How professionals learn while collaborating: Collaborative patient care across organisational boundaries

Abstract

Patients receiving care from both the primary care and secondary care settings need health care providers who collaborate and coordinate their shared care. General practitioners and medical specialists deliver their shared care across the boundaries of their work settings and organisations, while they are mainly trained within their own setting, and have little insight into each other's competences and capabilities. The increasing involvement of other professionals, such as nurses, physician assistants, nurse practitioners, with new responsibilities especially for patients with chronic diseases and multimorbidity, also increases the complexity of collaborating in shared patient care . With various methods (questionnaire, interviews, single case study) and theoretical backgrounds, we examine how healthcare providers arrange, shape and change their collaborative patient care across organizational boundaries and learn during these processes. Interprofessional collaboration is not a given, but requires commitment at the macro-, meso- and micro-level from all those involved. To achieve this commitment, professionals need to meet and negotiate their collaborative processes. To do research in this complexity, where change and uncertainty lead, the Change laboratory fits as a theoretical lens to analyse the expansive and collaborative learning. However, such informal learning is often not recognised as learning, and is still implicit. We argue that with time and place to reflect on the workplace, this collective learning can become more deliberate learning as well for trainees as supervisors. We find that when GPs and MSs participate in meetings to negotiate their care and create CPCAs, they learn collectively, and this benefits their common object, their patients. On a macro level, however, they have all experienced tensions that they have not been able to resolve, which have to do with the rules of government and insurance companies. Using the potential of professionals in CPCA meetings to negotiate their collaborative patient care, they learned and created a new patient trajectory visible in the final CPCA document. Multivoicedness of all involved professionals, including trainees, as well as patient perspectives, meeting time and place, and participants' facilitating roles were found to be prerequisites for expansive learning in the absence of a researcher-interventionist. All professionals with a role in collaborative care were able to facilitate the expansive learning process by identifying contradictions such as dilemmas and double binds. They could resolve contradictions, but they have difficulties in naming, explaining and analysing the contradictory 'conflict' and therefore missed opportunities for expansive learning. Within this thesis, Activity theory, Change lab, and expansive learning with the importance of identifying contradictions for learning and change, helped us to gain insight into collaborative care across boundaries in an ever changing world. This is a prelude to search ways to introduce collaborating professionals and managers and others to Change-lab's thinking in order to work on their potential for transformative agency in collaborating for patientcare. Its strength lies in linking the experienced contradictions with systemic causes.