Being both a healthcare worker and a healthcare educator can sometimes be a lonely endeavour and opportunities to improve our craft may not be accessible. Medical education courses and conferences abound, often at high price points and in locations a long way from home. Healthcare virtual communities of practice (HvCoP) offer readily accessible information, connection and community, and opportunities for growth on our most ubiquitous accessory – our phone. How can we as a thoughtful, concerned, healthcare community improve accessibility and provide sustainability for our friends and colleagues to the latest literature, most recent practices, evidence-informed materials and provide a truly supportive and evolving environment where we all feel safe to share and connect? This essay started as a first-person reflection of one clinician’s journey (BS), including the highlights, and challenges in developing and sustaining HvCoPs and was then guided and edited by the second author (KW’s) reflections, who has co-facilitated several HvCoPs abroad. Within this essay, BS’ original, personal reflections are signalled in italics, whereas standard text indicates the joint reflections of both authors.
What this essay adds
Described as ‘a group of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly’ [1], Communities of Practice have the potential to become the vivid and joyous heart of learning within an organization. For the last seven years, I’ve engaged extensively in creating healthcare virtual communities of practice (HvCoPs) for professional development in clinical and education settings using WhatsApp and internet blog posting. Doing so has profoundly impacted me. This process has become deeply embedded in my identity, opened professional doors I’d never imagined possible and helped me connect with hundreds of caring healthcare clinicians and educators during and beyond the pandemic. Communities of practice have linked me with simulation practitioners around the globe, helped me learn from the coaching of generous academics taking their time to explain a nuance or theory, and on one occasion, even lit the spark for a respected publication [2]. For me HvCoPs are an immense source of joy, particularly when seeing passionate minds connect to share a lightbulb moment or a meaningful reflection. I’ve seen HvCoPs contribute to the identity of units, to promote clinical change on the floor, to aid colleagues across continents and sometimes to nurture enough psychological safety that years later a trainee might reach out with a complex or personally overwhelming problem. I have found HvCoPs so immensely useful that in every job I move to one of my first steps is to create a new one. I adore them.
HvCoPs are a virtual environment where people can share a concern, a set of problems, or a passion about a topic and can deepen their knowledge and expertise by interacting on an ongoing basis [1,3].
My two primary experiences have been creating and facilitating:
These experiences share similarities and contrasts between that of my colleague and second author KW, who has had experience co-facilitating several HvCoPs in the United States, and has also experienced first-hand the power of connection, knowledge sharing and collaboration that HvCoPs can offer.
My perspective after 7 years of facilitating HvCoPs is that building and maintaining them requires careful facilitation, persistence, and humility in equal measure. Together we have also learned several theories, frameworks and techniques that underpin the work that may be useful to inform choices.
Within this essay, we will reflect upon:
- What a virtual community of practice is, with reference to Wenger’s foundational work on CoPs.
- The communities of inquiry framework, and how it can inform our understanding of HvCoP.
- Personal reflections on the wins and challenges of HvCoPs.
- Concepts from published experts that have been helpful for facilitation.
- Personal strategies that we have found useful through trial and error.
Making sense of the learning and sociocultural theories that underpin communities of practice can be somewhat daunting and yet necessary to understand more deeply how learning is achieved within this setting. We will describe the essential components of virtual communities of practice, including the concept of legitimate peripheral participation (LPP); as well as the separate theory of communities of inquiry (CoI) and how both concepts enrich our understanding of healthcare virtual communities of practice (HvCoPs) and inform their facilitation.
