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    • NURSING AND HEALTHCARE MANAGEMENT AND POLICYExploring knowledge work and leadership in online midwiferycommunicationFiona Brooks BA PhDReader, Centre for Research in Primary and Community Care, University of Hertfordshire, Hertfordshire, UKPeter Scott BA PhDHead of the Centre for New Media, Knowledge Media Institute, The Open University, UKAccepted for publication 27 January 2006Correspondence: B R O O K S F . & S C O T T P . ( 2 0 0 6 ) Journal of Advanced Nursing 55(4), 510–520Fiona Brooks, Exploring knowledge work and leadership in online midwifery communicationCentre for Research in Primary and Aim. This paper reports a study to answer the following question: if given a user- Community Care, friendly online system, that enabled communication across the practice community,Wright Building, would midwives function as knowledge workers?Hatfield Campus,University of Hertfordshire, Background. Globally, the demand for quality-led and innovative service deliveryHertfordshire, requires that nurses and midwives shift from being ‘information workers’, or passiveUK. receivers of managerial and organizational decisions, to become ‘knowledgeE-mail: f.m.brooks@herts.ac.uk workers’ who are able to create, lead and communicate service innovation and practice development. New communication technologies may offer a means fordoi: 10.1111/j.1365-2648.2006.03937.x healthcare professionals to interact as knowledge workers and develop supportive communities of practice. Methods. An online discussion forum was implemented as a low-cost technological intervention, deploying existing hardware and a standard hospital intranet. The evaluation of the forum was constructed as case-study organizational research. The totality of online communication, both traffic and content, was analysed over a 3-month period (193 messages downloaded 2003/2004), and 15 in-depth interviews were undertaken with forum users. Findings. Given simple, facilitative, innovative technology, supported by a positive working culture and guided by effective leadership, midwives could function as ‘knowledge workers’, critically reflecting upon their practice and translating knowledge into action designed to achieve change in practice. Participation occurred across all staff grades, and midwives were predominantly supportive and facilitative towards the contributions made by colleagues. Conclusion. Midwives may be well placed to exemplify the ‘ideal’ characteristics of the knowledge worker being demanded of modern healthcare professionals. The deployment of online interactive technologies as part of strategic vision to enhance knowledge work among healthcare professionals should be given attention within health systems. Keywords: decision-making, empirical research report, knowledge work, leader- ship, midwifery, nursing knowledge, online discussion forum510 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
    • Nursing and healthcare management and policy Exploring knowledge work and leadership Despite a recognition of the value for organizations ofIntroduction dispersed or team-based leadership there remains a continuedIn western healthcare systems, the demand for resource need to identify how communities of practice actually workeffective, quality and innovation directed services is leading together and can be supported through effective leadershiphealthcare professionals to embark on a remodelling of (Gabbay et al. 2003). In the United Kingdom (UK), fortraditional hierarchy-bound healthcare organizations. Know- example, every midwife is now asked to develop theirledge work theory asserts that the main strength of an leadership skills so that they are able to generate improve-organization lies in the knowledge held by the people within ments in service delivery and engage with policy-relatedit (Quintas 2002). ‘Knowledge workers’ are critical reflective decision-making (DOH 2003). Midwifery managers havethinkers who can creatively generate new meanings or also been challenged to improve their accountability andconceptualizations from experiences, thereby enabling them promote innovation in practice (Pashley 1998, Andrewsto perceive their working practices in a new light (Nonaka & 2004). Access to positive role models, the creation of strongTakeuchi 1995, Brockbank & McGill 1998). Moreover, they teams and ‘leaders with vision’ are likely to be critical factorsnot only create new knowledge, but can also identify how in improving organizational and professional cultures andnew understandings can be translated into action and change enabling future clinical development (Lavender & Chapple(Schon 1987). Due in part to the abstract nature of 2004). However, the transition to routine participation byknowledge, research on knowledge management faces staff in policy and organizational decision-making is unlikelypractical constraints (Schultze 2000). A particular gap in to be a straightforward process for the profession.the knowledge management field is research focussed on the The WHO Global Advisory Group on Nursing andactual practices of knowledge workers in situ (Blackler et al. Midwifery has consistently expressed concern that nurses1993). Consideration of how knowledge workers actually ‘do and midwives have remained relatively invisible andknowledge work’, as opposed to categorizing what they marginalized in health policy decision-making (Thompsonknow, is important for developing a better understanding of 2002). In western countries, midwifery is represented by anknowledge production and use. increasingly mobile and part-time workforce, with the result that broad-based participation in decision-making and even discussion about policy is logistically difficult. InBackground reinforcing task-focused medicalized care, healthcare orga-Practice-oriented investigations are important in relation to the nizations have been found to leave midwives who seek toknowledge work of