2. LITERATURE REVIEW 2. LITERATURE REVIEW........................................................................................................................ 1 2.1 OVERVIEW (500)(1363)........................................................................................................................ 1 2.1.1 Literature Search Strategy ........................................................................................................... 1 2.1.2 Organisation of the Review .......................................................................................................... 2 2.2 UNDERSTANDING “PEOPLE” IN “PEOPLE-CENTREDNESS” (500)(387) ..................................................... 4 2.2.1 Conceptions of Personhood (1000)............................................................................................... 4 2.2.2 Asserting Autonomy: Consumerism vs Citizenship Perspectives (1000)......................................... 9 2.2.3 Acknowledging Plurality: Taxonomy of Users and Providers in Health and Social Care (500).... 15 2.3 UNPACKING THE ORGANISATION OF HEALTHCARE SYSTEMS (1000) .................................................... 16 2.3.1 Conceptions of Integration (1000).............................................................................................. 17 2.3.2 Structural Reforms in Healthcare Systems (2000)....................................................................... 17 2.3.3 Team-working in Healthcare (2000)........................................................................................... 27 2.3.4 Integrated Care: Models versus Evidence (500) ......................................................................... 31 2.4 CENTRING THE ORGANISATION OF HEALTHCARE SYSTEMS ON THE PEOPLE (500)................................. 32 2.4.1 Micro Perspective: Clinician-Patient Interaction (1000)............................................................. 32 2.4.2 Meso Perspective: Service Personalisation (1000)...................................................................... 35 2.4.3 Macro Perspective: User Participation and Public Health (1000)............................................... 35 2.4.4 Inter-level Dynamics: From Conceptions of Personhood to Health Systems Organisation (500).. 36 2.5 RECONCEPTUALISING HEALTHCARE ORGANISATION WITH BOUNDARY THEORY (500).......................... 41 2.5.1 Conceptualising Boundaries in Health and Social Care (1500)................................................... 44 2.5.2 Managing Organisational Boundaries in Healthcare (1500)....................................................... 53 2.5.3 Boundary Structuration in Action: Dynamics of Identity, Culture, and Structure (1000) .............. 53 2.6 “PEOPLE-CENTRED” HEALTHCARE MANAGEMENT: THE STATE OF THEORY AND EVIDENCE (500) ........ 55 REFERENCES: .......................................................................................................................................... 57
2.1 OVERVIEW (500)(1363) Having established the policy and practice contexts and the rationales for the present study, I will now present a review of the literature that informed the key research questions addressed in this study. I will first briefly outline how I searched for materials on the two strands of literature relevant for the current study (“people-centredness” and healthcare organisation), and will then present the key themes from both the theory and evidence base under each of the two strands. I will then conclude the chapter by presenting a conceptual model developed from integrating the insights gained from the review of these literatures, which had implications for the design of the study as well as the subsequent interpretation of the study findings.
2.1.1 Literature Search Strategy Given the interdisciplinary nature of the subject matter, there are two primary streams of scholarship that inform the current study: the study of user and provider relationships in healthcare settings (from nursing and other clinical literature, as well as the general sociological and philosophical literature on conceptions of personhood); and the study of healthcare organisation (including health services / healthcare management research on service delivery and organisation, as well as general organisational studies, particularly on the topics of teamwork/collaboration and boundary management). Within each of these two strands, particular attention is also paid to studies reported in cardiovascular journals regarding the management of heart patients. These literatures were searched iteratively throughout the seven year period it took to develop and write-up the current study. Systematic keyword searches were performed on the TCD databases, including ABI/Inform, CINAHL, PubMed, Medline and SSCI, with additional regular searches on all British Medical Journal related publications on BMJ.com. Initial keywords applied included combinations of the following clusters of synonymous keywords (* signifying search wildcard to cater for different usages of the base term): a) “manag*” OR “organis*” OR “organiz*” AND “boundar*” OR “interface” b) “collaborat*” or “team” or “integrat*” c) “patient” OR “user” OR “client” OR “consumer” d) “centr*” OR “center*” OR “focus” AND “patient” OR “person” OR “people” e) “health” OR “social” OR “care” AND “system” OR “service” OR “organis*” OR “organiz*” f)
“cardiac” OR “cardiovascular” OR “coronary” OR “heart”
The above list of initial keywords generated a map of the theory and evidence base pertaining to boundary theory in organisational and management studies in general (combinations of “a” and “b” terms); secondly the literature on health system integration (combinations of “a”, “b” and “e”); and in
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particular on “patient-centred care” or “person/people-centredness” (combinations of “c” and “d” terms); and last but not least, all searches were refined using the terms in cluster “f” above to see if any of the studies found via the above clusters apply to cardiovascular services in general. Additional keywords suggested by individual databases and/or used by relevant articles were also added to expand or refine searches as appropriate. Search alerts were subsequently set up on different databases based on useful search combinations and on particular authors whose work are deemed to be particular pertinent to this study. Both backwardtracing (reference list searching) and forward-tracing (searching through citation maps) on a base list of key articles were performed to ensure that seminal articles are read in the original (backward-tracing), and that the literature review is kept up to date with the latest developments in the theory and evidence base (forward-tracing). Throughout the long duration of completing the present research, which coincided with one of the most tumultuous periods of health systems reforms in Ireland, official documents uploaded on the Irish Department of Health and Children website and the Health Service Executive website were regularly reviewed, in addition to keeping track of reform developments through the national news media and via Irishhealth.com.
