Knowledge Management Problems in Paediatrics and Paediatrics

Neurology Departments

A Case Study based on the Grounded Theory

Helvi Nyerwanire

, Erja Mustonen-Ollila

, Antti Valpas

and Jukka Heikkonen

Innovation and Software, Lappeenranta University of Technology, Lappeenranta, Finland

Department of Obstetrics and Gynaecology, South Karelia Social and Health Care District, Lappeenranta, Finland

Department of Information Technology, University of Turku, Turku, Finland

Keywords: Knowledge Management, Healthcare, Empirical Research, Case Study, Grounded Theory.

Abstract: Knowledge management means how information communication technology systems and intellectual

human capital is applied to support knowledge creation, as well as in the capturing, organization, access,

and use of an organization’s intellectual capital. This paper investigates knowledge management problems

in paediatric and paediatric neurology departments. The Grounded Theory approach is applied in data

collection and analysis. The analysis revealed 8 thematic categories as follows: Patient, Physician, Patient

Data, Nurse, ICT Systems, Patient Treatment, Diagnosis, and Learning and Experience. The categories are

related to each other, and we found 13 higher levels of abstraction of statements. A conceptual framework

of knowledge management categories, their relationships to each other, and propositions to our categories

was developed by using the Grounded Theory approach. The relationships between the knowledge

management categories enhance confidence in the validity of the categories and their relationships, and

expand the emerging theory.

1 INTRODUCTION

In this study the healthcare environment, denoted as

department, is referred to as a place in which

medical, clinical and nursing knowledge is ingrained

in practitioners (Räisänen et al., 2009). Knowledge

management is defined as a process where

information communication technology (ICT)

systems are applied to support the activities in

organizing knowledge, expertise, skills and

communication (Alavi and Leidner, 2001). In spite

of the definition above, there are several problems

that hamper knowledge management, such as the use

of ICT systems (Viitanen et al., 2011; Martikainen et

al., 2012; Nykänen et al., 2012), access to patient

data (Reddy et al., 2009), communication barriers

(Hayes et al., 2011), resources and workload (Chadi,

2009), acute and emergency patient care situations

(Nevalainen et al., 2012), coordination inside and

outside the hospital (Burgess et al., 2012),

appointment scheduling (Martikainen et al., 2012),

treatment paths (Viitanen et al., 2011; Nykänen et

al., 2012), diagnosis (Heilmann, 2010), and

interpretation of patient data and information

interpretation (Viitanen et al., 2011; Martikainen et

al., 2012; Nykänen et al., 2012).

Thus, plenty of knowledge management

problems exist in healthcare, but studies are missing

from the paediatrics and paediatrics neurology area

how improved healthcare quality, lowered

healthcare costs, care providers’ ability to offer

healthcare, changes in the process of patient care

delivery and improved cost efficiency by offering

new ICT technologies by remote access with the

patient can bring improvements to healthcare

environment. Therefore we have applied past studies

and empirical evidence to carry out a qualitative in-

depth case study (Benbasat et al., 1987; Yin, 2003)

that identifies problems in knowledge management

in two hospital environments. We analyzed the

collected data with the Grounded Theory (GT)

approach by using Glaser and Strauss’s (1967) and

Pawluch and Neiterman’s (2010) research approach.

GT investigates phenomena in their natural context

and a data analysis is used to build up a theory from

empirical findings. Data collection continues until

‘theoretical saturation’ is reached (Glaser and

234

Nyerwanire, H., Mustonen-Ollila, E., Valpas, A. and Heikkonen, J..

Knowledge Management Problems in Paediatrics and Paediatrics Neurology Departments - A Case Study based on the Grounded Theory.

In Proceedings of the 7th International Joint Conference on Knowledge Discovery, Knowledge Engineering and Knowledge Management (IC3K 2015) - Volume 3: KMIS, pages 234-241

ISBN: 978-989-758-158-8

Strauss, 1967). Our goal was to investigate

knowledge management problems in detail in a

paediatric department and paediatric neurology

department in a central hospital located in South

Karelia, Finland, and we found 401 knowledge

management observations supported by empirical

evidence. We categorized the observations with GT

analysis (Glaser and Strauss, 1967), and the analysis

revealed 8 thematic categories as follows: patient (2

observations), physician (83 observations), nurse (10

observations), patient data (61 observations), ICT

systems (147 observations), patient treatment (57

observations), diagnosis (16 observations), and

learning and experience (21 observations). The rest

of the paper is structured as follows. Section two

describes related research, section three presents the

research method, and section four outlines the data

analysis. Finally, section five contains conclusions

and discussion.

