Social Network Research
Analysis of networks is increasingly seen as important for understanding the patterns, processes, and consequences of social relationships in healthcare. Networks can be formal, mandated structures (e.g., a clinical network), can emerge from sharing a common passion, or can be from routine exchanges such as referrals. Braithwaite and colleagues (2009) call for the fostering of naturally emerging networks suggesting these underpin the delivery of healthcare and play an important role in driving quality and safety. Social network analysis (SNA) emphasizes patterns of relationships and interactions between network members (actors) rather than individual attributes/behaviors or abstract social structures. SNA conceptualizes networks as composed of nodes (the actors in the group) and ties (the relationship between the actors). Ties form the structure of the network, and the nodes occupy positions within that structure. This proves a basis to investigate a wide range of issues, including communication pathways between actors (including gaps, bottlenecks, or opportunities to increase connectivity), the presence of “tribes” or silos, key players, networks of social support, and patterns of social influences on behaviors. This also allows researchers to investigate relationships between network structures (e.g., communication flows) and important outcomes (e.g., rapid dissemination of ideas). In this chapter, we will introduce readers to key debates, concepts, methods, and applications of SNA, drawing on the authors’ own studies and the growing body of healthcare literature adopting this approach. This demonstrates the contribution of SNA to understanding different types of networks, including at the individual, group, and organizational level.
KeywordsInterprofessional relationships Collaboration Connectivity Brokerage Knowledge exchange
Analysis of networks is increasingly seen as important for understanding the patterns, processes, and consequences of collaborative relationships in healthcare. Networks can give a more holistic picture of the complex interactions which define the health system. Networks can be formal, mandated structures (e.g., a clinical network Haines et al. 2012), can emerge from sharing a common passion (e.g., a special interest group or community of practice Wenger et al. 2002), or can be from routine exchanges (e.g., referrals Fuller et al. 2007). Braithwaite et al. (2009) call for the fostering of naturally emerging, bottom-up networks, suggesting these underpin the delivery of healthcare and play an important role in driving quality and safety.
A network is any group of people or objects that can be said to interact or have some kind of relationship between them. Network theory provides a powerful lens through which to understand how the elements within such a group are organized, following a set of principles. The study of networks led to the realization that there are similarities between very diverse types of networks such as the neural networks of nematodes (Morita et al. 2001), power grids (Nasiruzzaman 2013), and the Internet (Carmi et al. 2007). In the social sciences, network theory is used to explain interpersonal relationships at various scales: from whole of communities (Putnam 1995) to a few clinicians exchanging information about a patient (Benham-Hutchins and Effken 2010). It provides insight into such phenomena as the influence of opinion leaders, why some companies have a competitive edge, and how effective teams work.
This chapter starts with a brief history of social network studies, followed by an introduction to basic network concepts and methods. We then describe studies which have used social network methodology to study aspects of health service delivery.
2 Network Analysis in the Social Sciences: A Brief History
The study of patterns of social relationships has been an enduring aspect of social science (Durkheim 1895; Simmel 1950). Here, we focus on social network analysis (SNA) as a distinct methodology, emerging in the mid-1930s in the social and behavioral sciences and advancing slowly but constantly over the next 60 years by a small core of researchers at Harvard. As Wasserman et al. (2005, p. 1) put it: “It was easy to trace the evolution of network theories and ideas from professors to student, from one generation to the next.”
The psychiatrist, Jacob Levy Moreno (1889–1974), is often cited as the father of network analysis although Freeman (1989) argues that the structure of networks was recognized long before this in the kinship structures such as descendant lists in the Old Testament (e.g., Genesis 5). The first use of the term “network” as it is understood today (Freeman 2004, p.35) was in Moreno’s seminal study on Hudson School for Girls and Sing-Sing Prison (Moreno and Jennings 1934). Moreno stated that the schoolgirls’ action of running away was influenced more by their position within their social network than with a conscious, independent decision. Moreno used the term “sociometry” to describe “the mathematical study of psychological properties of populations … methods which inquire into the evolution and organisation of groups and the position of individuals within them” (p.10). In other words, it is a method for eliciting and mapping the subjective feelings of individuals toward each other (Borgatti et al. 2009), focusing analytic attention on patterns of social relationships.
