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Collaboration and communities of practice nzcom
1. Collaboration and communities of
practice. The reality of rural midwifery
practice.
Presentation to NZCOM Conference
Wellington 2012
Carolyn McIntosh, Senior lecturer in Midwifery,
Otago Polytechnic.
2. Introduction
In this presentation I will cover the
following topics:
Communities of practice, what they are
and why they may be important.
Rural midwifery practice in the South
Island of NZ: What communities of
practice are midwives engaged with?
Challenges for rural midwives in practice
relationships which may influence
communities of practice and
collaboration.
Some possible benefits of effective
collaboration.
3. Communities of practice.
Midwives work in a variety of locations
alongside a variety of other health
professionals e.g.
◦ Midwives, Obstetricians, Plunket
nurses, GPs, Practice nurses, Ambulance
personnel, Radiographers, Physiotherapists,
Occupational therapists, Mental health
services.
And a variety of lay groups who support
women and families e.g
◦ La leche league, Plunket mothers groups, etc.
Etc.
◦ not forgetting women themselves and their
4. Communities of practice
Professional interactions with all of these
groups are centred on the care and
interests of the mother and her infant.
As matters of interest arise information
may be shared (within the bounds of
confidentiality) which may stimulate
investigation and exploration.
Group interactions provide a mechanism
for knowledge transfer and contextualising
evidence to the local practice situation.
5. Communities of practice
Wenger (1996)
Learning is primarily social and occurs through
the variety of communities to which
participants belong.
Learning is integrated into participation in
communities of practice (COP).
COP create their own identity and boundaries.
Boundaries are crossed and negotiated
between COP. Learning may be facilitated or
inhibited.
It is this negotiation between COP where
Innovation is most likely to occur “much
learning happens when boundaries are rich in
interactions”
6. Rural midwives communities of
practice.
Practice communities are unique to the
midwives geographical location.
Depends on the realities of the practice in the
area.
COP may be a local group of midwives or
may involve other health professionals in the
local area (Midwives, GPs, District
nurses, facility nurses, Plunket nurses, allied
health professionals)
COP may also be more geographically
distant,McIntosh (2007)
communicating through technology.
7. C.O.P.
May be influenced by:
Individual and group philosophy.
Local relationships between health
care providers.
How specialist services are accessed.
◦ Are there local specialist clinics or do
women have to travel to the main
centre for specialist services.
9. Midwife two F2F networks
Other
Rural
midwives Rural
Facility
Remote
Rural
midwife
Solo
Secondary
GP Facility
10. Creatively establishing
communities of practice.
In rural Australia advanced practice nurses (APNs) use a variety of
methods including face to face to connect with other health
professionals (Conger, Plager, 2008)
Geographically isolated rural midwives in New Zealand were found to
have a similar pattern of connectedness (McIntosh, 2007).
11. Other midwifery relationships
Midwives usually live in the communities in which they
work. Hence they are also involved in community
activities and have relationships outside work with women
and families for whom they also provide care. Rural
midwives are always a midwife in every social interaction.
(Baird, 2005; Patterson, 2007)
This is common to all rural health workers and creates
some additional challenges for health professionals.
(Bourke, Sheridan, Russell, Jones, Liaw. 2004 )
Rural midwives may also be involved with lay groups
which provide information and support to rural women
(McIntosh, 2007).
Learning may also be stimulated through interactions with
these lay communities.
12. “Boundaries between practices are
fertile grounds for innovation. As
communities of practice
collaborate, clash, merge, diverge, the
required process of
coordination, translation, and
negotiation is also a process of
learning”
(Wenger, 1996)
13. Team learning
Agreeableness is defined as being
friendly, trusting, tolerant, compliant and
modest.
High levels of agreeableness may have
a negative effect on problem solving as
compliance and consensus is reached
early.
Effective collaboration within and
between teams requires a full and critical
discussion of available data and ideas.
Participation in “constructive
controversy”.
