The knowledge brokering role of middle level managers (MLMs) in service innovation: Managing the translation gap in patient safety for elderly care

The knowledge-brokering role of the hybrid middle-level manager

Knowledge brokering across organisational and professional boundaries is particularly crucial for high-quality health-care delivery. Learning from PSK derived from ‘exogenous’ sources [e.g. National Institute for Health and Care Excellence (NICE) guidelines, National Patient Safety Agency (NPSA) alerts, and scientific research and publications], and ‘endogenous’ sources (e.g. experiential knowledge from the clinical front line, and patient safety incidents) is central to enhancing patient safety. 2

A knowledge broker is defined as an individual who uses their in-between vantage position to support innovation through connecting, recombining and transferring to new contexts otherwise disconnected pools of ideas, i.e. they get the right knowledge into the right hands, at the right time. 3,4 Middle-level managers (MLMs) play an important brokering role in understanding the functionality of the knowledge (i.e. for what purposes knowledge may be used) and how they can match the knowledge to potential opportunities. 5 In health-care organisations, a significant number of MLMs are ‘hybrid’, i.e. they hold responsibility for clinical service delivery as well as conduct a managerial role. 6 On the basis that H-MLMs have credibility with their clinical communities and, thus, enjoy legitimacy to broker knowledge within health-care organisations – more so than their generalist counterparts – H-MLMs are uniquely placed within organisations to broker the flows of exogenous and endogenous sources of PSK to improve the overall quality of care in four ways.

We highlight that H-MLMs are able to broker exogenous knowledge ‘downwards’ from external producers and disseminators of evidence – e.g. NPSA ‘safety alerts’ and NICE guidelines – and broker endogenous knowledge ‘upwards’ from within the organisation, for example through incident reporting and investigation, such as framed by the NRLS. 7–9 Further to this, we suggest that H-MLMs span the boundary between managerial structures for brokering PSK, such as clinical governance structures, and frontline clinical practice. They are, thus, uniquely positioned to fuse their understanding of local context (endogenous knowledge) with the more generic evidence base that constitutes exogenous knowledge, to ensure continuous development and implementation of high-quality service delivery that is patient-safe. Finally, if the necessary antecedents for H-MLM knowledge brokering are in place, such as H-MLM interaction with the external environment, then H-MLMs can effectively broker knowledge across organisations, as well as within organisations,10 to influence global best practice. We revisit our conceptualisation of the knowledge-brokering role of the H-MLM in Chapter 2.

Knowledge brokering

The nature of knowledge, and knowing, is an important starting point for any research that aims to understand how knowledge is mobilised. This has been covered extensively in a recent scoping review of the literature by Crilly et al. for the National Coordinating Centre for the Service Delivery and Organisation (NCCSDO). 11 In essence, we regard knowledge as a resource applied by social actors in an attempt to solve problems. It can never be removed from its context, as it is bound to its use and its user within the organisation. 12 We position the concept of knowledge brokering as one solution to the challenge of knowledge mobilisation.

Our review of the strategic role of the H-MLM in brokering PSK draws upon the knowledge-based view (KBV) of the firm. KBV focuses upon knowledge as the most strategically important resource for any organisation. 13 In this study, we adopt a practice-based view of knowledge,14 distinguishing, first, between knowledge which is tacit (personal) or explicit (can be codified),15,16 and, second, between that which derives externally to the organisation (exogenous knowledge, more likely explicit) or internally (endogenous knowledge, more likely tacit). In complex organisations, and where the dominant core of the organisation is characterised by professional knowledge as in health care, knowledge mobilisation is inherently problematic. 17 Specificity of context, combined with the personal nature of knowledge,18 engenders knowledge that is ‘sticky’ and, thus, difficult to broker within and across organisations. Evidence suggests that clinical professionals privilege more contextualised, endogenous knowledge over and above exogenous knowledge which is explicitly presented and accessible to the whole health-care community,19 a phenomenon that Gabbay and Le May20 have termed ‘mindlines, not guidelines’. Attempts at brokering both explicit and tacit knowledge for patient safety face considerable challenges. 21,22 Generating a deep understanding of the processes through which explicit and tacit PSK is brokered within and across health-care organisations, grounded in the larger social context, is critical to inform quality improvement in health-care delivery.

Strategic management

Strategic management literature considers MLMs to be well placed as brokers because they provide a unique ‘linking pin’ between operational and strategic contexts. 23 Despite this, the role of the MLM has been under scrutiny in the private and public sector since the late 1970s. An increasingly globally competitive environment encouraged senior organisational management to delayer MLMs on the basis that the latter did not add value to the organisation’s activities. 10,24–27 However, organisations have found that the expected reduction in costs has not been realised, in large part explained by the loss of ‘tacit’ knowledge as MLMs ‘walk out of the door’, and management consultants are hired to fill the knowledge gap. 10,28 This highlights that the value of MLMs is linked to their role as a knowledge resource, which may be ‘hidden’ in more populist prescriptions for delayering.

In particular, where they have a relevant professional background, MLMs act as ‘hybrid’ managers10,29 who bridge managerial and clinical contexts, i.e. some MLMs may be better placed than others to enact a strategic knowledge-brokering role. Llewellyn6 describes the hybrid concept using a metaphor of a ‘two-way window’. In the context of health care, H-MLMs with a clinical background act as ‘mediating persons’ capable of working through sets of ideas belonging to management and sets of ideas belonging to clinical practice. The strategic role of the H-MLM lies in their ability to look through a ‘two-way window’, to ‘broker’ tacit as well as explicit PSK across clinical and managerial knowledge domains for service improvement. 4–6,19,30

Summary of research context

In summary, the research brings the following literatures together to frame analysis of the processes through which H-MLMs broker PSK in health care: strategic management literature about KBV of the firm and the role of MLMs; organisation studies literature about knowledge mobilisation and brokering; and a more specific health-care policy and management literature about MLMs and knowledge mobilisation. Our study seeks to understand the external and internal contextual influences that impact the ability and disposition of H-MLMs to broker exogenous and endogenous PSK within the organisation and across the wider elderly care pathway to improve the quality of health-care delivery for older people specifically and other patient groups more generally.

Work package 1

Seventeen semistructured interviews were conducted with external, national- and regional-level producers, disseminators and auditors of PSK around falls, medication and transition, as outlined in our original proposal and in accordance with our research protocol. The primary purpose of interviews in work package 1 was to ascertain the expectations and perceptions of external producers of PSK regarding knowledge-brokering transfer from the ‘external producers’ to the ‘internal users’ of PSK.

Work package 2

Fifty-four interviews were conducted with individuals on and outside the main clinical governance structure, the Clinical Risk Committee (CRC), across three health-care organisations (two hospitals, cases A and B, and one mental health-care organisation, case C, with which the first two link around cognitive impairment of older patients in hospitals). These interviews focused, firstly, upon knowledge brokering of exogenous PSK produced or disseminated by external parties (e.g. in the form of ‘safety alerts’, broadly defined, or best practice guidelines) into clinical practice, by H-MLMs who are members of the CRC within a hospital. Then, secondly, we analysed the brokering of exogenous PSK from the CRC to the clinical front line. This provided an illuminating counterpoint to the expectations and perceptions of those producing and disseminating external evidence, who are interviewed in work package 1. Work package 2 examines, in detail, the social structures that impact upon knowledge-brokering roles.

We employed SNA to help us to identify key knowledge brokers and their characteristics. However, while our preliminary SNA data concur with our qualitative data in highlighting H-MLMs as key knowledge brokers, we found the ‘network’ to be very difficult to define. Questions about structural relations in the brokering of PSK yielded a range of answers regarding who was encompassed within the elderly care pathway through which PSK was brokered, commonly veering between ‘everyone’ and ‘no one’. While we do not present a specific SNA within this report, given the difficulties of defining any network in relation to PSK, our more qualitative assessment of the network following SNA, applied to interview transcripts, informs our analysis of relationships between H-MLMs at different levels within the organisation, and between H-MLMs and other actors within our hospital cases, and outside to external producers of PSK.

Supplementing interviews and SNA, we carried out observation of the CRC, and other relevant committees, such as the Inpatient Falls Committee (IPFC) and the Falls Operational Group, in hospital A. This amounted to approximately 20 hours’ observation of discussions related to PSK in elderly care, and helped to contextualise our research analysis.

Work package 3

Work package 3 focused upon the brokering of bottom-up or endogenous PSK. We traced knowledge brokering from serious untoward incidents (SUIs) related to falls, medication management and/or transition that resulted in unexpected patient harm (or death), anticipating that learning and quality improvement ensues. Recognising the importance of this work, one case study organisation, hospital A, requested an evaluation of the effectiveness of root cause analysis (RCA: a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened22) as a vehicle for learning and service improvement from patient safety incidents. Subsequently, the research team were asked to conduct focus groups with wards in order to work through problems and devise a plan for improvement. Work package 3 was consequently modified to involve more junior members of clinical staff located closer to clinical practice than participants in work packages 1 and 2 – i.e. registered and non-registered nurses, ward managers, matrons and junior doctors – in order to evaluate whether or not knowledge had been brokered to the clinical front line following a patient safety incident. Data collected in work package 3 provided a valuable insight into the importance of knowledge brokering to facilitate learning from endogenous PSK directly back to the ward where the incident occurred, and the challenge of brokering such knowledge upwards (and across) for wider learning across the hospital and to linked health and social care providers. Following this work, the research team conducted an evaluation of learning and service improvement from SUIs following RCA in a second case study organisation, hospital Z. This second evaluation allowed the research team to consider the generalisability of emergent research findings at hospital A about the brokering of PSK from RCAs for learning and service improvement in elderly care. Within work package 3, 56 interviews were conducted in total, supported by approximately 20 hours of observation of the day-to-day running of the wards and departments related to the SUI.

Middle management and the NHS

The efficiency drive to target MLMs has continued to escalate, with the current coalition government (elected in 2010) pledging a reduction in management costs in the English NHS by more than 45% by 2014. This drive to reduce management costs is reflected in recent figures published by the NHS Information Centre (March 2011), which highlights a decrease in the number of managers and senior managers by 6.2% between September 2009 and September 2010, alongside an overall expansion in the size of the workforce during this time. In their report to the King’s Fund, Walshe and Smith68 suggest that the widely professed rise of bureaucracy may actually be exaggerated. Their report concludes that ‘There is no persuasive evidence that the NHS is over-managed, and a good deal of evidence that it may be under-managed’ (p. vii). Further, they caution policy-makers: ‘the denigration of managers and the role they play in delivering high-quality health care will be damaging to the NHS and to patient care in the short and long term’ (p. vii).

Reflecting the bifurcated debate in generic literature, in the English NHS the attack on the utility of the MLM goes hand in hand with policy drives to reduce organisational costs. 10 We highlight that the justification for reducing the numbers of MLMs appears emotive, linking a strong emblematic association of the NHS with national values, and a need to reduce management costs and distribute savings to safeguard frontline care. 69 Provocative and captivating headlines in the popular press expose the evocative language employed by high-profile politicians in their efforts to reduce the numbers of MLMs in health care. 68 Disparaging terms have emerged to describe MLMs in health care within daily printed media and online communities, such as ‘faceless bureaucrats’, ‘idle pen pushers’ and ‘men in grey suits’. The depth of negative feeling about MLMs in health care is evidenced in the use of satirical language; for example, see ‘nhsmanagerturnedtrader.blogspot.com’ (last accessed 21 March 2013), describing one ex-NHS manager’s journey from ‘faceless bureaucrat to bad-assed trader’ [sic], and the ‘idlepenpusher.blogspot.com’, where the writer describes himself as ‘a public sector nobody’.

At the same time, from a strategic perspective, reflecting the more generic literature, arguments that MLMs should be delayered in health care lack an empirical evidence base. Rather, it may be that an enhanced role for MLMs is required. Developing this line of argument further, we now review the strategic management literature in line with a reconceptualisation of the MLM role as strategic. Our assertion is that MLMs, specifically H-MLMs, are central to the brokerage of PSK, meaning that they play a crucial role in enhancing service quality.

The knowledge-based view and the strategic role of the middle-level manager

Grant13 argues that organisations exist because they are more efficient at integrating and applying specialised knowledge than markets are. The KBV of the firm is an innovation within the resource-based view (RBV) of the firm. 13,79–81 Underpinning KBV is an assumption that knowledge is the most important resource of any organisation and, thus, strategy should be concerned with the development, protection and transfer of knowledge. 77,78 In many ways, KBV, with its emphasis on knowledge development and transfer, may be thought of as the link between the traditional static conceptualisation of the RBV and more recent developments surrounding dynamic capabilities theory,82 combinative capabilities83 and absorptive capacity. 84 As such, KBV suggests a significant role for MLMs in the management of an organisation’s knowledge for improving quality through the successful transformation of new knowledge for service improvement. To explain, MLMs, given a set of knowledge resources, play an important brokering role in understanding the functionality of the knowledge (i.e. for what purposes knowledge may be used) and how they can match the knowledge to potential opportunities. In doing so, ‘knowledge broker’ MLMs bridge multiple domains, learn about the knowledge resources within those domains, link that knowledge to new situations, and finally build new networks around the innovations that emerge from the process. To emphasise, a knowledge broker is defined as an individual who uses their in-between vantage position to support innovation through connecting, recombining and transferring to new contexts otherwise disconnected pools of ideas, i.e. they get the right knowledge into the right hands, at the right time. 3,4

The hybrid middle-level manager

Strategic management literature argues that MLMs are well placed as knowledge brokers because they provide a unique ‘linking pin’ between operational and strategic contexts and are capable of shaping strategic change. 23 Particularly where they have a relevant professional background, MLMs act as ‘hybrid’ managers10,29 who can bridge managerial and clinical contexts, i.e. some MLMs may be better placed than others to enact a strategic knowledge-brokering role. 85 ‘Hybrid’ refers to MLMs who are skilled in an alternative profession, hereafter referred to as ‘H-MLMs’. Llewellyn6 describes the hybrid concept using a metaphor of a ‘two-way window’. In the context of health care, for example, H-MLMs with a clinical background act as ‘mediating persons’ capable of working through sets of ideas belonging to management and sets of ideas belonging to clinical practice. 6 This dual sense-making activity requires skills of ‘discursive competence’,86 described as the ability to ‘perform the conversation’ and ‘set the scene’, skills which Rouleau and Balogun86 assert go beyond the capacity to speak the right words to the right people, additionally involving the use of language to trigger linkages and build acceptance of their position among others.

The two-way window implies greater communication between clinical practice and management, which were previously opaque to each other, i.e. constituted as one-way windows. On the basis that there are now both people and organisational tasks that cross the boundary between clinical practice and management, management within health care is no longer about ‘oiling the wheels’. 87 Instead, management represents an organisational arena where difficult and contentious clinical management decisions are required, which H-MLMs are well placed to make. H-MLMs command credibility within their clinical communities and, thus, enjoy a legitimacy to broker knowledge within health-care organisations – more so than their generalist counterparts – and, further, have a zeal for service improvement. 24,88,89

In health care, professionals value and pursue local and tacit knowledge in making clinical decisions about patient care. Indeed, clinical professionals may privilege more contextualised knowledge over and above knowledge which is explicitly presented and accessible to the whole health-care community, a phenomenon that Gabbay and Le May20 have termed ‘mindlines, not guidelines’. Consequently, any attempt at managing professionalised and tacit knowledge in health care through the mobilisation of explicit and codified knowledge faces significant challenge. 21,22 The significance of tacit knowledge in the professionalised setting of health care leads us to assert that IT is unlikely to supplant the role of the H-MLM. We posit that the strategic role of the H-MLM lies in his or her ability to look through a ‘two-way window’, to ‘broker’ tacit, as well as explicit, clinical and managerial knowledge domains for service improvement. 4–6,19,30,90 Conceptually, based on the extant literature, we characterise the potential knowledge-brokering role of the H-MLM in relation to PSK for service improvement in the following way. Firstly, H-MLMs are able to broker exogenous knowledge ‘downwards’ from external producers and disseminators of evidence, for example, in England, from NPSA ‘safety alerts’. Secondly, H-MLMs are able to broker endogenous knowledge ‘upwards’ from the clinical front line to inform learning and improvement at a systems level, for example through incident reporting and investigation. 9 Thirdly, H-MLMs who hold responsibility for clinical service delivery span the boundary between managerial structures for brokering PSK, such as clinical governance committees and frontline clinical practice. Thus, they are uniquely positioned to fuse their understanding of local context (endogenous knowledge) with the more generic evidence base that constitutes exogenous knowledge, so as to ensure continuous development and implementation of high-quality service delivery that is patient-safe. Fourthly, H-MLMs can effectively broker knowledge across organisations, as well as within organisations, where they interact with the environment.

Having reviewed at length the literature with regards to the strategic role of the H-MLM, we now turn to a more nuanced discussion related to the range of knowledge-brokering roles enacted by the H-MLM.