During the 1940s and 1950s, social network research developed through matrix algebra and graph theory, allowing the groups to be objectively identified within networks (Luce and Perry 1949). This led to work exploring concepts such as leadership, group cohesiveness, group productivity, cooperation, competition, communication and problem solving, and the spread of influence within groups (Borgatti et al. 2009; Freeman 2004). Around 1990, there was a massive rise of interest in networks, as other disciplines outside of sociology saw their potential, disciplines as diverse as physics and epidemiology (Wasserman and Faust 1994). A major contribution to network analysis was the characterization and modeling of small-world networks (Travers and Milgram 1969; Watts and Strogatz 1998). Small-world networks have been found in many settings including brain networks (Zhang et al. 2016) and food webs (Montoya and Solé 2002). Small-world networks display properties that transcend the characteristics of the individuals within it.
3 Social Network Concepts
SNA emphasizes patterns of relationships and interactions between network members (actors) rather than individual attributes. Actors can be individuals or entities such as departments or whole organizations, while relationships, which must be tightly defined, can be things such as collaboration, friendship, information exchange, or attendance at a particular event. While attribute data (e.g., gender, age, job position, seniority) is usually also collected, the focus is on this relational data that defines the network structure (Scott 2000). Different types of relational tie can lead to very different network structures; for example, a network of friendship ties between actors may be different from the same actors’ network of reporting ties.
Ties can be directional (e.g., providing information to, seeking advice from) or nondirectional (e.g., works in the same building, attend the same meeting). Ties can be recorded as simply present or absent or weighted to signify the weakness or strength of a relationship. This can be based on emotional intensity, level of reciprocity, or more usually frequency of contact (Granovetter 1973).
Relational tie data can be collected in different ways depending on the nature of the interaction. Face-to-face communication patterns may be directly observed (e.g., Obstfeld 2005). Referral patterns, email communications, or collaboration may be gathered using a self-report survey (Bishop and Waring 2012; Chan et al. 2016; Long et al. 2016) or documentary evidence (Fattore et al. 2009; Zheng et al. 2010).
Some social network terms and their definitions
A member of a network
An actor in a network that acts as an intermediary between two unlinked actors and clusters of actors
A strategy described by Burt (2005) of maximizing opportunities by increasing variation in the network through weak, bridging links to multiple, nonredundant contacts outside the group. This strategy contrasts with closure
The actor who is nominated most often or who interacts with the most other members of a network
A measure of which actor or actors are the most connected or who interact with the most other actors
A strategy described by Burt (2005) of increasing cohesion by reducing variation within a group by forming strong links to members of the network. This strategy contrasts with brokerage
A subgroup of a network in which the local density of ties is higher than across the whole network
The process of spreading disease (in epidemiology), ideas, knowledge, or uptake of new technology through direct contact or social influence in social networks
The number of ties that actors have to other actors
The ratio of the number of ties present in a network divided by the number of possible ties
A tie that contains information about who initiated the tie and who receives it (e.g., information given by Actor A and received by Actor B)
Element of interest in a network. In a social network, it may be an individual or organization. In nonsocial networks, it may be an object, e.g., a station in a railway network
Edge (or tie)
A link or relationship between actors in a network shown on sociograms as a line
Focal actor in a network
Social network of a single focal actor
Defined by Rogers (2003) as the extent to which linked actors share similar attributes such as education, gender, or social status
A tie is said to be reciprocated when both actors acknowledge the tie
A measure of the advantage that comes through social ties. May refer to the advantage held by an individual through their egonet (Burt 1992) or may refer to the quality of an entire group, e.g., an entire community (Putnam 1995)
Strength of tie
A measure of emotional intensity, level of reciprocity, or frequency of interaction associated with a tie
Strength of weak ties
A phenomenon described by Granovetter (1973) to describe the often advantageous, novel information that comes from weak links from outside of one’s closely tied network (who all tend to know the same information)
Tie (or edge)
A link or relationship between actors in a network shown on sociograms as a line
A tie that does not require information about who initiated the tie or who received it (e.g., two actors on the same board, kinship ties)
Whole network survey
A survey that aims to elicit data from every member of the network, rather than a sample of members
Social network theory has been used to understand processes and phenomena across a range of different industries and settings including market competition (Burt 1992; Uzzi 1997), generation of innovative ideas (Bercovitz and Feldman 2011; Hargadon and Sutton 1997), influence and leadership (Lambright et al. 2010; Long et al. 2013b; Valente and Pumpuang 2007), and group dynamics (Balkundi et al. 2009; Susskind et al. 2011).
