**Ioanna Karamitri 1, Fotis Kitsios <sup>2</sup> and Michael A. Talias 1,\***


Received: 25 February 2020; Accepted: 27 March 2020; Published: 31 March 2020

**Abstract:** Sustainable societies need to consider the connection between knowledge management (KM) and healthcare as a critical issue for social development. They need to investigate how to create knowledge and identify possible predictors of knowledge-sharing behavior that can support a hospital's sustainable knowledge-management strategy. KM strategies could help managers to increase the performance of hospitals and other healthcare organizations. The purpose of this paper is to present a valid and reliable questionnaire about KM in healthcare organizations. We develop a new knowledge-management questionnaire based on the use of an extensive literature review and health professionals' consensus. The Applied Knowledge Management Instrument (AKMI) questionnaire was pilot tested and retested on a small group of employees of healthcare organizations (n = 31). After the pilot process, a larger group of health professionals (n = 261) completed the questionnaire. Further investigation resulted in item reduction and verification of the dimensions of AKMI. Finally, we explore the psychometric properties of the developed tool. The developed questionnaire seems to be reliable, valid, and suitable to be used for studying the suggested nine dimensions of KM: perceptions of KM, intrinsic and extrinsic motivations, knowledge synthesis and sharing, cooperation, leadership, organizational culture, and barriers. The developed questionnaire can help policymakers and hospital administrators collect information about KM processes in healthcare organizations and this can result in higher performance of health organizations.

**Keywords:** knowledge management; knowledge creation; healthcare organizations; hospital; organizational learning; sustainable knowledge management; strategy; validation; questionnaire; quality of care

#### **1. Introduction**

Knowledge is a valuable resource for the growth of individuals and organizations. It represents a cognitive framework that makes possible the meaning and understanding of raw data and information [1] and sometimes leads to wisdom [2]. Scientists distinguish two types of knowledge, explicit and implicit [3–5]. Explicit knowledge can be expressed through words, numbers, or figures and represents the tip of an iceberg. Most of our knowledge is tacit, and it is hard to formulate and share. It is what Michael Polanyi [6] said: "We can know more than we can tell".

The cornerstone of knowledge creation and transfer theory was introduced by Nonaka and Takeuchi [5] with the SECI model. Since knowledge increases with interaction, it can be articulated and amplified in various entities where individuals cooperate, like businesses and other organizations, making them sustainable [7]. In the past, scientists insisted on the personal character of knowledge. Next, many agreed that organizational culture exists, especially the heuristic knowledge that is developed by employees while working. Organizational knowledge is achievable when organizations sustain a spirit of cooperation, motivate their personnel, and encourage them to innovate, which means that they have competent management [8].

Management embraced knowledge and, around the 1990s, a contemporary business philosophy attracted the interest of executive officers, researchers, and scholars. In this way, the interest in knowledge management (KM) has grown and has been sustained. An increasing amount of digitized information is available because the decision-maker allows an organization to outperform its competitors. The complexity of modern business needs proper information to minimize errors and ensure future success [9], and the need for quality and best economic outcomes within the business strategy management framework [10].

The definition and conceptualization of knowledge management are not easily distinguished [11] mainly because of the two disjointed approaches that identify KM as technology-centered and people-centered. The first suggests that KM resembles information system management, which uses high technology to make information available and accessible at the right time for the users. The latter focuses on managing knowledge via human resource management practices [12]. The perspective of this article is human-orientated. Like other scientists, we believe that information and communication systems are tools for effective knowledge management and that attention should be focusing on the human, organizational and cultural aspects of knowledge management [13]. Healthcare organizations are examples of the balance between humans and engines. Even if the provision of health services relies on modern technologies, health professionals take the final decision for the diagnosis and treatment of the patient.

