Expert Systems with Applications 25 (2003) 113122 www.elsevier.

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Knowledge sharing behavior of physicians in hospitals

Seewon Ryua,*, Seung Hee Hob, Ingoo Hanb
Information Management Research Team, Korea Institute for Health and Social Affairs, San 42-14, Bulgwang-dong, Eunpyeong-gu, Seoul 122-705, South Korea b Graduate School of Management, Korea Advanced Institute of Science and Technology, 207-43 Cheongryangri-dong, Dongdaemoon-gu, Seoul 130-012, South Korea
a

Abstract Recently, there has been much interest for knowledge sharing within professional group, especially physicians in hospital. This study investigates the factors affecting physicians knowledge sharing behavior within a hospital department by employing existing theories. The research models under investigation are the theory of reasoned action (TRA) and the theory of planned behavior (TPB). These models are empirically examined and compared based on the survey results on physicians knowledge sharing behavior collected from 286 physicians practicing in 28 types of subunits in 13 tertiary hospitals in Korea. The TPB model exhibited good t with the data and appeared to be superior to the TRA in explaining physicians intention to share knowledge. In the modied TPB model, subjective norms were found to have the strongest total effects on behavioral intentions to share knowledge of physicians through direct and indirect path by attitude. Attitude was found to be the second important factor inuencing physicians intentions. Perceived behavioral control was also found to affect the intention to share knowledge, though in a lesser degree than subjective norms or attitudes. Implications are also discussed for physicians knowledge sharing activities. q 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Knowledge sharing behavior of physicians; Theory of reasoned action; Theory of planned behavior; Knowledge management

1. Introduction Sharing knowledge of physicians within hospitals can realize potential gains and is critical to survive and prosper in competitive environments (ODell & Grayson, 1998). Physicians are knowledge-intensive and principal professional group in hospitals. Their theoretical and practical knowledge is vital to the care of patients, and the quality of specialty-based clinical practices is a major determinant for patients use of medical services. Knowledge sharing in this sense becomes all the more important for physicians in tertiary hospitals, because they are required to be research-oriented, creative in medical care, and ready to take new medical knowledge opportunities that can be acquired through various organizational learning mechanisms (OLMs) (Lipshitz & Popper, 2000). The ultimate objective of physicians knowledge sharing is to elevate the quality and efciency of care in hospitals.
* Corresponding author. Tel.: 82-2-382-8277; fax: 82-2-382-4581. E-mail addresses: seewon@kihasa.re.kr (S. Ryu), hsh@kgsm.kaist.ac.kr (S.H. Ho), ighan@kgsm.kaist.ac.kr (I. Han).

Knowledge sharing is the behavior of disseminating ones acquired knowledge with other members within ones organization. The focus of knowledge management is how to share knowledge to create value-added benets to the organization (Liebowitz, 2001). The process of identifying, sharing, and using knowledge and practices inside ones own organization is one of the tangible manifestations of knowledge management (Choi & Lee, 2002; ODell & Grayson, 1998). Knowledge sharing is a people-to-people process, and one of the knowledge management processes. In the knowledge management process, how to make individual knowledge into organizational knowledge is a major management issue (Grant, 1996; Nonaka & Takeuchi, 1995). To achieve high quality of care and performance of physicians in hospitals, academics and practitioners should explore physicians knowledge sharing behavior, and suggest more practical methods of physicians knowledge sharing for the hospitals goal. The objective of this study is to empirically examine physicians knowledge sharing behavior by adopting existing theories of social psychology, such as the theory of reasoned action (TRA) (Fishbein & Ajzen, 1975) and

0957-4174/03/$ - see front matter q 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0957-4174(03)00011-3

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the theory of planned behavior (TPB) (Azjen, 1991). TRA and TPB have been found to be useful in predicting a wide range of behaviors in social settings (Sheppard, Hartwick, & Warshaw, 1988). The TRA and TPB have not often been applied to studies in the area of knowledge sharing. Recently, Bock and Kim (2002) have investigated the TRA model and suggested its good applicability in the area of knowledge sharing in public organizations. However, there is a need for further studies to provide accurate explanation of knowledge sharing behavior of individual professional groups, and thus we aim to study the beliefbased factors affecting physicians knowledge sharing behavior. This article proceeds as follows. As a background to this study, we begin with a section which we review the knowledge sharing and TRA and TPB model. Following this, we present the research model and measurement development. Then, the methodology and results of the study are discussed in Section 4. In Section 5, we discussed the results to explain the implications of this study. Finally, we conclude with the contributions, managerial and technological implications, and limitations of this study.

