A systematic review of nurse-related social network analysis studies.

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Literature Review

A systematic review of nurse-related social network analysis studies D.C. Benton1 RN, PhD, F. Pérez-Raya2 RN, MSC, M.P. Fernández-Fernández3 RN, PhD & M.A. González-Jurado4

RN, PhD

1 Chief Executive Officer, International Council of Nurses, Geneva, Switzerland, 2 Presidente, Colegio de Enfermería de Córdoba, Cordoba, 3 Associate Professor of Nursing, 4 Professor of Nursing, Escuela Universitaria de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Madrid, Spain

BENTON D.C., PÉREZ-RAYA F., FERNÁNDEZ FERNÁNDEZ M.P. & GONZÁLEZ-JURADO M.A. (2014) A systematic review of nurse-related social network analysis studies. International Nursing Review Background: Nurses frequently work as part of both uni- and multidisciplinary teams. Communication between team members is critical in the delivery of quality care. Social network analysis is increasingly being used to explore such communication. Aim: To explore the use of social network analysis involving nurses either as subjects of the study or as researchers. Methods: Standard systematic review procedures were applied to identify nurse-related studies that utilize social network analysis. A comparative thematic approach to synthesis was used. Both published and grey literature written in English, Spanish and Portuguese between January 1965 and December 2013 were identified via a structured search of CINAHL, SciELO and PubMed. In addition, Google and Yahoo search engines were used to identify additional grey literature using the same search strategy. Results: Forty-three primary studies were identified with literature from North America dominating the published work. So far it would appear that no author or group of authors have developed a programme of research in the nursing field using the social network analysis approach although several authors may be in the process of doing so. Limitations: The dominance of literature from North America may be viewed as problematic as the underlying structures and themes may be an artefact of cultural communication norms from this region. Conclusions: The use of social network analysis in relation to nursing and by nurse researchers has increased rapidly over the past two decades. The lack of longitudinal studies and the absence of replication across multiple sites should be seen as an opportunity for further research. Implication for Nursing and Health Policy: This analytical approach is relatively new in the field of nursing but does show considerable promise in offering insights into the way information flows between individuals, teams, institutions and other structures. An understanding of these structures provides a means of improving communication. Keywords: Communication, Research Methods, Social Network Analysis, Systematic Review Correspondence address: Dr David C. Benton, International Council of Nurses, 3 Place Jean-Marteau, 1201 Geneva, Switzerland; Tel: +41-229080100; Fax: +41-229080101; E-mail: [email protected].

Funding: This study has not been supported by any funding or grant source. Conflict of interest: The principal author is the Chief Executive Officer of the International Council of Nurses (ICN) and has an interest in making sure that ICN policy positions and principles reflect the latest thinking and evidence.

© 2014 International Council of Nurses

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D. C. Benton et al.

Introduction Some of the concepts, such as directionality of communication, used in social network analysis (SNA) can be traced back to the ancient Greeks (Scott 2013). However, development of the approach is frequently cited as originating in the 1920s and 1930s. Furthermore, there is general consensus that the approach has not emerged from a single discipline but instead its origins can be traced from a parallel set of developments in the spheres of psychology, anthropology, mathematics and physics (Scott 2013). From these developments, Scott (2013) contends that the use of SNA has expanded and is a technique that can now be found in the literature of a wide range of disciplines. But what is SNA? In short, SNA is a means of identifying and measuring the local and global patterns of communication and influence within a group of individuals, teams, organizations or societies. Pow et al. (2012), in their exploration of the use of SNA, have highlighted the utility of this technique in understanding and examining complex interactions. When this perspective is linked to the role of the nurse, as defined by Henderson (2004) who highlights that not only are nurses pivotal in hands-on delivery of care and providing advice but also central in coordinating the contributions of other disciplines, then it would seem logical to examine whether SNA can help us understand how nurses communicate and influence. However, to this point it is not known to what extent network analysis is being used to analyse practice and understand the complexities and impact of nursing work. In general, the use of SNA as a technique to examine the interaction between individuals, groups and organizations has increased markedly over the past decade (Fig. 1). However, to

date, there has been no systematic review of how this technique is being used in nursing or by nurses per se. Some of the increase in utilization of this approach can be attributed to the development of technology that allows the relationships between larger datasets to be analysed and mapped by increasingly sophisticated computer software (Scott 2013). Furthermore, with the increased use of technology, Borgatti et al. (2013) have noted that there is now a far wider range of measures and statistical tests available that can be used at both the individual and network level. In addition, according to Everton (2012), increased investment in the technology and the analytics underpinning the science has, at least in part, been driven by the utility of the technique in understanding terror networks post the 9/11 attack and drug cartel behaviour. But these are general points and not specific to the use of SNA in nursing. As yet, a synthesis of the nursing and SNA landscape has not been explored. SNA and nursing

The focus of this paper is to conduct and derive, from a systematic review of the literature, an understanding of the current state of the application of this approach within nursing and by nurses. The paper does not go into a detailed exploration of the many analytical metrics that can be used or the underlying mathematical theorems that support the ever-increasing range of measures that can be applied in this field. To understand the techniques, the tools that can support analysis and the methodological design issues that may arise from the use of SNA, reference should be made to the many methodological texts that are available, such as Borgatti et al. (2013).

Fig. 1 Frequency count of social network analysis articles indexed in CINAHL, SciELO and PubMed from 1965 to 2013.


Social network analysis: a systematic review

What do we know?

Benton (1997), when looking at networking in the nursing domain, highlighted that whilst there was an emerging literature on the topic many of the papers published up until that point failed to apply any guiding theoretical or analytical frameworks. Instead of seeking to scientifically identify the nature and strength of connections between individuals and groups, so as to use this as part of a defined approach to lobbying or influencing, a haphazard approach was often used. Benton (1997) advocated for a more scientific approach. Subsequently, in the same paper, he introduced the reader to rudimentary concepts of SNA and argued for the use of the basic techniques, derived from matrix algebra and graph theory, to be systematically applied. More than a decade later, Pow et al. (2012) covered much of the same material as that explored by Benton (1997) but added a number of key points. Namely, Pow et al. (2012) were able to highlight the diversity of application of SNA to nursing-related topics. They went on to comment that studies had now started, based on an understanding of the social architecture of networks, to introduce intervention-based approaches rather than simply documenting the existing structures. The same authors highlight from their analysis of published papers a wider range of analytical techniques being used as well as positing a link between the results of a number of studies to the emerging literature on social capital. However, the basis upon which Pow et al. (2012) selected the particular studies cited is not stated. Therefore, the paper may or may not offer a coherent and unbiased picture of how SNA is being used to explore nursing. In short, the state of our knowledge is yet to be critically assessed.

