Keeping knowledgeable: How NHS Chief Executives mobilise knowledge and information in their daily work

From knowledge utilisation to knowledge mobilisation

A different way to summarise Rich’s32 criticism is to note that most of the study of knowledge mobilisation conducted in the 1980s and early 1990s is underpinned by a very specific view of knowledge (and information), which Cook and Brown34 described as the epistemology of possession. This view tends to conceive knowledge as a type of substance, resource or asset that can be accumulated, transmitted, diffused and utilised. The approach privileges explicit over tacit knowledge, and knowledge possessed by individuals over that possessed by groups. In so doing, it offers a view of knowledge that is severely undersocialised. This is in spite of the fact the knowledge utilisation research has consistently found that the most common facilitator of research use is personal contact between researcher and policy-maker. 35

The increasing attention to the role of social factors in influencing the use of scientific research by policy-makers is captured in the introduction of the concept of ‘knowledge mobilisation’. Knowledge mobilisation was defined by the Canadian Social Sciences and Humanities Research Council (SSHRC)9 as:

moving knowledge into active service for the broadest possible common good. Here knowledge is understood to mean any or all of (1) findings from specific social sciences and humanities research, (2) the accumulated knowledge and experience of social sciences and humanities researchers, and (3) the accumulated knowledge and experience of stakeholders concerned with social, cultural, economic and related issues.

The use of the word ‘mobilisation’ underscores the interactive, social and interpretive nature of the process, whereby individuals and teams acquire knowledge, absorb it and put it to work. According to Levin,36 mobilisation is preferred to utilisation because it emphasises the multi-dimensional, longer-term and often political nature of the work in comparison to earlier terms that seem to imply a ‘one directional and linear move from research to practice’. In contrast to the engineering, linear or ‘pipeline’ models described above as input–output, a socio-organisational view of knowledge mobilisation suggests that:

• Knowledge is socially constructed and its use takes multiple forms that can be more or less direct and more or less rapid, with slower and less direct impacts being more common. Given this broad view, there is much more use of research and evidence in practice than is generally thought.

• Knowledge takes shape and has effect in a wide variety of ways, but is always mediated through various social and political processes.

• Knowledge by itself is not enough to change practice, since practices are social and therefore reinforced by many elements such as norms, cultures and habits. Simply telling people about evidence and urging them to change what they do is clearly ineffective. 36

• The relationship between knowledge and use runs in both directions; practice affects research, just as research affects practice. Rather than knowledge transfer or mobilisation, we should conceive the process in terms of knowledge interaction. 37

• Personal contact and interaction remains the most powerful vehicle for moving evidence into practice.

• Third party organisations of all kinds – sometimes called mediators or brokers – play a critical role in the spread and impact of research. 36

In sum, the knowledge mobilisation approach suggests that the circulation and take-up of knowledge is heavily dependent on existing social relations and processes, and that these need to be brought to the centre of attention. A typically and often quoted example of this approach in health care is the work of Gabbay and Le May. 5 The scholars conducted an observational study of knowledge utilisation in primary care. Contrary to the precepts of knowledge utilisation, they found that explicit evidence was rarely used by doctors in their daily clinical decision-making. Rather clinicians used tacit ‘mind-lines’, which they defined as ‘collectively reinforced, internalised tacit guidelines’. 5 While mind-lines built on the doctor’s early training and experience, and while they were at times informed by short readings, they largely resulted from interactions with other clinicians and stakeholders (opinion leaders, patients, pharmaceutical representatives and other sources). The clinicians, in general, would ‘refine their mind-lines by acquiring tacit knowledge from trusted sources, mainly their colleagues, in ways that were mediated by the organisational features of the practice’. 5 The notion of mind-lines resonates with other concepts, such as ‘community of practice’38 and ‘network of practice’,39 which equally reject linear models of explicit knowledge take-up in favour of interactive models that put social relations and collective sense-making at centre stage. These theories are not discussed here, as they have been the subject of a recent extensive review of the literature funded by the NIHR. 21

What is notable here is that the adoption of a social understanding of knowledge mobilisation shifts the focus of empirical research towards an appreciation that:

• Knowledge is social in character: it resides in communities of practice, networks of practice and other types of collectives that sustain it, legitimise it and preside over its transmission to the next generation of practitioners via socialisation.

• Social networks, both informal and formal (e.g. professional associations), constitute at the same time the carriers and the conduits of knowledge and innovation. The nature and structure of networks matter to the circulation and take-up of knowledge. Brokers and boundary spanners acquire fundamental importance.

• Political considerations, peer pressure, social emulation and interests play a central role in knowledge mobilisation. The social position and social capital of the source and recipient constitute major factors in determining the diffusion and use of research for decision-making.

• Knowledge does not travel untouched through social interactions, but is necessarily modified in the process. Knowledge mobilisation is therefore necessarily a process of translation. The process allows for the same content to be utilised in different social and cultural contexts.

What is this knowledge that we seek to mobilise? Knowing as practice

As noted by Nicolini,14 while the social approach undermines naive instrumental views of knowledge in organisations, it is still ambivalent in terms of the meaning and status of the knowledge that needs to be mobilised. The social approach is in fact still compatible with the idea that knowledge is a substance that circulates through social ‘plumbing’, and that, once delivered at the right time and place, it can be used as a resource for action. For Greenhalgh and Wieringa,40 claiming that knowledge is created through social interaction and travels through social channels is not enough, as this view still assumes that knowledge equates to impersonal research findings; that knowledge and practice can be cleanly separated both empirically and analytically; and that practice consists of a series of rational decisions.

What is needed instead is recognition that knowing is always manifested in practice and through practice. Knowing is always knowledge-in-action, a form of social expertise and collective knowledgeability situated in the historical, social and cultural context from which it arises. While ways of knowing can be mediated through discourse, narratives, disciplined bodies, symbols and artefacts, knowing is always a practical accomplishment, and practice is where knowledgeability manifests itself and agency becomes possible. Practice, understood as the mediated performance of an activity where such performance has a history and a constituency, constitutes the figure of discourse that enables reconnecting knowing with working, and is the empirical grounds where such a relationship can be investigated. 14,40

Adopting a practice-based view thus completes the shifts initiated by the proponents of the social and contextual understanding of knowledge utilisation or knowledge mobilisation. It does so by indicating that to understand these phenomena one has to start by observing the practice itself, and asking what are the conditions and processes that underpin the individual and collective knowledgeability that enable the local accomplishment of the activity. The knowledge utilised in a decision-making process is in fact often personal, narrative and dialogical in nature. 40 In management, just as in clinical work or policy decision-making, knowledge is necessarily ‘knowledge-in-practice in context’. 7 Researchers should thus avoid approaching knowledge processes as if they were separate activities. Rather, their effort should be that of becoming sensitive to the knowledge dimension of mundane day-to-day work. This includes becoming sensitive to the local criteria of plausibility (what counts as rational, see Greenhalgh and Wieringa40); understanding the nature of the job and the rules of the game that govern it; observing the sociomaterial arrangements within which actors operate; and attending to the contextual constraints and power relations that are performed and sustained by different types of knowing (see, for example, Stevens41 for discussion of the role of power in the use of evidence in policy decision-making in the UK).

As we shall see in the next section, similar conclusions have been arrived at in the discussion of information-seeking behaviour. This research tradition, which stems from library and information studies, has traditionally investigated how people search for and utilise information. Here too there is an emerging sense that, to understand how individuals interact with information systems of all kinds, one has to focus on the mundane everyday activities of actors, asking how they deal with information as part of the conduct of their life and work tasks.

What counts as information in information behaviour studies

The shift in theoretical sensibilities guiding the research into human information-seeking and use was mirrored in the change and expansion of the core object of its study: ‘information’ itself. Summarising a complex debate that unfolded over several decades,42,47 we can note that information has been academically considered in an increasingly comprehensive way. Initially defined as what is transmitted between a source and a receiver, information is now more broadly understood as ‘a difference that makes a difference’. 48 In particular, the term is assumed ‘to cover all instances where people interact with their environment in any such way that leaves some impression on them – that is, adds or changes their knowledge store’. 42 Impressions can be emotional (as when we react to a piece of news), and the encounter with information can be negative or have no effect, as information can be ignored, denied or rejected. The shift is relevant, as it marks a move away from the idea that information constitutes a substance (the ‘message’), towards a more dynamic view that conceives of information as a process.

This development is, for example, visible in the work of Michael Buckland,49 who developed a widely cited typology that suggested that information can be understood in three different ways. The first is information-as-process. This view refers to the act of informing, or communication of information, and how a person’s state of knowledge is changed. The second takes information to be synonymous with (or similar to) knowledge. This usage denotes the content of what is transmitted or shared or processed (i.e. the knowledge communicated). Finally, information can also be considered as a thing; in this case, the reference is to information objects or products, such as data and documents. These are referred to as ‘information’ because they are regarded as being informative. 42,44 This and other similar typologies, for example McCreadie and Rice’s50 distinction between information as a resource, information as data in the environment (including sounds, smells and objects), information as a representation of knowledge and information as meanings that are created as people go about their lives and try to make sense of their world, are important for at least three reasons.

First, they suggest that a broad and inclusive understanding of information is critical if we want to cast our net widely enough to capture the different aspects of this complex phenomenon. Case,44 for example, suggests that any conceptualisation of information needs to be broad enough so that it:

1. allows for common-sense notions of information used in everyday discourse

2. allows for unintentional origins of information (e.g. observations of the natural world), as well as for purposeful communication among people

3. allows for internally generated information (e.g. memories, constructions), as well as externally generated information (e.g. reading a text)

4. allows for types of information beyond that needed for ‘solving a problem’ or ‘making a decision’

5. admits the importance of informal sources (e.g. friends), as well as formal sources (e.g. data or documents)

6. involves the human mind in the creation, perception or interpretation of information; to leave out such a requirement is to effectively declare that anything is information, which would leave us with no focus in our investigations. 44

Second, the above-listed, inclusive categorisations of information underline the need to examine information behaviour as a process and an activity, rather than a substance. Finally, they indicate that information and knowledge (and data) need to be kept provisionally (and analytically) separated. That is to say, whether the three are overlapping or different is an empirical, not a theoretical question: while sometimes information and knowledge coincide, at other times a variety of social and cognitive processes are necessary so that information can become knowledge.

Information user studies as the departure point: the system-oriented view

The systematic investigation of information-seeking and information retrieval dates back several decades. Until the 1970s, however, the interest of the analysts was limited to the study of the sources, artefacts and venues of information-seeking, and of their use in the context of information retrieval activities. The questions investigated in these studies, which Vakkari51 described as ‘system oriented’, were centred around information needs of a distinct segment of the population, and the capacity of formal systems (universities, libraries, professional conferences, media, schools, etc.) to satisfy them. In short, the main question asked in these studies was ‘how often is a system used and by whom?’

For example, in 1948 Urquhart52 suggested that the study of information-seeking was:

an effort to discover, by means of a questionnaire addressed to readers of publications borrowed from the Science Museum Library, some information on such questions as how references to publications are obtained, what the expected information is required for, and whether, in fact, the publications contain the desired information.

Library studies were accompanied by surveys of specific groups (for example scientists), in the effort to map what their reading habits were, where they got their information from and how they used catalogues. The main strategy for determining what information had actually been used was citation analysis; user satisfaction analysis was utilised, but was relatively rare. The results were often a list of sources, rankings of preferences and maps of resources. These were often used to produce recommendations on how to develop information systems and services. Indeed, many of these studies were promoted or sponsored by the administrators of academic and public institutions.

From information-seeking to information behaviour

Starting in the 1970s, a number of scholars started to recognise the limitations of the ‘system orientation’. This was because the system-oriented studies ignored the attributes of the individuals, and omitted to consider ‘how an individual will apply his or her model or view of the world to the process of needing, seeking, giving, and using information’. 43

The move towards a person-oriented approach to the study of information retrieval and use was initiated more or less independently by researchers such as Belkin,53 Dervin55–57 and Wilson. 54,58 Their work introduced a strong personal and cognitive dimension to the study of information-seeking, suggesting the need to explore both the cognitive state of information users (considered a variable dependent upon the context of the situation of information-seeking) and their cognitive style and individual personal characteristics. According to Belkin,59 ‘the essence of the cognitive viewpoint is that it explicitly considers that the states of knowledge, beliefs and so on of human beings (or information-processing devices) mediate (or interact with) that which they receive/perceive or produce’. 59 This means that for the study of information behaviour one needs to take into consideration ‘the phenomena and situations of relevance in terms of representations (usually mental) of knowledge, intentions, beliefs, texts and so on’. 59 The attention thus shifts from the institutional and ‘systemic’ conditions to the information, in order to identify the conditions, characteristics and recurrent patterns in information-seeking and retrieval. As the attention moves from externally observable behaviours to personal, cognitive and affective processes, this also requires the adoption of qualitative methods of inquiry, which represents a clear departure from the predominantly quantitative system approach. The differences between the system-oriented and the person-oriented/cognitive approach are summarised in Figure 1. 44

FIGURE 1.

Examples of differences between the system- and the person-oriented/cognitive approaches to information-seeking. Reproduced with permission from Case DO. Looking for Information: A Survey of Research on Information Seeking, Needs and Behaviour. 2nd edn. London: Academic Press; 2007. 44

The person-oriented/cognitive approach thus shifts the focus from the nature, availability and usability of information sources to the nature and determinants of the behaviour of information-seekers. The approach rotates around three conceptual poles:

• needs/motivations of the information-seeker

• personal knowledge structures

• actions.

Overall, the information behaviour approach thus proposes that information-seeking and other types of information behaviour constitute the response to a perceived state of need, or more generally an imbalance in the knowledge structures of individuals. This incompleteness, gap or deficiency, which can be experienced in either cognitive or affective terms, activates repair strategies conditioned by a combination of personal preferences and contextual factors.

Wilson,58 for example, argues that information behaviour arises as a consequence of:

A need perceived by an information user, who, in order to satisfy that need, makes demands upon formal or informal information sources or services, which result in success or failure to find relevant information. If successful, the individual then makes use of the information found and may either fully or partially satisfy the perceived need – or, indeed, fail to satisfy the need and have to reiterate the search process.

