An exploratory study of knowledge brokering in hospital settings: Facilitating knowledge sharing and learning for patient safety?

Social Science & Medicine 98 (2013) 79e86

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

An exploratory study of knowledge brokering in hospital settings: Facilitating knowledge sharing and learning for patient safety? Justin Waring a, *, Graeme Currie b, Amanda Crompton a, Simon Bishop a a b

Nottingham University Business School, University of Nottingham, Nottingham NG8 2BB, UK Warwick Business School, University of Warwick, UK

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 5 September 2013

This paper reports on an exploratory study of intra-organisational knowledge brokers working within three large acute hospitals in the English National Health Services. Knowledge brokering is promoted as a strategy for supporting knowledge sharing and learning in healthcare, especially in the diffusion of research evidence into practice. Less attention has been given to brokers who support knowledge sharing and learning within healthcare organisations. With specific reference to the need for learning around patient safety, this paper focuses on the structural position and role of four types of intra-organisational brokers. Through ethnographic research it examines how variations in formal role, location and relationships shape how they share and support the use of knowledge across organisational and occupational boundaries. It suggests those occupying hybrid organisational roles, such as clinical-managers, are often best positioned to support knowledge sharing and learning because of their ‘ambassadorial’ type position and legitimacy to participate in multiple communities through dual-directed relationships. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: Patient safety Organisational learning Knowledge brokering Knowledge sharing Ethnography UK

Introduction Knowledge brokering has become a prominent strategy for supporting learning, innovation and improvement within healthcare services (Canadian Health Services Research Foundation, 2003; Lomas, 2007; Nutley & Davies, 2001; Oborn, Barrett, & Racko, 2010; Ward, Smith, House, & Hamer, 2011). In broad terms, knowledge brokers build relationships between communities to support the creation, sharing and use of knowledge (Burt, 1992; Hargadon, 2002; Meyer, 2010). The contribution of knowledge brokers to healthcare improvement is commonly related to the diffusion of research evidence into clinical practice (Canadian Health Services Research Foundation, 2003; Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004; Lomas, 2007; Ward et al., 2011). Less attention is given to knowledge brokers at the intraorganisational level (Currie & White, 2010). That is, ’embedded’ actors who facilitate the sharing and use of knowledge between organisational departments, clinical teams and healthcare professions to support, for instance, more integrated, collaborative or patient-centred working. Two contingencies impact intra-organisational knowledge brokers in healthcare organisations. The first relates to the idea that * Corresponding author. E-mail addresses: [email protected], (J. Waring).

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0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.08.037

clinical practice is informed, to a great extent, by experiential know-how, which is situated within the routines of clinical communities. Unlike more explicit knowledge, this is difficult to articulate and share with others. Second, and linked to above, the close ties between practice-based knowledge and group membership make it difficult to share knowledge across occupational boundaries; especially where professional jurisdictions are premised on the acquisition and control of knowledge (Abbott, 1988; Waring & Currie, 2009). Research suggests, for example, that attempts to extend management access to clinical knowledge are often stymied by professional boundaries (Currie, Waring, & Finn, 2008; Ferlie, Fitzgerald, Wood, & Hawkins, 2005). Reflecting on these contingencies, further insight is needed about which healthcare actors might support knowledge sharing, focussing on their relationships and roles at the intra-organisational level. Our paper reports on an exploratory study that aimed to identify and compare ‘embedded’ knowledge brokers working at the intraorganisational level. It examines how brokers vary according to their structural positions and relationships within and between communities, and how this influences their ability to share and support the use of practice-based knowledge between professional and managerial communities. In particular, it compares the brokering activities of those with formal and less formal roles in regard to organisational learning. The study focuses on the challenge of knowledge sharing in the context of patient safety. Over the last decade patient safety has become a global health policy