Method This study utilizes the review methodology as set out by Moher et al. (2009) and follows the template prescribed via the PRISMA approach (Liberati et al. 2009). Figure 2 provides a high level summary of the results of the approach and the associated yield at the various stages. Data sources and search strategy

This study is based upon a search of the worldwide grey and published literature on the topic of social and organizational network analysis published in English, Spanish or Portuguese between January 1965 and December 2013. The material was identified from a systematic search using logical operator-based combinations of key terms to identify potentially relevant papers from the databases CINAHL, SciELO and PubMed. The database searches were conducted from the last week of March 2014 to the end of the first week of April 2014. While CINAHL and PubMed may be familiar to many readers, SciELO is a bib-


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liographic database focusing heavily on health literature in the Portuguese and Spanish languages. The papers identified from this process were downloaded into the reference management software package Endnote X4 (Thomson Reuters, Philadelphia, PA. USA) for Macintosh. A structured Google and Yahoo search using the same terms and strategies augmented the search of the published literature databases. Finally, a hand search of referenced work in the identified and retrieved papers was completed. Inclusion criteria

Only empirical research-based papers employing SNA were included in the systematic review. Although a number of master and doctoral dissertations were identified by the search strategy, these were excluded on the basis that they had not been subject to formal double-blind peer review. Papers published in any language other than English, Spanish or Portuguese were excluded from the review as these were the languages familiar to the authors and limited resources meant that papers in other languages could not be accurately translated. Any paper reporting the same data in two or more journals had the second and subsequent submissions excluded. Finally, for inclusion the papers needed to have been conducted by nurse researchers or featured a nurse as one or more of the authors of the paper or included nurses in whole or in part as the subjects under investigation. Data abstraction and analysis

A purpose-designed data extraction form based on the work conducted by Cunningham et al. (2010) and Chambers et al. (2012) in the more general domain of SNA and health workers was developed and piloted on a sample (n = 5) of papers. The sample papers used SNA in the health domain but did not focus on nursing, use nurses as the subjects of the study or have a nurse as part of the investigator/author team. The papers were drawn from the same journals from which articles that did focus on nursing were published. The pilot study confirmed that the extraction tool worked well and no amendments to the design were needed. The tool facilitated collection of authorship, date of publication, journal, volume, part and page numbers as well as the URL if the paper could be accessed via open access. In addition, information on the study purpose, method, metrics utilized to examine the network, results obtained and limitations of the study were also collected. The first two authors of this paper independently extracted the data. The extracted information was then compared and where there were differences, these were discussed with the remaining authors of this paper until agreement was reached. All studies that met the inclusion criteria were then uploaded, as full-text

D. C. Benton et al.

Screening

Identification

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Records identified through database searching (CINAHL, SciELO and PubMed with duplicates removed) n = 751

Records identified through other sources (Google, Yahoo and referenced articles) n = 27

Identified material downloaded to Endnote X4 for Mac Records remaining after duplicates removed n = 772

Records screened for focus on nurses or nursing n = 772

Records excluded n = 678

Eligibility

Articles excluded, with reasons Studies assessed for eligibility n = 94

• Excluded non-French, Spanish or English n = 2 • Exclude articles were thesis n = 7 • Exclude nor research based n = 46 • Exclude same study reported in two journals n = 1

Included

• Total number excluded n = 51

Remaining papers imported to NVIVO 10 for thematic analysis Studies included in systematic review n = 43

Fig. 2 Search and inclusion flowchart modelled upon Moher et al.’s (2009) PRISMA statement.

documents, into NVIVO 10, a qualitative analysis package that facilitates comparative thematic narrative analysis by supporting the coding of the paper line by line to develop descriptive themes (Popay et al. 2006; Thomas & Harden 2008). The processes of reading, reviewing and rereading all included


studies provided the basis to identify, cluster and group emergent themes. These themes were then further examined for similarities and differences in the data to ensure consistency of interpretation and adequacy of the emergent coding framework. Initial codes were subsequently refined and where neces-


sary new codes developed. This process was augmented by the use of memos that recorded the researchers emerging and evolving ideas about the material being reviewed. The second and third authors reviewed and challenged the first author’s work until such time as consensus was reached relating to the overarching themes that emerged.

Results and discussion The systematic review identified a wide range of papers which are presented in summary format under the headings of author and date, method and participants purpose, social network measures results and limitations. As a result of the volume of material to be considered, these data are reported and explored under two major headings, that is, quantity and basic characteristics of the studies (method, participants, purpose and social network measures) and thematic analysis of findings (results) and study limitations. Table 1 provides a brief summary of all the papers that met the inclusion criteria. While it is not possible to provide full details of all the material obtained via the data extraction tool, the table does offer sufficient content for readers to judge the appropriateness of the key findings presented in subsequent sections. Quantity and basic characteristics of the studies

A total of 43 papers met the inclusion criteria for this study. All papers were less than 20 years old, which is consistent with the rapid increase in the general use of SNA, indicated by Fig. 1. Indeed, 34 (79%) of the studies were less than 10 years old and, of those identified, 28 (65%) were published in the last 5 years. Therefore, we note that the use of SNA, although a relatively new approach in the nursing domain, is one that is rapidly expanding. Country of first author details have been extracted and summarized in Table 2 and shows that the majority of the studies are American in origin, with Canada at distant second, but collectively these two countries have contributed more than 58% of all included studies. This is an unremarkable finding as nursing research is long established and well developed in North America and these findings are similar to those reported by Cunningham et al. (2010) in their study of the application of SNA in the health domain per se, where 62% of the studies were also North American. Analysis of the authorship of the various papers contained in Table 1 demonstrates that several authors have contributed more than one paper. However, with the exception of the work by Benton, where the two papers are more than a decade apart, it is not possible to ascertain whether any of the authors with two or more papers have, at this stage, a sustained interest in


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applying the technique to different settings, with multiple groups or using a range of methodological approaches. Perhaps, in time, some of these authors will develop programmes of research that not only gather data from multiple sites but also utilize various analytical techniques thereby providing an opportunity to reach more widely based findings that utilize triangulation of approach and analysis. From reviewing the details of methods, it is seen that clinical teams and hospital staff are frequently the subjects of the research. These data sets can vary considerably in terms of size, ranging from less than 10 to over 100 individuals. In addition, surveys of larger groups of individuals with a common interest or affiliation who are geographically distributed were also identified (MacPhee & Scott 2002; Merrill et al. 2012). Studies where data are extracted from documents or organizational level interaction are, at this stage, few in number but do offer important insights into the flexibility of the approach. Specifically, when considering the work by Almero-Canet et al. (2013), there is the potential to identify and demonstrate how geographical and institutional scholarly dominance can exist within a specific country (Spain) in the discipline of nursing. Furthermore, in the case of Benton (1999), minutes of meetings from governmental committees were used to identify opportunities for nurses to influence policy. Both Almero-Canet et al. (2013) and Benton (1999) provided good examples of how secondary data analysis can form the basis for SNA approaches. Cross-sectional studies that seek to describe the existing network structure at a point in time, 32 of the 43 studies (74%), are by far the most common methodological approach. Very few studies gather time series or longitudinal data, five studies (12%). There is, however, some evidence to suggest that researchers are starting to explore the use of more complex research designs that introduce pre-test–post-test assessment of an intervention designed to influence the social network (Barrera & van de Bunt 2009; Benton & Fernández-Fernández 2014) and correlation studies where network architecture and other variables of interest are being explored (Effken et al. 2013; Yang et al. 2012a,b). These findings concur with and reinforce the results of the work by Pow et al. (2012) who concluded that the use of SNA is starting to move away from simple point-intime descriptive studies towards more sophisticated designs. These designs utilize the approach as part of a wider range of measures that examine impact or outcome rather than just the underlying network architecture. Measures relating to both individuals, such as in-degree and out-degree, and the network as a whole, for example, network densities are commonly used. However, the number of such measures in any one study tends to be limited in number although it did range from 1 to 17. On average, the number of

Method and participants

A bounded group interview survey of residents in a USA older adult persons care facility was conducted involving 10 residents and including information on 25 nursing and other care staff.

