This theme described the relationships between groups, how members of each group define their group boundaries and what knowledge is accepted within groups. The relationships can be explained by the theory of Legitimate
Peripheral Participation and Communities of Practice which were described in detail in Chapter 2.
My findings suggest that surgeons can enact LPP at any stage in their career, not just from the junior to senior level. This appeared to encourage the formation of a variety of CoP. For example, groups in this study were established through their physical location in site B, their surgical specialty in Site A i.e., hip surgeon versus hip revision surgeon, their level of academic interest in site C, and by their position within their organisation across all sites, as well as via their affiliation to professional societies as in site B1. This demonstrates that the intention of the individual surgeons to engage with a group and follow the group norms
appeared to be configured through a process of becoming a full participant in the sociocultural practice of that group. According to CoP theory, if this process does not occur, the individual remains an outsider who does not have the relevant knowledge and skills to belong.
Across all sites, the departmental managers were outsiders because they did not possess the knowledge, skills, discretion and superiority of orthopaedic surgery which would have otherwise legitimised their belonging. Departmental
managers I interviewed were all aware of their outsider status and their position outside the knowledge boundary, as presented in the quote below:
“First of all we just don’t we just (a) don’t have the knowledge of, you know, all the information and things that we got and all the procurement stuff, so we don’t have the knowledge. And (b) I think the thing is, I don’t have the medical kind of experience”. (INT M 37005)
They would often refer to themselves as “not being clinical” (INT M 37004).
This phrase was continually used during interviews. It appeared to be a
qualifying statement or defence mechanism for the managers’ decision-making and behaviour, rather than a positive difference in role type. For example, possessing managerial knowledge of the hospital and local network was essential for managerial as opposed to clinical decisions, but this was
underplayed. Distinguishing themselves as not clinical demonstrates how the members of the surgeon group exerted power over membership of their group.
CoP literature predicts that existing members create the knowledge and group norms that make membership possible or not.
5.4.9.1 Developing meaning for the group
Groups of surgeons appeared to have the power to renegotiate meaning and to construct new meanings for their group as circumstances changed. In site C, the ‘innovative insider surgeons’ became ‘outsider mavericks’ of practice when their newly introduced, yet unproven, implant technologies had negative outcomes for
patients in subsequent years. It was important to understand the overarching
group identity for each group, and how this related to surgeons’ knowledge and learning as a group.
Surgeons in site A negotiated their group identity and were keen to demonstrate that they performed evidence-based practice. They appeared to be responsible for defining the norms and characterising meaning for the group by
implementing the findings of their own RCTs into their clinical practice. This message came across in many of the surgeon interviews I conducted in site A. The differences between group meanings were evident when I investigated the definition and meaning attached to EBM and the conduct of RCTs for surgeons working at sites A and C.
Through observation, I learned that site A took a “pragmatic view of RCTs” and
implemented ‘what worked’ for their context (OBS notes A gen). This differed
from the academic surgeon group in site C, who conducted research which was not directly transferable into their practice. Interestingly, the surgeons working in site C tended to define EBM as the use of ODEP rated implants in practice. This suggested a national view of evidence, rather than the contextual view which site A took. Although both groups suggested they practiced EBM,
meanings differed and therefore the knowledge between the groups might not be easily mobilised. There was a variety of responses from the surgeon groups
making a distinction between a “pragmatic” (INT C 218008), an “evidence-based”
(INT C 190004) and a “research attached to clinical work” (INT C 190003)
5.4.9.2 Central and periphery membership in groups
The notion of centre and periphery membership in groups seems logical in theory. In practice, the groups I observed did not appear to have a tangible structure which could be designated as the periphery or the centre. For example, particular surgeons in the three sites did not physically sit on the periphery at group meetings. However, my observations of the discussions that took place in the hospitals revealed who were the core group members. It appeared that
certain surgeons “spoke more often” and it looked as though their “opinions were
valued by others” in the group, because they were not interrupted or argued
against (OBS notes site TPM).
Group membership for the surgeons might not necessarily be defined by the position of the group members. This is because within orthopaedic surgery, knowledge is a closed domain and there is an objective amount of learning that needs to take place for someone to be called an orthopaedic surgeon.
Membership of the group evolved over time. In site A, a new consultant was able to learn the group norms to move from his position on the periphery to full participation as defined by other members. According to this surgeon, he had to actively take part in the trials that were under way at the hospital because he understood that this type of work was important to the group.
This process of learning the principles of EBM appeared to allow this surgeon to gain access to a group by developing knowledge, understanding and involvement in RCTs. He was aware of the specific meanings and group norms that helped to define the group as a standalone and bounded community of practitioners which required members to conduct RCTs within their practice.