14. Constructive controversy
Communities of practice are identified by
shared wisdom and understanding
When this is in conflict with the
understanding of another group
resolution is required
This process requires
◦ Critically analysing the situation
◦ Transforming knowledge into argument
◦ Viewing the issue from different perspectives
◦ Synthesis and consensus
Johnson, Johnson and Smith, 2000
16. Constructive controversy
Although controversy can be
transformative and beneficial certain
conditions are required for this to
happen.
There are two possible contexts for
the controversy
Cooperative and Competitive
17. Cooperative (constructive)
Willing to listen
Clearly communicate ideas
Motivated to hear opposing arguments
Comfortable discussing opposing
perspectives and
Willingness to create new
understanding
Johnson, Johnson & Smith, 2000
18. Competative (not
constructive)
Personalise argument
Unwilling to hear alternative
perspectives
Closed minded
Combative
Disagreeing while implying the other is
incompetent
Johnson et al, 2000
19. Improving quality in primary
care
Lanham, McDaniel et al, 2009.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928073/
20. Advancing learning through communities of
practice:
The benefits of collaboration and connectedness
Interaction through COP advances
learning, working together towards a common
goal.
Interaction between different COPs can produce
tensions and controversy.
Controversy may lead to conflict amongst health
professionals which may impact negatively on
the quality of care
Resolving tensions, working constructively
through controversy and seeking common
ground can advance learning, leading to new
understanding and improved quality of care
These challenging boundaries of COP have
potential to improve understanding, develop
practice wisdom, transform and improve the
quality of care. Marshall and Robson, 2005; Wenger 1996)
(Bartunek, 2011;
21. Conclusion
COP are important for sustaining and
supporting practice.
Midwifery practice communities are
diverse, influenced by the area in which the
midwives live and work and may involve a
variety of health care professionals and lay
groups.
There is potential for controversy between
COPs
Being able to resolve controversy improves
understanding, can increase knowledge and
practice wisdom and improves the quality of
care for the families midwives work with.
Learning is advanced through interaction and
collaboration with a variety of COP.
22. References
Baird, M. (2005). Sustaining rural midwifery practice:
New Zealand Midwives’ experiences. Unpublished
masters thesis, Otago Polytechnic: Dunedin, New
Zealand.
Bourke, L., Sheridan, C., Russell, U.
Jones, G., DeWitt, D. and Liaw, S.T. (2004) Developing
a conceptual understanding of rural health practice.
Australian Journal of Rural Health. 12:181-186
Burtenek, J. M. (2011). . Intergroup relationships and
quality improvement in healthcare. BMJ Quality and
Safety, (Supplement 1).
doi:10.1136/bmjqs.2010.046169
Conger, M. M., Plager, K. A. (2008). Advanced nursing
practice in rural areas: Connectedness versus
disconnectedness. Online journal of rural nursing and
healthcare. 8 (1), 24-38. retrieved from
http://www.rno.org/journal/index.php/online-
journal/article/viewFile/156/194
23. Hollenbeck, J, R., Ellis, A,P, J., Humphrey, S.
E., Garz, A, S., & Iligen, D, R. (2011). Asymmetry
in structural adaptation: The differential impact of
centralizing versus decentralizing team decision
making structures. Organisation behaviour and
human decision processes.
114(1), http://dx.doi.org/10.1016/j.obhdp.2010.08.
003
Marshall, P., Robson, R. (2005). Preventing and
managing conflict: Vital pieces in the patient
safety puzzle. Healthcare quarterly. 8: 39-44.
McIntosh, C. (2007). Wise womens web: Rural
midwives’ communities of practice. Unpublished
maters thesis, Otago Polytechnic: Dunedin, New
Zealand
Patterson, J. (2007). Rural midwifery and the
sense of difference. New Zealand college of
midwives journal. 37: 15-18
Wenger, E. (1996). Communities of practice
the social fabric of the learning organization.
Editor's Notes
We adopt an initial perspective towards a problem based on our personal experiences and perceptions.The process of persuading others to agree with us strengthens our belief that we are right. When confronted with competing viewpoints, we begin to doubt our rationale.This doubt causes us to seek more information and build a better perspective, because we want to be confident with our choice. This search for a fuller perspective leads to better overall decision making.