Knowledge brokering literature and health care

Literature about knowledge brokering in health care resonates with strategic management literature, in emphasising the potential for MLMs to add significant value to organisations. 3,36,95–103 However, we suggest that the literature about knowledge brokering in health care is relatively normative regarding the role of MLMs. Further, it focuses mostly on external knowledge brokering (i.e. between research and practice), suggesting that health services are not very well organised or receptive to the application of exogenous knowledge for service development. 101 While this is relevant for our study, we highlight that brokering of endogenous knowledge remains under-researched, yet crucial where evidence is ‘complex’, i.e. not easily codified. Furthermore, the political dimension of knowledge brokering remains relatively unexplored, with a particular need to understand knowledge brokers’ legitimacy claim to carry out their activity, and also how others respond to brokerage activity, i.e. to shut it down where their interests are threatened. 85

In the next section, we build upon The hybrid middle-level manager in our discussion of the nature of knowledge and how this relates to the brokerage of PSK in the NHS.

Mobilising patient safety knowledge across the NHS

Reflecting the competing views of knowledge, as above, which coexist in health care, the problem of mobilising knowledge in this environment can also be conceptualised as one of two extremes. At one end, there exists a professionalised body of knowledge that develops increasing degrees of tacitness over time. This knowledge is localised, specialised and closely guarded within professions. 108 At the other extreme, there is a body of explicit knowledge, commonly presented as formal evidence, which is vast, expanding at a phenomenal rate and is ubiquitously accessible. 21 A literature review of knowledge management in health care by Nicolini et al. 21 finds that the highly fragmented and dispersed nature of clinically related knowledge lends itself well to electronic storage and retrieval to support the clinical decision-making process. The use of IT-based tools is considered important to enable health-care clinicians to access the vast array of scientific knowledge that is relevant to managing their practices and delivering quality of care to patients. 105 Perhaps paradoxically, the extant literature also portrays compelling evidence that professionals value and pursue local and tacit knowledge in making clinical decisions about patient care (e.g. Gabbay and Le May20). One might conclude that any attempt at brokering professionalised and tacit knowledge in health care through its conversion into explicit and codified knowledge is unlikely to succeed. 21 Overall, managing knowledge at the extremes is wrought with difficulty. Knowledge that is tacit-dominant tends to remain isolated in select circles with knowledge brokering ‘retarded’. 109 Knowledge that is explicit-dominant tends to be too voluminous, and so, despite its universal accessibility, the ability to first identify such knowledge and then broker it to the right person(s) in order to impact service is a formidable challenge.

The following section outlines two approaches to brokering knowledge across health-care organisations, which highlight this challenge. The first represents a structural solution designed to extract and codify ‘situated’ PSK (i.e. embedded in context) from individual health-care organisations in order to generate new PSK that is then brokered back to hospital organisations as ‘safety alerts’, usually prescribing remedial action regarding a patient safety issue. It exemplifies the challenge of pulling endogenous PSK upwards through a health-care system and converting this to exogenous PSK, which is then pushed back into health-care organisations for service improvement. The other approach is a much more informal arrangement, whereby tacit or endogenous knowledge is shared within CoPs110,111 to inform ongoing service improvement locally, but which remains insulated from other parts of the health-care organisation and system.

National Reporting and Learning System: a national approach to brokering knowledge across occupational and organisational boundaries

Following the publication of the Department of Health’s report entitled An organisation with a memory,2 in which it was estimated that around 10% of hospital admissions lead to the occurrence of an adverse event, i.e. unintended harm or near harm, a NRLS was implemented in England and Wales. The NRLS comprises a dedicated system for incident reporting throughout the health service. NRLS requires frontline clinicians to systematically report patient safety incidents (or near incidents) that they have experienced in order to generate national guidance and learning in the form of patient safety alerts. Patient safety alerts are issued to all NHS Trusts and are received through a central alert system, i.e. they represent exogenous sources of PSK for learning and service action to improve patient safety. Trusts are duly required to respond to alerts and to indicate when they have completed the actions required, or else to confirm that no action is required.

After a decade of incident reporting in England and Wales through the NRLS, the increasing number of incidents reported year on year by hospitals, and by other health-care providers, suggests that a responsible culture of incident reporting is being cultivated in the NHS England and Wales. Correspondingly, empirical research by Sheldon112 and Lankshear et al. 113 suggests that hospitals and other health-care providers are willing to follow guidance of this type. However, Lankshear et al. 113 find that, while health-care providers in the NHS England and Wales have succeeded in setting up systems to disseminate alerts to MLMs, implementation of recommendations by doctors is suboptimal. In a later study, the same authors found that medical directors were much less likely to be aware of medication-related alerts and rapid response reports (RRRs) than their nursing and clinical governance colleagues. Furthermore, around half of health-care providers in the NHS England and Wales reportedly struggle to communicate effectively and reliably with their junior doctors. 114,115 Such research raises questions about the efficacy of a national agency that systematically codifies knowledge from patient safety incidents across the NHS for transfer into practice and, correspondingly, the ability of MLMs to broker patient safety knowledge effectively to inform service action or influence strategy.

In summary, the NRLS comprises a dedicated system for incident reporting throughout NHS England and Wales, which requires frontline clinicians to systematically report patient safety incidents (or near incidents) that they have experienced. NRLS pulls endogenous and tacit-dominant PSK from the clinical front line as a basis for generating exogenous sources of PSK for brokerage across NHS England and Wales as a whole. It represents an approach that attempts to convert tacit knowledge into explicit for durable improvements for patient safety.

Conceptually, the efficacy of the NRLS as a vehicle for brokering PSK is challenged on the basis that the system is founded on a number of assumptions that violate both the nature of knowledge and the nuances of a professionalised context. For example, the first assumption is that incident-related PSK can be meaningful when codified and extracted from nuances of context. Second, that risk is a unified concept shared across professional occupations. Third, there is a misperception that doctors are amenable to being managed (and conceivably monitored) in a technocratic and managerial manner. 7,9,116,117 Waring and Currie9 subsequently report the unintended consequences of this approach as the strengthening (or blurring) of professional and managerial boundaries, as doctors seek to circumvent the NRLS through offering bespoke situated responses, which begin to cohere around a CoP110,111 and which limit management control over knowledge and reinforce claims to medical autonomy.

Communities of practice

Dopson and Fitzgerald88 are not entirely positive regarding the effects of CoPs upon knowledge brokering. The authors emphasise that professionalised contexts, such as health care, have differentiated knowledge domains, which are decoupled, and that this inhibits knowledge brokering. 85,88,109 So, there exist uniprofessional communities, which are self-sealing and highly institutionalised. These shut out neighbouring communities, and defend their professional jurisdiction, so creating a ‘cognitive lock-in’ to members of that community, and community ‘lock out’ to non-members. 85,88 In short, the challenge remains to join up self-sealing CoPs, so that a community of practitioners or interest is developed.

Oborn and Dawson118 offer a more optimistic view of the ability of CoPs to broker knowledge in a specialist health-care setting, where they encompass multidisciplinary activity. The authors initially observe the type of barriers to knowledge brokering typically associated with CoP, as outlined by Dopson and Fitzgerald. 88 However, they assert that the ability to broker knowledge across CoPs was gradually learned. Such learning was assisted by the development of boundary objects and processes such as the use of ‘ambassadorial’ brokers, who facilitated ‘a level of transparency into the knowledge held by the various CoPs’ (p. 853), enabling others to make sense and personalise the knowledge presented by the various CoPs.

In essence, Oborn and Dawson118 echo the knowledge-brokering role of the H-MLM as described earlier (see The hybrid middle-level manager). The ability of the H-MLM to broker clinical and managerial knowledge domains for service improvement is afforded not just by their epistemic ‘two-way’ window, but also in their ability to conjure credibility and legitimacy among others for their role to fuse knowledge from multiple perspectives in a multidisciplinary clinical setting.

To reiterate the value of two approaches to brokering knowledge, those that assume an objective view of knowledge, such as the NRLS, appear insufficiently contextualised. 9 Meanwhile, those assuming a subjective view of knowledge, such as CoPs, may suffer from ‘cognitive lock-in’ and the potential isolation of members from other knowledge perspectives. 88 Both approaches may be deficient, with potentially significant implications for the quality of care to service users and, ultimately, the long-term sustainability of the organisation, unless H-MLMs play a knowledge brokering role.

Our next section builds upon the KBV of the firm to explore literature relating to ‘combinative capabilities’. We consider how brokering of knowledge by H-MLMs is framed by the organisation’s ability to process knowledge for service improvement. Our focus upon combinative capabilities allows us to surface features of organisational context and its environment that represent contingencies that frame H-MLM’s knowledge brokering.

Work package 1 (17 interviews)

Work package 1 was particularly concerned to identify what PSK was generated and disseminated by external stakeholders and their expectations and perceptions of how that knowledge was brokered and by whom, thus linking to RQ1, RQ3 and RQ4. We also asked respondents in work package 1 about their perceptions of the contingencies of the knowledge-brokering process, i.e. what (do you perceive) are the limiting and facilitating contextual features for H-MLM knowledge brokering, and how can H-MLMs be enabled to broker PSK more effectively in older persons’ care? Thus, work package 1 also contributes to RQ6.

We conducted 17 semistructured interviews with external, national- and regional-level producers, disseminators or auditors of PSK around falls, medication and transition, as outlined on our original full proposal. Representatives from the following organisations were interviewed:

• Department of Health (three respondents)

• NPSA (two respondents)

• National Professional Applied Research Network (three respondents)

• strategic health authority (one respondent)

• local government commissioners of health and social care (two respondents)

• Royal College of Nursing Institute (one respondent)

• Age Concern (one respondent)

• university-based health-care professors (four respondents)

• GP representative on regional commissioning and quality structures (one respondent).

To summarise, in the interviews with external stakeholders, our aim was to elicit their expectations and perceptions (expectations and perceptions may differ) of how exogenous knowledge is brokered, and who they perceive is likely to broker knowledge into the local organisation, and onwards to clinical practice.

Work package 2 (54 interviews)

Work package 2 aligns to RQ1–6. We conducted 54 semistructured interviews with H-MLMs, from lower-status MLMs such as ward managers through to more senior MLMs such as directorate managers and patient safety governance managers, in order to examine the brokerage of exogenous and endogenous sources of PSK. These respondents helped us to identify further respondents for interview, based on their knowledge-brokering role within our case-study organisations. These interviews took place across three separate health-care organisations: two hospital trusts (cases A and B) and one mental-health-care provider (case C). We asked what knowledge gets brokered, to whom, how and why. We began by conducting interviews with more senior H-MLMs who are members of the CRC within our case-study hospital organisations in order to ascertain details about the brokering of PSK produced or disseminated by external parties (e.g. in the form of ‘safety alerts’, broadly defined, or best practice guidelines) into clinical practice, and details of endogenous PSK at the clinical front line brokered upwards into the clinical governance system. Table 1 outlines who we interviewed and whether or not they were members of the CRC. Within Table 1, we also identify where H-MLMs were research active (i.e. held a research grant in last 5 years), as well as delivering and managing clinical services.

As a precursor to SNA, we concluded our interviews by asking our respondents to identify who they discussed PSK with, who they sought out to discuss issues in relation to falls, medication and/or transition in relation to the care of older people, and who would come to them for advice or to broker knowledge regarding these issues. Many of our respondents found these questions difficult to answer, with answers frequently veering between ‘everyone’ and ‘no one’. In the light of this, establishing a bounded network was difficult. This data collection did, however, identify exceptional actors and supplemented our qualitative data regarding which H-MLMs broker PSK to influence strategy and service action. We include an illustration of SNA in Appendix 1.

So that readers have some understanding of the relationships across the stakeholders we interview, we direct them to an organogram (Figure 1), which identifies how we conceive the relationship between external stakeholders, H-MLMs in clinical governance structures, such as CRC, those H-MLMs managing service delivery, and the front line of clinical practice, as they relate to older persons’ care in a typical hospital.

FIGURE 1.

An organogram to illustrate relationships between external stakeholders, H-MLMs in governance structures and H-MLMs managing service delivery. NHSLA, NHS Litigation Authority.

Work package 3 (56 interviews)

Work package 3 took place on the ward where the incident occurred to establish whether or not staff were familiar with the incident; how they heard of the incident/from whom; whether or not they were familiar with the action and learning that is connected to the incident in question; and whether or not they knew if the actions had actually taken place. Our interviews were semistructured and took place with ward managers, deputy ward managers, registered nurses and non-registered nurses, who were selected on the basis that they were available on the day we conducted interviews. A total of 21 interviews were conducted at hospital A. Table 2 lists our respondents’ roles at hospital A.

Following analysis of data derived from the interviews described above, we were invited to convene focus groups at the request of one of our respondents (a geriatrician) in hospital A. The focus groups were established with staff working in areas where falls were identified by the organisation as an ongoing problem. Both doctors (e.g. surgeons as well as geriatricians) were invited. The objective was, first, to authenticate our emerging analysis, elaborate upon insights gleaned from fieldwork, and with a view to making practical impact, discussing ongoing (if any) organisational learning and service improvement. As readers might note, despite being invited, most doctors did not attend. As apparent later in empirical presentation, many doctors outside the ranks of geriatricians did not view patient safety related to older persons’ care as relevant for doctors. In total, two doctors and 41 ward managers, matrons and nurses attended four focus groups in July 2013. Our synthesis of outcomes from the focus groups was presented to hospital A in July 2013 (see Appendix 2).

At hospital Z, we studied one SUI involving a medication error, and interviewed 27 respondents working on the acute medical unit (AMU) where the incident occurred. Again, we studied the organisation’s high-level report prior to conducting semistructured interviews with the staff involved, following the same protocol employed at hospital A. A total of 27 interviews were undertaken with staff members in the AMU. The following roles and grades of staff were interviewed:

• three band 8 registered nurses

• three band 7 registered nurses

• three band 6 registered nurses

• eleven band 5 registered nurses

• five band 2 non-registered nurses

• two ‘F1’ doctors.

Within work packages 1 and 2, alongside interviews, our research design involved collecting archival data and observational field notes, in order to triangulate sources of evidence. 136 First, we observed relevant meetings, such as risk and governance committees and action groups (approximately 20 hours in total), concerned with reducing falls amongst frail older people in the hospital, and ward meetings concerned with service improvement for the care of frail older people. In work package 3, a further 20 hours were spent observing wards and departments (total observation = 40 hours). During the observations, the researchers took detailed notes and then wrote up a more expansive commentary post observation, where they reflected on what they had witnessed. The notes were written up on the day of the visit. Where available, we collected minutes of the meetings we observed, and similar meetings that preceded these over the previous 12 months, as well as documents that were submitted to the CRC to transfer data where information related to service quality from subcommittees. Second, we examined relevant government White Papers137 and associated publications (e.g. National Service Framework for Older People,138 Living Well with Dementia139). Third, at the organisational level, we collected strategy papers concerned with quality of care for frail older people and noted real-time data related to service quality at the level of individual wards and departments. In Gephart’s140 terms, we were able to collate ‘a substantial archival residue’ (p. 1469).

A knowledge competition: targets and money versus professional interest

At an individual level, external sources of PSK are considered so profuse that a ‘knowledge competition’ ensues with the individual recipient’s prior knowledge, experiences and special interest as key factors determining what is acquired and assimilated.

The big problem here is, of course, in terms of external guidance. There is simply far too much of it. I couldn’t possibly keep up with everything that NICE puts out. You don’t read every textbook, you don’t read every paper. People talk about the policy environment, but there is also the knowledge environment that it is impacted on by your own thinking, by stuff you come across, by experiences you have . . . it competes with an awful lot of other stuff and you tend to seek out what you are interested in.

Professor H, geriatrician and H-MLM, hospital A

The macro context, however, reveals a wider competition at the organisational level, where the geriatricians in our study perceive a trade-off between ‘risk and safety’ and ‘targets and money’:

There is another sort of competition, or tension, really. We work in an organisation, we work in a structure. The organisation has its policies, procedures, standing orders and so on and so forth. To an extent what we do is governed by that. If they say, ‘You will not use drug X, you will use drug Y, although we are not going to stop drug X’, but the amount of effort it will take to get drug X simply isn’t worth, you know, ‘We are going to do certain things, we are not going to do operations unless you have X, Y and Z, A, B and C signed off’.

Professor H, geriatrician and H-MLM, hospital A

I get an email every few days about how many patients the hospital has discharged and so on. I never get any information about how many times we’ve harmed anyone . . . but what we do have is traffic lights to tell us whether we’ve discharged patients from hospital quickly enough, because the length of stay is what they’re interested in.

Professor G, geriatrician and H-MLM, hospital A

The importance of targets and money has a significant influence upon the role of H-MLMs. H-MLMs operate across two worlds – a managerial world and a clinical world. However, sometimes, the reconciliation of managerial with clinical objectives was regarded as problematic. The following quotations imply a balancing act between clinical goals of quality of care on the one hand, and managerial performance-driven goals on the other, with the latter frequently dominating the former.

