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Collaborations for Leadership in Applied Health Research and Care: lessons from the theory of communities of practice

Collaborations for Leadership in Applied Health Research and Care: lessons from the theory of... Background: The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)–partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice. Discussion: The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared ‘collaborative’ identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of ‘bridges’ involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification. Summary: The CoP approach can complement traditional ‘stage-of-change’ theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging–an assumption that needs to be explored by further empirical research. Introduction currently being used to analyse and facilitate knowledge Since being identified as a mechanism through which sharing in a wide range of organisational environments, knowledge is held, transferred, and created, the commu- including, but not limited to, business sector, education, nities of practice (CoP) approach has become increas- information technology (IT) and healthcare organisa- ingly influential within management research and tions. In the healthcare sector, CoPs have been argued practice [1]. Originally developed by Lave and Wenger to play a role in the generation of social, human, organi- [2] in a study of situated learning, the CoP theory is sational, professional, and patient capital, thus being potentially useful for enhancing care, providing learning * Correspondence: [email protected] opportunities, analysing practice, problem-solving, shar- Manchester Business School, The University of Manchester, Booth Street ing knowledge, and generating ideas [3]. West, Manchester, M15 6PB, UK © 2011 Kislov et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kislov et al. Implementation Science 2011, 6:64 Page 2 of 10 http://www.implementationscience.com/content/6/1/64 This paper will use the CoP approach as a lens to look and thus address the ‘second gap in translation’–agap at interprofessional and inter-organisational joint work- in the translation of new medical interventions into ing within the Collaborations for Leadership in Applied everyday practice identified by Cooksey’s Review of UK Health Research and Care (CLAHRCs)–partnerships Health Research Funding [6]. They have three key inter- between the universities and National Health Service linked functions: conducting high quality applied health (NHS) Trusts aimed at conducting applied health research; implementing the findings from research in research and translating its findings into day-to-day clin- clinical practice; and increasing the capacity of NHS ical practice. It will briefly discuss some of the seminal organisations to engage with and apply research. It should also be noted that the CLAHRCs are situation- theoretical CoP literature as well as previous empirical research on the role of CoPs in healthcare collaboration, ally placed, with their agendas being determined by the using CoPs as a lens to reflect on potential challenges partnering organisations and tailored to the healthcare that the CLAHRCs will have to address in order to needs in their respective geographical areas. achieve their objectives. It will argue that the multipro- The CLAHRCs can be considered as a somewhat fessional and multi-agency nature of the CLAHRCs experimental approach designed to further our under- operating in the traditionally demarcated organisational standing of large-scale collaborations as an implementa- landscape of the NHS may present formidable obstacles tion tool–both by internal testing of new initiatives to knowledge sharing between various professional aimed at implementation of research findings into day- groupings, effective identification with the Collaboration, to-day practice, and as the subject of a number of and the formation of new multiprofessional commu- ongoing external evaluations commissioned by the nities within the CLAHRCs. NIHR Service Delivery and Organisation (SDO) pro- The paper will start with a brief discussion of the gramme [7]. These internal and external evaluations are structure and purposes of the CLAHRCs and the main supposed to contribute to the evidence base on the effi- premises of the CoP approach. It will then explore the ciency and effectiveness of collaboration and other stra- following three interrelated strands within the wider tegies aimed at increasing applied health research use in CoP literature: knowledge sharing across CoPs; CoP for- multiple populations and settings. However, the process mation and manageability; and CoP identity building. of evaluating the CLAHRC processes and outcomes is The paper will conclude by discussing the advantages of still at the initial stage, which explains why so little applying the CoP theory to healthcare partnerships, empirical research on the CLAHRCs has been published summarising the key issues that need to be addressed by so far. This paper will explore an alternative way of the CLAHRCs and similar organisations in order to looking at the subject; it will attempt to draw some les- achieve their aims, and reflecting on the implications for sons for the CLAHRCs by analysing healthcare colla- future research in this area. boration through the lens of CoPs. In doing so, it will refer to the seminal works on CoPs published by Eti- Background enne Wenger [2,8,9], as well as empirical studies that Collaborations for Leadership in Applied Health Research have used CoPs in healthcare settings, either as an ana- and Care lytical approach or as a knowledge management tool. In 2008, another major experiment was launched in the English NHS: CLAHRCs were established across Eng- Communities of practice land. Each CLAHRC represents a collaborative partner- A community of practice (CoP) is ‘agroup of people ship between one or more universities and their who share a concern, a set of problems, or a passion surrounding NHS organisations aiming to undertake about a particular topic, and who deepen their under- high-quality, patient-centred applied health research and standing and knowledge of this area by interacting on to support the translation of research evidence into clin- an ongoing basis’ [9]. CoPs can range in size; they can ical practice. In total, nine CLAHRCs were selected be long or short lived, co-located or distributed, homo- through an open competition out of twenty-two bids, geneous or heterogeneous, spontaneous or intentional, with particular value being placed on research proposals unrecognised or institutionalised. Organisations can in targeted at chronic disease and public health interven- turn be interpreted as the ‘communities of communities’ tions. Each of them will receive up to £10 m over five [10], or ‘constellations of interconnected CoPs’ [8]. years from the National Institute for Health Research Wenger formulates three defining characteristics of (NIHR), with additional matched funding to be secured CoPs. First, CoP members interact with one another, from the participating NHS organisations to at least the establishing relationships and negotiating meaning of same level as that provided by the NIHR [4,5]. their actions through mutual engagement.Second, The CLAHRCs are expected to enhance knowledge members are bound together by an understanding of a transfer between academic researchers and NHS staff sense of joint enterprise, which entails a common set of Kislov et al. Implementation Science 2011, 6:64 Page 3 of 10 http://www.implementationscience.com/content/6/1/64 tasks that CoP members can influence. Finally, they pro- rather than distinction, between ‘the theoretical’ and ‘the duce over time a shared repertoire of routines, words, empirical’ [15,16], the paper will look both at the semi- tools, stories, symbols, or concepts that become part of nal theoretical writings on CoPs and relevant empirical the CoP practice [8]. Iverson and McFee [11] argue that applications of the theory. Second, because critical rea- mutual engagement, joint enterprise, and shared reper- lism admits some form of theoretical eclecticism [16,17], toire can be used to determine the existence of CoPs, the paper will also be referring to other theoretical tra- distinguish between different CoPs, and evaluate com- ditions that have developed outside the CoP approach municative processes in them. However, in his later but are compatible with its premises (e.g., literature on work Wenger reformulates these characteristics and pre- professionalism, sociology of science, and knowledge sents the ‘structural model’ of CoPs consisting of three transfer). Finally, because the focus of the realist episte- fundamental elements: a domain of knowledge, which mology is ‘generative mechanisms’ producing outcomes defines a set of issues; a community of people who care in certain contexts [18,19], the paper will mainly con- about this domain; and the shared practice that they are centrate on the processes taking place in CoPs, rather developing to be effective in their domain [9]. than reflect on the definitional clarity of the concept or According to Wenger et al. [9], CoPs can be distin- lack thereof. guished from formal departments, project teams, com- It should also be noted that the analysis of Wenger’s munities of interest and informal networks along the germinal works shows that the concept and theory of following five dimensions: CoPs is still evolving. Originating as a mid-level analyti- 1. Purpose: to create, expand and exchange knowl- cal tool of the theory of social learning that embraces edge, and to develop individual capabilities; community, identity, meaning, and practice, it later was 2. Membership: self-selection based on expertise or seen as a technique deliberately used by managers to passion for the topic; improve knowledge transfer and organisational perfor- 3. Boundaries: fuzzy; mance. This resulted in the development of two differ- 4. What holds them together: passion, commitment, ent perspectives on CoPs: analytical, using CoPs as a and identification with the group and its expertise; theoretical heuristic to analyse practice; and instrumen- 5. Life cycle: CoPs evolve and end organically; they tal, used with an intention to cultivate CoPs or utilise last as long as there is relevance to the topic and inter- them in order to achieve desirable aims. Although there est in learning together. is an inherent tension between these perspectives, the This distinction has, however, been criticised for being paper will be referring to both of them: first, because rather vague and contradictory; for instance, the notion the instrumental approach to CoPs is a natural conse- of self-selection contradicts the generally accepted pre- quence of their use as a theoretical concept, for all mise that people from the same discipline automatically social science theories inevitably have practical implica- belong to the same CoP [12]. It also does not take into tions, especially in the field of implementation research account