Report of Research Project (10,000 words)

Unwillingness of Healthcare workers towards a new Healthcare Information System in a healthcare facility

MBA Major Project
Lecture 1
Dr Senaka Fernando

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Learning Outcomes
Understand the structure of the MBA Major Project
Understand the introduction Chapter (Ch 1)
Understand Methods Chapter(Ch 2)

What is Research ?
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What is Research ?

Research is an Original Contribution to Knowledge and practice
You must show two things
Identification of an unanswered question
The Answer !

Philosophical position in research -Ontology and Epistemology

Ontological position which deals with the fundamental nature of existence (what is there)
Reality (what is there to explore) – Organisational Conflict
( Example – Conflict between non-clinical managers and doctors )
Managers – Organisational conflict is a deviant behaviour
Doctors – Organisational conflict is good for the healthcare organisation. It creates opportunities for innovative ideas
Nurses- We need some conflict, but too much conflict reduces the quality of our service

There is no ONE realty
Researcher’s ontological position – Multiple Realities
People are constructing realities
Ontological Position of the researcher

How do you understand the reality (i.e. What is there)
Reality (Organisational Conflict )–Multiple realities
The researcher wants to understand these multiple realities
The researcher uses –Qualitative Research Methods

Epistemology

Qualitative research is expressed in words. It is used to understand concepts, thoughts or experiences (i.e. interpretations of reality ).
This type of research enables you to gather in-depth insights on topics that are not well understood.
Common qualitative methods include interviews with open-ended questions, observations described in words, and systematic reviews that explore the realty.

Qualitative Research

Reality –Heart Attacks among Asians in the UK

Heart Attack =F(cholesterol level, blood pressure, weight )
One Reality
Example from medicine -Ontological Position of the researcher

How do you understand the reality (i.e. what is there)
The researcher uses “ counting and measuring”- Quantitative research methods

E.G. Measuring blood pressure, cholesterol level, weight
Epistemology

Quantitative research is expressed in numbers and graphs.
It is used to test or confirm theories and assumptions. This type of research can be used to establish generalizable facts about a topic.
Common quantitative methods include experiments, observations recorded as numbers, and surveys with closed-ended questions

Quantitative Research Methods

Reality – Service quality in healthcare (SQH)
SQH = F (No of patients discharged/week, No of patients admitted without any delay/week, …..etc)
Ontological position of the researcher – One Reality
Epistemology – How do you understand the reality
The researcher uses “ counting and measuring”- Quantitative research methods

Ontology and Epistemology –Example from healthcare management

Potential Major Project Themes
Organisational Culture
Leadership
Women in Leadership
Power and Conflict
Technology and health information systems
Strategic Management

Potential Major Project Themes
Groups in Organisations
Organisational Structure
Organisational Change
Organisational performance
Organisational Decision Making
Entrepreneurship and Innovation
Organisational conflict

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What is a Postgraduate Dissertation or Major Project ?

Useful contribution to knowledge !
Readers will ask
what is the question here ?
is it a good question ?
is it adequately answered ?
is there a contribution to previous knowledge?

Systematic literature reviews

The original aim of a narrative systematic review is to synthesise all the available, high quality evidence to answer the research question

Steps of a Systematic Review

Identifying a research area
Formulating a research question
Locating and selecting studies
Critical appraisal of studies
Collecting Results
Analyzing Results
Answering Question by interpreting results
Improving and updating the existing knowledge
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Major project Structure
Abstract (Max word limit -300)
Chapter 1-Introduction (Max word limit-2500)
Chapter 2-Methods (Max word limit -1500)
Ch 3-Results and Chapter 4-Discussion (for Max word limit – 5000)
Ch 5-Conclusions (Max word limit -700)
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Abstract of the Major Project
What is already known on the topic (summary)
Research Question
Methods(summary)
Summary Answer
What this project has added to the existing knowledge (summary)
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Ch 1-Introduction
Introduce research topic area
Discuss the significance of research area
Background literature review
Develop research question
Tell the reader about the structure of the project (i.e. Signposting)

How do you develop Research question ?

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Research Questions
The research question (core/foundation)
concise statement of question
explain why question is worthwhile

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The Importance of Good Questions
A good research question:

Defines the investigation
Sets boundaries
Provides direction (e.g. reviewing research papers that use qualitative methods)

Examples
What are the key organisational factors that negatively influence motivation of employees in healthcare sector in developed countries?
What are the Key organisational factors leading to motivation of employees in healthcare sector in developing countries ?
What are the key aspects of clinical leadership leading to successful implementation of health information systems ?
What are the most effective communication strategies for enhancing physicians’ acceptance of planned organisational change in healthcare organisations in the UK?
What are the organisational barriers that result in physicians showing resistance towards electronic medical records in the healthcare sector in USA
Bad research questions:
What are the factors that shape the motivation of employees in the healthcare sector?
Be Specific

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Boundaries

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From Interesting Topics to Researchable Questions
An ‘angle’ for your research can come from insights stemming from:

personal experience
theory
observations
contemporary issues
engagement with the literature

Comprehensive Literature Review
Coherent synthesis of past and present research in the domain of study
Source: Dr Hazel Hall, Napier University
What are the main conclusions on previous research in this area?
What are the key areas of debate in this area?
Which aspects of this work are of most relevance to my study?
What are the key concepts in this area?
What have been the main research questions?
Where is existing knowledge “thin”?
How is this topic approached by others?
Where are the gaps in literature?
What are the main perspectives on this topic in previous research?
Do parallel literatures exist for this topic?
Which discussions?
Which sub-themes?
Which writers?
Which work is subject to challenge?
Who are these “others”?
Which existing work could be extended?
In which subject areas has the topic been studied?
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Narrowing and Clarifying
Narrowing, clarifying, and even redefining your questions is essential to the research process.
Developing the right ‘questions’ should be seen as an iterative process that is informed by reading and doing at all stages.

Developing a line of argument for the research question
Let us take the following example:
What are the perceived organisational barriers to implementing healthcare information systems in community mental services?

