Learning and Caring in Communities of Practice (original) (raw)
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The Annals of Family Medicine, 2010
We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires fl exibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and fl exible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would defi ne common goals, cocreate care plans, and engage in refl ective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.
Shared care requires a shared vision: communities of clinical practice in a primary care setting
Journal of Clinical Nursing, 2017
Aims and objectives: To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. Background: To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. Design: Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. Method: Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. Findings: Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through Accepted Article This article is protected by copyright. All rights reserved. respectful dialogue. These common values-respect, authenticity, autonomy, compassion, trust, care ethics, holism-underpin the development of a shared vision of care. Conclusions: A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. Relevance to clinical practice: A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.
Contextualizing learning to improve care using collaborative communities of practices
BMC Health Services Research, 2016
Background: The use of interorganizational, collaborative approaches to build capacity in quality improvement (QI) in health care is showing promise as a useful model for scaling up and accelerating the implementation of interventions that bridge the "know-do" gap to improve clinical care and provider outcomes. Fundamental to a collaborative approach is interorganizational learning whereby organizations acquire, share, and combine knowledge with other organizations and have the opportunity to learn from their respective successes and challenges in improvement areas. This learning approach aims to create the conditions for collaborative, reflective, and innovative experiential systems that enable collective discussions regarding daily practice issues and finding solutions for improvement. Methods: The concepts associated with interorganizational learning and deliberate learning activities within a collaborative 'Communities-of-practice'(CoP) approach formed the foundation of the of an interactive QI knowledge translation initiative entitled PERFORM KT. Nine teams participated including seven teams from two acute care hospitals, one from a long term care center, and one from a mental health sciences center. Six monthly CoP learning sessions were held and teams, with the support of an assigned mentor, implemented a QI project and monitored their results which were presented at an end of project symposium. 47 individuals participated in either a focus group or a personal interview. Interviews were transcribed and analyzed using an iterative content analysis. Results: Four key themes emerged from the narrative dataset around experiences and perceptions associated with the PERFORM KT initiative: 1) being successful and taking it to other levels by being systematic, structured, and mentored; 2) taking it outside the comfort zone by being exposed to new concepts and learning together; 3) hearing feedback, exchanging stories, and getting new ideas; and 4) having a pragmatic and accommodating approach to apply new learnings in local contexts. Conclusions: Study findings offer insights into collaborative, inter-organizational CoP learning approaches to build QI capabilities amongst clinicians, staff, and managers. In particular, our study delineates the need to contextualize QI learning by using deliberate learning activities to balance systematic and structured approaches alongside pragmatic and accommodating approaches with expert mentors.
CMAJ Open
Background: Patients with multimorbidity often require services across different health care settings, yet team processes among settings are rarely implemented. We explored perceptions of specialists and family physicians collaborating in a telemedicine interprofessional consultation for patients with multimorbidity to better understand the value of bringing physicians together across the boundaries of health care settings. Methods: This was a descriptive qualitative, interview-based study. Physicians who had previously participated in the Telemedicine Interprofessional Model of Practice for Aging and Complex Treatments (Telemedicine IMPACT Plus [TIP] Program) were invited to participate and asked to describe their experience of being a member of the program. Interviews were conducted from March to May 2016. We conducted an iterative and interpretive process using both individual and team analysis to identify themes. Results: There were 15 participants, 9 specialists and 6 family physicians. Three themes emerged in the analysis: creating new perspectives on care for patients with multimorbidity by sharing knowledge, skills and attitudes; the shift from a consultant model to an interprofessional team model (allowing a window into the community, extending discussions beyond the medical model and focusing on the patient's health in context); and opportunities for learners, including learning about interprofessional collaboration and gaining exposure to a real-world model for caring for people with multimorbidity in outpatient settings. Interpretation: Family physicians and specialists participating in a TIP Program believed the program improved their knowledge and skills, while also serving as an effective care delivery strategy. The findings also support that learners require more exposure to nontraditional consultant models in order to care for patients with multimorbidity effectively.