In his updated 1999 model of information behaviour,60 summarised in Figure 2, Wilson suggests that other people may be involved in the process. They can act both as sources (information can be exchanged among humans) and as recipients (information perceived as useful may be passed to other people).

FIGURE 2.

Wilson’s 1999 model of information behaviour. Reproduced with permission from Wilson TD. Models in information behaviour research. J Doc 1999;55:251. 60

As suggested by Figure 2, information needs and motivations are at the core of this approach. For example, Taylor61 suggests that information-seeking starts with an uneasiness or sense of dissatisfaction or curiosity that is often perceived in a very visceral way. In order for information behaviour to be activated, this uneasiness has to go through a number of steps, which aids the need in becoming first conscious and then rational (in the sense of being articulated and qualified). Only at this point does the individual take action in view of the constraints that the contextual conditions impose upon him or her. The final stage of the information-seeking process is thus necessarily a compromise between the information needs and the material opportunities offered by the environment – the implication being that the process may follow a satisficing, rather than completeness model (we stop when we are satisfied, rather than when we fulfil all our needs or obtain all the possible information; see Prabha et al. 62 for a discussion).

Kuhlthau63 found that the stages of the information search process followed by individuals are associated with specific feelings, so that information-seeking has to do with thoughts, actions and affect. The fundamental proposition is that:

the feelings of uncertainty associated with the need to search for information give rise to feelings of doubt, confusion and frustration and that, as the search process proceeds and is increasingly successful, those feelings change: as relevant material is collected confidence increases and is associated with feelings of relief, satisfaction and a sense of direction.

Wilson TD60

For example, the initiation of the search is associated with uncertainty; the selection of potentially relevant items with optimism; the exploration for further material with confusion, frustration and doubt; the formulation of a clear strategy with clarity; the collection of further material with sense of direction and confidence. Finally, the presentation of the results is associated with satisfaction or disappointment. 44,60,62

In partial disagreement with the previous authors, Dervin56,64 suggests that what triggers different types of information behaviour is not so much the immediate need to re-equilibrate our cognitive structures, but rather a more general tension to maintain and restore sense-making. The author consequently focused her attention on people as actors who strive to make sense of their daily world: ‘the individual, in her time and place, needs to make sense . . . She needs to inform herself constantly. Her head is filled with questions. These questions can be seen as her “information needs” ’. 64 The aim of information behaviour scholars is thus to explore the ways in which people face problematic situations and try to make sense of them by posing questions and seeking answers from various sources. Dervin’s approach, which builds on Dewey’s notion of inquiry, has the historical merit of questioning the idea that information is a substance that can be freely transferred without compromise. Information is, rather, created in specific circumstances by one or more humans. The implication is that, to understand information behaviour, one has to employ naturalistic methods, which can help us appreciate the contextual condition within which humans deal with information and turn information into meaning.

According to Dervin,56 such sense-making involves four constituent elements:63

• a situation in time and space (which defines the context in which information problems arise)

• a gap (which identifies the difference between the contextual situation and the desired situation, e.g. uncertainty)

• an outcome (that is the consequences of the sense-making process)

• a bridge (that is some means of closing the gap between situation and outcome).

Making sense thus implies filling a gap: ‘what is suggested is a gap that can be filled by something that the needing person calls “information” ’. 64 However, as noted by Case,44 for Dervin, ‘looking for “information” is only one response to a “gap” ’. Other responses could include ‘seeking reassurance, expressing feelings, connecting with another human being, and so forth’. 64 In addition, Dervin conceives situation, gap/bridge and outcome as mutually related (in some of her writings, she depicts them as corners of a triangle). 64

While the idea that information-seeking is triggered by a need to know or to reduce uncertainty and anxiety is appealing and largely intuitive, it presents several theoretical and empirical issues. First, needs are not observable. Therefore, whether needs ‘cause’ the search for information is debatable. Although, when asked, people may suggest that needs provide the reason for searching for information, the causal link is impossible to establish empirically. 58 Second, the idea that people seek information only when they need something flies in the face of the evidence that we very often obtain information unintentionally. Information behaviour is thus necessarily a more comprehensive category than information-seeking. Third, to bridge the determination of need and the initiation of action to satisfy the need, there must be an activating mechanism, such as those suggested by risk/reward theory65 or the concept of self-efficacy. Finally, what counts as ‘satisfaction’ of needs varies according to social and historical conditions.

Wilson60,66 tried to address these issues by broadening the idea of information behaviour to incorporate a variety of situations and elements. The author therefore conceived of information behaviour largely as a process of problem-solving that unfolds in stepwise fashion through four stages: problem recognition, problem definition, resolution, and resolution statement. 66 He proposed that information behaviour follows his 1996 model summarised in Figure 3. The model suggests that the needs for problem-specific information arise from the situations in which seekers find themselves; that is, any need for help or information is situationally based and dependent on a particular context. People also tend to look for the information that is most accessible, which is sometimes referred to as the principle of the least effort. Several barriers can prevent people from obtaining the necessary information so that the need can remain unsatisfied. The model also suggests, among other points, that information-searching and information-seeking are two (nested) categories of a broader class of (information) behaviours.

FIGURE 3.

Wilson’s model of information behaviour. Reproduced with permission from Wilson TD. Models in information behaviour research. J Doc 1999;55:257. 60 © Emerald Group Publishing Limited all rights reserved.

In Wilson’s own words:66

information behaviour is the totality of human behaviour in relation to sources and channels of information, including both active and passive information seeking, and information use. Thus, it includes face-to-face communication with others, as well as the passive reception of information, such as, for example, watching TV advertisements, without any intention to act on the information given. Information seeking behaviour is the purposive seeking for information as a consequence of a need to satisfy some goal. Information searching behaviour is the ‘micro-level’ of behaviour employed by the searcher in interacting with information systems of all kinds. It consists of all the interactions with the system, whether at the level of human–computer interaction (for example, use of the computer mouse and clicking on links), or at the intellectual level (for example, adopting a Boolean search strategy or determining the criteria for deciding which of two books selected from adjacent places on a library shelf is most useful), which will also involve mental acts, such as judging the relevance of data or information retrieved. Information use behaviour consists of the physical and mental acts involved in incorporating the information found into the person’s existing knowledge base. It may involve, therefore, physical acts, such as marking sections in a text to note their importance or significance, as well as mental acts that involve, for example, comparison of new information with existing knowledge.

The social perspective on information behaviour

While Wilson’s integrative model discussed at the end of the previous section goes some way towards recognising that information behaviour can be unintentional and context-dependent, it remains necessarily anchored to the principle that, to understand information behaviour and knowledge mobilisation, one has to focus ‘on the individual and on understanding the ways in which each person thinks or behaves in response to information needs’. 43

This assumption was questioned, however, in the 1990s by a group of scholars, who suggested that one of the main deficiencies of the cognitive approach is that it ignores the fact that dealing with knowledge is fundamentally a social process. As Cornelius put it:67

My claim is that information is properly seen not as an objective independent entity as part of a ‘real world’, but that it is a human artefact, constructed and reconstructed within social situations. As in law, every bit of information is only information when understood within its own cultural packaging which allows us to interpret it.

Accordingly, a number of scholars started to utilise social science theory to understand ‘the impact of interpersonal relationships and dynamics of the information flow and on how information sharing is part of human communication’. 43 This resulted in a number of concepts that tried to respond in social terms to some of the critical questions posed by information behaviour scholars: What prompts the search for information? Why do some needs prompt information-seeking more than others? Why are some sources of information used more than others? Why may, or may not, people pursue a goal successfully? What prevents them? And what is the role of social processes and interaction in all of this?

A first way to redefine the issue of information behaviour in social terms is to acknowledge that the social context within which this activity takes place strongly influences both our preferences and choice criteria, and the way we go about mobilising and dealing with information and knowledge. Moreover, the nature of sociomaterial context presides not only over the modes of transmission and circulation of information, but also over how such information will be assimilated and interpreted. Contexts are thus conceived interpretively and holistically as both carriers of relevance and ‘carriers of meaning’. 43

Studying the circulation of information among workers, Chatman68,69 suggested that the way in which people seek, use and communicate information is strongly influenced and largely organised according to the small worlds people inhabit. Small worlds are defined as ‘the social environments where individuals live and work, bonded together by shared interests, expectations and information behaviour and often economic status and geographic proximity as well’. 70 Small worlds are thus settings of everyday life where ‘people have little contact with people outside their immediate social milieu and are only interested in the information that is perceived as useful, that which has a footing in everyday reality, and responds to some practical concern’. 68 According to Savolainen71 small worlds stand for local and often small-scale communities in which activities are routine and fairly predictable. Because small worlds are underpinned by a specific world view and regulated by a shared system of typification (i.e. the roles individuals play are a function of the ways in which they are typed by other members), everyday information-seeking and -sharing is oriented by generally recognised norms, based on beliefs shared by community members. From this, it follows that information behaviour cannot be studied in isolation from the social conditions in which it takes place: in social settings such as small worlds, information behaviour takes a wide range of forms beyond the standardised, stepwise process described by traditional cognitive-oriented information behaviour research. This ranges ‘from the informal exchange of information among friends, to the posting of fliers, to the active avoidance of information that is for some reason deemed inappropriate or dangerous’. 72

The idea of small worlds is strictly related to the notion of information poverty put forward by the same author. According to Chatman,68 some people live in informationally impoverished small worlds, where individuals know that they could and should access useful information but high social costs associated with acquiring this information prevent them from doing so. In order to give others (and themselves) the impression of coping well with their situation, these individuals engage in self-protective conducts (i.e. they find suitable excuses), which seal the boundaries of their small impoverished world, contributing to its perpetuation. In other words, information poverty is a self-perpetuating mechanism. Importantly, the avoidance of information may or may not have anything to do with the actual value or potential usefulness of the information itself. For example:

In a given community, information about different cooking techniques may be actively and enthusiastically passed from person to person, while information about avoiding sexually transmitted diseases may be rejected outright or distributed only with great care, because it is considered to be socially unacceptable.

Chatman EA68

The idea that the way in which people access, exchange and interpret information is strictly related to the social conditions in which this takes place resonates with the results of the study of information-seeking from a social network analysis perspective. For instance, using social network analysis, Borgatti and Cross73 found that the probability of seeking information from another person is a function of knowing what that person knows, valuing what that person knows and being able to gain timely access to that person’s thinking. What the information system behaviour literature adds to the tenets of social network analysis, however, is the identification of specific forms of networking, which helps to explain not only the transfer of information, but also its interpretation and use.

A focus on the social dimension of information-seeking behaviour also underlines that the process whereby information is given meaning and put to work is itself social and discursive in nature. Consequently, information-seeking should be examined as a dialogical and discursive achievement; something that people do together, in communication with each other. The use of information is therefore seen as part of the communicative actions of an individual in context. 74

Information practices and information work

The increased scholarly attention to the role that contextual factors play in orienting people’s information-seeking (as distinct from the individualist approaches characteristic of the assumptions underpinning ‘information behaviour’) has led several authors to reconceptualise information behaviours in terms of practice. The turn to practice makes the argument that traditional studies, developed from an individualistic, cognitive and decontextualised viewpoint, miss the social and collaborative aspects of information acquisition and use. The traditional viewpoint also downplays the fact that information practices are and should be conceived as mundane activities that are implicated in constituting the context of members’ daily work. Information practices are thus always embedded in practical projects, either task-oriented (as in work situations), or as part of broader ways of life. 75

Talja and Hansen,76 for example, emphasise this embeddedness of information practices in work and other social practices, as well as their drawing on the social practice of a community of practitioners, a sociotechnical infrastructure and a common language. According to these authors:

information seeking and retrieval are dimensions of social practices and that they are instances and dimensions of our participation in the social world in diverse roles, and in diverse communities of sharing. Receiving, interpreting, and indexing information . . . are part of the routine accomplishment of work tasks and everyday life.

Talja S and Hansen P76

The social practice approach thus focuses on the joint accomplishment of work through the organisation of social interaction, and the use of supporting technologies and artefacts as an integral part of this interactive process. The approach mandates empirical research efforts that concentrate on actual organisational environments, and on routine and everyday ways of performing situated interactions with and through social and technical resources needed for their accomplishment. 77 Such studies would first seek to form a grassroots-level understanding of epistemic communities and work practices, and then work to base information-seeking and knowledge-sharing processes upon those understandings.

For example, Pettigrew78 studied social settings in which people share everyday information while attending to a focal activity. She suggested that certain social situations and spaces, such as doctors’ offices, hair salons and cafes (or water coolers), can become information grounds, defined as ‘synergistic environment(s) temporarily created when people come together for a singular purpose but from whose behaviour emerges a social atmosphere that fosters the spontaneous and serendipitous sharing of information’. 78 Information grounds are thus socially constructed on the combined perception of place, people and information. Certain locales become information grounds only thanks to the existence of shared projects and goals that descend from the condition of being involved in the same activity (going to the doctor, dealing with your hair or doing the same job).

The approach also allows us to redefine the notion of information literacy in terms of a combination of practices, rather than an individual’s single skills. Information literacy thus emerges as the result of information work, information-sharing and coupling, or ‘the capacity to bring together the explicit knowledge with experiential and relationally based knowledge to produce a way of knowing within the site that is intersubjectively understood’. 79 Information literacy is therefore enacted within a social site and ‘reflects the social, historical, political and economic ways of knowing the shape and characteristics of a specific site’. 79

Practices can also be mobilised to explain the preference for (and relevance of) certain sources of information and how such preferences become habitualised and are incorporated in the practices of the information-seekers. Savolainen80 investigated the information horizon of environmental activists, asking what kind of information sources they included in their information source horizons, in the context of seeking problem-specific information; according to what criteria they chose information sources in the above context; and what kind of information pathways they used? He found that human and internet sources were at the top of the list, with people often starting out by searching information on the internet, only to contact a relevant human person soon after. Most importantly, his study suggested that the individuals he interviewed operated within a set information source horizon, which both specifies what individuals consider to be the accessible sources of information and establishes a set of preferences. This is critical, as research suggests that individuals tend to select their sources of information on the basis of their accessibility and perceived reliability or, in case of the humans, social capital. 43 Information source horizons are thus important, as they explain both source preference and relevance.

