Our goal in this investigation was to help shed light on the very difficult process of collaboration between family physicians and specialists working at different levels of healthcare delivery. More precisely, and grounded on Giddens' structuration theory, our investigation aims to understand how medical collaboration emerges and develops around chronic patients. This was a longitudinal interpretive case study, the "case" being a continuum-of-care for patients suffering from diabetes, put in place in an urban health center in the Canadian province of Quebec. The study shows how the application of rules of signification and of legitimation, combined with domination resources, have supported the emergence of new forms of collaborative practices. Our analysis reveals, however, that new collaborative practices at the administrative level do not necessarily entail greater shared decision-making in patient management and the mobilization of knowledge across boundaries. The study also corroborates the mutual recursive influence of practices and structures. Our study's most important contribution concerns the impact of knowledge dynamics, that is, individual and collective learning, on the development of medical collaboration across levels of care.
Purpose:
The purpose of this paper was to help answer two persistent calls in the literature: the first asks to strengthen the understanding of medical collaboration across levels of healthcare delivery; the second one requests paying more attention to the individual experience of different forms of professional work. Accordingly, the study was guided by the following research question: How do family physicians and specialists working at different levels of healthcare delivery enact their professional identity when interacting in their situated clinical contexts?
Methodology:
This was a multiple interpretive case study in which, based on Giddens’ ideas, professional identity was viewed as a dynamic structural element of social life recursively related to professionals’ collaborative actions through sensemaking processes. The study involved 57 participants. Face-to-face individual semi-structured interviews and organizational documents were the main sources of data. Deductive-inductive thematic analysis was adopted as strategy for data analysis.
Findings:
Three prevailing physicians’ identity roles were elicited: medical expert, care coordinator, and team member. These professional identities, not mutually exclusive, were instantiated in three specific modalities of collaboration: quasi-inexistent, restrained, and extended. The entanglement of a particular identity role and a specific collaborative practice became meaningful through a complex net of organizational and institutional features, and patients’ nosological profiles.
The aim of this experiment was to test, in a driving simulator, how a subject can control his approach towards several simulated car-targets in different driving contexts. We assume that increasing complexity might influence driving performance according to the difficulty of perceiving distances properly. The subjects' first task consisted of placing their car at an equal distance between two preceding cars. In the second task, the subjects had to place their car level with the preceding car. The target cars were either static or running at 40 or 60 km / h. The results showed a more precise distance perception when the difficulty of the task decreased. In all conditions the subjects underestimated distances. Subjects were better at 60 km/ h than at 40 km/ h and the performance improved with smaller car distances. In conclusion, the alignment tasks produced better performances than the mid-distance tasks, as a consequence of their lower complexity. However, physical constraints due to the increase in velocity, as well as shorter distances between vehicles, improved performances.
The results suggest that telehomecare technology helps to create conditions that need to be met by health care organizations in order to improve service delivery to people with chronic diseases, particularly with regard to interprofessional collaboration, health professionals' access to information and expertise and active patient participation. However, the successful implementation of the technology requires a detailed analysis of the settings in which it is used.
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