Original Research

An Online Community of Practice to Support Evidence-Based Physiotherapy Practice in Manual Therapy

CATHY EVANS, PHD, MSC, BSCPT; EUSON YEUNG, PHD (C), BSCPT, MED, FCAMT; ROULA MARKOULAKIS, PHD; SARA GUILCHER, PT, PHD Introduction: The purpose of this study was to explore how a community of practice promoted the creation and sharing of new knowledge in evidence-based manual therapy using Wenger’s constructs of mutual engagement, joint enterprise, and shared repertoire as a theoretical framework. Methods: We used a qualitative approach to analyze the discussion board contributions of the 19 physiotherapists who participated in the 10-week online continuing education course in evidence-based practice (EBP) in manual therapy. The course was founded on community of practice, constructivism, social, and situated learning principles. Results: The 1436 postings on 9 active discussion boards revealed that the community of practice was a social learning environment that supported strong participation and mutual engagement. Design features such as consistent facilitation, weekly guiding questions, and collaborative assignments promoted the creation and sharing of knowledge. Participants applied research evidence to the contexts in which they worked through reflective comparison of what they were reading to its applicability in their everyday practice. Participants’ shared goals contributed to the common ground established in developing collective knowledge about different study designs, how to answer research questions, and the difficulties of conducting sound research. Discussion: An online longitudinal community of practice utilized as a continuing education approach to deliver an online course based on constructivist and social learning principles allowed geographically dispersed physiotherapists to be mutually engaged in a joint enterprise in evidence-based manual therapy. Advantages included opportunity for reflection, modeling, and collaboration. Future studies should examine the impact of participation on clinical practice. Key Words: communities of practice, online/computer-based education, profession-other, research trainingclinical, theory-social learning, physical therapy, manual therapy, evidence-based practice

The concept of community of practice (CoP) introduced by Lave and Wenger1–3 has sparked interest in health care and Disclosures: Cathy Evans reports that background research and work in preparation of this manuscript was funded by the University of Toronto. Dr. Evans: Assistant Professor, Department of Physical Therapy, University of Toronto; Mr. Yeung: Lecturer, Department of Physical Therapy, University of Toronto; Dr. Markoulakis: Graduate Department of Rehabilitation Sciences, University of Toronto; Dr. Guilcher: Affiliate Scientist, Li Ka Shing Knowledge Institute at St. Michael’s. Correspondence: Cathy Evans, University of Toronto, Department of Physical Therapy, 160-500 University Ave., Toronto, ON, M5G 1V7 Canada; e-mail: [email protected]. © 2014 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education • Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.21253

education, as the model provides the opportunity for creating and sharing knowledge and innovations in a socially constructed environment, essential for modern knowledgebased workplaces.4 For Wenger, a CoP is a collection of individuals sharing mutually defined practices, beliefs, and understandings over a period of time, in the pursuit of a shared endeavor.2,3 Learning occurs through social interaction, with opportunities to negotiate meaning related to the complexities of lived situations. Wenger suggests that mutual engagement, joint enterprise, and a shared repertoire are 3 components fundamental to the coherence of a CoP model.2,3 Mutual engagement refers to membership in a community in which participants, with their unique identities and diverse specializations, draw on each other and are engaged in doing things together. Joint enterprise is the practices of the community, defined as the result of a collective process of negotiation. Shared repertoire includes tools, routine, stories,

