THE KNOWLEDGE BROKERING ROLE OF THE HYBRID MIDDLE MANAGER: THE CASE OF HEALTHCARE & WARD MANAGERS

1. THE KNOWLEDGE BROKERING ROLE OF THE HYBRID MIDDLE MANAGER: THE CASE OF HEALTHCARE & WARD MANAGERS Professor Graeme Currie, Associate Dean Research, Warwick Business School

2. MIDDLE MANAGERS IN THE NHS: ‘MEN’ IN GREY SUITS? • Generic transfer of ideas from private sector to public sector regarding delayering of middle managers because they don’t add value • In NHS, policy rhetoric about delayering escalated since mid-1990s, when John Redwood, then Health Secretary, castigated them as ‘men’ in grey suits & set about reducing M2 grades • Current coalition government pledged a cull of middle management posts by 45 per cent

3. OR (WO)MEN WHO ADD STRATEGIC VALUE? • Private and public sector organizations find reduction in costs associated with delayering has not been realised • Why? because tacit knowledge is lost as middle level managers (MLMs) ‘walk out of the door’ (Floyd & Wooldridge, 2000) • This links to literature that characterises MLMs as ‘knowledge brokers’ (Shi et al. (Delmistri & Walgenbach, 2005; Shi et al., 2009), ‘knowledge engineers’ or ‘knowledge translators’ (Floyd & Wooldridge, 2000; Nonaka & Takeuchi, 1995; Pappas et al., 2004)

4. RESEARCH GAP? • Need more nuanced understanding of strategic value of MLMs -- in particular contexts, & which cadre of MLM

5. ‘HYBRID’ MIDDLE LEVEL MANAGERS • ‘Hybrid’ MLMs specifically has a knowledge brokering role, defined as, ‘getting the right knowledge to the right people, in the right place, at the right time’ (Hargadon, 2002) • Hybrid MLMs are not ‘men’ in grey suits, but managers that connect clinical & managerial worlds; e.g. from ward manager to clinical director (Llewellyn, 2001) • ‘Pure play’ or general managers are 3 per cent of staff in a hospital, with hybrids around 30 per cent, in a typical hospital • ‘Denigration of managers & role they play in delivering high quality care will be damaging to the NHS & patient care’ (Walshe & Smith, 2011) • In healthcare focus has been upon doctors as hybrid MLMs, but nurses are largest proportion of hybrid MLMs, worthy of greater attention, particularly around knowledge brokering for patient safety (see recent scandals, such as BRI paediatric heart surgery & Mid-Staffs)

6. KNOWLEDGE & KNOWLEDGE BROKERING • Located within strategic management literature: Knowledge-based resource of organization crucial to enhanced performance (KBV) (Teece et al., 1997) • Two types knowledge to be brokered: external or exogenous knowledge & internal or endogenous knowledge. Hybrid middle managers can fuse both for service improvement if certain contingencies are in place • Take a practice-based view of knowledge: Knowledge is context-specific, relational, subjective, tacit, so that it is ‘sticky’ to mobilise (Orlikowski, 2002). • In healthcare, knowledge mobilisation characterised by ‘(tacit) mindlines as much as (explicit & codified) guidelines’ (Gabbay & Le May, 2004) • Further, power differentials & cultural differentiation render knowledge mobilisation even ‘stickier’ • Knowledge management might even be an ‘oxymoron’ • Hybrid MLMs important role in understanding how knowledge can be used, & have credibility (professional legitimacy) to broker knowledge from/into their professional communities

7. RESEARCH DESIGN • 3 year study (2011-2013) of the role of middle managers in brokering internal & external patient safety knowledge for elderly care (funded by NIHR HS&DR) • Took place across 3 comparative hospital sites (Phases 2 & 3 of research). Hospital 1 ‘dropped out’. • Encompassed 150 interviews: In Phase 1, with external providers of knowledge (30). In Phases 2 & 3, with hybrid (nursing & medical backgrounds) & general middle managers (90) delivering service or in clinical governance, senior managers (30) • Complemented by observation of clinical governance meetings & wards (100 hours) & 8 focus groups of 2 hours each in Hospital 2 • Focused on most common SUIs in elderly care: falls, medication management, transition into/out of/across hospital (identified from NPSA documentation) • Comparative approach was successive cases, to allow for ‘progressive focusing’ • Mixed deduction (coding framed by literature) and induction (derived from data), as analysis moved from informant-centric to researcher-centric codes

8. PHASE 3: LEARNING & SERVICE IMPROVEMENT FOLLOWING RCAs RELATED TO FALLS IN HOSPITAL 2 • Undertook 30 interviews in Hospital 2 across 8 SUIs related to falls • Attended risk management committees, where RCAs were presented (provided some triangulation of interview data) • Followed up with 8 focus groups, year after RCA presentation, to assess learning & service improvement • Encouraged organization development through 2 presentations to Falls Operational Group (also authenticated analysis)

9. BEST PRACTICERCA CASE 4, HOSPITAL 2: KNOWLEDGE BROKERING BY A WARD MANAGER FOR PATIENT SAFETY IN ELDERLY CARE • The ward manager in case 4 took a proactive approach to improving falls prevention awareness after leading a team undertaking Root Cause Analysis of the serious incident. She brought together research-based evidence about what constituted best practice in falls management, and local understandings of the care system for frail elderly patients. She then delegated her deputy to undertake a project around falls in their clinical area, and subsequently made the deputy ward manager falls ‘champion’ for the ward. The ward manager also uses time out days to disseminate learning and actions from Root Cause Analysis, 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 two weeks now and when he gets agitated that’s usually a sign that he wants a wee. So look for signs of agitation and the 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’”. She described herself as embracing the managerial role because it allowed her to improve quality of healthcare beyond that possible as an isolated clinical practitioner.

