Development and Evolution of an Online Community of Practice

Nurse Practitioners Unite: Case Study of An Online Community of Practice

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.

While an online community seems to flourish with a defined initial goal, communities in practice evolve much like a living organism, to dynamically change and grow into something more than the original intent (Barab et al., 2003). CAZNAP did just that. The local nurse practitioner organization, The Arizona Nurse Practitioner Council, which met on a quarterly basis, had very poor overall communication with its members. Suddenly, CAZNAP members at these meetings would quickly suggest about distributing new information across the listserv, often confusing the lack of affiliation the listserv had with the nurse practitioner organization.

Eventually, the nurse practitioner organization offered a grant to help support the listserv activities, and the original goal of the listserv dissolved into a more complex sharing of practice. Engaging Members

Once a community is established, a challenging activity is in getting the members involved. This may require some strategies in order to encourage the constituents to share their thoughts and feelings.

In order to engage a community of practice, the moderator must build an atmosphere of trust and safety. Often privacy and security policies are recommended in order to better define the community and help with overall governance (Preece, 2000). The listserv was advertised as a private area only for nurse practitioners and nurse practitioner students. This gave many a sense of trust in posting to the group. In addition, sharing had never been required. Any member of this community could read the posts, but not be required to add to the conversation. As Preece

(2000) suggests, group members can become immersed in the group, know the participants, and feel they are members of the community, without ever posting a message to the listserv.

Critical mass is described as the point at which the group becomes too large to sustain any focus. This can be different depending upon the type and size of the group (Preece, 2000).

In a listserv as large as 300+, excessive information sharing can lead to ‘infoglut’. By giving people the option to share, but not requiring it, the level of discussion and interchange became much more complex. This became evident in the average 100-300 messages a month that the community had been averaging since the beginning. Because the initial focus seems to be well maintained, critical mass does not seem evident at this time.

The actual communication within the community can be a complex process. Initially there sometimes is a need to help push the community forward. The moderator focuses on this and can use all types of strategies including opening questions, offering advise, and focusing on general topics that need discussion. As the listserv grows, many of the members will take it upon themselves to propel the discussion forward without much intervention from the moderator.

In the beginning, the listserv would go into quiet episodes and stay there for extended periods of time. An open-ended question would be posted by the moderator to encourage the start of discussion. As the group evolved, each member started to post an open-ended question voluntarily, not because the silence was uncomfortable, but because each community member began to understand and respect the collaborative sharing and expertise that was present in this community.

It was common to see a statement like, “I usually don’t post here, but I wanted to respond to…” as an introduction, often from people that had been members for years.

The listserv continues to go into short periods of inactivity. This time of rest can be helpful in some ways by allowing the group a period of reflection and non-engagement that makes the experience far less stressful.

Growing pains

As a community grows, there is bound to be conflict within the group. At several times in the history of the listserv, someone has posted an inflammatory message that has offended people. Sometimes it has been as simple as a chain letter recommending that the group boycott a gas company. Other times, the offensive message has been on a much more emotional topic like religion or abortion.

In many cases, the group seems to police itself as someone takes the initiative to post that they may have been offended regarding a specific message. In some cases, a more formal interaction from the moderator has been required. The greatest success has been in reminding the community of the guidelines for etiquette within the group. These include respecting each as an individual, refraining from insults and name calling, and requesting that private conversations be moved to private areas (Preece, 2000).

There are no formal ground rules that are introduced when a person joins; rather the limitations seem to be the common sense of the group members in understanding this community. The group, being all nurses, seems to have a keen understanding of social environments, which perhaps adds to the level of professionalism and discipline that is displayed. In a different type of group, ensuring strict and clear ground rules is often recommended (Preece, 2000).

Privacy

Another important issue facing this community of practice is privacy. Nurse practitioners tend to be a group of individuals that companies focus towards in developing their advertising.

Frequently, the listserv owner is asked to advertise various items to the group. Often these companies will even request a mailing list so they may directly advertise. The policy has always been to protect the privacy of the group no matter what. This is an important issue in establishing the group and encouraging continued active membership. Though there has been no formal guidelines regarding privacy, at times individual group members have been contacted with this policy. Many times a privacy policy is essential, especially in a public group (Preece,

2000).

Privacy between group members is also important. By being a member of a group, one gives up some of their privacy. However, it is important to ensure as much privacy as possible within the group to develop and encourage a sense of trust and safety that is so important in community development.

Individual members do choose to compromise their privacy, often leaving a message for a specific person to email them as they may have lost the address. As long as this loss of privacy is voluntary, it does nothing to affect the group, and does encourage more of a sense of trust.

Limitations of CAZNAP

Though the listserv has been successful, there are many challenges and barriers that continue to threaten the well-being of this group. Software limitations and user knowledge are perhaps some of the biggest factors in these problems.

