This CoP, formed in 2009, was in its third year of operation at the time of study and was composed of approximately 60 individuals from across Ontario. It aimed to provide evidence-based and clinically relevant information to health professionals who provide oral care to older adults in LTC and hospital settings. The 11 CoP members who participated in our study (i.e. the core planning team) wanted to bring together informal and formal networks of health care and oral health professionals with frontline workers who guide or provide direct care for the frail elderly. The CoP members aimed to do this by raising awareness, providing education and learning opportunities, and by promoting collaboration and networking between the health care and dental care sectors. The CoP planning team included four co-leads, one knowledge broker, and one librarian. The core planning team held meetings to plan how to refine their process for creating the KT initiative, delivering it, and then appropriately archiving it for ongoing access by the target population. This case study focused on the planning, implementation, and evaluation activities of the core planning team related to the KT initiative.
The practice challenge
The Ontario long-term care sector, although engaged with quality improvement initiatives to enhance care for the elderly, has placed less emphasis on oral health care. As a result, health professionals (e.g. nurses, dentists) and related paraprofessionals lack the knowledge, experience, and resources to appropriately address the oral health care needs of their elderly clients.
The case, or KT initiative of this CoP, was a seven-part webinar series meant to transfer step-by-step skill-based knowledge through live and archived webinars. This series was built on the success of a previously developed series focused on basic oral care skills for the elderly. The purpose of the current initiative was to support practice-based skills in oral health in a specific population (stroke) and oral health condition (halitosis). The target audience for this initiative was frontline health professionals who provide care for older adults in LTC and hospital settings. The CoP identified the information for their initiative from a variety of places including best practice guidelines and synthesized research. Experts were also called on from the health and dental fields to aid in resource development. The research was repackaged into manageable and actionable learning segments that were viewed in real-time, interactive sessions or asynchronously via web-based archives and portable data devices. Each webinar was less than 15 minutes in length, with many images, directive words, and simple language. The live webinars incorporated a question and answer format at the end, resulting in a total time of the live webinars of 30 minutes. Each of the seven webinars was offered three times – the first two were trials, used to create questions for the final polished version (to be archived on a website). The goal was to post the final version of all seven webinars within 30 days.
The CoP’s experience in approaching the challenge
In this section we first briefly describe how the core planning team functioned internally to develop the webinars. Then, we turn the lens outwards and discuss how the CoP was challenged by organizational and LTC cultures within the broader context of health system and governmental structures.
The group was officially designated a CoP by the larger SHKN network. In addition, the functioning of the 60-member group exhibited several CoP characteristics identified in the literature . For example, identity in the CoP was supported by sign-up through a website (i.e. commitment), which clearly outlines the focus on the practice topic (i.e. a domain of interest) without restrictions on residency or professional background. Not only can members access resources like reading lists and newsletters but they can also participate virtually by interacting with colleagues in a members-only web area, indicating the value placed on members’ competence. Facilitating structures, such as live webinar technology and workshops, promoted discussions and joint learning. As described by one participant, “…I think we did 15 or 17 presentations, like one on one with staff mostly, like one on one, one to three ratio, so really good high levels and pretty intense interactions”. At the time of study, the 18-month work plan identified the following objectives: 1) to further develop the CoP through targeted growth and activity reviewing; 2) to undertake a membership evaluation survey and review data; 3) to develop and deliver a series of webinars on oral health skills; and 4) to archive oral health skills webinars and resources. As one participant said, “The purpose of the initiative is for people from across the province to work together to help improve oral care in residents in long term care in Ontario.” In this way the CoP continued to build a shared repertoire.
The case study revealed some evidence that suggests the core planning team functioned effectively. First, it included highly experienced health care professionals interested in dental and oral health who provided extensive content expertise. Their experiences, and their previous connections in the wider community, were vital to the group’s success. For example, one CoP leader persuaded an external organization to host the webinar series on its organizational websites for practitioners to access at their own convenience. Second, the diverse composition of the planning team was constantly refreshed through an evolving membership. New members brought innovative ideas and approaches. Despite this evolving membership, the common drive to improve oral health care among the frail elderly allowed for an ongoing common identity and clear vision. New members continued to draw on their own web of connections such that, over time, the CoP became a network of networks. Third, participants indicated that they were part of a positive collaboration. They spoke about sharing their brainstorming ideas with each other by email, indicating a level of mutual comfort. They praised each other (“she’s outstanding at taking the huge amounts of content that exists in any topic area and reducing it to its nuts and bolts…”, “I think everybody’s open, everybody’s very creative and everybody’s always looking for solutions”) and they spoke about what makes the team function well (“…so it’s worked really well so we sort of mutually challenge each other”).
Fourth, the CoP managed their workload by building on their past accomplishments. In particular, when they created their webinars, they made an important decision to focus on topics they had previously addressed. This “recycling” of ideas was less taxing on the group than starting with new topics. As one respondent explained:
“…I’ve done several presentations to the stroke audience on oral health so I’ll pull from that, from those slides that I’ve already done and take some of that information and put it in there. We’ve done dementia presentations several times and end of life care … and [person’s name] has done stuff on dry mouth and [person’s name] has done stuff on bad breath, so it helps if you’ve got something you can also pool from.”
