Development and Evolution of an Online Community of Practice
Nurse Practitioners Unite:
Case Study of An Online Community of Practice
by
Erich Widemark, MSN, RN, FNP
March 21, 2004
Introduction
The internet started with the sharing of education, and has grown into something bigger than many originally imagined. This virtual space has evolved into complex environments in which people live, learn, work, and socialize. One thing it has given is a shared distinctiveness, a duality that was never available on such a large scale before. Suddenly the individual has the ability to communicate and share their beliefs and knowledge with millions of others. A community has been created in the void of so called ‘cyberspace’. This has lead to the off-site education of millions, and the organization of many groups that now wield economic and political power that without the internet would have not been possible or economically efficient.
Communities of practice is an evolving concept that combines situated learning theory with action research, to create working groups of individuals that learn through shared experiences and expression. This case study discusses the development and evolution of a local online community of Nurse Practitioners. What started as a coffee house discussion has turned into a community of over three hundred local Nurse Practitioners communicating in cyberspace on how to improve their own physical communities and work environments. In addition, this community of practice offers an opportunity to improve the learning of the group members through collaborative experience. This description will discuss communities of practice, the implementation of the Coalition of Arizona Nurses in Advanced Practice (CAZNAP), barriers and strategies in this community’s development, and what the future holds for this virtual group.
Definition of Community
What makes a community? This is a complex question that often is answered more based on personal opinion than actual fact. When considering the internet as a community, the paradigm has shifted to a different definition. Before communications, community was thought of in an environment limited by geographic location and physical barriers. As technology started carrying video and sound over the world, definitions of community changed. Suddenly people were connected by phone, television, recording, etc. But groups were still limited in numbers and scope. Television offered a one way community in which the members were not able to interact with each other. Telephone was limited to a handful of people at a time when it became advanced enough to offer conference calling. But with the internet, the definition of community became much more complex.
As Preece (2000) suggests, an online community is a group of people that share words and ideas through the mediation of a computer network. She describes some common characteristics of an online community to include shared goals, engagement, participation, access to share resources, reciprocity of information, and shared contexts.
With the internets ability to create virtual spaces, new ideas need to be discussed about what makes a community. There is much conflict regarding the structure of an online community which has been interpreted as anything from a small close group to a public chat area in which anyone has access if they supply a valid password (Barab, MaKinster, & Scheckler, 2003). Does someone’s presence in an electronic environment identify them as a member of a group? Do they need to carry a specific belief or goal? Is it necessary that everyone knows they are a community member? How long are they considered a part of the community? These are all difficult questions that remain unanswered.
A more recent type of online group is a community of practice (COP). This concept shares the definition of an online community, but defines a more specific set of social circumstances. Kilner (2002) defines a community of practice as, “…voluntary associations of people bound together by a shared passion for a particular practice.” These COPs can be face to face or online. Another definition of COPs by Barab, McKinster, and Scheckler (2003) describe, “a collection of individuals sharing mutually defined practices, beliefs, and understanding over an extended time frame in pursuit of a shared enterprise.” These definitions are somewhat limited because they imply a specific problem of focus rather than a general improvement in overall practice and environment.
Perhaps the best description of communities of practice is defined as, “a persistent, sustained social network of individuals who share an overlapping knowledge base, set of beliefs, values, history and experiences focused on a common practice and/or mutual enterprise.” (Barab et al., 2003) The word overlapping is a good clear description of a community which includes diversity of multiple belief and value systems. This definition allows diversity, yet does not specify shared goals, only common ground.
Although communities of practice can be either physical or virtual, the newest evolution has moved them into the virtual environment. People now have the ability to be involved with many different communities without the need for travel and time constraints. Most of the communities remain text-based which is a limitation to consider when culture, disabilities, and other barriers are considered.
As technology advances, communities will become much more sophisticated, switching from text-based email messaging, to video and audio based communications. For now, these communities are limited by storage technology and accessible bandwidth.
Community Technology
There are many different types of technology that are used in the creation and maintenance of communities of practice. Two broad categories include asynchronous and synchronous communications. These two types of technology are often used together in the community building process, but each has its limitations.
Synchronous communications is best defined as a form of interaction that occurs simultaneously, or so-called ‘real-time’. Telephone is a good example of synchronous communications. On the internet, chat groups, voice over IP, and live webcasting are the most common types of this technology. Synchronous technology has its drawbacks. Community members all have to be present at the same time in order to interact. This leads to time and schedule conflicts especially when members live across various time zones. The quality of the communication is also affected. Group members are required to think and respond spontaneously to transmissions from others. This causes more difficulty in maintaining a high level educated discussion. It also impacts learning experiences because there is no reflective thought in the response of the individual.
Other limitations with synchronous communication include speed of the input medium, software incompatibilities, and limited bandwidth, especially with voice over IP, and video or sound.
Synchronous communication does have some positive aspects. One of these is the amount of human interaction and immediate feedback that is available. While other forms of messaging can sometimes seem artificial, synchrony offers a more personal interaction that often is welcome and necessary in any community.
Asynchronous communication relies on the ability of information systems to store communication and deliver it precisely to an intended audience. Some forms of internet based asynchronous activities include email, bulletin boards, websites, and listservs (Lynch, 2002). The main advantages of this form of communications include flexibility and reflective thinking. Bandwidth is not as much an issue and a much higher level of discussion with well thought out answers is possible.
