The rise of the collaborative ideal Implications for pharmacy practice and research?

The rise of the collaborative ideal

Implications for pharmacy practice and research?

My Background

Born & Raised

2002-6Hon B.A.

2006-11Stanford Ph.D.

2011-2Currie PDF

Wilson Centre

2012-3UCSF

Jan 2014Wilson Centre

Sociologist.

Sociology is the scientific study of social behaviour, including its origins, development,

organizations and institutions.

Sociologists investigate a wide range of social phenomena. Their expertise is defined by either or

both theoretical and methodological anchors.

We are adaptable and flexible, as I have shown by studying areas as diverse as…



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0.6We are adaptable and flexible, as I have shown by studying areas as diverse as…



My Research Programme

My Research ProgrammePart 1: Anchors

How does change happen in organizations?

Different theories of organizational change

Neo-institutional theory.

Meyer. 1977. Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology.

DiMaggio & Powell. 1983. The iron cage revisited. American Sociological Review.Meyer et al. 1997. World society and the nation-state. Am J of Sociology.

Policy

Policy Outcomes

Paradis & Whitehead. 2015. Louder than Words. Medical Education.

IPE


IPEBetter

Team-based Care


Something missing.

Policy Outcomes

Policy Practices Outcomes

IPE

Better Team-based Care

IPE

Better Team-based Care

IPEChanging Practices

Neo-institutional theory recognizes that reality is often messier

Decoupling

Decoupling

Meyer & Rowan. 1977. Institutionalized Organizations: Formal Structure as Myth and Ceremony. American Journal of Sociology.

Bromley and Powell. 2012. Decoupling in the Contemporary World. The Academy of Management Annals.

misalignment of policies, practices and outcomes.

Policy OutcomesPractices

Policy Practices

Policies are implemented at all, or

may not change practices.

Outcomes

Policy Practices

Practices may not yield the desired

outcomes.

Outcomes

Institutional Context

Policy


Three mechanisms for organizational change.

DiMaggio & Powell. 1983. The iron cage revisited. American Sociological Review.

Coercive. Organizations are told what to do and do it (for money, survival and legal reasons).

e.g. Research ethics board are implemented in universities worldwide.

Coercive. Organizations are told what to do and do it (for money, survival and legal reasons).

Mimetic. Organizations look at what others do and copy it (because it’s easy, legitimizing).

e.g. Countries worldwide implemented the same structures to support science and innovation (Finnemore. 1993; Drori et al. 2003).

Mimetic. Organizations look at what others do and copy it (because it’s easy, legitimizing).

Normative. Organizations do what they feel is right

(given the institutional climate, values).

Normative. Organizations do what they feel is right

(given the institutional climate, values).

e.g. Human rights are taught in schools worldwide (Meyer et al. 2010).

So when I ask “How does change happen in organizations?” I

want to know two things.

So when I ask “How does change happen in organizations?” I

want to know two things.

1.


Policy

1.


Policy

1.

Coercion?


Policy

Imitation?

1.


Policy

Norms?

1.


Policy

Norms?

Coercion?Imitation?

1.


Policy

2.

Policy Practices

2.

Policy Practices

?

2.

OutcomesPractices

?

If there is decoupling,use newly-gained insights to improve

policy, practices and outcomes.

Collaboration in Healthcare


Two areas.

Interprofessional Collaboration

Interdisciplinary Research


Definitions.

Professions = Healthcare Delivery

Professions = Healthcare Delivery

Anesthesia

Surgery

Intraprofessional

Anesthesia

Surgery

PharmacyMedicine

Intraprofessional

Interprofessional

Profession = Healthcare Delivery

Disciplines = Research

Interdisciplinary

Sociology

Public Health

Disciplines = Research

Anesthesia

Surgery

PharmacyMedicine

Intraprofessional

Interprofessional

Interdisciplinary

Sociology

Immunology


Anesthesia

Surgery

PharmacyMedicine

Intraprofessional

Interprofessional

Interdisciplinary

Sociology

Immunology

Collaborative Ideal

My ResearchPart 2: Some Findings


1 Award


(+ 1 Nomination)

8 PR publications

1 Award

(+ 4 under review)


