Collaboration and communities of practice. The reality of rural midwifery practice.

Presentation to NZCOM Conference Wellington 2012

Carolyn McIntosh, Senior lecturer in Midwifery, Otago Polytechnic.

IntroductionIn this presentation I will cover the following

topics:Communities of practice, what they are

and why they may be important.Rural midwifery practice in the South

Island of NZ: What communities of practice are midwives engaged with?

Challenges for rural midwives in practice relationships which may influence communities of practice and collaboration.

Some possible benefits of effective collaboration.

Communities of practice. Midwives work in a variety of locations

alongside a variety of other health professionals e.g.◦Midwives, Obstetricians, Plunket nurses,

GPs, Practice nurses, Ambulance personnel, Radiographers, Physiotherapists, Occupational therapists, Mental health services.

And a variety of lay groups who support women and families e.g ◦La leche league, Plunket mothers groups,

etc. Etc. ◦not forgetting women themselves and their

family members

Communities of practiceProfessional interactions with all of these

groups are centred on the care and interests of the mother and her infant.

As matters of interest arise information may be shared (within the bounds of confidentiality) which may stimulate investigation and exploration.

Group interactions provide a mechanism

for knowledge transfer and contextualising evidence to the local practice situation.

Communities of practiceWenger (1996) Learning is primarily social and occurs through

the variety of communities to which participants belong.

Learning is integrated into participation in communities of practice (COP).

COP create their own identity and boundaries.Boundaries are crossed and negotiated between

COP. Learning may be facilitated or inhibited.It is this negotiation between COP where

Innovation is most likely to occur “much learning happens when boundaries are rich in interactions”

Rural midwives communities of practice.

Practice communities are unique to the midwives geographical location.

Depends on the realities of the practice in the area.

COP may be a local group of midwives ormay involve other health professionals in

the local area (Midwives, GPs, District nurses, facility nurses, Plunket nurses, allied health professionals)

COP may also be more geographically distant, communicating through technology. (phones computers etc)

McIntosh (2007)

C.O.P.

May be influenced by:Individual and group philosophy.Local relationships between health

care providers.How specialist services are

accessed. ◦Are there local specialist clinics or do women have to travel to the main centre for specialist services.

Regional Midwives

RuralMidwife

Rural Facility

management

DHBaccessholders

StandardsReview

committee

PerinatalMortality

audit

Rural GPsObstetricians

RuralMidwives

Midwife one F2F networks

RemoteRural

midwife

Other Rural

midwives

SecondaryFacility

SoloGP

Rural Facility

Midwife two F2F networks

Creatively establishing communities of practice.

In rural Australia advanced practice nurses (APNs) use a variety of methods including face to face to connect with other health professionals (Conger, Plager, 2008) Geographically isolated rural midwives in New Zealand were found to have a similar pattern of connectedness (McIntosh, 2007).

Other midwifery relationships Midwives usually live in the communities in which they

work. Hence they are also involved in community activities and have relationships outside work with women and families for whom they also provide care. Rural midwives are always a midwife in every social interaction. (Baird, 2005; Patterson, 2007)

This is common to all rural health workers and creates some additional challenges for health professionals. (Bourke, Sheridan, Russell, Jones, Liaw. 2004 )

Rural midwives may also be involved with lay groups which provide information and support to rural women (McIntosh, 2007).

Learning may also be stimulated through interactions with these lay communities.

“Boundaries between practices are fertile grounds for innovation. As communities of practice collaborate, clash, merge, diverge, the required process of coordination, translation, and negotiation is also a process of learning”

(Wenger, 1996)

Team learningAgreeableness is defined as being friendly,

trusting, tolerant, compliant and modest.High levels of agreeableness may have a

negative effect on problem solving as compliance and consensus is reached early.

Effective collaboration within and between teams requires a full and critical discussion of available data and ideas.

Participation in “constructive controversy”.(Hollenbeck, Ellis, et al., 2011).

Constructive controversyCommunities of practice are identified

by shared wisdom and understandingWhen this is in conflict with the

understanding of another group resolution is required

This process requires ◦Critically analysing the situation◦Transforming knowledge into argument◦Viewing the issue from different

perspectives ◦Synthesis and consensus

Johnson, Johnson and Smith, 2000

http://www.mindtools.com/pages/article/newTMC_71.htm

Constructive controversyAlthough controversy can be

transformative and beneficial certain conditions are required for this to happen.

There are two possible contexts for the controversy

Cooperative and Competitive

Cooperative (constructive)Willing to listenClearly communicate ideasMotivated to hear opposing

argumentsComfortable discussing opposing

perspectives and Willingness to create new

understanding

Johnson, Johnson & Smith, 2000

Competative (not constructive)Personalise argumentUnwilling to hear alternative

perspectivesClosed mindedCombative Disagreeing while implying the

other is incompetent

Johnson et al, 2000

Improving quality in primary care

Lanham, McDaniel et al, 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928073/

Advancing learning through communities of practice:The benefits of collaboration and connectedness

Interaction through COP advances learning, working together towards a common goal.

Interaction between different COPs can produce tensions and controversy.

Controversy may lead to conflict amongst health professionals which may impact negatively on the quality of care

Resolving tensions, working constructively through controversy and seeking common ground can advance learning, leading to new understanding and improved quality of care

These challenging boundaries of COP have potential to improve understanding, develop practice wisdom, transform and improve the quality of care. (Bartunek, 2011; Marshall and Robson, 2005; Wenger 1996)

ConclusionCOP are important for sustaining and

supporting practice.Midwifery practice communities are diverse,

influenced by the area in which the midwives live and work and may involve a variety of health care professionals and lay groups.

There is potential for controversy between COPsBeing able to resolve controversy improves

understanding, can increase knowledge and practice wisdom and improves the quality of care for the families midwives work with.

Learning is advanced through interaction and collaboration with a variety of COP.

References

Baird, M. (2005). Sustaining rural midwifery practice: New Zealand Midwives’ experiences. Unpublished masters thesis, Otago Polytechnic: Dunedin, New Zealand.

Bourke, L., Sheridan, C., Russell, U. Jones, G., DeWitt, D. and Liaw, S.T. (2004) Developing a conceptual understanding of rural health practice. Australian Journal of Rural Health. 12:181-186

Burtenek, J. M. (2011). . Intergroup relationships and quality improvement in healthcare. BMJ Quality and Safety, (Supplement 1). doi:10.1136/bmjqs.2010.046169

Conger, M. M., Plager, K. A. (2008). Advanced nursing practice in rural areas: Connectedness versus disconnectedness. Online journal of rural nursing and healthcare. 8 (1), 24-38. retrieved from http://www.rno.org/journal/index.php/online-journal/article/viewFile/156/194

Hollenbeck, J, R., Ellis, A,P, J., Humphrey, S. E., Garz, A, S., & Iligen, D, R. (2011). Asymmetry in structural adaptation: The differential impact of centralizing versus decentralizing team decision making structures. Organisation behaviour and human decision processes. 114(1), http://dx.doi.org/10.1016/j.obhdp.2010.08.003

Marshall, P., Robson, R. (2005). Preventing and managing conflict: Vital pieces in the patient safety puzzle. Healthcare quarterly. 8: 39-44.

McIntosh, C. (2007). Wise womens web: Rural midwives’ communities of practice. Unpublished maters thesis, Otago Polytechnic: Dunedin, New Zealand

Patterson, J. (2007). Rural midwifery and the sense of difference. New Zealand college of midwives journal. 37: 15-18

Wenger, E. (1996). Communities of practice the social fabric of the learning organization. HealthCare Forum Journal,. 39 [4], 20-26