Impacto de las variables clínicas y de las mutaciones en la respuesta a azacitidina

The challenge of mobilising research knowledge into clinical practice can be conceptualised as boundary work. Although the knowledge mobilisation literature does not tend to analyse the properties of boundaries themselves, the concept of boundary work (in particular boundary objects), has gained some traction recently.

By accepting the need for some form of boundary work, most theoretical literature in this area takes a sociologically informed view of knowledge as something socially constructed in communities which does not simply ‘transfer’ to another community. Instead the boundaries are broadly assumed to be semantic or pragmatic (Carlile, 2004), and therefore assumes that the knowledge requires some form of translation or transformation. Further, the concept of boundary work is present in all three literatures (epistemic cultures, professions and organisational studies) outlined in the previous section.

Wenger (1998) identifies three types of boundary bridges used in boundary work between communities of practice – 1) people (boundary spanners or boundary brokers), 2) artefacts or boundary objects (Star & Griesemer, 1989), and 3) boundary interactions (spaces which enable people from different communities to come together). The theoretical literature largely focusses on the first two of these (people and objects). This section will therefore examine these two types of ‘bridges’ which may have relevance to the research/clinical practice boundary and the emerging organisational form of AHSCs.

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2.3.1 Boundary Spanners

Boundary spanners are those individuals who have access to two or more discrete communities enabling them to use, assimilate and mobilise knowledge across otherwise unconnected networks of individuals (Wenger, 1998). Work on boundary spanning actors is primarily located in the management literature on knowledge and the application of this work to knowledge mobilisation in healthcare has gained traction recently (I return to this below).

In the management literature, boundary spanning individuals are seen as those who facilitate the sharing of expertise by linking two or more groups separated by

function, location or hierarchy (Cross & Parker, 2004). Studies have examined the roles of IT professionals (Pawlowski & Robey, 2004), managers of research and development groups (Tushman, 1977) and engineers (Allen & Cohen, 1969;

Bechky, 2003) amongst others as empirical examples of those individuals spanning intra and inter organisational boundaries.

Many studies have examined these ‘designated’ boundary spanning roles and developed categorisations of the roles they are expected to perform, which are seen as important to the organisations’ ability to face the challenges of managing across boundaries (e.g., Aldrich and Herker (1977); Friedman and Podolny (1992); Leifer and Delbecq (1978); Tushman and Scanlan (1981)). Boundary spanners have variously been described as scout, ambassador, sentry and guard (Ancona & Caldwell, 1992) and others have identified key traits which ‘competent’ boundary spanners possess (Williams, 2002).

However, the multiple roles that ‘designated’ boundary spanners possess are often conflicting and can lead to stress and burnout (e.g. (Dubinsky et al., 1992; Lysonski, 1985; Singh et al., 1996). It is also challenging to find individuals who are both emotionally intelligent (Caldwell & O'Reilly, 1982) and capable in more than one domain (Nochur & Allen, 1992). Boundary spanning individuals are however often in management positions and may be reluctant to give up any element of their roles (Wiesenfeld & Hewlin, 2003).

Taking a practice based perspective, Levina and Vaast (2005), drawing on

Orlikowski (2002), usefully distinguish between nominated boundary spanners and boundary spanners in practice. Nominated boundary spanners are those who are expected to undertake boundary spanning activity as part of their formal job role.

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Boundary spanners in practice are those who actually undertake boundary spanning activity. These two roles are not mutually exclusive, yet the authors argue that ‘evidence suggests that the expectations of these roles and practices of boundary spanning often do not coincide’ (p. 339). Furthermore, formal organisational structures may not coincide with the reality of practice where actions can have unexpected consequences and diverse interests are represented (Wenger, 1998). This is an important consideration when studying the emerging organisational form of AHSCs.

