Table 2 Characteristics of included health studies [n = 13]

Addicott (2008)

Study design: triangulated qualitative study.

Unit of analysis: case studies of networks.

Method: semi structured interviews; document analysis; ethnographic observation.

Methodological approach: social science mixed methods.

Number: staff in 33 network meetings; 117 semi-structured face-to-face interviews.

Type: provider and commissioning representatives in health care.

When: 2002 to 2004

NHS; London, England; Cancer networks; examining mandated network structures.

Networks were under a command and control structure, under the auspices of a formalised bureaucracy. Vertical reporting rather than horizontal networking characteristics dominated. Minimal impact of these networks.

New public management theory; health services research perspective.

Braith- waite (2006)

Study design: ethnographic study.

Unit of analysis: staff in acute setting clinical directorates.

Method: observations of staff in clinical directorates in two large teaching hospitals.

Methodological approach: examination of social structure and culture of staff and leaders.

Number: multiple directorate staff; four leaders in particular.

Type: nurses and doctors.

When: 1996 to 1999.

Australia; staff in two states.

Structurally, although the boxes on the organisational charts were altered, clinical directorates did not achieve changes to deep seated social structural arrangements and professional identity. Tribal behaviours centred on professional interests and roles continued. Relationships across the professions remained partisan and political.

Culture theory; change, particularly structural change; clinical professional organisation.

Callan et al (2007)

Study design: survey.

Unit of analysis: staff in a large public teaching hospital.

Method: administration of questionnaire survey.

Methodological considerations: analysis of attitudinal data.

Number: 615 sampled respondents; 40% response rate.

Type: health employees: doctors, nurses, allied health and administrative staff.

When: 2005

Australia; Queensland public health system; large metropolitan teaching hospital; examining professional identity and responses to change.

Participants identified with small groups and departments rather than their organisation. Higher perceived status was associated with higher levels of job satisfaction, higher levels of openness to change, and lower levels of uncertainty. When threatened e.g. during change processes, people found their group identity is a protective mechanism.

Organisational change theory; psychological measurement of attitudes of health professionals.

Creswick et al (2009)

Study design: social network analysis.

Unit of analysis: emergency department staff.

Method: social network survey.

Methodological approach: assessing network characteristics in a time critical area.

Number: 109 clinical staff in an ED.

Type: doctors, nurses, allied health staff, administrative personnel.

When: 2007.

Sydney, Australia; cross-sectional analysis of an ED.

There are high levels of connectedness across the ED. ED staff mostly seek help from and provide assistance to colleagues in their own profession. There are lower levels of connectedness when staff seek help for or provide advice on medication, but this is still largely within their own profession. Participants also socalised tribally, with colleagues from their own profession.

Social network theory; social structural characteristics of various staff groups in health care.

Denis et al (2001)

Study design: triangulated qualitative study.

Unit of analysis: case studies of organisational change.

Method: employee interviews; document analysis; ethnographic observation.

Methodological approach: social science mixed methods.

Number: executive staff in 54 meetings; 117 interviews.

Type: key organisational leaders and decision-makers.

When: 1991-2001

Quebec, Canada; longitudinal change processes.

Leadership is diffused, as is power, across numerous stakeholders including external planning and funding agencies. Many forms of social structure manifest across different settings based on who dominates, how weakly or strongly coupled are teams and networks, and how change is processed. Change depends on top-group harmony; constellations of agents are fragile; change is cyclical; leadership and its relationship to those led is complex and iterative; various factors contribute to the standardization of change.

Strategic leadership process theory; organisational studies in health care.

Fortin (2008)

Study design: anthropological investigation.

Unit of analysis: observations and interviews of staff and clients in two specialty paediatric services.

Method: semi structured interviews; document analysis; ethnographic observation.

Methodological approach: social science mixed methods.

Number: observations of multiple stakeholders, particularly focused on doctors; 47 medical interviews;18 case studies of patients.

Type: doctors, other clinicians, patients and families.

When: 2005 to 2008

Montréal, Canada; University paediatric hospital examining multi-disciplinary clinical settings (intensive care and oncology).

Emergent culture of parents, paediatric patients and clinicians is characterised by participants employing differing frames of reference. Practice differs across settings. Team meetings are spaces within which negotiated order emerges from the differing perspectives. Various roles and perspectives intermingle; there are inequalities in power and relations between clinicians, amongst clinicians groups, and between clinicians, patients and families. Doctors dominate.

Micro-cultural account: anthropological- ethnographic perspective.

Helms and Stern (2001)

Study design: survey.

Unit of analysis: staff in dispersed aged care centres.

Method: administration of questionnaire survey.

Methodological approach: analysis of attitudinal data.

Number: 329 sampled respondents; 40% response rate.

Type: staff in aged care facilities.

When: ~1999.

United States of America; facilities distributed in a national organisation, covering 28 states.

Perceptions about cultural and sub-cultural features of organisations differed on six of 10 cultural dimensions. To some extent, attitudes vary across hierarchical levels, age, gender and ethnicity but not by staff tenure or functional area. The quest to create one big family across discrete organisational units which are part of a large chain is not likely to succeed, and homogenisation of culture via corporate encouragement and marketing strategies is problematic.

