Prepare a Brief: Healthcare Delivery Identify and describe a healthcare delivery organization or hospital close to you or for wh

Boutcher et al. BMC Health Services Research (2022) 22:11 https://doi.org/10.1186/s12913-021-07387-z

R E S E A R C H

The roles, activities and impacts of middle managers who function as knowledge brokers to improve care delivery and outcomes in healthcare organizations: a critical interpretive synthesis Faith Boutcher1*, Whitney Berta2, Robin Urquhart3 and Anna R. Gagliardi4

Abstract Background: Middle Managers (MMs) are thought to play a pivotal role as knowledge brokers (KBs) in healthcare organizations. However, the role of MMs who function as KBs (MM KBs) in health care is under-studied. Research is needed that contributes to our understanding of how MMs broker knowledge in health care and what factors influ- ence their KB efforts.

Methods: We used a critical interpretive synthesis (CIS) approach to review both qualitative and quantitative studies to develop an organizing framework of how MMs enact the KB role in health care. We used compass questions to create a search strategy and electronic searches were conducted in MEDLINE, CINAHL, Social Sciences Abstracts, ABI/ INFORM, EMBASE, PubMed, PsycINFO, ERIC and the Cochrane Library. Searching, sampling, and data analysis was an iterative process, using constant comparison, to synthesize the results.

Results: We included 41 articles (38 empirical studies and 3 conceptual papers) that met the eligibility criteria. No existing review was found on this topic. A synthesis of the studies revealed 12 MM KB roles and 63 associated activities beyond existing roles hypothesized by extant theory, and we elaborate on two MM KB roles: 1) convincing others of the need for, and benefit of an innovation or evidence-based practice; and 2) functioning as a strategic influencer. We identified organizational and individual factors that may influence the efforts of MM KBs in healthcare organizations. Additionally, we found that the MM KB role was associated with enhanced provider knowledge, and skills, as well as improved organizational outcomes.

Conclusion: Our findings suggest that MMs do enact KB roles in healthcare settings to implement innovations and practice change. Our organizing framework offers a novel conceptualization of MM KBs that advances understanding of the emerging KB role that MMs play in healthcare organizations. In addition to roles, this study contributes to the extant literature by revealing factors that may influence the efforts and impacts of MM KBs in healthcare organiza- tions. Future studies are required to refine and strengthen this framework.

Trial registration: A protocol for this review was not registered.

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Open Access

*Correspondence: [email protected] 1 Baycrest Health Sciences, 3560 Bathurst Street, Toronto, Ontario M6A 2E1, Canada Full list of author information is available at the end of the article

Page 2 of 17Boutcher et al. BMC Health Services Research (2022) 22:11

Contributions to the literature

• MMs may play an important KB role in healthcare organizations.

• Additional support for the MM KB role may help enhance quality of care in healthcare settings.

• An improved understanding of MM KBs will contrib- ute to this nascent area of inquiry in health care.

Background Health systems are under increasing pressure to improve performance including productivity, quality of care, and efficiency in service delivery. To promote optimal per- formance, health systems hold healthcare organizations such as hospitals accountable for the quality of care they provide through accountability agreements tied to performance targets [1, 2]. Despite such incentives, healthcare organizations face considerable challenges in providing high-quality care and research continues to show that the quality of hospital-based care is less than ideal [3–5]. Some researchers contend that this is attrib- uted, in part, to the challenges that healthcare organiza- tions face when integrating new knowledge into practice. Some challenges include dedicating sufficient resources to adopt or implement evidence-informed innovations that enhance service delivery and optimize patient health and outcomes [6].

