Communities of clinical practice in action: Doing whatever it takes.

Burgeoning numbers of patients with long-term conditions requiring complex care have placed pressures on healthcare systems around the world. In New Zealand, complex patients are increasingly being managed within the community. The Community of Clinical Practice concept identifies the network of carers around an individual patient whose central participants share a common purpose of increasing that patient's well-being. We conducted a focused ethnography of nine communities of clinical practice in one general practice setting using participant observation and interviews, and examined the patients' medical records. Data were analysed using a template organising style. Communities of clinical practice were interprofessional and included informal supports, services and non-professionals. These communities of clinical practice mediate practice, utilising informal networks to cut across boundaries, bureaucracy, mandated clinical pathways and professional jurisdictions to achieve optimum patient-centred care. Communities of clinical practice's repertoires are characterised by care and are driven by the moral imperative to care. They do 'whatever it takes', although there is a cost to this form of care. Well-functioning communities of clinical practice use patient's well-being as a guiding light and, by sharing a vision of care through trusting and respectful relationships, avoid fragmentation of care. The Community of Clinical Practice (CoCP) model is particularly useful in accounting for the 'messiness' of community-based care.

Shared care requires a shared vision: communities of clinical practice in a primary care setting.

AIMS AND OBJECTIVES: To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. BACKGROUND: To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. DESIGN: Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. METHOD: Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. FINDINGS: Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through respectful dialogue. These common values - respect, authenticity, autonomy, compassion, trust, care ethics, holism - underpin the development of a shared vision of care. CONCLUSIONS: A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. RELEVANCE TO CLINICAL PRACTICE: A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'.