Wenger et al. [1,4,5] describe several features of a community of practice and emphasize that not just any website or interest group constitutes an actual CoP. They highlight three core features:
Interestingly, when Wenger and Snyder described communities of practice in their 2000 Harvard Business Review article, they did not differentiate between virtual (v) and in-person communities and instead acknowledged that communities of practice exist both in person and in the virtual world. Their initial context was large corporate firms, and as such they comment on how CoPs and vCoPs assist in driving strategy and starting new lines of business. We have added Health (H) at the start of the vCoP acronym to denote CoPs created for and sustained by those who work within the healthcare industry as either clinicians or educators, as we believe vCoPs are contextual and Health vCoPs will have their own unique cultures with specific strengths and challenges. One of the key messages Wenger et al. describe is the paradox whereby the informal structures of CoPs require special managerial skills to develop and maintain and we will further explore this concept. LPP is defined as a descriptor of engagement in social practice that entails learning as an integral constituent. They say that LPP is a process in situated learning and CoPs, where newcomers become part of a community of practice, not just growing in knowledge and skills, but becoming a full participant in the socio-cultural practice of the HvCoP. In more simplistic terms, the concept describes in eloquent ways that relatable journey of starting out as a newcomer in the peripheries of a community where one may gently explore, listen and share while gradually contributing in more confident, knowledgeable and impactful ways that both shape the community itself and inspire a personal sense of belonging.
While independent from Wenger’s theories, Garrison’s CoI theory enriches our understanding of virtual communities of practice through a different lens. It was described in 2000 when online learning was becoming increasingly widespread in higher education and Institutions were embracing online education that could be delivered anywhere and anytime. Within this context Garrison et al. developed a conceptual framework that identified key elements of a successful online higher education experience.
Garrison et al. argue that individual learning is intrinsically entwined to community and is underpinned by three different ‘presences’:
The three presences were conceptually arranged as intersecting circles and Garrison et al. argued that the cognitive presence is the domain that is most key to success in higher education. This may also be true in HvCoPs where information exchange, connecting ideas and applying new ideas are key. In Table 1 we have listed these two theories with a brief description of each. We believe that both theories, although completely separate, have an impact on the quality and sustainability of HvCoPs. From our experience following the concepts outlined by each guides our facilitation as we support each HvCoP.
| Theory or framework | Author | Brief description |
|---|---|---|
| Communities of practice, including LPP | Lave and Wenger [4] | A group which meets either in person or online with three distinct features which include it being a joint enterprise, there is mutual engagement, and there is a shared repertoire. LPP refers to new members of a community becoming gradually more central to a group and moving towards full participation in their sociocultural practices. |
| Communities of inquiry | Garrison et al. (2000) | A theory of educational excellence where the educational experience is embedded within a community of inquiry that is composed of teachers and students. The theory assumes that learning occurs within the community through the interaction of three core elements; cognitive presence, social presence and teaching presence, and the key presence is the cognitive presence. This theory was not written in relation to vCoP but many of the concepts described have significant overlap. |
I vividly remember in 2020 joining an international WhatsApp group for simulation educators to share resources during the early days of the pandemic. Rapidly the separate message ‘pings’ from educators around the globe created a melting pot of responses: there was a sense of solidarity, much shared knowledge, but also shared emotions too: fear, grief and confusion enticingly laced with the slight sense of control that comes from taking action in uncertain times. In many ways I think the COVID pandemic was an accelerant for HvCoP uptake in general, due to that sudden dual need for human connection and rapid information transfer in a challenging time of isolation. This context, I believe decreased barriers to engagement in virtual spaces for healthcare professionals who may have been previously more resistant to the medium.
Within the HvCoPs I facilitate, Wenger’s work has heavily informed my understanding of what that community should ‘look like’. Understanding that not every online forum is a CoP reminds me to facilitate carefully and consider those 3 core features: When it comes to joint enterprise, what is the shared purpose for this group of professionals and how is that negotiated? I have regrettably found, for example, that it’s remarkably fun and easy to bring clinicians together online to celebrate photos of their pets or carve a quiet space for gallows humour, but remaining mindful of that concept of joint enterprise keeps me trying to facilitate us back to a more aspirational, meaningful target. In similar fashion, the concept of mutual engagement forces me to reflect upon the implicit and explicit social rules that exist within an online setting: how are doctors and nurses, for example, engaging in different ways within the chat and how can I explicitly set an expectation of mutual respect and collaborative, shared problem-solving in ways that ensure both streams are welcome and valued? Lastly shared repertoire invites me to consider the productivity of the HvCoP as a whole: what are we creating as a group, what resources are we collating, sharing and organizing and does that still remain consistent with our mission?