Organisational culture and sub-culture theory; health services studies focusing on aged care.

Hodges et al (2008)

Study design: in-depth, semi-structured interviews.

Unit of analysis: early career nursing attitudes.

Method: interviews until saturation achieved.

Methodological approach: examination of socialisation in acute care.

Number: 11 per purposively sampled staff.

Type: nurses with between 12 and 18 months of experience.

When: 2002 to 2003.

United States of America; acute care settings.

New nurses undergo a socialisation process of learning the milieu (e.g. embracing the culture, acquiring a skills set); discerning their fit and identity as a nurse; and moving through their career experiences encountering pivotal points, becoming more accomplished over time. Ultimately, these themes underpin professional resilience. Key success factors include clarifying boundaries, acquiring skills, enabling accomplishments and building relationships.

Nursing socialisation theory; acute nursing profession studies.

Hotho (2008)

Study design: in-depth, semi-structured interviews.

Unit of analysis: general practitioners.

Method: purposive interviews.

Methodological approach: investigations of GPs supportive of the formation of and leading cooperatives.

Number: 10 per purposively sampled staff.

Type: GPs with leadership roles.

When: ~2005.

NHS: Scotland; Local Health Care Co-operatives.

Even though they occupied leadership roles, participants were first and foremost clinicians rather than managers. They took on leadership roles to support professional rather than managerial interests. They at first felt idealistic about new collaborative ways of working, and self-identified as change agents, boundary-spanning medicine and management. Having a foot in each of two worlds later posed problematics for agency and professional identity.

Structuration theory; social identity theory; changing professional identities; use of scripts to narrate a meaningful story.

Matthews and Thomas (2007)

Study design: in-depth, semi-structured interviews.

Unit of analysis: health services professionals.

Method: purposive interviews.

Methodological approach: probing how knowledge about patient safety is captured in health settings.

Number: nine purposively sampled staff.

Type: seven clinicians, two managers.

When: ~2005 to 2006.

NHS: UK; secondary care NHS trust.

People prefer oral, informal communication over other methods. Communication in complex adaptive systems is fluid, dynamical and it does not necessarily support formal bureaucratic knowledge capture, and can hinder them.

Learning theory within complex adaptive systems; phenomeno- logical health studies.

Shanley and Correa (1992)

Study design: triangulated qualitative study.

Unit of analysis: case study of an organisational merger.

Method: employee interviews; document analysis; ethnographic observation; questionnaire survey.

Methodological approach: social science mixed qualitative- quantitative methods.

Number: 24 senior managers; 84 of 114 questionnaires (74% response rate) administered to decision-makers.

Type: all top managers in two organisations.

When: ~1990.

United States of America; an academic medical centre (the acquirer) and a community hospital (the acquired).

Decision processes in complex social-organisational environments is multi-dimensional. Dimensions of agreement include perceived agreement, actual agreement, accuracy and agreement and within one's own organisation. Personnel in organisations differ in views, and inter-group dynamics are key variables in understanding complex organisational interactivity and decision-making.

Decision theory in real world settings; acquisition theory; inter-group interaction studies.

West and Barron (2005)

Study design: telephone interviews of randomly sampled clinician-managers.

Unit of analysis: views of nurse executives and physician leaders.

Method: interviews eliciting information about participants' network boundaries.

Methodological approach: uncovering information about alters' ties.

Number: 50 medical and 50 nursing interviewees, all with managerial roles.

Type: all top managers in two organisations.

When: ~2003.

NHS; UK; cross-NHS Sample of experienced nursing and medical managers' social relations and social boundaries.

Nurses were tied to other nurses (60% of ties) and managers; doctors were even more strongly tied to other doctors (75% of ties). Professional homophily did not extend to each other's professions. Also strongly apparent were gender and age homophily. Participants' strongest ties were geographically close, and local communication is preferentially and normally face-to-face.

Social network theory; homophily characteristics; health services studies.

Wikström (2008)

Study design: Semi-structured interviews of purposively sampled dieticians; analysis of organisational documentation.

Unit of analysis: participants use of boundary work to increase their influence and power.

Method: interviews eliciting information about participants' advocacy vis-a-vis adjacent workplace groups.

Methodological approach: triangulated case study.

Number: 20 dieticians and two managers.

Type: clinical staff.

When: 2004 to 2005.

Sweden; University teaching hospital.

To exercise more influence, participants established a professional group, developed a narrative, advocated their competence and utility, related this to medical and nursing knowledge, developed relationships with target groups and established roles in those groups. Their influence increased as a result. Their boundary-spanning attributes included articulating competencies, emphasising collaboration, projecting social-professional identity, to some extent based on subservience to doctors and nurses. The preferred approach was not to threaten those groups. If doctors are the father and nurses the mother in a family metaphor, some dieticians describe themselves as the mistress.

Boundary roles and boundary- spanning theory; social influence theory; professional identity study.