Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report

8.2 - Links between projects and communities of practice

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8.2.1 Links between projects

The links that developed over the course of the EBPRAC program both within and between projects varied according to the different nature of the projects; particularly, according to whether content knowledge and leadership was concentrated in one organisation or more dispersed. Most activity was focused on building relationships within consortiums, especially between lead organisations and participating facilities, rather than between projects or between facilities.

An example of links within and between projects is the DATIS meds project in Round 1, led by the Drug and Therapeutics Information Service based in Adelaide, which involved a consortium that included the National Prescribing Service and a division of general practice in South Australia. The project built on previous collaborations between the three agencies, which together had contributed to the resource base of the National Prescribing Service. This collaboration continued into Round 2, with members being part of a consortium lead by the North East Valley Division of General Practice which used the same methodology (academic detailing) and resource base (National Prescribing Service). Similarly, the oral health project in Round 1 used the Australian Research Centre for Population Oral Health based at the University of Adelaide as the project’s external evaluator, building on a previously established relationship with the South Australian Dental Service (the project lead).

In some projects, EBPRAC provided the opportunity to realise long-held plans for collaboration between project partners. An example is the MU behav project where the local Primary Health Care Partnership and the School of Rural Health at Monash University had been seeking an opportunity to work with McCarthy Psychology Services to provide support in a way that addressed the specific needs of rural facilities. Similarly, the UTS behav project was a collaboration of well established aged care/dementia research centres (at La Trobe University, University of Technology Sydney and Queensland University of Technology) which had developed a similar philosophy and approach to care, and sought an opportunity to collaborate on a methodology and resource kit which could be applicable more generally.

In order to facilitate links between projects, a number of program-wide activities were undertaken, including the convening of six program workshops (one orientation and two annual workshops per Round), discussed in more detail in Section 8.1. In addition, three program-level email list-servers were established by the program evaluators to facilitate ongoing communication between projects, one for all lead organisations, one for the three palliative care projects in Round 2 and one for the three behaviour management projects, also funded in Round 2 (see Section 8.4 for details).

At the Round 2 workshop in February 2010, 10 people from the three behaviour management projects attended a meeting with the program evaluators. Discussion focused on the progress of each project and the major issues that had arisen along the way. Consideration was also given to the evaluation tools which were being used to collect data and whether there were opportunities to collect consistent data across the three projects to provide a more comprehensive picture of overall impact. All three projects used the same tool to assess the design of the physical environment within facilities but no other tools were identified to enable consistent data collection. The three projects collaborated in a symposium at the Hammond Care Conference in July 2010, where each of the project leads described the objectives, processes and preliminary outcomes of their individual projects.

A similar exercise was undertaken with the three palliative care projects at the Round 2 February 2010 workshop, resulting in a two-day workshop in Melbourne in July 2010, attended by 23 people from the three projects. The workshop provided an opportunity to share the lessons learnt from the EBPRAC program, identifying issues and recommendations across six key domains regarding the delivery of evidence-based palliative care within residential aged care:

• How to identify residents that require palliative care.
• Key processes of palliative care.
• End-of-life care pathways.
• Core educational topics and learning packages/resources.
• Education learning packages/resources that are not currently available or have not been used but have been identified.
• Sustainability and generalisability.

The outcomes of the workshop were the subject of a report to DoHA in September 2010 and are not repeated here. The workshop was the most successful example within the EBPRAC program of developing links between projects.
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Some of the largest providers in residential aged care were involved in the program e.g. Uniting Church aged care services (UnitingCare Ageing NSW.ACT, Blue Care in Queensland and Uniting Aged Care in Victoria), Baptist Community Services, Illawarra Retirement Trust, Bupa Australia, and Masonic Care. There is some evidence from stakeholder interviews of enhanced links within these organisations as they seek to capitalise on the lessons learned and resources developed as a result of participation in the EBPRAC projects. An example is the University of Queensland/Blue Care Palliative Approach Toolkit which has been graphically designed and distributed as part of the project. Blue Care subsequently indicated a strong interest in printing copies for all of their 60 facilities in Queensland at its own expense. A similar interest has been expressed by organisations that participated in the project including Padman Care (which owns 14 facilities in South Australia), Brightwater (20 facilities in Western Australia) and Brisbane South Palliative Care Collaborative, which supports 80 facilities in Queensland. For providers that participated in more than one project there is the potential to extend the impact more broadly within these organisations.

