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Knowledge sharing in Chinese surgical teams

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Knowledge sharing in Chinese surgical teams

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Content KNOWLEDGE SHARING IN CHINESE SURGICAL TEAMS
by
Hao Huang
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Doctor of Philosophy
(COMMUNICATION)
December 2005
Copyright 2005 Hao Huang
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UMI Number: 3220114
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DEDICATION
To
my parents,
Shui Qing Huang and Ya Ping Zhang,
who have inculcated in me the determination, persistence, and self-discipline to
complete this work and my doctoral studies,
for their endless love, encouragement and support through all the years .
And also to my younger sister,
Chun Huang,
for her love, faith and confidence in me.
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ACKNOWLEDGEMENTS
I would never have been able to complete this dissertation without the
guidance of my committee members, support from my parents and my younger sister,
help from Chinese surgical team members who participated in this study, and
encouragement from many friends.
First and foremost, I would like to thank my advisor, Patricia Riley, for being
such a great mentor. I want to thank her especially for her insightful comments and
suggestions, amazing patience, and unwavering support throughout my graduate
studies. I also want to thank her for always being willing to meet me whenever I
barged into her office. I owe a special note of gratitude to Janet Fulk and Ian Mitroff
for their generous time and incisive advice. It has been a great pleasure working with
them.
I am extremely thankful to my dad for helping me recruit the participants for
this study. This dissertation would not have been possible without him. I greatly
appreciate the time and efforts he spent helping me with this study. I also want to
thank him for being a great “dissertation nag.” I am no less indebted to my mother
who is a constant source of support. Her unflagging faith and confidence in me gave
me the drive to finish this dissertation. Thanks to my younger sister for her love,
enthusiasm, and the joy she has brought into my life.
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I owe a debt of gratitude to Chinese surgical team members participating in
this study for their generous time and valuable thoughts. Their greatly appreciated
feedbacks have helped improve this dissertation.
Last but not least, I would like to thank my fellow doctoral students for their
generous support and greatly needed encouragement. Thanks to Hongmei Li for
being a great friend and a source of wisdom and moral support. Thanks to Lu Tang,
Wei Peng, and Ying Li for the beautiful sunflower bouquet on the defense date and
encouragement along the way.
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TABLE OF CONTENTS
DEDICATION ii
ACKNOWLEDGEMENTS iii
LIST OF FIGURES viii
ABSTRACT ix
I. KNOWLEDGE SHARING IN CHINESE SURGICAL TEAMS 1
Knowledge Sharing in Surgical Teams 6
Chinese Surgical Teams 10
Preview of the Following Chapters 17
II. WEAVING THE FRAGMENTED THREADS TOGETHER 20
Surgical Teams 20
Attitude, Communication, and Teamwork in Surgical Teams 21
Clinical Training and Learning in Surgical Teams 30
Learning, Knowledge and Information Sharing in Teams 32
Learning in Teams 33
Knowledge and Information Sharing in Teams 43
Knowledge Sharing Within and Between Organizations 47
Chinese Surgical Teams 57
Training of Health Professionals in the Chinese Medical and 57
Nursing Education Systems
Human Resources Policies at Chinese Public Hospitals 67
Chinese Cultural Behaviors 78
Interpretive-Symbolic Approach to Knowledge Sharing in 87
Chinese Surgical Teams
Knowledge Sharing Practices 89
Expectations, Perceptions and Interpretations of Knowledge 94
Sharing
Table 2.1.: Salary Rate by Professional Post Grade and Step for 66
Health Professionals
III. CHINESE SURGICAL TEAMS IN ACTION 97
Methodology 98
Research Setting 100
v
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Data Collection 104
Data Analysis 106
Validity 108
Findings 109
Interdisciplinary Knowledge Sharing Among Surgeons, 112
Anesthesiologists, and OR Nurses
Intradisciplinary Knowledge Sharing Within Surgeons, 118
Anesthesiologists, and OR Nurses
Nature of Knowledge Shared 124
Knowledge Sharing Communication Strategies and Styles 129
Perceptions and Interpretations of Interdisciplinary 13 3
Knowledge Sharing
Anesthesiologists’ and OR Nurses’ Perceptions and 136
Interpretations of Intra-disciplinary Knowledge Sharing
Surgeons’ Perceptions and Interpretations of Intra-disciplinary 139
Knowledge Sharing
Knowledge Sharing Within a Surgical Team 174
Sharing of Face-threatening Knowledge 177
Knowledge Sharing Motivation 180
Summary 184
IV. SURVEY OF CHINESE SURGICAL TEAM MEMBERS 191
Method 201
Procedure 201
Sample 201
Instrument 202
Data Analysis 203
Measures 203
Results 208
Perceived Intradisciplinary and Interdisciplinary Knowledge 208
Sharing
Perceived Intradisciplinary and Interdisciplinary Teamwork 209
Perceived Intradisciplinary Peer and Vertical Knowledge 209
Sharing
Discipline and Perceived Organizational Climate 210
Discipline and Importance of Team Knowledge Sharing 211
Surgical Team Leadership 212
Seniority and Perceived Team Communication 213
Seniority and Perceived Interdisciplinary Knowledge Sharing 214
Seniority and Perceived Interdisciplinary Teamwork 214
Seniority and Perceived Organizational Climate 215
Seniority and Perceived Communication Climate 215
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Hierarchy 215
Job Satisfaction 216
Summary of Key Hypothesis Findings 217
Summary 219
V. DISCUSSION AND CONCLUSION 221
Research Settings and Methods 222
Discussion of Main Findings 223
Theoretical Implications 234
Practical Implications for Chinese Hospitals 236
Limitations 237
Areas for Future Research 239
REFERENCES 242
APPENDICES 266
Appendix A. Number of Medical Graduates from Colleges 266
and Secondary Schools in Mainland China
Appendix B Postgraduate Residency Training in the MOH 267
hospital
Appendix C Continuing Education Programs at Chinese 268
Public Hospitals
Appendix D Hospital Personnel Policies 269
Appendix E List of Chinese Communication-Related 275
Concepts and Their English Translations
Appendix F Chinese Hospital Accreditation 276
Appendix G Profile of Interviewees 277
Appendix H Interview Questions 279
Appendix I List of Codes with Frequencies 282
Appendix J Sample Codes and Quotations 285
Appendix K List of Networks Created 286
Appendix L Sample Networks and Corresponding Codes 287
Appendix M Department Conferences 288
Appendix N Profiles of Survey Respondents 289
Appendix O Survey Questionnaire and Marginals 291
Appendix P Survey Tables 301
vii
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LIST OF FIGURES
Figure 2.1. Knowledge Sharing Within and Between Organizations 49
Figure 3.1. Dimensions of Knowledge Sharing 111
Figure 3.2. Intrateam Knowledge Sharing Network 175
Figure 3.3. Sharing of Face-threatening Knowledge Network 178
Figure 3.4. Knowledge Sharing Motivation Network 180
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ABSTRACT
This study addresses the understudied topic of knowledge sharing in Chinese
surgical teams. In this study, I take the position that a proper understanding of
surgical team members’ knowledge sharing attitudes and behaviors has to take into
account relevant social, cultural, and historical trends, in addition to variables at the
individual, team, and organizational levels. This study examines knowledge sharing
in Chinese surgical teams from an interpretive-symbolist perspective.
This study uses a two-study design: a qualitative case study of 100 members
from 27 surgical teams at two Chinese public hospitals and a survey study of 86
members from one Chinese public hospital. The qualitative case study draws on data
from interviews, observation, hospital documents, and government agency policies.
The case study describes, analyzes, and interprets knowledge sharing attitudes and
behaviors of Chinese surgical team members. The findings suggested that Chinese
surgical team members’ knowledge sharing behaviors displayed a strong insider
focus in most cases and some unique features in certain cases (e.g., listening-
centered tendencies when sharing knowledge in public settings, and more active
sharing of face-threatening knowledge in private settings). The findings not only
highlighted the important roles played by certain Chinese national cultural traits,
broad social and institutional forces in shaping Chinese surgical team members’
knowledge sharing attitudes and behaviors but also emphasized the agency of
surgical team members in creating and shaping their own environment through their
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knowledge sharing behaviors and the meanings they create for their own and others’
knowledge sharing behaviors.
The survey study results revealed great attitudinal differences among Chinese
surgeons, anesthesiologists, and Operating Room Nurses in their perceptions of
intradisciplinary and interdisciplinary knowledge sharing and teamwork, as well as
their views of surgical team leadership. Chinese surgical team members were found
to concur in their perceptions of hospital climate and the importance of team
knowledge sharing. A surgical team member’s seniority was found to be related to
his or her team communication climate. A surgical team member’s job satisfaction
was found to be significantly related to perceived intrateam communication,
perceived communication climate perceptions, and teamwork style.
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I. KNOWLEDGE SHARING IN CHINESE SURGICAL TEAMS
It is well recognized that knowledge is the major source of competitive
advantage for knowledge-intensive organizations embedded in today’s turbulent and
highly competitive environment (e.g., Argote, 1998; Davenport & Prusak, 1998;
Grant, 1996; Leonard-Barton, 1995; Nonaka, 1994; Nonaka & Takeuchi, 1995).
Organizations have learned that they need to capture, create, share, disseminate, and
integrate knowledge rapidly and effectively in order to survive and succeed in
today’s fast-paced and rapidly changing market. Much of the knowledge
management work in many organizations (e.g., hospitals) is carried out in teams or
work groups as increasingly more organizations adopt team-based organizing (Earley
& Gibson, 2002; Mohrman, Cohen, & Morhman, 1995; Zarraga & Garcoa-Falcon,
2003). These teams’ abilities to combine, share, and create knowledge under time
pressures are closely linked to their organizations’ learning, performance and
adaptation to changes (Argote, Gruenfeld, & Naquin, 2001; Chan, Lim, &
Keasberry, 2003; Edmondson, 1999, 2002).
The past decade has seen an increase of interest among management,
communication, and psychology scholars in team knowledge management, including
but not limited to, team learning, team knowledge and information sharing, and
knowledge creation (e.g., Cannon & Edmondson, 2001; Cramton, 2001; Edmondson,
1999, 2002, 2003a, 2003b; Ellis et al., 2003; Gibson & Vermeulen, 2003;
Hollingshead, 1998; Huang, 2003). Researchers have examined learning, knowledge
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and information sharing in a wide variety of teams: surgical teams (Edmondson,
2003a, 2003b), work teams (Gibson & Vermeulen, 2003; Edmondson, 1999,2002;
Kasl, Marsick, & Dechant, 1997; Zarraga & Garcoa-Falcon, 2003), project teams
(Gibson & Vermeulen, 2003; Norrgren & Schaller, 1999; Sarin & McDermott,
2003), management teams and parallel teams (Edmondson, 1999; Gibson &
Vermeulen, 2003), newly formed multinational teams (Huang, 2003), and virtual
teams (Cramton, 2001; Cramton & Orvis, 2003; Hinds & Weisband, 2003; Kalman,
Monge, Fulk, & Heino, 2002; Majchrzak, Rice, Malhotra, King, & Ba, 2000).
Surgical teams are a type of Interdisciplinary Action Teams (IATs) where
members from different disciplines must "respond to unexpected events in a
coordinated way, often requiring a free and open transfer of information to enable
real-time, reciprocal coordination of action" (Edmondson, 2003b, p. 1421). The tasks
performed by surgical teams are knowledge-intensive and interdependent. Some of
them involve great uncertainty and high risks (e.g., Helmreich & Schaefer, 1994;
Rosenthal, 1995; Wilson, 1954). Furthermore, the membership of surgical teams is to
some extent unstable (Edmondson, 2003; Lammers & Krikorian, 1997). For
instance, new members might be added to teams to replace members who are
physically exhausted (Lammers & Krikorian, 1997)
The failure o f surgical team members to share knowledge and information
rapidly and effectively can result in small to great injuries to the patient or even the
death of the patient (Edmondson, Bohmer, & Pisano, 2001; Helmreich & Merritt,
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1998; Helmreich & Schaefer, 1994; Lingard, Garwood, & Poenaru, 2004). Poor
teamwork and coordination in surgical teams resulting from ineffective knowledge
and information sharing among surgical team members, particularly those from
different disciplines, has been suggested as one of the main causes of surgical and
anesthetic errors (e.g., Carthey, de Leval, & Reason, 2001; de Leval, Carthey,
Wright, Farewell, & Reason, 2000; Etchells, O'Neill, & Bernstein, 2003; Helmreich
& Merritt, 1998; Helmreich & Schaefer, 1994). The hierarchical structure of surgical
teams and the medical culture of shame, blame, and silence have also been suggested
to hinder the sharing of certain knowledge (e.g., problems, errors, and mistakes).
Effective knowledge management in surgical teams (including that among and
within different subgroups) could improve team communication and coordination,
facilitate the resolution of interpersonal conflicts, reduce the frequency and severity
of surgical errors, enhance the efficiency and the cost-effectiveness of operations,
and improve the quality of patient care (e.g., Edmondson, 2003a, 2003b; Helmreich
& Merritt, 1998; Helmreich & Schaefer, 1994).
Given the great stakes involved in knowledge and information sharing in
surgical teams, it is important to understand the dynamics of knowledge sharing in
surgical teams. However, a review of the literature shows that only some researchers
have examined knowledge and information sharing in surgical teams indirectly from
a team learning perspective or from a team effectiveness perspective (Edmondson et
al., 2001; Edmondson, 2003a, 2003b; Helmreich & Merritt, 1998; Helmreich &
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Schaefer, 1994). Much more has yet to be learned about knowledge sharing in
surgical teams.
Previous studies on learning, knowledge and information sharing in teams
tend to focus on variables at the individual, team, and organizational levels while
neglecting other higher-level variables (e.g., national culture and society trends)
(with the exception of Huang, 2003; Waller, Gibson, Carpenter, & Conte, 2003).
Surgical team members are also members of their society in addition to being
members of their teams and organizations. In this study, I take the position that a
proper understanding of their knowledge sharing attitudes and behaviors has to take
into account relevant broad social, cultural, and historical trends. Surgical teams at
Chinese public hospitals are embedded in a social, cultural, and institutional context
that is different from most European and North American surgical teams that have
been studied. I chose to examine these Chinese surgical teams in this study primarily
because it would enable me to surface broader social, cultural, and historical factors
that have been missing from the existing literature1 . As will be demonstrated later in
this study, the knowledge sharing attitudes and behaviors of surgical team members
at Chinese public hospitals have been found to be greatly influenced by many
There was another personal reason for my decision to study surgical teams at
Chinese public hospitals. Both my parents have worked on surgical teams. My
mother used to be a surgical nurse, whereas my father is still a senior oncologist. I
have always been fascinated by those workplace stories that they told me at dinner
table and wanted to know more about the workings of surgical teams. This study has
helped me to know my parents better, which is a gem in and of itself.
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cultural and societal level factors, including but not limited to, national cultural
values, the Chinese medical and nursing education systems, the market-based reform
of Chinese public hospitals and the capitalist style market reforms of the Chinese
economy as a whole.
In this study, I examine knowledge sharing in Chinese surgical teams from an
interpretive-symbolic perspective (Eisenberg & Riley, 2001; Krone, Jablin, &
Putnam, 1987). The interpretive-symbolic perspective highlights the agency of
organizational members in creating, sustaining, and changing their organizational
structures through their communicative behaviors, as well as the subjective, socially
constructed nature of organizational reality (Berger & Luckman, 1980; Weick, 1979,
2002; Weick & Ashford, 2001; Weick & Roberts, 1993; Weick, Sutcliffe, &
Obstfeld, 1999). In the existing literature, knowledge sharing is often examined as
the outcome variable of other cultural, structural, and social factors (e.g., dyadic
relationship, team hierarchy). Many researchers on knowledge sharing or
organizational learning have paid inadequate attention to the important role that
people’s knowledge sharing behaviors play in creating and shaping these social,
cultural, and structural features (Weick, 1993; Weick & Ashford, 2001; Edmondson,
2003a, 2003b). Adopting Eisenberg and Goodall’s (1993) definition of culture as
“something an organization is” (p. 143), Weick and Ashford (2001) stressed the
central role of social processes of communication and socialization to organizational
learning, and argued that the sharing of individual learning with the collective
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influences the collective culture by sustaining or changing the intersubjective
meanings within the collective.
The adoption of an interpretive-symbolic perspective facilitates the capturing
of the processes of “organizing and structuring of the communicative relationships”
(including knowledge sharing relationships) among surgical team members
(Eisenberg & Riley, 2001, p. 316). It also makes it possible to capture the wide
variety of perceptions, interpretations, and experiences of surgical team members of
different ranks and from different professional cultural groups as well as the
meanings they build around knowledge sharing processes within and between
surgical teams.
Knowledge Sharing in Surgical Teams
Teams are the building block of hospitals (Adler, 2003). They are everywhere
in hospitals: surgical teams, emergency medical teams, Intensive Care Unit care
teams, and many other health care teams (e.g., Edmondson, 2003b; Fried, Topping,
& Rundall, 2000; Lichtenstein, Alexander, McCarthy, & Wells, 2004; Shortell et al.,
1994; Wheelan & Burchill, 1999). Hospitals increasingly rely on them to deliver
health care service to patients.
The performance of surgical teams has come under closer and more
systematic scrutiny in the past decade (e.g., Berwick, 2002; Edmondson, 2003a,
2003b; Fox, 1992; Helmreich & Davies, 1996; Helmreich & Merritt, 1998;
Helmreich & Schaefer, 1994; Lammers & Krikorian, 1997; Lingard et al., 2004;
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Lingard, Reznick, DeVito, & Espin, 2002; Lingard, Reznick, Espin, Regehr, &
DeVito, 2002; Pettinari, 1988; Sexton et aL, 1998; Sexton, Thomas, & Helmreich,
2000). Part of these efforts come as a response to pressures from the public, as more
evidence has accumulated documenting the high error rates in surgery and other
health care services (e.g., Bogner, 1994; Kohn, Corrigan, & Donaldson, 2000;
Rosenthal, 1995; Studdert, Brennan, & Thomas, 2002).
Like the flight operation teams on aircraft carriers examined by Weick and
Roberts (1993), surgical teams at hospitals also operate in risky environments that
require ongoing reliable operation (Weick, 2002). The failure of surgical team
members to share information and knowledge openly, effectively, and in a timely
fashion might lead to small to great harms to the patient.
Although the negative consequences of ineffective knowledge and
information sharing in surgical teams are well recognized, there are many great
hindrances to the realization of open, thorough, and effective sharing of knowledge
in surgical teams. First, surgical teams are composed of members from different
disciplines, each of which has its own specialty training, work norms,
professional/functional cultures, and mental models (e.g., subgroups of surgeons,
anesthesiologists, operating room nurses, and technicians). Inadequate teamwork has
been shown to be particularly salient at the interfaces among these subgroups (e.g.,
Helmreich & Davies, 1996; Helmreich & Merritt, 1998; Helmreich & Schaefer,
1994; Lingard et al., 2004; Thomas, Sherwood, & Helmreich, 2003; Wilson, 1954).
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In their study of operating room team members at a European hospital, Helmreich
and Schaefer (1994) found that surgeons, anesthesiologists, surgical nurses, and
anesthesia nurses diverged greatly in their ideas of team coordination strategies and
effective leadership. Such disagreements have been suggested and found in some
cases greatly impede knowledge and information sharing across subgroups of
surgeons, anesthesiologists, and nurses (Helmreich & Schaefer, 1994; Sexton et al.,
2000).
Like most other interdisciplinary teams, surgical teams have been found to be
susceptible to communication breakdowns, interpersonal conflicts, and poor
coordination (e.g., Helmreich & Davies, 1996; Helmreich & Merritt, 1998;
Helmreich & Schaefer, 1994; Lingard et al., 2004; Sexton et al., 1998). Poor
coordination among members of operating room teams is an example of “heedless
interrelating”: it slows down the timely correction of errors and increases the chances
for small slips to escalate into accidents (Weick & Roberts, 1993) .
Second, the hierarchical structure of surgical teams has been suggested and
observed in some cases to hinder lower-status members from speaking up
(Edmondson, 2003b; Helmreich & Merritt, 1998). Among the three main subgroups
constituting a surgical team, surgeons rank the highest in status, followed by
------------------------------------------
According to Weick and Roberts (1993), heedless interrelating in a system refers to
the situations where actors of the system act independently without relating their
local actions to others in the system. Their focus on their local situation rather than
the joint situation hinders them from anticipating the possible responses from other
actors and from understanding the system implications of their own actions.
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-3
anesthesiologists and nurses . Within each subgroup, there are great status
differentials between members of differing seniority.
Third, surgical teams, like other action teams in health care, are characterized
by some degree of membership instability (Edmondson, 2003b). Surgical teams are
formed by drawing a subset of members from a larger pool of members
(Edmondson, 2003b; Lammers & Krikorian, 1997). Unstable membership might lead
to low familiarity among team members, which might hinder knowledge and
information sharing among them. For instance, a surgeon from another team might
later join a surgical team to replace the chief surgeon who is physically exhausted
when the operation takes much longer time than expected (Lammers & Krikorian,
1997). When the surgeon who later joins the team has not worked with other
surgeons, anesthesiologists and OR nurses on the team, the information and
knowledge sharing within the team might suffer.
Fourth, the much-deplored medical culture of shame, blame, and silence also
hinders the sharing of valuable knowledge such as lessons learned from problems,
errors, and failures (Tucker & Edmondson, 2003). The belief in the possibility of
perfection is suggested to be prevalent in the medical field: mistakes and errors are
seen as “a personal and professional failure” (Weick, 2002, p. 187). An emerging
_ --------------------------------------------
However, it has been noted that this traditional hierarchical structure is being
challenged in the United States as nurse anesthesiologists are used to replace
anesthesiologists for cost containment reasons (Helmreich & Merritt, 1998).
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body of literature has documented that the fears of litigation, of face loss, and of
professional damage as well as the cultural norms of non-criticism have led to the
covering up of many errors, mistakes, and problems among healthcare professionals,
including surgeons, anesthesiologists, and nurses (e.g., Edmondson, 1996; Etchells et
al., 2003; Rosenthal, 1995; Studdert et al., 2002; Tucker & Edmondson, 2003).
Chinese Surgical Teams
As discussed earlier, not much is known about knowledge sharing in surgical
teams. Much less is known about knowledge sharing in Chinese surgical teams. A
review of the literature shows that there is no research on knowledge sharing in
Chinese surgical teams, though there is some research on knowledge management at
Chinese public hospitals (Li, 2002; Fang & Ying, 2002; Ren, 2002; Sun, Wu, & Hu,
2004; Tan, Yang, & Yang, 2004; Zhou & Chen, 2003). This paper addresses the
understudied topic of knowledge sharing in surgical teams at Chinese public
hospitals.
As mentioned earlier, most of the studies on learning, knowledge and
information sharing in teams fail to take into account the possible influences of some
higher-level variables (e.g., national culture values, social and historical trends) (with
the exception of Huang, 2003; Waller et al., 2003). In this study, I take the position
that knowledge sharing within and between Chinese surgical teams is a complex
social phenomenon that can only be understood within the contemporary Chinese
cultural, social, and institutional contexts.
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For instance, all members of a typical surgical team at a Chinese hospital are
full-time employees of the hospital4. The proposed institutionalized professional role
conflicts between surgeons and nurses (i.e., the surgeons’ roles as private
practitioners and nurses’ roles as hospital employees) in the Western literature do not
usually apply to the Chinese context (Lingard et al., 2004). In a typical surgical team
at a Chinese public hospital, the subgroup of surgeons is relatively stable over a
certain period of time, the length of which varies with departments5. In most cases,
these surgeons are from the same medical care team and are familiar with the in
patients whom they perform procedures on. Most of the patients that surgeons
perform procedures on are under their daily care throughout their hospitalization:
surgeons interact with their patients on a daily basis. Anesthesiologists and
Operating Room nurses (hereafter referred to as OR nurses) on the team change
rather frequently. They are drawn from the pools of operating room nurses and
4 Sometimes a surgical team might have one or more members (mainly surgeons)
from another hospital when they possess expertise that is not available at the hospital.
These surgeons are usually from a hospital of a higher grade, or at least from a
hospital of the same grade.
5 At Chinese hospitals, all surgical departments (or units) are divided into a certain
number of medical care teams that are in charge of a certain number of patients
(usually 10 to 15 patients at a Grade-3 hospital, or higher if the department is
understaffed). A typical medical care team usually consists of 3 to 4 surgeons of
different professional titles (1 senior-level surgeon, 1 intermediate-level surgeon, and
1 to 2 junior-level surgeons like residents or visiting trainee surgeons). A Grade-3
hospital is the highest graded hospital under the Chinese hospital accreditation
system. Compared with Grade-1 and Grade-2 hospitals, Grade-3 hospitals have a
much larger number of beds, departments, staff, and equipment.
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anesthesiologists at the hospital and assigned to surgical teams on a case-by-case
basis. Surgeons at Chinese public hospitals have nodirect control over which
anesthesiologists and nurses they work with in the operating room. It is the head of
the Department of Anesthesia and the head nurse of the Department of Anesthesia
who are in charge of assigning anesthesiologists and OR nurses to surgical teams.
Neither do surgeons have the final control over who will be on their medical care
teams. The final teaming decisions lie in the hands of the head of the surgical
departments6. The relative stability of the surgeon subgroup might facilitate
knowledge sharing within surgeons on a surgical team but might hinder knowledge
sharing between surgeons on different surgical teams in the same surgical
department when the surgeons identify more strongly with their own teams but less
with their own departments (Edmondson, 2003b). The fluid membership of
anesthesiologists and OR nurses on a typical Chinese surgical team tends to result in
low familiarity between them and surgeons on the team, which in turn might lower
the quality of their teamwork and the depth and openness of inter-subgroup
knowledge and information sharing.
6 It should be noted that surgeons of all seniority could express their personal
preferences for whom they would want to work with together as a team directly to
the head of their department. Several heads of the surgical departments interviewed
in this study mentioned that they would take these opinions very seriously. They
further noted that even when people do not approach them with personal preferences,
they would take the interpersonal relations among surgeons into consideration and
would try their best to put surgeons who are on good terms on the same team. If
things do not work out among surgeons on the same team, the heads of the
department could always make changes and put them on different teams.
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Besides the earlier mentioned challenges (i.e., members from multiple
disciplines, the hierarchical team structure, team instability, as well as the medical
culture of shame, blame, and silence), surgical teams at Chinese public hospitals face
additional challenges in knowledge sharing. The current promotion and
compensation policies at most Chinese public hospitals de-motivate senior surgical
team members from sharing their knowledge with their junior teammates and their
peers on other surgical teams (Gu, 2004). Although all Chinese public hospitals still
use one-on-one apprenticeship training model, many physicians and nurses are not
motivated to train their juniors, because the quality of their teaching performance
carries very little weight in their evaluation and promotion, which tends to stress
their research achievements (Zhao & Ye, 2003). Furthermore, the current promotion
and compensation policies favoring physicians and nurses with a more advanced
degree discourage many senior physicians and nurses with a lower degree from
sharing their clinical skills and knowledge with their better-educated colleagues,
because their clinical knowledge is their important source of power against their
better-educated colleagues under the new and increasingly competitive personnel
system (Li, 2004; Zhang, Wang, & Gao, 2003).
The educational levels of practicing health professionals (including surgical
team members) in China vary greatly. According to the 2003 statistics offered by the
Ministry of Health (May 2004), the educational levels of the practicing physicians
and physicians assistants working at hospitals are as follows: 0.8% (doctor’s degree),
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3.0% (master’s degree), 38.8% (bachelor’s degree), 33.1% (associate degree), 20.6%
(secondary vocational diploma), and 3.7% (high school diploma or below) (p.20).
According to Jiang (2003), in 2000, less than 5% of the 1.19 million nurses in China
have an associate degree, less than 1% nurses have a bachelor’s degree or a higher
degree, whereas the rest only have a secondary school diploma or a lower degree.
Such wide variation in the educational backgrounds of practicing physicians and
nurses results from the evolution of medical and nursing education in China since the
establishment of the communist government in 1949, in particular, from the
reinstatement of collegiate nursing programs in China in 1983 and the reinstatement
of graduate programs in medicine in China in mid-1990s . The increasingly wide
variation in the age and the educational levels of Chinese surgical team members of
the same rank further complicates knowledge sharing within and between surgical
teams. Furthermore, certain Chinese national cultural values might also obstruct
open and thorough knowledge sharing within and between surgical teams at Chinese
public hospitals. Knowledge sharing is essentially a communicative behavior. The
small body of literature on Chinese interpersonal communication and organizational
communication suggests that the Chinese communication behaviors are greatly
shaped by their cultural values (e.g., harmony, humanism, ordering relationships by
7 See Appendix A for the detailed statistics on the number of medical students,
medical colleges and secondary medical schools from 1949 to 2003, as well as the
number of graduates from secondary medical schools and post-secondary medical
institutions from 1950 to 2003.
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status, and a relational and other-oriented sense of self) (e.g., Chen, 2001; Gao &
Ting-Toomey, 1998; Yu, 2002). The Chinese value developing and maintaining
harmonious relationships with their communication partners and make great efforts
to preserve their own mian zi (“face”) and the mian zi of others, particularly the mian
zi of their in-group members. In the context of Chinese surgical teams, team
members’ valuing of harmony and concern with mian zi might discourage them from
sharing face-threatening knowledge and information that might disrupt their
harmonious relationships with their teammates.
Mainland China is a moderately high power distance culture where people
tend to accept the unequal distribution of power and act in accordance with their
status roles in hierarchical relationships. The moderately high power distance culture
of mainland China is expected to exacerbate the suppression effects of the
hierarchical structure of surgical teams. Lower-status Chinese surgical team
members might be much less likely to share knowledge and information that
challenge the face of higher-status teammates. Chinese national cultural values might
also influence the communication channels and the communication style that
Chinese surgical team members use when sharing knowledge with others.
Most of the prior studies approach learning, knowledge and information
sharing in teams from a functionalist perspective, focusing on explicating how
several discrete variables influence the learning, knowledge and information sharing
behaviors of team members. Very few studies explored the communicative processes
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that constitute knowledge and information sharing. The adoption of a communicative
or symbolic-interpretive perspective in this study would enrich this emerging
literature on knowledge and information sharing in teams by highlighting the
meanings, interpretations, and sense-making of surgical team members in their daily
knowledge sharing activities. As will be demonstrated later, this study’s focus on the
complex system of meanings that surgical team members build through daily
communicative interactions with regard to their daily knowledge sharing activities
leads to a better understanding of knowledge sharing in surgical teams.
This study uses a two-study design. The first study is a case study of 100
members of 27 surgical teams at two large public hospitals in China8.1 gained access
to these two hospitals through my personal connection. This study describes,
analyzes and interprets knowledge sharing attitudes and behaviors of Chinese
surgical team members, with a focus on the communicative processes and the
meanings that surgical team members build around knowledge sharing. This study
draws on data from in-depth interviews, observation of team meetings, of department
meetings, of ward rounds, and of surgical operations, informal conversations, field
notes, hospital
_ .--------------------------------------------
In China, public hospitals fall into three categories: Ministry of Health (MOH)
hospitals, People’s Liberation Army (PLA) hospitals (under the administration of
Health Department, General Logistics Department of the PLA), and industrial
hospitals run by large state-owned enterprises (SOEs) (under the administration of
their affiliated Ministries (e.g., Ministry of Railway)). O f the two hospitals chosen
for this study, one is a MOH hospital, whereas the other is a PLA hospital.
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documents, and government agency policies. The second study is a survey of 86
surgical team members at one of the two hospitals under study in Chapter IV.
Preview of the Following Chapters
Chapter II summarizes and integrates research findings on surgical teams,
knowledge and information sharing in teams and small groups, knowledge sharing
and transfer in organizations, and Chinese cultural behavior (in particular Chinese
communication behavior), which have developed in parallel with little cross
fertilization.
Chapter III reports the findings of the case study of 27 surgical teams at two
large, public urban hospitals in a middle-sized east-coast city in China. The chapter
begins with a description of the methodology of interpretive case study, the research
settings, and the data collection methods. Following that is a detailed discussion of
the data coding and analysis using the content analysis software Atlas.ti. The main
part of the chapter focuses on the findings of the in-depth interviews and
observation. Chinese surgical team members’ knowledge sharing behaviors
displayed a strong insider focus in most cases and some unique features in certain
cases (e.g., listening-centered tendencies when sharing knowledge in public settings,
and more active sharing of face-threatening knowledge in private settings). Some
disciplinary differences were found to exist in the peer knowledge sharing behaviors
of surgeons, anesthesiologists, and OR nurses. A surgical team member’s seniority
was suggested to be related to his or her knowledge sharing behaviors and
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perceptions of knowledge sharing climate. The findings not only highlighted the
important roles played by certain national cultural traits, broad social and
institutional forces in shaping the knowledge sharing attitudes and behaviors of
Chinese surgical team members but also emphasized the agency of surgical team
members in creating and shaping their own environment through their knowledge
sharing behaviors and the meanings they create for their own and others’ knowledge
sharing behaviors.
Chapter IV presents some findings of a survey of 86 surgical team members
at one of the two hospitals under study in Chapter III. The survey results supplement
the rich qualitative data obtained in the case study. The chapter begins with a
description of the survey procedure, the sample, the measures, and data analysis
methods. Following that is a detailed discussion of the findings relevant to
knowledge sharing in Chinese surgical teams. Surgeons rated intradisciplinary
knowledge sharing more positively than interdisciplinary knowledge sharing,
highlighting the importance of improving knowledge sharing at the disciplinary
interfaces. Surgeons also rated intradisciplinary teamwork more positively than
interdisciplinary teamwork. However, anesthesiologists and OR nurses seemed to
draw a less distinction between intradisciplinary and interdisciplinary teamwork.
Great disciplinary differences existed between anesthesiologists and surgeons with
respect to surgical team leadership, while they concurred in their perceptions of the
hospital climate, and the importance of team knowledge sharing. Only junior-level
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surgeons were found to view peer knowledge sharing more negatively than vertical
knowledge sharing with other surgeons. A surgical team member’s seniority was
found to be positively related to his or her perception of intrateam communication
quality, but not to his or her appraisal of knowledge sharing with teammates from
other disciplines, or to perceived interdisciplinary teamwork, or to perceived
organizational climate, or to perceived communication climate. A surgical team
member’s teamwork style, perceptions of intrateam communication, and
communication climate were found to contribute to his or her job satisfaction.
Chapter V summarizes the findings from the qualitative case study and the
survey, discusses the theoretical implications of this study for future research on
knowledge sharing in teams and on organizational communication in mainland
China, as well as the study’s practical implications for Chinese hospitals. It ends with
a discussion of the limitations of the study, and of some promising areas for future
research.
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II. WEAVING THE FRAGMENTED THREADS TOGETHER
Open and efficient knowledge and information sharing within and between
teams is essential to the effective functioning of teams, particularly those cross
functional teams working on knowledge-intensive and interdependent tasks. The
failures of surgical team members to share knowledge and information efficiently
could have great consequences: the patient might suffer unnecessary injuries or even
die in some circumstances. Given the great stakes involved, it is imperative to
understand the dynamic workings of knowledge sharing in surgical teams. Although
few researchers have theorized about knowledge sharing in surgical teams, there are
multiple streams of research scattered in different disciplines that could help move us
toward a better understanding of knowledge sharing in surgical teams in general, and
Chinese surgical teams in particular.
In this chapter, I review and integrate the following streams of research that
have developed in parallel with little cross-fertilization: the surgical team literature,
the team learning, knowledge and information sharing literature, the literature on
knowledge sharing and transfer within and between organizations, as well as the
Chinese communication literature.
Surgical Teams
The past decade has seen an increase of interest among psychology,
management, and medical researchers in the workings of surgical teams along with
the burst of interest in medical errors and patient safety in general (e.g., Berwick,
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2002; Edmondson, 2003a, 2003b; Fox, 1992; Helmreich & Davies, 1996; Helmreich
& Merritt, 1998; Helmreich & Schaefer, 1994; Lammers & Krikorian, 1997; Lingard
et ah, 2004; Lingard, Reznick, DeVito et al., 2002; Lingard, Reznick, Espin et al.,
2002; Pettinari, 1988; Sexton et al.,1998; Sexton et al., 2000). The small body of
works on surgical teams has provided important insights into the work-related
attitudes of surgical team members, learning, communication and teamwork in
surgical teams. Researchers have identified some great attitude differences among
and within the subgroups of surgeons, anesthesiologists, and OR nurses, explored the
impacts of some discrete variables (e.g., team leadership and organizational context
support) on surgical team learning, and observed low-quality communication and
poor teamwork at the interfaces among the three subgroups constituting surgical
teams in some cases. The studies on surgical team learning will be reviewed later
under the section on learning, knowledge, and information sharing in teams.
There is another stream of research on the clinical teaching and learning
practices of surgical team members that is directly related to the study of knowledge
sharing in surgical teams. In this section, I will briefly review the literature in
Western culture. The literature on clinical teaching and learning of Chinese surgical
team members will be covered later under the section “Chinese Surgical Teams”.
Attitude, Communication, and Teamwork in Surgical Teams
Attitude Differences among Surgical Team Members. As a type of
interdisciplinary action teams, surgical teams are composed of members from
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multiple disciplines who must coordinate closely with one another in real time in
order to complete their team task successfully (Edmondson, 2003b). It has been
suggested and found in some cases that it is hard to achieve effective coordination
between surgical team members from multiple disciplines because of the disciplinary
attitudinal differences that result from each discipline’s specialized training,
language, norms, professional culture, and mental models (Edmondson, 2003b).
Researchers have identified great attitudinal differences regarding team leadership,
team structure, team procedures, teamwork, role perceptions, and communicative
motivations between the subgroups of surgeons, anesthesiologists, and OR nurses,
which might impede knowledge and information sharing in surgical teams (Flin et
al., 2003; Helmreich & Davies, 1996; Helmreich & Schaefer, 1994; Sexton et al.,
2000). Some studies have also identified some systematic differences with regard to
teamwork and leadership issues between surgical team members from the same
discipline but with different status (Flin et al., 2003; Sexton et al., 2000).
In their study of 156 surgical team members (including 53 surgeons, 45
anesthesiologists, 32 surgical nurses, and 22 anesthesia nurses) at a European
teaching hospital, Helmreich and Schaefer (1994) found that: (a) a greater percentage
of surgeons and surgical nurses endorsed hierarchical team structure where junior
members should not challenge the decisions by senior members than
anesthesiologists and anesthesia nurses, (b) a greater percentage of surgeons and
surgical nurses reported preferring the mild autocratic leadership style than
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anesthesiologists and anesthesia nurses, (c) a smaller percentage of surgeons reported
preferring the democratic leadership style than the other three subgroups, and (d)
anesthesia staff more endorsed the idea of the importance of a preoperative
debriefing for team coordination (pp. 237-238).
In their study of 851 operating room team members from 12 urban hospitals
(including both teaching and non-teaching hospitals) in Italy, Germany, Switzerland,
Israel, and the United States, Sexton et al. (2000) found that: (a) a greater percentage
of surgeons endorsed hierarchical team structure than surgical nurses and anesthesia
staff; (b) surgical members and anesthesia members did not necessarily hold a
common perception with regard to the quality of their teamwork with one another
(62% of surgical members reported high-quality teamwork with anesthesia members
whereas only 41% of anesthesia members reported high-quality teamwork with
surgery members); (c) a greater percentage of low-status members [surgical nurses
(39%), anesthetic residents (43%), and anesthetic nurses (48%)] reported low-quality
teamwork with consultant surgeons than did high-status members [consultant
anesthetists (less than 20%), consultant surgeons (9%), and surgical residents (7%)];
and (d) a much smaller percentage of low-status members [surgical nurses (28%),
anesthetic residents (10%), and anesthetic nurses (25%)] reported high-quality
teamwork with consultant surgeons when compared with high-status members
[consultant anesthetists (39%), consultant surgeons (64%), and surgical residents
(73%)]. These findings suggest that team members’ perceptions of the quality of
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teamwork with other team members are positively related to their status in the team
and provide some indirect evidence of the status hierarchy in operating room teams
where there are great status differentials between consultants and residents and
nurses.
The findings of Flin et al.’s (2003) study of 222 anesthetists from 11 Scottish
hospitals were consistent with the above two studies. Flin et al. (2003) found that
most of the anesthetists endorsed non-hierarchical team structure, were willing to
speak up when detecting safety-related problems, reported high-quality teamwork
with other anesthetists and low-quality teamwork with surgeons, and endorsed the
value of communicating plans and procedures. They also found significant
differences between consultant anesthetists and all other anesthetists in some
teamwork and leadership issues: consultants considered regular debriefing less
important, felt more comfortable speaking up and advising members from other
disciplines, perceived greater support from department leadership, found it more
insulting having to wait for other team members, were less tolerant with
inexperienced staff, and were more accepting of the inevitable nature of human error.
These differences could be explained by consultants’ seniority and greater expertise.
In their study of operating room teams at two small hospitals in Canada,
Lingard et al. (2004) documented great perception and motivation attribution
disagreement between surgeons and nurses regarding one another’s professional
roles, though they were found to share a similar role perception of anesthesiologists
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as “patient advocates” that was consistent with anesthesiologists’ self-perceptions.
Nurses reported “self-absorption” as the most common motivation for surgeon-
initiated communication (p. 696), whereas surgeons saw nurses as primarily
motivated by fear of punishment. Furthermore, Lingard et al. (2004) found that
nurses and anesthesiologists held identical negative views of surgeons: both groups
saw surgeons as “egotist/antagonist.” They also noted that nurses and
anesthesiologists often allied with one another against surgeons. Such discrepant role
and motivation perceptions among members of the operating room teams are
expected to impede knowledge and information sharing among them.
In their study of the interpretations of three tense communication cases
(where team members talk about the operating room’s temperature, patient
scheduling, and equipment) by 52 operating room team members with a focus on the
socialization of surgical trainees, Lingard, Reznick, DeVito, et al. (2002) found great
discrepancies in the three professional subgroups of surgeons, nurses, and
anesthesiologists. More specifically, they found the three subgroups’ interpretations
of the non-technical roles and communicative motivations of the other two
subgroups (particularly the interpretations by surgical trainees) tended to be narrow
and over-simplified, and were often inconsistent with the self-accounts given by the
subgroups themselves. Take the temperature discussion scenario for example. In that
scenario, the surgeon complained about the high temperature in the operating room
and the circulating nurse replied, saying that 55 was not that high. Lingard, Reznick,
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De Vito, et al. (2002) found that nurses tended to attribute the comment by the
circulating nurse to a concern for the patient, whereas many surgeons attributed it to
the nurse’s desire for power. In the scenario involving the cancellation of a
scheduled operation, the surgeon complained about not being able to move on
immediately to the case following the cancelled operation and suggested that all
patients scheduled for the day should be ready at the time scheduled for the first
operation, while the circulating nurse explained why the next patient couldn’t be
brought to the theater right away and expressed her reservation about the suggestion.
Lingard, Reznick, De Vito, et al. (2002) found that nurses interpreted the surgeon’s
reaction as unhappiness over the loss of the money for the cancelled procedure,
whereas surgeons saw the nurse’s communication as resulting from her status as “a
shift worker” who does not care about patients. They suggested that these simplified
interpretations might be rhetorical, mirroring the attempts of the three professions to
redefine or maintain the traditional hierarchy of surgeon-anesthesiologist-nurse in the
operating room team. However, it should be noted that such narrow, simplified
attributions might be partly explained by the design of their study where subjects are
asked to interpret the communication by imagined characters about whom they have
no personal information.
To sum up, these studies have shown a lack of consensus among surgeons,
anesthesiologists, and nurses on important leadership, coordination, team structure,
role perception and communicative motivation issues. In other words, it suggested
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that most surgeons, anesthesiologists, and nurses did not have shared team mental
models, which might exert a negative influence on their interaction, coordination and
performance.
Communication and Teamwork in Surgical Teams. Such attitudinal
discrepancies between the subgroups of surgeons, anesthesiologists, and nurses, were
suggestive of different professional subcultures (Helmreich & Schaefer, 1994;
Helmreich & Merritt, 1998; Sexton et al., 2002), and were found to match the
anecdotal evidence and the preliminary findings of observed teamwork behaviors in
real operating room teams (especially the observed teamwork between the surgical
and the anesthesia subgroups and the teamwork between surgeons and nurses)
(Cook, Green, & Topp, 2001; Espin & Lingard, 2001; Helmreich & Davies, 1996;
Helmreich & Schaefer, 1994; Helmreich & Merritt, 1998; Lingard et al., 2004;
Lingard, Reznick, DeVito, et al., 2002; Lingard, Reznick, Espin, et al., 2002;
Patterson, 1996; Schaefer, Helmreich, & Scheidegger, 1995; Sexton et al., 1998). It
could also be argued that surgeons, anesthesiologists, and nurses tend to identify
more strongly with their own specialty than with their teams. In other words, their
professional identification overrides their team identification.
Most of the errors, communication breakdowns, and teamwork failures (e.g.,
“unresolved conflicts”, “failure to establish leadership”) observed by Helmreich and
Schaefer (1994) in operating room teams at a teaching hospital occurred at the
interface of the subgroups, particularly between surgeons and anesthesiologists (pp.
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244-245). Helmreich and Davies’s (1996) observations of 39 operations at a
European teaching hospital found that: (a) “briefings and team formation-
maintenance” was rated as “unsatisfactory” or “meeting only minimum
expectations” during induction and operation in 20% to 30% of the operations, (b)
20% to 40% of the operations were rated as “below the standard” in terms of team
members’ asking “questions about team actions and decisions,” sharing decision
relevant information, and acknowledging decisions. In their observations of the
communication between the surgical and the anesthesia teams in 90 operations at a
European teaching hospital, Sexton et al. (1998) found that communication was rated
as “absent or unacceptable” in 20.3% of the operations, “barely acceptable/below
expectations” in 53.2% of the operations, “meets expectations” in 24.1% of the
operations, and “outstanding” in 2.5% of the operations.
Lingard, Reznick, Espin, et al.’s (2002) observational and interview data of
35 operations involving over 80 operating room team members at one teaching
hospital revealed 7 topic areas that were often associated with high team
communicative tension: “time (room turnover, patient cancellation, sending for the
next patient),” “resources (equipment allocation and distribution, personnel
distribution),” “roles (responsibilities, constraints) and relationships,” “safety and
sterility (aseptic technique),” and “situation control (temperature regulation,
recording activities)” (p. 234). Most of the highly tense communication was
documented between surgeons (including surgical trainees) and nurses. They also
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found that the communication among operating room team members was more
subtle and less militaristic and autocratic than what was depicted in popular culture
and that surgeons were more sophisticated communicators than their stereotyped
image suggests. The same set of high-tension themes was reported in a subsequent
study by Lingard et al. (2004) of operating room teams at two small hospitals in
Canada.
Great power differentials have been observed between OR nurses and the two
physician subgroups (surgeons and anesthesiologists): OR nurses possess much less
power than surgeons and anesthesiologists do (Helmreich & Merritt, 1998). Great
status differentials have also been documented within each subgroup. Such status
differences both within and between the subgroups of surgeons, anesthesiologists,
and nurses were suggested and found to impede low status members from speaking
up and hinder interdisciplinary communication between the three subgroups (Flin et
al., 2003; Helmreich & Merrit, 1998).
A series of recent studies has documented that an alarmingly high percentage
of perioperative nurses have experienced verbal abuse (defined as “verbal behaviors
that humiliate, degrade, or otherwise indicate a lack of respect for the dignity and
worth of another individual”) (Hadley, 1990 as cited in Cook et al, 2001) — a great
deal of which comes from surgeons (Buback, 2004; Cook et al., 2001). According to
a recent survey of 461 operating room nurses, 94% reported having experienced
verbal abuse (Watson & Steiert, 2002 as cited in Buback, 2004). Cook et al. (2001)
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found that 71 of the 78 perioperative nurses (91%) have experienced verbal abuse
from a physician in the past year. It has been suggested and documented in some
cases that such verbal abuse would lead to negative short-term and long-term
outcomes: lower morale, lower job satisfaction, lower self-esteem, high turnover,
impaired interpersonal relationships, decreased productivity, and increased errors
(Buback, 2004; Cook et al., 2001). Another survey of 300 OR Manager readers
