Background

Clinical Microsystem theory underlines the importance of doing improvements both in and between communities. The design and improvements of each clinical microsystem is as important as the pathway between microsystems. But how are uniform or differentiated standards negotiated in a community of practice compared to a network of practices?

Aim

The aim was to analyze discursive differences in the negotiation depending on whether practices were shared or differentiated. The study analyzed the interactive negotiation in a tightly coupled Community of practice compared with a loosely coupled Network of practices, with an interest of investigating what kind of pedagogical support different improvement groups need.

Method

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. A clinical ward meeting represents a tightly coupled Community of practice and a process team represents a loosely coupled network of practices. Critical discourse analysis was used and the social learning theory Communities of practice was the theoretical framework that explained the findings.

Findings

The analysis showed that the most important difference between a tightly coupled community of practice and loosely coupled network of practices is the explicit character of the negotiation. At the clinical ward meeting standards and traditional hierarchy were taken for granted and not explicitly negotiated. Initiatives of change had no impact because new standards were not discursively valued compared with old ones. In contrast to the ward meeting, the team had to negotiate and explain old standards as well as new ones because of the unfamiliar relation to each other. As they argued they mutually found out new meanings, and new solutions that could be more valuable for patients.

Discussion

Given the discursive perspective, the study shows that in the interface between adaptation and change the negotiation needs to be explicit if change is going to happen. This explicit improvement negotiation was more easily done in a differentiated practice which contradicts other research of Communities of practice in health care. Anglo-Saxon research has shown the difficulties of learning and change in networked practices because of rivalry between professionals or specialties. One explanation could be differences in culture between Swedish and Anglo-Saxon hierarchies in health care which has to be considered in future Community of practice analyzes.

Practical implications

The study indicates that external coaches of improvement work could be useful in tightly coupled communities of practice. An external coach can help the community create awareness of taken for granted issues and support an explicit negotiation.