A comprehensive analysis of the Spanish peer reviewed nursing literature was conducted based upon data extraction from SciVerse Scopus. Articles published between 1973 and December 2010 was used. A set of clear inclusion and exclusion criteria were used. A social network map was constructed on the basis of ties resulting from co-author relationships.

Cross-sectional data were extracted from the case records of patients who had undergone general or neurological surgery in an operating room department of a busy American hospital. This resulted in 4356 general surgical cases and 1645 neurological cases. The teams (surgeon, anaesthetist, nursing staff and scrub technicians) were then identified from the records and a two-mode affiliation network constructed resulting in the identification of 733 individual staff.

Author(s) and date

Abbott & Hampton (2012)

Almero-Canet et al. (2013)

Anderson & Talsma (2011)

Table 1 Summary of extracted and reviewed papers

© 2014 International Council of Nurses Cliques; isolates, in-degree and out-degree

Centrality; team coreness

To determine how the operating room staff of two surgical specialties compare in terms of social network variables.

Degree centrality

Social network measures

To analyse the social networks associated with the publication of Spanish scientific literature so as to define the evolution of geographic, institutional and interdisciplinary collaboration.

To develop and evaluate the feasibility of collecting sociometric (whole group) data among older adults in one assisted living neighbourhood.

Purpose

• A core periphery network structure was characteristic of both teams. • Team coreness (a measure of how often the teams work together) was associated with lengthy cases. • Late starting cases tended to be staffed with fewer core team members. • Registered nurses constitute the majority of core interdisciplinary team members in both groups.

• The production of Spanish nursing literature has a long history. • Nursing scientific literature has been growing over time. • The average number of authors per publication is 3.7 but 61% of these authors only publish one paper. • Barcelona and Madrid were the centres with the most number of authors producing scholarly articles. • Most authors had affiliation with hospital environments followed closely by authors belonging to the university settings. • The institutions that collaborate most as indicated through shared authorship are: Universidad de Barcelona, Universidad Autònoma de Barcelona and Hospital Clinic of Barcelona.

• The study demonstrated the feasibility of the technique; and • Data gathered suggest that the approach can be used for larger and longitudinally based studies.

Results

Because the data were cross-sectional involving an entire year of activity the dynamic nature of the team composition may have had an influence on the resulting network measures. It is recognized that the data boundary in an academic institution highlights the transient nature of staff in training who graduated then moved on.

Although the paper identifies that the majority of papers are published in Spanish nearly 21% were published in English and there was little reported comparative analyses between the two linguistic data sets. Although it was noted that a number of Spanish journals are not indexed, thereby reducing the pool of data, the implications of this in terms of a potential source of error is not explored.

accuracy of the data coming from the residents.

bias. The reliability of the data could have been improved by asking reciprocal questions to the staff group so as to help validate the

The sample size was small and agreement to participate meant that only 67% of potential residents and 74% of staff were involved in the sociometric data collection. This may have resulted in some selection

Limitations

6 D. C. Benton et al.


An ethnographic study of a small group of nurses (n = 10) that examines the interactions within the group over a 2-year period where two surgical teams and 59 nurses are providing open heart surgery to patients in an American hospital.

Chase (1995)

To describe the social context in which the process of critical care clinical judgment occurs from the nurses’ perspective.

To describe relationships among healthcare professionals using SNA so as to improve health service quality through strengthening health service management and leadership.

Survey of a random sample of French public hospital professionals (doctors and nurses) and administrators with 104 completed questionnaires returned.

Boyer et al. (2010)

To identify themes of interest to nursing and midwifery discussed at the inaugural meetings of the committees so as to prioritize and maximize lobbying activity of nursing leadership in Scotland.

To learn more about how healthcare providers communicate and exchange patient information during patient handoffs (transfers) between units in an acute-care setting.

To investigate the effects of information originating from social networks on the development of interpersonal trust relations in the context of a dialysis department.

To investigate whether SNA has the potential to assist in the identification of candidates for a train-the-trainers programme.

Cross-sectional documentary analysis of the minutes from the inaugural meetings of the 12 committees of the Scottish Parliament were subjected to a qualitative thematic analysis used to generate a social network map of common areas of interest between the committees.

other support nurses and ranged in group size from 11 to 20 providers working in the USA-based acute-care setting.

A convenience sample of five patient handoffs was selected and a snowball sample of respondents involved in the handoff was provided with a survey questionnaire. Each group consisted of nurses, doctors and

respondents varied from 39 to 42.

Longitudinal network data were collected from nursing and other staff in a dialysis unit in a Dutch hospital on a three monthly basis for 1 year. Respondents completed a survey questionnaire and the number of

Benton & An exploratory correlation analysis between a Fernández-Fernández set of individuals identified by expert (2014) opinion compared with those identified through consideration of a range of social network analysis (SNA) metrics. Participants were a closed group of 32 nurses from the Middle East participating in a 2-year leadership development programme.

Benton (1999)

Benham-Hutchins & Effken (2010)

Barrera & van de Bunt (2009)

Network density; in-degree and out-degree

Centrality; prestige and clique participants

In-degree; out-degree; degree connectedness; closeness centrality and betweenness

Out-degree; visualization of network via multidimensional scaling

centralization and hierarchy

Betweenness centrality; centrality closeness; centrality eigenvector; total degree centrality; network

Dyadic embeddedness; and network embeddedness

differences of opinion often resulted in conflict.

• Nurses and doctors were organized in parallel hierarchies • The parallel hierarchies allowed for checks in judgment both within and across professional lines • Communication of judgments took place both informally and formally, however,

• Centrality, prestige and clique indicatory were highly correlated; • Physicians had the highest scores for all three measures; and • Older age (greater than 45) was associated with higher centrality and clique number scores.

• SNA offers an opportunity to bring quantitative rigour to the selection of candidates for next generation trainers.

• A series of themes relevant to nursing and midwifery were identified; • Themes of interest were located across a range of committees rather than simply being generated by the health committee • Opportunities to maximize lobbying activities were identified by identifying themes that were of interest to multiple committees.

• Each handoff network demonstrated unique features.

Small-scale study involving only part of the clinical team involved in the care and treatment in a highly specialized area of care.