The concept of legitimate peripheral participation aids me in the strategic invitations I may make while facilitating: who is new to the group or might feel relatively ‘peripheral’, and how can I support them with an achievable simple task or social connection that will help move them from the peripheries to something more active and central in our community? Maybe I might invite an intern the opportunity to share a great case where they made an excellent diagnosis or ask an experienced but taciturn nurse to describe how they would approach a problem that I’ve seen them deal with well.
While I run the risk of muddling independent theories together, to me at a pragmatic ‘street level’ Wenger and Garrison’s separate foundational works are helpful in different but symbiotic ways. Both theories have deepened my understanding and reflection on vCoPs despite this academic mish-mash not being intended by the original authors.
To me, Wenger’s theory describes what a vCoP ‘looks like’ and as outlined above, helps me maintain the integrity of the community. Garrison’s Communities of Inquiry framework, however, helps me think more specifically about my facilitation and the other interactions that are happening online. In doing so, it assists me with steering discourse towards greater meaning and in some situations, in diagnosing why a particular forum doesn’t seem to be working.
For me the presences (Social, Cognitive and Teaching) have been valuable pillars to ‘diagnose’ issues within an online educational space and intervene accordingly. If a HvCoP isn’t functioning optimally it can be helpful to identify if there is a deficit in ‘social’, ‘cognitive’ or ‘teaching’ presence. For example, in a group who are reluctant to share professional uncertainty or ask questions, one might focus on building social presence through the sharing of stories, self-deprecating humour or funny gifs and memes. This might come at a cost: distracting my collaborators with humour might take us off task, but if the goal was to build more social presence, maybe that’s exactly what’s needed for that group. In contrast, for a group who are highly engaged but lack direction, we might add more teaching or cognitive presence using intentional, thoughtful questions and attempting to lead learners towards a deeper understanding of a particular concept.
In our first review of this paper, it was helpfully highlighted that there are risks to combining these models in ways unintended by the original authors. Garrison’s model, for example, has clear boundaries between teacher and student, in contrast to the CoP model where the role of teacher and student may not exist or may shift between community members in a mercurial manner. I would argue, however, that while teacher and student roles may not exist in a vCoP the core tasks highlighted in Garrison’s work around teaching presence, such as ‘Defining and initiating discussion topics, building understanding, focusing discussion and sharing personal meaning’ remain relevant for reflection. In a truly self-sustaining CoP I imagine these tasks would be widely distributed in a collectivist manner; however, in my practice an active, senior member of the HvCoP needs to continue to drive discussion.
The communities I’ve worked on have simultaneously enraptured and exasperated me. They can take intense facilitation to build and maintain and in truth I remain somewhat confused at the reluctance of participants to share an idea or ask a question. It can sometimes feel like I’m pouring enthusiasm into the virtual ether in search of a treasure trove of learning that I know exists, only to find gaze avoidance, silence, and a deeply entrenched fear of being wrong. When engagement occurs, it can spark transformative conversations, but forging a community where that occurs on a self-sustaining basis without continuous, close facilitation remains my great white whale.
For 5 years I ran the Simulcast Journal Club, a blog and podcast HvCoP based upon a model from the AliEM MedIC [6] series at Academic Life in Emergency Medicine: Each month I would propose an article, frame it within a case study and then invite discussants to share their thoughts about the paper in the comments, and an expert would provide a commentary as coda to the discussion at the end of the month. We promoted it heavily on twitter. All comments required approval prior to publication, although only one comment was ever revised. At the end of the month, I would create a pdf summary of the paper and the discussion, an expert’s opinion piece and often an infographic, that we would share online. After 12 months or so, with my co-producer, we began to record podcast episodes summarizing the month’s discussion.
As a HvCoP, the Simulcast Journal Club’s joint enterprise was simple: growing as simulation educators together, mutual engagement was the process of a variety of participants responding online and sharing their thoughts, and the shared repertoire came in the resources we developed along the way, including pdf and podcast summaries of the discussion.
