Boundaries in Action : An Activity-theoretical Study of Development, Learning, and Change in Health Care Organization for Patients with Multiple and Chronic Illnesses

This study examines boundaries in health care organizations. Boundaries are sometimes considered things to be avoided in everyday living. This study suggests that boundaries can be important temporally and spatially emerging locations of development, learning, and change in inter-organizational activity. Boundaries can act as mediators of cultural and social formations and practices. The data of the study was gathered in an intervention project during the years 2000-2002 in Helsinki in which the care of 26 patients with multiple and chronic illnesses was improved. The project used the Change Laboratory method that represents a research assisted method for developing work. The research questions of the study are: (1) What are the boundary dynamics of development, learning, and change in health care for patients with multiple and chronic illnesses? (2) How do individual patients experience boundaries in their health care? (3) How are the boundaries of health care constructed and reconstructed in social interaction? (4) What are the dynamics of boundary crossing in the experimentation with the new tools and new practice? The methodology of the study, the ethnography of the multi-organizational field of activity, draws on cultural-historical activity theory and anthropological methods. The ethnographic fieldwork involves multiple research techniques and a collaborative strategy for raising research data. The data of this study consists of observations, interviews, transcribed intervention sessions, and patients' health documents. According to the findings, the care of patients with multiple and chronic illnesses emerges as fragmented by divisions of a patient and professionals, specialties of medicine and levels of health care organization. These boundaries have a historical origin in the Finnish health care system. As an implication of these boundaries, patients frequently experience uncertainty and neglect in their care. However, the boundaries of a single patient were transformed in the Change Laboratory discussions among patients, professionals and researchers. In these discussions, the questioning of the prevailing boundaries was triggered by the observation of gaps in inter-organizational care. Transformation of the prevailing boundaries was achieved in implementation of the collaborative care agreement tool and the practice of negotiated care. However, the new tool and practice did not expand into general use during the project. The study identifies two complementary models for the development of health care organization in Finland. The 'care package model', which is based on productivity and process models adopted from engineering and the 'model of negotiated care', which is based on co-configuration and the public good.

Questions to Artificial Nature: A Philosophical Study of Interdisciplinary Models and their Functions in Scientific Practice

This thesis presents an interdisciplinary analysis of how models and simulations function in the production of scientific knowledge. The work is informed by three scholarly traditions: studies on models and simulations in philosophy of science, so-called micro-sociological laboratory studies within science and technology studies, and cultural-historical activity theory. Methodologically, I adopt a naturalist epistemology and combine philosophical analysis with a qualitative, empirical case study of infectious-disease modelling. This study has a dual perspective throughout the analysis: it specifies the modelling practices and examines the models as objects of research. The research questions addressed in this study are: 1) How are models constructed and what functions do they have in the production of scientific knowledge? 2) What is interdisciplinarity in model construction? 3) How do models become a general research tool and why is this process problematic? The core argument is that the mediating models as investigative instruments (cf. Morgan and Morrison 1999) take questions as a starting point, and hence their construction is intentionally guided. This argument applies the interrogative model of inquiry (e.g., Sintonen 2005; Hintikka 1981), which conceives of all knowledge acquisition as process of seeking answers to questions. The first question addresses simulation models as Artificial Nature, which is manipulated in order to answer questions that initiated the model building. This account develops further the "epistemology of simulation" (cf. Winsberg 2003) by showing the interrelatedness of researchers and their objects in the process of modelling. The second question clarifies why interdisciplinary research collaboration is demanding and difficult to maintain. The nature of the impediments to disciplinary interaction are examined by introducing the idea of object-oriented interdisciplinarity, which provides an analytical framework to study the changes in the degree of interdisciplinarity, the tools and research practices developed to support the collaboration, and the mode of collaboration in relation to the historically mutable object of research. As my interest is in the models as interdisciplinary objects, the third research problem seeks to answer my question of how we might characterise these objects, what is typical for them, and what kind of changes happen in the process of modelling. Here I examine the tension between specified, question-oriented models and more general models, and suggest that the specified models form a group of their own. I call these Tailor-made models, in opposition to the process of building a simulation platform that aims at generalisability and utility for health-policy. This tension also underlines the challenge of applying research results (or methods and tools) to discuss and solve problems in decision-making processes.

Kehittävän kuntoutuksen mahdollisuudet. : Tutkimus Aslak -kuntoutuksen työkytkennän ja asiakkuuden rakentumisesta.

