Australian Journal of General Practice
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In April 2020, a group of general practice leaders in NSW, Australia, established a COVID-19 virtual community of practice (VCoP) to facilitate rapid transfer and implementation of clinical guidance into practice. This research aimed to gain an understanding of the experience and effectiveness of the VCoP from leaders and members.
The study used a qualitative participatory action research methodology. A framework analysis was applied to focus group discussion, semi-structured interview and open-text written response data.
Thirty-six participants contributed data. In addition to a positive evaluation of the effectiveness of information transfer and support, a key finding was the importance of the role of the VCoP in professional advocacy. Areas for improvement included defining measures of success.
This study has reinforced the potential for VCoPs to aid health crisis responses. In future crisis applications, we recommend purposefully structuring advocacy and success measures at VCoP establishment.
On 30 January 2020, the Director-General of the World Health Organization announced that the outbreak of a novel coronavirus in China had been declared a Public Health Emergency of International Concern.1 At the time of that announcement, there were 7834 confirmed cases, 98 of those outside China.1 By April 5 2020, there were 1,133,758 cases of COVID-19 globally, with 62,784 deaths.2 At that time, Australia had 5805 COVID-19 notifications and 33 associated deaths.2
In the absence of an available vaccine or effective pharmacotherapy for COVID-19 in Australia during 2020, the mainstay of individual case management was prevention of transmission through identification and isolation of cases and, in severe cases, supportive care, including ventilation.3 Community management was recommended for the approximately 80% of patients with mild disease, provided there was capacity for counselling, isolation, support, monitoring and escalation to hospital-based care in the event of deterioration.3
As the principal providers of continuing healthcare for people living in the community, general practice shared community management and monitoring of Australians with COVID-19, in collaboration with public health units, virtual care clinics and hospital-in-the home teams. This was in addition to rapid adaption of practice workflows, implementing telehealth consultations, and testing and management of patients with COVID-like symptoms, with responses to the pandemic shared by primary care services internationally.4,5 This continuously evolving environment required assimilation and implementation of a very large amount of new and changing clinical guidance. Implementation of new evidence, guidelines or procedures into clinical practice is a challenge, especially where the change is complex with limited external support (such as facilitation) or previous applicable experience.6 All of these applied to the early stages of the COVID-19 pandemic.
Thus, as a contribution to addressing the COVID-19 crisis in Australia, in early April 2020 a group of general practitioner (GP) leaders in NSW established a COVID-19 GP virtual community of practice (VCoP). Communities of practice (CoPs) and VCoPs have been demonstrated to be effective in improving processes and outcomes in education, industry and healthcare.7 CoPs are defined as ‘groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly’.8
When a CoP is constructed primarily (although not exclusively) through internet-based interaction, it is termed a VCoP.7 The goal of the COVID-19 GP VCoP was to facilitate rapid implementation of the necessary changes in general practices through widespread sharing of knowledge (know-what) and experience of the application of that knowledge in practice (know-how). The VCoP leadership collectively initiated the process and provided a position statement concerning the role of general practice within the health system’s COVID-19 efforts. The VCoP was conceptualised as a network of networks of GP and general practices (or community of communities) to establish widespread communication channels. A tiered structure was used to facilitate movement of information from centralised authorities out to local networks, and just as importantly, sharing of experience concerning guideline and policy application among the VCoP members. This shared experience provided feedback ‘up the chain’ in real time to inform government policy and guideline development by central authorities, including having a voice in the politics of the health system. Figure 1 represents the COVID-19 GP VCoP structure.
Figure 1. COVID-19 GP VCoP structure GP, general practitioner; VCoP, virtual community of practice
The aim of the research presented in this article was to gain an understanding of the experience and effectiveness of the COVID-19 GP VCoP from the perspectives of both VCoP leaders and members. We also sought to identify major challenges, important barriers and facilitators, and key learnings for improvement to assist policymakers and clinicians dealing with a disaster or pandemic in the future.
Participatory action research (PAR) methodology provided an ideal platform to address the study aim and was embedded in the VCoP design.9 The overall structure of the project involved data collection, analysis, feedback and response. The leaders of the VCoP were involved as part of the research development process. They also reflected on and responded to member feedback, web-usage data and focus group discussion (FGD) findings, and suggested actions in response to any issues raised (Table 1).
The VCoP leaders and members were distributed across metropolitan, regional and rural areas in NSW and the ACT. As the key informants for the research, VCoP leaders and members were invited to participate in FGDs or a survey by email from the research officer on the project team. A web-based survey with the FGD questions (Step 2) enabled participants to be involved in the study by written responses. All FGD participants returned signed consent forms, while completion of the survey implied tacit consent.