(+ 1 Nomination)

8 PR publications

1 Award

(+ 4 under review)

1 Successful CIHR Grant as

CollaboratorPI: C.R. Whitehead


(+ 1 Nomination)

8 PR publications

1 CIHR Grant Application as PIw co-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead

1 Award

(+ 4 under review)




(+ 1 Nomination)

28 presentations(4 invited)

8 PR publications

1 CIHR Grant Application as PIw co-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead

1 Award

(+ 4 under review)

1 podcast with Medical Education

1 KT Video with PGME




(+ 1 Nomination)

Interprofessional Rhetoric and Operational Realities: Rounds in Four Intensive Care Units

This research was funded by the Gordon and Betty Moore Foundation.

CONTEXT

Interprofessional collaboration – defined as the provision of team-based care to improve quality and outcomes – has been championed for several decades now.

Kohn et al. 1999. To Err is Human; Health Council of Canada. 2009; World Health Organization. 1988, 2010.

Interprofessional rounds are one of three strategies to improve collaboration in care delivery.

Zwarenstein et al. 2009. Interprofessional collaboration: effects of practice-based interventions. Cochrane Library.

Early in our study, rounds stood out as a key place and moment of interprofessional interaction, negotiation and contention.

Early in our study, rounds stood out as a key place and moment of interprofessional interaction, negotiation and contention.

Overt conflict was rare, but dissatisfaction was palpable and often verbalized, despite strong commitment by both medical and nursing leadership on all units.

Therein lay a puzzle.

Therein lay a puzzle.

Why were rounds so contentious?

Why were clinicians so unhappy with a process that was

successful in the literature?

[ ]Why didn’t the new policy yield the desired outcomes?

[ ]Why did there seem to be decoupling?

Part of an ethnographic study of the factors that impact interprofessional collaboration on 4 American ICUs.

Paradis et al. 2014. Journal of Interprofessional Care 28(1).

Ethnography evolves as the study progresses, involves direct, sustained and extensive contact with participants, and uses participant observation and interviews to tell rich and credible stories that respect the complexity of the social world under observation.

O’Reilly. 2012. Ethnographic Methods; Leslie, Paradis et al. 2014. BMJ Q&S.

We collected detailed ethnographic fieldnotes for 576 hours of observation across our ICUs, conducted 56 interviews, and 47 shadowing sessions.

Ethics approval was obtained at all 4 sites.

Rounds-related events extracted and coded using the constant comparative method.

Boeije. 2002. Quality & Quantity; Glaser & Strauss. 1967.

What did we find?

While purportedly interprofessional, rounds typically looked like this: an inner circle of MDs,

surrounded by a peripheral circle of non-MDs.





They filled most of the

available space, most of the

time.

They were described as a cluster, a barricade, a forest. They counted

between 10 and 15 people, mostly MDs, and up to 5 WoWs.

They were “always in the way”

-- RN interview.

Bodies as Barrier

Dave, RN

The barrier is semi-permeable.

It is polysemic.

It is managed.

Boundary Work

“Boundary work” has typically been used in the context of knowledge production and demarcation (e.g. science vs.

pseudoscience, Gieryn. 1983. Am Soc Rev).

Boundary work in medicine has been used to discuss the different strategies used by physicians to maintain their systemic dominance and cultural authority (e.g. Fournier, 2000; Kuper & Whitehead, 2012, J Interprof Care 26(5)).

“Boundary work” has typically been used in the context of knowledge production and demarcation (e.g. science vs.

pseudoscience, Gieryn, 1983, Am Soc Rev).

Boundary work in medicine has been used to discuss the different strategies used by physicians to maintain their systemic dominance and cultural authority (e.g. Fournier. 2000; Kuper & Whitehead. 2012. J Interprof Care 26(5)).

Physicians’ boundary work is not necessarily a conscious attempt at domination. It can merely be a manifestation of traditional hierarchies, as suggested in other studies.

e.g. Long et al. 2006. The (im)possibilities of clinical democracy. Health Sociology Review 15(5).

Nurses & BW

Two types of responses: the “easy” way and the fight.