Websites are used as a form of asynchronous communications, but are limited by their one way delivery methods. As technology increases in complexity, future websites will be much more interactive as already seen by bulletin boards, blogs (web logs), and HTML based message systems.
Email is vastly becoming one of the most popular forms of asynchronous communication. The ability to send a message for free to any unique address of an individual, and copy that message to an unlimited amount of people makes the whole concept of community building using email very appealing. Listservs capitalize on email to deliver a message to a predefined list of people.
Listserv technology can be best described as an email mailing list that enables communication by all members to all members with minimal effort. With flourishing of email, listserv technology has become a powerful tool to unite groups of people into virtual communities.
Several companies offer listservs free of charge to the general public for the purpose of building communities. One of these companies is YahooGroups.com. Yahoo recently purchased this technology, and offers this free service to set up a public or private group for the purpose of communicating about special interest subjects. This is an effective method of developing COPs because of the ease of use, and the ability of the group to build itself. Barab et al. (2003) feels that the success of designing a virtual community may come from balancing complex dualities from within a group as opposed to applying design methods from outside the group. Yahoo accomplishes this successfully by merely supplying the software and allowing the community to build itself with the help of a designated moderator.
History of CAZNAP
The Coalition of Arizona Nurses in Advanced Practice (CAZNAP) started by an email to several key nurse practitioners working in Sun City, Arizona. The content included an invitation to meet for breakfast at a local restaurant to discuss issues that were pertinent to nurse practitioners in the local area. These included primarily financial and practice issues unique to that area of town, and was meant as a general brainstorming session about these barriers. A testament to the weaknesses of synchronous communications, only three people attended the meeting. Scheduling conflicts and geographic limitations were the main cause for this.
Acknowledging that there were many important issues facing this group of individuals, further thought was given to other ways of communicating with each other. A medium was needed that could connect local nurse practitioners in order to discuss and interact regarding the specific issues brought up at the original meeting. In April of 2000, a listserv was started to help with communication within this community of nurse practitioners. A free public internet listserv site was used, which eventually evolved into YahooGroups. Before there were people only sharing an occupation, now there was the beginning of a community of practice.
The introductory message for the Coalition listserv reads as follows:
“Advanced practice nurses have contributed to the delivery of health care for more than 30 years and many of us believe the time has come for APN’s to be reimbursed directly for services we provide and the failure to do so diminishes the value of our contribution. Visibility and accountability are hallmarks of a “professional”, and it can emphatically be said that the APN is a valued “health-care professional”. We feel any failure to reimburse APNs directly, whether, in the employment of a physician or in independent practice, is an unjust practice and may constitute restriction of fair trade.
We acknowledge that in the state of Arizona, Nurse Practitioners currently practice with physician collaboration. Although, this relationship is not clearly defined, we recognize the collaborative relationship on a clinical level, but emphasize that APNs, like physicians, function independently and should be reimbursed for the services they provide. This requires that insurers contract with and credential Advanced Practice Nurses, and ultimately, list of them as providers along with physicians.
As the Arizona State Board of Nursing moved forward to allow collaborative practice between physicians and nurse practitioners, insurance companies did not follow when it came to empanelment and reimbursement. Many insurers do not issue provider contracts to Nurse Practitioners and most still reimburse physicians for the services provided by Nurse Practitioners. Many insurers would be surprised to learn that most care provided by the APN occurs in the “absence” of a physician and by law requires “no supervision”.
When the insurer reimburses the physician for services provided by the APN, the insurer has no measure of the contribution the APN makes to the delivery of health care. When the APN is not identified as the provider of care, it often appears that the physician has delivered care in several different locations at the same time. And unfortunately, when the insurer compensates the physician financially for cost-effective management, the APN cannot claim their rightful share because they are not identified by the insurer.
For the APN seeking to establish a private practice, reimbursement is a mute issue if a provider contract cannot be obtained. Occasionally, an insurer will contract with an APN in independent practice. This usually occurs when there are too few physicians to serve a particular area, such as rural Arizona. However, when APNs in more populated areas seek to contract with insurers, they are usually denied. This policy of contracting with some independently practicing APNs and not others, continues to exist. When confronted, insurers usually have no reasonable explanation for their inconsistent policy. Without reimbursement for insurers few APNs have been able to succeed in independent practice.
Since that first meeting, in April of 2000, over 125 APNs have subscribed to the CAZNAP electronic mailing list (listserv) which averages around 300 messages per month, and many have shared their questions and concerns regarding reimbursement with each other. The Arizona Nurse Practitioner Council, an arm of the Arizona Nurses Association (AzNA), endorses the efforts of CAZNAP. On a national level, nurse practitioner organizations and individuals are following the CAZNAP listserv and lending support. This exchange of information has been invaluable and a number of objectives have grown out of this grass-roots coalition. We're pleased to have the opportunity to share them with you at this time.” (Widemark, 2000)
This introduction was offered on a website that was used as a support resource for the listserv. Almost immediately nurse practitioners were contacting the moderator to become members of this growing listserv. The community rapidly started developing into a stable group of people who were passionate and eager to discuss various issues regarding local nurse practitioners.
Developing CAZNAP
There are various issues important to the development of the community. The purpose is very important in the beginning. It often dictates to what extent the participants will communicate with each other (Preece, 2000). CAZNAP initially had a defined purpose to investigate insurance reimbursement in Arizona. People were notified of this purpose upon signing on, and it was the subject of initial discussion.