Major themes

Factors influencing knowledge transfer in the healthcare context

Our findings indicate that there were two broad categories of projects completion rates; projects that were completed on time and those that were not completed on time. For those projects that were completed on time, five main transfer themes enablers that illustrated the experiences of the managers emerged. Three of these themes were consistent and largely reflected the established categories represented in the literature for major transfer influences such as Baldwin’s and Ford’s conceptual model. The themes were; (i) training design, (ii) trainee characteristics and (iii) work environment. These results are in general agreement with significant standing findings in the area of training knowledge transfers. Additionally, two unique themes; (i) team-based coaching and (ii) occurring opportunities emerged. Further analysis led to the emergence of new subthemes such as attitudinal shift, power, position and political goodwill. Events such as devolution of health systems, endemic strikes in public health systems and political elections were categorised as the subthemes in the occurring opportunities. Table 2 displays a summary of enablers according to health facility type.

Enabler 1: training design

In all the three settings (public, private and faith-based facilities), managers identified the quality of the training design as the most critical factor influencing knowledge transfer at work environment. The relevance of curriculum content and team-based coaching that followed classroom-based training facilitated timely implementation of the projects. Baldwin and Ford found out that some of the critical training design factors include; the training curriculum or content, the learning approach and the structure of the training activities.24

‘…the training curriculum was very relevant to my personal and workplace needs, the training enabled us to identify a real challenge that was specific to our organisational need … under-delivery was not an option’ (Health manager at a public health facility).

Curry et al 41 cite that ‘when trainers realise that they are being evaluated by the amount of transfer that occurs, their training strategies will change and they will strive to transfer knowledge, rather than simply to entertain trainees’. This observed among the managers as illustrated in these quotes;

‘LeHHO programme is an impact-oriented training which ensures that classroom learning and acquisition of new skills alone is not adequate, but it should be demonstrated through practice and application of knowledge (…). We learnt to objectively analyse challenging situations then develop an actionable plan which in-turn catalysed the success of our project…’ (Health manager at a private facility).

It is evident from these comments that training effectiveness is determined by the thoroughness of the need assessment and the transfer intervention methods for before, during and after the training.

Enabler 2: trainee characteristics

Studies have found individual trainee characteristics such as personality traits, motivation level and ability to apply learnt knowledge and expectations from the training to be associated with a transfer of knowledge post-training. Our study data highlighted three trainee characteristics that are deemed significant predictors of transfer of knowledge to workplace challenges: (i) Motivation level, (ii) ability to apply knowledge and (iii) training expectations. These enablers were echoed across represented project teams during the interviews;

‘… my ability to lead a team was a great enabler, as the head of human resources…I learnt to communicate effectively and listen more to my team members, thus we formed a highly effective team which was unstoppable.’ (Health manager at a private facility).

‘…I am a trained doctor, and the only language I know is the technical language …(this is the problem, how do I fix it?)…the training enabled me to learn more about myself, now that I have self-awareness, I am confident that I can lead an effective team because I am a better leader who can enable others to face challenges…’ (Health manager at a public facility).

Enabler 3: work environment

Majority of the healthcare managers described their work environment climate including, support by board members and buy-in across the institution as a significant learning transfer enabler. Power and position was a uniquely emerging subtheme; those trainees who were in top leadership positions were able to facilitate timely implementation of projects. Another unique contextual enabler was political goodwill; in those counties where there was political support from the county government, projects were implemented on time;

‘…teamwork fostered positive work climate and effective communication during project implementation…being at the position of governance in our county enabled me to influence our juniors' buy-in on a shared vision. Additionally, we had all the necessary resources from human resource to finances.’ (Health manager at a public facility).

Participants reported the political aspiration towards quality and accessible healthcare for all Kenyans as a key enabler for learning transfer. One participant noted that one of the key concerns for many county governors was the provision of quality healthcare services. This was a critical measure by the followers to measure their leader's worthiness for their votes.

‘…the political goodwill for the public and a private partnership was a great enabler for our project…it increased access and utilisation of outpatient and inpatient services…this was made possible due to the launch of National Health Insurance Fund (NHIF) cards for private-sector health services cover.’ (Health manager at a private facility).

Enabler 4: team-based coaching

The increasing body of literature on coaching as a leadership development tool presents leadership coaching as a promising leadership development and has become a widely used intervention for leadership development.42 Coaching, therefore, is a means of supporting team improve performance, and the processes through reflection and dialogue.43 The team coach provides an objective view of the team and facilitates conversations that enable the team to adjust their ways of working together in service of their goals.44 Even though team coaching embedded in the training is delivered only in four sessions through the entire training, participants associated the coaching sessions with the success of their projects. This is evident in the following quotes;

‘Our lecturers and coaches motivated us even when we felt we will not achieve the project goals…the training really challenged and inspired us…consequently we inspired our nurses and other staff at the maternity, antenatal department, thus contribution to effective community mobilisation.’ (Health manager at a public facility).