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jargon, shortcuts, or any resource that may be used over time in a shared pursuit to negotiate meaning. Educators have recognized the potential role that CoP might play in the continuing education of health professionals.5–10 The broad application of CoP has come with considerable variation in the characteristics and interpretation of the model.11–13 A review of 31 health care studies by Ranmuthugala13 revealed how the diversity of CoP models presents challenges in assessing their overall effectiveness and attributing changes in practice to the CoP. A review of CoP studies in business and health care by Li11 found that the focus of research was mainly on how people shared information, created knowledge, and built identity. CoPs are not limited to face-to-face interaction.14 Numerous studies have shown how the advances in technology and social media can be used to develop and promote social learning through interactivity in online or virtual CoPs, allowing individuals with specialized interests who are geographically dispersed to collaborate.10,15,16 Online CoP characteristics vary in terms of membership, purpose, and structures, making it difficult to draw conclusions about overall effectiveness13,17 ; however, they may provide an opportunity for dynamic continuous education environments, with access to repositories of information and a common platform for discussion and exchange of ideas.15–18 When the Canadian Physiotherapy Association (CPA), Orthopedic Division, approached the Department of Physical Therapy at the University of Toronto in 2011 to develop a continuing education course in evidence-based practice (EBP) in manual therapy for its members across Canada, we decided to incorporate CoP concepts in a fully online environment. Online-based education has proven to be as effective as traditional classroom environments for postsecondary16 and health professional learners,19,20 particularly if there are opportunities for interaction.19,21 Our course was founded on social learning, constructivism, and situated learning principles.1,22,23 Social learning relates to the continuous reciprocal interaction, social participation, and relationship with persons in their environment.22 Constructivism involves the active building of knowledge as learners work together with materials to understand and create meaning.23 The constructivist model applied to professional development recognizes learning as an active process in which adult learner clinicians bring a variety of life experiences and interests to a group, which they can use to create knowledge and practice. The principles of situated learning specify that learning requires social and collaborative interaction, and learning should take place in authentic contexts, activities, cultures, and settings.1 Wong20 suggests that users prefer online courses that allow interactivity through dialogue and have “ease of use.” Our CoP model is based on the premise that if learners are given a virtual space with tasks founded on constructivism and social learning ap216

proaches, they will engage in social discourse through their common purpose and shared experiences, thereby building collective knowledge and sustaining the online community of practice. Much of the CoP literature examines the process of launching and implementing CoPs and describes the factors that influence their success19 or failure.24,25 CoPs also need to be assessed for their value and impact.10 Murillo’s work suggests that Wenger’s theoretical framework can be used to evaluate online CoPs.12,14 The purpose of this article is to describe the design features of an online CoP as a continuing education strategy and to explore how the community promoted the creation and sharing of new knowledge in evidence-based manual therapy using Wenger’s constructs of mutual engagement, joint enterprise, and shared repertoire as a theoretical framework. Methods Educational Intervention The goal of the course was to introduce learners to concepts that would enhance their ability to critically appraise and integrate research evidence in their manual therapy and teaching practices. The course was structured using a continuous, longitudinal approach and took place over 10 weeks. Each week, learners were introduced to a new topic (TABLE 1), provided with relevant online resources and access to the university library. To encourage participation and focus the collaborative asynchronous discussions, we provided guiding questions each week (TABLE 1). Learners were not restricted to discussion based on the guiding questions and were free to generate other topics. Guidelines as to frequency and length of postings were provided. Three assignments were created to promote collaboration and collective knowledge (TABLE 2). Two physiotherapists with expertise in manual therapy and research methodology facilitated the weekly online discussions. Evaluation Nineteen physiotherapists who participated in the November 2012–February 2013 online Evidence-Based Practice in Manual Therapy course were eligible to participate in this evaluation. Using a modified Dillman approach,26 a research assistant e-mailed an information cover letter and a consent form to participants when the course was completed. Over the next 2 weeks, participants were sent 2 additional e-mails to ask for consent to use quotes from the discussion boards, a standard feature of the learning management system Blackboard. An online consent was also included when feedback was solicited after the course was completed. All participants consented.

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Online Community of Practice for Physiotherapy TABLE 1. Online EBP in Manual Therapy Course

Module

Topic

1

Introductions CoP

2

Online Search

Members and EBP

Guiding Question Example

Threads

Please provide a paragraph introducing yourself to the class and include your clinical and

33

educational experience and what you hope to learn from this course. Post a research question that interests you and is relevant to your practice. It can be any

Strategies and

type (eg, the effectiveness of an intervention, diagnostic abilities of a test); please use

Developing

PICOT format. Do an online search using PubMed or Ovid to find an article that helps

Research Questions

199

to answer your question; post your reference (title author journal [#and year]).