Data were collected between June and October 2020. VCoP members participated in one FGD, while the leaders participated in two (one at the beginning and the second at the end of the project in response to member data). Participants who could not attend a member FGD were offered individual interviews. Surveys captured perspectives from further VCoP members with open-ended survey questions based on the FGD guide (Table 1). All FGDs were by videoconference on the Zoom platform, and interviews were by telephone. FGDs and interviews were digitally recorded and transcribed verbatim by a professional transcriptionist. All participants were allocated pseudonyms, differentiating leader FGDs, member FGDs, and interview or survey respondents.
Framework analysis was used to analyse the data, using the VCoP framework developed by Barnett et al. to code the data under the following headings: objectives and goals, champion and support, facilitation, a broad church, supportive environment, technology and community, measurement benchmarking and feedback.7,10
Five members of the research team individually coded two FGD transcripts. The rest of the data were coded by two members of the research team. The coding process and subsequent themes were refined by re-reading, group discussion and consensus within the research analysis team in an iterative fashion. The dataset was coded using NVivo 12. We engaged reflexively throughout the research process, and were aware that our backgrounds and personal experiences shaped our interpretation of the data.11
The study was approved by the Human Research Ethics Committee (reference number 2017/057).
The VCoP grew from initially 40 members to over 150 during the first 10 months of activity. Data were collected from a total of 36 participants (four leaders and 32 members). Two leader FGDs were held (two participants in each group) at the beginning of the study, and one post FGD with four leaders in the group. Two member FGDs (two participants in one group and five in the other) were held at the beginning of the study. We also conducted two individual interviews, and 23 survey respondents (14 females and nine males) answered open-ended questions based on the FGD guide (Table 1).
The participant sample in Table 2 shows variation by interview type, sex, age, years in medical practice, remoteness and socioeconomic status of practice area,12,13 and includes member and leaders. The leader group comprised two males and two females with senior roles in The Royal Australian College of General Practitioners (RACGP), academia and medical education.
The following provides an overview of the key themes identified within the seven VCoP framework headings and descriptors developed by Barnett et al.7
VCoP leaders perceived that their responsibilities were to provide advocacy and support, and to share information, including evidence-based information, with their members. These views were shared by the members, many of whom were motivated to join the VCoP to gain timely access to evidence-based information and up-to-date guidelines that they could implement in their own practices and share within their own local groups and networks. Some members were also motivated to join because of their previous experiences with VCoPs, while others believed that it would provide them with much needed support, including mental health support, during the stressful COVID-19 period.
VCoP leaders and members recognised that the VCoP was a conduit that could be used to tap into statewide, regional and local knowledge, and to share this knowledge among relevant healthcare providers and agencies (eg RACGP, NSW Ministry of Health, Australian Medical Association [AMA], academics, politically active GPs and local health districts [LHDs]). The members trusted and respected their VCoP leaders, whom they saw as committed, driven and approachable stakeholder champions who gave GPs a voice by advocating for them across the health sector – that is, supporting members’ legitimate role in the health system.
To help promote engagement and maintain standards, the leaders suggested that, as part of the VCoP set-up, it was important to consider leader and member expectations. They recognised the time and resource commitment needed to ensure member engagement. However, they acknowledged that the COVID-19 crisis had been an enabler and facilitator for the VCoP to be set up quickly and effectively engage members. In addition, both the leaders and the members felt that the VCoP facilitated communication between themselves and other key stakeholders about what worked, what did not work and how they were feeling.
VCoP leaders and members appreciated that the VCoP included a diverse group of members with differing levels of seniority and additional expertise beyond mainstream general practice. They believed this to be advantageous because it helped connect and promote communications between GPs and multiple providers from across the state, which included Health Pathways (online guidance for GPs around pathways of care), LHDs, primary health networks (PHNs) and the aged care sector. Refer to Table 3 for exemplar participant quotes.
The members commented that the VCoP provided a positive, supportive environment that encouraged networking and participation. Members described feeling a sense of togetherness, being listened to, and feeling reassured that they were all in it together and pulling in the same direction to achieve better outcomes for everyone. All of these aspects contributed to the positive nature of the VCoP.
The VCoP leaders noted that the selection of Basecamp software for the VCoP’s IT platform was based on its user-friendliness and ease of access.14 These sentiments were echoed by many of the members who found Basecamp to be a functional and practical platform for accessing and sharing information. They also appreciated that the Basecamp set-up provided them with flexibility in their level of engagement with the VCoP, depending on their availabilities and different stress levels throughout the pandemic. However, several members described being overwhelmed with the amount and organisation of information on Basecamp, and suggested investigating an alternative, more intuitive platform.
Recognising that communities are more likely to share knowledge when there is a mixture of online activities, in addition to Basecamp, the VCoP leaders noted the importance of having synchronous engagement by including regular videoconference meetings. These meetings were appreciated by the VCoP members who perceived them to be community building and more personal than just receiving information via Basecamp.
