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Abstract

Despite a growing interest in collective and distributed forms of leadership to meet the current challenges in healthcare organisations, little empirical research has focused on the manager role in studies with a collectivistic leadership ontology. To address this gap, we applied the concept of relatedness from Self-Determination Theory to analyse the work of managers across various organisational levels in a high-performing Swedish healthcare region. The analysis showed how the managers performed three types of work (contribution-, unconditionality-, and connection-work) that enabled autonomous motivation by supporting the basic psychological need for relatedness and, in turn, experienced that others were supporting their basic psychological need for relatedness. Thus, the study highlights the recursive nature of relatedness and the mutuality between organisational members. In addition, it reintroduces the role of managers into the collective leadership discourse by showing how they actively coordinate leadership towards the purpose of the organisation. The combination of Self-determination theory and collective leadership contributes to an alteration of the crucial question that managers should ask themselves, according to the Self-determination theory. Rather than asking, how can I, as a manager, create a work environment in which individuals motivate themselves, we propose the question of importance to be: How can we, as managers and employees, in this organisation, together create a work environment in which we can motivate ourselves?.

Keywords

collective leadership healthcare managers leadership relatedness self determination theory

Introduction

Previous research has shown that managers have significant influence over workplace motivation. It has been shown that managers can increase endurance, creativity, and well-being in organizations by adopting supportive interpersonal approaches, thereby creating a positive work climate (Deci et al., 2017; Kohnen et al., 2024; Skakon et al., 2010). The experience of one’s direct manager has been proposed as the most influential factor for employee engagement and motivation (Rigby and Ryan, 2018). Nevertheless, despite their crucial role in initiating and maintaining motivational processes, many managers are unsure how to motivate their staff and what behaviours and strategies to engage in (Forner et al., 2020). Therefore, research providing concrete examples of managerial behaviours and strategies that may increase autonomous motivation, performance and well-being, and enable a work environment where people thrive and develop is needed (Deci et al., 2017; Forner et al., 2020).

This is not least the case in the healthcare sector where a current workforce crisis, with a shortage of staff and experiences of deficient working environments leading to symptoms of stress and burnout (Riethof et al., 2020; Stehman et al., 2019; Woo et al., 2020), presents enduring and enormous leadership challenges (West et al., 2020). Deficient managerial leadership and unsupportive workplaces that lead to lack of engagement and motivation have been suggested as reasons why healthcare personnel, including staff and managers, leave healthcare (Atta Poku et al., 2025; Corin et al., 2022).

Lately, collective and distributed forms of leadership have been proposed as a way for healthcare organizations to meet these challenges (Beirne, 2017; Gillies et al., 2021). However, inconsistency in how to understand collective and distributed forms of leadership (Ospina et al., 2020) as well as the tendency to neglect the role of managers in collective leadership research (Holm, 2023) makes it hard to apply them in practice, neither as tools for analysis, nor for conceptualizing practitioners’ actions (Svensson and Von Knorring 2025). Even so, we argue that the collective leadership literature is imperative to attend to when understanding how engagement and motivation can be promoted in organisations.

In our research we adhere to theory that regard leadership to be a collective phenomenon (see for example Denis et al., 2012; Empson and Alvehus, 2020). In this study we will put focus on the manager role and adhere to perspectives that acknowledge the importance of how managers and other formally appointed leaders understand and think about their role, their work and their leadership, for the importance of the leadership that they execute (see for example Holm, 2023; Shondrick et al., 2010).

The research presented in this paper is part of a larger ethnographic study conducted in a high-performing (i.e. concerning quality of care, employee well-being and patient satisfaction) Swedish Healthcare Region. The overall purpose of the larger study was to explore how leadership (as distributed) was performed through every-day work by organizational members in different parts and on different hierarchical levels in a high-performing Region (see also Svensson and Von Knorring, 2025). The study presented here build on interviews with managers at various organisational levels in the Region and explores how the managers reason about their work and leadership.

The common nominator for collective leadership research has been to focus on “the dynamic, collective, situated, and dialectic qualities of leadership” (Denis et al., 2012: p. 68) performed by multiple individuals Crevani & Endrissat (2016). It thereby challenges traditional ways to understand leadership, which posits that leadership is typically done by a few designated individuals, particularly the formally appointed manager, at the advantage of understanding leadership as a distributed and collective process (Van De Mieroop, 2020) taking place through, and in, every-day interactions (Sergi, 2016). Collectivistic leadership theories embrace the idea that different people with different skill sets contribute to the total production of leadership, thereby improving the collective ability to meet challenges faced by organizations (Yammarino et al., 2012). Thereby, leadership is understood as a phenomenon which involves multiple people interacting over time to accomplish organizational goals (Gadelshina, 2020; Gronn, 2009; Yammarino et al., 2012). Yammarino et al. (2012) described this collective phenomenon in terms of a “we” (p. 382).

By providing all organizational members with greater levels of influence and autonomy, collective forms of leadership are thought to improve job satisfaction (Denis et al., 2012; Holm, 2023; Yammarino et al., 2012). However, while research on collective leadership has described how managers prevent collective leadership practices from evolving (Holm, 2023), not much collective leadership research has focused on how managers enable autonomy and autonomous motivation. Although the literature on collective leadership acknowledges that people occupying formal manager positions uniquely affect leadership (Elliott et al., 2020; Gronn, 2009; Harris, 2013), little empirical research has been done to understand the influence of formally appointed managers in studies with a collectivistic leadership ontology (Denis et al., 2012; Holm, 2023) and how the co-enactment of collective and hierarchical leadership can be understood in complex organizations (Fairhurst et al., 2020).

