A qualitative descriptive study of the role of nurse, allied health and physician middle managers who function as knowledge brokers in hospitals

Abstract

Background

Knowledge brokers (KB) are increasingly being employed in health care to implement evidence‐based practice and improve quality of care. Middle managers (MMs) may play a KB role in the implementation of an innovative or evidence‐based practice in hospitals. However, how MMs' broker knowledge in hospitals and their impact on practice has not been adequately studied.

Aim

To describe the role that MMs play in brokering knowledge in hospitals and their impact.

Method

A qualitative descriptive study was conducted to generate a detailed description of MM experiences as KBs in hospitals. Data were collected using semi‐structured telephone interviews with MMs in Ontario, Canada. Participants were purposively sampled to ensure variation in MM characteristics and a diverse representation of perspectives. Data were collected and analyzed concurrently using an inductive constant comparative approach.

Results

Twenty‐one MMs from teaching and non‐teaching hospitals participated. MMs described 10 roles and activities they enacted in hospitals that aligned with published KB roles. We found differences across professional groups and hospital type. Teaching status emerged as a potential factor relating to how MM KBs were able to function within hospitals. MMs reported enhanced patient, provider, and organizational outcomes.

Linking Evidence to Action

Middle managers may play an important KB role in the implementation of evidence‐based practice in hospitals. An improved understanding of the KB roles that MMs play may be important in boosting evidence base practice in health care to ultimately improve quality of care. Administrators need a better understanding of the current KB roles and activities MMs enact as this may lead to more organizational structures to support MM KBs in health care.

BACKGROUND

Leadership is an integral component of the healthcare system and critical to sustaining progress, organizing resources, increasing productivity, and improving quality of care in hospitals (Stetler et al., 2014). Middle managers (MMs) are leaders who play a pivotal role in facilitating high quality care in hospitals (Dainty & Sinclair, 2017). MMs are defined as managers at the mid‐level of an organization who are supervised by senior managers and who, in turn, supervise frontline clinicians (Burgess & Currie, 2013). In hospitals, MMs are usually managers of a clinical unit and are responsible for that unit's leadership and daily management. This role includes ensuring evidence‐based standards of practice are consistently implemented (Dainty & Sinclair, 2017). Despite their critical function, little attention has been paid to MMs relative to senior leaders in terms of their role in the sharing and using of knowledge in healthcare organizations (Birken et al., 2018; Urquhart et al., 2019).

Hospitals use knowledge translation (KT) approaches to promote the use of evidence‐based practices intended to optimize quality of care (Newman et al., 2020). 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 settings (Canadian Health Services Research Foundation, 2003; Gaid et al., 2021). Current research suggests that MMs, because of their mid‐level positions, may play a key role as internal KBs in facilitating the integration of new knowledge in hospitals to improve quality of care, as well as enhance patients' and families' safety, experience, and outcomes. (Birken et al., 2018; Boutcher et al., 2022). It has been proposed that MMs are well positioned to support knowledge sharing and learning because they are able to participate in multiple communities through their dual directed relationships. Thus, MMs are able to broker knowledge for service improvement (Currie et al., 2014). MMs appear to broker knowledge by helping clinicians appreciate the rationale for organizational changes and by translating adoption decisions into on‐the‐ground implementation strategies (Birken et al., 2018; Boutcher et al., 2022).

Knowledge brokers have worked amidst business, research, and policymakers for years but have only recently been implemented in health care (Chapman et al., 2021). Two studies explored KB roles and activities and generated frameworks suggesting that KBs may function across five key roles: (1) knowledge manager, (2) linking agent, (3) capacity builder, (4) facilitator, and (5) evaluator. However, these frameworks are not specific to MMs, and it is not clear whether these roles are achieved in health care (Bornbaum et al., 2015; Glegg & Hoens, 2016). KBs are often distinguished as external or internal to the practice community they seek to influence, but there has been little research focused on the role of internal KBs (Schleifer Taylor et al., 2014; Van Eerd et al., 2016). There is also a dearth of research on what impact KBs within organizations have in brokering knowledge in hospitals (Glegg & Hoens, 2016).