the possibility that, under certain conditions, a [20] and, second, because this combination may be par- project team may develop CoP characteristics and hence ticularly productive both for research and practice [21]. become a ‘true’ CoP [13]. This has led some authors to In line with the two main perspectives outlined above, suggest that the CoP is actually an umbrella term for a CoPs are being increasingly used both as a theoretical number of different organisational groupings that are approach to analyse healthcare organisations and as a characterised by the support for formal and informal practical tool enabling collaborative learning and knowl- interaction between novices and experts, the emphasis edge mobilisation. The CoP approach has previously on learning and sharing knowledge, and the investment been applied to the analysis of healthcare collaboration to foster the sense of belonging among members on at least one occasion. Bate and Robert [22] showed [12,13]. As shown by Li et al. [14] in their systematic that NHS quality improvement collaboratives, which are review, this rather loose interpretation of the CoP con- aimed at closing the gap between potential and actual cept gets reflected in the empirical research reports, performance by testing and implementing changes with the examples of CoPs including informal learning quickly across many organisations [23], are likely to groups, clinical placements, and healthcare remain time-limited projects unable to achieve sustain- collaboratives. able organisational change unless linked and active CoPs are formed within them. The paper develops this idea by Applying the CoP approach to the CLAHRCs providing a brief review of theoretical and empirical lit- The structure, content, and narrative of the paper will erature on CoPs that is organised around the following be underpinned by the critical realist epistemological three themes: knowledge sharing within and across CoPs; CoP formation and manageability; and CoP iden- approach adopted by the authors. First, because this tity building. It will attempt to analyse the processes of approach suggests that there is an interdependence, Kislov et al. Implementation Science 2011, 6:64 Page 4 of 10 http://www.implementationscience.com/content/6/1/64 joint working within the CLAHRCs using the CoP the- organisations. The problem of interaction and knowl- ory, identify potential problems that may arise in the edge sharing within the CLAHRC teams can potentially process of healthcare collaboration, and reflect on the occur at multiple points. First, there will be inevitable possibility of the development of new multiprofessional tensions in the communication between the ‘worlds’ of and multi-organisational CoPs within the CLAHRCs. researchers and practitioners, who can have difficulties communicating with each other given the differences in their epistemic cultures [39]. Second, it should be noted Discussion that both of these worlds are not homogeneous; on the CoP knowledge sharing contrary, they are represented by different professional The CoP concept emerged within the situated theory of learning that views practice–i.e., a domain of collective and occupational CoPs. Thus, we could expect tensions knowing and doing–as the means through which knowl- between clinical researchers employed by medical edge dynamics in an organisation unfold. In a socially schools, whose mode of functioning is largely based on situated view of learning, individuals continuously com- a positivist biomedical paradigm, and the implementa- bine and modify knowledge through their everyday tion researchers representing social sciences and often operations and interactions between each other [24-26]. adopting more descriptive ethnographic approaches to Apart from explicit, codifiable, ‘know-that’ knowledge, organisations grounded, for instance, in social construc- collective practice generates a great deal of tacit, ‘know- tionism and symbolic interactionism. Similarly, the how’ knowledge, which is embodied in the CoP members’ ‘world’ of clinicians also consists of multiple professional practical skills and expertise [27]. As a result, homoge- groupings: doctors, nurses, and allied health profes- neous and well-established CoPs create distinct epistemic sionals, with different medical specialities (e.g., surgeons, cultures–i.e., cultures that ‘create and warrant knowl- neurologists, cardiologists) tending to form their own edge,’ making up ‘howweknowwhatweknow’ [28]. communities, which often spread across organisations, Knowledge can flow relatively easily within such cultures, but are still likely to retain their own disciplinary whereas it can become sticky at the boundaries between boundaries when co-located in the CLAHRCs with them [29]. The boundaries between CoPs can be classi- other professions. Finally, there is a boundary between fied as syntactic (difference in language), semantic (differ- clinical practice and healthcare management–two fields ence in meaning), and pragmatic (difference in practice), with profound differences in cultures, perceptions of the latter being most difficult to overcome [30,31]. research evidence, and the nature of decision-making The presence of distinct epistemic cultures and processes [40]. To cross these boundaries, the CLAHRCs might utilise boundaries in healthcare has been demonstrated by pre- vious empirical research. It has shown, for instance, that the following types of bridges (see also Table 1 for more doctors, nurses, and managers have different attitudes to examples): organisational change that are deeply embedded in their professional cultures [32-35], and that there are multiple differences of values, structures, education, and relation- Table 1 ’Bridges’ that could be used by the CLAHRCs to cross the boundaries between CoPs ships between the acute and primary care sectors [36]. Professional CoPs in healthcare are predominantly uni- Type Examples disciplinary, tend to seal themselves off from neighbour- Knowledge brokers Clinical managers Clinicians involved in management ing professional communities and are highly Clinicians involved in research institutionalised, which facilitates knowledge flow within Clinicians involved in quality improvement their boundaries, but causes the ‘stickiness’ of knowl- Internal facilitators (e.g., knowledge transfer associates) edge across them [37]. The epistemic boundaries are External facilitators (e.g., management consultants) especially problematic when different professions are co- Boundary objects Dashboards located within multiprofessional organisations. The co- Websites existence of partially incompatible epistemic cultures Powerpoint presentations Quality and outcomes framework (QOF) challenges knowledge sharing that occurs in a context of Primary care registers potential tensions and conflict [38]. Patient alert cards These findings have direct implications for the Clinical pathways and protocols Assessment tools CLAHRCs as large-scale multiprofessional and multi- Boundary Face-to-face meetings agency network organisations that bring together mem- interactions Practice visits bers of different, well-established CoPs with clearly Learning sessions demarcated boundaries, distinct and partially incompati- Online forums WebEx conferences ble epistemic cultures and, especially in the case of med- Focus groups ical professionals, supported by powerful professional Kislov et al. Implementation Science 2011, 6:64 Page 5 of 10 http://www.implementationscience.com/content/6/1/64 1. Knowledge brokers–people who, having member- CoPinits ownright.One oftheCLAHRCaimsisto ship in several CoPs, seek to facilitate interaction and ‘link those who conduct applied health research with all coordinate practice between them. Knowledge brokering those who use it in practice across the health commu- is often performed by individuals with hybrid profes- nity covered by the collaboration’ [7]. This may be inter- sional roles–for example, clinical managers may span preted as an imperative for creating new boundaries between the management and the medical multiprofessional and multi-organisational CoPs within professions [41,42]. the CLAHRC projects, which would bring together 2. Boundary objects–artifacts, discourses, and pro- representatives of multiple communities. The following cesses possessing interpretative flexibility that allows subsection will explore the literature concerned with the them to overcome syntactic, semantic, and pragmatic development of multiprofessional and multi-organisa- boundaries, and hence contribute to knowledge transfer tional CoPs in collaborative settings. across CoPs [43,44]. For example, x-rays and treatment The issue of CoP formation has been viewed differ- protocols have been shown to play the role of boundary ently in the seminal CoP literature and remains an area objects in a multidisciplinary cancer care team [45]. of debate. CoPs, as defined by Lave and Wenger [2], 3. Boundary interactions among people from different cannot be deliberately designed by managers; an organi- CoPs–these include single or discrete boundary encoun- sation can only establish a team for a particular project, ters (e.g., meetings, visits, and delegations) and longer- which may later emerge as a CoP [1]. Wenger and Sny- lived practice-based connections, including cross-disci- der [48] suggest that managers cannot mandate CoPs plinary projects [8,24]. because the organic, spontaneous, and informal nature Cross-disciplinary projects, including those implemen- of the communities makes them resistant to supervision tedbytheCLAHRCs, canbeconsideredasa variantof and interference. At the same time they argue that CoPs boundary practice because participating in this kind of may benefit from cultivation by managers, who should project exposes practitioners to specific tasks going identify communities that can potentially enhance the beyond their normal practices and forces them to company’s strategic capabilities and provide the infra- negotiate their own competences with the competencies structure that will support such communities and enable of others. While it is possible that some of the CLAHRC them to apply their expertise effectively. More recent multidisciplinary projects may indeed become a bridge contributions suggest that CoPs can be cultivated inten- between different CoPs (this possibility will be addressed tionally; furthermore, these deliberate communities may in more detail in the next subsection), the following be more useful for an organisation than the organic potential obstacles to knowledge sharing within these ones [9,49]. projects need to be considered. First, these boundary Under the influence of the theoretical literature mainly projects can become CoPs in their own right and concerned with private sector organisations, deliberately develop their own boundaries, which can prevent them constructed CoPs are getting increasingly used as a from functioning as knowledge brokers between the knowledge management tool in healthcare. Although wider communities these newly formed CoPs had the empirical evidence is