Healthcare organizations use knowledge translation (KT) approaches to promote the use of evidence-based practices intended to optimize quality of care. The use of knowledge brokers (KBs) is one such approach. KBs are defined as the human component of KT who work collaboratively with stakeholders to facilitate the transfer and exchange of knowledge in diverse set- tings, [7–9]. KBs that facilitate the use of knowledge between people or groups have been referred to as opinion leaders, facilitators, champions, linking agents and change agents whose roles can be formal or infor- mal [10, 11]. These “influencer” roles are based on the premise that interpersonal contact improves the likeli- hood of behavioral change associated with use or adop- tion of new knowledge [12]. Research shows that KBs have had a positive effect on increasing knowledge and evidence-based practices among clinicians in hospitals, and on advocating for change on behalf of clinicians to executives [13–15]. However, greater insight is needed on how to equip and support KBs, so they effectively

promote and enable clinicians to use evidence-based practices that improve quality of care [13, 16, 17].

Middle managers (MMs) play a pivotal role in facili- tating high quality care and may play a brokerage role in the sharing and use of knowledge in healthcare organi- zations [18, 19]. MMs are managers at the mid-level of an organization supervised by senior managers, and who, in turn, supervise frontline clinicians [20]. MMs facilitate the integration of new knowledge in health- care organizations by helping clinicians appreciate the rationale for organizational changes and translating adoption decisions into on-the-ground implementa- tion strategies [18, 19]. Current research suggests that MMs may play an essential role as internal KBs because of their mid-level positions in healthcare organizations. Some researchers have called for a deeper understand- ing of the MM role in knowledge brokering, including how MMs enact internal KB roles [16–19, 21].

To this end, further research is needed on who assumes the KB role and what they do. Prior research suggests that KBs may function across five key roles: knowledge manager, linking agent, capacity builder, facilitator, and evaluator, but it is not clear whether these roles are real- ized in all healthcare settings [7, 21, 22]. KBs are often distinguished as external or internal to the practice community that they seek to influence, and most stud- ies have focused on external KBs with comparatively little research focused on the role of internal KBs [7, 9, 17, 23, 24]. To address this gap, we will focus on inter- nal KBs (MMs) who hold a pivotal position because their credibility and detailed knowledge of local context allows them to overcome the barriers common to external KBs. One such barrier is resistance to advice from external sources unfamiliar with the local context [25].

With respect to what KBs do, two studies explored KB roles and activities, and generated frameworks that describe KB functions, processes, and outcomes in health care [7, 22]. However, these frameworks are not specific to MMs and are limited in detail about KB roles and functions. This knowledge is required by health- care organizations to develop KB capacity among MMs, who can then enhance quality of care. Therefore, the focus of this study was to synthesize published research on factors that influence the KB roles, activities, and impact of MMs in healthcare settings. In doing so, we will identify key concepts, themes, and the relation- ships among them to generate an organizing framework that categorizes how MMs function as KBs in health care to guide future policy, practice, and research.

Keywords: Middle managers, Knowledge brokers, Critical interpretive synthesis

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Methods Approach We used a critical interpretive synthesis (CIS) to system- atically review the complex body of literature on MM KBs. This included qualitative, quantitative, and theoreti- cal papers. CIS offers an iterative, dynamic, recursive, and reflexive approach to qualitative synthesis. CIS was well- suited to review the MM KB literature than traditional systematic review methods because it integrates findings from diverse studies into a single, coherent framework based on new theoretical insights and interpretations [26, 27]. A key feature that distinguishes CIS from other approaches to interpretive synthesis is the critical nature of the analysis that questions the way studies conceptu- alize and construct the topic under study and uses this as the basis for developing synthesizing arguments [26]. We ensured rigor by complying with the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) criteria (Additional file 1) and other criteria of trustworthiness [28, 29]. We did not register a protocol for this review.

Search With a medical librarian, we developed a search strategy (Additional file 2) that complied with the evidence-based checklist for peer review of electronic search strategies [30]. We included Medical Subject Headings and key- words that captured the concepts of MMs (e.g., nurse administrator, manager), explicit or non-explicit KB roles (e.g., diffusion of innovation, dissemination, broker, and facilitator), evidence-based practice (e.g., knowledge, evi- dence) and setting (e.g., hospital, healthcare, or health care). We searched MEDLINE, CINAHL, Social Sciences Abstracts, ABI/INFORM, EMBASE, PubMed, PsycINFO, ERIC, and the Cochrane Library from January 1, 2001, to August 14, 2020. We searched from 2001 onward because the field of KT did not substantially investigate KBs until 2001 [7, 21]. We reviewed the reference lists of eligible articles for additional relevant studies not identified by searches. As is typical of CIS, this was an iterative process allowing search terms to be expanded to optimize search results [26, 31].