Fifth, the CoP recognized the need to tailor the content of the webinars to the intended audience. This involved careful consideration of the message, the audience, and the communication infrastructure. In terms of the message, the CoP used both explicit knowledge (such as research findings and best-practice guidelines) and tacit knowledge in their webinars. Knowledge derived from research and best practice guidelines was supplemented with skills-based knowledge (“some of it comes from research guidelines, some of it comes [from] a solid clinical knowledge base that exists there”). This tacit knowledge was communicated by providing a video demonstration of the techniques required for proper oral health. The CoP hoped that by demonstrating the actual skills, they could translate a message that is difficult to articulate using observed action. This tailoring of content was also evident in the way the webinars were packaged in multiple modalities (e.g. a live webinar with a question and answer session, a podcast, an archived webinar available on the internet, and a recorded webinar available on DVD). Further, the content was tailored to specific groups. For example, the webinar information was repackaged to speak more easily to professionals who are more disease-oriented (e.g. stroke) than technique oriented. The webinars were also ‘beta-tested’ by encouraging CoP members to test webinar components in their own institutions. Based on testing, the core planning team received feedback on the effective and ineffective aspects of the products as well as suggestions for improvements. Once the beta-testing showed that the approach was successful at the test sites, the webinars were delivered to the broader LTC community.
Study participants indicated that the main challenges encountered by this initiative had to do with the culture of LTC organizations and the structure (regulations, procedures) of the broader LTC sector. Clearly, these two forces interact, sometimes making it difficult to determine if common observations across organizations were indeed cultural in nature (i.e. reflecting a shared culture in the LTC sector) or instead were structure-related (i.e. reflecting policies). At the time of this case study, it was evident that most CoP members felt that, to implement the oral health care changes that were favoured by the CoP, it would be necessary to influence and change the culture of LTC. It was less evident that study participants saw a need to influence health care delivery priorities by pursing changes to provincial policies.
There is an awareness that those on the front-line who are providing oral health care need more training (both while in school and through continuing professional development) as well as more support from their organizations’ leadership. In most organizations, these seemed to be lacking. The CoP was working to create a culture of awareness and support from the bottom up. The challenge for this CoP seemed to be about finding a way to reach management, even though their primary audience has typically been on the front-lines of care. One CoP member described this challenge as follows:
“One of our biggest barriers is trying to figure out why staff won’t do oral care, and they feel quite justified in not doing oral care, yea if you say to them would you just ignore pericare and not do that? Well, no, they wouldn’t ignore that. But they, they are quite happy to ignore the oral care.”
Oral health is not seen as a geriatric health care concern in the larger context. When speaking about managers in LTC homes, for example, one participant noted that:
“It’s so hard to reach these guys and when you’ve got something that is just not seen as being really important, … because they won’t sit down long enough [for us] to explain that, so it’s just, so it’s getting that [message] out that’s really so important.”
Without leadership support it appears difficult to find resources or committed individuals who are willing to push the issue forward in an organization. As one participant noted “it is hard to rally the troops around this issue”, since there are currently so many other informal and mandatory training sessions required by staff on topics such as drug safety training and order entries. The lack of mandatory training around oral health suggests that the issue is a low priority for organizations or government. As one study participant put it: “But the challenge we have in hospital is there’s always so many learning needs and opportunities out there competing for staff time when they have so very limited time…”. Similarly, another participant explains:
“It’s tough and it’s getting a whole lot worse, … there’s so many things they [staff] have to do as mandatory education, … it’s just one thing after another for people who have no time in their day, so then, and this is not to minimize it in any way, but then to say hey, why don’t you come to an in-service on oral care, like it does seem almost preposterous really, ….this [oral care] is really important stuff, [staff] need to make sound decisions about what they become involved in or not, because it’s a hospital thing, you know, this [other training] is mandatory, you must [attend], so by the time those things get taken care of, there is next to no time left for what people would consider the nice to knows, people themselves think of them as need to knows. But you know some of the things that we value just don’t get high enough up on the radar.”
The quote above suggests that the organizational culture values high-quality care, and thus they are open to disseminating information on improved oral health care. However, the culture also values mandates, rules, and procedures, and hence front-line staff and managers focus on numerous competing priorities. As a result, not taking effective action on oral health care might be due to its absence in official organizational or government policy.
The CoP is at a stage where it can consider feedback and evaluations about their knowledge products and webinars with the future in mind. At the time of this study, the CoP had just started branding their product to achieve greater recognition and legitimacy. The CoP understands that changing organizational culture to address oral health will require incremental shifts in attitudes as well as developing organizational support tools (e.g. templates for oral health policies that organizations can adapt). Nevertheless, how to deliberately change organizational cultures through attitudes, support tools, and other mechanisms seems elusive at the moment. For example, one participant explains:
“Well I think, from my perspective, in addition to awareness raising, I think we’re probably a little bit beyond that, and awareness about oral health being an issue, but I think what we’re trying to do is extinguish some old practices and raise awareness and try to help people to see what the evidence is on some of the practices that haven’t been part of nurses’ basic care practices, and try to really kind of push those, so many people are talking about and they think it’s kind of commonplace and it becomes ingrained in current practice, so I think that that’s part of what we’re trying to achieve.”
The CoP did not seem to consider advocating for changes to governmental or LTC sector structures to support their current front-line efforts or future organizational cultural targets even though they recognized that getting leaders, who respond to legislative priorities, onside with the oral health care agenda was crucial for change.