The possibilities of developmental rehabilitation. A study on the construction of work relatedness and the customer in Aslak rehabilitation The challenge of work-related rehabilitation is to anticipate the factors threatening work ability and to affect them. The purpose of this study was to analyze how work-related rehabilitation is constructed in practice and what are the challenges and, at the same time, the possibilities of an innovative transformation of rehabilitation when trying to achive this goal. The theoretical basis is cultural-historical activity theory and developmental work research. Based on a historical analysis, I studied rehabilitation activity empirically using the data gathered from one Aslak programme (Aslak = occupationally oriented medical rehabilitation) over two years. I described and analysed the construction of Aslak using ethnographic data and interviews. The data includes audio- and video-recordings of the Aslak course, fieldnotes, documents and other materials used in the course. The study aimed to reveal rehabilitation practices from different perspectives carried out by different stakeholders and participants in the Aslak course. It focused on the Aslak trajectory produced by a multiorganizational subject. I analyzed the rehabilitation activity using the method of ethnographic analysis of infrastructure. The method of analyzing the construction of the object of rehabilititation the customer was a membership categorization analysis (MCD) based on the ethnomethodological research tradition. I analyzed the meanings denoting customers given by different parties during one Aslak process and the relations between the meanings. Based on this analysis, I studied the disturbances, ruptures, and innovations in the rehabilitation activity. The results of the study show that the infrastructure of Aslak has different basic ideas. Aslak is constructed most explicitly on the infrastructure of medical rehabilitation. The second layer has been provided with some tools of identifying and preventing well-defined occupation-specific load factors. However, it has failed to perform a new structure, as Aslak has encountered, at the same time, rapid changes in working life. The study identified some promising markers representing new kinds of work-related rehabilitation ideas, but they proved to be incomplete and fragile. As a consequence of the multilayered infrastructure, the contents of the Aslak course were split into fragmented phases and disconnected themes, which were blocked in by the master idea of medical orientation. Its relationship to work remained weak and obscure. The categorizations of customers in Aslak were manifold and contradictory. According to the results, the possibilities for transforming work-related rehabilitation lie both in changing the orientation to the customer to be more relevant to changing working life and forging the infrastructural innovations related to this change. The results showed that a new work-relatedeness would be difficult but possible to construct. What is needed is the construction of an infrastructure that will support a coherent master idea of work-related rehabilitation over the entire trajectory of a process. A shared idea of a rehabilitation object must be constructed in close collaboration between different stakeholders, such as Kela (the Social Insurance Institution of Finland), occupational health services, work organizations, and rehabilitation institutes. Key words: Aslak rehabilitation, work-related rehabilitation, development of rehabilitation, customer of rehabilitation, developmental work research, analysis of infrastructure, membership category analysis

Käsityksistä ajatuksen poluille : Ammattikorkeakoulun tutkimus- ja kehitystoiminnan kehittäminen

This study deals with the formation of the idea of research and development (r&d) activity at one particular university of applied sciences in Finland. In this study I proceed from examining the conceptions of management regarding r&d-activities to exploring the development of the complex concept that guides these r&d-activities. The aim of this study is, first, to describe conceptions of r&d-activities, and then, second, to describe the formation of a new concept for r&d-activities in one field of study at the university of applied sciences. I used phenomenographic analysis to elucidate the conceptions and collected the data in interviews of personnel (22) who belong to the management of the university of applied sciences. The data for analysing the obstacles faced and the ways of overcoming them during the formation process of the new concept consist of the video-recorded material from ten change laboratory sessions held for the specific field of study at the university of applied sciences. In researching the formation of the concept of the activity, such research and analysis methods are used in which the concept is understood as a material construction, and with the help of which one can work out the formation of the concept during the development process. When the systematic development of the r&d-work was underway, the management of the university of applied sciences held differing views regarding the content, target, factors and organisation of the r&d-activities, as well as regarding the position of dissertations as a part of r&d-activity. Obstacles for developing rd concerned the unclear object and outcomes of the new activity, not having the tools (such as adequate know-how) for the new activity and not having found the necessary solutions for the distribution of work. In addition the rules that quide the activities of the university of applied sciences did not support working according to the new way. To improve r&d-activity, the school’s management defined three development strategies to encourage adequate rd-activity to support working life, regional development and learning. The strategies were based on the expansion of existing methods, such as service activities, dissertation work and the research activities of the teachers. Of the three possible routes, the concept of dissertation in this study was expanded to integrate the services of organisation development and the occupational growth of the students. A group of teachers in the field of social and health studies participated in the development work. The change laboratory method was used as a tool for this work. Analysis of the cognitive trails indicated that, in addition to the cycle of expansive learning activities, microcycles with different purposes can exist. According to Cussins (1992), something already in existence in each microcycle is destabilised, and something else is stabilised to replace it. In this study three microcycles were identified, during which the teachers first destabilised the existing concepts of dissertation work that guided their thinking, and then began to use new concepts to structure their thinking. Secondly, they undermined the existing concepts with material structure that defined their practical work, and developed new practical models to replace them. Thirdly, the problems accumulating in researching and testing the new activities caused the developers to destabilise the r&d-strategies of the university of applied sciences and to define a new conceptual model for r&d-work in the field. During this third cycle, the teachers developed a research arena model, which was a significant expansive innovation. In the cognitive trails developing the new concept for the r&d-activity, the teachers indeed faced the obstacles the management had described as their conceptions. These obstacles manifested themselves as contradictions. During the development process, the nature of the obstacles (i.e. contradictions) changed as the development proceeded. Solving the first and second degree contradictions highlighted the third and fourth degree contradictions. To overcome the obstacles, the teachers had to to articulate the value and motive of the development work throughout the development process. Developing the new concept for r&d-activity required many reconfigurations of practical solutions to overcome the obstacles. Developing the new concept for r&d-activity, both at the level of representations and of new practices, requires universities of applied sciences to adopt new methods in which the actors are partake in construction of new concepts of activity through adequate discussion, analysis and debate. R&d -activity can progress, if instead of implementing partial solutions, the totality of the activities (i.e. the group of partial solutions acting together) will be constructed. The development of the activity system requires many simultaneous changes as well as wide-ranging know-how and discussion related to these changes. What is perhaps most important, however, is that the group of developers mature into a determined collective actor which can engage in many agentive actions. The development of the agency is fundamental to progress.

