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Table 1 Theme descriptions and illustrative key findings

From: Optimising the process of knowledge mobilisation in Communities of Practice: recommendations from a (multi-method) qualitative study

Main theme

Subtheme

Relevant i-PARIHS domains

Illustrative quote(s)

Identifying and interpreting knowledge

Types of knowledge

Innovation

Context

Q1. This is an opportunity to really fully embrace the evidence (P07-PC)

Obs1 (meeting 4 online). Telemedicine now important (covid pandemic). Group members presented existing research about remote consultations in msk, including a ‘virtual’ hip and knee class. Clinicians shared current clinical challenges and all seemed to find the research presented beneficial. Long group discussion about local applicability and what could be delivered in current context. Research team become aware of priorities from the ‘clinical coalface’

 

Knowledge creation and use

Innovation

Context

Recipients

Q2. It wasn’t just patients and the public that said, ‘This document’s too complex’ it was any type of clinicians, I mean it’s quite a thick review and no one’s got time really to read through it all (P06-PNC)

Q3. Being able to work alongside of people who you probably originally thought would have different thoughts to you, when it actually came together, you may have had similar ideas, but they were just put together differently but when you got a result, it was something that was mutual (P08-L)

 

Negotiating knowledge

Innovation

Context

Recipients

Facilitation

Q4. We really are just a service that gets on and does it. So we will look, ‘Okay, what’s the best evidence and who’s the best person that we’ve got?’….‘Okay, let’s get on and do it’. We can’t wait and see what’s the evidence, because we could be waiting five years and we’ve lost out (P14-PC)

Q5. As much as we would love to be like, ‘Right well evidence says that you need to provide 12 sessions of treatment for this particular condition’, that’s not within our gift, because of our service specification we can’t do that. But it’s then taking the bits that we can do and then ensuring that everyone’s aware of the evidence and I think that’s where our challenge is (P11-PC)

Q6. All the research that was in the Moving Forwards document they [HCPs] were all aware of anyway obviously. So, they sort of came to the community of practice with that knowledge of what they were looking at to implement in the future (P01-L)

Q7. They know I’m a patient… I hadn’t got to go in with all this knowledge (P01-L)

Obs2 (meeting 2, face to face). Lengthy discussion regarding current care for people with osteoarthritis. Local clinicians know that the service provided does not align with the number of sessions stated in Moving Forward research. Reluctance to alter this due to strong positive audit data. Other clinicians spoke of how the financial envelope would prevent the service delivering 12 sessions

Practical implementation of a CoP

Infrastructure and support

Facilitation

Context

Q8. It’s [the CoP] one of those Swiss watch, you know it just ticks away with no whistles and bells, it just happens (P02-L)

Q9. You need a strong support team underneath that lead because it’s important you don’t just go from meeting to meeting with no communication in between so, we’ve been well aware that we need to continually communicate whether that’s through newsletters, the website, bringing those members into other elements of our work (P15-PNC)

Q10. The way it was organised was fantastic you know, in the diversity of the people that were there and also how they went through things. And then having clear outcomes and things to work on (P05-PC)

Q11. It’s not just the project leads that have speared it, it’s everybody together and everybody has had the chance to take the floor and talk about their own context and how they can work together to drive the project forward (P06- PNC)

Obs3. (meeting 3 face to face also noted meeting 4 online) The group appear to ‘turn to’ or ‘lean on’ staff from the IAU for direction, set up, support. Would the CoP function without this?

 

Clarity of aims and purpose

Recipients

Facilitation

Q12. Keele had already started some work, they are your best bet because they are doing it as evidence-based practice specifications and trying to make sure they are put into practice. So rather than you duplicate, you are actually working with academics who have done this and who are doing this and who have a record of actually delivering that (P04-PNC)

Q13. So that’s basically how I then came onto the platform because I realised what I wanted to do was already happening elsewhere with another partner. Which is the university that they have the expertise and the skill and in a way the capacity and the manpower to be able to help that (P04-PNC)

Q14. I love research, I love to try and make a difference for my patients and I believe my contribution will somehow…I can facilitate the implementation of the evidence into clinical practice…and I saw the Moving Forward idea and the work done [in the CoP] as the best vehicle to get there (P13-PC)

Q15. I’m really interested, so because obviously I know from my perspective of how it is, but I’m really interested to hear the health professional’s perspective (P01-L)

Q16. I remember the first community of practice meeting everybody was a bit confused [laughs]. I think we were all sort of there, because it was right at the beginning, we had a blank piece of paper really. We knew we had this document; we knew we had this document with good research in it and we knew we wanted to get some of it out into practice, but we didn’t know how to get from A to B. We didn’t know which research studies in there would be the most important and I think everybody was kind of looking at each other for sort of one person to lead (P06-PNC)