A systematic review by Birken et al. (2018) suggested that MMs may play an important role in facilitating evidence‐based practice implementation in health care but offered little evidence on how MMs play a knowledge brokering role in hospitals. A recent synthesis of the literature by Boutcher et al. (2022) suggested that MMs enact KB roles in healthcare settings to implement innovations and practice change. Such insight is needed to inform strategies that support hospital MMs and build their capacity to promote evidence‐based practice and improve quality of care. To address this gap, the current study team focused on the role of MMs as internal KBs. Our premise was that their central role in organizations afforded them credibility and novel access to detailed knowledge of local context that allowed them to overcome barriers common to external KBs, such as resistance to advice from external sources unfamiliar with the local context (Waring et al., 2013). Hence, the overall aim of this study was to understand MMs' roles and impacts in hospital knowledge brokering.

METHODS

Given the limited prior research on MMs' role as KBs, a qualitative approach was employed. Qualitative research designs can answer “what” and “how” questions and are suitable for problem identification, hypothesis generation, theory formation, and concept development (Sandelowski, 2010). Specifically, an exploratory descriptive approach was used, involving semi‐structured telephone interviews to gain firsthand knowledge of the experiences of MMs as KBs and their perspectives on their efforts and impact. The descriptive approach is characterized by the direct description of a population, situation or phenomenon under study, and concurrent data collection and analysis (Neergaard et al., 2009).

Several techniques were used to maximize study rigor: maintaining a clear audit trail of coding decisions, field notes, memos, and an in‐depth methodological description to allow the study to be repeated; purposive sampling of participants with different professional designations from different settings; and engaging in researcher reflexivity and triangulation to reduce the effect of investigator bias (Shenton, 2004). Reflexive analysis was used to maintain an awareness of our influence on the research process and reflected on what influence our professional views and experience had on the findings. Memos and discussions were used among the research team to examine and consciously acknowledge the assumptions and preconceptions we brought to the study. Triangulation included the adoption of appropriate, well recognized research methods, and the analysis of negative cases.

We complied with the 32‐item Consolidated Criteria for Reporting Qualitative Studies (COREQ; Tong et al., 2007). The study was reviewed and approved by the University of Toronto Research Ethics Board. All participants were informed about the study's purpose and provided verbal informed consent. There was no prior relationship between the interviewer and participants.

Sampling and recruitment

We used purposive maximum variation sampling to recruit MMs based upon personal and contextual characteristics that could influence their perspectives, specifically: setting (teaching and non‐teaching hospitals, rural and urban), professional background (physicians, nurses, allied health), years of management experience, and years in current manager role. Eligible participants were MM clinicians responsible for overseeing clinical staff and who reported to a senior manager. Nurse and allied MMs were identified through professional networks (e.g., Interprofessional Education Leaders Network), and physician MMs through publicly available databases (e.g., College of Physicians and Surgeons of Ontario). The identified MMs were invited to participate through mail, email, and telephone. Interviewed MMs referred us (snowball sampling) to other MMs at their own hospitals. We aimed to interview a minimum target of 10 physicians and 10 nursing/allied health MMs, or 20 total. This is a typical minimum sample size for a qualitative descriptive study (Milne & Oberle, 2005). Sampling was concurrent with data collection and analysis, and proceeded until data saturation was reached, as established through discussion with the research team.

Data collection

Telephone interviews were conducted between January and June 2018 by FB, a registered nurse and doctoral student, and supervised by PhD trained health services researchers (ARG, WB, RU) who had expertise in organizational behavior, health services research, knowledge translation, and qualitative research methods. The interview guide (Appendix S1) was developed based on the extant MM and KB literature. MMs were asked to describe a specific project they led to create, share, or implement an innovative or evidence‐based practice to elucidate the KB roles and activities that MMs enacted and how they impacted the project. A three‐step critical incident technique was applied to the interview guide to elicit rich, detailed descriptions and avoid generalizations. Participants were asked to recount: (1) the incident and description of the project, (2) the actions and behaviors of those involved, and (3) the outcome of the project and incident (Victoroff & Hogan, 2006). This technique kept participants focused on their KB roles, activities, and impacts in a specific project. FB and ARG independently analyzed three pilot interviews. Revisions were discussed and agreed upon with WB and RU to improve the wording and flow of the questions. Interviews were conducted by FB, ranged from 30 to 50 min, audio‐recorded, and transcribed verbatim by an external transcriptionist.