Lacks detail of how the random sample was generated and the basis the sample size was determined. Several claims regarding quality and staff empowerment are made based on inference from other studies but the authors do not provide original results or effectively link the literature to their own study.

The study was based on a relatively small single group. The instrument lacked precision by failing to specify exact frequencies for terms such as ‘regularly’.

Data were obtained from a single-point cross-sectional documentary analysis and were aspirational rather than themes that the committees actually prioritized for policy work.

have had an impact on the accuracy of the network data obtained.

Due to the unique nature of each of the handoffs, generalizability is extremely limited. Informant bias as well as possible discrepancy between recall and self-reporting and/or actual behaviours may

secretaries was extremely small so a 1 person change resulted in a 50% turnover. The student group also saw considerable changes over the time frame.

• The communications networks reviewed overlapping use of synchronous and asynchronous methods; • No particular professional group dominated or coordinated information flow; and

large - but, for example, the number of

from information that they receive from colleagues and those with whom they have regular communication.

Although the sample size was small, the longitudinal nature of the design warrants further exploration. From initial observation the variations in the number of respondents at each some groups appeared

from their own past experiences as well as

• The results support the existence of a learning mechanism operating both within dyads and through social networks in which the dyads are embedded; and • Actors learn to trust (or distrust) each other

Social network analysis: a systematic review 7

A case study survey design examining both individual and group metrics based upon

Cott (1997)


A cross-sectional social network survey of staff working in a metropolitan Australian hospital renal ward including doctors, nurses, allied health professionals and a ward clerk. Forty-five out of the 47 staff completed the survey resulting in a response rate of 96%.

Data were gathered via a cross-sectional social network survey (response rate 94%) to all emergency department staff (n = 109) including doctors, nurses, allied health professionals, administrative staff and ward assistants working in a hospital in Australia. Three social networks were analysed – problem-solving, medication advice and socializing.

Data were gathered from two types of interaction: one online and the other offline conducted between 89 participants (47% of the total staff) drawn from nine rural and two urban emergency departments in Nova Scotia. The data analysis distinguished between knowledge-sharing and knowledge-seeking behaviours.

Creswick & Westbrook (2010)

Creswick et al. (2009)

Curran & Abidi (2007)

data from 93 health workers (doctors, nurses and support workers) in a multilevel geriatric care facility in metropolitan Toronto, Canada.


Author(s) and date

Table 1 Continued

Network density; connectedness; isolates; degree centrality; in-degree; out-degree; betweenness centrality; degree separation and reciprocity

Network density; in-degree; out-degree and Freeman’s degree centrality measures

To determine if an online discussion forum would serve as an effective means for emergency department practitioners seeking information to support their practice.

Network density; tie strength; reciprocation of relations; individual centrality and geodesic distance

equivalence

Network density; in-degree; out-degree and structural


To examine the problem-solving, medication advice-seeking and socializing networks of staff working in Australian hospital emergency department.

To examine the medication advice-seeking network of staff in a hospital ward.

between different groups of professionals.

To understand the structural relationships and social context

Purpose

support their practice

• The online discussion forum created an opportunity for emergency practitioners from multiple emergency department sites to engage in dialogue around topics that were relevant to their practice learning needs; and • The volume of sharing events linked with the seeking events suggests that this medium presents another alternative for practitioners looking for evidence-based information to

• In all three networks, individuals were more closely connected to colleagues from within their respective professional groups; • The problem-solving network was the most densely connected network, followed by the medication advice network, and the loosely connected socializing network; and • Emergency department staff relied on each other for help to solve work-related problems, but some senior doctors, some junior doctors, and a senior nurse were important sources of medication advice for their emergency department colleagues.

• On average, there is little interaction between each of the staff members in the advice-seeking network; • There is even less interaction between staff from different professional groups; and • The pharmacist is central to the social network with nurses located on one side and doctors on the other side of the structure.

Interactions were limited and therefore a longer data collection period of an increased number of staff participating in the study would have been useful. It is unclear whether the participating group differed significantly from those that did not use the platform.

The cross-sectional, single-site sample limits the generalizability of the results. While the social networks provide an understanding of the interactions taking place within the unit the nature and content of the interactions were not captured.

Data were collected from a single specialty ward and therefore the findings may not be transferable to other specialty or generalist settings. Data were generated on self-reported frequencies and this may or may not be an accurate recall of actual behaviour.

• The nursing team had a mechanistic structure mainly involved in task-orientated work; and • A clearly defined hierarchy existed between the two groups.

registered nurses and high numbers of support staff.

‘organic’ structure and was mainly involved in decision making and problem-solving;

Data were collected from a single institution. The relationship between the two groups may not be typical of the institution as a whole because of the selection of the

Limitations

clinical areas. For example, some clinical teams may demonstrate more collaborative team working than others such as intensive care units or emergency departments. Carers of the elderly units often have few

a nursing subteam; • Each subteam had different structures indicating differential involvement in different types of teamwork; • The multiprofessional subteam has an

• A common structure in two teams was identified: a multiprofessional subteam and

Results



Hough et al. (2005)

Documentary analysis of paediatric patient records to create networks of nursing

Gray et al. (2010)

convoy model of social network that uses the location of contacts within one of three concentric circles.

immunodeficiency virus (HIV) positive mothers living in an American urban setting and who attended a participating clinic. Data collection involved using the

A cross-sectional survey of 147 human

handoffs in an east coast specialist American hospital.

A cross-sectional exploratory study of data collected from five specialty areas involving 77 staff nurses employed in a 493-bed acute-care hospital in the USA.

methodology to collect data on staff communication and several quality outcomes measures for patients. A total of data from 226 respondent nurses were obtained working with a USA-patient group of 256 individuals.

The study utilized an exploratory, descriptive correlation design by using survey

days in an acute hospital service in western USA.

Using a survey methodology, data were collected from nursing staff working on seven patient care units on two different

Garrett & McDaniel (2001)

Effken et al. (2013)

Effken et al. (2011)

networks of sample of HIV positive urban dwelling mothers.

This study describes the social

satisfaction.

To examine nursing team structure and its relationship with family

To explore the relationships among environmental change in a range of different units through examination of factors relating to the nurse and perceptions of the work climate.

surgical units in three American acute-care hospitals.

To examine the handoffs between day and nightshift staff on seven medical

outcomes.

To identify patient care unit communication patterns associated with patient safety and quality

outcomes.

number of triads and number of cliques

density

Centrality and network

In-degree; out-degree and betweenness centrality

Network density; in-degree and out-degree

triads; eigenvector centrality; in-degree; isolates; hierarchy; component count weak; component count strong; clustering coefficient; diffusion

professional caregivers in the social networks of HIV infected women.

1979 contacts. • Members of the inner circle were younger and more densely connected. • The results showed an almost total lack of

• The 147 HIV positive women nominated

seen with less-consistent staffing.

patterns of newcomers to teams did not differ according to median, mean and repeat caregiver interval value; • Increasing problems with nursing care were

• For babies aged 2 weeks old, 50% of shifts were staffed by a newcomer nurse who had not previously cared for the child. The

• Team size increases with increasing length of stay;

• Perceived uncertainty was associated with three components of burn-out; • A positive social climate can mediate the negative effects of crisis and change; and • No significant relationship emerges from consideration of personal characteristics of the nurse (education and experience). However, because of homogeneity of the subjects, this may have masked small differences.

