articulo 4

NURSING AND HEALTHCARE MANAGEMENT AND POLICY

Exploring knowledge work and leadership in online midwifery
communication
Fiona Brooks BA PhD
Reader, Centre for Research in Primary and Community Care, University of Hertfordshire, Hertfordshire, UK

Peter Scott BA PhD
Head of the Centre for New Media, Knowledge Media Institute, The Open University, UK

Accepted for publication 27 January 2006

Correspondence: B R O O K S F . & S C O T T P . ( 2 0 0 6 ) Journal of Advanced Nursing 55(4), 510–520
Fiona Brooks, Exploring knowledge work and leadership in online midwifery communication
Centre 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 delivery
Hertfordshire, requires that nurses and midwives shift from being ‘information workers’, or passive
UK. receivers of managerial and organizational decisions, to become ‘knowledge
E-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 for
doi: 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 forum

510 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 of
Introduction
dispersed or team-based leadership there remains a continued
In western healthcare systems, the demand for resource need to identify how communities of practice actually work
effective, quality and innovation directed services is leading together and can be supported through effective leadership
healthcare professionals to embark on a remodelling of (Gabbay et al. 2003). In the United Kingdom (UK), for
traditional hierarchy-bound healthcare organizations. Know- example, every midwife is now asked to develop their
ledge 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-related
it (Quintas 2002). ‘Knowledge workers’ are critical reflective decision-making (DOH 2003). Midwifery managers have
thinkers who can creatively generate new meanings or also been challenged to improve their accountability and
conceptualizations from experiences, thereby enabling them promote innovation in practice (Pashley 1998, Andrews
to perceive their working practices in a new light (Nonaka & 2004). Access to positive role models, the creation of strong
Takeuchi 1995, Brockbank & McGill 1998). Moreover, they teams and ‘leaders with vision’ are likely to be critical factors
not only create new knowledge, but can also identify how in improving organizational and professional cultures and
new 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 by
knowledge, research on knowledge management faces staff in policy and organizational decision-making is unlikely
practical 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 and
actual practices of knowledge workers in situ (Blackler et al. Midwifery has consistently expressed concern that nurses
1993). Consideration of how knowledge workers actually ‘do and midwives have remained relatively invisible and
knowledge work’, as opposed to categorizing what they marginalized in health policy decision-making (Thompson
know, is important for developing a better understanding of 2002). In western countries, midwifery is represented by an
knowledge 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. In
Background
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 to
knowledge work of healthcare professionals, for whom the innovate, feeling marginalized. In the UK, for example, this
context 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, such
Knowledge workers in healthcare systems will need to function midwives even face negative sanctions and horizontal
not 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 has
service delivery. Although the role of vertical leaders or been poorly recognized and supported (Brodie 2002). This
managers remains important to the development of knowledge process of marginalization has resulted in some midwives
work, recent leadership theory has strongly emphasized the leaving the profession (Ball et al. 2002). Even more
centrality of ‘team-based’ knowledge work to the creation of significantly, in a number of countries studies have reported
innovation and change (Pearce 2004). Communication and that those in practice feel unable to respond positively to
discussion of work-based experiences within a team can create change or envisage how to develop innovations (Begley
new ‘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 as
team being able to mutually influence their fellows to improve knowledge workers represents a challenge for midwifery. In
and maximize the quality of practice, with the consequence the case of midwifery, it seems that effective participation in
that staff feel valued and have ownership over their decision- decision-making and developing a culture that can positively
making (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 cultural
of the community of practice are empowered to act as unofficial barriers to achieving effective communication structures that
leaders, 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 development