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priority with the introduction of various strategies to support organisational learning (Department of Health (DH), 2000; Institute of Medicine, 1999; WHO, 2004). More recently, the Public Inquiry into Mid-Staffordshire NHS Trust (Francis, 2013) further highlighted the systemic failure to learn and respond to unsafe patient care. However, reforms to enhance patient safety have been difficult to implement, exemplifying the broader challenge of knowledge sharing and learning at the intra-organisational level (Rowley & Waring 2011; Waring, 2005). The paper offers an elaboration of the challenges to learning in the context of patient safety and, drawing upon exploratory research with purposively selected groups, develops tentative suggestions for the wider role of knowledge brokers in healthcare. Knowledge brokering in healthcare organisations Knowledge brokers are actors, technologies and objects (Oborn et al., 2010), that enable the knowledge of one community to be shared with and used by those in another (Burt, 1992; Hargadon, 2002; Meyer, 2010; Michaels, 2009; Pawlowski & Robey, 2004; Ward et al, 2009a, 2009b). Following Burt (1992), they bridge the ‘structural holes’ between unconnected actors, and facilitate the “translation, coordination and alignment” of knowledge between communities (Wenger, 1998: 109). Elaborating how knowledge brokers support innovation, Hargadon (2002, 2003) suggests they identify and access knowledge located in different communities; build connections between knowledge pools; support capacity building; and facilitate social engagement and learning. With reference to healthcare innovation, the Canadian Health Services Research Foundation (2003) suggests knowledge brokers gather evidence and appraise knowledge; identify and seize opportunities; and mediate the boundaries between communities. One prominent way of developing the knowledge broker concept is to elaborate their structural position and relationships within and between communities (Meyer, 2010; Michaels, 2009). Gould and Fernandez’s (1989) seminal typology remains a key contribution to the literature and informs the analysis developed in this paper. By comparing knowledge brokers’ positions and relationships they differentiate between:  ‘coordinators’ who broker between two or more actors from their own community;  ‘itinerant brokers’ who mediate contact between actors within a community they themselves do not belong;  ‘gatekeepers’ who broker incoming exchanges from outgroups;  ‘representatives’ who broker out-going exchanges from their community;  ‘liaisons’ who broker exchanges between two or more communities to which they do not belong. Despite increased interest in knowledge brokers, and their contribution to healthcare improvement (Lomas, 2007; Ward et al., 2011); there is less attention to the position of brokers at the intraorganisational level (Currie & White, 2012), and importantly, the types of knowledge and boundaries these actors broker. Much of the policy literature conceives knowledge as an explicit resource that can be accessed, codified and exchanged for the purpose of learning (e.g. DH, 2000). A contrasting view suggests knowledge is ‘situated in practice’ and learning occurs through doing (Blackler, 1995). People acquire shared meanings, know-how and their sense of identity through participating and learning within a community (Brown & Duguid, 1991; Gherardi, 2006; Lave & Wenger, 1991). From this perspective, knowledge is experiential, tacit and bound by use, rather than evidential, explicit and abstract

(Blackler, 1995). In other words, knowledge is not a ‘thing’ that a community ‘has’, but rather it is what they ‘do’ and who they ‘are’ (Lave & Wenger, 1991). Following Szulanski (1996), this explains why some knowledge is ‘sticky’, or cannot be easily shared because it is only acquired through participation, used in context and privileged by membership. This literature highlights how social boundaries frame practicebased knowledge and learning (Lave & Wenger, 1991). Attention to the boundaries that distinguish and separate communities is essential for understanding the work of knowledge brokers (Meyer, 2010; Williams, 2002). Research suggests, for example, ‘boundary spanning’ involves the mediation of inter-personal, ideological, socio-cultural and hierarchical attributes that define and differentiate social groups (Abbott, 1995; Williams, 2002). With relevance to healthcare, professional boundaries are highlighted as inhibiting knowledge sharing, innovation and learning (Currie et al., 2008; Dopson & Fitzgerald, 2006; Ferlie et al., 2005). These are institutionalised through a variety of socio-cultural and political strategies, which commonly rely upon an occupation’s claims to exclusive knowledge (Freidson, 1970). Knowledge is therefore bound up, not only with group membership, but also professional legitimacy and power within the division of labour (Abbott, 1988). As such, professional groups are often reluctant to share knowledge where it might threaten their status or identity (Currie & White, 2012; Waring & Currie, 2009). The challenge for knowledge brokers is how to access, share and support the use of practice-based or sticky knowledge across these professional boundaries. This knowledge is not readily available for exchange, but needs to be acquired and diffused, in part, through participation and engagement in practice. Knowledge-use and learning is less likely to occur through passive communication, but through helping actors to incorporate knowledge into existing practices and by mediating institutionalised boundaries. Nonaka’s (1994) model of organisational innovation describes a similar process where the tacit know-how of one group is made explicit and ‘externalised’ so that it can be re-combined with and ‘internalised’ into the practices of others. In this sense, the knowledge broker not only has to build connections between organisational units, but also integrate the know-how of one group with the practices of another (Hargadon, 2003). Knowledge brokers therefore need forms of membership and legitimate participation within multiple communities to gain understanding of practice-based knowledge and to support practice-based change (Lave & Wenger, 1991). Applying these ideas to the intra-organisational level, the ability of an actor to broker knowledge across professional boundaries is likely to be shaped by their structural position and relationships within and between different communities. It might be tentatively proposed, for instance, that membership of a given community enhances understanding of practice-based knowledge, but might make it difficult to articulate the more taken-for-granted aspects of practice. Equally, those outside a given community might be able to discern innovative practices, but their position might limit their exposure or legitimate access to practice-based knowledge. The aim of this paper is to better understand how a broker’s structural position and relationships at the intra-hospital level influences the brokering of knowledge across organisational and occupational boundaries. In particular, it seeks to compare the experiences of those with formal and informal responsibilities for knowledge sharing. The challenge of brokering patient safety knowledge Our study focuses on the challenge to knowledge sharing and learning associated with patient safety improvement. It is typically argued that healthcare organisations should ‘learn the lessons’ of