Information source horizons are in turn created within the broader context of a perceived information environment, defined as ‘a set of information sources of which the actor is aware and of which he or she may have obtained use experiences over years’. 80 When construing an information source horizon, the actor judges the relevance of information sources available in the information environment and selects a set of sources, for example to clarify a problematic issue at hand. A graphic representation of a pathway is provided in Figure 4.

FIGURE 4.

Graphical representation of the information horizon. Reproduced from Savolainen R. Source preferences in the context of seeking problem-specific information. Inf Process Manag 2008;44:274–9380 with permission from Elsevier.

Perceived information environments are deeply rooted in an individual’s habits and tend to change quite slowly. Individuals thus develop information pathways, a notion that describes the sequences in which people use, intend to use or have actually used information sources placed in the information source horizon. Information pathways silently structure the perceived information horizon according to differential orders of relevance, so that certain sources (both human and non-human) are consistently considered as central or marginal. Information pathways and information horizons thus both structure and select (i.e. limit) our information horizon, creating intrinsic and invisible pragmatic biases in our ways of dealing with information.

Overall, the practice approach is underpinned by an increased attention to information work. Information work is firmly contextualised in mundane activities and is a necessary component of ‘the work of living’. 81 It is conceptualised as ‘something essential, dynamic, on-going and social that intermixes with, complements, supports and is supported by other kinds of work’ or ‘everyday life work’. 81 Studying information behaviour as information work therefore requires a focus on the ‘actual labour – the time, effort, resources and outcomes necessary in finding and using information’. 81 One critical implication is that information work is carried out together with, and as part of, other forms of work, and it should not be conceptualised as a separate activity.

What traditional studies have called information-seeking behaviour can thus be respecified in terms of ‘orders of monitoring’. 82 The idea suggests that information sources are monitored daily as a matter of habit; however, which sources are monitored is tightly bound to the routines of day-to-day life. The idea also suggests that information-seeking should be thought of as a stratified affair, progressing from the less to the more intentional. Quoting Erdelez,83 McKenzie84 consequently observed that the label ‘information-seeking behaviour’ ‘is a misnomer because passive and opportunistic information acquisition such as some types of browsing, environmental scanning or information encountering more resembles “gathering” than “hunting”, the active pursuit suggested in the term seeking’. In fact, empirically observed information practices include activities as different as identification of helpful sources, serendipitous encounters, being given information without active seeking, and planned encounters with sources (which can succeed or fail). 84 The author thus suggests that information practices should be ordered along a continuum from the more to the less intentional:

• active seeking

• active scanning

• non-directed monitoring

• by proxy.

This in turn implies that when addressing content (which together with availability and accessibility is the best predictor of the source of information preferred by seekers; see Savolainen80) we should distinguish between orienting and pragmatic information. While orienting information concerns current events and feeds our need for making sense of the world, pragmatic information derives from actively seeking practical information, which serves as the solution to specific problems. The two coexist, but are very different in nature. The former is fundamentally episodic and often results from some form of inquiry. The latter is regulated by both habit and chance. On the one hand, we all develop practices that feed our existential ‘infoscape’ [e.g. we read the newspaper, check Twitter (Twitter Inc., San Francisco, CA, USA) or chat to get the latest office gossip]; on the other hand, we may derive orienting information from encounters that were not intended for this purpose and are partially fortuitous. In this sense, information-seeking is less an active conduct and more an openness to information.

In sum, in the practice approach the emphasis is thus placed on ‘social practices, the concrete and situated activities of interacting people, reproduced in routine social contexts across time and space’. 45 In this sense, the recent developments of the study of information behaviour converge with the debate on knowledge mobilisation discussed in the previous section. Both research traditions suggest in fact that much is to be gained if we focus on everyday practices, as the context within and process through which knowledge is mobilised and information is acquired and dealt with. Mundane activities, knowledgeability and information work should thus be conceived as sides of the same coin (assuming a metaphorical three-sided coin exists). In this sense, while the concept of information practice and information work have been mainly applied to the study of information activities in everyday life, as opposed to professionally connoted situations, it is our tenet that their central assumptions can be meaningfully extended to the study of managerial practices, to shed light on the knowledge mobilisation activities of NHS CEOs.

Sampling strategy

The choice of cases was based on a theoretical (rather than statistical) sampling strategy. Our aim was to maximise diversity in the sample for analytical purposes (statistical relevance was impossible given the low number of cases). Our original sampling strategy, following a shift in analytical focus, aimed at including six to eight CEOs across mental health, acute and primary care sectors. However, as noted above, early in the project we made a decision with the advisory panel that we would focus on acute and mental health trusts only, as PCTs were being disbanded and subsequent organisational structures were in flux. In order to ensure diversity in the sample, we aimed to engage trusts that varied in size, physical location, the relevant Strategic Health Authority (SHA), financial health (as determined via relevant regulator performance ratings) and organisational type [i.e. a foundation trust (FT) or a non-foundation trust]. We also considered the personal characteristics of the CEOs, for instance gender, professional background, time in post and if this was their first CEO role.

Access to participants

Access was obtained through a combination of personal contacts and direct requests to CEOs who were deemed potentially interested, for example because they had previously participated in developmental events, such as the SDO Network CEO meetings. The collaboration of the NHS Confederation and the support of one member of the advisory panel were critical, especially in the early stages of recruitment. A letter detailing the research questions, possible contribution and distinct ‘benefits’ for the CEOs from the study was initially sent to five acute CEOs, who the panel member felt might be interested. We subsequently set up meetings with four of them and were successful in gaining access to two, who became the first two CEOs in our sample. The possibility of comparative feedback, but also the opportunity to discuss the findings in a coaching session at the end of the project appeared a key factor in the CEOs’ favourable decisions. We used the same process, facilitated by the members of the advisory panel, to recruit the rest of the cases.

Study participants

Our final sample for the study was seven NHS trust CEOs. The sample size reflected time constraints of the study, and our strategy regarding diversity in the sample. A summary of key characteristics of our sample can be seen in Figure 6.

FIGURE 6.

Key characteristics of the study sample. MH, mental health.

The sample includes an almost even ratio of men to women as intended in our sampling strategy. Equally, we were successful in meeting other key aspects of it, such as diverse professional backgrounds: management (two from the NHS; one from the private sector), nursing (two) and medical (one). In addition, the sample included CEOs who managed both successful and less successful trusts (one financially struggling acute non-FT; two financially struggling acute FTs; two successful acute FTs; two successful mental health FT). These assessments were based on external validations of financial and operational success by relevant regulator bodies, such as Monitor performance indicators. They are also reported broadly enough so that anonymity is not compromised. Finally, the CEOs were at different junctures in their posts and careers. For instance, two CEOs were shadowed within a year of starting their current post, while three had been in their present post for longer than 5 years. Similarly, we observed those with previous experience at CEO level (n = 4), and those for whom the present post was their first CEO appointment (n = 3, though all had been in post more than 2 years when studied, including one CEO whose current post followed a merger).

Observations and shadowing

The key method we used was shadowing, which involved closely following each CEO as she went about her working day, and observing as much of it as possible. This enabled us to understand the various nuances of CEOs’ practice as it actually happened. Practically, this meant we would normally speak to the PA a week before, to go over that week’s diary and highlight any meetings that were not appropriate to observe. Generally speaking, we had great success in terms of access, in that there were very few parts of the CEO’s day, particularly on site, that we could not observe. These were limited to some one-to-one supervisory meetings with more junior colleagues, human resources (HR)-related meetings concerning individuals, and private meetings (for instance with their pension advisors). We also mostly did not observe evening or day events of a particularly sensitive nature, or those that required extensive travel, as well as more informal chats the CEOs had with individuals, when it was made clear to us that this would not be appropriate. Finally, we could not observe the work the CEOs did at home, which was one of the notable limitations of shadowing as a method. This shortcoming was addressed by asking the CEOs to recount the work they did at home the following day, and accessing their e-mail correspondence wherever possible.

An average day of shadowing began with our arrival at the start of that CEO’s working day. We usually had a designated seat at each site while the CEO was in her office, normally behind or near the CEO’s desk, so that we could observe as she worked on her computer. We used an iPad, which allowed us to take immediate electronic field notes on the go, but also to look up any information online to understand better what or who was being discussed, which improved their quality. As the CEO went to her meetings, we followed along, chatting informally or staying quiet as appropriate. In all instances, the executive teams and closest collaborators were aware of the study prior to the start of fieldwork. As we entered each meeting, the CEOs would briefly introduce us and ask us to give a short overview, and then carry on with her task. We normally found a seat out of the line of sight, away from the table, and observed quietly. Normally, CEOs and their teams got used to our presence after a couple of days, so we were generally not introduced during later meetings. Similarly, if a patient or staff member stopped to chat with the CEO in the corridor, we either stayed while they finished, or left the CEO and returned to the office, if deemed more appropriate.

For practical reasons, we often spent 1–2 weeks with one CEO, then moved to another, then switched back. This allowed us to track issues over a longer period, and indeed observe how work changed over time. It was also a practical solution, as we found that CEOs found a stay longer than 2 weeks very demanding. This also avoided the researchers becoming too accustomed to the site to the extent that they no longer had a ‘fresh pair of eyes’ on it.

In total, we completed the following periods of intense shadowing (in consecutive order from when we first entered the organisation):

• CEO1: completed in December 2011 (total 6.5 weeks)

• CEO2: completed in November 2011 (total 5 weeks)

• CEO3: completed in February 2012 (total 5 weeks)

• CEO4: completed in June 2012 (total 5 weeks)

• CEO5: completed in May 2012 (total 5 weeks)

• CEO6: completed in June 2012 (total 4.5 weeks)

• CEO7: completed in September 2012 (total 3.5 weeks).

Notably, we mostly met our very challenging target of 5 weeks of shadowing per CEO, making this one of the most longitudinal, in-depth studies of senior executives ever completed. The exception was the final CEO, where because of pressing time restrictions of our project only 3.5 weeks of shadowing could be done. This was nevertheless an empirically rich period, and sufficiently long that we could observe some issues over time, thus meeting our analytical requirements.

Interviews

In addition to shadowing, we used formal interviews in some cases to supplement our observations. They allowed the CEOs to reflect in a structured way on their knowledge mobilisation and working practices, and to offer reflections on why we might have observed what we did. These were very useful to us in terms of clarifying or refining existing insights.

In particular, we conducted five formal, semistructured interviews during the study (see Appendix 1 for the interview schedule). These were conducted in the final week of observations, or some time following shadowing, depending on the CEO’s diary. They lasted between 38 and 65 minutes, and were recorded and transcribed verbatim. The two remaining CEOs were interviewed informally, as part of daily observations. In their case, the decision was made that formal interviews would not be appropriate, given that both CEOs shared their reflections extensively during on-site visits, and their diaries made scheduling a formal interview exceedingly difficult. These ethnographic interviews were also transcribed verbatim and used in the analysis. In addition, we conducted two formal interviews with two different PAs, which were recorded and lasted approximately half an hour each. Such interviews were not conducted in other settings because it was decided that, owing to pressing work commitments, these would be very difficult to arrange. Instead, as was the case also with the two PAs formally interviewed, the other PAs were frequently engaged informally, via ethnographic interviewing in situ.

Documents

A final key source of data were documents obtained during periods of observation, including meeting papers, articles referenced by the CEOs, and copies of publications consulted. Given the nature of each CEO’s work, particularly the number of large formal meetings attended, but also the level of comfort by each CEO with regard to sharing internal documents, the number of documents gathered for each site varied greatly, from thousands of pages to approximately 100. Such internal documents were supplemented by externally available information. This included, for instance, annual trust reports, news articles and regulator documents. We accessed these prior to our stay and throughout the study. This allowed us to gain a greater familiarity with the trust and the CEO before starting, but also to keep abreast of any major changes since our departure.

Feedback

A critical component of our research design was the individual feedback session with each CEO. These were envisaged as an opportunity to share in-depth comparative insights, and receive CEO feedback on its accuracy and helpfulness as part of a targeted validation exercise. The sessions were a great success, in that the CEOs overwhelmingly found it useful, and an accurate depiction of their work. Their detailed feedback in terms of clarifying certain points, or reflecting on how they and the trust had progressed since, provided further richness and accuracy to our material. In addition, the sessions were designed to work as a two-part development opportunity, where we would present emerging findings, and then a personal coach would work with the CEO to draw out relevant implications for their practice. Though we could not accomplish this in every instance, as some CEOs preferred to receive feedback without the coach, in three cases it was a very valuable and positive process, with seemingly great potential as a mode of facilitated learning and personal development for executives. We took careful notes of the three cases and will be reflecting on them with a view to developing a model for research engagement, for testing in future studies.

Anonymity and confidentiality

The highly sensitive work of the CEOs, the practicalities of shadowing as a method, and our assurances as part of the access agreement all meant that issues of anonymity and confidentiality were particularly acute. We met these challenges via several research strategies. For example, we took great care to protect the anonymity of the CEOs themselves, by never discussing our observations outside the project team, by writing fully anonymised notes, and by making a professional judgement regarding what was private and what was public. In particular, although we occasionally observed the CEOs during acutely sensitive conversations, we made sure not to take written notes, unless this was seen as absolutely necessary in giving an accurate depiction of the CEO’s working realities.

While in the field we employed standard principles of ethnographic (observation-based) practice to strike a practical compromise between retaining the anonymity of our CEOs as the chief participants and the ethical requirements which necessitated making every individual that we encountered informed. This was addressed chiefly by obtaining written consent prior to an observed encounter. When this was not possible or not appropriate, we made sure not to take any notes relating to that individual directly, but recorded afterwards that an encounter with an anonymised individual took place, and the CEO’s role in this engagement if appropriate. Importantly, the CEOs themselves occasionally asked us not to introduce ourselves before a meeting, as this might affect the tone of the meeting in question. Where such a request was made, we abided by it, as our method depended to a large extent on being as unobtrusive to the CEOs as possible. In general, explanations about our study were kept to a minimum and employed only when necessary. Again, this was essential in the light of our small sample, which meant that, if an individual knew we were studying the CEO on site, they could more easily deduce which of the CEOs we described in this report was the one they knew, thus effectively breaking confidentiality.