• A range of social network metrics can be used to examine specific patient outcomes.

• Unique network patterns were observed for different types of outcome variables; and

relationship of nursing communication patterns to patient safety and quality

centrality; Simmelian ties; betweenness centrality;

Network density; fragmentation; cliques;

• Communications patterns differed substantially by shift; and • The results demonstrated the utility of the approach to healthcare research and the

complex self-care and patient satisfaction) outcomes were found;

• Communication patterns that correlated with two safety (falls and medication errors) and three quality (symptom management,

isolates; network centralization in-degree; network centralization out-degree; eigenvector

network density; diffusion; fragmentation; hierarchy;

Clustering coefficient; component count strong; component count weak;

contacts in the respondents’ social network and as a result not all data were used and therefore the analysis may have a degree of error.

Results were generated only using the first 10

atypical.

Data were drawn from a highly specialized hospital and as such results may be

The small sample size and single point of data collection makes it impossible to determine whether sustained uncertainty has more or less of an impact than single point-in-time conditions.

Communications and outcome data were not collected at the same point in time.

The sample is small and homogeneous limiting the generalizability of the findings.

performing units across a range of metrics, it was not possible to calculate sample size.

not provide specific information on the total sample and how it was distributed over the seven units. Because data were presented as the highest and lowest

limited. More serious was the fact that the authors did

From the authors’ own commentary, this was an exploratory study and as such had a limited sample size so generalizability was


A mixed methods study that utilized both

Hurley et al. (2014)

© 2014 International Council of Nurses applications of this technique in assessing aspects of institutional culture at a medical centre.

SNA was applied to three settings in a New York hospital – team function in the intensive care unit, interdisciplinary composition of advisory committees for

53 federal career development awardees, and relationships between key function directors at an institution-wide Clinical Translational Sciences Institute (CTSI).

Laurie et al. (2009)

Lemieux-Charles et al. (2005)

To describe the basic concepts of SNA, which assesses the unique structure of interrelationships among individuals and programmes, and introduce some

A cross-sectional survey of 527 obstetricians, 138 family physicians and 80 certified midwives in California were surveyed resulting in a 57% response rate.

Kravitz et al. (2003)

dyads (574 individuals).

dementia networks in Canada using a standardized questionnaire to identify and capture administrative and clinical exchanges between agencies based on 267

A cross-sectional case study survey of four community-based not-for-profit

analysis

exchanges that occurred among the networked agencies.

‘shared administrative information’ activity.

with both administrative effectiveness and service-delivery effectiveness; and • Administrative effectiveness was positively correlated with clique overlap in the

• The number of cliques in the ‘referrals received’ activity was negatively correlated

problem areas in relationships among academic departments.

mentorship committees, it allows for summary descriptions of the degree of interdisciplinary of various clinical departments; and

• In the intensive care unit setting, SNA provides interpretable summaries of aspects of clinical team functioning; • When applied to membership on

• Regardless of discipline, opinion leaders held attitudes concordant with reducing caesarean section rate; • However, only 48% of opinion leaders supported the policies designed to achieve the targets set in Health People 2000; and • Nurse midwives had higher out-degree scores than family physicians.

were collected; for the advisory committees archival documentary data for n = 157 faculty were collected; and 12 directors provided data for the third Network density; centralization and clique overlap

assessed.

negotiations with men; and • Both the local and guest midwives ranked among the most influential social actors in their respective villages.

generalizable.

Data were drawn from a specialized area of work and therefore may not be

betweenness scores, no quantitative data are presented.

The authors use visualization of the networks to examine the network structure and, while some of the figures node size varied on the basis of

Some of the increased out-degree scores may be a function of reporting relationships rather than genuine opinion leaders’ status thereby introducing a source of error.

It was not possible to analyse the data using all the keywords; therefore, some granularity of the data may have been lost and some of the connections omitted.

the social network emerged hence the accuracy of the social network cannot be

• Specific challenges existed for guest and younger midwives and with midwives’

• The SNA method is useful for tracking changes in research topics overtime; and • Analysis identified that the most commonly researched topic over the period was ‘risk analysis’.

Data collection may have been influenced by the externality of the researcher. Due to the snowball sampling technique, when an individual could not be found, gaps in

Limitations

• Both local and guest midwives reported feeling high levels of social integration, acceptance and appreciation from the women in their communities;

Results

• When SNA is applied to relationships among leaders of an institution-wide research enterprise, it highlights potential

To assess the relationship between the types of administrative and service-delivery

In-degree; out-degree and betweenness

Out-degree and betweenness centrality

Degree centrality and in-degree

Freeman degree measures centrality; eigenvector geodesic distance; cliques and isolates


Different data collection strategies were used for each of the groups. Data for two teams (both n = 9) in the intensive care

To determine whether obstetric opinion leaders can be identified and characterized in terms of demographic and professional characteristics and attitudes to caesarean section.

Documentary analysis of the top 100 non-duplicate and most studied medical subject heading papers drawn from PubMed including both nursing and medical articles. (Korean authors)

To examine the feasibility of SNA as a valuable research tool for indicating a change in research topics in health care and medicine.

To explore the social connectedness of midwives in their communities.

Purpose

Jang et al. (2012)

networks in two villages in Mali resulting in social networks of n = 142 in one and n = 74 in the other.

social network analysis and semi-structured interviews. The research team from the John Hopkins Bloomberg School of Public Health conducted 29 semi-structured interviews with midwives and then looked at the associated social


Author(s) and date

Table 1 Continued



Merrill et al. (2012)

(2012)

Márquez-Serrano et al.

MacPhee & Scott (2002)

MacPhee (2000)

Lindholm et al. (2003)

from 1522 health officials and 477 named contacts (1999 individuals in total).

data obtained from the US National Association of County and City Health Officials 2010 profiles using SNA of data

A secondary analysis of cross-sectional

sample of 94 Mexican elders.

A post intervention survey of a snowball

networks.

A non-experimental, cross-sectional descriptive and comparative, correlational design was used to describe rural hospital nurses’ workplace social support networks in one geographic region of Colorado. The geographic region selected contains 10 hospitals in the mountains and plains and represents the rural diversity of the state. The total study population consisted of 350 nurses employed at these 10 rural hospitals. A database of nurses (n = 120) from one urban hospital in Colorado was available to compare the structural and functional aspects of nurses’ social support

shifts (n = 46) in a large, urban acute-care hospital in the western USA.

network might contribute to a high performing public health system by facilitating diffusion of innovation.

To determine how a health officials’ advice

network.

intervention by public health nurses on knowledge of acute respiratory infections on their incidence within a social

To explore the impact of an education

To describe the workplace social support networks of rural hospital nurses in one geographic region of Colorado. This rural sample was compared with data from a sample of urban hospital nurses in Colorado.