Q17. One of the patient members told me she felt like she was in the community of practice, I think it was maybe the fourth one, she said, ‘I feel like I’ve had my training wheels on and I’ve been learning to drive for the past three meetings, but now my training wheels are off and all of a sudden I’ve worked out how to do it’. So she said it was a kind of lightbulb moment of, ‘Oh, I get it now, I understand clinical pathways, I understand how research can fit into them, I now understand how to, how I can comment on that and maybe make a difference’ (P06-PNC)

Q18. I would say the outcomes of that meeting steered the direction for the next community of practice meeting. As we’ve gone on, we then realised that it would be effective to have a patient steering group run alongside so, it’s given oversight that’s challenged and questioned what the priorities are for the local area and that’s helped formulate the agendas going forwards (P15-PNC)

Q19. It’s (the CoP agenda) been driven by a combination of the members of the community of practice dictating from the outcomes of the work but also then influences from patients and influence from wider work within the unit (P15-PNC)

Obs4. (meeting 2 face to face) all public contributors appear confident in meetings, for example, all took turns to speak, raised hands, asked questions, interacted with others in group work

Obs5. (meeting 3 face to face) Session this morning slightly uncomfortable – tasks from the last meeting were distributed to clinicians/team shared on the screen and had not been completed ? due to time (too busy)

 

CoP membership

Recipients

Context

Q20. Having commissioners there and I know the GP was there…hearing them say what’s important to them might actually be more powerful than us from a service delivery point of view saying, ‘Well this is what we can do with the money that you give us’ and having the patient say, ‘Well actually this is what’s important to us’ and focus on that and how we then deliver services around that. So I think that’s where [the CoP], it brings those key players in and it’s not just a sort of provider, fund-holder decision all the time (P11-PC)

Q21. Having those two sides to my role has been really, I’m really fortunate because I’ve got access to the research and the researchers, and I’ve got time allotted to that, as well as the clinical networks that you need, and the influential role that I have being a consultant physio. So I get to go to meetings such as STP meetings where I’m meeting commissioners and meeting people….In lots of ways I’d got all the dominoes lined up, I’d just got to link them all together. So it was kind of knowing the area and knowing the people in the area in order to be able to influence them (P07-PC)

Q22. I have had user experience before in terms of patient participant groups from GP practices we’ve had to go and speak to and things, but it’s only ever been when we want to make a big change and actually – and I think what Moving Forward has I suppose opened my eyes to is that we shouldn’t just use them when we have to, they should be integrated into whatever we’re doing and it should be that sort of co-production, it shouldn’t again be, ‘Well this is what we’re gonna do because we think it’s the best way’. You know, it should be a joint decision (P11-PC)

Q23. I remember hearing quite a lot at the beginning about how amazing it was that patients and the public were there around the table, around the same table with commissioners and NHS partners. But I remember thinking, ‘This shouldn’t be something new, this should be taken for granted, this should be just normal (P06-PNC)

Q24. I think the patient group are very educated, very well informed. But I see some patients perhaps at the other end of the spectrum who perhaps aren’t able who articulate their problems very well, are still expecting someone can fix them. And there are still those barriers there, so around the table although we’ve got a patient group, a patient voice, it’s fantastic, I’m not sure it represents the spectrum of patients that we deal with. And that’s not a criticism because how do you invite them when they don’t know it’s really, really difficult isn’t it. Just as being mindful that in our patch we’ve got people who don’t speak English, lots of people. And very, very many and there are patches where we’ve got lots of deprivation. And I think my concern, and I’ve voiced it a couple of times, is social deprivation and inequalities (P07-PC)

Obs5. (meeting 5 online) Public contributors appear well versed in research. Good understanding of research process and methods. One public contributor made reference to the fact their neighbour ‘wouldn’t understand all of this’

Culture and relationship building

Relationships and opportunities

Innovation

Recipients

Context

Q25. What I found really interesting is having the commissioners there and being able to influence by showing them this is what we’re capable of, this is where we’re at in terms of influencing best practice, you know, best care for patients (P05-PC)

Q26. It’s trying to make them [commissioners] understand what is best practice and what should we be doing and getting them on-board and actually them saying, ‘Well here’s your money, you deliver it how you see fit’… and what’s best for the patient, how we as providers see fit to deliver it as opposed to them dictating, ‘Here’s your money, but we also want you to do X, Y and Z’ (P11-PC)

Q27. Finally, we have something that we can take to commissioners or to whoever. You know what, if you’d like evidence, yes, no problem I can give you the evidence, here’s the booklet (P13-PC)