still limited, it can be con- intended to link [46]. Second, as far as the level of indi- cluded that the formation of a genuine multiprofessional vidual knowledge brokers is concerned, full participation CoP is rare but possible [37]. The CoP approach has in one CoP may render brokering difficult: those with been demonstrated to enhance interprofessional clinical multimembership seeking to coordinate across CoPs practice [50], facilitate quality improvement, encourage may have difficulties participating fully as members of buy-in among participants, promote knowledge transfer one community if they have allegiances in another [24]. [51], and contribute to the development of services Finally, some of the more excessively formalised bound- spanning the interests of different stakeholders [52]. The ary objects, such as project plans, performance targets, following key factors that influence the development, or clinical guidelines can become a barrier to successful functioning and maintenance of multiprofessional CoPs collaboration by legitimising interprofessional differ- have been described: membership–selecting the mem- ences, reinforcing existing power structures, and main- bers, the extent (active or passive) and legitimacy of taining occupational control over task areas [25,47]. their involvement; commitment to the desired goals; relevance to local communities and the existing services; CoP formation and manageability enthusiasm; infrastructure to support the work of CoPs; As shown in the previous subsection, one of the ways to skills in accessing and appraising evidence; and enhance knowledge transfer and learning at the bound- resources [52]. aries between CoPs is the creation of a cross-disciplinary However, it should be emphasised that several crucial questions about the formation of multiprofessional CoPs project that can act as a bridge between CoPs and, still remain unanswered. First, it is not clear what under certain conditions, become a multiprofessional Kislov et al. Implementation Science 2011, 6:64 Page 6 of 10 http://www.implementationscience.com/content/6/1/64 organisational, group-level, and individual factors may personal, political, and professional agendas of the parti- enhance the transition from a team to a CoP. Second, in cipants [57]. It can thus be concluded that the deliberate spite of the reports describing the deliberate formation cultivation of multiprofessional CoPs within the of ‘genuine’ multiprofessional CoPs from scratch, their CLAHRCs might help to solve the problems of knowl- description is often not informative enough to judge to edge sharing outlined in the previous subsection, but what extent these groupings differ from the project the extent to which these CoPs can be constructed and directed remains unclear. teams in terms of achieving mutual engagement, joint enterprise, and shared repertoire. It may well be that the groupings that are labelled as CoPs represent a rhetori- CoP identity building cal device rather than organic CoPs characterised by The concept of identity building occupies one of the shared practice and sense of belonging. Finally, we do central places in the CoP approach that emphasises that not know whether and how horizontal, informal, egali- the negotiation of a common identity is a prerequisite tarian multiprofessional communities can emerge and for forming a community. Wenger [8] suggests the fol- function in acontext wherethey havetoco-existwith lowing characterisations of identity: the vertical, formal, command-and-control structures of 1. Identity as negotiated experience: participation in a the NHS, given the evidence suggesting that the exces- CoP and (often unspoken) negotiating the meanings of sive legitimisation and formalisation of ‘organic’ CoPs this experience with other CoP members; can disrupt, rather than support, their knowledge-shar- 2. Identity as community membership: translation of ing capacity [53,54]. the CoP membership into an identity as a form of Compared to the previous collaboration initiatives in competence; the NHS, the CLAHRCs are characterised by the more 3. Identity as a learning trajectory: a coherent process voluntary nature of involvement, placement in the con- of changing forms of participation within a CoP over text of local healthcare needs, and an emphasis on capa- time; city building and learning. These factors may increase 4. Identity as nexus of multimembership: an experi- the probability of supplying newly formed multiprofes- ence of multimembership in various CoPs and reconci- sional projects with enthusiastic members who will be liation of different identities to maintain one identity committed to achieving the relevant goals, thus addres- across boundaries; sing some of the factors mentioned above as prerequi- 5. Identity as a relation between the local and the glo- sites for the formation of multiprofessional CoPs. It has bal: negotiating local ways of belonging to broader con- also been suggested that the CLAHRC being co-funded stellations of CoPs. by the NIHR and the NHS Trusts will result in a colla- Regardless of whether there is an explicit intention to borative model of ownership with a broad range of sta- cultivate CoPs within the CLAHRC or any other colla- keholders having a vested interest in shaping the boration, the multiprofessional and multi-agency envir- strategic direction of the collaboration [55]. It is, how- onment in which these projects are located mandates an ever, unclear whether this will lead to the formation of understanding how a new ‘collaborative’ identity is CoPs, given the potentially conflicting partners’ agendas, negotiated by the participants. It should be noted, how- the continuous process of NHS reform distracting orga- ever, that the processes of identity formation in multi- nisational resources from joint working and, most professional and multi-agency CoPs are not specifically importantly, the dynamic membership within the addressed in the seminal CoP literature. To discuss CLAHRCs, given the potential for NHS trusts to opt potential problems related to the formation of the ‘colla- out of the collaboration should their priorities change. borative’ identities within the CLAHRC, it is helpful to Whether formed organically within the CLAHRC refer to the concepts of professional and organisational cross-disciplinary projects or deliberately cultivated by identification. the CLAHRC management, the multiprofessional CoPs Professional identity can be defined as ‘the relatively will have to be maintained, directed, and controlled to stable and enduring constellation of attributes, beliefs, achieve desired aims. Paradoxically, while it has been values, motives, and experiences in terms of which peo- suggested that managers play a critical role in construct- pledefinethemselvesinaprofessionalrole’ [58]. ing, aligning, and supporting CoPs [9,49], there is little Though professional identity is not static, there seems empirical evidence for these assertions. Furthermore, it to be a core identity that remains stable and with which has been argued that managers are incapable of making all members are able to identify. Around this lies an the CoP a direct instrument of policy and control [56]. extended identity that is subject to modification as the In spite of facilitation, the knowledge transfer in these result of widening fields of work, increased knowledge communities does not necessarily follow the model of and skills, changes in attitudes and values, or re-inter- evidence-based practice, but is shaped strongly by the pretation of old ones [59]. It should also be emphasised Kislov et al. Implementation Science 2011, 6:64 Page 7 of 10 http://www.implementationscience.com/content/6/1/64 that the development of professional identity in health- cross-disciplinary projects should also consider the care professions should be analysed in relation to the notion of organisational identification. This is defined as concepts of professional dominance, collegiality and a ‘form of psychological attachment that occurs when autonomy [60]. members adopt the defining characteristics of the organi- Several empirical studies are worth mentioning in this sation as defining characteristics for themselves’ [63]. A respect. In a qualitative study on interagency and inter- member’s level of organisational identification indicates the degree to which his/her membership in an organisa- professional teams in the NHS, Robinson and Cottrell tion is tied to the content of his/her self-concept [64]. [61] argue that in multiprofessional work, professional Organisational identification is most likely to occur knowledge boundaries can become blurred and profes- sional identity can be challenged as roles and responsibil- under conditions where the boundaries between one’s ities change. As a result, team members may struggle to own organisation and other organisations are salient, cope with the disintegration of one version of profes- when membership in the organisation is attractive, and sional identity before a new version can be built. Baxter when organisational categories best account for similari- and Brumfitt [62] examine interprofessional practice in ties and differences across individuals and groups [65]. multidisciplinary stroke care and conclude that the depth Organisations forming the CLAHRCs may have differ- of professional knowledge and skills is perceived as the ing organisational cultures as well as potentially conflict- core element in preserving professional differences; that ing motivations to collaborate and different although some role substitution is possible, there is little interpretations of the process of collaboration itself. It evidence of role boundary blurring between professions, can thus be expected that the identification with the and that there is variation among staff whether they con- CLAHRCs may be impeded by them being heteroge- sider themselves first as a member of a particular profes- neous, temporary, network-type organisations without sion, or mainly as a member of a local team. Finally, in clear boundaries or a distinctive organisational image. their study of a multiprofessional radiotherapy unit, Reconciliation of multiple organisational identities of the Tagliaventi and Mattarelli [26] emphasise the importance CLAHRC participants with a new collaborative identity, of flexibility of professional identities as a facilitator of which is necessary for the attainment of a shared vision, knowledge transfer at the boundaries of different com- could thus prove difficult. Finally, the functional separa- munities, when CoP members, faced with the need to tion of research and implementation strands, which cooperate, temporarily suspend their community identity occurs in some CLAHRCs, may limit the opportunities for sharing practice, negotiating new identities, and in order to capture the languages and actions proper to knowledge transfer between the communities of the members of other communities. This has a number of implications for the CLAHRCs. researchers and practitioners. First, building a new, shared collaborative identity may be