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substandard and unsafe care in order to limit reoccurrence (DH, 2000; NPSA, 2003; World Health Organization, 2004). An important idea is that threats to safety rarely stem from clinical behaviours alone, but from upstream factors that condition frontline practice (Reason, 1997). Organisational learning is premised on clinicians sharing their experiential knowledge of clinical risk so that organisational leaders can determine the latent factors and introduce system-wide improvements. Many healthcare systems have introduced formal knowledge management procedures, such as the UK’s National Reporting and Learning System (NRLS) (DH, 2000; NPSA, 2003). These include incident reporting procedures that enable clinicians to document and share their experiences of unsafe care (Barach & Small, 2000), which are then analysed to identify the ‘root causes’ of risk (Braithwaite, Westbrook, Mallock, Travaglia, & Iedema, 2006) and used to inform the development of safety enhancing interventions (NPSA, 2003). Research raises doubts about the ability of such procedures to foster organisational learning. First, there are significant social, cultural and technical barriers to incident reporting (Braithwaite, Westbrooke, Travaglia, & Hughes, 2010; Waring, 2005). For example, the fear of blame and litigation; cultural taboos; and professional identities discourage the sharing of knowledge with ‘outside’ groups, especially where exposure might lead to loss of credibility (Waring, 2005). Second, research questions whether structured investigation techniques engender learning (Nicolini, Mengis, & Waring, 2011). For instance, root cause analysis is often caught between competing priorities for learning, legitimacy and due process. Third, safety interventions can be poorly aligned with prevailing practices and cultures (McDonald, Waring, & Harrison, 2006). For example, they often involve standardisation and simplification, rather than more proactive forms of learning and resilience (Hollnagel, 2012). Research illustrates, therefore, how knowledge-type and professional boundaries inhibit learning. For example, policies reinforce the assumption that knowledge is an explicit resource that can be documented and reported (DH, 2000). Similarly, it is assumed that formal evidence and instructive guidance, e.g. checklists, will inform improvement in clinical practice (NSPA, 2003). This contrasts with a practice-based view where safetyknowledge is situated in practice and framed by professional boundaries. Supporting this view, research shows practice-based communities as important sites for learning in the wake of safety events, for example, where informal problem-solving supports rapid changes based upon shared understanding, collegiality, empathy and trust (Braithwaite, Runciman, & Merru, 2009; Waring and Bishop, 2010). Similarly, professional boundaries inhibit knowledge sharing and learning in the context of patient safety (Currie et al., 2008; Waring, 2007). A significant issue is the potential for safety-related knowledge to undermine professional credibility or lead to litigation, notwithstanding policy rhetoric around a no-blame culture (Waring, 2005). Professionals are often discouraged from knowledge sharing where it enables managers to better govern professional practice (Waring, 2007). Research suggests that anxiety about such systems, especially where it might damage professional reputation, can encourage clinical communities to develop alternate approaches of learning that limit outside groups to access practice-based knowledge (Waring & Currie, 2009). Given the experiential and situated nature of safety knowledge and the persistence of professional/managerial boundaries, patient safety provides an important case for investigating intraorganisational knowledge brokers. Policies have introduced formal management roles for safety improvement, which include responsibility for hospital reporting and learning systems (Waring, 2005). Importantly, these managers tend to be located within

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corporate or ‘topedown’ organisational positions and use bureaucratic channels to gather from and share knowledge with clinical departments (Waring, 2005). Research also highlights the potential for localised or ‘bottomeup’ learning and the possibilities for actors with less formal roles to support knowledge sharing and learning (Braithwaite et al., 2009; Waring and Bishop, 2010). This study aimed to identify and compare how different healthcare actors, including those with formal and informal responsibilities for patient safety, might broker knowledge across organisational and occupational boundaries in relation to patient safety and thereby generate broader lessons for healthcare learning and improvement. Study design and methods Our exploratory study aimed to identify and compare ‘embedded’ knowledge brokers working within and between organisational teams, departments and units, especially clinical and managerial groups. In line with the literature, the paper examines how structural position shapes brokers’ ability to access, share and support the use of practice-based knowledge across professional boundaries, comparing those with formal and informal roles in relation to patient safety. Given lack of research on intra-organisational knowledge brokers (Currie & White, 2012), especially in the context of patient safety, the research was designed as a two-stage exploratory study. This was undertaken between 2008 and 2011 in three teaching hospitals located in different regions of the English NHS, each with similar systems of risk management as a consequence of participation in the National Reporting and Learning System. The study received research ethical approval through NHS Research Ethics Service and R&D approval from each participating hospital. The first stage aimed to ‘discover’ embedded actors with formal or informal responsibilities for knowledge brokering. One researcher undertook intensive site-visits (5e10 days) within each hospital to review policies on clinical risk and safety; observe Clinical Risk or Clinical Governance Committees (c7 h); and interview key informants, including each Medical Director (3), Nursing Director (3) and senior managers responsible for clinical quality, safety and risk (5). This preliminary data was reviewed by two authors to describe each hospital’s formal and informal practices of knowledge sharing and learning. With reference to Gould and Fernandez (1989), this led to the identification of different brokers operating between hospital departments. Foreshadowing the findings, four types were elaborated according to their structural position and relationships, including whether knowledge sharing was a formal or informal part of their role. Risk Managers (RMs) held formal organisational responsibility for reporting and learning systems across their respective hospitals. Risk Officers (ROs) were responsible for supporting formal hospital reporting and learning at the clinical department level. Clinical Leaders (CLs) held administrative, managerial or leadership positions at clinical department level, including sisters, matrons and ward managers. Professional Leaders (PLs) were also located at the clinical departmental level and performed brokering activities as representatives for uni-professional interests in relation to quality and safety. Both CLs and PLs only had indirect responsibilities for reporting and learning. The second stage aimed to deepen knowledge on how position and role shaped knowledge sharing and learning. The selection aimed to facilitate comparison of the four broker types (RM, RO, CL, PL); and comparison across each hospital, i.e. selecting brokers in similar organisational locations; but also including comparison of differences in clinical speciality, i.e. theatres and pathology. In each participating hospital the RM (and deputy where available), and the ROs and CLs from each Operating Department were selected for

