Purpose

This study bases its interest in the discursive importance for change and how negotiation can be supported. The purpose of this study was to analyze what is at stake in the interface between adaptation and change, how improvements are negotiated, and if the negotiation differs between a uniform and a networked community of practice.

Theoretical framework

The result is explained in relation to a social learning theory, Communities of Practice and its scientific field. A complementary methodology of critical discourse analysis is used to investigate genre and style of the discourses that are produced in the negotiation of improvements.

Design

Observations of quality improvement conversations were made at an orthopedic- and rheumatology clinic in Sweden. Ward staff meetings represent a tightly coupled community and a process team represents a network of communities. The process team connects all communities that shape a process of care for a particular subgroup of patients. Two samples of recurrent central themes were chosen from the empirical data for more detailed transcriptions and a critical discourse analysis was made in three steps: descriptive, interpretive, and an explaining analysis.

The study used a participatory research design with recurrent learning seminars between staff and researchers. The staff took part in addressing the research problem, planning the research process and validated tentative findings.

Results

Traditional standards were at stake in the interface between adaptation and change and the negotiation needed to be explicit if change was going to happen. In the tightly coupled community standards were taken for granted and not explicitly negotiated. Initiatives of change had no impact because they 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 their unfamiliar relation to each other. As they argued they got hold of new meanings that could be more valuable for patients.

Limitations

This study has been limited to analyze how the interactive dialogue is produced and not the participation in a more quantitative sense. The analysis show supportive and equal participation from the samples that were selected. However, if you had looked at the overall texts and made a quantitative analysis of speech space it might have shown inequalities.

Practical implications

The study implicates 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 standards and support an explicit negotiation.

Value

The contribution of how to support improvement dialogues can be transferable and universal to other organizations that integrate both uniform and networked communities.