Running that journal club was one of the greatest professional privileges of my life. We were joined by ‘household names’ from the healthcare simulation community and engaged participation from simulationists in 6 continents. Novices and experts alike posted from month to month, and some of the discussions were truly remarkable, one even sparking new research. Editors in Chief of prominent journals and simulation gurus alike provided expert commentary for some of the summaries. The experience was a remarkable demonstration of the generosity of the simulation community. At a more selfish and personal level though, the experience was 5 years of monthly, deliberate practice in facilitating online discussion, synthesizing the conversation, and breaking down complex simulation literature into digestible and approachable chunks. As it turned out, running the journal club was a vector for my own professional development: through synthesizing and facilitating the wisdom of others, I had begun to become (and be seen as) a simulation expert myself.
In similar fashion, our Emergency WhatsApp group has experienced highs and lows. Drawing reluctant trainees into discussions is challenging, and there are times when I feel I can broadcast all the ‘intellectual candour’ [7] in the world and barely get a response. All that effort though comes with meaningful rewards: social capital that is often reciprocated with mutual respect and affection, comments from trainees who continue to engage years after they’ve left their department and occasionally a message from a trainee in distress who needs support and knows that they can touch base without fear of derision. Perhaps most personally there have also been moments where I’ve been at the gym resting between weight sets, genuinely moved as I watch on my phone as a group of nurses, doctors, pharmacists and social workers collectively come together in real time to share their perspectives and experiences about a case. With each ‘ping’ I see them co-create a collective understanding of a complex problem or solve an interesting ECG or connect each other to resources and experts who might help a real patient. In these moments, as I watch these hard-working professionals connecting online, many of them likely lying on their couches after a busy shift or answering messages once they’ve tucked their kids into bed, I remain astounded at our ability to continue to work at getting better at looking after sick children, together. These tiny collaborative miracles sustain my enthusiasm, and, in many ways, me.
These collaborations as well, contain the opportunity for moments of ‘cultural compression’ [8]. As we carve online spaces together to become better at our craft, we simultaneously send clear signals to each other about who we are and what our core values as a collective must be. There are so many benefits for individuals, teams, and organizations through the establishment of HvCoPs. Table 2 is a sample of some of these benefits, the outcomes that may follow and how to sustain these gains for all. The benefits of HvCoPs are quite varied ranging from individual personal and professional gains to professional connection, to offering feedback on events or ideas, and clinical quality improvement plans to name a few.
| Advantages | Outcomes | Nurturing longevity |
|---|---|---|
| Opening professional doors for members | Building professional credibility in their chosen sector | Sustained through ongoing sharing of experiences such as conference presentations |
| Connecting with large numbers of colleagues wrestling with similar goals | Crowdsourcing and adapting solutions to their own environment | Regular feedback on how proposed solution is being sustained |
| Offering immediate feedback to members | Instant peer review | Conversations can continue longitudinally |
| Contributing when schedules permit and feeling a sense of belonging | Welcomed accessibility | Ongoing professional support network even when members move to new jobs |
| Enabling linkages with experts for new members | Grows thinking | Expands scholarly connections with a range of expertise |
| Coaching from experts | Access to experts in the field | Think tank for excellence |
| Inspiring publications | Access to writing colleagues | Growth of publications in the field |
| Growing individual unit identity when several HvCoP members come from the same workplace. | Units gaining credibility in the scholarly space | Unit becomes known as an academic portal |
| Promoting clinical quality improvements | Evidence informed practice readily shared from all practice members | Quick mechanism for spreading change |
| Fostering personal and professional support for all members | Network of caring friends and colleagues | Still present when members change physical location and members need support |
These joys though, did not come without cost, as Mike Cadogan notes ‘The cost of free is immense’ [9]. Time investment can be significant, obviously, but the true expense has been the constant promotion and role modelling of enthusiasm that is required to maintain a modicum of voluntary engagement from others. It was quite a surprise for me that my colleagues and friends were nervous about commenting on Simulcast. After an initial burst of interest, the 5 years I ran Simulcast Journal Club involved a constant struggle to obtain sufficient participation. I had naively assumed that as simulation educators who promote risk-taking in the pursuit of higher learning that the threshold for engagement for making a comment online on a humble, nerdy blog would be low. I’ve learned instead that clinicians and educators hold their professional identities dear to their hearts, and being asked to express one’s opinion on a topic in writing constitutes a significant risk to many. In truth, I found the contrast between what we ask of our learners and what we’re willing to show of ourselves somewhat troubling.
