Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 https://doi.org/10.1186/s12913-019-4185-z RESEARCH ARTICLE Open Access Acceptability and feasibility of a virtual community of practice to primary care professionals regarding patient empowerment: a qualitative pilot study Carlos Jesús Bermejo-Caja1,11, Débora Koatz2,3, Carola Orrego2,3, Lilisbeth Perestelo-Pérez4,3, Ana Isabel González-González3,5,6*, Marta Ballester2,3, Valeria Pacheco-Huergo7, Yolanda del Rey-Granado1, Marcos Muñoz-Balsa1, Ana Belén Ramírez-Puerta1, Yolanda Canellas-Criado8, Francisco Javier Pérez-Rivas9, Ana Toledo-Chávarri3,10, Mercedes Martínez-Marcos11 and e-MPODERA group Abstract Background: Virtual communities of practice (vCoPs) facilitate online learning via the exchange of experiences and knowledge between interested participants. Compared to other communities, vCoPs need to overcome technological structures and specific barriers. Our objective was to pilot the acceptability and feasibility of a vCoP aimed at improving the attitudes of primary care professionals to the empowerment of patients with chronic conditions. Methods: We used a qualitative approach based on 2 focus groups: one composed of 6 general practitioners and the other of 6 practice nurses. Discussion guidelines on the topics to be investigated were provided to the moderator. Sessions were audio-recorded and transcribed verbatim. Thematic analysis was performed using the ATLAS-ti software. Results: The available operating systems and browsers and the lack of suitable spaces and time were reported as the main difficulties with the vCoP. The vCoP was perceived to be a flexible learning mode that provided up-to- date resources applicable to routine practice and offered a space for the exchange of experiences and approaches. Conclusions: The results from this pilot study show that the vCoP was considered useful for learning how to empower patients. However, while vCoPs have the potential to facilitate learning and as shown create professional awareness regarding patient empowerment, attention needs to be paid to technological and access issues and the time demands on professionals. We collected relevant inputs to improve the features, content and educational methods to be included in further vCoP implementation. Trial registration: ClinicalTrials.gov, NCT02757781. Registered on 25 April 2016. Keywords: Empowerment, Primary healthcare, Virtual system, Healthcare professional attitudes, Pilot study * Correspondence: aisabel.gonzalezg@salud.madrid.org 3 Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC) ISCIII, Madrid, Spain 5 Institut für Allegemeinmedizin. Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 2 of 10 Background promoting networking and collaboration. Online learning Knowledge is key to the advancement of organizations. has also shown beneficial results in changing attitudes, in- Learning and the implementation of practices, however, creasing knowledge and skills, as well as possible benefits does not only rely on explicitly developed knowledge. in patients’ related outcomes [16]. Discussion, interaction, observation and the exchange of A recent review [13] found that vCoPs allow profes- experiences between professionals all aid understanding sionals to be attracted to interprofessional learning activ- of formal knowledge, which thus acquires meaning in ities and collaboration among them that break down line with proposals regarding social theories of learning professional silos and barriers related to isolation, estab- [1], and imply an interaction between socially defined lishing a risk-free environment for participants that competences and personal experiences [2]. The commu- increases their participation and involvement. vCoPs allow nity of practice (CoP) is one strategy that facilitates this the possibility for professionals to be involved in activities type of learning [3]. that promote interprofessionalism, an important aspect A CoP, coined as a term in the 1990s [4], is, according for the provision of quality care and the goal of accom- to Wenger [5] “not just a website, a database, or a collec- plishing better health outcomes. tion of best practices. It is a group of people who interact, We developed a vCoP named e-MPODERA, a pun learn together, build relationships, and in the process de- combining the terms “empower” and “e-learning tech- velop a sense of belonging and mutual commitment”. niques”, aimed at improving primary care professionals’ Having others who share their overall view of the domain attitudes to the empowerment of patients with chronic and yet bring their individual perspectives on any given conditions. problem creates a social learning system that goes beyond e-MPODERA vCoP was created as a gamified virtual the sum of its parts. A CoP reflects a common field knowledge-sharing CoP based on a Web 2.0 platform (depending on the competences of the group) delimiting that offers learning activities and materials regarding pa- what is of interest to the group, the existence of a struc- tient’s empowerment. This platform uses forums as a ture that encourages interaction and relationships among main tool aimed at sharing experiences, practices and members, shared practices and a repertoire of resources resources, and makes collaborative learning a powerful such as ideas, experiences and information. A CoP differs way for sharing knowledge, sensitize for empowerment from other types of groups in that support takes the form concepts and develop real solutions to specific problems of formal and informal interactions between members and using open and inclusive technologies. The