‘…leadership knowledge and skill in business management gained from healthcare management course enabled us to work effectively as teams resulting in successful project implementation at workplace… the coaching sessions significantly increased the effectiveness of the programme in that our coach visited our work environment and kept the connection even after the implementation of the project.’ (Health manager at a faith-based facility).

Enabler 5: occurring opportunities

Riding on existing gains and opportunities were cited as key enablers. Participants alluded to the saying ‘success is when preparation meets opportunity’. Participants felt that their ability to scan their work environment and prioritise a challenge to be addressed as a catalyst project enabled them to consciously look at the gains and resources within their means. Ironically, some of the opportunities included industrial strikes, devolution and increased number of trained managers within the organisation. Absence of industrial disputes during the implementation period facilitated completion of the implementation of projects in the private sector facilities, compared with some public facilities that were affected by nurses’ strikes;

‘…nurse’s strike was an opportunity for the private sector due to increased patient load…our project enabled us to establish and operationalised digital medical record for both inpatient and outpatient to ensure fast turn-around time…we wouldn’t have prioritised the need if it was business as usual with low patient load…’ (Health manager at a private facility).

‘…Devolution brought decision-making and services closer to the people, therefore, health management teams are able to reach out to the county management team for support, and this worked… devolution works well also for patients in that they are now only a phone call away from airing their grievances to the county governor whenever their healthcare needs are not met…’ (Health manager at a public facility).

‘…our team had one major enabler that led to the successful implementation of our institutional improvement project, ‘devolution of the health systems’…devolved funds from the central government to county-level made it easy to access adequate resources to carry out projects…’ (Health manager at a public facility).

‘…our institution has heavily invested in capacity building of health managers… we are consistently paying fees for a minimum of four participants every year to attend the LeHHO training…each team has been able to implement a new project…this has accelerated the implementation of the strategic plan priorities leading to more gains than anticipated…’ (Health manager at a faith-based facility).

Factors that impeded implementation of the prioritised projects at the workplace per sector

For those projects that were not completed on time, the following were the main unique contextual barriers: (i) inadequate management support in provision of necessary resources for implementation, (ii) inadequate team and staff support, (iii) high staff turnover, (iv) misalignment of board’s verses manager’s priorities, (v) missing technical expertise required to implement the projects, (vi) endemic strikes, (vii) negative politics and (viii) poor communication management. Table 3 presents a summary of the knowledge transfer barriers according to the health facility type.

Impeder 1: inadequate management support in the provision of necessary resources for implementation

Those teams that did not have trainees in senior management positions did not get adequate management support to implement the projects.

‘The buy-in by the management was a great challenge… I was the only trained manager from my institution and no one in my department or other related department was willing to get involved… the board approved the project, however, there was a challenge in working together with other staff.’ (Health manager at a public facility).

Impeder 2: inadequate team and staff support

Inability to influence teams and the rest of the staff greatly affected the success rate of project implementation.

‘Our project was on improving staff retention…however devolution worsened the process because some staff left for county health facilities after the devolution of healthcare services… most of the transferring staff were unwilling to fill the exit form that would help identify challenges encountered…’ (Health manager at a faith-based facility).

Impeder 3: high staff turnover and poor retention

It was reported by the public and faith-based facilities that the rate of staff turnover was a great impediment to the implementation of the projects. In those teams where there was high staff turnover following the training, implementation of projects was delayed.

‘… our organisation as whole accepted changes for the improvement of services …we achieved the project goal by automating the patient medical records management system, however, it is worth mentioning that utilisation dropped by 35%, 6 months after implementation (…). Despite positive changes, our biggest challenge is staff retention; we train our nurses and are immediately absorbed in the big public or private hospitals.’ (Health manager at a faith-based facility).

Impeder 4: misalignment of board’s verses manager’s priorities

A subgroup of respondents identified misalignment of priorities managers priorities with the boards’ and the existing resources as a key challenge. Where there was a misalignment between Board and Management priorities, then implementation was delayed.

‘…even though the pressing priority need was establishing a human resources policy manual resources as a strategy towards recruiting, engaging and retaining our staff especially nurses; our board members did not support operationalisation of the developed policy document… our project was just not in the list of board’s priorities…so we have shelved our manual until when the time is right.’ (Health manager at a faith-based facility).

Impeder 5: missing technical expertise required to implement the projects

Some project required technical expertise that was not readily available at the facilities, thus delaying implementation of the projects.

‘…let’s say our greatest challenge was inadequate expertise…our project was anchored on technology, but the IT personnel in our institution lacked adequate capacity and relevant expertise to implement the project… this was worsened by scope creep, because automation involved different department and yet I was the only manager attending the training, this caused a major impediment from the onset of the project…’ (Health manager at a public facility).

Impeder 6: endemic strikes

Public health facilities were characterised by constant health worker strikes due to poor working conditions, staff shortage and low salaries.