Developing a line of argument for the research question
(1)Introduce your research area:
Healthcare information systems play significant role in healthcare services. Here you need to argue that they are better than paper based systems (e.g. efficiency and effectiveness of healthcare information systems)
(2) Argue that these systems can improve the quality, effectiveness, and efficiency of the mental health services as well (focus on the boundary)
(3) Argue that these systems can improve the quality, effectiveness, and efficiency of the community mental health services as well (more focus on the boundary)

Developing a line of argument for the research question
(4)Argue that although health information systems have potential to improve quality, effectiveness and efficiency of community mental health services, there are many barriers to implementing these systems
(5) Show that there are technological and organisational barriers
(6)Argue that many research/studies have been done on technological barriers
Argue that researching on organisational barriers are equally important but very few systematic review studies focus on organisational barriers(Gap in research –Significance of my research)
As a result my research will focus on organisational barriers and my research question is :
What are the perceived organisational barriers to implementing healthcare information systems in community mental services?

Background literature review to Research Question

Broad Issue
Studies that Overlap with Your Research
Studies that are directly related to your investigation
Research Question
Background literature review

Critical Review of Literature

Authors
Kallis Morkel Tahir Villers
Claim 1
Claim 2
Claim 3

Compare Contrast Author’ ideas
Compare Contrast Author’ ideas
Compare Contrast Author’ ideas

Critical Reading and Questions
Why am I reading this? (ie. what am I trying to find out?)
What are the authors trying to do in writing this? (eg. report on research, review others’ work, develop theory, express particular views or opinions, criticise what is currently done, advise about what should be done in the future)
What are the authors saying which is relevant to what I want to find out? (What is the essence of the message conveyed by the text? How does it relate to my interests/research area?)

Wallace and Wray (2011: 37-41)

How do you go about reading an academic text?
Critical Reading

Use parts of the text: abstract, contents, sub-headings, graphs, tables, introduction and conclusion
Skim to get the gist of the “argument” in the text
Read with a question (i.e. aim of your essay/dissertation) in mind
Your Decision: Relevant or Irreverent

What is an argument in an academic essay
In academic writing, an argument is usually a main idea, often called a “claim” or “thesis statement,” backed up with evidence that supports the idea.
In the majority of your university work, you need to make some sort of claim and use evidence to support it, and your ability to do this well will separate your work from those of students who see assignments as mere accumulations of facts and details
It’s at the heart of your essay. It determines your structure, evidence, reasoning, quotations, introduction and conclusion.

Developing an argument -Example :Organisational Culture
…… A strong culture in this context usually implied one in which management’s values were uppermost, and any deviation from this pattern was considered dysfunctional to the whole (Deal & Kennedy, 1982;Peters & Waterman, 1982).

Making Argument-Example :Organisational Culture
However, researchers have increasingly questioned the prescription of a top management dominated organizational culture (see Meyerson & Martin, 1987; Ogbonna & Harris, 2002; Willmott, 1993). In this regard, scholars have criticized the managerial, unitarist perspective of earlier writers and have commonly argued that organizational cultures are frequently heterogeneous, comprising multiple layers of identities and several diverse communities (see Alvesson, 1993; Martin, 2002).

Morgan P I and Ogbonna E (2008) Subcultural dynamics in transformation: A multi-perspective study of healthcare professionals, Human Relations, Vol 61(1), 39-65
Argument

Using Organisational examples to enrich your argument
Work intensification
Times Higher Education(Grove 2016) reports that most academics feel overworked, exploited and ignored by their institutes and considerable number of academics are looking to leave their current jobs:
“I am constantly being asked to do more with less, which translates into longer and longer working hours. As a result, the level of compensation is completely incommensurate with the working hours reasonably needed in order to do everything that is demanded,”
(A lecturer at a Russell Group university)

However, this fails to/does not appear to take account of —
Smith fails to fully acknowledge the importance of/need for —
A counter argument might be that —
This has been criticised/challenged by –
Critics (Smith, 2008; Jones, 2009) have argued that —
The X approach/model would be/have been more appropriate/beneficial in this case/these circumstances.
There are a number of limitations when following this approach/using this method/model.

Critical Writing – Useful Phrases (some examples)

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Good Question Checklist
Is the question right for me?

Will the question hold my interest?
Can I manage any potential biases/subjectivities I may have?

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Good Question Checklist
Is the question right for the field?

Will the findings be considered significant?
Will it make a contribution?

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Good Question Checklist
Is the question well articulated?

Are the terms well-defined?

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Good Question Checklist
Is the question doable?

Can information be collected in an attempt to answer the question?

Do I have the skills and expertise necessary to access this information? If not, can the skills be developed? (e.g. Library Data base skills)

Will I be able to get it all done within my time constraints?

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Good Question Checklist
Does the question get the tick of approval from those in the know?

Does my supervisor think I am on the right track?
Do ‘the research ’ shows my question is relevant/ important/ doable?

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Postgraduate Research ?

Useful contribution to knowledge !
Readers will ask
what is the question here ?
is it a good question ?
is it adequately answered ?
is there a contribution to previous knowledge?

Systematic literature reviews

The original aim of a narrative systematic review was to synthesise all the available, high quality evidence to answer the research question

Chapter 2-Methods
Tell the reader what you have done to collect and analyse data
Ethical Approval
Search Procedures
Quality Appraisal
Data Analysis

I have passed Research Ethics Quiz
I have completed the Stage 1 Research Ethics Application and my completed research ethics application indicates that this research does not need the ethical approval from the faculty or school ethic panel

Ethical Approval

Example Research Question:

What are the major organisational factors leading to motivation of employees in healthcare sector in deprived areas of Kenya ?