2.1.2 Organisation of the Review The discussion on the state of the theory and evidence base relevant to this study will be divided into two parts, in accordance with the distinct streams of literature identified earlier. I will first attempt to unpack the concept of “people-centredness” in the organisation of healthcare, by tracing through the varying conceptions of personhood that have pervaded medical and nursing discourses in decades past and present, linking them not only to the care versus cure debate that have animated healthcare scholars in different disciplines, but also to debates in the sociological-political literature on citizenship vs. consumerism, and communitarianism vs. libertarianism. Combining insights across these diverse literatures, I arrive at a taxonomy of different kinds of healthcare actors, whether in the position of the service user or provider, who are the subject of this study (i.e. the actual “people” referenced by the Irish policy ideal of “people-centredness” examined in this study). This will be followed by a discussion, in turn, of the organisation of contemporary healthcare systems. Specifically, I will examine the conceptions of integration and collaboration in the context of health and social care, so as to begin unpacking the drivers behind the immense structural reforms that we have witnessed in healthcare systems around the world over the past two decades. This discussion on the structural reconfigurations of health systems with the avowed aim of achieving seamless care will be supplemented by a review of the actual practices of teamworking among members of different
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professional disciplines and across different settings within the continuum of care. A comparison of the evidence base against prescriptive models of integration would allow us to see exactly where we are in progressing towards the ideals of integrated care. Having examined in-depth the theory and evidence base on the conceptions of personhood as well as health systems integration in the above manner, I will then dissect the literature on “peoplecentredness” at different levels of analysis: the micro level of clinician-client interactions, the traditional focus of much of the so-called “patient-centred care” literature; the meso level of service personalisation, to which end innovative service interventions such as integrated care pathways and case management models are aimed; and finally, on the macro level of public participation in healthcare, incorporating both patient advocacy groups, trade unions and professional associations as they work to ensure their leverage in decision-making on health policies in the public domain. This will be followed by a discussion on the inter-level dynamics of health systems organisation, where I will submit the argument that distinct conceptions of personhood by different actors have implications for different types of health service organisation at the micro, meso and macro levels, and how constraints at the meso and macro levels may in turn influence the user-provider relationships at the micro level. To compensate for the glaring theory deficit in much of current health services research, in the penultimate section of this literature review, I will seek to further illuminate the debates on peoplecentred healthcare integration through the combined lens of boundary and structuration theory, which provides a fruitful framework for looking at interactions between different actors across various predefined social domains. I will first start with an overview of different ways of conceptualising organisational boundaries at different levels of analysis, from both closed and open systems perspectives. I will then demonstrate how integrating care around users of the service is not merely a matter of restructuring the system from the top-down, but must take into account how organisational boundaries are perceived and acted upon in the daily management of patients and through the informal interactions between members of different professional disciplines and/or departments. More pertinently, I will argue for the proper recognition of the interplay between actors and structures, and the importance of organizing processes in healthcare management research. Borrowing the words and example of Dr. Martin Luther King, Jr., I will show how social order and human action are not only interrelated, but mutually-(re)inforcing, and thus when applied to the study of “people-centred” healthcare management, we need to take into account the dynamics of identity, culture and structure before we can get any semblance of a holistic account of the organisational phenomenon under study. Finally, I will conclude this chapter with a note summarising the state of the art in both theory and evidence base regarding people-centred healthcare management, and highlighting the gaps in our knowledge that remain to be addressed, which informs the key research questions for the present study.
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2.2 UNDERSTANDING “PEOPLE” IN “PEOPLE-CENTREDNESS” (500)(387) ‘People-centredness’, a term used to denote the fourth key principle of the Irish National Health Strategy (Department of Health and Children, 2001), is the latest iteration of what has been commonly known as the ‘patient-centred approach’ (PCA) to care. In clinical literature, a major strand of PCA scholarship is concerned with the relationship and power dynamics between clinicians and patients (Emanuel and Emanuel, 1992; Little et al., 2001; Lewin et al., 2002). Age-old approaches to care in the tradition of medical paternalism are countered by the recently developed principle of patient autonomy (Fulford et al., 2002: 3), emphasizing patients’ right to be recognised as a ‘key medical decision-maker’, adopting the role of ‘experts’ on their own conditions as much as their clinicians (Baker, 2000; Taylor, 2000; Clark and Gong, 2000; Deyo, 2001). The traditionally-accepted wisdom of ‘doctor know best’ was therefore juxtaposed with the newly-advocated principle of ‘patient know best’ (Fulford et al., 2002: 3-4; Scally, 2001). As will be detailed in the following sections, such ‘patient empowerment’ stems from conceptions of patients, on the one hand, as ‘moral citizens’ with rights to equal care opportunities and outcomes and responsibility for self management (Gaffney, 2001; Baker, 2000); and on the other, as ‘healthcare consumers’ with ever-increasing quality expectations (McAuliffe, 1998; Barrett et al., 2000; Kendall, 2002). While the former stems from the philosophical discourse on citizenship and civil society, the latter relates to the policy trend towards ‘new public management’, where public sector organisations are increasingly compelled to manifest business-like efficiencies and uphold customer orientation, with citizens reconstructed as consumers (Ryan, 2001; Fountain, 2001). This in turn reflects the debate in the wider sociological and political literature between collectivist/communitarian agenda versus individualistic consumerism (Baldock and Ungerson, 2001). In the following discussion, I will first present different conceptions of personhood within the context of the care vs. cure debate, and then summarise the key issues of service users’ autonomy in health and social care, supplementing the current legal framework of patients’ autonomy with the wider sociological and political considerations regarding citizen vs. consumer ideologies. I will then conclude with a taxonomy of different types of healthcare actors according to these different ideological approaches, which helps to illuminate just exactly what kinds of “people” from an interactional perspective are we talking about when we study the topic of “people-centredness”.
2.2.1 Conceptions of Personhood (1000)
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