Transcending boundaries for collaborative patient care

Abstract

Dutch general practitioners (GPs) and medical specialists (MSs) create collaborative patient care agreements (CPCAs) to improve intraprofessional collaboration. We set out to identify contradictions between the activity systems of primary and secondary care that could result in expansive learning and new ways of working collaboratively. We analysed nineteen semi-structured interviews using activity theory (AT) as a theoretical framework and using these two activity systems as the units of analysis. There were contradictions within and between the activity systems related, for example, to different understandings of 'care' in generalist and specialist settings. GPs and MSs were able to identify contradictions and learn expansively when they iteratively co-created CPCAs in groups. They found it much harder to tackle contradictions, however, when they disseminated these tools within their respective professional communities, leaving unresolved contradictions and missed opportunities for collaboration. This research shows the educational benefits of taking collective responsibility for improving collaborative patient care.

The pen is mightier than the sword. Reinstating patient care as the object of prescribing education

“…AT can help analyse complex problems and implement simple and effective solutions. (Meijer et al 2020; Engestr€ om and Py€ or€ al€ a 2020; Varpio and Teunissen 2020 in this Issue for other worked examples of these). Our central arguments are that: (1) education and clinical service delivery can be synergistic outcomes of an activity system whose object is caring for patients; and (2) an over-emphasis on off-the-job training and summative assessment is disruptive because it causes a fundamental contradiction in the object of prescribing education.…”

Destabilising institutions to make healthcare more equitable: Clinicians, educators, and researchers co-producing change

“…As residents-in-waiting, they now responded to nurses' requests to write orders so that patient care could proceed (Gillespie et al 2020). Written instruments, another example of a mediating tool, had a pivotal role in improving collaboration between GPs and specialists, and between the many practitioners caring for elderly people with complex needs (Engeström and Pyörälä 2020;Meijer et al 2020). Official rules made by government and insurers impeded collaboration between Dutch specialist and generalist care providers.…”

“…Official rules made by government and insurers impeded collaboration between Dutch specialist and generalist care providers. (Meijer et al 2020). Unofficial rules also influenced educational activity; for example, by perpetuating medical students' unsafe participation in practice (Gillespie et al 2020) and trivialising patient-centred behaviour (Reid et al 2020).…”

“…Unofficial rules also influenced educational activity; for example, by perpetuating medical students' unsafe participation in practice (Gillespie et al 2020) and trivialising patient-centred behaviour (Reid et al 2020). Regulators had a strong, potentially negative effect on a national practice community by positioning themselves as proxies for real patients (Gillespie et al 2020;Meijer et al 2020;Reid et al 2020).…”

“…Far from elite researchers taking primary responsibility for education development, patients, care-givers, students, managers and other interested parties work together to research and implement change. This takes place in purposefully planned Change Laboratory interventions, with which we improved multi-agency care, (Engeström and Pyörälä 2020) obstetric residency and medical student placement education, (Morris et al 2020) and collaboration between specialists and generalists (Meijer et al 2020). CHAT provided a lens through which to examine interprofessional collaboration, in all its on-the-ground fluidity, and to show why followership is as important to leadership as the reverse (Varpio and Teunissen 2020).…”