Several projects were built on existing relationships between lead organisations and individual facilities, and these are likely to continue. An example of ongoing capacity building activities is a local rural conference planned by the MU behav project. Management and staff from rural facilities in the Loddon-Mallee region in Victoria will be invited to attend, with contributions to the cost of the conference coming from project funds and the Bendigo-Loddon Primary Care Partnership. The conference will consist of short presentations by each of the seven facilities involved in the project.

In 11 projects the lead organisation ‘came in from the outside’ to work with a group of facilities. The remaining two projects involved what are effectively the ‘research and development’ arms of large providers (Hammond Care in New South Wales and Blue Care in Queensland), both primarily including facilities from other providers (6 out of 7 and 4 out of 6, respectively). Hence, residential aged care providers can be considered the junior partner in the program, which is accentuated by the turnover of staff in the sector (particularly facility managers) compared to the relatively stable staffing of most lead organisations. It seems reasonable to conclude that ongoing links across projects are more likely to involve the lead organisations and their existing networks, rather than participating facilities.

8.2.2 Communities of practice

The concept of ‘communities of practice’ was originally based on the idea that knowledge should not be separated from practice and that learning takes place in social relationships. Referring back to that original work this has been summarised more recently:
‘Many of the exchanges of practical information and problem-solving happened during informal gatherings where tradesmen exchanged stories about their experience. Novices could also consult with experts in a non-threatening environment. Through this process, gaps in the practice were identified and solutions were proposed. Individuals might apply the solution in their own practice, and the outcomes were fed back to their colleagues for further refinement of the solution. Eventually these informal communications became the means for sharing information for improving practice and generating new knowledge and skills’ (Li, Grimshaw et al. 2009, p 2).
This quote describes very well some of the most successful aspects of the EBPRAC program which involved either individuals or small groups working together or learning together as part of mentoring sessions, 1:1 or small group education, PDSA cycles, action research meetings, case conferences or having an experienced educator or expert in the field spending time in the workplace. The evidence from the literature about the extent to which these activities contribute in the longer term to the uptake of evidence-based practice is not clear (Li, Grimshaw et al. 2009).

Communities of practice within health care have primarily focused on ‘fostering social interactions at the workplace or during task-oriented activities (e.g. a journal club)’ and have some or all of the following characteristics:

• Social interaction – interacting in formal or informal settings.
• Knowledge-sharing – sharing relevant information between individuals.
• Knowledge-creation – developing new ways to doing things.
• Identity-building – the process of acquiring an identity.

As communities of practice become more mature there is tendency to develop all four characteristics (Li, Grimshaw et al. 2009).

Bate and Robert identified the importance of the following factors in determining the success or otherwise of a community of practice: ‘strong personal connections, a high degree of cognitive interdependence among participants and shared sense of identity and belongingness with one’s colleagues and the existence of cooperative relationships’ (Bate and Robert 2002, p 24).

The EBPRAC program helped to facilitate communities of practice at the level of individual facilities but these may become quite fragile as project support is withdrawn. Such local arrangements embody the characteristics of communities of practice such as social interaction and the sharing of knowledge. In some projects there was an element of identity-building, particularly for personal carers who arrived at a different understanding of their role:
Staff who generally had been seen as not formally involved in that side of care of residents, have had that recognition, that opportunity to learn, have just actually thrived. (P)
The PCAs and the domestic services staff, hotel services, gardeners, maintenance people have been far more receptive because their roles are not as carved in stone, and what they have been particularly receptive about is being recognised as being part of the care. (P)
The important question is the extent to which, if at all, a community of practice can be facilitated across the residential aged care sector, bearing in mind that a community of practice involves practitioners. Existing mechanisms in the form of professional associations and networks tend to involve managers and academics rather than nurses and personal care workers.

Some aged care providers are investing in practice development programs, which are designed to incorporate a broader spectrum of participants. Practice development has been described as ‘a function of the relationship between the evidence, context and facilitation’ (Tolson, McAloon et al. 2005). In their review of a practice development model in Scotland which used a ‘virtual college based on a situated learning model’, Tolson et al found that while there were some advantages (confidence building, strengthened sense of professional identity), the challenges were not dissimilar to those experienced in the EBPRAC program, in particular the absence of a learning-at-work culture and lack of time. There are some cultural and resource implications if communities of practice are going to be viable and sustainable within the aged care sector.
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