Tait Glendon R, Bates Joanna, LaDonna Kori A, Schulz Valerie N, Strachan Patricia H, McDougall Allan, Lingard Lorelei
Department of Psychiatry and Division of Medical Education, Dalhousie University, Halifax, NS, Canada.
Centre for Health Education Scholarship, Vancouver General Hospital, Vancouver, BC, Canada.
J Multidiscip Healthc. 2015 Aug 19;8:365-76. doi: 10.2147/JMDH.S85817. eCollection 2015.
Heart failure (HF), one of the three leading causes of death, is a chronic, progressive, incurable disease. There is growing support for integration of palliative care's holistic approach to suffering, but insufficient understanding of how this would happen in the complex team context of HF care. This study examined how HF care teams, as defined by patients, work together to provide care to patients with advanced disease.
Team members were identified by each participating patient, generating team sampling units (TSUs) for each patient. Drawn from five study sites in three Canadian provinces, our dataset consists of 209 interviews from 50 TSUs. Drawing on a theoretical framing of HF teams as complex adaptive systems (CAS), interviews were analyzed using the constant comparative method associated with constructivist grounded theory.
This paper centers on the dominant theme of system practices, how HF care delivery is reported to work organizationally, socially, and practically, and describes two subthemes: "the way things work around here", which were commonplace, routine ways of doing things, and "the way we make things work around here", which were more conscious, effortful adaptations to usual practice in response to emergent needs. An adaptive practice, often a small alteration to routine, could have amplified effects beyond those intended by the innovating team member and could extend to other settings.
Adaptive practices emerged unpredictably and were variably experienced by team members. Our study offers an empirically grounded explanation of how HF care teams self-organize and how adaptive practices emerge from nonlinear interdependencies among diverse agents. We use these insights to reframe the question of palliative care integration, to ask how best to foster palliative care-aligned adaptive practices in HF care. This work has implications for health care's growing challenge of providing care to those with chronic medical illness in complex, team-based settings.
心力衰竭（HF）是三大主要死因之一，是一种慢性、进行性、无法治愈的疾病。越来越多的人支持将姑息治疗的整体方法用于缓解痛苦，但对于在心力衰竭护理的复杂团队环境中如何实现这一点，人们的理解还不够。本研究调查了患者所定义的心力衰竭护理团队如何共同为晚期疾病患者提供护理。
每位参与研究的患者确定团队成员，为每位患者生成团队抽样单位（TSU）。我们的数据来自加拿大三个省份的五个研究地点，由来自50个TSU的209次访谈组成。基于将心力衰竭团队视为复杂适应系统（CAS）的理论框架，使用与建构主义扎根理论相关的持续比较法对访谈进行分析。
本文围绕系统实践的主导主题展开，即心力衰竭护理在组织、社会和实际层面是如何运作的，并描述了两个子主题：“这里的做事方式”，这是常见的、常规的做事方式；以及“我们让这里的事情运作起来的方式”，这是为应对突发需求而对常规做法进行的更有意识、更费力的调整。一种适应性实践，通常是对常规的微小改变，可能会产生超出创新团队成员预期的放大效果，并可能扩展到其他环境。
适应性实践不可预测地出现，团队成员的体验各不相同。我们的研究提供了一个基于实证的解释，说明心力衰竭护理团队如何自我组织，以及适应性实践如何从不同主体之间的非线性相互依赖中产生。我们利用这些见解重新构建姑息治疗整合的问题，即询问如何最好地在心力衰竭护理中促进与姑息治疗相一致的适应性实践。这项工作对于医疗保健在复杂的、基于团队的环境中为慢性疾病患者提供护理这一日益增长的挑战具有启示意义。
