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Kerosuo, H. (2006). Boundaries in Action. An Activity-theoretical Study of Development, Learning and Change in Health Care for Patients with Multiple and Chronic Illnesses. Helsinki: Helsinki University Press.
This study examines boundaries in health care organizations. Boundaries are sometimes considered things to be avoided in everyday living. This study suggests, however, that boundaries can be important temporally and spatially expanding locations of development, learning, and change in inter-organizational activity. Boundaries can act as mediators of cultural and social formations and practices.
The data of the study was gathered in an intervention project during the years 2000-2002 in Helsinki in which the care of 26 patients with multiple and chronic illnesses was improved. The project used the Change Laboratory method that represents a research-assisted method for developing in organizations.
The research questions of the study are: (1) What are the boundary donamics of development, learning, and change in health care for patients with multiple and chronic illnesses? (2) How do individual patients experience boundaries in their health care? (3) How are the boundaries of health care constructed and reconstructed in social interaction? (4) What are the dynamics of boundary crossing in the experimentation with the new tools and new practice?
The methodology of the study, the ethnography of the multi-organizational field of activity, draws on cultural-historical activity theory and anthropological methods. The ethnographic fieldwork involves multiple research techniques and a collaborative strategy for raising research data. The data of this study consists of observations, interviews, transcribed intervention sessions, and patients’ health documents.
The care of patients with multiple and chronic illnesses emerges as fragmented by divisions of a patient and professionals, specialties of medicine and levels of health care organization. These boundaries have a historical origin in the Finnish health care system. As an implication of these boundaries, patients frequently experience uncertainty and neglect in their care. However, the boundaries of a single patient were transformed in the Change Laboratory discussions among patient a, professionals and researchers. In these discussions, the questioning of the prevailing boundaries was triggered by the observations of gaps in inter-organizational care. Transformation of the prevailing boundaries was achieved implementation of the collaborative care agreement tool and the new practice of negotiated care. However, the new tools and practice did not expand into general use during the project.
The study identifies two complementary 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 the model of negotiated care, which is based on co-configuration and the public good.
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