triangulation, which consists of comparing information from the
multiple sources of evidence (interview, questionnaires and documents), so as to
determine coherence, accuracy and reliability.
LODJ 4. Findings and discussion
32,8 4.1 Characterisation of respondents/participants
The director of the organisation studied is 32 years old, began his professional career
as technical director and psychologist, and has a degree in psychology in the branch of
clinical and advice. Since 2008, he has held the post of director at Naturidade. Over his
professional career, he has enhanced his curriculum with very varied training, with a
794 special mention for his post-graduate studies in psychological consultancy and
psychotherapy.
After the questionnaires were completed (n ¼ 28 collaborators), it was also possible
to obtain a final sample of which the demographic and professional characteristics are
shown in Table II. Note that some of these collaborators exercise functions both in
MSRU and LSMU.
4.2 Organisational learning

Table III shows assessment of the level of learning performance according to
components/dimensions. From the information obtained from the questionnaires
administered to collaborators in the organisation studied and from descriptive
n Percentage
Age
20 to 24 21 75.0
25 to 29 6 21.4
30 to 34 1 3.6
Sex
Male 3 10.7
Female 25 89.3
Qualifications
Diploma 26 92.8
Post-graduate 1 3.6
Master 1 3.6
Professional situation
Nurse-coordinator 1 3.6
Nurse 18 64.2
Social worker 1 3.6
Director of services 1 3.6
Accounting 1 3.6
Administrative 1 3.6
Psychologist 1 3.6
Physiotherapist 2 7.1
Community worker 1 3.6
Speech therapist 1 3.6
Type of contract
Table II. Permanent position 1 3.6
Personal and professional Fixed term individual work contract 6 21.4
characterisation of Service provision 15 53.6
collaborators Work placement 6 21.4
Organisational
MSRU LSMU
Components/dimensions N1 % N2 % Chi-squared value learning
Vision
Basic level of performance 4 21.0 1 5.3
Fundamental level of performance 3 15.8 4 21.1 2.165 *
Strong level of performance 8 42.1 10 52.6 795
High level of performance 4 21.0 4 20.0
Infrastructure
Strong level of performance 8 42.1 8 42.1
Culture
Learning dynamics
Training investment
Strong level of performance 2 10.5 6 31.6 Table III.
High level of performance 6 31.6 5 26.3 Level of performance of
organisational learning
Notes: N1 ¼ 19; N2 ¼ 19; * Not significant by components
analysis, the results suggest that in the “vision” dimension in MSRU and in LSMU,
the greatest percentage of collaborators (42.1 and 52.6 per cent, respectively)
consider that the organisation they belong to presents a “strong level of
performance” (score of 18-20) believing therefore that “a systemic approach is in
place that is moderately responsive to the multiple requirements in this area. More
effort is required to ensure that learning is viewed and clearly communicated as an
essential part of the organisation’s success and employees understand how their
development and learning are connected to the success of the organisation” (The
Conference Board of Canada, 2009). However, the differences between these two
units are not statistically significant for this dimension.
Based on the interview held with the director, the present results also show that
organisational learning in Naturidade is set in the “vision” component. About this
dimension, the interviewee says:
Learning takes on special importance, in terms of vision, when in my view collaborators are
an integral part of a developing process which is expected to be solid and progressive, based
on sharing and motivation to attain objectives. Indeed, top management should make it clear
that learning is crucial for success.
LODJ Regarding the component/dimension of “infrastructure”, the results obtained indicate
32,8 that in MSRU the greatest percentage of collaborators (42.1 per cent) consider the
organisation presents a “strong level of performance” (score of 27-31) believing that “a
systemic approach is in place that is moderately responsive to the multiple
requirements in this dimension. More effort is required to ensure that the organisation
supports learning in concrete ways and employees have continuous learning and
796 development opportunities” (The Conference Board of Canada, 2009).
In LSMU the greatest percentage of collaborators (47.3 per cent) considers the
organisation has a “fundamental level of performance” (score of 22-26). Therefore, they
consider that “the beginning of a systemic approach to the basic purpose of this
component is evident. Organisations at this level are generally reactive to problems
rather than continuously striving for improvement. Major effort is required to ensure
that the organisation supports learning in concrete ways and employees have
continuous learning and development opportunities” (The Conference Board of
Canada, 2009). Also here, the differences between MSRU and LSMU are not
statistically significant.
As for “culture”, in MSRU the greatest percentage of collaborators (47.4 per cent)
believes the organisation presents a “strong level of performance” (score of 27-31). In