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comparison between hospitals. In addition, ROs, CLs and PLs were selected from a range of other clinical departments to examine differences between specialities (see Table 1). As an illustration, selection in Hospital A included the RM and deputy, the CL (Theatre Manager) and RO from the Operating Department, the CL from Stoke Care, a second RO from Support Services and PLs from Stroke Care and the Operating Department. Second stage data collection involved non-participant observations by one researcher with the 19 selected participants, including shadowing of work activities for 3e5 days (about 5 h per day, c250 h in total). For those with formal roles this involved observing how incident reports were received and processed; the use of ICT systems; face-to-face and informal meetings with colleagues; and attendance at management meetings, including RCAs and other learning events. For those with informal roles this involved observing daily clinical routines; attendance at departmental meetings and daily interactions with colleagues. Where feasible, additional participant observations were undertaken with RMs and ROs, where the researcher copied staff in processing incident reports and cataloguing evidence (total 10 h). All observations were recorded in hand-written field journals that were loosely structured with key prompts to record descriptions of settings, actors and (inter) activities with particular reference to the flows of knowledge between actors. Observations were recorded with parallel reflective interpretations by the observer. During observations, all participants were engaged in ongoing informal conversations to clarify their activities. All participants also agreed to semi-structured interview. In all cases, an interview was arranged at the start of the observations to determine professional backgrounds, roles and responsibilities; relationships with different departments; and experiences of knowledge exchange. This established an introductory context and narrative of brokering activities to inform subsequent observations. For all but four participants (2 deputy RMs, 1 PL and 1 RO), a second interview was undertaken at the completion of observations to clarify specific issues recorded in field records, e.g. when they might use telephone rather than email to share information. In line with the exploratory approach, data analysis followed in the interpretative qualitative tradition with the intention of identifying and developing empirical concepts (Strauss & Corbin, 1992). This involved close reading of observation records, interview transcripts and other documents, followed by a process of interpretation, in which data units were coded and compared for their internal consistency and coherence, and then re-coded as higher order categories and themes. Initial coding was undertaken by the field researcher, with a second researcher coding samples of data to test the internal consistency of codes and contributing to secondary coding. As data analysis progressed the research team reviewed the analytical process and contributed to the identification of empirical categories, which were cross-referenced with the literature to develop the themes (Table 2). Table 1 Location of selected knowledge brokers.

Risk managers (RM) Clinical leaders (CL) Risk officers (RO) Professional leaders (PL) Hospital total

Hospital A (locations)

Hospital B (locations)

Hospital C (locations)

Hospital-wide & deputy Operating dept. Stroke care Operating dept. Support services Anaesthetics

Hospital-wide

Hospital-wide & deputy Operating dept. Ortho. dept. Operating dept.

5

Pathology

4

7

Operating dept. Operating dept. Maternity Maternity Elderly care 6

6

N 5

5

19

Table 2 Illustration of analytical coding. Analytical theme

Coding

Relational position

Job role (formal/informal) Organisational location (clinical/administrative) Lines of reporting (hierarchical/collegial) Organisational interactions (boundary crossings) Context of interaction (when & why) Media of interaction (how & format) Focus of interaction (incident, guidelines, advice) Knowledge type (explicit/implicit) Awareness (where knowledge is found) Access (how knowledge is accessed) Externalisation (making knowledge explicit) Internalisation (make knowledge implicit) Membership (legitimacy & belonging with community) Authority (formal power within setting)

Relational activities

Knowledge

Professional power

Findings The findings describe each type of knowledge broker. Drawing on illustrative observations and quotes, we outline their primary organisational role and responsibility; locations and relationships within the hospital; and their knowledge sharing and learning activities. This provides the basis for subsequent interpretation and discussion. Risk managers (RMs) RMs held formal delegated responsibility for developing, communicating and managing hospital policies and procedures for patient safety. RMs described themselves as ‘senior managers’ and aligned their roles with corporate planning and governance, rather than clinical service delivery. All but one of the RMs had administrative careers and had worked in related fields, including Health and Safety and Quality Assurance, and two had experience of working outside the NHS. One RM had a background in nursing and had moved into the role of Patient Safety Manager as a part of their “promotion from ward management to senior management”. All RMs were located in designated Risk Management or Clinical Governance departments, supported by deputies and/or specialist administrators. Illustrating the alignment with senior management, these departments were co-located with other centralised administrative units, such as HR and finance. In terms of their primary intra-organisational relationships, RMs reported to senior hospital executives, e.g. Chief Nurse or Medical Director, who held overall responsibility for clinical quality. They also had formal lines of communication throughout each hospital with ROs and CLs located within clinical departments, usually in relation to formal reporting. RMs performed a number of knowledge sharing activities, primarily in regards to formal reporting and learning systems, linked to the NRLS. These systems provided the primary means of knowledge exchange between hospital managers and clinical practice on matters of patient safety. Interestingly, RMs rarely made direct use of incident reports, but relied upon data clerks to process reports with a specialised computer package. RMs then used ‘secondary data’ to identify incident trends or significant events, which became the subject of more detailed inquiry. On reflection, RMs seemed little concerned with individual safety lapses, but more with incident trends. It was also the case that RMs were not really knowledge brokers, but relied upon technology to ‘move’ explicit forms of ‘information’ within the hospital. As such, RMs had limited and largely bureaucratic relationships with clinical departments. “The data gives me the ability to look past the individual error or rather incident and to look for those root causes that seem common

