Networks and Communications

Research on organizational change has moved beyond reductionist measures of organizational structure, and increasingly embraces the complex role that networks and communications have on implementation of change interventions [1]. Connections between individuals, units, services, and hierarchies may be strong or weak, formal or informal, tangible or intangible. Social capital describes the quality and the extent of relationships and includes dimensions of shared vision and information sharing. One component of social capital is the internal bonding of individuals within the same organization [2]. Complexity theory posits that relationships between individuals may be more important than individual attributes [3], and building these relationships can positively influence implementation [4]. These relationships may manifest to build a sense of ‘teamness’ or ‘community’ that may contribute to implementation effectiveness [5]. In addition, the more stable teams are (members are able to be with the team for an adequate period of time; low turnover), the more likely implementation will be successful [5].

Regardless of how an organization is structurally organized, the importance of communication across the organization is clear. Communication failures are involved with the majority of sentinel events in US hospitals [6]. High quality of formal communications contributes to effective implementation [7]. Making staff feel welcome (good assimilation), peer collaboration and open feedback and review among peers and across hierarchical levels, clear communication of mission and goals (see Goals and Feedback), and cohesion between staff and informal communication quality, all contribute to effective implementation [7].

The Network and Communications construct in the CFIR consolidates several domains from Greenhalgh, et al. including organizational structure, intraorganizational communication, and intraorganizational networks [2]. Little is known about the interplay between formal structure, informal networks, and effective communication. Thus, we consolidate these concepts into a single construct to give wide latitude for researchers to take deductive approaches to explore alternate theories such as social networking [8] or complexity [1][9] theories. This construct, perhaps more than any other, requires a more grounded approach of study; leaning toward a constructivist approach for analysis [10] until we understand more about the role of networks and communications and especially how it interrelates with other constructs. Greenhalgh et al. cite strong or moderate influence of intraorganizational communication, intraorganizational networks, internal boundary spanning, and organizational structure on implementation [2]. Coordination across departments and specialties is essential for effective implementation to attenuate the “complex web of sources of power and covert and overt sources of influence” that all contribute to individual decisions about whether to cooperate [11, page 233]. A core principle of complexity theories leads to the idea that the actions of individuals and units affect implementation, positively or negatively, in predicted and unpredictable ways [12]. Integration to bridge traditional intra-organizational boundaries among individual components is one of five critical elements for driving transformation in patient care [13]. Connections between individuals, units, services, hierarchies may be strong or weak, formal or informal, visible or invisible. Physicians and nurses may struggle with routine (and role) changes that require coordination of activities and sharing of information across professions or units [14]. Clear role definitions (e.g., physician and non-physician roles) positively influences implementation [15][16]. The PARHiS model asserts that clearly defined physical, social, cultural, structural, and system boundaries contributes to research uptake [17][18]. Teamwork is emphasized as an essential “core property” for successful implementation of quality improvement initiatives [19, page 287]. Relationships with others, teamwork, and power and authority structures are all part of network and communications and influence implementation [17][18].

Strong horizontal and informal networks have positive relationship with adoption; e.g., physicians are influenced by the spreading of information through peers [2]. Strong intra-organizational communications are positively associated with implementation as is devolving decision-making to the front-line teams or individuals [2][20]. Strong communication includes having access to information (see Access to Knowledge and Information), being well-informed, and understanding the goals related to an intervention and all contribute to successful implementation [21]. Vertical and formal networks can also have a positive relationship with implementation; e.g., nurses may be most influenced by authoritative decisions [2].