As Peter Drucker, the renowned professor, stated [14], "Hospitals are the most complex human organizations ever derived ... and the fastest-growing in all developed countries". Even medium-sized hospitals occupy hundreds of employees from various scientific fields, educational backgrounds, socioeconomic status, and occasionally different cultures. Different groups of employees often have their regulations, perspectives, requirements, and accreditation. Still, they have to interact, cooperate, share information, transform it into knowledge, and perform efficiently to provide high-quality services to the patients and their caregivers. Consequently, it is difficult to share experiences and make comparisons between healthcare settings and other types of organization, and these should be studied independently via their social context and norms.

Healthcare agencies are late adopters of KM philosophy compared to the business sector [15]. Therefore, healthcare experts have just recently started to show interest in research for evaluating the existence and quality of a knowledge environment in hospitals. In 2015, we conducted a systematic review of knowledge management practices in healthcare settings. We accessed three databases (Medline, Cinahl, and Health Source: nursing/academic edition) for 10 years (1/1/2004-25/11/2014) and retrieved 604 articles, of which 20 articles were eligible for analysis. Most of the studies had a qualitative approach, and researchers collected data through interviews with a small number of individuals or focus groups. Details about preparation, analysis, and results of our systematic review are published [16]. We confirmed that quantitative research about KM in a healthcare settings is scarce, and there is a lack of an integrated self-administered questionnaire for health professionals who work in healthcare organizations.

Academics and practitioners from other scientific fields have developed appropriate questionnaires for KM [17]. Still, to our knowledge, no one has until now introduced a reliable quantitative tool that explores KM elements in healthcare organizations.

The purpose of this study is to develop and test a questionnaire to learn more about knowledge management in healthcare settings. We aim to create a tool that could explore attitudes, emotions, cognition, intention or behavior, and identify motivators of and barriers to employees about KM.

#### **2. Methods**

#### *2.1. Questionnaire Design*

Rattray and Jones [18] claimed that researchers who design a questionnaire should use various resources, such as discussions with experts, proposals of participants, and an extensive literature review to increase the face and content validity. Before creating this questionnaire, we conducted a systematic review of the literature [16]. This review identified six critical elements of KM in healthcare settings: perceptions of KM, synthesis, dissemination, collaboration, means of KM, and leadership. Furthermore, it detected several barriers, which restrict the implementation of knowledge management practices. These findings stimulated us to attempt the development of a questionnaire, which we named the Applied Knowledge Management Instrument or AKMI. The word "AKMI" is similar to the English word acme, which has a Greek origin and means the highest point or peak. We chose this name to stress that effective knowledge management could lead hospitals and other healthcare units to top performance.

#### *2.2. Ethical Issues*

The study protocol received approval by the scientific and the border committee of the General Hospital of Messinia, Greece. We composed a letter stating that the completion of the questionnaire is voluntary, and that we will protect the privacy of human subjects while collecting, analyzing, and reporting data by anonymity [19]. Furthermore, we clearly announced the purpose of the study, the significance of the contribution of each employee, and that the completion of the questionnaire will have a positive impact on the hospital and science in general [20]. A cover letter stated a brief definition of KM to clarify the term for those who were not familiar with it. In this way, we motivated potential participants to complete the questionnaire.

#### *2.3. Research Tool*

#### 2.3.1. Selection of the Factors

We selected the following factors of knowledge management for healthcare settings for analysis: perceptions about KM, intrinsic motives, extrinsic motives, knowledge synthesis, dissemination, cooperation, leadership, culture, and barriers. The items of the factors consisted of closed-ended statements, and participants completed AKMI by reporting their level of agreement on a five-point Likert scale. The first statement, for example, is, "Each hospital should implement KM politics." There is only one open-ended question, which asks, "In your opinions, which are the three most important barriers of knowledge management," to identify KM obstacles. Furthermore, the questionnaire had questions for job satisfaction, self-efficacy, and state anxiety, and six items for demographics. These questions were the last to diminish the possibility of drop-outs [18].