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to multiple events. That’s where we can start to think about change” (Ian, RM) RMs had a more direct relationship with clinical departments during formal investigations of major incidents, which aimed to determine the underlying causes of significant events. At the outset of these inquiries, RMs usually initiated contact with departmental leaders (CLs) to make arrangements for gathering further “evidence”. This revealed a contingent aspect of RMs work and their dependence on CLs to act as local gatekeepers. Investigations involved collecting “witness” statements and patient records to further understand the safety event. Although RMs worked closely with clinical staff through these processes, their relationship was largely unidirectional, i.e. with knowledge flowing from staff to the RM. Upon collecting this ‘information’, the RMs usually convened a case meeting with other departmental representatives (including CLs, and some PLs) to analyse evidence and identify contextual and contributing factors. In these interactions knowledge seemed to emerge through dialogue and discussions as different interpretations were explored (see below). Despite direct engagement with clinical staff and leaders during investigations, RMs tended to have few other opportunities for working with clinical staff: “I’m in regular contact with most of the ward managers, usually when arranging an inquiry. It’s an important relationship because we can’t easily find all the clinical staff” (Ian, RM) The findings of these investigations were usually communicated to departmental managers through face-to-face debriefings and formal reports (CLs). Interestingly, these reports also seemed to be uni-directional, with RMs providing analysis and recommendations, but with responsibility for implementing recommendations delegated to local service leaders. As such, RMs relationships with clinical departments tended to involve advice-giving or passive dissemination, rather than more active participation in change. Similarly, RMs disseminated monthly incident summaries for each hospital department, e.g. type, time and location of incidents, and other safety alerts. These similarly were “cascaded” via passive email and written notice to each departmental leader (CL) or departmental RO, without engaging clinical communities in implementing learning. “We can’t actually make change happen. We are too far removed from what goes on. So, the way I see it is that we are here to provide that additional insight, the more detailed or bigger picture if you like, but really it has to be those on the ground that make change happen” (Mitch, RM) RMs relied on formal topedown bureaucratic procedures to share or move information between management and clinical departments. They had limited direct engagement or understanding of practice-based knowledge, except when offering local training sessions to support staff participation in reporting. In comparison, deputy RMs and other support staff often had different relationships across clinical departments. For example, they had a more informal and supportive relationship with ROs through providing verbal up-dates on recent investigations and offering ‘parallel lines of communication’ alongside formal reporting channels. Unlike RMs, who tended to be ‘career administrators’, support staff often had clinical backgrounds, which they said facilitated shared understanding and more open communication with clinical departments. “I can appreciate the subtleties and nuances of what is being said in reports. It might seem black and white to the others but often there’s a story behind what’s been reported and I can see that.” (Sandy, Deputy RM)

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Risk officers (ROs) ROs supported formal hospital reporting and learning procedures within clinical departments. Physically located within clinical departments and wards, and often co-located with other administrators, ROs tended to have more routine day-to-day contact with frontline clinical communities. Importantly, their role involved reporting to and, in some ways, acting as a representative of the hospital RM at the departmental level. About half were former or part-time clinicians, usually nurses, wanting to develop a managerial career, whilst others were non-clinicians recruited on the basis of experience in risk management. These differences in occupational background played out in how ROs engaged clinicians, where the former seemed to have a closer and more knowledge-able understanding of clinical activities, and the latter more detailed understanding of reporting procedures and risk analysis. As such, ROs varied between more ‘clinician-facing’ or ‘managerial-facing’ relationships, which had a bearing on how they exchanged knowledge at the practice level. “Clinical knowledge is essential to be able to interpret policy into clinical practice, so you have got to have some understanding.of what it actually means to the ward.” (Jane, RO) ROs performed a number of activities related to knowledge sharing, primarily linked to formal reporting systems. They were frequently observed, for example, helping clinicians complete reports by advising on incident types or how to describe events in ways that conveyed the most appropriate ‘facts’. Those with clinical backgrounds appeared to help clinicians reflect upon events in more technical terms, such as how to explain a clinical procedure. Those with more administrative backgrounds focused on the accurate completion of reports. In one instance, for example, an RO was observed destroying a completed report because it was filled out “incorrectly” and then re-writing it to be more “informative”. “I am here to assist staff in making their reports and to provide that point of contact for feedback or follow-up action. we realised that the relationship with the risk management unit was too sporadic and they only seemed to talk to us when something disastrous had happened.” (David, RO) ROs also supported the work of CLs, for example, providing updates on recent reports or providing an additional line of communication with RMs. We also observed how ROs met regularly with CLs to give verbal updates on safety events or on-going investigations. They also provided weekly communications across their respective departments through attending team briefings and posting memos on notice boards. Importantly, there were differences in how these roles were undertaken with more clinical ROs able to translate new policies or guidelines into day-to-day practice. For example, they appeared more able to engage clinical staff in safety developments, while those with more administrative backgrounds tended to be more ‘office-bound’ and reliant upon formal settings to engage clinicians. Clinical leaders (CLs) At the clinical department or ward level, CLs held formal administrative or leadership responsibilities for service planning, delivery, coordination and governance. They all had clinical backgrounds, but had moved into hybrid professional-managerial positions (Dopson & Fitzgerald, 2006). This included matrons, sisters, ward managers and some medical leaders. As a part of their role, CLs held formal departmental responsibility for ‘quality and safety’ but not responsibility for reporting and learning systems.