Within healthcare, social network theory and analysis have been used to look at coordination and integration of health services (e.g., Ayyalasomayajula et al. 2011; Khosla et al. 2016; Lower et al. 2010; Ryan et al. 2013), interprofessional communication and practice (e.g., Benham-Hutchins and Effken 2010; Chan et al. 2016; Creswick et al. 2009), strategies for translational research (e.g., Long et al. 2016; Rycroft-Malone et al. 2011), influence and leadership (e.g., Grimshaw et al. 2006; Kravitz et al. 2003), and quality and safety (e.g., Cunningham et al. 2012; Meltzer et al. 2010).
4 Structure Versus Agency
A debate within SNA research is the difference between two conceptualizations, usually referred to as structure and agency to explain human behavior and social networks. A structuralist view focuses on the recurring patterns of social interactions that appear to provide opportunities to an individual or constrain their behavior (Ansell et al. 2009). Agency, on the other hand, refers to an individual’s power to act and purposefully change their world (Apelrouth and Edles 2008).
A structuralist perspective of networks takes the view that a certain individual’s position in a network influences their actions (and consequences) as network positions afford certain opportunities. An actor in a central position in a network might be expected to have the same opportunities and constraints as another central actor in a different network. This approach focuses on the presence or absence of ties and tends to ignore the actual content of the ties (“ties conceptualised as girders” (Borgatti and Foster 2003, p.1003)). An example of this approach is a study of hospital facility managers (Heng et al. 2005) in which they illustrated through a sociogram that managers were situated centrally in the overall network between departments. This meant that they were able to act as coordinators and brokers between the many departments with which they linked.
An agency perspective perceives the actor taking a greater role and using the resources of the network to his or her own end. Agency-focused studies of networks try to understand how the individual’s actions and behavior have shaped their environment. This approach focuses on the nature of the ties, more specifically, on the resources that are delivered in the ties (“ties conceptualised as pipes” Borgatti and Foster 2003, p.1003). A small study by Kalish (2008) considered the personality traits of students in brokerage positions in a multicultural class to understand the nature of personal agency in defining their network position.
Networks are not static structures, so some studies have used both agency and structural perspectives in the same study. For example, Johnson et al. (2003) described the relationships between crew members at an Antarctic science base over three successive winters. As well as network structural data (“who hung out with who”), they observed the social roles that people took within the networks (“clown,” “leader who got things done”). By combining the data, they were able to describe the emergence and evolution of the network. Both viewpoints have merit and are inherently interesting to explore. Borgatti and Foster (2003), in their review of network research, however note that the vast majority of SNA studies take a structuralist perspective.
Social network data can be collected through self-report surveys, observation, or use of documentary data (e.g., emails, minutes of meetings). Before starting to collect data, the most important step is to define the relationship of interest. Referral or specific advice relationships may be straightforward, but for self-report surveys especially, the tie needs to be understood in the same way by all participants. Long et al. (2016), for example, used the following explanation of collaborative ties since collaboration is a multifaceted concept that had the potential to be understood in a number of different ways: “By ‘collaboration’ we mean either formally (e.g., on a funded project) or informally (e.g., have discussed aspects of research, supplied expertise, advice or equipment to others) … Please select those people with whom you are currently collaborating on a network activity, event or project …” (p. 6). This allowed the researchers to capture informal collaborative ties as well as the formal.