Ó 2006 The Authors. Journal compilation Ó 2006 Blackwell Publishing Ltd 511

F. Brooks and P. Scott

and application of new discursive information and commu- This paper reports on the part of the AEC study that
nication 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 knowledge
consider the dynamic interactivity of new communication workers?
technologies (Ngwenyama & Lee 1997). Virtual discussion This central analytic task was then sub-divided into
groups 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 below
collaborative networks (Ruberg et al. 1996, Bishop & Levine for an explanation of UK midwifery staff grades) and
1999, 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 community
communication 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 of
expertise and knowledge (Hightower & Sayeed 1996,
Setting
Johnson 2001). In relation to healthcare systems, computer-
mediated communication has been shown to promote the The project was located in a non-teaching, acute hospital
emergence of effective channels of communication to vertical trust in central England with a largely stable midwifery
leaders 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 were
and Internet technologies that support clinical work and responsible for all aspects of care, including inter-partum care
audit 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 also
2001). 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
Design
medical and nursing informatics, studies that have considered
the 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 information
quently, there is a need for research to attend to how technologies. The methodology, being concerned with ‘real
midwives 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 usage
capture and use. (Tellis 1997, Yin 2003). Computer-mediated communication
also offers a number of advantages over traditional data
collection methods (Anderson & Gansneder 1995, Hine
The study
2000). It allows for the interpretation of naturally occurring
interaction without a constant visible presence or the
Aim
requirement that the researcher transcribes real world
The ‘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 interactional
through use of computer-mediated communication technol- pressures of normal face-to-face interaction (Mann &
ogies. Stewart 2000).



In the AEC project, use of discussion forum data made Technical maintenance of the forum was undertaken by
possible 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 on
generate 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 specific
Participants
patient satisfaction survey. However, due to requests from
Participation in the discussion was advertised as open to any midwifery staff the forum was kept open and discussion of
midwife 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 were
the 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 range
Advertising 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 grade
open 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 interviewees
demonstrated that midwives at the Trust viewed the design of were invited orally to participate, in the first instance, by the
the forum positively, were not technophobic and felt that the local researcher (17 approached, two refused due to time
discussion space was a valuable resource (Brooks et al. 2004, constraints). A member of the external research team
Brooks & 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 project
Data generation
prior to contact by the local researcher. The interviews
It was intended that technology-assisted discussion forums explored the technological features of the forum, the value
could be used to stimulate a connection between professional and ease of participation, perspectives on participation in
communities of practice, leading to possible innovation in decision-making, leadership and collegial support. All the
practice without staff ever leaving the ward. interviews were taped and transcribed.
The forums provided a means for midwives to send
views, ideas and responses directly and electronically to
Ethical considerations
other practitioners in a public discussion space. This
employed a commonly available set of low-cost software Approval for the study was gained from the Local Research
tools such as ‘web-forums’, which are now in wide use on Ethics Committee. Discussion in online forums represents a
the internet (see Scott & Quick 2003). The midwives’ data source that falls somewhere between semi-private
viewed 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 tended
network (intranet). The discussion forum concept used was towards the view that postings cannot be simply accessed
rather like a publicly accessible e-mail account, in which all without any ethical safeguards. In particular the use of
the text messages were available either to be read or pseudonyms has been advocated (Herring 1996a), and
responded to by anyone accessing the forum at their ensuring that participants are made aware that the intended
convenience. 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 and
Midwives from the project steering group participated in were reminded when they accessed the system that the forum
determining the layout and appearance of the forum web was part of an on-going research project. The system was not
pages to suit their needs. No formal training was required password protected so that authors of messages were able to
to use the forum, as it was designed to require only reading choose to post a message anonymously. The interviewees
short instructions placed next to the computer, or a were approached as described above, and were assured of
minimal (1–2 minutes) peer-led demonstration, for an confidentiality; pseudonyms have been used in this paper for
individual to be able to post and access messages. both the interview and forum data.