Data analysis

In keeping with the exploratory descriptive approach, themes, roles, and activities were identified inductively using constant comparison. These findings were reported with no further theoretical analysis, as is the case in other qualitative research approaches. The themes, roles, and activities were summarized in a figure. NVivo 12 software was used to manage the data. FB and ARG independently reviewed the first three transcripts and then discussed themes with the research team to determine the preliminary coding Scheme. FB analyzed the remaining data. ARG reviewed the data independently on May 14, 2018, and the research team reviewed data on May 17, 2018. FB used the team's feedback to clarify code labels and coding. An iterative process that involved interpreting and revisiting categories to develop unifying themes was used. Themes and exemplar quotes were shared with the research team on August 22, 2018, and their feedback was used to refine themes.

RESULTS

Participants

In total, 145 MMs were approached for study participation, 116 did not reply, five declined, and 24 agreed to participate. Three interviews were unusable because the participants were not in a MM role, leaving 21 MMs who participated in the study: eight nurses, seven allied health, and six physicians (Table 1). All MMs worked full‐time in a variety of clinical services (e.g., geriatrics, mental health, pediatrics, maternal‐newborn, surgery, medicine, diagnostic imaging, and laboratory services). No participants withdrew from the study.

TABLE 1.

Participant characteristics

Characteristics	Participants n (%)
	Allied health n = 7	Nurse n = 8	Physician n = 6	Total n = 21
Gender
Female	5 (71%)	7 (87.5%)	2 (33%)	14 (67%)
Male	2 (29%)	1 (12.5%)	4 (67%)	7 (33%)
Hospital type
Academic (Teaching)	5 (71%)	6 (75%)	3 (50%)	14 (67%)
Community (Non‐teaching)	2 (29%)	2 (25%)	3 (50%)	7 (33%)
Geographic location
Urban	5 (71%)	6 (75%)	3 (50%)	14 (67%)
Rural	2 (29%)	2 (25%)	3 (50%)	7 (33%)
Years as a manager
Less than 5 years	0	3 (37.5%)	2 (33.3%)	5 (23.8%)
5–10	5 (71%)	2 (25%)	3 (50%)	10 (47.6%)
11–20	2 (29%)	1 (12.5%)	1 (16.6%)	4 (19%)
More than 20 years	0	2 (25%)	0	2 (9.5%)
Years in current role
<5 years	3 (42.8%)	4 (50%)	3 (50%)	10 (47.6%)
5–10	3 (42.8%)	2 (25%)	2 (33.3%)	7 (33%)
11–20	1 (14.2%)	1 (12.5%)	1 (16.6%)	3 (14.2%)
20 years +	0	1 (12.5%)	0	1 (4.7%)

MM KB roles and activities

Middle manager KB roles and activities with select exemplar quotes are reported in Table 2. Participants described 10 activities that defined MM KB roles within three identified project phases of planning, implementing, and disseminating. Figure 1 illustrates the potential associations between roles, activities, and themes.

TABLE 2.

Themes and exemplar quotes for MM KB roles and activities

Stage of project	Theme/activity	Exemplar quotes
Planning	Come up with idea for the project	It was something that I had implemented in another hospital and had some success with. There was great research behind it (02 physician, teaching, urban)
	Gather background data	I had to do an evidence‐based review of the literature for the indications for TPN use from the surgical standpoint (03 physician community, rural)
	Bring stakeholders together	In many ways I help to clear the path and simplify the process so that our physicians had the ability to practice better; to enable I think is the key role that I played. I feel good about my role as an enabler of best practice and a path clearer to allow the project to happen (06 physician, teaching, urban)
	Convince others of the need for and benefit of project	When promoting your project, you must explain to nurses why it's important. If they see it as just another thing to do, then they do not embrace it and they do not care (08 nurse, community, rural)
	Identify and support champions	When you have frontline participation of a nurse champion you have better success (05 nurse, teaching, urban)
Implementing	Communicate with stakeholders	I had a lot of face‐to‐face interviews with the nursing staff, as well as the secretarial staff to understand their perspective on the issues with the old system that we might be able to improve. There was a lot of dialogue. Lots of early mornings to make sure I was connecting with night staff, as well as day staff (01 nurse, teaching, urban)
	Act as a go‐between	I offer myself as a “go‐ between” upper management and frontline staff. In middle management you are unique in that upper management takes a much higher‐level view of all these things and do not want to be bothered with the nitty gritty but as a middle manager you know what's going on at the frontline level and have a go‐between role (02 allied, teaching, urban)
	Monitor and evaluate the progress of the project	I used volume stats to monitor the change, as well as having personal interviews with the staff working in the clinic to see what the impact was for them (02 nurse, teaching, urban)
Disseminating	Facilitate dissemination of findings	If staff attended conferences, did projects or presentations, they presented the information to their peers. It's been quite good the sharing of ideas (02 allied, teaching, urban)
	Coach staff	I would coach the physicians in how to have conversations with families; sometimes we would role play‐ I would be the family member and they would practice with me first (06 physician, teaching, urban)

Note: Themes capture key activities that defined MM roles.