We attend to this gap, by combining a collectivistic understanding of leadership, in which we regard leadership as inevitably distributed in practice, with putting focus on the manager. Acknowledging how managers enable collective accomplishment (c. f. Ospina et al., 2020) we follow Denis et al. (2012) who stated that: ‘Scholarship in the field of leadership does not necessarily gain by moving from a view of leadership as individual heroism toward an equally naïve democratic ideal in which leadership is an organizational quality shared by all’ Denis et al. (p. 274). To push the exploration of leadership further and make collective leadership more relevant in practice, there is a need to move away from its (theoretical) separateness from hierarchy by acknowledging that collective leadership does not equate to the absence of any hierarchy in an organisation, as well as move beyond the question of what types of theoretical understandings is better, to how different understandings of leadership interrelate (Denis et al., 2023; Fairhurst et al., 2020; Souza et al., 2025). To do this, there is a need to acknowledge all members in an organisation, including those in formal managerial or supervisory positions, as part of the “we” in collective leadership research. In this study, we aim to make one contribution in this direction.

In focusing on the role of the formal manager to allow for organizational members to experience autonomous motivation, we applied the theory of self-determination (SDT) in analysing our data, comprising managers’ reasoning of their work and leadership. According to SDT, supporting an individual to meet their basic psychological needs of autonomy, competence, and relatedness enhances the highest-quality form of motivation (i.e. autonomous motivation), which is associated with increased performance, endurance, and job satisfaction (Ryan and Deci, 2000). We focus here particularly on the need for relatedness, which has been suggested as the connecting mechanism between the three basic needs in prior leadership research (Ann Roche et al., 2015). When the need for relatedness is met, this increases peoples’ sense of coherence, purpose and significance (Martela and Steger, 2016). Contrarywise, when feeling isolated and irrelevant to those around you the need for relatedness is unmet (Ryan and Deci, 2017) and we experience social alienation, exclusion, and loneliness (Vansteenkiste et al., 2020). As ingredients for relatedness, Martela et al. (2021) highlight the need to feel a sense of belonging, to feel valued and unconditionally part of a group and to work together for a common goal or purpose.

In sum, we argue that some of the claims made by the theory of SDT, and particularly concerning the notion of relatedness, enable the possibility to study and conceptualise what the formal managers do in high-performing healthcare organisations while supporting collective accomplishments as part of the collective leadership processes.

Theoretical frame of reference: Self determination theory

SDT and work motivation

SDT distinguishes two types of motivations: autonomous and controlled (Ryan and Deci, 2017). While autonomous motivation is grounded in the sense that your actions are based on your own free will, and considered personally valuable, controlled motivation is characterized by feeling pressured by external forces. These forces could come from the outside in the form of rewards or punishments, or from within, in the form of thoughts and internalized mindsets. The extent to which autonomous (ranging from internalized to intrinsic, see Figure 1) motivation is achieved depends on the fulfilment of basic psychological needs. SDT asserts that the three basic psychological needs (autonomy, competence, and relatedness) are essential ingredients for motivation, well-being and optimal functioning (Deci and Ryan, 2014). The basic needs have been conceptualized as “the underlying motivational mechanism that energizes and directs people’s behaviour” (Van Den Broeck et al., 2016: p. 982). An overview of the relationship between basic needs, controlled and autonomous motivation and behaviour outcomes can be seen in Figure 1.

Figure 1.

Overview of the motivational continuum. The figure is based on the work by Richard Ryan and Edward Deci and many other researchers in the field of Self-determination-theory. The terms mustivation and wantivation were coined by Maarten Vansteenkiste (The figure is created by Visser, 2017 ©).

According to SDT, both controlled and autonomous motivation have the potential to motivate human behaviour very powerfully, but in different ways and with diverse results (Ryan and Deci, 2017). Whereas controlled motivation can be a powerful type of motivation for a short-term rise in production and quantity in performance, autonomous motivation is associated with quality of performance and well-being in the long term (Deci et al., 2017; Rigby and Ryan, 2018). Hence, the two types of motivations are qualitatively different according to SDT. Extrinsic rewards are more suitable for monotonous, repetitive tasks, rather than for complex tasks that require creativity and endurance. Even so, external types of motivational rewards are frequently utilised also for environments in which complex tasks are prominent, such as for example healthcare (Biller-Andorno and Lee, 2013). To this end, focusing on internal experiences rather than external contingencies, SDT challenges previous assumptions on motivation that have focused on whether someone has more or less motivation (Rigby and Ryan, 2018).

To be able to ‘reach’ one’s autonomous motivation, the three basic needs need to be fulfilled. In this paper, we focus on the need for relatedness. Common for definitions of relatedness are that they refer to the need to feel a sense of belonging and that we are connected with others (Deci et al., 2017; Martela et al., 2021; Martela and Steger, 2016). Relatedness is a universal need and includes feeling supported while experiencing that others need and value our support – that we ‘matter’ to others (Ryan and Deci, 2017). Martela et al. (2021) also highlight the need to feel unconditionally part of a group and to work together for a common goal (Martela et al., 2021). Associated with this is the issue of trust between organisational members. Relatedness needs are fulfilled at work when organizational members feel respected and included at all levels of the organization, including their immediate managers, colleagues, and top management (Rigby and Ryan, 2018).