3

Designs

Complete the study design table on advantages and disadvantages (only your section).

4

Critical Appraisal

We will be completing a group critical appraisal. Please see attached and find your name

143

The weekly leader will summarize on one table. 134

and your section for the questions that you are responsible for answering. Post your answers on the discussion board. The leader/facilitator for the week will pull your group responses together so you have a final copy. 5

Outcome Measures

Identify one outcome measure that you are currently using in your practice or that you

145

think might be applicable to your practice (select a measure that no one else has yet posted). Describe two important psychometric properties (such as reliability, validity, minimal detectable change, minimal clinical important difference) of a measure used in your clinical practice. 6

Qualitative Research

Post a research question that is clinically relevant to you that can best be answered using a

160

qualitative design. Search online to find an article that uses qualitative methodology to answer your question. 7

Diagnostic and Screening Tests

Search online to find a diagnostic study for your question. What was the sensitivity and

186

specificity of the test? Calculate the positive and negative likelihood ratios. What do these numbers mean?

8

Clinical Prediction Rules (CPRs)

9 10

Clinical Practice Guidelines (CPGs)

Debate Week: I support the use of the CPR developed by Flynn et al (2002) for lumbar

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spinal manipulation because . . . Work on final assignment.

20

Identify and post a CPG related to physiotherapy and health. It does not have to be manual

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therapy related. Refer to the Agree document, select one domain (eg, Scope and Purpose or Stakeholder Involvement or one of the others) and identify how your CPG meets the standard or not.

Abbreviationas: CoP = community of practice; EBP = evidence-based practice; PICOT = population, intervention, comparison, outcome, time.

Discussion board responses underwent thematic analysis, a method for analyzing qualitative data.27 The goal of this method is to determine themes or patterns across a data set. Thematic analysis makes use of explicit “codes,” representations of themes that can simply organize observations made of the data or more deeply interpret underlying phenomena in the data. Codes were generated deductively from pedagogical theories around communities of

practice,2,3 constructivism,23 situated cognition,1 and change in practice. Additional codes were inductively created when striking patterns were noted in the data. Prior to beginning analysis, discussion board content was read through by 2 investigators (RM and CE) for the purposes of familiarization with the data set. Data were then reviewed and coded using deductive and inductive codes, as noted earlier. Finally, the information was interpreted based on the

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Evans et al. TABLE 2. Assignments

Assignment

Assignment 1

Objective

To develop the ability to

Develop a research question and

Features

Population

Learning Artifacts

Research questions and results of the

formulate clinical research

Intervention

online searches were shared online

perform an online search to

questions using PICOT

Comparison

for all participants to have access

answer the question

format and perform an

Outcome

to.

online search to identify

Time

articles that might help to

Online search using different

answer the question

strategies with full access to university libraries

Assignment 2



Collaborative

skills through a systematic



Worked in pairs

all appraisals to create final

examination of 1 of 3



Collective knowledge

collective appraisals for the 3



PICOT framework, the PEDro guides and worksheet



Collaborative



Worked in pairs (self-select partners)

To develop critical appraisal

Critical appraisal

research articles

Assignment 3



Write a review article suitable for publication in national association’s special interest newsletter

● ●

To further develop skills in critical appraisal To develop writing skills To disseminate research evidence and its application to practice to colleagues in the internal and external community



Collective knowledge



Integrated knowledge from the different modules



Situated—able to select article of interest, relevant to their practice



CAMPT website research review format

Leaders integrated information from

articles.

Review articles published on our community website and suitable for publication in newsletter.