Unlike nominated boundary spanners, boundary spanners-in-practice must actually engage in the activity of ‘relating practices in one field to practices in another by negotiating the meaning and terms of the relationship’ (Levina & Vaast, 2005, p. 339). They therefore call for further work to understand the processes through which individuals become boundary spanners in practice and argue that boundary spanners-in-practice develop new joint fields of practice between existing fields where the boundary work can take place. This framing of a boundary as a space for activity is more akin to taking an anthropological perspective than that drawn from the professions or science literatures which conceptualise boundaries as ‘lines or gaps’ (Lamont & Molnár, 2002).

Healthcare has provided much empirical data for studies on boundary spanners. As noted above, the constraining nature of professional boundaries to knowledge spread in healthcare has been well documented (Ferlie et al., 2005). There is now a growing interest in boundary spanning processes which challenge these constraints. These include policy driven organisational developments such as the establishment of multi-disciplinary teams which may be a breeding ground for boundary spanners in practice (Oborn & Dawson, 2010). There is also a substantial stream of literature examining the hybridisation of professional roles in healthcare, but this mostly relates to work across the medical/managerial domain (see professional boundaries section above).

There is a growing interest in the concept of boundary spanners in the knowledge mobilisation in healthcare field, but the literature remains fairly limited to highlighting empirical examples of nominated boundary spanners in recent translational

research initiatives, in particular CLAHRCs, e.g. Harvey et al. (2011). There are however some more theoretically informed examinations, such as Kislov et al.

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(2012) and Kislov (2014) who explores the development of communities of practice within the CLAHRC setting.

There are few studies which examine the role of boundary spanners in the earlier stages of the translational research pathway, but they are theoretically informed and useful. For example, Wainwright et al. (2006) explore the views of clinical scientists on human embryonic stem cell research in the field of diabetes. They demonstrate how translational research efforts are frequently limited due to a lack of

understanding of the respective other professional domains – clinicians often don’t understand the more scientific aspects of laboratory science, and biomedical

scientists may lack understanding of the social and organisational issues associated with undertaking research in humans in a clinical setting in the NHS.

This complements the findings of Wilson-Kovacs and Hauskeller (2012) who suggest that the recent clinical implementation of stem cell research brings new legitimacy to the role of the clinical scientist, who straddles the boundary between research and clinical practice and possesses specialist expertise in both domains. They demonstrate how randomised clinical trials help to increase the status of individual actors within their respective teams, but also as a collective group as leaders of change in knowledge translation, becoming clearly established as a ‘profession’ in their own right. Lander and Atkinson-Grosjean (2011) further highlight the importance of clinical scientists as boundary spanners in helping to capture the complexities taking place on the boundaries of translational science (in their study, a rare genetic defect), and in ensuring the delivery of a genuine piece of translational research. However, concurring with Levina and Vaast (2005), true boundary spanners, who are completely comfortable in two of more communities of practice are quite rare, as it is very difficult for one person to be ‘great at everything’ (Lander & Atkinson-Grosjean, 2011, p. 542).

2.3.2 Boundary objects

Whatever the characterisation of the boundary, be it organisational, epistemic or professional, the role of objects in knowledge mobilisation across those boundaries is a common feature of all of them, and as such is widely documented in a number of literatures (Trompette & Vinck, 2009). Boundary objects are flexible artefacts which act as translation devices at the boundaries between different disciplines, organisations or epistemic communities. The term originated in Star and Griesmer’s (1989) study of Berkeley’s Museum of Vertebrate Zoology where they describe it as

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an ‘object that lives in multiple social worlds and which has different identities in each’ (p. 409). They see these as being a translation tool between ‘several intersecting worlds’, where they are flexible enough to adapt to local needs, yet robust enough to maintain an identity across different sites. Since then, the role of objects in cross boundary work has been well documented (Bechky, 2003; Carlile, 2002). The concept of boundary objects has been widely applied to both the

healthcare and biomedical research settings, for example with reference to standard forms in multidisciplinary meetings (Oborn & Dawson, 2010), care pathways (Allen, 2009), human embryos (Williams et al., 2008) and telemedicine (Constantinides & Barrett, 2006).