activities that the emphasis is on voluntary participation, shared were designed using a competence framework based on learning and knowledge and the fostering of a sense of be- 4 learning objectives and 12 core competences (Table 1). longing [5]. While CoPs have largely developed in the Gamification is based on ranking, points, goals and business and education areas, they are increasingly being badges, added to interactive contents, like games, videos, used in the health sector [6–10]. and other individual and collaborative tasks. Content Information communication technologies have led to was developed considering patients’ health literacy and great growth in virtual CoP (vCoPs) in recent years, given self-efficacy, self-monitoring, shared decision-making, their greater flexibility, ease and speed of communication coping capacities, etc. Some of the main subjects tackled compared to other communities [11]. However, their were: attitudes towards empowerment, dimensions of establishment involves more than merely importing the empowerment, health literacy, share decision making, content of traditional communities into a new framework. self-management, communication skills, special morbid- Technological structures need to be created and barriers ity cases (i.e. obesity, diabetes mellitus, ischemic heart not present in face-to-face communities need to be over- disease, lung disease, elderly patient, falls prevention, come, mainly related to the fact that members may be stroke, dementia), care of the caregiver, etc. many, located in different geographical areas, not know The objective of the present study was to pilot the ac- each other and can have different organizational cultures. ceptability and feasibility of the e-MPODERA vCoP Further barriers are related to the availability and use of before testing its effectiveness to improve primary care the new technologies [12, 13]. professionals’ attitudes to the empowerment of patients Many of these limitations can be overcome by using dis- with chronic conditions in a cluster randomized control cussion forums and video-conferencing for real-time ex- trial [17]. changes and by appointing a facilitator to promote a greater sense of commitment and presence of participants Methods and to manage content and resources [14, 15]. Online Study design learning benefits from this type of communities of primary We used thematic analysis to perform this descriptive care professionals, related to a better management of their qualitative study [18]. Data was collected using the focus time constraints and to possible geographic barriers, group technique because interactions between the Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 3 of 10 Table 1 Framework of learning objectives and competences Learning Objective A: To improve awareness of patients’ and carers’ empowerment A1: To know the impact of patient empowerment and disempowerment A2: To know interventions and their effectiveness to improve patient empowerment Learning Objective B: To improve familiarity with the concepts of empowerment B1: To identify the dimensions of patient empowerment and skills related for applying them B2: To know the taxonomy related to patient empowerment B3: To know characteristics and theoretical and conceptual approach of initiatives that work on patient empowerment B4: To know new models and paradigms of patient-health professional relationships Learning Objective C: To improve perceived self-efficacy and confidence in one’s abilities C1: To apply strategies and tools to facilitate patient’s empowerment in daily practice C2: To identify barriers to empowerment and establish improvement actions C3: To develop content and materials on empowerment and / or feedback and contribute to the vCoP with new knowledge Learning Objective D: To improve credibility and expectations about favorable results of empowerment D1: To learn about Spanish, European and international initiatives of leaders or prominent organizations regarding empowerment D2: To enhance feedback and dialogue with professionals about the empowerment strategies used D3. To resolve myths and misconceptions about empowerment participants enable them to share and reflect on their (CJBC), who led the discussion, and 2 assistants (YR, experiences [19]. The study was designed in accordance MMB), who took notes and audio-recorded the sessions. with the Consolidated Criteria for Reporting Qualitative The moderator and assistants were qualitative re- Research (COREQ), a 32-item checklist for interviews searchers with training and experience in the field and and focus groups [20] (Additional file 1). with no direct relationship with the participants. Each group session commenced with a description of the ob- Setting jectives and a request for consent to both participation The study was carried out in 3 urban general practices and audio-recording. After each group session, the mod- in the Madrid region attended to by 38 General Practi- erator and assistants discussed the sessions and also took tioners (GPs) and 35 Practice Nurses (PNs), with an notes at these meetings. assigned population of 63,298 people. We prepared guidelines for the focus group which contained the topics to be explored (Table 3), although Participants the moderator was also allowed to inquire further re- We purposively sampled for the focus group discussions garding issues that emerged during the sessions. 