The information-seeking network of this public health department had low density and low reciprocity. People mainly partitioned together within their divisions, in terms of turning to peers for getting information; although there was frequent cross-divisional recognition of expertise and friendship ties. ‘Professional consultants’, managers and an epidemiologist were the most central people in information-seeking and recognition of expertise networks. The office of the Medical Officer of Health acted as a small bridge exclusively connecting to all divisions. With respect to brokerage roles there were also some coordinators with various job titles who were mainly approached by staff from the same division, who may or may not be connected to the other important actors such as managers and ‘professional consultants’ in the health department.
Given the essential role of networks in the process of organizational change, understanding the network structure of organizations, and the characteristics and positions of people and their clusters in their networks can help decision-makers to develop successful implementation strategies for organizational interventions. The findings of this study on information-seeking among staff in this public health department will be discussed in the following sections, and implications for planning organizational KT interventions will be proposed.
Distribution of connections
The sociograms suggest that the nature of inter-personal connections in the health department is localized, and public health staff generally turn to a handful of people within their own division to obtain information to assist in making practice decisions. This tendency has also been reported among other health professionals. For example, Keating et al.[31] showed that, primary care physicians in a hospital based academic practice had influential discussions with an average of 4 others during six months prior to the study. The reasons why health professionals may limit their ties to a small group of informants might be due to the importance of the ease of access to the information source, and the tendency to form circles of trust comprised of peers that are similar with respect to values and concerns [32].
Density
Innovations spread through social networks. People talk about new ideas and policies and share their concerns and experiences on a daily basis. Consequently, the level of dispersion of ideas and their internalization is higher in more connected organizations than detached isolated communities. High density and reciprocity of connections are indicators of strong ties among people, resulting in greater adoption of innovations [33]. However, the association between the network density and the success of adoption is not linear and straightforward. For example, when the innovation is intended to be diffused by community leaders, lower density may increase the adoption of new strategies due to strengthening the influence of leaders over their communities [34].
According to our study findings, the density of the information-seeking connections was very low (1.2%). However, it rose considerably when the divisions were studied separately. The densest division of the network was the office of the Medical Officer of Health, with a density of 13.6%. It was the smallest division in the network, consisting of 19 actors (of whom 11 responded to network questions), in which the people had relatively close connections with each other, as well as with the other divisions. Merrill et al. in a study on work-related communications between staff in a small public health department (with the size of 156 employees) reported a density of 15% [35]. Similar to our findings, they found that the overall density was much lower than the within-program densities (31-64%), and concluded that, between-program communications were much less than within-program ties.
However, it is not possible to make a conclusive statement as to whether the observed low density was a real feature of this network, or due to the under-reporting of connections and missing values. The large proportion of missing values, big size of the organization, reliance of respondents on memory instead of choosing from a roster list, and limiting the number of answers to 5 individuals, all signify that the findings of this study might have under-estimated the real interchange pattern of information in the health department.
Reciprocity
The reciprocity of information-seeking ties was around 20%. A priori, we did not expect a high reciprocity in the information-seeking network. Since, there were individuals in the department who professionally served as the consultants and information sources, the majority of the staff were turning to them for getting information; and reverse connections were not happening frequently. However, the reciprocity within the managerial subgroup was still low (23%). Creswick and Westbrook similarly reported reciprocity of 43% for work-related problem solving, and 26% for medication advice seeking in the emergency department staff of a hospital [36]. A high proportion of unreciprocated information-seeking is probably the result of compartmentalized professional activities in the department, meaning there are a few central information sources to whom many people turn to seek information. This may be due to the personal and professional capabilities of the central people in the network, lack of sufficient expertise for autonomous practice in the staff, the formal organizational bureaucracy, or a combination of all.
Central actors
A group of ‘professional consultants’, managers and epidemiologists were the most influential people in the department. ‘Professional consultants’ and epidemiologists were also recognized most often as being experts with respect to research evidence by staff. The centrality of ‘professional consultants’ in the information-seeking and recognition of expertise networks was expected from their formal responsibilities. The ‘professional consultants’, including project specialists and health promotion consultants, have the role of experts and professional advisors in the network. Their primary role is to conduct reviews of the literature (appraise, interpret and apply research evidence) so as to provide advice on the development and implementation of programs and policies.