Search Procedures
Develop set of keywords : a research question/ background literature review allows keywords to be identified (e.g. Motivation of employees in health sector AND financial incentives)

Herzberg’s two-factor theory –Employee Motivation
Theory

Search Procedures
(1) Identify databases
e.g. ProQuest, EBSCO, SSCI (social science citation index), Psychinfo, MedLine )

(3) Identify as many research studies as possible with the potential to answer the research question using keywords (Read the titles of the papers)
(4) Include qualitative, quantitative, and mixed methods research papers but exclude systematic reviews

Search Procedures
(5) Hand searching
These most commonly take the form of following up references in papers that are identified by previous methods (i.e. Reference chaining)

Inclusion and Exclusion Criteria
Use inclusion and exclusion criteria at this early stage is to weed out articles, based on two categories criteria:
whether the study’s content is applicable to the research question
Whether the study’s content satisfy the exclusion criteria
At this stage, the reviewer normally reads no more than the abstract of the articles to decide whether, for the purposes of the review, they are worth reading further or not.

Inclusion and Exclusion
Fink (2005, pp. 55-56) lists several criteria upon which studies can be reasonably included and excluded from consideration for practical purposes of limiting the scope of the study

Inclusion and Exclusion -Research question and topic area
(Fink 2005, pp. 55-56)
Content (topics or variables): The review must always be practically limited to studies that have bearing on its specific research question. (Dawson & Ferdig, 2006)

Example –Inclusion and Exclusion Criteria related to research question and topic area
Research Question:
What is the impact of clinical leadership on successful implementation of health information systems ?

Inclusion and Exclusion criteria:
The review included studies related to clinical leadership/involvement in health information systems programmes. The clinical leaders were defined as ……. The review excluded the studies that focus on the involvement of informal clinical leaders such as clinical champions, temporary project leaders,…

Inclusion and Exclusion –Language
(Fink 2005, pp. 55-56)
Publication language: Reviewers can only review studies written in languages they can read, or for which they have access to scholarly databases (e.g. English)

Inclusion and Exclusion – Setting , Participants
(Fink 2005, pp. 55-56)
Setting: Perhaps only studies conducted in certain settings, such as healthcare institutions, or services (e.g. mental health) might be consider
Participants or subjects: Studies may be restricted to those that study subjects of a certain gender, work situation (for example, full-time medical professionals as opposed to medical students), age, or other pertinent criteria.

Inclusion and Exclusion –Research Design
(Fink 2005, pp. 55-56)
Research design or sampling methodology: Studies might be excluded based on not using a particular research design
Qualitative -include
Quantitative –include
Mixed Methods –include
Systematic reviews-exclude

Inclusion and exclusion criteria
Inclusion and exclusion criteria is a very subjective part of the literature review
There are no absolute rights and wrongs here; however, there are considerations of what is reasonable and justifiable
On one hand, the screen must be broad enough to include a sufficient number of studies that can satisfactorily answer the research question
On the other hand, the review must be practically manageable, considering the reviewers’ constraints of time, money, and personnel
To a very large extent, it is the decisions made here that make the difference between a comprehensive and trustworthy literature review, and an unsatisfactory one

Quality Appraisal
Once all potentially eligible articles have been collected, the next step is to examine the articles more closely to assess their quality.
This quality appraisal serves two purposes:
First, in reviews where there is a minimum quality standard for acceptance, the quality appraisal becomes a second ―methodological‖ screen (Fink, 2005) to eliminate articles that do not meet the standard established by the reviewer.
Second, in all Systematic Reviews , there needs to be some scoring of the methodological quality of the articles included in the study, since the quality of the final review depends very much on the quality of the primary studies
Now you read the full paper

Quality Appraisal Criteria (Dixon-Woods et al 2006)
Are the aims and objectives of the research clearly stated? {score -1}
Is the research design clearly specified and appropriate for the aims and objectives of the research? {score -1}
Do the researchers provide a clear account of the process by which their findings were produced? {score -1}
Do the researchers display enough data to support their interpretations and conclusions? {score -1}
Is the method of analysis appropriate and adequately explicated? {score -1}
Rating the Studies according to the quality criteria:
A= 5 (satisfying all criteria)
B= 4 (satisfying 4 criteria)
C= 3 (satisfying 3 criteria)
D= 2 (satisfying 2 criteria)
E= 1(satisfying 1 criteria)
F= 0 (satisfying 0 criteria)

Paper Selections
Initial Screening using databases (e.g. 1,000 citations)
Screening of titles and abstracts using inclusion and exclusion criteria (e.g. 43 papers)
Full text reading meeting inclusion and quality criteria (e.g. 31 papers)

Studies for Final Systematic Review

Screening using inclusion and exclusion criteria
+ Quality Appraisal

Studies for Final Review

Methods -Data Analysis
Explain how you analysed the results generated from the review of studies
Thematic analysis

Research Questions (example)
What are the major organisational factors leading to motivation of employees in healthcare sector in deprived areas of Kenya ?

Results-Summary

Study Type How Identified Aims & Objectives of the Study Data Collection and analysis methods Quality Rating Main Findings

Ojakaa et al (2014) Empirical and Qualitative Electronic Data-base
EBSCO Investigate
factors influencing motivation and retention of HCWs at primary health care facilities in
three different settings in Kenya B

Smith (2008) Empirical and Qualitative
Hand Search Investigating the quality of working life in healthcare organisations in Kenya
B

Data Analysis
Begin with detailed inspection of the key findings related to your research question in the papers, gradually identifying recurring themes (e.g. many authors highlight the importance of “quality of leadership of line manager”)
A theme represents a level of patterned response or meaning from the data that is related to the research questions at hand.

