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Hannele Kerosuo
BOUNDARIES IN ACTION
An Activity-theoretical Study of Development, Learning and Change in Health Care for Patients with Multiple and Chronic Illnesses

2006
Price 30 €
ISBN 952-10-2678-2 (pbk)
ISBN 952-10-2679-0 (PDF)

Publisher
University of Helsinki
Department of Education

Orders
Helsinki University Press
Email: books@yliopistopaino.fi
WWW: www.yliopistopaino.fi/kirjamyynti

Author
Hannele Kerosuo


Abstract
 
This study examines boundaries in health care organizations. Boundaries are often considered harmful; things to be avoided in everyday living. This study suggests, however, that boundaries can be important temporally and spatially emerging locations of development, learning, and change in organizations and work practices. Boundaries are established distinctions and differences between and within activity systems that are created and agreed on by groups and individual actors over a long period of time while they are involved in those activities. As traces of past activities and emerging futures, boundaries trigger learning and development.

The data of the study was gathered in an intervention project during the years 2000-2002 in Helsinki in which the care of patients with multiple and chronic illnesses was improved. The research project used the Change Laboratory method that enables the development of work and work practices in organizations. The general research question of the study is: What are the boundary dynamics of development, learning, and change in health care for patients with multiple and chronic illnesses? The first research question is: How do individual patients experience boundaries in their health care? The second research question is: How are the boundaries of health care constructed and reconstructed in social interaction within a Change Laboratory intervention? The third research question is: What are the dynamics of boundary crossing in the experimentation with the new tools and new practice?

Conceptualizing chronic illnesses and the care organization of chronic illnesses emerges as multi-voiced in previous studies and the literature. The historical analysis of the study uncovers the formation of the boundaries between professionals and patients, levels of care, specialties, and market based and negotiated care in present health care organization and shows how boundaries have evolved during the history of health care organization. The historical analysis also illustrates the rise of multiple and chronic illnesses as an object of care and the phases of development of this rise, including the current challenges in Finnish health care. Chronic illnesses presently emerge as complex phenomena involving the intertwining of organisms, representations, and medical technologies. Multiple illnesses, aging, lifestyle illnesses, and medicalization increase the complexity of chronic illnesses, while the health care organization seems to be developing towards a diversity of multiple providers through specialization, market-based development, alternative models of service production, and new types of patient agency.

The review of the literature and earlier studies of boundaries in work, health care practice, and patient experience uncover the diversity and ambiguity of boundaries in health care practice, but studies that focus on the processes of development, learning, and change in terms of boundaries are still few. Therefore, the framework of the study suggests that boundaries are hybrid contexts of development, learning, and change in work and organizations. Boundaries provide potential for development and change while enabling expansive learning, during which the organizations can contribute to the creation of their possible futures.

The methodology of the study, i.e., the ethnography of the multi-organizational field of activity, draws on cultural-historical activity theory and ethnographic methodology. The ethnography of the multi-organizational field of activity makes connections and disjunctions between multiple locations of a patient's care. The focus on 'border zones' between health care organizations brings up aspects and processes of development, learning and change taking place at the boundaries in the multi-organizational field of health care. The ethnographic fieldwork of the study involves multiple research techniques and a collaborative strategy for raising new research data. The data of this study consists of observations, interviews, transcribed intervention sessions, and patients' health documents.

The central findings of the study describe the intertwining of practical activity, development, and learning in organizational development. The 'border zone' between health care organizations is fragmented by organizational and practice boundaries. Practitioners and patients mark the boundaries in their talk. Collective learning can, however, be a process of reconstructing boundaries, and joint reflection enables boundary crossing in the Change Laboratory sessions. The central focus of development is that patients frequently experience uncertainty and neglect in their care. In the effort to improve the care of patients with multiple and chronic illnesses, the questioning and transforming of the prevailing boundaries emerged as a demanding learning challenge among professional practitioners, patients and researchers. But dissolution, reshaping and stabilization of the prevailing routine practices can be achieved in tool creation and implementation, and providers are willing and able to produce solutions for the uncertainty and neglect in inter-organizational care. However, the adoption of the new tools and practices into general use did not succeed in the project.
The findings of the study contribute to the development of health care for multiple and chronic illnesses by identifying the current challenges and their possible solutions in the Finnish health care organization. Furthermore, the study provides insights about the processes of development in health care. The study identifies two alternative models for the development of health care in Finland. The care package model, which is based on productivity and process models adopted from engineering, and market values and the model of negotiated care, which is based on co-configuration, the public good, and care agreements. Contributions to boundary studies of organization, development, and change illustrate the enabling and restricting nature of boundaries. From the activity-theoretical perspective, the construction of an object is an essential aspect of giving sense and meaning to the processes of development, learning, and change in an inter-organizational activity. The limitations of the study and the research process are evaluated in terms of the reliability, validity, generalizability, utility and ethical dimension of the study.

Keywords: activity theory, border zone, boundaries, care of multiple and chronic illnesses, expansive learning, ethnography of change, change laboratory

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