identified surgeons as the group that displayed disruptive behavior most frequently
among all the staff working in operating rooms (Patterson, 1996).
There is no study on the attitudes, communication, and teamwork of surgical
team members at Chinese public hospitals. Knowledge of the attitudes of Chinese
surgical team members as well as their communication and teamwork will contribute
to a better understanding of their knowledge sharing behaviors. In Chapter IV, I will
report the findings of a survey of 86 surgical team members at one Chinese public
hospital that examined their attitudes on and perceptions of a number of knowledge
sharing, teamwork, communication, leadership, and climate variables. The
hypotheses examined in the survey study were greatly informed by the findings of
the qualitative study that provided some insights into Chinese surgical team
members’ attitudes and perceptions related to knowledge and information sharing.
Clinical Training and Learning in Surgical Teams
The second stream of research that is relevant to knowledge sharing in
surgical teams focuses on clinical teaching and the learning practices of surgical
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team members. Most of the literature is about the training and learning of trainees
and medical students in the specialties of surgery, anesthesiology, and nurses (e.g.,
Birtwistle, Houghton, & Rostill, 2000; Blue, Griffith, Wilson, Sloan, & Schwartz,
1999; Lyon & Brew, 2003). The century-old apprenticeship model is still the
primary training model in healthcare, including China (Walton, 2004).
There is a huge body of literature on the training and learning of trainees and
medical students in the specialties of surgery, anesthesiology, and perioperative
nursing in Western cultures (e.g., Britain, United States, Australia) (e.g., Birtwistle et
al., 2000; Blue et al., 1999; Gaba, Howard, Fish, Smith, & Sowb, 2001; Lyon &
Brew, 2003; Stark, 2003; Walton, 2004). This literature covered a wide range of
topics, including but not limited to the characteristics of effective clinical teachers or
trainers (e.g., enthusiasm, good communication skills, commitment to training) (e.g.,
Blue et al., 1999; Hargreaves, 1996), the perceived effectiveness of learning in
various teaching venues (e.g., operating theaters, conferences, and teaching rounds)
as well as productive learning strategies (e.g., reflection and problem-based learning)
(e.g., Lyon, 2003; Stark, 2003), the efficiency of different training or orientation
programs (e.g., Ford & Koehler, 2001; Smith, 2001; van der Hem-Stokroos,
Daelmans, van der Vleuten, Haarman, & Scherpbier, 2004; Wells, 1999), successful
teaching or training strategies (e.g., active coaching, small group teaching, and
giving constructive feedbacks) and tools (e.g., task-based learning, multimedia,
simulation, and case stories) (e.g., Anders, 2001; Chase, 2001; Cox, 2001; Harden,
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Crosby, Davis, Howie, & Struthers, 2000; Hargreaves, 1996; Kneebone & ApSimon,
2001; Sanson-Fisher, Rolfe, Jones, Ringland, & Agrez, 2002; Wall & McAleer,
2000), as well as the teaching and learning of specific clinical techniques (e.g.,
physical examination skills, surgical positioning, and knotting) (e.g., York, Niehaus,
Markwell, & Folse, 1999).
This stream of research provides insights into the knowledge acquisition of
medical students and trainees as well as the knowledge transfer from senior medical
staff to medical students and trainees. However, as most of the literature on surgeons
focuses on the teaching of medical students, much more has yet to be learned about
the training and learning of junior surgeons (e.g., identifying factors that facilitates
and hinders their learning) (Liverpool, 2000). Furthermore, as this stream of research
focuses on intra-professional knowledge transfer from senior medical staff to their
trainees within the same specialty, it sheds little insight on inter-professional
knowledge sharing among surgical team members.
Learning, Knowledge and Information Sharing in Teams
Only a few researchers have examined knowledge and information sharing in
surgical teams indirectly from a team learning perspective or a team effectiveness
perspective (Edmondson et al., 2001; Edmondson, 2003a, 2003b). Their studies
demonstrated that team leadership plays an extremely important role in facilitating
team learning behaviors (e.g., discussing and analyzing mistakes and problems, and
raising questions) in hierarchical surgical teams by fostering an open, non-punitive,
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and psychologically safe environment. Although these studies do not examine
knowledge sharing directly, they did contribute to our understanding of knowledge
sharing in surgical teams, because knowledge sharing, along with information
sharing, is the means through which most team learning behaviors occur. There is a
larger body of works on learning, knowledge, and information sharing in other types
of teams, or in teams in general. The major findings of this literature are reviewed in
the following pages9.
Learning in Teams
Team Leadership. Team leadership has been identified as an important factor
that influences team learning behaviors in both surgical teams and other types of
teams: it has been suggested to influence team learning behaviors both directly and
indirectly through shaping team members’ perceptions of team or work climate
and/or team shared beliefs (Cannon & Edmondson, 2001; Edmondson, 1996, 1999,
2003a, 2003b; Edmondson et al., 2001a, 2001b; Norrgren & Schaller, 1999; Sarin &
McDermott, 2003). In her study of 16 cardiac surgical teams learning a new surgical
technique (i.e., minimally invasive cardiac surgery), Edmondson (2003b) found that
effective team leader coaching (including “providing clarification and feedback,
seeking members' input, listening to concerns, and being accessible and receptive to
9 The findings on technology-mediated knowledge and information sharing in virtual
teams and distributed work groups (Cramton, 2001; Cramton & Orvis, 2003; Hinds
& Weisband, 2003) are excluded from this review because almost all Chinese
surgical teams are co-located teams.
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others' ideas and questions”) encouraged team members to speak up within and
across surgical teams (p. 1424). She explained that team leader coaching downplayed
power differences among surgical team members and alleviated members’ fears
about the value and desirability of their opinions, thus creating a climate of
psychological safety that encouraged communication and experimenting. In her
study of the same 16 cardiac surgical teams, Edmondson (2003a) also found that
effective team leadership facilitated team learning by creating a compelling vision
for their team and stressing team interdependence and teamwork. It has also been
suggested that surgical team leaders could further foster a learning environment by
engaging in “risky” team learning behaviors (e.g., admitting one’s mistakes) and
serving as a “fallibility model.”
The organizational status of the team leader was found to be positively
related to team learning in new product development teams (Sarin & McDermott,
2003). Participative and democratic team leadership style (e.g., encouraging and
valuing members’ input) was found to facilitate team learning both directly and
indirectly through creating a nurturing, climate of openness where failures can be
admitted and discussed without fear of reprisal (Cannon & Edmondson, 2001;
Edmondson, 1999; Sarin & McDermott, 2003). It was also found that setting clear
and compelling goals for teams by team leaders enhanced team members’
perceptions of the freedom, trust, idea support, and risk tolerance in their work
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climate (Norrgren & Schaller, 1999) and facilitated team learning (Edmondson,
2003a; Norrgren & Schaller, 1999; Sarin & McDermott, 2003).
Edmondson (1996) also demonstrated that supportive nurse managers
facilitated the creation of a non-punitive climate of openness through their learning-
oriented handling of mistakes, whereas authoritarian managers of nursing units
contributed to the creation of a punitive climate of fear through their blame-oriented
handling of mistakes and medication errors. Norrgren and Schaller (1999) found that
change-oriented team leadership contributed to enhanced perceptions of a trusting,
open work climate that encouraged new ideas and freedom of expression.
The results on the impact of considerate team leadership on team learning are
mixed. Edmondson and colleagues found that the availability of team leaders for
consultation with team members facilitated team learning both directly and indirectly
through creating a psychologically safe and supportive environment within the team
Cannon & Edmondson, 2001; Edmondson, 1999). Norrgren and Schaller (1999)
found that employee-centered leadership characterized by concerns for employees’
well-being was positively associated with perceived freedom, trust, idea support,
tolerance of uncertainty and diversity-based conflicts in the work climate, and
encouraged experimenting in team learning. However, they found that considerate
leadership did not encourage new product development members to speak up and
communicate with one another openly. Sarin and McDermott (2003) found that
considerate team leadership behaviors were not positively associated with team
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learning. Their explanation is that although the presence of a considerate team leader
might facilitate open and free intrateam information sharing, it might also result in a
learning-averse climate that prioritizes team cohesion at the price of constructive
conflicts, which are critical to effective team learning.
Furthermore, in their study of 6 cross-functional new product development
teams, Sarin and McDermott (2003) found that team leaders’ acts of defining the
procedures and daily activities of team members did not foster team learning,
suggesting a misfit between such behaviors and the innovative, highly uncertain
nature of the team task of new product development. These findings suggest that the
impacts of team leadership behaviors on team learning are contextual.
In their study of surgical team members in a European hospital, Helmreich
and Schaefer (1994) found that most surgical team members reported having
autocratic (“superior makes decisions and communicates them firmly, expects loyal
obedience and no questions.”) or mild autocratic team leadership (“superior makes
decisions promptly, but explains them fully, provides reasons to subordinates and
answers questions.”) (pp.23 8-239). The prevalence of these two types of leadership
styles might be partly explained by the hierarchical structure of the medical field
where leaders of surgical teams are selected primarily for their technical expertise
rather than for their leadership skills (Edmondson et al., 2001). In light with the
findings on team leadership and team learning, it might be speculated that the
predominance of these two leadership styles would have a negative impact on the
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learning experience of and the knowledge sharing practices of surgical team
members.
It has been suggested and documented that many Chinese business leaders
tend to exhibit paternalistic leadership behaviors: they display high degrees of
authoritarianism while showing benevolence to their subordinates (Bond, 1991; Farh
& Cheng, 2000; Fu, Peng, Kennedy, & Yukl, 2004, Redding, 1990; Tsui, Wang, Xin,
Zhang, & 2004). Such leadership style is attributed to Confucianism, particularly the
Confucian belief in the hierarchical nature of society. Therefore, although there is no
existing research on the leadership styles of surgical team leaders in China, it might
be expected that most leaders of Chinese surgical teams would also tend to exhibit
paternalistic leadership, which might be further reinforced by the fact that a
predominant percentage of Chinese surgical teams are led by male surgeons. The
impacts of these leadership behaviors on knowledge sharing in Chinese surgical
teams have yet to be examined.
Team Climate and Team Shared Beliefs. Having a learning-oriented team
climate marked by openness has been stressed by many researchers as critical to
successful team learning. There is a consensus among these researchers that most
learning behaviors in teams (e.g., discussing and analyzing mistakes and problems,
and raising questions) are potentially threatening and risky and that a non-punitive
climate characterized by mutual trust and care needs to be present to alleviate
people’s ego or image concerns (e.g., concerns about looking stupid, incompetent,
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and overly critical) that inhibit them from engaging in constructive team learning
behaviors (Cannon & Edmondson, 2001; Edmondson, 1996, 1999; Kasl et al., 1997;
Zarraga & Garcoa-Falcon, 2003).
In her study of 8 nursing units, Edmondson (1996) found that nurses in
nursing units with a non-punitive, open climate were more likely to report and
discuss medication errors than their counterparts in nursing units with a punitive
climate where people are blamed or punished for their errors. In her study of 51 work
teams in a manufacturing company, Edmondson (1999) found that the presence of
team psychology safety (i.e., “a shared belief held by members of a team that the
team is safe for interpersonal risk taking”), a product of effective team leader
coaching and supportive organizational context (e.g., having access to needed
resources and information), promotes team learning behaviors (e.g., seeking
feedbacks, and discussing mistakes and problems) (p.350). Using the same data from
Edmondson’s (1999) study, Cannon and Edmondson (2001) found that work groups
whose shared beliefs about failures are more learning-oriented (characterized by
greater tolerance of failure as well as direct and productive handling of failure) are
more likely to engage in constructive learning behaviors and to outperform those
whose beliefs are less learning-oriented (p.161)1 0 .
1 0 Cannon and Edmondson (2001) adopted a very broad definition of failure in their
study, ranging from small errors to misunderstandings that resulted from
communication breakdowns to interpersonal conflicts to major consequential
mistakes.
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Zarraga and Garcoa-Falcon (2003) proposed that perceived “high care” in a
work team promotes knowledge creation, transfer, and integration (CTI) within the
team. They described a high care team as one where members trust one another, are
willing to help one another, are considerate, are encouraged to experiment, and are
tolerant of mistakes and failures by other team members. In their study of 363
individuals working on teams at 12 large corporations in Spain, they operationalized
high care as a two-dimension variable: freedom of expression and mutual help. They
found that perceived mutual help within a work team facilitated knowledge transfer
and integration within the team and that perceived freedom of expression within a
work team was positively associated with knowledge creation within the team.
Kasl et al. (1997) also identified two team climate factors that facilitated team
learning: “appreciation of teamwork” (defined as the extent to which individual team
members value others’ views and contributions, cherish their team membership,
and identify with their team) and “individual expression” (defined as the degree to
which team members feel comfortable speaking up and the degree to which their
opinions are valued and could make a real difference in team decisions).
Team Composition. A few studies have examined the impact of team
composition on team learning (Ellis et al., 2003; Gibson & Vermeulen, 2003) in an
attempt to identify factors that facilitate or inhibit constructive learning behaviors in
teams. Effective team learning requires individual members to share information and
knowledge openly and to deal with conflicts arising from diversity constructively.
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Gibson and Vermeulen (2003) investigated how team heterogeneity and
“subgroup strength” (defined as “the degree of overlap across multiple demographic
characteristics among a subset of team members”) influence team learning (p.202).
They argued that a balanced team demographic composition (i.e., a relatively highly
heterogeneous team with moderately strong subgroups) is best conducive to team
learning in that the mix of demographic differences across subgroups and similarities
within subgroups allows team members to reap the benefits of diversity while
enjoying the cohesion and psychological support brought about by similarity. They
also proposed that members from teams composed of moderately strong subgroups
are more likely to interact with each other and to engage in learning behavior
(including “experimentation, reflective communication, and codification”) than
members from teams of very weak or very strong demographic subgroups. Their
study of 113 teams in 5 pharmaceutical and medical products companies confirmed
the hypothesized inverted U-shaped relationship between subgroup strength and
team learning behavior.
In their study of 109 interactive project teams, Ellis et al. (2003) found that
teams composed of highly agreeable members tend to display fewer learning
behaviors. They attributed this tendency to the fact that highly agreeable members
were less likely to share conflicting ideas with other team members and to critically
assess divergent opinions.
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Gibson and Vermeulen’s (2003) theory on subgroup strength and team
learning is highly relevant to the study of Chinese surgical teams in that it introduces
a more complex and broader concept of subgrouping than what is generally used in
the surgical team literature [i.e., subgrouping based only on functional background].
The functional background differences among surgeons, anesthesiologists, and
nurses might be mitigated by their similarities in other demographic characteristics
(e.g., age, team tenure, and sex) or further exacerbated by their differences in other
demographic characteristics. As suggested in Gibson and Vermeulen (2003), when
the functional background differences are further strengthened by differences in
other demographic characteristics, strong subgroup identification would emerge,
which would impede knowledge and information sharing between subgroups.
Furthermore, as the study of Ellis et al. (2003) suggests, the personality
composition of a team would influence the learning behaviors within teams. Thus, it
might be speculated that when demographic subgrouping overlaps with personality
distribution, the subgroup identification would be further enhanced. According to
Musson’s (2004) theory of professional personality differentiation, members of
professional groups tend to share a distinctive, profession-specific personality trait
profile that distinguishes them from other professional groups as well as the general
public. It is suggested that such professional personality differentiation results from
the Attraction-Selection-Attrition and socialization processes. It was found that
surgeons are more achievement striving, competitive, and dominant than
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anesthesiologists and nurses (Helmreich & Merritt, 1998). Another study of surgeons
and anesthesiologists from two European institutions found that (a) they were more
introverted than astronauts, pilots, and students (the normative group), (b) they were
higher on achievement striving than students, (c) gender differences existed between
male and female anesthesiologists1 1 , (d) anesthesiologists from the two institutions
differed significantly on conscientiousness and agreeableness1 2 , and (e) surgeons
from one institution were higher on achievement striving than anesthesiologists from
another institution (Musson, 2004).
The preliminary findings suggested that there might be significant personality
differences between the subgroups of surgical teams (Musson, personal
communication, July 28, 2004)l3, which somewhat overlaps with their functional
subgrouping.
1 1 The findings of the study showed that female anesthesiologists were higher on
expressivity (“interpersonal orientation”), neuroticism, and agreeableness, whereas
male anesthesiologists were higher on instrumentality (“goal and achievement
orientation”), bipolar instrumentality (“a bipolar scale with traditionally feminine
traits at one end and traditionally masculine traits at the other”), and mastery (a
desire to “undertake and master new and challenging activities”) (p. 12).
i 'j
Musson (2004) explained that it was possible that the detected differences between
anesthesiologists from the two institutions might partly result from organizational
influences.
1 T
Musson (personal communication, July 28, 2004) observed, “There is some
indication that significant differences exist between specialties in medicine, which is
in keeping with my experience and the experience of other physicians.”
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Knowledge and Information Sharing in Teams
Team Structure. It has been found that in heterogeneous-status groups, higher
status members tend to dominate group discussions where their opinions carry more
weight, whereas lower status members tend to contribute less to group discussions
(Berger, Rosenholtz, & Zelditch, 1980; Ridgeway & Berger, 1986; Smith-Lovin,
Skvoretz, & Hudson, 1986; Thomas-Hunt, Ogden, & Neale, 2003). This
phenomenon has been attributed to the differential performance expectations for
members with varying status: higher status members are expected to have more
valuable things to share that could facilitate the accomplishment of the group’s task
(Ridgeway & Berger, 1986). This impact of perceived presence of status hierarchy on
group information processing is particularly relevant to the study o f knowledge
sharing in surgical teams where great status differentials have been documented
among group members.
Research on transactive memory (TM) suggests that groups with stronger TM
systems manage knowledge more effectively and more efficiently than groups with
weaker TM systems (Austin, 2003; Hollingshead, Fulk, & Monge, 2002; Lewis,
2003; Liang, Moreland, & Argote, 1995; Moreland & Myaskovsky, 2000; Moreland,
Argote, & Krishnan, 1996). It has been proposed that in a TM system, members
specialize in different knowledge areas, stay up-to-date on the system’s expertise
distribution, allocate incoming information to members with the matching expertise,
and retrieve information from members with the needed expertise. It has been
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suggested that group members who share and have accurate knowledge about
expertise distribution (e.g., task-related expertise and knowledge of group members’
relationships to relevant non-group members) can contribute to efficient knowledge
encoding, storage, and retrieval, which in turn promotes group performance (Austin,
2003; Hollingshead, 1998; Lewis, 2003; Liang et al., 1995; Moreland &
Myaskovsky, 2000; Team stability has been suggested to contribute to the formation
of strong TM systems (Moreland & Myaskovsky, 2000).
Surgical teams are promising sites where TM systems might be developed
and sustained. The three subgroups of surgeons, anesthesiologists, and nurses have
their respective well-defined expertise areas. Their effective coordination inside and
outside the operating room requires them to keep track of the expertise distribution,
allocate relevant received information (e.g., the patient’s vital signs during the
operation) to the right team member, and retrieve the needed information from the
team member with the matching expertise. However, most Chinese surgical teams
are characterized by some degree of membership instability, particularly in their
anesthesiologist and OR nurse membership. Depending on their membership
stability, Chinese surgical teams might develop different degrees of transactive
memory systems, which might in turn influence their knowledge sharing.
Researchers have suggested that teams whose members have shared mental
models o f key features of their work environments (e.g., task, technology, roles and
responsibilities, strategies, goals, member expertise and personalities) coordinate
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more smoothly than teams without shared mental models because their shared mental
models enable them to form accurate predictions of their teammates’ actions and
needs, including their information and knowledge needs (Cannon-Bowers, Salas, &
Converse, 1993; Klimoski & Mohammed, 1994; Kraiger & Wenzel, 1997; Mathieu,
Heffner, Goodwin, Salas, & Cannon-Bowers, 2000; Mohammed & Dumville, 2001).
Their shared mental models allow them to push needed information and knowledge
to their teammates before being asked. Depending on their membership stability,
Chinese surgical teams might develop different degrees of transactive memory
systems, which might in turn influence their knowledge sharing.
Team Stability. Research on group information processing suggests that team
stability generates familiarity and enhances relationship building among team
members, which in turn facilitates knowledge and information sharing within the
team (Shah & Jehn, 1993). Familiarity among group members has been found to
make it easier for members to express divergent opinions regarding the team task
(Shah & Jehn, 1993). It has been shown that people are more likely to respond to a
request for knowledge help from someone they know (Ives, Torrey, & Gordon,
2000).
Research on transactive memory in groups indicates that members who work
together longer tend to share and have accurate knowledge about expertise
distribution within the group, which enables them to allocate and retrieve
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information more efficiently (e.g., Austin, 2003; Hollingshead et al., 2002; Lewis,
2003; Liang et al., 1995; Moreland & Myaskovsky, 2000; Moreland et al., 1996).
Compared with members in less stable teams, members in stable teams have
been suggested to be more likely to develop shared mental models, which allow
them to share information and knowledge more effectively and more efficiently.
As described earlier in Chapter 1, most surgical teams at Chinese public
hospitals are composed of a relatively stable surgeon subgroup, and less stable
anesthesiologist and OR nurse subgroups. The relative stability and instability of the
various constituting subgroups of surgical teams are expected to have a great
influence on their knowledge sharing patterns. This influence is to be explored later
in this study.
National Culture. Drawing heavily on the cross-cultural communication
literature, Huang (2003) explicated the impacts of cultural variability dimensions of
individualism/collectivism, power distance, and orientation to time on people’s
knowledge sharing intentions and behavior within newly formed multinational
teams. She proposed that such impacts are contingent on many contextual factors,
such as the nature of knowledge to be shared, and the relative status of the
knowledge recipient and of the knowledge source. Although her theorizing is
exclusively confined to newly formed multinational teams, the line of reasoning
underlying her exploration of the influences of power distance and individual self
construal (particularly the interdependent self construal that views self as connected
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to others with whom one is interdependent in specific situations) on people’s
knowledge sharing intentions and behaviors in multinational teams has great
relevance to this present study of knowledge sharing in Chinese surgical teams in
that it highlights the important role of certain cultural traits or characteristics in
shaping the knowledge sharing intention and behaviors of people in certain
situations.
The impacts of Chinese cultural values on Chinese surgical team members’
knowledge sharing attitudes, intentions, and behaviors will be explored later in this
study.
Knowledge Sharing Within and Between Organizations
Much more is known about knowledge sharing and transfer within and
between organizations compared to what is known about knowledge sharing within
teams. Researchers from many disciplines (e.g., management, communication, and
psychology) have examined knowledge sharing and transfer through multiple lenses:
the culture lens (e.g., De Long & Fahey, 2000; Husted & Michailova, 2002), the
social networks lens (e.g., Hansen, 1999, 2002; Tsai, 2001), the relational lens (Uzzi
& Lancaster, 2003), the transactive memory and public goods lens (Hollingshead et
al., 2002), and the expectancy lens (Kalman et al., 2002). They have investigated the
impacts of numerous organizational properties (e.g., organizational culture,
organizational structure, and organizational incentive systems), relationship
properties (e.g., dyadic relationship and network ties), unit properties (e.g., unit’s
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absorptive capacity), individual properties (e.g., organizational commitment,
organizational instrumentality belief, connective efficacy, information self-efficacy,
absorptive capacity, and willingness to accept knowledge transferred), and the nature
of knowledge (e.g., tacit/explicit knowledge, unique/shared knowledge,
private/public knowledge, and mistakes and failure) on knowledge sharing and
transfer (See Argote, McEvily, & Reagans, 2003 for a detailed review). Figure 2.1.
summarizes the current state of knowledge in this area.
As will be explained in greater detail in the following pages, some of the
existing research findings from this body of literature could greatly inform the
theorizing and investigation of knowledge sharing in Chinese surgical teams.
Surgical teams, like other types of teams, are embedded in organizations. The
knowledge sharing within and across surgical teams is expected to be influenced by
important organizational characteristics, including organizational culture,
organizational structure and systems.
Organizational Culture
Research has suggested that trust-based, cooperative, learning-oriented
organizational culture is more conducive to knowledge sharing across teams, units
and departments than low-trust, competitive, blame-oriented organizational culture
(e.g., Ahmed et al., 2002; De Long & Fahey, 2000; Husted & Michailova, 2002;
Orlikowski, 1993). High levels of organizational trust, trust in the knowledge source,
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J i
Nature of
knowledge
Relationship factors
Network tie
Dyadic relationship
Organizational knowledge
sharing (or transfer)
Inter-unit (or cross-functional)
Intra-unit
National culture
Individualism/Collectivism
Power distance
Organizational Factors
Organizational culture
Organizational structure
Organizational incentive
systems
Individual or unit factors
Organizational commitment
Connective efficacy belief
Absorptive capacity
Identification (team, unit, or
professional)
Unit culture or functional culture
Figure 2.1. Knowledge Sharing Within and Between Organizations
and trust in the knowledge recipient encourage people to share knowledge with
others and to accept knowledge contributed from others by reducing the perceived
risks and uncertainty involved in knowledge sharing (e.g., interpersonal risks
involved in the admission of one’s mistakes, doubt regarding the value of others’
knowledge, and uncertainty about others’ use of one’s knowledge). In learning-
oriented organizations, management accepts the unavoidable nature of mistakes and
failures, stresses them as valuable sources of learning opportunities, and encourages
people to discuss, analyze, and learn from them. In contrast, in blame-oriented
organizations, mistakes and failures are taboo topics for discussion, and are covered
up to avoid punishment (Husted & Michailova, 2002).
The healthcare industry has been described as an anti-learning industry that
has a culture of shame, blame, and silence (Senge, 1990). Researchers have shown
that many hospitals suffer from blame-oriented, punitive organizational culture that
encourages the covering up of errors, mistakes, and problems (Edmondson, 1996;
Johnson, 1997; Tucker & Edmondson, 2003; Waldman, Smith, & Hood, 2003;
Waldman, Yourstone, & Smith, 2003; Weick & Sutcliffe, 2003). The lack of a
supportive, psychologically safe organizational culture to mitigate healthcare
professionals’ fears of litigation, of face loss, and of professional damage as well as
the professional norms of non-criticism has led to the concealment of errors and
failures (e.g., Tucker & Edmondson, 2003; Etchells et al., 2003; Rosenthal, 1995;
Studdert et al., 2002). Furthermore, the healthcare industry norm on personal
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autonomy and vigilance for medical professionals has been found in some cases to
work against hospitals, hindering them from learning from problems and errors
encountered and committed by their employees (Tucker & Edmondson, 2003; Weick
& Sutcliffe, 2003; Walton, 2004).
Anecdotal evidence suggests that most Chinese public hospitals also suffer
from the culture of shame, blame, and silence (Gu, 2004). The suppression effect of
such culture is expected to show up, to varying degrees, in the knowledge sharing
behaviors of Chinese surgical team members, especially knowledge sharing between
surgical teams and knowledge sharing between surgeons and anesthesiologists and
OR nurses.
Units or functions might hold different beliefs about knowledge and
knowledge sharing (e.g., what counts as knowledge, what is the appropriate medium
to share knowledge, and what knowledge is okay to share). Such sub-cultural
differences have been suggested as hindering cross-unit or cross-functional
knowledge sharing (De Long & Fahey, 2000). For instance, Waller, Gibson,
Carpenter, and Conte (2003) proposed that different time perspectives between teams
slow down interteam knowledge sharing. Since Chinese surgical teams are composed
of members from different departments, department cultural differences might hinder
interdisciplinary knowledge sharing within the teams.
Organizational Structures and System
Organizational Structure. It has been suggested that organic organizational
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structures that are marked by high autonomy and flexibility (e.g., open, participative,
non-hierarchical, and flat structures) facilitate knowledge sharing and transfer,
whereas mechanistic structures (e.g., hierarchical, closed, divisional, and centralized
structures) inhibit knowledge sharing and transfer (e.g., Ahmed et al., 2002; Nonaka,
1994; Osterloh & Frey, 2000). Chinese public hospitals still use a hierarchical,
divisional structure: surgeons are affiliated with the surgical department whereas
anesthesiologists and operating room nurses are affiliated with the Anesthesia
Department. It might be speculated that such divisional structure would inhibit
knowledge sharing and transfer across departments.
Organizational Reward System. The consensus among researchers is that
organizations should provide sufficient incentives for units and individuals involved
in knowledge sharing and transfer. Many researchers have stressed that intrinsic
motivation is crucial for transferring tacit knowledge (Husted & Michailova, 2002;
Jarvenpaa & Staples, 2001; Nahapiet & Ghoshal, 1998; Osterloh & Frey, 2000).
They have pointed out that extrinsic motivators might have crowding-out effects:
individual performance rewards might inhibit knowledge sharing and transfer in
organizations because they create a competitive environment that is hostile to
knowledge sharing and transfer. Rather, they have suggested that organizations use
recognition rewards to foster intrinsic motivation among individuals. It has been
suggested that the reward system at many Chinese public hospitals fail to provide
surgical team members with adequate incentives to share knowledge with their junior
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teammates and peers on other teams (Gu, 2004). It is important to take into account
the influence of hospital reward system when understanding knowledge sharing in
Chinese surgical teams. A detailed review of the reward systems at Chinese public
hospitals will be covered later in this chapter.
Network Ties
The studies show that the impact of network ties on knowledge sharing and
transfer are contextual: it varies with the type of knowledge to be shared or
transferred. Some researchers have shown that strong, cohesive network ties
facilitate the transfer of highly complex (tacit and systemic) knowledge and private
knowledge, within and between organizations (Hansen, 1999, Szulanski, 1996, 2000;
Uzzi & Lancaster, 2003). Other researchers have shown that weak ties speed up the
search and transfer of codified knowledge (Hansen, 1999, 2002).
It has been demonstrated that knowledge flows and transfers more easily
among entities (e.g., individuals, teams, units, and organizations) that are similar
and/or are embedded in a social network or superordinate relationship (e.g., chain,
franchise, strategic alliance) than among independent entities (Baum & Ingram,
1998; Borgatti & Cross, 2003; Darr & Kurtzberg,, 2000; Darr, Argote, & Epple,
1995; Reagans & McEvily, 2003). People accord greater credibility to information
from others who are similar (e.g., Tsui & O'Reilly, 1989).
The impacts of network ties on knowledge sharing in Chinese surgical teams
are yet to be explored. Strong network ties might increase the likelihood of sharing
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risky and face-threatening knowledge (e.g., failures and mistakes) within and
between surgical teams. Tacit knowledge might be shared more among surgical team
members with a strong network tie than among those with a weaker tie. It might be
speculated that knowledge sharing occurs more frequently between surgical teams
that belong to the same department than between surgical teams that belong to
different departments.
Individual or Unit Properties.
Researchers examining the properties of individuals and units focus on their
ability and motivation to share knowledge and to use the knowledge learned from
other individuals or units. For example, Szulanski (1996, 2000) found that the lack of
absorptive capacity of the recipient unit greatly impeded effective transfer of best
practices across units. Kalman et al. (2002) found that individuals’ organizational
commitment and connective efficacy belief (a belief that their shared knowledge will
reach those who need it) predict their contributions of discretionary information to
database. It has been suggested that when individuals identify more strongly with
their own teams or units than with their organization, they are less likely to transfer
or accept knowledge from other teams or units (Argote & Ingram, 2000; Husted &
Michailova, 2002).
Surgical team members are affiliated with multiple entities (e.g., the surgical
team, their department, their hospital, and their profession). Their differing degrees
of identification with these entities would greatly affect their knowledge sharing
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behavior. For instance, a surgeon who is more identified with his or her team than
with his or her department is less likely to share knowledge with an outside team
member within his or her department than a surgeon who is more identified with his
or her department than with his or her team. Furthermore, it might be speculated that
the lack of absorptive capacity of a recipient entity (e.g., a surgeon, or a surgical
team) inhibits successful knowledge sharing.
National Culture
The theorizing of the influence of national culture on knowledge and
information sharing is still in its infancy (Chow, Deng, and Ho, 2000; Chow,
Harrison, McKinnon, & Wu, 1999; Chow, Hwang, Liao, & Wu, 1998; Huang, 2003;
Hutchings & Michailova, 2004; Michailova & Husted, 2003). Hofstede’s (1980,
1991, 2001) cultural variability dimensions of individualism-collectivism (the extent
to which individuals value individuals’ goals and interest over groups’ goals and
interest) and power distance (“the extent to which less powerful members of
organizations and institutions accept and expect that power is distributed unequally”)
(Hofstede, 2001, p. xiv) have been invoked to explain and predict contextual
variation in the knowledge sharing attitudes and behaviors of people from cultures
that differ on these two dimensions. Some researchers have also explored the
knowledge sharing behaviors of people who are from cultures with different time
orientations (past orientation, present orientation, and future-orientation as proposed
by Kluckhohn and Strodotbeck in 1961) (Huang, 2003). For example, Hutchings and
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Michailova (2004) explored how the strong in-group/out-group distinction (a
distinctive feature of a collectivistic culture) and the reliance on personal networks
(blat in Russia and guan xi in China) in the Russian and Chinese cultures would
facilitate people’s knowledge sharing with in-group members and people inside their
personal networks but impede people’s knowledge sharing with out-group members
and people outside their personal networks.
A few empirical studies have provided some preliminary support for the
contextual impacts of national culture on people’s willingness to share knowledge.
Using a student sample, Chow et al. (1998) found that Taiwanese (people from a
culture that is suggested to be significantly higher on collectivism and be greatly
concerned with face) made smaller distortions when communicating private
information to superiors in a resource-allocation setting than their US counterparts.
In their study o f middle-level Taiwanese (a culture higher in collectivism and with
greater face concern) and Australian managers in manufacturing firms, Chow et al.
(1999) found that Taiwanese managers were more likely to ask a clarifying question
in a meeting whereas Australian managers were more likely to express a challenging
opinion in a meeting. However, they failed to find any significant differences
between these two groups of managers regarding their likelihood of revealing a
previous personal job-related mistake in a meeting. In their study of knowledge
sharing intentions of PRC and US managers, Chow et al. (2000) found significant
differences between PRC (a culture claimed to be high in collectivism) and US
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managers (a culture high in individualism) only when the knowledge to be shared
entailed a self/collective interest. More specifically, PRC managers were found more
willing to share knowledge that threatened their self-interest but benefited their
company than US managers but less willing to share such knowledge with out-group
members than US managers.
This literature has great bearings on the knowledge sharing in Chinese
surgical teams in that it highlights the potential influence of national culture on
people’s knowledge sharing behaviors in certain contexts.
Chinese Surgical Teams
As I argued in Chapter I, the examination of knowledge sharing in surgical
teams at Chinese public hospitals should take into account their relevant social,
cultural, and historical contexts. In this section, I review the Chinese cultural
behavior literature, the line of research on training of health professionals in the
Chinese medical and nursing education systems, and the human resource policies of
Chinese public hospitals, which are prerequisite to understanding knowledge sharing
in Chinese surgical teams.
Training o f Health Professionals in the Chinese Medical and Nursing Education
Systems
As the topic of this study is knowledge sharing in Chinese surgical teams, a
short review of the literature on the clinical teaching and learning practices of
surgical team members at Chinese hospitals is in order. As the two hospitals chosen
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for this study include one Ministry of Health public hospital and one military
hospital (or the People’s Liberation Army hospital), the literature review focuses on
these two types of hospitals. An integral part of the literature comes from the
policies, rules, and regulations formulated and published by the Ministry of Health,
Health Bureaus at various administrative levels (e.g., Provincial Health Bureaus,
City Health Bureaus, District or County Health Bureaus), Health Department under
the General Logistics Department of the PLA, and individual hospitals1 4 .
Under the current Chinese medical and nursing education systems, the training of
health professionals (including physicians, nurses, pharmacists, and technicians)
comprises three stages: (a) basic education in medical educational institutions (e.g.,
medical universities or colleges or secondary medical schools), (b) postgraduate
education, and (c) continuing education (CE) (Chinese Ministry of Health, June
2004b).
Basic Education in Medical Education Institutions. Under the current
medical education system, physicians are trained in the following programs: (a)
vocational training programs in secondary medical schools and certificate-oriented
programs in some medical colleges (both are 3-year programs where most of their
graduates are expected to practice in rural areas), and (b) degree-oriented 5-year
programs (leading to a bachelor’s degree), 7-year programs (leading to a master’s
The Chinese government and its various administrative agencies still retain control
over the personnel policies of public hospitals (e.g., employee salary levels, employ
hiring and promotion) (Gu, 2004; Pei, Legge, & Stanton, 2002).
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degree), and 8-year programs (leading to a doctor’s degree) (Ba, 2001; Deng, 1999;
Gao, Shiwaku, Fukushima, Isobe, & Yamane, 1999; Schwarz, Wojtczak, & Zhou,
2004; Wang & Lin, 1995). According to the Practicing Physician Law passed in
1998, (a) graduates of 5-, 7-, and 8-year programs are qualified to sit for the National
Physician Licensure Exam after one year’s probation, and (b) graduates from
secondary medical schools and certificate-oriented 3-year programs are qualified to
sit for the National Physician Assistant Licensure Exam after one year’s probation
and later to sit for the National Physician Licensure Exam when they have met the
required minimum years of working experience (5 years’ working experience for
graduates from secondary medical schools and 2 years’ working experience for
graduates from certificate-oriented 3-year programs).
A predominant percentage of registered nurses in China are trained in secondary
vocational nursing programs (2-to-3 year curriculum for high school graduates and
3-to-4-year curriculum for junior high school graduates) (Chan & Wong, 1999;
Chang, 1999; Xu, Xu, & Zhang, 2000). According to the Chinese Ministry of
Education and the Chinese Ministry of Health (2003), about 85% of the 1.2 million
nurses in China are graduates of secondary programs. A small but increasing
percentage of registered nurses in China are trained in postsecondary programs:
zhuan ke programs (3-year programs, equivalent to the associate degree programs in
the United States), baccalaureate programs (5-year curriculum), masters’ programs
(3-year curriculum), and doctoral programs (5-year programs) (Chan & Wong, 1999;
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Chang, 1999; Xu et al., 2000)1 5 . According to the Regulation of Nurses in the
People’s Republic of China (1993) published by the Ministry of Health, only
graduates of secondary and associate degree programs are required to sit for the
National Nursing Licensure Examination (NNLE), while graduates of baccalaureate
programs are automatically accorded the licenses to practice as Registered Nurses
(RNs). Graduates of secondary and associate degree programs are qualified to sit for
the NNLE when they have a minimum of one year’s working experience. The
licenses are renewed every two years (Wong, Chan, & Yeung, 2000). As of 1997,
this regulation also applies to graduates in the PLA system (Chinese Ministry of
Health & Health Department, General Logistics Department of the PLA, 1997). The
amount of the clinical training one receives is directly associated with the length of
the program that one is enrolled in1 6 . Although internships and clerkships are an
China has seen a rapid growth in the number of post-secondary nursing
educational programs since 1983 when the reinstatement of the first baccalaureate
nursing program ended a 30-year closure of collegiate nursing programs (Xu, Xu,
Sun, & Zhang, 2001). According to the 2003 research report entitled “Opinions on
the Nursing Human Resources in China and the Strengthening of the Training of
Urgently Needed Nursing Personnel” issued by Chinese Ministry of Education and
Chinese Ministry of Health, the current enrollment of students in various nursing
education programs is as follows: 128 (graduate programs), 22457 (baccalaureate
programs), 68566 (associate degree programs), and 282400 (secondary programs). It
is forecasted that, by 2010, the distribution of the enrollment of nursing students in
China would be as follows: secondary nursing programs (50%), associate degree
programs (30%), and baccalaureate programs or higher degree programs (20%).
1 6 According to Schwarz et al. (2004), a student o f a typical 7-year program receives
2 years of clinical skills training through clerkship or internship whereas a student of
a typical 5-year program receive about 1 year’s training. A student of a typical 8-year
program receives 3 years’ clinical training.
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integral part of the curriculum for medical and nursing students in China, most of
these programs are not well developed. The quality of the teaching and training
offered by these programs varies a lot. The transient relationships between students
and their clinical teachers lead to the lack of continuity in their training. Furthermore,
in many cases, students receive little constructive feedback or supervision from their
i n
teachers who are often in charge of a large group of intern students . The line of
research on the clinical training of medical and nursing students in China suggests
the lack of commitment and the lack of adequate teaching training of clinical
preceptors as one o f the primary reasons for the deteriorating quality of such training
(Chen & Qiang, 2001; Li, 2004). It has been reported that many preceptors tend to
devote most of their time and energy to their own learning and research in addition to
their clinical work at the price of clinical teaching since they themselves are only a
few years out of medical schools and are in a critical stage o f their careers where
learning takes up a huge chunk of their time (Zhao & Ye, 2003). Another reason
proposed for the worsening quality of clinical training of medical students is that the
increasing fear of litigation has resulted in the reluctance o f many physicians to let
medical students participate in patient treatment, since under the current Chinese
1 7 At the MOH hospital chosen for this study, it is stipulated that a preceptor can only
be in charge of a maximum of 15 students at a time and that only senior residents
(residents in their fourth year) or physicians with a higher professional title can serve
as a preceptor (in most cases senior residents are charged with the teaching
responsibility). Both measures are aimed at enhancing the learning experiences of
students.
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legal system, the clinical preceptors are held accountable for mistakes committed by
medical students under their supervision (Chen & Zhu, 2003). Furthermore, many
patients refuse to letmedical students perform procedures on them in the belief that
they are more susceptible to suffering when being treated by these inexperienced
students compared with being treated by experienced medical professionals. This in
turn results in fewer learning opportunities for medical students (Chen & Zhu, 2003).
The third major reason suggested is the lack of enthusiasm and commitment on the
part of many medical and nursing students in clerkship or internship (Zhao & Ye,
2003). Many medical students, particularly those in the pre-graduation internship
programs, prioritize preparing for the graduate program entrance exam or job
hunting over learning (Zhao & Ye, 2003). Recently some efforts have been made to
improve the teaching skills of clinical preceptors by providing them with
pedagogical training (Chen & Zhu, 2003; Yuan, Zhu, Xian, & Yang, 2002; Zhang,
2004; Zhang, Wang, & Gao, 2003; Zhao & Ye, 2003). Some teaching hospitals have
begun to provide special teaching subsidies to better motivate clinical preceptors
(Chen & Zhu, 2003). However, much more has yet to be done.
Postgraduate Education. Although graduates of medical and nursing
education programs in China have received some clinical training at school, a huge
part of their clinical training occurs at work after their formal employment at health
care organizations (e.g., hospitals and township health centers).
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Compared with the clinical training medical and nursing students receive
during clerkship and internship, the in-service clinical training they receive as part of
their postgraduate education is better organized and more systematic, and is of higher
quality. In China, hospitals design their own postgraduate training programs for
medical and nursing graduates on the basis of the directives or regulations issued by
the relevant administrative agencies. Although MOH hospitals, PLA hospitals, and
industrial hospitals are under the administration of different agencies, there is a great
overlap in the directives that they receive from their own administrative agencies.
The postgraduate training focuses on three areas: basic professional knowledge,
basic specialty theories, and basic professional skills (known as “three basics”
training in China). The length and the content of the postgraduate training programs
vary with the academic degree of medical and nursing graduates. In a typical public
hospital in China, the residency training programs for residents with a master’s
degree or a doctor’s degree tend to be much shorter, more flexible, and more
individualized than those for residents with an associate’s degree (7-year residency)
1 8
or a bachelor’s degree (5-year residency) (See Appendix B for a detailed
description of the residency program at the MOH hospital under study).
The postgraduate training for nurses follows a similar format: nursing
Graduates with a master’s or doctor’s degree who have the professional title of
physicians in charge are exempt from residency training and are required to receive
continuing medical education.
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graduates of different educational level receive different training programs. The
training is 5 years (or 6 years in some cases) for nursing graduates with a secondary
degree, 3 years for those with an associate degree, and 1 year for those with a
bachelor’s degree. The postgraduate residency training for graduates with an
associate degree or a bachelor’s degree is much more rigorous and more
comprehensive than the postgraduatetraining for graduates with a master degree or a
doctor’s degree, which is attributed to the long-term nature of the training and the
longer history of these residency training programs (Zhang et al., 2003). Some
researchers have questioned the adequacy of the shorter residency training for
graduates with a master’s or a doctor’s degree, criticizing that the short training does
not given them sufficient opportunities to hone their clinical skills, especially when
considering the fact that most of them have received very little clinical training or
training on clinical diseases during their graduate education (Zhang et al., 2003)1 9 .
Unlike medical and nursing students in internship or clerkship, residents and
nurses, as formal employees of hospitals, are fully integrated into the patient
treatment process. Residents are assigned to medical care teams, work closely with
senior physicians, and are granted certain practice opportunities that correspond to
1 9 The graduate programs at most Chinese medical universities or schools used to
have a very strong laboratory research orientation. Most of the training one receives
in graduate education focuses on basic laboratory research. This has resulted in the
frequently observed problem of poor clinical skills on the part o f junior physicians
with a graduate degree. The past few years have seen the creation of clinical-oriented
graduate programs, which is aimed at solving this problem (Zhang et al., 2003).
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their seniority20.
There is a huge body of literature on the postgraduate training of residents
and nurses. These empirical studies have established the linkage between rigorous
postgraduate training and many positive outcomes, including but not limited to,
improved mastery of both theoretical knowledge and practical skills, reduced error
incidence, improved patient satisfaction, improved learning attitudes, and more
publication (Pi, Zhang, Yang, & Zheng, 2004; Sun, Su, & Shi, 2003; Tu & Fang,
1995; Wang, 1995; Wang & Chen, 2002; Yuan et al., 2002).
However, it has been reported that many senior physicians and nurses are not
well motivated to train residents and regard the teaching as an extra add-on, which is
mainly attributed to the prevalent promotion system at most public hospitals that
stresses one’s research achievements and ignores one’s teaching performance (Zhao
& Ye, 2003). As most public hospitals do not have a rigorous teaching quality
assessment system, it makes little difference whether one performs well or poorly in
one’s teaching. Therefore, many senior physicians and nurses tend to devote their
most of their limited time and energy to their own research in addition to their
clinical work, since the research achievement assessment system is much more
-----------------------------------------
For example, junior residents are allowed to perform surgical operations of minor
technical difficulty and involving simple procedures (or more exactly, Grade-D
surgical operations under the surgical operation classification system stipulated by
the provincial health bureau) under the supervision of senior surgeons. Senior
residents are allowed to perform operations of intermediate technical difficulty and
involving uncomplicated procedures (Grade-C surgical operations) under the
