Knowledge creation can be explained as a system of different activities and initiatives that contribute toward generating news ideas or products (Mitchell and Boyle, 2010). In the process of knowledge creation, individuals and teams within an organization and between organizations engage in sharing of tacit and explicit knowledge (Choi and Lee, 2002). Typically, knowledge creation occurs through individual experience from knowledge acquisition, communication and reflection, and organizational knowledge learning (Li et al., 2018). Knowledge creation can be labeled as the engine of innovation as this part of the KM process drives economic and social value. Moreover, knowledge creation enables organizations to create new knowledge, which can be understood as increasing their knowledge assets (Konno and Schillaci, 2021). Knowledge creation can have multiple internal and external organizational sources, and is also an antecedent that allows for the effective use of knowledge. Another characteristic is that it is based on collaboration of professionals from different organizational departments that engage in teamwork. Understanding the implications of knowledge creation is also important for managers in different organizations as knowledge is influential for organizational success, and they need to find ways to improve it, which is possible by encouraging employees to communicate, interact and collaborate, and ask for help (Stojanović-Aleksić et al., 2019), where teamwork has an essential role. In a similar vein, McEvily and Chakravarthy (2000) and Tiwana (2004) also state that numerous empirical studies argue that knowledge creation has the potential of improving organizational performance and quality of services. With our study of knowledge creation in NH and its influence on the quality of services, we partially fill a gap identified in existing literature that is necessary to enhance the understanding of the knowledge creation process (Stojanović-Aleksić et al., 2019). We believe that knowledge creation as part of the overall KM process has the potential to contribute to improving the overall quality of services that are offered to people in practice in NH.

We provide additional empirical research on the relationship between knowledge creation and the quality of services within the environment of NH:

Knowledge storage can be described as procedures and systems for storing, retrieving, and managing knowledge (Alegre et al., 2013). These are often information-communication technology-based systems that provide support and enhance the overall organizational knowledge storage and retrieval. Employees have the ability to create and acquire relevant knowledge, however, it is also possible that we as individual sometimes forget what we learn. So, knowledge storage represents an important characteristic of effective KM practices in organizations (Alavi and Leidner, 2001). After the initial phase of KM, knowledge creation, there is the necessity to codify and store knowledge in a knowledge database or similar knowledge-based system so that it is ready for retrieval, application, or reuse by other employees or teams in organizations (Samoilenko and Nahar, 2013). Prior research argues that even if an organization is able to obtain new knowledge, it does not necessarily have the ability to also store knowledge (Argote et al., 1990). Such an insight further highlights the necessity of adequately capturing such knowledge and making it available for the whole organization in the long term (Stein and Zwass, 1995).

Due to the increasing volume of knowledge, the constant changes in knowledge, and related activities and technologies, it is complex to store, update, search, and maintain an adequate knowledge base. As knowledge is dynamic in nature, it is important to also remove knowledge that becomes obsolete and replace it with up-to-date relevant knowledge (Wong and Aspinwall, 2005). It is also important to recognize that employee knowledge is valuable to the NH, as well as residents’ expectations and wishes. At the same time, we need to know what kind of knowledge we need and how we can ensure knowledge transfer between employees, since most knowledge exists within employees, in internalized or tacit forms rather than in an explicit (explicit) form. Such a situation is also present in NH. Moreover, in any environment it becomes important to identify and utilize the best available information-communication technology solutions available for the storage and later retrieval of knowledge (Samoilenko and Nahar, 2013). Especially in the environment of NH, knowledge storage and retrieval challenges remain inadequately explored. Understanding how to enable long-term storage and retrieval of explicit and especially tacit knowledge is integral as it represents an important element of organizational memory (Anand et al., 2021). Nursing homes are a repository of knowledge, experience, examples of good practice, and ideas in long-term care. For high-quality services, it is necessary to establish a KM system that preserves and strengthens knowledge in NH. Appropriate usage of storage and retrieval systems is relevant in maintaining internal organizational knowledge and is positively associated with reducing costs and as a prerequisite of efficient knowledge transfer (Taraszewski, 2017). Moreover, knowledge storage as an important part of the KM process has a significant impact on achieving the desired organizational performance outcomes in organizations (Alavi and Leidner, 2001), which also applies to the functioning of NH.

In our research, we gain additional empirical data on the relationship between knowledge storage and quality of services within the environment of NH:

Knowledge transfer is considered as a fundamental activity of KM, as it facilitates the ability of organizations to transform their knowledge into organizational assets and resources (Dawson, 2001). Kumar and Ganesh (2009) define knowledge transfer as different activities of sharing explicit or tacit knowledge between two parties, where one receives and applies the knowledge that was provided by the other. Knowledge transfer also refers to the movement of knowledge through different channels between individuals and teams (Abou Hashish, 2017; Hassan et al., 2017; Tassabehji et al., 2019; Xuan, 2020) or an organization (Joshi et al., 2007). Knowledge transfer is additionally influenced by both the employee willingness to interact with their colleagues and their openness to learn from their colleagues (Ibidunni et al., 2018). This is very important for the mentoring process, where new nursing staff acquire the necessary skills in teamwork and mentoring.

