LA TEORÍA DEL DOMINIO DEL HECHO

express concern/define problem/ get

assistance

2: Reception staff take details and speak to probably the duty GP who would advise on next step

3a: GP visit and assess – decide what needs to be done in light of assessment of patient’s condition 3b: if assessed as acute fall or immediate problem arrange hospital admission to local DGH

4b: If call Out-of-Hours and not acutely ill, duty dr might contact DNs to support patient until morning and if not Practice patient, ask for own GP Practice to review in morning – form processed through OOH hub. But probably admit if unstable because Rapid Response homecare nursing team not available 24/7 and DNs may not be enough support til morning and full assessment.

4: (If OOH call to NHS24)

5/6: GP assessment – physical exam and history, plus talk to friends/neighbours or family to find out patient’s normal state – if patient confused or signs of mental illness - decides non-acute but medical problem requiring treatment – seek DN input and mental health team input – ring Practice staff to arrange if in hours. ( If psychotic, admit to hospital) 5/6: DNs visit:

take blood and urine samples +/- monitor blood pressure

5: GP send tests from samples taken by DNs: full blood count, liver function tests, thyroid function, glucose levels, UTI, etc. – seek source of probably infection, chest infection or UTI.

7: if person needs support at home until test results available and treatment plan in place, GP or DN arrange Rapid Response Team in- hours only to support patient for a few days at home. 7b: GP perhaps

ask DN to visit over next few days to monitor blood pressure.

8: If person isn’t very unwell but simply cannot manage at home and has no family then hospital admission would be arranged. If unwell but able to manage at home overnight, Rapid Response team used in hours.

Harebell (cont)

8c: if patient not acute, but requires on-going support beyond few days provided by Rapid Response, refer to geriatrician for assessment, either as outpatient if they could get transport to hospital or domicillary visit by geriatrician. Geriatrician take over all aspects of medical, nursing and social needs/support from specialist DGH unit, inc follow-up.

GP electronic referral to DGH unit if to be seen at hospital, if not phone geriatrician to discuss domicillary assessment visit.

9: arrange ambulance for admission to DGH:

9a: GP contact Practice staff to arrange: staff write request in book and phone relevant ambulance hub number depending on level of urgency indicated by GP. Take ref number of call and explain hand carry or stretcher needed. Usually say within 1-2 hours to allow for patient’s preparations to be made from home.

9b: If acute arrange urgent ambulance: 1 GP would phone Practice staff to organise as for 9a, the other would use her own phone to call ambulance herself after discussing with hospital doctor re medical admission.

10: Ambulance take patient to local DGH

11: Patient admitted to local DGH: no action by primary care team until discharge 12: If not admitted but

has wound from falls ask DNs to dress regularly. Initiate investigations to provide information for underlying medical problem: GP ask Practice staff to contact DNs to request bloods and urine samples: Full blood count, liver function test, urine test, thyroid, glucose 13: GPs send tests away to local DGH lab 14: acquire & interpret results: if urgent lab will phone result to Practice same day, if not takes 2-3 days.

14b: results scanned by Practice staff into DocMan – appears on GP’s ‘workflow’ so know to look at it

15: Confirm diagnosis if at home and treat – probably UTI – prescribe antibiotics and monitor

16: Post-discharge with wound for dressing, DN. If continence problem, HV. GP refer domicillary physio or OT if not admitted. Unlikely: more usually as for 8c.

Signposts to context: differences rather than similarities

A focus on similarities is characteristic of certain research approaches when the aim is to generate theory or “good constructs” from data concerning the social phenomena under scrutiny (Eisenhardt, 1989). This reflects the idea that the complexity of social phenomena could or should be reduced in order to identify general issues which may then be universally applied to phenomena within the category under inquiry. As discussed in chapter 5, the focus of this research was practically the reverse: here, the aim was to identify specific issues and attributes about particularly chosen instances of the phenomena of organisational learning in primary care teams, in order to identify exactly the type of characteristics which would be “filtered out” within a reductionist or positivist research paradigm. In other words, the aim was to seek a contextual account of organisational learning in primary care teams through which theoretical insights may be achieved, albeit within a different research paradigm.