complicated by the perceived status differentials Summary between the professional groups, with medical doctors CLAHRCs and CoPs: the analytical perspective traditionally possessing more power, autonomy, and con- The CoP approach can be considered a mid-range the- trol. Second, professional collegiality, when members of a ory analysing the processes of joint working, identity profession have similar perceptions, values, and experi- building, and knowledge sharing as a function of smal- ences, may lead to the prevalence of traditional unipro- ler, sub-organisational groupings that are distinguished fessional CoPs over new multiprofessional communities. by shared practices, meanings, and epistemic cultures. Third, it is not clear to what extent those CLAHRC parti- Focusing on the issues related to learning, meaning, and cipants who work at the boundaries between uniprofes- identity within and across those groupings, it provides sional communities will be able to effectively extend their an insightful analytical approach that can complement professional identities and adjust to their new hybrid, more traditional, rationalistic, ‘stage-of-change’ theories boundary-spanning roles. Finally, at the individual level, used in the field of implementation research [66]. The it can be anticipated that committed participation in main strength of the CoP theory is that it is able to pro- cross-disciplinary CLAHRC projects might result in vide a basis for the development and delivery of theory- internal psychological conflicts, which may be repre- informed implementation interventions as well as their sented by the stressful disintegration of professional iden- evaluations, which is especially important in the current tity, as well as in tensions with those colleagues who still situationwhentheoryisnot sufficiently utilised in the operate in traditional uniprofessional communities. field of implementation research [67]. Because the CLAHRCs involve people who are at the All these factors make CoP a useful lens for looking at same time employed by other organisations, such as healthcare collaboration and analysing the range of universities, primary care trusts, and acute trusts, the issues that may be faced by initiatives such as CLAHRCs analysis of identity formation within the CLAHRC in the process of their interprofessional and inter- Kislov et al. Implementation Science 2011, 6:64 Page 8 of 10 http://www.implementationscience.com/content/6/1/64 organisational work. Although the CLAHRCs vary in solutions to the problem of joint working within the form and focus, they have to deal with the same set of CLAHRC. Instead, it suggests a brief list of questions to be major objectives, which can hardly be achieved without addressed when designing interventions and evaluations promoting effective collaboration between various groups informed by the CoP theory (See Table 2). of stakeholders. As highlighted by a recent external eva- The CLAHRCs have been charged with an ambitious luation of the CLAHRC for Leicestershire, Northampton- goal of creating a new, distributed model for the con- shire and Rutland, a special emphasis should be placed duct and application of applied health research that on the incorporation of social science and management links producers and users of research. It could be hypothesised that producing a sustainable change in the sciences into the CLAHRC projects, encouraging inter- disciplinary learning within the CLAHRC and developing ways applied health research is conducted and imple- a more integrated partnership for the operation of the mented might require the cultivation of new multipro- CLAHRC [68]. As the paper has attempted to demon- fessional and multi-organisational CoPs within the strate, the CoP approach may be a useful heuristic for CLAHRCs, united by shared practice and a shared sense understanding and informing these processes. of belonging. However, the formation of these commu- nities may be hampered by unfavourable contextual fac- CLAHRCs and CoPs: the instrumental perspective tors, while participants’ identification with the Like any other healthcare partnerships and collaboratives, collaborations may be influenced by issues related to the CLAHRCs have to co-exist and integrate with a con- professional power, autonomy, and collegiality–as well stellation of various well-established, mainly uniprofes- as their commitment to the institutions from which they sional, communities of researchers, doctors, nurses, originate. In addition, the evidence on the existence and managers, and other healthcare professionals. These com- effects of such CoPs remains sketchy; even if active and munities have distinct and partially incompatible epistemic effective CoPs, whether organic or deliberately culti- cultures, which leads to the formation of multiple seman- vated, develop within the CLAHRCs, their manageability tic, syntactic, and pragmatic boundaries hampering the is likely to remain limited. process of joint working. Not only can the CoP approach illuminate these boundaries; it can also suggest ways of Analytical and theoretical perspectives: integration and crossing them to enable knowledge transfer and organisa- future research tional learning. There may exist multiple ways of influen- The literature deploying the instrumental perspective on cing the CoPs involved in the CLAHRC projects that still CoPs and concerned with their ‘cultivation,’ tends to need to be assessed and evaluated by empirical research. take the very possibility of deliberate creation of such This paper will therefore avoid providing prescriptive communities for granted. It mainly focuses on the Table 2 Issues to be addressed by the collaborative projects informed by the CoP theory Area Questions to be considered Knowledge sharing between existing CoPs involved in a � What are the main CoPs involved in a project? multiprofessional/multi-organisational project � What are the boundaries between those communities? � What are the existing communication patterns within and across those communities? � What potential knowledge brokers can be involved in the project? � What boundary objects might be used to link separated CoPs? � What boundary interactions between the CoPs can be facilitated by the project? Development of new interdisciplinary and inter-organisational � What is being done to promote the formation of new boundary practices communities of practice centred around the activities of the collaboration? � What are the existing networks that the project can link to? � Is building a community recognised as a priority by the management of the project? � What is being done to make the boundaries of the new community permeable and promote knowledge transfer to other settings? Developing sufficient identification with the Collaboration � What is the distribution of power between the key individuals and communities involved in the project? � Does the project create a positive image that may persuade professionals to join it and work constructively in a collaborative way? � How is the development of functional flexibility and hybrid professional roles supported by the project? � How does the project satisfy expectations, agendas and motivations of different parties involved? � How can potential problems relating to multimembership in several communities be envisaged and prevented? Kislov et al. Implementation Science 2011, 6:64 Page 9 of 10 http://www.implementationscience.com/content/6/1/64 3. le May A: Communities of Practice in Health and Social Care. Oxford: advantages of using this approach, but does not seem to Wiley-Blackwell; 2009. provide sufficient explanation of how these newly 4. Collaborations for Leadership in Applied Health Research and Care. formed CoPs develop, what characteristics they possess, [http://www.nihr.ac.uk/files/pdfs/CLAHRC%20-%20Call%20for%20Proposals% 20for%20Pilots.pdf]. and how they interact with a wider organisational con- 5. NIHR Collaborations for Leadership in Applied Health Research and Care text. To address these issues, further empirical research (CLAHRCs). [http://www.nihr.ac.uk/infrastructure/Pages/ is required, based on the combination of the analytical infrastructure_clahrcs.aspx]. 6. Cooksey D: A review of UK health research funding. London: The and instrumental perspectives on CoPs outlined above. Stationery Office; 2006. This complex perspective may provide more insight in 7. Evaluating Partnerships between Universities and NHS Organisations: the processes taking place in CoPs that have been delib- Learning from the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC). [http://www.sdo.nihr.ac.uk/files/researchcall/ erately cultivated for enhancing knowledge exchange, 1075-brief.pdf]. learning, and innovation. It may also help to identify key 8. Wenger E: Communities of practice: learning, meaning and identity. differences between the ‘organic’ and ‘deliberate’ CoPs, Cambridge: Cambridge University Press; 1998. 9. Wenger E, McDermott RA, Snyder W: Cultivating communities of practice: a and answer the question of whether we should attempt guide to managing knowledge. Boston, MA: Harvard Business Press; 2002. to cultivate new CoPs or focus on fostering a better 10. Brown JS, Duguid P: Organizational Learning and Communities-of- relationship between the existing organic ones instead. Practice: Toward a Unified View of Working, Learning and Innovation. Organization Science 1991, 2:40-57. It should also be emphasised that both theoretical and 11. Iverson JO, McPhee RD: Communicating Knowing through Communities empirical CoP literature has mainly focused on unipro- of Practice: Exploring Internal Communicative Processes and Differences fessional CoPs. As a result, the development, function- among CoPs. Journal of Applied Communication Research 2008, 36:176-199. 12. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham ID: Evolution of ing, and effects of multiprofessional and multi-agency Wenger’s concept of community of practice. Implementation Science 2009, CoPs, be they organic or cultivated, remains an underre- 4:11. searched area. Further research is required to identify 13. Hildreth PM: Going virtual: distributed communities of practice. London: Idea Group Publishing; 2004. contextual factors that can facilitate their formation, 14. 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Pawson R, Tilley N: Realistic Evaluation. London: SAGE Publications; 1997. 19. Sayer A: Realism and Social Science. London: SAGE Publications; 2000. sational and multiprofessional CoPs. 20. Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N: Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of Acknowledgements research findings. Journal of Clinical Epidemiology 2005, 58:107-112. This paper is based on a literature review conducted for the study entitled: 21. Wenger E: Communities of practice and social learning systems: the ‘Multiprofessional Communities of Practice in Healthcare Organisations: career of a concept. In Social Learning Systems and Communities of Practice. Formation, Identity Building and Knowledge Sharing’ that is jointly funded Edited by: Blackmore C. London: Springer; 2010:. by Your Manchester Fund Research Impact Scholarship and CLAHRC PhD 22. Bate SP, Robert G: Knowledge management and communities of practice Studentship. 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Collaborations for Leadership in Applied Health Research and Care: lessons from the theory of communities of practice

