Are communities of practice an effective approach for achieving transformational change in health care?

I have a long held instinctive belief that community and human connection are powerful tools for meaningful and sustainable transformational change in health and social care.  Listening to Etienne Wenger speak at one of the Co Creation Network’s Basecamp events, consolidated this for me. The concept of communities of practice, as a collective social practice that brings together people with shared expertise and/or interests to learn from each other; to collaborate in finding collective solutions and as a vehicle for disseminating knowledge and learning across teams, organisations and beyond is a persuasive one to me. Within the context of my own health care career, I think that I have been most successful in leading and implementing change where I have unknowingly adopted a community of practice mind set.

Early on in my career as a Mental Health Nurse, sometime in the mid 1990’s to provide historical context, I was working as a staff nurse on a busy acute mental health ward. I can vividly recall returning to work after a period of leave to discover that one of the women who had been with us on the ward for a few months had taken her own life. She was quiet and unassuming and was only still on the ward because she was waiting for suitable accommodation to be discharged to.  The ward community were understandably very shocked and upset by the news of her death. She was a well-liked woman who had made a few friendships on the ward.

From talking to my colleagues, it became clear that in the immediate aftermath of her death, the team had struggled, not just with the emotional aftermath of her death, but also in knowing what to do from a very procedural point of view immediately and in the following days, weeks and months of a suspected suicide.

Along with a colleague, I contacted the Deputy Director of Nursing within the organisation where I worked. She was a very approachable and accessible leader and gave us lots of phone numbers for other acute mental health units around the country, as well as the gift of her permission and encouragement. Several phone calls later and we had discovered that no one seemed to have any formal guidance in place around how to deal with the aftermath of suicide within in patient settings. However, everyone thought that this would be a worthwhile piece of work and many people shared their own stories with us about their clinical experiences and lessons learnt.

From these small seeds of inquiry, we formed what I will now identify as a Community of Practice. In Community of Practice terms, we were a small but heterogeneous group, spanning across clinical disciplines. Our different backgrounds enabled diversity of thought, which was important in terms of the depth of the work, but we were also at the same time united by a shared commitment to our purpose or domain. We knew that the guidelines we were creating were relevant, meaningful and purposeful to clinicians just like ourselves. It was this that provided the energy to sustain our community’s work.

We didn’t have terms of reference or a governance structure, nor did we produce detailed agendas and minutes, but we often talked informally for hours and in our own time, about each element of the work, as we constructed it and we cared deeply about what we were creating. We also engaged with lots of people within the organisation and beyond, weaving each unique and personal story into the fabric of the guidelines we were producing. Stories were important

The stages of development identified by Wenger (1996) and reproduced below highlight the different stages of development that our community of practice flowed through. In time, the work we created was ratified by the organisation at a strategic level and resource was allocated in order to develop things further and ensure that this was a sustained change in practice and organisational culture. Nowadays, there is also national guidance available for dealing with the aftermath of suicide and resources are much easier to access via internet search engines and social networks.

The work we did was positive, but it was also of its time. On reflection, now what was missing was the voice of people who have accessed acute mental health services and their families and carers.  We developed a standard around holding remembrance services in the multi faith centre for people to come together as a community and remember those lost to them through suicide or unexpected death and these services were important and human, but what we didn’t do was co create this work with people with lived experience of mental health and nor was our core community represented directly by anyone who had accessed acute mental health services within the organisation. I think this was a definite gap in the development of this work.

Fast forward to about 2005, where I had the opportunity as a Clinical Manager for a Perinatal Mental Health Service (Mother and Baby Unit) to apply for a place on the Kings Fund ‘Enhancing the Healing Environment ‘programme. The aim of the programme was ‘to encourage and enable nurse led teams to work in partnership with patients to improve the environment in which they deliver care’

The programme aimed to be a catalyst for the NHS to consider the impact of the environment on recovery and the way that care is delivered.

We were keen at the outset to apply because we could visualise the benefits of transforming our not fit for purpose mother and baby unit into a more healing, nurturing environment. At the outset, we brought together women who had accessed or were continuing to access either our mother and baby unit or community services with nurses and nursery nurses as well as the wider multi disciplinary team, to talk about a future vision for the unit. We listened intently to stories about people’s experiences of care within the unit and we heard lots of ideas and suggestions about what a healing space for women and their babies on the unit would look like. The project had to have a strong arts focus, so we dreamed and we researched and we visited places of inspiration around healing and nature.

‘The intersection of personal meaning and strategic relevance is a potent source of energy and value.  Domains that provide such a bridge are likely to inspire the kind of thought leadership and spirit of inquiry that are the hallmarks of vibrant communities of practice’. (Wenger et al, 2002)

It was an organic process, but from this thinking space, emerged a strong vision around the transformative effects of nature and healing in relation to maternal mental health and recovery. We submitted our entry and we were chosen as the winning bid.

