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.

Kuntoutusosallisuuden diagnoosi : Tutkimus entisten rappiokäyttäjien kuntoutumisen muodoista, mekanismeista ja mahdollisuuksista

The main theme of the research centres on the idea that social inclusion can be analysed as inclusions and exclusions. The research is focused on the phenomenon of inclusion that is defined as widely understood social relationships and social binds emerging in a rehabilitation process. Information was gathered from 13 ex substance abusers, who had a background of heavy substance abuse for appr. 15 years and who have been sober for about 7 years. Also 34 persons who helped them to rehabilitate by the helped persons’ perspectives, were interviewed. The speciality of the research is that 5 of the ex abusers were also physically or mentally disabled. A Simmelian interaction process analysis was applied for the narrative analysis of the collected data. The aim of the analysis was to define different kinds of configurations of social relations and social binds. According to the research 3 different forms of inclusion are emerged in rehabilitation. At the early stage rehabilitation leans towards controlling the new sober life style (inclusion of life control). When people begin to rely on their temperance, they begin to make decisions about an own way of living (life political inclusion) and can also dissociate from the institutional thought patterns. People must also find a way into the circles of social relationships to develop own esteemed individual settings of codes for their action (inclusion of life orientation). The main result of the research represents the ‘mechanism of the social’ of rehabilitation. It is composed of the forms of inclusion mentioned above, their contents and the specific reflection mechanism of inclusion. It consists of the heavy structure of the disciplines of the rehabilitation system and the light structure of social worlds. Finally rehabilitation in the long run seems to lean on aesthetic of social relationships – how the person is connected to the circle of social relationships in this reflection. The conclusions are the following. The role of institutional disciplines is an important social resource for controlling life. Other institutions, i.e. the institutions of adult education offer opportunities to organize the abuser’s life. Unfortunately, the institutional rehabilitation seems to offer feeble help, especially to those who are actualising a kind of life orientation that does not comply with legitimated institutional thought patterns. If the helpers cannot define the need for aid in this situation, the helped easily becomes perversely socially excluded. In a discreet way the institutional rehabilitation is shaping subjectivities of the ex abusers by transferring responsibilities for them. This incident already increases the uncertainty of life of ex abuser, who is disposed towards feeling shame and inferiority. It is more secure to strengthen social binds with the institutional rehabilitation and its membership. Thus, getting individually responsible increases addictive behaviours.

Vaikuttavuusyhteiskunta : Sosiaalisten olojen arvostelusta vaikutusten todentamiseen

Evaluation practices have pervaded the Finnish society and welfare state. At the same time the term effectiveness has become a powerful organising concept in welfare state activities. The aim of the study is to analyse how the outcome-oriented society came into being through historical processes, to answer the question of how social policy and welfare state practices were brought under the governance of the concept of effectiveness . Discussions about social imagination, Michel Foucault s conceptions of the history of the present and of governmentality, genealogy and archaeology, along with Ian Hacking s notions of dynamic nominalism and styles of reasoning, are used as the conceptual and methodological starting points for the study. In addition, Luc Boltanski s and Laurent Thévenot s ideas of orders of worth , regimes of evaluation in everyday life, are employed. Usually, evaluation is conceptualised as an autonomous epistemic culture and practice (evaluation as epistemic practice), but evaluation is here understood as knowledge-creation processes elementary to different epistemic practices (evaluation in epistemic practices). The emergence of epistemic cultures and styles of reasoning about the effectiveness or impacts of welfare state activities are analysed through Finnish social policy and social work research. The study uses case studies which represent debates and empirical research dealing with the effectiveness and quality of social services and social work. While uncertainty and doubts over the effects and consequences of welfare policies have always been present in discourses about social policy, the theme has not been acknowledged much in social policy research. To resolve these uncertainties, eight styles of reasoning about such effects have emerged over time. These are the statistical, goal-based, needs-based, experimental, interaction-based, performance measurement, auditing and evidence-based styles of reasoning. Social policy research has contributed in various ways to the creation of these epistemic practices. The transformation of the welfare state, starting at the end of 1980s, increased market-orientation and trimmed public welfare responsibilities, and led to the adoption of the New Public Management (NPM) style of leadership. Due to these developments the concept of effectiveness made a breakthrough, and new accountabilities with their knowledge tools for performance measurement and auditing and evidence-based styles of reasoning became more dominant in the ruling of the welfare state. Social sciences and evaluation have developed a heteronomous relation with each other, although there still remain divergent tendencies between them. Key words: evaluation, effectiveness, social policy, welfare state, public services, sociology of knowledge