Abbreviations: PEDro = Physiotherapy Evidence Database; CAMPT = Canadian Academy of Manipulative Physiotherapy.

discussion board content contained within each code, to determine if and how key pedagogical goals were met through the discussion board. Rigor as described by Patton was maintained in this study in order to obtain valuable findings.27 Credibility was promoted by selecting facilitators who were knowledgeable in conducting courses of this kind and well versed in the course content. Thus, they were able to establish trustworthiness and rapport with participants and foster information-rich discussion among discussion board participants. Researchers were also aware of possible bias in analysis, and steps were taken to maintain reflexivity and prevent issues around projection, sampling, and mood and style.28 218

Bias in deductive coding was limited by ensuring that these codes were clearly defined, and that indicators of the presence of these codes in discussion board content were predetermined. Coding consistency was regularly checked to ensure that there were no subtle changes in meaning or effects of investigator fatigue over time.29 Triangulation also provided an important means to maintaining rigor by employing numerous sources of data such as multiple course weeks, modules, and activities to ensure that there was agreement across sources and lend strength to the study.30 Investigator triangulation involved 2 researchers (CE and RM) reviewing the data, providing their interpretations of the findings, and discussing points of assent or dissent.27 Preliminary

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findings were also summarized and sent to 1 of the course facilitators (SG) for opportunity to comment, allowing for an additional means of data triangulation, as the course facilitators’ discussions were not entered into analysis to better focus on course learners. Triangulation of multiple perspectives in this manner thus enhanced credibility of findings. The research was approved by the University of Toronto Research Ethics Board (REB# 29282). Results All of the 19 physiotherapists registered in the course agreed to participate. The sample consisted of 6 male and 13 female physiotherapists with representation from 4 Canadian provinces. All participants had more than 10 years of experience, worked clinically in private practices, were experienced manual therapy instructors, and contributed 1436 postings throughout the 10-week course on 9 active discussion boards including original threads and responses (TABLE 1). All 19 participants completed the course. The results are discussed in 4 main sections—mutual engagement, joint enterprise, shared repertoire, and situated practice—reflecting the findings related to the theoretical constructs on which the online CoP was designed and Wenger’s elements of CoP. Pseudonyms are used in quotes. Building a Social Learning Environment to Support Mutual Engagement In the first week, profiles were posted by participants as introductions. These were relatively formal; however, participants became increasingly social over time, as evidenced by the banter. The debate activity appeared to facilitate social learning as participants were mutually engaged in what they perceived as a competition. Are you giving up that easily? Really! I am on the opposer group and I could come up with more than that. Did we win yet? Disclaimer: the opinions voiced hear [sic] are strictly for the purposes of the debate. Any opinions do not necessarily reflect the opinions of the author and cannot nor should not be used against her in the future. Thank you :)

The social learning environment was strengthened and participants grew more comfortable joking online on a personal note, sometimes unrelated to course material.

specializations and expertise of participants by posing questions to each other. I don’t see a lot of these clinically, so maybe the sports therapist can clarify this for me—but are any of these surgically repaired?

In cases where new literature and new knowledge were shared with the group, participants tended to view the individual who posted the new information as the “expert” of the group in that particular area. They would then ask questions of that individual when they wished to learn more about the knowledge introduced. One question as I did not have the chance to read fully the two articles . . . if the Flexion rotation test is positive, ie, right rotation is less than 32 deg, does this mean that the restriction of movement is C1–C2 . . . but correct me if I am wrong . . . it does not mean that the right C1–C2 is the joint at fault correct? We still have to do our PAVMS [passive accessory vertebral movements] on each one to confirm the dysfunctional one?

Participants seemed willing to do additional research in order to answer questions from their peers. This contributed to the individual and collective learning process. I’m going to have to try to get the complete article. Medline only offered the abstract and when I clicked “get it,” I didn’t. I’ll spend some time tonight and let you know what I find.

We found many examples indicating that participants were actively engaged in drawing on each other’s expertise, and found confirmation in shared clinical experiences and the growing body of shared knowledge. Your article, as well as quite a few others that have been posted with regards to other tests, highlights what I think we all tend to already do clinically: perform a series of tests to confirm or negate a working hypothesis.

