Janet Long

Bridges, brokers and boundary spanners in collaborative networks: a systematic review

BackgroundBridges, brokers and boundary spanners facilitate transactions and the flow of information between people or groups who either have no physical or cognitive access to one another, or alternatively, who have no basis on which to trust each other. The health care sector is a context that is rich in isolated clusters, such as silos and professional “tribes,” in need of connectivity. It is a key challenge in health service management to understand, analyse and exploit the role of key agents who have the capacity to connect disparate groupings in larger systems.MethodsThe empirical, peer reviewed, network theory literature on brokerage roles was reviewed for the years 1994 to 2011 following PRISMA guidelines.ResultsThe 24 articles that made up the final literature set were from a wide range of settings and contexts not just healthcare. Methods of data collection, analysis, and the ways in which brokers were identified varied greatly. We found four main themes addressed in the literature: identifying brokers and brokerage opportunities, generation and integration of innovation, knowledge brokerage, and trust. The benefits as well as the costs of brokerage roles were examined.ConclusionsCollaborative networks by definition, seek to bring disparate groups together so that they can work effectively and synergistically together. Brokers can support the controlled transfer of specialised knowledge between groups, increase cooperation by liaising with people from both sides of the gap, and improve efficiency by introducing “good ideas” from one isolated setting into another.There are significant costs to brokerage. Densely linked networks are more efficient at diffusing information to all their members when compared to sparsely linked groups. This means that while a bridge across a structural hole allows information to reach actors that were previously isolated, it is not the most efficient way to transfer information. Brokers who become the holders of, or the gatekeepers to, specialised knowledge or resources can become overwhelmed by the role and so need support in order to function optimally.

A realist evaluation of the role of communities of practice in changing healthcare practice.

BackgroundHealthcare organisations seeking to manage knowledge and improve organisational performance are increasingly investing in communities of practice (CoPs). Such investments are being made in the absence of empirical evidence demonstrating the impact of CoPs in improving the delivery of healthcare. A realist evaluation is proposed to address this knowledge gap. Underpinned by the principle that outcomes are determined by the context in which an intervention is implemented, a realist evaluation is well suited to understand the role of CoPs in improving healthcare practice. By applying a realist approach, this study will explore the following questions: What outcomes do CoPs achieve in healthcare? Do these outcomes translate into improved practice in healthcare? What are the contexts and mechanisms by which CoPs improve healthcare?MethodsThe realist evaluation will be conducted by developing, testing, and refining theories on how, why, and when CoPs improve healthcare practice. When collecting data, context will be defined as the setting in which the CoP operates; mechanisms will be the factors and resources that the community offers to influence a change in behaviour or action; and outcomes will be defined as a change in behaviour or work practice that occurs as a result of accessing resources provided by the CoP.DiscussionRealist evaluation is being used increasingly to study social interventions where context plays an important role in determining outcomes. This study further enhances the value of realist evaluations by incorporating a social network analysis component to quantify the structural context associated with CoPs. By identifying key mechanisms and contexts that optimise the effectiveness of CoPs, this study will contribute to creating a framework that will guide future establishment and evaluation of CoPs in healthcare.

Nurses’ workarounds in acute healthcare settings: a scoping review

BackgroundWorkarounds circumvent or temporarily ‘fix’ perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses’ use of workarounds in acute care settings.MethodsA literature assessment was undertaken in 2011–2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses’ workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses’ conceptualisation and rationalisation of workarounds.ResultsThe majority of studies examining nurses’ workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses’ workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, ‘being competent’, and collegiality influence the implementation of workarounds.ConclusionWorkarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses’ individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses’ use of workarounds.

Patterns of collaboration in complex networks: the example of a translational research network

BackgroundThis paper examines collaboration in a complex translational cancer research network (TRN) made up of a range of hospital-based clinicians and university-based researchers. We examine the phenomenon of close-knit and often introspective clusters of people (silos) and test the extent that factors associated with this clustering (geography, profession and past experience) influence patterns of current and future collaboration on TRN projects. Understanding more of these patterns, especially the gaps or barriers between members, will help network leaders to manage subgroups and promote connectivity crucial to efficient network function.MethodsAn on-line, whole network survey was used to collect attribute and relationship data from all members of the new TRN based in New South Wales, Australia in early 2012. The 68 members were drawn from six separate hospital and university campuses. Social network analysis with UCInet tested the effects of geographic proximity, profession, past research experience, strength of ties and previous collaborations on past, present and future intended partnering.ResultsGeographic proximity and past working relationships both had significant effects on the choice of current collaboration partners. Future intended collaborations included a significant number of weak ties and ties based on other members’ reputations implying that the TRN has provided new opportunities for partnership. Professional grouping, a significant barrier discussed in the translational research literature, influenced past collaborations but not current or future collaborations, possibly through the mediation of network brokers.ConclusionsSince geographic proximity is important in the choice of collaborators a dispersed network such as this could consider enhancing cross site interactions by improving virtual communication technology and use, increasing social interactions apart from project related work, and maximising opportunities to meet members from other sites. Key network players have an important brokerage role facilitating linkages between groups.

