Ecuación 4. Coeficiente de fricción dinámico
2.9 NORMATIVIDAD SUELAS DE CALZADO DE SEGURIDAD
The epistemic element of the research/clinical practice boundary refers to the
factors which distinguish the different types of knowledge developed and used in the two domains, how the groups obtain this knowledge and the impact this has on how it is mobilised.
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The tracer cases in this study, as outlined in Chapter 5, were operating in different domains with different research and clinical knowledge bases. The Unitedepartment operated across the range of the ‘translational research’ spectrum – from basic science through to commercial clinical trials, through to treating patients with the NHS standard of care. The Connect case attempted to mobilise more applied knowledge into an unfamiliar clinical setting. As such, the epistemic cultures and their ontological underpinnings varied (Knorr Cetina, 1999). There were
however commonalities between the two cases.
This section first outlines the epistemic manifestations of the ‘basic science’
research/clinical practice boundary and draws some inferences from across the two cases. This epistemic boundary was largely anticipated from the literature review. However a further type of epistemic boundary emerged from the data in relation to the Connect project (unsurprisingly given its core aims) – that between mental and physical conceptions of health, healthcare and associated research. For the Connect project this mapped onto the research/clinical practice boundary (in that mental health researchers were mobilising knowledge to physical health clinicians) and as such warrants some analysis in this section.
6.1.1 Research and clinical practice
Despite the differences in organisational context, knowledges and epistemic backgrounds of the communities, the epistemic boundaries in both tracer cases showed similar features. The boundaries were visible yet permeable.
In both cases, the range of knowledges was represented and generated through different aspects of the teams’ work, which I observed throughout the data collection process. This distinction was visible though the various meetings, or boundary interactions (Wenger, 1998) held (see Table 2), which I observed, and was also alluded to in interviews. I make two related points in this section – firstly, I outline the differences between the epistemologies of knowledge in the two domains, and secondly that despite these, knowledge was not too ‘sticky’ (Szulanski, 2000) and the boundaries were permeable, and perhaps better conceptualised as a joint field of practice (Levina & Vaast, 2005).
6.1.1.1 Epistemology of knowledge in the two domains
In the ‘basic science’ domain in the Unite department, codified knowledge was generated through the traditional scientific method, through the study of cells and
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viruses in lab based settings. This knowledge was derived from work at themicroscopic level:
“So I’m still very much an immunologist and my background is cell biology and T-cells and K-cells, so I don’t necessarily do disease models either, I just try to figure out how T-cells and K-cells work and recognise target cells.” [Gamma AHSC, Unite case, Basic Scientist, Interview 47]
Codified knowledge was derived through lab based experiments and scientific models, generated both from the Unite department and also the wider (basic) scientific community. The process of knowledge generation was akin to that described by Löwy (1996) in her ethnographic study of a cancer trial.
The key features of this knowledge, and therefore the epistemic boundary, was its specialised nature, which appeared highly complex to those operating broadly in the clinical practice domain:
“I wouldn’t say I was particularly academic and going to some of the research meetings … I found that some of it was almost a bit too sci-fi. I thought, I need to probably understand a bit more about the methodology here and a bit more about the stats” [Gamma AHSC, Unite case, Nurse, Interview 39]
This was also the case for basic scientists when attempting to understand the more clinically based knowledge:
“all the questions in my head don’t get answered because they’re all very basic science questions.. I find the very clinical research […] there’s a bit of a difficulty to getting the backgrounds.” [Gamma AHSC, Unite case, Basic Scientist, Interview 47]
At the other end of the spectrum, clinical staff on the frontline treating patients gained their knowledge from many different areas, including research evidence, experience and the patient, as in the following quote from a clinical nurse specialist:
“Predominantly I’m employed to be a Nurse Specialist. So I deal with [specialty] patients. We do a lot of clinical trials so when we are doing a discussion and an assessment for patients, when we first see them we actually talk to them about the fact that we are a research unit and the availability for studies should they require them really. Or should they want to be involved in that and to have access to newer treatments. So that's part of what I do really. And the other part of my role is sometimes if patients don’t actually respond to the standard of care then you then talk to them about opportunities to be part of a clinical trial for their category; basically whether they’ve been a non-responder or a relapse..” [Gamma AHSC, Unite case, Nurse, Interview 28]
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“I still do general medicine, so I still have a general medicine take, I look after in-patients, out-patients, across two different sites and it’s a full time NHS job.” [Gamma AHSC, Unite case, Medical doctor, Interview 33]
On the clinical side, the knowledge generated was more sociologically informed. For example, within the clinical meetings [observations 37:14/01/13; 45:28/01/13; 61:11/02/13; 73:25/02/13; 83:11/03/13] where the multidisciplinary team discussed with patients would be eligible for clinical trials, clinical (particularly nursing staff) brought a dimension from the patient perspective:
One patient was highlighted as meeting the clinical criteria for a particular commercial trial. The Clinical Nurse Specialist explained that while he was very keen on getting onto a trial and starting treatment, his living conditions may not be suitable. She explained that he was currently seeking asylum and was staying in temporary accommodation. He was sharing a bedroom and therefore did not have anywhere private to lock away the injecting equipment and drugs he required. The Clinical Nurse Specialist felt that unless his circumstances changed this would make him unsuitable for the trial [observation 73:25/02/13]
This knowledge was developed through interactions with patients and was more tacit in nature. Experienced clinical (particularly nursing) staff gained this knowledge not through scientific experimentation but through interactions and experiences with patients, with tacit knowledge forming over time over which patients may be suitable for enrolment onto a trial.