Nuorten kokema yksinäisyys ja sen yhteys tulevaisuusorientaatioon

The aim of this study was to examine 1) how much and how adolescents experience loneliness, 2) how they orientate to the future, 3) are loneliness experiences and future attitudes associated with self-esteem and 4) are loneliness experiences associated with future orientation. The data (n=172) was collected in September 2003 and it consisted of 9th grade students living in countryside and city. The research was quantitative questionnaire study and it was statistically analysed. So far the problem of loneliness has not been noticed enough. People experience loneliness when there is discrepancy between actual and desired levels of interpersonal contact. In adolescence loneliness is quite common because young people go through the crises of human relationships and identity. In adolescence the meaning of friends and fellows increases and the relationship with parents changes. Future orientation becomes meaningful in adolescence because young people have to make realistic choices concerning their future life. In this study almost every adolescent had someone to be with and talk to. However 19% of adolescents experienced loneliness. Lonely adolescents experienced lack of friendships and fellowships. Lonely adolescents also felt that they left outside of others and that they were alone. Boys experienced more often lack of friendships and fellowships than girls. Girls experienced that they left more often outside and that they were more often alone than boys. Adolescents living in city experienced a little more loneliness experiences than adolescents living in countryside. Lonely adolescents had also difficulties to make social relationships and they experienced loneliness also related with parents. Lonely adolescents had also weak self-esteem. Adolescents orientated to the future mainly positively. The most important future target was health and the least important target was the universal peace and problems solving of the world. Adolescents believed that they affect to their future mainly by themselves and they planed their future about 5-10 years ahead. For adolescents it was important to have education and work to the future. In the future it was also important to have a lifelong companion and own family. For most of the young people it was also important to keep up social relationships and realize him/herself. Adolescents thought high standard of living and money also quite important things in the future. Girls preferred different future targets more important than boys. For the boys only money and high standard of living were more important than for girls. 18% of adolescents had pessimistic attitude to the future. For pessimistic adolescents many future targets were less important than for the adolescents having affirmative or optimistic attitude for the future. Adolescents who had pessimistic attitude to the future had also weak self-esteem. For the lonely adolescents it was not so important 1) to keep up social relationships and realize themselves in the future. Lonely adolescents did not prefer 2) lifelong companion and own family as important as other young people. Also 3) others acceptance and appreciation were not so important for lonely adolescents. 4) Travelling was also more insignificant for lonely than for others. Lonely adolescents future attitudes were quite pessimistic. Parent related loneliness explained future targets insignificance and pessimistic attitude for the future the most. The experience of loneliness seems to be associated with future orientation in many cases. That s why it is important to pay attention to adolescents loneliness experiences. Loneliness is real and serious problem which threats health. Thus we need to examine further loneliness in adolescence and as a result of that it is possible to develop and use interventions to help lonely adolescents to orientate positively to their future.

Työlähtöiset menetelmät työterveyshuollossa : Oppimisen johtaminen uuden toimintakonseptin käyttöönotto- ja vakiinnuttamisvaiheessa

Working life is changing. The core of the change is change in the production and service concepts of organizations. Changes at work are connected to problems in the well-being of employees. To respond to this challenge, occupational health care must develop a course of action. A group of occupational health care units has developed new activity theory-based methods, the object of which is to change the service concept of occupational health care. The focus is on the changes and disturbances in work activity. My aim was to study this development from the perspective of knowledge management; to clarify directors'/ managers' conceptions of the content and object of their managerial work and the tensions included in these conceptions; to examine the learning process involved in these methods and to bring to light the problems, developmental needs and challenges during the implementation and consolidation phases of the process. This was a case study which included 10 occupational health care units using or being trained to use activity theory-based methods. My data consisted of interviews with directors/managers and recordings of the meetings; 20 directors/ managers are represented; I interviewed seven directors/ managers who represented four units. Directors'/ managers' conceptions of the content and object of managerial work were divided into eight categories of description, which I connected to the historical forms of organizations and types of management. Intuitive and rational management are historically older forms of management. The categories of description representing intuitive and rational management contained many internal tensions, i.e. they do not satisfy the demands of the environment. On the other hand, the categories of description which represented management by results and the control of the development process contained very few or no tensions at all; they are effective in the present environment of occupational health care. The learning process of activity theory-based methods has been expansive in nature. The occupational health care units studied are in different phases of the learning process, and these processes have been different. In three units the focus was on work development; in one unit the focus was on development of the service concept. The most central problems, challenges and developmental needs during the implementation phase were related to learning and spreading of methods inside one's own unit, and during the consolidation phase to working with partners.