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Springer Journals
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Copyright © 2011 by Kislov et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Health Promotion and Disease Prevention; Health Administration; Health Informatics; Public Health
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Abstract

Background: The paper combines the analytical and instrumental perspectives on communities of practice (CoPs) to reflect on potential challenges that may arise in the process of interprofessional and inter-organisational joint working within the Collaborations for Leaderships in Applied Health Research and Care (CLAHRCs)–partnerships between the universities and National Health Service (NHS) Trusts aimed at conducting applied health research and translating its findings into day-to-day clinical practice. Discussion: The paper discusses seminal theoretical literature on CoPs as well as previous empirical research on the role of these communities in healthcare collaboration, which is organised around the following three themes: knowledge sharing within and across CoPs, CoP formation and manageability, and identity building in CoPs. It argues that the multiprofessional and multi-agency nature of the CLAHRCs operating in the traditionally demarcated organisational landscape of the NHS may present formidable obstacles to knowledge sharing between various professional groupings, formation of a shared ‘collaborative’ identity, and the development of new communities within the CLAHRCs. To cross multiple boundaries between various professional and organisational communities and hence enable the flow of knowledge, the CLAHRCs will have to create an effective system of ‘bridges’ involving knowledge brokers, boundary objects, and cross-disciplinary interactions as well as address a number of issues related to professional and organisational identification. Summary: The CoP approach can complement traditional ‘stage-of-change’ theories used in the field of implementation research and provide a basis for designing theory-informed interventions and evaluations. It can help to illuminate multiple boundaries that exist between professional and organisational groups within the CLAHRCs and suggest ways of crossing those boundaries to enable knowledge transfer and organisational learning. Achieving the aims of the CLAHRCs and producing a sustainable change in the ways applied health research is conducted and implemented may be influenced by how effectively these organisations can navigate through the multiple CoPs involved and promote the development of new multiprofessional and multi-organisational communities united by shared practice and a shared sense of belonging–an assumption that needs to be explored by further empirical research. Introduction currently being used to analyse and facilitate knowledge Since being identified as a mechanism through which sharing in a wide range of organisational environments, knowledge is held, transferred, and created, the commu- including, but not limited to, business sector, education, nities of practice (CoP) approach has become increas- information technology (IT) and healthcare organisa- ingly influential within management research and tions. In the healthcare sector, CoPs have been argued practice [1]. Originally developed by Lave and Wenger to play a role in the generation of social, human, organi- [2] in a study of situated learning, the CoP theory is sational, professional, and patient capital, thus being potentially useful for enhancing care, providing learning * Correspondence: [email protected] opportunities, analysing practice, problem-solving, shar- Manchester Business School, The University of Manchester, Booth Street ing knowledge, and generating ideas [3]. West, Manchester, M15 6PB, UK © 2011 Kislov et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kislov et al. Implementation Science 2011, 6:64 Page 2 of 10 http://www.implementationscience.com/content/6/1/64 This paper will use the CoP approach as a lens to look and thus address the ‘second gap in translation’–agap at interprofessional and inter-organisational joint work- in the translation of new medical interventions into ing within the Collaborations for Leadership in Applied everyday practice identified by Cooksey’s Review of UK Health Research and Care (CLAHRCs)–partnerships Health Research Funding [6]. They have three key inter- between the universities and National Health Service linked functions: conducting high quality applied health (NHS) Trusts aimed at conducting applied health research; implementing the findings from research in research and translating its findings into day-to-day clin- clinical practice; and increasing the capacity of NHS ical practice. It will briefly discuss some of the seminal organisations to engage with and apply research. It should also be noted that the CLAHRCs are situation- theoretical CoP literature as well as previous empirical research on the role of CoPs in healthcare collaboration, ally placed, with their agendas being determined by the using CoPs as a lens to reflect on potential challenges partnering organisations and tailored to the healthcare that the CLAHRCs will have to address in order to needs in their respective geographical areas. achieve their objectives. It will argue that the multipro- The CLAHRCs can be considered as a somewhat fessional and multi-agency nature of the CLAHRCs experimental approach designed to further our under- operating in the traditionally demarcated organisational standing of large-scale collaborations as an implementa- landscape of the NHS may present formidable obstacles tion tool–both by internal testing of new initiatives to knowledge sharing between various professional aimed at implementation of research findings into day- groupings, effective identification with the Collaboration, to-day practice, and as the subject of a number of and the formation of new multiprofessional commu- ongoing external evaluations commissioned by the nities within the CLAHRCs. NIHR Service Delivery and Organisation (SDO) pro- The paper will start with a brief discussion of the gramme [7]. These internal and external evaluations are structure and purposes of the CLAHRCs and the main supposed to contribute to the evidence base on the effi- premises of the CoP approach. It will then explore the ciency and effectiveness of collaboration and other stra- following three interrelated strands within the wider tegies aimed at increasing applied health research use in CoP literature: knowledge sharing across CoPs; CoP for- multiple populations and settings. However, the process mation and manageability; and CoP identity building. of evaluating the CLAHRC processes and outcomes is The paper will conclude by discussing the advantages of still at the initial stage, which explains why so little applying the CoP theory to healthcare partnerships, empirical research on the CLAHRCs has been published summarising the key issues that need to be addressed by so far. This paper will explore an alternative way of the CLAHRCs and similar organisations in order to looking at the subject; it will attempt to draw some les- achieve their aims, and reflecting on the implications for sons for the CLAHRCs by analysing healthcare colla- future research in this area. boration through the lens of CoPs. In doing so, it will refer to the seminal works on CoPs published by Eti- Background enne Wenger [2,8,9], as well as empirical studies that Collaborations for Leadership in Applied Health Research have used CoPs in healthcare settings, either as an ana- and Care lytical approach or as a knowledge management tool. In 2008, another major experiment was launched in the English NHS: CLAHRCs were established across Eng- Communities of practice land. Each CLAHRC represents a collaborative partner- A community of practice (CoP) is ‘agroup of people ship between one or more universities and their who share a concern, a set of problems, or a passion surrounding NHS organisations aiming to undertake about a particular topic, and who deepen their under- high-quality, patient-centred applied health research and standing and knowledge of this area by interacting on to support the translation of research evidence into clin- an ongoing basis’ [9]. CoPs can range in size; they can ical practice. In total, nine CLAHRCs were selected be long or short lived, co-located or distributed, homo- through an open competition out of twenty-two bids, geneous or heterogeneous, spontaneous or intentional, with particular value being placed on research proposals unrecognised or institutionalised. Organisations can in targeted at chronic disease and public health interven- turn be interpreted as the ‘communities of communities’ tions. Each of them will receive up to £10 m over five [10], or ‘constellations of interconnected CoPs’ [8]. years from the National Institute for Health Research Wenger formulates three defining characteristics of (NIHR), with additional matched funding to be secured CoPs. First, CoP members interact with one another, from the participating NHS organisations to at least the establishing relationships and negotiating meaning of same level as that provided by the NIHR [4,5]. their actions through mutual engagement.Second, The CLAHRCs are expected to enhance knowledge members are bound together by an understanding of a transfer between academic researchers and NHS staff sense of joint enterprise, which entails a common set of Kislov et al. Implementation Science 2011, 6:64 Page 3 of 10 http://www.implementationscience.com/content/6/1/64 tasks that CoP members can influence. Finally, they pro- rather than distinction, between ‘the theoretical’ and ‘the duce over time a shared repertoire of routines, words, empirical’ [15,16], the paper will look both at the semi- tools, stories, symbols, or concepts that become part of nal theoretical writings on CoPs and relevant empirical the CoP practice [8]. Iverson and McFee [11] argue that applications of the theory. Second, because critical rea- mutual engagement, joint enterprise, and shared reper- lism admits some form of theoretical eclecticism [16,17], toire can be used to determine the existence of CoPs, the paper will also be referring to other theoretical tra- distinguish between different CoPs, and evaluate com- ditions that have developed outside the CoP approach municative processes in them. However, in his later but are compatible with its premises (e.g., literature on work Wenger reformulates these characteristics and pre- professionalism, sociology of science, and knowledge sents the ‘structural model’ of CoPs consisting of three transfer). Finally, because the focus of the realist episte- fundamental