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Although not prescribed in their role descriptions, CLs were involved in several important instances of knowledge sharing and learning. Like ROs, they provided clinicians with an opportunity to reflect upon safety events in advance of reporting. We observed, for example, ward staff knocking-on the CLs’ office doors to ask for a “quiet word” to discuss a safety issue. Similarly, clinicians would often take incomplete incident reports to their CL for guidance and approval before filing. As such, CLs had direct access to and understanding of local service issues and provided an opportunity for staff to make-sense of their tacit experiences in a way that facilitated subsequent reporting and communication. “I like the idea of having an open-door so that I am still apart of the hum-drum, you know, I am still a part of the team and I am here to listen to the concerns of my team and I hope they feel they can approach me” (Jenny, CL) CLs also had an influential role during formal incident investigations. In collaboration with the RM and RO, they gathered relevant documents, organised interviews and reviewed evidence. Their authority and standing with the wider workforce legitimised the investigation process, thereby encouraging staff participation. They also had an influential role in the analysis stage of investigations. For example, in one meeting related to an incident involving a surgical swab, the CL countered the interpretation developed by the RM, which centred on the competence of a single staff member, by explaining how staffing shortages had necessitated that one person was managing multiple tasks. Through these activities, CLs therefore provided knowledge and understanding about frontline practices because those in more formal positions were unable to appreciate or articulate these issues. “I am regularly contacted by the risk people to explain this, that or the other. It’s understandable because the forms are so bloody useless they ask for more information” (Helen, CL) CLs also had a key role in the translation of safety recommendations into departmental procedures. In departmental meetings, for example, ROs summarised recent incidents, but CLs related these to departmental policies and sanctioned change. With hospital or national safety alerts, CLs were the primary conduit for communication with departmental staff by translating policies into local practice-context. These activities seemed to be premised on their understanding of “how the place worked” but also their authority within the department to legitimise and make change. This form of authority was often absent for other actors (RMs, ROs). Interestingly, several CLs expressed scepticism about risk management procedures, and often maintained that departmental managers were better placed to raise safety concerns. As such, it seemed that CLs occupied a difficult position between the bureaucratic requirements of hospital management and their clinical communities. Professional leaders (PLs) PLs were clinicians, or other specialists, who were appointed to or volunteered for professional leadership roles, often for career development. PLs included, for example, a senior midwife with supervisory training responsibilities; an anaesthetist responsible for professional incident reporting; and a pathologist nominated as the Quality Assurance lead. Most PLs described themselves as having a “special interest” in quality and safety, but primarily saw themselves as clinicians who provided leadership, rather than more hybrid professional-managers. They often described, for example, how they had attended a particular talk, read a specific publication or participated in a training programme that “sparked” this interest.

“I read the special issue of the BMJ [British Medical Journal] and just got it. I think it was staring many of us in the face, we need to think differently about risk and why things go wrong.” (Geoff, PL) PL roles were organised through their professional membership, and were distinct from hospital risk management systems. As such, their brokering activities tended towards promoting learning or change within uni-professional or department groups. For example, the midwife had a highly active role mentoring junior staff and providing support on learning around safety events. In comparison, the anaesthetist and pathologist organised distinct intra-occupational reporting on behalf of their professional colleagues. Significantly, little or no feedback was provided to other hospital actors about these activities. “We have an entirely voluntary national critical incident system which I coordinate here. It isn’t much work. the Royal College has a dataset and spread sheet which I have introduced across the department and I collate colleagues’ reports and send it off.” [Kirk, Anaesthetic PL] PLs participated in departmental and hospital committees related to quality and safety. By virtue of their specialist positions and knowledge of frontline practice, they described themselves as contributing to service development. As such, they seemed to have ‘access’ to CLs and ROs because they were regarded “professional representatives” on matters of quality and safety. A large part of their work seemed to involve communicating professional updates and guidance amongst colleagues through emails, weekly briefings, training events or other formal communications. That is, they helped broker research knowledge from their national profession into their local communities: “I am involved in a number of pilot studies and safety initiatives.it’s advantageous to the hospital and department because it means that we are at the cutting-edge of science, and because I can share new evidence with my colleagues” (PL, Elderly care) Discussion Our findings describe four distinct types of intra-organisational knowledge brokers working in the area of patient safety. They also highlight important differences in how these actors are involved in the sharing and use of practice-based knowledge within and across professional boundaries, especially how they vary in terms of their role and location within the hospital. Through comparative analysis of these findings, our discussion focuses on three linked themes that elaborate the connections between a brokers’ structural position and relationships within the hospital, the extent to which role formality influences knowledge sharing, and how these together influence the capacity for brokers to interact with different communities to both externalise and internalise knowledge across professional boundaries. The first theme explores the significance of a broker’s ‘structural position’ within the hospital. Following Gould and Fernandez (1989), the study investigated brokers’ location and relationships within and across hospital communities. In general, all brokers appeared to support the inward or outward flow of knowledge from one group or department to another and might be interpreted as ‘gatekeepers’ and ‘representatives’ (Gould & Fernandez, 1989). It might be suggested that some acted as ‘coordinators’ through brokering knowledge between members of their own clinical community (CLs, PLs). Significant, however, were those brokers with structured relationships that enabled them to interact within one or more community simultaneously, especially through being located in one community despite originating from another community. For example, ROs worked at departmental level, but