Leadership in complex networks: the importance of network position and strategic action in a translational cancer research network

BackgroundLeadership behaviour in complex networks is under-researched, and little has been written concerning leadership of translational research networks (TRNs) that take discoveries made ‘at the bench’ and translate them into practices used ‘at the bedside.’ Understanding leaders’ opportunities and behaviours within TRNs working to solve this key problem in implementing evidence into clinical practice is therefore important. This study explored the network position of governing body members and perceptions of their role in a new TRN in Sydney, Australia. The paper asks three questions: Firstly, do the formal, mandated leaders of this TRN hold key positions of centrality or brokerage in the informal social network of collaborative ties? Secondly, if so, do they recognise the leadership opportunities that their network positions afford them? Thirdly, what activities associated with these key roles do they believe will maximise the TRN’s success?MethodsSemi-structured interviews of all 14 governing body members conducted in early 2012 explored perceptions of their roles and sought comments on a list of activities drawn from review of successful transdisciplinary collaboratives combined with central and brokerage roles. An on-line, whole network survey of all 68 TRN members sought to understand and map existing collaborative connections. Leaders’ positions in the network were assessed using UCInet, and graphs were generated in NetDraw.ResultsSocial network analysis identified that governing body members had high centrality and high brokerage potential in the informal network of work-related ties. Interviews showed perceived challenges including ‘silos’ and the mismatch between academic and clinical goals of research. Governing body members recognised their central positions, which would facilitate the leadership roles of leading, making decisions, and providing expert advice necessary for the co-ordination of effort and relevant input across domains. Brokerage potential was recognised in their clearly understood role of representing a specialty, campus or research group on the governing body to provide strategic linkages. Facilitation, mentoring and resolving conflicts within more localised project teams were spoken of as something ‘we do all the time anyway,’ as well as something they would do if called upon. These leadership roles are all linked with successful collaborative endeavours in other fields.ConclusionsThis paper links the empirical findings of the social network analysis with the qualitative findings of the interviews to show that the leaders’ perceptions of their roles accord with both the potential inherent in their network positions as well as actual activities known to increase the success of transdisciplinary teams. Understanding this is key to successful TRNs.

Who are the key players in a new translational research network

BackgroundProfessional networks are used increasingly in health care to bring together members from different sites and professions to work collaboratively. Key players within these networks are known to affect network function through their central or brokerage position and are therefore of interest to those who seek to optimise network efficiency. However, their identity may not be apparent. This study using social network analysis to ask: (1) Who are the key players of a new translational research network (TRN)? (2) Do they have characteristics in common? (3) Are they recognisable as powerful, influential or well connected individuals?MethodsTRN members were asked to complete an on-line, whole network survey which collected demographic information expected to be associated with key player roles, and social network questions about collaboration in current TRN projects. Three questions asked who they perceived as powerful, influential and well connected. Indegree and betweenness centrality values were used to determine key player status in the actual and perceived networks and tested for association with demographic and descriptive variables using chi square analyses.ResultsResponse rate for the online survey was 76.4% (52/68). The TRN director and manager were identified as key players along with six other members. Only two of nine variables were associated with actual key player status; none with perceived. The main finding was the mismatch between actual and perceived brokers. Members correctly identified two of the three central actors (the two mandated key roles director and manager) but there were only three correctly identified actual brokers among the 19 perceived brokers. Possible reasons for the mismatch include overlapping structures and weak knowledge of members.ConclusionsThe importance of correctly identifying these key players is discussed in terms of network interventions to improve efficiency.

Health system frameworks and performance indicators in eight countries: A comparative international analysis:

Objectives: Performance indicators are a popular mechanism for measuring the quality of healthcare to facilitate both quality improvement and systems management. Few studies make comparative assessments of different countries’ performance indicator frameworks. This study identifies and compares frameworks and performance indicators used in selected Organisation for Economic Co-operation and Development health systems to measure and report on the performance of healthcare organisations and local health systems. Countries involved are Australia, Canada, Denmark, England, the Netherlands, New Zealand, Scotland and the United States. Methods: Identification of comparable international indicators and analyses of their characteristics and of their broader national frameworks and contexts were undertaken. Two dimensions of indicators – that they are nationally consistent (used across the country rather than just regionally) and locally relevant (measured and reported publicly at a local level, for example, a health service) – were deemed important. Results: The most commonly used domains in performance frameworks were safety, effectiveness and access. The search found 401 indicators that fulfilled the ‘nationally consistent and locally relevant’ criteria. Of these, 45 indicators are reported in more than one country. Cardiovascular, surgery and mental health were the most frequently reported disease groups. Conclusion: These comparative data inform researchers and policymakers internationally when designing health performance frameworks and indicator sets.