Trust Trust is exhibited when one individual is willing to be vulnerable to another individual. Trust is particularly important in health care because the relationships among members of health care teams are highly collaborative and interdisciplinary. Trust can be difficult to foster; the culture of health care delivery often works against the development of trusting relationships.12 Policies and procedures in HCOs may lead to distrust. Risk of litigation and clinical documentation requirements can also erode trust. A study of trust in the context of telemedicine showed that physicians must trust each other before physicians will use telemedicine in caring for patients.13 We believe that practices with high levels of trust will be able to have difficult conversations and will be able to openly discuss and learn from successes, failures, and near failures.Mindfulness Mindfulness is a social characteristic exemplified by the openness to new ideas and multiple perspectives,14 a fully engaged presence,15 a rich awareness of discriminatory detail,16 and the seeking of novelty, particularly in seemingly routine situations. Mindfulness is a purposeful cultivation of awareness. People in practices must be aware to be open to novelty. Mindfulness has been shown to be critical in the effective practice of health care.17–19 Mindful approaches are characterized by a continuous creation of new categories, openness to new information, and implicit awareness of more than one perspective.20 Mindfulness—which must be practiced because it is not innate—occurs when people question their assumptions about the nature of the world.Heedfulness Heedfulness occurs when an individual pays attention to his or her specific task at hand21 as well as to the task of the larger group. In heedful practices, people watch to see how their actions influence the actions of the group, and they seek awareness about how their actions are intertwined with the actions of other members of the practice. Heedfulness is difficult to achieve because of the many competing demands placed on health care professionals. Fostering heedfulness, however, might be an effective strategy for reducing medical errors because “when heed is spread across more activities and more connections, there should be more understanding and fewer errors.”21(p. 366)Respectful Interaction Respectful interaction is characterized by honesty, self-confidence, and appreciation of others. In relationships characterized by respectful interaction, new meanings often emerge through interaction.21 For example, in a staff meeting where practice members are interacting respectfully, it is likely that the solution to a particular problem will be created by the group, as opposed to an individual. Medical errors are an unfortunate part of the health care delivery process, but respectful interaction can enable learning from mistakes. Practices can learn from mistakes when people actively seek out and value the opinions of others (appreciation of others), freely share opinions even when these opinions may be unpopular (honesty), and willingly change their minds in response to new meaning created within the practice (self-confidence).Diversity Primary care practices are made up of diverse people. Here we focus on cognitive diversity. Cognitive diversity is the differences in perspectives and world views of individuals (how people think). Moderate levels of diversity can help organizations operate effectively in competitive environments, process information, and learn in real time.22 Too little diversity can block creativity and innovation, and too much diversity can block communication. Diversity in a primary care practice can increase people’s capacity for making sense of the world and broaden the range of available solutions for problems.Social and Task Relatedness Both social and task relatedness are important in practice relationships. Social relationships are personal in nature and are often based on friendships or family relationships that extend outside of work. Task relationships are focused on work issues. Members of a practice characterized by high task relatedness rarely discuss non-work-related topics with one another. The data from the four studies indicated that practices with relationships that were too socially oriented (conversations were dominated by personal topics) and practices with relationships that were too task oriented (conversations were dominated by work topics) tended to perform more poorly than practices with a mixture of social and task relatedness. Our findings suggest that social and task relatedness is not an “either/or” attribute. We suggest that both social and task relatedness are needed for practices to deliver high-quality health care.Rich and Lean Communication We noted the following commonly used communication channels (in the order of richest to leanest) in primary care practices: (1) face-to-face, (2) telephone, (3) personal documents (for example, letters, e-mails, reminders), (4) impersonal documents (mass e-mails and impersonal memos), and (5) numeric documents (appointment schedules and budgets). When ambiguity is high, practices should use face-to-face communication channels, which allow for rapid information flow and for the clarification of meaning in real time (one-on-one conversations and small-group meetings). Less ambiguous messages can be communicated using a leaner channel (memo or e-mail). The medical record—electronic or paper—is often a major communication channel in primary care practices, and its richness/leanness varies depending on the user and the specific context in which it is being used.