generate new knowledge, articulate alternative forms of
Data analysis
provision and suggest ideas for the resolution of issues in a
The totality of the online communication was considered, discursive manner (Brockbank & McGill 1998).
that is, the usage patterns and complete contributions to the
forum. Analysis of the online discussion was also undertaken
Findings
by grade of midwife (see above for an explanation of UK
midwifery grades). Thematic coding was employed and This section explores the levels of participation, and then
themes were generated both inductively from the raw data outlines the nature of the interaction with reference to the
and 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 members
of the inter-disciplinary research team (midwife, sociologist
Participation on the forum
and knowledge media specialist), data were categorized into
initial and higher codes and repeatedly searched for discon- Over the 3-month period, a broad-based community of
firming cases as part of the coding refinement process. The midwives posted 193 messages. Figure 1 illustrates the
interview data were specifically mined as part of the postings by grade of midwife. The system was available to
triangulation process to refine the emergent theory. The dis- all 96 midwives working in the hospital setting (day and night
cussion forum data was interrogated for: knowledge work, staff, all female), although because community midwives did
collegial and leadership relationships. They were also ana- not have access to the intranet, the system was not promoted
lysed for issues such as the general character of participation, to the community staff (n ¼ 37). However, three community
e.g. messages by grade, and entered into the statistical midwives did come into the hospital to access the intranet and
software 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 midwives
of 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. Among
munication 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 of
et al. 1999, Quintas 2002). To analyse knowledge work, a practice, such as smoking cessation. An additional nine
distinction was made between messages displaying solely postings were made anonymously, eight with just the title
information usage (e.g. reporting an event or policy) and ‘Midwife’ and one with the title ‘HCA’. From the in-depth
those applying knowledge in a discursive way. Information interviews it is known that at least two midwives posted
work 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) on
ted an ability to reflect critically upon new information or the discussion forums have been identified as likely to be
explicit 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%
Contribution

decision-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 10
manner that openly reflects upon current care and service Grade
(Number at each grade)
provision’ (Brooks & Scott 2006, p. 87). This definition of
critical reflective thinking also encompasses a willingness to Figure 1 Forum contribution (postings) by grade.



significantly 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 specialist
target community, across all grades of midwife, functioned as midwives had a means to disseminate this information to the
authors 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 to
1999, 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 work

express views without the normative interactional pressures
Thread: RE: Shortage of HCAS
of face-to-face communication was valued by interview Ellen Norton Apparently management are
respondents (irrespective of grade). This positive perception G grade midwife advertising for ·2 day
also included a sense that the removal of interactional Time: 08:17 and ·1 night CA-Midwifery staff
pressures increased the significance of the message:
In terms of the application of knowledge work, midwives
There’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 was
existing hierarchy in the hospital, there was some evidence perceived as a vehicle to enable a collective consideration
that respondents felt more usual forms of work-based of important issues that had previously not been attended to
interaction 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 valued
added their name to a message, they felt less open to negative being able to ‘critically reflect’ via the forum. Midwives
sanctioning 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 any
comeback. You can raise the issue and see what other people think …just to express an opinion really, just say what you think, instead of
about 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 experiential
nication patterns and to bring to the fore previously knowledge base of working with women. In the example
submerged issues and agendas. The next subsections focus below a midwife drawing on a patient-centred narrative has
on 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 a
Information work and knowledge work
resolution for further debate.
The online discussion was overwhelmingly characterized by
Forum extract 2: Initiating a knowledge work discussion
messages that displayed discursive discussion and critical
reflective 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 baby
with 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 the
valuable. 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 encourage
the knowledge work discussions. In any organization, by
this when dealing with the menu’s?
virtue of holding either a managerial or specialist position,



Within the ‘knowledge work’ coding, a striking feature was the form of encouragement for emergent leaders from within
the 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 a
proposals for resolution were composed, as in the example newly qualified midwife, on how to effectively lead on a
above, 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 leaders
posed resolution took the form of a request from a senior or
specialist midwife to undertake specific action to form a Thread: RE: Information Leaflets
working 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 from
necessarily 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-one
end of the 3 months of the forum, traffic on the forum else is writing them at the
relating to feedback on action was taking place. Five same time, i believe Jane Dickins
messages (which were coded themselves as information usually types them up so
work) related to the outcomes of issues initially raised on best check with her

the forum. Reported outcomes included the provision of fans
on the labour ward, the development of new information From the perspective of newly qualified staff, the forum
leaflets, and a policy on siblings visiting the labour ward after was seen as providing an opportunity to gain experience of
a 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 you
Dispersed 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 we
Collegial 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 major
contributor to low job satisfaction (Kirkham & Stapleton A final way midwives displayed horizontal leadership and
2000, Hunter 2004, Lavender & Chapple 2004). About one collegiality was through their support for others to use the
third (32Æ6%, n ¼ 63) of messages posted on the forum forum. The midwives actively promoted peer-learning
provided explicit support for the contribution and work of approaches to the use of the system.
other colleagues. A common pattern was to thank and praise
a previous contributor: Forum extract 5: Displaying horizontal leadership

