Despite 30 years of evidence-based practice and the emergence of implementation science, significant evidence- and best-practice gaps and clinical practice variation persist.1–3 A contributing factor is restriction of knowledge flow among practitioners because the social networks within current healthcare organization structures and cultures have created clinical silos, limiting networking and knowledge-sharing opportunities among healthcare professionals.4 Through the formation of virtual communities (VCs), social media platforms can mitigate this isolation and facilitate the spread of knowledge through professional social networks.4
The structure and practices of a social network and subsequent effects on knowledge sharing sit across several theoretical concepts including the “diffusion of innovation,”5 “community of practice” (CoP),6 and social network.7 Common to these theories is that for a social network to have access to new and/or contemporary knowledge, there must be
- 1. effective communication channels to distribute knowledge;
- 2. a shared bond and understanding among members so that knowledge is understood;
- 3. effective boundary practices to bring in new knowledge; and
- 4. network members who take on roles to facilitate knowledge identification and distribution.5–7
For healthcare organizations, diffusion of innovation (involving research, medical technologies, and best practice) is complex and influenced by several key factors.8 The ability of an organization to acquire, understand, process, and assimilate an innovation into everyday practice is termed “absorptive capacity.”9 Where organizational managers and leaders have professional networks outside their workplace, called an external orientation, the organization has greater access to novel information.10 Formal and informal connections or ties among organizational members and units that create the internal social networks reflect “interconnectedness” of the ecosystem.9 Importantly, these ties need to cross both departmental and professional boundaries if healthcare clinicians are to understand and respect the perspectives, knowledge, and skills of fellow clinicians.11,12 Effective identification and integration of knowledge require organizations to balance a dense homogenous internal social network with low-density diverse external social networks.7,8,12 The density of a social network is dependent on the number of ties and interactions among network members.7 Where there are holes in this network and/or a member has a tie with individuals in other social networks, there is an opportunity to access novel information or knowledge.11 For nurses, the role of ensuring patients receive care based on the best available evidence falls within the purview of nurses in boundary-spanning roles such as management and advanced practice, and knowledge-brokering roles, such as educators or nurse researchers.13,14
Current healthcare structures and professional cultures, however, limit both internal and external communication channels, creating clinical practice silos,4 making patient care contingent on what might be an imperfect local knowledge pool. These hospital social networks also tend to be monodisciplinary,15 which restricts development of a homogenous culture among disciplines12 and may adversely affect quality improvement and implementation programs. This is a particular problem for the working environment and culture of nurses, where access to new knowledge is constrained by inconsistent journal reading habits16 and ineffective professional social networks due to limited interpersonal communication channels.17
Conversely, the rapid development and increasing use of computer-mediated communication technologies, or as they are now referred to social media platforms, within society have broadened the scope of social networks for professional groups.18 Virtual or online communities created by conversational technologies, including discussion forums, mailing lists, weblogs, microblogs, and wikis, empower users to network with a broad range of colleagues.19,20 These VCs can overcome barriers of time, geography, and organizational structure to facilitate the exchange of experiential and local practice knowledge21,22 among network members. Gaining access to previously unknown knowledge is an essential benefit of networking.12
Healthcare professionals have been using social media since the 1990s, with longstanding online communities for (1) medical librarians (MEDLIB, 1991),23 (2) nurses (NURSING-L, 1991; and NurseNET, 1993),24 and (3) doctors (critical care medicine mailing list, 1994).25 A number of successful VCs have been described in the literature,26–30 although most reports did not include a detailed description of the social network or membership profile of the VC being examined. Many studies have instead evaluated discussion threads and e-mails or used member surveys, which tend to capture a minority of members.31 Most reports described a VC with members from a single healthcare profession (monodisciplinary), usually in a clinical specialty area.23,27–29,32,33 Only one study,34 regarding a Norwegian occupational health mailing list, provided any longitudinal data, describing rapid growth in membership over 4 years until a steady state was reached and then maintained for 6 years, with approximately 20% of potential members involved in the VC.