this way, collaborators consider that “a systemic approach is in place that is
moderately responsive to the multiple requirements in this area. More effort is required
by the organisation to encourage employees to be adaptable, curious, and independent
and to feel free to challenge established ways of operating” (The Conference Board of
Canada, 2009). In turn, in LSMU the greatest percentage of collaborators (57.9 per cent)
underline that the organisation presents a “fundamental level of performance” (score of
22-26), that is, according to the self-assessment tool, “the beginning of a systemic
approach to the basic purpose of this area is evident. Organisations at this level are
generally reactive to problems rather than continuously striving for improvement.
Major effort is required to ensure that the organisation encourages employees to be
adaptable, curious, and independent and to feel free to challenge established ways of
operating”. From the results presented, the differences between these two units are not
statistically significant for this component.
About this dimension, the director says that:
Culture concerns the management perspective where the whole must be much more than the
sum of its parts. We must set out from the individual to the global aspect, transmitting the
importance of each one individually and their responsibility for the whole.
According to the literature review, to reach a high level of performance in the aspect of
culture, organisations must have a philosophy that supports change and makes
collaborators feel free to challenge the way things are done (The Conference Board of
Canada, 2009). Collaborators should be encouraged to share knowledge and face
problems as work opportunities, as well as being encouraged to accept new tasks and
increase and improve their level of knowledge and learning.
In the dimension of “learning dynamics”, the greatest percentage of collaborators,
both in MSRU (57.9 per cent) and LSMU (52.6 per cent) consider the organisation at a
“strong level of performance” (score of 27-31). In this measure, the greatest percentage
of collaborators considers that “a systemic approach is in place that is moderately
responsive to the multiple requirements in this area. More effort is required to ensure
that continuous learning is at the core of how staff operates and practices are in place Organisational
to support both informal and formal learning. Systems and structures exist to ensure learning
that knowledge is captured and managed and staff can generally find the information
and knowledge required to operate” (The Conference Board of Canada, 2009).
Also concerning this dimension – learning dynamics –, the director states that:
Learning/doing with taking responsibility not being equal to punishment promotes a space of
individual, and consequently collective, growth. 797
Barrett (1995) corroborates this statement, arguing that collaborators should be guided
to develop their capacity to learn and that they learn from their successes and failures.
In the area of “training investment”, Table III shows a marked discrepancy among
collaborators in MSRU. Whereas 42.1 per cent consider the organisation at a “basic
level of performance” (score of 16 or less), 31.6 per cent consider the organisation at a
“strong level of performance” (score of 21-24). Therefore, the greatest percentage of
collaborators (42.1 per cent) considers that “there is little/no evidence that a systemic
approach to the basic purpose of this area is used. Continuous learning is not at the
core of how staff operates, and few practices (if any) exist to support continuous
learning in either formal or informal settings. Generally, systems and structures do not
exist to capture and manage knowledge. Substantial effort is required” (The
Conference Board of Canada, 2009).
As for LSMU, collaborators consider the organisation at a “strong level of
performance”. Therefore, the greatest percentage of collaborators (31.6 per cent)
believes that “a systemic approach is in place that is moderately responsive to the
multiple requirements in this area. More effort is required to ensure that continuous
learning is at the core of how staff operates and practices are in place to support both
informal and formal learning. Systems and structures exist to ensure that knowledge is
captured and managed and staff can generally find the information and knowledge
required to operate”. Note that the differences between these two units are not
statistically significant.
The director also states that learning dynamics is:
Fundamental for the organisation’s collective growth, as it allows the share of specific
technical knowledge, which allows the entire team of collaborators to acquire a much more
general body of knowledge.
Indeed, the interviewee considers “learning dynamics” to be fundamental as a factor of
the organisation’s quality and success, something which is claimed by the literature
revealing that organisations must invest in collaborators’ learning and training
(Pantoja and Borges-Andrade, 2009).
4.3 Style of leadership