public organizations (Bock & Kim, 2002). Another case study on the two information-technology based knowledge sharing systems underscored the importance of understanding human behaviors (Robertson, 2002). Sole and Applegate (2000) conducted to explain the effectiveness of knowledge sharing from particular technology in dispersed and cross-functional teams. For healthcare settings, Lipshitz and Popper (2000) investigated OLMs of physicians in internal medicine ward and cardiac surgery ward of a university-afliated hospital. Empirical studies on knowledge sharing of physicians in hospitals have not yet been conducted. Thus, this study is the rst to investigate physicians knowledge sharing behavior by using the TRA and TPB. 2.2. TRA and TPB The TRA suggests that a persons behavior is determined by his or her intention to perform the behavior and that this intention is, in turn, a function of the persons attitude and subjective norm toward the behavior (Fishbein & Ajzen, 1975). The TRA model is based on the premise that humans are rational and that the behaviors being explored are under volitional control (Fishbein & Middlestadt, 1997). According to the theory, a specic behavior dened by a combination of four components: target, action, context, and time (TACT) (Ajzen, 2001a). Attitudes and subjective norms shape a persons intention to perform a behavior. Finally, a persons intention determines the actually desired behavior. The TRA provides a framework for linking each of the above variables together. Because of its remarkable achievement in developing a behavioral predictive model, the TRA has been applied to a wide variety of research elds including psychology, management, marketing, and healthcare area (Chang, 1998; Fortin, 2000; Sheppard et al., 1988; Wilson, Zenda, McMaster, & Lavelle, 1992). In the area of knowledge management, Bock and Kim (2002) conducted a TRAbased study on knowledge sharing behavior in research institutes. Although this study proved the effectiveness of the TRA model, Sheppard et al. (1988) found that the predictive power of the TRA model is not valid if the behavior is not under full volitional control. The TPB model extends from the TRA model by incorporating an additional construct, namely perceived behavioral control, to account for situations in which an individual lacks substantial control over the targeted behavior (Ajzen, 1991). Even a person in an organization who is highly motivated by his or her own attitudes and subjective norms, may not actually perform the behavior due to intervening organizational conditions. Perceived behavioral control refers to peoples perception of the ease or difculty of performing the behavior of interest (Ajzen, 1991). The concept of perceived behavioral control is most compatible with Banduras (1982) concept of perceived

2. Theoretical background 2.1. Knowledge sharing In this study, knowledge sharing behavior is viewed as the degree to which physicians actually share their knowledge with their colleagues for professional tasks. In practice, knowledge sharing has two aspects: behavioral and technological. Sharing ones individual knowledge is not simply carried out (Davenport & Prusak, 1988). People are not likely to share their knowledge unless they think it is valuable and important. A previous survey showed that the biggest challenge organizations face in knowledge management is that of changing peoples behavior (Ruggles, 1998). Robertson (2002) also showed in his comparison of two knowledge sharing systems that knowledge sharing is a human activity and that understanding the humans who will do it is the rst step to the success of such systems. In general, there are several contextual factors that affect the success of knowledge sharing systems or knowledge sharing behavior, such as attention to the team structure and workow issues, collaboration practices, and the nature of documents being shared (Robertson, 2002). Also, task structure and leadership style have been considered as contextual factors facilitating physicians OLMs in hospitals (Lipshitz & Popper, 2000). Despite the emphasis placed on behavioral aspect of knowledge sharing, a few empirical studies on knowledge sharing have been conducted. Recently, an empirical study was conducted to develop the understanding of the factors that support or constrain knowledge sharing behavior in four

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self-efcacy. Perceived behavioral control has a direct effect on behavioral intention and actions in TPB model. In this study, the TRA and TPB models suggest that physicians intention to share knowledge is jointly determined by his or her attitudes, subjective norms, and perceived behavioral control.