elements: a domain of knowledge, which mology is ‘generative mechanisms’ producing outcomes defines a set of issues; a community of people who care in certain contexts [18,19], the paper will mainly con- about this domain; and the shared practice that they are centrate on the processes taking place in CoPs, rather developing to be effective in their domain [9]. than reflect on the definitional clarity of the concept or According to Wenger et al. [9], CoPs can be distin- lack thereof. guished from formal departments, project teams, com- It should also be noted that the analysis of Wenger’s munities of interest and informal networks along the germinal works shows that the concept and theory of following five dimensions: CoPs is still evolving. Originating as a mid-level analyti- 1. Purpose: to create, expand and exchange knowl- cal tool of the theory of social learning that embraces edge, and to develop individual capabilities; community, identity, meaning, and practice, it later was 2. Membership: self-selection based on expertise or seen as a technique deliberately used by managers to passion for the topic; improve knowledge transfer and organisational perfor- 3. Boundaries: fuzzy; mance. This resulted in the development of two differ- 4. What holds them together: passion, commitment, ent perspectives on CoPs: analytical, using CoPs as a and identification with the group and its expertise; theoretical heuristic to analyse practice; and instrumen- 5. Life cycle: CoPs evolve and end organically; they tal, used with an intention to cultivate CoPs or utilise last as long as there is relevance to the topic and inter- them in order to achieve desirable aims. Although there est in learning together. is an inherent tension between these perspectives, the This distinction has, however, been criticised for being paper will be referring to both of them: first, because rather vague and contradictory; for instance, the notion the instrumental approach to CoPs is a natural conse- of self-selection contradicts the generally accepted pre- quence of their use as a theoretical concept, for all mise that people from the same discipline automatically social science theories inevitably have practical implica- belong to the same CoP [12]. It also does not take into tions, especially in the field of implementation research account the possibility that, under certain conditions, a [20] and, second, because this combination may be par- project team may develop CoP characteristics and hence ticularly productive both for research and practice [21]. become a ‘true’ CoP [13]. This has led some authors to In line with the two main perspectives outlined above, suggest that the CoP is actually an umbrella term for a CoPs are being increasingly used both as a theoretical number of different organisational groupings that are approach to analyse healthcare organisations and as a characterised by the support for formal and informal practical tool enabling collaborative learning and knowl- interaction between novices and experts, the emphasis edge mobilisation. The CoP approach has previously on learning and sharing knowledge, and the investment been applied to the analysis of healthcare collaboration to foster the sense of belonging among members on at least one occasion. Bate and Robert [22] showed [12,13]. As shown by Li et al. [14] in their systematic that NHS quality improvement collaboratives, which are review, this rather loose interpretation of the CoP con- aimed at closing the gap between potential and actual cept gets reflected in the empirical research reports, performance by testing and implementing changes with the examples of CoPs including informal learning quickly across many organisations [23], are likely to groups, clinical placements, and healthcare remain time-limited projects unable to achieve sustain- collaboratives. able organisational change unless linked and active CoPs are formed within them. The paper develops this idea by Applying the CoP approach to the CLAHRCs providing a brief review of theoretical and empirical lit- The structure, content, and narrative of the paper will erature on CoPs that is organised around the following be underpinned by the critical realist epistemological three themes: knowledge sharing within and across CoPs; CoP formation and manageability; and CoP iden- approach adopted by the authors. First, because this tity building. It will attempt to analyse the processes of approach suggests that there is an interdependence, Kislov et al. Implementation Science 2011, 6:64 Page 4 of 10 http://www.implementationscience.com/content/6/1/64 joint working within the CLAHRCs using the CoP the- organisations. The problem of interaction and knowl- ory, identify potential problems that may arise in the edge sharing within the CLAHRC teams can potentially process of healthcare collaboration, and reflect on the occur at multiple points. First, there will be inevitable possibility of the development of new multiprofessional tensions in the communication between the ‘worlds’ of and multi-organisational CoPs within the CLAHRCs. researchers and practitioners, who can have difficulties communicating with each other given the differences in their epistemic cultures [39]. Second, it should be noted Discussion that both of these worlds are not homogeneous; on the CoP knowledge sharing contrary, they are represented by different professional The CoP concept emerged within the situated theory of learning that views practice–i.e., a domain of collective and occupational CoPs. Thus, we could expect tensions knowing and doing–as the means through which knowl- between clinical researchers employed by medical edge dynamics in an organisation unfold. In a socially schools, whose mode of functioning is largely based on situated view of learning, individuals continuously com- a positivist biomedical paradigm, and the implementa- bine and modify knowledge through their everyday tion researchers representing social sciences and often operations and interactions between each other [24-26]. adopting more descriptive ethnographic approaches to Apart from explicit, codifiable, ‘know-that’ knowledge, organisations grounded, for instance, in social construc- collective practice generates a great deal of tacit, ‘know- tionism and symbolic interactionism. Similarly, the how’ knowledge, which is embodied in the CoP members’ ‘world’ of clinicians also consists of multiple professional practical skills and expertise [27]. As a result, homoge- groupings: doctors, nurses, and allied health profes- neous and well-established CoPs create distinct epistemic sionals, with different medical specialities (e.g., surgeons, cultures–i.e., cultures that ‘create and warrant knowl- neurologists, cardiologists) tending to form their own edge,’ making up ‘howweknowwhatweknow’ [28]. communities, which often spread across organisations, Knowledge can flow relatively easily within such cultures, but are still likely to retain their own disciplinary whereas it can become sticky at the boundaries between boundaries when co-located in the CLAHRCs with them [29]. The boundaries between CoPs can be classi- other professions. Finally, there is a boundary between fied as syntactic (difference in language), semantic (differ- clinical practice and healthcare management–two fields ence in meaning), and pragmatic (difference in practice), with profound differences in cultures, perceptions of the latter being most difficult to overcome [30,31]. research evidence, and the nature of decision-making The presence of distinct epistemic cultures and processes [40]. To cross these boundaries, the CLAHRCs might utilise boundaries in healthcare has been demonstrated by pre- vious empirical research. It has shown, for instance, that the following types of bridges (see also Table 1 for more doctors, nurses, and managers have different attitudes to examples): organisational change that are deeply embedded in their professional cultures [32-35], and that there are multiple differences of values, structures, education, and relation- Table 1 ’Bridges’ that could be used by the CLAHRCs to cross the boundaries between CoPs ships between the acute and primary care sectors [36]. Professional CoPs in healthcare are predominantly uni- Type Examples disciplinary, tend to seal themselves off from neighbour- Knowledge brokers Clinical managers Clinicians involved in management ing professional communities and are highly Clinicians involved in research institutionalised, which facilitates knowledge flow within Clinicians involved in quality improvement their boundaries, but causes the ‘stickiness’ of knowl- Internal facilitators (e.g., knowledge transfer associates) edge across them [37]. The epistemic boundaries are External facilitators (e.g., management consultants) especially problematic when different professions are co- Boundary objects Dashboards located within multiprofessional organisations. The co- Websites existence of partially incompatible epistemic cultures Powerpoint presentations Quality and outcomes framework (QOF) challenges knowledge sharing that occurs in a context of Primary care registers potential tensions and conflict [38]. Patient alert cards These findings have direct implications for the Clinical pathways and protocols Assessment tools CLAHRCs as large-scale multiprofessional and multi- Boundary Face-to-face meetings agency network organisations that bring together mem- interactions Practice visits bers of different, well-established CoPs with clearly Learning sessions demarcated boundaries, distinct and partially incompati- Online forums WebEx conferences ble epistemic cultures and, especially in the case of med- Focus groups ical professionals, supported by powerful professional Kislov et al. Implementation Science 2011, 6:64 Page 5 of 10 http://www.implementationscience.com/content/6/1/64 1. Knowledge brokers–people who, having member- CoPinits ownright.One oftheCLAHRCaimsisto ship in several CoPs, seek to facilitate interaction and ‘link those who conduct applied health research with all coordinate practice between them. Knowledge brokering those who use it in practice across the health commu- is often performed by individuals with hybrid profes- nity covered by the collaboration’ [7]. This may be inter- sional roles–for example, clinical managers may span preted as an imperative for creating new boundaries between the management and the medical multiprofessional and multi-organisational CoPs within professions [41,42]. the CLAHRC projects, which would bring together 2. Boundary objects–artifacts, discourses, and pro- representatives of multiple communities. The following cesses possessing interpretative flexibility that allows subsection will explore the literature concerned with the them to overcome syntactic, semantic, and pragmatic development of multiprofessional and multi-organisa- boundaries, and hence contribute to knowledge transfer tional CoPs in collaborative settings. across CoPs [43,44]. For example, x-rays and treatment The issue of CoP formation has been viewed differ- protocols have been shown to play the