To contrast workplace socialization of nurses working flexible and traditional schedules in acute-care settings.

and support were associated with self-rated health, sick leave and salary.

in the study by answering a self-report questionnaire.

A two-group comparative research study was conducted to contrast workplace socialization of a total of 166 nurses working traditional (n = 120) and flexible

To investigate whether nurse managers’ professional networks, psychosocial work conditions; job support, social network

From a total of 268 Swedish nurse managers, active in management positions, 205 (77%) agreed to participate

transitivity; reciprocity; average centrality; clustering; effective network size and clique count

Network density; centralization;

eigenvalue centrality

Network density; out-degree and

Closeness

Network density and closeness centrality

Social support and social anchorage

clump within state boundaries suggesting gaps in information flows.

network exhibited minimal evidence of unified communication; and • Mutually connected small groups tend to

• A sparsely connected core periphery

knowledge, but this did not decrease the incidence of cases in their social network.

• Elders increased their self-care and

• The nurses’ networks were predominantly peer-based, but managers provided significant functional supports; • The types of support provided by managers depended on the managers’ placement in the nurses’ networks; and • Some managers provided only performance feedback and other managers offered physical assistance and emotional support; and • Rural nurses expected more guidance from management than did their urban counterparts.

significantly more peer members for different types of emotional support.

were also present in their networks; and • Nurses working traditional schedules used

• No significant differences were found in the nurses’ social networks; • Both types of nurses constructed peer-based networks and nurse managers

social network and social support outside work displayed increased odds for low self-rated health, independently of age, gender and education.

• It was also found that low level of support from professional network, job support,

• Nurse managers exposed to high job demands had significantly increased odds for low self-rated health; and

more extensive communication with peers could be masked as a feature of the design.

population so the findings reflect a subset of what may exist. Respondents were limited to naming only five contacts and in 814 cases this limit was reached so

may have occurred in the network as the data were collected. Data represent patterns of only 78% of the total

The data are cross-sectional and changes

network characteristics may have been masked.

a major public media campaign because of the H1N1 outbreak and without the use of a control group differences in

During the study, there was simultaneously

This was a small sample of rural hospital nurses from one geographic region of Colorado, which limits generalizability. This study focused on one variable known to influence job satisfaction, nursing recruitment and retention.

reliability of the findings.

The use of the questionnaire provided only a superficial look at the networks and the differences between them. The low response rate (42%) casts doubts on the

The study used an atypical approach to determining social network presence and effect.



A cross-sectional survey of staff working across all shifts at an American urban academic emergency department of a hospital took place over a 3-month period resulting in an 88% response rate equating to 103 respondents who were doctors, nurses, patient care technicians, healthcare coordinators and

Patterson et al. (2013)

administrative staff.

A closed group, 7-month, longitudinal analysis using the CONDOR SNA tool was used to examine email communication patterns among three distinct multidivisional teams based in the Cincinnati children’s hospital dealing with children that were in need of liver transplantation (n = 26); cerebral palsy interventions (n = 69) or intestinal rehabilitation (n = 31). A key individual was used to commence a snowball sample where individuals were included if they spent 20% or more of their time in the team.

individuals over a 5-year period employed in a large public health medical centre in the southern USA.

Betweenness centrality; contribution index; network density and structural holes

Network density; centrality and in-degree

To use SNA techniques to characterize patterns of communication among clinicians and staff employed in a busy academic emergency department over multiple points throughout the day.

out-degree

To assess the communication structure using SNA of multidisciplinary teams caring for children with complex conditions.

attitudinal and behavioural variables of a relational nature are predictive of employee turnover.

Network centrality, in-degree and

• SNA measurement techniques provide a comprehensive view of emergency department communication patterns; and • SNA revealed that frequency of communication as a measure of interdependence between clinicians varies by day/night shift and over time.

• The SNA indicates that email communications among actors of a healthcare team reflects distinct patterns; and • Differences between the various teams may provide opportunities, through structural redesign of the network to help improve productivity;

interpersonal citizenship behaviour, predicted turnover; • Considering relational variables had implications for the recruitment and retention of staff; and • Those forming a greater number of ties with co-workers become more embedded and had lower turnover.

• Two variables, network centrality and

played a central role on both occasions. To examine whether structural

• Network density increased from time 1 to time 2 and centralization decreased

student–faculty networks after a series of curricular enhancements across two doctoral programmes in just 1 year; • The networks at both time 1 and time 2 demonstrated scale-free properties; and

• Considerable change occurred in

US institution.

Survey and survival analysis of 176

Palazzolo et al. (2011)

Mossholder et al. (2005)

of social network mapping.

centralization and component counting

Network density; total in-degree

joint coursework assignments, scholarly seminars with extracurricular professional services activities influenced collaboration across programmes through the use

To understand how the inclusion of

Results

indicating a more even and dispersed communication structure although faculty

A pre-post intervention online survey to study differences and similarities in the collaboration characteristics of doctorate in nursing practice, PhD and faculty before and after programmatic enhancement at a research-intensive

Merrill et al. (2013)


Purpose

university school programme. Subjects include a population pool of 127 individuals on the first occasion and 99 one year later drawn from a prestigious


Author(s) and date

Table 1 Continued

The relatively brief time frame used to gather multiple data points must be viewed as a significant limitation. The cross-sectional surveys methodology can suffer from recall bias and the study failed to capture basic demographic characteristics such as gender which may impact on communication pathways.

Because the analysis only examined email communications, the resulting networks may represent only a subset of the interactions between team members. By setting the inclusion criteria at 20% of the individual’s time, key team members who may play pivotal roles such as brokers may have been omitted.

institution over a prolonged period and as a result temporal variable and culture within the organization may have changed and had a confounding effect on the results.

The data were collected from a single

try and please faculty.

what can be inferred from the data. Lower levels of participation at time 2 may have had an impact of the observed findings. It is possible that students may have exaggerated the number of connections to

With just two data points there are limits to

Limitations



An ethnographic study of communication between members of two primary care teams, collected over a 2-week period and including doctors, nurses and other support staff was used to generate social network matrices for analysis. Team one had a total of 26 participants and team two 31 individuals. Both practices were located in the USA.

A mixed methods study of six primary healthcare teams in the Ontario, Canada area. Quantitative data were collected using a questionnaire survey analysed using SNA of a total of 28 individuals including eight nurses, nine physicians, seven residents and four allied health professionals.

A descriptive analysis of the egonets of 20 Brazilian women living in a needy community in Rio de Janeiro who were experiencing the breastfeeding process with a child younger than 6 months of age.

Sibbald et al. (2013)

Souza et al. (2009)

Nursing report (12 committee members, 7 Robert Wood Johnson Foundation staff and four other stakeholders) designed to identify the individual and organizational social networks of these respondents.

A structured interview survey of 23 key individuals involved in the USA Future of

Scott et al. (2005)

Robert Wood Johnson Foundation (2012)

To discuss the contribution of the social network methodological framework to nursing care, through its application to women who breastfeed their children up to the age of 6 months.