In theory, when the modern matron initiative was launched, their objective was to look at quality issues, which is actually my passion. Having said that, once I got into this role, it’s a lot more to do with looking at finance, what your establishments are, what your overheads are, which although interest me, it’s not my passion.

Modern matron, H-MLM, hospital A

My role is the operational and strategic management and development of geriatric medicine and acute stroke services in the Trust . . . targets like infection control, they’re all driven, aren’t they, from a political bent rather than a clinical bent? It’s targets because targets are money. I have a little bit of difficulty with that as a nurse; not as a manager, as a nurse. As a manager, I understand that it creates the internal market because we are a business now, and it doesn’t matter how much we say as an NHS we’re not.

Head of Nursing for Geriatrics, H-MLM, hospital B

You’re not here as a business to make money. Yet finance generally is the first item on the agenda and then everything else follows it.

Patient safety manager, H-MLM, hospital B

Similarly, external producers of PSK perceive the wider problem to be one of ‘prioritisation, not knowledge’ (NPSA, respondent H, external knowledge producer).

Overall, the maxim ‘what gets measured, gets managed’ transpires into performance management rather than knowledge brokerage by H-MLMs with the aim of improving quality of care. This view is supported by a number of interviews with internal users:

There’s a general sort of truism in the NHS, and certainly in this organisation, which is that effectively what gets measured, gets managed. So the things that feature on the Trust Board’s monthly reports are, for example, healthcare associated infections. This has obviously been a massive issue in the NHS for the last number of years. Every month the Trust is seeing real-time data on MRSA infection and C. Diff infection. Because it’s been such a national priority, they take that very seriously. So there are very significant and well-established mechanisms for communicating back into the organisation ‘you must do better’. As a result, the levels of infection rates have steadily declined and, now, we perform very well.

Senior general manager, hospital A

A lot of stuff managers do have often nothing to do with safety or risk at all. They’re mainly charged . . . I mean the managers, you know, all they talk about here is meeting targets and coming in under budget.

Professor G, geriatrician and H-MLM, hospital A

I think the problem is that a lot of knowledge brokering is driven by policy from top-down. People who have influential, managerial capability tend to only work with the agenda that they’re given rather than any other interests about safety issues. For example, a manager may be interested in VTE [venous thromboembolism] about length of stay, but not about inpatient falls because it’s not a clinical agenda that we’ve been asked to deal about . . . because falls is not a big priority at Trust Board level, it’s not driven with the same importance as other issues.

Professor S, geriatrician and H-MLM, hospital A

How the NHS organisation responds to the exogenous patient safety knowledge environment

In both hospital A and hospital B, questions concerning the acquisition of exogenous sources of PSK led to the respondent identifying ‘patient safety’ as ‘someone else’s job’. This ominous and surprisingly frequent response reflects the organisation’s response to exogenous PSK: it is there to be managed. Thus, patient safety is viewed as the role of person X. The following quotes highlight the division between patient safety as understood by senior managers of the organisation and as viewed by H-MLMs and those on the clinical front line.

The medical director’s very clearly identified as the patient safety lead and champion for the organisation. It’s very prominent at the Board, which I think’s always important because effectively it shows that there’s top-level, absolutely top-level commitment to patient safety in the organisation. Where it starts to get more tricky, and I guess which is where your questions kind of come into their own is, at the end of the day there is a bureaucratic process that sits around all of this. Somebody at the Department, or in one of the agencies nationally, writes something and says, ‘Right, this needs to change,’ or ‘This is dangerous,’ or this is whatever, sends it out to the service and in many instances, bureaucratic processes in the NHS are kind of people just go, ‘Oh, another piece of paper. Another instruction, another bit of work to do’. Actually that’s not necessarily a motivating and empowering thing.

Senior general manager, non-hybrid MLM, hospital A

Certainly the Trust governance structure, such as audits, incidents, Clinical Risk Committee, is heavily influenced by government or regulatory/CQC [Care Quality Commission] requirements. They talk about safety and risk, but in clinical practice, safety is seen in a more holistic sense; for example, in assessing cognition and insight, in decision-making, and in day-to-day practice. This involves the whole multidisciplinary team, other doctors, nurses, OTs [occupational therapists] physios, speech therapists, social workers, as well as patients and families.

Professor H, geriatrician and H-MLM, hospital A

Reflecting the comment above, that formal patient safety structures and processes may be fragmented or narrow, respondents with a dedicated role for ‘patient safety’, many of whom carry ‘patient safety’ in their professional title (e.g. the following titles are identified in our data set: ‘patient safety lead’, ‘patient safety manager’, ‘head of patient safety’, ‘clinical quality, risk and safety manager’) are predominantly focused upon outward- and upward-facing governance-based activities and explicit PSK. Examples include the ‘global trigger tool’ (a methodology for sampling patient records to identify harm and the root cause of that harm), submitting and analysing data through systems such as Dr Foster (a provider of health-care information solutions in England, and a joint venture with the Department of Health), Datix (web-based patient safety software for health-care risk management applications, used for submitting and analysing safety incident data) and the NHS Litigation Authority (NHSLA: provides indemnity cover for legal claims against the NHS. Accreditation is correlated to the amount of premium NHS organisations have to pay). However, we note that it seems to have a positive effect upon quality improvement, albeit in a restricted domain.

The number one priority for the Trust at the minute is the financial position. I think the CQC come hotly after that in terms of quality and accreditation visits. For me the other next priority is NHSLA accreditation . . . The other thing I do for the executive medical director is I administer and support him in running a mortality group. So I support him in putting the meetings in, putting the agendas together, getting the data together for Dr Foster from a mortality point of view. So reactively, we look at the areas that are alerting. The other work that we’re doing currently is we’re proactively looking at the areas where we think we should be a bit better, but it’s not actually ‘pinging’ an alert off [via Dr Foster]. So we look at the data. So I prepare the data and present it at those meetings, then we discuss it and we decide who’s going to take it forward, who’s going to do the work around that diagnosis basket. Then I get the data off and my team get the case notes if we want to do a case-note review. So that’s been on-going for a while. So that’s sort of like a patient safety improvement project really, because it pulls out particular diagnosis groups.

Patient safety manager, non-hybrid, hospital B

Patient safety managers in our study represent more senior MLMs than a geriatrician, for example. They report directly to senior governance managers such as the medical director and participate on the CRC. However, they are not necessarily H-MLMs, and may have a generalist rather than a clinical background. These more senior MLMs appear to have limited engagement with the operational front line, typically relying upon others (mostly nurses) to broker strategy ‘down’ through the organisation as liaison knowledge brokers.

When patient safety initiatives come from external sources into the Trust . . . let’s take Safety Express, for example. How do you communicate Safety Express within the Trust? How do make people at the frontline aware of it?

It’s mostly nursing. So we take it down through the operational nursing route through the heads of nursing down onto the main wards.

The governance infrastructure represents the central vein for downwards knowledge brokering. The infrastructure comprises a complex network through which external knowledge should get brokered down and across the whole organisation:

So, in terms of external sources of patient safety knowledge and the elderly, how does knowledge about patient safety get cascaded across the organisation?

The structure we have in terms of a governance structure is probably the main way we do it. So I go to the clinical risk committee normally, and there are other committee meetings that different members of the directorate and the management team go to. So, at the moment in the Trust, there’s the quality and safety operational group and then under that there’s the clinical risk committee, the clinical effectiveness committee and organisation risk committee. So from a Directorate point of view, we have representation on each of those. We have our own directorate governance meeting monthly, which all the speciality leads come to. Then each speciality has their own governance meeting. So healthcare of the older person speciality will be coming to that and they have their own governance meeting. So, in terms of spreading information about patient safety, that’s probably the structure we have to do it.

Our data highlight how exogenous sources of PSK are brokered downwards by nursing professionals enacting H-MLM roles as part of a hierarchical infrastructure that forms a tightly linked chain. However, their role does not extend to brokering knowledge across the medical ‘side’ of the organisation, i.e. external sources of PSK are considered more challenging to broker across to medical professions by nurses due to the latter’s subordinate status to the former.

There are very different structures between the medical and nursing side. I’m much, much more reassured that if I had an important message, I can cascade it through the nursing side. I’m less confident that I would cascade it effectively through the medical side. That’s why many of those communications come with my name or the medical director’s name on it just to give it a little bit more impetus when it’s being progressed through the Trust.

Head of CRC, senior H-MLM, hospital A

The difference between nurses and doctors is, with nurses you can lead them, you can make them do it if you want. It’s not my style, but you can. Nursing is very hierarchical and if I say ‘jump’. . . I wouldn’t want to, but people could say ‘how high?’ You can influence. It’s not the right way, but you can. That’s renowned in nursing. You can’t do that with medics. They’re seen very much as individual, professional, very senior experts and you have to therefore use different tactics.

Director of Nursing, senior H-MLM, hospital B

In terms of fusing exogenous PSK with endogenous PSK, there appears little upwards flow of PSK to those who undertake a ‘patient safety manager’ role. Respondents in two of our case-study organisations suggested that the patient safety role is significantly under-resourced. This limits their ability to fuse of endogenous PSK with exogenous sources, as they are required to focus on the outward-facing priorities of the organisation, i.e. to evidence performance to external regulators.

My substantive post is patient safety manager, but I’m actually doing three jobs at the moment because of the way that the NHS is in saving money. I’m managing the research staff. I’m managing the clinical audit staff, the clinical effectiveness staff, the risk management staff. We haven’t got a clinical risk manager in post, so I’m picking that up as well. I’m driving NHSLA as part of that. I’m being pulled into gathering evidence for CQC compliance visits. I’m also the lead for emergency planning.

Patient safety manager, non-hybrid MLM, hospital B

Do you see yourself as able to influence the executive team in terms of their understanding of risk and how they perceive it?

Only responding to their concerns, so it is reactive rather than proactive at the moment. I do think the Trust could invest more in their own risk management team at corporate level. They are a very, very, small team which tells me a lot about the organisation and how they view risk and its importance. We did have a Risk M for the organisation that has got 7000 staff and God knows how many patients. That is a huge job for one person. I think that speaks volumes. They expect it to be done but I think they need to invest at Trust level a bit more and they need bums on seats to get work done and to raise awareness.

In hospital A, one patient safety manager’s previous nursing role allows her to span the boundary between senior management and the operational levels of the organisation. She was thus able to broker exogenous PSK that is fused with endogenous knowledge, in order to implement strategy:

People will regularly ring me and say, ‘Something’s happened. I need to talk to you about it.’ I kind of supervise and manage people with their investigations into serious incidents and high-level incidents. You will have heard my name kind of round and about because people will go, ‘I’ll just ask [Patient Safety Manager W] about that.’ So they’ll just say, ‘I’ve had this thing happen. Can I just tell you about it?’

Patient safety manager W, H-MLM, hospital A

However, organisational priorities have led to the distancing of this hybrid patient safety manager from endogenous sources of PSK knowledge, in order to focus upon outward-looking data for the NHSLA. NHSLA are insurers for NHS organisations, paying all of the Trust’s litigations, and the Trust pays them a premium in return. What ‘level’ of risk the Trust is judged to be at by the NHSLA determines the discount they get:

My big corporate role is to look after the Clinical Risk Committee. My other corporate role is I look after on-line incident reporting. So, for clinical incidents, we generally look after a couple of directorates each and we provide governance support to the directorates and then we have a couple of committees. Now I used to support the Falls Committee [IPFC] and the Transfusion Committee. Currently I’m not, because I’ve been taken out of some of my work to concentrate on NHSLA.

Patient safety manager W, senior H-MLM, hospital A

Summary of section

Data presented in this section have highlighted the distinction between the organisation’s view of PSK as something explicit, that must be managed and complied with, and the more abstracted clinical professional view of PSK as ‘implicit in everything we do’. Consequently, the NHS organisation’s response is to build systems and infrastructure in order to manage PSK and demonstrate compliance externally. However, we find that PSK from exogenous sources is not brokered ‘down’ or ‘across’ the organisation – the exception being national patient safety initiatives that are nursing orientated, which are ‘pushed’ down the nursing hierarchy in a tightly linked broker chain from senior nurse manager to matron, then on to the ward manager and finally to the ward.

In terms of brokering PSK more generally, we find that patient safety managers (including those with a clinical background) are not likely to be as clinically engaged as we might expect, because their priorities are shaped by external influences in the form of targets and money. Patient safety managers are unlikely to enact a downwards knowledge-brokering role, as their primary concern is to satisfy external regulators, by evidencing performance and compliance through policies, protocols and procedures. Thus, unlike the linked ‘broker chain’ that characterises the nursing profession, we evidence broken linkages between more senior hybrid managers and the clinical front line.

Hybrid middle-level managers maintaining close allegiance to their profession (e.g. heads of nursing, matrons and geriatricians), continuing to deliver aspects of a clinical role and remaining in clinical-facing positions (i.e. they interact with medical and nursing staff) perceive two separate but interdependent worlds: a managerial world that is orientated towards targets and money, and a clinical world which is focused on patient care.

Summary of section

Information technology is shown to be a valuable tool for enabling H-MLMs to identify and pull exogenous sources of PSK that are operationally relevant, and to broker knowledge within their professional groups. In particular, our data suggest that more junior H-MLMs use IT to ‘pull’ exogenous sources of PSK that are relevant to their clinical work on an ‘as and when needed’ basis, while more senior H-MLMs develop their own systems to automatically scan the exogenous environment PSK according to their individual knowledge interests, and then broker that knowledge across to their subordinate peers. We highlight in this section that H-MLMs, who are predominantly clinical facing, broker PSK to more junior counterparts on an ‘as and when’ basis, and via a teaching model, i.e. they adopt a gatekeeping role, navigating the profuse exogenous knowledge environment, sifting through evidence and sharing what they deem as relevant within their professional cohorts.

Our next section builds upon the first to examine in greater detail the influence of context upon the brokerage of exogenous PSK, and how the organisation transforms and exploits exogenous sources of PSK for organisational learning and service improvement. To frame contextual influences, we structure our findings around combinative capabilities83 to further examine the ‘how’ and ‘why’ (or ‘why not’) of knowledge brokerage relating to exogenous PSK.

System capabilities

Aligned to the literature, our data highlight the influence of government policy upon performance management. Specifically, we highlight emphasis upon financial incentives and targets in those performance systems imposed upon health-care organisations, i.e. these shape systems capabilities in a health-care organisation. As one geriatrician complained, ‘Important areas of risk and safety for elderly care have to fight against things which are far bigger – targets and money’ (geriatrician G, H-MLM, hospital A). This argument is supported by an ‘admission’ from one (non-hybrid) member of hospital A’s executive board that ‘what gets measured gets managed’. Consequently, the health-care organisation designs system capabilities to evidence compliance. The following quotes demonstrate the dominant influence of performance management and financial incentives as antecedents to the design of systems capabilities, and the impact of this influence on the acquisition of new PSK:

If the hospital stands to lose money either directly or indirectly as a consequence of compliance, then you comply.

Director of Strategy, non-hybrid senior manager, hospital A

Sometimes the order and the priority in which that [service action] has come about have been rather skewed by some of the financial targets.

Geriatrician G, H-MLM, hospital A

The knowledge that organisations seek becomes limited to:

How do you do it? How do you shunt them? What do you do? How do you get round this problem? That was the knowledge they [executive management] wanted, not safety knowledge. Because they want to hit our targets and get money and don’t want to be penalised.

Geriatrician G, H-MLM, hospital A

To emphasise, systems capabilities are shaped by ‘political’ incentives, with proof of compliance as the organisation’s priority, as opposed to the pursuit of quality improvement:

If the government says, ‘You’ll treat everybody within 18 weeks’, then you create an industry that makes sure that not only do you treat them within 18 weeks, but you can demonstrate that you treated them within 18 weeks . . . everybody’s running around making a computer system that can record and demonstrate it.

Director of Strategy, non-hybrid senior manager, hospital A

Aligned to this, our data suggest that an organisational focus upon compliance deflects some (more senior and managerial facing) MLMs away from brokering PSK for service improvement in favour of outward-facing activity to evidence performance, to satisfy regulators and, at the same time, reduce the financial costs of the organisation. As discussed in Chapter 5 (see Power differentials impact the brokerage of patient safety knowledge), we see that respondents with a dedicated role for ‘patient safety’ in particular, many of whom carry ‘patient safety’ in their professional title (e.g. patient safety lead, patient safety manager, head of patient safety) are predominantly focused upon a myriad of outward- and upward-facing governance-based activities.

The clinical effectiveness locomotive is so enormous, and is so worked up that it predominates above and beyond anything relating to patient safety, anything about the patient experience.