Participants also showed evidence of becoming more comfortable challenging each other and seeking feedback and accepting critiques in instances where doing so could broaden their learning.

Since I’m a real dinosaur when we talk about technology, here I am reposting . . .

I hear what you’re saying from a clinical point of view. However the scaphoid shift test has been pretty well studied and so ulnar deviation may well be a good predictor of occult # since it would create a stress to the bony injury? . . . Just my preliminary thoughts. Any feedback or criticism is appreciated.

Evidence of mutual engagement included the active sharing of expertise as the community capitalized on the unique

Finally, there was strong evidence that participants were engaged in working together. They supported each other and,

No surgery for me . . . turns out I had an acute, then chronic, case of “Wussitis”;)

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particularly in the debate module, relied on their team members to mutually construct their arguments. This contributed to the knowledge generated and the learning experiences of the group as a whole.

The collaborative assignments also provided participants with learning artifacts such as templates, critical appraisals of recent studies, and evidence-based clinical case reports that could be used in their own clinical and teaching activities (TABLE 2).

I also would like to support John’s and Mary’s points regarding the Hancock et al validation study. There is so much more to add, but I’ll have others completing the argument. Go team!

Use of Collaborative Learning Design to Support Shared Repertoire Participants demonstrated evidence of a shared repertoire that included tools, common practices, stories (cases), and jargon in their shared pursuit to negotiate meaning. They routinely used language and jargon specific to their roles, qualifications, and expertise as manual physiotherapists. I’ve completed my AFCI certification for Acupuncture and FCAMPT certification. I’ve always loved teaching in any capacity, and am starting to TA level 2.

Participants also understood the meaning of the shared stories (cases) relating to each other’s clinical experiences. As their knowledge in evidence-based practice developed, they demonstrated an ability to compare and contrast suggestions in the literature with their own experiences of clinical decision making, building a conversation around the information being learned. Participants thus indicated engagement with the course content and shared learning process. Frequently, I will find patients with a diagnosed disc herniation via MRI can have a normal SLR but a positive SLUMP test, but I don’t think I’ve had a patient with a positive SLR and a negative SLUMP. Given the higher sensitivity and specificity of the SLUMP, I would be more inclined to use the SLUMP test as the better neurodynamic evaluator.

Participants developed the ability to search literature databases and found this a useful tool in addressing topics of interest. They were also able to discuss search strategies with confidence. Following reading some of the other posts, it would be interesting to see if US or MRA are helpful in confirming diagnoses of wrist pathologies. Offhand I didn’t see any articles relating these tests to diagnostic manual tests but maybe I will take another look.

Constructivism to Build Knowledge Through Joint Enterprise Participants had clear knowledge goals as to their reasons for taking the course and worked collaboratively to construct new knowledge by negotiating and building on the ideas of others. I wanted to take this course not only to help my students, but also to learn how to critically read articles for myself to gain a better understanding of the research, thereby making a better link between the clinic and the research.

Their shared goals contributed to the common ground established in developing collective knowledge about different study designs, how to answer research questions, and the difficulties of conducting sound research. Participants considered new knowledge in light of their clinical expertise and actively helped each other determine how knowledge could be applied to their practice. If we talk about the duration of the symptoms, of course, it is not the majority of our patients who comes in with the pain for less than 16 days. . . . But for the ones who come in less than 16 days, I think it can be a great way to achieve pain relief and get them to move better quicker. . . . Of course, after manipulating, we need to do our normal stuff: education, exercise prescription. . . .

Some participants expressed concerns over the limitations in the research knowledge on a specific topic. Although no specific solutions were offered, participants expressed hope that these concerns would improve with time. When I have a specific question, finding a precise answer is difficult. I will often find related articles but not quite what I need. I think we are still at the early stages of research in physio. There are a lot of questions that aren’t answered yet, but I guess it is improving all the time.

When you did your search and retrieved too many articles, did you try using the filters on PubMed or using the Clinical Queries on PubMed?