Existing research posits that knowledge transfer has important consequences for a number of organizational processes and outcomes, namely the sharing of best practices (Szulanski, 1996), organizational learning (Reagans et al., 2005) and organizational performance (Hansen, 1999), which can also be understood as the quality of services in the context of NH. Similarly, Argote and Fahrenkopf (2016) support the claim that knowledge transfer is an important tool for improving the performance of individuals, teams, and organizations as the recipients of new knowledge. Additional existing research provides further support for knowledge transfer due to its part in improving organizational performance (Van den Hooff and De Ridder, 2004), while some studies even consider knowledge transfer as a key factor that contributes toward improving organizational performance (Sheng et al., 2013; Oyemomi et al., 2016). In spite of the significant benefits that knowledge transfer brings to organizational performance, knowledge transfer does not automatically happen in organizations (Argote and Miron-Spektor, 2011). Moreover, the up-to-date literature that examines the impact of knowledge transfer on the quality of different services (Radević et al., 2021) in NH remains scarce.

In the opinion of Zaim et al. (2019), organizations should enhance their efforts to promote knowledge transfer as it enables them to improve their overall performance. Another potential benefit of knowledge transfer is its ability to improve the capacity of organizations to function by influencing and improving their core values (Sheng et al., 2013). Due to the numerous positive effects of knowledge transfer on organizational performance, we further highlight the necessity to also regularly update the organizational knowledge base and pursue toward creating new knowledge in order for any type of an organization to gain or maintain their competitive edge and in the case of NH to have better quality services that are also dependent on knowledge transfer between individuals, teams, and organizational units (Radević et al., 2021).

With our paper, we additionally explore the constructs of knowledge transfer and quality of services in the context of NH:

Knowledge implementation is explained as the application of knowledge that an individual or a team have (Lee et al., 2013). It is considered as an organizational tool to store, retrieve, access, and apply knowledge effectively to reach the strategic purposes and goals of an organization (Gold et al., 2001). To gain additional insight into the topic of knowledge implementation, Obeidat et al. (2016) state that it is defined as a combination of social, technological, and operational aspects. Knowledge is only really important when it is utilized and applied in practice to create added value for any type of an organization. Knowledge implementation in general can also be described as the process of using knowledge for a specific purpose, and this can occur when knowledge is deliberately put into action to support managers, employees, decision makers, and policymakers. Without being applied, knowledge does not hold any real value (Al Ahbabi et al., 2018). Such a state suggests that other capabilities of an organization such as knowledge creation, storage, and transfer can be very vague if that organization does not have the ability to apply and use the knowledge in practice in an effective and efficient manner (Mahmoudsalehi et al., 2012).

When knowledge is implemented in practice it also becomes part of the organizational behavior, memory, and processes that are utilized for solving complex problems in the organization, and on a daily basis within the functioning of the organization (Chen et al., 2012). Existing literature additionally empirically supports that knowledge implementation facilitates organizational performance (Mardani et al., 2018). Similarly, Martelo-Landroguez and Cepeda-Carrión (2016) state that knowledge implementation is one of the key organizational processes as it positively influences organizational performance. On an individual level, the positive outcome of knowledge utilization is that it expands one’s expertise and experience and in the long-term enables them to become an expert in their work (Al Ahbabi et al., 2018). Organizations are therefore advised to support employees to use and utilize their knowledge and to rely on an organization’s knowledge repository as a way toward solving existing problems as well as to propose new ways of doing things. This implies the ability to improve the overall quality of services (Chan and Chao, 2008), which is especially relevant in the context of NH (Figure 2). However, it is important to reiterate that knowledge holds little value until it is directly applied in the practice of an organization (Chen and Huang, 2009). Moreover, knowledge implementation is considered as one of the key activities that can help increase individual employee performance in organizations (Bosch-Sijtsema et al., 2009).