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reported to hospital managers, and some deputy RMs worked in management but had previous careers in clinical practice. These ‘liaison’ type brokers therefore benefited from dual-directed structural relationships and rather than acting as intermediaries between two different communities they had a more ‘ambassadorial’ role, in that they were co-located with another community to provide more direct and timely relations of exchange. This type of ambassadorial role is not easily accommodated in Gould and Fernandez’s (1989) model, but illustrates how brokers can originate or have allegiance with one community while being located within another. This modifies the idea of a representational broker in that they not only undertake outward representation but also inward representation. Significantly, these ambassadorial brokers also tended to have ‘hybrid’ organisational roles that combined and blurred traditional boundaries, especially between professions and management (ROs, CLs) (Waring & Currie, 2009). Importantly, this blurring enabled brokers to more easily mediate knowledge and cultural differences that would traditionally inhibit knowledge sharing (Currie, Waring, & Finn, 1998). This theme is developed below. Second, brokers varied according to their formal role both within the organisation and in relation to patient safety. For some, knowledge sharing and learning appeared to be a formal element of their role (RMs & ROs). These brokers tended to be positioned in administrative positions that corresponded to bureaucratic procedures for reporting and learning, and prevailing organisational hierarchies. For others, brokering activities tended to be a more informal component of a wider role portfolio that included other clinical or administrative functions (CLs & PLs). These more informal knowledge brokers appeared to be orientated less to established hospital reporting channels, utilising instead a range of inter-personal or professional relationships. Interestingly, those in more formal managerial positions appeared to find it difficult to engage in other less formal practice settings, i.e. their relationships were constrained by role specification and bureaucratic procedure. Furthermore, the study suggests that those with more informal roles in relation to patient safety seemed more effective at brokering knowledge because they relied less on bureaucratic procedures for their authority and more on other professional and relational qualities. This included a degree of intra-professional hierarchy, i.e. ‘senior’ doctors, ‘supervising’ midwives and nurse ‘leaders’, but also qualities such as reputation, trust, shared understanding and common purpose. As such, the study suggests that those with more informal roles might be more effective at brokering patient safety knowledge given their access to and understanding of clinical practice. Again, these informal roles tended to be associated with hybrid organisational actors who could move more easily between different communities and interactional settings, including the formal (e.g. incident investigation) and informal (e.g. workplace conversation). These hybrids also seemed to use ‘parallel channels’ to support knowledge sharing, i.e. formal reporting and informal dialogue. However, it is arguably the case that with their wider role portfolio these hybrid actors might struggle to balance responsibilities and provide continuous attention on safety issues. Third, the observed brokers also varied in terms of the type of knowledge shared and the types of activities performed to support learning. As described above, structural position and role influenced the level and form of participation across different hospital communities, which in turn gave variable degrees of access to and appreciation of different forms of knowledge. More formal brokers (RMs, ROs) tended to rely upon documented or explicit knowledge, which is known to give only a partial or narrow perspective on safety (Waring, 2009). Furthermore, research continually suggests reporting remains inhibited by concerns of blame and disciplinary