healthcare professionals, for whom the innovate, feeling marginalized. In the UK, for example, thiscontext of knowledge and information use is shaped by very is particularly problematic (Kirkham 1999, Kirkham &different organizational structures than for private industry. Stapleton 2000, Kirkham et al. 2002). Indeed, suchKnowledge workers in healthcare systems will need to function midwives even face negative sanctions and horizontalnot as subordinates, but as leaders who hold important tacit violence from colleagues (Leap 1997). In Australia also,knowledge, the communication of which is vital to effective there is evidence that midwives potential for autonomy hasservice delivery. Although the role of vertical leaders or been poorly recognized and supported (Brodie 2002). Thismanagers remains important to the development of knowledge process of marginalization has resulted in some midwiveswork, recent leadership theory has strongly emphasized the leaving the profession (Ball et al. 2002). Even morecentrality of ‘team-based’ knowledge work to the creation of significantly, in a number of countries studies have reportedinnovation and change (Pearce 2004). Communication and that those in practice feel unable to respond positively todiscussion of work-based experiences within a team can create change or envisage how to develop innovations (Begleynew ‘collective knowledge’ (Seeley-Brown & Duguid 1991). 2002, Hughes et al. 2002).Team-based or dispersed leadership results in members of a Existing international research indicates that functioning asteam being able to mutually influence their fellows to improve knowledge workers represents a challenge for midwifery. Inand maximize the quality of practice, with the consequence the case of midwifery, it seems that effective participation inthat staff feel valued and have ownership over their decision- decision-making and developing a culture that can positivelymaking (Wenger & Snyder 2000). In this model, leadership is a respond to innovation is likely to be dependent upon‘shared’, as opposed to a ‘vertical’ process. Different members addressing both the practical and the professional culturalof the community of practice are empowered to act as unofficial barriers to achieving effective communication structures thatleaders, taking forward issues or projects (Senge 1990, Kitson support knowledge work. A potential solution to the com-et al. 1998, Kirkman & Rosen 1999). munication needs of midwifery may lie in the developmentÓ 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 511
    • F. Brooks and P. Scottand application of new discursive information and commu- This paper reports on the part of the AEC study thatnication technologies. examined the following question: If given a user-friendly The assumption that new technology creates a passive online system, that enabled communication across the prac-recipient of information has been criticized as failing to tice community, would midwives function as knowledgeconsider the dynamic interactivity of new communication workers?technologies (Ngwenyama & Lee 1997). Virtual discussion This central analytic task was then sub-divided intogroups are now being seen globally, and in multiple sectors, consideration of the following:as the means to achieve a knowledge based organization, by • What levels of discursive debate, decision-making interac-ensuring staff participation in knowledge sharing decision- tions and critical reflective thinking was found to occur?making processes and by enabling staff to expand their • Would participation involve a range of grades (see belowcollaborative networks (Ruberg et al. 1996, Bishop & Levine for an explanation of UK midwifery staff grades) and1999, Wood 2000, Ardichvilli et al. 2003). Specific features would dispersed leadership be evident? How would verti-of online discussion may also offer advantages over both cal leadership be displayed in the discussion?face-to-face communication and written forms, for example, • To what extent would the use of computer based discus-in combining both the ‘interpersonal’ features of verbal sion technology support the development of a communitycommunication and the opportunities for ‘expanded’ thought of practice? Would midwives be supportive of each other –of written communication (Herring 1996b). Among geo- or would an open discussion lead to the types of margi-graphically isolated staff, computer-mediated discussion nalization, horizontal violence and the negation of inno-groups have also enabled staff to access a wider community vation found previously in other studies?of practitioners and thereby draw on a greater reserve ofexpertise and knowledge (Hightower & Sayeed 1996, SettingJohnson 2001). In relation to healthcare systems, computer-mediated communication has been shown to promote the The project was located in a non-teaching, acute hospitalemergence of effective channels of communication to vertical trust in central England with a largely stable midwiferyleaders from an empowered workforce (Scott 2004). workforce. Maternity provision was based in an obstetric Midwives have also responded positively to multimedia consultant unit with midwifery-led care. Midwives wereand Internet technologies that support clinical work and responsible for all aspects of care, including inter-partum careaudit midwifery practice (Betts & Washbrook 1995, Shirazi in the hospital. Separate core teams provided ante-natal,& Meija 1996, Carroll 1997, Littler & Weist 1998, Furber inter-partum and postnatal care. An additional team also2001). In the USA, web-based graduate education for nurse- worked exclusively in the community.midwives has also been positively evaluated (Avery et al.2003). However, in contrast to a burgeoning literature in Designmedical and nursing informatics, studies that have consideredthe specific needs and experiences of midwives in relation to Case-study organizational research as an approach is partic-new