To retain anonymity in our public feedback (e.g. final event) and in this report, we decided to refer to all CEOs by the feminine pronoun. This was done for easier reading, instead of the more cumbersome ‘s/he’, but also as a seemingly appropriate compromise given our promises of anonymity and our analytical focus on the practices of NHS CEOs, not their genders. Equally, our promises of confidentiality, but also analytical interest in the practices (as opposed to the organisations) of the CEOs, meant that we had to strike a compromise with regard to the contextual information we could publicly share regarding the trusts that the CEOs ran and their immediate institutional environments. In particular, though there are over 200 acute and mental health trusts in the NHS in England, this is nevertheless a relatively small community of peers, each with considerable insight into other trusts, as we occasionally found during our research stays as well. However, as the particular context in which the CEO worked emerged as a critical component to understanding their knowledgeability in practice, we had to provide sufficient insight into organisational structures, wider institutional drivers and particular objectives each CEO was working towards for the reader to understand at least some of the differences between the research settings, and how these may have contributed to the emergence of a particular knowledge infrastructure. A summary of pertinent contextual information relating to all seven trusts can be found in Table 1.

Patient and public involvement

The particularities of this study meant that involvement of patients and the public remained limited to the final phase of communicating the results. This aspect of the research was discussed and agreed with members of the University/User Teaching and Research Action Partnership (UNTRAP), based at the University of Warwick. In particular, as the study’s practical relevance was for the leadership community of the NHS, as opposed to the broader public or patients, to ensure that the study was appropriately informed by views of NHS practitioners, we included notable figures from the NHS community in our advisory panel. In addition, confidentiality concerns prevented us from involving the public directly, as it was important to minimise the number of individuals aware of the identities of our participants. It is our intention to meet the obligations of publicly funded research by post-project dissemination via other media than academic publishing, allowing us to share central insights from our study with a broader audience who may be interested.

Chief executive officers’ sources of information: from the formal to the many and complex

The first aspect of acquisition or sourcing work that must be addressed is what are the sources of information or ‘evidence’ that are accessed and brought to bear by observed NHS trust CEOs in order to accomplish their everyday work. Specifically, we asked CEOs ‘what external sources of information do you find (more) relevant to your job and therefore consult?’ As is the convention with regard to qualitative semistructured interviews, CEOs were normally asked a conversational approximation of this question, i.e. it was not read out verbatim, though all the major components of the question, including its tone, remained. In addition, in the case of two CEOs, this discussion took place during daily observational periods, rather than in a structured interview environment, due to restraints of fieldwork on those sites. Table 2 summarises the major reported sources of external information in particular, and the reasons why each was seen as more or less pertinent by the CEO.

A crucial observation from Table 2 is the diversity of external sources, despite a few common ones. Of the latter, the Health Service Journal (HSJ) is perhaps unsurprising, though almost none of the CEOs found its more research-based pieces helpful or reported consulting them often. Instead, it was apparently seen as a medium through which CEOs could gauge the ‘feel’ of the sector and policy. Indeed, some CEOs were openly dismissive of it as ‘just tabloid journalism’, whereas others, such as the CEO of a large acute FT, normally flicked through the publication when the trust was referenced, or before a trust board, as she found that non-executive directors (NEDs) often asked questions referencing the latest stories. In other words, though the publication was consumed by the CEOs, albeit often hastily, its major research-based pieces seemed to have little traction in their daily work.

Interestingly, the HSJ appeared as the only unifying source of external information across the CEOs we observed; either it was referenced in the interview or we observed it during shadowing. Some other sources were commonly referenced, such as the regulator websites (e.g. Monitor, the Care Quality Commission), SHA comparative information pieces, publications from sector bodies such as the Foundation Trust Network (FTN), the NHS Confederation, and the Association of UK University Hospitals (AUKUH), and summary e-mails from the DH (e.g. The Week and The Month). One CEO identified accessing regulator websites and information pieces as ‘maintenance stuff’, which allowed her simply to ‘keep up to date’. Another commented that the Department of Health (DH) publications help her ‘make sense of the world out there’. Some CEOs also actively sourced information from beyond health care, for instance the Harvard Business Review (HBR), which some found particularly helpful regarding their leadership tasks, and mainstream management books, such as autobiographies of prominent CEOs, but also wider public sector publications, including The Guardian Society section.

The CEOs did not only cite written documents or publications as a key source of relevant information, however. Events, such as Institute of Directors (IoD) seminars and meetings of groups of CEOs, but also people, such as management consultants and the informal network of ‘people of integrity’ used by a mental health CEO, were also highly pertinent. Indeed, what quickly became apparent, once we compared the interviews with our observations, is that CEOs consulted more different sources of insight than the EBP movement would suggest. These included some sector publications based on traditional conceptions of evidence, such as King’s Fund reports, but also ‘gossip’ e-mails, ‘quirky little meetings’ with external organisations without immediate relevance, sessions with personal coaches, and informal telephone calls with a former Action Learning set, to name but a few referenced during our observations. As we shall see, these were equally important as those ‘evidence-based’ sources of formal information in enabling CEOs to be informed as part of their role.

Before we discuss the diverse sources of information accessed by CEOs in their daily work, and the subsequently necessary expansion of what constitutes sourcing ‘good’ information in practice, we should reflect on some notable absences with regard to CEOs’ external sources of information. In particular, we recorded only one reference to NHS Evidence as the epitome of a gateway enabling EBP in health care. We also did not observe any CEOs consulting scholarly journals, with the exception of the HBR, which aims to simplify and filter scholarly work for easier consumption. Equally, with the exception of one particularly learning-oriented CEO, whose steady organisational context enabled dedicated time for exploratory sourcing, we observed few instances of CEOs accessing external guidelines and processing them themselves. More commonly, if these were accessed, they were distributed to other staff as part of an ongoing conversation, for them to mobilise further. Similarly, management scholarship was rarely referenced, with the exception of the same CEO, who mentioned in an informal discussion with a colleague a piece of research as ‘good emerging evidence’ regarding how medics and managers learn differently. Notably, this insight was also originally obtained via a conversation with a colleague, rather than her reading the actual study. This again brings into question EBP’s reliance on external, written, research-based, directly accessed information as the sole ‘evidence’ appropriate for ‘best practice’ sourcing. As we found, everyday practices of NHS CEOs reveal a much more complex and multifaceted picture.

A key part of this more nuanced picture was the various criteria we observed being employed to judge a source or insight as more or less relevant. In particular, what struck us were the greatly differing bases for decision-making, which reflected both practical concerns at that moment given the task at hand, but also personal preferences for accessing information, and in what format. For instance:

[Monitor and FTN are] less useful . . . I need to know what they’re up to but it doesn’t have so much resonance [. . .], it doesn’t help me in my world.

Acute FT, CEO1

I tend not to look at a lot of websites unless I’m chasing something specific.

Mental health FT, CEO1

Here, the acute CEO saw Monitor and the FTN as less pertinent because they ‘don’t help [her] in [her] world’. In other words, because there is little perceived temporal contextual relevance, the information itself was simply irrelevant. Similarly, the mental health CEO noted that she visited websites mostly as part of a specific search, depending on the task. In other words, the particular context and task at hand mattered greatly in determining whether a source is accessed or information considered as potentially germane. For instance, a CEO commented when asked if there are specific times or settings that are more useful for knowledge acquisition:

I think it depends on what the task is. So for example if I was writing a paper, you know, something quite technical then I would rely on more formal sources of information, because you’d need to reference them. If it was something less formal, then I would gather information from probably more informal sources.

Acute FT, CEO4

We thus observed that different sources of information were accessed at different times, for different purposes and to different ends. As the same CEO noted later on in the interview:

I mean, there’s a maintenance job to be done, isn’t there, making sure you’re professionally up to date but then there might be a specific job of work to be done and for me it’s, you know M&A, where I’ll say okay, if there’s something coming up, [I’ll attend an event specifically on that issue].

Acute FT, CEO4

Equally, experience played a significant role regarding what sources CEOs found useful and accessed regularly. We observed that CEOs learned over time what sources ‘worked for them’, and tended to rely on a ‘trusted few’ making up their particular personal knowledge infrastructure. Though CEOs did reflect on these and change or adjust them as they went along, as we will illustrate, we saw that certain sources appeared simply as ‘theirs’: always consulted, like a habit.

I think it’s quite limited, my sources of information. [. . .] And I suppose I’ve honed it over the years.

Mental health trust, CEO2

Importantly, along with limiting sources of insight, experience also acted to occasionally ‘liberate’ CEOs from needing to rely on definite information as key to a ‘good’ decision or deliberation. Some reported that with experience came the ability to ‘say no’ to information, particularly formal external information, and instead draw on other, less formal, but equally relevant and situationally legitimate insights.

I think I’m more confident now. And I think therefore going through the ins and outs and if anybody challenges you being able to prove that it’s in paragraph 5, subsection 6. [. . .] I think I’ve gained a lot through not having to have that piece of paper behind me to have the confidence to be able to say it.

Acute FT, CEO4

The twin matters of purpose and experience are important because a key suggestion of the EBP movement is that the take-up of ‘evidence’ is chiefly determined by the inherent qualities of the ‘evidence’ itself, most notably its scholarly credentials, format and perceived timeliness. Instead, we observed CEOs judging sources more or less relevant for many different reasons, all of which contributed toward a personal ‘ranking’ making up a CEO’s own preferred consultative horizon. Furthermore, the CEOs also identified preferences regarding the kind of information they generally favoured. In particular, when we asked what kind of information they prefer to receive, we found that the CEOs had either a declared or an in-practice apparent preference for verbal information, reflecting our observation that much of their daily work was conversational. Unsurprisingly, therefore, a great deal of their sourcing was accomplished in conversation as well.

I think my preferred source of information is what people say and do with me, so whether it’s in the office or in the environment. [. . .] So I think that’s where I’ve got a particular orientation, as opposed to enjoying reading tables of figures or even reading lots of material [. . .] people think I read all these set papers and I don’t at all. But I know which bits to read to be able to get a whole picture sort of thing.

Mental health FT, CEO2

The head of quality comes in a minute later and asks [the CEO] if they could have a private word about the issue she raised with [the CEO] on Monday. The CEO says yes of course, and notes she is happy for me to hear it (the head of quality checks beforehand). They go to the private meeting room and have a detailed discussion there about a grievance issue that has come up . . .

Excerpt from field diary, mental health FT, CEO2

Here, the CEO confirmed her tendency to engage with information in a conversational manner, as visible in just one example from our observations. When she has to read papers, which here refers in particular to internal meeting papers, she reads them to get at the ‘whole picture’, as opposed to reading in depth. She also commented that although she does have a liking for ‘gossip’, namely informally obtained insights that allow her to compare her organisation with others, this is combined with an emphasis on formality of presentation regarding written information.

I think when I say I like gossip, it’s always within a business context and it’s always bounded. So actually I think I’m probably [. . .] less informal than most chief execs. [. . .] I like professional presentation of information [. . .] where I like to gossip is a bit of my rivalry self.

Mental health FT, CEO2

The other mental health CEO in our sample voiced a similar preference, referencing another crucial insight we observed, namely preference for concise written information:

. . . verbal probably the preference and if it’s in writing it’s got to be succinct and brief. I particularly dislike long reports and I dislike reports particularly if I have to read to the end to find the [gist] [. . .] Having seen the headlines, the context and a bit of research stuff, the summaries and recommendations, then I do a lot of enquiry with people [. . .]; well, hang on, that’s not telling me this [. . .] I don’t need to read the whole report, you should tell me.

Mental health FT, CEO1

Intriguingly, this CEO linked this to her ways of working, influenced by limitations of her memory. As she noted later, ‘I don’t take everything verbatim, I take the gist, and then run with the gist. I have a crap memory and that’s how I work’. In other words, though the observed CEOs largely seemed to prefer receiving information in dialogue, as we shall see in more in-depth examples later, any written information had to be easy to consume: structured, brief, to the point. Indeed, there was a sense that a short document focused on a few key messages was perceived much more easily as a ‘good’ source of information than a longer one. We observed this preference even for more detail-oriented CEOs. The associated danger was that a document not fitting such criteria would simply not be read, or that it could more easily be dismissed and sent for further reworking, thus delaying a particular decision. We observed that the same consequence could also easily be relevant for externally produced ‘evidence’: longer documents risked being disregarded simply because they are longer, not because of the value of their contents.

[A longer document] automatically probably would incline me either not to pay attention [. . .] so there is a risk that poor decisions are made on the back of it or I’ll throw it out and get it reworked.

Mental health FT, CEO1

Some stuff I just don’t want. We get a vast overload of information and the outside world is extremely lazy about their communication systems so they believe if they’ve sent everything to the chief exec they’ve done their duty. In actual fact, all that does is overload my inbox, so it is likely not to get any attention.

Acute FT, CEO3

Given the volume of stuff that comes through if there’s not an executive summary I’m stuck, actually I won’t actually go into something usually [. . .] The business knowledge stuff I skim read so I don’t do detail unless I think I need to go back to do that. So I tend to read the executive summary and then I, if necessary I’ll dive into the detail. And if something isn’t structured like that then I find it quite inaccessible. As far as the sort of developmental knowledge [. . .] again I will usually read the abstract first and so I get a sense of what it’s all about, then I can make a decision whether it’s something that is going to be helpful to me or interesting and then I can go into it.

Acute FT, CEO1

Similarly, sitting in front of their computer or reading at a desk was not the only setting where we observed CEOs accessing information. Based on our observations, valuable information crucial to each CEO’s work was accessed in various settings and from various sources, ranging from impromptu encounters and formal external meetings to ward or site visits. Notably, we observed that such occasions often provided more than just one insight, and that a single instance, such as a meeting, could be useful to the CEO for more than one reason. One example of this was given by a mental health CEO in her interview, for whom a local CEO group meeting was a particularly valuable source, not just because it provided an occasion for gaining first-hand insight into latest policy, but because of the more informal aspect of engaging with her peers, who provided her with comparative insights. The latter was seen as more important than the formal policy information presented. This is because it was through that informal exchange of insight, which she referred to as ‘just chatting’, that she was able to get a ‘real’ sense of where her organisation stands; a critical task of concern to a trust CEO.