The key feature of a boundary object is that it is flexible and can be interpreted differently by groups on either side of the boundary, yet their structure is such that they provide a common frame of reference for both (Bijker et al., 1987). They enable co-ordination across boundaries without the need for consensus or shared goals as they allow individuals’ local understanding to be reframed to form part of wider activities (Bechky, 2003). Building on his analysis of knowledge boundaries, Carlile (2004) suggests that different types of boundary object are used depending on the form of collaborative working. When the situation is routine and familiar, and information simply needs to be transferred, a simple object such as a single word will suffice (syntactic co-ordination). If the situation is more complex, actors may need to establish common meanings and the boundary object would need to contain more information (semantic co-ordination). Finally if negotiation and compromise are required, the object requires flexibility to enable a change or transformation (pragmatic co-ordination).

However Nicolini et al. (2012) argue that the notion of boundary objects has become a portmanteau concept which tries to explain all boundary interaction, with the consequence that it loses its analytical power. They therefore advocate a pluralist approach to examine the different roles objects may play in facilitating cross

disciplinary work. Objects may hold a tertiary, secondary or primary role, and each role is best understood through a different theoretical lens. They suggest a

framework through which objects may move as they adapt and change their meaning and role in cross disciplinary collaboration.

A tertiary object performs a basic function relating to the material infrastructure of the project. This could be a building, email system or telephone list: ‘boring objects’

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(Star, 1999) which enable the project to run but do not drive collaboration. The role of these objects is best understood using infrastructure theory.

A secondary object facilitates the flow of knowledge across boundaries. Here, the traditional notion of a boundary object functioning as a translation artefact between different disciplines or professions provides the theoretical framework (Star &

Griesemer, 1989). Objects are flexible enough to be interpreted in different ways by different groups on either side of the boundary, yet hold their structure to enable cross disciplinary work. Examples include forms, slides or drawings (Bechky, 2003).

Finally, primary objects are those that drive and motivate, rather than just facilitate, cross disciplinary collaboration. Here, Nicolini et al. (2012) draw on Science and Technology Studies and frame tertiary objects as epistemic objects. These objects provide platforms for both innovation and conflict, and the nature of the object becomes important as it drives different ways of working. Examples include the scientific puzzle, or the ‘unknown’.

Objects therefore provide a useful framework through which to analyse boundary work across epistemic, organisational and disciplinary/professional boundaries within AHSCs. Nicolini et al. (2012) call for future research in this area to examine what objects are used in cross disciplinary collaboration and when, and what is the meaning of the objects and for whom.

Several studies from the management and IT literature also emphasise the

importance of both the instrumental effects of objects and their symbolic value. For example, Bechky (2003) demonstrates that objects (in her study engineers’

drawings) can be used to signify status as well as share understanding, thus

reinforcing boundaries using symbolic power. Pawlowski and Robey (2004) provide an example of how IT systems are used by IT professionals as objects to facilitate knowledge brokering. Levina and Vaast (2005) develop the concept of ‘boundary objects-in-use’ (p. 354) which acquire shared social capital when developed in association with a new joint field of practice. For example, the symbolic value of the paper prescription to the profession of medicine and pharmacy and to patients is important (Cooper, 2011).

In the biomedical field, Swan et al. (2007) consider both the instrumental and symbolic aspects of boundary objects in an early policy initiative encouraging the translation of research into practice - the Genetics Knowledge Park. They

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demonstrate that when objects are symbolically associated with positive ideology and values, it is this that is crucial in facilitating interaction across boundaries, rather than the instruments (such as databases) themselves. The study identified that the objects had high levels of flexibility in how they could be interpreted, which gave them considerable symbolic value which could be leveraged across a range of communities to raise interest in the project. The symbolic association also corresponded with pre-existing policy discourses behind the Knowledge Parks, including the vision of combining cutting edge research with improved clinical practice. In a further example, studying software development teams, Barrett and Oborn (2010) show how the same object can take on different roles over the course of a collaborative project and that it can also highlight and reinforce asymmetrical power relations between the two communities.

