From boundary object to boundary subject; the role of the patient in coordination across complex systems of care during hospital discharge

From boundary object to boundary subject; the role of 1 the patient in coordination across complex systems of 2 care during hospital discharge 3 4 Abstract 5 Advocates for patient involvement argue that seeking the active contribution of 6 patients and families in the coordination of care can help mitigate system 7 complexity, and lead to improvements in quality. However, sociological and 8 organisational research has identified barriers to involving patients in care 9 planning, not least the power of, and boundaries between, multiple professional 10 groups. This study draws on literature from Science and Technology Studies (STS) 11 to explore the patients' role in coordinating care across professional-practice 12 boundaries in complex care systems. Findings are drawn from a two-year 13 ethnographic study (including 69 qualitative interviews) of hospital discharge 14 following hip-fracture care, and describe the changing role of the patient as they 15 move out of hospital into community settings. Findings describe how 'the patient' 16 plays a relatively passive role as boundary object while recovering from surgery 17 within hospital, where inter-professional coordination was prescribed by 18 evidence-based guidelines, leaving little space for patient voice. As discharge 19 planning begins, patient involvement is both encouraged and contested by 20 different professional groups, with varying commitment to include patient 21 subjectivities in care. As patients move into home and community settings, they, 2