Geriatrician R, H-MLM, hospital B

Our data suggest that systems capabilities neglect the brokerage of PSK downwards and across the organisation for service action. To further evidence this, we use the example of a patient safety ‘alert’ released by the NPSA to signal action to prevent inpatient falls. The following excerpt describes the implementation of the NPSA bed-rails safer-practice policy that made recommendations for preventing falls within a health-care setting during 2007. Only half of hospitals in England adopted the recommendations, and so in January 2011 a RRR was issued, which dictated that all hospitals in England must have implemented a bed-rails policy by July 2011. Following the deadline for the RRR, all hospitals in England signalled compliance, i.e. they formally confirmed that they had devised a policy to explicitly describe the use of bed-rails. However, an automatically generated news feed set up by one of our respondents (a representative of NPSA), via Google, identified a patient death following a fall at a hospital where it was revealed that no policy was actually in existence, despite the hospital signalling its compliance:

I keep a Google alert for bed rails, which brings up inquests. On paper, every Trust in the country is compliant with bed rail policy . . . [but] an elderly lady falls out of a bed in August in a hospital where nothing was documented on bed rails, no policy on bed rails, no documentation format to prompt the nurses to think about whether bed rails are good or not, no observation after she hits her head.

NPSA H, external body

In the above example, we see that a formalised process (a ‘systems capability’) to demonstrate ‘compliance’ did not result in PSK being brokered to the frontline to improve patient safety. Thus, while we identify external political pressure and targets as primary antecedents of systems capabilities, we highlight that such systems capabilities are designed to react to external regulators with the aim of compliance, and not with the intention of brokering PSK to the front line for service improvement. The following quote from a chief hospital pharmacist (H-MLM) supports this.

I am going to have to write a guideline that I put on the intranet that says, ‘When you give medicines we are supposed to do this,’ which will make no difference at all, I can meet the requirement it is not a problem, [but] it is not worth doing.

Pharmacist, H-MLM, member of National Professional Applied Research Network, external body

Conversely, and reflecting a more positive effect of performance management policy, we find that exogenous sources of PSK linked to financial incentives can represent a lever for more powerful health-care professionals, such as doctors, to galvanise the organisation towards service action and innovation beyond the pursuit of compliance. Financial incentives emerge from our empirical data as a potential ‘co-ordination capability’ that can successfully mediate between externally orientated managerial goals, as dictated by the external political environment, and internally orientated clinical goals as derived from practice. One example of this professional ‘lever’ in action is the Commissioning for Quality and Innovation (CQUIN) payment framework. This framework enables commissioners to reward excellence by linking a proportion of the providers’ income to the achievement of local quality improvement goals. In short, CQUINs combine target-based incentives that secure the attention of managers at the top of a health-care organisation, while providing the resources and incentive for professions to acquire and transform new PSK for quality improvement at the front line.

We will put a CQUIN in that says you have got to do it better and there is money if you do it better, and then of course you galvanise an organisation to do it better because there is money behind it.

Pharmacist, H-MLM, member of National Professional Applied Research Network, external body

The external drivers are all pretty much financial pressures that we are feeling as a trust . . . but also there is a pot of money to work with. So the right drivers are in there.

Geriatrician H, H-MLM, hospital A

The critical role of financial incentives to mediate between the top-down, externally orientated goals of the organisation, which are driven by policy, and bottom-up, professional clinical goals, is further demonstrated in the example of the National Dementia Strategy. 139 In implementing the National Dementia Strategy, the Department of Health held a substantial consultation process across 2 years, holding over 50 stakeholder events attended by 4000 individuals. The draft strategy was reportedly ‘very well received by the public and professionals alike . . . the recommendations it set out were seen as being the right ones if dementia services are to fully meet the needs of people with dementia and their carers’ (p. 11). 139 However, the ability of the National Dementia Strategy to transform PSK into service action was reportedly hampered by a lack of financial incentive. One respondent, a commissioner of care services for older people, recalls the arrival of the National Dementia Strategy as a ‘damp squib’:

There was an expectation that the dementia strategy was going to revolutionise care for older people with dementia. Then, when it happened, there was no money attached to it really because the economic situation had changed practically overnight.

Commissioner, local authority, external body

In summary, our findings suggest that systems capabilities of health-care organisations are predominantly shaped by the external operating environment, in particular performance measures and targets. MLMs, who undertake a predominantly managerial role (regardless of hybrid status), are compelled to develop systems capabilities to evidence compliance, rather than brokering PSK downwards and across the organisation for improving the quality of care. Our data present evidence that systems capabilities in isolation do not broker PSK effectively to the operational front line for service action. Ultimately, our data imply that, at a managerial level, evidencing compliance is perceived to be more pertinent than brokering PSK for service improvement at the front line. On a more positive note, financial incentives that can be leveraged by those who make up the professional core of the organisation emerge as an important co-ordinating capability for the brokerage of exogenous PSK for improving patient safety in elderly care.

Socialisation capabilities

In the first section, and aligned to the sociology of professions literature, we evidence the role of status and power as a continuing and pre-eminent characteristic of medical and surgical professions that governs an individual’s legitimacy to broker knowledge. Our data suggest that junior doctors and nurses are socialised into the behaviours of their respective professions early on in their careers, which negatively impacts the ability of PSK to reach the clinical front line and improve practice. The following example describes a F2 (second-year graduate) junior doctor training event, where junior doctors were discouraged by their more senior counterparts from reporting PSK, arising from adverse events:

Hands up who’s made a report last year of any adverse event – that is, you know, a near miss or an actual harm event. How many put their hands up? It was extraordinary – none. It’s worse than you can think and one of them said in their hospital they were told, ‘Don’t bother your barney.’

Geriatrician M, H-MLM, hospital A

The following excerpt from interview highlights the preservation of professional silos through the shaping of socialisation capabilities, prior to professional registration, as part of professional education and training:

Classically, the relationship that’s most fundamental in the NHS, is the consultant’s relationship with everybody else. They decide what happens or, as you heard [the clinical manager] say off-line, if the consultants aren’t behind the clinical manager who’s a medic, then what she’s trying to do will just fall apart. Too often, consultants have been allowed to destroy or break up or compromise change for petty or non-petty reasons. So I think in our institution our belief is having co-location will break down the tension that exists in all hospitals between doctors and nurses. I think in our hospital there’s now a strong tension, but a healthy one, between doctors and nurses as professional groups. We should all be one team and I myself say this phrase, ‘One team’. We’re in it together. [But regardless,] people will view their professional identity in their own vision. So a nurse will have the right to question a consultant. Of course their professional society, their training, their education, their ethical duty is to ensure that, but lots of nurses don’t do that. They don’t feel able to do it and they don’t feel empowered to because of that mainly hierarchical structure. I mean you won’t get rid of hierarchy overnight, but having one team’s very good.

Geriatrician K, H-MLM, hospital A

The above respondent implies that a multidisciplinary approach, working across professions as ‘one team’, is continually impeded by the organisational structure, which is shaped by power and status. In our empirical case study, a hierarchical infrastructure is the health-care organisation’s formal ‘co-ordination capability’ for brokering knowledge across the organisation. Health-care organisations typically operate via an infrastructure comprising a myriad of committees, each reporting into a clinical risk committee and/or a clinical effectiveness committee. A committee infrastructure may act as a conduit for the brokering of PSK from external sources into the organisation. However, the effectiveness of such committees, in terms of acquiring and mobilising new external knowledge, depends on the linkages with members of the organisation who are located outside of the committee infrastructure:

You can have a committee with no local advocates – it doesn’t work. You can have people with a great interest, but no support in the local committee or in the infrastructure – that doesn’t work. You need local advocates outside the committee working with the committee, being empowered by the committee, but the advocates go at a fairly, you know, front-end level – talk to people, raise awareness. You can’t just do it with e-mails.

NPSA, C, external body

Legitimacy to broker knowledge does not necessarily go hand in hand with a position on a committee, particularly within medical and surgical professions. In hospital A, the chair of the CRC, a hybrid senior manager, observed a distinction between the organisation’s ability to cascade new knowledge through the ‘nursing side’, where hierarchy imparts power and status and a tightly linked broker chain ensues, and the ‘medical side’, where hierarchy is more ambiguous and knowledge brokerage is impeded:

If you were to look at a Directorate which has a clinical lead, every nurse in that directorate will in some way be in a structure which is below that clinical lead – either near the top of the structure or near the bottom of the structure, it doesn’t matter. There will be a pathway through that lead. In medical staff that is not the case because there’s not that recognised hierarchy that the heads of service are some way superior . . . they’re seen as equals. One of them happens to be head of service, but in no way are they in an elevated position. So that makes it complex.

Surgeon A, hybrid senior manager, hospital A

Thus, the intraprofessional hierarchy of the nursing profession supports the downward brokerage of PSK into service action. We see this in the successful implementation of numerous nurse-led interventions to improve patient safety in hospitals; for example, reducing health-care-acquired infections, reducing pressure ulcers, implementing ‘patient safety express’ [Safety Express is the name of the QIPP (Quality, Innovation, Productivity and Prevention) Safe Care work stream test pilot programme which ran in 2011], ‘care round the clock’ (an implementation of hourly ward rounds based on a US model by hospital A) and the ‘productive ward’ (Productive Ward is a national initiative developed by the NHS Institute for Innovation and Improvement, designed to improve the efficiency and effectiveness of the day-to-day running of the ward), to name but a few recent initiatives.

In order to broker PSK for service change across professional groups, however, committees need to be governed by individuals with the most senior power and status. For example, in hospital A, the formation of an operational group (OG) was the organisation’s response to more serious concerns that required a step change in management. An OG is generally chaired by an executive director and was, thus, able to enforce service action through strict performance management processes. With this in mind, one of our respondents describes his personal pursuit of a falls ‘OG’ with executive leadership, in a bid to drive the transformation of PSK into service improvement for patient safety:

Through the Inpatient Falls Committee [IPFC], we’ve made some progress. We’ve certainly got some of the structures and the infrastructure in place that we need to be able to monitor performance and indeed to try and disseminate the organisational learning from individual events, which is good, but I haven’t got the clout. I haven’t got one of the hammers if you like. [Interviewer: What would give you the clout?] Well, I’d say the executive director needs to be on my Inpatient Falls Committee. In fact they need to chair it. . . very few people would not go to a meeting which is chaired by either the chief executive, the medical director or the director of nursing, whereas they feel they can do that to me and, you know, what can I do?

Geriatrician M, H-MLM, hospital A

In another attempt to mediate the organisational infrastructure, one H-MLM, with a clinical-facing and academic policy-orientated role, explains how participation in policy writing can enable him and policy-makers to push PSK through the organisation’s infrastructure top-down because it is clinically relevant.

In summary, the organisational infrastructure, at first glance, represents a co-ordination capability because it is a formal mechanism for cascading knowledge across the organisation. However, ‘hierarchy’, and associated power and status, is the characteristic that appears to govern legitimacy to broker knowledge; thus, professional behaviours can impede knowledge brokerage for service action. The infrastructure itself, made up of committees, is perhaps more reflective of a procedural systems capability designed to service the organisation’s priority to comply with regulations, targets and financial incentives. As already discussed, systems capabilities alone narrow the scope and breadth of PSK, and often lack the ability to transform PSK into service action at the front line. Ostensibly, the organisation’s response to this known deficiency is to introduce further procedural checks as part of the senior committee meeting. For example, during our observation of the CRC, we noted the recurrence of the following question: ‘Can we be reassured, that “said” alert/incident/policy has been dealt with?’ One respondent describes the use of terms such as ‘assurance’ to echo the language of the NHS regulator, the CQC:

When they [CQC] come into a Trust they’ll say, ‘Well where’s your assurance? If you’re sat on a Board where’s your assurance?’ And that’s what we’re working on a lot and I think every NHS Trust is doing that . . . And why you’re hearing that is because of CQC because that’s their terminology. How are you assured? How are you reassured? What mechanisms do you use to make sure you are assured? It’s all that kind of language.

Head of nursing, H-MLM, hospital B

Mediating between system and socialisation capabilities to facilitate knowledge brokering between organisations

Earlier, in System capabilities, we identified financial incentives as a potential co-ordination capability that mediates between system and socialisation capabilities to instigate service action aligned to improving patient care. Alternatively, our data reveal how some individuals are better able to broker exogenous PSK than others by virtue of their diverse professional background and experiences. We see this in our interviews with representatives from external organisations, as well as those on the clinical front line. Applied researchers at the NPSA explained how they are able to exploit prior knowledge, relationships and linkages derived from their own professional background to nurture a network of ‘friendly hospitals’, and in turn to inform the development of exogenous PSK in the form of ‘patient safety alerts’. In another example, a H-MLM describes how she combines her existing role (commissioning health care), with her prior knowledge and relationships in a different but related professional area (social work), to inform others unofficially about necessary service changes that draw upon external PSK. This enables the respondent to develop mutually beneficial relationships across health and social care organisations to facilitate a two-way flow of knowledge across these organisations and commissioning:

I see this role as ‘in the middle’, because I come from a social work background, have been a social worker, been a team manager, been an operational manager. So I’ve got that experience, but also can see what’s coming from above. I might have an idea about developing something or how something’s going to work, and then I need to go and talk to my [prior] colleagues, often in an informal way and say, ‘I’ve got this idea. What do you think? How will it work?’ and they’ll say, ‘Well that’s a good idea, but it won’t work quite like that because of this or that,’ or, ‘We could tweak that and that’ll work’.

Commissioning manager, primary care organisation, external body

A geriatrician in hospital A explains how he furthers his own patient safety interest through his involvement with the Department of Health. In recognition that target-based guidelines attached to exogenous PSK enter the organisation top-down with greater velocity and veracity than PSK that is endogenous, the geriatrician effectively bypasses the limitations posed by socialisation capabilities, transforming PSK related to the care of older people into a format that will be prioritised in the same way that other target-based initiatives and guidelines are prioritised, i.e. the organisation will respond with the introduction of system capabilities to illustrate compliance.

Policies that move down quicker are probably those that are attached with targets and financial incentives, whereas those about good practice and essence of care tend to sort of move down a bit sort of slower. Hence, a lot of my efforts recently, in the years I’ve been working at Department of Health level, have been about influencing policy and writing guidelines informed by my clinical practice.

Geriatrician S, academic H-MLM, hospital A

The brokering of exogenous sources of PSK across professional groups within health-care organisations was evident between (hybrid) mental health nurses not employed by, but working within, the hospitals, and clinicians working on the hospital wards. Many doctors and nurses who care for older people are not skilled in treating patients suffering from forms of cognitive impairment, such as dementia, and this can compromise the quality of care provided. We spoke to mental health nurses working on a temporary basis (as part of a funded research pilot) within hospital A. Successful brokering of new exogenous sources of PSK occurred as a result of nurturing socialisation capabilities within the organisation, specifically via mental health nurses working alongside doctors and nurses in a situated way to build team-based relationships and trust:

They [mental health nurses] spent quite a long time embedding themselves to become credible within the team. The way they did that, by and large, was by working as auxiliaries, health-care assistants to start with, to show that they could wash a patient and they were happy to sit with somebody who was very agitated and so on. We also wanted them influencing the ward culture, in terms of policies and procedures and defining a role for themselves.

Geriatrician H, academic H-MLM, hospital A

The quote above highlights the need for ‘diversity of background knowledge’ at a team level as a co-ordination capability, with socialisation mechanisms facilitating the brokering of external PSK for service improvement at the middle levels of the organisation. This approach allowed the mental health nurses to cultivate legitimacy for their knowledge brokerage from one profession to another, initially becoming valued members of the clinical care team, before seeking to influence ward practice and culture. In hospital B, mental health nurses did not spend time ‘embedding’ themselves on the ward. Rather, they adopted the role of itinerant broker,91 distributing knowledge on a peripatetic basis, as and when needed. These mental health nurses were also afforded legitimacy, but on the basis they were imparting scarce, valuable knowledge as and when required:

I had two major concerns. First, how is a doctor going to react to being given advice by a nurse? However, it has been 99.9% arms open, thank you for coming! My other concern was to do with the ward staff. I thought that what we would get would be, ‘Why are you coming to tell us our job, don’t teach your grandmother to suck eggs, we know the basics,’ and all this. However, it was the exact opposite: ‘Thank God, the cavalry is here. We have been crying out for this for so long, thank you’.

Mental health nurse, H-MLM, hospital B

We discuss the brokerage of knowledge from mental health nurses across professions in greater detail in Chapter 5.

Summary of section

In this section, our empirical data have presented system capabilities and socialisation capabilities as two juxtaposing worlds. The first is driven primarily by compliance towards external stakeholders. The second is driven by locally generated PSK and innovation for service improvement, but narrowly orientated towards distinct professions. Each stymies the brokerage of exogenous sources of PSK to the clinical front line. While we make no suggestion that the intention of external providers of PSK is for organisations to focus upon compliance over and above improving health-care delivery for patient safety, our data do suggest that systems capabilities are primarily shaped to focus the role of more senior MLMs upon evidencing compliance to meet targets and reduce financial operating costs, as opposed to brokering PSK to the clinical front line for service action. We deduce co-ordination capabilities from our data that play a role in mediating between these two worlds, most notably the use of financial incentives by more senior H-MLMs who use incentives as a lever to galvanise the organisation towards service action and improvement, and the benefit of diverse knowledge and experience to mediate limitations of system and socialisation capabilities with regard to the brokering of exogenous PSK. In essence, we see that antecedents of systems and socialisation capabilities, such as financial incentives and professional hierarchy, can also be recast as shaping co-ordination capability to enhance the brokering of exogenous PSK. Meanwhile, the role of H-MLMs as a co-ordination capability for brokering exogenous PSK is significant. Finally, hybridity, in the form of MLMs’ understanding of, if not experience across, professions and organisations, engenders the diverse perspective helpful for brokering exogenous PSK.