technology have remained comparatively few. Conse- ularly valuable for studies concerned with informationquently, there is a need for research to attend to how technologies. The methodology, being concerned with ‘realmidwives might actually engage with such systems, partic- life’ events, offers a means to describe technological inter-ularly to assess potential support for knowledge creation, ventions and explore outcomes and the context of usagecapture and use. (Tellis 1997, Yin 2003). Computer-mediated communication also offers a number of advantages over traditional data collection methods (Anderson & Gansneder 1995, HineThe study 2000). It allows for the interpretation of naturally occurring interaction without a constant visible presence or theAim requirement that the researcher transcribes real worldThe ‘midwifery discussion forum’ reported here was part of interactions into text that the becomes data (Flick 1998).a larger project, the Assisted Electronic Communication Online discussion may offer a highly reliable means of(AEC) project, which sought to enable nurses and midwives accurate identification of feelings and opinions, as respon-to incorporate knowledge work into their daily practice dents construct their messages outside of the interactionalthrough use of computer-mediated communication technol- pressures of normal face-to-face interaction (Mann &ogies. Stewart 2000).512 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
    • Nursing and healthcare management and policy Exploring knowledge work and leadership In the AEC project, use of discussion forum data made Technical maintenance of the forum was undertaken bypossible a ‘naturalistic’ examination of exactly how midwives the hospital information technology department.communicate with each other, display leadership skills and This paper draws on a new data set of the total traffic ongenerate decision-making interactions. the forum over a 3-month period, downloaded 2003/2004 (n ¼ 193 messages). Originally, the forum was intended to function for 1 month to enable staff to respond to a specificParticipants patient satisfaction survey. However, due to requests fromParticipation in the discussion was advertised as open to any midwifery staff the forum was kept open and discussion ofmidwife in the study hospital. The promotion of the topics continued.discussion forums to potential participants (on the advice of The perceptions and experiences of participants werethe steering group) adopted the ‘usual’ channels employed by explored at the end of the forum’s operation through 15 in-the hospital to promote innovations and developments. depth qualitative interviews, sampled to represent the rangeAdvertising and promotion of the system occurred in the of midwifery grades (E grade or newly qualified midwife,form of posters, a piece in the hospital newsletter and one n ¼ 4; F grade or experienced staff midwife, n ¼ 5; G gradeopen meeting for midwives to see a demonstration of the or equivalent sister or clinical specialist midwife, n ¼ 3;system. All publicity also highlighted that the forums were H grade or midwife with senior management responsibilities,part of an on-going research project. Previously, it has been n ¼ 2) plus one midwifery assistant (HCA). The intervieweesdemonstrated that midwives at the Trust viewed the design of were invited orally to participate, in the first instance, by thethe forum positively, were not technophobic and felt that the local researcher (17 approached, two refused due to timediscussion space was a valuable resource (Brooks et al. 2004, constraints). A member of the external research teamBrooks & Scott 2006). subsequently contacted the 15 interviewees, and all re- confirmed their agreement to be interviewed. All interview- ees, as forum participants, were aware of the research projectData generation prior to contact by the local researcher. The interviewsIt was intended that technology-assisted discussion forums explored the technological features of the forum, the valuecould be used to stimulate a connection between professional and ease of participation, perspectives on participation incommunities of practice, leading to possible innovation in decision-making, leadership and collegial support. All thepractice without staff ever leaving the ward. interviews were taped and transcribed. The forums provided a means for midwives to sendviews, ideas and responses directly and electronically to Ethical considerationsother practitioners in a public discussion space. Thisemployed a commonly available set of low-cost software Approval for the study was gained from the Local Researchtools such as ‘web-forums’, which are now in wide use on Ethics Committee. Discussion in online forums represents athe internet (see Scott & Quick 2003). The midwives’ data source that falls somewhere between semi-privateviewed the discussion forum as a series of web pages via communications and open, publicly authored acts (Mann &any computer connected to the hospital internal computer Stewart 2000). However, researchers in the field have tendednetwork (intranet). The discussion forum concept used was towards the view that postings cannot be simply accessedrather like a publicly accessible e-mail account, in which all without any ethical safeguards. In particular the use ofthe text messages were available either to be read or pseudonyms has been advocated (Herring 1996a), andresponded to by anyone accessing the forum at their ensuring that participants are made aware that the intendedconvenience. In addition, the software offered midwives a audience of the posting includes the researcher (Mann &means automatically to structure or group their discussion Stewart 2000).in a themed way relating to topics of their choice. All participants used the discussion tool as volunteers andMidwives from the project steering group participated in were reminded when they accessed the system that the forumdetermining the layout and appearance of the forum web was part of an on-going research project. The system was notpages to suit their needs. No formal training was required password protected so that authors of messages were able toto use the forum, as it was designed to require only reading choose to post a message anonymously. The intervieweesshort instructions placed next to the computer, or a were approached as described above, and were assured ofminimal (1–2 minutes) peer-led demonstration, for an confidentiality; pseudonyms have been used in this paper forindividual to be able to post and access messages. both the interview and forum data.Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 513
