Care for patients with multiple illnesses is often provided by several professionals from different parts of the health care system. In these cases, there seem to arise new demands for the communication and the cooperation between different professionals in the primary and the specialized care. In this paper, I shall describe how these challenges are met in an encounter which is a part of interventions called “Implementation Laboratories”. In these encounters, a new tool (care agreement) and a new practice (care (...) negotiation) are introduced and elaborated in internal-medicine patient care. I conceptualized the Implementation Laboratories as “border zones” where the learning processes between different communities are intensified. Learning in the Implementation Laboratories resembles learning at the Boundary Crossing Laboratory described by Engeström, Engeström &Vähäaho (1999a; 1999b). It is interwoven into the process of analyzing problems, planning and testing of solutions in order to improve the medical patient care. Learning appears as collisions between the different perspectives of the patient and professionals of different organizations, and may sometimes lead to reconstruction of boundaries. (shrink)

The care of patients with many illnesses often appears fragmented by many boundaries in the health care system when the care is provided in several locations of primary and secondary care. In the article, boundaries are examined in an interaction between patients and multiple providers in an effort to develop collaboration in inter-organizational provision in a Change Laboratory intervention. Firstly, it will be traced how the boundaries are expressed in the interaction. Secondly, it will be studied how the boundaries expressed (...) in the interaction relate to health care organizations and patient care practices. Thirdly, the practical activity that was embedded in the interaction between patients and providers will be focused on at the laboratory. The expression of boundaries was examined in activity theoretical terms as discursive actions. In discursive actions the ‘lived past’ becomes involved in the situational actions that orient towards future activity. The findings suggest that expressing boundaries uses various linguistic means and it seems relevant to propose that boundaries cannot be studied in a formal way; the analysis needs to be related to the organizational context of the specific study. However, the linguistic means may serve as useful “landmarks” or “pointers” of boundaries that are often expressed implicitly in the interaction. The laboratory session provides an opportunity to study boundaries “on the spot”, or “in their own right”. The realization of the emergent inter-organizational care at the session created challenges for the provision while contradicting some elements of the prevailing provision. During these kinds of interaction, the boundaries between providers became obvious. Furthermore, challenging the boundaries in the normal flow of interaction may be a potential for boundary crossing and even further, a re-constitution of boundaries. Consequently, a boundary crossing represents an interesting unit of analysis for future studies of boundaries and boundary crossing in interaction and discourse. At the laboratory setting was displayed the ability to control others through an indirect use of power that may reflect a simultaneous value system supported by the prevailing hierarchies. In the studies to come, it will be important to pay attention to these implicit power linkages when monitoring the boundaries in horizontal collaborations. (shrink)