Q28. I think the very fact that they’ve got that document now, and they’ve got the evidence that backs it, it’s much easier to go and sell that to a service if you’ve got endorsement from all areas, the researchers, the commissioners, the patients (P07-PC)

Obs6. (meeting 3 face to face) The commissioner is always ‘popular’ at break times. Clinical staff appear to gravitate towards the commissioner. Several questions this morning directed towards the commissioner

 

Power balance

Recipients

Facilitation

Q29. I think with hindsight that’s probably a very good thing to empower them. They went into those meetings knowledgeable, probably more knowledgeable than the clinicians and others that were hearing it for the first time (P03-PNC)

Q30. So they’ve gone through it, they knew what Moving Forward was, they’ve reviewed the evidence, they’d thought about it where they thought the priorities were and they went into that meeting with everyone saying you’ve got an equal voice, but they were prepped with it. Whereas all the other clinicians and the commissioners and the managers just came in blind. You know, they’d been sent a copy of it, but we hadn’t done that prep work. We expected them as professionals to be able to read it (P03-PNC)

Q31. I feel privileged and honoured to be in the inner sanctum and have a seat at the top table, little old me, at a relatively low-level position, i.e. a service user (P02-L)

Q32. The challenges first of all were to gain the confidence to accept that you are on an equal footing and that what you have to say is as important (P08-L)

Q33. I think what’s been special about erm our community of practice moving forward is that it doesn’t feel like a normal meeting…it doesn’t feel like a meeting of stakeholders coming together to discuss something, put a plan in place and then go home again. It feels – everyone looks forward to it. Erm because we’re using different creative methods to get us thinking, we’re not just staring at a PowerPoint and making notes or you know, brainstorming on a piece of paper, we are – xxx getting everybody up and talking to each other. You know, talking about –using personal things to get people having that conversation to really start to breakdown those boundaries erm and just sort of thinking a little bit differently (P06-PNC)

Q34. Everybody is given a little section throughout all the different community of practice meetings. We’ve heard from the commissioners, we’ve heard from the clinicians, we’ve heard from the patients, we’ve heard from knowledge brokers, we’ve heard from project managers, so it’s not just the project leads that have speared it, it’s everybody together and everybody has had the chance to take the floor and talk about their own context and how they can work together to drive the project forward (P06-PNC)

Q35. Nobody is being talked down to or talked at, whoever it is that’s talking. So you know, the coaching and mentoring bit is quite soft and subliminal, but it’s there. Erm lots of delegation going on, it’s not you know, ‘You will do this, you will do that’, it’s you know, ‘How can we do it? Who would like to take this on?’ and people are cajoled in a sort of roundabout sort of way to putting their hand up (P01-L)

Q36. So, there’s been a lot of prep work. In terms of the meetings, there’d been a lot of thought about who would go with whom. So we knew we’d break out into groups… we made the decision to have mixed groups when we broke up into groups. So it would be a patient, a commissioner, a GP, a clinician, and a facilitator from the IAU, facilitators had been prepped – this is the tool going to use and how to get there (P03-PNC)

Q37. In putting the agendas together, considering what areas we want to cover, understanding and thinking about how PPIE fits in with that and how the patient voice can be brought through the community of practice so getting that balance right that we’re not just producing an agenda that fits the needs of the clinicians that are coming to make sure that patients are fully involved (P15-PNC)

Q38. We always get really positive feedback from xxx and xxx and xx to say you know, ‘Thanks for grounding us again and keeping us focused on what we are actually trying to achieve here and what direction we’re going’. Because as lay people, if we don’t understand what’s going on then for me it’s like well what’s the point? (P10-L)

Q39. We had this discussion about ‘Who’s gonna chair?’ and of course xxx and I never even dreamed that it’d be us. It was like, ‘Which one of you professionals are gonna do it?’ and xxx just threw into the ring, ‘Why don’t we have someone who’s not you know, not involved in the research day to day?’ and she said, ‘What about you’? (P10-L)

Q40.It’s not very often that they [clinicians] have to engage a patient in that capacity. They're usually only have to give instructions, I know that sounds harsh but that’s what they're there for, to give instructions. So, to be on an equal standing, it took a little bit of time for that to develop (P08-L)

Q41.You could see the surprise, you could see the almost discomfort I think at times that you know we don’t work with, we don’t see patients in this capacity, I’m normally treating you I never ask you what you think and you know the two way working they’re just not used to, but interestingly although we could see that emotion come through in the meeting and nobody backed out of the community of practice so, we didn’t get clinicians walking away going, ‘I can’t work in this environment’ so, it was a challenge that they accepted (P15-PNC)