‘Industrial action by nurses and doctors was a big challenge and we couldn’t achieve our projects’ DMR, which was focusing on increasing antenatal fourth visit by pregnant women… without the frontline health services staff, our hospital became ‘ghost town’ … our project remained on paper and was never actualised…’ (Health manager at a public facility).

Impeder 7: negative politics

The challenge of promises for new development in exchange for a vote compounded by scarce and mismanagement of resources due to corruption was cited as a key barrier.

‘Failure to actualise our project was hinged on political interference and prioritisation (…). The project involved working with county governments…even though some county boards shot down the projects, those who accepted lacked the will and commitment to prioritise and allocate the necessary resources.’ (Health manager at a private facility).

Impeder 8: poor communication management

Inadequate communication skills and people management was constantly reported as a key barrier to teamwork hence poor project results.

‘…I realised our biggest challenge is not lack of adequate resource but how we communicate with one another…I hold a technical rather than managerial position and tagging along with other departments into my project from initiation was critical…’ (Health manager at a public facility).

Suggestions on context-specific best practices and strategies for enhancing training transfer

The managers felt that their experiences during the training have equipped them with new knowledge and skills such. To optimise transfer and the training outcome in diverse health systems in Kenya, the programme alumni proposed the following strategies: (i) effective allocation and efficient utilisation of resources especially the financial and human resource, (ii) prioritisation of intervention in alignment with organisational priorities, resources and staff input, (iii) effective communication among partners for buy-in, (iv) longitudinal coaching post-training and (v) training the pre-existing workplace teams.

Strategy 1: effective allocation and efficient utilisation of resources (financial and human resource)

Poor allocation and utilisation of resources such as finance and human resources were identified as a key challenge in healthcare management.

‘Addressing human resources for health challenges such as recruitment, engagement and retention of personnel especially the nurses is the best way towards tackling implementation issues and promote sustainability and scaling up of good practices.’ (Health manager at a private facility).

Strategy 2: prioritisation of intervention in alignment with organisational priorities, resources and staff input

Managers recommended that the ultimate measure of transfer should not focus on the project implementation results only, but other areas of improvement within the institutions which could be also attributed to leadership training.

‘We did not succeed to implement our project; however I benefited greatly from the personal coaching and wish they could be explored more (…). My suggestion on how to improve the training to support the actualisation of projects is through the provision of assistance on how to select the ‘right’ project that fits institutional needs…involving all the stakeholders and departments from the onset of training…this can be achieved with the support of the training institution.’ (Health manager at a faith-based facility).

Strategy 3: effective communication among the key stakeholders

Evidently, communication among partners and within institutions especially during the change process is critical. The shared vision should be well-articulated and communicated to all stakeholders to ensure adequate buy-in and support during implementation.

‘Communication and buy-in was a major impediment to the success of our project (…). I suggest that Strathmore Business School going being a training institution and champions of leadership and governance, to act as a bridge in such projects in order to attain goodwill from the county management.’ (Health manager at a private facility).

Strategy 4: longitudinal coaching

Another significant finding of this study is that the participants were concerned with the coaching engagements duration.

‘Coaching sessions were definitely effective and very recommendable…but I would say they were ended ‘prematurely' at the end of the training when some action plans implementation had just started (…). I, therefore, pose this question to Strathmore Business School, ‘How can you partner closely with our institutions to ensure continuity and institutionalisation of coaching session beyond the training period?’ (Health manager at a faith-based facility).

Strategy 5: training pre-existing workplace teams

Another proposed area of possible intervention was an emphasis on team recruitment from the same institution to ensure continuity of knowledge, speedy buy-in and continuous implementation of the activated projects.

‘I would recommend strict adherence to team recruitment from each facility to ensure that each team member contributes to the project implementation and the sustainability of the project results in the event that some members are transferred to other institutions.’ (Health manager at a private facility).

Strengths and limitation of this study

The objective of the study was clearly stated and a high proportion of the invited respondents participated in the study. This is the first qualitative inquiry study to explore the enablers and barriers of leadership development knowledge transfer in a healthcare context in sub-Saharan Africa. Despite the strengths and contributions of the current study, several potential limitations should be noted. First, the findings are based on data collected from a single training programme thus its interpretation and recommendations are applicable to the ongoing programme, but may not be as relevant to other leadership development interventions. Second, our study employed a qualitative design; hence the findings on knowledge transfer enablers and barriers should be cautiously interpreted because they are based on the perceptions and views of health managers; excluding views of team members or institutional team members who cooperated in the project. Third, the study lacked a comparison group, and therefore it is not possible to explicitly conclude that transferability of knowledge occurred as a result of the implementation leadership development practices alone. Fourth, this is a single-site study and the findings could be only transferred or adapted to similar project-based experiential learning programme interested in transferring knowledge from class to real workplace challenges.