supervision of senior surgeons.
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rigorous (Zhao & Ye, 2003).
Continuing Education. At public Chinese hospitals, health professionals
(including surgeons, anesthesiologists, and nurses) must earn a minimum number of
continuing education (CE) credits every year21. The policies regarding CE for health
organizing CE activities (e.g., hospital-run seminars or conferences, and grand ward
professionals are made by the CE department at relevant health administrative
agencies and generally follow a similar format, though the specifics vary across the
country (Edwards, Hui, & Xin, 2001). Most hospitals have a CE department that is in
charge of rounds run by multiple departments). The implementation of the CE
policies varies with hospitals (Zhu & Gao, 2002). However, there is an increasing
trend, among Chinese hospitals, of tying a health professional’s CE closely to his or
her performance appraisal, employment, promotion, post assignment, and licensing
(See Appendix C for details about the CE programs at the MOH hospital and the
PLA hospital under study).
The implementation of the CE policies at Chinese public hospitals has been
shown to be associated with some positive individual learning outcomes (e.g.,
improved mastery of clinical skills and theoretical knowledge, more publication, and
more positive learning attitudes) and some organizational outcomes (e.g., improved
2 1 According to the “Tenth Five-Year Plan for Continuing Medical Education” issued
by the Ministry of Health in June, 2004, the primary objective of the CE initiative is
to expose health professionals to the new theories, new knowledge, new technology,
and new methods that have been developed or are being developed in the medical
field, focusing on advanced, relevant, and practical materials.
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patient satisfaction) (Edwards et al., 2001; Ma, Lu, & Zhang, 1997; Pan, Mei, Xiao,
& Wang, 1997; Tu & Fang, 1995; Xu & Han, 1997; Wang, 1995). Furthermore,
these CE programs contribute to more knowledge sharing among hospital
departments and hospitals. However, many researchers have questioned the quality
of these CE programs, suggesting that the lack of sound program monitoring and
appraisal systems has resulted in many low-quality programs, particularly those
programs run by individual hospitals (Cai & Wang, 2003; Li, 2001; Zhu & Gao,
2002).
The above reviewed literatures have improved our understanding of the
training and learning of medical and nursing students, physician trainees and nursing
trainees, and senior physicians and nurses at Chinese public hospitals. However,
since these literatures primarily focus on one-way knowledge transfer from senior
members to junior members and future members within the professional groups of
surgeons, anesthesiologists, and nurses, they provide little insight on how surgeons,
anesthesiologists, and nurses share and transfer knowledge with their colleagues of
the same seniority within their specialty, not to mention how they share knowledge
with colleagues from other specialties. These questions will be explored later in
Chapter III.
Human Resources Policies at Chinese Public Hospitals
According to the “Guiding Opinions on the Reform of the Urban Health Care
System” issued by China’s Ministry of Health and other 6 ministries in 2000,
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Chinese public hospitals are not-for-profit institutions (or Public Service Units) that
are owned by the Chinese government. Although Chinese public hospitals have been
granted increased autonomy as a result of the health care system reforms initiated by
the Chinese government since 1980s, many aspects of their operation are still, to a
great extent, controlled by the government, including but not limited to their
personnel management, their service pricing, and the compensation of employees
(Pei et al., 2002; Tang, 2003). Many Chinese public hospitals are overstaffed and
have a disproportionately large logistics staff, which negatively impacts their
efficiency and productivity (Gu, 2004).
Employee Incentive System. It is widely acknowledged that the salaries of
physicians (including surgeons and anesthesiologists) and nurses at public hospitals
in China are much lower than those of their counterparts at non-public hospitals in
China (including private hospitals, joint venture hospitals, and foreign-funded
hospitals), not to mention those of their counterparts in developed countries and
many other developing countries (Pei et al., 2002). According to Gu (2004), the
average annual salary income of a health care professional in the public health sector
in 1999 was 9,896 RMB yuan (about $1,207), which was slightly over the overall
average annual salary income for all occupational groups - 8,346 RMB yuan ($
1,018). It has been repeatedly pointed out that the low salary of health care
professionals is not proportional to the highly risky and highly knowledge intensive
nature of their work (Gu, 2004).
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The salary of a health professional in the public service sector comprises two
major parts: the professional post grade salary (stipulated by the government and
universal across China) and the subsidy salary. Under the current professional post
salary grade system, professional posts of physicians and nurses fall into five grades,
each of which is further divided into 11 to 16 steps. The five grades are as follows:
(a) posts of chief physicians and of chief senior nurses, (b) posts of assistant chief
physicians and of assistant chief senior nurses, (c) posts of physicians in charge and
of senior nurses in charge, (d) posts of physicians and senior nurses, and (e) posts of
physician assistants and of nursing assistants. Table 2.1. presents the latest monthly ..
salary rate by professional post grade and step for health professionals that was
stipulated by the Chinese Ministry of Personnel and Ministry of Finance in 2001. As
the table indicates, the post grade salaries for nurses in China are the same as those
for physicians.
Unlike the fixed professional post grade salary, the subsidy part of a health
professional’s salary is flexible and is under the control of individual hospitals. The
subsidy salary a health professional receives is mainly tied to his or her professional
post, his or her tenure, the grade of and the location of his or her institution, and
sometimes his or her performance (Gu, 2004). For instance, nurses in public Chinese
health care institutions receive a special subsidy called hu ling (i.e., the number of
years one has worked as a nurse). Surgeons at most hospitals receive surgical
operation subsidy, the amount of which is directly tied to the difficulty of the
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Table 2.1. Salary Rate by Professional Post Grade and Step for Health Professionals
_____________________________________________________________ Unit: RMB yuan per month
Professional
Post Grade
Professiona Post Salary
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Chief
physicians
and chief
senior nurses
880 945 1010 1090 1170 1250 1330 1410 1490 1570 1650
Assistant
chief
physicians
and assistant
chief senior
nurses
643 686 729 772 815 870 925 980 1035 1090 1145 1200 1255 1310
Physicians
in charge
and senior
nurses in
charge
481 508 535 562 589 626 663 700 737 774 811 848 885 922 959 996
Physicians
and senior
nurses
392 410 428 454 480 506 532 558 584 610 636 662 688 714 740 766
Physician
assistants
and nursing
assistants
346 361 376 398 420 442 464 486 508 530 552 574 596 618
Notes: According to the Ren Xin Fa [1988] File No.22, the salary rate o f nursing assistants should be raised by 10%.
Source: On the Implementation o f the Adjustment o f the Salary Standards o f Employees o f Public Service Units (Chinese
Ministry o f Personnel and Ministry o f Finance, 2001, February 8)
- j
o
operation and one’s role in the operation (e.g., head surgeon, the first assistant, or the
second assistant) (Xu, Fu, Yang, & Zhu, 2003). A greater percentage of the operation
charge is allocated as for subsidies for major operations than for minor operations.
Head surgeons receive a higher percentage of the subsidy than first assistants and
second assistants.
Medical and nursing graduates joining a hospital are assigned to a grade,
depending on their educational level and/or previous working experience. In cases
where the graduate has no previous working experience, he or she starts at the
minimum step of the assigned grade, and receives one step increase within the grade
every two years provided that he or she passes the appraisals (including ongoing
appraisals and the annual appraisal). He or she remains within the grade until he or
she has passed the qualification exam or the review for the next higher grade
professional title, and is assigned to a corresponding post.
The salary program used in Chinese hospitals is a hybrid longevity/merit
system: the progress from one step to the next within a grade is determined by the
length of service, but progress from one grade to the next is determined by one’s
performance at the qualification exam or one’s achievements at the areas stipulated
by one’s hospital (including minimum technical and professional competence,
research and publication requirements, foreign language proficiency and computer
skills requirements).
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It should be noted that the base salary program adopted by Chinese public
hospitals used to be a primarily longevity-based system: almost everyone gets
promoted when the stipulated waiting period is up, unless he or she performs
extremely poorly. Employees tend to be much less motivated after they receive the
coveted highest-level professional title. Such practices have resulted in the
disproportionately high percentage of senior physicians and the disproportionately
low percentage of junior physicians at many public hospitals, which has added great
financial burdens to these hospitals (Gu, 2004).
According to the latest personnel policies for health care institutions issued
by the Organization Department of the CCP Central Committee, Chinese Ministry of
Personnel and Ministry of Health (2000), health care professionals no longer
automatically receive the base salary that corresponds to their professional title.
Their base salary is tied to the professional post for which they are hired. For
instance, if one possesses an associate senior-level professional title but works in an
intermediate-level post, one only receives the base salary for the intermediate-level
post. This policy change is aimed at introducing competition to health care
institutions, enhancing the motivation of health professionals, and improving the
efficiency and productivity of these institutions. However, this policy is poorly
implemented in most public hospitals, where almost everyone would be appointed to
a post equivalent to one’s professional title (Li, 2004).
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The bonus payment system was established as part of the health care
institution reform with an aim of motivating hospital staff by linking their bonus with
their performance (Pei et al., 2002)22. Besides the fixed post grade salary and the
subsidy salary, a health professional at Chinese public hospitals also receives
bonuses on a monthly, quarterly, and/or annual basis, often from their departments
(Zhang, Wang, Zheng, & Wang, 2004). Departments at a hospital might vary greatly
in their bonus payment plans: the bonus plan could be at the individual level, the
team level, or the department level, or any combination of the three. In many cases,
the bonus is tied to one’s professional post and the revenue of one’s department or
one’s medical care team, which leads department staff or team members to focus on
revenue maximizing at the price of service efficiency (Gu, 2004; Pei et al., 2002)23.
In departments using an individual/department hybrid bonus plan, surgical members
of the same professional post receive the same bonus and those of a senior-level post
receive the highest bonus. In departments using an individual/team hybrid bonus
plan, the bonus that a surgical team member receives is tied to the revenue of his or
---------------------------------------
The bonus payments are funded by the hospitals from their profits.
2 3 The main sources of revenue for Chinese public hospitals are the prescriptions of
medications and high technology tests. These hospitals have their own in-house
pharmacies. The pricing of basic medical services is tightly controlled by the
government and is artificially set below the actual cost (Pei et al., 2002). However,
the government’s control over the pricing of medications and tests is much more lax.
Thus, the profit margins in these two areas are much higher. According the 2003
statistics issued by the Chinese Ministry of Health, medication revenue accounts for
47% of an average Chinese general hospital’s business revenue.
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her team as well as his or her professional post. Surgical team member of the same
professional post but on different teams might receive different amounts of bonus.
When a large part of a surgical team member’s bonus comes in the form of team
bonus, the adoption of the individual/team hybrid bonus payment plan is expected to
contribute to his or her team identification and team cohesiveness, which might in
turn facilitate intrateam knowledge sharing but hinder interteam knowledge sharing.
When a large part o f a surgical team member’s bonus comes in the form of
department bonus as in the individual/department hybrid bonus plan, it is expected
that a surgical team member will make a less distinction between members within his
or her team and those on other teams in their knowledge sharing decisions and
behaviors.
Other sources of income for physicians and nurses are the commissions paid
by sales representatives from pharmaceutical corporations. The commissions are
paid either directly to physicians or to department heads who later distribute them to
staff within their departments (Pei et al., 2002). As the amount of commissions one
receives is directly tied to the number of patients that one is in charge of, this
practice might lead to competition among some medical care teams for patients with
big budgets (Pei et al., 2002).
The pay structures in public hospitals have been criticized for being
egalitarian and failing to discriminate high performers from poor performers, thus
severely demotivating their employees (Gu, 2004; Li, 2004). Some policy changes
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have been recently introduced, aiming at eliminating such “da guo fan” (“big rice
pot”) phenomenon that is characterized by the lack of linkage between pay and
performance. In the “Opinions on Deepening the Reform of Personnel Systems in
Health Care Institutions”, Organization Department of the CCP Central Committee,
Chinese Ministry of Personnel, and Ministry of Health (2000) stipulated that, (a) in
the new personnel system, the compensations of health care professionals should be
tied to their professional posts, their tasks, and their performance, and (b) the
compensation plans should focus on employees’ performance and contribution and
favor key posts and high-performing employees. Some hospitals have begun to
model their compensation plans after this policy, and have achieved some success in
enhancing employee motivation (Du, Gong, Xue, Qi, & Li, 2003; Zhang et al.,
2004).
Recently there has been a growing trend among many Chinese public
hospitals to attract physicians with graduate degrees with competitive compensation
packages (e.g., great housing subsidy) (Li, 2004). Such practices have led to the
resentment among some of the existing employees who view these practices as
unjust (Hui, 2003; Li, 2004). Such practices also affect knowledge sharing among
surgical team members, as will be demonstrated later in Chapter III.
Personnel Policies. As of 2000, the Chinese Ministry of Health, Ministry of
Personnel, the Organization Department of the Chinese Communist Party Central
Committee, and other government agencies at the provincial, municipal, and county
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levels have issued a series of directives that are aimed at speeding up the personnel
management system reform at public health care institutions24. The rigid existing
personnel system has been cited as one of the main reasons for the brain drain of
public hospitals (Li, 2004). The primary goal of the reform is to gradually phase out
the old personnel system established under the planned economy that is characterized
by guaranteed lifelong employment and low employee mobility, and to establish a
new personnel system that fits the new market economy. The new personnel system
is characterized by contract employment and high employee mobility. Under the old
system, local managers at public hospitals have very limited control over the hiring,
firing, and promotion of their staff (Li, 2004; Pei et al., 2002). They might be
coerced by upper management to hire new employees irrespective of their expertise
simply because of these employees’ personal connections with higher authorities.
2 4 The major national regulations include “Opinions on Deepening the Reform of
Personnel Systems in Health Care Institutions” (issued by the Organization
Department of the CCP Central Committee, Chinese Ministry of Personnel and
Ministry of Health on March 30, 2000), “Notice on the Strengthening of the
Appraisal and Hiring o f Health Care Professional Posts” (issued by the Chinese
Ministry of Personnel and Ministry of Health on December 3, 2000), “Guiding
Opinions on the reform of Internal distribution system of health care institutions”
(issued by Chinese Ministry of Health on December 27, 2002); “Provisional
Regulation on the Implementation of Annual Salary System at Health Care
Institutions” (issued by Chinese Ministry of Health on December 27, 2002),
“Provisional Regulation on the Appraisal of Staff at Health Care Institutions” (issued
by Chinese Ministry of Health on December 27, 2002), “Guiding Opinions on the
Reform of the Selections and Appointment of Managers at Health Care Institutions”
(issued by Chinese Ministry of Health on December 27, 2002), and “Guiding
Opinions on the Splitting of Logistic Services from Health Care Institutions” (issued
by Chinese Ministry of Health on December 27, 2002).
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The new policy of appointing employees to posts on a contract basis gives local
managers greater authority over their employees. The new personnel system also
allows hospitals to hire part-time clinicians, which enhances the mobility of health
care professionals (Gu, 2004). Although the new personnel system holds promising
potentials, its implementation is problematic in that the new policies are binding for
employees recruited after the reform but less so for veteran employees. Furthermore,
health care institutions are instructed by the government agencies to take care of
those staff who do not have post appointments in the new system either by creating
new employment opportunities for them within the institutions or by helping them
find new employment. Such contradicting demands from the government make it
very hard for most health care institutions to achieve operation streamlining.
Under the current contract management responsibility system (CMRS),
Chinese public hospitals enjoy greater but still limited autonomy in their personnel
management. A great part of their personnel policies are still stipulated by
government administrative agencies concerned. For instance, government personnel
agencies at various levels set the quota for the number of professional posts of
various levels that a public hospital could have (Pei et al., 2002).
The promotion policies of most public hospitals in China are in favor of those
employees with higher academic degrees: they tend to move up the post title system
much more quickly than those with lower academic degrees because (a) they are
more likely to meet the requirements in the areas of research, publication, foreign
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language proficiency, and computer skills thanks to their longer and more intensive
education, and (b) they have a shorter waiting period when it comes to promotion to
intermediate-level and senior-level professional titles (Zhang et al., 2003) (See
Appendix D for a detailed account of the professional title application and review
policies of the MOH hospital under study)25. Furthermore, promotions in many
communication, management, and cultural studies have examined China’s cultural
value orientations and their impacts on the Chinese’s cognition, emotion, and
behavior hospitals are still based on seniority and guanxi rather than on merit (Pei et
al., 2002).
Chinese Cultural Behaviors
In recent years, a growing body of literature on cultural values (particularly
work-related cultural values) and practices in China has accumulated with China’s
\ c
According to the “Provisional Regulations on the Professional Title Qualification
Exam for Clinical Health Care Personnel” issued by the Chinese Ministry of Health
and Ministry of Personnel (2000), medical personnel with a doctor’s degree can be
promoted to the intermediate-level professional title immediately after graduation;
whereas medical personnel with lower degrees must have a minimum amount of
clinical experience in order to be qualified for the exam (a minimum of 2 years’
clinical experience in the post of physician for those with a master’s degree, a
minimum of 4 years for those with a bachelor’s degree, a minimum of 6 years for
those with an associate degree, and a minimum of 7 years for those with a secondary
diploma). The current standard waiting period for a physician with a bachelor’s
degree for the intermediate-level professional title is 5 years. The waiting period
might be longer in some hospitals (e.g., 6 years). The waiting period for a physician
with a doctor’s degree to be qualified for the associate senior-level professional title
is 2 years after he or she is awarded the intermediate level professional title, whereas
that for a physician with a master’s degree is 5 years after he or she is awarded the
intermediate level professional title (Zhang et al., 2003).
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increasing integration into the international economy and its growth into a major
player in the global market. Scholars from multiple disciplines, including
psychology, (e.g., communication style, conflict management style, performance,
efficacy, organizational commitment, and other work-related attitudes and behavior)
(e.g., Bond, 1986, 1996; Earley, 1989, 1993; Earley, Gibson, & Chen, 1999;
Francesco & Chen, 2004; Fu et al., 2004; Gao & Ting-Toomey, 1998; Ralston, Egri,
Stewart, Terpstra, &Yu, 1999; Ralston, Holt, Terpsta, & Yu, 1997; Yu, 2002). A
large number of scholars have drawn on concepts developed in the West, such as
Hofstede’s (1980, 1991, 2001) dimensions of cultural variability (individualism-
collectivism, power distance, and uncertainty avoidance), Kluckhohn and
Strodotbeck’s (1961) time orientation, and Hall’s (1976) cultural dimensions (highl
and low-context cultures), whereas other scholars have used indigenous Chinese
concepts, such as mi an zi (face), gan qing (feeling), ren qing (human feeling), bao
(reciprocity), in their studies. Although the line of research using cultural concepts
developed in the West has contributed to our understanding of the positioning of the
Chinese culture in relation to other cultures and enabled cross-cultural comparisons
between the Chinese culture and other cultures, the line of research using indigenous
Chinese cultural values and norms provides a more coherent, comprehensive, and in-
depth account for Chinese behavior.
There is a general consensus in the literature that mainland China is a culture
with moderately high power distance (where less powerful members of organizations
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accept and expect the unequal power distribution), high long-term orientation (or
Confucian dynamism where people value “persistence,” “ordering relationships by
status and observing this order,” “thrift,” and “having a sense of shame”), and
moderately high masculinity (marked by a clear social role differentiation for
genders where “men are supposed to be assertive, tough, and focused on material
success” and “women are supposed to be more modest, tender, and concerned with
quality of life”) (Hofstede, 2001, p. 297). Several empirical studies have confirmed
these characterizations of the Chinese culture (Chinese Culture Connection, 1987;
He, Zhu, & Peng, 2002; Nicholson & Stepina, 1998; Ralston, Gustafson, Cheung, &
Terpsta, 1993; Ralston, Gustafson, Elsass, Cheung, & Terpsta, 1992). The
moderately high power distance variability of the Chinese culture might hinders
knowledge sharing in Chinese surgical teams by suppressing low-status members
from speaking up and challenging opinions and decisions made by higher-status
members.
In the literature, mainland China has often been described as a collectivistic
culture where people make a clear insider/outsider distinction and have a strong
group orientation. A recent national values survey by Nicholson and Stepina (1998)
of managers, professionals, and business students in the People’s Republic of China
confirmed that the Chinese culture was less individualist-oriented and more
collectivistic. Yet there are some recent studies indicating or observing increasing
individualism in mainland China (Lau, 1992; Hu & Grove, 1999; Ralston et al.,
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1999; Ralston, Gustafson, Terpstra, & Holt, 1995). In their longitudinal study of
work values among young managers in the Shanghai area over a period of 2.5 years,
Ralston et al. (1995) documented a shift among these managers toward more
individualistic work values. In their study of 869 managers and professionals
working in state-owned enterprises, Ralston et al. (1999) found that New Generation
managers and professionals (those who grew up in the Social Reform era (1977 to
the present)) were more individualistic (scoring higher on dimensions of “power,
achievement, hedonism, stimulation and self-direction”) and less collectivistic
(scoring lower on “benevolence, tradition and conformity”) when compared with
Current Generation managers (those who grew up during the Great Cultural
Revolution (1966-1976)) and professionals as well as Older Generation managers
and professionals (those who grew up before 1965). They also found that New
Generation managers and professionals scored much lower in Confucianism
(consisting of the dimensions of “societal harmony, virtuous interpersonal behavior,
and personal and interpersonal harmony”).
As knowledge sharing is essentially constituted in communication activities,
a review of the research on Chinese interpersonal communication and organizational
communication is in order. The theorizing and research on Chinese interpersonal
communication and organizational communication is still in its early stage.
Furthermore, the amount of empirical evidence on interpersonal and organizational
communication in mainland China is discouragingly small: a large proportion of the
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existing empirical studies on Chinese interpersonal and organizational
communication examined Chinese in Taiwan and Hong Kong (e.g., Bilbow, 1997;
Ma, 1992). One should be cautious in extrapolating findings on Chinese in Taiwan
and Hong Kong, as the three societies operate under different political and economic
systems and have their own unique characteristics (Fu et al., 2004). Some studies
have documented the systematic differences in cultural values among the three
societies (Ralston et al., 1993). A review of the literature reveals two major
theoretical models: the self-other perspective by Gao and Ting-Toomey (1998) and
the harmony theory by Chen (2001) (See Appendix E for a list of all the Chinese
terms in these two theories and their English translations).
Self-Other Perspective. Situating Chinese communication in the larger
cultural context, Gao and Ting-Toomey explored how Chinese concepts of self,
Chinese relational principles, and the Chinese concern for mian zi (“social image”)
shape their communication behaviors. They argued that in Chinese culture, self is
relational and other-oriented: one’s sense of self is defined by one’s role and
hierarchy relationships with others in one’s social networks. Chinese are expected to
act in accordance with their differentiated status roles in those hierarchical
relationships: lower-status individuals are expected to respect, obey, and submit to
higher-status individuals who are expected to offer protection and support in return.
Chinese follow different interaction rules and apply different value standards when
interacting with zi j i ren (“insider”) and wai ren (“outsider”). They cooperate with zi
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j i ren, attend to their needs and wishes, and are more tolerant toward them. In
contrast, they seldom cooperate with wai ren and are less lenient and attentive to
them.
Gao and Ting-Toomey (1998) also examined three important Chinese
relational concepts that are closely tied to Chinese other-oriented self: gan qing
(“feeling”), ren qing (“human feeling”) and bao (“reciprocity”). A relationship with
gan qing is marked by reciprocity, mutual support, and affective empathy. It can be
cultivated through acts of mutual help and mutual care. Ren qing refers to the
interpersonal resources one gives to (e.g., helping others) and takes from (e.g.,
requesting help from others) others. Bao refers to the principle of reciprocating or
paying backing others’ favors and help.
Gao and Ting-Toomey suggested that the desires to maintain harmony with zi
ji ren and to preserve one’s own mian zi (face) and the mian zi of one’s zi ji ren lead
Chinese to communicate in a style that is marked by han xu (“implicit
communication”), ting hua (“listening centeredness”), and ke qi (“politeness”)
(p.3 7). Han xu refers to “a mode of communication (both verbal and nonverbal) that
is contained, reserved, implicit, and indirect” (p. 37), which is similar to Hall’s
(1976) concept of high-context communication. Han xu is particularly important
when the message to be communicated threatens one’s own face or other insiders’
faces or might disrupt the relationship harmony (e.g., strong and negative emotions).
Ting-hua refers to the asymmetrical communication between individuals of different
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ranks or statuses: (a) higher status individuals engage in more talking and lower
status individuals engage in more listening, and (b) lower status individuals are
deferential and respectful when communicating with their superiors. Ke qi refers to a
style of communicating that is self-effacing and/or other-enhancing, which mirrors
the cherished Chinese value of modesty. Another feature of Chinese communication
identified by Gao and Ting-Toomey is its focus on zi j i ren\ Chinese tend to
communicate more personal, private, and sensitive information with insiders than
with outsiders, and are more likely to communicate unpleasant and confrontational
information with outsiders.
Gao and Ting-Toomey (1998) also suggested that the prevalent concerns for
mian zi among Chinese lead them to use “face-directed communication strategies”
that are indirect, unassertive, and non-confrontational (p.60). For instance, instead of
directly confronting someone in public, Chinese might engage in yi lun (“to gossip”)
in private settings to convey their messages indirectly in order to preserve that
person’s face.
There are some empirical findings and cultural observations that support Gao
and Ting-Toomey’s characterization of Chinese communication as “han xu”, “ting-
hua” and "ke qi”. The literature on conflict resolution and management in mainland
China has demonstrated that Chinese tend to use indirect, non-confrontational
resolution styles for face concern and for relationship sake (e.g., using the avoiding
style, using intermediaries to resolve conflicts) (e.g., Chen & Hao, 1997; Hu &
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Grove, 1999; Liu & Chen, 2002; Lu, 1998; Peng, He, & Zhu, 2000; Yu, 2002). Some
researchers have documented that Chinese tend to use hinting (e.g., metaphor,
analogy) to express their disapproval and criticism indirectly and that many Chinese
use strategically ambiguous, indirect verbal messages with their not-so-close
communication partners (e.g., acquaintances and relatives) (Chang, 1999; Chen &
Hao, 1997; Ma, 1996). It has been observed that Chinese often use intermediaries to
create connections and make request (Chang & Holt, 1991; King & Bond, 1985).
It has also been observed that Chinese are deferential when communicating
with their superiors and seniors and reluctant to initiate direct communication with
their superiors in conflicts (Hu & Grove, 1999; Lu, 1998; Young, 1994). Research
and observations have shown that Chinese are reserved and contained in their
emotion expression in public (Bond, 1993; Ma, 1992).
Harmony Theory. As its name indicates, Chen’s (2001) harmony theory of
Chinese communication highlights harmony as the fundamental cultural value that
directs and shapes the communication behaviors of the Chinese people. Chen argued
that the Chinese culture sees human communication as a “transforming, cyclic, and
never-ending process” (p.57) whose ultimate end is to establish and maintain a
harmonious, conflict-free interpersonal relationship between communication
partners. Therefore, Chen proposed that in the Chinese culture, a competent
communicator is one who is capable of developing and sustaining harmonious
relationships with his or her interactants.
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Chen proposed that the realization of harmony in communication requires an
individual to internalize the values of jen (“humanism”), yi (“righteousness or
appropriateness”), and li (“rite” or “norms and rules of proper behavior in a social
context”); to be aware of shi (“temporal contingencies”), wei (“spatial
contingencies”), and j i (“the first imperceptible beginning of movement”); and to
appropriately handle guan xi (“interrelation”), mientz (“face”), and power (pp. 58-
65). More specifically, he proposed that a competent communicator in the Chinese
culture is one who is: (a) “reciprocal and empathic” \jen\; (b) “flexible and
adaptable” [y/]; (c) keqi (polite), skilled at using honorific language, adroit at
managing hierarchical relations, adept in controlling one’s emotion and displaying
no aggression [//]; (d) aware of the appropriate time to act [shi\; (e) attentive to the
environment and the social context (particularly the hierarchical relationships
between the interactants) [wei\; (f) sincere and sensitive to potential outcomes of an
interaction [/'/]; (g) adept at building and maintaining good guanxi with others, and
adroit at discerning in-group and out-group members [guanxi]; and (h) good at
enhancing others' mientz and showing renqing (doing favors) to others, and feeling
grateful to others who have helped oneself [mientz]. Chen also posited that senior
and powerful persons tend to be perceived as more competent communicators than
their junior and less powerful counterparts.
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It must be noted that Chen did acknowledge that the principle of harmony
applies best to Chinese communication with their in-group members and much less
to their communication with out-group members.
There is some overlap in the cultural traits covered by Chen (2001) and Gao
and Ting-Toomey (1998). Both theories stress the influences of mian zi, ren qing, ke
qi, the insider/outsider distinction, reciprocity, and hierarchical social structures in
Chinese communication behaviors, which confirms the centrality of these concepts
in understanding Chinese communication.
As knowledge sharing is constituted in communication, the knowledge
sharing behaviors of Chinese surgical teams are expected to display some important
features of Chinese communication (e.g., an implicit, listening-centered, and polite
style of communication), which will be covered in detail later in this chapter.
Interpretive-Symbolic Approach to Knowledge Sharing in Chinese Surgical Teams
Most of the previous studies on knowledge sharing and transfer within and
between teams or organizations approach knowledge sharing and transfer from a
functionalist perspective, focusing on the constraining or enabling influences of a
few discrete organizational structural and cultural variables, while neglecting the
agency of organizational members in producing and reproducing these elements.
Furthermore, most of these studies have paid insufficient attention to the
communicative processes that constitute knowledge sharing and transfer (with the
exception of Blackler, 1996; Boland & Tenkasi, 1995; Brown & Duguid, 1998;
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Szulanski, 1996, 2000; von Krogh & Roos, 1996). Communication plays a central
role in organizational or team knowledge sharing: it is the means by which
knowledge is created, interpreted, negotiated and shared among organizational or
team members. Knowledge sharing, constituted in communication, is part of the
process through which organizational members create and recreate organizational
culture, structures, and power systems by constructing and negotiating meanings and
interpretations of their individual and shared experiences (Schneck, 2004; Weick &
Ashford, 2000). The mutual dependence between structure and agency is well
captured in the concept of “duality of structure” in Giddens’ structuration theory,
which means that “the structural properties of social systems are both medium and
outcome of the practices they recursively organize” (Giddens, 1984, p.25).
In this study, I examined knowledge sharing in Chinese surgical teams using
an interpretive-symbolic perspective (Eisenberg & Riley, 2001; Krone et al., 1987).
Unlike the mechanistic perspective and the psychological perspective of
organizational communication that tend to conceive human communication as being
passively shaped by organizational characteristics, the interpretive-symbolic
perspective conceptualizes organizational communication as “patterns of coordinated
behaviors that have the capacity to create, maintain, and dissolve organizations”
(Krone et al., 1987, p. 27). The interpretive approach focuses on uncovering how
meanings for actions and organizational events are created, negotiated, and modified
and shared among organizational members through social interaction. The
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interpretive approach enables researchers to yield “dense theories” that provide a
finer and more comprehensive account of organizational reality by incorporating the
perspectives of organizational members than do the mechanistic or psychological
perspectives that typically focus on a few organizational variables deemed important
by the researcher (Glaser & Strauss, 1967; Krone et al., 1987). This approach is
particularly useful in the present study of knowledge sharing in Chinese surgical
teams that are composed of members from different disciplines and with varying
status, because it allows for the capturing of diverse meanings and interpretations
members develop for knowledge, events, policies, and norms in their daily work.
This study addresses the understudied topic of knowledge sharing in Chinese
surgical teams.
Knowledge Sharing Practices
To understand the dynamics of knowledge sharing in Chinese surgical teams,
the first step is to examine their knowledge sharing practices, or more specifically,
the issue of “sharing what knowledge with whom, when, where, and how”. This
leads to the first research question.
RQ1: What knowledge do Chinese surgical team members share with one
another? How, where, and when?
Interdisciplinary and intradisciplinary knowledge sharing. Surgical teams are
composed of members from multiple disciplines, including but not limited to
surgeons, anesthesiologists, nurses and technicians (e.g., perfusionists in cardiac
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surgical teams). Knowledge sharing within a surgical team comprises knowledge
sharing among members from the same discipline (intradisciplinary knowledge
sharing) and knowledge sharing among members from different disciplines
(interdisciplinary knowledge sharing).
Disciplinary differences have been suggested to inhibit communication and
shared understanding (Dougherty, 1992). The surgical team literature has
documented some great attitudinal differences with regard to team leadership, team
structure, team procedures, teamwork, role perceptions, and communicative
motivations between the subgroups of surgeons, anesthesiologists, and OR nurses,
which have been suggested to result from their different professional or functional
training and culture (Flin et al., 2003; Helmreich & Davies, 1996; Helmreich &
Schaefer, 1994; Sexton et al., 2000). Inadequate and low quality communication and
teamwork have also been documented among surgeons, anesthesiologists, and
nurses, particularly between surgeons and the subgroups of anesthesiologists and
nurses (Cook et al., 2001; Espin & Lingard, 2001; Helmreich & Davies, 1996;
Helmreich & Schaefer, 1994; Helmreich & Merritt, 1998; Lingard et al., 2004;
Lingard, Reznick, DeVito, et al., 2002; Lingard, Reznick, Espin, et al., 2002;
Patterson, 1996; Schaefer et al., 1995; Sexton et al., 1998). Chinese surgical teams
might also be susceptible to similar communication and teamwork problems
resulting from disciplinary differences.
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Furthermore, knowledge sharing among Chinese surgical team members
from different disciplines is expected to be less frequent than that among members
from the same discipline, because members from different disciplines have fewer
interactions with one another outside the operating room when compared to those
from the same discipline and from the same department. Therefore, the following
research question is asked:
RQla: Is interdisciplinary knowledge sharing within surgical teams less
frequent and of lower quality than intradisciplinary knowledge sharing within
surgical teams?
Nature o f Knowledge Shared. Open and thorough knowledge and information
sharing within and between teams is essential to both individual learning and team
learning, which in turn contributes to team effectiveness and organizational learning.
However, it has been observed that people are less likely to share certain types of
knowledge and information that might make them look ignorant, incompetent,
disruptive, and undesirably critical (e.g., failures, disagreement, criticism, and
tentative knowledge) and those that might threaten their status and authority (e.g.,
expertise) (Cannon & Edmondson, 2001; Edmondson, 1996, 1999, 2003a, 2003b).
Failures are a valuable source of clinical knowledge. Errors, mistakes,
problems, incidents, and medical mishaps are all examples of failures that could lead
to valuable knowledge when reflected on. As discussed earlier, the issue of covering
up errors, mistakes, and problems is very salient in the medical field because the
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cultural norms of shame, blame, and silence and the litigation risks in addition to the
interpersonal risks discourage health professionals from open and thorough
knowledge sharing. The hierarchical structure of surgical teams has also been
suggested to further hinder low-status members from speaking up, costing surgical
teams valuable learning opportunities (Edmondson, 2003a, 2003b). Chinese cultural
traits of valuing harmonious relationships with their communication partners and
their excessive concern with their own and others’ mian zi might further hinder
Chinese surgical team members from sharing face-threatening knowledge,
particularly with those with higher status. This leads to the following research
question:
RQlb: With whom and where do Chinese surgical team members share face-
threatening knowledge?
People’s reluctance to share their expertise with others has been well
documented in knowledge-intensive organizations, especially in organizations that
fail to provide their employees with sufficient incentives and fail to foster a nurturing
and cooperative working environment (Davenport, Eccles, & Prusak; Empson, 2001;
Husted & Michailova, 2002). Hospitals are knowledge-intensive organizations where
health professionals’ jobs and roles are defined by the unique knowledge they hold.
As described earlier, the relationships among peers from the same discipline are
quite competitive at most Chinese public hospitals, because they compete for a fixed
number of professional posts under the new personnel system. In Chinese public
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hospitals, peers of surgical team members who are from the same discipline are on
other teams in most cases. Such competitive relationships might inhibit interteam
sharing of expertise between peers from the same disciplines. On the other hand,
sharing of expertise is more likely to occur within surgical team members from the
same discipline because: (a) senior surgical team members have the duty and
responsibility to train more junior teammates, (b) the interpersonal relationships
within a surgical team are good in most cases, (c) the interdependent nature of their
task promotes the sharing of task-related expertise, and (d) teammates have shared
interests. This leads to the following research question:
RQlc: Are Chinese surgical team members more likely to share their
expertise with teammates from the same discipline than with people on other
teams, particularly with peers on other teams?
Communication Strategies and Style. Knowledge sharing is constituted in
communication. The Chinese communication literature suggests that the Chinese
tend to use a style of communication that is indirect, listening-centered (the
asymmetrical communication between individuals of different ranks or statuses), and
polite (Gao & Ting-Toomey, 1998). More specifically, it is suggested that the
Chinese tend to use a deferential, indirect, and polite style of communication when
interacting with higher-ranking and/or elder colleagues (Gao & Ting-Toomey, 1998).
Chinese surgical team members might also employ such a style when sharing
knowledge with their higher-ranking and/or elder colleagues both within and outside
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their teams. Their inclination to use face-directed communication strategies might
lead them to choose informal communication channels to share face-threatening
knowledge (Gao & Ting-Toomey, 1998). However, it is not clear from the literature
whether the Chinese use an indirect and polite style of communication when sharing
knowledge with their peers and subordinates. Chinese surgical team members might
or might not use an indirect and polite style of communication when sharing
knowledge with their peers and subordinates. Therefore, the following research
questions are asked:
RQld: Do Chinese surgical team members use a deferential, indirect, and
polite style of communication when sharing knowledge with higher-ranking
and/or elder teammates?
RQle: Do Chinese surgical team members use an indirect and polite style of
communication when sharing knowledge with their peers and subordinates
who are not older than them?
RQlf: Do the knowledge sharing behaviors of Chinese surgical team
members exhibit a listening-centered tendency?
Expectations, Perceptions and Interpretations o f Knowledge Sharing
The second step in examining knowledge sharing in Chinese surgical teams is
to explicate the surgical team members’ expectations, perceptions, and
interpretations with regard to knowledge sharing within and between surgical teams.
Members’ expectations, perceptions, and interpretations of knowledge sharing are
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socially constructed: they emerge out of members’ daily interactions with their
teammates and people on other teams and are continually negotiated and recreated
(sustained or modified) in these daily interactions. They are shaped by many cultural,
structural, and social factors spanning multiple levels of analysis (e.g., organizational
culture, team culture, and organizational reward systems). An understanding of
surgical team members’ expectations, perceptions, and interpretations of knowledge
sharing is essential to explicating the dynamics of knowledge sharing within and
between surgical teams because members’ expectations, perceptions, and
interpretations not only directly influence their actual knowledge sharing behaviors
but also reflect the cultural norms on knowledge sharing and the processes of
meaning negotiation involved in knowledge sharing. Thus, this leads to the second
research question guiding this study:
RQ2: How do members of Chinese surgical teams perceive, interpret, and
account for knowledge sharing within and between surgical teams, including
their own knowledge sharing behavior?
The above-mentioned research questions will be explored through the
qualitative case study. The survey study will examine additional hypotheses and
research questions with respect to Chinese surgical team members’ attitudes and
perceptions related to knowledge sharing, communication, and teamwork. The
details of hypotheses and research questions studied in the survey study will be
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covered in Chapter IV, because they will be greatly informed by the findings of the
first case study.
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III. Chinese Surgical Teams in Action
This study takes the position that knowledge sharing in Chinese surgical
teams is a complex organizational communication phenomenon that could only be
properly understood by explicating the dynamic interplay of multiple relevant
cultural, social, and structural factors. Surgical teams at Chinese public hospitals face
tremendous obstacles to open and thorough knowledge sharing. In addition to the
challenges posed by their interdisciplinary composition, their hierarchical team
structure, their fluid team membership, as well as the medical culture of shame,
blame, and silence, Chinese surgical teams face additional impediments posed by
their unique social, cultural, and historical context (e.g., Chinese cultural values of
cherishing harmonious relationships and excessive concern for mian zi). This study
identifies these challenges facing Chinese surgical teams, describes knowledge
sharing practices in Chinese surgical teams, uncovers the expectations,
interpretations, and perceptions of diverse surgical team members, and demonstrates
how surgical team members’ knowledge sharing behaviors are continually shaped by
and shaping relevant cultural, structural, and social factors.
I used both qualitative methods (mainly interviews and observation) and
quantitative survey methods in my study. The results of the survey study will be
presented in Chapter IV. This chapter reports the findings from the qualitative case
study of 27 surgical teams at two Chinese public hospitals.
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Methodology
This study employed an interpretive multiple-case study research strategy
(Eisenhardt, 1989; Gomm, Hammersley, & Foster, 2000; Yin, 2003) to examine
knowledge sharing in surgical teams at Chinese public hospitals. The topic of this
study favors the use of a case study approach, which is defined as “an empirical
inquiry that investigates a contemporary phenomenon within its real-life context,
especially when the boundaries between phenomenon and context are not clearly
evident” (Yin, 2003, p. 13). Knowledge sharing within and between surgical teams at
Chinese public hospitals is a complex social phenomenon that can only be
understood or examined within the contemporary Chinese cultural, social, and
institutional contexts. The ongoing reforms in the Chinese healthcare industry and in
the Chinese medical and nursing education systems have posed unique challenges to
knowledge sharing within and between Chinese surgical teams. The case study
approach enables me to capture such “holistic and meaningful” contextual features of
the phenomenon under study (Yin, 2003, p. 2).
This study aims to understand knowledge sharing within and between
Chinese surgical teams through the eyes of diverse surgical team members. Since
very little is known about knowledge sharing in Chinese surgical teams, this study is
primarily motivated by broad exploratory research questions. I am using a case study
approach to integrate and inform the disparate streams of research that are highly
relevant to knowledge sharing in Chinese surgical teams, generating new insights
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inductively from qualitative data while testing research questions derived
deductively from existing theories. As will be described in detail later in this chapter,
I mainly relied on interviews and observation to construct an interpretive portrait of
surgical team members’ experiences and perceptions of knowledge sharing not only
with teammates from the same professional group but also with teammates from
other professional groups.
Knowledge sharing within and between surgical teams is essentially an
organizational communication phenomenon, which often involves strong emotion
and great cognitive efforts. As described earlier, the adoption of the interpretive-
symbolic perspective enables me to produce a more nuanced and more
comprehensive account of knowledge sharing in Chinese surgical teams by
incorporating the perspectives of diverse surgical team members (Eisenberg & Riley,
2001; Krone et al., 1987). This approach is particularly useful in the present study in
that it allows me to capture the diverse meanings that members from different
cultural groups (e.g., professional/functional cultures, status groups, and age and
gender groups) develop and negotiate in their knowledge sharing practices. It
highlights the agency of surgical team members in enacting, sustaining, and
changing their organizational reality.
This study examined a total of 27 surgical teams at two Chinese public
hospitals: one MOH hospital and one PLA hospital. The use of a multiple-case study
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design contributes to the robustness of the case study findings (Eisenhardt, 1989;
Yin, 2003).
Research Setting
I gained access to surgical team members at these two hospitals through
personal connection. Both hospitals are accredited Grade-3, Class-A general public
hospitals (See Appendix F for information about the hospital accreditation system in
China).
The MOH Hospital. The MOH hospital is a university-affiliated teaching
hospital. It has a 1000-bed capacity. Some of the facilities housed by the hospital
include the city eye bank, the city cardiovascular disease research center, the city
cardiovascular disease intervention center, the city peripheral vascular disease and
oncology intervention center, the city clinical nuclear medicine treatment center, and
the district first-aid station under the city first-aid center. The hospital has many
departments that have won the title of “key provincial and/or municipal department,”
including the emergency center, the oncology center, the department of
cardiothoracic surgery, the department of general surgery, and the radiology
department. The hospital has 150 staff with a senior-level professional title (among
which there are 87 staff who hold the title of professor or associate professor, 23
preceptors of doctoral and master students, and 18 staff who received a special
subsidy awarded by the State Council). It has 9 teaching and research sections, 11
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graduate programs, and 4 research centers. It has about 650,000 annual outpatient
and emergency patient visits, and about 18,000 inpatient visits.
The hospital is known in its province for its pioneering efforts in utilizing
many of the latest technologies. Its surgical staff delivers high-quality surgical care
by employing new leading techniques. For instance, its staff from the department of
cardiothoracic surgery has performed about 500 coronary artery bypass operations in
the past few years, with a success rate of 99%.
The PLA Hospital. Established in 1947, the PLA hospital is a teaching
hospital affiliated with 10 universities. It has a 750-bed capacity, 86 staff with a
senior-level professional title (including 51 staff who hold the title of professor or
associate professor) and 150 staff with an intermediate-level professional title. It has
a total of 39 clinical departments and houses the national PLA oncology center, the
regional research institute for liver diseases, and the regional obstetrics, pediatrics,
and gynecology center. The hospital also has a very strong medical staff and
provides high-standard patient care by utilizing new leading techniques and
equipment.
I studied a total of 100 members from 27 surgical teams at these two
hospitals, including 84 surgeons, 6 anesthesiologists, and 10 OR nurses). Of the 16
teams studied at the MOH hospital, there are 2 oncology teams, 5 general surgery
teams, 3 orthopedics teams, 2 neurosurgery teams, 2 cardiothoracic teams, 1 urology
team, and 1 plastic and bums team. Of the 11 surgical teams studied at the PLA
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hospital, there are 3 oncology teams, 1 general surgery team, 3 orthopedics teams, 1
neurosurgery team, 2 cardiothoracic teams, 1 urology team, and 1 plastic and burns
team.
The inclusion of surgical teams from different departments (or specialties) in
this study provides me with access to a larger pool of surgical teams and to capture
both common knowledge sharing practices used across surgical teams and unique
knowledge sharing practices used by individual surgical teams. It also allows me to
portray a richer and more comprehensive picture of knowledge sharing in Chinese
surgical teams. All members of the surgical teams studied are full-time hospital
employees. They live close to one another in apartments provided by their hospitals.
At these two hospitals, the department head and the associate department heads of
each department (including various surgical departments and the anesthesia
department) share one office. Senior physicians (including surgeons and
anesthesiologists) either share one office designated for senior physicians or share
one office with all the intermediate-level and junior-level physicians. These offices