Two main methods of eliciting relationship data in the self-report survey method are roster style and name generator. If the boundaries of the network are known (e.g., people signed up to an online community of practice, staff on a ward, members of a committee), a roster of names may be used (pending ethical and governance approval). In the roster style survey, the members of the network are listed, and the respondent is asked to consider each person as a potential tie. In the name generator style of survey, the respondent is asked to write down the names of the people with whom they consider they have the defined tie without any prompting. This is useful if the membership of the network is not known (e.g., social support networks). The following resources provide detailed discussion of SNA methods and the various advantages and limitations associated with them (Borgatti et al. 2013; Scott 2000; Wasserman and Faust 1994).
6 Key Players in Collaborative Networks
Brokers are actors that link together individuals or groups of individuals (see Fig. 1b). They have been identified using a range of terms, the most common being bridges (Burt 1992; Valente and Fujimoto 2010), brokers (Cross and Prusak 2002; Gould and Fernandez 1989; Shi et al. 2009), and boundary spanners (Howse 2005; Tushman 1977). The broker is considered a key player as their position is inherently powerful; they may be the sole link between two noncommunicating groups. This can be used for a competitive advantage in business (e.g., having information from group A that group B does not, means the broker has a competitive edge) or to cause mischief (e.g., hoarding relevant information and not passing it along; acting as a gatekeeper and not allowing access to resources held by the other group). More positively, in collaborative networks, they can broker beneficial introductions, mediate between parties that are at odds, or provide a service of some kind to both parties (e.g., an interpreter, an expert).
Both key player roles have costs associated with them as well as advantages (Long et al. 2013c). Maintaining ties is a time-consuming exercise and beyond a certain number is unfeasible (Burt 1992, 2002).
7 Social Network Analysis and Healthcare Research
Social network analysis is a powerful approach to apply to healthcare settings. It can provide a framework to examine information flows, social and professional influence, and the phenomenon of siloed thinking and action (Long et al. 2016). While SNA has been well noted for its potential to map epidemiological phenomenon (e.g., the spread of HIV (Lin et al. 2012) or SARs (Chen et al. 2011)), over the past 10 years, it has also been increasingly taken up in research on healthcare organizations and systems. A number of reasons for this interest can be suggested. The increasing focus on the shape of social networks can be seen to follow from a concern with network forms of governance and policy attempts to engage with, and harness, embedded professional networks. Rather than an integrated hierarchy, it has increasingly been recognized that multiple “decentered” professional and organizational networks are involved in shaping and controlling health systems; SNA offers an approach to study such network forms.
A related concern of healthcare researchers is the nature of relationships between heterogeneous professional and occupational groups, how work is divided, and the implications for the coordination of care and fostering of collaboration. Rather than focusing on the aggregate relations, as has been common in perspectives such as sociology of the professions, SNA allow empirical investigation of patterns of relationships at the individual and subgroup level.
Third, an increasing concern of healthcare researchers over the past 15 years has been how knowledge, particularly new knowledge from research evidence and innovation, is translated and diffused into practice. SNA has also been used to examine the strategy of using translational research networks to bridge the “valley of death” (Butler 2008) between basic science and bedside, “real-life” practice. Again, SNA has shed light the patterns of relationships that underpin this process and how knowledge translation and improvement efforts can be supported. Two examples of author projects demonstrate recent applications.