role of boundary ently in the seminal CoP literature and remains an area objects in a multidisciplinary cancer care team [45]. of debate. CoPs, as defined by Lave and Wenger [2], 3. Boundary interactions among people from different cannot be deliberately designed by managers; an organi- CoPs–these include single or discrete boundary encoun- sation can only establish a team for a particular project, ters (e.g., meetings, visits, and delegations) and longer- which may later emerge as a CoP [1]. Wenger and Sny- lived practice-based connections, including cross-disci- der [48] suggest that managers cannot mandate CoPs plinary projects [8,24]. because the organic, spontaneous, and informal nature Cross-disciplinary projects, including those implemen- of the communities makes them resistant to supervision tedbytheCLAHRCs, canbeconsideredasa variantof and interference. At the same time they argue that CoPs boundary practice because participating in this kind of may benefit from cultivation by managers, who should project exposes practitioners to specific tasks going identify communities that can potentially enhance the beyond their normal practices and forces them to company’s strategic capabilities and provide the infra- negotiate their own competences with the competencies structure that will support such communities and enable of others. While it is possible that some of the CLAHRC them to apply their expertise effectively. More recent multidisciplinary projects may indeed become a bridge contributions suggest that CoPs can be cultivated inten- between different CoPs (this possibility will be addressed tionally; furthermore, these deliberate communities may in more detail in the next subsection), the following be more useful for an organisation than the organic potential obstacles to knowledge sharing within these ones [9,49]. projects need to be considered. First, these boundary Under the influence of the theoretical literature mainly projects can become CoPs in their own right and concerned with private sector organisations, deliberately develop their own boundaries, which can prevent them constructed CoPs are getting increasingly used as a from functioning as knowledge brokers between the knowledge management tool in healthcare. Although wider communities these newly formed CoPs had the empirical evidence is still limited, it can be con- intended to link [46]. Second, as far as the level of indi- cluded that the formation of a genuine multiprofessional vidual knowledge brokers is concerned, full participation CoP is rare but possible [37]. The CoP approach has in one CoP may render brokering difficult: those with been demonstrated to enhance interprofessional clinical multimembership seeking to coordinate across CoPs practice [50], facilitate quality improvement, encourage may have difficulties participating fully as members of buy-in among participants, promote knowledge transfer one community if they have allegiances in another [24]. [51], and contribute to the development of services Finally, some of the more excessively formalised bound- spanning the interests of different stakeholders [52]. The ary objects, such as project plans, performance targets, following key factors that influence the development, or clinical guidelines can become a barrier to successful functioning and maintenance of multiprofessional CoPs collaboration by legitimising interprofessional differ- have been described: membership–selecting the mem- ences, reinforcing existing power structures, and main- bers, the extent (active or passive) and legitimacy of taining occupational control over task areas [25,47]. their involvement; commitment to the desired goals; relevance to local communities and the existing services; CoP formation and manageability enthusiasm; infrastructure to support the work of CoPs; As shown in the previous subsection, one of the ways to skills in accessing and appraising evidence; and enhance knowledge transfer and learning at the bound- resources [52]. aries between CoPs is the creation of a cross-disciplinary However, it should be emphasised that several crucial questions about the formation of multiprofessional CoPs project that can act as a bridge between CoPs and, still remain unanswered. First, it is not clear what under certain conditions, become a multiprofessional Kislov et al. Implementation Science 2011, 6:64 Page 6 of 10 http://www.implementationscience.com/content/6/1/64 organisational, group-level, and individual factors may personal, political, and professional agendas of the parti- enhance the transition from a team to a CoP. Second, in cipants [57]. It can thus be concluded that the deliberate spite of the reports describing the deliberate formation cultivation of multiprofessional CoPs within the of ‘genuine’ multiprofessional CoPs from scratch, their CLAHRCs might help to solve the problems of knowl- description is often not informative enough to judge to edge sharing outlined in the previous subsection, but what extent these groupings differ from the project the extent to which these CoPs can be constructed and directed remains unclear. teams in terms of achieving mutual engagement, joint enterprise, and shared repertoire. It may well be that the groupings that are labelled as CoPs represent a rhetori- CoP identity building cal device rather than organic CoPs characterised by The concept of identity building occupies one of the shared practice and sense of belonging. Finally, we do central places in the CoP approach that emphasises that not know whether and how horizontal, informal, egali- the negotiation of a common identity is a prerequisite tarian multiprofessional communities can emerge and for forming a community. Wenger [8] suggests the fol- function in acontext wherethey havetoco-existwith lowing characterisations of identity: the vertical, formal, command-and-control structures of 1. Identity as negotiated experience: participation in a the NHS, given the evidence suggesting that the exces- CoP and (often unspoken) negotiating the meanings of sive legitimisation and formalisation of ‘organic’ CoPs this experience with other CoP members; can disrupt, rather than support, their knowledge-shar- 2. Identity as community membership: translation of ing capacity [53,54]. the CoP membership into an identity as a form of Compared to the previous collaboration initiatives in competence; the NHS, the CLAHRCs are characterised by the more 3. Identity as a learning trajectory: a coherent process voluntary nature of involvement, placement in the con- of changing forms of participation within a CoP over text of local healthcare needs, and an emphasis on capa- time; city building and learning. These factors may increase 4. Identity as nexus of multimembership: an experi- the probability of supplying newly formed multiprofes- ence of multimembership in various CoPs and reconci- sional projects with enthusiastic members who will be liation of different identities to maintain one identity committed to achieving the relevant goals, thus addres- across boundaries; sing some of the factors mentioned above as prerequi- 5. Identity as a relation between the local and the glo- sites for the formation of multiprofessional CoPs. It has bal: negotiating local ways of belonging to broader con- also been suggested that the CLAHRC being co-funded stellations of CoPs. by the NIHR and the NHS Trusts will result in a colla- Regardless of whether there is an explicit intention to borative model of ownership with a broad range of sta- cultivate CoPs within the CLAHRC or any other colla- keholders having a vested interest in shaping the boration, the multiprofessional and multi-agency envir- strategic direction of the collaboration [55]. It is, how- onment in which these projects are located mandates an ever, unclear whether this will lead to the formation of understanding how a new ‘collaborative’ identity is CoPs, given the potentially conflicting partners’ agendas, negotiated by the participants. It should be noted, how- the continuous process of NHS reform distracting orga- ever, that the processes of identity formation in multi- nisational resources from joint working and, most professional and multi-agency CoPs are not specifically importantly, the dynamic membership within the addressed in the seminal CoP literature. To discuss CLAHRCs, given the potential for NHS trusts to opt potential problems related to the formation of the ‘colla- out of the collaboration should their priorities change. borative’ identities within the CLAHRC, it is helpful to Whether formed organically within the CLAHRC refer to the concepts of professional and organisational cross-disciplinary projects or deliberately cultivated by identification. the CLAHRC management, the multiprofessional CoPs Professional identity can be defined as ‘the relatively will have to be maintained, directed, and controlled to stable and enduring constellation of attributes, beliefs, achieve desired aims. Paradoxically, while it has been values, motives, and experiences in terms of which peo- suggested that managers play a critical role in construct- pledefinethemselvesinaprofessionalrole’ [58]. ing, aligning, and supporting CoPs [9,49], there is little Though professional identity is not static, there seems empirical evidence for these assertions. Furthermore, it to be a core identity that remains stable and with which has been argued that managers are incapable of making all members are able to identify. Around this lies an the CoP a direct instrument of policy and control [56]. extended identity that is subject to modification as the In spite of facilitation, the knowledge transfer in these result of widening fields of work, increased knowledge communities does not necessarily follow the model of and skills, changes in attitudes and values, or re-inter- evidence-based practice, but is shaped strongly by the pretation of old ones [59]. It should also be emphasised Kislov et al. Implementation Science 2011, 6:64 Page 7 of 10 http://www.implementationscience.com/content/6/1/64 that the development of professional identity in health- cross-disciplinary projects should also consider the care professions should be analysed in relation to the notion of organisational identification. This is defined as concepts of professional dominance, collegiality and a ‘form of psychological attachment that occurs when autonomy [60]. members adopt the defining characteristics of the organi- Several empirical studies are worth mentioning in this sation as defining characteristics for themselves’ [63]. A respect. In a qualitative study on interagency and inter- member’s level of organisational identification indicates the degree to which his/her membership in an organisa- professional teams in the NHS, Robinson and Cottrell tion is tied to the content of his/her self-concept [64]. [61] argue that in multiprofessional work, professional Organisational identification is most likely to occur knowledge boundaries can become blurred and profes- sional identity can be challenged as roles and responsibil- under conditions where the boundaries between