Overall, our application of combinative capabilities theory presented in this section have highlighted how senior management solicit system capabilities primarily for evidencing compliance to the requirements of external regulators. The external political environment represents a dominant influence upon the shaping of system capabilities. In parallel, socialisation capabilities that characterise the professional core of the organisation stymie the top-down brokerage of exogenous sources of PSK across professions, exacerbating the knowledge-brokering gap between senior management and the clinically engaged professional cadre of the organisation. This finding echoes that of the recent Francis Report,149 where a managerially led ‘culture of assurances’ towards external targets is thought to have prevailed over improving the quality of care, suggesting that the problems encountered at Mid-Staffordshire NHS Trust, which led to many hundreds of avoidable deaths, may also be encountered in other health-care organisations. To highlight a particularly significant section of the report for our study:

[Within Mid-Staffordshire NHS Foundation Trust] this culture of assurances was operating in a structure where identifying systems and processes and meeting targets were the main measures of performance. Outcomes-based performance and risk-based, intelligence-informed regulation were still developing concepts.

Francis Report, paragraph 1.114149

Summary of section

Through our empirical data, we have shown how power and status can prove a challenging matter for brokering endogenous PSK. We begin by highlighting the nature of PSK in relation to brokering knowledge across professions. We suggest that PSK related to elderly care is generalist and, therefore, not interesting or ‘sexy’ to higher-status professionals, who specialise in a single issue. We also highlight the prevalence of the ongoing division between generalist and specialist professionals and how this is nurtured as part of education and early career socialisation. To summarise our findings, our data reveal some very specific characteristics of knowledge brokerage linked to power, status and hierarchy that create a challenging environment for upwards knowledge brokerage by lower-status actors. Peer-to-peer knowledge brokering is common among lower-status actors, and this may take place in various committees. However, these actors lack ‘teeth’ to broker knowledge across professional groups, due to power and status differentials.

In the next section, we illustrate how H-MLMs seek to mediate power and status differentials, to broker knowledge upwards and across professional groups to shape organisational strategy.

The ‘representative’ knowledge broker

In order to broker patient safety knowledge across the organisation, lower-status actors may enlist the help of a higher-status H-MLM to present endogenous PSK on their behalf. Thus, the H-MLM acts as a representative knowledge broker, often brokering knowledge on behalf of others marginal within the organisational or professional hierarchy. For example, a geriatrician (often a H-MLM themselves) wants to galvanise the organisation towards proactive falls prevention for patient safety – an issue that is not just pertinent to the care of older people, but relevant right across the organisation to young patients, new mothers, cardio patients, stroke patients and so on. In order to influence strategy across the whole organisation and broker endogenous PSK across professional groups, the issue of inpatient falls needs to be raised at the apex of clinical governance: the CRC. The representative broker in this case was a senior H-MLM, with a nursing background, whose role as ‘clinical quality, risk and safety manager’ requires her to participate in the CRC, working closely alongside the CRC chair. Working collaboratively with the geriatrician, and acting as a representative broker, translates the falls issue, so that it attains priority status, by presenting data in a format which conveyed in managerial terms the relevance of the issue to the senior members of the CRC. In the excerpt below, the clinical quality, risk and safety manager described how she brought falls to the attention of executive managers and directly influenced organisational strategy via a ‘representative’ type of knowledge-brokering role.

We used to know that people fell. We used to know that they might have had a fracture. However, we didn’t know that they then went on to die because we stopped at that point. We didn’t gather any more data. Now we’ve measured it, which enabled us to increase our risk score for falls. It’s now up the agenda and we can have something done about it.

Clinical quality, risk and safety manager, senior H-MLM, hospital A

The above example demonstrates two specific techniques employed by a lower-status actor, in this case a geriatrician, himself a H-MLM, to broker knowledge ‘upwards’ effectively across professional groups and the organisation to influence strategy. First, the lower-status actor enlists the help of a higher-status ‘representative’ broker, a senior H-MLM, who is a member of the organisation’s most influential committee, the CRC, and is therefore positioned structurally to broker knowledge to the right people (senior managers) in the right place (CRC) at the right time (at meetings of the CRC) and in a way that registers shared interest (avoidable patient deaths which can lead to regulatory intervention and penalties). In response to the presentation of data by way of a representative knowledge broker, the organisation was motivated to launch an ‘operational group’ to actively broker knowledge about falls prevention across the whole organisation. The issue was regarded as so important that the Falls Operational Group was set up and led by the chief executive himself, ensuring that the issue was a priority interest on everybody’s agenda.

The Falls Operational Group is a realisation that we have a big problem with people falling and that our activity to date is suboptimal. The beauty of the operational group is that they are generally chaired by an executive director, so they’ve got great power in that respect and they are therefore well attended.

Chair of CRC, hybrid executive manager, hospital A

In another example, a respondent of relatively low status intraprofessionally, a GP describes her own endeavour to broker PSK across professional groups in a way that would influence organisational strategy. The respondent conducted lengthy and detailed audits to determine the cause of high levels of patient readmission. The data revealed that a large number of patient readmissions were related to a miscommunication of patient medication (both intradepartmental and interorganisational) and that more than 50% of such readmissions were preventable. The respondent describes her frustration as attempts to broker important PSK across professional groups were stymied by a lack of knowledge mobilisation outside subcommittees at the middle levels of the organisation. As above, the subcommittees are made up of lower-status groups of ‘interested people’ who have limited ability to broker knowledge effectively across professional groups in a way that will influence strategy and improve practice. Faced with this obstruction, the respondent enlisted the help of a representative broker (a fellow GP, academic H-MLM) to publish the data in the British Medical Journal in order to gain the attention of senior hybrid managers and translate the data into financial repercussions in order to establish priority.

I naively thought that once you’d said something [at a committee], that would be it, and knowledge would flow and something would happen. But I realised after a period of time, it was not enough to say something once, you have to keep repeating it and putting it in different contexts. The Medicines Safety Group and the Medicines Management Committee are very supportive, and [representative knowledge broker] helped me get that audit to the point of publication. Then I got a paper published with more robust data, so I was able to do more presentations based on more robust evidence, supported by [representative knowledge broker]. I thought, ‘OK, I’ve got doctors thinking in numbers and managers thinking in numbers and they like to know percentages of this and that.’ So the result of that was we did [eventually] make some progress . . . it wouldn’t have happened without the links that I’d made with [representative knowledge broker].

Discharge team member and part-time GP, hospital A

In contrast, without a representative knowledge broker of sufficiently high status and social position, senior management can resist attempts by lower-status actors to raise issues of importance at the apex of the organisation. Our data revealed examples of such resistance in hospitals A and C.

We have lots of things in place to manage and reduce falls, but on our risk register we rate it as highly likely, fatal, as elderly people quite often die as a result of a fall later on. With our particular client mix (elderly patients with cognitive impairment), you concentrate that risk tremendously. Our Risk Management Committee didn’t agree and asked us to reduce the risk. This is where you get tensions between the tail wagging the dog rather than the other way round.

Clinical governance manager, non-hybrid MLM, hospital C

I manage the risk register for acute medicine. I took an issue to the governance lead for acute medicine, which is a consultant, and we talked through what the risk was, and it was agreed that this needed to go on the risk register. So I went through the right process, put it on the risk register and it created mayhem because I recorded it as a 15, which is a high risk. This means it has to be then escalated through the organisation. Then I got, ‘Well, have you told this person? And what about this person? Then, well, you know, we need to come and re-evaluate this risk,’ because they wanted to downgrade it. I refused to allow them to downgrade it. So it stayed as a 15, which is a high risk, and they keep telling me, ‘But a 12’s still high’. I went, ‘So if 12’s still high, I’ll leave it at 15. It doesn’t matter, does it?’ So they had no argument. So at the moment it still sits there as a 15, although they still want to come and review it.

Matron A, H-MLM, hospital A

In hospital A, the ‘practice development matron’ (H-MLM) plays a key representative type brokering role, spanning several trust-wide groups to facilitate the brokerage of PSK to acute medicine wards.

The role of [the practice development matron is] developing staff and getting the knowledge and the information out there to the staff, doing the training and the education and the development of the staff. It’s also about writing the policies and the guidelines and the procedures that help staff to do what they do. And also our job from an acute medicine point of view is being involved in a lot of Trust-wide groups, so that we can represent acute medicine and bring back to acute medicine what’s happening from developments such as dementia strategy, nutrition group, the falls group, all those sorts of things. We will bring all the information about what’s happening back down to our directorate and the staff that work within our directorate.

Matron A, H-MLM, hospital A

The liaison knowledge broker

Hierarchical relations are considered an aspect of social capital. Across the nursing profession, we see many levels of the hierarchy, encompassing and facilitated by H-MLMs, creating a neatly linked broker chain, where each actor is connected to someone who is of higher status and of lower status. Those in the nursing profession enact a liaison type of knowledge-brokering role, capable of cascading PSK down the ranks of nurses to align service action to externally derived PSK and to implement new initiatives for patient care.

We take [PSK] down through the operational nursing route, through the heads of nursing down onto the main wards. In terms of Safety Express (an external and national patient safety initiative), there’s the safety thermometer data collection that happens every month. It now has to happen on exactly the same day everywhere and we’ve just done that last week.

Patient safety manager, H-MLM, hospital B

This very linear structure creates a linked broker chain across which a liaison type of knowledge brokerage is enacted from top to bottom, which, as outlined in Chapter 4, is useful for brokering exogenous PSK to the clinical front line. However, while hierarchy aids the brokering of PSK downwards into clinical practice, hierarchy appears to impede the upwards flow of PSK between nurses at an operational level and nurses at a more strategic level.

I went onto a ward a few months ago and one of the non-registered nurses asked me if I wanted a Mars bar. She stopped me and said, ‘Have you had anything to eat today?’ I said, ‘No’. She said, ‘Do you want my Mars bar?’ She had just bought it off the trolley as I was standing there. I joked with her and said something like, ‘Oh gosh, I’m at Weight Watchers. I can’t eat that. I’d love to, but I can’t’. It was a really nice conversation. When I went back to that ward later on, she came over and said, ‘I’m really sorry if I offended you on the Mars bar’. The Ward Sister had told her that it was inappropriate to talk to me that way. I tell this story to illustrate communication blockages when we are disseminating knowledge. Ward Sisters don’t want me to hear things, because that’s a reflection on them. So I have to circumvent and go round and look at the data, and I imagine every director of nursing would have that problem really. You know, I was the same when I was at that level in the organisation. I did not want my boss to know everything, because that it might reflect failure on me.

Director of nursing, hybrid senior manager, hospital B

We find similar behaviour in hospital A, where the clinical nurse lead for the Acute Medicine Directorate acknowledges that nursing staff are unlikely to raise issues directly with her.

When I came into my post as clinical lead it was like, ‘Oh she’s a senior manager, don’t talk to her!’ As a change agent I need to be part of the team as well as a senior [middle] manager.

Clinical lead T, H-MLM, hospital A

To circumvent behaviour linked to such cultural norms, senior H-MLMs conduct ‘patient safety rounds’ in an attempt to pull PSK directly from the nurses on the ward.

The problem with the hierarchy we have is that with more junior nursing staff, for example, it would really be a very big deal for them to knock on the door or email me. It does happen occasionally, but from that point of view it’s much more me [going] to find them. We have patient safety rounds and the director of nursing walks around quite a lot in the Directorate. What we are trying to move towards really is that kind of shared governance thing really of visible leadership, I suppose, in terms of people at all levels – in terms of directors and people like me – being visible to people on the wards talking about issues, not just safety, but safety would definitely be one part of it.

Clinical lead M and senior nurse, H-MLM, hospital A

In hospital B, the director of nursing deploys a similar tactic to pull PSK from frontline nurses:

I go out and work on the wards. We have ‘back to the floor’ on Friday, so all the senior nurses are expected to be out on the floor on Friday on the wards in their uniform. For me, that’s about building the relationship, so that when I’m working with somebody, they’ll provide me those little bits that I start to think, ‘Hmmm’. Because, I’ll be honest, I don’t think many people are going to knock on my door and tell me. I don’t think they’d come to me with the minutiae, but the minutiae is important because it builds a picture, if you see what I mean. So that’s really the balance.

Director of nursing, hybrid senior manager, hospital B

The above examples highlight the strategic role of these more senior managers, including those senior in the ranks of H-MLM, synthesising knowledge from the operational front line with knowledge from above. This approach reflects a Liaison II type of knowledge-brokering role, where knowledge is brokered upwards from junior staff via a specific mediating intervention (see Shi et al. 85).

The cosmopolitan broker

A cosmopolitan-type brokerage role has been shown to be effective at brokering PSK across professions in elderly care. Within mental health issues in particular, our data reveal two approaches to broker mental health knowledge across professions. In hospital A, the cosmopolitan broker is localised and situated on a specialist dementia ward environment, while in hospital B, the cosmopolitan broker is an itinerant broker, working on a peripatetic basis across the organisation.

In hospital A, a geriatrician, who was positioned as an academic H-MLM, established a specialist dementia ward within the Medical and Mental Health Unit (MMHU), where mental health nurses from a major provider of specialist mental health services for older people were subcontracted to work on the ward. The aim of the intervention was to broker knowledge about dementia across organisations and professions. The following excerpt from interview describes the knowledge-brokering approach enacted by the academic geriatrician – what we characterise as a cosmopolitan type of knowledge-brokering role. This highlights the challenge of brokering knowledge to the clinical front line in ward environments, where many professionals outside the core nursing team come ‘in and out’ of the ward, which necessitates a need for a ‘situated’ approach:

In our experiment, which is strictly in a research context, we have parachuted in some extra expertise [mental health nurses]. That is not to say it is not a two-way relationship. They have had to learn things about the speed of acute hospitals. All the mental health staff we talked to and asked what their first impression was, and they were like, ‘The pace, the franticness, we never knew that you worked at this pace’. Nursing teams can be quite close knit at ward level, and then there are professionals, who are related, but on the periphery like the doctors and the occupational therapists. The occupational therapists have a department somewhere else and they come in and do their bit and they go away again. They may be there every day, but they are not part of that very close-knit core team. So that was what they had to infiltrate. The way they did that, by and large, was by working as health-care assistants to start with, to show that they could wash a patient and they were happy to sit with somebody who was very agitated and so on. We then began to say to them and others, ‘Well, we didn’t employ three relatively expensive people as health-care assistants’. We wanted them to give opinions, to make assessments of your hard cases and so on. We also wanted them to educate through modelling, co-working, coaching, on-the-job sort of training stuff.

Geriatrician, academic H-MLM, hospital A

The early results of this approach are promising with nurses operating on the ward observed to be ‘completely different to nurses on other wards . . . they’ve just absorbed the learning’ (matron A, H-MLM, hospital A).

In hospital B, a mental health liaison team, specifically their H-MLM, brokers knowledge on a peripatetic basis. The team have built credibility across the organisation and across professions based on the distinctiveness, the value and accessibility of their knowledge base with regard to caring for patients presenting with acute cognitive impairment.

Until the [mental health liaison team] service was up and running, the management of these people [older people with cognitive impairment] was just completely haphazard. 50% of the elderly inpatients are going to have cognitive problems of one sort or another. So it’s a huge population and we miss them. There is a more consistent approach to the way that they’re managed that’s evidence based. We complement formal evidence with the sort of anecdotal stuff in terms of feedback both from patients and relatives, but also from staff on wards.

Geriatrician R, H-MLM, hospital B

With us actually being based here, we now practically know everybody on the health care of the older people’s ward. Around the hospital, I think that one of the things about doing this type of job is because you are doing something slightly different, everybody knows you. They get to know you much quicker because you are the unusual. You are the celebrity visitor, if you like.

Mental health nurse, H-MLM, hospital B

He’s [mental health nurse and H-MLM] very good. We can manage things and he knows that when we get to that stage of referring to him that his input is needed. He’ll come and give practical advice around managing patients. Once a patient’s referred to him he comes and says, ‘This is what the diagnosis is. This is what we need to do with them’. So there’s a lot of interaction that way. So there’s that sort of learning.