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action (Waring, 2005). As outlined above, it is important to see knowledge, not as an explicit resource that can be easily codified, translated and exchanged, but as experiential, situated in practice and bound by use (Blackler, 1995; Lave & Wenger, 1991). As such, only those with legitimate membership and participation within clinical practice communities (CLs, PLs, some ROs) were able to experience, understand and share this know-how. Notwithstanding the importance of being able to access and understand practice-based knowledge, knowledge brokering also relies upon the ability to combine different forms of knowledge and support knowledge-in-use across community boundaries (Hargadon, 2003). This therefore highlights key differences in what knowledge brokers ‘do’ as a reflection of their role and relationships, with some reliant upon the passive communication of explicit ‘information’ and others able to participate in the use of knowledge in practice. The study again suggests that those in hybrid roles, especially CLs, were more able to develop links between the more explicit and implicit forms of knowledge because of their structural opportunities and legitimacy to participate within different communities. However, the range of activities involved in sharing and supporting the use of knowledge, e.g. building connections, translation and supported learning, are arguably beyond the capabilities of individual actors, especially hybrids with large role portfolios. Interestingly, and worthy of further research, the study indicates that where brokers linked to each other in the form of ‘broker chains’ it was possible to progressively share, transform and support the use of knowledge between different communities, for example where formal reporting systems linked to informal practice via the connections between RMs, ROs and CLs. Conclusions At the outset, our paper highlighted two contingencies as inhibiting knowledge sharing and learning within healthcare organisations, namely the difficulties associated with sharing tacit know-how and with sharing knowledge across professional boundaries. With reference to contemporary patient safety reforms, the paper examines which embedded actors might be able to broker safety-related knowledge across the boundaries between professionals and managers. Analysing how brokers vary in terms of their structured relationships, roles and knowledge sharing practices, the study suggests that it is rare for any one individual to fulfil the full range of knowledge brokering activities, especially where they have formal roles and responsibilities for patient safety. Returning to the work of Nonaka (1994), effective knowledge brokering involves the ability to externalise local know-how so that it can be translated or aligned with the needs of others, before being shared and internalised into the practices of other communities. The study suggests that many formally designated actors struggle to support the sharing and use of knowledge because of their limited engagement and legitimacy within clinical practice, and over-reliance of formal bureaucratic processes. Those actors more adept and effective at brokering knowledge across boundaries tended to be those with ‘ambassadorial’ and ‘hybrid’ type roles and relationships at the intra-organisational level, including Clinical Leaders, and other middle-managers. Importantly, hybrids are able to straddle and legitimately participate in multiple communities simultaneously through their conjoint professional-managerial role and dual-directed relationships with both practice-level staff and organisational leaders. These actors not only have legitimacy to participate in multiple organisational communities but also the ability to externalise and share practice-based knowledge, and at the same time the ability to internalise and support the use of evidence for learning and change at the local level (Nonaka, 1994). More attention to the work and

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competencies of these ambassadors and hybrids in other healthcare arenas is encouraged, especially in relation to the diffusion of research evidence into practice (Ward et al., 2011). This might also look into how brokers combine and work together across organisational boundaries in the form of ‘broker chains’ or networks. Finally, the paper offers some specific conclusions for patient safety research and practice. It suggests that reliance upon formal learning systems, such as the NRLS, is unlikely to foster the type of practicebased learning and change envisaged in policies, because of the reliance upon more explicit reports and the lack of engagement with clinical practice. In short, differences in knowledge and the persistence of professional boundaries continue to reinforce the separation between professional and managerial communities. As such, advances in patient safety might be supported through supporting learning and change within local communities but utilising the brokering capacity of hybrid leaders to ensure learning is shared more widely and local change reflects wider priorities. References Abbott, A. (1988). The system of professions. Chicago: Chicago University Press. Abbott, A. (1995). Things of boundaries. Social Research, 62(4), 857e882. Barach, P., & Small, S. (2000). Reporting and preventing medical mishaps: lessons from non-medical incident reporting systems. British Medical Journal, 320, 759e763. Blackler, F. (1995). Knowledge, knowledge work and organizations: an overview and interpretation. Organization Studies, 16(6), 1021e1046. Braithwaite, J., Runciman, W., & Merru, A. (2009). Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Quality and Safety in Health Care, 18(1), 37e41. Braithwaite, J., Westbrooke, M., Travaglia, J., & Hughes, C. (2010). Cultural and associated enablers, and barriers to, adverse incident reporting. Quality and Safety in Health Care, 19, 229e233. Braithwaite, J., Westbrook, M., Mallock, N., Travaglia, J., & Iedema, R. (2006). Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Quality and Safety in Health Care, 15(6), 393. Brown, J., & Duguid, P. (1991). Organizational learning and communities of practice: towards a unified view of working, learning and innovation. Organization Science, 2(1), 40e57. Burt, R. (1992). Structural holes. Cambridge: Harvard University Press. Canadian Health Services Research Foundation. (2003). The theory and practice of knowledge brokering in Canada’s health system. Ottawa: CHSRF. Currie, G., Waring, J., & Finn, R. (1998). The Limits of Knowledge Management for UK Public Service Modernization: the case of patient safety and clinical quality. Public Administration, 86(2), 363e385. Currie, G., Waring, J., & Finn, R. (2008). The limits of knowledge management for UK public service modernisation: the case of patient safety and service quality. Public Administration, 86, 363e385. Currie, G., & White, L. (2012). Inter-professional barriers and knowledge brokering in an organizational context: the case of healthcare. Organization Studies, 33(10), 1333e1361. Department of Health. (2000). An organisation with a memory. London: TSO. Dopson, S., & Fitzgerald, L. (2006). The role of middle management in the diffusion of innovation. Journal of Nursing Management, 14(1), 43e51. Ferlie, E., Fitzgerald, L., Wood, M., & Hawkins, C. (2005). The non-spread of innovations: the mediating role of professionals. Academy of Management Journal, 48(1), 117e134. Francis, R. (2013). Report of the Mid-Staffordshire NHS foundation trust public inquiry. London: TSO. Freidson, E. (1970). The Profession of Medicine: A study in the sociology of applied knowledge. Chicago: University of Chicago Press. Gherardi, S. (2006). Organizational Knowledge: The texture of workplace learning. Oxford: Blackwell.

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