    • F. Brooks and P. Scott generate new knowledge, articulate alternative forms ofData analysis provision and suggest ideas for the resolution of issues in aThe totality of the online communication was considered, discursive manner (Brockbank & McGill 1998).that is, the usage patterns and complete contributions to theforum. Analysis of the online discussion was also undertaken Findingsby grade of midwife (see above for an explanation of UKmidwifery grades). Thematic coding was employed and This section explores the levels of participation, and thenthemes were generated both inductively from the raw data outlines the nature of the interaction with reference to theand deductively employing the theoretical framework extent of evident knowledge work and the way leadership is(Boyatizis 1998). All digital participation was logged and displayed and enacted via the usage of the forum.coded separately for inter-rater reliability by three membersof the inter-disciplinary research team (midwife, sociologist Participation on the forumand knowledge media specialist), data were categorized intoinitial and higher codes and repeatedly searched for discon- Over the 3-month period, a broad-based community offirming cases as part of the coding refinement process. The midwives posted 193 messages. Figure 1 illustrates theinterview data were specifically mined as part of the postings by grade of midwife. The system was available totriangulation process to refine the emergent theory. The dis- all 96 midwives working in the hospital setting (day and nightcussion forum data was interrogated for: knowledge work, staff, all female), although because community midwives didcollegial and leadership relationships. They were also ana- not have access to the intranet, the system was not promotedlysed for issues such as the general character of participation, to the community staff (n ¼ 37). However, three communitye.g. messages by grade, and entered into the statistical midwives did come into the hospital to access the intranet andsoftware package SPSS (SPSS Inc., Chicago, IL, USA). post messages. Three named midwifery assistants (HCA) and Case study research can be a useful means to explore two nurses also participated at the invitation of the midwives.existing theory as well as the generation of new revelations Overall, 44 named hospital staff participated and 39 (40% of(Yin 2003). For this project, in order to analyse the operation the total targeted population) were identified as midwivesof knowledge work among nurses and midwives, existing working for the hospital. About half of the staff (21 of the 44)theory relating to knowledge management and virtual com- were part-time and nine were exclusively night staff. Amongmunication primarily relating to other contexts was participating G grade midwives (equivalent to sister grades)employed to guide the coding (Mantovani 1994, Milton three held specialist positions in relation to specific areas ofet al. 1999, Quintas 2002). To analyse knowledge work, a practice, such as smoking cessation. An additional ninedistinction was made between messages displaying solely postings were made anonymously, eight with just the titleinformation usage (e.g. reporting an event or policy) and ‘Midwife’ and one with the title ‘HCA’. From the in-depththose applying knowledge in a discursive way. Information interviews it is known that at least two midwives postedwork encompassed messages that solely reported on explicit messages both anonymously and with their names attached,knowledge without an additional discursive or reflective depending on their perception of the sensitivity of the issue.element. In contrast, ‘knowledge work’ messages demonstra- The proportion of active authors (posting messages) onted an ability to reflect critically upon new information or the discussion forums have been identified as likely to beexplicit knowledge of the organization by adding personal,theoretical and tacit knowledge acquired from contributors’ 40·0% 38·0%own experience. Underlying our coding was an argument that 35·0%the character of knowledge work would be displayed via 30·0% Contributiondecision-making interactions (Condon & Cech 1996). When 25·0% 22·6% 22·8%coding forum messages, particular attention was given to the 20·0%presence or absence of critical reflective thinking in decision- 15·0% 10·0% 9·3%making interactions as a measure of knowledge work (Schon 5·2%1987). In our framework, critical reflective thinking was 10·0% 2·1%defined as ‘the display of an ability to employ experience in a 0·0% HCA E F G H UK 4 44 73 44 18 10manner that openly reflects upon current care and service Grade (Number at each grade)provision’ (Brooks & Scott 2006, p. 87). This definition ofcritical reflective thinking also encompasses a willingness to Figure 1 Forum contribution (postings) by grade.514 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
