32 SES 09 B, Innovation in/of Healthcare Organizations
Premises and perspective:
This is a transdisciplinary research, located at the crossroads between migration studies, medical sociology and social pedagogy. It seeks to explore the dynamics and effects of knowledge circulation between actors of a healthcare field in implementing inclusive practices.
Rather than a Knowledge Management paradigm or a learning organizations paradigm (Cfr. Senge 1990), shaped for the private business sector, the chosen approach is social innovation (Moulaert et al. 2013; Elsen & Lorenz 2014), conceiving service institutions as inclusive and people-centered systems, and considering the power dynamics involved in processes of inclusion (Ahmed 2012). This perspective is in accordance with international healthcare policy frameworks (WHO 2010), which call for migrant-sensitive healthcare organizations, European policy (Parlamento Europeo 2011) and Italian national law (Parlamento Italiano 1998) which grants migrants similar conditions of treatment as national citizens. However, the current European legal framework seems to offer migrants de jure entitlement to health care, while failing “to create provisions designed to alleviate de facto barriers that inhibit the ability of migrating people to receive health care” (IMO 2009). Realizing that integration of migrants is a two-way street (Boccagni & Pollini 2012), this gap between a policy based on inclusive principles and an effectively inclusive service provision (Cfr. Phillimore et al. 2016; for the Italian case: Tognetti Bordogna 2012; Perna 2016), and the challenges of immigration as a social determinant of health (Castañeda et al. 2015) as well as health inequalities in general (Marmot 2015) constitute core motivations of this work.
San Maurizio, the biggest hospital in South Tyrol, with the highest density of migrant population, is experiencing a process of innovation of healthcare practices and services to address barriers experienced by migrant patients. Three wards are being studied: 1. Undocumented migrants clinic (innovating diagnostic and treatment protocols); 2. Neonatal intensive care (innovating mediation services and training initiatives) and 3. Dermatology (innovating relations with vulnerable patients and processes in documenting signs of torture). The practitioners’ point of view is being prioritized. Nevertheless, their narratives will be triangulated with accounts by other actors in the field (patients, mediators, administrators…) and with quantitative data.
How can context-relevant knowledge circulate between actors of this field as to contribute in shaping services and contrasting barriers? Specifically, under which conditions can migrant patients and healthcare practitioners gain reciprocal knowledge to innovate practices and services?
Structural conditions of superdiversity (Vertovec 2007; Meissner & Vertovec 2015) increase population complexity and give rise to new and intersectional vulnerabilities, causing many immigrant patients to lack the knowledge and skills they need to interact effectively with welfare institutions, while their needs and barriers often remain undetected by the system, making it hard to appropriately target services (Cfr. Phillimore et al. 2016).
The study argues that context-specific knowledge can be created, circulated and invested as capital in the creation and circulation in the process of innovation of practices to overcome barriers experienced by migrant patients (e.g. Lechner & Solovova 2014). Janet Shim (2010), drawing from Bourdieu (1990), has defined “cultural health capital as the repertoire of cultural skills, verbal and nonverbal competencies, attitudes and behaviors, and interactional styles, cultivated by patients and clinicians alike that, when deployed, may result in more optimal health care relationships”. Reaching beyond notions of individual skill as intercultural competence or sensitivity (Castiglioni 2008), the research analyzes the processes by which actors within the healthcare system might cooperatively experience, interpret and circulate key elements of context-relevant knowledge, and apply them to the innovation of healthcare interactions and practices with migrant patients, either helped or hindered by institutional conditions.
Mixed methods are being applied (Cfr. Schensul & LeCompte 2016; Kirby et al 2006), with a transformative aim and a collaborative approach to participants in the field, considered as research partners: o quantitative contextualization of migrant-intensive areas in hospital services ○ qualitative contextualization of new practices being implemented using ethnographic methods. o recursive dialogue with research partners (main actors of innovative practices in hospital) in identifying emerging knowledge being applied in innovation initiatives o Interviews with doctors and nurses of three wards (STP clinic, neonatal intensive care and dermatology) about migrant patient’s needs and barriers, interactional learning processes and systemic conditions. o Group meetings with participants to present emerging data and obtain feedback o Dialogue with other actors: mediators, administrators, patients, and with the Direction of Hospital about emerging data to obtain feedback o The theoretical framework as well as the recursive data circulation between actors will ground the resulting data analysis. o A final report with recommendations to the hospital are going to be produced.