one’s ities change. As a result, team members may struggle to own organisation and other organisations are salient, cope with the disintegration of one version of profes- when membership in the organisation is attractive, and sional identity before a new version can be built. Baxter when organisational categories best account for similari- and Brumfitt [62] examine interprofessional practice in ties and differences across individuals and groups [65]. multidisciplinary stroke care and conclude that the depth Organisations forming the CLAHRCs may have differ- of professional knowledge and skills is perceived as the ing organisational cultures as well as potentially conflict- core element in preserving professional differences; that ing motivations to collaborate and different although some role substitution is possible, there is little interpretations of the process of collaboration itself. It evidence of role boundary blurring between professions, can thus be expected that the identification with the and that there is variation among staff whether they con- CLAHRCs may be impeded by them being heteroge- sider themselves first as a member of a particular profes- neous, temporary, network-type organisations without sion, or mainly as a member of a local team. Finally, in clear boundaries or a distinctive organisational image. their study of a multiprofessional radiotherapy unit, Reconciliation of multiple organisational identities of the Tagliaventi and Mattarelli [26] emphasise the importance CLAHRC participants with a new collaborative identity, of flexibility of professional identities as a facilitator of which is necessary for the attainment of a shared vision, knowledge transfer at the boundaries of different com- could thus prove difficult. Finally, the functional separa- munities, when CoP members, faced with the need to tion of research and implementation strands, which cooperate, temporarily suspend their community identity occurs in some CLAHRCs, may limit the opportunities for sharing practice, negotiating new identities, and in order to capture the languages and actions proper to knowledge transfer between the communities of the members of other communities. This has a number of implications for the CLAHRCs. researchers and practitioners. First, building a new, shared collaborative identity may be complicated by the perceived status differentials Summary between the professional groups, with medical doctors CLAHRCs and CoPs: the analytical perspective traditionally possessing more power, autonomy, and con- The CoP approach can be considered a mid-range the- trol. Second, professional collegiality, when members of a ory analysing the processes of joint working, identity profession have similar perceptions, values, and experi- building, and knowledge sharing as a function of smal- ences, may lead to the prevalence of traditional unipro- ler, sub-organisational groupings that are distinguished fessional CoPs over new multiprofessional communities. by shared practices, meanings, and epistemic cultures. Third, it is not clear to what extent those CLAHRC parti- Focusing on the issues related to learning, meaning, and cipants who work at the boundaries between uniprofes- identity within and across those groupings, it provides sional communities will be able to effectively extend their an insightful analytical approach that can complement professional identities and adjust to their new hybrid, more traditional, rationalistic, ‘stage-of-change’ theories boundary-spanning roles. Finally, at the individual level, used in the field of implementation research [66]. The it can be anticipated that committed participation in main strength of the CoP theory is that it is able to pro- cross-disciplinary CLAHRC projects might result in vide a basis for the development and delivery of theory- internal psychological conflicts, which may be repre- informed implementation interventions as well as their sented by the stressful disintegration of professional iden- evaluations, which is especially important in the current tity, as well as in tensions with those colleagues who still situationwhentheoryisnot sufficiently utilised in the operate in traditional uniprofessional communities. field of implementation research [67]. Because the CLAHRCs involve people who are at the All these factors make CoP a useful lens for looking at same time employed by other organisations, such as healthcare collaboration and analysing the range of universities, primary care trusts, and acute trusts, the issues that may be faced by initiatives such as CLAHRCs analysis of identity formation within the CLAHRC in the process of their interprofessional and inter- Kislov et al. Implementation Science 2011, 6:64 Page 8 of 10 http://www.implementationscience.com/content/6/1/64 organisational work. Although the CLAHRCs vary in solutions to the problem of joint working within the form and focus, they have to deal with the same set of CLAHRC. Instead, it suggests a brief list of questions to be major objectives, which can hardly be achieved without addressed when designing interventions and evaluations promoting effective collaboration between various groups informed by the CoP theory (See Table 2). of stakeholders. As highlighted by a recent external eva- The CLAHRCs have been charged with an ambitious luation of the CLAHRC for Leicestershire, Northampton- goal of creating a new, distributed model for the con- shire and Rutland, a special emphasis should be placed duct and application of applied health research that on the incorporation of social science and management links producers and users of research. It could be hypothesised that producing a sustainable change in the sciences into the CLAHRC projects, encouraging inter- disciplinary learning within the CLAHRC and developing ways applied health research is conducted and imple- a more integrated partnership for the operation of the mented might require the cultivation of new multipro- CLAHRC [68]. As the paper has attempted to demon- fessional and multi-organisational CoPs within the strate, the CoP approach may be a useful heuristic for CLAHRCs, united by shared practice and a shared sense understanding and informing these processes. of belonging. However, the formation of these commu- nities may be hampered by unfavourable contextual fac- CLAHRCs and CoPs: the instrumental perspective tors, while participants’ identification with the Like any other healthcare partnerships and collaboratives, collaborations may be influenced by issues related to the CLAHRCs have to co-exist and integrate with a con- professional power, autonomy, and collegiality–as well stellation of various well-established, mainly uniprofes- as their commitment to the institutions from which they sional, communities of researchers, doctors, nurses, originate. In addition, the evidence on the existence and managers, and other healthcare professionals. These com- effects of such CoPs remains sketchy; even if active and munities have distinct and partially incompatible epistemic effective CoPs, whether organic or deliberately culti- cultures, which leads to the formation of multiple seman- vated, develop within the CLAHRCs, their manageability tic, syntactic, and pragmatic boundaries hampering the is likely to remain limited. process of joint working. Not only can the CoP approach illuminate these boundaries; it can also suggest ways of Analytical and theoretical perspectives: integration and crossing them to enable knowledge transfer and organisa- future research tional learning. There may exist multiple ways of influen- The literature deploying the instrumental perspective on cing the CoPs involved in the CLAHRC projects that still CoPs and concerned with their ‘cultivation,’ tends to need to be assessed and evaluated by empirical research. take the very possibility of deliberate creation of such This paper will therefore avoid providing prescriptive communities for granted. It mainly focuses on the Table 2 Issues to be addressed by the collaborative projects informed by the CoP theory Area Questions to be considered Knowledge sharing between existing CoPs involved in a � What are the main CoPs involved in a project? multiprofessional/multi-organisational project � What are the boundaries between those communities? � What are the existing communication patterns within and across those communities? � What potential knowledge brokers can be involved in the project? � What boundary objects might be used to link separated CoPs? � What boundary interactions between the CoPs can be facilitated by the project? Development of new interdisciplinary and inter-organisational � What is being done to promote the formation of new boundary practices communities of practice centred around the activities of the collaboration? � What are the existing networks that the project can link to? � Is building a community recognised as a priority by the management of the project? � What is being done to make the boundaries of the new community permeable and promote knowledge transfer to other settings? Developing sufficient identification with the Collaboration � What is the distribution of power between the key individuals and communities involved in the project? � Does the project create a positive image that may persuade professionals to join it and work constructively in a collaborative way? � How is the development of functional flexibility and hybrid professional roles supported by the project? � How does the project satisfy expectations, agendas and motivations of different parties involved? � How can potential problems relating to multimembership in several communities be envisaged and prevented? Kislov et al. Implementation Science 2011, 6:64 Page 9 of 10 http://www.implementationscience.com/content/6/1/64 3. le May A: Communities of Practice in Health and Social Care. Oxford: advantages of using this approach, but does not seem to Wiley-Blackwell; 2009. provide sufficient explanation of how these newly 4. Collaborations for Leadership in Applied Health Research and Care. formed CoPs develop, what characteristics they possess, [http://www.nihr.ac.uk/files/pdfs/CLAHRC%20-%20Call%20for%20Proposals% 20for%20Pilots.pdf]. and how they interact with a wider organisational con- 5. NIHR Collaborations for Leadership in Applied Health Research and Care text. To address these issues, further empirical research (CLAHRCs). [http://www.nihr.ac.uk/infrastructure/Pages/ is required, based on the combination of the analytical infrastructure_clahrcs.aspx]. 6. Cooksey D: A review of UK health research funding. London: The and instrumental perspectives on CoPs outlined above. Stationery Office; 2006. This complex perspective may provide more insight in 7. Evaluating Partnerships between Universities and NHS Organisations: the processes taking place in CoPs that have been delib- Learning from the NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC). 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Implementation Science – Springer Journals

Published: Jun 23, 2011

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