3. Research model The potential of knowledge sharing among members of a hospital has long been recognized in practical and theoretical perspectives. This study examines the physicians knowledge sharing behavior based on the TRA and TPB. To achieve the purpose of this study, the investigated models use behavioral intention, which has been regarded as an essential basis for examining individual physicians knowledge sharing behavior, as a dependent variable. In theoretical point of view, a considerable number of studies in the past have reported a strong and signicant causal link between behavioral intention and targeted behavior (Sheppard et al., 1988; Venkatesh & Morris, 2000). Given this strong link between intention and behavior, it is theoretically justiable to use behavioral intention as a dependent variable to examine physicians knowledge sharing (Chang, 1998; Chau & Hu, 2001; Mathieson, 1991). Also, in a survey-based research, Agarwal and Prasad (1999) argued that intentions are more appropriate than actual behavior as they are measured contemporaneously with beliefs. Thus, the use of physicians intention to share knowledge as a dependent variable is considered adequate and desirable. From the perspective of social psychology, the TRA and TPB have gained substantial empirical support. A number of studies have shown that subjective norm was found to inuence attitude (Chang, 1998; Shepherd & OKeefe, 1984; Shimp & Kavas, 1984; Vallerand, Deshaies, Cuerrier, Pelletier, & Mongeau, 1992). The specic models examined in this study are TRA, TPB, and a modied TPB that include a causal path from subjective norm to attitude. The research model is shown in Fig. 1. Based on the TRA and TPB, we offer the following hypotheses concerning the physicians knowledge sharing behavior. H1 Physicians attitude toward knowledge sharing has a positive effect to the intention to share knowledge. H2 Physicians subjective norm related to knowledge sharing have a positive effect to the intention to share knowledge. H3 Physicians perceived behavioral control related to knowledge sharing have a positive effect to the intention to share knowledge. In our analysis, we also propose that the causal path from physicians subjective norm to knowledge sharing have inuence to physicians attitude like previous research in

Fig. 1. Investigated research model.

other areas. H4 Physicians subjective norm to knowledge sharing has a positive effect to his or her attitude toward knowledge sharing.

4. Research method The unit of analysis for this study is individual physician in tertiary hospitals. This study focuses on the physicians knowledge sharing behavior based on social psychological perspective. 4.1. Measurement development The measures used to operationalize the constructs in the research model were mainly adopted from some of the related studies conducted in the past (Ajzen, 2001b; Bock & Kim, 2002; Fishbein & Ajzen, 1975), with minor wording changes tailored to the physicians knowledge sharing context. All measures were dened in terms of their TACT according to the construct guideline (Ajzen, 2001a). Principles of compatibility, specicity and generality were applied to all constructs. A multi-item method was used to increase the accuracy of measurement, and each item was based on a ve point Likert scale. Nineteen measured variables were used to reect the components of the TRA and TPB models. All operational denitions of instruments and their related literature are summarized in Appendix A. 4.2. Sample and data collection The target subjects were physicians who were practicing at tertiary hospitals in Korea. The 1000 sample questionnaires

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were mailed to the chiefs of Graduate Medical Education (GME) Department of the 43 tertiary hospitals in Korea. Finally, 334 responses were received from the 28 types of subunits in 13 hospitals representing a response rate of 33.4%. The survey questionnaires were gathered from August to October 2002. In the cover of each questionnaire, an encounter letter was attached to describe the purpose of the study and ensure the necessary condentiality. Personal visits and/or telephone calls or e-mail were made to the department chiefs to request them to provide detailed information. Twenty-eight of these contacted departments agreed to participate in the study. With the assistance of the chiefs of service, questionnaire packets were delivered to individual physicians practicing in the participating departments. Each subject was asked to return the completed questionnaire to his or her department secretary, from whom the questionnaire was collected at a later time. Of the responded cases, 48 cases were those returned incomplete and discarded, leaving a total of 286 completed questionnaires. The respondents consisted of internists (23.4%), surgeons (21.0%), dentists (29.0%) and other specialty doctors (26.6%). On an average, the responding physicians had 3.5 years of experience in their respective specialty areas after graduating from medical schools. The descriptive characteristics of the respondents are shown in Table 1. 4.3. Measurement assessment 4.3.1. Content validity Content validity of the survey instrument was established
Table 1 Prole of respondents Measure Career Item Over 21 years 1620 years 1115 years 710 years 26 years Chief Director Staff Fellow Resident Internal medicine Surgical Obstetrics and gynecology, and pediatrics Ophthalmology, and ear, nose, throat (ENT) Dermatology and urology Dental Ancillary Total Frequency 18 16 23 52 177 3 31 39 36 177 67 60 35 20 7 83 14 286 Percent (%) 6.3 5.6 8.0 18.2 61.9 1.0 10.8 13.6 12.6 61.9 23.4 21.0 12.2 7.0 2.4 29.0 4.9 100.0