The most common reason cited for establishing a healthcare VC was to facilitate networking and knowledge sharing among healthcare professionals,27,28,32,35 with the exchange of experiential domain specific knowledge the most frequent online activity.26,28,34,36 Some findings suggested that nurses may be motivated by their job role to belong to a VC28 and that posting may be further influenced by involvement from their nurse managers.33 One survey found members with knowledge-brokering aspects in their employment, such as educators or researchers, tended to translate this role to a VC.28 A national health foundation trust established intranet discussion forums (in midwifery, cardiology, and aged care) to facilitate interaction among clinicians in an effort to improve clinician engagement in policy development.33 Findings revealed that posting in the midwifery forum was egalitarian and included affirming contributions from midwife managers. Conversely, activity in the other two forums was oriented toward senior nurses.33 Online posting behaviors were commonly restricted to a limited number of VC members in other studies,23,30 a finding similar to behavior and activity in nonhealth communities.31
Understanding the social network created by a VC is important as increasing numbers of organizations, professionals, and patients are considering social media platforms to facilitate communication, interaction,37 and uptake of best practice.38,39 Missing, however, from the current evidence base are descriptions of how the membership profile or social network of an online community evolves over time. This includes the types of members and their roles in a healthcare organization, healthcare professional type or specialty, the distribution of members across an organization or locations, and the uptake and maintenance of membership by the potential population of members.
Establishing Intensive Care Virtual Community
An intensive care (IC) monitoring unit was established in 2003 to provide the health department in one Australian state with accurate data regarding the provision and outcomes of care delivered to adult IC patients. During introductory meetings, senior clinicians described professional isolation and were concerned about the potential impact on patient care. To address this problem, the mailing list, IC-VC, was launched in December of the same year to facilitate communication and knowledge sharing between clinicians working in 43 ICUs across the state.
The primary study aim was to describe the IC-VC social network by examining how the membership evolved over the first 6 years of existence without any direct intervention to increase membership. Specifically, we sought to describe how the demographic characteristics of membership, including healthcare profession, type of nursing role, and level of ICU, had changed over time.
We also wanted to determine whether there were any relationships between demographic variables and length of membership or retention of membership. Finally, we wanted to ascertain the uptake of VC membership by potential members. The study findings would therefore provide valuable preliminary data about the use of this VC by ICU clinicians, enabling consideration of whether social media platforms are able to create lasting communication channels among healthcare professionals, among ICUs, and across organizational boundaries.
A retrospective descriptive design was used to examine how the membership profile of IC-VC had evolved from foundation in 2003 to 2009. The study was approved as a “low risk/negligible risk” project by the relevant Human Research Ethics Committee as the dataset was retrospective and included only deidentified demographic information.
In Australia, the majority of healthcare is provided by the public sector, centrally funded by the federal government but delivered by state-based services and a smaller private sector. Most states organize this care using geographically based networks of healthcare facilities of various sizes and complexity. In 2009, there were approximately 158 ICUs in Australia and 29 in New Zealand.40 There are national and state standards covering the structure and staffing of ICUs.41–43 The level of ICU reflects the complexity of care provided. The College of Critical Care Medicine (CICM) has a three-level classification system for ICUs:
- CICM 3: large tertiary referral ICUs should be able to provide the highest levels of critical care services for an indefinite period, including respiratory, cardiovascular, and renal monitoring and support and have at least six beds. In addition, a small number of these ICUs are resourced to provide extremely complex therapies such as extracorporeal membrane oxygenation or organ transplants
- CICM 2: metropolitan or major rural or regional ICUs should be able to provide critical care services of a high standard and have at least four beds
- CICM 1: provide short-term noncomplex critical care services as well as immediate resuscitation for critically ill patients
- a high-dependency unit (HDU) provides intermediate care between an ICU and a general ward41,42
The majority of public ICUs use a closed model, where an attending IC specialist oversees patient care and the bulk of direct patient care is provided by RNs.41 The attending specialist manages a small team of junior physicians who may be in training. The availability and clinical input of allied health professionals, including physiotherapists, speech pathologists, dietitians, pharmacists, and social workers, varies according to the level of ICU.
A team of nurses in management, education, and advanced practice roles is responsible for ensuring that patients receive high-quality care from RNs. The availability of these roles generally depends on the level of ICU. The nurse with overall responsibility for management of the unit may be a nursing unit manager or nurse manager (termed clinical unit manager in this study). Clinical nurse educators and nurse educators deliver informal and formal in-service education programs at the ICU level. For CICM 2 and three ICUs, there is also usually a nurse responsible for developing practice. These last two roles have been termed as knowledge brokers13 because they are charged with integration of external knowledge into internal practices. Depending on the function of the ICU within its facility, there also may be one or more nurses who provide clinical services to patients outside their designated ICU (termed clinical nurse–external). This may include post-ICU follow-up services (nurse liaison), vascular access services, and rapid response teams.