As part of this study, member feedback was provided to the VCoP leaders by the research team. However, it was acknowledged by the leaders that the VCoP was difficult to benchmark; in particular, the difficulty in ascertaining whether the VCoP facilitated the implementation of COVID-19-related guidelines and evidence within practices. They therefore suggested that potential benchmarking could be considered as a future strategy that could include advocacy activity as a measurement tool; member feedback regarding the ease of usability of the VCoP software and the information that was being provided; and a predefined measure of success, which could include member engagement. Refer to Table 4 for exemplar participant quotes.
Overall, the findings demonstrated that the NSW COVID-19 GP VCoP was highly valued by the leaders and the members involved in the study. It helped to bring sections of the GP community together from different parts of the state to engage in dialogue and information exchange to address the challenges posed by the COVID-19 pandemic. In keeping with previous research, members concurred that timely access to relevant and useful, evidence-based, up-to-date information was a key driver for joining the VCoP.15,16 Also, in congruence with the literature, members expressed a sense of togetherness and support in delivering outcomes for the community.17 The virtual nature of the CoP (both synchronous and asynchronous) as a key supporting tool enabling knowledge sharing across communities has been previously reported.17,18 Beyond the well-described potential for knowledge sharing, participants expressed that the communication channels, developed with a broad range of stakeholders, gave GP members an advocacy voice across the health sector. The two-way dissemination of information was a critical feature. Information was not only dispersed from top to bottom, but from grassroots to health sector leaders, allowing member perspectives to be available for consideration in health system and professional organisation responses to the pandemic. Thus, the VCoP empowered its members within the health system, a process facilitated by the feedback and reflection intrinsic to the PAR process.19 As opposed to an educational activity, the reciprocal nature of the VCoP information exchange blurred power relationships; the members were empowered to have their voices heard, and the leaders’ advocacy functions were empowered by the immediacy of the members’ communication. This research describes an advocacy role for purposefully constructed health VCoPs that has not been widely articulated previously in the literature, particularly in general practice. Web-based forums are ubiquitous, and there are examples of professional group-based forums established specifically to assist with the COVID-19 response, including general practice in the UK.20 In addition, CoPs have been established to support the COVID-19 response in public health in the USA,21 data sharing in the Asia Pacific22 and clinical craft groups in NSW, Australia.23 This description of the NSW COVID-19 GP VCoP provides a unique insight into a pandemic-specific VCoP sitting alongside, and simultaneously interacting with, existing organisational structures, such as the RACGP, NSW Ministry of Health, AMA, PHNs and LHDs.
The uptake of the VCoP appeared to be facilitated by an external, urgent need in the rapidly changing work environment generated by the COVID-19 pandemic. While enhancing the growth of the VCoP, the rapid design and set-up contributed to weaknesses identified as part of the research process. In the leadership group reflection FGD, the main areas identified for improvement of the VCoP were in benchmarking and feedback to members. This was partly due to difficulty in deriving usage data from the software selected, but also due to not defining objective success markers at the VCoP set-up. Barriers identified included the need to assimilate the very large amount of information that the VCoP generated and some technical limitations in the software platform.
Previous research has identified that the success of VCoPs is reliant on the availability and time commitment of the leaders.24 This raises concerns for the sustainability of this online community, which is maintained on a volunteer basis. However, given that the VCoP has maintained member engagement over a period extending to 12 months, it could be argued that it has been an effective way for GPs to communicate during a crisis when need and motivation were high. The extent to which it has enabled GPs to implement and comply with best evidence information and guidelines is not known.
The findings from the study need to be interpreted in light of its limitations. The data are based on one VCoP based in NSW/ACT and might not be broadly translated to other jurisdictions. It is also possible that enthusiastic participants in the VCoP were more likely to undertake FGD, interviews or surveys, providing a biased account of experiences. Nonetheless, the study provides a useful description of a rapidly deployable and scalable means of bi-directional knowledge translation during a health crisis. It is anticipated that context-specific health VCoPs will be deployed in the future at times of significant need for rapid adaptation and information transfer. Indeed, the VCoP continues to provide a mechanism for aiding implementation of the rollout of COVID-19 immunisation in NSW general practices. In addition to previously well-described attributes of successful VCoPs,7 our study suggests that building an effective political advocacy role for a VCoP contributes to the uptake and participation by members. We also recommend establishing effective means of feedback to members concerning VCoP activity, benchmarking the usefulness for implementation of evidence into practice and definitions for success at the establishment phase of a VCoP. Future research is required to understand the extent to which such VCoPs are instrumental in gaining advocacy outcomes, enhance clinical practice or foster resilience among members during a health crisis. The findings also highlight the need for further research into the role of networks in addressing power relations within the structural organisation of the health system and primary care.
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COVID-19Health services research