Abbreviations: KB, knowledge broker; MM, middle manager.

FIGURE 1.

Middle managers who function as knowledge brokers in hospitals

Planning the project

To plan a project, most MMs described that they were able to come up with the idea for the project, gather background data, bring stakeholders together, convince others of the need for and benefit of the project, and identify and support champions.

Come up with the idea for the project

To come up with the idea for their project, MMs described that either senior management mandated the project or they had previous experience implementing it in another hospital. Most physician MMs had previous experience implementing the project in another hospital, whereas most nurse and allied MMs identified that senior management often mandated their projects.

Gather background data

To gather background data, MMs described analyzing information, conducting environmental scans, and site visits. MMs conducted literature searches and needs assessments to understand the issue that their project aimed to address. Several engaged in project coordination activities such as recruitment of participants for data collection and applying for funding.

Bring stakeholders together

Most MMs worked to identify and connect with suitable stakeholders and secured their participation through in‐person meetings. They facilitated relationship building among stakeholders by encouraging teamwork and facilitating interactions:

We talked about the stakeholders we needed for the project. We had our core group – pharmacy, dietary, but we looked at the other departments that we needed to bring in. (03 physician community, rural)

Convince others of the need for and benefit of a project

Middle managers described strategies that they used to encourage senior management and staff to buy‐in to their project. To get senior management buy‐in, MMs wrote business cases. To get staff buy‐in, MMs role modeled their enthusiasm and commitment to the change, explained the rationale for the project, held frequent face‐to‐face meetings, and used incentives such as offering staff to present at conferences. These strategies were especially important for nursing and physician MMs:

It is important that I role model the way. That I am enthusiastic and excited about what's coming even though I may be feeling overwhelmed by how I'm going to pull it off. I cannot do it alone. I must get the team engaged. (05 nurse, teaching, urban)

Identify and support champions

Most nurse and physician MMs stressed that identifying a champion was a key strategy to engage staff because getting buy‐in was more successful when staff champions were involved. MMs derived great personal satisfaction from their mentorship roles and saw the development of staff champions as a strategic investment. This was not articulated by allied MMs:

I get joy in watching the growth of a frontline champion. I believe in picking staff that are enthusiastic, want to learn, and develop the skills because the more champions I have on the unit, the easier it is for me to implement projects. (05 nurse, teaching, urban)

Implementing the project

During implementation, MMs described how they communicated with stakeholders, acted as go‐betweens, and monitored and evaluated the progress of a project.

Communicate with stakeholders

Most MMs described spending time on their unit promoting projects, listening to staff concerns, setting clear expectations, and checking in with staff to establish and maintain open channels of communication. Most provided regular updates to senior management and were strategic about when to raise a new idea for an initiative to maximize the chances that it would be approved and implemented:

I scan the environment so that I'm aware of what's going on at upper management. I'm strategic and wait to present my case. I do not go during major budget discussions. (02 allied, teaching, urban)

Go‐Betweens

Acting as “go‐betweens” was a recurring theme with physician and allied MM participants. They described themselves as the link between staff and senior management – playing a bridging role by linking daily operations to the larger strategic goals of the organization and using their networks to make connections with stakeholders. This was not articulated by nurse MMs.

Monitor and evaluate progress

Middle managers described that a critical aspect of their role was to monitor and evaluate the progress of a project. Most emphasized how their participation in data collection and analysis was important not only to evaluate the impact of the project on staff and resources, but also to determine next steps and to adjust projects. Many MMs from community hospitals felt that it was essential to hold regular team meetings to identify what was working and what was not.

To get a project back on track, MMs adjusted the project plan based on feedback from staff and patients. MMs removed obstacles, provided staff with practical feedback, and addressed performance issues. MMs felt it was important to be attuned to the moods and needs of staff to help them manage their emotions about the change:

I was aware when staff were feeling stressed with their need to balance clinical work with QI work. I cannot pay overtime, but I can lean on the team to cover here and there, or just make them aware of what their colleagues are doing. (02 allied, teaching, urban)

Disseminating the project

To communicate the project findings, MMs described how they coached staff and facilitated the dissemination of findings.