The centrality of two ‘professional consultants’ in division #4 was extraordinarily higher than that of their counterparts in other divisions. The highly centralized roles of these two ‘professional consultants’ could be due to the geographical proximity of staff, the exceptional capabilities of these ‘professional consultants’, or specific tasks and responsibilities in this division. The high number of individuals seeking information from a few people may result in overload and reduced productivity over time. Reducing the work load of overly centralized people through redesigning alternative information flow routes could be considered as an improvement strategy [37]. Fujimoto et al.[34] in a network study on community leaders regarding adoption of evidence-based prevention strategies suggested that decreasing the centralization of advice networks and increasing the centralization of informal discussion networks improved adoption outcomes. In our study network, empowering the local information sources in division #4 in order to reduce the exclusivity of connections to two central actors, will probably provide the staff with more alternatives for obtaining the required information, and consequently may facilitate greater flow of information.
A number of managers in different divisions were among the people with highest centrality in information-seeking, recognition of expertise, and friendship networks. Managers have the responsibility of managing and controlling the programs and services. They have the financial and operational responsibility over the processes. They have the role of decision-makers and planners in the department. The mentioned formal roles explain the influential positions of managers who connected their divisions to the OMOH. West and Barron report a similar finding for hospital managers in acute-care hospitals in the United Kingdom [32]. They found that, both groups of doctors and nurses mainly turned to managers to discuss professional matters, and much less to each other. Managers had a considerable brokering role in connecting traditional clinical disciplines (physicians and nurses) in their hospital. They suggested managers could facilitate the communication between nurses and physicians as part of their professional role in the hospital.
Due to effects of organizational hierarchy, it was expected that seeking information from managers by staff with lower organizational status might be limited to formal connections. According to social exchange theory [38], people recognize the advisee’s status (importance) as an incentive to seek information; however, many people may be hesitant to consult prestigious figures because it highlights their own lower status and lack of knowledge and exposes them to the judgment of superiors. But surprisingly, the managers in each division were among the people with the largest network of friends in that division as well. This characteristic highlights the pivotal role of managers as central people in divisions, formally and informally; and could be considered as a valuable potential for organizational change. In a study on sales managers in a financial services firm, Mehra et al. found that the centrality of managers and group leaders in friendship networks with their sub-ordinates was positively and significantly associated with group performance and the leaders’ reputation [39].
Clusters and bridges
The OMOH formed a central cluster in the department, bridging different divisions, with the highest density in the network (12.4%). The OMOH is responsible for the management of public health programs and services; and advises the Regional Council; which are consistent with the central bridging place of the OMOH in our study. The exclusively central role of the OMOH as a directing and coordinating division of the health department may affect the knowledge flow between divisions. Tsai showed that, in multi-unit organizations, the more control headquarters exercised on their sub-units, the less those units interacted with each other [40]. While the importance of the OMOH should be acknowledged and nurtured, efforts also should be made to directly connect divisions with each other to shorten the inter-divisional distance. Research on multi-unit organizations has shown that, by spanning sub-unit boundaries and promoting inter-unit connections, organizational units obtain new knowledge more easily and complete their projects faster [41].
Summarizing various centrality and brokerage roles, we can assume a four-level semi-formal hierarchy of the information flow in this health department (Figure5). These include 1) the staff who have a limited circle of information sources and friends; 2) practitioners in each division who play the role of local coordinators; 3) ‘professional consultants’ and some managers who are the central figures and also representatives of their division; 4) and the OMOH at the top as the central bridge connected to all divisions.
Hierarchy is an important structural determinant influencing the diffusion of innovations [42]. Increasing the levels of hierarchy makes communication between levels more difficult, and therefore hampers the flow of information. A few people at the higher levels of the hierarchy have more opportunity to control the flow of information, and there is less horizontal flow in the lower levels. As shown in Figure5, in each division there were different local coordinators, who were connecting their neighboring peers in the division, and might or might not be directly connected to managers, ‘professional consultants’, and the OMOH. They had a variety of job titles (including ‘professional consultants’, supervisor, public health nurse, nutritionist, dental educator). These people could only be identified as local coordinators by means of social network analysis, because their position in the network is not defined in their formal job descriptions. Identifying the local coordinators, who were mainly practitioners and clinical staff, and enhancing their connections to the professional information sources, including the ‘professional consultants’ and epidemiologists, could be an organizational intervention to reduce the number of hierarchical levels in information flow, and facilitate the adoption of EIDM as a sustained organization change.