are adjacent to one another. The office for head OR nurse and the office for other OR
nurses are also next to one another.
The surgical teams studied varied in terms of membership stability. A typical
Chinese surgical team comprises a moderately stable subgroup of surgeons and
highly fluid subgroups of anesthesiologists and nurses who are chosen from the
pools of anesthesiologists and OR nurses at the hospital. However, there are some
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teams with less fluid anesthesiologists and OR nurses subgroups. Take the cardiac
surgical teams at the MOH hospital for instance. They have their own operating
suites that are staffed with specialty anesthesiologists and OR nurses who specialize
in the field of cardiothoracic surgery. The anesthesiologist and OR nurse subgroups
of cardiac surgical teams are more stable than those of other surgical teams.
Furthermore, the relative stability of the surgeon subgroup varies greatly with
departments. Take the MOH hospital for example. Surgical teams at its neurosurgery
department have a less stable surgeon subgroup than surgical teams at other
departments (e.g., general surgery and oncology). The main reason is that most of
their operations are acute cases, which requires them to put together a surgical team
at very short notice, choosing from the pool of surgeons available on spot. Surgical
teams from the orthopedics department also have a rather unstable surgeon subgroup,
which changes on a monthly basis.
Surgical teams studied have hierarchical team structures. Each of the
constituting subgroups of surgeons, anesthesiologists, and OR nurses is composed of
members with varying ranks. Take the surgeon subgroup for instance. It is drawn
from surgeon medical care teams in surgical departments, most of which consist of 3
to 4 surgeons working in professional posts across 3 levels (the senior level, the
intermediate level, and the junior level). Among the three subgroups, the surgeon
subgroup enjoys the highest status, followed by the anesthesiologist subgroup, and
finally by the OR nurse subgroup.
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Data Collection
I conducted a total of 100 semi-structured interviews with 100 members from
27 surgical teams at these two hospitals: 65 interviews with members from 16
surgical teams at the MOH hospital (including 51 surgeons from six surgical
departments, 4 anesthesiologists, and 10 OR nurses) and 35 interviews with members
from 11 surgical teams at the PLA hospital (including 33 surgeons from six surgical
departments, and 2 anesthesiologists) (See Appendix G for the demographics of the
interviewees).
All the interviews were conducted face-to-face at the department’s general
physician office or at the office of the head of the department or at the nurse’s office.
For the sake of protecting the interviewees’ privacy and minimizing the possible
social pressure coming from their colleagues who are present, I interviewed the
subjects in one-on-one settings. The interviews ranged from 25 minutes to 70
minutes, with most taking about 30 minutes.
After obtaining the approvals from hospital management and department
management, I left recruitment pamphlets at the general physician’s offices of seven
surgical departments and the department of anesthesia as well as the nurse’s office at
the department of anesthesia at both hospitals, inviting surgical team members to
contact me if they were interested in the study. Some of the interviewees were
recruited this way. These interviewees also helped in persuading their teammates in
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participating in the study. I also visited the physician’s offices and the nurse’s office
to recruit subjects.
The interviews were guided by a protocol with open-ended questions. Yet not
all questions were asked of each participant. For example, I only posed the question
about electronic patient records to cardiac surgeons at the MOH hospital after
learning their department was the only department at the hospital that had such a
system. The order in which questions were asked was roughly similar. But in some
cases, some questions were asked earlier when the interviewee touched upon these
questions before their turns were up, in order to allow for the smooth flowing of
conversations. Also new questions were added as I became more familiar with
surgeons’ work and learned about unexpected important issues. For example, I began
asking questions about the surgeon/internist personality distinction after some
interviewees mentioned it. The standard interview questions included the
interviewee’s specialty, professional title, academic degree, views on knowledge and
knowledge sharing (e.g., the perceived benefits and undesirable consequences of
knowledge sharing), appraisal of knowledge sharing in his or her team and
department, knowledge sharing practices in his or her team and department, his or
her own knowledge sharing behaviors in certain hypothetical scenarios, and possible
factors that influence knowledge sharing. The English version of the initial set of
interview questions can be found in Appendix H.
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In addition to the interviews, I also took my field notes (including notes taken
from observations of department meetings, team interactions in the operating room,
in the office, and in surgical wards), and had access to hospital documents and
government agency policies.
Data Analysis
Only 41 interviews with surgical team members were digitally recorded. The
rest of the interviewees (59 in total) declined to have the interviews recorded. I
transcribed all digital files, interview notes, and field notes, and then translated them
into English. I used Atlas.ti, a visually oriented qualitative data analysis software, to
analyze the transcripts that were reformatted into a text file readable by the program.
Atlas is essentially a text management program: it assists the researcher in
organizing and analyzing rich qualitative data and enables the researcher to build
conceptual networks that illustrate the relationships among theoretical categories or
themes which either emerge from the data or have been previously established. I
segmented the transcripts into indexed passages that were in most cases an
interviewee’s answer to an interview question or a part of a long question posed. The
length of the passages ranged from one line to several paragraphs. Most of the
passages were of one paragraph’s length. I created a total of 98 codes to identify
common themes that emerged from the data. The code list was constantly modified:
new codes were added, overlapping codes were merged, and redundant codes were
removed. Coded transcripts were continually revisited and coded whenever there was
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a change in the code list. Comments were added throughout the coding processes to
describe codes and their relationships with other codes. Appendix I lists all the codes
with their frequencies. Appendix J includes sample quotations with matching codes.
The network view feature of Atlas.ti enabled me to build conceptual
networks to explicate theoretical relationships between codes found in the data
coding process (e.g., “prevents” “is a cause of,” “mutual influences” and “is
associated with”). Like codes, these conceptual networks were also constantly
modified throughout the coding process. Related codes were put together into a
conceptual network and linkages were built between them as suggested by the data.
All the codes that emerged from the data were grouped into 9 broad themes, each
represented by a network (See Appendix K for a complete list of networks created).
For example, the “Interteam Knowledge Sharing” network spells out the
relationships between codes such as “team identification,” “department
identification,” “department cohesiveness,” “department culture,” and “interteam
knowledge sharing” (See Appendix L for a list of sample networks with their
constituting codes). The visual representation of codes and the nature of their
interrelationships in the networks offer a useful tool for theory building. Key
networks will be presented and elaborated on later in the findings section of this
chapter.
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Validity
Long-term, deep immersion in the culture under study is required for
researchers to understand the symbolic meanings that cultural members associate
with particular behaviors and rituals (Geertz, 1973). Although my study of these two
hospitals last only for 5 weeks, I have had an intimate understanding of these two
hospitals, especially its surgical departments and surgeons, as my father has been
working at the MOH hospital as an oncologist for over 8 years and had worked as an
oncologist at the PLA hospital for about 6 years. Furthermore, I have been well
acquainted with surgical cultures at public Chinese hospitals in general, since I have
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lived among surgeons for over 20 years . My personal experience has contributed to
my “thick description” of knowledge sharing among members of Chinese surgical
teams (Geertz, 1973).
Triangulation (i.e., the use of multiple sources of data or multiple data
collection methods) has been proposed as an effective way of increasing the validity
of a case study (Gomm et al., 2000; Yin, 2003). This study uses multiple methods of
data collection, such as interviewing, observation, document analysis, and surveys.
The endorsement of the credibility of a study’s findings and interpretations by case
2 6 In China, almost all public hospitals provide apartment housing for their
employees who live very close to one another. Some of the apartments are located
very close to the hospitals, which are only a few minutes’ walk. As both my parents
(my mother is a surgical nurse) work in hospitals, I have lived in hospital housing for
over 20 years. I used to play with my friends in surgeons’ offices and nurses’ station
when I was a kid. I have participated in many events held by my parents’
departments (e.g., dinner gatherings, sightseeing tours, and parties).
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study respondents is another important way of enhancing the validity of a case study.
Feedback was constantly solicited from interviewees throughout the study: concepts
and interpretations proposed by an interviewee were posed to other interviewees to
check their credibility. I also sought feedback from interviewees regarding my own
understanding of the interview findings during the interviews. One summary of
results of the study that focused on the knowledge sharing among surgeons in
surgical teams was presented to 3 surgeons (including one senior-level surgeon, one
intermediate-level surgeon, and one junior-level surgeon). All of them endorsed my
conclusions and interpretations.
Findings
RQ1: What knowledge do Chinese surgical team members share with one another?
How, where, and when?
The first step in investigating knowledge sharing within and between Chinese
surgical teams is to uncover their knowledge sharing patterns. Understanding what
knowledge is shared through what communication channels under what manner with
whom is prerequisite to the explication of the dynamics of knowledge sharing within
and between surgical teams. Five specific questions were proposed under the first
research question to explore the issues of “what, with whom, how, where, and when”.
In the teams of study, surgeons, anesthesiologists, and OR nurses relied
predominantly on face-to-face communication to share knowledge with their
teammates and others outside their teams. Interdisciplinary knowledge sharing
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within and between surgical teams was found to be less frequent, less open, and less
active than was knowledge sharing among surgical team members from the same
discipline. Face-threatening knowledge, such as failures, disagreement, criticism, and
tentative knowledge, was found to be shared often within a department. Active
sharing of face-threatening knowledge was found more often within surgical teams
than between surgical teams, and more often in private settings than in public
settings. The sharing of expertise was also found to be more often within surgical
teams than between surgical teams. Interviewed surgeons, anesthesiologists, and OR
nurses tended to use a deferential, indirect, and polite style of communication when
sharing knowledge with higher-level or elder members both within and outside their
teams, but a more direct style of communication with sharing knowledge with lower-
level teammates and peers who are of the same sage as them or are younger than
them.
Based on the interviews, I identified three dimensions of knowledge sharing:
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(a) the depth dimension , (b) the initiative dimension, and (c) the location
dimension. The depth dimension is a continuum with very superficial knowledge
sharing at one end and very deep knowledge sharing at the other end. Many
interviewees commented that the nature of their task determine that they have to
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I have proposed elsewhere that knowledge sharing has a depth dimension (2003).
In that paper, I classified knowledge sharing into surface and deep knowledge
sharing. Surface knowledge sharing was defined as “sharing of the how component
excluding the why component”, while deep knowledge sharing was defined as
“sharing of both the why and the how components” (p. 9).
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engage in knowledge sharing because otherwise the patient’s life would be at risk.
Yet they also noted that the depth of their knowledge sharing differed greatly. The
initiative dimension is also a continuum with passive knowledge sharing and active
knowledge sharing at the two poles. The location or formality dimension is a
categorical dimension: knowledge sharing in public settings and knowledge sharing
in private settings. These three dimensions are important in that they provide me
with a more precise vocabulary to talk about knowledge sharing. See Figure 3.1.
Deep
Sharing
Depth
Superficial
Sharing
Private
settings
Location
Public Settings
Passive
Sharing
Initiative Active
Sharing
Figure 3.1. Dimensions of Knowledge Sharing
RQla: Is interdisciplinary knowledge sharing less frequent and of lower quality than
intradisciplinary knowledge sharing within surgical teams?
I l l
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All interviewed surgical team members reported that face-to-face
communication was the predominant means through which knowledge sharing with
their teammates and outside team members occurred. Only a few interviewees
reported using other communication media, including telephone, e-mail, notes, and
memos.
Interdisciplinary Knowledge Sharing Among Surgeons, Anesthesiologists, and OR
Nurses
Consistent with what was suggested in the literature, in the teams of study,
knowledge sharing among the three subgroups of surgeons, anesthesiologists, and
OR nurses was found to be far less frequent than knowledge sharing within the
subgroups. Knowledge sharing was found to be the least frequent between OR nurses
and surgeons. The quality of interdisciplinary knowledge sharing was also reported
to be worse than that of intradisciplinary knowledge sharing, which will be covered
in detail later under the section examining surgical team members’ perceptions and
interpretations of knowledge sharing within and between surgical teams. The results
provided some additional support for the documented inadequate and poor
communication among surgeons, anesthesiologists, and nurses.
In the teams of study, interdisciplinary knowledge sharing among surgeons,
anesthesiologists, and OR nurses occurs mainly in the operating room, preoperative
case conferences, and surgical wards.
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Operating Room. As the primary location where surgical team members of
different disciplines gather together to perform their team task, surgical procedures,
the operating room is also where most of the interdisciplinary knowledge sharing
occurs, though the interviews and my observations suggested that there was not
much interdisciplinary knowledge sharing in the operating room for routine
operations. This is consistent with the observations of some researchers (Lammers &
Krikorian, 1997; Sexton et al., 1998). It was reported that most of the
interdisciplinary knowledge sharing in the operating room took place between
surgeons and anesthesiologists. The amount of task-related communication
(including knowledge sharing) between surgeons and anesthesiologists was
suggested to be negatively associated with the smoothness of the operation, the
familiarity between surgeons and anesthesiologists on the team, and the expertise of
surgeons and anesthesiologists on the team. A number of surgeons reported having
more task-related communication with young, inexperienced anesthesiologists. One
senior-level anesthesiologist at the PLA hospital, whom I have observed in one
procedure, made the following comment:
Surgeons are in charge of the patient’s disease. Anesthesiologists are in
charge o f the patient’s life. Our communication with surgeons is rather
limited and scripted. In most cases where the operation goes smoothly and
nothing unexpected crops up, there is very little task-related communication
between us. This is particularly true when we have worked together before
and are familiar with one another’s work. With one look or one gesture, we
just act and do what is expected of us. We tend to communicate more when
something goes wrong or when something unexpected happens. We need to
notify them of unusual conditions and keep them updated. We might make
suggestions like “please suspend the operation temporarily so that the
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patient’s conditions could stabilize,” “the patient’s conditions are not well.
Please finish the operation as soon as possible”. Some of the communication
between us might qualify as knowledge sharing.
One senior-level oncologist at the MOH hospital also shared his opinions on
his knowledge sharing experiences with his anesthesiologist teammates:
If the operation is highly complex and involves a new technique that I am
learning, there tends to be more knowledge sharing between the senior
anesthesiologist on the team and me. As a matter of fact, we should have
consulted each other prior to the procedure. It is a hospital policy that we
should invite the anesthesiologists and OR nurses assigned to our case to join
us in our pre-operative case discussion. In the meeting, we would cover
issues like the anesthesia plan for the case, measures to prevent possible
surgical and anesthesia incidents. But you can’t predict everything.
Sometimes many unexpected things crop up. We have to share knowledge
with one another in real time to deal with those incidents.
The interviews indicated that there was little knowledge sharing between OR
nurses and the other two physician subgroups in the operating room. Most of their
communication was one-way, from surgeons and anesthesiologists to OR nurses in
the form of demands and requests. Surgeons ask for certain tools, and the OR nurses
just hand them over as requested. Most surgeons mentioned that they tended to have
more direct, verbal communication with new, inexperienced, or less familiar OR
nurses. The interviews also suggested that the communication between the
circulating nurse and the anesthesiologist(s) was also one-way: the latter makes oral
prescriptions, which are then implemented by the circulating nurse. Not much of the
communication between OR nurses and surgeons or anesthesiologists qualifies as
knowledge sharing. Rather, most only involves the sharing of work-related or social
information.
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Each surgeon has his own style. He might use certain tools more frequently
during the operation. He might use tools in a particular order. If the scrub
nurse on your team is a new, inexperienced nurse, someone you have never
worked with before, you would have to explicitly tell her which tool you
want her to hand over to you. Sometimes you have to repeat your instructions
several times before she gets it. Yet if the nurse is someone whom you have
worked with before, and she is familiar with your style, she could anticipate
your needs. In that case, you don’t have to tell her explicitly. Sometimes a
glance will do. She would know exactly which tool you want her to hand
over. (Junior-level General Surgeon at the PLA hospital)
Every time when there is a new group of nurses fresh from school, we know
we are in for a rough ride. It would take these new nurses longer to find the
instrument you want. If the nurse is experienced, she will know what
instrument you want and give you what you want the minute you stretch out
your hand. (Intermediate-level Cardiac Surgeon at the PLA hospital)
Preoperative Case Conferences. Preoperative case conference is another
important venue where interdisciplinary knowledge sharing occurs. In both hospitals
of study, anesthesiologists and in some cases, a senior-level OR nurse, are invited to
join the preoperative case conferences held by surgical departments. Preoperative
case conferences are required only for major surgeries, surgeries involving a new
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technique, and surgeries involving complex and difficult cases . For surgeries
involving a new technique, the head of the department of anesthesia and senior-level
OR nurse(s) are invited to join the conference. For other surgeries that require a
preoperative case discussion, in most cases, only an anesthesiologist who is
scheduled to take part in interdepartmental consultations during the particular day is
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Preoperative case conferences are often chaired by the head of the surgical
department or a surgeon with a senior-level professional title. The head nurse of the
department might be invited to participate in these conferences when the surgeries
involve a new technique
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invited. The anesthesiologist who joins the preoperative case conference is not
necessarily the one who is assigned to the procedure for that case. At a preoperative
case conference held in a surgical department, members of the surgeon team in
charge of the patient take turns in presenting the case in ascending order of seniority,
beginning with the most junior surgeon and ending with the most senior surgeon.
The case presentation usually includes a report on the patient’s conditions, his or her
diagnosis, his or her preoperative treatment and preparations, proposed surgical
procedures, patient positioning, incision, and proposed preventive measures or
countermeasures for possible postoperative complications. The invited
anesthesiologist shares his or her opinions on the appropriate
anesthetic procedures and preventive measures of possible anesthetic incidents. The
invited OR nurse also shares her informed opinions.
The interviewed junior-level and intermediate-level anesthesiologists
mentioned that interdisciplinary knowledge sharing in the preoperative case
conference held by surgical departments helped them gain a better understanding of
the tasks performed by the surgeons and facilitated their coordination with surgeons
at the operating room. A number of surgeons, most of whom were junior-level and
intermediate-level surgeons, concurred with the anesthesiologists, acknowledging the
usefulness of knowledge shared by the anesthesiologists, whereas other surgeons
seemed to discount the value of such knowledge.
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The department of anesthesia at both hospitals also holds weekly
preoperative case conferences, which are attended by anesthesiologists and OR
nurses affiliated with the anesthesia department. Some knowledge sharing occurs
between anesthesiologists and OR nurses during these conferences. Many
interviewed junior-level OR nurses commented that these conferences helped them
gain a better understanding of anesthesiologists’ work, which in turn facilitated their
coordination with anesthesiologists.
Surgical Wards. Anesthesiologists and surgeons also exchange and share
knowledge in surgical wards prior to the day of surgery. As stipulated by the hospital
rule, the assigned anesthesiologist(s) should pay a preoperative visit to the patient to
take a preanesthetic history and physical before choosing the anesthesia plan for the
patient. The anesthesiologist would usually consult the patient’s medical records and
share knowledge with surgeons on the team. Quite a few surgeons mentioned that
there might be some pre-operative communication about the patient’s anesthesia
expenses, though they admitted that they couldn’t form an informed judgment about
the anesthesiologist’s choice of medications.
The anesthesiologist might not know about a particular patient’s budget. The
patient’s budget is of no concern to him. Yet for us, this is a big issue. If the
operation leads to an over-running of the budget and the patient can’t pay
what’s above the budget, the hospital has a rule of deducing that amount from
our salary. (Attending Orthopedist at the MOH hospital)
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Intradisciplinary Knowledge Sharing Within Surgeons, Anesthesiologists, and OR
Nurses
In the teams of study, much more knowledge was shared among members
«
from the same discipline than among members from different disciplines.
Interviewed members reported sharing technical specialty knowledge (e.g., surgical
skills, diagnostic skills, and theoretical medical knowledge), social knowledge (e.g.,
patient-physician communication skills, interpersonal skills, knowledge about other
team members, and knowledge about department and hospital norms, rules, and
policies), and knowledge of other disciplines (e.g., English and computer skills) with
others from the same discipline, particularly their teammates from the same
discipline.
Like other Chinese public hospitals, the two hospitals under study still use the
traditional one-on-one apprenticeship model for training surgeons, anesthesiologists,
and OR nurses. The training of surgeons takes place in teams where they are
assigned a more senior supervisor or a mentor. As mentioned earlier, surgeons on a
Chinese surgical team typically come from the same medical care team that consists
of surgeons with professional titles across the senior level, the intermediate level,
and the junior level. The senior-level surgeon supervises the training of the
intermediate-level surgeon, whereas the intermediate-level surgeon supervises the
training of the junior-level surgeon. A great proportion of knowledge sharing among
surgeons on a medical care team flows downward from the senior-level surgeon to
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the intermediate-level surgeon and from intermediate-level surgeon to the junior-
level surgeon. The training of anesthesiologists is somewhat different from that of
surgeons. Only junior-level anesthesiologists are assigned supervisors on a one-on-
one basis, most of whom are intermediate-level anesthesiologists. Intermediate-level
and senior-level anesthesiologists have no direct personal supervisors. The training
of OR nurses differs from that of both surgeons and anesthesiologists. Only
unlicensed OR nursing trainees and OR nurses transferred from other institutions are
assigned a supervisor and they must work directly under the supervision of their
supervisors until they are properly licensed or pass the required skill and knowledge
test.
When a new nurse fresh from the school is hired into our department, the
department will assign a senior, experienced nurse as her mentor. The
mentor-disciple arrangement would last for at least one year. The actual
length varies with nurses. Yet if a new nurse is transferred from another
hospital and has some working experience, she will receive re-training that
lasts from 3 to 6 months. The nurse will be tested for her professional skills.
If she passes the exam, she can work on the night shift on her own. Before
she passes the exam, she can only work on the night shift with her mentor.
(Intermediate-level OR Nurse at the MOH Hospital)
In the teams studied, intradisciplinary knowledge sharing within a team
comprises primarily downward knowledge sharing from senior members to less
senior members, followed by limited upward knowledge sharing from lower-level
members to higher-level members, and some occasional peer knowledge sharing in
teams with two members of the same rank. Only 3 out of 27 teams studied had two
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surgeons of the same rank, whereas 24 teams had a surgeon subgroup that consists of
three surgeons across the junior, the intermediate, and the senior levels.
We have a one-on-one trainer-trainee relationship in our department. You
will be assigned a more senior anesthesiologist who supervises your training.
Most of the knowledge sharing between you and your supervisor is one-way,
from your supervisor to you, because your supervisor is the one with richer
clinical experience. (Intermediate-level Anesthesiologist at the MOH
hospital)
I would say a huge part of the knowledge sharing is from the mentor to the
disciple. The mentor teaches you a lot of things, like good hygiene habits,
how to prioritize tasks, and how to put the operating table together. For
instance, my mentor taught me that I should meet the surgeon’s immediate
needs first. Let’s say, we have a patient on the operating room who is
bleeding a lot. The surgeon asks you for the gauze. You should hand him the
gauze first, and sanitize the contaminated instruments later. The things that I
learned from my mentor really helped me a lot in my work. (Junior-level OR
Nurse at the MOH hospital)
The top two formal venues of intradisciplinary knowledge sharing reported
by surgical team members are: (a) the operating room, and (b) department
conferences (including but not limited to preoperative case conferences, complex
clinical case conferences, mortality conferences, departmental teaching conferences,
and regular daily morning department conferences). Another important formal
venue mentioned by surgeons is ward rounds (including team ward rounds, teaching
and grand ward rounds).
Operating Room. Operating room is an important training venue for
surgeons, anesthesiologists, and OR nurses of all seniority. Most of the
intradisciplinary knowledge sharing flows downward from senior members to more
junior members. Take the surgical training of surgeons in Chinese surgical teams for
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instance. It roughly follows the seven-step model of progression described by
Hargreaves (1996): “step 1: trainee observes” “step 2: trainee assists the coach” “step
3: trainee does under coach’s supervision” “step 4: trainee does with the coach in the
vicinity” “step 5: trainee does on his or her own” “step 6: trainee perfects it through
regular practice” “step 7: trainee now a teacher and teaches it” (p. 1636).
Such teaching starts from the very basic stuffs. You first learn how to walk.
Later on you will learn how to run and even how to do some acrobatics. You
have to take your time. You can’t build up your constitution on one mouthful.
The department will assign surgeons with increasing seniority to mentor you.
When your supervisor feels you are competent enough, they will give you
chances to do the solo flight, while watching you closely from a distance
(Intermediate-level Cardiac Surgeon at the PLA hospital).
Many interviewed surgeons reported that the amount of intra-operative
knowledge sharing among surgeons was positively associated with the degree of
routinization of the surgical procedure and the smoothness with which the procedure
went. A few surgeons explicitly pointed out that the degree of a procedure’s
routinization was not necessarily associated with the procedure’s difficulty. It was
suggested that some simple and low-risk procedures might require much real-time
communication during the procedure because some decisions had to be made on the
If the surgery goes smoothly and everything is under control, you could
afford to spend some time teaching. If nothing unexpected crops up and the
patient’s condition is stable, you could afford to explain the steps in details
while performing the surgery. You might give him [her] chances to touch the
tissues to get a feeling of the organization. If the patient’s condition is very
severe and the surgery does not go smoothly, you are already strained and
totally preoccupied with the surgery. You don’t have the time and energy to
teach. You might choose to teach him [her] after the operation, if he [she] has
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specific questions about the case. (Intermediate-level Cardiac Surgeon at the
PLA hospital)
However, some junior-level surgeons observed that there were cases of very
little teaching in routine surgical procedures in their teams. Some orthopedists at
both hospitals added that intra-operative knowledge sharing might decrease when the
patient was conscious during the operation.
Most of our patients receive local or regional anesthesia instead of general
anesthesia. And they remain conscious throughout the procedure. You don’t
do much teaching in those procedures. You do it outside the operating room.
You do more teaching in cases where patients receive general anesthesia.
(Intermediate-level Orthopedist at the PLA hospital)
Department Conferences. A wide variety of department conferences have
been reported by many surgical team members as major venues for intradisciplinary
knowledge sharing, including but not limited to, preoperative case conferences,
complex clinical case conferences, mortality conferences, as well as daily and
weekly department working conferences (See Appendix M for a detailed description
of these conferences). Many surgeons and anesthesiologists, particularly those with a
junior-level title or an intermediate-level title, indicated that they learned many
valuable things from these conferences that exposed them to a larger pool of cases
than what was available in their own teams and to the knowledge and expertise of
senior members from other surgical teams.
Ward Rounds. Ward rounds, including team ward rounds and grand ward
rounds, were reported by most interviewed surgeons in the teams of study as an
important venue for intradisciplinary knowledge sharing. Every morning the
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surgeons on these teams have a team ward round, the length of which varies with the
number of patients they have and the severity of the patients’ conditions. Senior
surgeon(s) on the team share their diagnosis and treatment skills with their junior
teammates in the rounds.
Surgeons on these teams also participate in a weekly grand ward round,
which is headed by the administrative head of their respective department. The grand
ward round usually has a teaching component, in which the head of the department
tests surgeons of all levels on general diagnostic and treatment knowledge, thus
facilitating the inculcation of these knowledge. The weekly grand ward round could
last for up to 3 hours.
Besides the three venues of operating room, conferences, and ward rounds,
surgical team members also mentioned many other venues, such as the physicians’
office and the nurses’ office, and shift handovers, where they might have formal or
informal discussion and conversations. For instance, quite a few surgeons reported
having informal preoperative case discussions with their surgeon teammates and
trusting colleagues on other teams at the physicians’ office for those cases that do not
require to be presented in preoperative case conferences. Some surgeons also
reported having informal postoperative case discussions with their teammates and
colleagues on other teams in addition to the formal mortality and morbidity
conferences.
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Nature o f Knowledge Shared
RQlb: With whom and where do Chinese surgical team members share face-
threatening knowledge?
Consistent with Gao and Ting-Toomey’s (1998) characterization of the zi jin
ren (“insider”) focus of Chinese communication, Chinese surgical team members
studied reported a tendency to voluntarily share more sensitive, personal knowledge
(e.g., one’s own mistakes and errors) with insiders (often including both their
teammates from the same discipline and their circle of trusting colleagues) than with
outsiders. Such sharing was reported to take place more often in private settings than
in public settings.
Failures are an important type of face-threatening knowledge: the sharing of
one’s own failures involves great interpersonal risks and potential damage to one’s
career. In the medical field, the owning up of one’s failures often puts one in a
vulnerable position when it comes to litigation. Although it is widely acknowledged
that failures are an important source of clinical knowledge, it has been documented
in the literature that health professionals tend to cover them up if possible (Tucker &
Edmondson, 2003; Weick & Sutcliffe, 2003; Walton, 2004).
In this study, examples of coded failures included errors, mistakes, problems,
incidents, and medical mishaps. In the teams of study, the sharing of failures
exhibited the following patterns: (a) minor failures were shared less often than major
failures in public settings, (b) most of the sharing of failures occurred behind closed
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doors and was often contained within the department with which the responsible
surgical team member was affiliated, and (c) senior-level members were more likely
to voluntarily share their failures (particularly past failures) with their teammates
than intermediate-level and junior-level members were.
The nature of surgical teams’ task dictated that it was very difficult to hide
failures, particularly failures with great, direct consequences, from one’s teammates
and colleagues on other teams.
Let’s say one surgeon wounded a patient’s spleen by mistake during
gastrectomy. The sharing of such knowledge would set off the alarm for other
surgeons. They would make great efforts to avoid making the same mistake
when performing gastrectomy in the future. Inside our department, we don’t
hide our failures and mistakes from one another. We discuss them frankly
and openly to make sure such failures and mistakes will not occur again. I
admit that there are some surgeons who don’t want to talk about their failures
and mistakes out of face concern or out of concern about medical disputes.
They might distort their records. They might say cutting the patient’s spleen
is part of the original operation program. In some cases, during radical
operations for gastric cancer, it’s all right to cut the spleen along with the
stomach in order to clear the contaminated lymph nodes. Yet if the cutting of
the spleen were not in the original operation program, we onlookers would
have easily detected this mistake. (Senior-level Oncologist at the MOH
hospital)
Hospital policies stipulate that major failures should be investigated. This
means that surgical team members are forced to share major failures with others in
formal, public settings. Such public sharing is usually confined within a department.
The quality of passive, public sharing was suggested to be much lower than that of
active, private sharing between the surgical team member involved and his or her
trusting colleagues (often including his or her teammates).
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You might be able to cover up small failures within your medical care team.
But it is almost impossible to cover up major failures. You have to share your
failures with surgeons from other medical care teams in your department,
whether you like it or not. That’s required by hospital and department
policies. The quality or openness of such sharing varies with surgeons, but is
not very high in most cases, especially when such sharing occurs in
department meetings. There are lots of reasons for that, like people’s mian zi
(face), and their fear of litigation. Under today’s increasingly harsh health
care environment, you can’t expect people to be very frank and open when
discussing their own failures. But I would say most surgeons have a strong
desire to find out what caused their failures. You either figure it out on your
own by consulting textbooks, journals, and other publications, or consult with
your friends and colleagues you trust. The quality of sharing is much higher
in such private settings. (Senior-level General Surgeon at the MOH hospital)
Many interviewees drew a distinction between the sharing of one’s own
failures and the sharing of others’ failures. They suggested that they tended to focus
on the failures per se rather than blaming the parties involved when discussing
others’ failures, particularly in public settings. For example, one intermediate-level
oncologist from the PLA hospital commented:
Failure stories are not taboos. In most occasions, we wouldn’t try to cover
them up. I would say we talk more about failure stories than about success
stories in our department. If you failed your operation, made some errors, or
even had malpractices, all people in the department would know about it. We
would touch on these experiences during our discussion. But it was kind of
tricky when discussing such failure stories. Usually, you wouldn’t bring
others’ failures up during discussion. It’s very improper. It’s all right if you
talk about your own failures though.
They also pointed out that many surgical team members tended to admit
failures involving highly complex or technically demanding cases but were less
likely to own up to failures involving less complex or routine cases out of face
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concerns. Minor failures were suggested to be often covered up within surgical teams
and excluded from outsiders.
Senior surgical team members who were more experienced and more
confident expressed much less hesitation sharing their failures with their teammates.
One senior-level general surgeon at the MOH hospital said that he sometimes
intentionally told such stories to more junior surgeons on his team to show his
empathy, to encourage them, and to cheer them up when they ran into difficulty.
The literature has suggested that the hierarchical structure of surgical teams
hinders lower-level surgical team members from speaking up (Edmondson, 2003 a;
Helmreich & Merritt, 1998). The same pattern occurred in the Chinese surgical
teams studied. Many interviewed junior-level and intermediate-level surgical team
members reported that they were less likely to speak up and share their disagreement,
criticism, and tentative ideas with higher-level members on their own teams and
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those on other teams than with their peers in public, formal settings . Senior surgical
team members reported less hesitation in sharing such knowledge.
RQlc: Are Chinese surgical team members more likely to share their expertise with
teammates from the same discipline than with people on other teams, particularly
with peers on other teams?
In the teams of study, many surgeons, particularly those senior-level and
-----------------------------------------
When asked whether they would speak up when the actions or decisions of higher-
level members threaten the patient’s safety, most interviewed surgical team members
answered yes, though many of them added that such occasions were rare.
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intermediate-level surgeons made a clearer distinction between their colleagues
within and outside their teams than anesthesiologists and OR nurses did. They
reported sharing expertise with other surgeons on their team more frequently than
with surgeons on other teams. However, the few interviewed anesthesiologists and
OR nurses reported making a less distinction between inside and outside team
members. They reported that the y were as likely to share expertise with their
teammates as with others outside their team. As a matter of fact, many of them
reported regarding all their colleagues from the same discipline as their teammates.
This difference between surgeons and anesthesiologists as well as OR nurses
resulted from the varying stability of these three subgroups. As mentioned earlier,
surgeons on Chinese surgical teams studied are much more stable than
anesthesiologists and OR nurses are. They tended to identify more strongly with their
individual teams than with the department as a whole, whereas anesthesiologists and
OR nurses tended to identify with their department more strongly.
A great many intermediate-level and senior-level surgeons were found to be
unwilling and unlikely to share their expertise (e.g., surgical skills) with peers on
other teams, who competed with them for desirable resources (e.g., promotion,
bonus, and housing). In contrast, junior-level surgeons were found to be more likely
to share their expertise with their peers. Peer knowledge sharing among
anesthesiologists was suggested to be adequate, whereas peer knowledge sharing
among OR nurses of all seniority was found to be smooth, open, and good.
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Knowledge Sharing Communication Strategies and Styles
RQld: Do Chinese surgical team members use a deferential, indirect, and polite style
of communication when sharing knowledge with higher-ranking and/or elder
teammates?
RQle: Do Chinese surgical team members use an indirect and polite style of
communication when sharing knowledge with their peers and subordinates who are
not older than them?
Status and the nature of knowledge play a very important role in influencing
interviewed Chinese surgical team members’ choices of communication strategies
when sharing knowledge with others. Almost all interviewed surgical team members
reported adapting their communication styles to the relative status of the recipient
when sharing knowledge, especially when sharing face-threatening knowledge. The
following comment made by an intermediate-level plastic surgeon at the MOH
hospital represented the typical strategy used by most interviewed surgical team
members:
Of course, you should adjust your communication style to the relative status
of the person you are sharing knowledge with. If he [she] is of a higher rank,
I would use a more polite, more indirect way of communication. But if he
[she] was of the same rank as I or of a lower rank and I knew him [her] well,
I would be more direct and less reserved in my sharing.
Almost all interviewed surgical team members stressed that it was important
that one should appear humble, modest, agreeable, and respectful when
communicating with one’s superiors and that one should express one’s opinions in a
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subtle, polite, indirect, non-threatening, and face-saving way (e.g., using phrases like
“perhaps,” “maybe,” “I’m not sure,” “why not,” and “it might also work”). Many
interviewed junior-level and intermediate-level surgical team members further added
that they were less likely to share face-threatening knowledge with higher ranking
surgeons in public settings because doing so conflicted with the cultural rule of
“giving others face” that disapproved of public disagreements. They mentioned that
they preferred to share such knowledge in private settings in order to preserve
interpersonal harmony and the hierarchy. For example, one intermediate-level
neurosurgeon at the MOH hospital commented,
In mortality and morbidity conferences, you should never directly criticize
others, saying their course of treatment is wrong. Rather, you might say
things like, “your course of treatment is okay, yet we might need to consider
using another course of treatment in future cases.” You should soften your
advice and make it less threatening to them. You need to appear respectful
and modest. You shouldn’t give them the impression that you are using this
opportunity to show off your knowledge. This way you could express your
opinion while at the same time saving their faces. This is particularly
important when the surgeon responsible is your senior.
One junior-level orthopedist at the PLA hospital also concurred with the
importance of using a subtle, indirect style of communicating disagreement with
higher-ranking surgeons.
I will speak only once. I will not insist on my opinion. If the senior surgeon
does not follow up on it, I just let it pass. If the senior surgeon shows some
interest in my advice and probes me with more questions, I will elaborate on
it. Another thing is that you should express your disagreement in a subtle
way. You should not pass a value judgment on his [her] opinions. I will never
put it so bluntly, saying your opinion is wrong, mine is right. This is not a
matter of right and wrong. The opinions differ only in terms of their degrees
of goodness. (Junior-level Orthopedist at the PLA hospital)
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Almost all interviewees reported using a more direct style of communication
when sharing knowledge with their peers than with their higher-ranking colleagues.
But many of them made a distinction between peers who were elder than them and
those who were not: they reported using a more polite, indirect, and deferential style
of communication when sharing knowledge with elder peers, but a more direct style
of communication with peers who were of the same age as them or were younger
than them . This distinction could be traced back to the Chinese cultural norms of
being respectful and deferential to their elders. Another qualification made by quite a
few interviewees is regarding the nature of knowledge to be shared. They observed
that if the knowledge to be shared was face-threatening, they would tend to share
such knowledge in a polite, subtle, and face-saving manner, even with peers with
whom they had a good relationship.
When you make suggestions to others [your peers], there is always the risk
that others might misinterpret your suggestions as mean criticism. Therefore,
you have to take this risk into consideration when making suggestions. If you
are on good terms with them, you know they won’t misinterpret your
suggestions. This makes it easier for you to say unpleasant things. If you are
not on very terms with them, you might as well hold your tongue. Even if you
are on good terms with them, you might want to have the discussion in
private settings and be careful with the words and phrases you use. It’s better
to make your suggestions indirectly. You could say things like “why not put
the plate another way” or “why not use the other plate”. (Junior-level
Orthopedist at the MOH hospital)
__
As mentioned earlier, the age variation among Chinese surgical team members of
the senior level and the intermediate level has increased because of the promotional
policies favoring physicians and nurses with an advanced degree. Therefore, I
explicitly asked the interviewed surgical team members whether they made a
distinction between peers who were their elders and those who were not.
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Most interviewed intermediate-level and senior-level surgical team members
reported using a direct style of communication when sharing knowledge (including
face-threatening knowledge) with their lower-ranking colleagues, except when the
latter are older than them. They said that they used a less direct style of
communication with elder colleagues who were of lower ranks.
RQlf: Do the knowledge sharing behaviors of Chinese surgical team members
exhibit a listening-centered tendency?
The asymmetrical patterns of superiors talking and subordinates listening
described by Gao and Ting-Toomey (1998) as part of the listening-centered feature
of Chinese communication also received some support from the interviews’
descriptions of knowledge sharing in formal settings, including but not limited to
department meetings and conferences, inter-department conferences, ward rounds,
and operating rooms. Many interviewees reported that senior-level surgeons,
anesthesiologists, and OR nurses tended to dominate these discussions and engage in
more active knowledge sharing than their intermediate-level and junior-level
colleagues did. Intermediate-level surgeons, anesthesiologists, and OR nurses were
said to speak up more often than their junior-level colleagues. An interesting
sidenote to this is that the case discussion policies issued by the MOH hospital
explicitly stipulated that surgeons with an intermediate-level professional title or a
senior-level professional title should actively participate in complex clinical case
conferences and preoperative case discussions by speaking up.
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RQ2: How do members of Chinese surgical teams perceive, interpret, and account
for knowledge sharing within and between surgical teams, including their own
knowledge sharing behavior?
The first research question examines the knowledge sharing patterns in
Chinese surgical teams. The second research question investigates Chinese surgical
team members’ expectations, perceptions, and interpretations of both
intradisciplinary and interdisciplinary knowledge sharing within their teams, of
knowledge sharing between surgical teams, as well as their interpretations of their
own knowledge sharing behaviors.
Perceptions and Interpretations o f Interdisciplinary Knowledge Sharing
As described earlier, interdisciplinary knowledge sharing among surgeons,
anesthesiologists, and OR nurses in the teams of study was far less frequent and of
lower quality than intradisciplinary knowledge sharing among them. The fluid and
temporary membership of anesthesiologists and OR nurses on a surgical team was
suggested to decrease and hinder interdisciplinary knowledge sharing,
communication, and coordination within the team.
Surgeons on my team are much more stable than anesthesiologists and OR
nurses on my team. I am more familiar with my surgeon teammates than with
those anesthesiologists and OR nurses whom I work with. I have better mo qi
(“shared mental model”) with my surgeon teammates. We know each other’s
strengths and weaknesses, personality, and work styles. We share knowledge
with each other openly and quite effectively. In contrast, knowledge sharing
with anesthesiologists and OR nurses is less open and less effective. Since the
anesthesiologists and OR nurses assigned to my team change from procedure
to procedure, we are not that familiar with one another. This makes
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coordination and knowledge sharing more difficult. (Senior-level Oncologist
at the PLA hospital)
Knowledge sharing between surgeons and OR nurses was less often when
compared with that between surgeons and anesthesiologists and that between
anesthesiologists and OR nurses. The varying frequency of knowledge sharing
between these three subgroups was attributed to the differing level of coordination
required between them and the differing frequency of interaction between them. It
was suggested that the coordination between surgeons and anesthesiologists was
more complicated and more critical than that between surgeons and OR nurses and
that between anesthesiologists and OR nurses. Furthermore, surgeons interact with
anesthesiologists more often outside the operating room than with OR nurses:
anesthesiologists attend the preoperative case conferences held by surgical
departments and visit surgical wards. OR nurses interact with anesthesiologists more
often with surgeons outside the operating room due to their common affiliation with
the same department and the resulting physical proximity.
Although almost all interviewed surgical team members agreed that
interdisciplinary knowledge sharing in surgical teams was of lower quality than
intradisciplinary knowledge sharing, surgical team members of differing status
varied in their perception of the exact level of quality. In the teams of study, surgical
team members with a senior-level professional title tended to perceive
interdisciplinary knowledge sharing more favorably than those with an intermediate-
level or junior-level title. They reported less hesitation in sharing their opinions with
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teammates from other disciplines and explained that their opinions were more valued
by their teammates. A number of interviewed junior-level surgeons mentioned that
they were hesitant to seek knowledge from more senior anesthesiologists and OR
nurses, though they came from a higher-status subgroup.
In most teams of study, there was a clear “us vs. them” mentality among
surgeons, anesthesiologists, and OR nurses, who identified more with their
individual subgroups than with the team as a whole. Many interviewed surgeons
discounted the value of knowledge shared by anesthesiologists and OR nurses, which
reflected the status hierarchy among the three subgroups. They saw themselves as the
most important group, followed by anesthesiologists, and finally by OR nurses. They
believed that the successful completion o f the surgical procedure was determined
mainly by their technical expertise. In contrast, the few interviewed anesthesiologists
saw themselves play an equally important role in the procedure. Such differences in
role perceptions between surgeons and anesthesiologists hindered their coordination,
communication, and knowledge sharing. A couple of incidents involving task-related
conflicts between surgeons and anesthesiologists were brought up in the interviews.
However, most interviewed OR nurses seemed to accept the existing hierarchy in
surgical teams and reported engaging in limited interdisciplinary knowledge sharing
with the two physician groups.
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Anesthesiologists ’ and OR nurses ’ Perceptions and Interpretations o f
Intradisciplinary Knowledge Sharing
Only a total of 6 anesthesiologists and 10 OR nurses were interviewed in this
study. The findings on their perceptions and interpretations of intradisciplinary
knowledge sharing among anesthesiologists and OR nurses were preliminary and
suggestive. As described earlier, only junior-level anesthesiologists (resident
anesthesiologists), unlicensed OR nursing trainees, and OR nurses transferring from
other institutions have personal supervisors at these two hospitals under study. The
interviewed anesthesiologists at both hospitals reported good vertical knowledge
sharing and adequate peer knowledge sharing within their department. The majority