Data Analysis
Then generate initial themes that help to explain the phenomena being study (e.g. motivation of employees in healthcare sector in deprived areas of Kenya)
The theory on employee motivation could help you labeling the themes

Initial themes -Example
Look at the quality of their arguments/claims, depth of their arguments

Initial Themes Studies included in your review

Performance related pay David (2013), Alison (2008), Davidson (2012), Caves (2011), Carnal ( 2015)

Training Smith (2014), Parker (2008), Newton and Kelly (2014), Carnal ( 2015)

Quality of working life Markus (2018), Newton (2001), Smith (2014), Brown (2017), Carvel(2018)

Organisational Structure Kotter (2018) X

Data Synthesis
Combine initial themes into overarching themes that accurately depict the data. It is important in developing themes that the researcher describes exactly what the themes mean,

Data Synthesis

Initial Themes Final Themes

Performance related pay

Employee benefits such as pensions and sick pay Financial Rewards

Achievement

Recognition of contribution

Scope to use the developed skills Non Financial Rewards

Training

Quality leadership of the line manager

Job design and role development

Meaningful work Work Environment

Quality of working life

Now you have written about methods (i.e. Ch 2 Methods)

References
Fink A (2005), Conducting Research Literature Reviews: From the Internet to Paper, Thousand Oaks, sage
Dawson K & Ferdig R E (2006) Commentary: Expanding Notion of Acceptable Research Evidence in Educational Technology: a Response to Schrum et al. Contemporary Issues in Technology and Teacher Education ,6(1), 133-142
Singh G , Haddad K M & Chow C W (2007) Are Articles in Top Management Journals Necessarily of Higher Quality? Journal of Management Inquiry, 16(4), 319
Dixon-Woods et al (2006), Conducting a Critical Interpretive Synthesis of the literature on access to healthcare by vulnerable groups , BMC Medical Research Methodology , 6;35 pp1-13

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MBA Major Project Lecture 2
Chapter 3- Results
Chapter 4- Discussion
Conclusions
Dr Senaka Fernando

Ch 3 -Results

Research Questions (example)
What are the major organisational factors leading to motivation of healthcare professionals in healthcare organisations in the deprived areas of Kenya ?

The flow diagram depicts the flow of information through the different phases of a systematic review.
It maps out the number of studies identified, included and excluded, and the reasons for exclusions.

PRISMA Flow Diagram

Summary of the Results

Study Purpose of the Study Study Population Study Design Quality Appraisal
(Score) Methods of Data Collection and Analysis Key Findings related to my research question

Palmer I and Pearson D (2015) Investigate
factors influencing motivation and retention of healthcare employees at primary health care facilities in
three different settings in Kenya
Doctors, Nurses, Healthcare Administration staff Qualitative 4 In-depth Interviews and Focus Group interviews

Thematic Analysis The organisational factors that contribute to the motivation of doctors in deprived areas of Kenya include adequate supervision and support from line managers, and adequate opportunities for professional development

The key findings in the table should be elaborated
Write a couple of paragraphs on the key findings in each study (e.g. Palmer L and Pearson D 2015)

Results

Results –Presenting Results Thematically
Begin with detailed inspection of the key findings related to your research question in the papers, gradually identifying recurring themes
A theme represents a level of patterned response or meaning from the data that is related to the research questions at hand.
(Thematic Analysis)

Results – Presenting Results Thematically
Then generate initial themes that help to explain the phenomena being study (e.g. major organisational factors leading to motivation of healthcare professionals in healthcare organisations in the deprived areas of Kenya ) comparing them with theoretical constructs (i.e. Literature) developed in the papers
(Thematic Analysis)

Labelling the theme(Example)

Your Label Researchers’ labels

Not enough necessary equipment (Jones 2018)

Quality of working life Old Buildings (Judge 2017)

High noise level (Jenkins 2015)

Over crowded wards (Janda 2016)

Not enough doctors (Guest 2019)

Developing Initial Themes (Example)
Describe data in qualitative terms

Initial Themes Studies included in your review

Quality of leadership of the line manager David (2013), Alison (2008), Davidson (2012) , Palmer and Pearson (2015), Boyne and Boyle(2019), Branch (2015)

Job Design and Role Development Smith (2014), Parker (2008), Newton and Kelly (2014), Palmer and Pearson (2015)

Quality of Working Life Jones (2018), Judge (2017), Jenkins (2015), Janda (2016), Guest (2019)

In analysis you need to discuss these themes referring to the studies.

Example:
Seven studies described insufficient training as a barrier to case management (Bamford et al 2014; Eack et al 2009;….)
Describing the themes

Use research participants’ quotations (in the studies selected for your review) to enrich your description

Example: Research area- women leadership in surgery
Theme-Work-family conflict
“Women are not treated equally. We cannot have children during training. The strong women finish, but it is difficult and involves great sacrifice”
Describing the themes

Here you synthesise key themes to answer the research question

Chapter 4-Discussion

What are the major organisational factors leading to motivation of healthcare professionals in healthcare organisations in the deprived areas of Kenya ?

Example Research Question

Results – Presenting Results Thematically
Combine initial themes into overarching themes that accurately depict the data. It is important in developing themes that you describe exactly what the themes mean,
(Thematic Analysis)

Results –Data Synthesis – Final Themes (need to revisit theory as well)

Initial Themes Final Themes

Achievement

Recognition of contribution Non Financial Rewards

Scope to use the developed skills

Training

Quality leadership of the line manager Leadership Skills of the line manager

Job design

Meaningful work Work Environment

Quality of working life

Chapter 4-Discussion –Answers

This section is very important as well. You interpret the data

Research Question :
What are the organisational factors leading to
motivation of employees in healthcare sector in the deprived areas of Kenya ?
Answer 1: Sound Reward Management Strategy
Answer 2: Displaying Appropriate leadership behaviours by line managers
Answer 3: Improving Work Environment

Here you synthesise key themes to answer the research question
Your argument can be enriched by drawing on literature from other sources (i.e. Sources which were not included in the review )

Answer 2: Displaying Appropriate leadership behaviours by managers
This review reveals that the line managers’ leadership skills as an important organisational factor that contribute to the motivation of healthcare professionals in deprived areas of Kenya (David 2013, Alison 2008, Davidson 2012). The leadership skills of the manager serve as a starting point for determining healthcare professionals’ motivation(David 2013). The results suggest that since healthcare professionals in deprived areas already face some level of frustration, it is important that managers demonstrate sound leadership qualities, especially developing trustworthy relationship with clinical staff (Alison 2008, Davidson 2012). Here, this review highlights the importance of displaying transformational leadership styles by the managers to energise and inspire healthcare professionals in order to change their current way of doing things (Davidson 2012). The research on employee motivation supports this argument as the leadership…… (Henry 2018).