Analysis of leadership style was based on situational leadership, more precisely on the
model by Hersey et al. (2001). This model indicates there is no one universal style for all
situations.
The director states that faced with resolving a situation:
Everything depends on the growth shown by the group over time, but to intervene and
implement, it becomes important to diagnose well, and I think that aspect would be the
starting point for resolving the solution.
LODJ The interviewee also states that faced with a fall in workgroup productivity:
32,8 I would try to strengthen the group spirit, and promote the positive relationship through
group dynamics that would give awareness of the individual’s importance in the whole, so
that together it became possible to reach objectives, besides involving collaborators in
decision-making.
798 Orientation to productivity and to interpersonal relationships is notable in the

characteristics of the “selling or persuading” style. According to the literature review,
this leadership style is based on great orientation to the task or productivity and also
great orientation to interpersonal relationships. Indeed, Papworth et al. (2009) claims
that in this style, leaders adopt a stance that shows people the change can be beneficial.
This idea is reinforced by the interviewee when answering that, in the case of increased
productivity in his work team:

I would try to maintain levels of satisfaction and productivity, implementing or maintaining
motivational strategies, which could be positive reinforcement of behaviour and some reward
strategies (days off, financial bonuses . . .).
The director also says that faced with a problem the work team did not manage to
solve:
I would make personal help available or suggest strategies that helped to get a group
decision, which could be specialised opinions from outside the group.
The leader of this health organisation also states that, faced with a restructuring
process, suggestions presented by his collaborators would be:
Fundamental, and if appropriate from the group’s point of view, they would have a strong
chance of being implemented as soon as possible.
Through this content analysis of the interview held with the Director in the case study,
we find the predominant leadership style is that of “selling or persuading”. According
to Hersey and Blanchard (1979), in this style most of the direction is still provided by
the leader. Through two-way communication and explanations, the leader may guide
the followers towards desired behaviours. The leader should therefore adopt a
persuasive stance, adjust the message to the characteristics of the receivers and show
people how the change can be beneficial for them.
4.4 A comparative analysis

According to the results obtained from the collaborators (quantitative method), was
find that the components to improve the performance level of learning in this
organisation are “infrastructure” and “culture” (LSMU) and “training investment”
(MSRU). However, from analysis of the interview with the Director (qualitative
method), we found these dimensions are the least explored in Naturidade.
The interviewee only mentions that, in the area of organisational culture and
knowledge and management of infrastructure, it is important to know that the whole is
more than the sum of its parts and that it is important to transmit to each member his
importance and responsibility in the whole. However, in the area of culture, according
to the literature, for a learning culture there should be incentives for collaborators to
learn and experiment (Barrett, 1995; Leitch et al., 1996) and life-long learning processes
covering learning and continuous training.
In this connection, collaborators should feel free to challenge the way things are Organisational
done in the organisation and the organisation itself should encourage collaborators to
face problems as learning opportunities and discuss failures with them from a critical
learning
point of view. According to Amagoh (2009), a leader influences people’s thoughts,
behaviour and/or feelings, having an impact on the culture of the organisation. It is
therefore important for top management to actively support change and frequently get
involved with collaborators in important decision-making. 799
As for the dimension of “infrastructure”, the literature review demonstrates that to
reach a high level of performance, an organisation should adopt a position of firm
support for knowledge and learning. It is fundamental that this knowledge is captured,
shared and is easily accessible to those who need it. What is more, the literature claims
that an organisation that achieves this component globally is a challenging
organisation that encourages its collaborators to accept new tasks and increase and
improve their level of knowledge.
Concerning the component of “training investment”, no relationship is found
between the results of the level of performance of this dimension and what is claimed
by the head of the Naturidade organisation. The interviewee states that “training
investment” is fundamental for the organisation’s growth. However, despite this being
the component presenting the lowest level of performance in UMDR, this fact was not
confirmed in LSMU.
In the other dimensions: “vision” and “learning dynamics”, no differences were
found between the results obtained qualitatively (interview) and quantitatively
(survey) – Figure 2.
Figure 2 shows that the components of organisational learning, namely vision,
infrastructure, learning dynamics and training investment are associated with a
particular kind of leadership style (selling or persuading) practised in the health
organisation studied, more precisely, in the context in which the organisation has been
operating. In addition, organisational learning and leadership impact at different levels
of organisational performance.
5. Conclusions and implications

In the current climate, it is important that health organisations are prepared to face
change, and the need therefore exists for them to strengthen their capacity to respond
Figure 2.
Synthesis of qualitative
analysis vs quantitative
analysis
LODJ accordingly. In this connection, developing organisations’ learning capacity is the
32,8 basic requirement for them to consolidate professional competences, teamwork and
form democratic relationships with leadership. To be transformed into a “learning
organisation” an organisation needs its leader’s support. Thus, the objective of our
study was to understand the role and association of leadership and organisational
learning in a Portuguese healthcare organisation.
800 Based on the results obtained, in terms of management, a “selling/persuading”
leadership style was identified in the organisation studied where, according to Hersey
and Blanchard (1969, 1979, 2001), there is concern with task behaviour (defining tasks,
deadlines and patterns of action) and with relationship behaviour (facilitating group
interaction, supplying information, being open to change, decisions supporting the
group, concern about people, etc.).
Still in terms of management, the study showed that least marked

dimension/component of organisational learning in management policy was culture. In
addition, this study also confirmed that in this health organisation there is a relationship
of influence between leadership style and performance level of organisational learning.
From another angle, it was found that the dimensions where top management gave less
emphasis (culture) were those which revealed a lower level of performance. This fact
corroborates the statement that there is a relationship between the dimensions on which
the organisation’s learning is based and those which increase the learning capacity.
In this study, the implications for practitioners are particularly evident. There is a
common premise among managers, researchers and consultants that due to
globalisation, intensified competition and rapid changes in technologies, customers’
priorities and so forth, organisations’ ability to learn fast and effectively becomes
crucial for their adaptability and survival. In practice, systematic efforts by
organisational leaders to create and maintain learning in organisations have been
practically marginal. The study shows not only the kind of dimensions necessary for
organisational learning to occur and be effective, but also exemplifies the role of certain
leader behaviours in organisational learning in the health context.
This paper also provides several insights and managerial implications, in terms of
organisational learning and leadership. Thus, we present some recommendations:
.
It is important that health managers/leaders recognise the value of learning as a
continuous collective process. Productive organisational learning is important
for both the organisations and for the quality of working life.
.
Health organisations that engage in organisational learning enable staff at all
levels to learn collaboratively and continuously and put this learning to use in
response to social needs and the demands of their environment.
.
Leadership practices are important in developing specific training programs
(technical as well as behavioural) in order to help collaborators articulate a
shared organisational vision that is task-oriented, inspiration-oriented and
communication-oriented.
.
The role of leader is crucial to help all collaborators to establish certain
mechanisms of organisational learning, as well as encouraging the staff to act in
ways that seem helpful in making the vision operational within health
organisations.
This study has some limitations. One of the main limitations concerns the fact that this Organisational
study is restricted to just one case/organisation (study of a single case). Although this learning
type of investigation approach provides wide and specific knowledge, it implies results
and implications only for one particular case which cannot be generalised. Thus, future
studies should extend the research to different kinds of organisations, addressing
different purposes, environments, workforces, and so forth.
Another suggestion for future research would be application of this study, after 801
some time, in order to confirm if the organisation studied here or others evolve towards
a high level of organisational learning performance. Also the adoption of direct
observation as a methodological procedure to allow more detailed and thorough study
in this area of investigation should be considered. Despite these limitations, we
nevertheless believe the results obtained and the conclusions drawn from this study
can form a valuable contribution towards understanding the subject of organisational

learning and leadership in health organisations.
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LODJ Appendix
32,8
Dimension Score Level of performance
Vision Score of 21 or more Level 4 (High level of performance)

Score of 18-20 Level 3 (Strong level of performance)
Score of 14-17 Level 2 (Fundamental level of performance)
806 Score of 13 or less Level 1 (Basic level of performance)
Infrastructure Score of 32 or more Level 4 (High level of performance)
Score of 21 or less Level 1 (Basic level of performance)
Culture Score of 32 or more Level 4 (High level of performance)

Learning dynamics Score of 32 or more Level 4 (High level of performance)
Training investment Score of 25 or more Level 4 (High level of performance)
Table AI. Score of 16 or more Level 1 (Basic level of performance)
Summary of results in
“self-assessment survey” Source: Adapted from The Conference Board of Canada (2009, pp. 9-10)
About the authors

Mário Franco is an Assistant Professor of Entrepreneurship and SME Administration at the
Department of Management and Economics, Beira Interior University, Portugal. He received his
PhD in Management from Beira Interior University in 2002. In 1997, he was a doctoral candidate
and participated in the European Doctoral Programme in Entrepreneurship and Small Business
Management in Spain and Sweden. His research focuses on strategic alliances, business
networks and organisational learning. He is also a member of a Research Unit (NECE) and
currently involved in several research projects. Mário Franco is the corresponding author and
can be contacted at: mfranco@ubi.pt
Joana Almeida is Coordinating Nurse at Naturidade Rio Maior – Unit of Integrated
Continuous Care. She graduated in Nursing in 2008 at Coimbra College of Nursing. She
completed a Master in Health Unit Management in 2010. The investigative work she has carried
out deals with the role of leadership in organisational learning in healthcare organisations.
To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

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1. Johan M. Berlin. 2015. Doctors’ functional leadership in psychiatric healthcare teams – a reversible
leadership logic. Team Performance Management: An International Journal 21:3/4, 159-180. [Abstract]
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Leadership & Organization Development Journal

Organisational learning and leadership styles in healthcare organisations: An

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Unit of Integrated Continuous Care, Arrouquelas, Rio Maior, Portugal

organisational performance, including organisational learning. For Roberts (1970),

2.3 Organisational learning and leadership in health organisations

Telling or directing High Low There is great orientation to the task or

bureaucratic control (Boyle, 2002).

3.2 Case selection and characterisation

3.3 Data selection and measurement

personal relationships and task development. Therefore, according to Hersey et al.

3.4 Ethical procedures and data analysis

4.2 Organisational learning

4.3 Style of leadership

798 Orientation to productivity and to interpersonal relationships is notable in the

productivity in his work team:

4.4 A comparative analysis

5. Conclusions and implications

Still in terms of management, the study showed that least marked

can form a valuable contribution towards understanding the subject of organisational

Universidade Aberta, Lisboa, ISBN: 978-972-674-231-9.

Psychiatry, Vol. 16 No. 3, pp. 173-8.

Vision Score of 21 or more Level 4 (High level of performance)

Culture Score of 32 or more Level 4 (High level of performance)

About the authors

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