Ward manager C, H-MLM, hospital B

In hospital B, unlike the local situated approach to a cosmopolitan-type of brokering role portrayed in hospital A, the itinerant approach has the benefit of accruing ‘social capital’ by virtue of the mental health nurse’s peripatetic approach. This gives rise to diverse network connections across the organisation, which is facilitated by his position as H-MLM. Further, the nature of mental health knowledge plays a part in facilitating a knowledge-brokering role for the relatively low-status H-MLM that the mental health nurse represents. Mental health knowledge is described in stark contrast to the more scientific status of medical knowledge more generally: ‘Psychiatry is a huge grey fog and we are somewhere in the grey fog. We don’t go for certainty, we go for potential’ (mental health nurse, H-MLM, hospital B).

Despite this, a ‘cosmopolitan/itinerant’-type of knowledge brokerage in a context where resources (i.e. knowledge) pertaining to that brokered are in high demand, yet of scarce availability (a high-value resource, in market terms), affords traditionally lesser status actors the opportunity and ability to build many ‘weak’ social ties across the whole organisation, based on shared interests.

In contrast, the localised approach to cosmopolitan brokerage exhibited at hospital A closely resembles a CoP, which coheres around the patient cohort, i.e. older patients with likelihood of cognitive impairment, such as dementia. Perhaps unfortunately in this case, the driver for such an arrangement is a funded research study. Consequently, the knowledge generated by the research is ‘guarded’ in line with the need for academic rigour. While applicable to other localised settings within hospital A, the tendency of the prototype CoP is more insular than might be expected, with the H-MLM leading the research study not predisposed towards brokering knowledge more widely. The characteristic downside of this approach is a failure to broker learning beyond the CoP to exploit best practice across the organisation. To demonstrate, we present an example of an elderly patient at hospital A with a diagnosis of both dementia and delirium who falls five times during a 6-week hospital stay. The patient in question had suffered a stroke and, while recovering on the stroke specialist ward, was reportedly exhibiting challenging behaviour that was both verbally and physically aggressive. A high-level enquiry was launched at hospital A due to a concern that the patient had fallen as a result of excessive sedation. However, the report concluded that this was not the case; instead, it highlighted the impact of poor levels of knowledge brokering in relation to the management of patients with cognitive impairment across the hospital. Specifically, the report highlights that junior nurses, having received no specific training with regards to the management of such patients, reported feeling ‘out of their depth’, and that there was inadequate use of the MMHU where specialist dementia nurses and a wealth of mental health expertise were available for consultation, specifically connected to the research described above. Reflecting on this last point, the ward manager stated that she was told that the MMHU would not be able to outreach their services because the ward was situated on another site approximately 4 miles away:

There was a suggestion that we should have sort of had an outreach from them for them to oversee. I actually know the ward manager on there and I spoke to her and asked, ‘Is it feasible for that to happen?’ and she said, ‘Well, no’. They struggled even when they were doing some research to actually outreach to that campus, let alone over to this campus.

Ward manager D, H-MLM, hospital A

In this case, the ward manager for MMHU conducted a gatekeeping role, preventing an itinerant cosmopolitan brokerage role being enacted. However, this conversation between ward managers was not included in the final report following the patient’s final fall. The report prescribed system-based changes to prevent a recurrence and to try to broaden access to expertise on the ward:

The availability of specialist nursing expertise in the Medical Mental Health Unit should be publicised, and contact details circulated to all charge nurses on both campuses.

Anonymous RCA report, hospital A

Other examples of cosmopolitan-type knowledge brokering by H-MLMs can be seen where geriatricians broker knowledge outside the organisation. As described in Chapter 4, one geriatrician describes how he has positioned himself as an academic hybrid, brokering academically orientated clinical knowledge through national committees to influence policies coming into the Trust top-down from the Department of Health.

Nationally, I work with NICE for hip fracture and I sit on the NICE inpatient falls working group. I’m chair of the British Geriatrics Society and I sit on Department of Health falls and fragility fracture board which is about improving health-care services . . . the success of the hip fracture care has been because one’s been able to input to the different committee levels nationally, and I think that does help bring things on quite quickly.

Geriatrician S, H-MLM, hospital A

Another geriatrician in a H-MLM role positions herself as a cosmopolitan and representative knowledge broker on regional committees to influence the approach to preventing falls both in the community and in the hospital, thereby brokering knowledge across organisations in a bid to manage the flow of elderly patients into the hospital.

I’ve established close links with the different forms of [falls] prevention teams that are community based. I got to know some of the therapists, just by being there and speaking with them. This is how I opened up the communication. I was part of the county-wide steering group and that steering group had representation from the commissioner, and I asked for direct referrals of patients to myself [cutting out doctor] to be formally agreed.

Geriatrician A, H-MLM, hospital B

A co-ordinator knowledge-brokering role

The need to develop new roles to co-ordinate across the structural holes of a fragmented care pathway for elderly patients has been recognised in both hospitals A and B. One example at hospital B illustrates how the need for architectural knowledge relating to the transition of patients from the hospital to the community creates an opportunity for lower-status actors to develop social capital. This facilitates the development, by H-MLMs, of a liaison type of knowledge brokerage role across professional groups. In short, H-MLMs do not need to necessarily broker PSK themselves, but can instead strategically respond to the need to bridge structural holes. In this example, the low-status knowledge broker, who was formerly employed as a ‘housekeeper’ for the ward, had developed a reputation for being indispensable, with several respondents commenting on the value of this employee’s vast knowledge and connections with providers of social care in the surrounding area. The H-MLM, ward manager in her area, developed a specific role that leveraged the value of the housekeeper’s social capital. This allowed the Integrated Discharge Team ‘to form that link between social care or the community that is not actually seen,’ but which ensures patient safety:

We’ve developed a role on here called patient pathway facilitator. I found a lot of my trained staff were spending time chasing Social Services and chasing occupational therapists to support safe transition. So we developed the role that [former housekeeper] is doing. She does all the ward rounds. So physiotherapists, occupational therapists and social workers, everybody goes to her. She knows everything.

Ward manager B, H-MLM, hospital B

A gatekeeper-type knowledge-brokering role

In Chapter 4, we identified H-MLMs, such as geriatricians and pharmacists, as gatekeepers of exogenous sources of PSK. They manage the knowledge environment to prevent deluge at the front line, at the same time as brokering knowledge that they deem relevant to their subordinate peers. In terms of endogenous knowledge sources, ward managers are also identified as enacting a gatekeeping knowledge-brokering role. At the level of the ward manager, we see they prevent an upward flow of PSK from nursing staff, as well as limiting the downwards flow of PSK to nurses on the ward. The ward managers are at the lower end of the H-MLM spectrum and the closest operationally to the patients. Ward managers have responsibility for balancing and managing resources, and are subject to a number of operational procedures and targets, at the same time as managing the daily minutiae of the ward. Given the busy nature of their role operationally, their knowledge-brokerage role is necessarily on a ‘need-to-know basis’. The extent to which they broker PSK varies, dependent upon their disposition. Some ward managers exhibit proactive brokering of PSK, others less so.

Individual leadership on wards is sometimes what is missing from all of the safety episodes. The truth is that the systems are in place. This means it is very much something that ward managers need to own. Each time there is a [patient safety] incident, it’s that much more pressure on their time. They often want to stop incidents, but don’t have time, so the systems don’t work.

Geriatrician M, H-MLM, hospital A

Another geriatrician describes a randomised controlled trial of bed sensors to alert nursing staff when high-risk (of falls) patients attempt to leave their beds. The project appeared to be successful, with particularly good use of technology on show for the management of localised knowledge. However, the trial was later abandoned when it transpired that the initiative would not succeed without strong ward leadership, i.e. knowledge brokering required leadership from H-MLMs.

In the pilot work there was a lot of leadership from myself, the ward manager and deputy ward manager saying every day, ‘We’ve got to do it, it’s best for patients’. However, on some wards, there was no leadership and the nurses were saying, ‘Oh, we hate this alarm going off. It’s another alarm,’ and equipment would be taken off beds, pagers would be left lying on their desk, batteries taken out, equipment would be sabotaged. That’s real-life NHS.

Geriatrician S, H-MLM, hospital A

When ward managers are leading change, remarkable improvements can happen. The following example relates to the work of a ward manager to reduce inpatient falls from 42 per month to nearly zero:

We have a ward here that takes pretty much all of the people with alcohol problems, but on that ward they’ve virtually reduced the fall risk to zero, by a set of tailored interventions. It is about one to one, providing nursing care on an individual basis, or at the very least, cohorting two or three people at very high risk together. So there’s something about the leadership that she [ward manager] provided there. It’s fantastic. She won’t accept when people say, ‘We’re not going to stop this,’ or ‘There’s nothing we can do here’. She won’t accept that and it’s about her leadership in the ward team that matters.

Geriatrician M, H-MLM, hospital A

The ward manager describes her approach as a ‘whole team’ effort that includes doctors, from whom she selected a consultant to act as a representative broker to engage junior doctors:

Looking back, our highest falls one month was 41. We just accepted that, that was normal. So we set the target at four a week and probably achieved it one week out of the month, if that, and the rest of the month we were always well over it at six, seven, eight per week. We had a meeting. I picked one consultant particularly because I’ve known his character. I knew that he would back me up and he would challenge the medical staff. So, in this instance, you have me as the ward manager leading the nursing staff and challenging them in their behaviour, but you also need somebody from the medical side that will challenge them because I don’t feel it’s my role and necessarily that they would listen to me. They may do because they’re juniors, but they’re going to take it more from a consultant as their peer and their senior than they are from me, even though I’ve been nursing for donkey’s years. It’s not just me making the target, it’s not just me saying we have to have less than so many falls a month, it is everybody’s job to stop people from falling.

Ward manager E, H-MLM, hospital A

So, as well as brokering commitment to the cohorting intervention through others, more powerful in the professional hierarchy, we see the ward manager also moving away from top-down imposition of targets. This seems a relatively straightforward intervention that might be brokered more widely across hospital A. To achieve this, the ward manager took an opportunity to broker her experience directly to the chief executive (a cosmopolitan brokering role) in order to shape strategy in relation to falls prevention across the whole organisation. She claims to have been responsible for co-opting the chief executive into leadership of the Falls Operational Group at hospital A. The following excerpt from interview recounts the story of how the ward manager above challenges the chief executive to address falls more seriously across the organisation:

I joined the Inpatient Falls Committee meeting [IPFC], in which I happened to say to the chair, ‘No disrespect to you as the Chairperson, but why is it you are the only consultant that attends this meeting?’ We listen to all the RCAs, the fractures and all the rest of it and why does nobody from the Board come? If you get an incident related to infection, for example, on your ward, you’ve got to go and answer to it in front of the Board and say what have you done, what are you not doing, slap on the wrist, go beat the staff up and all that sort of stuff. I said, ‘Why is it falls are not seen as a major issue? People die from falls’. Then I did the RCN leadership course last year, where you had to pick a topic, so of course mine was obvious – let’s pick falls. And during that course you have to present to your director of nursing and your chief executive. I said, ‘I’ve got a question for you. Why does nobody from the Board think it’s important to attend the Inpatient Falls Committee meeting [IPFC]?’ Two months later, the Falls Operational Group was in place, with the chief executive as chair.

Ward manager H, hospital A

Asked to reflect upon her actions as a nurse, the ward manager stated, ‘I’m a very mouthy person. I’m the sort of person that gets the bit between my teeth and I’ll go with it and if I feel very strongly about something I’ll just cut the middle man out and go straight to the top’. Based on this example, and the example of knowledge brokering by mental health nurses, we conclude that an individual’s ‘social capital’ comprising motivation, agency and opportunity150 can mediate power to broker PSK across professions and even directly to the organisation’s most influential actor, the chief executive. However, at the same time, we highlight the specific intervention of cohorting proved slow to spread throughout hospital A. During focus groups facilitated by the authors at the request of hospital A, it was noted that some wards were still not aware of the benefits of cohorting patients according to their falls risks.

Summary of section

Our data reveal how lower-status actors seek to mediate power and status differentials, so as to broker knowledge upwards and across professional groups and help to shape organisational strategy. Mental health nurses, particularly when enjoying H-MLM status, for example, are shown to be capable of enacting cosmopolitan knowledge-brokering roles by virtue of their knowledge being in high demand across disparate professions. Lack of knowledge relating to mental health across the organisation creates an opportunity for knowledge brokerage across structural holes, and the growing need for mental health knowledge creates motivation in other professional groups to solicit such knowledge. However, this may take place in very specific circumstances. At hospital A, for example, the mental health nurses do not extend social ties outside of the research environment (the ward), to broker knowledge effectively into other clinical areas. In contrast, within hospital B, the mental health nurse (H-MLM) and his team appear less constrained. Treated by other professionals ‘like a celebrity’, he is not constrained to work within a specific clinical area, and works on a peripatetic basis across the whole hospital, thus brokering mental knowledge more widely. We also highlight that geriatricians are similarly extending their social ties outside of their local areas, and attaining similar success in employing representative, liaison and cosmopolitan-type knowledge-brokering roles across professional groups to improve patient care and shape organisational strategy across hospitals A and B.

Challenge of brokering patient safety knowledge upwards

Root cause analysis investigation was commonly undertaken, written and presented to the IPFC by ward managers, or in two of our eight cases, by the deputy ward manager. Junior and non-registered nurses were not involved in most cases, although, in several instances, ward managers did identify the potential value of involving junior members of staff in the process. One ward manager (H-MLM, SUI no. 8, hospital A) described the potential value of junior staff being involved in RCA investigations:

I feel that it’s good experience to get people to write them and to do the investigating. When it’s just the ward managers or the practice development matrons, or the other senior staff, you don’t often get the trickling of the message downwards that you want to get. If one of the Band 5s looked into it more in depth, the information would get out there more.

Another ward manager agreed, but suggested that junior staff would need to be supported in attending, for example, the IPFC:

I don’t want them to panic and to have that fear of going . . . I think they’d probably think, ‘Oh, I’m in trouble and I’m going to have to go and present this.’

H-MLM, SUI no. 7, hospital A

This opinion is supported by junior nurses’ views of the IPFC:

I think it’s quite tense because obviously if you’re in the position to be presenting the RCA you don’t want to admit error.

Registered nurse band 5, SUI no. 1, hospital A

Apparently they can be quite scary.

Non-registered nurse, SUI no. 1, hospital A

While ward managers took responsibility for actions, and were able to give examples of ways in which they brokered knowledge downstream after attending the IPFC, frontline staff interviewed were often less clear on where learning and changes to practice had originated:

No, I don’t think I did [relate a change in ward practice to the RCA] because I think it was a little while after the incident. We’re always being introduced to new changes, so I don’t think I put it down to that in particular.

Non-registered nurse, SUI no. 2, hospital A

A lack of accountability for the implementation of service actions following presentation at the IPFC does little to establish the brokering of PSK as a priority between the IPFC and the ward for service improvement. As one ward manager highlights:

Because you have so many things to do and then once you feel like you’ve done the initial thing, then I suppose some of the other actions could get a bit put on the back-burner.

Ward manager, H-MLM, SUI no. 3, hospital A

Our data suggest that there is a knowledge-brokering gap between the level of the subcommittee (IPFC) where the incident and remedial actions are discussed and the ward where the incident occurred. This gap relates to several areas, notably, first, where RCA learning is being brokered by ward managers, it is often in a non-specific and informal manner, and so staff may not make the connection between IPFC recommendations and changes in practice. Second, actions set out during the RCA process are not necessarily being followed up at a later date, and knowledge brokering for service improvement may not occur at all.

Root cause analysis as compliance rather than learning?

The RCA process was viewed in various ways by ward managers who had completed investigations. For some, the completion of the documentation was seen as a ‘chore’:

The amount of time invested in sort of trawling through the notes and seeing what was done and what wasn’t done and so on and so forth, I’m not necessarily convinced is value for money, so to speak.

Ward manager, H-MLM, SUI no. 4, hospital A

For others, the documentation seemed very ‘black and white’, and risked decontextualising the incident:

Because filling it in is just a timeline, isn’t it, and anyone could really [do that], you know.

Deputy ward manager, H-MLM, SUI no.1, hospital A

However, for others, completion of the RCA document was considered a logical and valuable process:

It’s quite long, but to be fair, with the falls RCA, they’re very structured, so you can give a yes or no answer, or it’s not applicable. You’ve not got masses of variability, which I do think helps you then come to an outcome at the end of it, or a root cause at the end of it, rather than it be airy-fairy.

Ward manager, H-MLM, SUI no. 7, hospital A

Completion of RCA documentation was seen as a potential learning tool for more junior members of staff:

I think they would learn more doing that than me saying to them afterwards.

Ward manager, H-MLM, SUI no. 7, hospital A

While writing RCA documents was not seen as a particularly useful part of the process, presenting to the IPFC did hold value for ward managers, and this element of the RCA process appeared to represent an opportunity for brokering PSK for service improvement:

It’s not the most pleasant experience because you are under the spotlight . . . [but] it is still a good thing to do because sometimes when you work in an area you can’t see the wood for the trees and other people help you see better. Then you move on to discussing solutions. Action plans are discussed and I find that a really positive thing to do.