Discussion (Answering the research Question) –Example
From your Review
Not from your review

Conclusions
Summary –Key points
Strengths of your study
Limitations of your study
Future research

Structure of The Major Project
Chapter 1 – Introduction An explanation as to what the Major Project is all about and why it is important by critically analysing what other researchers have said and where your topic fits in. As a result this chapter should include back ground literature review that shows awareness of the most and relevant theories, models, and empirical studies relevant to your topic area. Your research questions should be derived from this background literature review.

Chapter 2 – Methods Why certain data was collected and how it was collected and analysed. Aim to provide support for your choice of methodos. This can be done on the basis of using academic references or referring to previous work that also used a methodos similar to your own.

Structure of The Major Project
Chapter 3 – Results- A presentation of your research results and themes .

Chapter 4 – Discussion. Discussion using final themes , answering the research questions
Chapter 6 – Conclusions A description of the main lessons to be learned from the study and what future research could be carried out. In addition, use this as an opportunity to cite any potential limitations that you foresee with your research. Limitations are constraints in your research

References – References are a detailed list of sources from which information has been obtained and which has been cited in the text.

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Think of the Reader
Make no unreasonable assumptions about your audience
Examiners hate to be made to work hard on trivia
– to understand poorly named sections, disorganised ideas in your work that generate very weak structures and wade through complex sentence structures

Bibliography
Fink A (2005), Conducting Research Literature Reviews: From the Internet to Paper, Thousand Oaks, sage
Dawson K & Ferdig R E (2006) Commentary: Expanding Notion of Acceptable Research Evidence in Educational Technology: a Response to Schrum et al. Contemporary Issues in Technology and Teacher Education ,6(1), 133-142
Singh G , Haddad K M & Chow C W (2007) Are Articles in Top Management Journals Necessarily of Higher Quality? Journal of Management Inquiry, 16(4), 319
Woods et al (2006), Conducting a Critical Interpretive Synthesis of the literature on access to healthcare by vulnerable groups , BMC Medical Research Methodology , 6;35 pp1-13

Poor Working Relationship between

Doctors and Hospital Managers

– A Systematic Review

A Dissertation submitted in part fulfilment of the requirements

for the degree of Master of Business Administration (MBA) in

Healthcare Management of the Anglia Ruskin University, UK

Date: January 2020

Word Count: 9,428

ABSTRACT

Background: At a time when healthcare organisations worldwide including the United

Kingdom’s (UK) National Health Service (NHS) are faced with limited financial

resources, changes in patients’ demographics, rising aging population and rapid

technological advancement, the need for doctors and hospital managers to work

effectively together for the successful running of the organisation has become vital

now, more than ever. Previous studies have drawn attention to the poor working

relationship between doctors and hospital managers on the quality of healthcare they

provide, however, despite the significance of the problems, there is limited systematic

review in this area.

Objectives: This study is a systematic review, investigating the organisational factors

contributing to the poor working relationship between doctors and hospital managers

with a view to recommend potential solutions to address them.

Methods: A comprehensive search was undertaken of AMED, MEDLINE, CINAHL

Plus with Full Text, SportDiscus and EBSCO Ebooks from January 2000 to July 2019

and updated in November 2019. Mixed methods, qualitative studies and quantitative

studies that explored doctors and managers working relationship in hospital or

healthcare services were included in this review. The settings of the included studies

were hospitals or healthcare service centers. Studies that were published in English

language in peer reviewed journals between January 2000 and December 2016 were

included. Study selection, data extraction and appraisal of study were undertaken by

the researcher (PO). Quality criteria were selected using CASP (Critical Appraisal

Skills Programme, 2013), which is a Qualitative Research Checklist comprising 10

questions, used in assessing the rigor and quality of the selected papers.

Results: A total of 49,340 citations were retrieved and screened for eligibility, 41

articles were assessed as full text and 15 met the inclusion criteria. They include 2

mixed method studies, 8 qualitative studies, and 5 quantitative studies. The studies

were analysed qualitatively as meta-analysis of these multiple studies was not

possible.

Conclusion: This study found that poor collaboration and effective communication,

cultural issues, power and autonomy, finance and resources issues, as well as

educational differences were among the organisational and professional factors that

contributed to poor working relationship between physicians and hospital

administrators. This study recommends that healthcare policy makers, administrators

and funding providers should create and implement strategic plans such as a

consensual agreement that is flexible and includes frequent dialogue and greater

organisational transparency in decision making to improve doctor-manager

relationships – which ultimately could lead to improved quality of care, better work

performance and job satisfaction.

Key Words: Doctors, physicians, hospital managers, administrators, poor relations,

poor working relationship.