    • Nursing and healthcare management and policy Exploring knowledge work and leadershipsignificantly lower than those who just read the discussion some staff will have access to information that is not widely(Nonnecke & Preece 2000). The fact that nearly half of the available. Through the discussion forum, senior and specialisttarget community, across all grades of midwife, functioned as midwives had a means to disseminate this information to theauthors on the system suggests a successful forum in terms of wider community. The following example is a good illustra-online discussion communities. tion of such valuable information work. A senior midwife is In line with findings from other settings (Bishop & Levine able to convey action that the organization is taking to1999, Ardichvilli et al. 2003) features inherent to computer address a problem raised by the midwifery staff.mediated communication made participation from the per-spective of the midwives an attractive option. The ability to Forum Extract 1: Information workexpress views without the normative interactional pressures Thread: RE: Shortage of HCASof face-to-face communication was valued by interview Ellen Norton Apparently management arerespondents (irrespective of grade). This positive perception G grade midwife advertising for ·2 dayalso included a sense that the removal of interactional Time: 08:17 and ·1 night CA-Midwifery staffpressures increased the significance of the message: In terms of the application of knowledge work, midwivesThere’s no pressure on, so you’re hopefully getting exactly what deployed tacit knowledge (grounded in practice experiences)people are thinking instead of what they think you want to hear, or with either the discursive raising of an issue (20%, n ¼ 39)the hidden agendas. (Midwife G grade) or to give additional explanatory force to suggested resolu-Although we did not set out to examine the nature of the tions/action (34%, n ¼ 66). The online discussion wasexisting hierarchy in the hospital, there was some evidence perceived as a vehicle to enable a collective considerationthat respondents felt more usual forms of work-based of important issues that had previously not been attended tointeraction could leave them open to negative sanctioning if within the organization. Accounts from the in-depth inter-they expressed opinions. In contrast, when respondents views also indicated that participants particularly valuedadded their name to a message, they felt less open to negative being able to ‘critically reflect’ via the forum. Midwivessanctioning on the forum than through more usual routes of repeatedly expressed a desire to move away from function-communication, such as meetings: ing as task-focused information workers to knowledge workers:It’s, you know, a free atmosphere; to be able to do it without anycomeback. You can raise the issue and see what other people think …just to express an opinion really, just say what you think, instead ofabout it, without worrying that it goes against what is expected. just sitting at the back and doing your job and not being heard really.(Midwife F grade) (Midwife E grade)From the outset midwives appeared to approach online In many cases, midwives initiated a ‘knowledge work’communication as a means to improve on existing commu- discussion by posting messages drawn from their experientialnication patterns and to bring to the fore previously knowledge base of working with women. In the examplesubmerged issues and agendas. The next subsections focus below a midwife drawing on a patient-centred narrative hason the nature of the discussion. taken a comment by a patient, subsequently critically reflected on service provision and raised the issue for discussion with colleagues. Importantly, she also proposes aInformation work and knowledge work resolution for further debate.The online discussion was overwhelmingly characterized by Forum extract 2: Initiating a knowledge work discussionmessages that displayed discursive discussion and criticalreflective thinking. This was coded as ‘knowledge work’(88%, n ¼ 172). In contrast, messages that were concerned Thread: RE: Mealtimes when visiting Special Care Baby Unit (SCBU) Jane Petch I was speaking to a patient whose babywith posting or requesting explicit knowledge were coded as E grade midwife was in SCBU. She found it very strange‘information work’ (9%, n ¼ 16). Time: 17:55 that staff would ring down whilst she was It should be noted that ‘information work’ can be very feeding to tell her that her meal was on thevaluable. Indeed, the ‘information work’ contributions were ward, as the baby was her priority! She did,predominantly characterized by messages that added detail to however, state that she always ordered a cold meal. Maybe HCA’s could encouragethe knowledge work discussions. In any organization, by this when dealing with the menu’s?virtue of holding either a managerial or specialist position,Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 515
    • F. Brooks and P. Scott Within the ‘knowledge work’ coding, a striking feature was the form of encouragement for emergent leaders from withinthe number of messages (34%, n ¼ 66) that proposed a the ranks of participants. In the following example, a more‘resolution’ of the issue raised. In the majority of these cases experienced midwife offers encouragement and guidance to aproposals for resolution were composed, as in the example newly qualified midwife, on how to effectively lead on aabove, in a question format that invited further debate and patient information issue that she had raised.refinement by other midwives. In seven messages the pro- Forum extract 4: Encouragement for emergent leadersposed resolution took the form of a request from a senior orspecialist midwife to undertake specific action to form a Thread: RE: Information Leafletsworking party to achieve change, for example, to write a new Helen Friedman why don’t you write them Amy,information pack. F grade midwife you don’t need to be specially In practical terms, the final resolution of issues will Time 16:07 designated to do so i think. (Note: this message was we need more input fromnecessarily occur outside of the virtual discussion making in reply to an E midwives in these areas.actual change difficult to track online. However, towards the grade