In recruitment conversations with nervous participants the barriers to engagement in online learning were surprisingly consistent: being time poor, a near constant sense of imposter syndrome [10], bad experiences from online forums and a palpable fear that leaving one’s comments on a niche website’s blog post would be heavily scrutinized by the universe at large.
In many ways these themes recall the barriers outlined by Rudolph et al. in their paper ‘Creating a Safe container for learning in Simulation’ [11], in particular professional identity threat and poor buy-in. These barriers, however, are refracted through a digital lens which creates several format-specific impacts upon online psychological safety. Text-based communication reduces interactivity and emotional reciprocity, and the elimination of non-verbal communication makes ‘miscommunication or misalignment both harder to detect and to repair’ [12]. Additionally, the open-access website format on Simulcast allowed easy worldwide engagement but created a secondary knock-on effect: a sense that the whole world was somehow watching. This feeling was further enhanced by the marvellous support of worldwide simulation experts and academics. While the site hits and retweets peaked when internationally admired simulation academics joined the discussion, colleagues would privately disclose to me a discomfort with the idea of critiquing a paper and potentially having an expert of such calibre reading their ‘unworthy’ comments.
Additionally, adequate motivation remained a challenge; when it came to risk versus reward those who watch passively could enjoy a meaningful conversation without taking the risk of contributing or sharing their perspectives. While those who engaged received encouragement, guidance, validation, and the opportunity to steer the conversation towards their own learning goals, those willing to take that risk remained rare. At one point I calculated the ‘site hit’ to ‘response’ ratio, and for every 100 site hits one comment, on average was received. It seemed clear that many readers were reluctant to engage despite finding the conversation valuable enough to visit regularly. It also led me to the conclusion that in a public HvCoP, we needed to recruit a significantly broad readership to obtain a modicum of interaction.
These challenges: imposter syndrome, format concerns and risk avoidance can be mitigated through strategies to generate stronger social, cognitive and teacher presence. Table 3 describes strategies we’ve found helpful while facilitating HvCoPs and through the lens of Garrison’s CoI model we can ensure that the three presences are addressed.
| Cognitive presence | Teacher presence | Social presence |
|---|---|---|
| Using the practical inquiry model to understand learners’ needs. What triggers their learning, is the group supporting exploration, and are the learners integrating their knowledge and demonstrating resolution to their inquiry | Explicit welcoming and appreciative text to overcompensate for the lack of body language and eye contact in app-based communication | Participants identifying with the community, communicating purposefully in a trusting environment, and developing interpersonal relationships |
| Facilitating online discussions in ways that link participants to each other | Overt invitations and sometimes naming the dynamic to invite engagement when none is forthcoming | Using humour through gifs, sharing personal moments and self-deprecation to promote a social connection and flattened hierarchies |
| Using existing online resources to save time and link participants to expert’s wisdom | Tight and unambiguous boundary setting when psychological safety breaches occur | Role modelling vulnerability with intellectual candour |
| Gradually facilitate discussants from more superficial narrative and perspective sharing towards developing a deeper understanding of the topics discussed | Identifying ‘first followers’ comfortable with the medium and encouraging/elaborating on their contributions | Limiting exponential growth in early phases to allow generation of psychological safety within initial members |
| Encouraging members to contextualize their knowledge and probe/question concepts being discussed | Delivering micro-tutorials utilizing YouTube videos or podcasts | Carving space for fun and human connection |
People don’t tend to click on tweets about academic minutiae; they click on funny gifs and cat videos. While this might seem a bit depressing to those hoping to disseminate important research, a potential reframe is that people respond to visual wit, relatable humour and light-hearted engagement. BS and his colleagues attempted to harness this in the journal club in several ways. Social media output, particularly on Twitter, was used more as appetizers than main course. With a 100:1 hit-to-response rate, there was a need to increase audience responsiveness to engage the 1% who were willing. Twitter wasn’t great for academic discussion given the limitation of 180-character statements, but a tweet of a visually arresting infographic was retweeted more heavily, which could then be used to draw readers into a deeper discussion on the blog. Social media became virtual breadcrumbs that could lure potential online participants to the ‘base camp’ of the journal club website.