2 RELATED RESEARCH

Plenty of knowledge management problems have

been presented in the literature. They include for

example difficulties in making a diagnosis (Tucker,

2007) and difficulties in clinical investigations,

because investigations need a lot of time, experience

and knowledge (Curley et al. 1990). There is lack of

access to medical information journals (Norbert and

Lwoga, 2013), and lack of access to patient

information (Reddy et al., 2009). Reddy et al. (2009)

state that there is a communication barrier in ICT

systems in healthcare environments. In addition, the

oral information received from a patient is not clear

and the physicians can freeze in critical patient care

situations (Heilmann, 2010). Martikainen et al.

(2012) mention appointment scheduling and

consultation problems. According to Burgess et al.

(2012), there are coordination problems between

different caregivers. Mandl et al. (2001) state that

patient rights and parents’ permission complicate

physicians’ work. Martikainen et al. (2012) refer to

problems in ICT outcomes in patient work, as well

as physicians’ negative attitudes to ICT systems or

to patients (Viitanen et al., 2011). Chadi (2009)

mentions physicians' limited time and too many

patients. Nykänen et al. (2012) state that there is lack

of reliability of data or information. Dias et al.

(2003) argue that physicians' work is stressful, such

as late night working, many patients, or patient care

cases. Martikainen et al. (2012) claim that separate

subsystems need separate checking and each patient

must be treated differently, and physicians are not

too eager to search for follow-up data. There is

malfunction in lab tests, subsystems and procedures

(Viitanen et al., 2011). A lot of time is needed to

give information to the patient, and making a

rehabilitation plan needs a group of people from

different areas (Poskiparta et al., 2000). Brixey et al.

(2010) mention interruptions in daily work. Thus,

despite a growing interest in knowledge

management problems in healthcare, their

relationships have not been recognized in the

literature. Our study aims to respond to this lack of

studies and to provide useful information of

knowledge management in one specific paediatric

department and one paediatric neurology

department. Paediatrics carries out medical care of

children and paediatrics neurology carries out

medical care which specializes in treating nervous

system problems in children. The nervous systems

can be damaged permanently because the brain’s

development, and making the diagnosis and

treatment of neurological problems need a special

attention. The children’s diseases also need special

knowledge in order to be treated properly. Thus, this

study could bring benefits both to the patients and

care givers in this research context by discovering

what are the main knowledge management problems

and their relationships with each other. Based on

past studies, we have formulated the following

research questions:

RQ1: What are the main knowledge management

problems in paediatrics and paediatrics neurology?

RQ2: How are the knowledge management

problems in paediatrics and paediatrics neurology

related to each other?

3 RESEARCH METHOD

This study utilizes both qualitative and quantitative

research processes and theory building approaches.

It takes an in-depth case study, theory building and

Grounded Theory (GT) perspective involving

specific healthcare environments in which

knowledge management problems are studied

(Glaser and Strauss, 1967; Benbasat et al., 1987;

Eisenhard, 1989; Yin, 2003; Cresswell, 2007;

Pawluch and Neiterman, 2010). In these healthcare

environments, the cases were selected so that they

would either predict similar outcomes (i.e. literal

replication) or to produce contrasting results but for

predictable reasons (i.e. theoretical replication) (Yin,

2003). Theory triangulation was applied by

interpreting a single data set from multiple

perspectives to understand the research problems

Knowledge Management Problems in Paediatrics and Paediatrics Neurology Departments - A Case Study based on the Grounded Theory

235

(Denzin, 1978). The concepts and their relationships

were validated with the grounded theory approach

(Glaser and Strauss, 1967; Eisenhardt, 1989). During

the research, theoretical background knowledge was

gained, which increased the credibility of the study

(Miles and Huberman, 1994). According to

Eisenhardt (1989), the combination of case study

with the grounded theory approach has three major

strengths: it produces a novel theory, the emergent

theory is testable, and the resultant theory is

empirically valid. In the GT approach the theory

emerges from the data. According to Glaser and

Strauss (1967), there is no need to review any

literature of the studied area before entering the

field, and this is in line with our research.

Specifically, each interview transcript was analysed,

and major emergent themes and concepts were

identified in order to form similar categories (Myers

and Avison, 2002). In our case study, one paediatric

department and one paediatric neurology department

were the units of analysis in the Social and Health

Care District of South Karelia in Finland and its

central hospital (Eksote, 2013).