I do rely, I do like gossip. [. . .] I don’t do social dinners and I don’t do socialising at work. But what I do is I attend meetings that I’ve been booked into [. . .] and I use that as another data source. But like the chief execs group, [. . .] I actually find that an incredibly valuable source of data because we usually have [. . .] people like director generals from the Department of Health [who give] us their take on policy. [. . .] But the really valuable bit for me is being in a room with peers and just chatting about what your current issue is, and then you get a real sense of where we sit, as kind of benchmarking data.

Mental health trust, CEO2

The importance of comparative insight is evidenced further, for example, by the same CEO adding later that that she scans the regulator websites often ‘just to see and I do look at the benchmarking data. There will be an issue I want to look at that provider [. . .] I also increasingly look at other trusts’ websites, just to see what they’re focusing on, how we compare.’

In summary, the traditional analytical focus on external, written sources of ‘evidence’ as the prima facie source of insight must necessarily be expanded once one observes the realities of everyday CEO practices. In particular, what became obvious from our observations and interviews was that, just as written evidence was not the only source of insight for the CEOs, neither did they solely rely on a structured, purposeful approach to sourcing. It is to this question of how sourcing is accomplished in practice that we turn next.

Sourcing in practice: the ‘how’ question

Though separating the two analytically is exceedingly difficult, not least because the what informs the how and vice versa, the question of what sources CEOs find more or less useful must necessarily be supplemented and refined further via an in-depth discussion of how those different sources get accessed in practice. In particular, as we will demonstrate, this work is accomplished via particular structures set in place by the executive. Notably, these in turn depend on the circumstances of that acquisition and of what is being acquired. In other words, we observed the CEOs actively constructing and maintaining distinct mixes of ‘tools of the trade’, which together came to what we call a personal knowledgeability infrastucture. Engaging elements of this infrastructure allowed CEOs to go about their work appropriately informed. We observed that each CEO also had a particular personal style, which represented a distinct manner in which such sourcing was usually accomplished. CEOs’ infrastructures included a specific collection of distinct props (e.g. formal meetings, informal visits, long telephone calls, frequent coaching sessions), but also a particular way in which these were brought to bear on each emerging issue or task, as we demonstrate.

As mental health CEO2 told us, ‘her approach these days is to process information as she goes along’ (excerpt from field diary). What was notable for us was the implied distinction of ‘these days’, suggesting the influence of time and experience, but also the revelation that this is done ‘as she goes along’, as part and parcel of her everyday work. An acute CEO similarly reflected:

A lot of knowledge acquisition to me is a by-product of something else I’m doing. So when I’m out on the wards, it’s not about that. I’m not there to look for things, I’m there for my visibility issues and to see staff and to sort of recognise the contribution they’re making. But at the same time I’m soaking up this knowledge too.

Acute FT, CEO1

We meet two men at 11.05 and the CEO introduces me as shadowing her. They walk together and she asks them to start with the history of the unit, listens to replies. Asks about who the patients are, how many are there, etc. They discuss use of facilities and funding, CE[O] notes should be locally done so when funding runs out, it doesn’t just stop. Everyone should be on board, rather than just one person. Discuss staffing, how they work, what their goals are, what the competitors are. CEO then meets several patients in the day unit, then goes to a meeting room where she meets staff informally. She is very engaged, asking each member what their biggest challenges are. They discuss new ideas, for instance introducing physicians’ assistants from the US (she is urged to do something). She tells me afterwards that this is really helpful for her, but also nice for staff to know that she cares.

Excerpt from field diary, acute FT, CEO1

As this CEO explained, and this and other observations of CEOs in our sample confirmed, while distinct instances of purposeful or occasioned sourcing existed, these are relatively infrequent or at least limited in comparison. Instead, acquisition often appeared more like ‘soaking up’ insights as one went along, as a ‘by-product’ of a CEO’s changing tasks. This acquisition of ‘raw informational material’ for CEOs’ daily performances appeared to a notable extent an instinctive practice, honed over time, and rarely reflected on explicitly: a tacit process of know-how developed over time. We particularly observed this key influence of experience on how information is sourced and how different sources were given priority in practice. As this CEO commented, sourcing is about setting up a particular ‘structure’ by which information and insights can best be obtained, given the CEO’s growing experience, and then applying that to the varied tasks at hand. The question of prioritisation subsequently becomes a habitual process of making choices as one goes along, informed by what has come before.

It’s sort of again just creating structure or using a structure that had worked for me in the past and that’s about experience really. [. . .] When you’re first chief executive all these things it’s, it’s really hard to work out what is the most important but after a while it just . . .

Becomes instinctive.

That’s right, yeah.

We found that, just as the CEOs were aware of the particular preferences they had regarding sources and formats they received, they were equally aware of those they did not prefer, or that required different approaches to processing. In response, we observed them making appropriate adjustments to how they acquired and ‘consumed’ information to address these.

I suppose I’m just a natural speed reader [. . .], so I don’t read in depth, and [. . .], I don’t want to get absorbed by the technicality of what’s being said. What I want to do is get what’s the thrust of this, what’s the message. And so that’s kind of my approach to processing information really quickly. [. . .] I’m conscious [though] that numbers are not my natural processing information, so I’ll spend time, and graphs, so that’s why you’ll see I often print out those to read them carefully.

Mental health trust, CEO2

We also found that it was not only sources and formats that CEOs recognised as being less ideal, but also approaches to engaging with information. As one CEO of a smaller FT acute shared, she recognised in herself a tendency to jump to conclusions without ‘hard’ information as occasionally unhelpful ‘hastiness’.

I can leap to decisions, I know that from my insight. You know, usually if I’m talking to somebody, it doesn’t take me too long to come to a conclusion, then I have to pull myself back to say was that the right conclusion. So I know I can be a bit hasty.

Acute FT, CEO4

Again, we observed CEOs often recognising such tendencies, and putting in place structures that allowed them to effectively address possible resulting issues. For instance, the above-cited CEO told us (and we also observed) that she uses her deputy in particular as a sounding board before any big decision, for example concerning disciplining another executive. The deputy will then often act as a safety check, and will step in to encourage further reflection or caution if needed. We thus observed that a central role in CEOs’ everyday information work was played by distinct individuals making up their referential environment. Importantly, each was often assigned a particular ‘scope’ of knowledge-ness, for which the CEO would consult him or her as appropriate, given the task. Sometimes this reflected a formal body of knowledge of that executive, for instance the medical director (MD) referenced here:

There’s different paths for different information. So [. . .] I know [an executive] connected into an external organisation and he’s giving me lots of information. [The MD] is very well connected with the medical profession. So you know, when [the MD] gives you a snippet of information, I’m encouraged to pick it up. [Another executive] does a different role and I’m expecting him to give me some stuff outside the sector. So I am looking for people to start giving me more information and ultimately the challenge for each of them is if they’re not bringing stuff back in from either their sectors or whatever, then what value are they adding other than doing their job.

Mental health FT, CEO1

Similarly, we observed that, because certain issues were deemed more relevant in light of what the CEO was attending to at that moment, information relating to those will be prioritised, which occasionally meant shifting into a different mode of information work.

If it’s something that [comes via e-mail that] I think oh yes, I actually need to understand this, so before I pass it on I will try and prioritise reading it. And that means actually take it home and doing it at eleven o’clock at night because that’s the only time I can actually sit and focus on it.

Acute FT, CEO1

Our observations thus suggested that, while CEOs may have a personal style of informating (i.e. keeping knowledgeable) as part of their work, this style was not always the situationally appropriate approach, so it could and did change. In particular, we saw that it also depended on the task and context at hand, which changed constantly.

The how of sourcing in practice: an example of an acute foundation trust chief executive officer

In order to best demonstrate the complex interaction between different sources, the personal style of the CEO, and her context and tasks at hand, in relation to the practices of sourcing in particular, we consider one case in depth, namely a CEO of a large FT acute trust.

In terms of hard knowledge, because as you know my diary is so congested, if something sort of weighty comes and I know I need to actually get to the bottom of it, I either put it to one side and wait until I’m on a train journey or something like when I can read it, or actually give it to the director as I know who’s going to be actioning it and ask them to do a briefing. [. . .] But I do try and tend for the really important things that I need to understand, all the nuances, I like to read it myself. [. . .] Or if I’m interested in something or concerned about it I’ll go looking for it on websites and whatever and pull it off. Now in terms of actually soft data as you know from your field work I spend quite a lot of time actually in ward areas and beginning to develop patterns that I then go and test out [. . .] And I also, I network a lot, so I spend quite a lot of time talking to others about how they think about things.

Acute FT, CEO1

For us, several key insights emerged from this example. Firstly, the CEO makes a distinction between ‘hard knowledge’ and ‘soft data’, with each category featuring a distinct approach to sourcing and processing. For instance, ‘hard knowledge’, which here implies a certain ‘weightiness’ and a need to address the task seriously in order to ‘get to the bottom of it’, is sourced as part of daily work via structures that match its nature. In this case, it is a ‘train pile’: a folder we observed being compiled by the PA, normally over a period of several weeks, and given to the CEO prior to a work trip. The underlying working logic of this ‘tool of the trade’ seemed to be that it provided focused time away ideal for in-depth reading, which a ‘weighty’ document demanded.

Another structure we recorded the CEO setting up for sourcing key insights from such ‘hard knowledge’ is a briefing produced by the director whose area the document addresses. What was important is that such a briefing did not solely perform the function of informing the CEO of key insights. As she commented following the feedback presentation we gave, asking a director for a briefing, or to come back with a short document that highlights key messages following a team discussion, also performed the task of assuring the CEO. More specifically, it allowed her to assure herself that this issue was being attended to, but also that the director in question understood what the issues were and could address them in an appropriate manner. In other words, it again seemed that information might be sourced to inform a particular decision or discussion, but it might also be sourced to ensure that there is a common understanding of issues, or that certain tasks are being attended to in a satisfactory manner as perceived.

The CEO also suggested that sourcing is not something done solely by herself, with the sole purpose of informing her own practice or tasks. Instead, sourcing was largely a social, and occasionally a directly other-people-facilitated process, which was at times directed towards the CEO’s own practice, while at others it is put towards informing the work of others. At the same time, it mattered what was being sourced, as much as to what end. In particular, as the CEO explained, ‘I do try and tend for the really important things that I need to understand, all the nuances, I like to read it myself’. In other words, here sourcing was done directly by the CEO wishing to ‘stay on top of things’ that are important. This can also be seen in the sentence that follows, when the CEO stresses that ‘if I’m interested in something or concerned about it I’ll go looking for it on websites and whatever and pull it off’. Again, the implication was that, if the issue was of particular concern, the CEO took a proactive stance toward obtaining any necessary insight to address it, rather than waiting for the information to come to her via other sources.

Importantly, the proactive stance towards sourcing apparently ‘important’ information also reflected the CEO’s personal style of working. Namely, while we observed this CEO to be highly invested in the questions of strategy, direction and ‘sharing the vision’ for the organisation, her working style on a daily basis was closely focused on the detail underpinning and informing those tasks. In relation to sourcing, this meant she would actively seek out individuals, such as her executives, to obtain additional insights, she ‘drilled down’ into minute detail when a particular issue was of concern, visited wards and departments, and picked up the telephone, e-mailed or accessed documents herself when needed. Even though she had an ‘open door’ policy in the office, with frequent visits by executives with the ‘latest’ information, more often than not she was ‘out there’ sourcing first hand, as this example demonstrates.

At 12.30, the CEO asks the PA if she is ringing the Chair or the Chair is ringing her. Just then the [director of nursing (DN)] walks in and notes she just needs to see the CEO really quickly, walks into her office and closes the door. She is back out in five minutes. The CEO continues to read a document at her desk and write notes in margins. At 12.40 the PA checks in about the Chair call, the CE notes she will have to go see the FD [finance director] in a minute and will bring her mobile with her. Continues reading through the document and writing notes on it. She goes out at 12.43 with the paper, tells the PA she will give the Chair a ring when she returns.

Excerpt from field diary, acute FT, CEO1

In particular, for this CEO, conversational engagement with individuals, such as visits to wards and conversations with directors, was a key mode for sourcing what she called ‘soft data’. As she reflected:

I spend quite a lot of time actually in ward areas and beginning to develop patterns that I then go and test out or just sort of see what happens and then get some new stuff to them to be tested out [. . .] I network a lot, so I spend quite a lot of time talking to others about how they think about things.

Acute FT, CEO1

For the CEO, key to this kind of sourcing was simultaneously developing patterns, testing thinking, and talking about different ways that others ‘think about things’. This suggested to us that this instinctive, tacit work of sourcing was really about (at the same time) piecing together of information and insights in order to make sense. It is to this process of sense-making as a precursor and complement to mobilisation, which we observed this and other CEOs highlight as being crucial, that we turn next.

Sense-making in practice: an example of an acute foundation trust chief executive officer

As before, we felt the most comprehensive way to depict sense-making in practice is via an in-depth presentation of a single case, namely a CEO of a sizeable acute FT. Firstly, the CEO relied heavily on sourcing via informal conversations with her executives, who would frequently pop into her office with the latest news. These conversations were facilitated by an open door policy and the physical proximity of all the executives on the same floor. The CEO would also frequently seek out information as she needed it, by visiting the executives’ own offices. As she told the researcher on site one day, ‘I realised with you being here how much I get up and walk around’ instead of picking up the telephone, adding she ‘cannot work on anything that requires focus here because she is constantly interrupted by people and also goes out to seek people out too, which she thinks is the right way of going about things, as it would feel quite different if she kept her door closed’ (excerpt from field diary). Such a preference for conversational sense-making was also reflected in the relative absence of written information, such as large sets of meeting documents or external guidelines or publications. Whereas the offices of some CEOs featured desks overflowing with papers, and briefcases filled every evening with documents to read at home, we observed only a thin folder of documents prepared for this CEO every day. The CEO indeed actively worked on keeping her desk as clear of paper as possible. As she flippantly noted to the on-site researcher, ‘you know I don’t read anything’ (though this was not entirely true in practice). However, the CEO practically ‘made up’ for such distancing from written, both internal and external, documents via a notable reliance on a highly formal internal IT system registering performance across the trust. As she repeatedly stressed during our research stay, she ‘couldn’t manage this organisation without the systems they have’. She accessed the system regularly first thing in the morning, which appeared to allow her to get a sense of where the organisation stood in terms of performance in a way that was tangible and that she trusted. However, this was never the ‘be all and end all’ of her practice of being informed as a CEO.

