Complexity and the Practices of Communities in Healthcare: Implications for an Internal Practice Consultant

Abstract

Current literature regarding quality health services frequently identifies interprofessional collaboration (IPC) as essential to patient-centred care, sustainable health systems, and a productive workforce. The IPC literature tends to focus on interprofessionalism and collaboration and pays little attention to the concept of practice, which is thought to be a represented world of objects and processes that have pre-given characteristics practitioners can know cognitively and apply or manage correctly. Many strategies intended to support IPC simplify and codify the complex, contested, and unpredictable day-to-day interactions among interdependent agents that I argue constitute the practices of a community. These strategies are based in systems thinking, which understand the system as distinct from experience and subject to rational, linear logic. In this thinking, a leader can step outside of the system to develop an ideal plan, which is then implemented to unfold the predetermined ideal future. However, changes in health services and healthcare practices are often difficult to enact and sustain.This thesis problematises the concept of ‘practice’, and claims practices as thoroughly social and emergent phenomenon constituted by interdependent and iterative processes of representation (policies and practice guidelines), signification (sense making through negotiation and reflective and reflexive practices), and improvisation (acting into the circumstances that present at the point and in the moments of care). I argue that local and population-wide patterns are negotiated and iteratively co-expressed through relations of power, values, and identity. Moreover, practice (including the practice of leadership or consulting) is inherently concerned with ethics, which I also formulate as both normative and social/relational in nature. I argue that theory and practice are not separate but paradoxical phenomena that remain in generative tension, which in healthcare is often felt as tension between what we should do (best practice) and what we actually do (best possible practice in the contingent circumstances we find ourselves in). I articulate the implications this has for how knowledge and knowing are understood, how organisations change, and how the role of an internal practice consultant is understood. An important implication is that practice-based evidence and evidence-based practice are iterative and coexpressed(not sequential), and while practice is primordial, it is not privileged over theory.I propose that a practice consultant could usefully become a temporary participant in the practices of a particular community. Through a position of ‘involved detachment’, a consultant can more easily notice and articulate the practices of a community that for participants are most often implicit and taken for granted. Reflective and reflexive consideration of what is taken for granted may change conversations and thus be transformative.