Implications for practice
Knowledge brokers
In a qualitative study by Dobbins et al. public health decision-makers stated their need for assistance managing the vast quantities of evidence [2]. A ‘knowledge broker’ or ‘connector’ who is skilled in interpretation and application of research evidence and provides links between research producers and end-users has been proposed as a mechanism for facilitating KT in health care [43, 44]. The significance of knowledge brokers in promoting KT in health organizations has been assessed only in limited studies [44, 45]. Dobbins et al. described the relationship development, support, customization, and capacity development as the main roles of knowledge brokers [44]. In order to fulfill these roles competently, the knowledge brokers should, on the one hand, be recognized as evidence experts, and on the other hand, develop trust and positive relationships with end-users. In our study, the network analysis identified existing staff members who could be candidates in this health department to be trained as knowledge brokers. One such group was the ‘professional consultants’ whose role it is to synthesize the evidence and assist in application of the evidence into practice. These people, if trained and supported, could enhance the process of organizational change towards EIDM. As the early adopters of organizational interventions, ‘professional consultants’ and managers can diffuse the innovation more easily through channels of social influence.
Interdisciplinary communication
Lack of optimal communication “and clear channels for input” between managers to the staff has been proposed as a barrier to EIDM in public health [3]. Merrill et al. reported that the SNA findings of staff in one public health department led managers in that department to develop cross-programmatic teams and to encourage teamwork through tasks that required distributed decision-making, in order to address the limited communication across program areas [35]. Our study findings also highlight the need for developing enhanced channels of information flow across department divisions on the one hand, and between the managers and front line staff (local coordinators) on the other hand.
Communities of Practice
The findings of network analysis could also be utilized in the development of communities of practice (CoP). A CoP approach to KT has been utilized increasingly in recent years [46]. The CoP models suggest that providers interact creatively with colleagues, instead of practicing individually in a prescribed and predictable way [12], and people learn through practice and interaction with others. Norman and Huerta performed a SNA study on a multi-disciplinary Web-assisted tobacco intervention (WATI) team prior to implementation of a CoP strategy [47]. They used the network results as a map of the journey towards building a new community. They suggested that the process of building a network map with participants and exploring their motives for collaboration increased their receptiveness to getting involved in CoP teams. According to our findings, influential actors in different divisions can form CoPs to overcome the current divisional barriers and also harmonize and reinforce their efforts for building the capacity of EIDM in the health department. Network analysis can help to identify eligible people to form CoPs; and, over time, its presentation to the team, depicting the formation of new links and connections among the people and divisions, can positively influence their motivation to collaborate.
Future research
To our knowledge, this is the first study investigating the organizational structure and the formal and informal roles of staff of a public health department in Canada with respect to EIDM. The generalizability of the observed semi-formal hierarchy of information flow could be assessed in other public health organizations. There is also a need for more in-depth analysis of the roles and effectiveness of ‘professional consultants’ in public health organizations in building capacity for EIDM. In addition, the role of the OMOH as the bridging division, and its potentials for facilitating brokerage and communication between health disciplines should be investigated in interventional studies.
This study provides a foundation for longitudinal network analysis of the effect of an organization-wide, tailored KT intervention on the capacity of one health department for EIDM. The evolution of the network over time, as well as the role of a tailored KT intervention on the overall shape and specific characteristics of the network are being assessed in the larger study. The impact of various network characteristics on the effectiveness of the KT interventions being implemented in the larger study, and which have been influenced by these SNA results will be investigated by the primary author in future studies.
The notion of information seeking among the staff of the health department should also be investigated more thoroughly in a qualitative study, by seeing the social networks from the actors’ perspectives. While not commonly used in SNA context, a qualitative approach may provide important insights to aid in interpreting the findings from SNA studies.
Limitations
Some limitations in the current study were identified. People solely relied on their memory, and they might have easily forgotten to include someone on any or all of the four SNA questions. Recalling and enlisting the names of information sources and friends took much more time than was expected, which could explain why 32 people who participated in the larger study did not answer any of the social network questions.
While the majority of top level and influential staff answered the SNA questions, the large proportion of the staff who did not answer these questions is an important threat to external validity. It implies that, the findings regarding the managerial and professional staff in the network, who are in fact the main targets and promoters of the EIDM, are more dependable. The patterns seen in the peripheries should be used cautiously, since the people with the lower organizational ranks (practitioners and administrative staff) were under-represented in the sample. Nevertheless, other potential biasing factors which might have resulted in low response rate should also be taken into account; for instance, the non-responders might not be interested in EIDM, might not consider it relevant to their practice, might not see the importance of participation, or simply might be too busy to participate.
Additionally, there were a few managers and ‘professional consultants’ in each division who did not differ from other staff in terms of centrality. Due to the large proportion of non-respondents, it is not possible to conclude that managers and ‘professional consultants’ did not fulfill their consulting and coordinating roles very well. They might be central information sources for groups of people who did not answer the survey.
Even though we provided detailed explanations of the meanings of some terms like ‘evidence’ and ‘decisions’ in the questionnaire, we cannot exclude the possibility of miscomprehension and diversity in understanding of the meaning of these terms, as a threat to internal validity of observed patterns.