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TABLE OF CONTENTS

ABSTRACT ………………………………………………………………………………………………….. i

CHAPTER 1 INTRODUCTION ……………………………………………………………………… 1

1.1 Introduction ……………………………………………………………………………………. 1

1.2 Purpose of the Study ………………………………………………………………………. 9

1.3 Research Question …………………………………………………………………………. 9

1.4 Chapter Summary …………………………………………………………………………. 10

1.5 Introduction to Chapters Two to five ………………………………………………. 10

CHAPTER 2 METHODS ……………………………………………………………………………. 11

2.1 Introduction ………………………………………………………………………………….. 11

2.2 Data Source and Search Strategy …………………………………………………… 12

2.3 Inclusion and Exclusion Criteria …………………………………………………….. 16

2.3.1 Inclusion Criteria …………………………………………………………………….. 16

2.3.2 Exclusion Criteria ……………………………………………………………………. 16

2.4 Search Strategy and Search Outcome ……………………………………………. 17

2.5 Quality Appraisal …………………………………………………………………………… 19

2.6 Data Extraction and Synthesis ……………………………………………………….. 20

2.7 Chapter Summary …………………………………………………………………………. 20

CHAPTER 3 RESULTS ……………………………………………………………………………… 21

3.1 Organisational Causes of Poor Doctor-Manager Working Relationships
……………………………………………………………………………………..30

3.1.1 Theme 1: Poor Collaboration and Communication…………………….. 30

3.1.2 Theme 2: Cultural Issues …………………………………………………………. 31

3.1.3 Theme 3: Power and Autonomy ……………………………………………….. 33

3.1.4 Theme 4: Finance and Resources Issues ………………………………….. 35

3.1.5 Theme 5: Education Differences/Challenges …………………………….. 37

3.1.6 Chapter Summary ……………………………………………………………………. 38

CHAPTER 4 DISCUSSION ………………………………………………………………………… 39

4.1 Chapter Summary …………………………………………………………………………. 47

CHAPTER 5 CONCLUSION ………………………………………………………………………. 48

REFERENCES …………………………………………………………………………………………… 51

APPENDICES: …………………………………………………………………………………………… 61

Appendix 1: Critical Appraisal Skills Programme (2013) Qualitative Research
Checklist ……………………………………………………………………………………………………. 61

Appendix 2: Summary of Main and Subthemes of Included Studies …………………… 67

LISTS OF TABLES

Table 1: Qualitative Search – Combined Results of Electronic Database Searches of
AMED, CINAHL, CINAHL Plus with Full Text, eBook Collection (EBSCOhost),
MEDLINE, SPORTDiscus ……………………………………………………………………………. 15
Table 2: Inclusion and Exclusion Criteria ……………………………………………………….. 17
Table 3: Summary of the Included Studies ……………………………………………………… 23
Table 4: Summary of Thematic Analysis: Organisational Factors Causing Poor
Doctor-Manager Relationships ……………………………………………………………………… 28

List of FIGURES

Figure 1: Proposed PRISMA Flow Diagram ……………………………………………………. 18

CHAPTER 1 INTRODUCTION

1.1 Introduction

The problem of poor relationship between doctors and hospital managers is a common

feature of many healthcare systems worldwide, including the United Kingdom’s (UK)

National Health Service (NHS) (Edwards, 2003, Drife and Johnston, 1995). According

to Powell and Davies, (2016), good working relationship between physicians and

hospital executive are essential ingredients for the effect performance, improved

patients’ wellbeing and quality of the NHS care (Powell and Davis, 2016). Therefore,

a poor working relationship could have a significant impact on the quality of healthcare,

as it could lead to higher mortality rates, near misses, low staff performance as well

as low patient satisfaction (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).

Several authors (Powell and Davis, 2016 and Rundall and Kaiser, 2004), have

suggested that the lack of understanding and agreement between managers and

doctors in the management of hospital services is not only common but that they have

negative impact on healthcare services. They have also suggested that the problem

is likely to deteriorate in the coming years. Furthermore, despite the significant impact

poor working relationship between doctors and managers could have on quality of

care, staff performance and patient experience, there is limited systematic review in

this area (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998). This is one of my

motivations for this study.

Previous healthcare models involved government appointment of hospital board of

administrators with members not necessarily working in the hospital for example,

former military officers or politicians with a level of experience as public servants

(Vlastarakos and Nikolopoulos, 2007). However, one of the criticisms of these

practices is that it was not effective because it lacked competent technocratic leaders

who have the requisite knowledge and experiences of long-term planning and better

management of hospital systems (Vlastarakos and Nikolopoulos, 2007). Furthermore,

with the growth of healthcare management and the emergence of healthcare

professionals in hospital administration, the acceptance of these models among

hospital professionals have been limited, more so that they lacked multidisciplinary

collaboration and cooperation (Vlastarakos and Nikolopoulos, 2007, Spurgeon, 2001).

However, according to Spurgeon (2001), growth in healthcare and involvement of

managers who are empowered to enforce government policy and the role of hospital

professionals such as doctors in hospital administration have led to tensions or poor

working relationships between the two groups.

A study on doctor-manager relationships in the United States (US) and the United

Kingdom (UK), found that both groups agreed that relations between them were poor.

In the UK study, both the hospital administrators and clinical executive were optimistic

about the state of their relationships (Rundall and Kaiser, 2004). About 76% of hospital

executives rated the quality of current relationships between the two groups as very

good, compared with just 37% clinical directors. Furthermore, 78% of chief executives

believed the communication and interactions between doctors and hospital managers

would improve over the coming year, compared with just 28% of clinical directors

(Rundall and Kaiser, 2004). Similarly, in the US study, managers were perceived more

favourable regarding their relationships with the doctors (Rundall and Kaiser, 2004).

The researchers also observed that 26% of clinical directors and 29% physician

executives were of the view that the relationship between them and their chief

executive counterparts would likely deteriorate over time. Despite the obvious

differences between the US and the UK system of healthcare delivery, the survey

revealed how doctors in both countries were more pessimistic than managers about

the state of their working relationships. A strength of this study is that a significant

percentage of doctors and managers (24% to 44%) were unhappy with the time,

resources and energy committed to developing effective relationships locally (Rundall

and Kaiser, 2004).

Similarly, a recent UK research by Nuffield Trust (Powell and Davies, 2016), found

that 72% of chief executives were more optimistic about their relationship compared

with only 50% of clinical directors. Although 80% of hospital executives believe that in

the coming year, progress would be made, only about 35% of clinical directors held a

similar viewpoint. Surprisingly, more than half of the clinical directors (51%) and only

18% of chief executives were of the view that physician-hospital manager relationships

were likely to decline in the coming year. Although both the clinical directors and chief

executives were dissatisfied about the relationship between the two groups, the

number was higher in the clinical director group.

Although both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studies

used a questionnaire survey method for data collection, the former utilised a face to

face interviews and focus groups for data collection. While questionnaires are a very

useful survey tool for gathering information from a large cohort with relative ease, they

require extensive planning, time and effort (Jones, et al., 2013). A strength of the

Powell and Davis, (2016) study is that it involved a larger cohort (472 respondents)

compared to the study by Rundall and Kaiser (2004), which had only 117 respondents.