To explore how clinically orientated research knowledge flows through multidisciplinary primary healthcare teams and influences clinical decisions.

To describe how SNA can be used to characterize and compare communication patterns in primary care practices.

implementation of the findings through the ties that the respondents have with individuals and organizations.

The study was designed to identify priorities to facilitate the

Network density and egonets

In-degree; out-degree and network degree centrality

Network density; centrality; and hierarchical and clustering coefficients

Out-degree

• The family environment is the first place of reference for women experiencing the breastfeeding process post-delivery; and • The secondary network in the breastfeeding process, especially health professionals, was not reported as being most involved during the process.

• It was found that obtaining research knowledge was a shared responsibility among team members; • The application of research-based knowledge was viewed as the responsibility of the team leader which usually was the senior physician; and • Member of the team acknowledged the need for resources for information access, synthesis interpretation and management.

• The two practices show distinctions between practices for all the social network measures; • These measures suggest that it may be appropriate to use different types of approach to inform and influence the two groups because of the underlying differences in communication pathways; and • Decision-making patterns differed widely between the two practices.

and the media.

philanthropic organizations, rural health

They had fewer connections with business and even less to charities, think tanks,

connections with different levels of government and professional associations.

and top private institutions with only four connections to community colleges; and • The advisory committee had notable

universities and colleges, almost all of these were with large public universities

membership and advocacy organizations and had in general a broad range of connections within the healthcare field; • While advisory committee members had a fair number of connections with

• Members of the strategic advisory committee had the most connections with

Although the egonets of the individual participants were recorded and visualized, the researchers failed to report any quantitative analysis of the data. Accordingly, there exists a missed opportunity to validate the findings determined through qualitative analysis.

The sample was based on purposeful selection and therefore may not have generated typical results. The small sample size limits the inferences that can be made. The failure of some team members to participate in the study may indicate a different perspective on the use of evidence in practice.

Since the data were constructed from qualitative data that recorded the interactions between team members, the results generated may be different from those that could have been obtained if a more standard survey design had been used.

the data requested and committee members’ recall of all relationships.

methodology and its importance may have resulted in some confusion about

of some respondents to answer specific questions presented a limitation to the capture of a full network map. Lack of an overview presentation to the strategic advisory committee members on the

Non-response and unequal contributions of some respondents, along with the refusal



Secondary analysis of data previously collected via a telephone survey of a random sample of 50 nurses and 50 doctors working in the UK.

Survey data were gathered by telephone from a random sample of nurse and medical directors in England (50 nurses and 50 doctors).

West & Barron (2005)

West et al. (1999)

dementia units in the Netherlands using a convenience sampling approach with subjects being recruited from four regions in the Netherlands. This resulted in data from 474 nursing staff representing a 55% response rate.

A cross-sectional survey design with data being collected in 37 long-term care

To describe the professional social networks of two groups of professionals, clinical medical directors and nursing directors in England.

To describe the social and geographical boundaries around the networks of senior nurse executives and physician leaders and managers.

approach among nursing staff and networks of staff with relatives and acquaintances of residents so as to examine how the underlying structures relate to the staff’s treatment of residents.

To study care processes in long-term dementia care from a social network

to ascertain if the social networks of staff relate to job satisfaction.

from 35 long-term care units in the Netherlands.

Van Beek et al. (2013)

To identify the structure of communication and advice networks of nursing staff in long-term care; to determine if social networks are related to the size of the units and characteristics of staff members; and

Correlation study of the social network structure with staff characteristics (age, gender, years on unit), contract of employment (part/full time, permanent position), type of unit and size of unit. The sample consisted of 380 nursing staff

Van Beek et al. (2011)

Purpose


Author(s) and date

Table 1 Continued

Network density; centrality and centralization

Out-degree

Network density

Network density


social networks and that this information could be used to help design strategies for influence.

• Nurse directors are more central to their networks than medical directors and their networks are more hierarchical; • Clinical directors of medicine tend to be more densely embedded in their networks and tend to form cliques; and • Professional socialization and structural location are important determinants of

• Both groups tended to discuss important professional matters with others who were similar to themselves; • Gaps in the network of informal ties that impeded dissemination of information were identified; • Managers (non-clinical qualified colleagues) appear to occupy powerful brokerage roles; and • Informal networks mainly composed of local ties.

resulted in care that demonstrated greater respect and friendlier dialogue with residents; • Communication networks of nursing staff were positively related to staff’s identification with the facility when no boundary-crossing ties existed; and • Organizational identification in turn related to work motivation which when aggregated to unit level was positively correlated to positive treatment of residents.

• Units where nursing staff reported more contacts with relatives and acquaintances

• Negatively related to the number of staff and residents on the unit; and • More dense when there were more part-time workers.

Communication and advice network density were • Relatively dense and congruent with the need to cooperate to provide good quality care; • Positively correlated with the age of staff;

Results

No rationale is given for the sample size or information on the total population available.

The study was not able to differentiate between those that are currently working as managers but who come from a professional nursing background. No rationale is given for the sample size or information on the total population available.

The question on boundary-crossing was answered by only 44% of nursing staff raising uncertainly as to whether this indicated that they had no activity or if the question lacked clarity. Although data were corrected for certain staff characteristics, the diverse number of units may mean that key features of the network may be contingent on other factors such as leadership and management that were not measured.

The response rate to the social network measures was limited.

working in the units and two units needed to be excluded because of a low response rate (less than 15%).

Data were only obtained from 55% of the staff

Limitations



A quasi-experimental design with a pre-intervention and post-intervention survey was used to collect data from 20 nurses in a single surgical ward in a hospital in Taiwan.

A cross-sectional survey of a closed group of nurses working in a hospital in Taiwan was conducted resulting in data to construct social networks for 333 nurses representing a 74.8% response rate.

Yang et al. (2012b)

others, the nurses’ job satisfaction scale and a custom-designed instrument to gather advice and friendship network data.

A closed group survey of 29 Taiwanese nurses participating in an on-the-job training scheme completed a series of instruments to measure propensity to connect with

Yang et al. (2012a)

Yang et al. (2009)

To explore whether social network support has a link to job satisfaction and professional commitment.

To evaluate the effect of on the job training on job satisfaction and professional commitment.

To evaluate the relationship between the propensity to connect with others, social networks and job satisfaction.

In-degree; out-degree and efficiency (the ratio of actual centrality to potential centrality)

In-degree; out-degree and efficiency (the ratio of actual centrality to potential centrality)

Out-degree and efficiency (the ratio of actual centrality to potential centrality)

• Efficient social support networks at ward level are a good predictor of job satisfactions and professional commitment; and • Efficient social support networks are negatively correlated with workload.

• The introduction of on-the-job training improved advice interactions between respondents and also improved, to a limited extent, measures of job satisfaction; and • The other two measures, professional commitment and human relationship, showed no change.

positively correlated with job satisfaction across the three dimensions of benefits and promotion, human relationships and feedback; and • In the case of the advice network, this was only positively correlated with benefits and promotion.