Understanding the influence of knowledge implementation on the quality of services in the context of NH requires additional research:

E-Qalin is a Europe-wide model of quality management in social institutions, the development of which was supported by the European Community. It was created due to the requirements of the development of modern society, social policy, and the social care system. Its creation was conditioned by the requirements of the development of social welfare organizations, their need for quality standards and for a specific model of quality management, which should be recognized nationally and on a European level. Participants were organizations or individuals from Austria, Slovenia, Italy, Germany, Luxembourg, and the Netherlands. In the pilot phase, the model was tested by 29 NH from Austria, Germany, Italy, Luxembourg, and Slovenia, after which an evaluation was carried out and the final version for NH was produced. The quality management system includes the structures, processes, and results of the NH. The quality of all three areas is checked with the help of a self-assessment. The expected effects of quality management according to E-Qalin are mainly: better service quality for users, higher staff motivation and satisfaction, support for management and staff in facilities in providing and improving service quality, national and international comparability of facilities, and certification of a specific activity and brand. The E-Qalin model is currently distributed in the following countries: Austria, Czech Republic, France, Croatia, Italy, Germany, Luxembourg, Slovenia, and the United Kingdom. In NH, after the training of the group leaders and facilitators, the self-evaluation of the criteria is started. According to public data, 21 nursing homes have the certificate E-Qalin so far in Slovenia (Firis, 2022).

Nursing homes managers state that they have noticed an improvement in relationships, communication, and transfer of knowledge in the NH after the implementation of E-Qalin. In the E-Qalin system, there are regular multidisciplinary team meetings involving each of the different professional groups and residents, and there is no longer a problem or issue that concerns only one unit of the home, but a new organizational culture is developed – “we all work for the benefit of our residents.” Innovations and implementations that arise on team meetings are stored in information system, where they are available to all staff and for evaluation of changes (Kejžar et al., 2020).

The company DEOS d.o.o. performs the activities of institutional care for the elderly (87,300 – the activity of accommodation facilities for the elderly and disabled), social services in assisted living apartments and home care (DEOS, 2022). DEOS has developed an internal quality management system to monitor and develop quality, which also consists of various criteria. Unlike E-Qalin quality management, the employees of the different units do not meet weekly, but the monodisciplinary teams (the same professionals from each home and without residents) meet regularly and discuss protocols and search for improvements. This means that they can monitor the quality and deviations within their NH in constant comparison with the results and developments in the other seven NH. The structure of team is monodisciplinary with clear protocols and procedures, achieved goals, and results which are monitored monthly. The quality system is managed by quality manager, who also takes care of organizational knowledge in the data base.

To obtain primary data from our respondents, we utilized an adapted online and in-person questionnaire. Our research was conducted in 2022 on a sample of four NH in Slovenia, of which two (state NH) have the E-Qalin certificate and two (private NH) have their own quality management and consist of 80 employees. To elaborate on some of the most important characteristics of our sample, 76.6% respondents were women, 16.9% respondents were men, while 6.5% respondents did not want to provide an answer regarding their gender. The largest share of respondents (36.4%) belongs to the age cohort from 20 to 29 years. The second largest share of our respondents (28.6%) belongs to the age cohort from 40 to 49 years. The vast majority of our respondents (64.9%) had successfully acquired a high school diploma. Moreover, our respondents had been working in the NH on average for ~8 years (Table 1).

We collected data from employees in NH that either have or do not have the E-Qalin certificate by using convenient sampling. Despite the fact that random sampling is often considered the gold standard of research sampling strategies, due to its ability to influence biases and the possibility to evaluate the reliability of the resulting estimates (Tiwari and Chilwal, 2014) researchers are often faced with a trade-off between the desire for randomization and pragmatic considerations when deciding on the sample. As was in the case of our research, random sampling is not always feasible and possible in practice given our constraints in time and resources. Existing research posits that purposive strategies also have the ability to ensure representative samples (Toppl et al., 2004). Moreover, data for all our variables were obtained from individual respondents in a one-time single survey. Therefore, common method bias might potentially have an influence on some of the hypothesized relationship in our research model. To explore the presence of common method bias, we opted to apply Harman’s single factor test (Harman, 1976). The first factor accounted for 59.7% of the overall variance. As this result is slightly above the recommended threshold (50.0%) as supported by existing literature such as Podsakoff et al. (2006), we posit that common method bias might be an issue in our research study.

To gain insight into individual constructs, we selected measurement scales that are in line with predetermined criteria: (a) often cited in novel research papers that are recently published in relevant scientific journals; (b) they have been utilized in contemporary literature; and (c) are well established and commonly used by prominent authors of our researched topics. In the context of our study, we opted for the five-point Likert scale ranging from 1 (I strongly disagree) to 5 (I completely agree) to gain insight into the respondent’s agreement about the presence of knowledge creation, knowledge storage, knowledge transfer, knowledge implementation, and their influence on the quality of services that are offered in practice by NH.