Research from an SDT perspective on hospitals has shown that the need for relatedness tends to be less satisfied for those organizational members who work across wards than for those who work within the same units (Hood and Patton, 2022), indicating a need to focus on relatedness across an organization to ensure a good work environment. More, given the need for teamwork and working across organizational borders in healthcare (c.f. West et al., 2014), it is particularly imperative to pay attention to the need for relatedness in these settings, since working with both external and internal relationships has been shown as crucial to facilitate a work climate that enables high-performing healthcare organizations (Fabisch et al., 2024).

SDT and leadership

The way SDT is applied in this paper enables a possibility to combine new and critical ways of understanding leadership as a collective endeavour, in which leadership is inevitably distributed, at the same time as not overlooking the (important) role of the formal manager. While some (Gond et al., 2016; Knights, 2021, referred to by Edwards and Bolden, 2022: p. 178) ‘warn of a double notion of performativity whereby remaining ‘critical’ sits uncomfortably next to ‘making organizations perform’, we believe that these perspectives can be combined for the purpose of conceptualizing managers’ work in collective leadership (processes).

SDT researchers have been suggested to focus on understanding how managers should reason and act so that they facilitate autonomous motivation, through the way organizations are managed and designed (Ryan and Deci, 2017). According to Deci (2012), managers should thereby not ask themselves: how can I motivate my employees but rather: how can I create a work environment that enables employees to motivate themselves?

Studies have demonstrated that if managers are supportive of their employees’ autonomy, then employees will develop more positive and trusting attitudes also toward their managers’ managers (Martela et al., 2021). These managers can be several levels above the employees in the organizational hierarchy, and the employees may not have any direct contact with them (Deci et al., 1989). Thus, when members of one part of an organization have access to their autonomous motivation this can spread; studies at hospitals have shown that when the healthcare personnel experienced more autonomous motivation, they were less controlling towards their patients (Clegg et al., 2022). Linking relatedness to trust, Martela et al. (2021) found that trust in leaders enhances the positive interpretation of their messages. Additionally, openness and transparency in communication were found to foster trust and mutual bonds, supporting a sense of a shared identity and relatedness between members of an organization.

Despite an identified need to focus on how managers can promote an organizational work climate that enables autonomous motivation (Deci, 2012), much work-related research on SDT and leadership has focused on individuals’ fulfilment or lack of fulfilment of the three basic psychological needs (Deci et al., 2017; Ryan and Deci, 2019; Van Den Broeck et al., 2016). Hence, there is a disconnect between theoretical knowledge of SDT and its practical application for managers (Deci and Ryan, 2014; Forner et al., 2020). More, it has previously been noted how SDT research has overlooked the importance of providing a sense of an overarching purpose in organizations and, through this, providing an appropriate [organizational] structure for the basic needs to be met (Graves and Luciano, 2013). However, while Graves and Luciano (2013) argue that these aspects could be covered by integrating SDT and Transformational leadership, we argue that SDT, together with ontological understandings of leadership as a collective process could better capture this.

Methods

Our interview study was conducted in one of Sweden’s 21 healthcare regions, the overarching authority for healthcare in the country, including acute care hospitals, psychiatric care, and primary healthcare. The Region was chosen for the study as it stood out in national comparisons as a high-performing region when it came to employee satisfaction, patient satisfaction, and care quality at the time of data collection (2018-2021) and has shown sustainable development over time (SALAR, 2024). The Region is still one of the top-scoring healthcare regions in Sweden when it comes to the inhabitants’ experience of access to care and waiting times, and their general trust in the healthcare provided in the Region. The Region also continues to score high in national comparisons when it comes to the employees’ trust in their managers, both in their immediate manager and the Region’s top management. It is also top scoring when it comes to the motivation and engagement in patient safety.

In a Swedish context, the Region is medium-sized. It includes both rural and urban areas, has around 250,000 inhabitants and has a rather high proportion of elderly in its population. In total, approximately 6000 people (including 250 managers) work in the different parts of the healthcare organization in the Region (i.e. hospitals, primary healthcare or psychiatric care).

Research design and data collection

Data here was collected through semi-structured interviews with 20 healthcare managers responsible for one (in one case two) of 21 different operational areas including primary care, psychiatric care, and acute care hospitals. Top managers at the regional level, hospital managers, clinical directors, as well as second and first-line managers at more operative levels were among the interviewees (12 women and 8 men). The following roles were represented: 4 regional-level managers (regional director, human resource director, planning director, development director), 1 hospital director, 8 clinical directors and 7 second- and first-line managers.

The last author conducted the interviews. The interviewees had been informed that the researcher, an experienced leadership scholar, was visiting the Region for 3 months and had chosen to study leadership in the Region due to the Regions’ high performance. All interviews were conducted face-to-face. Interviewees were recruited through purposeful sampling to secure informants from various organizational levels in both hospitals, primary care and psychiatric care.

The interviews were conducted at the managers’ workplaces. The interview guide used was constructed for the larger project and structured around different themes relating to how leadership was manifested and performed in daily practice and how a good working environment was created through every day (leadership) work across all parts and levels of the Region. The semi-structured nature of the interview guide allowed for variations in questions and responses across the interviews, including the possibility for the interviewees to reflect freely. Interviews lasted approximately 1.5 hours each, were audio-recorded, and transcribed verbatim. All interviewees gave their written consent to participate in the study. They were also informed of their right to withdraw from the study at any time without giving any reason.