The results of the “experimental” exercise conducted with participants through their collective reflection on an “epistemic object” (Miettinen and Virkkunen, 2005), drawn from routine or mundane primary care practice (Kendrick and Conway, 2003) and presented in diagrammatical form, revealed a very different picture to that produced when seeking similarities between accounts. It became evident that activity was undeniably similar across all three teams which echoed the distal view, but from the visual depiction it became equally and importantly evident that activity was simultaneously different in each team. This paradoxical finding mirrored the issues raised in the first phase of this research when participants raised self-identified issues of importance within their primary care teams to illustrate their answers to the questions posed about the “who”, “what”, “where”, “when”, “how” and “why” of organisational learning.

In effect, the findings of this second research phase initially suggested that each team

appeared to be doing the same thing differently. When these differences were

considered from an activity theoretical perspective, context began to emerge from the shadows:

For activity theory, contexts are neither containers nor situationally created experiential spaces. Contexts are activity systems. An activity system integrates the subject, the object, and the instruments (material tools as well as signs and symbols) into a unified whole.

(Engestrom, 1993 p.67)

These differences will be introduced next, grouped in two categories: first, the aspects of activity only mentioned as routine in relation to one team’s activity but not the activity of the other two; and second, aspects of activity mentioned in more than one team’s activity, but where there were differences between teams in relation to such mutuality.

As will become clear through subsequent discussion, these two categories of differences were not as clear-cut as they appeared initially: significant overlaps between them will become evident. However it is helpful to delineate them from one another at first in order to show subsequently the complexity of the linkages between them in relation to the activities of the three teams. This will provide an important insight into the central importance of the relational nature of context and activity, so that it will be possible to discern that not only were teams doing things differently, but that the object of their activity was not the same, despite first impressions.

The two categories of differences (“absolute differences” and “internal category differences”) are presented separately in the following two sections. The “internal category differences” will then be discussed in more depth which sets the scene for consideration of the overlaps between these and the apparent “absolute differences” between the three teams’ activities.

“Absolute differences” in activity

Given the regularity with which the scenario, presented through the epistemic object exercise, seemed to occur in the routine work of primary care teams, it was illuminating to identify the things which participants from one team either mentioned when the other two teams’ participants did not, or did not mention when the other two teams’

participants did. These have been termed “absolute differences” and have been set out in table 6:

Table 6: Absolute differences between teams

Team Mentioned Did not mention

Rowan Community Hospital:

- inpatient service - outpatient service - Radiography - SALT - Physiotherapy - Occupational Therapy - OOH GP - Consultant Geriatrician - DGH medical admission - Rapid Response Team - Pharmacy

Primrose - Private Nursing Home

- Police

- Health Visitor - Physiotherapy

Harebell - 999 call operator

-Community alarm key holder

“Internal category differences” in activity

As well as these absolute differences between the three primary care team activity systems, there were “internal category differences”. These signified apparently similar things mentioned by all teams but which, upon closer consideration of the activity system within which they were identified, exhibited differences which could only be discerned by viewing them through an activity theoretical lens.

These differences related to the following aspects of the activity surrounding the hypothetical, but nonetheless routine, care of an older female patient in primary care teams, including:

• the hospital;

• occupational therapy service;

• mental health input;

• pharmacy provision;

• Rapid Response Team;

On the face of it, these postulated “absolute” and “internal category” differences look unconnected and could be viewed as demonstrating nothing more than that primary care teams were, perhaps predictably, different from one another. It could be argued that this in itself was reason to take a reductionist approach, seeking out the similarities rather than the differences, in order to ‘correct’ for these apparently confounding and seemingly universal contextual differences between each situation and the next.

However, this would be to miss the point entirely and fail to take the opportunity afforded by studying routine activity across the three purposively sampled participating teams. When combined, these differences in teams’ accounts of their usual activity, in relation to the object of identifying and meeting the complex needs of an older female patient, enabled some purchase to be achieved on the slippery concept of context in relation to collective learning. But in order to see this alternative picture, each aspect of each activity system needed to be considered in relation to internal system dynamics, as well as to inter-linked activity system dynamics. In short, the activity of each primary care team required to be seen “in context” in order to demonstrate these differences and from there, to go some way towards explaining why this occurs.

Taking the findings of the initial research phase as the departure point, this chapter has introduced the process and initial findings of the second research phase from an activity theoretical perspective. Findings from the epistemic object exercise have been presented which showed that the activity of each team was different from that of the others, despite surface similarities suggested by more abstract approaches. These differences have been identified and form the basis for discussion in the next chapter.