The need for collaboration
Western health care systems are challenged to provide accessible, relevant, and integrated services. To confront these challenges, publicly-funded health systems must find effective ways to increase inter-professional and inter-regional collaboration so that expertise can be enhanced, disseminated, and more effectively translated into practice.
Recently funded by the federal government, the Canadian Partnership Against Cancer (CPAC) is an innovative response to the need for forward nation-wide strategic planning to help the Canadian population meet the challenges that will accompany the growing burden of cancer. Because cancer program delivery, like the rest of health care in Canada, is the responsibility of different jurisdictions, such as provincial governments, national solutions rely on fostering inter-provincial collaborations. The Partnership has thus embarked on an ambitious agenda that recognizes the need to develop both technological and social platforms to facilitate and nurture sustainable pan-Canadian collaborative efforts. In this context, the Partnership has been exploring the utility of Etienne Wenger's "communities of practice" (CoP) concept. The Partnership's CoP Project was conceived to identify and evaluate the effectiveness of communities of practice to enhance collaboration and knowledge translation in cancer control across Canada. Here we describe what we have learned from preliminary stages of the CoP Project, and offer further insights into this promising model of collaboration.
Since the early 1990s, CoP-type structures have been implemented primarily in the business and development sectors; however, their application to health care is a more recent consideration. In this paper, we identify the potential application of Wenger's concept to health care settings, based on a literature review and our experience with the CoP Project. Our aim is to gain a more precise understanding of communities of practice, including their capacity as a form of social infrastructure to further knowledge translation and sustain collaborative efforts across traditional health care jurisdictions and disciplines. The terms collaboratives and groups are used generically throughout the paper to denote interactive work groups.
The communities of practice concept
"Communities of practice are groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis".
This definition of communities of practice captures the three structural elements of a community of practice, namely, its domain, practice, and community. It is worth elaborating on these three elements in the context of Wenger's other writings to understand this concept more fully.
The domain of a community of practice refers to the common "concern, set of problems, or passion about a topic" that all members share and around which they organize. It is the area of members' overlapping expertise, and it provides the initial centripetal pull uniting individuals who might otherwise work in separate organizational units, disciplines, or locations. Members have an abiding concern about their common topic, and collaborate to solve problems relating to it. They are also "passionate" about it. Wenger observed that, "If members don't feel personally connected to the group's area of expertise and interest...they won't fully commit themselves to the work of the community" .
According to Wenger, communities of practice form serendipitously when members recognize their common domain. Communities of practice are thus "fundamentally informal and self-organizing" entities, and can "benefit from cultivation" , which is the agricultural metaphor employed extensively by Wenger. The largely organic and non-prescriptive origins of these groups provide the conditions for members to participate creatively in practice .
Practice is the second structural element of the communities of practice concept, and represents the basic body of knowledge the group shares and builds. Members of a community of practice aim to "deepen their knowledge and expertise" on a topic by learning from each other. More specifically, members learn from peers and through practice, which is why members of a community of practice are practitioners. Here Wenger draws from earlier work with Jean Lave on guild systems and apprenticeship models, where learning and its application take place in the same setting . "Through its practice--its concepts, symbols, and analytic methods--the community operates as a living curriculum," according to Wenger et al .
Communities of practice value both tacit and explicit forms of knowledge. They recognize the need to complement individuals' intuitions, perceptions, and vernacular knowledge with the more explicit concepts of an evidence-based paradigm. "The knowledge of experts is an accumulation of experience--a kind of 'residue' of their actions, thinking, and conversations that remains a dynamic part of their ongoing experience" . In this respect, communities of practice are social learning structures: they are open venues of exploration, "where it is safe to ask hard questions and speak the truth" and where members "develop the habit of consulting each other for help" .
The third structural element of a community of practice is the idea of community, although scholars have also identified it as the most troublesome to reconcile. Community denotes a set of interpersonal relationships arising out of people's mutual engagement in learning through practice. Significantly, these relationships do not indicate members' specific roles per se, but refer to their reciprocal ties of accountability, dependency, trust, and communication. These bonds of connectivity, together with the community's negotiated meanings and shared expertise, can be thought of as providing the cohesion that lends a community of practice its identity and coherence over time. Ideally, a community of practice engenders a strong sense of identity and belonging across members, even those who do not interact regularly or face-to-face. To regard collaborative groups as communities underscores their deeply normative character, which specifies the behaviours, meanings, and routines acceptable to each group.
Wenger et al argued that when the three structural elements function well together, they "make a community of practice an ideal knowledge structure--a social structure that can assume responsibility for developing and sharing knowledge" (emphasis in original) . Here, knowledge and sociability are not just linked, but are mutually informing, and the dynamic between them generates the specific know-how the group builds, shares, and manages.