Forum extract 3: Collegial support Thread: Chat Room
Sandra Jones If you have looked at this site or
Thread: RE: Information packs F grade midwife posted a message then you know how
Anne Webber Harriet Smith’s suggestion of an A5 Time 19:59 to use it. Could you please pass this
F 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 more
supportive per author than the other grades, e.g. nearly twice senior midwives appeared prepared to support horizontally
as many messages that were coded as supportive than E grade emergent leaders, facilitating participation and responsibility
midwives. Collegial or horizontal support was also found in for taking actions forward.



Forum extract 6: Horizontal ownership of resolution
Vertical leadership

Transformational leaders are concerned with the promotion
Thread: RE: Drinks
of visionary perspectives that challenge established prac- Shelia Corrigan I agree we ought to investigate re-introduction
tices, enable and maximize potential (Kouzes & Posner (H grade midwife) of drinks machine. There will I presume be
1997, 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 and
edge workers as it involves the ability to inspire and create communicate SUGGEST to be discussed
at ward meetings as a matter of urgency
an environment where team members can be influential
on organizational culture (Kramer & Hafner 1989).
Consequently, it is valuable to consider the specific This was articulated as an overt strategy adopted by the
contribution of vertical midwifery leaders within the senior manager, designed to give midwives experience of
midwifery forum. change management, but also to encourage a culture
Vertical leaders or managers were defined as midwives of whereby midwives perceived themselves as being drivers
H grade and above, and postings by them amounted to 18 of change by thinking about how to achieve the innovation
messages (9Æ3% of the total sample) from four individuals. or change they were advocating. In the same way, posting
Postings 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 to
amounted 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 support
First, they validated contributing to the forum as a discursive debate and participation in specific ways, for
worthwhile activity. Secondly, they provided concrete sup- example, by being regular and diffused throughout the forum
port for action arising from the discussion. Validation for and by giving ownership of the discussion back to staff. The
participation on the forums was expressed either through resolution messages posted by senior managers consisted of
overt commitment to ‘keep using the forum’ or through suggestions for action that opened the debate for further
explicit supportive praise and feedback to authors of comments rather than closing the discussion by posting a
messages. solution.
A potential disadvantage of public discussion in the
workplace is that the increased visibility that comes from
Discussion
active participation could result in individuals being fearful
that they might be negatively sanctioned by management, a We found clear evidence that the online discussion system
fear 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 of
suggested by other studies, the discussion forums in this virtual communities such as, freedom from normative group
study operated as a tool whereby senior management could and interactional pressures (including immediate visible
positively 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 which
their 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 achieve
was a really good idea. (Senior Manager)
broad based horizontal participation among communities of
Six 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, midwives
forum participants could take forward. However, in all demonstrated the ability to discuss previously uncodified
cases, the ownership of the issue and responsibility for its knowledge held by virtue of their position as frontline
resolution was explicitly given back to the forum partic- workers. The working discussions captured here represent
ipants. tacit and experiential knowledge derived from the practice



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 to
experiences of the individual workers. In this forum, the access personal and professional support from their
individual’s knowledge becomes public and part of a work- colleagues and leadership, both vertically and horizontally.
ing, shared discourse. For knowledge work theory, it is
precisely this aspect of knowledge capture that is not only
Study limitations
vital to effective knowledge work, but is often so hard to
achieve (Quintas 2002). In illuminating how midwives The study was a small-scale ‘naturalistic’ observation of
function as knowledge workers within a community of midwives using a novel software tool in a single hospital. The
practice, this study further adds weight to the knowledge small number of participants and short timescale of the
work literature that calls for the study of knowledge workers observations reported here clearly limit the claims that we
in 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 appear
to conform to many of the positive aspects of communities of
Conclusion
practice. For example, users demonstrated the ability to share
knowledge and experiences creatively and were facilitative of This research highlights the relevance of knowledge work
continued discussion by others in the community (Brown & theory to understanding how midwives can collaboratively
Duguid 2000, Wenger & Snyder 2000, Bate & Robert 2002). communicate as knowledge workers to enhance knowledge
As a ‘community of practice’ they were able to critically creation, capture and use. A continued research focus on the
reﬂect on their experiences of providing care and re-concep- work practices of knowledge workers in naturalistic settings
tualize 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-



