In this paper, we make explicit the changing configurations of power relations that currently characterize the Brazilian Emergency Care System (SAMU) team in Belo Horizonte, Brazil. The SAMU is a recent innovation in Brazilian healthcare service delivery. A qualitative case study methodology was used to explore SAMU's current organizational arrangements, specifically the power relations that have developed and that demonstrate internal team struggles over space and defense of particular occupational interests. The argument advanced in this paper is that these professionals are developing their work in conditions of exposure, that is, they are always being observed by someone, and that such observational exposure provides the conditions whereby everyday emergency care practices are enacted such that practice is shaped by, as well as shapes, particular, yet recognizable power relationships. Data were collected through the observation of the SAMU's work processes and through semi-structured interviews. Research materials were analyzed using discourse analysis. In the emergency care process of work, visibility is actually embedded in the disciplinary context and can thus be analyzed as a technique applied to produce disciplined individuals through the simple mechanisms elaborated by Foucault such as hierarchical surveillance, normalizing judgment, and the examination.
In this paper we use Alvesson and Sandberg's strategy of problematisation to analyse the assumptions embedded in the development and use of the concept of ‘care-giver burden’. We do this in order to develop an explanation as to why decades of research into the experience of providing home-based care to a family member with dementia has had little effect in relieving or reducing the ‘burden’ of that care. Though some part of this is undoubtedly political, our analysis suggests that key assumptions of the research limit both knowledge development and intervention effectiveness. Especially problematic are first, an overriding focus on the isolated care-giver–recipient dyad as the appropriate object of inquiry and target of intervention, and second, an absence of an analysis of the materiality of care and care-giving practices. The heterogeneity of care situations, including interrelations among people, technologies, objects, spaces and other organisational worlds, appear in much of the research primarily as methodological problems, variables to be subdued through a more rigorous application of method. The high volume of research and acknowledged low impact of interventions, however, suggests that rethinking the nature of care practices, and how we come to know about them, is necessary if we are to develop and implement strategies that will contribute to better outcomes for people.
Objective: Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the "Transitions of Care" (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions. Design: Here we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study. Setting and participants: All 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, longterm care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged 65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews. Results: Taken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC. Conclusions and implications: With comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.
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