through the adoption of validated instruments by other researchers in the literature (Straub, 1989). Denitions and items concerning attitude, subjective norms, perceived behavioral control, and intention to share physicians knowledge were based on the original TRA and TPB models (Ajzen, 2001a; Fishbein & Ajzen, 1975) that are widely accepted in micro-social level of analysis in social psychology (Stephen & Stephen, 1990). With satisfactory content validity established, the measurement items were further tested for consistency, ease of understanding, and sequential appropriateness by a pretest of 10 physicians from different specialty areas. Comments on or suggestions about the question sequence, wording choices, and measures were also solicited, leading to several minor modications to the questionnaire. The nal questionnaire items used to measure each construct are listed in Appendix B. Subjects who had participated in the pretests were excluded from the subsequent main study. 4.3.2. Internal consistency reliability Internal consistency reliability to test unidimensionality was assessed by Cronbachs alpha and item-total correlations. The resulting alpha values ranged from 0.79 to 0.91, which were above the acceptable threshold (0.70) suggested by Nunnally and Bernstein (1994). One item of perceived behavioral control with item-total correlation lower than 0.5 was dropped (Table 2). 4.3.3. Construct validity Since each latent construct was measured by the multiitems, tests of construct validity were performed. There are many aspects of construct validity that have been proposed in the psychometric literature (Bagozzi, Yi, & Philips, 1991). In this study, we follow Straubs (1989) processes of validating instruments to test construct validity in terms of convergent and discriminant validity. Convergent validity, the degree to which multiple attempts to measure the same concept are in agreement, was evaluated by examining the factor loading within each construct, composite reliability, and variance extracted (Anderson & Gerbing, 1988; Hair, Anderson, Tatham, & Black, 1998). We used conrmatory factor analysis (CFA) with AMOS 4.0 to examine the convergent validity of each construct. The CFA model is shown in Fig. 2. The factor loadings are ranged from 0.662 (PBC3) to 0.883 (PBC2), and these are greater than the recommended level of 0.35, which is based on 250 samples and 0.05 signicance level (Hair et al., 1998). All composite reliabilities and varianceextracted measures of constructs exceed the recommended level of 0.8 and 0.5 each. Table 2 summarizes the results of internal reliability and convergent validity for constructs. The overall model t was assessed in terms of eight measures from three perspectives: absolute t, comparative t to a base model, model parsimony. Among the absolute t measures used to evaluate the CFA model are x2 statistics divided by its degrees of freedom, goodness-of-t index

Position

Department

S. Ryu et al. / Expert Systems with Applications 25 (2003) 113122 Table 2 Internal reliability and convergent validity test results Latent construct Item Internal reliability Cronbach a Physicians intention to share knowledge (IN) IN1 IN2 IN3 IN4 IN5 0.9074 Convergent validity

117

Item-total correlation Factor loadinga 0.7797 0.7596 0.7978 0.7324 0.7632 0.6956 0.8123 0.8024 0.7648 0.7554 0.6047 0.6777 0.6684 0.7009 0.7305 0.6350 0.7202 0.6239 0.4551 0.6519 0.7416 0.5990 0.836 0.820 0.849 0.768 0.795 0.730 0.860 0.855 0.816 0.809 0.660 0.710 0.747 0.772 0.825 0.776 0.868 0.674 0.494 0.776 0.883 0.662

Composite reliability Variance extracted 0.986 0.933

Physicians attitude toward knowledge sharing AT1 (AT) AT2 AT3 AT4 AT5 Physicians subjective norm to knowledge sharing (SN) SN1 SN2 SN3 SN4 SN5

0.9074

0.986

0.936

0.8595

0.969

0.864

Physicians perceived behavioral control to knowledge sharing (PBC)

PBC1 0.7934 PBC2 PBC3 PBC4 PBC1 0.8131 PBC2 PBC3

0.970

0.895

0.972

0.920

Factor loadings are from conrmatory factor analysis.

(GFI), and root mean square error (RMR). The comparative t measures used to evaluate research model are normed t index (NFI), adjusted goodness-of-t index (AGFI), and comparative t index (CFI). Parsimonious t measures used

to evaluate are parsimonious goodness-of-t index (PGFI) and parsimonious normed t index (PNFI). The CFA reected a good t to the data in all three t measures (Hair et al., 1998) (see Table 3).