Observations, 19 March 2013

Roger (RN) sat behind the rounding team as they presented his patient today. Later I asked him how he decides where to stand during rounds. Nervously, he answered: “I just stand where I want to stand.” I pushed further.

E: So you don’t really make a decision.

Roger: Sometimes you just elbow in, to be involved, other times I just stand at the computer, because they want to ask about vitals trends… Whatever you can do easily. It’s just a giant, you know, cluster of people and you just have to huddle up as best as you can, and… get in where you can.

E: And do you think that most of the time you can get in when you want to get in?

Roger: Yeah. Part of the time. … It works out.

Interview with Zoe (RN)

E: So one of the things that I have noticed is when [physicians] do their rounds, they make a circle.

Zoe: Right, try and get around them, it’s close to impossible.

E: ... Anything else you notice about their circle formation?

Zoe: Well, you have to fight to get in it. As a nurse, as a person at the bedside, I will walk through the

whole thing. I’ll say, “Excuse me,” and I’ll kind of go in there, and I want to hear.

Pharmacists & BW

They have knowledge that is highly valued by physicians, and their presence has been demonstrated to cut costs and reduce adverse events in inpatient settings (e.g. Kopp et al. 2007).

Pharmacists are in a somewhat privileged situation.

Yet some research suggests that they are reluctant to intervene if they perceive that it may taint their relationship with physicians (Lambert. 1995, 1996; Basak et al. 2015).

There are also important cultural differences between pharmacy and medicine, some of which are anchored in status and power differentials (Austin, Gregory and Martin. 2007).

Amelia, PharmD

Bradley, MD

Interview with Amelia, Pharmacist

[T]here are times where I’ll want to be part of [rounds], and then there’s just not enough physical space ... Sometimes I do get kind of – I wouldn’t say pushed out of the way, but there are other people that are part of the discussion that … can stand a little bit of in front of me, … so that is kind of frustrating.


And that is something that even in pharmacy school, we just know that we have to make ourselves visible and we have to be part of that circle. And most teams are not going to say, “Oh, hey, come on in.”


And that is something that even in pharmacy school, we just know that we have to make ourselves visible and we have to be part of that circle. And most teams are not going to say, “Oh, hey, come on in.”

DISCUSSION

The vignettes discussed here show us that different healthcare providers see, navigate and experience the space occupied by physicians’ bodies differently.

In a context where a history of medical dominance, of structural imbalances, of

incompatible incentives, of pay differences, etc. taint interprofessional relationships…

It is not hard to see why the interprofessional rounds we observed

failed to deliver on their goals.

The rhetoric of interprofessionalism clashed with operational realities defined

by limited time, limited space and the conflicting goals of IPC and med ed.

Σ

IPR

IPRColl.

practices

IPRColl.

practices

Team-based, pt-centred

care

Decoupling

=

Depressing?

No!

Recognition of these failures led to the revision of policies and practices on two study units.They have also inspired a new study of

bullet rounds in a TAHSN hospital.



Mathieu Albert & Ayelet Kuper

Funded by SSHRC Grant

1 PR publication


1 PR publication

2 book chapters


1 PR publication

2 book chapters

6 presentations


1 PR publication

2 book chapters

6 presentations

SSHRC Grant Application as Co-IPI: M Albert; Co-I: A Kuper


CONTEXT

In 2000, CIHR was created to promote

interdisciplinary health research; in 2009, SSHRC

decided to stop funding health-related research.

How has the health research field changed as a result, esp. in medicine?

How has it adapted to the presence of SSH scholars?

We asked:

We analyzed key policy documents and interviewed 29 SSH scholars about their experiences working in 11 faculties of medicine in Canada.

Interviews were recorded, transcribed and analysed using content analysis. Categories were generated reflecting the various experiences expressed by participants.

Interviews were then re-analyzed based on these categories (vertical analysis) and compared across participants (transversal analysis).

What did we find?

1A telling absence of SSH scholars on key decisional committees at CIHR, such that their views are unrepresented.

2Many SSH scholars adapted their knowledge production to match the expectations of faculties of medicine, but the field has not adapted to them.