of senior-level and intermediate-level anesthesiologists at both hospitals were said to
be willing to share their knowledge with their more junior colleagues when
requested. The good vertical knowledge sharing was attributed to department
cohesiveness, the open and supportive department knowledge sharing climate,
exemplary department leadership, as well as their department’s
individual/department hybrid bonus plan.
If there is anything that I can’t handle during the procedure, I would ask my
supervisor. If he [she] still can’t fix it, we would invite other senior
anesthesiologists who are working in other operating rooms to our table to
discuss the case. If no senior anesthesiologist happens to be around, we might
page whoever is available to seek his [her] opinion. (Junior-level
Anesthesiologist at the MOH hospital)
The head of my department shares knowledge openly with us. He also
encourages us to speak up. He values what we say. He sets a very good
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example to us. I feel very safe and comfortable speaking up. (Intermediate-
level Anesthesiologist at the MOH hospital)
We have a total of 10 anesthesiologists at our department. There is not much
intentional knowledge hoarding. Senior-level anesthesiologists share their
expertise openly with their juniors. This has a lot to do with the trusting and
open climate at our department. (Senior-level Anesthesiologist at the PLA
hospital)
Knowledge sharing among peer anesthesiologists was said to be acceptable,
despite being less open and active than vertical knowledge sharing among
anesthesiologists. As one intermediate-level anesthesiologist at the MOH hospital
put it, “you can’t expect people of the same grade to be completely open and
thorough with one another. After all, they compete with one another for promotion. I
would describe the peer knowledge sharing at my department as acceptable and
adequate.”
The interviewed OR nurses at the MOH hospital reported good vertical and
peer knowledge sharing among OR nurses at their department. Good interpersonal
relationships, as well as open and safe department knowledge sharing climate were
suggested to contribute to high-quality knowledge sharing.
We [OR nurses] are like a family. We have a culture of mutual help and
cooperation. As long as a nurse shows proper respect to her seniors and puts
the request politely, most of the senior nurses will willingly share their
experiences with her. (Intermediate-level OR Nurse at the MOH hospital)
I often share my failure experiences with other junior OR nurses in my
cohort. They are very sympathetic and provide very strong emotional
support. I just feel more comfortable talking about these experiences with
them. Another reason is that I believe they would benefit more from my
experiences. Since we are on the same starting line and have a similar level of
knowledge, we are likely to make similar mistakes. If I share my lessons with
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them, it would prevent them from repeating my mistakes. (Junior-level OR
Nurse at the MOH hospital)
When asked about the good peer knowledge sharing they had, most of the
interviewed OR nurses explained that: (a) they had fewer interest conflicts with their
peers because their department used the individual/department hybrid bonus plan and
they, unlike surgeons, did not compete with one another for patients, and (b) their
work did not involve much complicated skills and techniques that could be withheld
and are worth being withheld from others. It was said that most o f the knowledge
they used in their work could be readily found in books and journals and were also
mastered by other OR nurses. They said that it did not make sense to intentionally
hoard one’s knowledge from others, since it would harm one’s relationships with
those knowledge seekers who could learn it through other ways. Two interviewed
anesthesiologists also made similar comments. As will be discussed later, some
interviewed surgeons also made comments in this regard.
I coined the term “knowledge hoarding efficacy” to describe this belief held
by an individual regarding the feasibility and the cost/benefits of withholding certain
knowledge from others. An individual who believes in the low feasibility, high costs,
and low benefits of withholding certain knowledge from others is said to have low
knowledge hoarding efficacy with regard to the knowledge under question. The OR
nurses and anesthesiologists described in the previous paragraph are good examples
of individuals with low knowledge hoarding efficacy. An individual who believes in
the high feasibility and high benefits of withholding certain knowledge is said to
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have high knowledge hoarding efficacy with regard to the knowledge under
question. The preliminary data from this study suggested that a surgical team
member’s knowledge hoarding efficacy regarding a particular knowledge was
suggested to be negatively related to his or her sharing of that knowledge. In other
words, a surgical team member with a low knowledge hoarding efficacy regarding a
particular knowledge was found to be more likely to share it with others.
Surgeons ’ Perceptions and Interpretations o f Intradisciplinary Knowledge Sharing
Intrateam vs. Interteam Knowledge Sharing. In the teams of study,
knowledge sharing among surgeons on the same team was reported to be much more
often, more open, more thorough, and more active than that among surgeons on
different teams. The intrateam/interteam knowledge sharing quality and frequency
distinction was attributed to: (a) the good, cooperative relationships among surgeons
on the same team and the potentially competitive relationships among surgeons on
different teams, and (b) the duty of senior-level and intermediate-level surgeons to
share knowledge with their more junior surgeon teammates but not with other junior
surgeons outside their teams. The intrateam/interteam knowledge sharing frequency
distinction was also attributed to the more interdependent nature o f surgeons on the
same team when compared to those on different teams. This insider/outsider
distinction was greater in those surgical teams with more stable surgeons, and in
surgical teams using an individual/team hybrid bonus plan.
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Cooperative & Competitive Relationships. Most surgeons on the teams of
study reported getting along with their surgeon teammates. The cohesive
relationships among surgeons on the same team partly resulted from the way surgeon
subgroups were formed and the composition of these surgeon subgroups. As
explained earlier, although surgeons on these surgical teams do not have final control
over which other surgeons they will be working with on the same team, they do have
some say in choosing their teammates. Many interviewed surgeons reported that
their expressed preferences for or against particular individuals as their teammates
were often taken seriously by the head of their department who made the final
teaming decision. This was further confirmed by several interviewed heads of
surgical departments at both hospitals, who commented that they would put surgeons
who got along with one another on the same team, if conditions permitted.
If I were on very good terms with a higher-level surgeon, I would ask the
head of my department to put me on that surgeon’s team. If I don’t like a
higher-level surgeon who is not that skilled and is difficult to get along with,
I would tell the department head explicitly that I don’t want to be on his team.
This is the same with the higher-level surgeon. They would also express their
preferences. The head of the department would take our opinions seriously.
He doesn’t want to cause himself unnecessary trouble if the people on the
same team don’t get along with one another. When you work with people you
like, this makes your work much easier. You could count on them for help
and guidance. You could learn more things from them. (Junior-level
Orthopedist at the MOH hospital)
I am on very good terms with my teammates. We share knowledge with one
another very openly. I guess it is like a virtuous cycle. We are on the same
team, working toward the same goal. We have shared interests. We get along
with one another. Naturally, we share knowledge openly with one another.
The open knowledge sharing among us in turn further cements the great
interpersonal relationships we have. Then another cycle starts. Another thing
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is that if people on the same team don’t get along with one another and it
affects the quality of their work, the head of the department could always
intervene, pull one member out, and put him [her] on another team.
(Intermediate-level Oncologist at the MOH hospital).
In 24 out of 27 teams studied, surgeons on the same team were of different
ranks, therefore not competing with one another directly for promotion. Such
composition of these teams was said to obviate potential competitive relationships
and make it easier for surgeons to form and maintain cooperative relationships with
their teammates. The absence of competitive relationships among surgeons in these
teams was suggested by many surgeons to facilitate open, thorough, and active
knowledge sharing, including the active or voluntary sharing of face-threatening
knowledge, among them.
Only 3 out of 27 teams had 2 surgeons of the same rank31. Although
knowledge sharing among peers was less likely and of lower quality than vertical
knowledge sharing in general, the shared team membership of peers on these 3 teams
and their good interpersonal relationships were suggested to mitigate their potentially
competitive relationships and to facilitate knowledge sharing between them.
As explained earlier, the composition of surgeons on surgical teams
determines that one’s peers are often outside one’s team. Peer relationships at the
surgical departments studied and the two hospitals in general were suggested to be
3 1 Of the three teams, there were 2 orthopedics team (one with 2 intermediate-level
orthopedists and one with 2 senior-level orthopedists) and 1 cardiac surgery team
(with 2 senior-level cardiac surgeons) at the MOH hospital.
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quite competitive. It was partly attributed to the newly adopted personnel and reward
policies and practices, which was a part of the nation-wide public hospital
marketization reform in China. As described earlier, the current personnel policies
stipulate that a surgeon’s base salary is tied to his or her professional post, rather
than his or her professional title, and that a surgeon is hired for a professional post on
a contract basis, rather than on a permanent basis. These policies were said to result
in increased competition among surgeons with the same professional title, who
competed with one another for a fixed number of professional posts32.
You might not believe this. But there are cases where a surgeon is more
willing to share his [her] knowledge with people in other hospitals than with
his [her] peers at his [her] own hospital. The reason is pretty simple, because
people in other hospitals do not pose a direct threat to him [her] when it
comes to promotion, housing, bonus, and other rewards. This shows how
severe the competitions among surgeons of similar qualifications in Chinese
public hospitals are. (Intermediate-level Orthopedist at the MOH hospital).
Chinese cultural traits of “infighting and inability to cooperate”, “excessive
concern with mian z f \ and “narrow-mindedness and intolerance” were evoked by
many interviewed surgeons to explain the observed poor interteam knowledge
sharing in their department. These three cultural traits were rated as the top three
weaknesses of the Chinese culture in an ongoing online survey on the weaknesses
__-----------------------------------------
The intense competition for professional posts was suggested to be related to the
fact that a surgeon’s salary, bonus, housing, and other benefits were, to a great extent,
determined by his or her professional post. Like other Chinese public hospitals, these
two hospitals provide housing for their employees. The size and the conditions of the
apartment allotted to employees are to a large extent determined by the grade of their
professional title and their organizational tenure.
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and strengths of the Chinese people33. These concepts could be traced back to Yang
Bo, a Taiwanese intellectual, and his book titled “The Ugly Chinaman”
(1985/1991)34. In that book, Bo compared a Chinese person as a dragon who was
capable of achieving great things when working on his or her own, but he further
noted that, “when three fiery Chinese dragons get together, they can only produce as
much as a single pig, or a single insect, if that much.” (p. 12) Many interviewed
surgeons quoted this metaphor by Bo to describe the competitive relationships
among peers in their department. There are many other household sayings quoted by
the interviewees, such as “one monk drinks from the water bucket on his back; two
.-------------------------------------------
This survey is being conducted at
http://book.sina.com.cn/nzt/1099295539 chouloudezhongguoren/index.shtml. By
January 18, 2005, a total of 19,098 persons had participated in the survey. The
survey asks participants to choose the No. 1 strength of the Chinese people from a
list of 6 categories and the No. 1 weakness of the Chinese people from a list of 9
categories. The distribution of the weakness results was as follows: “infighting and
inability to unite” (24.32 %), “concern for mian zi” (17.43%), “narrow-mindedness
and intolerance” (13.88%), “lacking the capability of independent thinking and
openness to experience” (11.98%), “breaking up in a hubbub” (9.86%), “tendency to
compromise” (8.24%), “carelessness in one’s job” (7.36%), “over-fastidiousness”
(4.74%), and others (2.18%).
3 4 In that book, Yang Bo characterized the Chinese culture as a “soy paste vat” where
the “virus of traditional Chinese culture” still persists in the form of numerous
deplorable national cultural traits (e.g., “filth, sloppiness and noisiness,” “lacking the
capability of independent thinking,” “infighting and inability to cooperate,” and
“propensity to bragging and boasting.”) Although Bo is not an academic on the
Chinese culture, his personal observations and his critique of the traditional Chinese
culture have their own merits and shed important insights into the Chinese culture
that enriched the current cross-cultural and intercultural communication literatures
on China. The popularization of his books testifies to the fact that a huge population
in China buys into his argument.
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monks drink from the water bucket they carry on a pole; three monks have no water
to drink.” (Bo, 1985/1991, p. 12) and “People of the same occupation are enemies”
to explain the observed poor knowledge sharing between surgical teams.
Interpersonal relationships in our department are very complex. There is a lot
of infighting going on. There is severe competition among surgeons of the
same rank. They rarely share their success experiences with one another.
There is like what is described in the saying, “tong hang shi yuan jia .”
[“people of the same occupation are enemies.”] The same could be said of
almost all Chinese organizations. Like what Yang Bo described in his book,
Chinese people are very egoistical. They simply don’t get along with each
other and always fight among themselves. (Intermediate-level General
Surgeon at the MOH hospital)
Many Chinese people are narrow-minded and cannot tolerate having others
more competent than themselves. Some simply downplay or refuse to
acknowledge others’ competence. Others might even scheme against their
successful colleagues. There are a lot of Chinese sayings that warn about the
risks associated with fame and excellence, like “ren pa chu ming zhu pa
zhuang,” [“fame protends trouble for men just as fattening does for pigs,”]
“shu da zhao feng,” [“a tall tree catches the wind” or “a person in a high
position is liable to be attacked,”] and “qiang da chu tou niao.” [“the most
conspicuous bird is to be shot down.”] We have been told that it is not wise to
be the crane standing out among chickens [“standing head and shoulders
above others”] because that will invite a lot of criticism and envy. You could
see many examples of low tolerance of others’ different opinions in
department conferences. Such attitudes hinder department knowledge sharing.
Your colleagues would not volunteer to share their disagreement with you
when they know you would not appreciate or might even resent their
opinions. (Senior-level Oncologist at the MOH hospital)
Competitive peer relationships between the leaders (often a senior-level
surgeon) of two surgical teams were said to often result in a tense, competitive, or
even hostile relationship between the two surgical teams. Junior-level and
intermediate-level surgeons were said to be the collateral damages of such
interpersonal competition: they were not only excluded from tapping into the
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knowledge possessed by surgeons on other surgical teams but also were not
permitted to share knowledge with members on other competing surgical teams, at
least not in public settings without the approval of their team leaders.
There are some cases where two surgical teams have a very competitive
relationship. There is very little knowledge sharing between them at least in
public settings. There is not much you can do in those situations. If the leader
of my team considers the leader of another team as his [her] competitor, I
can’t seek knowledge from him [her] in the presence of my leader without
first consulting my leader. If I did it, my loyalty to him [her] would be called
into question. I can’t share knowledge with members from that team in the
presence of my leader either. Otherwise, I would be considered as a traitor.
Of course, you could seek the opinions of the members on the competitive
team in private, if you have good interpersonal relationships with them. Let’s
say the leader of the competitive team is willing to share the needed
knowledge with me. I still have to consult my team leader and ask for his
approval. I might hide the source of the knowledge from him. But I still need
his approval. Otherwise, I can’t use the new knowledge that I gained. (Junior-
level Cardiac Surgeon at the PLA hospital)
Interteam competition has always been here and is here to stay. It is mainly a
competition between the team leaders in their surgical skills and their
interpersonal skills. Great surgical skills are a big respect earner in our field.
The surgical skills of the team leader are directly related to the number of
patients his [her] team would have. Not many senior surgeons are willing to
share their skills with their peers because of the great financial stakes.
Interpersonal skills are also very important. Let’s say the leader of one team
is very friendly, likes to help others, and is good at communicating with the
patients and securing their trust. This begins a benign circle. The patient
might refer his [her] friends to the surgeon. This might result in a high
demand for this surgeon’s service and increase the surgeon’s popularity.
(Senior-level Urologist at the MOH hospital)
Many interviewed surgeons at the PLA hospital made the general observation
that interteam relationship was less competitive at military hospitals than at civil
public hospitals. They attributed it to the organizational culture of military hospitals
that stressed unity and mutual help and prioritized the collective over individuals.
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It was suggested that many surgeons tended to discount the value of
knowledge held by their peers, did not actively seek knowledge from their peers, and
did not use the knowledge shared effectively. As one interviewed senior-level
orthopedist at the MOH hospital aptly put it, “quite a few surgeons are reluctant to
acknowledge that their peers possess knowledge that they don’t have. They tend to
think that they are on the same level with their peers. It is a mian zi [face] thing. So
they see little point in seeking knowledge from their peers.” It was similar to the
“not-invented-here” syndrome discussed in the knowledge sharing literature.
Peer knowledge sharing was said to be less open, less thorough, and less
active among surgeons with an intermediate-level professional title or a senior-level
professional title than that among surgeons with a junior-level title. This peer
knowledge sharing quality difference between junior-level surgeons and their senior
counterparts was explained by the greater risks and stakes involved in peer
knowledge sharing among senior-level and intermediate-level surgeons. The
competition for senior-level professional posts is much greater and more severe than
the competition for intermediate-level professional posts at both hospitals under
study. Therefore, it was suggested that senior-level and intermediate-level surgeons
at both hospitals were more de-motivated from sharing their expertise and their
failures with others, which might cause them lose their competitive advantage and
increase their peers’ bargaining power.
There is severe competition among surgeons of the same seniority. Under the
current system, people have no incentive to share knowledge with their peers.
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Or more exactly, they have great incentives to hoard knowledge from their
peers. The number of posts at our hospital each year is fixed. It was like a
zero-sum game. If you share your knowledge with your peers, you are
helping them to beat you in the promotion competition. In addition to the
promotion competition, there is the competition over patients. Many senior
surgeons have this concern that if they share their surgical skills with their
peers, it might have a negative impact on their future patient volume. (Senior-
level Neurosurgeon at the MOH hospital)
Furthermore, the increasingly wide variation in the age and educational levels
of intermediate-level and senior-level surgeons at both hospitals, which resulted from
the promotion policies favoring surgeons with a doctor’s degree or a master’s degree,
was suggested to further hinder interteam peer and vertical knowledge sharing
among intermediate-level and senior-level surgeons by introducing new sources of
potential conflicts.
The age variation among surgeons with the same professional title used to be
much smaller. The vast majority of surgeons have a bachelor’s degree. They
move up the hierarchy at a similar rate. But now the age variation among
surgeons with an intermediate-level or a senior-level title is much larger
because surgeons with a graduate degree, particularly those with a doctor’s
degree, get promoted more quickly. A surgeon with a doctor’s degree can be
promoted to an associate senior-level post 3 years after graduation. But a
surgeon with a bachelor’s degree often needs to wait a minimum of 10 years
before being promoted to the same post. Surgeons with an advanced degree
tend to have more research experiences but much less clinical experience
than their peers with a lower degree. It is much harder to motivate surgeons
who are o f the same rank but have varying degrees and age to share
knowledge with one another. (Senior-level Neurosurgeon at the MOH
hospital)
A number of interviewed senior-level and intermediate-level surgeons
expressed their disagreement with such promotion practices and the favorable
treatment received by surgeons with an advanced degree, describing them as unfair
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and unjust, on the grounds that a surgeon’s academic degree was not necessarily
positively related to his or her clinical performance at work.
The current incentive system is unfair. Hiring talents is a wise strategic and
tactic move. As the Chinese saying goes, “shu nuo si ren nuo huo.” [“A tree
dies when being moved to a new location but a person thrives when moving
to a new place.”] The flow of talents leads to a better use of their expertise.
Some hospitals might simply jump on this bandwagon of hiring people of
high degrees, and call it “to keep up with the times.” These are simply
“image projects.” Most hospitals would definitely include information like
how many surgeons with a doctoral degree or a master’s degree they have
and how many full professors they have in their pamphlets and place it near
the beginning of their introduction. I would say that the majority of surgeons
with a graduate degree truly possess valuable knowledge. Yet some surgeons
do not live up to the expectations. This is like the Chinese saying, “liangyou
bu qi.” [“The good and the bad are intermingled.”] This involves the tricky
issue of how to balance hiring outside talents and promoting from the inside.
I explicitly pointed it out during last year’s hospital-wide quality assurance
meeting. We should treat outside talents and inside talents equally. We
should provide them with equal training opportunities, research resources,
and living resources. We shouldn’t favor outside talents over inside talents.
Some surgeons hired from outside the hospital were worthy of the name of
talents, and did contribute to the development of their respective departments.
Yet some surgeons did not live up to their reputation. The perceived over
rewarding of these surgeons definitely demotivated many surgeons inside the
hospital. Our hospital provides a surgeon with a doctoral degree with a large
apartment, helps secure a job for his [her] spouse, and finds a good school for
his [her] child. Some of them are not good at clinical work, and don’t make
any contributions to the hospital. Some even don’t report to work, yet still
receive their salaries. Yet on the other hand, some senior surgeons, even
those receiving the State Council subsidy, live in a 60-square-meters
apartment. Those recently hired talents live in apartments that are 130 to 140
square meters. (Senior-level General Surgeon at the MOH hospital)
Quite a few o f them explicitly mentioned that they saw no point in sharing
their rich clinical experience with those colleagues who were already over-rewarded
and intimated that their knowledge hoarding was a self-protection act against the
unfair system. It was also remarked by a few interviewed senior-level surgeons that
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some surgeons with an advanced degree were quite arrogant and disdained to seek
knowledge from their higher-ranking colleagues or more senior colleagues on other
teams with a lower degree, which further demotivated the latter from sharing clinical
knowledge with the former.
The interview data suggested that the intrateam/interteam knowledge sharing
frequency and quality distinction was greater in surgeon teams that were relatively
stable than in those less stable teams. It was said that membership stability in
surgeon teams facilitated open, thorough, and active intrateam knowledge sharing by
increasing the familiarity among surgeons, enhancing their relationships, and
fostering their identification with their team. Many interviewed junior-level and
intermediate-level surgeons in stable surgeon teams commented that stable
supervisor-trainee arrangements in their team improved the quality of knowledge
transferred from their supervisors to them because their supervisors had a good idea
of their knowledge structure, their strengths and weaknesses, as well as their
preferred learning style, which allowed them to be more personalized when sharing
knowledge with them. Some interviewed junior-level surgeons in less stable teams
also commented on the detrimental impact of team instability on downward
knowledge transfer to them.
Personally speaking, I prefer working on a team with more stable
membership. My senior teammates would have a better idea of my
knowledge structure, my strengths and weaknesses. This allows him [her] to
be more targeted when choosing which knowledge to share with me. But
teams are regrouped on a monthly basis at our department. When I am
assigned to a new team, the knowledge transfer from my seniors to me often
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suffers, because he [she] might not know which knowledge I need and which
I don’t. (Junior-level Orthopedist at the MOH hospital)
However, membership stability in surgeon teams was also said to hinder
interteam knowledge sharing, particularly the sharing of knowledge that might
threaten or work against their team. As mentioned earlier, many interviewed
surgeons reported that minor failures were often covered up within surgeon teams
and not shared with outside surgeons. Furthermore, surgeons on teams with more
stable membership tended to describe the relationship between their teams and other
teams within their department in more competitive terms than those on teams with
less stable surgeon membership.
Surgeons on teams with more fluid surgeon membership (e.g., orthopedist
teams at both hospitals and neurosurgical teams at the MOH hospital) reported fewer
differences between intrateam and interteam knowledge sharing in terms of quality.
I rarely draw the distinction between surgeons on my team and those outside
my team. At my department, we are assigned to a different team every
month. Surgeons who are on the same team with me this month would be on
a different team next month. For me, surgeons at my department are all my
teammates. It is a much broader sense of team. (Intermediate-level
Orthopedist at the MOH hospital)
Interteam competition was greater in surgical departments using the
individual/team hybrid bonus plan than in those surgical departments using the
individual/department hybrid bonus plan. The interview data suggested that the use
of team bonus might hinder interteam knowledge sharing through enhancing
surgeons’ identification with their individual teams. Interteam knowledge sharing in
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surgical departments using the individual/team hybrid bonus (including the
Department of Oncology, the Department of General Surgery, and the Department of
Urology at the MOH hospital and the Department of Oncology at the PLA hospital)
was said to be less open, less thorough, and less active than that in surgical
departments using bonus plans without a team bonus element (including the
Department of Neurosurgery, the Department of Cardiac Surgery, and the
Department of Orthopedics at the MOH hospital as well as the Department of
General Surgery, the Department of Orthopedics, the Department of Cardiac
Surgery, the Department of Urology, and the Department of Plastic Surgery at the
PLA hospital). Some interviewed surgeons further added that the fact that a
surgeon’s “grey income” (the prescription commissions paid by pharmaceutical
companies and the hong bao [“red packet” or monetary gifts] from patients or their
family) was directly related to the number of patients that his or her team was in
charge of further increased the interteam competition, as surgeon medical care teams
in a department might compete for patients with big budgets. Such interteam
competition for patients was suggested by quite a few interviewed surgeons at the
MOH hospital to be more prevalent at civil hospitals than at army hospitals. They
explained that “grey income” was more prevalent and more tolerated at civil
hospitals than at army hospitals where there was a stricter crackdown on such illegal
practices.
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Knowledge Sharing Duty. The second factor proposed by most interviewed
surgeons to account for the quality difference between intrateam and interteam
knowledge sharing was the perceived duty of senior-level and intermediate-level
surgeons to share knowledge with their more junior surgeon teammates but not with
other junior surgeons outside their teams. There was a consensus among interviewed
junior-level and intermediate-level surgeons that their supervisors (i.e., more senior
surgeons on their teams) had the duty to share their knowledge with them, whereas
more senior surgeons on other teams did not have such duty. They perceived the
knowledge transfer from their supervisors to them as part of their supervisors’ job
requirements and the knowledge transfer from more senior surgeons on other teams
as voluntary.
Knowledge sharing is very open within my team. Knowledge transfer from
senior surgeons to junior surgeons is part of their job duties. As a junior
surgeon, I naturally expect my senior teammates to answer my questions. But
I don’t expect senior surgeons on other teams to answer my questions and
teach me skills. Ideally, they should also share their knowledge with us. But
it is not compulsory. It is at their discretion. They could choose to share
knowledge with you or choose to hoard it from you. (Junior-level Cardiac
Surgeon at the PLA hospital)
The compulsory/voluntary distinction between intrateam and interteam
downward knowledge sharing was also reported by the majority of interviewed
senior-level and intermediate-level surgeons. These surgeons agreed that it was their
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If
duty to teach and share knowledge with their junior teammates , whereas the
knowledge sharing with more junior surgeons outside their teams was voluntary in
nature. Their knowledge sharing with more junior surgeons outside their teams was
less active that with their junior teammates. In other words, they were much less
likely to voluntarily share knowledge with junior surgeons on others’ teams than
with their junior teammates without being asked. The openness of interteam
downward knowledge sharing varied with individual surgeons. Some surgeons
reported that they were equally open with their trainees and other surgeons’ trainees,
whereas other surgeons reported that they were more open with their own trainees.
I am equally open when sharing knowledge with my own student and others’
students. The only difference is that I do not volunteer to teach others’
students. I would help them with their problems if they ask me. We are
talking about the life of a patient. You wouldn’t intentionally give them
wrong instructions. It won’t work if they result in risks for the patient. I will
point out the mistakes of my student and correct them the minute that I detect
them. Sometimes he [she] might not be doing it the correct way. He [she]
won’t be aware of it unless you point it out for him. (Intermediate-level
Neurosurgeon at the MOH hospital)
Intrateam downward knowledge sharing, particularly the sharing of tacit
knowledge, was reported to be more thorough than interteam downward knowledge
sharing, particularly in surgical departments with stable surgeon teams. This
thoroughness difference was also partly attributed to the perceived duty factor.
---------------------------------------------
As will be demonstrated later in this chapter, interviewed senior-level and junior-
level surgeons interpreted this teaching duty differently, though they agreed that
technically speaking, it was their duty to teach and share knowledge with their junior
teammates.
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Task Interdependence. Greater task interdependence among surgeons on the
same team was the third factor proposed to account for the observed differences
between intrateam and interteam knowledge sharing among surgeons in terms of
frequency. Surgeons on the same team work closely with one another and depend on
one another for the successful completion of their team task. In contrast, there is very
little task interdependence among surgeons on different teams. Their interactions
with surgeons outside their teams are less frequent than their interactions with their
teammates, which means correspondingly much fewer chances of informal
knowledge sharing.
Vertical Intrateam Knowledge Sharing Among Surgeons. In the previous
section, I discussed surgeons’ perceptions and interpretations of their knowledge
sharing with their surgeon teammates in comparison with their knowledge sharing
with surgeons on other teams, focusing on their differences. In this section, I
examine intrateam knowledge sharing among surgeons in greater detail, focusing on
the vertical knowledge sharing among surgeons of different levels. As mentioned
earlier, vertical knowledge sharing among surgeons on the same team comprises
much downward knowledge sharing and some upward knowledge sharing.
Upward Knowledge Sharing. The majority of the interviewed surgeons
reported valuing the knowledge shared by their more senior teammates, particularly
their experiential clinical knowledge. A smaller percentage of interviewed senior-
level surgeons reported valuing the knowledge possessed by intermediate-level
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surgeons on their team. A much smaller percentage of interviewed senior-level and
intermediate-level surgeons reported valuing the knowledge possessed by their
junior-level teammates. Intermediate-level surgeons were often seen as a less
important contributor in the intrateam knowledge sharing activities than senior-level
surgeons, whereas junior-level surgeons were seen as the least important contributor
to the knowledge sharing in their teams. Many interviewed senior-level and
intermediate-level surgeons saw their junior-level teammates as more of a passive
recipient. Senior-level and intermediate-level surgeons who subscribed to this view
tended to discount and discourage knowledge sharing initiatives by their more junior
teammates. This might cause tensions within their teams when the junior-level
and/or intermediate-level surgeons on their teams disagreed with such assigned roles.
Many junior-level and intermediate-level surgeons, particularly those with a graduate
degree, believed that they had valuable knowledge to share with their more senior
teammates and wanted to have their voices heard. They mentioned that their greater
computer skills and English skills provided them with access to a larger pool of new
knowledge (e.g., Internet and international journals published in English) . They
-----------------------------------------
Almost all junior-level surgeons and anesthesiologists recently recruited by grade-
3 Chinese public hospitals have at least a bachelor’s degree. An increasing
percentage of them have a master’s degree or a doctor’s degree. Graduate programs
in medicine were reinstated in Chinese medical universities and colleges in mid-
1990s. Those with a graduate degree receive more intensive training in English.
Undergraduates in Chinese universities (including medical universities or colleges)
are required to pass the National College English Test Level 4 (CET-4) before being
granted their bachelor’s degrees. Graduate students are required to pass the National
College English Test Level-6 (CET-6) before being granted their degrees. As
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further added that their graduate training provided them with a more solid mastery of
theoretical medical knowledge, which complement the rich clinical experiential
knowledge possessed by their senior teammates.
More senior surgeons possess rich clinical experiences. They share with us
their valuable clinical experience. Yet as medical knowledge is updating very
rapidly nowadays, we also need to share new knowledge with one another,
such as new surgical methods, new medicine, and new therapies. Junior
surgeons like me are, generally speaking, more familiar with and more skilled
at using computers and the Internet than senior surgeons. We could share the
knowledge that we have found in the Internet with them. (Junior-level
Oncologist at the MOH hospital)
Some senior-level and intermediate-level surgeons acknowledged the active
role of their more junior teammates in intrateam knowledge sharing and the value of
their potential knowledge contributions. Some of them quoted the household Chinese
idiom “bu chi xia wen” (“do not feel ashamed to ask and learn from one’s
subordinates”) to describe their position , saying that their subordinates might have
valuable things to offer.
Junior surgeons have their own strengths. There is a Chinese saying that
goes, “hou sheng ke wei.” [“a youth is to be regarded with respect”]. In
today’s information age, young surgeons are at an advantage at assimilating
new knowledge, thanks to their age and the rigorous education that they get.
I believe in the saying, “qing chuyu lan er sheng yu lan” [“indigo blue is
extracted from the indigo plant, but is bluer than the plant it comes from” or
mentioned earlier, an increasing percentage of OR nurses recruited by grade-3
Chinese public hospitals in recent years have an associate’s degree or a bachelor’s
degree. They are more proficient in English and are more skillful with computers.
3 7 This idiom was attributed to Confucius in the book Analects.
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“the younger generation will surpass the older generations”]. (Senior-level
Orthopedist at the PLA hospital)
You have to speak up. If you try to save others’ faces and don’t speak up, it
will cause physical harm to the patient. If the senior surgeon has made a
mistake, he [she] should admit it frankly. Face should not be the No. 1
concern because the life of the patient is at risk. Let’s say, I made a mistake
during my surgical procedure. The junior member on my team detected the
mistake. He [she] should tell me directly, “chief, I have noticed that you
might have made such and such a mistake.” I would think it over and take the
advice gladly and willingly if I think the junior surgeon has raised a valid
point. I would thank and even praise the junior surgeon for the advice. I
prefer a junior surgeon who speaks up, as this shows that the junior surgeon
is actually learning. A surgeon who fails to detect a mistake at procedures is
not a good surgeon. It is different from an executive order in which the chief
has the absolute say. In the army, you have to obey the order from your
superior. If he or she orders you to make a left turn, you have to do exactly
what you are told. No one dare to disobey the leader. Yet the surgical team is
a completely different scenario. The junior surgeon might obey the wrong
order from the head surgeon the first time. Yet the second time around the
junior surgeon will not obey the same order from the head surgeon. When it
comes to the sphere of learning, we should “let a hundred schools of thought
contend, let a hundred flowers blossom”. We shouldn’t be constrained by
titles. We would run into a lot of trouble if we go completely by titles.
Senior-level Oncologist at the PLA hospital)
The expectations of senior-level and intermediate-level surgeons with regard
to the value of the knowledge possessed and shared by lower-level surgeons on their
teams were said to greatly influence how likely the intermediate-level and junior-
level surgeons on their teams were to speak up, and to share their ideas, observations,
and criticisms with their teammates. The attitudes of the senior-level surgeon on a
team were said to play a big role in shaping the team culture and the team knowledge
sharing climate. Some intermediate-level and junior-level surgeons reported that the
senior-level surgeon on their team was open to and appreciated their ideas and input,
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which contributed to the creation of an open, trusting, and safe team climate and
culture. For instance, the intermediate-level and the junior-level surgeons on the
team headed by the above quoted senior-level oncologist said that his openness to
and appreciation of their input encouraged them to speak up, without worrying too
much about making a fool of themselves and about their ideas being rejected.
A couple of interviewed surgeons commented on the tendency among
Chinese supervisors and managers to favor obedient subordinates over troublesome
subordinates who challenge the existing power structure. This cultural trait was also
covered in Bo (1985/1991) and Gao and Ting-Toomey (1998). This trait was closely
related to the commonly held cultural belief in obedience as a key quality of a good
employee and Chinese people’s excessive concern with mian zi. Chinese supervisors
were said to favor obedient subordinates who do not challenge but enhance their
mian zi. One senior-level urologist from the MOH hospital compared obedient
subordinates to “little lambs”, saying that they often got promoted more quickly than
their less obedient but more competent colleagues at his hospital. Such practices
were suggested to negatively influence surgical team members’ knowledge sharing
intentions and behaviors: surgical team members were discouraged from sharing
knowledge that challenges the face of their supervisors. His opinions were echoed by
another senior-level oncologist from the MOH hospital:
Chinese people have a tradition of favoring more obedient but less competent
subordinates over less obedient but more competent subordinates.
Supervisors feel more threatened by those more competent but less obedient
subordinates, because they are more likely to challenge their mian zi [“face”].
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At many Chinese public hospitals, people get promoted less on their
professional expertise, but more on their ability to get along with their
supervisors. To succeed in this flawed system, it makes more sense to
withhold information and knowledge that might threaten the mian zi [“face”]
of your supervisor.
Downward Knowledge Sharing. Although it was said that the compulsory
nature of knowledge transfer from senior-level and intermediate-level surgeons to
their more junior teammates contributed to more often and higher quality knowledge
sharing within a team, surgeons were found to differ in their interpretations of what
this duty involved. The two hospitals under study provide very little monetary
incentives for surgeons to train their trainee(s): only a very small amount of monthly
teaching subsidy is offered. Like most other public hospitals in China, neither of
these two hospitals have a rigorous teaching quality appraisal system. Furthermore,
the quality of one’s teaching makes very little difference to one’s promotion.
Therefore, the quality and quantity of the downward knowledge sharing within a
surgical team was said, to a large extent, to be contingent on the intrinsic motivation
of the senior-level surgeon and/or the intermediate-level surgeon. Surgeons had great
discretion in deciding how much time and energy they should spend on training
junior teammates.
Some senior-level and intermediate-level surgeons were said to take their
training duties very seriously and to view it as an integral and essential part of their
job, whereas other surgeons were said to treat it as an unimportant part of their job,
something to attend to when they were done with their clinical duties.
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As a senior surgeon, I would examine my junior member’s work after it is
completed, even though it is not in my job description. I would check if he
has done it properly. If not, I would point it out and ask him to redo it if
necessary. Yet some senior surgeons in other departments might not check
their junior members’ work. Some proactive junior members might report to
their team leaders after they have completed their work, and even ask them to
check their work. Their team leaders might find such requests rather
annoying and become very impatient with them. (Senior-level Urologist at
the MOH hospital)
Some senior surgeons may not be very patient. The first time you ask him a
particular question, he might give you a proper answer. Yet if you still don’t
get it and ask him for the second time, he might scold you for not paying
enough attention earlier. (Junior-level Orthopedist at the MOH hospital)
It was suggested that surgeons who were noble-minded (with high morality
or high levels of spiritual development) were more likely to take their teaching duties
seriously than those who were less spiritually developed. The trait of noble-
mindedness is related to the Confucian concept of junzi. A junzi is a considerate,
well-cultivated and morally refined gentleman who loves to help others (Lu, 2000).
Many interviewees suggested that noble-minded surgeons were intrinsically
motivated to share their knowledge with others, as they enjoyed helping others to
learn.
People’s willingness to share their knowledge with others is tied closely to
their personality. Those who are noble-minded and spiritually developed will
share their knowledge with others without reserve. Only those who are
egoistic will hoard knowledge in order to protect their own interest. (Senior-
level Urologist at the MOH hospital)
Those surgeons who reported taking their teaching duties seriously further
added that the actual sharing was contingent on whether the students met their
expectations of “a good student” with the right attitude. A good student was
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suggested to be modest, honest, conscientious, studious, agreeable, diligent,
deferential to his or her mentor, enthusiastic about his or her work, and to be of high
morality. They commented that they tended to share more knowledge with
subordinates who met their expectations of “a good student”. Some of them quoted
the household Chinese idiom “ yi ren wei shi, zhong sheng wei fu ,” (“one day my
teacher, my father for the rest of my life,”) in their discussions of the proper
supervisor-trainee (or master-disciple) relationship. They subscribed to the view that
the supervisor-trainee relationship was hierarchical in nature and should be modeled
after the prescribed Confucian father-son relationship where the father protects the
son while expecting obedience and deference from the son.
It [the depth of knowledge sharing] depends on the trainee’s su zhi
[“quality”]. Let’s say the junior member on my team is of excellent character,
shows me proper respect, is eager to learn, and is conscientious, reliable, and
honest. Of course, I would be willing to share more with him. On the
contrary, if the junior member is boastful, impractical, lazy, and disdains to
do mundane work, I would share less knowledge with him. (Senior-level
Urologist at the MOH hospital).
Most of the interviewed junior-level and intermediate-level surgeons seemed
well aware of such expectations on the part of their seniors.
Let’s say the senior surgeon on your team thinks highly of you, as you are
respectful to him and eager to learn, he might share his own experience with
you, teach you the key techniques and point out things that you should pay
attention to. If he thinks that you are not modest or respectful to him, he
would simply hold his tongue and wouldn’t share the knowledge with you.
(Intermediate-level Oncologist at the MOH hospital)
Knowledge sharing is two-way interaction. As the junior surgeon, you must
be modest and show proper respect to senior surgeons. You must leave them
a good impression. You must make them feel it’s worthwhile teaching you. If
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you don’t work hard and let them down, it’s only natural that they don’t want
to share their knowledge with you. I believe that senior surgeons make such
decisions on a case-by-case basis. (Junior-level Urologist at the PLA
hospital)
Many interviewed senior-level and intermediate-level surgeons as well as
some junior-level surgeons subscribed to the view that the primary responsibility for
learning lies with the student rather than with the teacher whose duty is to teach the
student the fundamental knowledge and to assist the student in their learning. Many
of them quoted an old kung fu (martial arts) saying, “shi fu ling jin men, xiu xing zai
ge ren” (“the teacher will lead you through the door, but what the student can
achieve afterwards is up to the student”) to illustrate their interpretations of the duties
of the teacher and of the student. Surgeons who subscribed to this view tended to
take greater initiative in their own learning, to hold less strict expectations of the
amount of knowledge imparted from their teachers, and/or to be more demanding of
their students in terms of expecting them to take greater initiative in their own
learning rather than waiting for the teacher to explain everything. Quite a few
surgeons compared the learning of surgical skills to the learning of kung fu and
stressed the importance of learning through observations and perfecting one’s skills
through practice.
You can’t expect others to teach you all the knowledge you need for your
work. It’s unrealistic. You are responsible for your own learning. As a good
and studious student, you should not impose too much on your teacher. You
should do your homework before raising questions. You could find answers
to some of your questions in textbooks. (Junior-level Orthopedist at the PLA
hospital)
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In the teams of study, many surgeons’ interpretations of their teaching duties
were heavily influenced by their own previous training experience as well as
negative cases at their hospital where surgeons shared their expertise with others and
ended up hurting their own careers. Many interviewed senior-level and
intermediate-level surgeons said that they gave back what they got in their previous
training: they tended to treat their students the same way that their old supervisors
treated them when they were a junior-level surgeon and/or an intermediate-level
surgeon. Some surgeons commented that their previous supervisors shared
knowledge openly with them and provided them with high-quality training, so they
made great efforts to provide similar training for their trainees. Other surgeons
remarked that their previous supervising surgeons did not share much knowledge
with them when they were a junior-level and intermediate-level surgeon, so they did
not see why they should be different when it came to training their students. One
senior-level general surgeon at the MOH hospital commented, “I only share with
them what is necessary for them to carry out their jobs. Just like what my previous
supervisor did with me. This is only fair.”
Quite a few surgeons at the MOH hospital added that they couldn’t afford to
share their expertise with their students without reserve at their work although it was
a noble and admirable act. They perceived great threats in such knowledge sharing
behaviors. They cited cases at their hospital where people were treated unfairly after
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sharing their knowledge with their trainees to explain why. Such living examples of
getting unfairly exploited were said to inject fear into many surgeons’ heart.
The former head of the cardiac surgery department was not rehired and
simply let go after he had trained his successor and shared his knowledge
with him. Incidents like this had very bad influence. It alerted people of the
negative consequences of open and thorough knowledge sharing. People just
wise up and do not share knowledge without reserve in order to protect
themselves. (Senior-level General Surgeon at the MOH hospital)
Many interviewed surgeons at the PLA hospitals commented that surgeons at
civil public hospitals were less likely to share knowledge, particularly surgical skills,
with their trainees than those at military hospitals. This suggested difference was
confirmed by a few interviewed surgeons at the MOH hospital. They explained that
the lower mobility of surgical team members at civil public hospitals when compared
with their counterparts at PLA hospitals was one main factor that demotivated them
from sharing knowledge with others, including their trainees. PLA hospitals in China
have had higher turnover rates than their MOH counterparts: they have undergone
several rounds of downsizing as part of the many rounds of disarmament initiated by
the Chinese government. Using the words of a senior-level urologist at the MOH
hospital, the knowledge sharing risks were greater for surgical team members at
MOH hospitals because of their greater mobility.
Some surgeons feel threatened by their disciples. There is a Chinese saying,
‘ jiao hui tu di, er si shi fu ” [“if you transfer all your skills to your disciple,
you will lose all your customers to him and end up dying hungry.”] Many
people still buy into this way of thinking. I would say such mentality exists to
a less extent at our military hospital. I noticed that it existed to a greater
extent at civil hospitals that I visited. If conditions permit, I would stand in
the place of the first assistant and let the competent lower-ranking surgeon to
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stand in the place of the surgeon-in-charge. Yet at civil hospitals it is very
rare for senior surgeons to delegate to their junior teammates. Junior surgeons
won’t be able to perform the critical steps and would have to wait until they
become senior surgeons and obtain the qualifications to perform (Senior-level
Oncologist at the PLA hospital)
The interviews revealed tensions surrounding the sharing of surgical skills
and techniques in many surgeon teams of study both at the MOH hospital and the
PLA hospital. At these two hospitals, like other public Chinese hospitals, there are
very strict regulations on the scope of surgical procedures that a surgeon with a
particular professional title is qualified to perform alone unsupervised . The speed,
scope, and depth of downward sharing of surgical skills at surgical teams of study
were found to vary. Some intermediate-level and junior-level surgeons complained
that surgical technique training was too slow at their teams and interpreted it as
intentional knowledge hoarding, whereas their supervisors disagreed, saying that the
speed made perfect sense and was not slow at all given the capability and the wu
xing (“absorptive capacity”) of the trainee. The Chinese concept of wu xing is similar
to the concept of absorptive capacity in that it refers to an individual’s ability to
understand, assimilate, and apply the learned knowledge. However, it also refers to
TS-------------------------- ! --------------------------------
There is variation among surgeons with the same professional title in the scope of
surgical procedures that he or she could perform unsupervised. Surgeons with the
same professional title are further divided into two groups, those who have held that
title for less than three years and those who have held that title for over three years.
Surgeons who have held that title for over three years are allowed to perform more
types of surgical procedures than their peers who have held that title for less than
three years.