Data analysis

The data analysis had a reflexive thematic qualitative approach inspired by Braun and Clarke (2006, 2020). During the first step, familiarization with the data, the interviews were initially read through by the first author to capture work and practices that were performed by the managers that potentially could contribute to the success of the region. The broad question that guided this explorative, inductive phase was: How do the managers describe what they do in their work? Interest was also directed toward how the managers thought about and understood what they perceived as leadership. In this initial reading it was noted how the managers reasoned about leadership as a collective phenomenon in several instances. The initial analysis also showed that the managers described how they both worked for, as well as experienced work and practices, related to what SDT refers to as autonomous motivation and particularly theorized as the need for relatedness. Going back to the interviews and using SDT as our conceptual framework, we coded the data based on how the managers reasoned about what they did. These codes were then grouped into themes which inductively captured the types of work conducted by managers. Thereafter, as defined in the steps by Braun and Clarke (2006, 2020), the themes were reviewed, defined and named. When having defined the three types of work identified in the analysis (i.e. contribution, connection, and unconditionality work) we went back to the literature on relatedness c.f. Martela et al., 2021), collective leadership (c.f. Denis et al., 2012; Holm, 2023; Ospina et al., 2020), and successful healthcare organisations (Fabisch et al., 2024; West et al., 2020) to answer the crucial question: “what is going on here?” (Gioia et al., 2013: p. 20). This enabled capturing the more abstract 2^nd-order themes (Gioia et al., 2013) of managers doing and experiencing relatedness. Continuing to question our data and what was going on, particularly concerning collective leadership processes, we took a step back and re-visited our 1^st and 2^nd order themes and their content yet again. Focusing on collective accomplishment (c.f. Ospina et al., 2020), we posed the question of what was accomplished in the organisations, according to our data? Throughout our material, it was evident how the managers in their statements returned to the patient (and their well-being), as guidance for their activities. While we had chosen to particularly highlight this aspect in the ‘contribution work’ theme, following the deductive frame of analysis using SDT, this subject was also shown to underline the other themes, therefore, it is presented in Table 1 as an aggregated dimension and theoretically understood as it was towards this end that the managers supported the collective leadership. In Table 1, we have separated the work done by managers and their experiences of work being done to them; however, sometimes, in practice, these activities happened simultaneously.

Table 1.

Overview of data structure.

1st order concepts	2nd order themes	Aggregated dimensions
Managers guiding towards the purpose by focusing on the patient’s need	Managers doing contribution work	Managers doing relatedness	Patient’s well- being guiding activities throughout the organisation
Managers avoiding the use of unnecessary hierarchical practices	Managers doing contribution work
Managers curating relationships within and across organizational boarders	Managers doing connection work
Managers using inclusive wording and communication
Managers creating a joyful atmosphere
Managers creating a no-shame and blame culture	Managers doing unconditionality work
Managers acknowledging deficient processes rather than pinpointing individuals	Managers doing unconditionality work
Managers experience a lack of unnecessary hierarchical practices	Managers experiencing contribution work	Managers experiencing relatedness
Managers experience having connection with top management	Managers experiencing connection work
Managers experience being trusted and protected	Managers experiencing unconditionality work

The concepts, themes and dimensions were developed and refined by all three authors several times until consensus and “theoretical saturation” (Gioia et al., 2013) was reached to produce our data structure (table 1) and thereafter to analyse the relationship between our themes and dimension (Figure 2).

Figure 2.

Relationship between doing and experiencing relatedness in high-performing health care regions.

In the findings, /…/ is used to indicate omissions, and […] indicates that text has been added or clarified. Where alterations have been made, these have been done to clarify the content and/or to protect the anonymity of the interviewees. The overall meanings of the citations have not been changed. All quotes have been translated from Swedish to English. All quotes from the managers are labelled according to their anonymous code that was given to them as interview persons (Ip) in the work with the larger study, where also other members of the organization with non-managerial positions were included why the numbers may exceed the 20 participants in this study.

The dynamic relationship between our concepts is presented in Figure 2

Findings

Below we conceptualise what the formal managers did in the high-performing healthcare organisation studied. Analysing our material based on the theoretical understanding of relatedness in SDT, the result focuses on how formal managers enable (and are enabled) autonomous motivation through relatedness work. The three types of work inductively analysed and thereafter conceptualised, all related to core elements of relatedness according to SDT: understanding and appreciation of everyone’s contributions to ‘the whole’ and the purpose of the organization (contribution work), feelings of being connected in meaningful ways (i.e. connection work), and being unconditionally part of a group (unconditionality work).

Contribution work

The findings show the presence of contribution work, throughout the organization, expressed in how managers appear to both understand and enable an understanding of individuals’ and groups’ contribution to ‘the whole’ and the purpose of the organization. Two types of contribution work were identified in the analysis: guiding towards the purpose by focusing on the patient and avoiding unnecessary hierarchies.

Guiding towards the purpose by focusing on the patient

Throughout the interviews, managers described that even though conflicts between organizational units could arise, concerning responsibilities, when ending up in such conflicts, a strategy was to go back to focus on the patient and from there figure out a solution. One manager exemplifies this:

Whenever we end up in conflicts with other care providers, we take a step back and go back to the patient. (Ip 40).