Journal of Comorbidity
Background: The increase in multimorbidity or co-occurring chronic illnesses is a leading healthcare concern. Patients with multimorbidity require ongoing care from many different professionals and agencies, and often report a lack of integrated care. Objective: To explore the daily help-seeking behaviours of patients with multimorbidity, including which health professionals they seek help from, how professionals work together, and perceptions and characteristics of effective interprofessional, interagency multimorbidity care. Design: Using a case study observational research design, multiple data sources were assembled for four patients with multimorbidity, identified by two general practitioners in New Zealand. In this paper, two case studies are presented, including the recorded instances of contact and communication between patients and professionals, and between professionals. Professional interactions were categorized as consultation, coordination, or collaboration. Results: The two case studies illustrated two female patients with likely similar educational levels, but with different profiles of multimorbidity, social circumstances, and personal capabilities, involving various professionals and agencies. Engagement between professionals showed varying levels of interaction and a lack of clarity about leadership or care coordination. The majority of interactions were one-to-one consultations and rarely involved coordination and collaboration. Patients were rarely included in communications between professionals. Conclusion: Cases constructed from multiple data sources illustrate the complexity of day-today , interprofessional, interagency multimorbidity care. While consultation is the most frequent mode of professional interaction, targeted coordinated and collaborative interactions (including the patient) are highly effective activities. Greater attention should be given to developing and facilitating these interactions and determining who should lead them.
Patients and Health Care Teams Forging Effective Partnerships
NAM Perspectives
1 interactions with health professionals and providing feedback that strengthens the relationship and their mutual understanding of the patient's needs and how they may best be addressed. Strong primary care, the care setting focused on in this paper, is critical to achieving better patient outcomes, especially as the prevalence of multiple chronic health conditions increases (AHRQ, 2014a). More than 75 percent of U.S. health care spending is devoted to treating persons with chronic conditions (CDC, 2009). Of course, specialists and subspecialists also play very important roles. The complexity of care and services often required today requires health professionals across the system to work with people in a coordinated, collaborative way and to consider the whole person-not just the condition or array of conditions that a person might have (Bodenheimer et al., 2002). All patients bring unique expertise regarding their preferences, skills, knowledge, and experiences into a potential relationship with a health care team. Patients-and, often, their families and caregivers-live with their conditions and symptoms 24 hours a day, 7 days a week. Patients are experts in knowing how they feel from moment to moment and day to day. However, not all patients are well informed about their medical conditions and how best to manage them (Fagerlin et al., 2010). Relatively few come to medical encounters with the same technical skills, clinical knowledge, and detailed understanding of the health care system that most clinicians have. Some patients prefer to be involved at a more detailed level, others less so (Alston et al., 2012). But many patients and family members have acquired, and many more are capable of developing, considerable knowledge, skills, and confidence in decision making that could influence their outcomes positively-especially those outcomes that matter most to them. Only recently, with increased attention on patient-centered care at the practice level, has it become evident that a large percentage of patients who have personal physicians and, especially minorities, do not have an effective health care team (Beal et al., 2007). When people have a personal physician and an effective practice team, their outcomes are better (Beal et al., 2007; Havyer et al., 2014). There is still much to learn about the practical realities of patients becoming true partners in their care, and the most effective teachers will be patients themselves. When patients and clinicians have an effective partnership, the relationship becomes more fluid. It transcends the traditional roles of learner and teacher, leader and follower. Valid, ongoing assessments of team functioning and performance, including assessments by patients themselves, will be important to identify and illuminate team functioning and the strength of the partnership with patients, and to inform improvement efforts so that demonstrably better patient outcomes can be achieved consistently. Methods Given the scope of the project, an early decision of the authors was to divide our work into three informal activity streams, each with a specific focus-literature review, patients' insights, and clinicians' and organizational insights. In the course of the work, discussions have been conducted through the IOM Best Practices Innovation Collaborative meetings, May 2013 and March 2014, which have provided helpful guidance and suggestions to us that were incorporated into writing this paper.