Eligibility We generated eligibility criteria based on the PICO framework (population, intervention, comparisons, and outcomes) (Additional  file  3). Populations refer to MMs functioning as KBs in hospitals or other healthcare set- tings but did not necessarily use those labels. Because the MM literature is emergent, we included settings other than hospitals (e.g., public health department, Veteran Affairs Medical Centres). We included studies involv- ing clinical and non-clinical administrators, managers,

directors, or operational leaders if those studies met all other inclusion criteria. The intervention of interest was how MM KBs operated in practice for the creation, use and sharing of knowledge, implementation of evidence- based practice(s), or innovation implementation. Study comparisons may have evaluated one or more MM KB roles, approaches and associated barriers, enablers and impacts alone or in comparison with other types of approaches for the sharing or implementation of knowl- edge, evidence, evidence-based practices, or innovations. Outcomes included but were not limited to MM KB effectiveness (change in knowledge, skills, policies and/ or practices, care delivery, satisfaction in role), behaviors, and outcomes. Searches were limited to English language quantitative, randomized, or pragmatic controlled trials, case studies, surveys, quasi-experimental, qualitative, or mixed methods studies and conceptual papers. System- atic reviews were not eligible, but we screened references for additional eligible primary studies. Publications in the form of editorials, abstracts, protocols, unpublished the- ses, conference proceedings were not eligible.

Screening FB and ARG independently screened 50 titles and abstracts according to the eligibility criteria and com- pared and discussed results. Based on discrepancies, they modified the eligibility criteria and discussed how to apply them. Thereafter, FB screened all remaining titles, and discussed all uncertainties with ARG and the research team. FB retrieved all potentially eligible arti- cles. FB and ARG independently screened a sample of 25 full-text articles, and again discussed selection discrep- ancies to further standardize how eligibility criteria were applied. Thereafter, FB screened all remaining full-text items.

Quality appraisal We employed quality appraisal tools relevant to differ- ent research designs: Standards for Reporting Qualitative Research (SRQR) [32], the Good Reporting of a Mixed Methods Study (GRAMMS) tool [33], Critical Appraisal of a Questionnaire Study [34], Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) tool [35], and the Critical Appraisal Checklist for Quasi-Experimental Studies [36]. FB and ARG indepen- dently assessed and compared the quality of a sample of seven studies each. Thereafter, FB assessed the quality of the remaining 24 studies.

Data extraction We developed a data extraction form to extract informa- tion on study characteristics (date of publication, country, purpose, research design) and MM KB characteristics,

Page 4 of 17Boutcher et al. BMC Health Services Research (2022) 22:11

roles, activities, enablers, barriers, and impacts. To pilot test data extraction, FB and ARG independently extracted data from the same 25 articles, then compared results and discussed how to refine data extraction. Thereafter, FB extracted data from remaining articles, which was independently checked by ARG, and then reviewed by the research team.

Data analysis FB and ARG conducted an initial reading and coding of a sample of articles independently. Codes were assigned to significant elements of data within the results and conclusions sections of the eligible articles and grouped into relevant categories with shared characteristics and organized into preliminary themes. This was an itera- tive process that involved ongoing consultation with the research team, who provided feedback on the codes and themes.

We created a matrix of MM KB roles and activi- ties from extant MM and KB theory [7, 18, 22, 37] and deductively mapped themes from included studies with the matrix to help inform the analysis and interpretation of our findings. As per CIS methodology, we developed an integrative grid (matrix table) where themes pertain- ing to MM KB roles and activities formed columns, and themes mapped to those roles/activities from individual studies formed rows [31]. The grid helped us integrate the evidence across studies and explore relationships between concepts and themes to inductively develop syn- thetic constructs [31, 38]. Using a constant comparative approach, we critiqued the synthetic constructs with the full sample of papers to identify conceptual gaps in the available evidence in relation to our aims, and to ensure that the constructs were grounded in the data [31, 38]. Our interpretive reflections on MM KB roles, activi- ties, factors, and impacts led us to develop “synthetic arguments” and we used the arguments to structure our findings (attributes, roles, activities, impacts, enablers, barriers) in an organizing framework to capture our interpretation of how MMs function as KBs in healthcare organizations. We used NVivo 12 software to assist with data analysis.