The nurse-patient ratio depends on a patient’s severity of illness and resulting treatment and monitoring requirements. Intensive care patients are critically ill and unstable and require invasive monitoring and treatment for one or more organ failures. As the patient’s condition stabilizes to where these treatments and monitoring are being removed, patients are reclassified as high dependency and may remain in the same bed or moved to a HDU. The nurse-patient ratio is 1:1 for IC patients and 1:2 for high-dependency patients. Most patients with a cardiology diagnosis are cared for in separate coronary care units (included within non-ICU units).
The entire membership of the VC was included in the study. Members were assigned both a healthcare professional group and a nurse group according to how best their job designation on enrolment fitted the descriptors. Place of work and level of ICU were assigned according to Australian national guidelines.41,42
Data Collection and Analysis
The IC-VC member database was established when the community was created in 2003 using Excel (2003, 2007; Microsoft, Redmond, WA). Members were informed that their details would be recorded on this database when they applied to join the VC. Following data cleaning, a deidentified dataset was exported into SPSS (version 18, 2009; SPSS Inc, Chicago, IL) for analysis. Data included each member’s unique identifier and demographic information from inception of the VC in December 2003 to December 31, 2009. This end date was chosen because in 2010 staff from the state unit conducted site visits with the specific intent of raising the profile of unit and IC-VC with clinical staff. The dates selected therefore enabled exploration of how membership of IC-VC evolved prior to specific promotion.
To evaluate changes in member demographics, we used each calendar year. An individual member’s length of membership was calculated using subscription data. The variable “retention of membership” was calculated by comparing the total number of individuals who had subscribed with how many were still members at the end of 2009. The participation rate (uptake of VC membership by the potential population of members) could only be evaluated for RNs, for whom population data were available using a national IC resources report.40
Continuous variables were initially examined using descriptive statistics to assess distribution. Nonparametric testing (independent k-samples) was used for variables with nonnormal distributions to compare groups. Categorical variables were examined using frequencies and proportions with χ2 test used to identify relationships. P = .05 was considered significant.
The findings are presented in the following order: (1) the core characteristics of the IC-VC members, (2) healthcare professional and nurses’ group profiles, (3) length and retention of the VC membership by healthcare professional and nurse group, (4) distribution of members by level of ICU, and (5) uptake of membership by the potential population of members.
Core Characteristics of the Intensive Care Virtual Community
A total of 1340 healthcare professionals subscribed to IC-VC since 2003; 296 subscribers had unsubscribed by the end of 2009, leaving 1042 members (retention rate = 78%). Of the original 130 members, 83% remained members. The median length of membership was 2.65 years (interquartile range [IQR], 1.1–4.47 years). In Figure 1, note the steady and consistent increase in membership for years 2004–2006, with some plateau in growth for 2007–2008, before a further rise in 2009.
At the end of 2009, members were located in 225 departments from 155 hospitals distributed across 29 healthcare organizations worldwide, 16 healthcare companies, and 14 universities. Originally confined to one state, the geographic distribution of members progressively changed over time. By the end of 2009, 83% of the VC members were from the original state, 12% elsewhere in Australia, and 4% in 9 other countries (2% unknown). No statistical comparison could be undertaken because of the changing distribution of members across geographical locations over the study period.
Healthcare Professional and Nurse Group Profile
When IC-VC was launched, 94% (122/130) of the members were nurses; within 12 months, the proportion of nurses declined to 85%, with 10% physician and 5% allied health or bureaucrats. Over the following 5 years, these proportions remained relatively unchanged (see Table 1). The nurse group profile did, however, change significantly over time (χ230 = 169; P = .000) (Figure 2); the most marked increases occurred in proportions of nurses providing direct clinical care (clinical nurse–internal) and clinical managers. In the first year, clinical nurse manager and knowledge broker nurses together accounted for 87.6% of members and 92.6% of nurse members, with the proportion of each approximately equal. Within a short period, however, nurses with a direct clinical care role became the largest proportion of all members, and this was maintained to the end of 2009, accounting for 40% of all members (46% of nurse members). Conversely, clinical nurse managers accounted for only 13.1% of all members (15.2% of nurse members) and knowledge broker nurses 28.7% of all members (24.8% of nurse members) by 2009.
Length of Membership and Retention of Membership by Healthcare Professional Group
Over the study period, there were significant differences in length of VC membership and retention of membership according to healthcare professional type (Table 1). Physicians had the longest length of membership followed by nurses, with industry professionals having the shortest (independent k-samples; P = .037). As a group, industry professionals have chosen to retain their membership more than other groups, followed by nurses and physicians. By contrast, retention of membership by academics, healthcare bureaucrats, and allied health professionals was less than overall VC retention (χ27 = 17.841; P = .015).