Emerging data: Some context-relevant topics emerging from the field are: - a shared reflection on the definition and quality indicators for mediation services, - relational strategies when documenting torture wounds to avoid further traumatising the patient and favoring his re-acquisition of a sense of control over the body, - adaptation of prevention discourses and practices to situations of high mobility and vulnerability Expected outcomes: ○ Specific understanding of how context-specific knowledge circulation in public service organizations might contribute to create an effective nexus between policy frameworks and actual practices and to better target service delivery in a context of superdiversity. ○ A process of reflexivity in medical professionals, which can raise awareness on how learning relations between health professionals and vulnerable patients might contrast healthcare inequalities by shaping migrant-sensitive practices and services. ○ Conclusive recommendations for healthcare organizations on conditions which contrast health inequalities by fostering knowledge circulation, e.g. time and space frame of health interactions, issues of language, professional training, mediation services, managing staff diversity, written communications with the public, issues of mobility, amongst others.
Ahmed, S. (2012). On being included. Racism and diversity in institutional life. London: Duke University. Bourdieu, Pierre (1990). The Logic of Practice. Stanford: Stanford University Press. Boccagni, P., & Pollini, G. (2012). L’integrazione nello studio delle migrazioni. Teorie, indicatori, ricerche. Milano: Franco Angeli. Castiglioni, I. (2009). La differenza c’è. Gestire la diversità nell’organizzazione dei servizi. Milano: Franco Angeli. Elsen, S., Lorenz, W., & (eds.). (2014). Social Innovation, Participation and the Development of Society. Bolzano: BU. Kirby, S. L., Greaves, L., & Reid, C. (2006). Experience research and social change. Methods beyond the mainstream. Ontario: Broadview Press. Lechner, E., & Solovova, O. (2014). The migrant patient, the doctor and the (im)possibility of intercultural communication: silences, silencing and non-dialogue in an ethnographic context. Language and Intercultural Communication, 14(3), 369–384. Marmot, M. (2015). The health gap. The challenge of an unequal world. London: Bloomsbury. Meissner, F., & Vertovec, S. (2015). Comparing super-diversity. Ethnic and Racial Studies, 38 (4), 541–555. Moulaert, F., MacCallum, D., & Hillier, J. (2013). Social Innovation: intuition, precept, concept, theory and practice. In The international handbook on social innovation (pp. 13–124). Cheltenham; Northampton: Edward Edgar Publishing. Parlamento Italiano (1998) Legge 6 marzo 1998, n. 40. "Disciplina dell'immigrazione e norme sulla condizione dello straniero." Gazzetta Ufficiale n. 59 del 12 marzo 1998, SO 40. Parlamento Europeo. (2011) Riduzione delle disuguaglianze sanitarie nell'Unione Europee. Risoluzione n. 2010/2089 (INI) del 8 marzo 2011. Perna, R. (2016). Salute e migrazioni. Ricostruire il dibattito tra approcci e prospettive. Autonomie Locali e Servizi Sociali, 2 (settembre), 373–386. Phillimore, J., Klaas, F., Padilla, B., Hernández-Plaza, S., & Rodrigues, V. (2016). Adaptation of Health Services to Diversity: An overview of approaches. IRiS Working Paper Series, No. 15/2016. Schensul, J. J., & LeCompte, M. D. (2016). Ethnography in action. A mixed methods approach. London: Rowman & Littlefield. Senge, P. M. (1990). The fifth discipline: the art and practice of the learning organization. New York: Doubleday. Shim, J. K. (2010). Cultural Health Capital. Journal of Health and Social Behavior, 51 (1), 1–15. Tognetti Bordogna, M. (2012). Accesso ai servizi sanitari e costruzione della cittadinanza dei migranti. Autonomie Locali E Servizi Sociali, 1 (marzo), 111–124. Vertovec, S. (2007). Super-diversity and its implications. Ethnic and Racial Studies, 30 (6), 1024–1054. World Health Organization (2010). Health of migrants: the way forward: report of a global consultation, Madrid, Spain, 3-5 March 2010. Madrid, Spain, (March), 112.
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