midwife) However, do check that no-oneend of the 3 months of the forum, traffic on the forum else is writing them at therelating to feedback on action was taking place. Five same time, i believe Jane Dickinsmessages (which were coded themselves as information usually types them up sowork) related to the outcomes of issues initially raised on best check with herthe forum. Reported outcomes included the provision of fanson the labour ward, the development of new information From the perspective of newly qualified staff, the forumleaflets, and a policy on siblings visiting the labour ward after was seen as providing an opportunity to gain experience ofa delivery. engaging in debate with colleagues and more senior staff and The remaining sections consider how the work on the therefore to have a more ‘visible’ presence in the organiza-forums displayed leadership skills and served to facilitate a tion:functioning community of practice. It gives you a chance to…chat and put your views forward on various subjects and discuss them with lots of your colleagues; mostly youDispersed leadership and collegial support wouldn’t even have that chance or see that many colleagues. I noticed very senior members of staff used it and they then can see what weCollegial support is an aspect of midwives’ working lives that feel and discuss change with us. (Midwife E grade)appears to be highly valued and, when absent, a majorcontributor to low job satisfaction (Kirkham & Stapleton A final way midwives displayed horizontal leadership and2000, Hunter 2004, Lavender & Chapple 2004). About one collegiality was through their support for others to use thethird (32Æ6%, n ¼ 63) of messages posted on the forum forum. The midwives actively promoted peer-learningprovided explicit support for the contribution and work of approaches to the use of the system.other colleagues. A common pattern was to thank and praisea previous contributor: Forum extract 5: Displaying horizontal leadershipForum extract 3: Collegial support Thread: Chat Room Sandra Jones If you have looked at this site orThread: RE: Information packs F grade midwife posted a message then you know howAnne Webber Harriet Smith’s suggestion of an A5 Time 19:59 to use it. Could you please pass thisF grade midwife flyer is excellent. I wonder about the information on to your colleagues.Time 02:51 percentage of women that attend the USE IT OR LOSE IT!!!!!!!!! ward tour, perhaps it would be better to hand the leaflet out at the 34 weeks ante-natal check. A supply on all the In this forum midwives strongly demonstrated an ability to wards for those who deliver prematurally provide collegial support and to promote the development of would be useful other midwives and also included several messages that encouraged access to the system by midwifery assistants F grade midwives posted more messages that were (HCAs). In addition, within their community practice moresupportive per author than the other grades, e.g. nearly twice senior midwives appeared prepared to support horizontallyas many messages that were coded as supportive than E grade emergent leaders, facilitating participation and responsibilitymidwives. Collegial or horizontal support was also found in for taking actions forward.516 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
    • Nursing and healthcare management and policy Exploring knowledge work and leadership Forum extract 6: Horizontal ownership of resolutionVertical leadershipTransformational leaders are concerned with the promotion Thread: RE: Drinksof visionary perspectives that challenge established prac- Shelia Corrigan I agree we ought to investigate re-introductiontices, enable and maximize potential (Kouzes & Posner (H grade midwife) of drinks machine. There will I presume be1997, Markham 1998, Clegg 2000). This form of leader- Time: 11:59 a cost implication but can overcome this.ship is particularly essential to the development of knowl- We need to discuss location andedge workers as it involves the ability to inspire and create communicate SUGGEST to be discussed at ward meetings as a matter of urgencyan environment where team members can be influentialon organizational culture (Kramer & Hafner 1989).Consequently, it is valuable to consider the specific This was articulated as an overt strategy adopted by thecontribution of vertical midwifery leaders within the senior manager, designed to give midwives experience ofmidwifery forum. change management, but also to encourage a culture Vertical leaders or managers were defined as midwives of whereby midwives perceived themselves as being driversH grade and above, and postings by them amounted to 18 of change by thinking about how to achieve the innovationmessages (9Æ3% of the total sample) from four individuals. or change they were advocating. In the same way, postingPostings from the two most senior midwifery managers a relatively small number of messages diffused across the(post holder changed during the duration of the project) forum was a strategic decision by the head of midwifery toamounted to 11 messages in as many threads (i.e. 11 of 41 prevent participation being perceived as an elite activity;threads). Two features defined the input from senior ‘a senior thing’.midwives and most senior midwifery managers in particular. Overall, the messages from senior staff appeared to supportFirst, they validated contributing to the forum as a discursive debate and participation in specific ways, forworthwhile activity. Secondly, they provided concrete sup- example, by being regular and diffused throughout the forumport for action arising from the discussion. Validation for and by giving ownership of the discussion back to staff. Theparticipation on the forums was expressed either through resolution messages posted by senior managers consisted ofovert commitment to ‘keep using the forum’ or through suggestions for action that opened the debate for furtherexplicit supportive praise