Coach staff

Middle managers utilized several strategies to coach and build staff capacity and confidence to lead projects. This support was particularly important during the dissemination phase of projects because staff were concerned about publicly presenting their work. MMs helped staff rehearse, held debriefing sessions, and engaged in role‐play:

I coached my resident to take the lead. I showed him how to lead projects in this hospital, so in the future he can comfortably lead on his own. (03 physician, community, rural)

Facilitate dissemination of project findings

Middle managers facilitated knowledge diffusion by reporting project findings to hospital committees and presenting at conferences. To support information sharing, many established communication channels and initiated ongoing communication with staff and patients.

Impact on service delivery and outcomes

Table 3 shows the outcomes of the projects MMs implemented. Four themes emerged from our analysis: (1) cohesive team, (2) sustainability of the innovation, (3) challenges to implementation, and (4) impact.

TABLE 3.

Characteristics and key outcomes of innovations

Characteristics			Key outcomes
Participants	Innovation	Adopted	Provider	Patient	Administrative
01 Allied Community	Implementation of program designed to improve care of older adults	Y	Increase in nurses' knowledge re: care of older adults	Decrease in delirium and functional decline	NR
02 Allied Academic	Quality improvement project‐ program for residents with dementia	Y	Promoted teamwork	NR	Decrease in referrals and more appropriate referrals
03 Allied Academic	Quality improvement project‐ Implementation of a model for trauma therapy services	Y	Clinicians satisfied	NR	Increase in referrals
04 Allied Academic	Quality improvement project‐ Automation of Transfusion Services	Y	Increased staff satisfaction and confidence	Reduced technician time	Cost‐effective, increased efficiency‐ able to do more tests
05 Allied Academic	Quality improvement project‐ Redesign of Outpatient services	Program not fully integrated	NR	NR	NR
06 Allied Academic	Quality improvement project‐ an alternative to conscious sedation	Y	Increased staff satisfaction and understanding of collaborative practice	Increased parent satisfaction Provided alternative to conscious sedation	Increased efficiency and tests Decreased wait times
07 Allied Community	QBP – Implemented a total knee outpatient replacement program	Y	Surgeons were satisfied with results	Class was equal if not better than ono‐to‐one treatment	Increased efficiency Increased cost savings
01 Nurse Academic	QBP – Improved access to clinic for breastfeeding and bilirubin follow ‐up	Y	Nursing staff and pediatricians satisfied	Patient satisfaction, decreased LOS,	Increased volumes in the clinic
02 Nurse Academic	QBP‐ Preventing post‐op surgical site infection	Y	NR	Decrease in surgical site infection	NR
03 Nurse Academic	Change of practice – Midwives monitoring and managing epidurals	Y	Increased satisfaction of Midwives	Patient satisfaction Increased efficiency	NR
04 Nurse Academic	Quality improvement project‐ ER Hallway toolkit	Y	MM satisfaction	NR	NR
05 Nurse Academic	Guideline implementation – Intentional night rounding	Y	MM satisfaction	Reduced falls	NR
06 Nurse Academic	Upskilling of nursing staff in pediatrics	Y	MM satisfaction. Positive experience for team.	Increase in rates of immunizations and breastfeeding	NR
07 Nurse Community	QBP‐ design and implementation of a new endoscopy unit	Y	NR	Patient satisfaction	Increased efficiency, increased patient volumes
08 Nurse Community	Quality improvement project‐ implementation of a care pathway for knees and hips	Y	Increased knowledge for nurses	Decreased LOS from 4 days to 2.	NR
01 Physician Community	Quality improvement project‐ change in medicine on‐call resources	Y	Increased satisfaction of physicians	Decreased hospital admissions by 60%, decreased LOS by 15%	Decreased wait times, Improved workflow in ER
02 Physician Academic	Guideline implementation‐ enhanced recovery protocols for post‐surgical patients	Adopted 11/12 steps of protocol	Increased satisfaction of staff and physicians	Decreased nausea and vomiting, pain, post‐op ileus, narcotic usage Increased patient satisfaction	NR
03 Physician Community	Quality improvement project‐ Implementation of TPN in organization	Y	Increased staff and MM satisfaction	Decreased costs and appropriate usage of TPN	NR
04 Physician Community	Quality improvement project‐ Formation of pediatric patient care teams	Y	Increased nurse and physician satisfaction	Increased continuity of care, increased patient satisfaction	NR
05 Physician Academic	Quality improvement project ‐Improved central intake process	Y	NR	Increased continuity of care, increased patient satisfaction	Decreased wait times, increased efficiency
06 Physician Academic	Guideline implementation – promoting appropriate use of antipsychotics	Y	Increased staff and physician satisfaction, felt empowered	Decreased use of antipsychotics from 24 to 16%	Decreased emergency transfers

Abbreviations: ER, emergency room; LOS, length of stay; MM, middle manager; NR, not reported; QBP, quality‐based procedure; TNP, total parenteral nutrition; Y, yes.