The definitions of knowledge management and

the objectives of the research formed the basis for

the interviews and data collection. In order to

address the research questions, we conducted nine

audio-recorded unstructured and semi-structured

interviews that investigated experiences in

knowledge management issues in the chosen

healthcare environment. The interview rounds were

carried out in March - May 2014 in the Paediatric

department, and in March - June 2014 in the

Paediatric Neurology department. The interviewees

were the chief physician in paediatrics neurology,

chief physician in paediatrics, one senior physician

in paediatrics, three junior physicians in paediatrics,

and three paediatric nurses. The interviewees had

been involved in many knowledge management

issues and processes in their own fields of expertise

during their working careers that extended over

periods of 6 to 14 years among the nurses and 3 to

43 years among the physicians, in different positions

either in South Karelia Social and Health Care

District or other healthcare environments in the

private or public sector in Finland.

3.1 Data Collection and Categorization

The interviews included frequent elaboration and

clarification of the meanings and terms, they were

audio-recorded, and the recordings were transcribed,

yielding over 206 pages of transcripts. After

transcribing the interviews, we used the Grounded

Theory based on our own intuition and knowledge in

fragmenting and reassembling our knowledge

management problems into thematic categories

(Glaser and Strauss, 1967; Pawluch and Neiterman,

2010) according to relevant terminology and past

studies that were the most refereed work in

categorizing concepts in the studied research area.

Since each thematic category was decomposed into

multiple items (traits) by using content analysis, the

items were matched with actual categories (in situ).

Thus, for each category a certain number of items

were identified that were likely to influence the

category at that point. Finally, the items were

validated with past studies. An example of each of

the thematic categories’ observation is presented in

Table 1. The problem with the thematic categories

was whether there would be enough proof found in

the data to derive the categories as valid and reliable,

and whether the categories discovered in the data

would be the correct ones.

4 ANALYSIS

After creating the chain of evidence in data

categorization, the total number of 401 different

empirical observations under 8 thematic categories

(see Table 1) were found by using Glaser and

Strauss’s (1967) and Pawluch and Neiterman’s

(2010) grounded theory analysis instructions, which

support the finding of categories grounded on data,

and also based on the researchers’ own intuition and

knowledge. Specifically, we have involved

fragmentation and reassembled our data into

thematic categories by trying to capture a broader

social system of ideas from the experience of the

social actors (Glaser and Strauss, 1967; Pawluch and

Neiterman, 2010), in this case the actors working in

the paediatrics and paediatrics neurology

departments. As shown in Table 1 above, eight

thematic categories were formed in the study:

Patient, Physician, Nurse, Patient Data, ICT

Systems, Patient Treatment, Diagnosis, and

Learning and Experience. The Patient category had

2 observations and 1 item; the Physician category 83

observations and 21 items; the Nurse category 10

observations and 7 items; the Patient Data category

61 observations and 14 items; the ICT Systems

category 147 observations and 17 items; the Patient

Treatment category 57 observations and 16 items;

and the Learning and Experience category had 21

observations and 6 items. The sum total of empirical

item observations (items) was 401, and the sum total

of different items was 88. Our conceptual

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236

Table 1: An example of an observation concerning each thematic category, category definition, item number (item no),

item, and item definition.

Thematic

Category

Category Definition Item

Item Item Definition

Patient A patient receives care and

treatment by a physician or

nurse

1 Patient

anxiety

In patient care situations the patients can be

sometimes afraid and the patient’s worry about

him/herself affects the physician’s decision-

making (in diagnosis and treatments).

Physician A physician needs

knowledge of anatomy,

physiology, and medical

science, as well as

knowledge of how to apply

this knowledge in practice

1 Negative

attitudes

towards ICT

systems

There are negative attitudes because computer

programs are a hindrance to work and

subsystems are used via main systems, and

physicians are very anxious about using systems

this way.

Nurse A nurse is a trained nurse

specialized in patients'

(children) illnesses

1 Interruptions There are a lot of interruptions in daily work and

they make the nurse to forget what she/he was

doing, and also patients interrupt working in data

saving etc. issues.

Patient data Patient’s personal data,

medical history, treatments,

tests, examinations,

diagnoses, and consultation

requests

1 Information is

missing in the

systems,

paediatric

ward and

about patients

The systems miss task lists for staff, paper

information about patients is missing, check-up

lists are missing in the paediatrics ward,

instructions on how to handle double time data

saving and checking are missing, and acute

treatment guideline books must be available.

ICT

Systems

There are hundreds of ICT

systems in use at hospitals,

and the physicians and

other professionals use

them in their daily work

with patients.