Length of Membership and Retention of Membership by Nurse Group
Over the study period, there were significant differences in length of VC membership and retention of membership based on nurse member’s roles (Table 2). Clinical unit managers had the longest length of membership followed by knowledge broker nurses, whereas academic nurses had the shortest. Facility management nurses retained their membership more than any other nurse group followed by nurses in the clinical unit manager, knowledge broker, and clinical nurse–external groups. All other groups had retention of membership rates less than the overall study sample.
Distribution of Members by Level of ICU
Over time, the type or level of ICU also influenced the demographic profile of IC-VC members, with differences in length and retention of membership, as well as distribution across the aforementioned ICU descriptions. Length of membership was significantly different depending on the type or level of ICU (independent k-samples P < .000). Members from CICM 3 had the longest membership (6.62 years; IQR, 1.64–5.02 years), followed by HDU (3.50 years; IQR, 1.07–4.81 years), CICM 2 (2.84 years; 1.02–4.35 years), CICM 1 (2.35 years; IQR, 1.02–4.35 years), non-ICU (2.20 years; IQR, 0.74–3.34 years), and private ICU (2.15 years; IQR, 0.54–3.24 years). Retention of membership was also higher in the larger, more complex units, for CICM 2 (82%) and CICM 3(80%), compared with individuals from HDU (71%) or CICM 1(72%) or those who were not working in an ICU/HDU (73%) (χ26 14.854; P = .021).
The distribution of members according to type of ICU also changed significantly over time (Yates χ236 = 83.963; P = .0000). The most marked changes occurred for CICM 3, where the proportion of members fell from 52% to 39%, and non-ICU/HDU workplaces, where the proportion increased from 6% to 20%. Minor proportional changes were also noted in the private ICUs (increased from 2% to 6%) and HDUs (fallen from 4% to 1%), whereas the proportion of VC members in small (CICM 1) and metropolitan or major rural/regional (CICM 2) units remained largely unchanged.
Uptake of Intensive Care Virtual Community Membership
In 2009, 8975 RNs were rostered to Australian ICUs, and 8.28% (n = 743) were VC members. The original state (New South Wales [NSW]) had the highest participation rate (21.88%; n = 653/2985) followed by Australian Capital Territory (17.6%; n = 25/142) and Tasmania (3.6%; n = 8/225), with participation across other jurisdictions less than 2%. Across the home state, there were differences between membership rates across the levels of ICUs with CICM 1 ICUs having the highest level (57%; n = 62/108) followed by CICM 2 (34%; n = 232/689), CICM 3 (18%; n = 319/1778), and private (10%; n = 40/410) (HDU data are not available).
This study has described how the social network of IC-VC evolved over the first 6 years of its existence. The key finding was that the VC evolved from a single-state nurse-specific network in 2003 to an Australia-wide multidisciplinary IC network in 2009. This network developed significant boundary crossing as evidenced by the range of represented organizations and jurisdictions involved. Of note, IC professionals appeared to value the IC-VC, as they chose to remain members, leading to sustained membership growth. Within the modified virtual community typology,44 IC-VC would be classified as a large online community with an interdisciplinary culture and stable membership, a medium geographic distribution, and an open and voluntary enrolment.
An Online Community for ICU Nurses
By 2009, the professional profile of IC-VC was multidisciplinary, but continued to be dominated by nurses, with significant differences in length and retention of membership across healthcare disciplines. A multidisciplinary CoP can facilitate knowledge absorption by developing a shared meaning across disciplines about how external codified knowledge applies within a local context.45 Maintaining membership in a VC has been shown to be influenced by the value found and a sense of community.35 Knowledge sharing in online communities has been demonstrated to be mediated by a sense of belonging to a group of likeminded individuals with access to a multiplicity of views and the chance to interact with peers.46 The multidisciplinary profile of this VC suggests a sense of shared values and culture among the nursing and medical disciplines, but not yet allied health professionals. The reasons for this are unclear. These findings, given the majority of the VC members are nurses, indicate discussion threads are likely to be oriented toward nursing knowledge needs. As a consequence, allied health clinicians may not be able to contribute and leave because they are not getting anything of value from the VC. Therefore, at this time, the IC-VC also reflects the existing trend for VCs to be limited to or dominated by a single discipline.
A Multiorganizational Geographically Dispersed Communication Network
In 2003, membership of the VC was limited to the 43 ICUs of NSW, the state health department, and one university. Six years later, members worked in 225 individual units distributed across hospitals, wider healthcare structures, healthcare industry, and tertiary institutions. Because of this high level of organizational and geographic boundary crossing, significant opportunities are created for collaboration, learning, and information sharing6,47,48 within the Australasian IC community.