Vital signs monitoring on general wards: clinical staff perceptions of current practices and the planned introduction of continuous monitoring technology

OBJECTIVE Early detection of patient deterioration and prevention of adverse events are key challenges to patient safety. This study investigated clinical staff perceptions of current monitoring practices and the planned introduction of continuous monitoring devices on general wards. DESIGN Multi-method study comprising structured surveys, in-depth interviews and device trial with log book feedback. SETTING Two general wards in a large urban teaching hospital in Sydney, Australia. PARTICIPANTS Respiratory and neurosurgery nursing staff and two doctors. RESULTS Nurses were confident about their abilities to identify patients at risk of deterioration, using a combination of vital signs and visual assessment. There were concerns about the accuracy of current vital signs monitoring equipment and frequency of intermittent observation. Both the nurses and the doctors were enthusiastic about the prospect of continuous monitoring and perceived it would allow earlier identification of patient deterioration; provide reassurance to patients; and support interdisciplinary communication. There were also reservations about continuous monitoring, including potential decrease in bedside nurse-patient interactions; increase in inappropriate escalations of patient care; and discomfort to patients. CONCLUSIONS While continuous monitoring devices were seen as a potentially positive tool to support the identification of patient deterioration, drawbacks, such as the potential for reduced patient contact, revealed key areas that will require close surveillance following the implementation of devices. Training and improved interdisciplinary communication were identified as key requisites for successful implementation.

Medicine information exchange networks among healthcare professionals and prescribing in geriatric medicine wards

AIMS Effective transfer of information is vital for rational drug therapy. This is particularly important for older patients, who have a high prevalence of polypharmacy and are managed by multidisciplinary teams. We aimed to assess medicine information exchange (MIE) networks in geriatric medicine wards and whether they are associated with prescribing patterns. METHODS We conducted network analysis in acute geriatric medicine wards from four hospitals to characterize MIE networks among multidisciplinary team members. Corresponding patient data were collected to analyze high-risk prescribing in conjunction with network characteristics. RESULTS We found that junior doctors, senior nurses and pharmacists were central to MIE across all four hospitals. Doctors were more likely than other professions to receive medicines information in three hospitals. Reciprocity and the tendency to communicate within ones own profession also influenced network formation. No difference was observed in prescribing practice between hospitals. CONCLUSIONS Understanding MIE networks can identify gaps in multidisciplinary communication that can be addressed. Networks may identify targets for dissemination of interventions to improve prescribing.

When complexity science meets implementation science: a theoretical and empirical analysis of systems change

BackgroundImplementation science has a core aim – to get evidence into practice. Early in the evidence-based medicine movement, this task was construed in linear terms, wherein the knowledge pipeline moved from evidence created in the laboratory through to clinical trials and, finally, via new tests, drugs, equipment, or procedures, into clinical practice. We now know that this straight-line thinking was naïve at best, and little more than an idealization, with multiple fractures appearing in the pipeline.DiscussionThe knowledge pipeline derives from a mechanistic and linear approach to science, which, while delivering huge advances in medicine over the last two centuries, is limited in its application to complex social systems such as healthcare. Instead, complexity science, a theoretical approach to understanding interconnections among agents and how they give rise to emergent, dynamic, systems-level behaviors, represents an increasingly useful conceptual framework for change. Herein, we discuss what implementation science can learn from complexity science, and tease out some of the properties of healthcare systems that enable or constrain the goals we have for better, more effective, more evidence-based care. Two Australian examples, one largely top-down, predicated on applying new standards across the country, and the other largely bottom-up, adopting medical emergency teams in over 200 hospitals, provide empirical support for a complexity-informed approach to implementation. The key lessons are that change can be stimulated in many ways, but a triggering mechanism is needed, such as legislation or widespread stakeholder agreement; that feedback loops are crucial to continue change momentum; that extended sweeps of time are involved, typically much longer than believed at the outset; and that taking a systems-informed, complexity approach, having regard for existing networks and socio-technical characteristics, is beneficial.ConclusionConstruing healthcare as a complex adaptive system implies that getting evidence into routine practice through a step-by-step model is not feasible. Complexity science forces us to consider the dynamic properties of systems and the varying characteristics that are deeply enmeshed in social practices, whilst indicating that multiple forces, variables, and influences must be factored into any change process, and that unpredictability and uncertainty are normal properties of multi-part, intricate systems.