Results Search results The initial search yielded 9936 articles. Following removal of duplicates, 9760 titles were not eligible, and 176 items were retrieved as potentially relevant. Of those, 135 were excluded because the study design was ineli- gible (25), they did not examine MMs (27) or MM KBs (34), were not focused on the evaluation of an MM KB role (39), were editorials (4), or the publication was a duplicate (6). We included 41 articles for review (Fig.  1

PRISMA flow diagram). Additional file 4 includes all data extracted from included studies.

Study characteristics Eligible articles were published between 2003 and 2019. Three (7.3%) were conceptual and 38 (92.7%) were empir- ical studies. Conceptual articles discussed MM and KB theoretical constructs. Table 1 summarizes study charac- teristics. Studies examined the impacts of change efforts (47.3%), barriers to practice change (34.2%), and evalua- tion of KB interventions (18.4%). Most were qualitative (52.6%) and conducted in the United States (36.8%). Of study participants (34.2%) were MMs. In most studies, participants were nurses (63.1%) or allied health (13.2%) and based in hospitals (68.4%). Otherwise, (31.6%) were based in public health or occupational health depart- ments, primary health care centers, Veterans Affairs Medical Centres, community care, and a senior’s care facility.

Quality assessment findings A critical analysis of the included studies revealed issues related to research design, varying from data collected from heterogeneous healthcare settings and diverse types of MMs to the type of analyses completed (e.g., qualita- tive, mixed methods), to the strength of conclusions drawn from a few studies’ results (e.g., correlational, or causal). Fifteen (39.5%) studies met the criteria for qual- ity. Twenty-three (60.5%) studies had minor methodo- logical limitations (e.g., no research paradigm identified in qualitative studies, and mixed methods studies did not describe the integration of the two methods) (Addi- tional  file  5). These methodological flaws did not war- rant exclusion of any studies as they provided relevant insights regarding the emerging framework.

MM KB attributes Seven (18.4%) studies described MM KB attributes (Table  2). Of those, 4 (10.5%) identified MM attributes, 2 (5.2%) identified KB attributes, and 1 (2.6%) identi- fied nurse knowledge broker attributes. MM KBs were described as confident, enthusiastic, and experienced with strong research skills [41, 45]. They were also responsive and approachable, with an understanding of the complexity of an innovation and the organizational context [42–44].

MM KB roles and activities Table  3 summarizes themes pertaining to roles and activities. A total of 63 activities were grouped in the fol- lowing 12 MM KB roles: (1) gather data, (2) coordinate projects, (3) monitor and evaluate the progress of a pro- ject, (4) adjust implementation to organizational context,

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(5) disseminate information, (6) facilitate networks, (7) bridge the evidence-to-practice gap, (8) engage stake- holders, (9) convince others of the need for, and ben- efit of a project, (10) coach staff, (11) provide tools and resources and (12) function as a strategic influencer. Roles did not differ among MM KBs in hospital and non- hospital settings.

Table  4 summarizes the frequency of each of the 12 MM KB roles across included studies. The two most common MM KB roles were to monitor and evaluate the progress of a project (14, 36.8%) [40, 41, 47–51, 54, 57, 60, 63–66] and to convince others of the need for, and benefit of a project (12, 31.6%) [46–48, 50, 51, 55, 58, 61, 64–67]. For example, MM KBs played an important role in moni- toring the progress of projects to evaluate and reinforce practice change [41, 50]. To convince others of the need for, and benefit of a project and to promote staff buy-in, they held ongoing conversations with staff to help them understand the rationale for change, reinforce the mes- sage, and encourage staff to consistently maintain the innovations on their units [46, 48, 66]. The least common MM KB role was project coordination (4, 10.5%) [39, 47, 48, 56].