#### 2.3.2. Perceptions about Knowledge Management (KM)

The theory of reasoned action assumes that there is a relationship between attitudes and volitional behavior [21]. As a result, a positive attitude or perception towards KM could lead to action like knowledge creation or sharing. Chang et al. [22] claimed that better comprehension of KM improves employees' performance at hospitals. Another study revealed that a positive attitude for KM could give a competitive advantage and can increase innovation [23]. Another supposition is the existence or absence of a correlation between positive perceptions about KM and self-efficacy, as it appears in a sample of librarians in Israel [17]. This factor consists of five items.

#### 2.3.3. Motives

Motives activate individuals to fulfill their needs [24]. If the reward from a specific action is endogenous (e.g., feeling of satisfaction), the motivation is intrinsic, and if it is exogenous (e.g., financial compensation), the motive is extrinsic [25]. The exploration of the motivations that drive employees to knowledge creation and sharing is one of the main goals of our study. Two factors are needed to represent motives; one for the intrinsic features and one for the extrinsic characteristics. Each latent factor consists of four items.

At the intrinsic motives, the person draws satisfaction from other external rewards, like the challenge of completing a difficult task. It is hard but possible for managers to handle intrinsic motives [26]. Comprehension of human behavior could help managers. For instance, people seek purposes to fulfill their life, and a shared goal promotes collaborative relationships. On the contrary, the lack of use places a psychological burden on employees [27]. Intrinsic motives for participating in KM procedures could be the satisfaction of having and transmitting knowledge, and the joy of helping others [28].

The reinforcement theory suggests that individuals are motivated when their behavior is reinforced positively (with rewards) or negatively (with the reduction or removal of positive rewards) [29]. The theory has received some criticism, but tangible rewards are significant motivators for other methods as well [25]. Recorded extrinsic motives for KM are personal, professional, and financial rewards for participating in KM procedure, work safety and stability, and other ways of individual support. Effects of extrinsic and intrinsic motivation on employees' knowledge-sharing intentions were examined in Taiwan, using structural equation modeling. The sample was 172 employees of a big group of firms [30]. A comparison of these results with participants from a Greek public hospital could be rather interesting.

#### 2.3.4. Knowledge Synthesis

Knowledge synthesis is a fundamental element of KM [31] and healthcare settings [14]. Results showed many ways of creating knowledge, such as interactions of colleagues [32], formal and informal meetings [33], and recorded evidence [34]. The synthesis will attempt to clarify which groups of employees are more involved in the process and whether it connects strongly with other factors like perceptions, culture [35], or leadership [36], in different environments besides hospitals.

#### 2.3.5. Knowledge Sharing and Collaboration

Knowledge sharing through collaboration is fundamental for KM because it can be carried out by all employees, regardless of their ability to create knowledge. Next, we will examine whether this factor (using five items) relates to various motives. Furthermore, we will test if knowledge sharing correlates with personal and demographic characteristics [37]. The "openness" to cooperation will also be examined [38] with four items, as stated in the case that collaboration among different groups of health professionals increases the likelihood of innovation [39]. Pezeshki Rad et al. [40] designed a questionnaire for knowledge sharing at the Iranian Ministry of Agriculture that had some interesting questions, which we modified and adopted for this factor.

#### 2.3.6. Leadership

Leaders have a significant impact on businesses and organizations. They are expected to ease access to information, encourage innovation, and empower employees to implement KM practices [41]. The way they act is fundamental to the success of knowledge sharing [42]. They should build a culture of knowledge [43], reinforce continuous learning, and create communication channels [22]. Leaders have the power to provide support and rewards [43]. Factor "leadership," which consists of three items, will be tested for correlations with culture, extrinsic motives, and self-efficacy, to clarify its impact on KM.

#### 2.3.7. Culture

Knowledge culture represents the factor with the most items (nine items). Here, it is examined if a healthcare setting supports innovation, research, and cultivates a learning environment. Organizational culture is a broad term that refers to ideologies, practices, norms, and social behaviors. It gives integration and differentiation opportunities [44]. Sibbald et al. [45] found that leadership and organizational culture are instrumental in supporting knowledge management procedures in hospitals. We will also examine the relationship between corporate culture and perceptions of employees about KM.