12 professionals, 6 GPs and 6 PNs, out of the 26 profes- sionals that participated in the e-MPODERA vCoP, Data analysis considering not only their level of participation in the The interviews were audio-recorded and later transcribed vCoP (high, medium and low), based on the degree of verbatim. Two researchers (CJBC, MMM) first read the participation in forums, comments and entries on the transcriptions for both groups in their totality to ensure fa- platform, but also age, sex and experience in primary miliarity with the texts. Using a thematic analysis approach, care (Table 2). the transcriptions were then coded independently by the 2 During the piloting, content was gradually incorpo- researchers (CJBC, MMM) using the ATLAS.ti software rated into the vCoP over a 4-month test period (June to program, with open coding followed by categorization and September 2016). All participants entered the vCoP and abstraction. 31% contributed with comments. The topics inviting Following the steps identified by Braun & Clarke [21], most comments were health literacy, shared decision- we followed six simple steps to conduct a thematic ana- making and communication. lysis: 1) familiarizing ourselves with the data; 2) generating initial codes; 3) searching for themes; 4) reviewing the Procedure themes; 5) defining and naming the themes; 6) preparing Two focus group sessions were held, one with 6 GPs the report. and the other with 6 PNs, in November 2016. The focus Researchers (CJBC, MMM) met regularly to discuss and group sessions lasted between 60 and 90 min, were held debate findings until consensus was reached [22, 23]. To in a neutral venue and were facilitated by a moderator enhance validity, findings were reviewed by other Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 4 of 10 Table 2 Socio-demographic characteristics of the participants in highlighted the usefulness of vCoP material like tuto- the focus groups rials, videos and demonstrations, indicating that this ID number Focus group Age Sex Primary care vCoP content led them to reflect on how they approached experience participation clinical practice; they also reported that the interaction (years) levela with other professionals led them to contemplate other GP 01 1 53 M 25 Medium approaches to address the empowerment of patients GP 02 1 46 M 17 Low with chronic conditions. However, they pointed some GP 03 1 51 F 23 High difficulties in accessing the vCoP. GP 04 1 58 F 34 Medium See Table 4 for more detailed information on the GP 05 1 62 F 27 Low emerging themes and subthemes. GP 06 1 50 F 17 Low vCoP: a novel kind of training PN 01 2 42 F 19 Low Clinical practice is perceived by the participants as taking PN 02 2 47 F 19 Low place in a context of multiple demands - by the organization, PN 03 2 42 F 17 Low the population and society as a whole. The participants re- PN 04 2 60 F 10 High ferred to the need to have new and up-to-date resources, PN 05 2 29 M 3 Medium easily implemented as a work aid and capable of responding effectively to the needs of patients with chronic conditions PN 06 2 60 F 28 Low while adapting to the context of their health centre. GP: general practitioner (n = 6); PN: practice nurse (n = 6) a The level of participation was defined considering the degree of participation The vCoP was viewed as a learning mode that met in forums, commentaries and entries in the platform participants needs through activities that could be accessed in a flexible way according to the time avail- members of the research team who contributed to the able, including from home. thematic analysis. The findings were transmitted to the focus group participants to obtain their feedback [19]. “And it's practical, they give you a day a week when, if you want, you can see the class live and it's a Ethics video-conference and if you download anything it’s The study complied with Good Clinical Practice stan- recorded and you watch it when you can, the hour dards and the principles of the latest version of the and a half or two hours that the class lasts and Helsinki Declaration (Brazil, 2013) and was approved by then you see the instructor, who explains things the Clinical Research Ethics Committee of Ramón y and you ask. I find that very useful.” PN 04 Cajal University Hospital in Madrid (ACTA 303), Nues- tra Señora de Candelaria University Hospital in Santa This form of learning was considered of interest insofar Cruz de Tenerife (PI-18/16) and IDIAP Jordi Gol in Bar- as it could provide the participants with useful materials, celona (C2748). Confidentiality and anonymity were defined as up-to-date resources allowing easy access from guaranteed in accordance with Spanish Law 15/1999 on the point of consultation and responding to the needs of personal data protection and all participants in the study patients. GPs perceived a greater need for this type of in- gave their informed consent. formation accessible at the point of care, information not available to them from other available resources. Results The participants expressed great interest in the vCoP “Specific things that help us, that facilitate things learning environment, which allowed them to access with the patient because we do not have time ...and content even from home and at times that suited when you don’t have time, of course, you can’t be them always using a personal computer. They there, looking through a hundred thousand things to see which is the most interesting.” GP 05 Table 3 Focus group guidelines (topics) •Problems that have hindered participation in the vCoP In relation to the potential of the vCoP as a training •Reasons for participating or not participating in the vCoP •vCoP barriers to improving patient empowerment element, the professionals indicated that it should contain •How could the vCoP and e-MPODERA bring about change in professional up-to-date, specifically primary care work-related and practice that promoted patient empowerment? evidence-based information previously selected as espe- •What resources would foster this change? •How do you think this kind of vCoP improve the exchange of knowledge? cially relevant by those responsible for development of the •What activities would you like the vCoP to offer? vCoP. This information should also be easily accessible •What activities would you like to eliminate from the vCoP? from the point of consultation in order to ensure more •The role of the vCoP facilitator rapid answers than provided by existing resources. Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 5 of 10 Table 4 Emerging themes and subthemes THEME THEME THEME Novel kind of training Benefits for patient empowerment Difficulties using vCoP SUBTHEMES SUBTHEMES SUBTHEMES Flexible accessibility for learning Opportunity to reflect on their own clinical practice Technological difficulties Provision of useful materials in Share tips and demonstrations. Tutorials that do not facilitate the use consultation Interaction / exchange of experiences among of the platform Information based on evidence professionals Information in non-native language Possible ways to address problems Resources to motivate the chronic patient No availability of time to access the Motivation for learning work environment Little ease for access from home “If you had that information directly, scientific of on approaches to chronic patients in their clinical practice course, in 5 minutes you could read it or a summary and to analyse alternative approaches. Tutorials and dem- paragraph. Many of the platforms do not address onstration videos were considered especially useful as they that and if we have to find things ourselves, we have enabled patients to be managed from a more comprehen- to do very exhaustive searching that takes a long sive perspective with the goal of empowering them. time.” GP 02 “... I was doing activities, many that I found very Regarding the opportunities offered by the vCoP for appropriate and good for teaching. The truth is, interaction and the exchange of experiences, mainly they even make you think a little and elaborate on through forums and interactive video-conferencing ses- things. It made you discuss sometimes … what you sions, participants indicated that this helped them con- usually do in consultations.” GP 01 sider alternative approaches to similar problems or clinical situations applicable to routine practice. Both The nurses placed more emphasis on the usefulness of groups of professionals considered useful opportunities the vCoP in terms of tips and demonstrations that could for interaction and exchange of experiences with other be used with their patients to address specific issues professionals. “That's what I was referring to, like when someone “I found them very interesting because I found them helps you see the light, so [ you tell the patient] useful for practice ... with the patients, to deal with ‘protect the fingertips’ or ‘take some holidays’, those some issues that maybe hadn’t occurred to me, that phrases that seem silly when it comes to consulting, I’d looked at superficially, to notice and consider I used them.” PN 02 them.” GP 01 New approaches and ways of doing things, as one par- For the vCoP to become consolidated as a training tool, ticipant commented, could be learned from the opinions, it requires the appointment of an individual or team to se- judgements, experiences and procedures of other profes- lect relevant and easily accessible information from the sionals. The interaction between professionals fostered large amount of information available and to assume a by the vCoP was considered to be an opportunity to ad- motivational role in encouraging professionals to enter the vance learning. community, consult information, participate in forums, etc. … figure that both PNs and GPs considered necessary. “... you access to see more things, to see what they comment, the impressions of another person, the “Facilitators. People who filter maybe and who help game that’s played between colleagues, what one us a little with managing things at a specific moment. does, what the other does, we could learn new ways The most important things. So that you don’t have of acting.” GP 01 to, what she said before, access a load of information, that there’s a kind of filter of what’s most important Some expectations were not fulfilled by the vCoP in or most relevant.” GP 06 this pilot phase, specifically by the PN group. These include the availability, to use during consultations, of previously prepared resources aimed specifically at re- vCoP: benefits for patient empowerment inforcing patient knowledge. Among these resources, The vCoP activities were considered, by both groups of special mention was made of information resources professionals, to be an opportunity to examine and reflect for patients or to work conjointly with them. Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 6 of 10 “Yes, maybe a library of resources with teaching “Then the times that I’ve been able to connect have materials to help the patient would be useful, always been at home, which just seemed a bit … which we, in the consultation … well, if they are uff. Because then from home, it depends on things, young or are used to the internet, we could easily because you have more or less time.” PN 05 download useful information on their chronic illnesses and give them that didactic material to Other difficulties described by the participants re- train them too.” PN 05 ferred to access to the virtual platform itself. It was al- ways necessary for the user to remember their user Since one frustration for professionals was patients not name and password information, and options to recu- adhering to guidelines or advice, a suggestion was to in- perate this information were less than satisfactory. In clude resources aimed at stimulating the interest of general, PNs expressed more difficulties related to limi- patients in addressing adherence, as both GPs and PNs tations on access to the platform. manifested. “For me in practice access has sometimes been “As a professional, maybe I miss some kind of difficult. The first part, doing the survey went very methodology to motivate them, some line or strategy, well, that was easy. Then you go back and what’s that’s to say, techniques or something, you know? the password. I took a photo and even with a photo To emphasize things so they leave the consultation it was difficult to access.” PN 02 motivated to say, you're right, you know what I mean?” PN 02 The tutorial designed to facilitate use of the vCoP was not considered useful, given its location in the platform and the fact that it was considered complicated. vCoP: difficulties using it During the focus group sessions, the study participants “Well, other than that, the tutorial was a bit pointed to several difficulties with using the e- complicated. We talked to one of them [on the MPODERA vCoP, with the main difficulty generally re- platform] and I think it was located in ... or in lated to access issues. another place, because it was at the side, right? Participants referred to great difficulty in using vCoP The truth is I did not understand very well at the in their workplace, since the computers there had oper- beginning, when I got into the tutorial.” GP 03 ating systems and browsers that made it difficult to access the platform. This technical difficulty was due to While most of the documents and activities for use by equipment obsolescence, not to participant capacity to the professionals were in Spanish, some were in English. use the technology, and there were no differences in this Because the professionals, specially the PN group, had to respect between the GPs and PNs. When software prob- use online translators, these documents were less con- lems, such as inexplicable system crashes and error mes- sulted and less likely to be read and used. sages, occurred during workplace use, the professionals became frustrated and stopped using the tool. “I would ask just one thing, it’s probably also my ignorance. That not everything would be, that not “If at work in the centre it’s impossible, we don’t much information would be in English.” PN 02 have access, access is impossible. You click, it blocks, the page stays blank, you go back and it’s just impossible.” PN 04 Discussion Professionals generally viewed virtual learning environ- Not all work centres had the same difficulties, as some ments like e-MPODERA vCoP with interest. Use of the centres with up-to-date computer equipment offered Internet for ongoing training purposes has increased in better accessibility. recent years. In the health area, a significant percentage Another access difficulty for participants was to find a of health professionals use the Internet daily for work- suitable space and time to use the vCoP in a meaningful related reasons, mainly to locate information for pa- way. Both GPs and PNs reported how the burden of pa- tients, but also for self-managed ongoing training via tient care and administrative tasks consumed their work- online reading and learning activities [24]. ing hours, leaving very few opportunities for innovation Participants in the study considered important to have and learning. Consequently, many participants reported up-to-date equipment and resources that responded to accessing the vCoP from home, although here too fitting the needs posed by patients in consultations, and most es- access in with family demands was not always easy. pecially, information that was not available from other Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 7 of 10 resources, as the goal is to be able to provide rapid re- though they themselves could not participate actively, for sponses. Participants preferred to have resources that they instance, due to a lack of time [29]. In some cases, non- could use in routine practice, such as demonstration vid- participation was due to a fear that a contribution might eos and educational materials, but available in the local be trivial or irrelevant [30]. However, in most vCoP 90% of language. Barnett [25] confirms that perceived usefulness participants act as observers and never contribute, 9% is a key predictive factor in any intention to use a vCoP. contribute just occasionally and 1% are always active [32]. The vCoP was perceived as an encyclopaedia that would As McLoughin et al. showed [13], several strategies have always be available for use when necessary [26]. Barnett been reported to increase participation such as increasing [25] reported that the resources most valued by doctors- trust among members, focusing vCoP on common inter- in-training and tutors are the possibility of sharing clinical ests or focusing vCoP on the patient by providing re- practice guidelines and other documents, followed by dis- sources based on easily accessible evidence. cussion forums. The sustainability and maturation of a The vCoP facilitator played an important role, according vCoP relies on resources such as technical documents, to the participants in the study. A facilitator motivates demonstration materials, videos, photos, etc. available in