Instead, the information accessed via the IT system was supplemented with subsequent informal discussions with her executives, but also unprompted visits on Saturdays or early mornings to particular wards, in order to ‘see for herself’ and make sense of what the ‘hard data’ of the IT system was telling her, as she told the researcher in informal discussion. Equally, the various information gathered as part of her working day, from formal external meetings, e-mails, telephone calls or informal chance encounters, was never simply taken on board. Rather, we witnessed it occasioning a process of iterative sense-making, where the CEO would think through and make sense of it mostly by speaking informally to her executives as the key referential mode of engagement. Crucially, this often seemed to happen almost as a by-product or ‘side act’, in the sense that the CEO would be visited or would visit an executive to discuss an informal matter, or a specific issue, only to continue with a prolonged informal discussion of another, as this example demonstrates.

[The CEO and MD finish a meeting with an internal representative of a new sub-specialty, who] leaves at 09.58. The MD stays and [he and the CEO] chat about what they have on today. She tells him about the afternoon visit, which is a business pitch. Also notes she cancelled the next meeting because she read the info again and just didn’t think it should happen [MD nods]. Reports to him what happened yesterday dealing with the regulator situation, adds there were tears. Also discuss the mistake made re their risk rating, which the NEDs were very mad about, and that she spoke to the lead (corporate) regarding what he needed to do to acknowledge his mistake and he didn’t do it. CEO tells him about the access to the system she had this morning, which happened then didn’t again. Asks him if he saw an e-mail from a person, she thought ‘oh here we go’, shows him on her telephone, he laughs . . . MD leaves at 10.11 as he has another meeting.

Excerpt from field diary, acute FT, CEO3

In other words, this CEO’s sense-making was rarely an A → B proposition. Instead, for her, one conversation as a space of sense-making often moved between several different topics, informing a number of different issues, and engaged towards a number of different ends, some of which were not the ends originally conceived. In particular, the amount of time spent in such conversations, which included discussion not only of operational or strategic (that is ‘work’) issues, but also of broader, informal topics, suggested to us that these also had the purpose of contributing to a construction of a particular social ‘tribe’, a key aspect of which was a shared understanding of the ‘world’. This acted as an effective filter by which the CEO could assure herself that the distributed components that effectively kept her knowledgeable were processed and presented in a manner that she would find appropriate.

The importance of her immediate team for this CEO as part of her sense-making was reflected also in the high degree of delegation and trust she placed in her executives as a source of information. For instance, following one meeting with an internal staff member who raised a complaint, she turned to her MD, and asked ‘how much of that was a whinge and how much had substance?’ She then carefully listened to the MD’s reply in order to aid her in making sense of the complaint. However, when the chairperson commented regarding how she learns about what is going on inside the organisation being executives in the room, her response was ‘you would be surprised’. Again, despite this trust and the great amount of time spent with them, she did not solely rely on them to make sense. Other sources, such as the aforementioned ward visits and informal encounters, along with the IT system, also played an equal part. Equally, whereas the CEO frequently highlighted the value of the longevity and coherence of her team, and saw the shared vision they had as a tangible benefit, she was also aware of the shortcomings of too much sameness, which was why she brought in a particular executive, who she stressed had a very different approach to the rest of the team in terms of how she thought, and was therefore a good counterweight in discussions.

A final crucial component that appeared highly relevant in our analysis of this CEO and her practices of sense-making was the specific context of her organisation. In particular, because of the high degree of success, but also the size and prestige of the organisation, the trust and its executives saw themselves as a ‘maverick organisation’. This implied a great faith in their own abilities and approach, with frequent informal dismissal of many of the other trusts and regulators as sources that the CEO and team can learn from and make sense with. For instance, during a meeting with external visitors, the CEO described their approach as:

let’s just do it. Let’s not bother talking to anyone else, let’s just do it. And when it is a fantastic success, publicise it. The MD then adds that this approach of getting on with it and not worrying about what the Department says is how they have been living for a decade (people around the table nod).

Excerpt from field diary, Acute FT, CEO3

Such an organisational approach, in conjunction with other components of the context, such as a close-knit team that has been together for over 4 years, and an emphasis on ‘doing the right thing’ even when they are not rewarded via Commissioning for Quality and Innovation (CQUIN) (in the CEO’s own words), meant that sense-making in practice often proceeded in deliberate ignorance or at least slight avoidance of certain external information. This included for instance some regulator pronouncements, previous SHA leadership and the local group of CEOs, all of which we observed the CEO dismiss in conversation. Instead, other trusted sources, such as a particular national group of CEOs, were used to think through issues as recognised peers and therefore viable ‘partners’ to the CEO’s sense-making.

The nuanced interaction of these various elements in the CEO’s process of sense-making can be seen in a further example from her daily work, namely an unplanned discussion with the FD concerning the emerging problems within the executive team in light of a misjudgement made by one director in her absence. Though the FD stopped by to discuss another matter, and the conversation subsequently addressed a number of other issues, it eventually turned to an impromptu reflection by the CEO on the fallout from a HR reorganisation that was initiated by one executive without consulting other executives or indeed the CEO, leading to significant unrest inside the organisation and within the team. Prior to this encounter, the CEO had a more formal discussion as part of her regular meetings with the chief operating officer (COO) in order to address the particular issue and set the scene for putting a stop to it. In this conversation, she moved from addressing the particular task at hand, i.e. taking corrective action to stabilise the organisation, to verbalising concerns in order to make sense of their wider implications, and of what the subsequent actions might need to be for the team itself.

They discuss other CE[O]s, local trust issues, then the CEO notes ‘at the moment I don’t think this team is functioning very well. There is a lot of friction’. Notes individual tensions between directors, the FD didn’t know it was that bad. CEO adds ‘what I can’t have now is a complete lack of trust’ between different parts, she is seeing cracks appear and she can't have that. Notes need to work on bringing people back to keel, because it is not going to work without trust. FD notes this normal in evolution of team and may be time for some to leave. CE[O] notes yes, but they may not agree with her assessment of who. Notes may not come to that, but she is having to refocus them more and more. This was the first time they had a significant error in judgment that disrupted the organisation, which they shouldn’t have. They needed to have systems in place, but were ignored, which means she needs to get more control over things. Notes this wouldn’t have happened in early days, because people would have discussed more. Trying to understand why that was done is still hard for her, because it doesn’t make sense. Notes quite a few people not feeling very good at the moment. ‘Don’t get me wrong, this team is still out-performing any other by a country mile’, but she is aware of it.

Excerpt from field diary, acute FT, CEO3

What is important again is that such sense-making appeared as part of everyday, mundane work. This process of seeking understanding was often, as was here, unplanned and conversational: accomplished with other people, in informal discussions. Finally, such sense-making also prompted a reassessment of the issue (‘how good is my team as it stands?’), but also what the solution might be (‘she needs to get more control over things’, i.e. adapt the existing structure to insert more formal systems, with greater consultation).

Factors that determined the personal knowledgeability infrastructures for sourcing and sense-making

The examples in the sections above and our comprehensive analysis suggested that three factors in particular appeared relevant to how CEOs sourced and made sense of information in relation to what we analytically came to describe as personal knowledge infrastructures, namely context, nature of work and personal style. These were reflected in the relationships, structures and objects, which together made up a particularly knowledgeability infrastructure, reflecting the nuances and interactions of different components for each CEO. In order to present the empirical grounding for these in a structured, but sufficiently comprehensive, way, we discuss each factor in relation to one CEO observed, which also allows us to highlight how these overlapped and informed each other in practice.

Props and mediators

Two crucial components enabling CEOs to remain knowledgeable in relation to certain ends were what we analytically termed props and mediators, or the object- and people-based infrastructures. These were distinct mundane objects and specific individuals or relationships by which CEOs kept knowledgeable and acted on their emerging knowledge. As before, these differed between CEOs (see also Table 2).

We saw that a very simple, yet very important, prop for some CEOs was their notebook or diary. Though a few CEOs almost never wrote things down, others appeared highly dependent on it. Not only did we notice that they had the notebook with them at all times, they also relied on it heavily in terms of jotting down key insights from each interaction, particularly formal meetings. They then reflected on those at a later stage, and brought those subsequent insights forth in different conversations.

I tend to write things down in my notebook because the day after I’ll have forgotten them but if they’re written down then they’re there. [. . .] So for example if I’m going to a chief exec’s meeting I will write notes and then something occurs to me about well, we’ve done this, you know, I’ll asterisk it or whatever so that I make sure that at the next information exchange that is raised.

Acute FT, CEO1

A further example was of a mental health CEO, who recorded notes at the back of her diary as she went along, which helped her organise her thinking, but also direct appropriate information toward appropriate ends. For instance, we observed her linking the work she has been doing in recent weeks to ‘things happening out there’, by recounting the various meetings she attended in her monthly update to the Leadership Board of senior staff.

Another mundane, but highly important object by which we observed CEOs both receiving and directing or mobilising different insights was e-mail. Like meetings and other structures, e-mails were a source of many different insights, each with a different mode of engagement by the CEO.

I have about 60 e-mails a day after [the PA has] sorted [the inbox]. So they’ll range from information about the bed space and things like that, which I look at very quickly and if it’s okay I just delete it. If I’m worried about it, I’ll go into more detail and find out what’s going on. Then there’s just messages from people, [. . .] it’s like conversation but electronic. Then there is the stuff coming in from outside that as I say I need to read this.

Acute FT, CEO1

In particular, e-mails often prompted further action. The CEOs would thus often forward it on to the appropriate staff member with a short note explaining why it was deemed relevant for a particular piece of work.

. . . tells me what she is doing now is addressing quite a few e-mails that came in with reports attached, and just filtering them out, so forwarding them on with a note to say which parts are particularly of note.

Excerpt from field diary, mental health FT, CEO1

Equally however, we often observed CEOs receive an e-mail, forward it on and then follow up immediately with a brief visit to that executive’s office. Though this appeared to be double work, it actually was part of a prompted sense-making occasion for the executive, where the e-mail acted not just as a piece of information, but as part of a larger insight of ‘what does this mean for us’. The CEO discussed and made sense of this alongside the executive in the follow-up visit. Though occasionally such sense-making work was quite specific and targeted (‘I think we should do this about it’), we saw that just as often it was an occasion for a larger discussion about key issues of concern to the CEO.

Third, other mundane objects also acted as key props allowing CEOs to continue being informed as part of their work. This included BlackBerrys^® and laptops, which allowed them to continue to work and be ‘in the know’ from home and other locations. The CEOs would thus often have another ‘working mode’ in the evenings at home, attending to tasks such as clearing their inbox, writing reports or reading larger documents. How these were brought in often reflected the personal styles and approaches to work that the CEOs had, as we saw above.

Finally, a number of people played a mediating role in this constant whirl of information, insights and intelligence around the CEO. Of these, we have already highlighted the importance of the immediate executive team and ‘trusted others’ as a regular consultative network through which CEOs made sense. However, an individual equally key to CEOs’ keeping knowledgeable, and not discussed so far, was the PA. In particular, we observed the PAs facilitating the process of information sourcing by limiting calls, marking news stories with Post-its^® and preparing them for the CEO alongside other information (e.g. complaints, post, messages from individuals who visited while the CEO was away), and filtering and occasionally responding to e-mails. They also acted in a key supporting role in enacting the necessary boundary maintenance strategies to allow the CEO to do her work. For instance, though most CEOs had an ‘open door’ policy that meant they received a constant stream of visits and insights, they occasionally found that a particular task demanded their undivided attention, which necessitated breaking with that norm. At such moments, PAs frequently acted to ‘stop the flow’ of information, and limit what could be known right then, so that CEOs could attend to the key task of the moment.

As the PA walks out, she asks ‘do you want to be shut in?’ The CEO replies ‘a bit, not a lot’.

Excerpt from field diary, acute FT, CEO3

Conversations

Conversations, which largely took place informally, outside the structured confines of a meeting, played a key part in terms of CEOs sourcing, making sense of and bringing into ‘play’ various insights as part of their daily work. Indeed, a great proportion of the CEO’s work that could be characterised as ‘knowledge mobilisation’ happened in such conversations. These were frequent, highly nuanced and seemingly never-ending, in the sense that a conversation concerning a particular topic actually meant a great number of separate interactive engagements over a period of time. Put simply, we observed that a great proportion of a CEO’s day was spent talking, with different people, about different things.

[A]s you’ve seen, the sort of variety of the job and the fact that all these instruments [of information] are incredibly different and one minute I might be talking to [the FD] about the financial plan, the next minute I’m talking to [the MD] about dealing with a difficult doctor, and the next minute I’m talking to [head of nursing] about patient experience issues.

Acute FT, CEO1

The CEO hears a person [who presented the architectural plans at last week’s operational meeting] talking in the corridor, calls him in, then asks him about the units located nearby, would like to go and see them. She then asks if a particular location is where the learning development centre would be located, notes this would be preferable. The man leaves after a couple of minutes, the CEO tells me she wants to go see the units to see if they are sending the right messages i.e. if they are central and accessible, not whether they are operationally sound. This is of major concern to her.

Excerpt from field diary, mental health FT, CEO1

Importantly, these conversations ranged from the deeply mundane to the highly strategic. Indeed, we often saw a CEO switch from a humorous discussion of, for example, gifts received abroad, to a serious conversation about a problematic ward and what to do about it in the space of a minute. Thus, it appeared simply normal to move constantly between such different modes; it was the way NHS trust CEOs worked.