An Online Community Valued by Members
Intensive care VC members appeared to value this virtual network, as the majority chose to remain members. Over the life of IC-VC, four-fifths of healthcare professionals who joined remained members, with a stable membership growth and meaningful uptake of membership by ICU nurses, approximately one-tenth nationally and almost one-quarter in the original state.40 For an online community to be viable, membership numbers need to be both stable and refreshed by new members so that the knowledge base is revised by new content.44 Our findings also suggest that Australian ICU nurses in boundary spanning or knowledge broker roles have an orientation toward networking, and the VC may serve a vital function in fulfilling this need. To be effective in their roles of achieving best practice within their ICU, it is important that these nurses position themselves where they have access to new knowledge, and external networks provide valuable fertile grounds for new ideas.48 Unfortunately, there are no available data describing the relative proportions of different types of nurse roles in place within the Australian ICU environment. Therefore, we do not know whether nurses in knowledge broker and management roles are proportionally represented on the VC. It is, however, likely that these nurses are overrepresented as they usually comprise only a small proportion of the nursing staff establishment.43
The value members found in the VC may also be demonstrated by the possible grassroots growth of membership. Since it was established, IC-VC has not been systematically promoted except through passive mass media communication channels such as newsletters. It is possible that members spoke about the VC and recommended it to colleagues, leading to recruitment growth. This is in keeping with the idea that adoption of information and communication technologies is highly influenced in both directions by peers.49 This grassroots growth is also supported by the strong uptake of membership in CICM 1 ICUs in the original state where individual staff members are more likely to interact with a greater percentage of colleagues than those in larger ICUs.50
Study Strengths and Limitations
The key strength of the study was that all members were included in analyses; methods used in previous research limited their samples to a minority of members. Another strength was evaluation of the uptake of membership by potential members, also largely missing from previous studies. Use of a retrospective descriptive design meant that data may not have been accurate, especially for longstanding members. In addition, we did not examine whether member e-mail addresses were still active; however, literature indicating how long individuals maintain a particular e-mail address is nonexistent. This implies that conclusions based on demographic data should be considered cautiously. Despite these issues, member numbers were accurate as nonfunctional e-mail addresses are routinely removed from the member database. Importantly, as we did not triangulate our data with online posting data or a member survey, we cannot definitively confirm that members are actively engaged in the VC. Although it is common for a minority of members to post in a VC,31 a social network will not have been created unless members are actually reading posts. The actual level of active participation (writing and/or reading posts) by members is unknown. Unfortunately, the technology used for IC-VC does not provide data on reading behaviors. A survey may therefore provide more data on member behaviors as well as the value they find in belonging to IC-VC.
Relevance to Clinical Practice
Intensive care VC evolved from a single-state nurse-specific network in 2003 to an Australia-wide multidisciplinary and multiorganizational virtual IC network in 2009. Intensive care VC provides nurses in leadership and practice and professional development roles with valuable external communication channels, enhancing access to new information. High levels of professional, organizational, and geographic boundary crossing strongly suggest that healthcare organizations could further leverage virtual communities to facilitate knowledge flow between professions and across organizational units. These online communities could aid in reducing clinical practice silos and facilitate the flow of knowledge to create new opportunities for collaboration, learning, and information sharing.6,47
This study adds to the current social media evidence base, demonstrating the viability of these technologies to create a broad-ranging social network across a healthcare discipline. Because most previous studies were limited to surveys or online observation of VC posters,31 little, however, is known about the vast majority of VC members. A number of questions remain unanswered: Why do the majority of healthcare professionals join a VC? What benefits do these members gain from belonging to a VC? If gaining access to novel information is a key benefit of networking, then higher-quality research examining the content of discussion threads is required, especially if the purpose of the VC is to facilitate the distribution and uptake of best practice knowledge. What do VC members do with this new knowledge? Is this knowledge used to change practice and lead to improved patient outcomes?
We described how a VC specifically designed for ICU clinicians evolved over the first 6 years of its existence. To our knowledge, this is the first study to examine the membership profile of a social network associated with a longstanding VC. Our findings demonstrated how a mailing list technology enabled and maintained a diverse professional network of VC members to facilitate knowledge flow for healthcare professionals with an intention to directly affect healthcare. Finally, the relative longevity of IC-VC demonstrates that nurses caring for critically ill patients appeared willing to use membership of a mailing list technology to network and share information with colleagues.
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