Q42. It gave the patients a platform, it empowered them to challenge and then from that challenge they could then coproduce going forward it almost gave them permission then to work alongside the clinician (P15-PNC)

Q43. I think they’ve [lay contributors] given a reality check, you know, when I’ve been in meetings, they’ve given a reality check. But they’ve also given an aspirational view, as a patient, ‘this is what I want’. But I think maybe, it may have also given them a reality check as well, ‘okay we want this but there are some barriers’ (P07-PC)

Obs7. (meeting 5 online) feedback following group work—Public contributor used language indicative of power imbalance ‘you’re the experts’, yet appear very confident feeding back to group and expressing opinions

Obs8. (meeting 2 face to face) IAU staff regularly checking that public contributors ‘are ok’. There is a dedicated person (knowledge broker) to support public contributors who has good relationship with them. No one appears to ‘check’ that clinical staff are ok—? assumed

Obs9. (meeting 3 face to face) Social icebreakers to each session are excellent…..great energy, welcoming, feels like the meeting starts by levelling the playing field by talking about something that is accessible to everyone…..social space for lunch, coffee, cake appears an important focal point of the morning. Good integration at these times—Public contributors don’t appear to ‘stick together’ because they know each other

 

Enabling co-production

Recipients

Facilitation

Q44. The beauty of it was that we were all in the same boat together and that discussion between us all led to a solid plan (P06-PNC)

Q45. That has been the big aim that everything is coproduced, so, no one is right or wrong but we’re all together, I think we had an idea of that, but we weren’t sure just how it would work. Whether our patient voices or public voices would be heard and whether they would be valued because obviously it’s a learning curve for some of the professionals (P08-L)

Q46. At first, we were kind of like rabbits in the headlights, you know when we met each other at lunchtime, cause we were sort of, are you getting this, you know do you understand and I think just the fact that we all felt the same, was enough support to know that we weren’t going wrong anywhere, we were all just not used to this sort of communication if you like (P08-L)

Q47. She’s [lay contributor] definitely found her voice and she has after every community of practice recently has emailed to say how much she’s enjoyed it and how much she feels like she’s starting to make a difference, whereas at the beginning she kept questioning why she was there and what difference, why would she make a difference, why would her voice be important (P06-PNC)

Q48. Once you understand what mobilisation means and you know, all the different things that they use, once you understand what they mean then you can just use our normal day to day language – they would understand me as a patient (P01-L)

Q49. I saw the GP and commissioner’s mind change because of what the patient said, and I also saw the patient’s mind change. And that to me was collaborative practice (P03-PNC)

Obs10. (meeting 2 face to face) All activities appear very social, well planned, involve moving/going outside/require different skills. This facilitates contribution from everyone. Questioning from patients this morning prompted reflection from clinical lead

Responding to external context

 

Context

Facilitation

Q50. Now (during covid) it’s easier because with the message facility on here I can just put a message on and say, ‘I don’t understand what you mean (P10-L)

Q51. Although Covid, you wouldn’t wish it on anybody would you or this situation or pandemic at all, it kind of gave us an opportunity in one sense if you look at the silver lining to step back from that clinical work and concentrate on what is the current evidence out there? What should we be doing and how can we now translate that into our clinical practice? (P11-PC)

Q52. I saw it as an opportunity to make those changes, to have the time to implement that we’d never had before (P05-PC)

Q53. The first lockdown what we did, because we didn’t have as many patients coming through the doors, we’ve done a lot of pathway work and looking at best practice…. It probably would’ve taken us years before and now I think we’ve already done the research part; we’ve done the looking at the evidence (in the CoP) (P11-PC)

Q54. I think Covid has changed the priorities, but I think our community of practice have helped to stay connected with important issues (P03-PNC)

Obs11. Tension noted re discussion ‘should we change priorities in light of covid’ (overlap with negotiating knowledge) – local clinical guidance and shared best practice on remote consultations. Obvious divide and mixed opinions between members who felt that the Moving Forward priorities should be revisited and clinicians, whom for some, there was a strong sense of ‘we can’t cope with anything else right now’. Members appeared frustrated at the thought of ‘starting from scratch’. IAU staff helped facilitate compromise for next steps

Obs12. This was the first online CoP post covid – a very emotional meeting indicative of a ‘safe space’ for all to share experiences. Bereavement of friends and colleagues discussed. This ‘emotional offload’ appeared important to let members know they were supported (lots of positive messages of support in the chat box) and to set the tone and agenda for future sessions. Everyone made mistakes together regarding technology etc. using MS Teams – a strong sense of learning together

  1. PC professional clinical, PNC professional non-clinical, L lay member