members to participate and also helps by filtering more repositories or in information sections in external websites relevant and important information, especially that based [10, 27–29]. Another advantage of the vCoP pointed out on evidence. On the other hand, facilitators play an import- by participants was that general or specific information ant role in ensuring clear rules, focusing the discussions was available almost immediately [30]. As McLoughlin et and promoting the involvement and respect among the al. [13] outlined, this aspect is key for the engagement of members [13]. In this study, the facilitator was a primary professionals in the vCoP. care professional who participated by leading and develop- Participants also emphasized the speed of responses ing the vCoP. In different vCoPs analysed by Barnett [33] from the rest of their team [25, 28]. Indeed, interaction be- the facilitator may be the person who initiates and launches tween the vCoP participants in general was considered to the vCoP or may emerge from the group of participants, es- be crucial, as it offered the opportunity to exchange ex- pecially from among more active participants. The role of perience, to learn of alternative approaches to patients facilitators is usually to enhance cooperation, but they also with chronic conditions, to examine, reflect on and ana- can ensure that the rules of engagement are clear, ensure lyse other perspectives related to routine practice and to focus on discussions, establish procedures for member in- observe the skills and even practical demonstrations of clusion and lead commitment to and maintenance of the other participants. The most valued vCoP areas regarding vCoP. The facilitator also identifies relevant content and the empowerment of chronic patients were the forums saves it correctly to bring it back when it is necessary [9]. In and interactive sessions such as video-conferences with this study, clinically active facilitators were key to the devel- external experts. opment of the vCoP in terms of recognizing the contribu- Interaction between vCoP participants is an aspect tions of participants and in guiding them [29, 33]. Another highlighted in other studies, not only in relation to exchan- contribution of the facilitators was notifying new entries ging documentation, but also in terms of resolving doubts and frequent participants. and problems through the contributions of other partici- A vCoP needs a technological infrastructure that will pants sharing experiences and exchanges aimed at improv- support online operation and use and so requires more ing knowledge and skills [26, 29, 31]. Interaction between careful design than traditional learning formats. As professionals in the same field of work in normal working pointed out by Barnett [33], ensuring that a technology conditions is crucial, and in a vCoP, the interaction format is easy to use enhances the potential success of a vCoP. that generates the most shared knowledge is that which In our study we observed difficulties fundamentally combines face-to-face and online interactions, followed by related to access, such as obsolete or incompatible face-to-face interactions [25, 28, 31]. Barnett [29] reported browsers and the lack of suitable additional software to that participants using a vCoP stated that they benefited access all the available resources. Another identified dif- mainly from online interactions aimed at generating trust- ficulty was the need to create and remember an access ing relationships, but also from the confidence generated password. Such difficulties lead to frustration and aban- by prior knowledge shared by participants. donment of vCoPs. Certain barriers to interaction were identified. Active Other difficulties identified by the professionals that participation by all members was considered by some par- participated in our study are common to the ones found ticipants to be crucial for the proper functioning of the in the literature [24, 31, 33–36] such as slow connec- vCoP [29]. Indeed, under-participation can lead to failure tions, problems downloading information and docu- of this form of learning [13]. Even so, the less active partic- ments, workplace restrictions on Internet access by ipants were of the opinion that they also benefited from employees, incompatibilities with tablets and mobile reading the contributions of the other participants, even phones and audio problems. Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 8 of 10 The main difficulty reported by the professionals in our Conclusions study was a lack of time, which hinder access to learning The results from this pilot study show that the e- environments, especially from the workplace [35]. The MPODERA vCoP was considered useful for learning how to main advantage of a vCoP for professionals, according to empower patients. However, attention needs to be paid to previous studies [26, 31], is the flexibility of this kind of technological issues, and the time demands on professionals. learning environment, as it allows access at the time and in We collected relevant inputs to improve the features, con- the place considered most convenient. Most professionals tent and educational methods to be included in further in piloting of the e-MPODERA vCoP preferred to access vCoP implementation (Table 5). the vCoP resources from home (43.9%), followed by those who accessed from both home and work (33.2%) [24]. Additional file Technical problems, as corroborated by several authors [24, 31, 37], combined with a lack of time at work led many Additional file 1: COREQ (COnsolidated criteria for REporting