10. BEST PRACTICERCA CASE 2, HOSPITAL 2: KNOWLEDGE BROKERING BY A WARD MANAGER FOR PATIENT SAFETY IN ELDERLY CARE • In case 2, the ward manager mentored main grade nurses in Root Cause Analysis, including alerting these nurses to external sources of evidence, so that organizational learning following a serious falls incident was widely distributed to engage all staff in taking necessary service improvement actions: “Actually as you do them [Root Cause Analyses] 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 … 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”. At the same time, the ward manager was able to link upwards to the falls committee, chaired by the CEO of the hospital, and shape governance systems and processes, so that they were better coupled with clinical practice. She described herself as “having all the social connections to make things happen”.

11. BEST PRACTICERCA CASE 5, HOSPITAL 2: KNOWLEDGE BROKERING BY A WARD MANAGER FOR PATIENT SAFETY IN ELDERLY CARE • The ward manager in case 5 described how she led organizational learning amongst her peer professional group: “It’s basically the senior nurses. We meet as a directorate and it’s all band 7 s 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 emails, and we also have a board which we update for more regular information”. Meanwhile, having equipped senior members of her team with skills and knowledge around quality and safety improvements, the ward manager was able to spend time accessing latest best practice, “through internet searches, but also through external events, where I learn what other hospitals are doing, and what the latest policy and research advice is”.

12. COMMON PRACTICE • A ‘blame’ rather than learning culture ensues, so that ward managers and other nurses become defensive • Mere compliance with RCA process, rather than learning & service improvement (risk committee doesn’t follow through) • Ward manager & deputy ward manager deal with RCA process, and don’t involve others • Doctors don’t see RCA as their responsibility, with senior doctors influencing junior doctors regarding this • If there is learning & service improvement, it is very localised

13. KNOWLEDGE BROKERING BY WARD MANAGERS: FALLS IN ELDERLY CARE • Hybrid MLMs can broker exogenous knowledge ‘downwards’ from external producers & disseminators of evidence, & broker endogenous knowledge ‘upwards’ from clinical frontline, for learning & improvement • Hybrid MLMs are uniquely positioned to potentially fuse exogenous & endogenous knowledge for learning & improvement because they span the boundary between managerial structures for clinical governance & local clinical context • Hybrid MLMs can broker across organization(s)/departments, as well as within organizations/departments • Potentially, hybrid middle managers could broker knowledge between external environment & organization, through research or policy roles (more taken up by those with medical background) • But not all hybrid MLMs broker knowledge in this way (see Francis Report, 2013)? Why?

14. CONTINGENCIES FRAMING STRATEGIC ROLE OF HYBRID MLMs • Knowledge brokering roles framed by power differentials, which is a consequence of inter- and intra-professional status hierarchies. But it is often those closer to clinical frontline (& of lower status) that are best positioned for knowledge brokering. How do we mediate? • Lower status knowledge brokers may be willing to broker knowledge, but need to develop social capital to mediate status differentials; i.e. connecting across hospital, upwards (as well as downwards), even into more powerful groups, through the development of understanding, trust & reciprocity (seems more available to ‘exotics’) • Hybrid middle managers (including lower status actors) may be unwilling (as well as unable) to broker knowledge. This is a matter of their disposition towards their managerial role, which might be viewed as a transition in identity

15. CONCLUSION • We should recognise strategic value of middle managers, including the knowledge brokering role of relatively low status, hybrid, MLMs • Hybrid MLMs can fuse exogenous & endogenous knowledge for learning & improvement • This is contingent upon: professional legitimacy; social capital; identity

16. SO WHAT? PRACTICE RELEVANCE, AS WELL AS ACADEMIC RIGOUR • Normative approach at the individual level (for doctors & nurses): Mentoring, coaching, and other socialisation tactics, such as induction, education about patient safety, leadership development interventions, putting hybrid middle managers in touch with external evidence. • Normative approach at the organizational level: Develop a learning, rather than blame, culture; develop networks of hybrid middle managers • Coercive approach: Performance management system that does not merely require hybrid middle managers to undertake root cause analysis after a serious untoward incident, but to actively promote learning and service improvement across their team following this.

17. WHAT ARE THE ACADEMIC OUTCOMES? • Academic publications: Conceptual paper about knowledge brokering role for hybrid middle managers in British Journal of Management (special issue on public services organizations); HR orientated paper for Human Resource Management about HR prescriptions to support knowledge brokering role for hybrid middle managers; Paper about organizational ambidexterity for Human Resource Management; More theoretical paper, drawing upon Bourdieu’s notion of ‘capital endowments’ to explain how mediate lack of power and disposition towards knowledge brokering (for Organization Science); Paper about ‘absorptive capacity’ for Journal of Public Administration Research & Theory • Academic Impact: REF requires this, & working into Hospitals 2 & 3 to support changes in processes & structures around learning & service improvement from SUIs. Policy report written for NIHR HS&DR. Employed corporate communications company to write accessible communications to disseminate to all NHS organizations • Academic Research Income: Used some of the ideas (notably absorptive capacity) induced from study, to gain further funding from NIHR HS&DR to examine critical review capacity in CCGs

18. ACKNOWLEDGEMENT This study was supported by the National Institute for Health Research (NIHR) HS&DR Project grant 09/1809/1073 which is currently undergoing editorial review. The views expressed are those of the authors and not necessarily those of the funders.