The CEO goes out, chats to the people waiting outside (five of them just got out of the interviews) for a minute, then the MD and [another executive] come in, she invites them to read her e-mail (re a trip abroad). They sit down and joke about the lead for the trip, who they don’t seem to think is very good. The CEO jokes about sending the FD and another director, which went so well last time (sarcastic), adding they need to understand who is also attending this trip, i.e. are they going alone or as part of a delegation, and with what consequences. They laugh then about their last trip, teasing the executive, then about toasters in the news (CE[O] jokes about ‘tired of never seeing deities in your breakfast?’ toast), then the executive updates the CEO on the decision made to appoint just now . . .

Excerpt from field diary, Acute FT, CEO3

Significantly, therefore, we observed that what could easily seem at first glance to be ‘chatting’ was actually serious work, through which many important issues were discussed, sense was made and the ground was laid for further discussions and considerations elsewhere. Crucially though, this was not only because they raised important issues for the CEO to consider and address, but also because they enabled the emergence of a community with a shared world view, which was equally important, as we will see in the final section.

Not only did CEOs constantly have different conversations about different topics, they also frequently mobilised the same insights toward many different ends. As we will see in more detail in the next section, on CEOs as weavers, such directional ‘placing’ or mobilising of information in a repetitive way was often part of the task of creating narratives that convince (differently, based on different audiences). For instance, in the smaller acute trust, the researcher saw the CEO receive news during an informal site visit with a PCT cluster CEO that the local clinical commissioning groups would fund a particular stream of activity. The CEO subsequently employed this as part of a conversation to convince clinicians in her trust that they have to take responsibility for good trust performance as well (‘we’ve got the money, now we have to deliver’), but also in a conversation with a local Member of Parliament, to convince him that positive things are indeed happening despite present challenges.

Similarly, the same informal conversation, in this case with the PCT cluster CEO, was the source of multiple relevant insights, which the CEO then appropriated and mobilised toward different audiences, depending on the context and the task at hand. In such mobilisation, this insight was then considered in an ecology of other available ones, for instance from other executives, and operationalised accordingly.

The executives raise the issue of [a service], the CEO notes she met with the PCT cluster head, who was impressed with them on that score. She thinks the strategy should be to speak to him, and also the local commissioners’ lead to say it’s unproductive for them to ignore [a particular service] and not to spend their money there. She is told this decision was actually made by the cluster heads, but the CEO notes this isn’t the information she is getting from the cluster CEO we met yesterday, and the Director of Finance supports her on that, given that he had a similar conversation with the cluster CEO last week.

Excerpt from field diary, acute FT, CEO4

Occasionally the CEOs also used external intelligence gained in conversation to validate internal figures, as part of their everyday process of ‘triangulation’ or sense-making.

[In conversation with a representative of a sector data organisation], they discuss a staff member not being trusted ‘out there’, the CEO asks him to tell her if there are rumours out there questioning their figures [which is of particular concern to the CEO at the moment]. Notes the NHS is really bad for gossip, she would appreciate knowing what is out there.

Excerpt from field diary, acute FT, CEO4

It was not just external intelligence that acted as a prompt for certain action, but informal internal conversations too. This was especially the case as part of the CEO’s role as the symbolic figurehead, who could add weight to a particular discussion or issue by becoming involved. Here, insight was normally shared as part of a situation where an executive or staff member found himself or herself unable to address a particular issue. In such a situation, we saw the CEO marry that intelligence with other appropriate ‘tools of the trade’, such as written documents, or additional insights from other sources, and direct those together toward addressing the issue. Based on our observations, the act of mobilising insights thus often occurred via written documents and structured e-mails, though the sourcing and sense-making that informed it were performed via informal conversations.

[The CEO and an executive are having] a very frank conversation about a project and how it is going, with the executive reporting details of the existing relationship with the contractors. The CE[O] notes she wants to chair the next meeting between them. When the executive mentions how silly the RAG [Red Amber Green] document that the other side produced is, the CEO asks if she has an electronic copy and to send it to her. She will then e-mail the other CEO to say this is a joke. Suggests they involve the lawyers, then asks what another person’s view on this is. The CEO asks the executive if she has a list of all these issues, adding she would like it written down, bullet point style, in a document that she can take with her when she goes to see the other CEO.

Excerpt from field diary, acute FT, CEO3

In summary, as a smaller acute trust CEO reflected, CEOs found informal conversations such as the one with the PCT cluster CEO, in which intelligence was shared, highly valuable sources of insight to be considered alongside relevant others.

She also tells me she finds it very valuable to have meetings like this [with the PCT cluster CEO], because really this isn’t the kind of information that will come to her written down, but the information she receives will very much play a part in her decision making.

Excerpt from field diary, acute FT, CEO4

Meetings

Meetings were another crucial component of the CEOs’ personal infrastructures, facilitating an engagement with information and insights in particular ways. A pertinent example is from an executive meeting in a successful mental health trust, where we witnessed the CEO looking at the RAG document and struggling to make sense of seemingly competing insights regarding where they stand performance-wise, in an effort to make sure they all share a common view.

‘It looks very red [referring to the RAG rating document] for us to be having a discussion that is so comfortable. Can I just ask: as a team, do we know how we are performing?’, could they go out and talk about their performance, ‘what is the story about our performance?’ When the lead says it is one of continuous progress, the CEO adds ‘do we all know that, do we share that, where is the drive for it?’ She seems to be challenging her team. Stresses again she isn’t sure they have a shared sense of their performance. Notes they need some time to properly consider the report, because she sees red and gets worried, but then hears the discussions and the nuance and it doesn’t sound that bad.

Excerpt from field diary, mental health FT, CEO1

Thus, internal meetings frequently acted as a highly useful setting for CEOs to make (joint) sense of their organisations in conversation, weigh different insights against each other and secure consensus on how to proceed next. However, such meetings were not solely about sense-making between the executive team. Indeed, though a meeting occasionally appeared to be about one thing, for instance finding out where the organisation is performance-wise, meetings often allowed the CEO to accomplish a number of different things, some of which were not obvious unless the CEOs were able to reflect afterwards.

[K]nowledge acquisition is an important part of that but it’s actually subjugated to the chairing of the meeting. But when I’m going to an external meeting then knowledge acquisition is an important part of it, and again what I tend to do is I try and take notes in a way that makes sense so that . . . Because I can then prepare to brief my team or whatever as I write my notes . . .

Acute FT, CEO1

This was also the case for the following CEO, who outlined afterwards the multiple objectives she accomplished during a particular committee meeting:

she adds that one of her tasks during that meeting was assessment of the meeting chair [who is a NED], as part of the trust Chair’s process of annually assessing the NEDs. She also picked up the issue of vacancy and the staff survey in her notes from the meeting, which the head nurse and her will pick up later and discuss. In addition, she tells me she did a bit of leadership observation in terms of the two assistant directors and their personal performance as part of their development commentary for the annual review. Finally, she explains the context behind the discussion re vacancy [. . .], her instinct is to raise the issue and make it a cause for change.

Excerpt from field diary, mental health FT, CEO2

Similarly, much like with conversations, CEOs made sense of insights gathered from meetings in the context of the task they are currently attending to and the ongoing issues, which they then brought to bear toward those in different settings as appropriate.

[L]ast Friday she was at a mental health CEOs meeting and had various discussions there which she will then bring to different meetings. Today, for instance, the discussions on safety [will be brought] to the first Quality meeting and then the information on needing to think a lot more holistically about mental health to the afternoon one, which came from her discussions with the Scotland and Wales Medical Directors last week [at a different event].

Excerpt from field diary, mental health FT, CEO2

Networking

Though some CEOs found external networking a personally challenging task, creating and maintaining appropriate referential networks of peers was seen as operationally useful, not merely as an information source (‘what is happening out there in the world?’), but also as an aide to sense-making (‘what does that mean for me, my trust and the approach we are taking?’). Most of the CEOs in our sample spent considerable time networking during their working week, by attending conferences and giving talks in order to maintain the profile of the organisation, taking meetings with external executives potentially useful to the trust or joining local and national meetings of peers, such as the National Leadership Council or the local Chief Executives Forum. As part of these meetings, the CEOs gained formal insights, but also informal ‘feelings’ on particular issues via informal conversations with their colleagues.

Notably, this ‘talking to others’ in an external, networking-oriented way was a critical means by which CEOs made sense of their ecologies of information in practice, by sharing insights and testing their own thinking. They reported that this allowed them either to be more certain of their particular understanding, or to be challenged in considering another, potentially useful perspective.

I network a lot, so I spend quite a lot of time talking to others about how they think about things. And I find that fascinating because I think there’s a very clear line of sight on something and very often people will confirm that, but equally often they’ll actually give me a different perspective.

Acute FT, CEO1

However, networking was seemingly useful not just in the context of the CEO making sense. Occasionally, establishing those networks also had a direct operational consequence, in that other executives or individuals would contact the CEO with latest news of potential consequence, which would enable the CEO to action this insight further within the organisation to avoid any negative repercussions, or to steer existing work in another direction. Such sharing would also enable a shared worldview to emerge, as can be seen from this example we observed:

The CEO takes a call from a chief exec of a local community organisation, who are in negotiations with the PCT about their CQUINs and wanted to check in whether they were also subject to this clause that said if anyone in the patch fails any of the CQUINs, none will be paid out. The CE[O] listens and says she will check with the FD. When they finish, she calls the FD quickly and explains the situation, asking whether he has committed their organisation to a similar commitment. Agree to speak in the office. She then tells me that if you get relationships right, people will call you before they do things, which is very helpful.

Excerpt from field diary, mental health FT, CEO2

Decision-making

Finally, decision-making was a particular setting where similarly we observed different sources being considered and made sense of together, including personal experience, informal insights and formal ‘hard’ evidence. We introduce one case of decision-making in practice as the most effective means of presenting the material, namely whether the CEO of a successful acute FT trust and her team should proceed with more in-depth discussions concerning possibly taking over a struggling trust.

In particular, the CEO received an e-mail from a company leading on this process to enquire if they would be interested. In order to address this question, the CEO convened an informal meeting of her executive team plus the head of informatics (HI), in order to discuss the issue and decide collectively. Before we introduce the meeting however, it is important to stress that such instances of focused decision-making (i.e. one decision made following one focused meeting whose sole purpose was to address this very question) were exceedingly rare in our observations. Instead, we observed that for the most part CEOs made decisions over time, interactively and in a piecemeal fashion.

The CE[O] kicks off the discussion at 14.45, with the e-mail from the consultants on the screen. Notes she feels this was a particularly poor document, explains to the director of nursing (DN) what a super chain is. Reads what the other trust’s current performance is from the document, the head of informatics (HI), with a wad of documents in his hand, adds it is actually not bad, though mortality is. DN notes yes, no money and bad mortality. The CE[O] then asks the head of informatics to say in more detail what the trust’s performance is like. He speaks to print outs (maybe twenty five pages, with individual graphs displayed on single sheets) and tells them what it is re outliers, mortality, letters of complaint, in-patient activity, and A&E. CE[O] asks what their A&E numbers are, COO says. DN, who lives locally, gives more insights. HI goes through [two figures], FD notes they should be making quite a bit of money on that. HI notes second worst on a particular surgery nationally, shows on the chart/map where their patients come from. DN notes because of location it is likely that it is [particular] patients who will show up there. HI shows referral sources, execs discuss individual numbers. HI notes market share is flat, MD asks to clarify [. . . Another figure is] ok, but significant outliers in two areas (MD and COO note for one of the areas they don’t have the clinical experts there, which probably explains it). [. . . They discuss capital, and the characteristics of the local population.] CEO sets up Google Maps [Google Inc., Mountain View, CA, USA] so they can see what the hospital looks like. [. . .] COO asks why struggling then, DN replies. [. . .] CEO says ok, they can now say no, or explore it further. Several executives say immediately they should explore further. The FD asks [where the request came from], MD notes [a local policy lead] would be supportive based on their conversation. CEO notes the first thing they should do is get a hold of this person who sent them the offer, the CEO met him but can’t remember. Head of Corporate says he knows him, CEO asks if he is alright. The impression is he may be looking for a job with them. Head of Corporate notes another trust already tried, but failed. CEO notes should meet with the man next and asks who would like to come along. [They agree who will attend the next meeting and confirm that they should see first what the consultant says, before deciding anything further. The meeting is disbanded after approximately 25 minutes.]

Excerpt from field diary, acute FT, CEO3

What was particularly notable for us regarding this case was not only how the discussion seamlessly went from information from their systems, to executives’ less formal experiential insights, and back again. It was also the level of detail discussed, which supports our observations elsewhere that CEOs did not make decisions ‘on the back of the envelope’, that is hastily, without due consideration. As this example demonstrates, CEOs more often than not carefully considered different sources over time, seeking consensus and a proper basis of (situatedly appropriate) ‘evidence’ before proceeding with a particular course of action, even when it was a relatively low-risk matter such as continuing the conversation or not.

Weaving in practice: the case of a mental health chief executive officer

A notable example of the many nuances of such weaving in practice toward the creation of strategic narratives was the case of public accountability, which the CEO of a successful mental health trust weaved over time into a strategic narrative of the membership organisation, as a viable vision of the future for the trust. Crucially, as part of this weaving, insights in support of the issue were also refined and repeated in conversation with notable individuals, as part of a conjoined effort to get everyone ‘on the same page’.

Specifically, at the start of our research stay in the organisation, the CEO shared that one of her aims was ‘to introduce public accountability in a much more meaningful way’, which she repeatedly stressed in other fora, for instance at an internal meeting of staff, where she noted ‘getting open and accountable will be a stronger drive for this year’ (excerpt from field diary, mental health FT, CEO2). Her goal in particular was to make governors much more meaningfully involved.

However, one obstacle for this vision was the board chairperson, who had particular reservations about public meetings of the board as one means by which public accountability was being defined by the regulators. In order to address this, the CEO met with the chairperson, another NED supportive of greater public engagement and the head of corporate governance, who had detailed knowledge of the necessary legal requirements. During the meeting, the CEO first linked the strategic drive toward greater public accountability with her vision for the trust as a membership organisation, as a unique organisational identity by which they could effectively distinguish themselves from others.