Ward manager, H-MLM, SUI no. 2, hospital A

From the ward managers’ perspective, the RCA process seems to be a mixture of compliance (paperwork) and brokering knowledge for learning at the ward manager and subcommittee level (presenting and discussing at IPFC). However, the required actions appear largely around compliance with the falls prevention policy in hospital A, rather than service improvement. The majority of actions revolved around issues of staff compliance with, for example, the falls training policy, and risk assessment and care plan documentation. However, less clear was evidence of any structured mechanism for ensuring that these actions were completed. This finding mirrors that of Chapter 4, where the implementation of system capabilities results in compliance but not necessarily service action.

Linked with this issue of compliance is the brokering of RCA learning and actions after the Falls Committee meeting (IPFC). Our findings suggest an unstructured process of brokering, decoupled from the RCA process itself.

Examples of this can be found in SUI no. 2. One of the actions was that the RCA author (a band 6 nurse, who also presented to the IPFC) should feed back findings and actions to all staff on the ward. However, the ward manager, who had been proactive in enabling the band 6 nurse to write and present the RCA, admitted that this was yet to happen:

I mean I know it was February and we’re now July. However, there are so many other things going on . . . I would have liked this to have been presented sooner to staff.

Band 6 nurse, SUI no. 2, hospital A

The non-registered nurse interviewed from this clinical area believed that it would be useful to have the RCA findings presented at a ward meeting ‘sooner rather than later’:

I think that would perhaps be an opportunity to discuss issues like this. I think that would be good. However, we don’t seem to have many ward meetings now.

Non-registered nurse, SUI no. 2, hospital A

It should be noted that this non-registered nurse is the one referred to earlier, who did not believe that changes to ward practice had come about as a direct result of this RCA. This adds support to our contention that the learning from the RCA process is not brokered through to frontline staff.

On the other hand, respondents in some clinical areas were able to give examples of changes to ward practices, which had come about following the RCA process:

We’ve been very focused on falls since [the RCA]. I can’t remember specifically what she [the ward manager] said about what happened with that lady, but obviously we’ve had a lot of things highlighted and changed a few things on the ward since then.

Registered nurse, SUI no. 3, hospital A

Staff have been told about the root cause analysis. They have been given the information. It has been cascaded to them. So they do have an awareness of what happened and why it happened and what we can try to learn from it.

Deputy ward manager, H-MLM, SUI no. 4, hospital A

It’s a bit of paper exercise that’s completed and no one’s really thought about it seriously and put into place what needs to be put into place, such as the evidence that a falls care plan should have been done. But I think recently due to this [fall], it’s been highlighted as a problem and now the staff have certainly been aware of what we can do.

Registered nurse, SUI no. 6, hospital A

When looking at the mechanisms used by ward managers in brokering knowledge from RCA, no clear picture emerges. A wide variety of methods are employed, with varying degrees of success and adoption at ward level. Methods might be described as indirect or direct.

Indirect methods include blanket e-mails to ward staff reminding them of the need to adhere to hospital policy, poster displays in the clinical area and in staffrooms, notices on the staffroom board, and the practice of leaving important documents, which are expected to be read by all staff, in the off-duty folder. More direct methods include cascading of information at time-out days designed to capture all ward staff, ward meetings, falls training sessions, and, most commonly, shift handover.

Managers and frontline staff had varying opinions on the value of the various knowledge-brokering methods, and no single ‘best practice’ emerged from the data. The ward manager linked to SUI no. 5 summed up the principal theme seen throughout the interviews:

I think it’s very difficult because not everybody reads their e-mails, you can’t get everybody there at a staff meeting. We have to try and use as many mediums as possible in order to filter that information down and pass it on.

Ward manager, SUI no. 5, hospital A

Committee culture: learning versus punishment

Ward managers, and their deputies, who presented the RCA to the IPFC described the experience as ‘threatening’:

They really come down on you, you know. It wasn’t nice presenting it at all . . . I wouldn’t present it again.

Deputy ward manager, H-MLM, SUI no. 1, hospital A

Some people made you feel a bit stupid really and were a bit condescending. It was a bit punitive in a way. They were generally just quite sarcastic about things you’d said, and it just felt a bit intimidating.

Ward manager, SUI no. 3, hospital A

While these experiences were described in fairly negative terms, those who had presented RCAs to the IPFC were generally understanding of the process and the necessity to investigate in depth:

It was my first ever RCA I’d presented as well, and I was petrified. I hated it because it’s horrible that it happened in the first place and then you’ve got to say what was missed and your heart just sinks that it should never have happened really. I felt responsible because it was my shift. I was sweating. But they have to ask their questions, don’t they? I think they were fair because they have to get to a point and find out how it happened. They’ve got to be direct about it. It was just nerve-racking really.

Deputy ward manager, H-MLM, SUI no. 5, hospital A

Where there was a more positive view of presenting to the IPFC, this was linked to the process being perceived as non-punitive:

I think they make quite an effort at all of these things that it’s not about blame, it’s about learning. I’m not one for feeling intimidated by things like that anyway. But you go, you’ve already looked at it, so you already know your failings as it were, and they’re not in the game of beating you up about it.

Ward manager, H-MLM, SUI no. 6, hospital A

The ward manager in SUI no. 8 echoed this point, suggesting that the IPFC is there to expand on points raised during the RCA document completion process:

It’s quite daunting . . . [but] I think it’s good. I think it’s a really good learning experience because things that you may not have thought about while you’re writing your RCA are often brought up, picked up, questioned. So for me, I always think they’re a good learning curve.

Ward manager, SUI no. 8, hospital A

Of note in the RCA writing and presenting experience is the lack of involvement by doctors in the process. In only one case was a consultant involved in writing the RCA, and no consultant attended IPFC in all eight cases examined. The ward managers interviewed did not express any opinion about the lack of medical involvement, but a striking point from the RCA documents is that, in every case seen, the required medical post-fall sticker was not completed. This is reflected in the separation of nurses and doctors in relation to falls prevention training, where there is no co-ordinated approach.

Is root cause analysis really root cause analysis?

The RCA process may be seen as more of a ‘signing off’ exercise than an example of knowledge brokering for in-depth organisational learning aimed towards service improvement. While there is evidence of learning and change at ward level, some interviewees question whether or not the root cause of incidents has been properly addressed. While actions post RCA addressed issues such as adequate falls training for staff, or adherence to hospital policy on timely and appropriate risk assessment and subsequent care planning, it could be argued that a deeper issue was missed.

I just think rather than it saying, ‘The staff are not filling in the paperwork correctly,’ the learning might be that, ‘they weren’t filling it in correctly because they were so stretched and they’d been really pulled so paper thin at that stage that something had to give and unfortunately in this case it ended up being detrimental’.

Ward manager, H-MLM, SUI no. 5, hospital A

While actions are largely confined to ensuring staff compliance post RCA, there was little evidence of actions reflecting deeper issues mentioned in interviews.

The [risk assessment] paperwork was a paperwork exercise. So people were doing the assessments, but it does not mean anything. It’s not changing their practice. And then, so a patient falls and you do all the checklists and stuff after that, but it’s not actually influencing how they look after the patient.

Ward manager, H-MLM, SUI no. 6, hospital A

To emphasise, RCA in hospital A appears to be more about compliance than learning, and that system-level issues at a deeper level are not being addressed during the RCA process. Actions are largely confined to easily manageable, tangible areas of care, rather than the more nebulous, and systemic, problems described by interviewees.

Pockets of good practice

From the evidence presented so far, it is apparent that good practice relies on individual H-MLMs, rather than structures in relation to knowledge brokering after RCA in these cases. Dissemination of actions and learning is often unco-ordinated and happens on an ad hoc basis. However, it should be noted that there are pockets of good practice visible in many of the RCAs in hospital A. As identified in Chapter 5, leadership by H-MLMs appeared crucial to this, with ward managers and, in some cases, their deputy ward managers, central to the involvement of others in knowledge brokering, and in fusing exogenous knowledge and endogenous knowledge for service improvement. Examples of these pockets of good practice include:

• The ward manager in SUI no. 4 took a proactive approach to improving falls prevention awareness after undertaking RCA. She encouraged her deputy ward manager to undertake a project around falls in their clinical area, and, subsequently, the deputy ward manager was made Falls Champion for the ward. The ward manager also uses time out days to disseminate learning and actions from RCA, utilising her deputies to capture any staff not attending the time-out day. She describes the thinking behind her approach, which involves encouraging staff to think ahead rather than a culture of retrospective learning: ‘They’re focused on what happened after the fall whereas I’m trying to push them to think about, “Well, you know, Fred’s been with us 2 weeks now and when he gets agitated that’s usually a sign that he wants a wee. So look for signs of agitation and then consider using a bottle or going to the toilet or whatever so that he’s not getting so agitated he tries to stand up and ends up having a fall”‘.

• In SUI no. 2, the ward manager encouraged one of the band 6 nurses to complete and present the RCA, with her support: ‘Actually as you do them [RCAs] it’s a really good way of joining the dots, finding out why, and I use them really quite constructively and think of them constructively now. So [the band 6 nurse] did this one. It was the first time she’d done one and presented it and she was able to connect the dots and she found it really useful to do’. This manager also encourages staff to view RCA as an effective learning tool: ‘When I talk to staff about them I do put it in a positive light. You know, it is an investigative tool. We need to find out what happened, but it’s not all about you’ve done wrong and it’s not punitive.’

• The ward manager in SUI no. 5 described how best practice in relation to falls prevention is being dealt with at directorate level: ‘It’s basically the senior nurses. We meet as a directorate and it is all band 7s off the ward, band 6s if they can be released as well. Personally I like my band 6s to go. Not all of them because that wouldn’t be okay, but they take it in turns to go. Practice development matrons, matrons, health and safety matrons, anybody who kind of might have to get the information together, but it’s just like the nine wards specifically.’ This shared learning is then communicated back to the ward: ‘And we report back to them here via staff meetings, forwarding e-mails, and we also have a board which we update for more regular information.’

These examples of good practice are evidence of effective leadership at ward manager level. They show H-MLMs making a personal investment in changing practice and developing staff, and peer-level learning and information sharing.

In contrast, there are also examples of less than ideal practice apparent across the cases. The main areas for criticism include:

• An ad hoc, unstructured approach to knowledge brokering. This is particularly evident in interviews where members of staff have observed changes to ward practice, but are unaware of the basis for the alterations. For example, one non-registered nurse describes a change in practice that happened while she was on leave: ‘I’ve just been off for a fortnight where I haven’t got a clue what’s happened in the last fortnight while I’ve been away. Nobody’s sort of said, “Oh, this has happened and this has changed” sort of thing and I’ve just suddenly found that there’s all these yellow stars everywhere on the backs of boards and people have got yellow bands on and I’ve had to ask, “Well, what are they for?” “It’s for the falls risks.” Okay, well it would have been nice to be told that things like this have changed because if you’re not told then you don’t know’ (non-registered nurse, SUI no. 6).

• A lack of direct communication of RCA findings and actions, particularly in relation to staff not having access to the RCA report itself. In SUI no. 6, the Falls Champion for the ward had not seen the RCA report until it was shown to her during the interview, and had never attended a Falls Committee meeting either.

Evidence from the interviews suggests that while there are pockets of good practice, these are often based on the individual actions of particular H-MLMs, specifically some ward managers. More often, knowledge brokering after RCA is lacking in co-ordination, and undertaken on an ad hoc basis, with the result that knowledge is not being brokered effectively downstream to the clinical front line for a service improvement effect. Meanwhile, knowledge brokered upwards through clinical governance structures has little strategic impact; rather, it shows ‘mere’ compliance with the need to show that SUIs have been dealt with.

The Falls Champion

The role of Falls Champion was prominent throughout the interviews in hospital A. Once again, there was evidence of a lack of co-ordination in the development and enactment of the role:

• Falls Champion selection happened via two mechanisms. There were cases where an individual had embraced the role, or had actively sought it out. However, there was also evidence that the role was being ‘given’ to band 5 nurses. The deputy ward manager in SUI no. 5 described how the Falls Champion on her ward came about the role: ‘So at the time a lot of staff nurses had got their own link nurse roles and [xxx] had come in without anything and this role needed filling, so [xxx] sort of fell into it really, which happens sometimes’.

• While the role of Falls Champion was seen as an opportunity for knowledge to be brokered at peer level, with the majority of Falls Champions being a relatively low-status band 5 or 6, there was evidence of a lack of support for them in effectively enacting the role. This was apparent at ward and organisational level. In SUI no. 5, the deputy ward manager seemed unsure as to what exactly the Falls Champion did: ‘Now I’m talking to you, it’s made me think about things that I need to discuss with [her] about what she’s teaching and what data and making sure she’s putting current data on the board’. Similarly, in SUI no. 6, there was evidence of a lack of cohesion, with the Falls Champion not having seen the RCA report, despite her name appearing against some of the actions. This Falls Champion also described the difficulties of achieving her allotted protected time to undertake the role effectively: ‘I’m supposed to be given 6 hours a month which I’ve not actually had, so it’s been difficult’.

The Falls Champion role seems ideally suited to enhancing knowledge brokering in the clinical area, and there is potential for the role to be developed in this way. However, evidence from these cases suggests an underutilisation of Falls Champions, with patchy and sporadic approaches seen across clinical areas. Some respondents suggested that it may be best if the role falls to H-MLMs, such as deputy ward managers, with some legitimacy in the nursing hierarchy to ‘make things happen’.

The limitations of knowledge brokering via informal conversation

With the exception of one registered nurse band 6 (who had no knowledge of the SUI), all respondents across all nursing bands stated that they had heard about the SUI, but that they had heard about it informally through conversations with colleagues. In many cases, the conversations were prompted by withdrawal of drug administration duties for two registered nurses, which consequently increased the workload for their colleagues on shift. While many respondents referred to ‘an open communication culture’ among their peers, it was evident that little knowledge had been brokered within nursing that placed the incident into context, i.e. that the nurses involved were under pressure from the patient’s family to get the patient home to die, but experienced difficulties of communication between the family and the community district nursing team. Instead, the focus of conversation about the medication/transition incident was on the SUI being a result of using a syringe driver. The resultant learning from the incident appeared to be restricted to the correct and careful use of a syringe driver, with many respondents reporting a heightened sense of fear, with some even admitting that they would avoid its use.

I remember the first time I actually found out about it. Two of the staff that were involved were on shift and a colleague from another zone asked me to come and check how to set up a syringe driver. Although I’d had the initial training, I’d never physically used the driver myself, so I said, ‘Oh, I haven’t been here for a year. I’m not the best person. I’d want to watch it a few times’. Then I said, ‘Why don’t you ask [xxx]? She replied, ‘I can’t ask her because she isn’t allowed to do it any more’. There was fear in everybody’s face. It was so scary. You would come into work and you could be working with three or four people that couldn’t do drugs. That made your workload go up 10 times and I felt more at risk of my own PIN number [nursing registration] and me making mistakes because you were having to do double your workload for somebody else and, to be perfectly honest, I think it was very poorly managed.

Registered nurse band 5, hospital Z

Owing to the lack of formal detail disclosed about the incident, combined with the very visible consequence for two members of staff (the removal of drugs responsibility), the learning from the incident is consistently reported by nurses across all bands as one of ‘fear’ and caution. This finding is supported by band 7s and 8s:

From my point of view, I don’t feel that the changes are completely embedded yet because staff are still fearful of using the syringe driver.

Registered nurse band 8, hospital Z

The following excerpt from interview reveals how a registered nurse equates the use of a pump brought into the hospital by the patient to the use of a patient’s own drugs and inhalers as encouraged by pharmacy:

If a box came in from the community like that, would you administer the drugs from it?

Patients come in with their own medications all the time and, yes, we do administer from those. We’re actually told by pharmacy that if a patient has their own drugs, then we should use these drugs. If they run out, that’s when we order. So because of the expense of the medications and things like inhalers and any kind of unusual medications that we wouldn’t ordinarily have in stock, we use the patient’s own. So I suppose if it’s all in date, if it is the correct dose and you’re familiar with that pump, I wouldn’t see why it wouldn’t be used.

It’s actually against policy [to use external equipment].

Really?

Registered nurse band 8, hospital Z

Conversely, other nurses express surprise that a registered nurse would use equipment from outside the Trust. Meanwhile, they also exhibited that they had gleaned little knowledge of the details of the SUI, other than that via informal conversations among colleagues.

I’m surprised though that they would use equipment that’s come from outside of the Trust. [Interviewer: Yes, that was the mistake – that it shouldn’t have been used.] However, I don’t know the full incident. I assumed that we [hospital Z] had two different syringe drivers and we’d used the wrong one, not that we had used one from the community.