Participation in the programme was transformative for the unit, both in terms of the design and structure of what we developed. This included the construction of a conservatory and reconstruction of the dining room, which allowed us to maximise space for 1:1 and group work. This included the provision of holistic therapies such as baby massage, as well as the development of a broader group programme.

During the programme, I took maternity leave, but it didn’t in any way weaken the leadership of the programme because each and every person within the community of practice acted as a leader in some way, whether as a community organiser, artist, thought leader or strategic lead within the organisation. The strength of the group was in its social capital, with each person offering something different, but of value to the community. The group was then connected together by its shared vision and purpose.

Both the examples described occurred before the emergence of social media for professional development. As I write this, I’m reflecting on how much social media has changed the world we live in, particularly in relation to the accessibility and immediacy of information available, as well as its global reach and boundary spanning capabilities.

If communities of practice are defined as social learning systems with human relationships at their core, then the potential for online communities of practice seems like an important area to explore.

For the past few years, along with two colleagues, I have been running an online mental health community on Twitter called @WeMHNurses which is for mental health nurses and those interested in mental health.  Over time, @WeMHNurses has become a really established community, providing space for people interested in mental health to come together online to debate, share ideas and learning and generally connect about topical issues relating to mental health. It’s a collaborative and generous community and I never fail to stop being inspired by the energy and creativity of the conversations that occur.

Furthermore, conversations held in a public online space often appear to have a democratising effect by providing a non institutional setting within which clinicians, managers, policy makers, people with lived experience, citizens and carers can come together to discuss and debate issues relating to mental health. It seems that quite often new knowledge emerges from the bringing together of people from different backgrounds and with different perspectives.

At a time when the NHS is being challenged to be more values led, online communities appear to provide a vehicle for humanising conversations. For example, conversations about social justice become more potent when talking online with someone directly affected by inequality, as opposed to having a singular academic or clinical discussion on the topic. I also know that over time, my connection to the online mental health community has made me feel more connected to my profession and more engaged in broader political issues.

Unlike face-to-face communities of practice, members of online communities of practice (defined as followers on twitter) tend to be dispersed across wide geographical areas, with the potential for a global reach in the time it takes to compose a tweet. Whilst this is a favourable feature of online communities, it can also invite different levels of participation from its members.

This concentric diagram by Wenger et al, 2002 nicely highlights our own observations about participation within our online community.

The core group represents the three of us who lead and coordinate the community by running the account, arranging twitter chats and all other activity relating to the communities identity and purpose.  As a core group, it is worth noting that our meetings with each other are generally enabled via technology, as we are not based close to each other and therefore tend to use digital platforms and Skype for communication.

Beyond the core group, we have an active group of members, who we would define as those who regularly contribute content and actively participate in many of the conversational threads and twitter chats. Our greatest number of participants fall within this category.

Moving away from the active group are our peripheral members, who tend to engage sporadically or periodically and this appears to be influenced by factors such as the nature of the topic being discussed.

Finally, there are the outsiders, who are perhaps defined as those people who are aware of our community and who might passively read our posts, but do not necessarily contribute any content. This doesn’t necessarily mean that they are not engaged. They may be the listeners within the community and just like listeners in a conversation off line, it may be that they develop a much broader understanding of the community and its members, which can be of great value as social capital, both online and offline.

I have been thrilled recently to have the opportunity to work with the Co Creation Network support team. We have been out and about engaging with existing communities of practice as well as promoting the network generally where we think it might add value. Please do get in touch if you would like to talk to us!

In my reflections above, I have tried to offer some fairly diverse examples of communities of practice that I have been involved with personally. I have chosen these particular examples because they are meaningful to me and to the path I have followed. We would love to hear your thoughts on these examples and about communities of practice more generally.

We hope that by engaging with the Co Creation Network, you are able to learn, share and collaborate with others within the Yorkshire and Humber region by adopting a community of practice framework and then by sharing your learning with the wider network. We believe that communities of practice as an improvement approach have the potential for improving organisational culture, patient experience and outcomes within the health care setting.

@vanessag

@VanessaLGarrity

Reference

Wenger E, McDermott R and Synder W (2002)

‘A guide to managing knowledge: Cultivating Communities of Practice’

www.harvardbusiness.org/press

Image via Creative Commons

Comments

  1. Carolyn jackson

    Great blog Vanessa. At the England Centre for Practice Development we have a number of communities of practice we have established over the past 5 years which are international and national and some which are longer standing with collective interests in practice development. We have just developed the Venus Model for person centered sustainable transformation based on our body of work which I would be happy to share with you. Check us out at https://www.canterbury.ac.uk/health-and-wellbeing/england-centre-for-practice-development/england-centre-for-practice-development.aspx. You might also want to join our international fellowship scheme which you can find on the website.

  2. Vanessa Garrity Post author

    Hi Carolyn,

    Thank you very much for taking the time to comment on my post. I would be very interested in hearing about the Venus Model for Person Centred Sustainable Transformation that you refer to, as well as finding out more about your fellowship scheme. Best Wishes, Vanessa