• Propensity to make connections and out-degree were correlated with job satisfaction; • In the friendship network, out-degree was

Data were gathered from a single district hospital.

Few details of the content of the training intervention are given other than global figures on duration and diversity of approaches used. The data were derived from a single ward.

evidence presented and go beyond the conclusions that could reasonably be inferred.

The initial intent to examine efficiency was not conducted and no reason for this is given. The practical implications of the results are not fully supported by the


16

D. C. Benton et al.

Table 2 Summary of countries of principal author American Canadian British Dutch Taiwanese Australian Brazilian French Korean Mexican Middle East Spanish Swedish Total

21 4 3 3 3 2 1 1 1 1 1 1 1 43

measures used was 3.6 with a mode and median number of three measures. Unsurprisingly, the most frequently reported measures were in-degree, out-degree, network density and network centrality. This result is consistent with the large number of studies that collected data at a single point-in-time to examine and analyse the basic network architecture of interactions between actors. Thematic analysis of results and limitations

With a significant number of cross-sectional studies, it is to be expected that the most commonly occurring themes are related to that of ‘network architecture’ and the ‘roles that individuals played’ within the described networks. Network architecture, such as that described by Anderson & Talsma (2011) or that featured in the work of Creswick & Westbrook (2010), captured the geography of the nodes and the associated connectedness of the network (its density and centrality). The roles that individuals played examined the number of connections that individuals had to other actors. Roles such as broker of information or in some cases the leadership position that they appeared to occupy as a key opinion former were common but the level of analysis was often quite superficial (Benton & FernándezFernández 2014; Merrill et al. 2012). Many of the studies, including those by Curran & Abidi (2007) and Effken et al. (2013), were exploratory and descriptive in nature and therefore sought to identify whether the technique of SNA could be used within the researcher’s field of interest to accurately describe ‘communication structures’. Although sample sizes were often small, the majority of researchers concluded that the technique was helpful in mapping information flows among the actors. In relation to those studies that obtained data from interdisciplinary teams, ‘power relationships’, ‘opinion leaders’ and


‘differing advice-seeking patterns’ were featured as common themes. In exploring these themes, findings were often coded to two or more themes rather than to a single definition. It is therefore important to note these overlaps and as a result the authors of this review consider that the more general theme of the ‘roles that people played’ could be used to better embrace all three elements. The most significant limitation of the work conducted and published in the literature to this point relates to the one-off nature, single point-in-time and often small sample sizes exhibited by many of the studies. The lack of replication, both over time or with differing clinical care groups in the same location and/or the use of comparisons between similar groups in multiple locations, means that the generalizability of the various reported findings is extremely weak even within the same location at a different point in time. Although relatively easy-to-use techniques for validating the accuracy of data, such as the use of reciprocal questioning of respondents (I get information from – I give information to), are acknowledged by methodological experts such as Borgatti et al. (2013) as being important, such tactics were rarely used. This weakness must therefore be taken into account when estimating the potential reliability of findings. In recent times, the ready availability of software to map and display social networks would seem to have contributed to an increase in the number of researchers including such figures within their published work. However, features that allow the use of individual level subject nodes or connectors to be varied in size and presented according to, for example, number of outor in-degree connections or the strength of the relationships are at this time uncommon, resulting in images that are often difficult to interpret. Limitations of this systematic review

A number of papers had to be excluded because of the inability to read the language in which they were published. Although the number of papers rejected (n = 2) on these grounds was small, their content may have helped to ameliorate the second identified limitation. The dominance of literature from North America may be viewed as problematic as the underlying structures and themes identified in the analysis may be an artefact of cultural communication norms from this region and not applicable on a global basis. Finally, it must be recognized that not all journals report the qualification of the authors and hence it may be possible that papers have been missed. The authors of this paper did attempt to guard against this by conducting Internet searches of the names of authors listed on identified papers to try and determine qualifications when these were not reported (n = 1).


17

Implications for nursing and health policy

Conclusions

From a policy perspective, although the use of this SNA is relatively new to the field of nursing and dominated by material from North America, it does show considerable promise in offering insights into the way information flows between individuals, teams, institutions and other structures. An understanding of these structures would, at least in some cases, provide a means of improving team communication and associated quality of care (Merrill et al. 2013; Palazzolo et al. 2011). Furthermore, the range of data sources observed – primary quantitative survey data, secondary analysis of survey and literature sources, as well as the use of semi-structured interviews – highlights the flexibility of applying this technique and may thereby facilitate triangulation of evidence from multiple sources when considering both practice and policy issues.

The use of SNA in relation to nursing and by nurse researchers is rapidly increasing. The lack of longitudinal studies and the absence of replication across multiple sites should be seen as an opportunity for further research. In addition, there is sufficient methodological guidance available to avoid the common weaknesses and limitations identified by this systematic review of studies. The state of the science is still rather embryonic with the majority of studies being purely descriptive. There is a need to conduct more intervention-based studies where the underlying network structure is explored to gain insights into the outcomes of differing structures as well as the contribution that different actors play and how various intervention impact on network outcomes. The increased availability of software to support SNA could be exploited in pursuing more robust and sophisticated designs, more complex analysis and the clearer display of results. Finally, although a number of recurring themes were identified, caution should be exercised in interpreting the applicability of these internationally as the analysis may have been overly influenced by the domination of North American studies, often from a single location and at a particular point in time.

Implications for future research

The use of SNA is increasing across a wide range of domains. In particular, SNA studies relating to nursing have been published with increased frequency over the past decade. However, at this time some of these nursing studies have significant methodological limitations. Articles tend to use single point-in-time, small-group designs that limit our understanding of the potential of this approach. In terms of how this technique might further contribute to our understanding of interventions on such factors as team communication or on the consequences of various learning interventions, more sophisticated designs would be required. However, the current dearth of multicentre and time-series designs could be viewed as a potential opportunity for further work. There is some evidence that the technique can be used with geographically dispersed groups and is also capable of deriving useful information from secondary sources such as the documentation of policy discussions, clinical records, email correspondence and the publication history of researchers (Anderson & Talsma 2011; Benton 1999; Merrill et al. 2012). Use of such data may facilitate collaboration between researchers with similar interests and assist – as was suggested by the work of Almero-Canet et al. (2013) – to identify the location of individuals with common interests across academic institutions so as to assist in developing programmes of research. The rapid development of software to support SNA both in terms of numerical measures and visualization of underlying structures enables an increased range of metrics to be considered. At this time, the use of such metrics is often limited to a relatively small number of measures. It is likely that a greater number and a more sophisticated range of measures will need to be used as researchers increase the complexity of their designs.


Author contributions David C Benton contributed in the conceptualization of the problem, literature search and synthesis and in the writing of the initial draft. Florentino Pérez-Raya assisted in designing the methods, validated the analysis and reviewed the initial draft. Ma Pilar Fernández-Fernández assisted in designing the methods, validated the analysis and reviewed the initial draft. Máximo Antonio González-Jurado assisted in designing the methods, validated the analysis, reviewed the initial draft and reviewed the draft paper.

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