The research and example (The EDARA Study) pertaining to this case study can be found on the ‘using this theory’ page.
Case Study 1: A health care trajectory
The management of pathways of care through modern health services is a profoundly complex enterprise. Health care is a work of “many hands” (Aveling, Parker, & Dixon-Woods, 2016): Patients receive input from a range of providers and specialists, and they may also be required to move between different departments and organizations.
While professionals and policy makers use the language of teamwork to describe practice, much of everyday service provision is characterized by action and knowledge that is distributed across time and space, fragmented and multiple understandings of the patient, and largely independent staff contributions.
Understanding these processes, their interrelationships, and impacts is challenging. In even the simplest of cases, the strategic action field framing an inpatient care trajectory will involve different departments (service directorate, portering, catering, laboratories, administration, procurement) each with its own staff and internal divisions of labor (nurses, doctors, allied health professionals, clerks, porters, caterers, technicians).
While all might agree on the higher order goal of ensuring the patient’s recovery, actors’ enrollment in the care of a particular patient is shaped by different concerns, reflecting the organizing logics that drive their activity. Doctors are concerned with diagnosis and treatment, nurses with care and comfort, allied health professionals with rehabilitation, and managers with patient care episodes and organizational efficiency.
Initial mobilization of health care trajectories is typically generated through multiple processes of object formation.
This is achieved through the deployment of a range of materials (equipment, laboratories, information) and interpretative repertoires (diagnostic categories, assessment tools, mental models, guidelines, administrative codes) through which different actors make sense of and translate the qualities of individuals into categories that enable them to do their work.
While this looks like repetition to patients, the configuration of the case that emerges for the purposes of reaching a medical diagnosis is different from that generated by nursing staff assessing care needs or the allied health professionals planning rehabilitation, and different again from the patient data created by service managers.
These practices are embedded in established organizational routines and formal procedures that are important mechanisms of mobilization in a context in which project members must be interchangeable to provide 24◊7 ongoing care.
For certain parts of the care trajectory, progress is possible because goals are sufficiently broadly defined to enable parallel paths of action.
Take preparation of an individual for surgery, for example. Nurses can ensure that the patient has received information about his or her operation and what is expected in the postoperative period, doctors can mark the operation site and obtain informed consent, and the laboratory technicians can group and crossmatch blood without the requirement for interaction.
At certain junctures, however, it is necessary for these different versions of the patient to be articulated to enable concerted action to progress. In some instances, this can be achieved through formal coordinating mechanisms, such as the preoperative checklist that functions to ensure that the work of nursing, medical, and laboratory staff in preparing a patient for surgery is accomplished at the point that the individual goes to the theater. In other instances, mobilizing health care depends on more than the alignment of activity; it requires patients to be translated from an object of practice of one actor to that of another. An obvious example is hospital discharge, where understanding of the patient’s needs in the acute setting has to be reassessed in the light of the new context for care and aligned with the work of community team that, unlike the 24-hr hospital service, can offer only intermittent support.
A whole host of arrangements exist through which this can be achieved in different combinations depending on the complexity of the case: specialist discharge management nurses, case review meetings, home visits, discharge summary letters, formal referral pathways, and interprofessional negotiations.
Trajectory mobilization involving transfers of care across organizational interfaces often entails the negotiation and renegotiation of both the “needs” of the case and the “work” of the receiving agency to secure a match (Allen, 2015a) and brings into sharp relief the relationship between mobilization and institutionalization processes.
The hospital setting is characterized by multiple processes of formal and informal reflexive monitoring, reflecting its complex division of labor, the unpredictability of individual trajectories of care, and the need for staff to manage competing priorities, which can create disarticulation and drift (Berg, 1997).
First, individual staff and teams review their workload and respective contributions by checking case notes, making sense of different kinds of information, holding discussions with colleagues, and participating in formal handover processes.
Second, actors need to maintain an overview of the whole case and to understand where their contribution fits in with that of others. Hospital life is punctuated with ward rounds and team meetings designed for this purpose although compared with the speed that trajectories evolve, these are relatively infrequent occurrences and rarely, if ever, attended by all actors involved in given case.
As Allen (2015b) has shown, nurses have an important role in supplementing these formal coordination events, through the generation and circulation of “trajectory narratives” that encapsulate the status of a patient’s overall care and can be shared in different formats according to the needs of the recipient.
Third, another facet of reflexive monitoring in health care entails keeping oversight on the whole system of care to effectively deploy resources and staff. Visual management techniques—such as white boards—are increasingly common and particularly important for monitoring organizational or departmental status in fast flowing environments such as Emergency Units although their utility depends on the quality and currency of the information they display.
Trajectories and health care organizations are bound together with sensemaking processes as staff draw together resources to construct a case, plan care and treatment, negotiate patient transfers, and account for their actions, and in doing so they give meaning and substance to the institutional context and structures that shape activity and condition future action.