The CE[O] notes it is important to go with their values, which is what makes them unique. For her it is about how far they have gotten as a membership organisation, how can the technicalities of the public board meeting not compromise their work on involving, and public accountability to their members. Adds there is ‘a massive opportunity to do this differently than other people’, compares them to [another MH trust], which even though it is a leader still sees governors as something to deal with, not work with. It is a big strategic opportunity for them, but it is hard work [. . .]. Notes this would give her and the Chair a platform for some public work, which they haven’t done in years.

Excerpt from field diary, mental health FT, CEO2

Thus the CEO here mobilised or weaved different sources in order to convince the chairperson that the particular operational task (e.g. holding board meetings in public) made sense as part of a greater narrative of who they wish to be as an organisation. Importantly, the conjoined process of winning over the chairperson and constructing a strategic narrative of the ‘membership organisation’ did not stop here. In particular, some days later, the CEO received an e-mail with information about the meeting of the new commissioning board, streamed online in real time, which she forwarded on to the chairperson and followed up with a call to explain why it is pertinent to their discussions. She also later accessed a PDF document from Monitor outlining arrangements for FT public board meetings, telling us this was ‘a part of the dialogue she is having on that’. Similarly, a few days later, at a meeting of CEOs at the local SHA, after the SHA lead highlighted the need to listen to people out there and their staff as the key things that will emerge as critical from the Francis Report,100 as will accountability, the CEO turned to her chairperson and quietly commented that this is what they were talking about at their earlier meeting.

Interestingly, the next day this insight was linked via repetition to internal concerns at a meeting of the executive team, when the CEO brought up the previous day’s meeting, and noted that she wanted to highlight how important their work on being an engaged organisation was in the context of last night’s emphasis. She then also linked this to the concerns from the DH regarding what will come out of the Mid Staffordshire NHS FT investigations, but also to her views on accountability and their work as an organisation on clinical leadership. Similarly, during a service event some days later, the staff members there told the CEO about the presentations that morning, which the CEO linked to the discussions with the chairperson about them as a trust moving beyond just their governors in terms of public engagement, and being a lot more local and community based about it. When the researcher later commented how interesting it was to observe the kind of links the CEO made to their ‘big picture’ work on public accountability, and the membership organisation, the CEO agreed, noting that was why ‘those things are so useful’ (excerpt from field diary). In other words, though the emerging narrative of the membership organisation was brought to bear towards the task of convincing the chairperson of the board of a particular course of action, it is also used to inform other narratives in that context, such as the importance of their work on clinical leadership, with the effect of extending and ‘strengthening’ it further.

The personal knowledgeability infrastructure of chief executive officers

The observations discussed in previous parts of this report indicate that, in order to fulfil the information and knowledge demands and expectations derived from the combination of factors discussed above (i.e. context, personal style and demands of the job), CEOs usually relied upon a particular mix or arrangement of people, objects, practices and sources. Taken together, these ‘tools of the trade’ enabled CEOs to become appropriately knowledgeable in relation to the different issues and demands of their work.

We defined such an arrangement as the (personal) knowledgeability infrastructure of CEOs. Our observations suggest that each CEO creates, maintains and continually adapts a specific and very personal configuration of tools of the knowledge and information ‘trade’ that they use to make themselves knowledgeable. The knowledgeability infrastructure is itself context- and time-dependent, based on personal choices and continuously evolving. For example, our observations demonstrated that the personal knowledgeability infrastructure develops and changes as the going concerns of the work change. In one of the trusts we observed the need to ‘find out the root cause of problems’ in one particular instance escalate from the use of e-mails and performance indicators, through encounters and personal interactions aimed at ‘really understanding what is going on’ (excerpt from field diary), to the establishment of a small, fact-finding team that carried out an evaluation review of the division. Another example was a trust CEO whose organisation was commencing talks concerning a possible merger, which was something she had little direct experience of previously. This led her to actively expand her current infrastructure to ‘fill the gap’, by attending a number of specific external events where mergers and acquisitions, and knowledge related to them, were presented and discussed (excerpt from field diary). Via such an engagement, the organisation directing the event was enveloped into the ‘fold’ of that CEO’s personal infrastructure going forward, while the issue itself continued to prompt further additions, by acting as an intentional sourcing guide directing further information work engagements (interview). In addition, we found that the personal knowledgeability infrastructure also changed depending on ‘where the CEO is’ in terms of personal trajectory and organisational conditions. For example, in our sample we observed different types of knowledgeability infrastructures (i.e. different combinations of tools, practices and sources) in relation to:

• the experience of the CEO (how long she has been doing this job)

• the tenure in the particular post

• the composition, ‘maturity’ and tenure of the executive team and board

• the legal and regulatory environment

• the type of pressures from the organisational and institutional environment

• the type of tools and technologies available and preferable.

Finally, personal considerations about ‘what kind of manager would I like to or feel I should be’ (e.g. the desire to act and be seen as a ‘transparent manager’) also contributed to shaping the personal knowledgeability infrastructure. For instance, for one CEO studied, personal accountability and ensuring the best for each patient meant a key role in her infrastructure was played by an IT system, which allowed her to understand at all times the relative performance across the trust. This was supplemented by regular informal updates by the executives, but also by her frequent unannounced visits to the wards to observe the work as it happened and talk to staff directly. All of this made it possible for this CEO to ‘know what is happening in my hospital’, so that she could be effectively accountable, but also ensure that good patient care was being provided at all times, even when her duties necessarily took her away from the trust (excerpt from field diary).

It should be added that each configuration of people, objects and ‘tools of the trade’ did not sit passive in the background, but had an active role in defining a certain way of doing ‘being a trust CEO’. The CEOs were therefore partly ‘at the mercy’ of the arrangements they had set up (or not set up, or not modified as necessary). As a result, they always risked finding themselves locked within a specific perceived information environment, which might not be aligned with the current demands/needs of their job or their own expectations. In other words, the knowledge infrastructure that an executive operates can be (and in our study sometimes was) partially misaligned with other aspects of the work of that CEO. It can therefore become ‘dysfunctional’ in view of the local demands of the job, or in conflict with who the CEO seeks to be as a manager.

For example, if a CEO wants to take a strategic view, but her infrastructure draws the attention to and presents her with operational issues only, the CEO is likely to be sucked into a role different from what she wished. The idea of personal knowledge infrastructure thus alerts us to the fact that CEOs may find themselves locked in an (informational) iron cage of their own making. In particular, the personal knowledge infrastructure enacts in fact a specific perceived information environment, which reflects both the style and habits, but also the prejudices and blind spots, of the CEO. The personal knowledge infrastructure may therefore contribute to the fact that CEOs do not see what they do not see – they are not aware of the blind spots that their infrastructure creates for them. They realise this only when something happens that was not ‘on their radar’ (‘how can this happen without me knowing’ was one of the often-mentioned things that the observed CEOs tried to avoid at all cost).

Summarising from the above, our study suggests that much is to be gained if we respecify knowledge utilisation or mobilisation as a practical accomplishment (a doing) that emerges at the intersection of contextual demands, personal skills, experience, tools of the trade and organisational arrangements. Figure 8 summarises our findings and the proposed shift in graphic form.

FIGURE 8.

How NHS CEOs stay knowledgeable for all practical purposes.

Specifically, the model suggests that knowledgeability always has an object (it is never in the abstract), as well as a time, so that there is no single best way of addressing the knowledgeability needs of CEOs, given that what counts as appropriate changes as the circumstances change. The model also suggests that how the knowledgeability demands will be interpreted (i.e. what is the necessary information, what type of information is appropriate, how it will be obtained, what are the preferred or more trusted sources, etc.) is highly contingent on the institutional and organisational conditions as perceived, as well as personal and job factors. Finally, the model suggests that CEO knowledgeability is accomplished through and by a personal knowledgeability infrastructure composed of people (relations), practices (routines, structures) and ‘tools of the trade’ (objects and technologies, trusted sources, recurrent tactics). The personal knowledgeability infrastructure will also be attuned to personal preferences and contextual conditions, and may of course change as problems change (according to the principle of ‘horses for courses’).

In order to observe the nuances underpinning this model in practice, Appendix III provides in-depth examples of the personal knowledgeability infrastructure from two CEOs observed. The examples show how they resolved their emerging and contingent knowledgeability demands via a particular personal knowledgeability infrastructure and a certain approach or posture towards maintaining knowledgeability. These examples also illustrate that, when it comes to understanding the practice of knowledge mobilisation and information work in general, context matters. In addition, they re-emphasise our point that there is no one best way to address the knowledgeability demands that the job presents to NHS CEOs, as a number of alternative configurations can all satisfy such demands (although some could be more effective than others, depending on the particular components of the combination of context, style and work at hand). As we discuss later, this potentially has significant practical implications, as it points to the coherence of the arrangement and its contextual and temporal ‘fit’, rather than the nature of its components, as the crux of the matter.

Finally, the examples reiterate how the knowledge work necessary to become and remain knowledgeable for all the practical purposes required by the job constitutes a dimension of what CEOs do already: a skill. In this sense, our findings resonate with authors who have shown that, when practitioners move from being novices to experts, their grasp of the problems and the available solutions just happens. 7,102,103 They also echo previous findings from Gabbay and Le May,7 who repeatedly heard experts say ‘it all depends’, as the CEOs frequently told us as well as they answered our questions concerning their information and knowledge practices. The answer ‘it depends’ suggests that the process of knowledge work at this level is akin to a form of ‘connoisseurship’: it is work aimed at determining not just what the problem might be, but also how it might be dealt with given the situation at hand. Crucially, recognising what might ‘work’ where is a key feature of this expertise.

Narrative sense-making is at the core of the chief executive officers’ way of dealing with knowledge, information, intelligence and evidence

One of the key findings of our research is that the activities of sense-making and sense-giving are mostly conducted dialogically, that is through ‘serious’ conversations with others, carried out in a variety of forums and opportunities. These conversations constitute one of the central types of work carried out by the trust CEOs, and are accomplished through diverse media (mainly face-to-face conversations, e-mail and telephone). This emerges both from our empirical presentation in Chapter 4 and from the above discussion on the extensive use of narrative as sense-making and sense-giving activities. A considerable part of the work of CEO knowledgeability thus involves roping in others and ensuring that they know and act on an insight, rather than the CEO herself. In this sense, the information and knowledge work of CEOs should be considered a distributed practice carried out with and through others. Two factors may be critical here. One is the attitude of the CEO and her propensity to encourage, foster and/or prompt others to engage in information-seeking and intelligence-gathering. The other is the nature and maturity of the top executive team.

The dialogical nature of the CEOs’ work also means that the composition and nature of the relationship with their immediate social circle is a critical factor to their knowledgeability. Trust is fundamental in this sense. In fact, all the CEOs in our sample relied heavily on an inner conversational circle (usually composed of selected members of the executive team), with whom they had the most intense level of interactions. The flipside of this finding is of course that the inner conversational circle can hamper the effectiveness of CEOs and their capacity to make sense of events or make useful distinctions (e.g. because nobody provides alternative views or critical feedback). The nature and relationships with the conversational inner circle can also contribute to maintaining the (relative) information poverty of the CEO (e.g. by filtering too much). Importantly, many of the CEOs observed hedged this risk by intentionally creating for themselves redundant information environments that allowed them to receive alternative and potentially discordant pieces of information, or in certain cases consciously engaging executives who are ‘different’ (or at least ‘different’ from them in the way they think and perceive the world). A central figure here was often the chairperson of the board of directors, who constitutes (or can constitute) a critical node in the information horizon of the CEOs. Other specific sources were also made significant by CEOs on an individual basis, for instance personal coaches or trusted colleagues from former organisations.

Depicting CEOs as ‘conversational beings’ does not imply in any sense that they live moment to moment, or are not reflective or learning-oriented. In fact, the contrary is true. All the CEOs we observed were highly reflective, although they tended to reflect collaboratively and conversationally, rather than relying only on solitary introspection. They did the same when it came to constructing ‘evidence’ and ‘facts’ out of information and intelligence. Furthermore, all the CEOs we observed relied on a formal and informal personal reflection infrastructure (composed of, for instance, coaches, members of present or past action-learning sets, trusted peers), whom they used to reflect on what they do or what their plans are. CEOs, based on our observations, thus often think and reflect ‘externally’. Similarly, CEOs continuously learn new things and expand their horizons through reading, browsing the web and proactive engagements of other kinds. However, this rarely constitutes their main source of information and inspiration. Instead, most of the novelty is derived from conversations and encounters.

Objectives

• Getting a ‘broader picture’ insight into the CEOs style of informating and managing.

• Allowing the CEO to express in their own words their thought processes and decision-making as it relates to key aspects of their work.

Do you feel there is a particular style or approach you have when it comes to both searching for and processing information?

Is there a particular format in which you prefer to receive information from your colleagues or from external sources (e.g. concise vs. elaborate, informal vs. formal, etc.)? Does this differ between the two?

Are there particular settings (e.g. meetings, conferences, etc.) that you find particularly useful, or times that you dedicate to the task of information gathering?

What external sources of information do you find relevant to your job and therefore consult? How do you access these?

Who do you ask when you need information for decision-making? Is there a particular person you trust more?

How do you prioritise between these given time limitations?

What would you say is the role of e-mail in your work? In other words, how do you use e-mail and for what purpose(s)?

When making a decision, is there a particular grounds on the basis of which you decide a certain set of information is more pertinent or persuasive than another? In other words, what constitutes persuasive information or knowledge for you?

How would you describe your job if a stranger asked you what you did?

What are some of the key tasks of your job as you perceive them?

How do you prioritise those tasks in your everyday work? Is there a basic principle of some sort that you employ?

What would you say are the greatest challenges of your job?

Would you say you have a particular style when it comes to managing? If so, how would you describe it?

Would you say there is a difference between your work in this post and that in your previous job? If yes, how would you describe it?

How would you say your particular context influences your work (i.e., if you are a mental health CEO, is there something about managing a mental health trust that you can discern is different from managing an acute trust)?

What do you feel is the greatest misconception(s) people have regarding your job?

What for you is ‘good management’ (specifically when it comes to NHS CEOs)?