Several of the identified MM KB roles aligned with five KB roles in prior published frameworks [7, 22] and MM

Fig. 1 PRISMA flow diagram

Table 1 Study Characteristics

Participants n (%)

MMs 13 (34.2)

MMs & hospital staff or senior leaders 25 (65.8)

Clinical Background Nurses 24 (63.1)

Allied Health 5 (13.2)

Not specified 9 (23.6)

Study Design Qualitative 20 (52.6)

Mixed Methods 8 (21.1)

Quasi-experimental 1 (2.6)

Survey 6 (15.7)

Program Evaluation 3 (7.9)

Country Australia 4 (10.5%)

Canada 12 (31.5%)

UK 5 (13.2%)

USA 14 (36.8%)

Sweden 2 (5.2%)

Taiwan 1 (2.6%)

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role theory [18, 37] (Table  5). For example, 31 (81.6%) studies described MM KB roles of gather data, pro- ject coordination, disseminate information, and adjust implementation to organizational context, which aligned with the roles and activities of a KB knowledge manager. Twenty-nine (76.3%) studies described the MM KB roles of provide tools and resources, convince others of the need for and benefit of a project, and coach staff, which aligned with the roles and activities of a KB capacity builder. We found overlap between the MM KB roles and the four hypothesized roles in MM role theory: (1) disseminate and obtain information, (2) adapt information and the innovations, (3) mediate between strategy and day to day activities, and (4) selling innovation implementation) [18, 37]. For example, we found that as capacity builders, MM KBs also mediated between strategy and day-to-day activities such as coaching staff and providing resources, and in the role of knowledge manager, MM KBs obtained, diffused, and synthesized information [18, 37].

While MM KB roles identified in included studies aligned with the five previously identified KB roles, the CIS approach we employed identified 12 distinct roles that were further characterized based on corresponding

activities associated with each of the 12 roles. There- fore, while this research agrees with prior work on MM KB roles, it represents a robust framework of MM KB roles and activities by elaborating the complexity of MM KB roles and activities.

We fully described two roles compared with prior frameworks: to convince others of the need for and ben- efit of a project, and function as a strategic influencer. To convince others of the need for and benefit of a pro- ject (e.g., a quality improvement, best practice guideline implementation, or innovation), MM KBs used tactics such as role modelling their commitment, providing the rationale for the change, being enthusiastic about its adoption, offering positive reinforcement, and pro- viding emotional support [47, 50, 58]. The role of stra- tegic influencer featured in 7 (18.4%) studies [39, 48, 52, 56, 62, 65, 68]. For example, MM KBs were influ- ential at the executive level of the hospital, advocating for innovations among less involved team members and administrators, including the hospital board, were members of organizational decision-making groups for strategic planning, and served as an authoritative con- tact for initiatives.

Table 2 MM KB Attributes

Study Role MM KB Attributes

Bullock 2012 [39] MM Fellow • Willing to learn and contribute to research • Engaging • Proactive • Ongoing connection with workplace and professional colleagues to exchange knowledge and insights

Donahue 2013 [40] MM • Visionary

Kakyo 2017 [41] MM • Professional • Enthusiastic • Expert skills in managing resources

Kitson 2011 [42] MM • Confident • Knowledgeable • “Can do” attitude • Able to work effectively with teams • Understands the complexity of the innovation task

Schreiber 2015 [43] KB • Strong understanding of clinical/organizational contexts • Strong research skills • Enthusiastic • Accessible

Traynor 2014 [44] KB • Expert in research methodology • Approachable and patient • Comfortable dealing with people at multiple levels • Trustworthy • Flexible • Strong communication skills • Knowledgeable about evidence-informed decision mak- ing and information management • Able to pick up new knowledge quickly

Catallo 2015 [45] Nurse KB • Experienced in research methods • Credible clinical expert • Accountable and trustworthy • Culturally compatible

Page 7 of 17Boutcher et al. BMC Health Services Research (2022) 22:11

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