Finally, participants also offered solutions to concerns that might arise in clinical settings, typically addressing concerns by references to taking an evidence-based approach in their practice and teaching.

The design of the collaborative assignments provided a structured activity that guided participants to work together.

It appears as though there will soon be a study that considers a cluster of tests to diagnose labral tears. Seldom do we have

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a gold standard test for anything. Even the Lachman test for the knee is not perfect. Thanks for posting this article—very timely for me as I am teaching a Level 3 Upper. . . . Before using this in clinical practice or teaching it to students, we should wait for more independent studies for validation. We should all be patient before applying this to our patients or teaching it in our courses.

As the course progressed, participants grew more comfortable expressing their opinions regarding the literature, and took up new knowledge in light of their critiques. Participants were able to consider the strengths and weaknesses of the literature early in the course. I would not use the Clinical Predicative Rules as outlined by Flynn in 2002 because of the lack of internal validity of the 3 validation studies by Cleland 2009, Hancock 2008, and Childs 2004. One of the reasons I would not consider this CPR was the inconsistency of the level of competency of the physical therapist delivering the treatment between the initial determination study by Flynn in 2002 and the 3 other studies.

Throughout the course, participants weighed what they were learning against what was already known. They often engaged in conversation about what they found surprising, new, and interesting. Participants shared new knowledge to construct meaning as a group. They posed questions to each other and discussed issues arising in the literature they were reading. Thx—I had these very questions about how good (or not) our common clinical tests (quadrant, Fabere’s) are at picking up labral tears. Also interesting to read how effective ultrasound is at picking them up.

Finally, participants helped each other consider new knowledge in light of their clinical expertise. Surgical management seemed to have a superior result for return to overhead sports at a competitive level, so in this case it would appear surgical management would be preferable. Hope this helps.

Application to Situated Practice Participants often applied what they were learning to the contexts in which they worked, typically through reflective comparison of what they were reading to its applicability in their everyday practice. In some cases, geopolitical contexts were of importance in considering the applicability of a specific technique. The fact that this technique is not something taught in Canada does not mean it is not useful. Maybe the Canadian manual

therapy system needs to take a look at the use of this and similar techniques. This is a technique used in other countries with apparently great success and should not be overlooked by us simply because of the technique.

Participants also speculated about how they would apply what they were learning to their clients. I have definitely had patients come in who have been told to stop running by doctors/health care providers/family because of knee OA and it is good to have some evidence to support them continuing in their chosen activity.

In some instances, participants found that evidence was not applicable or contradictory to their typical clinical practice. Well, this sport therapist is sad to report that the treatment algorithm for the suspected syndesmotic injury is less than consistent and clear.

Participants weighed what they were learning with their own clinical expertise, resolving to balance between both in future practice. They also engaged in reflective inquiry, formulating hypotheses pertaining to clinical practice, based on knowledge gleaned from critically appraising the literature, and recognized the limits of evidence. [W]hich leads me to ponder . . . will we ever have a enough GOOD studies to answer this type of question that physios are supposed to be asking ourselves every day?

Discussion This study demonstrated how Wenger’s constructs of mutual engagement, joint enterprise, and shared repertoire could be enacted in a fully online CoP to promote a social learning environment to generate and share knowledge in manual therapy. Despite the lack of face-to-face encounters, the community exhibited strong engagement with timely participation and no attrition. The community relied solely on interactive, online, asynchronous discussions, which are often difficult to sustain.9 The success of a CoP is thought to be influenced by factors including (1) instructional design features,19,31 (2) role of the leader or facilitator,11,19 and (3) the intrinsic motivation of the participants and an interplay between these factors.32 In terms of design, Blackboard provided an easily accessible knowledge management system. We created guiding questions each week often designed as debates to stimulate the sharing of ideas and to discourage individual, isolated postings. We assigned or had members self-organize into groups19 for all assignments to create a sense of shared responsibility2 and to enhance collaboration.

