PERMEABLE BOUNDARIES DEVELOPING

2.3.1 Within UoAs

I start to see at this point the relational boundaries become ‘leaky’ and permeable within the group itself and generally more cooperative. This ‘leaking’ is important as it starts to move the group toward cohesiveness, a more shared stance and co- ordinated practice. For example, from the interview data I can highlight the following quote that indicates the importance of the interaction across the disciplinary boundaries and how this will lead on to further involvement i.e. co-ordinated practice.

‘I think it does [multidisciplinary approach useful], I think that’s really, really important. I think that those that aren’t directly involved in actually doing the medication reviews are a little bit peripheral at the moment but as it becomes more widespread through the hospital and then when the medication passport is added, and if we look to it being in the community, then that part will become much more valuable’.(10154)

Whilst the move toward cross boundary interaction as described above was evident there were also comments made relating to the difficulty of crossing professional boundaries. The quote below highlights this with reference to the administration and clinical team boundary. Here it is clear that they are seen as separate, which led ultimately to resistance from clinicians.

‘it’s still seen as two different job streams, but actually we’re all trying to achieve the same thing, but I think the clinical and administrative sides are still seen as opposite ends of the magnet, which is a shame, really………they had a lot of consultants who were very protective of their turf and didn’t feel they wanted any administrators meddling with it’. (10159)

I still note, however, that at this stage in the process whilst there was engagement across the boundaries it was not necessarily comfortable within the UoAs. A senior member observed this with reference to the interaction between patient representatives and clinicians and between pharmacists and doctors as respectively demonstrated in the two quotes below:

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‘for the pharmacists seeing the patients was fantastic because I could really see how it was relatively easy for me, as somebody senior, to talk to the patients just like they were a colleague and the junior staff just couldn’t. You know, they were treating these patients and were really uncomfortable, really uncomfortable in a meeting if I was disagreeing with a patient rep’. (10094)

‘but the junior people of the team, and they’re not desperately junior, the middle rank file, found that much harder. And they used to, sort of, ooh, ah, revere, revere, revere, which comes with being a pharmacist actually because we revere, revere, revere doctors, and then we were doing it to patients’. (10094)

I was also from the quantitative data able to analyse the interaction across pre- defined boundaries. In order to this I utilised a calculation termed E-I index. This provides a measure of homophily i.e. how much of the interaction is ‘like with like’. In other words the extent to which the group interacts within their predefined boundary. The E-I index is from -1 to +1. 0 to 1 is heterophilous i.e. the interactions are with others from a different partition and under 0 with those from the same partition. The three types of boundaries I predefined were – job role (professional), where based (hospital or community) and stage in career.

At this point in the process the data indicated that regarding job role and where based the UoA had become more homophilous in terms of interaction i.e. doctor to doctor or hospital to hospital based. This is demonstrated when I compare the figures from before the process to during for the COPD project and IMPE H project team. In both cases the calculated E-I index changes to a more homophilous figure e.g. from an E-I score of 0.12 to -0.21. (See appendix 1 for SNA tables). Whereas with regard to stage of career the UoAs had become more heterophilous i.e. early stage to later stage. For example, the COPD project team had moved from an E-I score of -0.11 to 0.05.

2.3.2 Outside the UoAs

At this stage the UoAs had started to attend facilitated networking events such as the CLD. Here, I noted that encounters outside of their immediate team were brief if at all and where they did interact the exchange was a more general interaction than specifically useful take away information. Equally, there was a clear sense of ‘how does this benefit me’ and in doing so was concerned about the value they were attaining from attending. So, there was low contact and low traction. The quotes below highlight both these aspects of this type of relational tie.

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‘I don't remember these people’s names but I met them. There's a nurse on there that I met; I just can’t remember what her name is. Because I saw her [I can remember that I met her]….it was general. It wasn’t very specific [discussion]…well, it was but I was just listening to them. (100077)

‘And I want to really get something that’s useful out of that [a CLD meeting]. And while it’s interesting to learn about other projects they seem very different….. A lot of them happen in very different environments, a lot of them happen in teaching hospitals, where there are more staff available to do this kind of work, a little bit more used to doing this kind of work. And have to do less juggling, they probably have less clinical work’. (10154)

The characterisation of the relational ties perceived at this point outside of the UoA is difficult to define with reference to commonly used definitions of either weak or strong. Clearly, the tie was within the realm of ‘weak’, however, as these relational ties were compared across the process it was clear that there were differences between the ‘types’ of relational tie at different stages. Here, the relational ties outside of the UoA were of limited contact and limited traction i.e. value. At this point the ties were characterised by the brief encounters where nothing really sticks or was more general interaction than specifically useful take away information. . When compared across the other characterisations found across the process I termed this a footprint ‘trace’. This definition and term was synthesized from the analysis of the results and not an applied term and definition from literature.

2.3.3 Between UoAs and CLAHRC organisation

The SNA data indicated an increase in interaction between the UoAs and the CLAHRC organisation at this point. The COPD project team and IMPE H project team increased by 0.64 and 0.46 respectively (see appendix 1).

I did note at this point that between CLAHRC and the UoA that alongside this increase in interaction a ‘strain’ had developed as the quotes below demonstrate.

‘the bureaucracy and protocol and the start-up, and all the rest of it, was appalling. And their driver diagrams and this, that and the other that was not intuitive, and it caused a lot of tension between us because I had, for both projects we seconded bright young middle grade pharmacists who were just being consumed in this documentation bureaucracy’. (10094)

‘I wrote last week to say, are we going to get any feedback? And I haven't even had a response to that email…. and we did a sustainability review meeting in October where we had to do a presentation, fill out some documentation; they came and we had to present it, and then we discussed it and then we don't know what the point was, because we didn't get feedback on it .’ (10094)

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