With the continual rise and fall of the “dot-coms”, email domain names seem to change on a regular basis. Updating and maintaining these email addresses for a listserv that now numbers over 300 can be very time-consuming. This sometimes leads in a breakdown of communications with group members because of these domain changes. When, for example, email addresses “@cox.com” changed to “@cox.net”, a large amount of people were “bounced” from the list. This required extensive editing of the member list to ensure maintained communication. Everyone with a “@cox.com” address needed to be removed and reinstated under the new email address. Because of the software safeguard against mass email advertising

(called spam) on the list, reinstatement emails were limited to only ten per day. This added an additional challenge to work with.

Another common barrier is the large amount of email messages that can be passed from day to day. In a group of 300, even if half of them responded to discussions, there would still be over 150 messages per day. At this time, the listserv averages about 20-30 messages on a daily basis. One way YahooGroups has found to combat this, is to offer a digest format in which all the messages for the day are put into one message and sent at the end of everyday. Advantages of this include a significant decrease in daily mail. Disadvantages include significantly long messages with repetitive text from people replying and allowing the original message and thread to stay in with the reply. This creates a lot of extraneous information that the community member may miss because of the difficulty in reading such large amounts of material.

Dealing with technology can be very challenging. It is assumed that everyone should have some basic education concerning computer and internet usage. In reality, there are people who need significant technical support in sending an email message. Often much of this frustration can be alleviated by smooth running software that offers a usability which is consistent and intuitive (Preece, 2000). Although YahooGroups has a lot of advantages, the software is not always that perceptive.

CAZNAP and Participatory Research

One of the hallmark events that established the CAZNAP listserv as an important part of the community was a situation that was brought forth by one of the members for discussion. A nurse practitioner, working in primary care, made additional income and offered a service to the community by doing sports physicals on high school students before the various seasons.

Recently, she had done physicals for one particular high school, which were rejected by the coach of the team because they lacked a signature of a physician. In Arizona, a nurse practitioner is well within the scope of practice to perform and clear a student for high school athletics without the need of a physician. The nurse practitioner posted a message describing this event to the group. Within 24 hours, a surge of replies established the inappropriate nature of the situation and the need to address this to the community.

Several group members did research which found guidelines from both state law and national standards. It was found that the policy of one specific high school district contradicted this, and thus the coach was within his rights to deny these physical exams.

Entirely online, the group established an agenda, and various members with connections within the school board called for an agenda item and policy change at the next meeting.

The meeting took place and several of the CAZNAP group members testified in front of the school board and convinced them to change the policy. Several of these group members had never met face to face until the night of the meeting, yet communicated online for several months before.

This was a good example of how a community of practice can make significant local political changes for the good of the shared group. Several other similar circumstances have since ignited the group into further political action for their shared passion.

Communities of Practice and Education

One important function of a community in practice is the education of the group members. With CAZNAP, this is evident on a regular basis. Many of the members continue to be in private practice in the medical field in various specialties. The nurse practitioners often utilize the group both as a resource, and as an instructional medium.

Using a collaborative environment, members often post case studies of individual patients that they may have seen. Often they are perplexed by clinical problems, and ask the group for advice. Through a large diverse population, multiple answers are usually suggested, and group shared knowledge is successful.

As Barab et al (2003) suggests, this demonstrates the duality in a community that allows diversity while at the same time maintaining a sense of coherence. At times there is disagreement among group members as to the answers that are given to clinical problems. In this diverse group, this is recognized as the cost of building a community, and accepted among its members.

The Future of CAZNAP – integrating strategic planning

As a community of practice, this listserv is successful. But the potential possibilities for the future are powerful. The integration of new technology promises to increase the community building process by offering other tools and resources to enhance the environment. One of the qualities of a community of practice is shared resources (Preece, 2000). The listserv software already offers a community calendar, file area, voting/polling process, and other resources for the purpose to enhance the community. But just because the resources are there does not mean that they are used or needed.

Schwen and Hara (2003) gives a few examples of communities of practice in which the available technology is not often utilized for various reasons including a lack of bonding within community members, difficulty using the software, and the lack of internal support of the product. He suggests that one of the primary goals of designing the software for a community of practice is to understand the social fabric of the community.

Creation of a strategic plan using a collaborative process among the group members could help the development of this future community. By agreeing on shared goals among the community members, further learning and political action can empower this community of nurse practitioners to work towards increased scope of practice, and future learning needs.

Conclusion

Since April 2000, the Coalition of Arizona Nurses in Advanced Practice has grown from a small list of ten people to a major communications medium which includes three hundred nurse practitioners and students. This has at times been a difficult process that has been plagued with technical inexperience, accelerated growth, and a lack of general purpose or organization.

What has made the process invaluable is the slow and steady evolution and continual reevaluation that has allowed the moderator to identify needs for the future, and plan their implementation.

What is left is a community that would not have existed without the internet. This new local political force has enabled social advancement of nurse practitioners, and increased learning through experience from within the group that will ultimately benefit the delivery of health care in the state of Arizona, and act as a model for other local nurse practitioner organizations to do the same. Perhaps Schwen and Hara (2003) stated it best when they said,

“Communities of practice are about content – about learning as a living experience of negotiating meaning – not about form.” The software ultimately does not matter. The process of connecting people together is the ultimate goal that seems to work best with a community of practice. References