Despite the different contexts and purposes of the Connect project, similar findings were noted about the epistemic boundaries. In this case, the ontological
underpinnings of the research domain (broadly members of the Connect project team) were more applied. Their ‘research generated’ knowledge was not derived from laboratory based experiments. Rather, it came from (undertaking and reading) more epidemiologically informed studies, with the subject matter being humans rather than cells or viruses. Further, the senior individuals in the core team also practiced clinically, and therefore had an understanding of the ontological and epistemological underpinnings of clinical practice. The epistemic framing of the physical health clinical teams was similar to that of the clinical domain in the Unite case.
The way knowledge was generated within the respective communities did not appear to block knowledge mobilisation between them. In both cases, in the interactions I observed, there appeared to be sufficient respect and
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underpinnings) had something to contribute to achieving the goals of thedepartment. Interestingly, within the teams there did not appear to be much conflict between those on either side of the epistemic boundary. The boundary appeared to be one of joint work rather than demarcation. I reflect on the boundary work
undertaken in this joint space in Chapter 7 and on the conceptualisation of boundary as joint space rather than demarcation further in Chapter 8.
6.1.1.2 The epistemic boundary as a joint field of practice
The second related finding was that despite the drive for knowledge mobilisation across the two domains, and the ability of staff to understand both camps, the epistemic boundary was not necessarily seen as a negative manifestation or a block to knowledge mobilisation. Participants acknowledged that the knowledge bases of scientists and clinicians were different and this was not necessarily problematic. Some of the basic science undertaken in the Unite department did not yet have any clinical implications and scientists were not necessarily working on disease models. Clinicians reflected that they did not need to have an in depth understanding of molecular biology in order to treat patients effectively, even when discussing clinical trial options with them. However, participants did acknowledge that, in order to facilitate advances in translational research, where ‘science’ is applied to a clinical problem, work at the epistemic boundary was needed. This manifested itself as ‘new knowledge’ being generated in a joint field of practice – this concept will be explored further in the next chapter.
The joint fields of practice (Levina & Vaast, 2005) demonstrated that the epistemic boundary was permeable in both tracer cases, but this was for different reasons. In the Unite department, many staff had grounding in both epistemic communities. Most of the medical staff were either clinician scientists or NHS clinicians with a significant research component to their work. This also applied to the nursing staff, where NHS nurses had a significant research component to their practice and were trained appropriately (such as through good clinical practice certificates, or by undertaking further academic work such as through a Masters in Research). As such a significant proportion worked in the joint field of practice between the
research and clinical practice domains. How these individuals worked as boundary spanners in practice will be analysed further in the next chapter.
Within the Connect project, the epistemic boundaries were also permeable. This appeared to be because the ontological underpinnings of the research undertaken
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by the Connect project team (collecting patient reported outcomes) was more‘applied’ - it did not involve molecular biology, or mice. In the linear model, it was ‘further along’ the continuum towards clinical practice. This made it accessible to clinical groups operating in a different specialty, as I observed in interactions between the teams. Also, like the Unite department, once boundary work was incentivised (in this case primarily through a desire to improve the mental health of acute trust patients), ‘new knowledge’ generated in the joint fields of practice required the skills and practice based knowledges of both domains. In the Connect project, this joint work manifested itself as a boundary object (Star & Griesemer, 1989) in the form of collaboration around patient data.