Journal of Clinical Nursing, 2020
Article type : Original Article Health care professionals providing care coordination to people living with multimorbidity: An interpretative phenomenological analysis Aims and objectives: To explore the health care professional experience of providing care coordination to people living with multimorbidity. Background: There is increasing interest in improving care of people living with multimorbidity who need care coordination to help manage their health. Little is known about the experiences of health care professionals working with people living with multimorbidity. Design: Phenomenological approach to understanding the experiences of health care professionals. Methods: We interviewed 18 health care professionals, including 11 registered nurses, working in care coordination in Melbourne, Australia. We used interpretative phenomenological analysis to identify themes from descriptions of providing care, identifying and responding to a person's needs, and the barriers and facilitators to providing person-centred care. Results: We identified four themes: (1) Challenge of focusing on the person; (2) 'Hear their story', listening to and giving time to clients to tell their story; (3) Strategies for engagement in the program; and, (4) 'See the bigger picture', looking beyond the disease to the needs of a person. Our results are reported using COREQ. Conclusions: The health care professionals experienced challenges to a traditional approach to care when focusing on the person. They described providing care that was person-centred, and acknowledged that optimal, guideline-oriented care might not be Accepted Article This article is protected by copyright. All rights reserved achieved. They took the necessary time to hear the story and see the context of the person's life, to help the person manage their health. Relevance to clinical practice: For registered nurses in care coordination programs, focusing on the client may challenge traditional approaches to care. Providing care involves developing a relationship with the client to optimise health outcomes.
Revista Panamericana de Salud Pública, 2007
Objectives. Health care systems throughout the world are in the process of restructuring and reforming their health service delivery systems, reorienting themselves to a primary health care (PHC) model that uses multidisciplinary practice (MDP) teams to provide a range of coordinated, integrated services. This study explores the challenges of putting the MDP approach into practice in one community in a city in Canada. Methods. The data we analyzed were derived from a community-based participatory action research (CBPAR) project, conducted in 2004, that was used to enhance collaborative MDP in a PHC center serving a residential and small-business community of 11 000 within a medium-sized city of approximately 300 000 people in Canada. CBPAR is a planned, systematic approach to issues relevant to the community of interest, requires community involvement, has a problem-solving focus, is directed at societal change, and makes a lasting contribution to the community. We drew from one aspect of this complex, multiyear project aimed at transforming the rhetoric advocating PHC reform into actual sustainable practices. The community studied was diverse with respect to age, socioeconomics, and lifestyle. Its interdisciplinary team serves approximately 3 000 patients annually, 30% of whom are 65 years or older. This PHC center's multidisciplinary, integrated approach to care makes it a member of a very distinct minority within the larger primary care system in Canada. Results. Analysis of practice in PHC revealed entrenched and unconscious ideas of the limitations and boundaries of practice. In the rhetoric of PHC, MDP was lauded by many. In practice, however, collaborative, multidisciplinary team approaches to care were difficult to achieve. Conclusions. The successful implementation of an MDP approach to PHC requires moving away from physician-driven care. This can only be achieved once there is a change in the underlying structures, values, power relations, and roles defined by the health care system and the community at large, where physicians are traditionally ranked above other care providers. The CBPAR methodology allows community members and the health-related professionals who serve them to take ownership of the research and to critically reflect on iterative cycles of evaluation. This provides an opportunity for practitioners to implement relevant changes based on internally generated analyses. Health services research, primary health care, interprofessional relations, patient care team, health care reform, Canada.
International Journal of Environmental Research and Public Health
Patient-centered care (PCC) has the potential to entail tailored primary care delivery according to the needs of patients with multimorbidity (two or more co-existing chronic conditions). To make primary care for these patients more patient centered, insight on healthcare professionals’ perceived PCC implementation barriers is needed. In this study, healthcare professionals’ perceived barriers to primary PCC delivery to patients with multimorbidity were investigated using a constructivist qualitative design based on semi-structured interviews with nine general and nurse practitioners from seven general practices in the Netherlands. Purposive sampling was used, and the interview content was analyzed to generate themes representing experienced barriers. Barriers were identified in all eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, emotional support, family and friends, continuity and transition, and coordination of care). They i...