izational 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 of
online 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 transition
collegial 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’s
emergent leaders more visible, online discussion forums also Health 48(6), 418–425.
Ball L., Curtis P. & Kirkham M. (2002) Executive Summary of why
offers the potential to contribute to reducing the global
do Midwives Leave? http://www.rcm.org.uk
invisibility 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 the
found 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 Nursing
the 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 management
communication. Further attention should also be given to the and technology benefit midwives. British Journal of Midwifery
implications 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 Relations
healthcare 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: Thematic
We 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 in
midwives and staff in the Trust who contributed to the
Higher Education. Society for Research into Higher Education and
forums. 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 – Australian
Macintyre, 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: new
tragic 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 and
FB 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. FB and PS made critical
In Computer-mediated Communication: Linguistic, Social, and
revisions to the paper. FB and PS contributed to the design Cross-cultural Perspectives (Herring S., ed.), John Benjamins,
of the system. Philadelphia, pp. 65–80.
DOH (2003) Delivering the Best: Midwives Contribution to the NHS
Plan. The Department of Health, London.
References Flick U. (1998) An Introduction to Qualitative Research. Sage,
London.
Anderson S. & Gansneder B. (1995) Using electronic mail surveys and
Furber C. (2001) Interactive multimedia in midwifery education.
computer monitored data of studying computer mediated com-
British Journal of Midwifery 9(8), 502–505.
munication systems. Social Science Computer Review 13(1), 33–46.