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an individual’s natural talents and high perceptivity, which is not confined to the
specific area of knowledge being shared. The supervisors commented that it was
unsafe to let trainees to perform steps that were above their capability because it
would cause unnecessary threats to the patient’s life. Since supervisors are held
legally liable for permitting a trainee to perform steps that are beyond his or her
stipulated scope, the safe precautions on the part of supervisors helped protect them
from potential malpractice suits.
Some intermediate-level and junior-level surgeons also complained about the
scope and depth o f surgical training at their teams, saying that their supervisors
intentionally hoarded critical surgical skills and techniques. Many of them attributed
such knowledge hoarding to negative individual traits of their supervisors, like
lacking in noble-mindedness, low conscientiousness, and low open-mindedness.
They added that it was because their supervisors did not want to lose their bargaining
power and perceived great threats in sharing such skills and techniques with them. I
coined this term “knowledge-sharing efficacy” to describe the above mentioned
individuals’ belief about the possible outcomes of knowledge sharing. The term
knowledge-sharing efficacy refers to an individual’s belief that knowledge sharing
leads to more positive outcomes than negative outcomes. These supervisors
mentioned above were said to have low knowledge-sharing efficacy because they
perceived greater potential negative consequences of knowledge sharing. Those
surgeons who believed that they could sustain their competitive edge after
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knowledge sharing were said to have high knowledge-sharing efficacy, focusing on
the positive consequences of knowledge sharing.
Such surgical skill hoarding behaviors were suggested and found to be
greater in surgery teams working in highly specialized areas like neurosurgery and
cardiac surgery. One senior-level general surgeon at the MOH hospital made the
following comment, “There is very little knowledge hoarding in my department.
Most of the patients that we deal with in our daily work suffer from common surgical
diseases. There are not many cases that involve the use of highly sophisticated
specialty knowledge. Yet neurosurgery lends itself more to knowledge hoarding than
general surgery does, as certain surgical steps or skills in neurosurgery are elusive
and are less likely to be mastered by everyone.”
A few interviewed surgeons further added that knowledge hoarding behaviors
became more prevalent since the market-based reform of Chinese public hospitals
that started in early 1980s. It was said that surgeons had become more individualistic
and the increasingly greater financial stakes involved in knowledge sharing had led
to a dramatic decrease in the depth of and the openness of knowledge sharing both
within and between surgical teams. The increasing individualism was suggested to
be a result o f the hospital market-based reform and the overall market reform of the
Chinese economy.
I have noticed great differences in surgical team members’ knowledge
sharing behaviors before and after the marketization reform of hospitals. In
today’s market economy, knowledge is money. It’s only natural that some
people might be conservative when it comes to knowledge sharing. Take the
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surgical skills involved in difficult surgical procedures for example. Before
the reform, the head of a department seldom put his [her] personal interest
before the interests of the collective. His [her] primary concern was how to
transfer his knowledge to others fast and thoroughly. He [she] seldom
withheld knowledge intentionally for self-protection reasons. From my own
experience, I would say that 99 percent of the time he [she] put the collective
first. His [her] choice of the methods of knowledge transfer, and the staffing
plan tended to focus on how to better promote the development of his
department and the hospital. He [she] was also concerned about the “echelon
development” [“the practice of having surgeons at higher levels teaching
surgeons at lower levels”] at his [her] department. Before the reform, the
students were very respectful to their teachers. The teachers were also eager
to share their knowledge with their students. Yet as the reform deepens over
time, people become more preoccupied with chasing monetary things while
neglecting their spiritual pursuits. In such an environment, department heads
and other senior surgeons tend to put their personal interests first. They are
always concerned about protecting their reputation and status. Besides, young
surgeons are keen on outperforming others. The old teacher-pupil mentality
no longer exists. To put it bluntly, materialism prevails. The market economy
has led to the gradual weakening of collectivism and the rise of individualism.
People’s coordination has become less harmonious, with fewer and fewer
people cherishing the spirit of voluntary sharing. People won’t do a thing
unless it could bring them fame or gain. People weren’t like this before the
market reform. (Senior-level General Surgeon at the MOH hospital)
Some interviewed surgeons also commented that unsuccessful sharing of tacit
knowledge within their teams was due to the inadequate communication skills on the
part of the supervisors and to the lack of adequate wu xing on the part of their
trainees.
Senior surgeons differ in terms of their communication skills. Some surgeons
are very good communicators. They are skillful at transferring their
knowledge. Yet some surgeons are very poor communicators. They do not
know how to best transfer their knowledge even though they want to do so. I
have encountered such surgeons. (Junior Cardiac Surgeon at the MOH
hospital)
The success of knowledge sharing, to a large extent, depends on the wu xing
of the recipient. Surgery is an experiential, hands-on discipline. The same
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knowledge shared might have different impacts on different recipients.
Trainees with high wu xing could grasp the surgical skills very quickly, while
others could not. Training surgeons is not like producing products on the
assembly lines where you could get two products that are exactly the same.
There would be great variation in the knowledge learned among trainees who
study under the same coach. (Senior-level Urologist at the MOH hospital)
An interesting concept that emerged from the data is that individuals differed
in their expectations of what counted as good knowledge sharing. A few interviewed
surgeons expressed great satisfaction with intrateam and/or interteam knowledge
sharing after rating them at 70 out of 100. When asked to explain this seeming
contradiction, they commented that it was because they, unlike others, held very
realistic expectations of the level of knowledge sharing that could be attained in the
workplace and were satisfied that their expected level of knowledge sharing had
been attained in their team and department. This raised an important point that
people’s expectations of intrateam and interteam knowledge sharing greatly
influence their satisfaction with the quality of knowledge sharing in their team and
department. In other words, members who are in the same unit (e.g., team,
department, or hospital) but have different knowledge sharing expectations might
rate knowledge sharing in their unit differently: those with a higher expectation
would rate it less favorably whereas those with a lower expectation would rate it
more favorably. I coined this term “attainable knowledge sharing expectations” to
capture this individual belief regarding the level of knowledge sharing that could be
achieved at a particular context.
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I don’t see any contradiction there. I agree that open, thorough, unreserved
knowledge sharing is something that we should strive for. But I believe it is
only an ideal state that is virtually impossible to achieve in real workplace.
There will always be some people who are unwilling to share all their
knowledge with others. Even if we assumed that everyone was willing to do
so, just for argument’s sake, not all the audience would want to embrace the
knowledge shared or would be able to assimilate the knowledge. The reason
that I said I was satisfied with the knowledge sharing at my department was
that it met my expectations. It might appear to be substandard, reserved
knowledge sharing to those with higher expectations. But to me, it was good
knowledge sharing. (Junior-level General Surgeon at the MOH hospital)
The interpersonal processes inherent in knowledge sharing both within and
between surgical teams involve competition among surgical team members from
multiple disciplines and surgical team members with varying seniority to define,
sustain, and challenge the social structure of and the inter-subjective meanings of
surgical teams. As mentioned earlier at the beginning of this paper, most researchers
focus on the constraining or enabling effects of structural features (e.g., interpersonal
relationship, team cohesiveness, team culture, and organizational culture) while
neglecting the important role played by team members (with the exception of team
leadership) in enacting, creating, sustaining, and changing these structural features.
The interviews provided some preliminary support for the active role played by
knowledge sharing processes in giving rise to, changing, and sustaining relevant
structural factors. This notion of structure as both the outcome and the antecedent of
surgical team members’ knowledge sharing behaviors is a good example of the
duality of structure described by Giddens (1979) in his structuration theory.
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Many interviewees explicitly discussed the active role played by surgical
team members, including the modeling roles of team leadership and department
leadership, in creating, sustaining, and/or changing team cohesiveness, team culture,
team knowledge sharing climate, department cohesiveness, department culture, and
department knowledge sharing climate. As discussed earlier in this chapter, some
interviewed surgical team members talked about the two-way influence between
knowledge sharing and interpersonal relationships.
Interpersonal relationships are not static. Rather, they are dynamic. They
might change over time. Lots of factors could influence their development.
Let’s say, I have two students on my team. One is very diligent and
conscientious. The other is less diligent and less conscientious. At first, I
would share knowledge with both of them equally. But when I get to know
them better, I would change my knowledge sharing behaviors. I would share
knowledge more frequently with the diligent student and much less with the
lazy student. My knowledge sharing behaviors would affect the quality of my
interpersonal relationships with them. I would have a better relationship with
the diligent student than with the less diligent student. That might further
influence my future knowledge sharing practices. Of course, this is just an
over-simplified imagined case. The reality is much more complicated. But
the idea is the same. Knowledge sharing and the quality of interpersonal
relationship influence one another. (Senior-level Oncologist at the MOH
hospital)
The majority of the interviewees acknowledged the important role played by
leadership in shaping team culture, team knowledge sharing climate, team
cohesiveness, department culture, department knowledge sharing climate, and
department cohesiveness. They observed that the knowledge sharing behaviors of the
team leader or the department leader influenced their subordinates’ knowledge
sharing attitudes and behaviors both directly and indirectly through team culture,
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team knowledge sharing climate, and team cohesiveness, or department culture,
department knowledge sharing climate, and department cohesiveness.
I totally agree that the leadership’s attitude and behavior have a big influence
on their subordinates’ knowledge sharing intentions and behaviors. If the
head of the department does not share knowledge openly with his [her]
colleagues, it is very likely that others in the department would behave in a
similar way. This is what we Chinese call “shang liang bu zheng xia Hang
w a ir [“if the upper beam is not straight, the lower ones will go aslant” or
“when those above behave unworthily, those below will do the same.”]
(Intermediate-level Cardiac Surgeon at the PLA hospital).
The interviews indicated that senior-level surgical team members who were
in leadership positions were also well aware of their agency in creating and affecting
team culture and team knowledge sharing climate and/or department culture and
department knowledge sharing climate. However, it should be noted that the team
that most of them referred to was their own subgroups, rather than the whole team.
Our department has a very good tradition of respecting the truth, regardless of
one’s status. I remember very clearly one incident early in my career when I
was still a junior-level surgeon. We had this case. Four higher-level surgeons
in my department preferred one surgical plan. But another lower-level
surgeon and I strongly preferred another plan. There were only two of us.
Obviously we were the minority. Yet the head of my department let us fully
express our opinions and decided to go with our plan after deliberating on it.
This incident has left a very deep impression on me. Now I have become the
head of the department. I also want to cultivate such a culture where
everyone would speak up. (Head of the Orthopedics Department at the PLA
hospital).
Some surgical team members who were not in leadership positions also
reported that their knowledge sharing practices helped sustain and strengthen their
team culture, team knowledge sharing climate, and team cohesiveness and/or
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department culture, department knowledge sharing climate, and department
cohesiveness.
I agreed that team culture was, to a great extent, shaped by the team leader.
But I wanted to add that other team members also played a part in creating,
sustaining, or even changing their team culture. Let’s say there is one surgeon
team with a trusting culture where the team leader shares knowledge openly
with his [her] subordinates. Lower-level team members might follow his or
her example, take the initiative in seeking knowledge and feedbacks from
their teammates, and share their success and failures with their teammates
openly. Such practices helped sustain and even strengthen the open and
trusting team culture. (Intermediate-level Neurosurgeon at the MOH hospital)
The knowledge sharing patterns within and between the three subgroups of
surgeons, anesthesiologists, and OR nurses also produce and reproduce the existing
power structures within and between surgical teams. The previously described
asymmetrical patterns o f higher-ranking surgical team members dominating the
discussions at subgroup, team, and department meetings or conferences and lower-
ranking members listening are a very good example of how the hierarchy of surgical
teams is produced and reproduced by such knowledge sharing (or communicative)
practices. The downward knowledge sharing of higher-ranking surgical team
members with their lower-ranking teammates demonstrates and strengthens the
authority of and the expert status of these higher-ranking members. The acceptance
and learning of knowledge shared from higher-ranking members by lower-ranking
team members also reinforce the existing hierarchy. The upward knowledge sharing
of lower-ranking surgical team members with their senior teammates represents their
attempts to establish their expert status and to challenge the existing hierarchy of the
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surgical teams. The different responses of higher-ranking team members to accept or
reject the knowledge shared by lower-ranking members further reproduce the
existing hierarchy: the virtual hierarchy is instantiated and sustained even when the
higher-ranking members acknowledge the validity of knowledge shared by lower-
ranking members because higher-ranking members have the final say in accepting or
rejecting the knowledge.
Knowledge Sharing Within a Surgical Team
In the previous sections, I have discussed the interdisciplinary knowledge
sharing as well as intradisciplinary knowledge sharing within a surgical team. In this
section, I integrated the findings. The network below was generated in Atlas.ti to
further spell out the relationships between codes that emerged from the data and
were relevant to knowledge sharing within a surgical team.
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Figure 3.2. Intrateam Knowledge Sharing Network
national cutture-power distance {105-5} j
1 department cohesiveness {44-6} :
^ s u rg e o n prolessional personality (45-2)
^ te a m decision-making {76-2}
knowledge sharing {141-14}- i
'status, seniority (age), hierarchy ;
{155-11} j
^in tra te a m intradisciplinary knowledge i
sharing {142-4} ;
nature of knowledge {126-14} j
^ te a m performance {22-2} j
^ intrateam interdisciplinary knowledge !
sharing {101-1} j*
^ te a m communication {115-4}
j intrateam knowledge sharing {208-28}-
;team culture {51 -6}
^ te a m knowledge sharing climate (84-5)
' qi (shared mental models) {78-6} j*> ® team coordination {116-6}
^ te a m in g history {74-2}
p r o le s and responsibilities {99-2} |
cohesiveness
^ te a m leadership {86-4}
! team identification {34-7} :
| interpersonal relationship (trust,
caring) {85-6}
^ te a m stabiBy {104-5} |
Key: <=> mutual influence [] is part o f
=> is cause o f X prevents
Intrateam knowledge sharing was found to be both an antecedent of and an
outcome of team knowledge sharing climate, team culture, team cohesiveness,
interpersonal relationships, and team hierarchical structure. As discussed earlier,
surgical team members’ knowledge sharing behaviors with their teammates play an
important role in creating, sustaining, or changing these structural features. Strong
team identification, as a result of high team stability, team cohesiveness, and one’s
high status and (age) seniority, was said to facilitate intrateam knowledge sharing.
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The proposed surgeon professional personality of extroversion and
straightforwardness was also said to facilitate intrateam knowledge sharing within
the surgeon subgroup of a surgical team.
Many interviewed surgeons commented that based on their own observation,
surgeons tend to be more straightforward, more extroverted, more risk-taking, more
decisive, and easier to get along with than internists, although a few surgeons saw no
such personality distinction between surgeons and intern medicine specialists.
I agree that there is such a personality distinction between surgeons and
internal medicine specialists. From my personal experience, surgeons tend to
be more straightforward, more decisive, and more extroverted than internists.
I think it has a lot to do with the nature of our work. We communicate with
many different people in our daily work, like our teammates, nurses, patients
and their family members, and colleagues from other departments. To get
your work done efficiently, you have to be a good communicator. We often
have to make decisions very quickly, like in emergency cases. The results of
our work, like surgical operations, show up very quickly. A straightforward
person is a good fit for the surgeon job. I believe that surgeons with that type
of personality just self-select themselves into our field. (Senior-level General
Surgeon at the MOH hospital)
It was also said that intrateam knowledge sharing along with other types of
team communication gave rise to the formation of mo qi (“shared mental model”)
among members of a surgical team, which in turn further facilitated intrateam
knowledge sharing and team communication. The Chinese concept of mo qi, when
used in the context of teams, is similar to the concept of team mental model in that it
refers to team members’ shared knowledge of the key features of the work
environment (e.g., roles and responsibilities, member expertise and personalities).
However, it could also be used in the context of dyadic relationships. For example, it
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could be used to describe the shared mental models between surgeons on different
surgical teams. In this respect, it is more inclusive than team mental model. Like
team mental model, it is a broader concept than transactive memory: it is not
restricted to the knowledge of the task-related expertise distribution within one’s
team.
Team stability, long teaming history (referring to previous teaming
experience among surgical team members, particularly members from different
disciplines), the institutionalized roles and responsibilities of individual team
members, team communication (including intrateam knowledge sharing) were
suggested to facilitate the formation of mo qi within a surgical team. The presence of
mo qi, team communication, intrateam knowledge sharing, and institutionalized roles
and responsibilities were suggested to facilitate team coordination, which in turn
improves team performance. Intrateam knowledge sharing was also said to be
positively associated with team performance.
Sharing o f Face-threatening Knowledge
In earlier sections, I have discussed the sharing of face-threatening
knowledge within and between Chinese surgical teams and Chinese surgical team
members’ own interpretations of such knowledge sharing patterns. In this section, I
integrated these findings and focused on factors that influenced surgical team
members’ likelihood of sharing face-threatening knowledge.
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The network below was generated in Atlas.ti to identify relationships
between codes that emerged from the data and were relevant to the sharing of face-
threatening knowledge (including failures, disagreement, criticism, and tentative
knowledge) within and between surgical teams. A surgical team member’s
likelihood of sharing face-threatening knowledge was found to be a function of his or
her perceptions of the risks involved in knowledge sharing, safety concerns, as well
Figure 3.3. Sharing of Face-threatening Knowledge Network
U Department know ledge sharing climate j ^ t e a m knowledge sharing climate (84-5) j
^ d e m a n d in g health care environm ent j ___ ...................... . ....... I
{51 -1 } j \ ^ in te rp e rs o n a l relationship (trust, respect,
I ” ■> caring) {85-6}
/ ^ -----------------------------
^ litig a tio n concerns {54-3}
^ (p e r c e iv e d know ledge sharing risks I
^ o rg a n iz a tio n a l culture {26-3}
knowledge sharing e ffic a c y {36-8}
^ f a i l u r e {96-4} t ^ s a f e t y concerns {39 -2 }
sharing o f face-threatening know ledge
< 109' 1 6 > l< y - X - — status, seniority (age), hierarchy
{155-11}
^ te n ta t iv e knowledge {45 -3 }
© co m m u n ica tio n strategy {113-7}
\ \
^ d is a g re e m e n t, criticism {88-3}
^ k n o w le d g e sharing depth, frequency
{120-5}
[) \ © national culture - concern w ith mian zi
(•‘fa c e ') {125-7}
^ p a s s iv e -a c tiv e know ledge sharing {95-5}
^ n a tio n a l culture-pcw er distance {105-5} >
^ p u b lic /p riv a te settings {89 -3 } |
^ n a tio n a l culture-narrow-m indedness and
intolerance {21 -5}
Key: = is associated with [] is part o f
=> is cause o f X prevents
x } is property o f
as his or her relative status and seniority. More specifically, it was found that a
surgical team member was more likely to speak up: (a) when he or she perceived
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lower risks in knowledge sharing, (b) when he or she enjoyed high status and
seniority relative to others, and (c) when the patient’s safety was threatened.
Furthermore, Chinese national cultural traits of concern with mian zi (“face”) and of
narrow-mindedness and intolerance were found to hinder a surgical team member
from sharing face-threatening knowledge with others, particularly others outside his
or her team.
A surgical team member’s perception of knowledge sharing risks was said to
be a function of the perceived knowledge sharing climates of his or her team and
department, the quality of his or her interpersonal relationship with the knowledge
recipient(s), organizational culture, as well as by his or her relative status and
seniority (age). More specifically, it was suggested that (a) good interpersonal
relationship characterized by mutual trust, respect, and care, (b) trust-based and
learning-oriented team and department knowledge sharing climates, (c) trust-based
organizational culture would alleviate the perceived risks entailed in sharing face-
threatening knowledge. It was also suggested that a surgical team member’s status
and seniority was negatively related to his or her perceived risks in sharing face-
threatening knowledge.
As indicated in Figure 3.3., the sharing of face-threatening knowledge has
three interrelated facets: the depth facet, the passive-active facet (or the initiative
facet), and the location facet. It was suggested that the depth facet was positively
related to the initiative facet: active sharing of face-threatening knowledge was
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reported to be more thorough than passive sharing. It was also reported that surgical
team members were more likely to engage in active sharing of failures in private
settings than in public settings (e.g., department conferences).
Knowledge Sharing Motivation
The network below was generated in Atlas.ti to identify relationships among
codes that were relevant to an individual surgical team member’s knowledge sharing
motivation.
Figure 3.4. Knowledge Sharing Motivation Network
U te a m ci
p t e a m knowledge sharing climate {84 -5 1'
8 department identification {45 -7 } | =>
" " ” > \
knowledge sharing m otivation {90-27} j
d epartm eri culture {84-7} j ^
l O - [I — ^ lailure (96' 41 i
^ II-
^ te n ta t iv e knowledge 145-3 ) |
status, seniority (age), hierarchy
{155-11}
team culture {51 -6 }
P expertise {76-2} team identification {34-7}
know ledge sharing e fficacy {36-8}
P s u c c e s s stories {31-1}
nature o f know ledge (126-14)
P organizational culture {26-3}
P national cuiture-infightlng and inability to
cooperate {40-4}
P re c ip ie n t's w uxing-absorptive capacity
{69-2}
P p e rs o n a lity traits {67-1)
p national cuRure-power distance {105
P n a tio n a l culture-narrow-m indedness and
intolerance {21-5}
8 Department know ledge sharing climate
{60-8}
^ interpersonal relationship (trust, respect,
caring) {8 5 -6 } '
___ _ _ ^ ^
P h c s p ita l incentives and support (lack)
{71-4}
P d is a g re e m e n t, criticism {88-3}
, a :
\ p k n o w le d g e hoarding e fficacy {11 -3}
^ national cuRure - concern w ith mian zi
("fa ce ") {125-7}
P re c ip ie n t's absorptive attitude {74 -1 } j
Key: [] is part o f
= is associated with
= > is cause o f
X prevents
A Chinese surgical team member’s knowledge sharing motivation was
suggested to be influenced by: (a) the nature of the knowledge in question (failure,
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disagreement and criticism, tentative knowledge, and success stories), (b) his or her
personality traits (e.g., noble-mindedness, conscientiousness, and open-mindedness),
(c) his or her knowledge sharing efficacy (as a function of his or her status and
seniority and the nature of knowledge), (d) his or her knowledge hoarding efficacy,
(e) his or her team identification and/or department identification, (f) his or her
interpersonal relationship with the potential knowledge recipient, (g) the recipient’s
personality traits, (h) the recipient’s wu xing (“absorptive capacity”), (i) the
recipient’s absorptive attitude, (j) the culture and the knowledge sharing climate of
his or her team (when the recipient is his or her teammate), (k) the culture and the
knowledge sharing climate of his or her department (when the recipient is on another
surgical team but belongs to his or her department), (1) hospital support and
incentive, (m) the organizational culture of his or her hospital, and (n) national
Chinese culture.
More specifically, it was found that surgical team members were less
motivated to share failure, disagreement and criticism, tentative knowledge, and
success stories with outside team members than with their teammates when they
strongly identified with their team, and that they were more motivated to share such
knowledge with outside team members within their department when they strongly
identified with their department or when they had a good interpersonal relationship
with the recipient that was characterized by mutual trust, respect, and care.
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Higher-ranking and older surgical team members who tended to possess
greater expertise were said to have higher knowledge sharing efficacy than their
lower-ranking and younger counterparts who tended to be less skilled, and therefore
were more motivated to share knowledge with others. It was also said that surgical
team members with a higher knowledge hoarding efficacy were less motivated to
share knowledge with others than those with a lower knowledge hoarding efficacy.
It was said that surgical team members who scored high in certain personality
traits (e.g., noble-mindedness, conscientiousness, extroversion, and open-
mindedness) were more motivated to share knowledge with others (including both
their teammates and outside team members) than those who score lower. Surgical
team members were said to be more motivated to share knowledge with recipients
who scored higher in certain personality traits (e.g., conscientiousness and
agreeableness) than with recipients who scored lower.
Surgical team members were said to be more motivated to share knowledge
with recipients who have sufficient wu xing (in relation to the knowledge to be
shared), the right absorptive attitude and high integrity.
In the teams of study, trusting and cooperative team culture as well as open
and supportive team knowledge sharing climate were said to increase surgical team
members’ motivation to share knowledge with their teammates, whereas distrusting
and competitive team culture as well as poor team knowledge sharing climate were
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said to decrease team members’ motivation to share knowledge with their
teammates.
Trusting and cooperative department culture as well as open and supportive
department knowledge sharing climate were said to enhance surgical team members’
motivation to share knowledge with outside team members within their department,
whereas distrusting and competitive department culture as well as poor department
knowledge sharing climate were said to decrease team members’ motivation to share
knowledge with outside team members within their department.
Cooperative and unified organizational culture of the PLA hospital,
compared with the more competitive culture of the MOH hospital, was suggested to
enhance surgeons’ motivation to share knowledge with other surgeons at their
hospital,. The lack o f hospital incentives and support at both hospitals was found to
demotivate surgical team members to share knowledge with one other.
Certain national cultural traits (e.g., infighting and inability to cooperate,
narrow-mindedness and intolerance, power distance, and concern with mian zi) were
found to demotivate surgical team members to share knowledge with others.
However, it should be kept in mind that the influence of these national cultural traits
is not context-free but rather is contingent upon many other factors (e.g.,
organizational culture, department culture, and team culture).
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Summary
The findings presented in this chapter provided important insights into the
knowledge sharing behaviors of surgeons, anesthesiologists, and OR nurses at two
Chinese public hospitals, as well as their expectations, perceptions, and
interpretations of knowledge sharing within and between surgical teams. This study
surfaced three dimensions of knowledge sharing: the depth dimension (superficial-
deep sharing continuum), the initiative dimension (passive-active sharing
continuum), and the location dimension (public sharing vs. private sharing).
Knowledge sharing behaviors of Chinese surgical team members in the teams
of study were found to display certain important features that were consistent with
what was depicted in the existing Chinese communication literature and some
features that were inconsistent with the literature. First, the knowledge sharing
practices of Chinese surgical team members were found to exhibit a strong focus on
insiders in many cases. More specifically, (a) in the teams of study, intradisciplinary
knowledge sharing within the three subgroups of surgeons, anesthesiologists, and
OR nurses was found to be more often and of higher quality than the
interdisciplinary knowledge sharing between the subgroups; (b) intrateam knowledge
sharing among surgeons, particularly the sharing of face-threatening knowledge
(failures, disagreement, criticism, and tentative ideas) and expertise (e.g., surgical
skills), was reported to be more often, more open, more thorough, and more active
than interteam knowledge sharing among surgeons, particularly in teams with more
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stable surgeons and in teams using an individual/team hybrid bonus plan; and (c)
sharing of face-threatening knowledge among surgeons was also reported to be more
often, more active, and more thorough with trusting colleagues outside one’s team
(considered as insiders) than with other colleagues outside one’s team (considered as
outsiders).
Second, consistent with what is suggested in the literature, in the teams of
study, most surgeons, anesthesiologists, and OR nurses reported using a deferential,
indirect, and polite communication style when sharing knowledge, particularly face-
threatening knowledge (e.g., disagreement or criticism), with higher-ranking
colleagues. They also reported using an indirect, polite style of communication (a)
when sharing knowledge with peers and lower-ranking colleagues who are their
seniors in age, and (b) when sharing face-threatening knowledge with peers.
However, they reported using a more direct communication style when sharing
knowledge with their peers who are not older than them. Furthermore, most
interviewed senior-level and intermediate-level surgeons, anesthesiologists, and OR
nurses reported using a direct style of communication when sharing knowledge,
including face-threatening knowledge, with their lower-ranking colleagues who are
not older than them. These preliminary findings suggested that the indirect
communication style tendency described of the Chinese people is contextual and
depends on the relative status of the two communicators and the nature of knowledge
to be shared.
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Third, consistent with what is suggested in the literature, in the teams of
study, the knowledge sharing behaviors of surgeons, anesthesiologists, and OR
nurses in formal, public settings (e.g., department meetings and conferences, and
operating rooms) were found to display some listening-centered tendency: higher-
ranking surgeons, anesthesiologists, and OR nurses tended to engage in more active
knowledge sharing than their junior-level counterparts. Furthermore, it was found
that junior-level and intermediate-level surgeons, anesthesiologists, and OR nurses
tended to share their disagreement, criticism, and tentative ideas with their higher-
ranking teammates in private settings.
Senior-level surgeons, anesthesiologists, and OR nurses tended to perceive
knowledge sharing within their teams, including both intradisciplinary and
interdisciplinary knowledge sharing, more positively than their intermediate-level
and junior-level teammates. They were also found to be more likely to share face-
threatening knowledge than were their intermediate-level and junior-level
teammates.
Unlike surgeons most of whom reported favoring other surgeons on their
teams over outside surgeons in their knowledge sharing, interviewed
anesthesiologists and OR nurses reported making a less distinction between inside
and outside team members, which was attributed to their more fluid and temporary
membership in surgical teams. Peer knowledge sharing was suggested to be good
among OR nurses and adequate among anesthesiologists, whereas peer knowledge
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sharing among surgeons was reported to vary greatly, ranging from very limited to
adequate. Good peer knowledge sharing among OR nurses was attributed to their
low knowledge hoarding efficacy and fewer financial interest conflicts (using the
individual/hybrid bonus plan).
The observed quality and frequency differences between intrateam and
interteam knowledge sharing in many surgeon teams of study were attributed to: (a)
intrateam cooperation and interteam competition, (b) the perceived duty of
downward intrateam knowledge sharing as compared with the voluntary nature of
downward interteam knowledge sharing, and (c) the greater task interdependence
among surgeons on a surgical team as compared with the task interdependence
among surgeons on different teams. Current personnel and reward policies and
practices adopted as a part of the national public hospital market-based reform (e.g.,
contract employment and favorable promotion of surgeons with a graduate degree)
were said to lead to increased interteam competition among surgeons, particularly
peer competition among senior-level and intermediate-level surgeons on different
teams, as well as competition among surgeons with varying educational levels.
Interteam competition among surgeons was suggested to be more intense in civil
hospitals than in military hospitals. Interteam knowledge sharing among surgeons
were further hindered by Chinese cultural traits of “infighting and inability to
cooperate,” “narrow-mindedness and intolerance,” and “concern with mian zi.”
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In the teams of study, the suppression effect of surgical team hierarchical
structure on upward knowledge sharing within and between surgical teams was
found to be mitigated by supportive team leadership that encourages and values the
contributions of lower-ranking surgeons and reduces the perceived risks in speaking
up, but aggravated by the moderately high power distance dimension of Chinese
culture, as well as Chinese national cultural traits of “favoring obedient
subordinates,” “narrow-mindedness and intolerance,” and “concern with mian zi.”
In the teams of study, senior-level and intermediate-level surgeons with
varying interpretations of their training duty were found to be engaged in downward
knowledge sharing with different degrees of openness and thoroughness. Noble-
minded surgeons, surgeons with positive previous training experiences, and surgeons
with greater knowledge sharing efficacy were suggested to be more likely to share
knowledge openly and thoroughly with their trainees.
This study surfaced tensions regarding the training of surgical skills and
techniques in many surgeon teams of study. Many supervisors and surgical trainees
differed in their views of the appropriate speed, scope, and depth of surgical training.
While trainees attributed the perceived slow, limited training to dispositional
attributes of their supervisors, the supervisors deemed the training speed, scope, and
depth to be proper given their perceived wu xing, capability, and absorptive attitude
of the trainees.
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The preliminary findings of this study suggested that knowledge sharing
behaviors of Chinese surgical team members were not passively shaped by
structural, cultural, and social factors, but, rather, were simultaneously (re)shaping
and (re)shaped by these factors. Team leadership, department leadership, and non
leadership surgeons, anesthesiologists, and OR nurses were found to play an active
role in defining, negotiating, sustaining, and modifying many structural, cultural, and
social factors (e.g., “mo qi”, team knowledge sharing climate, team culture, team
cohesiveness, department knowledge sharing climate, and department cohesiveness)
through their knowledge sharing and knowledge hoarding behaviors as well as
through their other communication and interaction. The downward intradisciplinary
knowledge sharing among surgeons, anesthesiologists, and OR nurses enacted and
strengthened the existing power structures of the three groups, whereas the upward
intradisciplinary knowledge sharing among them challenged the existing power
structure. The interdisciplinary knowledge sharing among surgeons,
anesthesiologists, and OR nurses also produce and reproduce the existing power
structure among the three professional groups: (a) primarily one-way knowledge
sharing from surgeons and anesthesiologists to OR nurses, the lowest status group,
reinforced the existing hierarchy; and (b) knowledge sharing between surgeons and
anesthesiologists involved negotiation over their roles and status in the surgical team.
The adoption of the interpretive-symbolic perspective in this study helped
uncover the multiple meanings that surgeons, anesthesiologists, and OR nurses of all
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grades and of different ages attach to knowledge sharing within their teams, between
surgical teams, and their own knowledge sharing behavior. This study also surfaced
some new concepts, including “knowledge sharing efficacy,” “knowledge hoarding
efficacy,” and “attainable knowledge sharing expectations”.
The next chapter will report findings of a survey of 86 surgical team
members at one of the two hospitals studied in the qualitative case study. As will be
shown later on, the results from the qualitative study greatly inform the survey study.
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IV. Survey of Chinese Surgical Team Members
Chapter III provided a rich description of and an in-depth analysis of
knowledge sharing-related beliefs and behaviors of surgical team members at two
Chinese public hospitals, which shed important insights into knowledge sharing in
Chinese surgical teams. I also conducted a survey of surgical team members at the
MOH hospital under study using a modified version of the Operating Team Resource
Management Survey (OTRMS)39. The survey measured surgical team members’
attitudes on and perceptions of teamwork, leadership, information and knowledge
sharing, stress and fatigue, error, work style, and organizational climate. The survey
results further contributed to our understanding of surgical team members at Chinese
public hospitals. In this chapter, I report those results that were relevant to
knowledge sharing dynamics in Chinese surgical teams, which supplemented the rich
qualitative data described in the previous chapter.
Previous research has indicated some great attitudinal differences among
surgeons, anesthesiologists, and OR nurses on certain teamwork and leadership
issues (Flin et ah, 2003; Helmreich & Davies, 1996; Helmreich & Schaefer, 1994;
Sexton et ah, 2000). However, little is known about whether such attitudinal
differences also exist among Chinese surgeons, anesthesiologists, and OR nurses. In
3 9 The Operating Room Management Attitudes Questionnaire (Helmreich, Sexton, &
Merritt, 1997) was part of the Operating Team Resource Management Survey
(Helmreich & Merritt, 1998). However, Helmreich and Davies (1996) did not report
the reliability of individual scales.
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this study, I examined whether surgeons, anesthesiologists, and OR nurses differ in a
set of knowledge sharing, teamwork, communication, leadership, and climate
perception variables, specifically, I explored: (a) whether Chinese surgical team
members drew a distinction between intradisciplinary and interdisciplinary
knowledge sharing as well as that between vertical and peer intradisciplinary
knowledge sharing, (b) whether Chinese surgical team members viewed
intradisciplinary and interdisciplinary teamwork differently, (c) whether Chinese
surgeons, anesthesiologists, and OR nurses differ in the importance they attach to
team knowledge sharing, their perceptions of the hospital climate, and surgical team
leadership, (d) whether Chinese surgical team members’ professional title seniority
was related to their intrateam communication perceptions, interdisciplinary
knowledge sharing perceptions, interdisciplinary teamwork perceptions, hospital
climate perceptions, and communication climate perceptions, and (e) whether
Chinese surgical team members’ intrateam communication perceptions,
communication climate perceptions, and teamwork style contribute to their job
satisfaction.
Before I proceed to discuss the hypotheses to be tested in this study, it is
important to note that in addition to deductively derived hypotheses (theory-driven
hypotheses), one grounded hypothesis based on the findings of the earlier qualitative
study is also examined in this study. In this chapter, a hypothesis refers to a
deductively derived hypothesis unless indicated otherwise.
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It has been documented that lack of rich, extensive, and effective
interdisciplinary communication and teamwork has contributed to the failures of
many interdisciplinary teams (or cross-functional teams) (Parker, 1994). Surgical
teams are no exception. Interdisciplinary communication breakdown and inadequate
interdisciplinary teamwork have been documented to be salient at surgical teams
(Helmreich & Davies, 1996; Helmreich & Merritt, 1998; Helmreich & Schaefer,
1994; Lingard et al., 2004; Thomas et al. 2003; Wilson, 1954). The sharing of the
same professional (or functional) culture and the possession of similar expertise,
training, and perspectives are suggested to facilitate communication, coordination,
and teamwork among team members from the same discipline (or function), whereas
the lack of a shared professional (or functional) culture and the resulting differences
in training, expertise, experiences, and perspectives are suggested to hinder
communication, coordination, and teamwork among team members from different
disciplines (or functions) (Parker, 1994). In surgical teams, the professional
disciplinary cultures of surgeons, anesthesiologists, and OR nurses were also
proposed to hinder communication as well as team coordination across professions
(Helmreich & Schaefer, 1994; Sexton et al., 2000). For example, Sexton et al. (1998)
found that the communication between surgeons and the anesthesia team was rated
as “being unacceptable” or “barely acceptable” in over 70% of the 90 operations they
observed at a European teaching hospital. Since knowledge sharing was an integral
part of communication, it was expected that surgeons, anesthesiologists, and OR
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nurses might appraise their knowledge sharing with other surgical team members
from their own discipline and that with other surgical team members from other
disciplines differently. More specifically, it was expected that (a) surgeons view their
knowledge sharing with other surgeons more positively than that with
anesthesiologists and OR nurses, (b) anesthesiologists view their knowledge sharing
with other anesthesiologists more positively than that with surgeons and OR nurses,
and (c) OR nurses view their knowledge sharing with other OR nurses more
positively than that with surgeons and anesthesiologists.
As described earlier in Chapter II, Sexton et al. (2000) found that a greater
percentage of consultant surgeons (64%) and surgical residents (73%) reported
having high-quality teamwork with consultant surgeons than did anesthetic residents
(10%) and anesthetic nurses (26%) and that a smaller percentage of consultant
surgeons (7%) and surgical residents (9%) reported having low-quality teamwork
with consultant surgeons than did anesthetic residents (39%) and anesthetic nurses
(43%). Their findings suggested that surgeons (including surgical residents) rated
teamwork with other consultant surgeons more positively than did anesthesiologists
and OR nurses. The disciplinary differences between consultant surgeons and
anesthetic team members (including anesthetic residents and OR nurses) could partly
explain their lower ratings of teamwork with consultant surgeons as compared to
surgeons’ higher ratings. The shared professional culture as well as the shared
backgrounds and training among surgical team members from the same discipline
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are expected to contribute to smooth intradisciplinary teamwork, whereas the
professional cultural differences and the segregated professional training among
surgical team members from different disciplines are expected to hinder
interdisciplinary teamwork in surgical teams. Thus, surgical team members were
expected to view intradisciplinary teamwork more positively than interdisciplinary
teamwork in their surgical teams. In other words, it was expected that (a) surgeons
were expected to rate teamwork with other surgeons more positively than teamwork
with anesthesiologists and OR nurses, (b) anesthesiologists view their teamwork with
other anesthesiologists more positively than that with surgeons and OR nurses, and
(c) OR nurses view their teamwork with other OR nurses more positively than that
with surgeons and anesthesiologist. Therefore, the following hypotheses were
proposed:
H I: Surgical team members view their knowledge sharing with members
from the same discipline more positively than that with members from other
disciplines.
H2: Surgical team members view their teamwork with members from the
same discipline more positively than that with members from other
disciplines
The interview data suggested that most surgeons tended to draw a distinction
between peer knowledge sharing with other surgeons and vertical knowledge sharing
with other surgeons who had a more senior or a more junior professional title, and
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rated intradisciplinary peer knowledge sharing more negatively than intradisciplinary
vertical knowledge sharing. Such distinction was partly attributed to the competitive
nature of most peer relationships among surgeons at Chinese public hospitals, some
of which, as described earlier in Chapter III, involved financial interest conflicts
(e.g., competition for patients with big budgets). In contrast, the interview data
suggested that most anesthesiologists and OR nurses draw a much smaller or no
distinction between intradisciplinary peer knowledge sharing and interdisciplinary
vertical knowledge sharing. Therefore, the following grounded hypothesis was
proposed:
H3: Surgeons tend to perceive intradisciplinary peer knowledge sharing more
negatively than intradisciplinary vertical knowledge sharing.
It might be speculated that surgeons, anesthesiologists, and OR nurses hold
dissimilar views of the climate of their hospital, due to their differential status. In
Chinese hospitals, surgeons are high up in the medical hierarchy, followed by
anesthesiologists and finally by OR nurses. Previous research has suggested that an
individual’s status is positively associated with his or her perceptions of the
organizational climate (Johnson, 2000; Kwaniewska& Ne, 2004; Patterson, Warr, &
West, 2004; Payne & Mansfield, 1973). Therefore, the following hypothesis was
proposed:
H4: Surgeons, anesthesiologists, and nurses differ in their perceptions of the
organizational climate of their hospital.
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The degree to which surgical team members value team knowledge sharing
activities is expected to be associated with their knowledge sharing behavior. It is
important to find out whether there is a consensus among surgeons,
anesthesiologists, and OR nurses regarding the importance of team knowledge
sharing. In their study of 156 surgical team members at a European hospital,
Helmreich and Schaefer (1994) reported a general agreement among surgical team
members (including surgeons, anesthesiologists, surgical nurses, and anesthesia
nurses) that team communication is important for team efficiency. Since knowledge
sharing among surgical team members falls under team communication, it is
expected that surgical team members at Chinese hospitals would also agree on the
importance of team knowledge sharing. Therefore, the following hypothesis was
proposed:
H5: Surgeons, anesthesiologists, and nurses do not differ in the importance
that they attach to team knowledge sharing.
Helmreich and Merritt (1998) provided some anecdotal evidence regarding
the disagreement between surgeons and anesthesiologists with respect to who is in
charge in the operating room. Therefore, the following hypothesis was proposed:
H6: Surgeons and anesthesiologists differ in their belief regarding surgical
team leadership.
Previous research on teams, including cross-functional teams, indicates a
positive linkage between the status of a member and his or her likelihood of speaking
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up (Cott, 1997; Estrada, Brown, & Lee, 1995; Forelli, 1988; Fried et al, 2000;
Lichtenstein et al., 2004). It has been suggested that higher status members of
surgical teams would initiate communication more frequently than lower status
members who are hindered by the formal power differences in their teams
(Edmondson, 2003a). High status surgical team members are expected to be more
likely to rate communication within their teams more positively than their more
junior counterparts. High status surgical team members are also expected to be more
likely to share knowledge with teammates from other disciplines than are low status
members. The ranking of a surgical team member’s professional title is an important
status characteristic. In Chinese surgical teams, team members with a senior-level
title are expected to have a more favorable view of knowledge sharing with
teammates than those with an intermediate-level or a junior-level title. The findings
of Sexton et al. (2000) suggested a positive link between surgical team members’
status and his or her perceptions of the quality of teamwork with other teammates.
Hence, it is expected that a surgical team member’s professional title seniority might
be positively related to their perceptions of the quality of his or her teamwork with
teammates from other disciplines. Therefore, the following hypotheses were
proposed:
H7a: A surgical team member’ (professional title) seniority is positively
related to his or her perception of the quality of communication within his or
her team.
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H7b: A senior-level surgical team member views his or her knowledge
sharing with teammates from other disciplines more positively than his or her
intermediate-level and junior-level counterparts.
H7c: A surgical team member’s (professional title) seniority is positively
associated with his or her perceptions of the quality of his or her teamwork
with surgical team members from other disciplines.
It was speculated that a surgical team member’s professional title seniority
might also affect his or her perceptions of the organizational climate of his or her
hospital. Previous research has suggested a positive link between an individual’s
status and his or her perceptions of the organizational climate (Johnson, 2000;
Patterson et al., 2004; Payne & Mansfield, 1973). As mentioned earlier, the
professional title of a surgical team member is an important status indicator. It might
be expected that surgical team members of greater seniority might perceive the
organizational climate more positively because of their higher status. However, it is
possible that some Chinese surgical team members of greater seniority might
perceive the hospital climate more negatively for various reasons, such as perceived
low compensation for their work (as mentioned earlier, the pay of a surgical team
member is determined by the level of the professional post he or she is assigned to,
which could be below the professional title he or she has), unfair promotion practices
(e.g., promotion based on guan xi rather than on merit), perceived inadequate
research support and inadequate training opportunities (Gu, 2004; Li, 2004).
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Furthermore, surgical team members of greater seniority might not necessarily view
communication climate of their workplace more positively. Competition between
surgical teams might make it harder for surgical team members of greater seniority to
speak up against their competitors in public at the department level (Gao & Ting-
Toomey, 1998). Senior-level surgical team members are more likely to have tense
relationships with department leadership due to their potentially competitive peer
status than junior-level and intermediate-level members who interact less closely
with department leadership. Therefore, the following hypothesis was advanced:
H7d: A surgical team member’s (professional title) seniority is associated
with his or her perceptions of the organizational climate of his or her hospital.
H7e: A surgical team member’s (professional title) seniority is associated
with his or her perceptions of the communication climate of his or her
workplace.
Previous research has shown that high-quality intrateam communication and
an open communication climate contribute to team member job satisfaction
(Greenbaum & Query, 1999; Hirokawa & Salazar, 1997). It could also be argued that
surgical team members who are comfortable working in team settings are more
likely to experience satisfaction at work. Therefore, the following hypotheses were
proposed:
H8a: A surgical team member’s perceptions of intrateam communication are
positively associated with his or her job satisfaction.
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H8b: A surgical team member’s perceptions of the communication climate of
his or her workplace are positively associated with his or her job satisfaction.
H8c: A surgical team member’s teamwork style contributes to his or her job
satisfaction.
Method
Procedure
The survey was conducted at the MOH hospital under study with the help of
a key informant who coordinated the distribution and collection of the
questionnaires. A total of 120 copies of the questionnaire were given to surgeons at
seven surgical departments (including the Department of Orthopedics, Department of
Oncology, Department of General Surgery, Department of Urology, Department of