It is also worthy to note that in the study by Powell and Davis (2016), the inclusion of

face to face interviews and focus group as additional methods of data collection

improved the trustworthiness of their research findings.

Both the Powell and Davis, (2016) and Rundall and Kaiser, (2004) studies have

highlighted the need to further investigate the poor working relationships between

doctors and managers because it is likely to deteriorate over the coming years. This

is one of motivations for this study. Furthermore, despite the significant impact this

poor relationship could have on the quality of care, there is limited research in this

area (Schultz, 2004, Edwards, 2003 and Aiken, et al., 1998).

Globally, the role doctors and hospital managers’ play in the administration of

healthcare service has more than ever before, continued to be in the spotlight of both

the general public and the media due to the increasing demands for improve quality

of life, quality of healthcare and cost effectiveness (Vlastarakos and Nikolopoulos,

2007). These difficulties may be attributed to the modern expensive high-technological

medicine, to the growing demands and awareness of patient’s rights and to the

increasing financial constraints facing hospital administrators, which include both

doctors and managers (Stadhouders, et al., 2018, Vlastarakos and Nikolopoulos,

2007, and Pollitt, 1996). Furthermore, with the introduction of the market into the

healthcare industry, increasing the drive for efficiency, there is a well-established shift

in public sector management for improved quality of healthcare, better clinical

outcomes and improved patient satisfaction (Degelin, et al., 2003). In order to meet

these growing demands facing healthcare services, which is not only unique to the

National Health Services (NHS), both hospital doctors and managers must collaborate

and work in harmony. However, differences in opinion between doctors and managers

have not only led to poor working relationships between the two groups, but also

affected their ability to meet these healthcare demands.

A study by Gallup found that physicians who were fully engaged with hospital

administration were 26% more productive than physicians who were dissatisfied

(Burger and Giger, 2014). This increase equates to an average of $460,000 in patient

revenue per physician per year’ (Burger and Giger, 2014). The study also found that

when physicians are fully engaged with hospital administration, the outpatient and

inpatient referrals increased on average by 3% and 51% respectively. One particular

strength of this study is that it highlights the benefits of physician involvement with

hospital administration in the delivery of healthcare services. Conversely, lack of

physician-manager engagements could not only lead to decrease in hospital revenue

from low physician productivity, but it could also ultimately affect the quality of patient

care.

Besides, with the current unsustainable growth in the UK NHS healthcare expenditure

that is characterised by higher scarcity of resources, fiercer competition with a

monumental shift towards public-private partnerships and strict cost-containment

policies, managers and physicians must work collaboratively to achieve better

outcomes for the healthcare industry, members of the public and funding providers

(Stadhouders, et al., 2018, Powell and Davis, 2016 and Kaissi, 2005). This partnership

between doctors and managers together could be under a conjoint responsibility or a

shared authority (Kaissi, 2005). According to the Guardian publication by William

(2017), “with an army of more than 1.5 million NHS staff, a £11 billion budget and

millions of patients and service users to look after, it is very important that the NHS is

well managed by doctors and managers”

Although the success of healthcare services in efficiently and effectively achieving

these outcomes is theoretically pursued by all involved in hospital function, differences

in understanding between doctors and managers may jeopardise this objective

(Kaissi, 2005). Several factors have been argued to be associated with poor working

relationship between doctors and managers such as cultural and behavioural

differences, as well as differences on philosophy of managing care strategies (Kim, et

al., 2017, Kaissi, 2005, Drife and Johnston, 1995).

Powell and Davies, (2016), suggested that financial constraints in the NHS were

associated with poor working relationship between managerial and clinic staff such as

doctors; and that the situation is likely to continue to deteriorate if nothing is done to

prevent it. These economic challenges are associated with the challenges in

healthcare delivery arising from economic liberalisation policies such as privatisation,

deregulation, and cuts in government spending in order to increase competition in

public services such as the NHS (Powell and Davies, 2016, Schultz, 2004). It has been

argued that there are fundamental differences between the mentality of doctors and

non-medically educated managers who are often responsible for hospital

management (Freidson, 1972). Another source of tension between doctors and

managers as noted by Freidson (1972) is the huge gap between the mentality of

physicians (doctors) and that of non-medically educated managers who often are

responsible for oversight functions of the doctors. It has been argued that doctors hold

this clinical mentality as they believe that their fundamental role or allegiance is to their

patients. On the other hand, managers typically have a managerial mentality as they

believe their primary duty is to the organisation and they are responsible for the

financial management and organisational strategy (Freidson, 1972).

The traditional roles of physicians and hospital administrators are similar, however,

the root causes of poor working relationships between these two groups and the

manner in which this issue is manifested may vary from one country to another

depending on the specific arrangements for financing, organising, and delivering

healthcare services (Rundall and Kaiser, 2004). For instance, in the US, there are

some states where hospitals are prohibited from hiring doctors as employees due to

corporate practice of medicine laws in those states. In those instances, doctors remain

in private practice, but they are permitted by hospital staff to refer patients to the

hospital (Rundall and Kaiser, 2004). The doctor who referred the patient to the

hospital, manages the hospital care of the patient as the “visiting medical doctor”

(Rundall and Kaiser, 2004). The services provided by the private doctor are

reimbursed by the hospital depending on their health insurance policy (Rundall and

Kaiser, 2004). In this example, the doctors are independent from corporate control and

they exercise the autonomy of being able to admit patients to any hospital where they

have credentialing privileges (Rundall and Kaiser, 2004). This is in contrast to the UK,

where most hospitals are managed by the NHS Trusts, patients who are referred to

the hospital by their general practitioner (referring physician), are overseen and

managed by hospital-based doctors employed by the hospital or under contract with

the NHS, and the care provided is free of charge to patients (Rundall and Kaiser,

2004).