Gabbay J., LeMay A.H.J., Webb D., Lovelock R., Powell J. & Milton N., Shadbolt N., Cottam H. & Hammersley M. (1999)
Lathlean J. (2003) A case study of knowledge management in Towards a knowledge technology for knowledge management.
multiagency consumer-informed ‘communities of practice’: impli- International Journal of Human-Computer Studies 51, 615–641.
cations for evidence-based policy development in health and social Ngwenyama O. & Lee A. (1997) Communication richness in elec-
services. Health 7(3), 283–310. tronic mail: critical social theory and the contextuality of meaning.
Herring S. (ed.) (1996a) Computer Mediated Communication: MIS Quarterly 12(2), 145–167.
Linguistic, Social and Cross-cultural Perspectives. John Benjamins Nonaka I. & Takeuchi H. (1995) The Knowledge Creating Com-
Publishing, Amsterdam. pany: How Japanese Companies Create the Dynamics of Innova-
Herring S. (1996b) Two Variants of an Electronic Message Schema. tion. Oxford University Press, New York.
In Computer-Mediated Communication: Linguistic, Social and Nonnecke B. & Preece J. (2000) Lurker demographics: counting the
Cross-Cultural Perspectives (Herring S., ed.), John Benjamins, silence. In CHI Conference on Human Factors in Computing
Amsterdam/Philadelphia, pp. 81–108. Systems, Vol. 2 (Turner T., Szwillus G., Czerwinski M., Peterno F.
Hightower R. & Sayeed L. (1996) Effects of communication mode & Pemberton S. eds), ACM, Hague, pp. 73–80.
and prediscussion information distribution characteristics on Palloff R. & Pratt K. (1999) Building Learning Communities in
information exchange in groups. Information Systems Research Cyberspace: Effective Strategies for the Online Classroom. Jossey-
7(4), 451–465. Bass, San Francisco.
Hine C. (2000) Virtual Ethnography. Sage, London. Pashley G. (1998) Management and leadership in midwifery: part 2.
Hughes D., Derry R. & Lovatt A. (2002) A critical ethnographic British Journal of Midwifery 6(8), 536–538.
approach to facilitating a cultural shift in midwifery. Midwifery Pearce C. (2004) The future of leadership: Combining vertical and
18, 43–52. shared leadership to transform knowledge work. Academy of
Hunter B. (2004) Conflicting ideologies as a source of emotion work Management Executive 18(1), 47–57.
in midwifery. Midwifery 20, 261–272. Quintas P. (2002) Managing knowledge in a new century. In Man-
Johnson C. (2001) A survey of current research on online commu- aging Knowledge (Little S., Quintas P. & Ray T., eds), Sage,
nities of practice. Internet and Higher Education 4(1), 45–60. London, pp. 1–14.
Kirkham M. (1999) The culture of midwifery in the National Ruberg L.F., Moore D. & Taylor C. (1996) Student participation,
Health Service in England. Journal of Advanced Nursing 32(2), interaction and regulation in a computer mediated communication
465–472. environment: a qualitative study. Journal of Educational Com-
Kirkham M. & Stapleton H. (2000) Midwives support needs as puting Research 14(3), 243–268.
childbirth changes. Journal of Advanced Nursing 32(20), 465–472. Schon D. (1987) Educating the Reﬂective Practitioner. Jossey-Bass,
Kirkham M., Stapleton H., Thomas G. & Curtis P. (2002) Checking San Francisco.
not listening: how midwives cope. British Journal of Midwifery Schultze U. (2000) A confessional account of an ethnography about
10(7), 447–450. knowledge work. MIS Quarterly 24(1), 3–41.
Kirkman B. & Rosen B. (1999) Beyond self management. Ante- Scott P. (2004) Innovative technologies and leadership development.
cedents and consequences of team empowerment. Academy of In Leadership in Organizations: Current Issues and Key Trends
Management Journal 42(1), 58–75. (Storey J., ed.), Routledge, London, pp. 138–151.
Kitson A., Harvey G. & McCormack B. (1998) Approaches to Scott P. & Quick K. (2003) Technologies for electronically assisting
implementing research in practice. Quality in Health Care 7, 149– nursing communication. The IADIS International Journal of
159. WWW/Internet 1, 15–28.
Kouzes J. & Posner B. (1997) The Leadership Challenge. Jossey Bass, Seeley-Brown J. & Duguid P. (1991) Organizational learning and
San Francisco. communities of practice: towards a unified view of working,
Kramer M. & Hafner L. (1989) Shared values: impact on staff nurse learning and innovation. Organization Science 2, 40–57.
job satisfaction and perceived productivity. Nursing Research 38, Senge P.M. (1990) The Fifth Discipline: The Art and Practice of the
172–177. Learning Organisation. Doubleday/Currency, New York.
Lavender T. & Chapple J. (2004) An exploration of midwives’ views Shirazi R. & Meija A. (1996) A computer model to assess continuity
of the current system of maternity care in England. Midwifery of care. Modern Midwife April, 10–11.
20(4), 324–334. Tellis W. (1997) Results of a case study on information technology at
Leap N. (1997) Making sense of ‘horizontal violence in midwifery’. a university. The Qualitative Report 3(4), 76 paragraphs.
British Journal of Midwifery 5(11), 689. Thompson J. (2002) The WHO global advisory group on nursing and
Littler C. & Weist A. (1998) Front-line evidence-based midwifery. midwifery. Journal of Nursing Scholarship 34(2), 111–113.
RCM Midwives Journal 1(9), 282–284. Wenger E. & Snyder W. (2000) Communities of practice: the
Mann C. & Stewart F. (2000) Internet Communication and organisational frontier. Harvard Business Review 78(Jan-Feb),
Qualitative Research: A Handbook for Researching Online. Sage, 139–145.
London. Wood L. (2000) Small business use of electronic networks. In Women
Mantovani G. (1994) Is computer-mediated communication Work and Computerization: Charting a Course to the Future
intrinsically apt to enhance democracy in organizations? Human (Balka E. & Smith R., eds), Kluwer Academic Publishers, Neth-
Relations 47(1), 45–62. erlands, pp. 284–291.
Markham G. (1998) Gender in leadership. Nursing Management Yin R. (2003) Case Study Research: Design and Methods, 3rd edn.
3(1), 18–19. Sage, London.


articulo 4

Recommended

Recommended

More Related Content

What's hot

What's hot (19)

Viewers also liked

Viewers also liked (14)

Similar to articulo 4

Similar to articulo 4 (20)

More from sarciemad

More from sarciemad (13)

articulo 4