and feedback to authors of comments rather than closing the discussion by posting amessages. solution. A potential disadvantage of public discussion in theworkplace is that the increased visibility that comes from Discussionactive participation could result in individuals being fearfulthat they might be negatively sanctioned by management, a We found clear evidence that the online discussion systemfear which, as previously discussed, may be well founded for supported the midwives in this study to undertake midwifery-many midwives (Leap 1997, Kirkham & Stapleton 2000, specific knowledge creation, capture and use.Ball et al. 2002). In contrast to the vertical sanctioning The midwife participants appeared to value the features ofsuggested by other studies, the discussion forums in this virtual communities such as, freedom from normative groupstudy operated as a tool whereby senior management could and interactional pressures (including immediate visiblepositively and publicly support and acknowledge midwives’ reactions, approval and disapproval) as well as the oppor-contribution: tunity to take part in an asynchronous ‘reflective’ discussion (Herring 1996b, Palloff & Pratt 1999, Johnson 2001).What really pleased me was that midwives used their voice and put Moreover, our findings also support the literature whichtheir name to it. Then I could say to Jill thanks for putting that on, it emphasizes the value of virtual forums as a means to achievewas a really good idea. (Senior Manager) broad based horizontal participation among communities ofSix of the 11 messages from the head of midwifery were practice (Johnson 2001, Ardichvilli et al. 2003, Brooks et al.concerned with concrete resolution of issues, such as 2004).offering resources, or suggesting resolution strategies that In terms of functioning as knowledge workers, midwivesforum participants could take forward. However, in all demonstrated the ability to discuss previously uncodifiedcases, the ownership of the issue and responsibility for its knowledge held by virtue of their position as frontlineresolution was explicitly given back to the forum partic- workers. The working discussions captured here representipants. tacit and experiential knowledge derived from the practiceÓ 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 517
    • F. Brooks and P. Scott real practice issues that were of direct relevance to women’s What is already known about this topic experience of care. • Organizational and professional structures have resul- One transformational effect of computer-mediated com- ted in midwives remaining relatively invisible and munication is the potential it offers for displaying, and marginalized in healthcare policy decision-making. thereby making visible to the organization, the contribution • New communication technologies may offer a means of certain types of worker (Wood 2000). The virtual for healthcare professionals to interact more effectively community of practice also offered junior members of staff with each other and increase their visibility in decision- a means to function as emergent leaders and take forward making processes. actions resulting from the discussion. Furthermore, senior • There is research on knowledge work in business and managers were able to display characteristics of ‘transforma- management, but very little on the application of tional leadership’ through expressing overt and practical knowledge work theory to healthcare workers partic- support for innovation, actions and discursive debate (Kouzes ularly in relation to knowledge creation, capture and & Posner 1997, Markham 1998, Clegg 2000). Innovative use. individuals and horizontal leaders could be publicly sup- ported and ‘rewarded’ (thanked) for their input, thereby positively reinforcing a culture of knowledge work among the What this paper adds midwifery staff-base. • Knowledge work theory is relevant to the work of Previous midwifery literature has highlighted an absence of midwives. support for colleagues as a factor in the isolation of • Online software tools such as interactive discussion innovators and poor staff retention (Leap 1997, Kirkham forums can enhance midwifery practice. 1999, Kirkham & Stapleton 2000, Ball et al. 2002, Begley • Midwives can function as ‘knowledge workers’, with a 2002, Brodie 2002). A suggested feature of virtual interaction major element of the communication being supportive is the potential to encourage contribution from across of the knowledge work of others. hierarchies, as the absence of a physical presence allows for greater equity in the exchange (Johnson 2001). The discus- sion forum seemed to provide a mechanism for midwives toexperiences of the individual workers. In this forum, the access personal and professional support from theirindividual’s knowledge becomes public and part of a work- colleagues and leadership, both vertically and horizontally.ing, shared discourse. For knowledge work theory, it isprecisely this aspect of knowledge capture that is not only Study limitationsvital to effective knowledge work, but is often so hard toachieve (Quintas 2002). In illuminating how midwives The study was a small-scale ‘naturalistic’ observation offunction as knowledge workers within a community of midwives using a novel software tool in a single hospital. Thepractice, this study further adds weight to the knowledge small number of participants and short timescale of thework literature that calls for the study of knowledge workers observations reported here clearly limit the claims that wein situ (Blackler et al. 1993, Schultze 2000). can make. Some of our findings are nevertheless striking and Collaboration between midwives within a community of may offer important insights for the development of know-practice was established remotely and virtually. The mid- ledge work in healthcare systems.wives’ interaction with each other in this project did appearto conform to many of the positive