These differences in the management systems, professional relationships and

financial responsibilities between the U.S. and UK healthcare models are likely to

affect the way doctors and managers interact. In 2003, a U.S. study by the Governance

Institute (2003) involving 60 hospital managers, revealed that competition between

hospitals and doctors for outpatient services and physicians covering on-call duties

without compensation were two significant factors that affected the working

relationships of these two groups. The study found that because of the poor manager-

doctor relationships, some of the doctors who were displeased with the hospital

administration thought of referring patients elsewhere, while some attempted to

compete with the hospital (The Governance Institute, 2003). In the UK, a study (Davies

et al, 2003) found that the rejection of the NHS medical consultant contract in England

and Wales by the doctors was partly due to doctor’s mistrust of managers and fear

that might lose their autonomy. In both countries therefore, doctor-manager

interactions have consequences not only for policy and funding providers but also for

the efficiency of local patient care processes (Rundall and Kaiser, 2004).

Previous studies (Powell and Davis, 2016 and Rundall and Kaiser, 2004) have

highlighted the need to investigate the lack of cooperation between doctors and

managers further because of the impact on healthcare provision. Furthermore, despite

the significant impact that a poor working relationship between the two groups could

have on quality of care, there is limited systematic review in this area (Schultz, 2004,

Edwards, 2003 and Aiken et al, 2003). The problem does not only persist, but it is

likely to deteriorate with the growing risks of doctors disengaging from management.

Therefore, further research is necessary to investigate organisational factors, which

contribute to the poor working relationship between doctors and managers with a view

of recommending potential solutions to address them. This is my main motivation for

undertaking this study.

1.2 Purpose of the Study

The purpose of this study is to undertake a systematic review of literature on the

evidence regarding poor working relationships between doctors and managers in

hospitals with a view to identify possible root causes of the problem and suggest ways

to overcome them. The expectation is that this study will add to the body of knowledge

required to help improve doctor-manager relations, which in turn could potentially lead

to better outcomes for patients and their families, healthcare services, policy makers

and funding providers.

In order to address the gap in the current knowledge regarding poor working

relationships between doctors and hospital managers, a main research question was

formulated which is: “what are the organisational factors which contribute to the poor

working relationship between doctors and hospital managers?”

1.3 Research Question

1. What are the organisational factors that contribute to poor working

relationship between doctors and hospital managers?

1.4 Chapter Summary

Chapter 1 has introduced the research topic and presented why poor working

relationships between doctors and managers is a problem. It discussed the background

literature on this issue, highlighted some of the causes and consequences of the

problem on healthcare services, the knowledge gap and the purpose of this current

study. This chapter also stated the research question. The remainder of the study is

organised into four chapters.

1.5 Introduction to Chapters Two to five

Chapter 2 presents a systematic review of the literature on poor working relationships

between doctors and managers in hospitals. Chapter 3 presents the results of peer-

reviewed journal articles that were included in this systematic review including the

summary of the included studies and the identified key themes. In Chapter 4 the

discussion on the findings of the systematic review are presented. Chapter 5 contains

the conclusion, the limitations of the study, and recommendations for further research.

CHAPTER 2 METHODS

2.1 Introduction

This chapter deals with the study design, which is a qualitative systematic review, the

data source and search strategy, the inclusion and exclusion criteria, as well as the

search outcome. It includes quality appraisal of the included studies, data extraction

and synthesis.

Research designs are different, and they include a single observational case study, a

cohort or case-controlled design, non-randomised and randomised controlled trials

(RCTs), qualitative studies and systematic reviews. Each method has its own

advantages and disadvantages. The choice of which method to adopt is dependent

on factors such as the research question, ethical issues, sample size and funding

(Hicks 1999). Therefore, the choice of this research methodology, which is a

systematic review was because this is a secondary research – that is a review of

previous studies, as well as a result of the research question. According to Higgins

and Green, (2011), “a systematic review is a secondary research (study of studies)

that seeks to gather all primary studies that fit prespecified eligibility criteria in order to

address a specific research question, aiming to minimize bias by using and

documenting explicit, systematic methods” (Higgins and Green, 2011).

To undertake a systematic review, the researcher usually develops a protocol, which

guides the whole process of the review. This is to ensure that the findings of the review

are of a high-quality evidence (Butler, et al., 2016). Therefore, the qualitative

systematic review defined by Ring and her colleagues (2010) and the York Centre for

Reviews and Dissemination (2019) guided the methodological protocol for this study.

It also ensures that both the inclusion and exclusion criteria follow logically from the

review question. It has been suggested that an important step in the development of

a qualitative systematic review is to have a research question (Bettany-Saltikov, 2012).

The framework for developing a research question in qualitative studies that was

suggested by Stern, et al., (2014) was adopted by this review and it involves the

Population, Exposure, Outcome (PEO) framework, which is readily used by qualitative

studies.

2.2 Data Source and Search Strategy

The aim of the search strategy was to maximally retrieve relevant papers that were

appropriate to the research question, as well as reduce retrieval of papers that are not

relevant (Higgins & Green 2006). To achieve this objective, several widely accepted

databases were searched. These include:

I. A search for papers was conducted through the search engine of the Anglia

Ruskin University Ebscohost, using AMED (Allied and Complimentary

Medicine), MEDLINE (Medical Literature Analysis and Retrieval System),

CINAHL (Cumulative Index to Nursing & Allied Health Literature) Plus with Full

Text, SportDiscus and EBSCO Ebooks from January 2000 to July 2019 and

updated in November 2019.

II. Reference Lists: These were searched from the relevant primary and review

studies

III. Grey Literature: The following was searched via –

a. SIGIE (System for Information on Grey Literature in Europe)

IV. Conference Proceedings: These were searched via:

a. ZETOC

b. ISI (Institute for Scientific Information) web of science

V. Cochrane Library

VI. The Internet: The following were searched

a. Department of Health (http://www.dh.gov.uk)

b. Google Scholar (http://www.scholar.google.co.uk)

c. Google (http://www.google.co.uk)

In addition to the above, relevant healthcare management textbooks were consulted

for information on manager-doctor relations.

The search was limited to studies published in English language. Non-English

language studies for example, French and Chinese were not included because of the

constraints of translation into English language such as time and money. According to

Bettany-Saltikov., (2012), an electronic search strategy should in general have three

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