Lander and Atkinson-Grosjean (2011) suggest that boundary objects translate or articulate between domains enabling those on different sides of a dispute to identify a common goal and work towards it. Hence, they argue that a particular scientific or clinical problem can act as a boundary object and bring the separate epistemic cultures of science and medicine together. They explore this idea through the use of a rare genetic defect (IRAK-4 deficiency) as a boundary object that linked the academic laboratory and the clinic. In this case, unlike in Mørk et al. (2008), no turf wars were observed. This may be in part due to the lack of direct competition between the epistemic communities, and the overall nature of the scientific puzzle being of greater importance than individual goals.

Linked but subtly different to the notion of boundary objects is that of boundary concepts (Allen, 2009; Löwy, 1992). A boundary concept is a loose concept, but one that is powerful enough to bring diverse groups together. The key feature of a boundary concept is its ‘vagueness’ – this ‘facilitates communication and co-

operation between members of distinct groups without obliging members to give up the advantages of their respective social identities’ (Allen, 2009, p. 355). Löwy (1992) applies this to the construction of interdisciplinary alliances in science; Allen (2009) builds on this analysis by applying it to care pathways. It would be

interesting to explore whether the ‘bench to bedside’ heuristic operates as a boundary concept within AHSCs, drawing scientists and practitioners together to unite around this ‘vague’ notion of translating research into practice.

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2.3.3 Boundary work – gaps identified in the literature

The concept of boundary work and the role of people and objects associated with it have received attention from the healthcare and knowledge mobilisation literatures and the concepts, in particular boundary objects, are quite well developed

theoretically. However there are some gaps in the literature which a study of the emerging organisational form of AHSCs could contribute to.

Firstly the role of clinician scientists makes an interesting empirical case through which to examine the distinction between nominated boundary spanners and boundary spanners-in-practice (Levina & Vaast, 2005) and what impact this has on their ability to form joint fields of practice. Do the roles of potential boundary

spanners-in-practice in AHSCs (such as clinician scientists) coincide with nominated boundary spanners (perhaps those in management positions in the organisations), and how does this impact on their (and the organisations’) ability to undertake boundary work across the research/clinical practice boundary?

Do these individuals establish new joint fields of practice or are they reluctant to leave their respective fields and therefore reinforce the (organisational, epistemic and professional) boundaries rather than span them? Are these individuals

developing into a new professional hybrid, carving out a new area of jurisdiction on this boundary? How do they deal with the competing mission tensions manifest in the research/clinical practice boundary?

The literature on boundary spanners is also light on the organisational context of boundary spanning activity and how this may help or hinder the process. As AHSC partnerships have been established with the ‘mission’ of spanning the boundaries of research and clinical practice, but they have been formed from sovereign

organisations with histories, they may be interesting cases through which to explore whether the organisational forms complement or challenge the reality of boundary spanning in practice. To examine this, it will be useful to consider both meso and micro level actions in the AHSCs and how the two interact.

An appreciation of the symbolic value objects can hold is often neglected in studies of knowledge and innovation which typically focus on their instrumental

characteristics (Swan et al., 2007). Linked to this, the political nature of objects (who uses them, how, to what end and how does this change over time?) is under- researched (Nicolini et al., 2012). In exploring the composite nature of the

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research/clinical practice boundary it may be helpful to analyse the symbolic role of boundary objects across the different (epistemic, professional and organisational) composite domains. Can objects which acquire high symbolic value encourage boundary work across the different elements simultaneously? For example, in the AHSC context, would a shared IT system between partner organisations have value beyond the organisational benefit? Does it enable boundary work across less tangible epistemic and professional boundaries and, if so, how?

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