Plastic Surgery and Burns, Department of Neurosurgery, and Department of Cardiac
Surgery) as well as anesthesiologists and OR nurses at the Department of Anesthesia.
A total of 86 completed questionnaires were collected. The response rate is 71.7%.
Sample
A total of 86 surgical team members completed the questionnaire. The
sample was composed of 63 surgeons (73.3%), 13 anesthesiologists (15.1%), and 10
operating room nurses (11.6%). The sample consisted of 30 members with a senior-
level professional title (34.9%), 28 members with an intermediate-level professional
title (32.6%), and 28 members with a junior-level title (32.6%). A further breakdown
of the surgical team members who participated in the survey according to their
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specialty, seniority, and educational level is shown in Table N .I. The average age of
the participants is 36.24, ranging from 24 to 66. The average specialty tenure of the
participants is 13.1 years, ranging from 3 months to 41 years.
Table N.2. reported a further breakdown of the age distribution of
participants according to their title seniority. As suggested by the table, there was a
much greater variance in the age distribution of surgical team members with a
senior-level professional title than that for those with an intermediate-level or a
junior-level professional title. This wider variance can be explained by the
previously discussed promotion policies implemented in most public hospitals in
China that favoring physicians and nurses with more advanced degrees. Although the
variance among intermediate-level and junior-level surgical team members was
much smaller when compared with that among senior-level members, the ranges of
the age of intermediate-level and junior-level surgical team members were quite
wide: 28 to 45 years of age for intermediate-level members and 24 to 35 for junior-
level members. As discussed in Chapter III, the mix of members who vary a lot in
age in the same rank posed a challenge to knowledge sharing within and between
hospital departments.
Instrument
As mentioned at the beginning of this chapter, the questionnaire used in this
study was primarily based on the Operating Team Resource Management Survey
(OTRMS) (Helmreich & Merritt, 1998), which was specifically designed for
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operating room teams. All the items were translated into Mandarin, the native
language of the participants. A large number of items were directly imported from
OTRMS, whereas only a few items were modified to fit Chinese surgical teams (e.g.,
the titles of Chinese surgical team members). The questionnaire measured surgical
team members’ attitudes on and perceptions of information and knowledge sharing,
leadership, work style, teamwork, stress and fatigue, error, and organizational
climate.
Only the results of those items that have direct bearing on knowledge sharing
in surgical teams are presented in this chapter. See Appendix O for the English
version of the questionnaire and marginals.
Data Analysis
Both univariate and bivariate methods were used to analyze the survey data.
More specifically, t-tests, analysis of variance, and correlation tests were run on the
survey data to test the relationships between key variables. Due to the ordinal nature
of some variables (e.g., perceived intrateam communication) and the non-normal
distribution of some variables (e.g., a surgical team member’s seniority), non-
parametric correlations were run when required.
Measures
The main dependent variables include perceived intrateam communication,
knowledge sharing, teamwork, and job satisfaction.
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Perceived intrateam communication. The one-item scale of Edmondson
(2004) was used to measure the perceived quality of communication within a
surgical team. The item was measured using a 3-point scale ranging from limited
communication (1) to open reciprocal communication (3).
Knowledge Sharing. Perceived knowledge sharing with various surgical team
members was measured using one item, asking subjects to describe their personal
perception of the quality of knowledge sharing they have experienced with these
surgical team members using a 5-point scale, ranging from very low (1) to very high
(5).
Teamwork. Perceived teamwork with various surgical team members was
measured using one item from Helmreich and Merritt (1998) that asked subjects to
describe their personal perception of the quality o f teamwork they have experienced
with these surgical team members using a 5-point scale, ranging from very low (1) to
very high (5).
Job Satisfaction. A surgical team member’s job satisfaction was measured
using one item from Helmreich and Merritt (1998) that asked subjects about their
agreement with the statement that “I like my job.” The items were rated on a 5-point
scale ranging from strongly disagree (1) to strongly agree (5).
Seniority. The variable of surgical team members’ seniority was measured
using a 3-point scale, based on the level of their professional titles, including junior-
level (1), intermediate-level (2) to senior-level (3).
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Organizational Climate. Two items were adopted from Helmreich and
Merritt (1998) to measure the perceived organizational climate. The two items were
as follows: 1) Working for this hospital is like being part of a large family, and 2) I
am proud to work for this hospital. The items were rated on a 5-point scale ranging
from strongly disagree (1) to strongly agree (5). These two items when combined
had a reliability of .58 (See Table P .l. for the inter-item correlations).
Communication Climate. Four items were adopted from Helmreich and
Merritt (1998) to measure the communication climate that surgical team members
worked in. The items included: 1) The department provides adequate, timely
information about events in the hospital which might affect my work, 2) Senior staff
should encourage questions from junior medical and nursing staff during operations
if appropriate, 3) I am encouraged by my leaders and co-workers to report any
incidents I may observe, and 4) I always ask questions when I feel there is something
I don’t understand. These four items were rated on a 5-point scale ranging from
strongly disagree (1) to strongly agree (5). These four items were combined and
averaged to form a Communication Climate index (alpha = .57) (See Table P.l. for
the inter-item correlations).
Teamwork Style. Nine items were adopted from Helmreich and Merritt
(1998) to measure surgical team members’ work style. The items were as follows: 1)
I try to be a person that others will enjoy working with, 2) I enjoy working as part of
a team, 3) I am ashamed when I make a mistake in front of other team members, 4) I
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value the goodwill of my fellow workers - 1 care that others see me as friendly and
cooperative, 5) I sometimes feel uncomfortable telling OR members from other
disciplines that they need to take some action, 6) It is an insult to be forced to wait
unnecessarily for other members of the OR team, 7) My performance is not
adversely affected by working with an inexperienced or less capable team member,
8) Personal problems can adversely affect my performance, and 9) Effective OR
coordination requires members to take into account the personalities of other team
members. The items were rated on a 5-point scale ranging from strongly disagree (1)
to strongly agree (5). These nine items were combined and averaged to create a
Teamwork Style index (alpha = .76) (See Table P.2. for the inter-item correlations).
Hierarchy. Four items were adopted from Helmreich and Merritt (1998) to
measure surgical team members’ attitudes regarding the hierarchical structure of
surgical teams. These four items were as follows: 1) Senior staff deserve extra
benefits and privileges, 2) Junior OR team members should not question the
decisions made by senior persons, 3) It’s better to agree with other OR team
members than to voice a different opinion, and 4) Team members should not
question the decisions or actions of senior staff except when they threaten the safety
of the operation. These items were rated on a 5-point scale ranging from strongly
disagree (1) to strongly agree (5). Due to the low reliability of these four items when
combined (.50) and low inter-item correlation, the Hierarchy index was not created.
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Importance o f Team Knowledge Sharing. Three items were adopted from
Helmreich and Merritt (1998) to measure surgical team members’ attitudes regarding
the importance of team knowledge sharing. The items were as follows: 1) A regular
debriefing of procedures and decisions after an OR session or shift is an important
part of developing and maintaining effective crew coordination, 2) Team members in
charge should verbalize plans for procedures or actions and should be sure that the
information is understood and acknowledged by the others, and 3) The pre-session
team briefing is important for safety and for effective team management. The items
were rated on a 5-point scale ranging from strongly disagree (1) to strongly agree (5).
The three items were combined and averaged to form an Importance of Team
Knowledge Sharing index (alpha = .55) (See Table P.3. for the inter-item
correlations).
Preferred Leadership Style. The preferred leadership style was measured
using an item from Helmreich and Merritt (1998) that identified four different
leadership styles, including autocratic leadership (1), mild autocratic leadership (2),
consultative leadership (3), and democratic leadership (4).
Encountered Leadership Style. The preferred leadership style was measured
using one item from Helmreich and Merritt (1998) that identified four different
leadership styles, including autocratic leadership (1), mild autocratic leadership (2),
consultative leadership (3), and democratic leadership (4).
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Surgical Team Leadership. The surgical team leadership was measured using
one item from Helmreich and Merritt (1998) asking participants for their agreement
with the statement that “leadership of the OR team should rest with surgeons”. The
statement was rated on a 5-point scale ranging from strongly disagree (1) to strongly
agree (5).
As reported above, the Cronbach’s alphas of the organizational climate,
communication climate, and importance of team knowledge sharing indices were
unexpectedly low in this study, though the reliability of all scales derived from the
Operating Room Management Attitudes Questionnaire were reported to be
satisfactory
(.55 to .85) (Helmreich & Davies, 1996). The potential reasons for the low
reliabilities of these above-mentioned scales and the potential impacts of these low-
reliability scales on the results will be discussed in detail in Chapter V.
Results
Perceived Intradisciplinary and Interdisciplinary Knowledge Sharing
Hypothesis 1 was partially supported. A t-test was conducted to examine
whether surgeons, anesthesiologists, and OR nurses view their knowledge sharing
with members from the same discipline more positively than did with members from
other disciplines. The t-test showed a statistically significant difference between
surgical team members’ rating of intradisciplinary knowledge sharing (mean = 3.62)
and that of interdisciplinary knowledge sharing (mean = 3.13) (t = 6.28, p <.001). A
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series of post-hoc t-tests were run for surgeons, anesthesiologists, and OR nurses.
Surgeons were found to rate knowledge sharing with other surgeons (mean = 3.65)
higher than that with anesthesiologists and OR nurses (mean = 3.16) (t = 6.88, p <
.001). Anesthesiologists were found not to rate knowledge sharing with other
anesthesiologists than that with surgeons and OR nurses (t = 1.52, p = .08). OR
nurses were found not to rate intradisciplinary knowledge sharing with other OR
nurses more positively than that with surgeons and anesthesiologists (t = 1.69, p =
.06). The failure to detect a significant difference for both anesthesiologists and OR
nurses could be attributed to their small sample sizes (See Table P.4. for a summary).
Perceived Intradisciplinary and Interdisciplinary Teamwork
Hypothesis 2 was partially supported. The t-test showed that surgical team
members rated teamwork with teammates from the same discipline (mean = 3.67)
more positively than that with teammates from other disciplines (mean = 3.50) (t =
2.49, p < .01). Post-hoc analysis showed that only surgeons rated intradisciplinary
teamwork more positively than interdisciplinary teamwork with anesthesiologists
and OR nurses (t = 2.69, p < .01). Neither anesthesiologists nor OR nurses drew such
a distinction (See Table P.4. for a summary).
Perceived Intradisciplinary Peer and Vertical Knowledge Sharing
Hypothesis 3 was partly supported. A t-test showed that surgeons did not rate
knowledge sharing with other surgeons who have the same professional title
differently from surgeons who do not share their professional title (t = -1.48, p =
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.08). Since the vertical knowledge sharing score was an average score that fails to
distinguish upward and downward knowledge sharing, it makes sense to conduct
further refined t-tests that distinguish upward and downward knowledge sharing. The
t-tests showed that (a) junior-level surgeons viewed knowledge sharing with other
junior-level surgeons more negatively than did knowledge sharing with intermediate-
level surgeons (t = 2.92, p < .01) and with senior-level surgeons (t = 1.84, p < .05);
(b) intermediate-level surgeons were found to view knowledge sharing with other
intermediate-level surgeons more positively than with junior-level surgeons (t =
4.03, p < .001); and (c) senior-level surgeons were found to view knowledge sharing
with peer surgeons more positively than with junior-level surgeons (t = 1.79, p <
.05). (See Table P.5. for a summary).
The small number of anesthesiologists does not allow me to use t-testS to
directly examine whether they draw a distinction between intradisciplinary peer
knowledge sharing and intradisciplinary vertical knowledge sharing. Furthermore,
the survey only asked about OR nurses’ rating of knowledge sharing with other OR
nurses in general rather than with OR nurses across three levels of seniority.
Discipline and Perceived Organizational Climate
Hypothesis 4 was not supported. Because of the vast discrepancies in the size
of the three occupational groups of surgeons (N = 63), anesthesiologists (N = 13),
and OR nurses (N = 10), two one-way ANOVAs were conducted. The first ANOVA
examined the three groups without adjusting the size of the surgeon group, whereas
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in the second ANOVA I randomly selected 20 surgeons out of the 63 surgeons. The
first one-way ANOVA showed that surgeons, anesthesiologists, and OR nurses did
not differ significantly from one another in terms of their perceptions of the climate
of their hospital (F (2, 83) = 2.70, p = .07). The Levene’s test showed that the error
variances of the three occupational groups in their perception of hospital climate are
equal (p = .90). The second one-way ANOVA also showed no differences between
surgeons, anesthesiologists, and OR nurses (F (2, 40) = 1.22, p = .31). The Levene’s
test indicated equality of error variances of the three groups in their hospital climate
perceptions.
Discipline and Importance o f Team Knowledge Sharing
Hypothesis 5 was supported. Two one-way ANOVAs were also conducted:
one without adjusting for the size differences and another that randomly selected 20
surgeons. The first one-way ANOVA showed that surgeons, anesthesiologists, and
nurses did not differ significantly from one another in terms of the importance they
attach to team knowledge sharing (F (2, 83) = .13 , p = .88). The Levene’s test
indicated equality of error variances among these three occupational groups in their
team knowledge sharing importance ratings. There was a consensus among them that
team knowledge sharing was important (mean = 4.46, s.d. = .54). The ratings of
surgical team members from these three disciplines were as follows: surgeons (mean
= 4.44, s.d. = .51), anesthesiologists (mean = 4.51, s.d. = .72), and OR nurses (mean
= 4.50, s.d. = .50).
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The second ANOVA obtained similar results: surgeons, anesthesiologists,
and OR nurses agreed on the importance of team knowledge sharing (F (2, 40)) .03,
p = .97). The Levene’s test showed that the equality of error variances assumption
was met (p = .42).
Surgical Team Leadership
Hypothesis 6 was supported. Two t-tests were run: one without adjusting for
the size differences between surgeons and anesthesiologists, and another that used
only 20 surgeons randomly selected. The first t-test showed a significant difference
between surgeons and anesthesiologists with regard to surgical team leadership (t =
2.95, p < .01). Surgeons agreed more strongly with the statement that surgeons are
the leadership of surgical teams (mean = 4.43, s.d. = .93) when compared with
anesthesiologists (mean = 3.54, s.d. = 1.27). The second t-test obtained similar
results: surgeons were found to endorse surgeons as the leader of surgical teams
more than were anesthesiologists (t = 1.73, p < .05).
A t-test further showed that OR nurses also agreed more strongly with
surgeons as surgical team leader (mean = 4.4, s.d. = .84) than anesthesiologists (t = -
1.85, p < . 05).
Consistent with Helmreich and Schaefer’s (1994) findings, the majority of
surgeons (77.8%), anesthesiologists (61.6%), and operating room nurses (80%)
reported experiencing autocratic or mild autocratic leadership in their actual work
(See Table P.6. for summary statistics).
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A large proportion of the surgeons studied indicated their preference of the
consultative leadership style (58.7%), followed by democratic leadership (30.2%),
whereas the majority of anesthesiologists (69.2%) and operating room nurses (90%)
preferred the democratic leadership style. Only a very small percentage of surgeons,
anesthesiologists, and nurses reported favoring the autocratic leadership style or the
mild autocratic leadership style (See Table P.7. for summary statistics). This finding
is somewhat different from Helmreich and Schaefer’s (1994) finding that a modest
percentage o f surgeons showed preference for the mild autocratic leadership style.
Seniority and Perceived Team Communication
Due to the ordinal nature of the perceived communication variable and the
seniority variable, a non-parametric Spearman correlation was run to test whether
there was a positive association between surgical team members’ seniority and their
perception of the communication within their teams. Hypothesis 7a was supported.
As expected, surgical team members’ seniority was found to be positively correlated
with their perception of the team communication (rho = .21 ,P < .05). Senior-level
surgical team members rated intrateam communication the highest (mean = 2.17, s.d.
= .59). However, junior-level surgical team members rated intrateam communication
(mean = 1.86, s.d. = .59) slightly higher than did their intermediate-level
counterparts (mean = 1.75, s.d. = .58). The majority of surgeons (63.3%),
anesthesiologists (60.7%), and OR nurses (64.3%) rated intrateam communication as
“respectful but guarded”. A greater percentage of senior-level surgical team
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members (28.7%) rated intrateam communication as “open reciprocal” than did
intermediate-level (7.1%) and junior-level members (10.7%). However, a greater
percentage of intermediate-level surgical team members (32.1%) rated intrateam
communication as “quite limited” than did senior-level (10%) and junior-level
members (25%). This result provided some evidence supporting the finding from the
previous qualitative study reported in Chapter III, suggesting that surgical team
members’ perception of intrateam communication is influenced by their seniority.
Seniority and Perceived Interdisciplinary Knowledge Sharing
Due to the small sample size of anesthesiologists and OR nurses in this study,
I only tested this hypothesis on surgeons. A number of t-tests were run to examine
whether senior-level surgeons held a more positive view of interdisciplinary
knowledge sharing with anesthesiologists and OR nurses than did their intermediate-
level and junior-level counterparts. Hypothesis 7b was not supported. Senior-level
surgeons were found not to rate interdisciplinary knowledge sharing with
anesthesiologists and OR nurses more positively than were intermediate-level
surgeons (t = -.61, p = .27). Neither were they found to differ from junior-level
surgeons in their appraisal of interdisciplinary knowledge sharing with
anesthesiologists and OR nurses (t = .97, p = .17) (See Table P.7. for a summary).
Seniority and Perceived Interdisciplinary Teamwork
Hypothesis 7c was not supported. Due to the ordinal nature of the seniority
variable, a non-parametric Spearman correlation test was run. A surgical team
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member’s professional title seniority was found not to be positively associated with
his or her perceptions of the quality of his or her teamwork with surgical team
members from other disciplines (rho = .09, p = .22).
Seniority and Perceived Organizational Climate
Hypothesis 7d was not supported. Correlation tests showed that the seniority
of a surgical team member, whether he or she is a surgeon, an anesthesiologist, or an
OR nurse, was not significantly associated with his or her perception of the
organizational climate of his or her hospital (rho = -.11, p = .16).
Seniority and Perceived Communication Climate
Hypothesis 7e was not supported. A one-way ANOVA showed that a surgical
team member’s professional title was not related to his or her communication climate
perception (F (2, 83) = 2.39, p = .10). The Levene’s test indicated that the equality of
error variances assumption was met (p = .75). This result is inconsistent with the
finding from the previous qualitative study reported in Chapter III that suggested that
surgical team members’ perception of communication climate was positively related
to their seniority. A possible explanation is that the low reliability o f the
communication climate measure confounds the results.
Hierarchy
Due to the low reliability and low inter-item correlations, no hierarchy index
was created. I briefly reported the finding on the individual items that measure the
hierarchical structure of surgical teams. Most surgical team members of all seniority
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studied strongly endorsed the statement that “the senior person, if available, should
take over and make all decisions in life-threatening emergencies.” (mean = 4.67, s.d.
= .79). Surgical team members of different seniority disagreed about whether senior
staff deserved extra benefits and privileges: it was found that surgical team
member’s seniority was significantly correlated with their beliefs regarding extra
benefits and privileges for senior staff, with senior surgical team members subscribe
to the view most strongly (rho = .30, p < .01). Most surgical team members
(including all seniorities) reported slight or strong disagreement with not allowing
junior team members challenging senior members (mean = 1.99, s.d. = .95). Surgical
team members of all seniorities concurred that it was important for surgical team
members to speak up when they held different opinions. There was great variation
among surgical team members with regard to whether it is okay for surgical team
members to challenge senior decisions or actions when patient safety was not
threatened (See Table P.8. for summary statistics).
Job Satisfaction
Hypotheses 8a, 8b, and 8c were all supported. A surgical team member’s job
satisfaction was found to be significantly associated with his or her perceptions of
intrateam communication (r = .28, p < .01), his or her communication climate
perceptions (r = .20, p < .05), and his or her teamwork style (r = .43, p < .001). It was
found that the more freely communication flowed in their work environment, the
more surgical team members reported liking their jobs. Surgical team members, who
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perceived their environment to be more communication friendly, reported greater job
satisfaction.
Surgical team members with a teamwork style (i.e., surgical team members
who were more attentive to the details and requirements of working closely with
other team members and more adapted to working in a team) reported enjoy their
jobs much better than those who are less attentive and less adapted. This makes
perfect sense when considering the fact that working in a surgical team entails much
coordination and cooperation with other surgical team members: surgical team
members who are not accustomed to working in a team context are less likely to
enjoy their jobs.
Teamwork style was found to be positively related to the perceived
importance of team knowledge sharing (rho = .30, p < .01). In other words, those
surgical team members who were more aware of and better adapted to working
closely with others in a team context better recognized the importance of team
knowledge sharing to the successful management of surgical teams.
Summary o f Key Hypothesis Findings
Surgeons rated their intradisciplinary knowledge sharing with other surgeons
significantly higher than their interdisciplinary knowledge sharing with
anesthesiologists and OR nurses. However, neither anesthesiologists nor OR nurses
drew such a distinction between intradisciplinary knowledge sharing and
interdisciplinary knowledge sharing. Surgeons rated intradisciplinary teamwork with
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other surgeons higher than interdisciplinary teamwork with OR nurses and
anesthesiologists. However, neither anesthesiologists nor OR nurses rated
intradisciplinary teamwork more positively than interdisciplinary teamwork. The
proposed distinction between peer and vertical knowledge sharing among surgeons
was supported only for junior-level surgeons. The data suggested that the negative
impact of competitive peer relationships was mitigated by the level of the expertise
possessed by a surgeon’s colleague, which will be explained in detail in Chapter V.
Surgeons, anesthesiologists, and OR nurses were found to concur in their
perceptions of the hospital climate and the importance of team knowledge sharing.
However, anesthesiologists were found to differ from surgeons with regard to
whether surgeons should be the leader of surgical teams: the latter more strongly
endorsed surgeons as the leader of surgical team.
A surgical team member’s seniority was found to be significantly correlated
with his or her perception of the intrateam communication in a positive direction.
Senior-level surgeons were found not to differ significantly from intermediate-level
and junior-level surgeons in their ratings of knowledge sharing with
anesthesiologists and OR nurses.
The tests failed to detect a significant relationship between a surgical team
member’s seniority and perceived interdisciplinary teamwork. Neither did the test
find a significant relationship between a surgical team member’s seniority and
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perceived hospital climate or that between seniority and perceived communication
climate.
A surgical team member’s job satisfaction was found to be significantly
related to perceived intrateam communication, perceived communication climate
perceptions, and teamwork style.
Summary
The survey data suggested that surgeons tended to view intradisciplinary
knowledge sharing much more positively than interdisciplinary knowledge sharing.
Surgeons were also found to rate intradisciplinary teamwork higher than
interdisciplinary teamwork. However, anesthesiologists and OR nurses were found
not to draw a distinction between intradisciplinary and interdisciplinary knowledge
sharing. Nor did they draw a distinction between intradisciplinary and
interdisciplinary teamwork.
Only junior-level surgeons were found to rate knowledge sharing with peer
surgeons more negatively than that with surgeons who are not their peers. There
seemed to be agreement among surgeons, anesthesiologists, and OR nurses in their
perceptions of the hospital climate and the importance of team knowledge sharing.
However, significant differences were found between anesthesiologists and surgeons
with respect to surgical team leadership. The results lent some support to Helmreich
and Merritt’s (1998) observation about the competition between surgeons and
anesthesiologists over surgical team leadership.
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The results confirmed a significant positive relationship between a surgical
team member’s seniority and perceived intrateam communication. However, the tests
failed to confirm that senior-level surgeons perceive interdisciplinary knowledge
sharing with anesthesiologists and OR nurses more positively than did intermediate-
level and junior-level surgeons. A surgical team member’s professional title seniority
was found not to be associated with perceived interdisciplinary teamwork, perceived
organizational climate, or perceived communication climate.
A surgical team member’s job satisfaction was found to be significantly
related to perceived intrateam communication, perceived communication climate
perceptions, and teamwork style.
These findings, including the unexpected findings, will be discussed in the
next chapter along with the findings of the qualitative study.
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Chapter V. DISCUSSION AND CONCLUSION
This study has taken an interpretive-symbolic perspective (Eisenberg &
Riley, 2001; Krone et al., 1987) to examine knowledge sharing in Chinese surgical
teams and to explicate the diverse meanings and interpretations that surgical team
members create for their actions and relevant organizational events. This study takes
the position that knowledge sharing attitudes and behaviors of Chinese surgical team
members not only are shaped by their cultural traits, their social and institutional
environment but also are shaping their cultural, social, and institutional environment.
Previous studies on knowledge sharing have failed to pay adequate attention
to the important roles played by national cultural traits, social and institutional
forces, focusing instead, and almost exclusively, on individual-level, team-level, and
organizational-level factors. This study seeks to overcome this narrow focus by
uncovering and incorporating relevant cultural traits, social and institutional factors
that shape Chinese surgical team members’ knowledge sharing attitudes and
behaviors. Furthermore, this study highlights the agency of surgical team members in
creating and shaping their own environment through their knowledge sharing
behaviors and the meanings they create for their own and others’ knowledge sharing
behaviors.
Little is known about Chinese surgical teams, though there is a small body of
works on surgical teams in Europe, United States, and other countries. Some great
attitudinal differences have been documented among and within the subgroups of
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surgeons, anesthesiologists, and anesthesia and surgical nurses, which led to low-
quality communication and poor teamwork in surgical teams, particularly at the
interfaces between these occupational groups. Knowledge of the attitudes and
perceptions of Chinese surgical team members regarding certain teamwork,
communication, leadership, climate, and knowledge sharing issues would provide
important insights into the functioning of Chinese surgical teams. This study seeks to
fill in the gap by exploring the attitudes and perceptions of surgeons,
anesthesiologists, and OR nurses in Chinese surgical teams regarding the above-
mentioned issues.
Research Settings and Methods
This study consisted of two parts: one qualitative multiple-case study and one
quantitative survey study. Study 1 was a 5-week long study of 27 surgical teams at
two public hospitals in a middle-sized city in China. The teams studied mainly
included surgeons from six surgical departments and a few anesthesiologists and OR
nurses. These teams varied in terms of the stability of the surgeon, anesthesiologist,
and OR nurse membership. This study employed multiple methods of data
collection, including in-depth interviews, informal conversations, observation of
meetings, of surgical procedures, and of ward rounds, as well as analysis of hospital
documents and government agency policies. This study described knowledge sharing
practices of Chinese surgical team members, identified factors that inhibited or
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facilitated their knowledge sharing, and explicated their interpretations and
perceptions of their own and others’ knowledge sharing behaviors.
Study 2 was a survey study of 86 surgical team members at one of the two
public hospitals studied in Study 1. The respondents included 63 surgeons, 13
anesthesiologists, and 10 OR nurses. Surgeons came from seven surgical
departments. This study reported surgical team members’ attitudes and perceptions
of a set of important teamwork, communication, leadership, climate, and knowledge
sharing factors.
Discussion of Main Findings
The first two research questions were answered by the interview data.
RQ1: What knowledge do Chinese surgical team members share with one
another: How, where, and when? In the teams under study, surgeons,
anesthesiologists, and OR nurses reported mainly using face-to-face communication
to share knowledge with one another. Knowledge sharing in Chinese surgical teams,
particularly that among surgeons in teams with stable membership and in teams
using an individual/team hybrid bonus plan, was found to have a strong insider
focus, lending some support to Gao and Ting-Toomey’s (1998) characterization of
Chinese making a clear insider/outsider distinction.
Interdisciplinary knowledge sharing among surgical team members was said
to be less frequent and of lower quality than was intradisciplinary knowledge
sharing. O f the three subgroups of surgeons, anesthesiologists, and OR nurses,
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interdisciplinary knowledge sharing was the least frequent between surgeons and OR
nurses. Interdisciplinary knowledge sharing was suggested to occur mainly in the
operating room, preoperative case conferences, and surgical wards. Intradisciplinary
knowledge sharing among surgical team members was suggested to occur primarily
in the operating room, department conferences, and ward rounds. Intradisciplinary
knowledge sharing was found to be comprised primarily of downward knowledge
sharing from senior members to less senior members, in addition to some upward
knowledge sharing and some peer knowledge sharing.
Surgeons were found to be more likely to share knowledge, particularly face-
threatening knowledge (e.g., failures, criticism, and disagreement) and expertise with
their teammates and trusting surgeons outside their teams than with other surgeons
outside their teams. Intrateam knowledge sharing among surgeons was suggested to
be more open, more thorough, and more active than interteam knowledge sharing
among surgeons in teams with relatively stable surgeon membership and using an
individual/team hybrid bonus plan. In contrast, anesthesiologists and OR nurses were
found to view all their colleagues from the same discipline as insiders.
Peer knowledge sharing was said to be good among OR nurses and adequate
among anesthesiologists, whereas peer knowledge sharing among surgeons was said
to vary greatly, ranging from being very limited to being adequate.
The interview data provided some support to the described tendency of the
Chinese people to use an indirect and polite communication style (Gao & Ting-
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Toomey, 1998). Most surgeons, anesthesiologists, and OR nurses reported using
such a style of communicating when sharing face-threatening knowledge (e.g.,
disagreement or criticism) with higher-ranking colleagues, and peers and lower-
ranking colleagues who are older. However, they also reported using a more direct
communication style when sharing such knowledge with peers and lower-ranking
colleagues who are younger. These findings highlighted the contextual nature of the
described tendency of the Chinese to use an indirect and polite communication style:
it depends on the nature of the knowledge to be shared and the relative status of the
two parties involved.
Furthermore, it was found that the knowledge sharing behaviors in public
settings of Chinese surgical team members under study displayed some listening-
centered tendency, i.e., more senior surgical team members tended to engage in more
active knowledge sharing whereas their less senior counterparts tended to assume the
role of listener.
RQ2: How do members of Chinese surgical teams perceive, interpret, and
account for knowledge sharing within and between surgical teams, including their
own knowledge sharing behavior?
The knowledge sharing behaviors of Chinese surgical team members
interviewed appeared to be greatly influenced by certain relevant Chinese cultural
traits, the moderately high power distance dimension of the Chinese culture, the
Chinese medical and nursing education systems, the “marketization” of Chinese
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public hospitals and the capitalist style market reforms of the Chinese economy as a
whole.
Chinese national cultural traits of “infighting and inability to cooperate,”
“narrow-mindedness and intolerance,” and “concern with mian zi” were found to
hinder interteam knowledge sharing among surgeons. Chinese national cultural traits
of “favoring obedient subordinates,” “narrow-mindedness and intolerance,” and
“concern with mian zi” as well as the moderately high power distance dimension of
the Chinese culture seemed to affect junior surgical team members, particularly
junior surgeons, by preventing them from speaking up.
The recent changes to the personnel and compensation policies and practices
of Chinese public hospitals as part of China’s national public hospital market-based
reforms (e.g., contract employment and favorable promotion of better-educated
surgeons) were said to result in increased competition between surgical teams,
particularly increased peer competition among senior-level and intermediate-level
surgeons on different teams, as well as competition among surgeons with varying
levels of education, which in turn hindered interteam knowledge sharing among
senior-level and intermediate-level surgeons. Some tensions were noted to exist
between senior-level surgeons with a bachelor’s degree and rich clinical experience
and senior-level and intermediate-level surgeons with less clinical experience who
are better-educated: the former reported not feeling motivated to share their clinical
knowledge with the latter. The market reform of the Chinese economy as a whole
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was also suggested by a few of the surgeons as the reason for increased interpersonal
competition among surgeons, which in turn hindered open, active, and deep
knowledge sharing among them.
Intrateam knowledge sharing among surgeons was observed to occur more
often, more open, more active, and more thorough than interteam knowledge sharing
among surgeons. Such observed quality and frequency discrepancies between
intrateam and interteam knowledge sharing among surgeons in many surgical teams
of study were attributed to: (a) cooperative relationships among surgeons within a
team (due to their teaming process, their seniority composition, and their shared
interests) versus competitive relationships among surgeons on different teams
(particularly those among peer surgeons with a senior-level title or an intermediate-
level title) (due to their conflicting interests and peer competition); (b) the perceived
obligation of sharing knowledge with less senior teammates versus the perceived
voluntary nature of sharing knowledge with less senior surgeons on other teams; and
(c) the greater task interdependence with one’s teammates.
The interview data identified a set of factors spanning multiple levels of
analysis that shape a surgical team member’s knowledge sharing motivation: (a)
team, department, and organizational cultures as well as national cultural traits, (b)
the nature of the knowledge, (c) his or her personality, knowledge sharing efficacy,
knowledge hoarding efficacy, as well as team/department identification; (d) the
recipient’s personality trait, wu xing (“absorptive capacity”) and absorptive attitudes,
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and (e) interpersonal relationship with the knowledge recipient. Many factors that
were identified overlapped with factors suggested in the literature on knowledge
sharing and transfer within and between organizations, whereas some factors
identified were new additions to the field (e.g., knowledge hoarding efficacy). This
study surfaced tensions between some surgical trainees and their supervisors with
regard to the appropriate speed, scope, and depth of surgical training.
The preliminary findings of this study highlighted the agency of surgical
team members in creating, negotiating, sustaining, and modifying their work
environment (e.g., team culture, department knowledge sharing climate, team
cohesiveness, and interpersonal relationships) through their knowledge sharing or
knowledge hoarding behaviors. The downward intradisciplinary knowledge sharing
among surgeons, anesthesiologists, and OR nurses enact and reproduce the existing
hierarchy within these three groups. The interdisciplinary knowledge sharing
between surgeons, anesthesiologists, and OR nurses also enact, strengthen, or
challenge the existing hierarchy among the three disciplines.
The survey study examined whether surgeons, anesthesiologists, and OR
nurses differ from each other and among themselves in a set of knowledge sharing,
teamwork, communication, leadership, and climate perception variables.
The survey data provided moderate support to the proposed distinction
between intradisciplinary and interdisciplinary knowledge sharing perception drawn
by Chinese surgical team members. Chinese surgeons were found to perceive
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knowledge sharing with other surgeons more positively than with anesthesiologists
and OR nurses. These are consistent with the interview findings as well as previous
research on communication in surgical teams (Helmreich & Schaefer, 1994; Sexton
et al., 1998). However, the findings on Chinese anesthesiologists and OR nurses
turned out to be not significant at the 5% level, though both are significant at the
10% level. The non-significant results could be partly explained by the small sample
size of anesthesiologists (N = 13) and OR nurses (N = 10), which reduces the power
of these tests.
The proposed distinction between intradisciplinary and interdisciplinary
teamwork ratings drawn by Chinese surgical team members was partially supported.
Surgeons reported experiencing better teamwork with surgeon teammates than that
with anesthesiologist and OR nurse teammates. However, neither anesthesiologists
nor OR nurses were found to draw such a distinction between intradisciplinary and
interdisciplinary teamwork. The shared department affiliation between
anesthesiologists and OR nurses could partly explain the lack of this distinction.
The data suggested that the negative effect of the competitive relationships
among peer surgeons on surgeons’ rating of peer knowledge sharing is mitigated or
exacerbated by the nature of the knowledge possessed by other surgeons. As
predicted, junior-level surgeons reported viewing intradisciplinary peer knowledge
sharing more negatively than they did intradisciplinary knowledge sharing with other
intermediate-level and senior-level surgeons. Intermediate-level surgeons viewed
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knowledge sharing with other intermediate-level surgeons more positively than with
junior-level surgeons, but not with senior-level surgeons. The significant rating
discrepancy could be partly explained by the expertise gap between intermediate-
level and junior-level surgeons. Although the presence of competition among peer
intermediate-level surgeons might inhibit the frequency of knowledge sharing among
them, it makes sense that such knowledge sharing, when it does occur (e.g., among
peers who are friends with one another), would prove more valuable with
intermediate-level surgeons than with junior-level surgeons, since knowledge tends
to flow one way from intermediate-level surgeons to junior-level surgeons. Senior-
level surgeons viewed knowledge sharing with other senior-level surgeons more
positively than with junior-level surgeons, but not with intermediate-level surgeons.
The expertise gap between senior-level and junior-level surgeons could partly
explain the significant rating discrepancy. Despite its low frequency resulting from
the competition among senior-level surgeons, knowledge sharing with other senior-
level surgeons, when it does occur, proved more valuable to senior-level surgeons
than knowledge sharing with junior-level surgeons.
The survey data suggested that surgeons, anesthesiologists, and OR nurses
did not differ significantly from each other in their hospital climate perceptions. This
finding could be partly explained by other relevant factors that might have
influenced surgical team members’ perceptions of organizational climate, such as
interpersonal relationships, personality, and job characteristics (Johnston, 1976).
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It was found that surgeons, anesthesiologists, and OR nurses all attached
great importance to team knowledge sharing, which in turn contributed to the
effective functioning of surgical teams. Consistent with the anecdotal evidence cited
by Helmreich and Merritt (1998), anesthesiologists were found to differ significantly
from surgeons in that the former only slightly endorsed surgeons as surgical team
leaders whereas the latter strongly agreed that surgical team leadership rests with
surgeons. It was further found that anesthesiologists differ from OR nurses in that the
latter more strongly endorsed surgeons as surgical team leaders.
As predicted, a surgical team member’s seniority was found to be positively
associated with his or her perception of intrateam communication quality. Senior-
level surgical team members (including surgeons, anesthesiologists, and OR nurses)
rated intrateam communication higher than did intermediate-level and junior-level
members.
Although the interview data suggested that senior-level surgical team
members tended to view knowledge sharing with teammates from other disciplines
more positively than did intermediate-level and junior-level team members, the
survey data failed to establish this relationship for surgeons. One possible
explanation is that although high status surgical team members might face less risks
when sharing knowledge with teammates with other disciplines, they might not
necessarily engage in more knowledge sharing, and even if they do, the high
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frequency of knowledge sharing does not say anything about the nature of the
knowledge sharing.
A surgical team member’s seniority was found to be unrelated to perceived
interdisciplinary teamwork. The routine nature of the teamwork that surgeons have
with OR nurses might partly explain why surgeons of all seniority viewed teamwork
with OR nurses similarly and why OR nurses of different seniority viewed teamwork
with anesthesiologists similarly. The routine nature of the teamwork that surgeons
have with anesthesiologists in common procedures might be one possible reason for
the failure to detect differences among surgeons of different seniority in their
perceptions of teamwork with anesthesiologists as well as the failure to detect
differences among anesthesiologists of different seniority in their perceptions of
teamwork with surgeons.
A surgical team member’s seniority was unrelated to perceived
organizational climate, which was inconsistent with the previous finding on the
positive link between an individual’s status and his or her organizational climate
perception (Johnson, 2000; Patterson et al., 2004; Payne & Mansfield, 1973). As
explained earlier, a surgical team member’s status is not the only factor that
influences his or her organizational climate perception. An individual surgical team
member’s organizational climate perception is also influenced by other factors like
the leadership style of his or her direct supervisor, the leadership style of the
department head, and his or her personality (Daniel, 1985; Johnston, 1976).
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Moreover, an individual’s perception of the justness of the hospital compensation
policies and of the promotion policies might also influence his or her organizational
climate perceptions. The low reliability of the organizational climate index (alpha =
.58) might also confound the finding.
A surgical team member’s seniority was found to be unrelated to perceived
communication climate. The low reliability of the communication climate index
(alpha = .57) might confound the results obtained. The Chinese cultural trait of
“excessive concern with face” might mitigate the positive effect of status on a
surgical team member’s communication climate perceptions. Junior-level surgeons
might perceive asking questions the least threatening and tend not to take it
personally because it is natural for them to not have answers to many questions given
their limited professional experience. In contrast, senior-level surgeons might felt it a
great loss of face when asking a dumb question given their high status and long years
of experience, and might instead choose to find out the answers on their own.
Another possible explanation is that senior-level surgical team members rely more
on department leadership for information affecting their work than intermediate-level
and junior-level surgeons whose primary work information source are their
immediate supervisor rather than department leadership.
Surgical team members’ perceptions of intrateam communication and of
communication climate were found to be positively related to their job satisfaction,
which confirm the findings of previous studies (Greenbaum, 1999; Hirokawa &
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Salazar, 1997). Surgical team members’ teamwork style was also found to contribute
to their job satisfaction.
Theoretical Implications
The results of the present study have great implications for theorizing about
knowledge sharing in surgical teams. The findings highlighted the important role
played by national cultural traits, social and institutional forces in shaping surgical
team members’ knowledge sharing behaviors and the meanings they attached to their
own and others’ knowledge sharing behaviors. The relevant national cultural traits
emerging from the study demonstrated that the use of indigenous cultural values
would provide a more coherent and deep account for the knowledge sharing
behaviors of people in a particular culture than relying exclusively on cultural
concepts developed in the Western literature. The findings also stressed the agency
of surgical team members in shaping and reshaping their own environment.
The qualitative study surfaced three dimensions of knowledge sharing: the
depth dimension (the superficial-deep continuum), the initiative dimension (the
passive-active continuum), and the location dimension (public/private setting
dichotomy). These three dimensions contributed to the existing body of literature on
knowledge sharing by providing researchers with a more precise vocabulary to study
knowledge sharing. For instance, great quality discrepancies were suggested to exist
between active sharing of failures and passive sharing of failures. Given the quality
discrepancies, it is important for researchers to pay more attention to this initiative
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nature of knowledge sharing when theorizing about knowledge sharing in
organizations.
This study also has great implications for research on organizational
communication in mainland China. The study not only lent some empirical support
to Gao and Ting-Toomey’s (1998) self-other perspective but also suggested the
necessity of fine-tuning some of their theorizing. For example, the listening-centered
feature of Chinese communication was confirmed only for knowledge sharing in
public settings. The rich empirical data on the communicative behaviors of Chinese
surgical team members greatly enriched the discouragingly small body of works on
organizational communication in mainland China.
The present study of Chinese surgical teams enriched the existing body of
works on surgical teams that comprise almost exclusively surgical teams in Western
cultures. More specifically, it provided rich empirical data of the attitudes and
perceptions of Chinese surgeons, anesthesiologists, and OR nurses with regard to
teamwork, communication, leadership, climate, and knowledge sharing.
Last but not least, this study highlights the importance of taking China’s new
market structure into account as researchers theorize about knowledge sharing in
Chinese surgical teams, since, as suggested in this study, increasing competition
resulting from the market-based reform of Chinese public hospitals has the
unintentional consequence of demotivating surgical team members from sharing
knowledge. If the reform deepened, Chinese medical system would start to look
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more like a Western capitalist system, which in turn, coupled with the hierarchical
structure of surgical teams, would make knowledge “stickier” and knowledge
sharing more problematic. In other words, future theorizing about knowledge sharing
should be more contextually integrated.
Practical Implications for Chinese Hospitals
The findings of this study have some policy implications for Chinese public
hospital management (including department heads). The findings on the negative
impacts of the individual/team hybrid bonus plan in hindering interteam knowledge
sharing suggested that department heads need to be cautious implementing this
incentive plan. They should make great efforts to cultivate identification at the
department level, if they decide to use the individual/team hybrid bonus plan. The
inclusion of a department-level bonus element into the individual/team hybrid bonus
plan would help diminish the interteam competition resulting from the team-level
bonus element.
The findings suggested that the promotional policies favoring surgeons with
an advanced degree had led to unhappiness and even resentment among surgeons
with a lower degree, who responded by intentionally hoard clinical skills (e.g.,
surgical skills) from those better-educated but less clinically experienced. The
hospital management should address the unfairness concerns of those surgeons.
The adoption of a more vigorous training evaluation system and proper
rewarding of surgical team members’ training efforts may increase the motivation of
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senior-level and intermediate-level surgical team members to share their knowledge
with their trainees.
Limitations
This study represents a first step in examining knowledge sharing in Chinese
surgical teams. However, it suffers from several limitations that should be taken into
account when interpreting the findings of this study. First, the small number of
anesthesiologists and OR nurses participating in this study determines that the results
on the knowledge sharing intentions, behaviors, perceptions, and interpretations on
the part of anesthesiologists and OR nurses in Chinese surgical teams are very
preliminary. Future empirical research studying a much larger number of
anesthesiologists and OR nurses of all seniority is needed to refine, extend, and
establish the validity of the preliminary findings of this study. Moreover, as
mentioned earlier, the small number of anesthesiologists and OR nurses participating
in the survey study diminished the power of the tests, and led to the failures to detect
significant relationships between important variables (e.g., intradisciplinary vs.
interdisciplinary knowledge sharing).
Second, the survey study included members from different surgical teams and
failed to discriminate surgical team members who were on the same team from those
who were on different teams. This failure might partly account for the many detected
non-significant relationships between a surgical team member’s seniority and
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important knowledge sharing-related variables (e.g., perceived interdisciplinary
teamwork).
Third, quite a few measures used in the survey study have very low
reliability. For example, the low reliability of measures for communication climate
might have partly resulted in the somewhat counterintuitive negative relationship
between a surgical team member’s seniority and his or her perceived communication
climate. The use of more robust measures would strengthen the survey results.
Furthermore, the fact that several important measures have only one item also cast
some doubt on the validity of the findings with regard to these variables. The low
reliability of the measures imported from Helmreich and Merritt’s (1998) the
Operating Team Resource Management Survey (OTRMS) in this study indicated
that the wording of the items should be modified to suit the Chinese context. For
instance, as suggested by the literature and the case study, the Chinese make a
distinction between communication in public settings and communication in private
settings. A Chinese surgical team member who endorses the hierarchical structure of
a surgical team might agree with the statement “Junior OR team members should not
question the decision made by senior persons in public”, but disagree with the
statement “Junior OR team members should not question the decisions made by
senior persons” used in OTRMS. Moreover, in their study of anesthesiologists from
Scottish hospitals, Flin et al. (2003) also reported low reliability for similar measures
that they imported from the Operating Room Management Attitude Questionnaire,
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which was part of Helmreich and Merritt’s (1998) OTRMS. This suggested that
