6.1.2.1. From a negative definition…

Historically, the hospital is a welcoming place of compassion that has no space for questions of leadership. In French-speaking countries, a hôtel-Dieu (hostel of God) was a church-run hospital oriented towards the chapel, where patients (the etymology of which is “those who suffer”) prepared their soul for the afterlife [IMB 91]. This long period stretches from the birth of the hospital in the 13th Century to the end of the 18th Century, with the birth of the clinic [FOU 63], and even more specifically, the official introduction of the medical profession into hospitals at the beginning of the 1940s. Along with the arrival of new medicines and treatments, the hospital then entered into the era of effectiveness wherein the doctor embodies a “hero” triumphant in the face of illness.

6.1.2.2. … to a heroic leader defeating illness

The traditional battles fought by doctors since medicine’s cures began to be widely effective, that is to say for no more than 60 years, were classically easily identifiable: the face of the enemy is disease and death, and the doctor has therefore been classically presented as the hero of modern times, much like Dr Rieux in Albert Camus’ The Plague. This fight took on different forms throughout the 1980s when institutional medical practice was geared towards obtaining new technologies the use of which was under the control of the administration. However, the fight was certainly worth it, and everyone’s place remained legitimate, clear and comprehensible. Since then, the “advances” of medicine have perhaps been less spectacular, from the feeling of helplessness in the face of HIV/AIDS, cancer, chronic diseases, etc.

The doctor’s place in society has also evolved: M. Robelet and N. Lapeyre [ROB 06, ROB 08] have shown the ways in which junior doctors’ expectations and their social values system are much more aligned with a conventional model (that is, one that conforms to the expectations of “normal” citizens) than their elders.

Furthermore, the doctor’s responsibility in society has moved somewhat from the moral field (exemplarity) to the penal field, experienced as traumatic and as a source of nightmares and verbal tics that express a feeling of loss of the profession more than real facts: it is a fact that the phenomenon has been made public through the media that is unbearable to a community historically constructed on notions of sacrifice and sacredness.

Another element contributes to destabilizing the traditional model: the growing demands of formalization in written documents, which always puts into question the informal relationships between the doctor, nurses and the patient. Indeed, while written documents make assurances for the traceability of doctors’ acts, it puts forward from the offset a demand for proof, that the act be formalized in writing, thus substituting trust for mistrust (it is at least perceived as such).

In the end, the doctor’s legitimate field of action is becoming not only more and more porous, but also more and more vague.

6.1.2.3. Skills separated into good management of the public, healthcare skills and medical-technical skills

Hospitals must meet various demands: personalizing patient treatment, reducing the length of patient stays, welcoming all parts of the population, and also training and progressing research, all within a fraught economic context. The hospital as an institution has therefore witnessed, within its very organization, the development of skills that are increasingly precise, technical, and also more and more closed off from one another. The medical efficiency seen in the second part of the 20th Century contributed to a hyperspecialization of healthcare professionals, tending to compartmentalize patient treatment and thereby leaving behind a more general approach. According to the diagnosis-related groups (DRGs) system, the medicalized database system, the ultimate proof of this compartmentalization, splits patients into hundreds of “homogenous patient groups”, whose shared similarity nearly exclusively refers to the pathology being treated. Similarly, the ever-growing pressure to disclose to the State the use of public funds has caused the processes of pricing, of the formalization of service quality and of engineering project activity to become hyper-technical, in order to be able to respond to bids. In short, healthcare skills have been left by the wayside, just as the “interpersonal” has been abandoned for the benefit of a formalized follow-up system meant to ensure that treatment is continued, both in the hospital and at other stages of treatment. As a result, for different yet simultaneous reasons, the three traditional jobs of the hospital have undergone a transformation of their function to one that is more technical, all the while keeping the essence of their fundamental aims. It is, therefore, logical, under these circumstances, that the traditional representations of hospital leadership will also evolve by following different models.

6.1.3.1. Leadership skills, a primarily interpersonal phenomenon

Leadership, as understood in a relationship of exchange, traditionally appears in two forms: transactional leadership and transformational leadership [BAS 85, BAS 90].

Transactional leadership founds the relationship of exchange on a “contribution/reward” sort of approach, taking inspiration from the contractualist movement. The transactional leader thus manages their team by making exceptions, evaluating the gap between performances and the defined rules and terms of the contract. The immediate consequence is that this type of leadership is only apprehensible through sanctions and rewards.

Transformational leadership transcends this definition, relying on the idea that the vision, enthusiasm and energy of a leader play key roles in their ability to mobilize a team. For this leader, it is a question of making their vision and values as explicit as possible, and committing to creating an atmosphere of trust through certain ethics of action. According to this point of view, the transformational leader makes themself visible, and expresses their vision through their attitude and acts, acting as a sort of “role model” for others. Theories of transformational leadership [BUR 78, BAS 85] associate the emergence of leadership with a process wherein leader and team members outdo themselves on an emotional basis and interests in common or of the need to fulfill oneself. Leadership is therefore largely founded on the appropriate manipulation of language. The leader tells a “story” that lends an appropriate meaning to the situation at hand, at least for those who are listening [FAI 96]. They know, through their communication, how to reduce the complexity of the surrounding social and informational context, and/or play a mediating role between the actions of the group and its environment [WEI 69, WEI 95, WEI 78, BAR 96, THA 88]. The leader commits to constructing and then giving a meaning to the content communicated as well as different ways of communicating, with the goal of encouraging members of the group to excel.

Belet [BEL 13], referencing Dierendonck and Patterson [DIE 10], appeals to the term “servant leadership”, attributed to Greenleaf, which dates back to 1970. Here, it is a matter of moving from a classical logic of authority and control of subordinates to an attitude of listening, service and support in a context where all participants are given responsibility. According to Greenleaf, “servant leadership” differs from other approaches of leadership both in the way of acting it encourages and the principles behind this.

In addition to transformational leadership, another emergent theory of leadership is “spiritual leadership”. This form of leadership allows the leader to develop skills on different levels. They are thus able to manage emergency situations, know how to connect with others, construct efficient procedural systems, delegate responsibility, share an inspiring vision, cooperate with others, have compassion and cultivate wisdom [VOY 11]. In this model, the leader makes an effort to develop values that transcend his or her ego. They value people, listen to them and put others’ needs before their own. In this respect, the theory is similar to “servant leadership” and the “ethics of care”, which we will discuss later.

It is important to note that the models of “servant leadership” and “spiritual leadership” do not bring out the person’s innate characteristics, or even traditional acquired skills, but rather demands working continuously on personal development, tackling aspects of their identity on a professional, emotional, mental, psychological and spiritual level.

Breaking with leadership approaches that center on a single person, in recent years work has been carried out in tandem with the work of Retour [RET 02] on collective skills, which stresses the collective, indeed the communal, nature of leadership. This work evokes shared and distributed leadership [BOL 11] or even “communityship” [MIN 08].

The evolution of organizations and the way they function towards more transversal models that are decentralized in favor of networks put into question leadership focused on one or a few people. Thus, leadership here would not concern solely “top management”, but all different levels of management, including line managers [VER 13].

Shared leadership is thus defined:

“a dynamic and interactive process of influence between individuals of a group, whose aim is to achieve certain objectives, both individual objectives and those shared by the group […] this process often involves lateral influence or influence between peers, and also influence from above or below in the hierarchy” (Pearce and Conger, 2003, translated and cited by Vernazobres [VER 13]).

In this approach, each person’s leadership potential represents their ability to express their opinions, their personal vision, their own value system and their commitment to action. The implementation of conditions favorable to contact and exchanges of points of view is thus carried out on the basis of these skills, values and behaviors.

This vision of shared leadership interests us because of the new polar organization that is being put in place in hospitals. Shared leadership could be a suitable model for an organization known for its tendency toward compartmentalization and power struggles, as are hospitals.

6.1.3.2. Towards a co-constructed or shared leadership in hospitals

This exploration of the different conceptions of leadership allows us to better understand to what extent trying to integrate new public management into the hospital’s setup is a real change for an institution accustomed to bureaucratic management. By trying to base the methods and tools it uses on those used by a private company, without considering the cultural specificities of the hospital and without giving particular attention to the specificity of treatments and bedside care, NPM can be both harmful and cause professionals to reject the changes. In this context, the search for efficiency, and indeed for performance, cannot occur without a genuine wider reflection on health, on personal treatment (and not solely general “healthcare options”, which can become depersonalized) and on the population benefiting from this healthcare. The raison d’être of the hospital is changing as, after three decades of being concerned above all with the treatment of acute bouts of illness, it has had to adapt to treating an increasingly older population with chronic diseases. This population also wishes to be more informed and is able to search, on Internet forums for example, for information about the hospital and/or the clinic where they have been (or should be) hospitalized. A drastic evolution is thus taking place in the heart of healthcare relations, which the rationalizing research of the NPM model will struggle to transform into indicators of performance.

The rationalization of organizational processes, if necessary, does not suffice to transform the hospital. The overturning of the concept of leadership that we have just discussed leads us to think that hospital management can be enriched through the development of “shared leadership” by developing leadership skills throughout the different levels of the hierarchy, and also within teams with the support of experts who favor the transmission of skills.

A model of shared leadership, in the case of the hospital, implies that individual professionalism be taken into account, in terms of what comprises the core of each large professional group’s job. By encouraging people’s talents and assisting in the development of individual skills, combatting compartmentalization with interaction and professional exchanges, shared leadership would hypothetically facilitate an evolution towards a system of organization based on both learning and collective intelligence.

6.1.3.3. Emergent skills: patient expertise

“This is one of the paradoxes of the hospital: welcoming each patient by recognizing their most human qualities and being constantly at the cutting edge of medical techniques. Technique will never eclipse human beings. Constantly thinking about the other in the nursing relationship is one of the founding tenets of our ethics” [EVI 02].

The user, even if he or she is not yet referred to as the client, no longer wants to be known as the “patient”. They are becoming an increasingly informed participant, in particular because of the Internet. They learn about diseases and therapies, and enquire on forums about how renowned a clinic is and/or the skills of the professionals they are likely to be referred to by their general practitioner.

In hospitals, the personnel responsible for such “expert patients” are more and more distanced from treatment. They may feel as if they are spending more time on administrative tasks than with patients. Holistic treatment, put forward from the 1970s through to the 1990s, a form of treatment that proposed taking the patient into account in their totality, is increasingly giving way to technical acts to be carried out by following protocols and precise procedures, meant to guarantee the quality of treatment with pressing time constraints. Yet prescribed work never coincides with real work and a too strict application of the former would impede the proper functioning of organizations (Faberge and Ombredane, 1955 cited in [DUJ 12]). Real work includes a part of the intelligence engaged in tandem with prescribed work, to arrive at the ultimate result of accomplished work. Experienced work refers to the way in which the subject undergoes, interprets and gives meaning to the work being done, including the conditions under which this work is completed. It corresponds to the overall interpretation made by the subject, and the meaning they give to their actions [DUJ 12].

Today, this experience has progressed to a feeling of no longer doing the job you initially signed up for. Thus, we might speak of a feeling of “impeded” work. The vast majority of nurses, doctors and medical support staff complain of not doing what should constitute the core of their job. They vocalize the fact that increasingly numerous and time-consuming administrative tasks distance them from the patient. They do not spend as much time as they would like around patients, to listen and support them, and apply, under the suitable conditions, the skills they have acquired. However, this dimension of the job (their vocation) was one of their main motivations when they became junior doctors. This feeling of not doing one’s job well, where the job you wanted to do is merely dreamed of, creates a feeling of unease that can cause suffering at work.

A lack of autonomy, ethically motivated distress, and the degradation of interprofessional relationships are often expressed as factors of exhaustion and psychosocial risks at work. The agents in question also seem to be exhausted by, or rather suffer from, the lack of any middle managers. To support them, it would be necessary to liberate middle managers, too occupied with both the reporting activities necessary to keep the “management machine” running and with various meetings, “the participative management style” [DET 13]. “Discussion spaces” could make it possible for personnel to rediscover or reconstruct the meaning of their work.

According to Chaine [CHA 12], “management seems to be in the process of becoming a risky practice, potentially making companies a place that produces victims”. The hospital does not escape this fate. However, as a place of care par excellence, we could imagine that it retains at its heart certain knowledge sets and know-hows to maintain health and prevent as many health risks as possible. “Care taking” now concerns patients as much as it does hospital professionals and creates an unexpected paradox in the nature of the relationships between patients and nurses, the consequence of which is a hybridization of professionals’ skills.

6.1.3.4. The consequences for skills: a hybridization between management, care-related and medical skills

The hospital director must also become a manager that “transmits meaning” in this chaotic context, where change is no longer a one-off occurrence but near constant. Many young professionals no longer want to go into the health sector, nor to work in hospitals as a vocation; they are looking for a career in which they will be recognized and listened to. D’Iribarne [CHE 12] points out that young people want to see a genuine evolution in management practices, putting into question:

“the management tools (reports and forms of procedural management) that overwhelm them, because these tools distract them from what they have to do, and furthermore they know that these are for the most part not useful as they are not put into use”, but also “the internal contradictions of the demands of management (those notoriously paradoxical demands with no practical solution)” and “the managerial practices the verticality of which contrasts with participative discourses: you are our colleagues, we need you and your involvement, you are the true worth of the company […] but you must not cost us too much”.

Naturally directors and middle managers are aware of these changes and take a noticeable interest in models of innovative management that could be adapted to the hospital of today and tomorrow. Certain philosophers are becoming increasingly familiar with, or being invited into, the world of managers to analyze the similarities and conflicts between technocracy, rationalization and ethical values to be encouraged in the context of the transformations hospitals are currently undergoing.

6.2.2.1. Leadership skills geared towards healthcare teams

Denis, Lamothe and Langley [DEN 01] have shown that leadership in hospitals now implies more of a team leadership than a leadership of the “heroic” type. In this perspective, the doctor is clearly positioned in the role of scenario-management, or “enrolment” as Weick understands the term, to the extent that it is a question of making as visible as possible the plan, so that it becomes irreversible. We can understand organizational leadership in this particular framework, to the extent that it does not call for traditional managers, but professional healthcare workers trained for management. McNulty and Ferlie [MCN 02] have empirically shown that all changes in a hospital initiated solely by managers are bound to be marginal and of limited consequence. As a result, emergent leadership skills are indeed interfacing skills between several professional communities, notably doctors and managers.

6.2.2.2. Hybrid leadership skills for “medical management”

In a “professional bureaucracy” such as the hospital, Mintzberg [MIN 79] explains that the by-and-large autonomy of professionals can come into conflict with the administrative hierarchy, but also with the technostructure if the latter does not integrate the professionals. Thus, sources of motivation are to be sought after in all aspects characterizing the professional skill of the clinical doctor, with regard to knowledge as well as clinical practices. We can interpret this position as the necessity to give a medical finality to management processes. This requires on the part of the clinician a detailed knowledge of logic and management techniques, at the risk of his or her becoming demotivated because of the time it takes to acquire these methods.

The hybridization of skills between managers and doctors also depends on the voluntary construction of communal and interpersonal rules in the clinical management of the hospital. However, this can reveal a major problem in hospital management, running the risk of confusing people’s roles creating a scenario wherein, for example, a clinical leader might try to tackle management problems without the necessary skills for the task. It is therefore essential to make the rules of the game explicit when it comes to both sets of people’s intervention, and to recognize each professional’s legitimacy in their role. Thus, power is no longer thought of from a personal point of view, but in light of the skills and roles that each person is willing to fulfill and that the institution of the hospital is willing to entrust them with.