Mobilising knowledge across the (epistemic) research and clinical practice boundary was more than information sharing, it required some form of knowledge ‘translation’, (e.g. through clinician scientists, or in interactions such as ‘trials’ meetings). Further, as noted above, contrary to what might be expected from the literature (e.g. Knorr Cetina (1999)), epistemic elements of the research/clinical practice boundary in the frontline tracer cases appeared to not create much conflict or political difficulties, unlike the professional and organisational domains at the meso level within the AHSC partnerships (as outlined in the previous chapter). Therefore, in Carlile’s (2004) language, the epistemic boundaries in this case appeared to be primarily semantic rather than pragmatic or syntactic.
6.1.2 Mental and physical health
The second feature of the epistemic boundary between research and clinical practice in the Connect project was that of mental and physical health. Interest in this element emerged inductively from the observation and interview data as part of my ongoing analysis. Despite extensive searches and asking relevant experts in the field who may be able to guide, I did not find any literature directly examining the mind/body dualism as an epistemic boundary. It was, however, a key feature in the Connect project case, appearing to be another dimension of the (epistemic)
research/clinical practice boundary and therefore I consider it here.
A key feature of the mental/physical health epistemic boundary appeared to be to what extent communities and individuals considered a ‘whole person’ approach to the care of patients. In other words, were patients’ mental health needs thought about alongside their physical ones as part of a care package and were care givers
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aware of the inter-relationship between the two? As a Connect project teammember reflected:
“it can be a challenge to get physical health teams really on board about the importance of mental health. It doesn’t seem to be … it’s not prioritised or integrated into their way of thinking.” [Delta AHSC, Connect case, Non- Clinical Researcher, Interview 8]
This difficulty was despite physical health teams self-selecting to be part of the Connect project, and therefore already acknowledging the importance of mental health in treating their patient cohort. One Connect project team member reflected on the ‘whole person approach’ distinction when describing how education sessions with the different teams were shaped:
“So some teams have really not seen any alternative to dealing with psychological need, the way they’ve always approached it is with their patients as .. whole people. And often they don’t have specific knowledge, and maybe muddle through a bit, but their intention has been very much to address the whole person, and that takes you such a long way. And to be able to start from that framework …and to .. add in some booklets and some strategies, that’s quite easy, really.
It’s the beginning to talk about psychological stuff that’s more difficult to do. I mean, in some services there’s a .. culture of .. very frantic, very fast moving, and they’re just not feeling that there’s any space to do more psychological stuff.” [Delta AHSC, Connect case, Clinician, Interview 11]
It may be that the different epistemic cultures on either side of the mental/physical health boundary stem from the fact that knowledges about mental and physical health are formed in different ways. Physical manifestations of an individuals’ ill health are often visible or can be validated with external diagnostic tests using biological data (e.g. blood). Mental health diagnosis and treatment (knowledge) often cannot be diagnosed in the same way, may not be visible or validated through physical specimens and therefore may be considered less tangible. The knowledge used to identify mental ill health may be more tacit in nature. Whereas care
providers may be confident in using their knowledge to manage a variety of physical conditions, even if not their specialty, they may be less certain about mental illness. The Connect project team saw overcoming this boundary as part of their role:
“one of the main goals of the Connect project is to just raise awareness and for people to not feel that identifying addressing, managing psychological need is difficult or beyond them or onerous or scary.” [Delta AHSC, Connect case, Clinician, Interview 11]
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The epistemic boundary between mental and physical health was visible within the Connect project and, like the wider research/clinical practice boundary, waspermeable through interactions (such as the education and training of clinical teams [observations 14:16/07/12]), and objects (such as establishing appropriate care pathways (Allen, 2009)) by trained boundary spanners (psychologists and liaison psychiatrists, and researchers) in the Connect project team. I will expand on these approaches in Chapter 7.
In summary this section has considered the epistemic elements of the
research/clinical practice boundary. The overarching finding was that although visible, the epistemic boundaries in both cases were permeable (through competent boundary work) owing broadly to their cognitive natures as well as having fewer pragmatic qualities (Carlile, 2004). Further, this section has briefly introduced the concept of a mental/physical element to this epistemic boundary, a finding
inductively driven from the Connect case. The paucity of literature on boundary framings of the mental/physical health dualism, together with the findings noted above, makes this a potentially exciting area for future research, which I will return to discuss briefly in Chapter 8.
The different epistemic cultures of the research and clinical practice (and mental/physical healthcare) domains are inextricably linked to the professional cultures of the communities they bound. The distinctive (and broadly separate) training and socialisation of different groups of clinicians, or researchers in their respective professions reinforce the concept of boundaries between the domains. It is to these ‘professional’ boundaries I now turn.