Fig. 2. Conrmatory factor analysis model.

118 Table 3 Overall t indices of the CFA model Fit index Absolute t measures Scores

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Recommended cut-off value Near to degree of freedom The greater, the better # 2; # 3 or 5 $ 0.90; $ 0.8 # 0.05 or 0.08 $ 0.90 $ 0.90; $ 0.80 $ 0.90 The higher, the better The higher, the better

Incremental t measures Parsimonious t measures Acceptability:

**

x2 d.f. x2 /d.f. GFI RMR NFI AGFI CFI PGFI PNFI

398.179 129 3.087** 0.858** 0.035** 0.883p 0.812** 0.917** 0.647p 0.744p

models, and Table 6 shows the overall t indices of the models. The TRA model did not provide good GFI in absolute t, incremental t, and parsimonious t measures. The TPB and the modied TPB model exhibited reasonable levels of overall t, while NFI did not exceed their acceptance levels. The modied TPB model exhibited a similar level t with original TPB model in such GFI as x2 / d.f., NFI, PGFI, and PNFI. TPB (SMCIN 0.461) also appeared to be superior to TRA (SMCIN 0.367) in explaining a physicians intention to share knowledge. 5.2. Path coefcients The path coefcients and their signicance levels for each model are shown in Table 7. All the standardized path coefcients of the three models had acceptable statistical signicance levels. Of the nine path coefcients, six were signicant at the 0.001 signicance level, one (from subjective norm to intention to share knowledge in the modied TPB model) at the 0.05 signicance level, and the remaining two (from perceived behavioral control to intention to share individual knowledge in the original and modied TPB model) at the 0.1 signicance level. The paths from attitude and subjective norms to behavioral intention were signicant for all three models. Perceived behavioral control, on the other hand, was judged signicant on behavioral intention at the 0.1 signicance level and had a similar size of coefcient in both the original and modied TPB models. In addition, the path from subjective norm to attitude was signicant at the 0.001 signicance level and had a relatively high coefcient of 0.532 in the modied TPB model. 5.3. Effect on intention The effect of all the variables on intentions is also summarized in Table 7. Attitude, while found to have the strongest effect on behavioral intention in the original TPB model, was the second strongest in the modied TPB model. The direct effect and the indirect effect (via attitude) of subjective norm on physicians behavioral intention to knowledge sharing were 0.260 and 0.217, respectively. Thus, physicians subjective norms to knowledge sharing showed the strongest effect on behavioral intention in the modied TPB. The total effect of perceived behavioral

(acceptable), p(marginal).

Discriminant validity can be tested by using chi square difference test, where the chi square values for two models are compared (Chin, 1998). We tested discriminant validity among scales for three categories of social psychological constructs (physicians attitude toward knowledge sharing, physicians subjective norm to knowledge sharing, and physicians perceived behavioral control to knowledge sharing). The results of discriminant validity test are shown in Table 4. The chi square differences range from 180.366 (between attitude and subjective norm) to 118.031 (between subjective norm and perceived behavioral control) among three categories of social psychological constructs. The differences are much larger than the 3.84 threshold, indicating that each pair of constructs is indeed distinct. Discriminant validity is also tested by Phi values from the CFA. We present the factor intercorrelation matrix in Table 5. Intercorrelations among the latent variables ranged from 0.416 to 0.633, and none of the condence intervals had a value of one p , 0:001; which further conrms discriminant validity. 5. Analysis and results 5.1. Testing the research models After deleting the item of perceived behavioral control which has low item-total correlation, we examined and compared the models with the structural equation modeling (SEM). We tested the specication of the investigated

Table 4 Measurement model t: discriminant validity Fixed correlation d.f. ATSN ATPBC SN PBC 35 20 20 Chi square 352.264 227.436 226.163 Freely estimated correlation Correlation 0.520 0.413 0.630 d.f. 34 19 19 Chi square 171.898 61.888 108.132 180.366 165.548 118.031 Chi square difference

S. Ryu et al. / Expert Systems with Applications 25 (2003) 113122 Table 5 Intercorrelations among the latent variables 1 Intention to knowledge sharing Attitude toward knowledge sharing Subjective norms Perceived behavioral control 0.602 0.565 0.476 2 3

119

0.522 0.416

0.633

All correlations are signicant at the 0.001 level (2-tailed).