Perhaps the most unanticipated discovery, however, was how strongly readers responded to humour and storytelling. Each month the Simulcast Journal Club involved a case study but after a few months, inspired by Armistead Maupin’s ‘Tales of the City’ (a newspaper serial from the 1970s) [13], the characters within our case studies began to slowly overlap and interact, forming an increasingly complex absurdist soap opera involving friendship, rivalry, romance and eventually even a murder mystery. The comments that followed on the blog clearly showed that some participants enjoyed engaging both in the discussion, and the telenovela storylines that had evolved.
Utilizing humour in this manner also had a secondary benefit beyond generating traffic, as John Cleese once said, ‘Laughter is a force for democracy’, and it appears to defuse tension very effectively regarding online participation and flatten perceived hierarchies within discussion groups. It seems it is harder to worry about one’s insecurities when smiling at self-satire.
From a pragmatic perspective, humorous gifs and memes can be a great way to generate social presence in phone-based apps like WhatsApp. Finding a provocative or amusing gif related to the emotion or situation being described or experienced in the chat group can be a great way to prompt a response.
Role modelling passion, humility and intellectual candour [7] can be useful techniques in online facilitation. In many ways I think my origins as a ‘non-expert’ allowed deliberate role modelling of acknowledging my own limitations and ignorance of many educational concepts. In our podcast summaries, the fact that my co-presenter could take the role of a more experienced expert, while I took the role of the less sophisticated ‘coal face’ educator could empower participants and listeners to feel less imposter syndrome and to align or hear a perspective that may more have matched their own. In many ways the richest and deepest online discussions we had involved novices willing to ask big questions, and experienced simulationists willing to spend time explaining their understanding.
When I began facilitating, I would often thank participants for their comments; however, it turns out that this can have detrimental consequences, and it turns out there’s more research than I’d realized investigating optimal facilitation techniques.
While building culture and approachability through gratitude and humility online makes sense, Tirthali and Murai [14] identify that saying ‘Thank you’ at the end of a thread post is strongly associated with an end of the conversation. Their sequence analysis showed that thanking contributors for discussion only extends the conversation if it was followed by the rest of a post that was ‘content rich’. Similarly, they identify that comments associated with an increased response rate tend to start with storytelling, personal anecdotes and shared personal experiences.
At the base level, online discussion can tend to be a series of monologues rather than an effective dialogue. In analysing arguments in general, Kuhn and Goh [15] describe this phenomenon as allowing the activity to ‘relapse into nothing but consecutive self-expression, first on the part of one student, then another. It does not matter much what each student says, and no student needs to listen to another. In this worst-case scenario, the only attention the next student pays to the speaker is to wait to observe a signal that this speaker is about to finish, so that he or she can begin. If everyone gets their share of turns to speak and no one speaks too long, there is a wealth of opportunity for self-expression. Yet, no further purpose is fulfilled’.
When facilitating online discussion, this inherent danger can be mitigated by deliberately making conversational connections between different participants. In doing so, the facilitator can shift ‘a critical and opinion centred debate’ to ‘a more constructive conversation that is aimed at the processing of content and a deepening of understanding’ [12]. An example of connecting participants together is provided from a screenshot from our WhatsApp group below. Figure 1 shows how the facilitator connects participants through inviting each other to reflect on the other’s role modelling.
Connecting participants: strategies of facilitation
In summary, effective online discussion facilitation requires a variety of strategies for recruitment, retention and conversational facilitation. Establishing a sense of online psychological safety is a longitudinal task that can be built through long-term role modelling of receptivity, enthusiasm, humour, and warmth and deliberate cultivation of social, teaching and cognitive presence. With effective recruitment of sufficient participants, discussion can be further improved by encouraging storytelling, perspective sharing and deliberately turning serial monologues into effective group dialogues that assist learners in processing, digesting and deepening their understanding of educational concepts.
The authors would like to acknowledge Dr Debra Nestel who supported our journey in the creation of this manuscript through thoughtful feedback, advice and academic rigour. Both authors are extremely grateful for this sage guidance.
None declared.
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Learning in healthcare virtual communities of practice; let’s rethink how we connect and grow
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