CoP use of knowledge for decision-making

The literature described in Chapter 2 suggests that communities form so that knowledge can be exchanged between group members. The surgeon group at site A had recently decided to change the method of fixing an orthopaedic implant based on the results of one of its key members’ clinical trials. According to conversations with the surgeons, this did not involve changes to the clinical pathway or involvement of the management team. Instead, as a community they

decided to perform a technique in a different way, and then enacted that

decision. This change in practice was acceptable within the community because the group had a shared understanding of what the results of the RCTs meant for practice.

In addition to professional clinical education and training, I observed various knowledge skills that appeared to be important for a wider definition of

professional orthopaedic practice. They included the technical skills of surgery, i.e., how to perform a hip replacement, but also implicit knowledge that enabled surgeons to function within the hospital organisation that has rules, processes and professional hierarchies.

However, knowing what knowledge is accepted might become problematic when the epistemic cultures between different groups and different hospitals do not align. Time spent at the three hospitals revealed that the surgeons at site A appeared to learn, share and produce knowledge related to EBM, whereas

surgeons in site B seemed to focus on operational efficiency and throughput. The surgeons at site B tended to emphasise learning and knowledge production to make their theatres and surgical list planning more efficient. This knowledge was grounded in evidence from the group’s practice and examination of data at the hospital level, not from academic institutions and multi-centre RCTs.

Across the three sites, I sought to understand how knowledge and evidence was produced through negotiation amongst surgical colleagues. Over time, it

appeared that some surgeons regarded evidence as the best way to do things in their context (site C). Others privileged knowledge produced over time, as the group solved problems of orthopaedic practice through clinical trials (site A). Surgeons at site B appeared to concentrate their efforts on improving service provision, efficiency and local learning, for example they created a triage service and had a project underway to improve the post-surgery pathway. These types of improvement activity were not observed in the other hospitals to the same extent. In all three sites, group norms appeared to mutually reinforce the ‘correct’ sources of evidence, knowledge, interaction and experiences for the

group. These patterns of behaviour varied considerably and reflect

manifestations of the underlying systems of meaning and practice held by each of the CoP.

5.4.10.1 Sustaining CoP and membership to groups

CoP consist of, and depend on, the membership of its members to survive. What was important for the surgeon groups was that once the CoP was established in their hospital, its members were responsible for continually reproducing it in order to prevent it from disappearing. This was particularly apparent in site C, where surgeons would often not make important group

decisions without consultation with their peers at the team meeting (OBS notes

site C gen).

Within each hospital, more than one CoP existed, and it became obvious over the course of the observation and studying as to which surgeons belonged to which group. For example, at site A two CoPs had evolved, one senior member of a CoP

would openly mock the ‘leader’ and the principles of the other. Junior surgeons

in site B reported feeling uncomfortable when they worked alongside surgeons from the other CoP. The distinction in this group was a strong reporting

hierarchy as the norm, compared to a flatter structure in the opposing CoP. The surgeon quoted below commented on the accepted personality styles and behaviours within one CoP:

“A couple of personalities that you think, you know maybe not, yes. There are the three specialists and maybe one of them I would choose not to go to whereas the other two I wouldn’t have a problem with at all but other than that I still wouldn’t, you know, he’s a good surgeon. It’s just his personality. But everybody throws their toys out the pram at some point”. (INT C 31013)

5.4.10.2 Outsiders and movement within CoP

Across all the CoP that I observed, the members of the group appeared to create the norms that had to be learned and accepted by outsiders to establish their legitimate access. For example, in site A, these norms were an interest in EBM and the application of research in clinical practice. Surgeons were aware of the requirements for membership and strived to become insiders.

There were strong goals for the learners who sat on the periphery, as they had to develop an initial view of what each CoP stood for and what could be gained by joining. On the other hand, it appeared that an awareness of what knowledge needed to be learned could discourage some surgeons from aligning to a CoP and inspired them to look elsewhere. In the case below, a surgeon focused her

efforts on medical education to legitimise herself with another respectable group

within the department, using her phrase she “got to sell myself as teaching”:

“But this was the perfect job, because I’m not researchy at all. I was always told that would be a bad thing. No, when you sell yourself as a consultant, you’ve got to sell yourself as something… so I got to sell myself as teaching. I love it, it’s good.” (INT C 218005)

According to the literature, the aim of any outsider of a CoP is to become a respected group member who then has authority within the group. In my study, it appeared that the surgeons achieved this through a process of legitimate peripherality which involved them learning through participation, immersing themselves in the norms and culture of the clinical practice of the hospital. Group norms and accepted knowledge can change over time as different

individuals move from the periphery to the centre. New knowledge is allowed to move into the group and old knowledge decreases and becomes less important, as is the case with the increasing importance attached to NICE guidance.

Knowledge was important in becoming part of the CoP, but a greater

appreciation of the values of participation in the community appeared to develop from the surgeon becoming a part of the group.

During the observations, I sensed that the surgeons attempted to maintain a strong sense of individuality, but that this was coupled with a need to feel part of a powerful clinical group. During my period of data collection I did not

encounter any surgeon who actively wanted to be a lone worker, on the outside of their community. The surgeons appeared to gain personal and professional advantages from group membership.

In interviews, surgeons revealed that they would commit time and effort, and be willing to take more responsibility for their group tasks. As their membership roles increased, it appeared that they were able to achieve a greater sense of identity within the group. My findings suggest that the development of surgeon group identity was intrinsically linked to career pathways, and their ability to succeed within the wider profession. There was an inherent importance

attached to being on the inside of a CoP; the sense of membership was essential.

5.4.10.3 Variation from CoP

A key feature was that learning within CoP was situated, i.e., context-dependent. Knowledge and evidence could not be considered in isolation, manipulated in subjective terms or analysed as separate from the social relationships that occurred within the three hospitals. The use of evidence and the variation that played out between the groups needs to be considered in the context of the group situation. Therefore, learning and knowledge was a characteristic of the community within which it developed. This might help to explain why the CoP in each hospital appeared to demonstrate different behaviours, practices and methods for decision-making in hip replacement.

Each CoP could be viewed as providing the surgeon group with an intrinsic condition for the existence of their knowledge. In essence, it enabled the individuals and groups to distinguish what they did as correct and made sense for them. Training was a way of connecting with the traditional established practice of the other surgeons in the hospital and participating in the social life of the CoP. Groups of surgeons appeared to share an understanding of what they were doing and what that meant for their practice and for their communities. This understanding and meaning varied between my case studies and will be likely to be different in different hospitals, cities, regions or countries. The variation I observed might not be considered ‘right’ or ‘wrong’, but instead reflected norms for each CoP.