Table 6 Overall t indexes of the investigated models Fit index Absolute t measures TRA TPB 398.179 129 3.087p p 0.858p p 0.035p p 0.883p 0.812p p 0.917p p 0.647p 0.744p p 0.461 Modied TPB 401.098 130 3.085p p 0.857p p 0.036p p 0.882p 0.812p p 0.916p p 0.652p 0.749p p 0.285 0.458

Incremental t measures Parsimonious t measures Squared multiple correlation

x2 d.f. x2 /d.f. GFI RMR NFI AGFI CFI PGFI PNFI SMCAT SMCIN

387.481 88 4.403 0.846p p 0.098 0.866p 0.790 0.893p 0.620p 0.726p p 0.367

Acceptability: p p (acceptable), p(marginal). SMCAT squared multiple correlation to physicians attitude toward knowledge sharing, and SMCIN is that to physicians intention to share knowledge.

control was least inuential on behavioral intention. Accordingly, empirical results of this study signicantly support four hypotheses based on the TPB. 6. Discussion The results of this study indicate that the TPB outperformed the TRA in predicting physicians knowledge sharing behavior, and physicians intention to share knowledge is positively inuenced from attitude, subjective
Table 7 Path coefcients and strengths of individual paths

norm, and perceived behavioral control. The modied TPB model improved the goodness of t to the data and proved to be better than the original TPB model in explaining the effect of subjective norms to intention to share knowledge. Our result shows that attitude and subjective norm are not as independent of one another, which is consistent with the ndings of previous studies (Chang, 1998; Shepherd & OKeefe, 1984; Shimp & Kavas, 1984; Vallerand et al., 1992). The effects of these variables on behavioral intention have been found in this study to be signicant in explaining physicians knowledge sharing behavior, although Ajzen (1991) maintained that the relative importance of attitude, subjective norm, and perceived behavioral control in the prediction of behavioral intention were expected to vary across behaviors and situations. Subjective norm was found to be the most inuential factor on behavioral intention to share knowledge in terms of direct plus indirect effect. This nding was consistent with prior research (Shepherd & OKeefe, 1984; Taylor & Todd, 1995), but not with Chau and Hu (2001) who studied telemedicine adoption in healthcare setting. Taylor and Todd (1995) and Chau and Hu (2001) claimed that physicians specialized training and practice in their highly autonomous profession do not have a signicant effect on their IT use or telemedicine adoption. However, Lipshitz and Popper (2000) suggested that the two contextual factorstask structure and leadership stylecome into play to facilitate the organizational learning of physicians in hospitals. Freidson (1988) found that committees reviewing the credentials of physicians seeking staff privileges, the medical records, and laboratory analysis of tissue removed by surgery are most common in accredited hospitals that are in line with the minimum standards set by the Joint Commission on the Accreditation of Hospitals. Thus, we can interpret the positive and strong effect of subjective norms on physicians behavioral intentions to share knowledge as resulting from their highly activated OLMs and selfregulatory professional characteristics. Attitude was found to be the second factor inuencing physicians intention to share knowledge. We also found

TRA Path coefcient AT ! IN SN ! IN PBC ! IN SN ! AT AT SN PBC SN AT SN PBC 0.476*** 0.375*** 0.476 0.375 0.476 0.375

TPB 0.406*** 0.265*** 0.140* 0.406 0.265 0.140 0.406 0.265 0.140

Modied TPB 0.406*** 0.265** 0.143* 0.534*** 0.406 0.265 0.143 0.217 0.406 0.482 0.143