1 Systems are

not in concord

The electronic prescription does not recognize

the treatment. The patient has a third system at

home, and in the university there is a fourth one

and none of these are totally in concord.

Patient

treatment

In the patient care process a

physician makes a

diagnostic decision and

determines the proper

treatment for the patient.

1 Treatment

based on

'Käypähoito'

does not work

In some clinical situations the treatment based

on 'Käypähoito' does not work and it is more

complicated to find the exact treatment strategies

from journal sources.

Diagnosis A process to examine the

patient s and define the

essence and circumstances

of a disease

1 No check-up

patient

information in

wards and

paediatrics

There are no check-up lists in wards and

paediatrics, check-up lists or staff used at the

wards do not exist in the systems.

Learning

and

experience

Acting to get new

knowledge or skills by

experience or reading, or

evaluating information or

data

1 New

information

or data need

studying,

evaluation

and critical

thinking

The biggest problem is that medicine is such a

huge concept, it has huge amount of information

that cannot all be remembered, and new

information needs to be studied or new results

must be waited for.

framework of the discovered categories (see Figure

1 below) is grounded on empirical evidence and

theories reflecting the findings in the field (Glaser

and Strauss, 1967; Pawluch and Neiterman, 2010).

In Figure 1, the categories are shown as ellipses, and

the bold lines marked with letters (A to O) describe

the relationships between the categories. The small

arrows with numbered circles pointing to the

categories are the multiple items (traits) to each

category composed by content analysis. After the

categories and relationships and items had been

found, we determined the properties of the

categories and propositions (hypotheses) on how the

categories were related on the basis of data (See

Table 2). Constant comparison between the data and

concepts in past studies in order to accumulate

Knowledge Management Problems in Paediatrics and Paediatrics Neurology Departments - A Case Study based on the Grounded Theory

237

evidence convergence on simple and well-defined

categories led us to 13 higher level of abstraction of

statements about the relationships between the

categories. This theorizing was in line with Pawluch

and Neiterman’s (2010) suggestions of creating a

grounded theory with Glaser and Strauss’s (1967)

approach.

5 CONCLUSIONS AND

DISCUSSION

The qualitative, empirical case study based on the

Grounded Theory approach (Glaser and Strauss,

1967) and nine in-depth interviews revealed that

many knowledge management problems can be

found in paediatric and paediatric neurology

department.

The study is in line with past studies concerning

problems in making diagnoses (Tucker, 2007), hard

clinical investigations (Curley et al., 1990), lack of

access to medical information journals (Norbert and

Lwoga, 2013), lack of access to patient information

and communication barriers in ICT systems (Reddy

et al., 2009), unclear oral information from a patient,

physicians freezing in emergency situations

(Heilmann, 2010), appointment scheduling and

consultation problems (Martikainen et al., 2012),

coordination problems between caregivers (Burgess

et al., 2012), patient rights and parents’ permissions

complicating physicians’ work (Mandl et al., 2001),

problems in ITC outcomes, physicians’ negative

attitudes to ICT systems and patients (Martikainen et

al., 2012; Viitanen et al., 2011), physicians limited

time with too many patients (Chadi, 2009), lack of

data reliability (Nykänen et al., 2012), physicians’

stress (Dias et al., 2003), systems needing double

checking, physicians’ not wanting to search for

follow-up data (Martikainen et al., (2012),

malfunctions in lab tests, subsystems and procedures

(Viitanen et al., 2011), long time needed to give

information to the patient and making a

rehabilitation plan needing a group of people from

different areas (Poskiparta et al., 2000), and

interruptions in daily work (Brixey et al., 2010).

Our results validated the conceptual framework,

Figure 1: Conceptual framework of categories.

Learning and

experience

ICT Systems

Nurse

Patient

Diagnosis

141

Patient Data

Patient Treatment

Physician

2 6

M L

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Table 2: Properties of categories and propositions (hypotheses) on how the categories are related on the basis of the data.

Category/Categories Properties of categories and propositions (hypotheses) on how the categories

are related (lines marked with the letters A to O in Figure 1) on the basis of the

data

Lines marked

with letters in

Figure 1

Physician, Learning

and Experience

The staff make harsh comments about the patients, parents, colleagues, even

themselves, and expertise is shared this way

Nurse, Learning and

Experience

Nurses look for evidence on how a medicine has helped elsewhere, and nurses

contact outside hospitals in Finland and find out how a certain disease is

treated or medicine is used, and then the department makes its own guidelines

on how to use it.