Sosiaaliturvan ulkopuolella - kokemuksia kansalaisuuden reunalta

Muuttaessaan maasta toiseen ihminen kohtaa useita rajoja. Ylittäessään kohdemaan valtion rajan hän kulkee läpi ensimmäisestä maahanmuuton portista. Toinen raja erottaa tilapäiset asukkaat pysyvistä: tämän maahanmuuton toisen portin läpikulkemisen myötä yksilö pääsee osalliseksi sosiaalisista oikeuksista. Maahanmuuton viimeisestä portista kuljettuaan yksilö saavuttaa kyseisen valtion kansalaisuuden. (Hammar 1990, 21.) Tässä pro gradu -tutkielmassa tarkastelen toisen maahanmuuton portin aukeamista ja sosiaaliturvan piiriin pääsyä odottavien maahan-muuttajien kokemuksia. Käytän tarkastelussa sosiaalisen kansalaisuuden ja marginaalisuuden käsitteitä. Tutkielmassa selvitän, miten sosiaali- ja terveyspalveluiden sekä toimeentuloturvan ulkopuolelle jääminen vaikuttaa maahanmuuttajien arkeen ja miten he kokevat osallisuutensa ja jäsenyytensä yhteiskunnassa. Tutkimus on lähtökohdiltaan fenomenologis-hermeneuttinen ja sovellan lähestymistapana ko-kemuksiin keskittyvän narratiivista tutkimusta. Tutkimusaineisto on koottu kevään 2011 aikana ja se koostuu 10 teemahaastattelusta. Haastateltavien maahanmuuton keinot ja syyt vaihtelivat: he olivat saapuneet Suomeen perhesyistä, työn vuoksi tai hakeakseen turvaa. Haastateltavat tavoitettiin Helsingin Diakoniaopiston, Pro-tukipisteen, Kansainvälisen seurakunnan ja tuttava-verkostojen kautta. Aineiston analyysi toteutettiin sisällönanalyysillä Atlas-ohjelman avulla syksyn 2011 aikana. Toisen maahanmuuton portin aukeamisen odottaminen oli raskaaksi: tuota aikaa leimasi epä-varmuus, tyhjyys ja yksinäisyys. Sosiaaliturvan ulkopuolella jääminen aiheutti osalle haastatel-tavista taloudellisia vaikeuksia sekä ongelmia terveydenhuollon palveluiden piiriin pääsemisessä. Toisaalta apua hakeneet haastateltavat olivat sitä lopulta saaneet. Auttamistyön ammattilaiset ja maistraatti saivat haastateltavien kertomuksissa portinvartijan aseman. Kaikille sosiaaliturvan ulkopuolelle jääminen ei ollut ongelma vaan he kokivat sosiaaliturvan puutetta suuremmaksi ongelmaksi työnteko-oikeuden puuttumisen. Kuulumisen ja ulkopuolisuuden kokemus voivat olla läsnä samanaikaisesti, ja kuulumisesta neuvotellaan jatkuvasti esimerkiksi sosiaalisessa kanssakäymisessä tai palveluita hakiessa. Insti-tutionaaliset käytännöt ja poiskäännyttämisen kokemukset tuottavat marginaalisia identiteettejä. Tasavertainen oikeus sosiaaliturvaan vahvistaa kokemusta kuulumisesta ja kodista. Sosiaaliturva ei kuitenkaan yksin määritä kuulumisen ja kodin kokemusta vaan siihen vaikuttavat myös muut tekijät. Näistä tärkeimmät ovat kehon fyysinen sijoittuminen Suomeen, perhe- ja ystä-vyyssuhteet, työ, asunto ja rasismin kokemukset.