Effect on physicians intentions to share knowledge

Direct effect

Indirect effect Total effect

***p , 0:001; **p , 0:05; *p , 0:1:

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that physicians attitude towards knowledge sharing is inuenced by their subjective norms. In recognition of the importance of the mediating role of subjective norm, managers should pay much more attention to physicians attitude towards knowledge sharing, though the effect of attitude on behavioral intention to share knowledge was not the strongest factor. Perceived behavioral control was found to have signicant direct effect on behavioral intention to share knowledge. This result coincides with the ndings of previous studies on IT adoption (Mathieson, 1991; Taylor & Todd, 1995) and, telemedicine acceptance (Chau & Hu, 2001). The effect of perceived behavioral control was smaller than that of attitude or subjective norm. This can be explained by the fact that perceived behavioral control was highly correlated with subjective norm g 0:650 while least correlated with intention. 7. Conclusions The main contribution of this study is that is the rst to explore physicians knowledge sharing behavior using existing theories of social psychology. In this study, the authors have shown the applicability of the TPB in explaining knowledge sharing behavior of physicians and found physicians subjective norm to have the strongest total effect (direct plus indirect) on their behavioral intentions to share knowledge. Also, attitude and perceived behavioral control were found to have signicant effect on physicians knowledge sharing behavior. Managerial and technological implications can be drawn from this study. First, from the managerial perspective, the managers and chief knowledge ofcers of hospitals should pay more attention to create an environment where physicians can have positive subjective norms and attitude towards knowledge sharing. Achieving this will require fostering a number of cultural factorsprofessional autonomy (Jones & James, 1979; Stevens, Diederiks, & Philipsen, 1992), communication structure (Cohen &

Levinthal, 1990), cohesiveness (Decotiis & Koys, 1980), and partnership (Henderson, 1990), which were suggested by previous studies (Davenport & Prusak, 1988; Gurteen, 1999; ODell & Grayson, 1998). From the technological point of view, the knowledge management systems should be established, based on all these factors, in such a way that they function in a more efcient manner. Particularly, those responsible for knowledge management systems should make more efforts to enhance the accessibility of physicians to workplace communication. This study has a few limitations. First, the relevance of this study remains conned by and large to the area of knowledge sharing behavior among one particular professional group: physicians. Thus, the ndings and implications drawn from this study cannot be readily generalized to other professional groups. Second, even though there will be contextual factors that facilitate physicians knowledge sharing behavior as Lipshitz and Popper (2000) suggested, this study did not consider the other factors like task structure or social factors in hospitals. Third, despite the rigorous examination on the credibility and appropriateness of the collected data, this study may have some common method bias, as is often the case with survey research studies. As has been implied, there is a need for further research efforts focused on accumulating further empirical evidence and data and surmounting the limitations of the present study. These efforts should involve studies identifying the cultural factors affecting such independent variables as subjective norm, perceived behavioral control, and attitude. Also, special attention should be geared towards nding differences in knowledge sharing behaviors of physicians that may stem from the varying task structure and leadership style of different departments in a hospital.

Appendix A. Operational denition

Variables Physicians intentions to share knowledge Physicians attitude toward knowledge sharing Physicians subjective norm to knowledge sharing Physicians perceived behavioral control

Operational denition The degree to which physician believes that he or she will engage in a knowledge sharing act The degree to which a physician has a favorable or unfavorable evaluation of performing the knowledge sharing behavior A physicians perceived social pressure to perform or not to perform the knowledge sharing behavior The physicians perceived ease or difculty of performing the knowledge sharing behavior

Related literatures Ajzen, 1991, 2001a,b; Bock & Kim, 2002; Chang, 1998; Chau & Hu, 2001 Ajzen, 1991, 2001a,b; Bock & Kim, 2002; Chang, 1998; Chau & Hu, 2001 Ajzen, 1991, 2001a,b; Chang, 1998; Chau & Hu, 2001 Ajzen, 1991, 2001a,b; Chang, 1998; Chau & Hu, 2001

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Appendix B. Questionnaire items Construct Physicians intentions to share knowledge (IN; 5 items) Items I always will IN1: planned to share knowledge with my colleague IN2: try to share knowledge with my colleague IN3: make an effort to share knowledge with my colleague IN4: make an effort to share knowledge with my colleague IN5: intend to share knowledge with my colleague, if they ask If I share my knowledge with other members, I feel AT1: very harmfulvery benecial AT2: very unpleasantvery pleasant AT3: very badvery good AT4: very worthlessvery valuable AT5: very unenjoyablevery enjoyable SN1: It is expected of me that I share knowledge Most physicians who are important to me SN2: think that I should share knowledge with others SN3: share their knowledge with others Physicians whose opinions I value SN4: would approve of my behavior to share knowledge with others SN5: share their knowledge with others PBC1: PBC2: PBC3: PBC4: For me to share my knowledge is always possible If I want, I always could share knowledge It is mostly up to me whether or not I share knowledge I believe that there are much control I have to share my knowledge with others

Physicians attitude toward knowledge sharing (AT; 5 items)

Physicians subjective norm to knowledge sharing (SN; 5 items)

Physicians perceived behavioral control (PBC; 4 items)

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