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The role of the facilitator is often linked to the success or failure of the CoP, although the responsibilities are often not well defined.11 We used a model in which the facilitator’s role was to correct misperceptions, pose new questions, and draw attention to exceptional or controversial postings for further discussion. They had a visible presence but did not respond individually to each member but rather to the group on a daily basis to ensure that they were not perceived as the experts or pivotal point of the discussions.32 Hartnett et al33 suggests that motivation in online learning is complex and multifaceted. In this study, CoP participants were leaders in the field of manual therapy and likely to have strong intrinsic motivation for lifelong learning, a trait commonly valued in physiotherapy leadership.34 There were influences embedded in the design such as the weekly deadlines, dependence on others for group assignments, and the public nature of the discussion forums that may have influenced motivation.24,25 We found several advantages to a socially constructed CoP compared to instructor-driven didactic courses. Participants were able to model and build on the postings of others, which raised the quality of the discussions to higher levels and supported the collaborative sharing of knowledge.35 For example, when an individual provided articles to support her ideas, others soon modeled this approach, leading to collective application of research evidence.22 There are few time constraints in asynchronous discussions that allowed the participants to submit thoughtful and reflective postings.36 Participants often used narrative cases to share their own experiences and find meaning that “makes sense” in the knowledge they were creating.35 In a didactic learning situation, the instructor controls the information flow. In this social learning community, we found that although discussions were initially guided by questions posed by the facilitator, the online conversations often took different directions as participants interpreted and contextualized knowledge based on their real-world interests, workplace, values, and past experiences.35,37 The public nature of the discussion board allowed participants to recognize that they often viewed the material differently and discuss these perspectives and interpretations. In the field of physiotherapy, most professional development courses continue to take place in traditional face-to-face environments. The preference for course directors to offer workshops may be reflective of the perception that expertise in physiotherapy requires hands-on skills best achieved through kinesthetic learning.38 However, physiotherapy has evolved from being solely hands-on to a knowledge-based profession that requires time spent on cognitive work in a collaborative environment.

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Limitations This study achieved a high degree of participation among participants who were physiotherapists and manual therapy instructors. Future studies should determine if the same results would be found in a heterogeneous community of physiotherapists who are less experienced in manual therapy. The study did not examine whether the participants continued to be engaged in a CoP after the course was completed. Further follow-up is needed to determine long-term participation and impact on clinical practice. Conclusions An online community of practice promoted the creation and sharing of new knowledge in evidence-based manual therapy using Wenger’s constructs of mutual engagement, joint enterprise, and shared repertoire as a theoretical framework. Design features founded on principles of social learning, constructivism, and situated learning supported sustained participation and collaboration.

Lessons for Practice ●





Continuing education courses founded on community of practice principles can provide opportunities for collaborative, interactive learning. Participants in an online community of practice can share and create knowledge related to their practice through mutual engagement in shared endeavors. Design features such as guiding questions, instructor facilitation, and collaborative assignments help to create active, sustained participation in a fully online course.

References 1. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge, England: University of Cambridge Press; 1991. 2. Wenger E. Communities of Practice: Learning, Meaning and Identity. New York, NY: Cambridge University Press; 1998. 3. Wenger E. Cultivating Communities of Practice: A Guide to Managing Knowledge. Boston, MA: Harvard Business School Press; 2002. 4. Saint-Onge, H. In: Wallace D, ed. Leveraging Communities of Practice for Strategic Advantage. Boston, MA: Butterworth-Heinemann; 2003. 5. Andrew N, Tolson D, Ferguson D. Building on Wenger: communities of practice in nursing. Nurse Educ Today. 2007;28:246–252. 6. Kilbride C, Perry L, Flatley M, Turner E, Meyer J. Developing theory and practice: creation of a community of practice through

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JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—34(4), 2014 DOI: 10.1002/chp

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An online community of practice to support evidence-based physiotherapy practice in manual therapy.

The purpose of this study was to explore how a community of practice promoted the creation and sharing of new knowledge in evidence-based manual thera...
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