An overarching focus on the well-being of the patient was described as increasing possibilities to enhance collaboration and solve potential conflicts and controversies, both within the organization and with external organizations. One manager described his role as a leader as to guide his staff towards what unites them at work and why they are there, i.e. for the well-being of their patients (in this case children), and emphasized the importance of always keeping such dialogue alive:

As a manager and leader, I think that one of my most important roles is still to be ‘the cicerone’, to keep a focus on our core business /…/ Because somewhere, after all, we are here for the children. And to come back to that and talk about that kind of values /… / we need to talk about what unites us as co-workers, and that is our values and goals ... to keep that dialogue alive (is important). (Ip 36)

Adding to the quote above, this general sense of ‘collectiveness’ seemed to guide the work in the Region. One manager reasoned about the need to downplay the focus on individual leadership and instead focus on the collective efforts that build healthcare:

I think it will be evident in a number of years that you (have) put too much focus on believing that you can overcome the healthcare crisis by finding great managers, because you won’t. There aren’t very many people who are interested in putting in the huge amount of time and energy that is needed for a single person to be able to run the operations. It’s instead about finding completely different forms … Everyone is involved in leading and developing health care. (Ip 31)

Another way of emphasizing the contribution of all was to acknowledge all organizational members’ ideas and skills through the promotion of an open climate where opinions were actively asked for, in which both managers and other organizational members were able to give feedback to each other, to enable improvement. Words such as ’supporting’ and ’helping’ were used to describe the relations between organizational member:

They [the employees] are super skilled and I am to help them, or we together, our management team, will help them to lead and steer and give them the prerequisites for the operations to work. (Ip 31)

More, to further acknowledge the contribution of all, it was described how the Region provided forums where representatives from different parts of the organizations and departments could meet and discuss issues together.

Working for a sense of ‘collectiveness’ was also shown through short daily stories of everyday work that were shared in different ways within the Region – an active strategy decided by top management. These stories were believed to enable an increased understanding of the contribution of all parts of the organization, and their importance for the Region. For example, one of these “day-to-day stories” described the laundry operations and how the sharing of their story made the contribution of the laundry operations understandable and increasingly appreciated in the organization.

Avoiding and experiencing lack of unnecessary hierarchies

Another aspect of contribution work was shown in how the managers valued and acknowledged all organizational members’ contributions to the purpose, regardless of their professional background or role in the organization. One manager, referring to a situation during the beginning of the COVID-19 pandemic when much information was needed on how to treat this disease, described that one of his colleagues (an assistant nurse) was impressed by the possibility for her to directly phone a doctor at the infectious clinic when she had questions on how to handle a situation:

Manager quoting assistant nurse: I'm so impressed, what an organization we have here. What support I received. There was a doctor sitting and answering my questions from the infectious disease clinic /.../ when you need it [support], it's there. (Ip 40)

The avoidance of unnecessary hierarchies was also shown in that managerial roles were also distributed among professions:

We moved away from that fairly early on, that it should /…/ be a doctor [who is the manager] /... /. (Ip 07)

It was noted in the data how there were ongoing work to avoid unnecessary hierarchical practices, something that was believed to better enable all organizational members to contribute to the purpose of the organization, i.e. the patient’s well-being. For example, managers described how profession was not a big issue in daily work and that the focus was on how to collaborate the best:

We do not look at the name tags /… / we work together with our patients. (Ip, 12)

Another manager describes how she has worked to open up the climate at her unit and encourage her organizational members to ask each other questions across professional roles. She said:

… I don't want any hierarchies, that you can't ask this or that, we're here for the same reason ... (Ip 43)

Some hierarchical practices were considered obsolete and based on traditions or professional status rather than on their usefulness for practice and the purpose of the operations. One manager described that previously there had been an informal rule that special tables in the cafeteria were reserved for physicians. The manager described how he actively had worked to change this:

… now there are no seats, no tables, no groupings. When you bring your coffee or your lunch, you sit down anywhere in any constellation. (Ip 31)

The practice of being able to sit wherever in the lunch area, regardless of professional role, was used as an example by the manager to illustrate the importance of creating a sense of “we” in the Region.

Connection work

The findings also show the occurrence of different types of connection work throughout the organization. Specifically, four types of connection work were identified in the analysis: curating relationships within and across organizational boarders, using inclusive wording and communication, creating a joyful atmosphere, and work that enabled close connection with top management.

Curating relationships within and across organizational boarders

The managers worked actively to enable a sense that different parts and members of their own as well as collaborating (external) organizations ‘mattered’ and were connected in meaningful ways. A perception permeating the interviews was the importance of arranging the work so that other, collaborating, yet external, organizational units would not feel like “we’re ‘dumping’ a lot of patients on them …” (Ip 21).

Here, the different parts of the Region and their collaborating external organizations were often mentioned alongside each other and not as separated in terms of the importance of collaboration and the creation of relationships:

We help each other as best we can, and this includes the municipalities, primary care, the administrations … (Ip 43)

Work to connect various parts, often referred to by the interviewees as collaboration, led to the actors helping each other and easing each other’s burdens. This in turn created a sense of security and enabled a ‘give and take’ mentality, across borders. In the interviews, several accounts of managers trying to help and support each other were described. It was experienced as easy to get help from managers from other units if, and when, needed. One manager explained how it was enough to tell about a situation, and then people immediately showed up to help:

… you don’t even have to ask, you can just mention how it is … and following such an explanation, colleagues will show up to help. (Ip 23)

Using inclusive wording and communication

Connection work was also shown in the deliberate ways of working with communication to increase feelings of connectedness. Managers often used and emphasised the importance of the words ’we’ and ‘together’ when talking about accomplishments and relationships. One example of this was a manager who, when asked about the purpose of the operations answered:

… to try and work together as much as possible [is the main purpose of the operations]. (Ip 07)

To actively work towards a ‘we’, at the same time as recognising the importance of formal responsibility for patients, words such as ‘borrowing’ and ‘lending’ (patients) were used to emphasize who was responsible for the patient even though the patient at times might need treatment or care from other parts of the system:

We lend them to the hospital sometimes but then they return to primary care, because we know them over time. (Ip 40)

In addition to using inclusive wording, non-inclusive wording was purposefully omitted. Examples of such words were those that signal giving other units’ assignments or units having precedence in interpretations:

We have deleted such concepts. (Ip 40)

Creating a joyful atmosphere

Connection work was also shown in that managers worked to create a joyful atmosphere. Across the material, it was noted how ‘having fun’ was seen as an important part of the work environment by the managers, particularly during collaborations. An example of this is how one manager described how she was part of developing an operation that required extensive collaboration across organisational borders, which included schools and public transport as well as with the municipalities. The work was described in terms of joy and familiarity:

We felt like a family, and it was great fun! (Ip 12)

(Experiencing) connection with top management

Throughout the interviews, the managers described their organization as, being big, but feeling small, which enabled the experience of being connected across units and hierarchical levels. Particularly, the managers’ easy access to the top management was emphasized:

We have a good dialogue and easy access to the top management. We know each other and [we] know who they are, even if the Region is big and there are many employees /…/ you understand each other. (Ip 27)

The managers described the top management as genuinely interested in the operations, signalling a vertical connection between hierarchies in the Region. One manager formulated it like this:

Our top manager /…/ is very accessible to both managers and employees. He likes to come out /…/ he sits down and talks to people and has no problem seeing different parts of the organization and being curious and taking part in it. (Ip 39)

Unconditionality work

The findings highlight the occurrence of unconditionality work expressed in how managers, rather than blaming individuals, reasoned about roles that were unclear and/or identified deficiencies within the system if problems arose. Safety and trust were experienced at various levels and less successful events were shared and seen as opportunities for learning. Three types of work were identified in the analysis that supported unconditionality: establishing a no-shame and blame culture, acknowledging deficient processes rather than pinpointing individuals, and work that enabled trust and feelings of being protected.

Establishing a no-shame and blame culture

One way in which unconditionality work was expressed, was in how less successful events were able to be shared without blame and seen as opportunities for learning. According to several of the managers, the sharing of successful as well as less successful events was believed to be possible because people were not scared to be left out if they made mistakes. Hence, mistakes were encouraged to be shared openly which enabled the possibility to learn from mistakes and reflect together.

Acknowledging deficient processes rather than pinpointing individuals

The analysis showed that managers worked actively to create a culture in which individuals were not singled out, rather processes and procedures were discussed in relation to organizational issues needing improvement. One manager expressed it like this:

We do not want to pinpoint a Peg-Leg Pete. (Ip 12)

In times of success, the managers emphasized the collective effort and how also collaborating organizations were contributing to the success, rather than recognizing individuals or their own organization:

We, are talking about ‘our success’ rather than signalling individual effort. (Ip 34)

(Experiencing) trust and protection

Feelings of unconditionality were also expressed in that the managers articulated how they themselves felt safe in relation to their own managers and by that were able to express ‘shameful’ feelings. One manager exemplified this with a hard situation that was tough to manage, with others being ignorant. To be able to get through this situation, the manager described how:

I called [the closest manager] /…/and I had a meeting with him and other senior managers, during which I cried like a baby! And I said: ’I just need to get this off my chest, you’ll have to put up with this’. (Ip 43)

Managers gave accounts of how they trusted their managers and felt that their managers had their best interests at heart, this was true for both their immediate, but also for the top management:

I felt that the [top] management was trying to protect us from the craziest political whims /…/ We would be allowed to develop what we had instead, and I found that reassuring /…/ I’m proud of the organization I work in, and I think they do a lot of good, those who sit above me in the hierarchy. I trust them. (Ip 40)

The feeling of being trusted by one’s manager also impacted directly on the work. Several interviewees described how they trusted their managers to care for them and protect them and how that made them feel more secure in their leadership. One manager formulated it like this:

With stable ground underneath your feet, you dare and have the energy to lift the gaze, if not to the horizon, at least upwards and onwards. (Ip 24)

Discussion

In this study, we have explored how managers reason about their work, roles and leadership in a high-performing Swedish healthcare region in terms of employee satisfaction, patient satisfaction and care quality.

We position our findings in the intersection of research focusing on managers’ leadership and work and recent research focusing on collectivist forms of leadership (Denis et al., 2012; Empson and Alvehus, 2020; Holm, 2023). This helps to bring the role of the formal leader to collective leadership understandings, as well as increase understanding of the work conducted in successful healthcare organizations. Hence, the study combines an understanding of leadership as a collective endeavor, distributed between all organizational members of an organization (c.f. Ospina et al., 2020), yet at the same time we focus on the formal manager role and the managers reasonings about what they do, which was here analysed and theorized as enabling autonomous motivation in the organisation and a collective delivery on purpose.

The data was analysed using the theory of SDT and particularly the basic psychological need for relatedness. Three types of relatedness work were identified in the analysis as contributing to enabling organizational members to fulfil the need for relatedness: contribution work, unconditionality work and connection work. These types of work were done by managers who also experienced they, in turn, were recipients of such work, something which shows the mutuality between organisational members in the high performing organisation studied.