Our study has several implications to the literature on KM and quality management in NH. First, our results add to the body of literature that emphasizes the knowledge-based view of the organization (Kogut and Zander, 2003; Hislop and Helms, 2018) as we promote the crucial role of knowledge in the context of the functioning of NH. Second, we add to existing research that theoretically advances the aforementioned field with a conceptual model and empirically testing the phases of the KM process that can positively influence quality of services in NH (Grant, 1996; Martin and Javalgi, 2019). Third, with that we fill a gap, as the literature on KM in NH is scarce, and as we could see from the answers in our study so is the knowledge about KM in NH. Moreover, this paper shows that tacit knowledge does have its place in NH practice, but it needs to be supported by a wider workplace learning framework to maximize the potential for consistent good care in NH. Greater awareness about the importance of tacit knowledge in relation to nursing practice as explored in this study may contribute to the acknowledgement that teamwork increases transfer of knowledge and benefits toward creating a stable working environment and to daily changes and adaptations in care processes. With teamwork, we especially raise awareness about set goals and encourage creative and innovative solutions in the daily implementation of services. Our findings are in line with Erhardt (2011) that teamwork is always good and has the potential to achieve, maintain, and even improve the quality of services in NH.

Practical implications are aimed at managers, directors, and practitioners in the environment of NH. The findings of our research present opportunities for improvements in NH, through better understanding and knowledge of KM, quality management, and teamwork as factors that influence the quality of services provided to users in practice. Based on empirical findings, our study helps stakeholders in understanding the importance of KM activities and teamwork to encourage knowledge creation, knowledge storage, knowledge transfer, and knowledge implementation in the ever-changing environment of NH. Problems that can seriously threaten the quality of care services in NH are related to lack of well-trained nursing staff, frequent new jobs, and the employment of foreign workers, where the role of managers is especially essential. Moreover, the role of teamwork here is key in promoting the transfer of expertise, which in turn involves knowledge of the residents and their care plan. In a similar vein, managers in NH have to also understand why the authocratic system of management is not well aligned to encourage knowledge transfer, and what to do with all of the ideas that arise at team meetings in organizations. Team members’ perception during day-to-day teamwork through the lens of complexity science helps us to understand how and why caregivers behave in this way as a “perceptual information guides our decision and actions, and shapes our beliefs” (Pype et al., 2018). Teamwork is therefore the basis of work in nursing homes, enabling knowledge management, the transmission of values and the promotion of the creation of new knowledge, thus constantly improving the quality of services. Factors such as the shortage of well-trained caregivers, the high turnover of staff and the role of the user, who becomes a co-designer of his own care plan, require that management be prepared for a strategic approach to knowledge management.

Another important practical implication is focused on the knowledge of users of services – residents – which can lead to quality services that comply with care protocols on one hand and are tailored to the user on the other. Residents are the ones we can learn from – their wishes, expectations, needs, and their own perceptions of quality in aging in NH. With the awareness that users are the ones who determine the quality of services, we are shifting the paradigm of determining quality from the perspective of experts to a co-creative social model in which we research together with users. This is why the teamwork method, where we also involve residents in finding better solutions, is so important. By involving residents and taking their opinions into account, we move from the role of an expert planning the process of care and support within the system to the role of a partner in the process of planning everyday life in the NH. As residents’ expectations, desires and goals change over the generations, it is also necessary to change the culture of the NH – from planning the process of service delivery for residents to planning with residents.

Even with the theoretical and practical implications of our research, we need to address limitations of our study as well. First, in our study, we included four homes, which hinders the generalizability of our findings. To overcome this limitation, we propose to conduct similar research on a bigger sample size of more than 100 NH in Slovenia, or to also extend it to foreign countries in order to increase the reliability and validity of our research findings. Second, one limitation is that there is lack of awareness, understanding, and knowledge with the concept of KM in NH, both from managers and nursing staff. One potential solution is to develop common terminology to reduce potential bias in answers provided by respondents. Third, the methodological issue of common method bias should be taken into account, which can be understood as a limitation of our model. In a similar vein, researching only direct relationships between dependent and independent model can be viewed as a limitation of our study, which can be overcome by exploring potential moderating effects of different variables on the hypothesized relationships in our model. Furthermore, we believe that measuring the concepts of quality management and teamwork would add additional value to our hypothesized research model. Fourth, the complexity of the environment of NH potentially hinders the responses from our respondents as they are continuously working in difficult conditions and in a complex and demanding profession.

For future research, we recommend follow-up studies and more prior training on the topic as it would increase building a KM ecosystem in NH in a systematic and constant manner. With organizational elements such as formal and informal communication, regular teamwork (with residents), information systems, written protocols, a personalized care plan for residents, NH becomes a system of knowledge in long-term care. In addition, future research might explore potential moderating effects of organizational factors such as leadership style and information-communication technologies on the relationship between KM and quality of services in NH. For future research, it might be beneficial to distinguish between the differences in NH, such as organizational size measured by the number of employees, which can be understood also as an additional control variable in the study. Considering the complexity of the NH and its profession, it could be beneficial to apply also a qualitative research design such as in-depth semi-structured interviews or case studies to gain more in-depth insight into specific research constructs that were utilized in our study. Moreover, in order to overcome the limitation of the study that is conducted only in one country, we suggest to conduct a follow-up study on an international sample.