Cohesive team

Most allied and nurse MMs articulated that working on a project contributed to a more cohesive team:

The project helped facilitate a deeper understanding of interprofessional collaboration because the team had to work together. (02 allied, teaching, urban)

Sustainability of the innovation

Middle managers recounted how the changes that they made quickly became normalized and staff could not imagine a time when it was ever any different:

It was eye opening for us. We had staff who still thought that 1–1 care was the better option. We were very pleased that the results showed that we could see several patients at the same time and still have equal or better outcomes. (07 allied, community, rural)

Challenges to implementation

Allied and physician MMs from teaching hospitals described how they faced challenges with the implementation of the innovations including staff who were nervous, upset, or refused to change. Several MMs described that their initiative was ultimately adopted, but not without difficulties.

Impact of the project

Most MMs, in all professional groups, described the implementation of their projects as positive, with sustained benefits over several years and described patient, provider, and organizational outcomes (Table 3). Only two MMs, one allied health and one physician, from urban teaching hospitals stood out as negative cases. Although their projects were ultimately implemented, both described challenges such as staff resistance and poor patient outcomes with the uptake of their innovations resulting in some unintended outcomes.

Differences across professional groups and setting

Differences across professional groups based on their roles, activities, and settings were found. For example, nurse and physician MMs emphasized the important strategic investment of developing staff champions as facilitators as a key strategy for getting buy‐in for the implementation of initiatives. This was not articulated by allied MMs:

I had a nurse champion because when you have frontline participation you have better success. (05 nurse, teaching, urban)

Nurse and physician MMs described the importance of motivating staff to implement their projects by role modeling their commitment to change and removing barriers to allow staff time for project activities. This was not identified by allied health MMs or MMs from non‐teaching hospitals.

Allied and physician MMs acted as go‐betweens by using their networks to make connections to bring together individuals with common interests and relevant expertise to address an issue and were often the link between staff and senior management. This was not articulated by nurse MMs:

I offer myself as a “go between” between upper management, frontline staff, and the manager group. Upper management takes a high‐level view and does not want to be bothered with the nitty gritty, but middle managers know what's going on at the frontline. (02 allied, teaching, urban)

We also found several differences based on the teaching status of hospitals. MMs in urban teaching hospitals described having greater access to resources to invest in the professional development of staff than MMs in non‐teaching hospitals. For example, MMs had the funding to promote their projects, engage staff, and celebrate success that MMs in rural, community non‐teaching hospitals did not identify. This was especially important for nursing and physician MMs in teaching hospitals.

Alternatively, some MMs described that the complex organizational structure of large urban teaching hospitals acted as a barrier to moving projects forward. Both allied and nurse MMs described how this complexity led to disconnects with the senior team, who were unaware of what was happening at the unit level.

We found a few notable differences described by physician MMs in rural community hospitals compared to their counterparts in urban hospital settings. In smaller community hospitals, physician MMs had more contact with teams and better alignment with organizational strategy because they knew and built close working relationships with staff at all levels. On the other hand, because their offices were often not situated in the hospital, physician MMs found that they lacked visibility and were unable to attend daily team huddles. Physician MMs in community hospitals also identified several challenges to the implementation of evidence‐based practices. A lack of incentives and the physician fee‐for‐service model, interfered with their ability to lead projects because they were paid for seeing patients but not for doing evidence‐based QI projects.

Recommendations to support MM KBs

Middle manager KBs made five recommendations they needed to implement innovative or evidence‐based practice in hospitals: (1) a peer support network, (2) coaching from senior management, (3) staff to support implementation, (4) opportunities for professional development; and (5) methods to promote innovation.