Example 1 SNA of translational research strategies
Translational research undertakes the crucial role of moving biomedical discoveries out of the highly controlled laboratory environment and applying it in the complexity of patient and service delivery realities (Goldblatt and Lee 2010; Woolf 2008). Expertise and understanding through collaboration between both fields are necessary to achieve this, yet the gaps between research and clinical domains are widening through increased specialization and complexity (Schwartz and Vilquin 2003; Zerhouni 2005). Translational research networks are a strategy to facilitate collaboration by establishing a clear, joint vision and setting up an administrative structure to provide funding for joint projects, project officers, and shared resources as well as a social structure to maximize opportunities for collaboration, innovation, and knowledge exchange. While potential partners in such networks may abound, clusters within disciplines, professions, or geographic sites and the gaps between them may hinder their initiation. This study used SNA at baseline and three further points in time to examine changes in collaborative ties between members with reference to these clusters (Long et al. 2012, 2013a, b, 2014, 2016).
The translational research network of interest was established in late 2011, and initial membership was 68 cancer clinicians and researchers drawn from 6 hospital and university sites in New South Wales. An online, whole network survey was administered to all registered members of the network in early 2012, in 2013, and again in 2015. Membership changed in that time from 68 to 263 to 244 (respectively) as people joined or left. SNA showed that at baseline, ties of the original members were reflective of long-standing teaching and research arrangements and clustered by field (clinician or researcher) and by geographic proximity. Over the next 4 years, collaborative ties were shown to be bridging the field gap and including consumers in both research- and clinically based projects, although geographic proximity remained a feature. Key player analysis showed that the network manager was enacting a significant brokerage role in bringing new collaborative partners together, a quantitative finding that was confirmed through interviews (Long et al. 2013b).
Example 2 Mixed methods SNA: relations between health and social care
The second example focuses on a study of knowledge sharing on issues of patient safety within a UK NHS hospital day surgery department. In light of well-recognized professional silos within health organizations (Waring 2004; Currie et al. 2008), this study aimed to investigate the patterns of knowledge sharing within and between professional groups. The methodology involved both a quantitative SNA survey and a period of ethnographic observations. The quantitative SNA survey was designed to elicit respondents’ close advice-giving contacts, asking respondents to provide named individuals within the department from whom they most commonly sought knowledge around patient safety, as well as the frequency of advice. Demographic data was also collected on the professional background, tenure, and work role of the respondent. Full network data was sought from all members of the department, identified both through an initial staff list and through following up new individuals identified in the name generator of respondents (n = 47, 85% response rate). Alongside this, 250 hours of ethnographic observations were undertaken, focusing on working practices and communication across settings within the department, as well as 40 qualitative interviews (see Bishop and Waring 2012).
Alongside the quantitative SNA findings, the qualitative component of the study allowed further exploration of the patterns of advice giving within the quantitative SNA and provided insight into the meaning of the identified relationships. This work included examination of how work practice shaped the opportunities for interaction and hence knowledge sharing within and between groups. It also explored important factors shaping how individuals sought to negotiate relationships within the department while responding to conflicting demands. Bringing together quantitative SNA and qualitative research methods could, therefore, help to develop both an understanding of the structure of social relationship and the way these relationships are formed and maintained within the everyday practice of health organizations.
8 Conclusion and Future Directions
Researchers of health systems are increasingly recognizing that the socio-professional relationships are an essential component of quality, safety, and efficient delivery of care. SNA is a valuable tool to quantify these relationships at both an individual and organizational level. Patterns of collaboration, referral, and knowledge exchange are revealed by SNA and in combination with complementary qualitative methods such as ethnographic observation or interviews, fleshed out to give insight into social processes in healthcare. In addition, SNA is an important methodology for understanding emergent networks which have been shown to drive safety initiatives (Braithwaite et al. 2009).
SNA is an important methodology to analyze new social structures to drive policy and reform, cross-sectoral collaboration, integration of services, and dissemination of best practice. The use of SNA to reveal the utility of translational research networks as a strategy to create a common vision and broker-bridging relationships has been shown. SNA is also an important methodology for examining managed network structures as mechanisms of policy and reform. As public policy emphasizes dispersed leadership and accountability within networks, an understanding of the strength of relationships and how network roles such as brokerage are enacted is important. Further theory around network development and durability of relationships is another avenue for future research.
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