Nurse, Physician The nurses must decide who is the best physician to decide about new

medication

Physician,

Diagnosis

A diagnosis has to be done even if the patients denies to give samples of blood

or urine, and it is difficult to treat children if they refuse the tests

Diagnosis, Patient In patient care situations patients can be sometimes afraid and the patient’s

worry about him/herself affects the physician’s decision-making (in diagnosis

and treatments)

Patient, Nurse The nurses are checking the child patients before they meet the physician, and

the physician then checks the same things again

Patient, Physician A lot of time is used to give information about the disease, how it affects the

patient, and about the medicine in order to make sure that the patients takes the

medicine and follows the instructions at home

Physician, ICT

Systems

The physicians have only very basic knowledge of data systems H

Physician, Patient

Data

The diagnosis must be formed in one's mind on the basis of the symptoms. The

physician must react to the things she/he is expecting, such as results, and the

physician must decide him or herself and on the basis of information in the

computer

Physician, Patient

Treatment

In acute situations investigations and treatments must be handled quickly,

decisions must be made quickly, and handling acute situations is difficult.

Patient Treatment,

Patient

The problem is every treatment cannot be evidence-based because there is not

enough research and there are cases which cannot be based on a proper study.

Patient Data, Patient It is not easy to combine patient information from different sources and people,

and too much patient information can be controversial, and one must form

one's own opinion about it

ICT Systems,

Patient

The information systems slow down patient work, take time from daily patient

care and take the focus away from the patient

Patient Data, ICT

Systems

It is difficult to know what is the fastest way to find information, sometimes

one cannot use one's personal codes, one has to use the clinical codes of the

whole clinic to find something and things are not found from one system, but

in Effica and subsystems.

Patient Treatment,

Patient Data

In an emergency situation, electricity failure is crucial because there is not

access to patient data

which became the discovered theory for the

phenomenon. The data which confirmed the

emergent relationships enhanced confidence in the

validity of the relationships. The past studies with

similar findings were important because they tied

together the underlying similarities in phenomena

not associated with each other, and stronger internal

validity was achieved.

Several conclusions can be drawn from this

study. First, there is a huge number of knowledge

management problems which affect patient care

work daily. There is a real difference between acute

and emergency situations and normal daily routine

patient care situations. The first ones need a lot of

experience and knowledge which must be learned in

similar situations in a long time period. Therefore, a

junior physician must not be in charge in acute and

emergency situations but should work side by side

with a senior physician in order to learn the right

procedures. The management, leadership, and

treatment paths are important tasks to be solved in

departments in every situation before any patient is

Knowledge Management Problems in Paediatrics and Paediatrics Neurology Departments - A Case Study based on the Grounded Theory

239

involved, so that the interpretation of results and

tests will go right away to the right person who is

able to interpret them correctly. The several similar

investigations by different patient care providers

must be coordinated so that there is no need to do

the same investigations all over again when the care

giver changes. Physicians and nurses on every level

of healthcare must be given proper education and

training so that patients can rely on them in spite of

who is in charge. When doing so, maybe the patients

would also start telling the truth about their

symptoms. The patients could also tell about all their

symptoms better if they could rely on the

confidentiality of the ICT systems, so that cannot

misused by anyone else than the physician in charge.

Finally, the physicians' and nurses' negative attitude

problems towards ICT systems and child patients

must also be taken care of because they can affect

the patient care situation, and also the care providers

themselves. The reasons for the knowledge

management problems may just be too much work

with too many patients with limited knowledge at

hand, which makes the care providers tired,

frustrated or exhausted in their work. On the other

hand, they can also be a consequence of motivation

problems, or missing right knowledge in the work

they are currently doing. This can be seen as

uncertainty in their work, which is full of restrictions

and perhaps a feeling that there is no possibility to

influence one's own work, but it is dictated from

above.

There are several limitations in this study. First,

the results may not be readily applicable to other

departments, as the phenomena were atypical.

Second, the use of only two departments in a central

hospital affected our findings, and thus

generalization of the results can be difficult, but not

necessarily impossible. Third, we performed a

limited number of interviews, and only the chief

physician of the paediatrics neurology department

was interviewed personally. Our analysis provided

better understanding of the different types of

knowledge management problems and their

relationships with each other affecting to patient

safety which lead to better understanding of

problems in healthcare. This is the main research

contribution of our study. Finally, our study was

supported with a study conducted in medical domain

(de la Tassa et al., 2013) concerning the importance

of patient safety and this supports our findings of

knowledge management problems.

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