title: Collaboration and entanglement: An actor-network theory analysis of team-based intraprofessional care for patients with advanced heart failure.
abstract: Despite calls for more interprofessional and intraprofessional team-based approaches in healthcare, we lack sufficient understanding of how this happens in the context of patient care teams. This multi-perspective, team-based interview study examined how medical teams negotiated collaborative tensions. From 2011 to 2013, 50 patients across five sites in three Canadian provinces were interviewed about their care experiences and were asked to identify members of their health care teams. Patient-identified team members were subsequently interviewed to form 50 "Team Sampling Units" (TSUs), consisting of 209 interviews with patients, caregivers and healthcare providers. Results are gathered from a focused analysis of 13 TSUs where intraprofessional collaborative tensions involved treating fluid overload, or edema, a common HF symptom. Drawing on actor-network theory (ANT), the analysis focused on intraprofessional collaboration between specialty care teams in cardiology and nephrology. The study found that despite a shared narrative of common purpose between cardiology teams and nephrology teams, fluid management tools and techniques formed sites of collaborative tension. In particular, care activities involved asynchronous clinical interpretations, geographically distributed specialist care, fragmented forms of communication, and uncertainty due to clinical complexity. Teams 'disentangled' fluid in order to focus on its physiological function and mobilisation. Teams also used distinct 'framings' of fluid management that created perceived collaborative tensions. This study advances collaborative entanglement as a conceptual framework for understanding, teaching, and potentially ameliorating some of the tensions that manifest during intraprofessional care for patients with complex, chronic disease.
authors.affiliation: Health & Rehabilitation Sciences-Health Professional Education, Western University, London, ON, Canada; Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada. Electronic address: amcdougall@royalcollege.ca.
authors.forename: A
authors.initials: A
authors.lastname: McDougall
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Dept. of Medicine, Division of Internal Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Goldszmidt
authors.affiliation: Health & Rehabilitation Sciences-Occupational Therapy/Health Professional Education, Western University, London, ON, Canada; Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
authors.forename: E A
authors.initials: EA
authors.lastname: Kinsella
authors.affiliation: Dept. of Medicine, Division of Cardiology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Smith
authors.affiliation: Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada; Dept. of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Lingard
mesh_terms: D002170:Canada; D002309:Cardiology / Q000379:methods; D003299:Cooperative Behavior; D006333:Heart Failure / Q000628:therapy*; D006801:Humans; D007400:Interprofessional Relations; D009398:Nephrology / Q000379:methods; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards*; D014882:Water-Electrolyte Balance
keywords: Actor-network theory; Canada; Entanglement; Fluid management; Heart failure; Intraprofessional collaboration; Palliative care