aspects of communities of Conclusionpractice. For example, users demonstrated the ability to shareknowledge and experiences creatively and were facilitative of This research highlights the relevance of knowledge workcontinued discussion by others in the community (Brown & theory to understanding how midwives can collaborativelyDuguid 2000, Wenger & Snyder 2000, Bate & Robert 2002). communicate as knowledge workers to enhance knowledgeAs a ‘community of practice’ they were able to critically creation, capture and use. A continued research focus on thereflect on their experiences of providing care and re-concep- work practices of knowledge workers in naturalistic settingstualize those experiences into both ‘proposals for change’ and is likely to yield valuable insights into how to further develop‘resolution of issues’. The high level of suggested resolutions effective communities of practice in healthcare organizations.within the online discussion indicates that the midwives The potential of participation in online forums to circum-(across grades) were able to solve problems concerned with vent negative sanctions by people more senior in the organ-518 Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd
    • Nursing and healthcare management and policy Exploring knowledge work and leadershipizational hierarchy is an important feature for the nursing and Andrews S. (2004) Managerial implications of expanding practice.midwifery professions, who still need to overcome traditional British Journal of Midwifery 12(2), 114–119. Ardichvilli A., Page V. & Wentling T. (2003) Motivation and bar-hierarchy-bound working practices. Consequently, virtual riers to participation in virtual knowledge-sharing communities ofonline discussion may provide a means to assist with the practice. Journal of Knowledge Management 7(1), 64–77.process of change towards dispersed leadership and improved Avery M., Ringdahl D., Juve C. & Plumbo P. (2003) The transitioncollegial relationships in nursing and midwifery. to web-based education: enhancing access to graduate education Through making the contribution of innovators and for women’s health providers. Journal of Midwifery and Women’semergent leaders more visible, online discussion forums also Health 48(6), 418–425. Ball L., Curtis P. & Kirkham M. (2002) Executive Summary of whyoffers the potential to contribute to reducing the global do Midwives Leave? http://www.rcm.org.ukinvisibility and marginalization of nurses and midwives. Bate S. & Robert G. (2002) Knowledge management and commu- Finally, the positive impact of on-line communication nities of practice in the private sector. Lessons for modernizing thefound in this study can be achieved using low-cost software National Health Service in England and Wales. Public Adminis-tools and existing network capabilities. Healthcare profes- tration 80(4), 643–663. Begley C. (2002) ‘Great fleas have little fleas’: Irish student midwives’sionals and organizations should consider how to use fully views of the hierarchy in midwifery. Journal of Advanced Nursingthe capacity of such network tools and capabilities, and 38(3), 310–317.should implement strategies to facilitate professional online Betts H. & Washbrook M. (1995) How information managementcommunication. Further attention should also be given to the and technology benefit midwives. British Journal of Midwiferyimplications of such discursive technologies to enhance 3(9), 478–482.leadership development and the management of change in Bishop L. & Levine D. (1999) Computer mediated communication as employee voice. A case study. Industrial and Labour Relationshealthcare systems. Review 52(2), 213–233. Blackler F., Reed m. & Whitaker A. (1993) Epilogue: An agenda for research. Journal of Management Studies 30(6), 851–862.Acknowledgements Boyatizis R. (1998) Transforming Qualitative Information: ThematicWe would like to thank Christine Rospopa and all the Analysis and Code Development. Sage, Thousand Oaks, CA. Brockbank A. & McGill I. (1998) Facilitating Reflective Learning inmidwives and staff in the Trust who contributed to the Higher Education. Society for Research into Higher Education andforums. Many thanks for their advice and support also go The Open University, Milton Keynes.to Sally Kendall, Marianne Mead, Kevin Quick, Maria Brodie P. (2002) Addressing the barriers to midwifery – AustralianMacintyre, and Sue Longhurst. Many thanks also to our midwives speaking out. Australian Journal of Midwifery 15(3), 3–4.helpful reviewers. We would also like to make special Brooks F. & Scott P. (2006) Knowledge work in nursing and mid-mention of the contribution of Sharon Hodsdon to the wifery: an evaluation through computer mediated communication. International Journal of Nursing Studies 43, 83–97.discussion forums, a true knowledge worker and midwife, a Brooks F., Rospopa C. & Scott P. (2004) Midwifery on the net: newtragic loss. This research was funded by the UK Department communication technology. British Journal of Midwifery 12(2),of Health, under the information and Communications 107–110.Technologies Research Initiative (121-7184). Brown J. & Duguid P. (2000) Balancing act: how to capture knowledge without killing it. Harvard Business Review 78, 73– 78.Author contributions Carroll T. (1997) A strategy for empowerment: the role of midwives in computer systems implementation. Computer Methods andFB and PS were responsible for the study conception and Programs in Biomedicine 54, 101–113.design and drafting of the manuscript. FB and PS performed Clegg A. (2000) Leadership: improving the quality of patient care.the data collection and data analysis. FB and PS obtained Nursing Standard 14(30), 43–45.funding and provided administrative support. FB and PS Condon S.L. & Cech C.G. (1996) Functional comparison of face- to-face and computer-mediated decision-making interactions.provided statistical expertise. 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