Qualitative participants to use the vCoP in the home setting, even research) Checklist. (PDF 497 kb) though they would have preferred use in the workplace as most suitable from a training perspective. Abbreviations CoP: Community of Practice; e-MPODERA: Effectiveness of a Virtual Intervention One limitation of the study is that it was carried out in 3 to Improve Healthcare Professional Attitudes to Patient Empowerment; urban, city-based, general practices (in Madrid) and so GP: General Practitioner; PN: Practice Nurse; vCoP: Virtual Community of Practice excluded rural centres. Therefore, it was not possible to access the perceptions of professionals working in more Acknowledgements The authors would like to thank Ailish M J Maher for translating the article isolated settings. Besides, only a limited number of profes- into English. sionals were invited to participate in this pilot study (26 e-MPODERA Group: primary care professionals) and vCoP enrich with the par- Concepción Alejo-Díaz Zorita. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, ticipation of more professionals, not being able to reach a Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. saturation of the speech. Another limitation was that the Email: concepcion.alejo@salud.madrid.org duration of use of the vCoP (6 months) was probably not Cynthia A. Barbero-Macías. Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio long enough for relationships of trust between the partici- Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. pants and a feeling of belongingness in a community to Email: cynthiaakira.barbero@salud.madrid.org develop. The difficulties accessing the platform did not Fernando Borrell-Punzón. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, help in this matter. Finally, perceptions of the vCoP may Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. have been affected by the fact that participants in the Email: fernando.borrell@salud.madrid.org study, while employed by the Madrid Health Service, work Beatriz Bueno-Rodriguez. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, in different autonomously managed health centres; thus, Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. exchanges between professionals may have been limited Email: bbueno@salud.madrid.org by a certain homogeneity in the organizational criteria of Begoña Colmena-Martin. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, the different centres. Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. Email: begona.colmena@salud.madrid.org Table 5 Facilitators and barriers to the use of the vCoP Isabel del Valle-de Joz. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, Facilitators Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. The use of information and knowledge technologies allows the Email: isabel.valle@salud.madrid.org development of vCoP with flexible accessibility for the training of Juan Carlos Gamboa-Puñal. health professionals. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, The inclusion of evidence-based and updated materials is a necessary Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. and useful tool for healthcare activity. Email: juancarlos.gamboa@salud.madrid.org Maintaining and providing useful and updated information motivates Concepción García-Valverde. the use and functioning of the vCoP. Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, The vCoP is a medium that allows interaction between professionals Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. from different locations and enables sharing approaches, opinions, Email: concha.garcia@salud.madrid.org experiences and ways of performing. Luis Miguel Gómez-Garzón. The presence of easy-to-understand tutorials, with the necessary infor- Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio mation for the use of vCoP, would improve access to the included re- Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. sources and participation. Email: luismiguel.gomez@salud.madrid.org Arturo Gómez-López. Barriers Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. The use of out-of-date or inappropriate hardware and software limits Email: arturo.gomez@salud.madrid.org and hinders access to and participation in a vCoP. Alejandro Hernaz-Guijo. The inclusion of documents and resources in non-native language Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio causes difficulties in understanding information. Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. The time restrictions in work environments can limit access to a vCoP. Email: alejandro.hernaz@salud.madrid.org Bermejo-Caja et al. BMC Health Services Research (2019) 19:403 Page 9 of 10 Walter Nery Herrera-León. design, is the PI for the Canary Islands region and collaborated proofreading Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, the manuscript. CJBC conceived the study, participated in its design, is the co-PI Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. for the Madrid region and collaborated with the first draft and final writing of Email: walternery.herrera@salud.madrid.org the manuscript. CJBC coordinated the pilot testing of the vCoP in Madrid, Irene Iniesta-González. organized the focus groups and led the discussions. CJBC and MMM analyzed Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, and interpreted professionals’ data. YRG, MMB, ABRP, YCC and FJPR contributed Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. with the implementation of the vCoP in the primary centers and in the different Email: irene.iniesta@salud.madrid.org phases of the pilot study. DK, MB contributed developing the vCoP. JCGP, MRV, Margarita Leza-Leza. BBR, DPB, MRL, JIVDPTG, FBP, BCM, MAMC, SMA, CBM, NPGAHG, LMGG, CVS, Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, CSC, AGL, AOF, MJSE, ASE, MLL, IIG, WNHL, CGVIVJ and CAZ participated in the Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. piloting of the vCoP and as members of the focus groups. All authors read Email: margarita.leza@salud.madrid.org and approved the final manuscript. María Aránzazu Melchor-Canelo. Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio Funding Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. This study was financed by Instituto de Salud Carlos III and Cofinanced by Fondo Email: mariaarantzazu.melchor@salud.madrid.org Europeo de Desarrollo Regional (FEDER). Ministerio de Economía Sagrario Muñoz-Quirós Aliaga. y Competitividad. Gobierno de España. (PI15/00164, PI15/00586, PI15/00566). Dr. Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio Ana Isabel González-González. Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. The funding source played no role in study design, data collection, analysis or Email: smunozq@salud.madrid.org interpretation, or the writing of the manuscript. The researches retain complete Ángela Oria-Fernández. independence in the conduct of the study. The FIS evaluation committee will Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, annually inspect study progress and adherence to the study protocol. Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Email: angela.oria@salud.madrid.org Availability of data and materials Nuria Pertierra-Galindo. Not applicable. Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. Ethics approval and consent to participate Email: nuria.pertierra@salud.madrid.org The study fulfils GPC standards and the principles of the latest version of Mª Dolores Prieto-Barbosa. the Helsinki Declaration (Brazil, 2013). The project has been approved by the Centro de Salud Caramuel, Gerencia Asistencial de Atención Primaria, Clinical Research Ethics Committee of Ramón y Cajal University Hospital in Servicio Madrileño de Salud, Calle Fuenteovejuna 17, 28011 Madrid, Spain. Madrid (ACTA 303), Nuestra Señora de Candelaria University Hospital in Email: mprietob@salud.madrid.org Santa Cruz de Tenerife (PI-18/16) and IDIAP Jordi Gol in Barcelona (C2748). Milagros Robledo-Vázquez. In accordance with Spanish Law 15/1999 on personal data protection, Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, confidentiality and anonymity is guaranteed. We obtained written informed Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. consent from all participants. Email: milagros.robledo@salud.madrid.org Marta Ruiz-López. Consent for publication Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Not applicable. Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Email: marta.ruiz@salud.madrid.org Competing interests M Carmen Sánchez-Cruz. The authors declare that they have no competing interests. Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Author details Email: mscruz@salud.madrid.org 1 Unidad de Apoyo Técnico, Gerencia Asistencial de Atención Primaria, Mª Ángeles Sánchez-de Eusebio. Servicio Madrileño de Salud, Calle San Martín de Porres 6, 28035 Madrid, Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Spain. 2Instituto Avedis Donabedian, Universidad Autónoma Barcelona, Calle Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. ProvenÇa 293 pral, 08037 Barcelona, Spain. 3Red de Investigación en Email: mseusebio@salud.madrid.org Servicios de Salud en Enfermedades Crónicas (REDISSEC) ISCIII, Madrid, Spain. Mª Jose Seijas-Martínez Echevarría. 4 Servicio de Evaluación y Planificación, Dirección del Servicio Canario de la Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Salud, Centro de Salud El Chorrillo, Camino Candelaria s/n, 38109, El Rosario, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Santa Cruz de Tenerife, Spain. 5Institut für Allegemeinmedizin. Johann Email: mariajose.seijas@salud.madrid.org Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Carmen Paola Tovar-García. Germany. 6Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Primaria, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Spain. 7EAP Turó, Vilapicina 8C, Barcelona, Spain. 8Centro de Salud Monóvar, Email: mcpaola.tovar@salud.madrid.org Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Calle Jose Ignacio Vicente-Diez. Monóvar 11, 28033 Madrid, Spain. 9Departamento de Enfermería, Facultad de Centro de Salud Monóvar, Gerencia Asistencial de Atención Primaria, Servicio Enfermería y Podología, Universidad Complutense de Madrid, Plaza Ramón y Madrileño de Salud, Calle Monóvar 11, 28033 Madrid, Spain. Cajal, s/n, 28040 Madrid, Spain. 10Fundación Canaria de Investigación Email: joseignacio.vicente@salud.madrid.org Sanitaria, Centro de Salud El Chorrillo, Camino Candelaria s/n, 38109, El Cristina Villanueva-Sanz. Rosario, Santa Cruz de Tenerife, Spain. 11Departamento de Enfermería, Centro de Salud Vicente Muzas, Gerencia Asistencial de Atención Primaria, Universidad Autónoma de Madrid, Calle Arzobispo Morcillo 4, 28029 Madrid, Servicio Madrileño de Salud, Calle Vicente Muzas 8, 28043 Madrid, Spain. Spain. Email: cvillanueva@salud.madrid.org Received: 11 December 2018 Accepted: 28 May 2019 Authors’ contributions CO conceived the study, participated in its design, coordinated all phases of the trial, is the principal investigator (PI) for the Catalonian region and collaborated References proofreading the manuscript. AIGG conceived the study, participated in its 1. Bandura A. Social learning theory. 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