2SSH scholars responded in 5 different ways to their work environment and its academic standards:

2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion,

2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation,

2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation,

2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation, resistance

2SSH scholars responded in 5 different ways to their work environment and its academic standards: conversion, reaffirmation, partial adaptation, resistance and self-exclusion.

Type of Response N

Conversion 3

Reaffirmation 3

Partial adaptation 18

Resistance 2

Self-exclusion 3

Total 29

Type of Response N

Conversion 3

Reaffirmation 3


Resistance 2

Self-exclusion 3

Total 29

Type of Response N

Conversion 3

Reaffirmation 3


Resistance 2

Self-exclusion 3

Total 29

Partial Adaptation

I have a publishing strategy where I divide my efforts between more theoretically-oriented work and more applied empirical work. I want to have some measure of respect within the social science world, but I also do more empirical papers that are oriented to traditional audiences. (SSH07)

I feel almost alienated from myself doing that kind of work [publishing in clinical journals]. I feel like the work I’m doing is irrelevant. What am I contributing, what am I helping to develop around social theory? Nothing. So I feel irrelevant. And it hurts, right? It’s painful. (SSH10)

Partial Adaptation

Staying a sociologist was the biggest challenge of my career. I personally was never interested in betraying my discipline. So I tried to achieve promotion by other means so that I didn’t have to compromise my integrity, because that would have been a horror to have to turn out junk. (SSH05)

Resistance

I’m not on an upward swing, because in a way I’ve kind of just given up. I find myself in a game that I can’t stand. I can’t stand the basic struggle for legitimation. I’m really repulsed by these criteria. I can hardly wait to retire. (SSH15)

Self-Exclusion

Σ

Policy Practices

Policies to promote interdisciplinarity have not changed practices:

SSH scholars do not feel welcome in their new

environment.

Decoupling

=

Depressing?

No!

We have been sharing our findings with SSH faculty across Canada and have been receiving

emails from around the world.There has also been growing interest in non-

experimental research in faculties of medicine.




What is going on?

Why are initiatives designed to foster collaboration not delivering

on their goals?


Collaborative Ideal

A new belief which suggests that better-quality outcomes will emerge from work that combines multiple perspectives, ideas, skills, personalities, etc.

Collaborative Ideal

Is the gradual and increasing institutionalization and formalization of collaboration in healthcare delivery and research, to the point that questioning its value is somewhat heretical.

Collaborative Ideal

I am not saying that collaboration has no place in healthcare, or that is new.

What I am saying is that:


1. there has been a growing interest in collaboration, its demonstration and its effects over the past decades;

2. is now almost universally seen as the best way to do things.


1. there has been a growing interest in collaboration, its demonstration and its effects over the past decades;

2. collaboration is now almost universally seen as the best way to do things.

Broad claims.

?How do I know that a new collaborative ideal has emerged in healthcare?

Massive rise of research on collaboration.

19601962

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15,000

20,000

Figure 1: Number of articles using collaboration-related terms in the PubMed database, 1960-2013

Communication Collaboration IP MeSH Teamwork

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Figure 2: Percentage of all articles in the PubMed database using col-laboration-related terms, 1960-2013


Massive growth of the literature on educating for collaboration (IPE).

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Figure 3: Annual count of articles on IPE in the PubMed Database, 1954-2013 (n = 1,411)

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Figure 4: Percentage of all articles on IPE in the PubMed database, 1954-2013 (n = 1,411)

Multiplication of reports and white papers by influential healthcare

organizations.

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Figure 5: Number of Archived Reports on IPE and IPC Pub-lished Each Year in Canada, 1964-2014

105

?But what about pharmacy?

?Has it seen the rise of the collaborative ideal?

19601962

19641966

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19841986

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Figure 6: Number of articles in the pharmacy literature using col-laboration-related terms, PubMed database, 1960-2013


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19641966

19681970

19721974

19761978

19801982

19841986

19881990

19921994

19961998

20002002

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Figure 7: Percentage of all articles on pharmacy in the PubMed database using collaboration-related terms, 1960-2013

Communication Collaboration IP MeSHTeamwork Combined

Strategic Plan Tomorrow. Today.

1Delivery.