Most MMs described the importance of having access to a strong peer support system during the implementation of their initiatives:

To be successful as a middle manager you need a peer support network to talk to about what you can do to make things better. It's also important to have the right manager peer group that deals with the same type of issues. (06 allied, teaching, urban)

Middle managers repeatedly spoke of the necessity of having an experienced director or vice president to coach them, especially if they were new to their role. They also identified that it was critical to have the appropriate staff on the ground to facilitate change when they could not be there because of other demands:

I could have used a dedicated practice leader allocated to the project. Having a resource to facilitate, and search for available evidence would have saved a lot of time. (07 allied, community, rural)

Allied and physician MMs described the need for professional development and training opportunities. This was especially important for physician MMs in community hospitals who received little training in project management:

Before we can lead a project, we need to learn the “basics” to design and move projects along. This should be available to all physicians but is sorely lacking. We're not even taught how to manage an office, let alone projects. (03 physician, community, rural)

Nurse and physician MMs emphasized the importance of promoting innovation. For example, MMs were not looking for financial compensation, a simple “thank you” was enough from senior leaders to acknowledge their hard work and long hours.

DISCUSSION

MMs enact KB roles in hospitals

Our analysis showed that hospital MMs did enact KB roles and activities when implementing innovative and evidence‐based practice. These findings corresponded to the theoretical characterization of KBs as knowledge managers, linking agents, capacity builders, facilitators, and evaluators. It was found that MMs' experiences in practice validated extant theory and contributed new insight into the KB roles MMs enact in hospitals. Figure 1 provides further clarity and expansion of the theoretical constructs identified in the literature (Birken et al., 2018; Bornbaum et al., 2015; Glegg & Hoens, 2016). For example, this study found that MMs were heavily involved in gathering background data. These activities are congruent with the knowledge manager role, corroborate previous KB reviews, and overlap with the hypothesized MM role of obtaining and diffusing information (Birken et al., 2018; Bornbaum et al., 2015). Yet, our findings extended beyond the roles proposed in the Birken et al. (2018) theory. In addition to gathering background data, we found that MMs also engaged in coordination of activities such as writing business cases. This corroborates with the Urquhart et al. (2018) finding that the coordinator role was a key MM role in innovation implementation.

Several novel findings helped clarify how MMs function as KBs in hospitals. For example, we found that MM KBs played a vital role in planning and monitoring the improvement of practices throughout the project lifecycle, including evaluating outcomes and sustaining knowledge. MM KBs played an active role in data analysis and engaged in dialog with staff to address any challenges. MM KBs facilitated and sustained staff engagement in projects by enacting the roles of facilitator and evaluator. These KB roles overlap with the hypothesized MM role of mediating between strategy and day‐to‐day activities. In contrast to previous research, our findings revealed that MM KBs not only identified and adapted knowledge to the local context but actively monitored knowledge use, evaluated outcomes, and sought strategies to sustain new knowledge (Girard et al., 2013; Lortie et al., 2012).

Additionally, we found that convincing others of the need for and benefit of an innovative or evidence‐based practice was described as a central part of the MM KB role, highlighting the important capacity‐building role MM KBs play in identifying and supporting champions. MM KBs viewed the development of staff champions as a strategic investment because once “groomed” they became facilitators in the implementation of future initiatives. This MM KB role aligned with the capacity builder role and overlapped with the Birken et al. (2018) MM role of selling innovation implementation. Our findings extend Birken et al.’s description and contribute a novel interpretation of this process. For example, how MMs described their KB roles and associated activities during project implementation indicated that they were uniquely positioned within the organizational leadership structure to exercise their operational authority to elevate and prioritize their KB role, and to identify, train, and integrate champions (i.e., allocate resources) to convince others of the need for and benefit of an innovative or evidence‐based practice.

Impact of MM KBs

Our findings enhanced our understanding of the impact of MM KBs on service delivery. We found that MM KBs perceived the implementation of their projects as positive and described sustained patient, provider, and organizational outcomes (e.g., patient satisfaction, improved knowledge of staff, performance metrics) over several years. Our findings are consistent with several reviews of the role and effectiveness of MM KBs; however, it should be noted that we documented the subjective perceptions of participants on the impact of their innovations in hospitals and did not look at objective outcome data (Birken et al., 2018; Bornbaum et al., 2015; Van Eerd et al., 2016). This highlights a need for additional research to establish rigorous evidence of the impact of MM KBs on service delivery.

Differences in hospital type and across professional groups

Our study revealed that teaching status was a potential factor relating to how MM KBs were able to function within hospitals. MMs were recruited from both teaching and non‐teaching hospitals across Ontario, Canada. In large teaching hospitals, there were many opportunities for support and access to resources to enable best practices. Yet, MMs became frustrated when they had to fight for resources. This is consistent with research highlighting the challenges that MMs face in hospitals (Jeffs et al., 2016).