Our analysis, based on SDT, enable an increased understanding of how managers can support the basic need for relatedness to be met, but also how they experience others’ work to enable them to meet their basic need for relatedness. This aligns with previous research that has highlighted how, and that, organizational members and managers are mutually developing in high-performing healthcare organisations (Fabisch et al., 2024).

In addition, as our study focused on ‘ordinary’ ongoing work, we highlight the interconnectedness of the work conducted and experienced by the managers studied, between them, their managers, and their staff. In that, we could see how the managers enabled collective accomplishments, yet not abandoning their formal responsibilities as managers. The managers contributed to relatedness and thereby autonomous motivation, we argue, in the sense that they increased the feeling that different individuals within the organization ‘mattered’ to each other, contributed to, as well as articulated, the common goal and purpose of the organization, gave and received support and, through the ‘no shame and blame’ culture in combination with trust and dialogue, signalled to all organizational members that they were unconditionally part of the workplace in the sense that it was okay to admit mistakes that had been conducted.

Collective accomplishment to deliver on purpose

Moreover, our analysis shows how the managers’ work was done in a context in which the purpose of the organization was guiding its operations, which is in line with previous research on high-performing healthcare organizations (see Fabisch et al., 2024; West et al., 2020) as well as research on relatedness (Martela et al., 2021) and collective forms of leadership (Denis et al., 2012; Gadelshina, 2020). The analysis showed how manager’s viewed practices of leadership as performed by all members of the organization, i.e. not only those in the capacity of the formally appointed leaders or managers. Rather, our interpretation of the managers’ reasonings is that they understood the role of the manager to enable all to lead, and to guide the collective leadership towards the purpose of the organisation.

Combining SDT and collective leadership

By combining SDT, with a focus on relatedness, defined in practice in part as to guide towards the purpose of the organisation (Martela et al., 2021) with collective leadership theory, we highlight how manager’s viewed practices of leadership as performed by all members of the organization, i.e. not only those in the capacity of formally appointed leaders or managers. Rather, our interpretation of the managers’ reasoning is that they understood the role of the manager to enable all to lead, and to guide the collective leadership towards the purpose of the organisation. By this, we acknowledge, and emphasize, that collective leadership is not the same as merely doing things together but should rather be understood as a directed effort. Following Raelin and Trehan (2015) and regarding leadership as an ongoing collective and distributed phenomenon in organizational practice “we do not have to wait for people to be mobilized by formal leaders. Staff and workers are already mobilized and in motion; it is rather how that motion or activity is channelled” (p. 128) that becomes the issue of importance.

Further, our study gives an increased opportunity to answer the crucial question of how to create a work environment which enables autonomous motivation and the basic psychological need for relatedness is met (see Deci, 2012). It does so by emphasising the mutuality between organizational members at various levels of a high-performing healthcare organization, and by noting the importance of purpose; the managers in the organization studied viewed delivering on purpose as a collective accomplishment. Deci (2012) highlighted the crucial question: ‘How can I, as a manager, create a work environment that enables individuals to motivate themselves?’. Studying the mutuality and recursiveness of relatedness (recursiveness referring to that relatedness work was reflected by different managers throughout the organisation, creating back-and forth loops of relatedness work, see also Figure 2) between managers and organizational members at various levels of a high-performing healthcare organization, and their collective accomplishment, we propose an alteration and development of the question put forward by Deci (2012). Rather than asking what I can do, we suggest the question to be: How can we, as managers and employees in this organization, together create a work environment in which we can motivate ourselves?

Positioning our findings in the intersection of research focusing on managers’ leadership and work, and recent research focusing on collectivist forms of leadership, the study advances theoretical understanding through integrating SDT with collectivistic leadership perspectives, emphasizing that leadership is distributed but needs to be directed and guided towards something (the collective accomplishment). Practically, our study offers concrete examples of how managers could contribute to create environments where all organizational members feel valued, connected, and motivated. This dual focus on theory and practice provides a nuanced understanding of leadership as a relational and purposeful endeavour, contributing to both leadership research and the development of supportive, high-performing healthcare organizations.

Future research

The study has implications for future research. First, zooming in on SDT, theoretically (see for example, Clegg et al., 2022), supporting healthcare staff to meet their need for relatedness would also increase their ability to support their patients’ need for relatedness. This could be one explanation for the high outcome regarding patient satisfaction in the Region we studied. Research applying SDT indicates that when the need for relatedness is met for clinical staff, they are more resilient and better able to handle the demands of their roles, which is likely to impact the relationship with their patients (Patrick and Williams, 2012) in terms of for example greater patient involvement (Ryan et al., 1995). With this as a backdrop, it would be of interest for future research that studies the recursiveness and collectiveness of leadership work in healthcare to also account for patients’ leadership. Here, questions of interest are, for example, in an organization that supports the basic need for relatedness to be met, what does the leadership of the patient look like? Is it acknowledged? If so, how and in what way? Here, recent theorising on power and collective leadership to study the relationship between patients and health care appears fruitful avenue for future research (c. f. Clegg et al., 2023).

Second, in this study, we have relied on interviews and not observations to capture leadership practices. Future studies ought to use complementary methods to capture leadership and relatedness in practice, such as observations and shadowing (Larsson and Alvehus, 2023).