1“A health care team-approach to patient care is emerging. Political pressure is influencing pharmacy practice and all health care providers to move to an

interprofessional model.”

p. 5

Delivery.



p. 5

Delivery.



Coercion!!

p. 5

Delivery.

2Research.

2“The focus of our research has to change from isolated individual research … to one of

collaborative endeavours if we are going to maintain our status of a first class research

Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research

must continue to have an impact on healthcare.”p. 12

Research.





Research.




must continue to have an impact on healthcare.”

Mimetic pressures!

p. 12

Research.



Faculty … Collaborative initiatives will undoubtedly enhance success rates in research funding during times of austerity. Our research must continue to have an impact on healthcare.”

Coercion!

p. 12

Research.





Normative pressures!

Research.

3“nurturing a collaborative culture” (p. 15) & “tapping the major synergistic potential” (p. 16).

Collaborative ideal

Partly explains why the initiatives I studied failed to foster

collaboration.

They did not arise out of a local need to collaborate but rather by a translation of the

collaborative ideal into policies.

Policies

Normative

CoerciveMimetic

Collaborative ideal

By making the collaborative ideal visible, I believe that we can study

its influence, but also…

Policies

Policies Practices

Policies Practices Outcomes

My Future

Vision?

Sociology of

Pharmacy Practice & Education

Sociology of


Students

Sociology of


Students

Policy

To bring sociological theory and methods to the design and conduct of

high-quality empirical research

with a specific emphasis on

collaboration.

How has pharmacy been influenced by the rise of the collaborative ideal? How can policies in support of collaborative care and research be

designed to yield their desired outcomes?

What do I bring?

Theory

Theory

NIT

Theory

NIT

Pierre Bourdieu

Theory

NIT

Pierre Bourdieu

S of Education

Theory

NIT

Pierre Bourdieu

S of Education

S of Professions

Theory

NIT

Pierre Bourdieu

S of Knowledge

S of Education

S of Professions

Methods

Methods

Ethnography

Methods

Ethnography

Bibliometry

Interviews

Methods

Ethnography

Bibliometry

Interviews

Methods

Ethnography

Bibliometry

Surveys

Reviews

Interviews

Methods

Ethnography

Bibliometry

Surveys

?What would my future research in pharmacy look like?

1

CIHR Grantco-Is H. Boon; S. Nelson; S. Spadafora; C.R. Whitehead

CIHR GrantStudies the rise and impact of the collaborative ideal at UT/TAHSN.

Phase 1: Interviews and document analysis.

CIHR Grant

Phase 1: Who were the individual and organizational actors who built the current collaborative ideal at UT/TAHSN and what were their objectives?

CIHR Grant

Policies


Norms?

Coercion?Imitation?

CIHR GrantPhase 2: Ethnography (observations, interviews and document analysis).

CIHR GrantPhase 2: How are intra- and inter-professional boundaries and identities redrawn, renegotiated and transformed in an era where collaboration is the ideal? How do healthcare providers perceive the rise of the collaborative ideal? How do they enact collaboration during patient care activities?

Policies

Policies Practices

Policies Practices

?

CIHR Grant2 sites: Comparative study that follows anesthesia and family medicine residents.

CIHR Grant2 sites: Comparative study that follows anesthesia and family medicine residents.

Data collection could focus specifically on relationships with pharmacists.

2

Legitimate knowledge and the profession of pharmacist


Interviews and questionnaires.


What types of knowledge do pharmacy students see as valuable and critical to their role as pharmacist? Does this understanding change over the course of their studies at the LDFP?


Are pharmacy students engaging in boundary work when they discuss various types of knowledge and their relevance?


This research could tell us about the impact of multidisciplinary environments such as the LDFP on students’ appreciation for different forms of knowledge.


Ultimately: Are we training pharmacists that are ready to provide high-quality, team-based and patient-centred care by tapping into the knowledge that is best suited to these goals?


Ultimately: Are we training pharmacists that are ready to provide high-quality, team-based and patient-centred care by tapping into the knowledge that is best suited to these goals?

If not, how do we get there?

The rise of the collaborative ideal

Implications for pharmacy practice and research?

Documents

The rise of the collaborative ideal Implications for pharmacy practice and research?