Since there has been little prior research on physician MMs, some findings from the physician MMs in community non‐teaching hospitals merit careful consideration. While working in a smaller hospital helped physician MMs develop close working relationships with their teams because they had more contact with them, they also identified several challenges to implementation of evidence‐based practices. Access to the team was a challenge for many physician MMs whose offices were situated outside the hospital and those with smaller departments struggled to stay on the radar of senior management. These findings are areas for future research to enhance our understanding of how hospital size and teaching status may be important factors influencing implementation climate and MM KB role and activities.

Implications for practice

Middle manager KBs made recommendations that hospital administrators and service providers can use to strengthen the role. First, MM KBs described that access to peer support was critical. Consistent with our findings, the literature suggests that having mentorship opportunities with those more experienced can be important for novice MM KBs (Catallo, 2015). This finding underscores the need for administrators to formalize mentorship programs to ensure that novice MMs can learn from experienced MMs and connect with each other through formal and informal networks. Second, the need for senior management support was a consistent theme running through our findings. MMs perceived the need for recognition and support from both directors and their executive team as critical to functioning as KBs and their initiatives' success. This corroborates previous research that senior leadership support is essential to navigate the challenges of innovation implementation (Birken et al., 2015; Urquhart et al., 2019).

Additionally, MM KBs indicated that having access to appropriate “on the ground” support, such as staff champions, was essential to achieving successful implementation of evidence‐based practices. MM KBs saw the development of staff champions as a strategic investment because the more they had, the easier it was to get buy‐in and implement initiatives. Frontline champions were able to facilitate implementation and convince their colleagues of the change when MM KBs could not be there because of other demands. There is increasing support for the use of champions. Research has encouraged MMs to leverage champions to achieve innovation implementation (Bunce et al., 2020; Miech et al., 2018). We highlight the need for administrators to endorse the allocation and training of unit‐based champions to boost the role of MM KBs when implementing innovative or evidence‐based practices.

Finally, we found that MM KBs sought more and better training to lead and implement evidence‐based practices. Of note, the need for project management training was stressed by physician MMs who found that they were often unprepared and “flying by the seat of their pants” without any training or previous management experience. This finding supports Urquhart et al. (2018), who found that without formal training in project or change management, MMs were constantly trying to learn new knowledge and skills that would help them succeed in their roles, but this training was primarily self‐directed. Administrators must offer ongoing professional development opportunities to build MM capacity to lead corporate initiatives that many already do in addition to their operational responsibilities.

Limitations

First, few participants were physicians, and few represented community or rural settings. Second, although qualitative methods allowed for an in‐depth understanding of MM KB roles and activities, our results remain exploratory, and our findings only pertain to the sample studied. Thus, the extent to which our findings are transferable is unknown. Future research should validate these findings among larger groups of MMs in different settings. We also used a critical incident interview technique to elicit detailed descriptions; however, it is possible that this technique led participants to respond with examples of successful implementations rather than unsuccessful projects. We must acknowledge that our study was conducted nearly 4 years ago, so MM KB roles may have changed or evolved since then.

LINKING EVIDENCE TO ACTION

• MM KBs described 10 roles and activities that they enact in hospitals to implement innovative or evidence‐based practices.

• MMs may play an important KB role in the implementation of evidence‐based practice in hospitals.

• The unique position of MM KBs within the organizational leadership structure may provide them operational authority and accountability to elevate and prioritize their KB role and activities.

• Administrators need a better understanding of the current KB roles and activities MMs enact as this may lead to more organizational structures to support MM KBs in health care.

• An improved understanding of the KB roles MMs play may be important in boosting evidence base practice in health care to ultimately improve quality of care.

CONCLUSION

Our study provides valuable insights into the impacts and roles that MMs play in brokering knowledge in hospitals. We found that MMs enacted the five published KB roles and activities in hospitals to implement innovative or evidence‐based practices. Our findings also contribute to the extant literature by providing actionable insights that administrators and policy makers can use to strengthen, better equip, and more broadly implement MM KBs to improve quality of care.

Supporting information

Appendix S1

Boutcher, F. , Berta, W.B. , Urquhart, R. & Gagliardi, A.R. (2022) A qualitative descriptive study of the role of nurse, allied health and physician middle managers who function as knowledge brokers in hospitals. Worldviews on Evidence‐Based Nursing, 19, 477–488. 10.1111/wvn.12594