Third, broadening the perspective, future research should continue to investigate how the ontology of collective leadership can be promoted, yet not overlooking the role and responsibility of the formal manager. In addition, in this study, we have chosen to label managers’ activities that support relatedness as ‘leadership’ given the (collective)s leadership ontology adopted. The question of what the boundaries are for leadership and day-to-day activities performed by managers, and others, in an organization (see for example, Denis et al., 2023; Fairhurst et al., 2020), is an ongoing debate that will require further attention.

Limitations and considerations

A limitation is that we have relied on interviews to capture leadership practices. We are aware that some of the quotes can be interpreted as a form of ‘meta-talk’, (Fischer and Alvesson, 2025), however our analysis include data in which the managers were asked to describe their work, and were repeatedly asked to give concrete examples of what they did (in practice). Thereby our analysis includes our interpretation of the managers’ reasoning about their work and does not only build on their answers to direct questions about how they understand leadership.

A strength with the study is that we have interviewed managers at various levels, which also shows the mutuality of enabling and receiving relatedness between the managers.

The managers we studied had no specific training in SDT. This we believe, is a strength compared to previous research (for example, Forner et al., 2020) as we were able to analyse work in terms of SDT, yet this was work occurring naturally within the organization studied. This research design, we argue, further bridges the gap between theoretical understandings of SDT and the practical ditto, focusing on how managers, and other organizational members, can promote an environment in which the individuals motivate themselves (Deci et al., 2017; Gagné and Deci, 2005; Ryan and Deci, 2019; Van Den Broeck et al., 2016).

Although we cannot say that the basic need for relatedness is satisfied (we have not measured that) we know that the region was high performing on several quality indicators at the time of data collection and continues to score high in 2023. What this study does provide is the acknowledgement that connection work, unconditionality work and contribution work occurred at the same time as the Region was high performing. Through our study design, we were able to give details of the setting and provide quotes, which helped to increase the transferability of our results. Results from the larger study of which this study was a part have also been presented elsewhere (Svensson and Von Knorring, 2025), which further enables a deeper understanding of the local context and increases the possibility of transferring results. Nevertheless, given the approach to data analysis, we cannot say that this was the only way that relatedness was done in the organization studied. Even so, the illustrations prove a rich example of how relatedness was and can be done in practice. In addition, one further limitation of our study is that we only focused on the need for relatedness. However, by doing this, we were able to investigate this need in-depth. Previous research has also shown that the three basic needs are connected – fulfilling one could enhance the likelihood of fulfilling the others (Ann Roche et al., 2015).

Conclusions

This study contributes both to the growing body of research on collective leadership and to research on SDT. It does so by highlighting the often-overlooked role of formal managers in collective leadership studies. In the same vein, notwithstanding a large body of research supporting SDT in the workplace, there is currently very little empirical guidance for leaders who want to translate the theory into practical relevance (Forner et al., 2020).

The study has three main contributions: Firstly, the study reintroduces the role of formal managers into the collective leadership discourse by showing how they actively coordinate leadership towards the purpose of the organisation.

Secondly, the findings show that relatedness is not only something managers facilitate for others, but also something they experience, underscoring the mutual and recursive nature of relatedness and (collective) leadership in practice.

Thirdly, the results contribute to an alteration of the crucial question that managers should ask themselves, according to SDT. Rather than asking, how I, as a manager, can create a work environment in which individuals motivate themselves, we propose the question of importance to be: How can we, as managers and employees in this organization, together create a work environment in which we can motivate others and ourselves?

Footnotes

Acknowledgements

We thank interviewees who shared their experiences and welcomed the researcher to visit their organizations.

ORCID iDs

Ingrid Svensson

Linda Sturesson Stabel

Ethical considerations

The project was approved by the Regional Ethics Review Board in Stockholm (registration number 2018/1452–31/5). All methods were carried out in accordance with national guidelines and regulations. All participants received written and verbal information about the study’s aim and procedures. Written or verbal informed consent was obtained from all participants as approved by the ethical review authorities.

Author contributions

MvK obtained the funding for the study and collected the data. IS and MvK developed the design and conceptualization. Data were initially analysed by IS and LSS in discussion with MvK. All authors contributed to the analysis and interpretation of the data. IS drafted the first version of the manuscript and, together with MvK, contributed to the revision of the manuscript. All authors read and agreed on the final submitted version of the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Open access funding provided by Karolinska Institute. The visit that enabled the data collection was funded by Vinnova (dnr 2018–00772). The data collection and analysis of data was funded by Strategic Research Area Health Care Science (SFO-V) (dnr 2–2764/2018). The funders had no role in the design of the study, data collection, analysis, or interpretation of data, nor in writing of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data collected and analyzed in this manuscript are not publicly available due to participants not having consented to public availability. Aggregated data in Swedish are available from the corresponding author upon reasonable request.*

Author biographies

Ingrid Svensson, PhD in Technology Management and Economics from Chalmers University of Technology, is an assistant professor at Karolinska Institutet and a licensed psychologist. Her research and teaching take an interest in relationships between professionals and occupational groups, the development of new organizational roles and leadership practices within these processes.

Linda Sturesson Stabel, PhD is a researcher at Karolinska Institutet. She also holds an MA in Ethnology. Her research is specifically directed towards climate leadership in healthcare.

Mia von Knorring, PhD is a licensed psychologist and holds the title of docent at Karolinska Institutet in Healthcare organisation. She is an experienced leadership researcher and lecturer with an interest in collective forms of leadership and practice based views on organizing.

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