Registered nurse band 5, hospital Z

Confusion remained in AMU about syringe drivers. A matron on AMU recalls the following recent incident:

There was an incident the other day and somebody said, ‘Oh, this patient’s on this syringe driver (one provided by the community)’. I said, ‘You need to speak to the doctor and ask him to prescribe something in the interim whilst you set up one of our syringe drivers’. And she said, ‘Why?’ I asked, ‘Do you not recall the incident?’ She went, ‘Well yes’. I said, ‘So they don’t stay on it’. She knew about the previous incident, but didn’t relate it to the similar situation she faced.

Registered nurse band 8, hospital Z

There also appears little or no attempt to formally rectify the situation and embed learning locally, other than H-MLMs ‘telling off’ staff when they see them doing the wrong thing. Clearly, while this may rectify the immediate behaviour of the individual, this relies on H-MLMs, such as matrons and ward managers, ‘watching’ staff at all times. The feeling of being ‘watched’ is a theme that emerged from a number of interviews, with adverse consequences for staff in terms of confidence in their own practice:

Because this [SUI] has happened, they’re [H-MLMs] picking up on every single thing and it is making people paranoid that you’re being watched. Then, because you’re being watched, you doubt your own practice and your own skills, because there’s that pressure, if you get one thing wrong, then . . .

Registered nurse band 6, hospital Z

Many staff viewed the decision to suspend two nurses linked to the SUI from drug administration as ‘punishment’, which was deemed humiliating to the individuals concerned.

I really felt for those two nurses suspended from drug administration. Yes, there was an error, but they were humiliated. I know obviously you have to go through certain protocols, but it was very demoralising.

Registered nurse band 5, hospital Z

While punishment has sent a very clear message that a SUI has occurred, it does not effectively promote or enable learning from the incident. Reflecting upon the learning gained from the SUI, two senior nursing respondents discuss how things could have been done differently in order to learn from the incident for improving the quality of care:

I think if we were to do it again, if I was the manager, I’d be talking to the individuals more and saying, ‘Can we discuss it? It could have happened to any of us under that pressure. We need to talk about it and let everybody know. You haven’t failed’. However, I think they think they’ve failed and they feel guilty, don’t they, and they’re frightened.

Registered nurse band 7, hospital Z

In summary, an absence of formal knowledge brokerage by H-MLMs about the SUI has created an environment where nurses have been forced to rely upon informal conversations between colleagues to understand why their colleagues have been suspended from administering drugs. The consequence of such informally based conversations is the evolution of what was frequently referred to by nursing staff in AMU as ‘Chinese whispers’, where certain details are incorrect and/or progressively exaggerated. Rather than learning about the dangers of using drugs and equipment originating from outside the Trust, staff learned to be fearful of using the Trust equipment, compromising the quality of care to patients. In short, in this SUI, we see the effects of H-MLMs not enacting a knowledge-brokering role for service improvement. Not only did service improvement not occur, but the quality of care seemed to actually get worse. This was exacerbated by top-down pressure from managers to move patients.

I just see the managers coming in to push people out, get people in, push people out, but they’re not concerned about what we have to do with the patients while they’re here.

Registered nurse band 5, hospital Z

A number of registered nurses state that they feel unsupported by management, creating a situation of low morale:

Management are more interested in the way things look, than the way they are.

Registered nurse band 6, hospital Z

In summary, pressures in AMU to move patients shaped the way that H-MLMs enacted their role. At the same time, we note that those H-MLMs applying pressure to staff on AMU were doing so because other H-MLMs situated on wards are slow to take in patients, often because they too faced similar pressures. Again, the metaphor of a ‘broken chain’ seems apt.

Because of the uniqueness of the unit, you’re under pressure. A lot of the wards can say, ‘No, we’re not ready yet’. We don’t have that privilege here. Our doors are always open. We have them queued up down the corridors and you’ve just got to keep on top of it.

Registered nurse band 5, hospital Z

Knowledge brokering at the system level

While there was some variability among nurses with regards to their awareness of hospital Z’s policy about drugs and equipment originating from outside the organisation, when informed of the context in which the SUI occurred (that the patient was at ‘end of life’, and did not wish to die in hospital), many understood the pressures faced by the nurses, and were not certain that it would not occur again.

People don’t do end-of-life 9 to 5. It’s a 24-hour service. However, community service tends to be 9 to 5, when patients can be discharged at 7 or 8 o’clock. I know people are desperate to get home, and if a patient’s wish is that they want to get home . . .

Registered nurse band 5, hospital Z

As intimated above, the patient was unable to get a bed at the hospice, as was his wish, due to the bed manager in the hospice working only daytime hours. The patient thus expressed his wish to return home to die, rather than to wait in hospital overnight, with the aim of transfer to the hospice in the morning.

They [the hospice] were basically saying, ‘Well, you’ll have to call back at 9 o’clock tomorrow morning’. I was like, ‘He has to go tonight. What do I do?’ No help at all. And then the family were adamant that he wasn’t to die in hospital, and so was he. Then we contacted district nurses, but it was out of hours again, and there was only a messaging service.

Registered nurse band 5, hospital Z

Once aware of the wider context surrounding the SUI, we asked whether or not the report findings and recommendations had been shared with the community. While hospital Z policy does recommend ‘Learning from the incident should be shared with the community services to raise awareness and minimise the potential of a similar incident occurring’, there was no knowledge among our respondents that this has been achieved. A band 8 registered nurse suggests that the community nurses involved in the incident have failed to co-operate:

My understanding is that there wasn’t very much co-operation in the initial stages of the investigation and obtaining statements from those individuals with a community perspective. They denied any knowledge of discussions (about the patient in AMU). Then there was a lot of, ‘We’re not getting involved. It’s nothing to do with us. We’re not providing statements’. In the end, when the first individual that was doing the investigation left and the second took over, they bypassed the community because they weren’t getting anything from the manager at all.

Registered nurse band 8, hospital Z

In summary, not only is brokering of knowledge absent within the organisation, but around medication management, and more notably transition of patients, there exists a significant challenge of brokering knowledge between organisations. At least in hospital Z and this particular SUI, no H-MLM is able to enact the necessary knowledge-brokering role for service improvement.

Mechanisms for knowledge brokering

Like much of the knowledge brokering discussed in previous empirical sections, across all our hospital cases, there was a strong sense from those on the clinical front line that managerial diktat was imposed from above, often via e-mail. The use of e-mails as a mechanism for brokering knowledge was generally met with disdain, with all staff stating that they did not have time to read e-mails, many even claiming that they often did not get a break:

You know, on a shift, when do you get a chance to check your e-mails? I’ve got hundreds and honestly I don’t have time to delete them.

Registered nurse band 6, hospital Z

One band 8 registered nurse, however, has a very different view from all other respondents. H-MLMs may need to engender a stronger learning culture among frontline staff should they want to broker knowledge for service improvement.

But they [registered nurses and non-registered nurses] have time to go for breaks, they have time to go to cigarette breaks and they have time to go and have a break. If an individual wanted to access information from e-mails, they can. There are several computer points throughout the wards that they can access because they access their e-roster from those points on a frequent basis. Time is not an issue. They are busy, I’m not disputing that at all, but if you can go for a break, go for a cigarette and you can access your e-roster, why can’t you access your e-mails?

Registered nurse band 8, hospital Z

Similarly, time constraints are cited as preventing staff from looking at the noticeboard in the staffroom, and time for completing online training assessments was limited.

On a more positive note, there was considerable support across all nursing bands, including non-registered nurses, for home access to e-mails and online training modules. However, while the option to access e-mails and online training modules during personal time was welcomed, some respondents were wary of being held accountable for home-based learning in excess of their working hours. This raises the spectre of work–life balance.

I’m all up for learning at the end of the day, but obviously if it was at home, as long as it didn’t become too regular that it became a lot of homework, as long it was out of your own choice, and as long as you don’t get punished for not looking at certain things at home.

Non-registered nurse, hospital Z

A number of staff recalled a time when the noticeboard was kept up to date and colour-coded with information, creating a visual display that was deemed valuable for brokering knowledge, with emphasis on the positive rather than a punitive approach to improving the quality of care.

It went from being all these different colours, which does draw you in. Then it was serious things, such as, ‘We didn’t reach 100% in this audit, so we need to try better’. It had a positive spin; now it’s almost like a ‘how poor we’re doing’ board. We didn’t do this well. You didn’t do this. We’re all rubbish’. Everything’s just very negative at the minute.

Registered nurse band 5, hospital Z

As at hospital A, there was considerable support for ‘link’ roles, where someone has responsibility for championing specific issues, representing a knowledge broker between the H-MLM with formal responsibility for patient safety and learning and the clinical front line. The role of champion or link worker was welcomed by all, but always with the caveat of ‘protected time’ for individuals. Many appeared sceptical that this would happen, highlighting the low morale among nurses on AMU with regard to feeling supported in their training needs. So, even if health-care professionals are able to enact the H-MLM role, they may be unwilling to do so because they might feel that they are not sufficiently resourced:

You’ve got to look at it and say, ‘Okay, if we’re going to do this, we need somebody to be given time to go away from this and do this role’.

Registered nurse band 6, hospital Z

Teaching sessions led by one H-MLM (a medical doctor) were mentioned frequently by respondents across all nursing bands, including non-registered nurses. The description of (a doctor’s) teaching highlights that he attempts to broker the right knowledge, to the right people, in the right way, at the right time.

He did actually do teaching sessions specifically for nurses, stuff we actually use. He actually started those again before he actually went on sick leave. I don’t know whether he has plans to restart them, but they’d be a fantastic help because, as I say, he does provide so much information. He makes sure that your knowledge is correct to actually receive the information in the first place. He actually starts with a question-and-answer thing, and then tells you more about what he wants you to know.

Registered nurse band 6, hospital Z

There were, however, mixed feelings regarding the usefulness of ward meetings for brokering knowledge. Many suggested that the ward meetings tend to be used to ‘air frustrations’. The following quote suggests that tensions between non-registered nurses and registered nurses come to surface at ward meetings:

Some of the higher bands blame the lower bands [Interviewer: Could it get a bit heated?] Yeah, it has done in the past.

Non-registered nurse, hospital Z

In contrast, there was considerable support for the idea that knowledge could be brokered formally and on a daily basis at handover.

During your handover you get a quick 5-minute session about anything, but nothing’s discussed in depth [by H-MLMs]. You’re given a brief overview of any incidents, or any kind of new issues that we’re dealing with now, and that’s it. If we could spend 5 or 10 minutes just going over particular issues that have come up, if it was communicated and cascaded down to the staff that way, I think that would be very beneficial.

Registered nurse band 5, hospital Z

The handover could also be used in a similar vein to broker knowledge upwards from the nurses themselves to more senior managers, through H-MLMs, although again it is not currently felt to be effective:

Well we’re quite vocal to our managers. They’re quite good. They’re really good ward managers as in we can go up and I can say anything to them, as in, ‘I don’t think this is right,’ and we can moan and say what we want about it and a lot of the time they do agree with us. They know that there’s certain points of this unit it just doesn’t work, but then it seems to . . . I mean I’m pretty sure that they will tell the matron and they will tell their bosses because that’s the kind of people they are, but it seems to stop there, do you know what I mean, and it feels like nothing goes further.

Registered nurse band 5, hospital Z

In summary, there is a range of potentially useful mechanisms for knowledge brokering highlighted by respondents. However, the organisation does not take full advantage of these, specifically supporting the role of H-MLMs for knowledge brokering. At some point, in brokering knowledge upwards, the chain appears to break.

The doctors’ voice

The doctors’ voice is evident in our study, but relates mainly to those geriatricians positioned in H-MLM roles and who brokered PSK. The voice of other doctors is notable by its absence. Indeed, when running focus groups in work package 3 around organisational learning and service improvement following RCAs, most did not attend. Outside the ranks of geriatricians, doctors did not appear to see patient safety as a domain that they sought to impact (although we assume that they took it seriously in their professional practice). Thus, while we were able to interview geriatricians relatively easily, we interviewed few doctors beyond their ranks (e.g. GP, consultant acute medicine, doctors in senior clinical governance roles). As they are major actors in delivery of older person’s care, the lack of a medical perspective beyond the ranks of geriatricians is significant. Consequently, we encourage more research to examine doctors’ interaction with the issue of patient safety beyond their immediate clinical practice, which addresses the challenge of drawing them more into the patient safety domain as potential knowledge brokers.

Focus on falls

In work package 1, we explored falls, medication management and transition, with those external disseminators of PSK; for example, two of the three respondents from the Department of Health focused upon medication management as the issue of main concern. However, in work packages 2 and 3, falls came to the fore. To a large extent, our focus here was driven by managers and clinicians’ emphasising the importance of falls as an issue to which they had to respond, and was, therefore, of strategic priority for them, i.e. falls represented the area to which gatekeepers in the hospital cases were prepared to give privileged access. In part, the patient safety issue of falls represented a more bounded area to empirically investigate, i.e. there was an element of pragmatism in our choice. However, we suggest both that falls is an exemplary issue for our theoretical and empirical concerns, and that falls, medication management and transition are interdependent; for example, a fall may result from an older person transitioning into a general medical ward, where there is less expertise in this domain of patient safety, and the prospect for a fall may be fuelled by a complex medication regime. Nevertheless, we sought to counter the emphasis upon falls, when examining the SUI in hospital Z. This we categorised as a medication management issue, but we highlight that it also encompassed transition across hospital accident and emergency department, primary care and social care settings.

Comparative sample sizes

Hospital case A proved the site in which the most interviews, observation and documentary analysis ensued. Mental health case C was a specialist provider of care and staff, working into the hospital, specifically to support care for those older persons that were cognitively impaired (and may suffer more than most from falls, for example), hence we undertook a smaller number of interviews. Hospital Z, we used as a validation case for our emerging analysis, and within which we focused on a medication management (encompassing transition) patient safety issue. Readers may, however, question the relatively smaller number of interviews carried out in hospital case B (n = 16) than in hospital case A (n = 27), during work package 2. That there was a difference in number of interviewees is revealing of one our analytical themes, which relates to the effect of external performance management to which health care organisations are subjected. Hospital case B had been subject to external scrutiny from a government body, focused on inadequacies in older persons’ care, in the course of our research. This had a ‘suppressant effect’ upon their disposition to learn from failure, and gatekeepers failed to respond to communication via e-mail to continue their identification and accessing of relevant respondents for interview. Thus, we withdrew from the site of hospital B, recognising the situation faced by our gatekeepers and other managers and clinicians within hospital case B that caused them to indirectly withdraw support. We suggest that each organisation may have different structures and cultures, which impact brokering of PSK by H-MLMs, which may necessitate a need to unpick such local-level contingencies. Nevertheless, institutional level antecedents related to policy pressure and professional hierarchy are likely to play out in a similar way across all health-care organisations around the brokering of PSK by H-MLMs. 90

Use of social network analysis

Social network analysis proved particularly challenging in the light of brokering relationships that ostensibly veered between ‘everyone’ and ‘no one’ across the pathway for older persons’ care. Our difficulty in reliably bounding a brokering network around PSK related to the care of older people mirrors the contrasting views of our respondents where more generalist professionals (e.g. geriatricians, matrons, nurses) view elderly care as ‘mainstream business’, recognising the very high proportion of older people who occupy hospital beds, and those more specialist clinicians (often more senior H-MLMs, and non-hybrid senior managers) who neglect to recognise the more general applicability of PSK relating to the care of older people to their own patients (many of whom are older people). Given this, we report SNA not within the main body of our report, but within Appendix 1. Our purpose in reporting within an appendix is to illustrate the type of data generated by SNA, which in the case of this study, however, we warn is not sufficiently robust to include as part of our central analysis. For an exemplar of use of SNA in health-care research, which combines well with the type of qualitative data that formed the bulk of this study, we refer readers to Currie and White’s study of knowledge brokering in paediatric nephrology. 19 We note increasing use of SNA in health-care research, including that commissioned by NIHR HSDR, but also that others have also reported it as challenging regarding bounding the network and generating the necessary sociometric data. 170,171 Consequently, we suggest that SNA should be used with care, relevant to particular settings, and this may represent a pragmatic decision. Nevertheless, we highlight, our SNA does identify some exceptional actors within our data set, who are capable of brokering PSK upwards, downwards and across the organisation. These actors are more senior H-MLMs who are connected to the organisation’s most senior committee and correspond with our more qualitative findings of work packages 2 and 3. SNA data can be found in Appendix 2.

Moving onwards from inductive theory development

Our study approach has been one derived from a more qualitative organisational science tradition, which privileges as procedural assessment criteria the importance of theory development. Our study develops theory to (i) render visible why some H-MLMs are more disposed, and more able than others, to broker PSK for service improvement; (ii) understand how the chain of knowledge brokering might be enhanced so that exogenous and endogenous knowledge is better fused for service improvement effect. Nevertheless, we recognise that other disciplines, specifically clinician-scientists,172,173 might privilege more positivist, deductive approaches to addressing the problem of brokering of PSK by H-MLMs. With this in mind, we suggest that other, more positivist researchers might derive more testable propositions from our model of knowledge brokering presented in Figure 2.