some of these measures needed to be revised and re-tested for their reliability.
Areas for Future Research
As noted earlier, the findings on anesthesiologists and OR nurses are
preliminary, given the small number of anesthesiologists and OR nurses participating
in this study. Future research involving a larger number of anesthesiologists and OR
nurses is needed to better understand their knowledge sharing attitudes and
behaviors. Furthermore, although the interview data suggested that surgeons’
seniority was related to their knowledge sharing attitudes and behaviors in some
cases, the survey failed to confirm those findings, which might be attributed to the
failure of the survey study to distinguish surgeons who were on the same team from
those who were on different teams. It is possible that this failure to distinguish
surgeon who are teammates from those who are not might have made it difficult to
tease out the potential impacts of seniority on surgeons’ knowledge sharing attitudes
and behaviors. Future study should examine surgeons and their surgeon teammates
who are of different seniority levels directly to see if the suggested attitudinal and
behavioral differences are present.
Researchers could also directly examine the conceptual networks that
emerged from the qualitative study, such as the sharing of face-threatening
knowledge network, and the knowledge sharing motivation network. Although the
case study suggests that certain factors influenced surgical team members’
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knowledge sharing motivations and behaviors (e.g., team stability and incentive
plan), the relative influences of these individual factors are not clear. Additional
empirical work is needed to directly test the influences of these factors. For instance,
the study suggested team stability hindered interteam knowledge sharing, though it
contributed to intrateam knowledge sharing. It would be interesting to examine if the
incorporation of a department-level bonus into the bonus plan for surgical teams help
mitigate the negative impact of team stability on interteam knowledge sharing. If the
department-level bonus were found to mitigate the negative influence of team
stability on interteam knowledge sharing, it would have great practical implications
for hospital management.
There are many other questions that merit further investigation. As a type of
interdisciplinary action teams, understanding of knowledge sharing in surgical teams
would inform studies on knowledge sharing in other types of interdisciplinary teams.
An interesting area for future research would be to see if the three dimensions of
knowledge sharing that surfaced in Chinese surgical teams could be extended to
knowledge sharing in other types of teams. The case study suggested that interteam
competition among surgeons was more intense in civil hospitals than in military
hospitals. It would be interesting to compare surgical teams in civil hospitals with
those in military hospitals to see whether such differences exist. Future researchers
could also study knowledge sharing in surgical teams in other countries to see if
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what differences and similarities exist in the knowledge sharing behaviors and
attitudes of surgical team members from different countries.
Chinese surgical teams represent an interesting “hybrid” type of team that is
composed of a relatively stable core subgroup and some relatively fluid subgroups.
The practical significance of a better understanding of knowledge sharing dynamics
in surgical teams further underscores surgical teams as an important context to study
knowledge sharing in teams. This study examined knowledge sharing in Chinese
surgical teams using an interpretive-symbolic perspective. It highlighted the
influences of national cultural traits, social and institutional forces. It has great
implications for knowledge sharing in surgical teams and teams in general, as well as
for organizational communication in mainland China.
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Appendix A: Number of Medical Graduates from Colleges and Secondary Schools in
Mainland China
Years Colleges Secondary Schools
1950-1952 6393 31264
1953-1957 25918 96042
1958-1962 60135 169545
1963-1965 72882 69513
1966-1970 78246 100956
1971-1975 44167 126437
1976-1980 116612 256473
1981-1985 152054 329218
1986-1990 179431 392637
1991-1995 243052 464913
1996-2000 305437 625354
2001 62638 141989
2002 79500 144593
2003 111356 302174
2004 154187 340554
Note: There were a total of 9499 graduates from medical colleges from 1928
to 1947. There were a total of 41437 graduates from secondary medical
schools before 1949.
Source: Education Statistical Yearbook in China (as cited in the Synopsis of
Chinese Health Statistics in 2005 (p. 118)).
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Appendix B: Postgraduate Residency Training at the MOH hospital
The postgraduate residency training programs at public hospitals in China are
very similar. The following is a brief review of the residency programs in the MOH
hospital under study, which are typical of residency programs in public hospitals in
China.
At the MOH hospital chosen for this study, the residency training is 5 years
for physicians with a bachelor’s degree and 7 years for physicians with an associate
degree. The residency training focuses on theoretical knowledge and clinical skills.
The residency training comprises two phases: (a) the rotation phase (also known as
Phase I) (2 to 3 years for graduates with a bachelor’s degree and 4 to 5 years for
graduates with an associate degree), and (b) the specialty training phase (also known
as Phase II) (2 to 3 years). During the rotation phase, graduates are first assigned to a
level-1 department (e.g., the large surgical department, the non-surgical department,
the anesthesiology department, or the radiology department) and do rotations at
level-2 departments (or units) under their assigned level-1 department or other
related specialties. They receive basic clinical training and theoretical education.
Residents who pass the end-of-rotation evaluations and end-of-rotation written
examination move on to the specialty training phase during which they might be
assigned personal preceptors (usually physicians of intermediate-level professional
titles) and receive more advanced clinical and theoretical training in the specialty of
their choice. Residents who pass the provincial end-of-training written examination
(a test of theoretical knowledge) and the clinical practical skills assessment are
recommended on the basis of their score as candidates for the promotion to the
professional title of physician in charge and/or as candidates for master graduate
program.
At this hospital, the residency programs for residents with a master’s degree
or a doctor’s degree are much shorter, more flexible, and more individualized. These
residents work under 1 to 2 preceptors with a senior-level professional title and are
trained under a customized postgraduate education program. According to the
directives from the Provincial Health Department, they are required to do a minimum
of 1-year rotation, are exempt from the Phase I examination, and only need to sit for
the end-of-training examination and assessment.
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Appendix C: Continuing Education Programs at Chinese Public Hospitals
The exact number of credits a health professional is required to take every
year varies with his or her professional title, the nature of his or her hospital (e.g., a
MOH hospital, a PLA hospital, as well as the grade of his or her hospital), and the
location of his or her institution. Take the MOH hospital chosen for this study for
example, a health professional with an intermediate-level or a senior-level
professional title is required to earn a minimum of 25 credits every year (including a
minimum of 10 Type I credits and 15 Type II credits), whereas a health professional
with a junior-level professional title (excluding residents who are enrolled in the
postgraduate education program) must earn a total of 15 credits (including a
minimum of 6 Type I credits and 9 Type II credits). Only accredited national and
province-level CE programs award Type I credits. All health professionals at this
hospital (a Grade-3 hospital) are also required to have a minimum of 10 credits from
national CE programs.
The number of credits one earns from participation in a CE program is
determined by the duration and quality of the program as well as one’s degree of
participation (Edwards, et al., 2001). For instance, one earns more credits for
teaching a CE program than for attending it. At the MOH hospital under study, a
health professional also earns credits by: (a) publishing journal articles and books
(including translations of works in a foreign language), (b) presenting papers at
accredited academic conferences, (c) completing an approved independent study and
writing a research report, (d) producing teaching materials (e.g., slides, and audio
video materials) for CE courses (e.g., adult education courses, graduate-level courses,
and accredited distance learning courses), and (e) taking up teaching duties (e.g.,
teaching interns). The number of credits granted varies with the length and/or quality
of one’s publication, research report, teaching materials, conference presentation,
and teaching sessions. For example, one earns more credits when (a) publishing
papers in peer-reviewed, top-tier journals than in lower-tiered journals, and (b)
presenting a paper at an international conference than at a national conference. In
addition, the first author of a publication earns more credits than the second author.
The CE program at the PLA hospital studied is slightly different from that at
the MOH hospital studied: its CE credits fall into three types rather than two types.
However, the way in which CE credits are awarded is the same: one earns CE credits
by attending accredited CE programs and degree courses (e.g., associate degree
courses), publishing papers and books, presenting papers at academic conferences,
writing research reports, taking up teaching duties, or doing self-study.
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Appendix D: Hospital Personnel Policies
Source: Ministry of Health Hospital (2004). Opinions and Instructions on the
Application for, Review and Assessment of the Professional Titles in 2004
Physicians and nurses who are in one of the following conditions are not allowed to
take the professional title qualification exam:
(a) those who have been found responsible for a medical
malpractice that occurred during the past three years;
(b) Those who have found responsible for a medical error that was
made within the last year;
(c) Those who are still in the disciplinary sanction period;
(d) Those who have used a fake degree or those who have cheated
in exam during the past 2 years;
(e) Other conditions stipulated by provincial health administrative
agencies.
The requirements for applying for the professional title of chief physician or chief
senior nurses are as follows:
1. Technical and Professional Competence: one should meet the following
conditions after being accorded the professional title of assistant chief
physician or assistant chief senior nurse:
a. Has completed the required amount of clinical or technical work;
b. Has rich experience in diagnosing and treating diseases in one’s
specialty or relatively strong professional competence, is capable of
solving difficult and complicated problems in one’s specialty as well
as organizing and managing one’s professional work;
c. Is competent in training and teaching professionals with post titles
below oneself (i.e., junior, intermediate-level and assistant-senior-
level professional titles) in one’s specialty, has taught professionals in
one’s specialty and trained physicians in charge or nurses in charge,
or has participated in the training of physicians or nurses with a
master’s or doctor’s degree;
d. Is competent in keeping track of the latest development in one’s
specialty, in doing independent research, in designing and organizing
advanced projects and writing research reports.
2. Achievements: one should have attained one of the following achievements
after being accorded the professional title of assistant chief physician or
assistant chief senior nurse
269
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a. Principal investigator in a project that has won the Third Science &
Technology Advancement Prize at the city (or bureau) level (or
equivalent awards) or higher prize (need to provide one’s award
certificate);
b. Principal investigator in a project that has won the Prize of
Introducing New Advanced Medical Technology above the provincial
level;
c. Has over 1 national patent on new technology (or technique) in one’s
specialty;
d. Has participated ini research project above the city (or bureau) level
or 2 research projects at the county level as the principal investigator
or as the technical director, the project(s) either has passed the final
evaluation or has been completed.
3. Publication: one’s publication must meet at least one of the following
requirement after being accorded the professional title of assistant chief
physician or assistant chief senior nurse:
a. 4 academic papers published in journals with a formal journal serial
number (as the first author) (at least one paper should be published in
a core journal or a journal of the Statistical Source of Chinese Science
and Technology Papers);
b. Has edited over 2 monographs in one’s specialty (as chief editor or
associate chief editor) or has written 1 monograph of fairly high
academic values (the monograph must be over 200,000 words in
length).
4. Foreign Language Proficiency: one should meet at least one of the following
requirements:
a. Has a master’s degree or doctor’s degree;
b. Has taken the national or provincial professional-title foreign
languages examination, and has shown that one’s foreign language
skills are sufficient for one’s job;
c. Has passed the national foreign language skills examination for
people who are going abroad on business before leaving China and
has studied or worked abroad for over 1 year;
d. Meets the requirements stipulated by the provincial personnel
(professional title) agencies.
5. Computer Skills: one must meet at least one of the following requirements:
a. Has a bachelor’s degree majoring in computer science or a higher
level degree;
270
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b. Has taken the national or provincial professional-title computer skills
examination, and has shown that one’s foreign language skills are
sufficient for one’s job;
c. Has completed the CE training on computer skills for professionals
that is organized by the provincial bureau of personnel, passed the
evaluation, and received the certificate;
d. Have passed that national computer programming skills qualification
exam.
The requirements for applying for the professional title of assistant chief physician or
assistant chief senior nurses are as follows:
1. Academic Degrees: one must meet one of the following conditions:
a. Has a bachelor’s degree and has worked for over 5 years in one’s
specialty after being accorded the professional title of physicians in
charge or senior nurses in charge;
b. Has a master’s degree and has worked for over 4 years in one’s
specialty after being accorded the professional title of physicians in
charge or senior nurses in charge;
c. Has a doctor’s degree and has worked for over 2 years after being
accorded the professional title of physicians in charge or senior nurses
in charge.
2. Technical and Professional Competence: one should meet the following
conditions after being accorded the professional title of physician in charge or
senior nurse in charge:
a. Has completed the required amount of clinical or technical work;
b. Has fairly rich experience in diagnosing and treating diseases in one’s
specialty or relatively strong professional competence, is capable of
solving relatively difficult and complicated problems in one’s
specialty as well as organizing and managing one’s professional work;
c. Is competent in training and teaching professionals with intermediate-
level professional titles in one’s specialty, has taught professionals in
one’s specialty or has participated in the training of physicians or
nurses with a master’s or doctor’s degree;
d. Masters the expertise in choosing research topics, project design, and
research methodology, is competent in proposing projects that are tied
to one’s daily work, doing research, and writing research reports.
3. Achievements: one should have attained one of the following achievements
after being accorded the professional title of physician in charge or senior
nurse in charge:
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a. Principal investigator in a project that has won the Science &
Technology Advancement Prize at the city (or bureau) level (or
equivalent awards) (need to provide the award certificate);
b. Main investigators in a project that has won the First Science &
Technology Advancement Prize at county level (the first three main
investigators, need to provide the award certificate);
c. Principal investigator in a project that has won the Prize of
Introducing New Advanced Medical Technology above the city level
(need to provide the award certificate);
d. Has over 1 national patent on new technology (or technique) in one’s
specialty;
e. Has participated ini research project above the county level or 2
Research projects above the county level as the principal investigator,
the project(s) either has passed the final evaluation or has been
completed.
4. Publication: one’s publication must meet at least one of the following
requirement after being accorded the professional title physician in charge or
senior nurse in charge:
a. 3 academic papers published in journals with a formal journal serial
number (as first author);
b. 1 monograph in one’s specialty fairly high academic values (the
monograph must be over 50,000 words in length);
5. Foreign Language Skills: one should meet at least one of the following
requirements:
a. Has a master’s degree or doctor’s degree;
b. Has taken the national or provincial professional-title foreign
languages examination, and has shown that one’s foreign language
skills are sufficient for one’s job;
c. Has passed the national foreign language skills examination for
people who are going abroad on business before leaving China and
has studied or worked abroad for over 1 year;
d. Meets the requirements stipulated by the provincial personnel
(professional title) agencies.
6. Computer Skills: one must meet at least one of the following requirements:
a. Has a bachelor’s degree majoring in computer science or a higher
level degree;
b. Has taken the national or provincial professional-title computer skills
examination, and has shown that one’s foreign language skills are
sufficient for one’s job;
272
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c. Has completed the CE training on computer skills for professionals
that is organized by the provincial bureau of personnel, passed the
evaluation, and received the certificate;
d. Has passed that national computer programming skills qualification
exam.
A physician or nurse who has met the following conditions could be promoted to
chief physicians or chief senior nurses (known as the full senior-level professional
title) as an exception: one has worked for over 4 years after being accorded the
professional title of assistant chief physician or assistant chief senior nurse, and has
been the principal investigator in a project that has won the Second Class Science &
Technology Advancement Prize at the province (or ministry) level (or equivalent
awards) (one needs to provide the award certificate).
A physician or nurse who (a) has had outstanding job performance, (b) has made
relatively big breakthroughs in one’s academic research or the application of one’s
technical research findings, (c) has had at least one annual review rating of
excellence, and (d) has met at least one of the following conditions can apply for the
professional title of assistant chief physicians or assistant chief senior nurses as an
exception to the rules stipulated above:
2. Has worked in one’s specialty for over 20 years since graduating from
medical colleges with an associate degree, and has worked in one’s specialty
for over 6 years after receiving the professional title of physician in charge or
senior nurse in charge;
3. Has worked in one’s specialty for over 4 years after receiving the
professional title of physician in charge or senior nurse in charge, and has
been the principal investigator of a project that has won the Third Class
Science & Technology Advancement Prize at the province (or ministry) level
(or equivalent awards) (one needs to provide the award certificate).
Physicians in charge and senior nurses in charge need to meet one of the following
conditions in addition to meeting the minimum requirements (e.g., foreign language
skills, computer skills, publication, and research) in order to be qualified for
exceptional promotion:
1. Has been commended as “advanced individuals” by municipal governments
or governments at higher levels;
2. Has been chosen as an Outstanding Young and Middle-Aged Expert at the
city level or above;
3. Has been the principal investigator in a project that has won the Third Class
Science & Technology Advancement Prize at the city (or bureau) level (one
needs to provide the award certificate);
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4. Has been one of the top three main investigators or coordinators of a
provincial-level or ministry-level research project (including a research
project at the deputy-provincial level) in one’s specialty that either has passed
the final evaluation or has been completed;
5. Has been one of the top three main investigator or coordinator of a funded
city-level or department-level research project (including a research project at
the deputy-provincial level) in one’s specialty that either has passed the final
evaluation or has been completed;
6. Has outstanding job performance and rich working experience, has published
3 papers in journals with a formal journal serial number (as first author) (at
least one paper should be published in a core journal or a journal of the
Statistical Source of Chinese Science and Technology Papers), and has been
commended by higher competent agencies or has been chosen as a member
of the division committee of a city-level professional association or a
committee member of a district-level or county-level professional association.
Physicians and nurses who apply for intermediate-level and junior-level
professional titles must pass the professional qualification examination organized by
the Ministry of Health and the Ministry of Personnel.
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Appendix E: List of Chinese Communication-Related Concepts and Their
English Translations
Chinese
Communication-
Related
Concepts
English Translation
Bao “reciprocity”
Gan qing “feeling”
Guan xi “interrelation”
Han xu “implicit communication”
Jen “humanism”
Ji “the first imperceptible beginning of movement”
Ke qi “politeness”
Li “rite” or “norms and rules of proper behavior in a social
context”
Mian zi or
mientz
“social image” or “face”
Ren qing “human feeling” or “doing favors”
Shi “temporal contingencies”
Ting hua “listening centeredness”
Wai ren “outsider”
Wei “spatial contingencies”
Yi “righteousness or appropriateness”
Yi lun “to gossip”
Z iji ren “insider”
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Appendix F: Chinese Hospital Accreditation
Under the current Chinese hospital accreditation system, Chinese accredited
hospitals fall into three grades (Grade-1, Grade-2, and Grade-3) and ten levels
(Grade-1 and Grade-2 hospitals are further divided into three classes: Class A, Class
B, and Class C, whereas Grade-3 hospitals are divided into four classes: Special
Class, Class A, Class B, and Class 3) (Gu, 2004). A Grade-3, Special-Class hospital
is the highest graded hospital in China. The classification of hospitals into different
grades focuses on the “hardware” of a hospital: the number of beds, the scope of
departments (clinical departments and other support departments), staff, building
(e.g., construction area per bed), and equipment. For instance, a Grade-3 hospital
must at least have 500 beds, 1.03 health professional per bed, 0.4 nurse per bed, 2
clinical nutritionists, and 60 square meters’ construction area per bed. Furthermore,
technicians must account for at least 1% of the hospital’s staff, and the head of the
departments must have a senior-level professional title.
The further classification of hospitals into different classes within a grade is
primarily based on hospital performance (e.g., quality of healthcare services
provided and hospital management efficiency) and hospital capacity development
(e.g., staff training and research achievements).
According to the Synopsis of 2004 Chinese Health Statistics, as of 2003,
China has a total of 12599 general hospitals, including 617 Grade-3 general hospitals
(389 Class-A general hospitals, 217 Class-B hospitals, and 11 Class-C hospitals),
3391 Grade-2 hospitals, and 2217 Grade-1 general hospitals (p. 6).
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Appendix G: Profiles of Interviewees
Table G. 1. Profile of Interview Participants from the MOH Hospital
Gender Number
Male 54 (83.1%)
Female 11 (16.9%)
Job Function
Surgeons 51 (78.5%)
Anesthesiologists 4(6.1%)
OR nurses 10(15.4%)
Educational Level
Secondary vocational diploma 1 (1.5%)
Associate degree 6 (9.25%)
Bachelor’s degree 38 (58.5%)
Master’s degree 14(21.5%)
Doctor’s degree 6 (9.25%)
Professional Title
Junior-level 20 (30.8%)
Intermediate-level 23 (35.4%)
Senior-level 22 (33.8%)
Age
20s 22 (33.8%)
30s 25 (38.5%)
40s 14(21.5%)
50s and over 4 (6.2%)
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Appendix G: Profiles of Interviewees (Continued)
Table G.2. Profile of Interview Participants from the PLA Hospital
Gender
Male 35 (100%)
Job Function
Surgeons 33 (94.2%)
Anesthesiologists 2 (5.8%)
Educational Level
Associate degree 1 (2.9%)
Bachelor’s degree 22 (62.9%)
Master’s degree 9 (25.7%)
Doctor’s degree 3 (8.6%)
Professional Title
Junior-level 12 (34.2%)
Intermediate-level 11 (31.4%)
Senior-level 12 (34.2%)
Age
20s 10 (28.6%)
30s 13 (37.1%)
40s 7 (20.0%)
50s and over 5 (14.3%)
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Appendix H: Interview Questions
1. What do you think of the concept “knowledge”? How would you define it?
What kinds of knowledge do you usually use in your daily work?
2. Have you ever heard of the concept of knowledge sharing? What do you
think of it (any advantage or disadvantage)? What do you think of
“knowledge hoarding”? Why do you think people tend to hoard knowledge?
What do you think are the main motivators for people to initiate voluntary
knowledge sharing in your hospital?
3. Does your hospital have any information management system and/or its own
web site? Does your hospital publish any internal journals or newsletters?
How often do you visit your hospital’s web site? What activities do you
usually do when visiting that web site?
4. Does your hospital store patients’ records electronically? What is the
traditional way of managing patient’s records? Are you satisfied with the
traditional system? Why?
5. Are there knowledge management projects going on at your hospitals? Are
there formal forums in which you could openly share knowledge with others?
How are new medical techniques and equipment knowledge disseminated
throughout your hospital (department or team)?
6. How would you describe the practice of knowledge sharing at your hospital
(department or team)?
7. How would you describe your organizational attitude toward knowledge
sharing? Would you say that your hospital has a culture that supports
knowledge sharing? Could you give me specific examples?
8. Could you describe the performance evaluation and incentive system of your
hospital? Would you say that it encourages knowledge sharing? (e.g., any
special funds for knowledge sharing initiatives)? How are research funds and
the funds for equipment purchase allocated? Would special consideration be
paid to cross-disciplinary collaborative research requests? How does your
hospital reward researchers?
9. Please briefly describe the composition of your surgical teams (e.g.,
education, profession)
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10. Please briefly describe the culture of your surgical team.
11. How do you determine the technical expertise of other members on your
surgical teams (e.g., reputation, direct experience, education)?
12. Do you find it is hard to communicate with other team members?
13. Which communication media do you use in your knowledge sharing efforts?
Could you give me some examples of how you share explicit and tacit
knowledge with others?
14. Are there mentor systems for new employees in your hospitals (department or
teams)?
15. Does your relationship with other team members influence your knowledge
sharing decisions and activities? If so, how? How’s the communication
among team members during operations in terms of frequency, quality, and
direction? If team members have any doubt about the operation procedure or
instructions, would they verbalize their doubt on the spot? Would changes in
the operation or anaesthesia plan be verbalized? Who makes the decisions
concerning the operation, the surgeon or the whole team? How would
describe the coordination among your team members? Do you trust other
teammates’ expertise?
16. Imagine the following scenario: The patient has complications during the
operation. The surgeon has decided on a particular plan. Yet you happen to
know another plan that is superior because you have encountered it in other
surgical teams or have read about it in an academic journal. Would you speak
up?
17. Specific communication skills: do you think that your long-term cooperation
has provided you with a good understand of the expertise and personality of
other team members so that you could anticipate their knowledge needs
and/or behaviors?
18. Is there any briefing on the operation? How about some examples?
19. Would your team summarize the experience as a whole after the operation? If
the operation is a special case that you have not dealt with before, and you
happen to know that some other teams have treated patients with similar
conditions, would you ask them for help?
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20. Do you think that the head surgeon’s attitude towards knowledge sharing
influences the whole team’s attitude towards knowledge sharing? If so, how?
21. Would you share knowledge with team members that directly or indirectly
threaten the competence face of other teammates? Would it further deter you
when that person is at a higher position? How about people of better
education? Do gender and age of the recipient matter in your decision?
281
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Appendix I: List of Codes with Frequencies
Code # o f
Occurrences
# of Codes
Networked
to
Intrateam knowledge sharing 208 28
National culture 180 9
Status, seniority (age), hierarchy 155 10
Intrateam intradisciplinary knowledge sharing 142 4
Department knowledge sharing 141 14
Knowledge sharing challenges 141 11
Knowledge sharing venues 131 9
(knowledge sharing in) Operating room 130 3
Nature of knowledge 126 14
National culture - concern with mian zi (“face”) 125 7
Knowledge sharing depth, frequency 120 5
Downward knowledge sharing 119 3
Team coordination 116 6
Team communication 115 4
Communication strategy 113 7
(knowledge sharing in) Conferences 110 2
Sharing of face-threatening knowledge 109 15
National culture-power distance 105 5
Team stability 104 5
Benefits of knowledge sharing 102 3
Interteam knowledge sharing 101 21
Face-to-face knowledge sharing 101 3
Intrateam interdisciplinary knowledge sharing 101 1
Communication channels of knowledge sharing 100 6
Roles and responsibilities 99 2
Knowledge definition 97 1
Failure 96 4
Passive-active knowledge sharing 95 5
Knowledge sharing satisfaction 95 6
Knowledge sharing motivation 90 27
Educational level 90 5
Public/private settings 89 3
Disagreement, criticism 88 3
Interteam knowledge sharing 87 20
Team leadership 86 4
Interpersonal relationship (trust, respect, caring) 85 6
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Appendix I: List of Codes with Frequencies (Continued)
Code # o f
Occurrences
# of Codes
Networked
to
Department culture 84 7
Team knowledge sharing climate 84 5
Mo qi (shared mental models) 78 6
Department leadership 77 5
Team decision-making 76 2
Expertise 76 2
Teaming history 74 2
Recipient's absorptive attitude 74 1
Team composition 72 5
Hospital incentives and support (lack) 71 4
(knowledge sharing in) Ward rounds 70 2
Recipient's wuxing-absorptive capacity 69 2
Vertical knowledge sharing expectations 67 2
Personality traits 67 1
Preoperative, postoperative case discussion
(informal)
67 1
Peer knowledge sharing 66 3
Department knowledge sharing climate 60 6
Procedure smoothness and complexity 58 1
Litigation concerns 54 3
Perceived knowledge sharing risks 52 13
Team culture 51 6
Demanding health care environment 51 1
Team cohesiveness 49 6
Interteam competition 46 6
Department identification 45 7
Tentative knowledge 45 3
Tacit-explicit knowledge 45 3
Surgeon professional personality 45 2
Department cohesiveness 44 6
Hospital human resources policies 43 5
Physical proximity 41 1
National culture-infighting and inability to
cooperate
40 3
Safety concerns 39 2
Knowledge sharing efficacy 36 8
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Appendix I: List of Codes with Frequencies (Continued)
Code # o f
Occurrences
# of Codes
Networked
to
Department size and status 36 1
Team identification 34 7
Upward knowledge sharing 32 3
Hospital marketization 32 1
Success stories 31 1
Documentation 26 2
Organizational culture 26 3
Equity issues 24 4
Communication skills 23 2
Knowledge legitimacy contest 22 3
Team performance 22 2
National culture-narrow-mindedness and
intolerance
21 5
National culture- Confucianism 20 2
Mediated knowledge sharing 17 2
Electronic patient records 17 1
Attainable knowledge sharing expectations 16 1
Chinese medical education system issues 15
Inter-departmental consultation 14 1
Knowledge creation 12 1
Hospital knowledge sharing 11 11
Knowledge hoarding efficacy 11 1
Peer knowledge sharing expectations 9 1
Downsides to knowledge sharing 9 1
National culture-favoring obedient
subordinates
9 2
Shift handover 8 1
Inter-hospital knowledge sharing 7 4
Computer-mediated knowledge sharing 6 2
Continuing education 5 3
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A ppendix J.
Sample Codes and Quotations
Code(s) Sample Quotes
National culture - concern with
mian zi (“face”)
Sharing o f face-threatening
knowledge
Failure
Nature o f knowledge
“Chinese people are known for being extremely concerned about their mian zi [“face”].
They are over-protective o f their mian zi. It’s rare for a Chinese, including a Chinese
surgeon, to admit his or her errors in public. What’s more, Chinese surgeons might cover up
the mistakes o f their teammates in order to protect their teammates’ mian zi. This is not
good for the department, because others are deprived o f the opportunities to learn from these
errors and mistakes. There is an old Chinese saying, “bi men si guo.” [“Contemplate your
faults behind closed doors.”] Such mentality has glaring weaknesses. It’s not enough that the
surgeon who has committed the error learns from it. Such learning should be shared with
others as well.” (Intermediate-level Cardiac Surgeon at the MOH hospital)
National culture- concern with
mian zi (“face”)
Disagreement
Nature o f knowledge
Sharing o f face-threatening
knowledge
Public/private settings
I wouldn’t disagree with my senior teammates in public settings, like at department
conferences. I prefer discussing my different opinions with them in private settings. Public
disagreement with your superiors is considered very impolite and inconsiderate in the
Chinese culture. It’s important for teammates to protect each other’s mian zi.
to
00
on
Appendix K: List of Networks Created
Sharing of Face-threatening Knowledge
Knowledge Sharing Venues
Intrateam Knowledge Sharing
Interteam Knowledge Sharing
Knowledge Sharing Satisfaction
Knowledge Sharing Motivation
Knowledge Sharing Challenges
Hospital Knowledge Sharing
National Culture
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Appendix L: Sample Networks and Corresponding Codes
Sample Networks and Corresponding
Codes (selected)
Network Corresponding Codes
Knowledge Sharing Satisfaction Attainable knowledge sharing expectations
Peer knowledge sharing expectations
Vertical knowledge sharing expectations
Knowledge sharing efficacy
Knowledge hoarding efficacy
Intrateam knowledge sharing
Interteam knowledge sharing
Sharing o f face-threatening knowledge
Knowledge sharing motivation
Knowledge definition
Downsides to knowledge sharing
Benefits o f knowledge sharing
Knowledge creation
Upward knowledge sharing
Downward knowledge sharing
Peer knowledge sharing
National culture- Confucianism
Knowledge sharing challenges Hospital incentives and support (lack)
Educational level
Team stability
Team composition
Hospital marketization
Knowledge legitimacy contest
Knowledge sharing motivation
Status, seniority (age), hierarchy
Chinese medical education system issues
Hospital human resources policies
Equity issues
National culture - favoring obedient
subordinates
National culture - inability to unite
National culture - concern for mian zi
National culture - narrow-mindedness
National culture - power distance
Nature o f knowledge
Tacit-explicit knowledge
Communication skills
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Appendix M: Department Conferences
At both hospitals studied, surgical departments and the anesthesia
departments hold many department conferences that facilitate knowledge sharing
between surgical teams. Preoperative case conferences are not only held by surgical
departments but also by the department of anesthesia. However, the preoperative
case conferences held by the department of anesthesia are only attended by
anesthesiologists and sometimes OR nurses within the department.
Complex clinical case conferences are held at surgical departments when the
surgeon team in charge of a patient fails to finalize their diagnosis or when the
treatment fails to improve the patient’s conditions five days following the patient’s
hospitalization. The case presentation by the surgeon team follows a similar format
like that in preoperative case conferences.
Mortality conferences focus on the questions of “how and why did the patient
die?” and of “whether the patient’s death is unavoidable”. Usually the surgeon in
charge of the patient (the most junior surgeon on the team) would first report the
patient’s conditions, the treatment process, the rescue and the dying process. Then
other surgeons would raise their questions and concerns about the diagnosis and/or
the treatment. If all surgeons agree that the surgeon team has done their best to
rescue the patient and that the patient’s condition is too severe to be cured, the
discussion would end. If the patient’s death is not justified, the case would be
referred to the relevant hospital administrators who would in turn pass the case to the
relevant medical audit committees.
Weekly working conferences often take the form of mini-lectures. Weekly
mini-lectures at surgical departments and the department of anesthesia at these two
hospitals usually last for 30 minutes (a 20-minute presentation followed by 10
minutes’ discussion). Surgeons, anesthesiologists, and OR nurses in a department
take turns in hosting those lectures. The topics of the lectures are very flexible. They
could be a case study of a new technology or technique, a summary of one’s own
experiences, and a talk about one’s research project.
288
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Appendix N: Profiles o f Survey Respondents
Table M .l. Surgical Team Members by Specialty, Seniority and Educational Level
Secondary
Degree
Associate
Degree
Bachelor’s
Degree
Master’s
Degree
Doctor’s
Degree
Total
Number
Surgeons with a Senior-level
Title
0 2 12 7 5 26
Surgeons with an
Intermediate-level Title
0 0 11 8 0 19
Surgeons with a Junior-level
Title
0 1 12 5 0 18
Anesthesiologists with a
Senior-level Title
0 0 3 0 0 3
Anesthesiologists with an
Intermediate-level Title
0 0 4 0 0 4
Anesthesiologists with a
Junior-level Title
0 0 4 2 0 6
OR Nurses with a Senior-
level Title
0 0 1 0 0 1
OR Nurses with an
Intermediate-level Title
0 4 1 0 0 5
OR Nurses with a Junior-
level Title
1 2 1 0 0 4
1 (1.2%) 9(10.5% ) 49 (57.0%) 22 (25.6%) 5 (5.8%) 86
t o
oo
vo
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Appendix N: Profiles o f Survey Respondents (Continued)
Table N.2. Age Distribution o f Participants by Title Seniority
Seniority Minimum Age Maximum
Age
Mean Standard
Deviation
Variance
Surgical Team Members with a
Senior-level Title (N =29)
37.00 66.00 45.69 7.68 58.94
Surgical Team Members with an
Intermediate-level Title (N = 28)
28.00 45.00 34.86 2.93 8.57
Surgical Team Members with a
Junior-level Title (N = 28)
24.00 35.00 27.82 2.44 5.93
ro
o
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Appendix O: Survey Questionnaire and Marginals
Items Strongly
Disagree
Slightly
Disagree
Neutral Slightly
Agree
Strongly
Agree
Mean
1. The senior person, if available, should take over and
make all decisions in life-threatening emergencies
0 5 2 9 70 4.67
2. The department provides adequate, timely information
about events in the hospital which might affect my work
0 5 16 43 22 3.95
3. Senior staff should encourage questions from junior
medical and nursing staff during operations if appropriate
1 1 0 6 78 4.84
4. Even when fatigued, I perform effectively during critical
phases o f operations
10 27 20 9 20 3.02
5. We should be aware o f and sensitive to the personal
problems o f other OR team members
1 4 4 53 24 4.10
6. Senior staff deserve extra benefits and privileges 1 2 3 43 37 4.31
7 . 1 do my best work when people leave me alone 0 5 10 44 27 4.08
8 . 1 let other team members know when my workload is
becoming (or about to become) excessive
1 5 17 48 15 3.83
9. It bothers me when others do not respect my professional
capabilities
2 3 2 41 38 4.28
10. Doctors who encourage suggestions from OR team
members are weak leaders
60 15 6 0 5 1.55
11. My decision-making ability is as good in emergencies
as in routine situations
11 41 13 6 15 2.69
12. A regular debriefing o f procedures and decisions after
an OR session or shift is an important part o f developing
and maintaining effective crew coordination
0 4 3 36 43 4.37
13. Team members in charge should verbalize plans for
procedures or actions and should be sure that the
information is understood and acknowledged by the others
3 2 6 39 36 4.20
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Appendix O: Survey Questionnaire and Marginals (Continued)
Items
Strongly
Disagree
Slightly
Disagree
Neutral Slightly
Agree
Strongly
Agree
Mean
14. Junior OR team members should not question the
decisions made by senior persons
26 46 5 7 2 1.99
1 5 .1 try to be a person that others will enjoy working with 0 3 0 44 39 4.38
1 6 .1 am encouraged by my leaders and co-workers to
report any incidents I may observe
0 5 20 37 24 3.93
17. The only people qualified to give me feedback are
others o f my own profession
44 24 10 4 4 1.84
18. I f s better to agree with other OR team members than to
voice a different opinion
42 32 8 3 1 1.71
19. The pre-session team briefing is important for safety
and for effective team management
0 0 1 13 71 4.80
20. It’s important that my competence is acknowledged by
others
0 1 1 36 48 4.52
2 1 .1 am more likely to make errors or mistakes in tense or
hostile situations
2 2 7 46 29 4.14
22. The doctor’s responsibilities include coordination
between his or her work team and other support
departments
2 1 7 32 44 4.34
2 3 .1 value compliments about my work 1 1 1 42 41 4.41
24. Working for this hospital is like being part o f a large
family
11 16 26 21 12 3.08
25. OR team members [should] share responsibility for
prioritizing activities in high workload situations
1 6 4 17 58 4.45
26. As long as the work gets done, I don’t care what others
think o f me
1 9 11 42 23 3.90
27. Successful OR management is primarily a function o f
the doctor’s medical and technical proficiency
5 21 25 27 8 3.14
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Appendix O: Survey Questionnaire and Marginals (Continued)
Items Strongly
Disagree
Slightly
Disagree
Neutral Slightly
Agree
Strongly
Agree
Mean
28. A good reputation in the OR is important to me 1 2 2 41 40 4.36
29. Error is a sign o f incompetence 26 43 12 4 1 1.97
30. Departmental leadership listens to staff and cares about
our concerns
3 5 40 22 16 3.50
31.1 enjoy working as part o f a team 0 3 5 60 18 4.08
32. If I perceive a problem with the management o f a
patient, I will speak up, regardless o f who might be affected
7 11 5 44 19 3.69
3 3 .1 am ashamed when I make a mistake in front o f other
team members
1 5 13 52 15 3.87
34. In critical situations, I rely on my supervisor to tell me
what to do
8 31 28 12 7 2.76
35.1 value the goodwill o f my fellow workers - 1 care that
others see me as friendly and cooperative
0 2 2 58 24 4.21
3 6 .1 sometimes feel uncomfortable telling OR members
from other disciplines that they need to take some action
0 5 11 54 16 3.94
37. Team members should not question the decisions or
actions o f senior staff except when they threaten the safety
o f the operation
10 29 15 23 9 2.91
3 8 .1 am less effective when stressed or fatigued 0 0 0 53 33 4.38
39. It is an insult to be forced to wait unnecessarily for
other members o f the OR team
0 0 2 54 30 4.33
40. Mistakes are handled appropriately in the hospital
where I work
8 12 34 23 9 3.15
41. Leadership o f the OR team should rest with surgeons 1 8 5 23 49 4.29
42. My performance is not adversely affected by working
with an inexperienced or less capable team member
1 34 13 21 17 3.22
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Appendix O: Survey Questionnaire and Marginals (Continued)
Items Strongly
Disagree
Disagree Neutral Agree Strongly
Agree
Mean
'43. To resolve conflicts, team members should openly
discuss their differences with one another.
0 0 1 5 80 4.92
44. Team members should monitor each other for signs of
stress or fatigue
1 6 2 66 11 3.93
4 5 .1 become irritated when I have to work with
inexperienced medical staff
7 7 12 52 8 3.55
4 6 .1 am proud to work for this hospital 4 10 22 42 8 3.47
47. All members o f the OR team are qualified to give me
feedback
0 1 4 18 63 4.66
48. A truly professional OR team member can leave
personal problems behind when working in the OR
0 8 4 34 40 4.23
49. There are no circumstances where a junior team
member should assume control o f patient management
12 52 13 4 5 2.28
50. Team members should feel obligated to mention their
own psychological stress or physical problems to other OR
personnel before or during a shift or assignment
0 1 2 50 33 4.34
51. In the OR, I get the respect that a person o f my
profession deserves
1 3 10 54 18 3.99
52. Human error is inevitable 9 13 4 27 33 3.72
53. The concept o f all OR personnel working as a team
does not work in our hospital
4 8 21 45 8 3.52
54. Personal problems can adversely affect my performance 0 12 21 42 11 3.60
55. Effective OR coordination requires members to take
into account the personalities o f other team members
0 0 6 59 21 4.17
5 6 .1 like my job 0 1 7 51 27 4.21
5 7 .1 always ask questions when I feel there is something I
don’t understand
0 0 8 28 (32.6%) 50 (58.1%) 4.49
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Appendix O: Survey Questionnaire and Marginals (Continued)
Part T I.
Please read the following descriptions o f four different leadership styles, and answer the questions that follow. Thank o f your immediate
supervisor when answering the next two questions.
Style 1 Leader usually makes decisions promptly and communicates them to subordinates clearly and firmly. Expects them to carry out the
decisions loyally and without raising difficulties.
Style 2 Leader usually makes decisions promptly, but, before going ahead, tries to explain them fully to subordinates. Gives them the reasons for
the decisions and answers whatever questions they may have.
Style 3 Leader usually consults with subordinates before reaching decisions. Listens to their advice, considers it, and then announces decisions.
Expects all to work loyally to implement it whether or not it is in accordance with the advice they gave.
Style 4 Leader usually calls a meeting o f subordinates when there is an important decision to be made. Puts the problem before the group and
invites discussion. Accepts the majority viewpoint as the decision.
___________ 58. Which one o f the above styles o f leadership would you most prefer to work under?
1.2% Style 1
10.5% Style 2
45.3% Style 3
43.0% Style 4
59. In your organization, which style do you find yourself most often working under?
50.0% Style 1
25.6% Style 2
14.0% Style 3
10.5% Style 4
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Appendix O: Survey Questionnaire and Marginals (Continued)
Part III.
Please describe your personal perception o f the quality o f teamwork and cooperation/communication you have experienced with the following
staff, using the following scale:
1. Very low; 2. low; 3. adequate; 4. high; 5. very high
Mean Standard Deviation
60. Chief surgeons and assistant chief surgeons 3.66 .83
61. Surgeons in charge 3.67 .60
62. Surgeon residents or visiting surgeons 3.58 .79
63. Chief anesthesiologists and assistant chief anesthesiologists 3.49 .76
64. Anesthesiologists in charge 3.47 .79
65. Anesthesiologists 3.36 .81
66. OR nurses 3.63 .91
67. Department leadership 3.30 .61
Part IV.
Please describe your perception o f the quality o f knowledge sharing you have experienced with the following staff, using the following scale:
1. Very low; 2. low; 3. adequate; 4. high; 5. very high
68. Chief surgeons and assistant chief surgeons
69. Surgeons in charge
70. Surgeon residents or visiting surgeons
71. Chief anesthesiologists and assistant chief anesthesiologists
72. Anesthesiologists in charge
73. Anesthesiologists
74. OR nurses
75. Department leadership
Mean Standard Deviation
3.51 .99
3.72 .85
3.27 1.10
3.22 .89
3.27 .91
3.19 .87
3.15 1.07
3.19 .69
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Appendix O: Survey Questionnaire and Marginals (Continued)
Part V.
76. Please choose one item that best describes communication among members o f your team:
22.1 % 1. Communication that is quite limited, with some members extremely hesitant to speak up
62.8% 2. Respectful but guarded communication (picking the right moment to speak, pronounced awareness o f power differences)
15.1% 3. Open reciprocal communication (very free and effortless)
Comments:
77. How can the effectiveness o f OR teams be increased?
(N = 65)
Suggestions Number o f Citations
Improve team coordination 25
Cohesion-building 19
Improve communication 16
Better leadership (team, department, and hospital) 15
Better knowledge sharing 12
Greater respect for one’s teammates 10
Improve team members’ expertise and work attitudes 9
Improve hospital administration 8
Better resource sharing 5
Foster mutual trust 5
More efficient division o f labor 5
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A p p en d ix O: Survey Q uestionnaire and M arginals (C ontinued)
78. How can the job satisfaction o f OR teams be increased?
(N = 62)
Suggestions Number o f Citations
Mutual respect 18
Higher pay 16
More supportive work environment 13
More open communication 13
Greater mutual trust 10
More clear and proper team member role assignment 9
Better supervision (e.g., more feedbacks) 5
Improved team cooperation 7
Competent and high-quality teammates 4
Increase learning opportunities 4
Greater participation 4
Improved team efficiency 2
Good interpersonal relationships 1
Background information
79. Gender: (1) M (N = 72), (2) F (N = 14)
80. Age: Mean = 36.24 (s.d. = 8.91)
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Appendix O: Survey Questionnaire and Marginals (Continued)
81. Position:
4.7% Chief surgeon (N= 4)
25.6% Assistant chief surgeon (N= 22)
22.1% Surgeon in charge (N =19)
20.9% Surgeon residents or visiting surgeons (N = 18)
2.3% Chief anesthesiologists (N = 2)
1.2% Assistant chief anesthesiologists (N = 1)
4.7% Anesthesiologists in charge (N = 4)
7.0% Resident anesthesiologists (N = 6)
1.2% Assistant chief senior OR nurse (N = 1)
5.8% OR nurse in charge (N = 5)
4.7% OR nurse (N =4)
82. Academic degree:
1.2% Secondary diploma (N = 1)
10.5% Associate degree (N = 9)
57.0% Bachelor’s degree (N = 49)
25.6% Master’s degree (N = 22)
5.8% Doctor’s degree (N = 5)
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'O
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Appendix O: Survey Questionnaire and Marginals (Continued)
83. Department where you work
26.7% Department o f General Surgery (N = 23)
26.7% Department o f Anesthesia (N = 23)
14% Department o f Orthopedics (N = 12)
10.5% Department o f Cardiac Surgery (N = 9)
7% Department o f Urology (N = 6)
7% Department o f Oncology (N = 6)
4.7% Department o f Plastic and Burns (N = 3)
3.5% Department o f Neurosurgery (N = 4)
84. How much experience do you have in this specialty (years)? Mean = 13.0912
o
o
Appendix P: Survey Tables
Table P.l. Inter-item Correlations, Scale Reliability, and Summary Statistics for
Organizational Climate and Communication Climate Indices
Organizational Climate Index
Correlation Matrix
(N = 86)
I 2
1. Part of a large family -
2. Proud .42 -
Cronbach’s alpha - .58 Scale Mean = 3.27 Standard Deviation = .93
Communication Climate Index
Correlation Matrix
3
I I
00
3
I 2 3 4
1. Information
provision .25 -
2. Encourage questions .26 .23
3. Report incident . 15 .16 .43
4. Ask questions Scale Mean = 4.14 Standard Deviation = .48
Cronbach’s alpha = .57
301
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Table P.2. Inter-item Correlations, Scale Reliability, and Summary Statistics for Teamwork
Style Index______________________________________________________________________
Correlation Matrix
(N = 86)
I 2 3 4 5 6 1 8
1. Others enjoy working with -
2. Part of a team .17
-
3. Ashamed of making mistakes .09 .07
-
4. Value others’ goodwill .59 .36 .15
-
5. Uncomfortable telling others .33 .31 .56 .37
-
6. Insult waiting unnecessarily .25 .31 .16 .43 .29 -
7. Inexperienced members .29 .25 .24 .33 .33 .45 -
8. Personal problems .26 .16 .13 .27 .14 .26 .32 -
9. Others’ personalities .34 .37 .32 .29 .29 .22 .34 .40
Cronbach’s alpha = .76
Scale Mean = 4.0 Standard Deviation = .45
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ro
Table P.3. Inter-item Correlations, Scale Reliability, and Summary Statistics for
Importance of Team Knowledge Sharing Index____________________________
Importance of Team Knowledge Sharing Index
Correlation Matrix
(N = 86)
2 3
1. Debriefing
2. Verbalize plans
3. Team briefing
Cronbach’s alpha = .55
.37
.21 .32
Scale Mean = 4.46 Standard Deviation = .54
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Table P.4. Intradisciplinary and Interdisciplinary Knowledge Sharing and Teamwork for Surgeons,
Anesthesiologists, and OR Nurses
Intradisciplinary Interdisciplinary Intradisciplinary Interdisciplinary
Knowledge Knowledge Teamwork Teamwork
Sharing Sharing
Surgeons 3.65 ----- -------- 3.16 3.70 -------------- 3.48
(N = 63) (.80) (.91) (.56) (.73)
Anesthesiologists 3.28 . . . . _____ 2.83 3.58 3.47
(N = 13) (.86) (.91) (.61) (.63)
OR nurses 3.90 3.28 3.80 ____ ____ 3.67
(N = 10) (.74) (.58) (.63) (.33)
Note: A solid line stands for a significant difference, whereas a dashed line stands for a non-significant difference.
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Table P.5. Intradisciplinary Peer and Vertical Knowledge Sharing Perceptions
___________________________among Surgeons__________________________
Knowledge
Sharing with
Junior-level
Surgeons
Knowledge Sharing
with Intermediate-
level Surgeons
Knowledge
Sharing with
Senior-level
Surgeons
Junior-level 3.06 3.72 3.39
Surgeons (1.35) (.75) (1.24)
(N = 18)
1
1
Intermediate- 3.58 4.05 3.89
level Surgeons (.90) ------ ( .9 1 )----------- ------- (.81)
(N = 19)
Senior-level 3.35 3.96 3.73
Surgeons (1.09) (.60) ----------------- (.72)
(N = 18)
Note: A solid line stands for a significant difference at the 5% level, while a
dashed line stands for a non-significant difference at the 5% level.
305
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Table P.6. Summary Statistics for Surgical Team Members’ Actually
Encountered Leadership Style
Specialty Autocratic
Leadership
Mild
Autocratic
Leadership
Consultative
Leadership
Democratic
Leadership
Surgeons 32 17 8 6
(N = 63) (50.8%) (27%) (12.7%) (9.5%)
Anesthesiologists 4 4 3 2
(N = 13) (30.8%) (30.8%) (23.1%) (15.4%)
Operating Room 7 1 1 1
Nurses (70%) (10%) (10%) (10%)
(N = 10)
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Table P.7. Summary Statistics for Surgical Team Members’ Preferred Leadership
Style
Specialty Autocratic
Leadership
Mild
Autocratic
Leadership
Consultative
Leadership
Democratic
Leadership
Surgeons
(N = 63)
1
(1.6%)
6
(9.5%)
37
(58.7%)
19
(30.2%)
Anesthesiologists
(N = 13)
0 3
(23.1%)
1
(7.7%)
9
(69.2%)
Operating Room
Nurses
(N = 10)
0 1 (10%) 0 9
(90%)
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Table P. 8. Summary Statistics for Hierarchy Measures
Junior-level
Surgical Team
Members
Intermediate-level
Surgical Team
Members
Senior-level
Surgical
Team
Members
Seniors making all
decisions in life-
threatening emergencies
4.82 4.46 4.73
Extra benefits and
privileges for senior staff
4.14 4.32 4.47
No questioning of senior
decisions from junior
members
1.96 1.92 2.07
Better agree than voice
different opinions
1.75 1.68 1.70
No questioning senior
except concerning safety
2.75 2.82 3.13
308
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Asset Metadata

Creator Huang, Hao (author)

Core Title Knowledge sharing in Chinese surgical teams

Degree Doctor of Philosophy

Degree Program Communication

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, health care management,health sciences, medicine and surgery,OAI-PMH Harvest,speech communication

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Riley, Patricia (committee chair), Fulk, Janet (committee member), Mitroff, Ian I. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-608565

Unique identifier UC11342126

Identifier 3220114.pdf (filename),usctheses-c16-608565 (legacy record id)

Legacy Identifier 3220114.pdf

Dmrecord 608565

Document Type Dissertation

Rights Huang, Hao

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA