Renewing the object of work as a trigger for inter-organizational learning

Marta Piria (Department of Psychology, Universita Cattolica del Sacro Cuore, Milano, Italy)
Mara Gorli (Faculty of Economics, Department of Psychology, Catholic University of Milan, Milan, Italy)
Giuseppe Scaratti (Department of Psychology, University of Bergamo, Bergamo, Italy)

Journal of Workplace Learning

ISSN: 1366-5626

Article publication date: 17 October 2022

45

Abstract

Purpose

The study refers to a health-care organization engaged in adopting “home health care” as a new object of activity. This study aims to explore how the reconfiguration of the object influences the transformative perspective, affecting not just a service but a broader approach and meaning behind patient care. It also investigates the main contradictions at play and the levers to support inter-organizational learning while facing the new challenges and change processes.

Design/methodology/approach

The work is based on a qualitative and ethnographic methodology directed to examine cultural, practical and socio-material aspects. The activity theory is assumed as a powerful approach to understand collective learning and distributed agency processes.

Findings

The renewal of the new object of work is analyzed as a trigger for shifts in representations, cultural processes and collective support implemented by the organization. Three agentic trajectories – technical, dialogical and collaborative agency – were cultivated by the management to deliver home health care through joint exercises of coordination and control, dialogical spaces and collaborative process.

Research limitations/implications

The data collection was disrupted by the pandemic. A follow-up study would be beneficial to inquire how the learning processes shifted or were influenced by the contextual changes.

Practical implications

This contribution provides a practical framework for health-care organizations aiming to navigate and explore the physiological tensions and contradictions emerging when the object of work is changed.

Originality/value

The paper develops the field of intra- and inter-organizational learning by presenting an intertwined and structural connection between these processes and the renewing of the object of work. It advises that processes of transformation must be handled with attention to the critical and collective dynamics that accompany sustainable and situated changes.

Keywords

Citation

Piria, M., Gorli, M. and Scaratti, G. (2022), "Renewing the object of work as a trigger for inter-organizational learning", Journal of Workplace Learning, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/JWL-03-2022-0034

Publisher

:

Emerald Publishing Limited

Copyright © 2022, Marta Piria, Mara Gorli and Giuseppe Scaratti

License

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode


Introduction

The solicitations for innovative organizational evolutions and connected learning are triggered by increasing and diffused changes in the work setting (Bennett and Lemoine, 2014). Dealing with quick and volatile mutations, mobilized by revolutionary processes (i.e. Fourth–Fifth Industrial Revolution) and dramatic crises (terroristic, financial, migratory, ecologic, pandemic, warlike), the organizational landscapes are facing the transformation of work lived experience and related expertise. Within this general scenario, health-care and service organizations struggle while facing an even more intense pace. Current times are witnessing the need to rethink the configuration of services, produce and engage with bold reforms and cope with consequent disruptions in experiencing work practices. On the one hand, the workplace and the organizational processes of differentiation and integration are becoming ever more fractional (Law, 2002), requiring coping with plural and often divergent perspectives, interests, power dynamics, objects and lives. On the other hand, people engaged in contemporary organizational contexts are asked to change their daily practice, seeking to address plural features, developing processes of learning from the fields and looking for new and different knowledge not yet available nor actionable (Scaratti et al., 2021; Scaratti and Ivaldi, 2021), due to the complexity and the ambiguity of the contexts. In health care, moreover, the actual organizational shapes are frequently those of pluralistic organizations, which are – according to Denis et al. (2007) – “organizational contexts characterized by three main features: multiple objectives, diffuse power and knowledge-based work processes” (pp. 179–180). Pluralistic tensions are typical in the public sector and particularly in health care, where bureaucratic cultures, practices and processes collide with specialists’ cultures, different professional families and autonomous ways of functioning, alongside administrative pressures and constant changes in the population’s needs (Cuccurullo and Lega, 2013; Denis et al., 2001). Organizations must therefore navigate different goals and interests among both internal and external groups (Jarzabkowski and Fenton, 2006) enhancing cross-boundary collaboration processes to cooperate through unfolding dynamics of organizational accomplishment.

The changing nature of work practices (Czarniawska-Joerges, 2004) refers to work fragmentation and multiple contexts to inhabit professionally, with increasing exposition to uncertain and contradictory conditions (Engeström, 2008).

In such contexts under strain, it becomes strategic to develop inter-organizational collaboration and learning – the one capable of sustaining attentive and durable transformation (Corvino et al., 2022; Beeby and Booth, 2000). Through inter-organizational learning, contexts challenge themselves to change their view and acquire more complex representations and ways to proceed and tackle the incoming issues.

There is no inter-organizational learning, though, if there is not a rethinking of the object of work, represented as something “constructed by actors as they make sense, name, stabilize, represent and enact foci for their actions and activities” (Engeström and Blackler, 2005, p. 310).

Nicolini et al. (2012) explore the role of objects, understood as “something people act toward and with” (Star, 2010, p. 603), in cross-disciplinary collaboration, adopting different theoretical lenses (boundary object, epistemic object, infrastructural object, activity object) to depict the other nature, configuration and function things play in the unfolding activities.

The reconfiguration of the work object is necessary to sustain and accompany the organizational change. However, if organizations need to consolidate the change and make it permeate work practices and cultural habits, they need to explore and interrogate the new meanings associated with object reconfiguration.

In health care, the change of the object of work is often imposed top-down by reforms or urgencies. Meaning-making activity associated with new objects is therefore crucial as a trigger to inter-organizational learning for pluralistic challenges.

The paper focuses on inter-organizational learning as strategic leverage to change. It aims to investigate how this may happen by working on the object of work at the meaning-making level.

The paper focuses on the object, assuming the activity theory (AT) as the “potentially powerful approach to the social construction of knowledge” (Engeström, 2000, a, b). By inquiring on a specific case of health and service organization with a specific pluralistic configuration, the paper analyzes how work on an object and its meaning can produce collective learning and distributed agency (Blackler and Regan, 2009), involving professionals in facing new forms and meanings of work. A case study in context (Flyvbjerg, 2001) can detect practical implications and the dynamic between structure and agency (Daniels and Edwards, 2010) that generates emergent objects of work and specific forms of practice in the fluid and unfolding intra- and inter-organizational processes. The case refers to an Italian not-for-profit health-care organization engaged in adopting home health care as a new object of its activity. Home health care becomes a way to reconfigure the work practices and a symbolic meaning for revising and transforming competencies, rethinking professional knowledge and developing sustainable trajectories of organizational renewal.

Our research explores the ways the reconfiguration of object (home health care) influences the transformative perspective affecting not just a service but a broader approach behind patient care; it also investigates the main contradictions at play when a new vision and form of the object of activity is developed, and the levers (e.g. key people, processes, resources) to support inter-organizational learning while facing the new challenges and change processes.

The paper unfolds as follows: first, we provide an essential literature overview, focusing on the description of the AT (Engeström, 1987, 2015) approach as an appropriate and suitable perspective for our research purpose and empirical analysis; then, we describe the organizational case and the methodology adopted to detect empirical knowledge related to the research questions described; after that, we present and discuss the main findings acquired; we conclude highlighting some transversal key criticalities to be managed to enhance the expansive learning process and the collective agency at stake for developing sustainable transformation inside concrete inter-organizational contexts.

The adoption of the object lens as a trigger for inter-organizational learning

The notion of object constitutes a relevant issue for organization studies, especially related to the emergent scenario of collaboration in inter-organizational fields.

Nicolini et al. (2012) underline three characteristics of objects as emergent, fragmented and constantly expanding nature: they can be instruments of translation (as per boundary objects), sources of attraction (as per epistemic objects) and triggers of contradictions and negotiation (as per activity objects). The objects are partly given and partly emergent. In the health system, different professionals have diverse and plural views about the same object, as the different interpretations of “patient” (person, client, user, etc.) and of “care” (cure, care, dedication, charge, etc.). Physicians, nurses, administrators and strategic boards will see patient care from different positions and change their investment accordingly.

The object refers to socio-material unfolding dimensions, and it is temporally shifting and heterogeneous, plural and potentially conflictual (Law, 2002).

Also, material infrastructures play a potential role as barriers to collaboration or opportunities for innovations.

Sullivan and Williams (2012) underline how objects play a crucial role in mediating the transfer of knowledge and learning across boundaries of specialized practice: objects can perform as symbols, as models and concepts, as bridging mechanisms, as the story of practice or social identity formation. Things (material/immaterial, tools, artifacts, technologies, spaces, concepts) are not meaningful per se, but they achieve their provisional meaning through a socially interactive process (Dameron et al., 2015). Objects play a relevant influence depending on their use in the functions they support (broadcasting, generation of ideas, epistemic stances, enhancing stages in the development of strategic decision-making and intra/inter-organizational collaboration). Needless to say, the achievement of a common and appropriate use of such dimensions entails both specific trajectories of learning processes and transversal conditions for their pursuit.

Daniels and Edwards (2010) point out the epistemological and methodological need to capture the generation and mobilization of knowledge related to changing practices, detecting learning processes across boundaries and agencies, arguing the perspective of a relational agency as a prerequisite of an object-oriented collaboration.

Blackler and Regan (2009) highlight the connection between the adoption of a practice lens (Schatzki, 2021) and the organization studies, specifically oriented to processes of organizational learning and transformation (Brown and Duguid, 1991; Lave and Wenger, 1991; Orr, 1996). They refer to the contribution of Knorr-Cetina (1997;2001) and Schatzki (2002;2005) as the innovative perspective through which detecting the multi-professional work dimension and the emergent phenomena of inter-collaboration and integration between agencies and services in different fields. Knorr-Cetina addresses the relational dynamic backbone of practice, related to the creative/disruptive ways in sharing and shaping collective intentionality around epistemic objects that become vitality triggers for inspirational involvement in the practice. Schatzki explores the nature of distributed agency, suggesting that social practices, as informed by meanings, convey a common understanding of how to do things, the rules that guide what we have to do and the objectives to be pursued. Summing up, “Knorr-Cetina provides a practice account of intentionality; Schatzki theorizes agency as a networked process” (Blackler and Regan, 2009, p. 163), looking toward practical implications both for practitioners and researchers. Blackler and Regan (2009) point out an interesting connection between the above contributions and the AT framework (Engeström, 1987, 2015) as the “Activity Theory conceptualizes collective intent and distributed agency through the terms ‘activity system’ and ‘object of activity.’ It follows a dialectical approach to conceptualizing practice, which suggests an approach to intervention” (Blackler and Regan, 2009, p. 164). It is underlined the interventionist and transformative stance that characterizes the AT approach, which entails the acknowledgment of criticalities and tension, reflecting on their historical manifestations and evolution, the challenge of seeking alternatives and the collectively reshape of an activity.

In this perspective, the inter-organizational processes, triggered by the multi-professional, pluralistic and fragmented work contexts, have the potential to enhance the emergence of new objects of activity, to be acknowledged and negotiated (as the different professional and cultural views are at stake) to achieve a convergent and good enough commonality as collective intentionality. Similarly, the inter-organizational dimensions challenge the intra-organizational field to improve and develop a distributed agency by valorizing roles, functions and competencies in a more integrated and tuned way (Scaratti et al., 2021).

Following Blackler and Regan’s suggestions, we assume the cultural-historical AT (CHAT), also known as the AT (Engeström, 1987, 2015), as a carrier of developmental, collective and multivoiced perspective. Engeström (1987) describes the CHAT as rooted in a robust historical background, from Spinoza to Hegel, Marx, Vygotsky, Leont’ev, Luria, Davidov and others. We can identify four generations of activity-theoretical studies (Engeström and Sannino, 2021). Each of them underlines some key pillars of the CHAT, which conceives and studies the activity system as collective, object-oriented and mediated by culture and artifacts.

The first generation refers to the Vygotskyan concept of cultural mediated action, highlighting how the relation between the subject and the world depends on the symbolic and cultural system available. The temporal and historical evolution through which such a relation is shaped and transformed is, thus, attentively addressed.

The second generation depicts the concept of activity as object-oriented and contradiction-driven: on the one hand, the object of a system of activity can be seen as the glue that connects different dimensions inter-related: subjects working within a community, coping with tools, roles, rules and a division of labor that, together, form an essential unit of analysis, allowing us to understand better the dynamics among these elements and the ongoing development of the activity system; on the other hand, historically accumulated tensions characterize the single elements of the activity as well as the relations within and between the activity systems.

The third generation points out the interconnection and interdependency among plural activity systems, involved in seeking to achieve possible partnership, alliance and plural possible ways of collaboration, never taken for granted.

The fourth generation focuses on creating heterogeneous coalitions, tackling societal problems and seeking to create a sustainable alternative to some in-use capitalistic mainstream carriers of social injustice, inequality and socio-economic failures.

The four generations share three basic transversal assumptions:

  1. The runaway object. The concept of a runaway object refers to the continuous achievement of a not-taken-for-granted balance between evolution and conservation as the motive of activity both influences and is shaped by the intertwined personal, social, situational, historical, material and immaterial dynamics. These elements are connected to the plural components of the system of activity itself in relation to other multiple systems. This process happens in every activity in which rules, roles, division of labor tools, subjects, languages are dynamically intertwined and developing. The object is cyclically transformed: it can be seen as an enacted achievement rather than something that is pre-given as a fixed dimension. The concept of a runaway object upsets the idea of the object as something stable, defined and given as a common object can be conceived quite differently by different collaborators. It could be said that in the AT approach, whatever the evolutive model, the object is an emergent issue related to processes of accomplishment, taking together material and immaterial components. The object has to be coherent enough to allow collaborative contingent activities; otherwise, it becomes incredibly difficult to work together valorizing the contribution of the existing differences. The relative coherence and stability of the joint effort support the commonality to be achieved as a result that is not a given, starting from the differences at stake.

  2. The multivoicedness. Due to the existing differences (regarding levels of commitment, sharing, activating, engaging), the specialists, particularly the health organizations, have to negotiate an agreement (Mol, 2002), seek an emergent configuration of work and deal with the multiple and unfolding development at stake. The expected integration depends on social, dialogical and practical competencies and the positive matching between subjects involved and the organizational context at stake. This entails acknowledging multiple participants who carry their histories and interpretations, and the activity system itself reflects different layers of history in its artifacts, rules and conventions. The plurality and multivocality are multiplied inside networks of activity systems and can represent a source of trouble, innovation and change.

  3. The transformative nature of activity systems. Stemming from some key learning concepts, like the zone of proximal development or the waiting experiment by Vygotsky, the idea of expansive learning promoted by CHAT provides, through the method of change laboratory (Engeström, 2015), concrete approaches for enhancing sustainable transformations in organizational contexts, developing patterns of the transformative agency. The reflexive analysis of criticalities and contradictions becomes the principal source of change and innovation, prompting critical encounters in which participants share a common experience to think differently, influencing the activity system. Enabling new paths of learning and collective agency may generate innovative and emancipatory forms of organizational activity.

The above considerations motivate the choice of CHAT as the theoretical model for exploring and analyzing an organizational case where the efforts were put into the reshaping of the object within the activity: CHAT allows a dynamic reading of the experience under study, with the opportunity to achieve a critical framing about its proximal development and evolution through changes, triggered criticalities and learning paths.

The case and the research context

This work was conducted in a not-for-profit health-care organization with over 20 branches and over 2,000 accredited places in northern Italy. The institute has a long history of supplying social and health support to people with disabilities, people with behavioral disorders and the elderly. In recent years, the shift in the demand for care has impacted the organization in many ways. The vastity of services, facilities and people involved as working personnel has met increasing demands from the outside world. The development of home health care has become not only an organizational service unit but a challenging metaphor for looking differently at the whole activity system while taking an innovative stance.

The institute, grown and consolidated throughout history as one key player in the assistance services area, was facing the presence of many players on the territory offering care and support. Two different management teams, the social management and the health management, had to answer to the mandate stated in the strategic plan of the organization and supported by recent laws and regulations on territorial care. The health management and social management had been located in the institute headquarter but separated in different parts of the building and in terms of services, with the health management focused on providing care to outside patients and the social management focused on patients hosted inside the institute’s facilities (residency or daycare). The regional decrees from 2015 pushed the institute, along with many health and social-health organizations, to revise their offer and implement at-home paths of care for patients who could not move from home or would have benefitted from staying at their homes during the caring period. Proposals and services were to be appointed or modified to deliver care at the home of the patient as a fundamental part of the organization’s offer to the territory rather than a facultative option left to other competitors. The social management, in particular, was at the center of a substantial reconfiguration to manage the delivery and continuity of care and the access and guidance for the patients and/or their caregivers. Such vision required shifts and adaptations to move from a perspective of dispatching health-care outputs to a focus on multi-perspective listening and analysis of the caregivers’ and patients’ needs and requests. The social management formed a stable group of staff – the social director, a support figure in charge of the relations with the public and accreditation processes (we will call this person “Social Management Support”), the home health services coordinator and the head of quality – dedicated to coordinating and providing these services. The director also created one integrated “Home Health Care Team”: professionals in charge of delivering at-home care in all the different facilities accredited by the institute in Lombardy were from that moment having regular meetings and an appointed coordinator working closely with the main staff composing the social management. The appointed coordinator, once responsible only for integrated care at-home assistance, had been moved to lead all the projects related to at-home assistance. The home health-care services had been implemented in the past couple of years to bring physical care to the home of the patient, with nurses being organized on turns and equipped with a “travel backpack” featuring the technical supplies needed and administrative staff and social workers being highly involved in the communication and orientation of patients and caregivers toward the resources available to them. Whereas before the administrative staff dealt only with documentation and the bureaucratic aspects of the access to services, it was now required to offer directions and information to users at their first arrival in the institute, a function they had never covered before. Another specific project was dedicated to providing a phone number managed by social workers who listened to the requests and activated the network of contacts, facilities and services needed. A second experimental version of the project involved a year of at-home visits by health-care professionals, along with the organization’s services of integrated care at-home and open residential care home (allowing patients to access facilities during parts of the day without a full hospitalization). The reconfiguration also meant figuring out adjustments and connections with the health management, in charge of aspects of the health facilities and services at the institute and with external realities such as hospitals, general practitioners, social and health services, residential care facilities, local and regional administration. In recent years, a nurse working in the social-care part of the institute was appointed as a support for the health management (we will call this person “Health Management Support”) and started to work closely with the social management support on supervising the nursing services and accreditation processes.

The plural reception and conveyance of home care generated a need to create better and clearer relations both at an intra-organizational level (inside the main facility) and at an inter-organizational level (between the many branches and the external organizations in the territory) and to sustain learning activities that could connect three different teams composed by various professional groups: the health-care staff, the administrative staff and the social staff involved in the home health-care delivery.

To study the effects of the home care lens as a transformative perspective and organizational reconfiguration affecting not just a service but the broader approach behind patient care, our research also pointed at exploring what happens when a new vision and form of the object of activity is developed, resulting on contradictions to cross and on some key levers to use (e.g. key people, processes, resources).

Methodology

Our methodology was based on an in-depth exploration of the processes activated by the key people chosen by the organization to support transformations and integrations among different organizational services, activities and projects.

We entered the field through an ethnographic method (Czarniawska-Joerges, 2007; Van Maanen, 2011; Watson, 2011) agreed with the organization. After initial meetings with the general director and the social director of the institute, we accessed the field in three main phases: observation of the organizational spaces and activities, during which we were either accompanied by key members of the staff (mainly social and health management support persons) or allowed to station in the main areas of the building where the at-home services were coordinated and delivered. Specifically, we concentrated our ethnographical observation on the home health-care team’s offices and administrative desks, and on some tours of the more historically consolidated services (facilities for residential care for the elderly, and daytime care).

While spaces and daily practices were observed in situ, the research team negotiated with the social management moments of observation of routine meetings related to the at-home services reconfiguration and support. We had access to meetings with the administrative staff and the social workers involved in structuring a more integrated initial access and orientation of patients and caregivers; we also attended meetings within the social management team.

The health director was also contacted in the early stages of the work, and we were put in touch with the health management support person. She was collaborating with the social management on evaluation and accreditation processes; we could also access meetings held with health personnel around internal practice revisions. The health management too was reconfiguring better integration with the social management, although such process was yet at an early stage.

Observations and meetings allowed the research team to identify members of the different professional groups mainly involved in the reconfiguration of the service. We then focused on these people who accepted a various range of research tools that we conducted along one-year exploration on the field: semi-structured interviews; the shadowing of specific activities; observations of meeting and discussion tables on specific artifacts; self-produced video diaries. We involved the social management core staff, the social workers, the administrative staff and also the health management support person who worked as a connector between the social management team and the health one.

By exploring and observing the reconfiguration of the organizational processes while it was happening, we aimed to understand the learning processes, resources and limitations at play, the movements and approaches, the tools and practical strategies used to bring about change around home health care. We also fostered moments to collectively build understanding and questioning upon the issues emerging from the field, to share critical elements and to bring them to new levels of reflection. The work brought up reflexive stances upon work practices, roles and perspectives that generated awareness of pressing needs and contradictions active in the social and health management teams. The collected materials were organized, analyzed and then reported back to the teams involved.

Table 1 below summarizes the tools and participants involved between January and October 2019.

Findings

The research uncovered two main phenomena: the renewal of home health care as a work object and different processes at play in developing a distributed agency. In the following paragraphs, we will draw from data excerpts to highlight examples and situations in which intra- and inter-organizational dynamics interweave to open new interpretations and orientations linked to the reconfiguration of the work object. We will also point to tensions and contradictions from the field that provided additional elements to consider while working on the renewal of the work object and the implementation of practices that support intra- and inter-organizational learning.

Home health care as a new work object to renew

The shifts and changes pushed by the territorial and institutional context impacted on how home health care was discussed and oriented in the institute. The emerging interpretations among the groups and workers show how the new concept of home health care was initially highly challenging to the organization, requiring an important shift from “caring ‘like at home’ inside the facilities” to delivering care in different spaces – including at the patient’s home. These challenges are not resolved yet: home health care represents both a service and an approach to patient care:

We are working on an integrated view on home health care, to catch and answer needs even when they are not strictly our responsibility. It is stated in the Strategic Plan, but it’s a change we still have to practically implement. It is a change of mindset. For example, “home health care” means that we need to find a way to welcome the patient that goes beyond informative needs. Even if your waiting lists are full, we need to find a way to make the patient feel welcomed (interview with the social director).

One significant challenge was the integration between historical and cultural trademarks and new ways to conceive and revise service practices with the aim to answer current needs:

[The organisation] has always dealt with fragility, but it was in terms of chronic fragilities […]. We now have to change approach to care for the acquired disabilities because people with acquired disabilities need an answer in 24 hours (interview with a social management support person).

As a [unit] coordinator, I perceive the struggle of my staff, especially the “historical” members of the personnel, and that’s because of the cultural change that is asked: caring about the patient’s interests and desires, not just their physical needs – (field notes, tour of the foundation, exchange with disability unit coordinator).

Such declaration and circulation of a renewed perspective of what home health care entails, influenced the concrete ways in which the social management, in collaboration with the health management on specific issues, developed processes and trajectories to mobilize resources and learning spaces around a new configuration of the home health care focal topic.

The agentic trajectories: concrete processes supporting the home health-care renewal

The institute was actively attempting to integrate mandatory reporting and accreditation activities with a collective construction of learning in the form of sharing the roles, responsibilities and practices among the staff and the meanings that connected them with the newly proposed home health-care perspective. We identified three main ways in which a collective agency around the new approach to home health care was cultivated by the social management. These agentic trajectories supported learning inside the institute as a whole organization, but also among sides of the organization that were initially separated in their function and daily activities, the social management and the health management; another level of learning and change supported is the level between the organization and local authorities, institutions and other services.

Technical agency: it is the joint exercise of coordination and control through practical work activities among different professionals and professional groups.

Regular meetings were held and supervised by the social management with the administrative staff and the social workers to make them familiarize with a renewed home health-care concept and approach. These meetings were opportunities to discuss and share how to practically manage and deliver services according to the new vision.

[the video shows the Social Management Support person and the head of Quality sitting together at a desk full of paperwork, with tired expressions on their faces] “Today, we are at the Quality office, preparing for the next staff meeting. We are discussing the crucial aspects we need to elaborate on with the administrative staff: how to present the new concepts, how to make them feel competent, how to remove resistances and engage them adequately” (video diary, social management support person).

Different tools were used to discuss home health care from different angles a the new orientation required a new administrative approach as well as new health- and social-care approaches. In meetings, presentations and hand-written posters were used to highlight keywords, definitions, connections between them and joint reflections. Documentations and checklists were created to map and analyze how home health care and support services were communicated, delivered and verified in their quality and effectiveness.

[The Health Management Support is sitting alone in her office, looking pensive]. “We are preparing some forms for the educators who accompany patients so that critical issues can emerge, and the Health Management can take them into account if they require access to our health facilities [[…]] [shows quickly a pile of printed paper] I also proposed to W. [head nurse] that we think of a way to gather more detailed information when we accept new guests in our units[…] it’s a work in progress» (video diary, health management support person).

The working spaces also required changes and revisions to negotiate, implement and inhabit in collaboration between services and different professional groups: the administrative offices, while waiting for a more drastic reconfiguration, were relocated at the entrance of the social management space. New signs and indications to guide patients and caregivers appeared to orient them to the first contact. The social care offices started closing their doors to facilitate the patients’ and families’ directions and paths. A notice board filled with services pamphlets was appointed close to the entrance.

Dialogical agency: it is the cooperation supported by listening and sharing through dedicated spaces that integrate a collective construction of meanings with the mandates and organizational requests.

Along with the many practical activities implemented, the social management continuously elaborated ways to address changes and made efforts to translate mandates for different professional groups into meaningful proposals and directions.

Reiterating and discussing the goals and aims of each meeting and activity was often used to address arguments around the meaning of changing the “way we have always done things around here” (field notes, administrative staff member during a staff meeting), as reported by many members of the staff.

Ah, the reception[…] we now have to do it differently. Before, when somebody came, we (the secretariat) were the ones giving information[…] now we found ourselves answering more broadly, we have to welcome people[…] and we are meeting a lot to try and understand how we should move now, although it’s difficult to change (interview with Administrative B).

A:« Some data are collected to show how many requests and applications we deal with, it shows to the General Management that you all have done an enormous job[…] »

B:«The other day, I reported some data about our activity during a meeting and everyone's jaw dropped! It is essential to present what we do to the outside world.» [quoting conversations during staff meeting between the social director (A) and the social management support person (B) – field notes].

The social director regularly met with the home health-care manager, head of quality and social management support person, who oversaw intra- and inter-organizational processes in collaboration with the health management support person. These staff meetings were dedicated to preparing group learning and supervision and sharing technical information and news about regional and local mandates.

We want to take stock of the situation and check how we are going on compared with the mandates we gave ourselves[…] it is hard, you can see it written on my face, probably, but it’s also stimulating our thoughts and reflections on directions, ways to proceed and contents that are needed[…] (video diary, social management support person).

Collaborative agency: it is the communication, reflexivity and negotiation processes that happen within the planning, organizing and translating of the practical delivery of home health care.

Two prominent levers used to foster collaborative connections and reflexivity across groups were the two social management support and health management support persons, who were put in charge of integrative processes among the health-care facilities of the institute, both inside the main building and across the territory of northern Italy. Their different perspectives and educational background in education and nursing were used to see the organizational challenges and needs from different perspectives and through the eyes of the diverse professional families and approaches to care and home health care. These two persons supervised and monitored the group activities. Quality assessment and checklist controls allowed a closer support during the reporting activities for the regional administration.

Today we [together with the Social Management Support person] are together for supervising professionals in inquiring about the appropriateness of the checklists they use. We will facilitate the discussion among the group and help them consider possible integrations or changes in line with the regulations and their daily activities and needs (Video diary 1, health management support person).

How can we make visible the value produced by the Social Management? The challenge is visibility both in the inside and outside the organisation (staff meeting, social director).

The integration of information coming from this group during meetings with administrative and social workers was used by the social management to promote mutual knowledge between the health and social teams at work.

We work to understand which procedures are correct - in terms of regulations and norms – and sensible – with respect to the way we work (social management support person, referring to a checklist meeting).

Connecting renewal of the object and agentic trajectories: the example of the “bedsheet”

From the researcher’s perspective, observing how the institution approached the new home health-care vision and delivery through the activation and support of learning processes was very interesting. We would like to bring one example of particular artifacts that show the tight knot between agentic trajectories and the renewal of the work object.

During an observation of the administrative office and the home health-care team office, one of the researchers noted:

The administrative A. seems very proud to show me an extensive printed copy of an Excel sheet, that she keeps on her desk. She says: ‘We never used to have a clear division of work. Now we have reviewed our workloads, writing down roles, functions, activities that we carry out. We now share what we do, each of us! We have created this document, we call it “the bedsheet”, as it is wide! I can tell the bedsheet is a way to understand what goes on inside the office […] (field notes, observation of the administrative office).

The first thing I noticed while entering the home health care office is a wide paper glued on the wall […] they say it is a way to remember objectives, deadlines and important things to do. The office is a flurry of professionals coming in and out, rarely sitting down for more than a couple of minutes. This one has a similar function to the “bedsheet” in the administration. These tools make transparent a system of the many activities and practices at play. They serve to support a more involved, cooperative action between the professional groups involved (field notes, observation of the home health-care team office).

Such “bedsheets” were located in crucial spaces of the activity to support the new home health-care approach. They were tools crafted by professionals to support daily processes and collective sharing of objectives and activities. They represented a joint effort (technical agency) to build meanings around aspects of work, and served to put on paper some agreements after having discussed them together (dialogical agency). Such agreements made work visible, talkable and monitorable (collaborative agency).

Challenges and contradictions emerging from intra- and inter-organizational learning process

The social management conducted many learning initiatives, while it also kept reconfiguring processes and resources to deliver home health care. This led to some confusion and frustration inside and across groups, particularly among the administrative staff who were asked to “drastically change the way they worked” (interview with social director). The staff expressed some uncertainty in dedicating “so much time for a checklist,” as there was not complete understanding of the processes in place. The challenge was to not only create and preserve time for the learning spaces but also to recall and reopen meanings and interpretations around home health care. The progress made and the results obtained were also reported to be “rarely acknowledged” by the broader organization.

Why are we always the children of a minor god? We have complexities to manage, but we are lacking phones, updated numbers, computers […] Other offices have more resources than ours! (social management meeting, secretary).

The giant contradiction here is the fact that we produce accounts, hours of investments, transparent pathways and documents to communicate our idea of home health care, although we are not receiving much recognition from the organization (social director).

The effort to combine representations and enrich interpretations on home health care required continuous tuning, discussion and reflections inside the social management and health management teams. Although this put particular strain and pressure on people in roles of coordination, they did not always find the necessary support from the organization. The many meetings, groups and connections produced an amount of information and data that were often difficult to circulate; knowledge systematization was often scarce due to ongoing changes affecting languages and representation. The complexity of processes somehow overwhelmed the capacity of organization to follow the change.

Discussion

The study illustrates the ways the reconfiguration of the work object (home health care) influences the transformative perspective affecting not just a service but a broader approach behind patient care. The achievement of collective intentionality and distributed agency, as related to the object of activity and the plural dimensions of the activity system, is not taken for granted. The inter-organizational perspective requires a learning process to explore the plural and often contradictory systems of meaning at play and to provide suitable and appropriate answers to complex problems. The collaboration among multiple affordances related to different professional practices entails a relational agency (Daniels and Edwards, 2010) capable of dealing with the contradictions that are at play when a new vision and form of the object of activity are developed.

The findings highlight transversal dynamics (Ivaldi and Scaratti, 2020) within and between the two management teams and the levers (e.g. key people, processes, resources) to support inter-organizational learning while facing new challenges and change processes.

We here highlight some key points emerging from the case we explored:

  • there is an intertwined and structural connection between the renewing of the object of work and the organizational learning at stake: both inter- and intra-organizational processes challenge and trigger the enhancement of new roles and rules, division of labor, organizational paths and professional practices, seeking to develop a more integrated work among internal and external organizational boundaries, in a constant attempt to pursue progressive and convergent shared commonalities;

  • the reshaping of the object is an unfolding and not-taken-for-granted process of accomplishment, which entails the impossibility of separating the renewal of the object from the concrete learning and transformative processes that translate it into practice; otherwise, we risk falling into an abstract reduction. While we agree with the Lewinian statement that there is no better practice than a good theory, we claim the need to get close to the ways practitioners transfer into practice their theories, as well as the awareness of their assumptions; and

  • as a methodological implication, such a position requires the adoption of a research approach suitable to detect practical experiences and the dynamic between structure and agency lived in specific contexts.

This perspective entails the improvement of a hybrid professionality culture and adhocratic models of organizing (Mintzberg, 2009, 2012; Scaratti et al., 2021; Ivaldi and Scaratti, 2019), developed as knotworking activity (Scaratti et al., 2017) in which organizational processes (made by rules, subjects, division of labor, internal and external dynamics) unfold without a stable center, but through an extension of differentiated and sustainable contributions. At stake is the possibility of enhancing “mycorrhizae activities” (Engeström, 2006), spreading their potential to create e wildfire expansion effect (Engeström, 2008) by promoting pilot experiences supported by institutional mandate and suitable investment. Such positive contamination allows for expansion and generates further possibilities for organizational learning as a cultural and meaning-making process that challenges or sometimes reinforces possible organizational and inter-organizational paths, mediated by key people involved in different teams (Hawkins and Rezazade, 2012; Williams, 2013). These levels of learning can be developed in relation to the reconfiguration of the object as a trigger for new representations and work processes, as well as temporary organizations formed to deal with pressures and issues caused by managing change.

Seeking a collective development and endeavor requires to cross complex dynamics related to the acknowledgment of tensions and contradictions (Galuppo et al., 2019): it also implies the possibility to reflect on them, discuss sustainable alternatives, reconceive the object and reshape systems of activity. Such a transformative stance conveys the assumption of a relational lens, capable of combining and connecting individuals, groups, formal organizational processes and artifacts (Blackler and Regan, 2009).

As conclusive remarks, we get back to our initial research exploration related to the ways the reconfiguration of the object (home health care) influences the transformative perspective.

By reconfiguring their system of activity around the complex, runaway object of home health care, social and health professionals were called to reflect upon challenges and changes through multivoiced, plural settings and perspectives, at times conflicting and facing resistances and contradictory situations. Home health care becomes an emerging and progressively unfolding shared object that embodies and deals with organizational challenges and practices related to the enhancement of knowledge circulation, the experimentations of pivotal pilot practices, the spreading use of existing common artifacts and devices, the diffuse acknowledgement of the complexity of the patient in charge.

In such a progressive unfolding, the object makes emerge different representations and interpretations of common procedures that have to be adopted, different uses of tools and artifacts created for collaborative possibilities, and contradictions that raise the need for new meanings negotiation among the people involved. At stake are, e.g. the lived contradictions between the charge of administrative procedures (sometimes perceived as excessive) and the meaning attributed to one’s professional work.

As for the levers to sustain inter-organizational learning, the findings provide empirical support to three agentic trajectories as learning supports to instate a home health-care vision and delivery:

  • Technical agency: the joint exercise of coordination and control through practical work activities among different professionals and professional groups.

  • Dialogical agency: the cooperation supported by listening and sharing through dedicated spaces that integrate a collective construction of meanings with the mandates and organizational requests.

  • Collaborative agency: communication, reflexivity and negotiation processes that happen within the planning, organizing and translating the practical delivery of home health care.

In crossing spaces and boundaries between groups, but also offices, facilities and organizations, the three trajectories were alternated and integrated at times, favoring organizational learning in situations where the risk was to lose the staff among resistances and perceived “injustice” or hardship brought by change.

Conclusion

The paper’s contribution goes in the direction to enrich, through an in-depth exploration of a concrete case study, the phenomenology of intra- and inter-organizational learning as a lever for sustainable change and the opportunity of a practical and reflexive set of resources for the organizations and the professional groups involved. Moving inside collaboration and inter-organizational fields means facing physiological resistances and conflicts that need to be crossed: it means using resources and opening questions; it means challenging roles and perimeters of action, languages, cultures and practices in the effort to redesign them in a relevant, contextually sensible way.

The limitations of the paper refer to the interruption, due to the pandemic lockdown, of the field observations connected to the process outcomes of renewing the object: we could not elaborate on the achievement of more articulated empirical data resulting from the unfolding learning processes, as the organization had to move to other emergencies. Future studies would benefit by promoting evaluative studies to follow up the change processes activated and the reflection connected to durable effects of the inter-organizational learning.

Nevertheless, the paper highlights how promoting learning across boundaries and agencies, and adopting an object-oriented lens, requires a commitment to an innovative concept of research capable to blur the boundaries between the generation of knowledge and to welcome the uncertain interrogations that characterize the actual organizations.

Tools and participants involved in the research

Tool used Participants involved
Semi-structured interview of key people of the organization Social management director
Health management director
General director
Social management support person
Health management support person
Head of the home health-care team
2 members of the administrative staff
2 members of the social worker group
(Total: 10)
Participant observation of coordination meetings 4 staff meetings of the social and health managements
3 coordination meetings between administrative staff and social worker group
1 home health-care team meeting
2 Health equip meetings
(Total: 10)
Participant observation of organizational spaces 2 residential care facilities for the elderly
1 disability daycare facility
Main office of the health management facility
Main office of the health management facility
Home health care team office
(Total: 6)
Self-recorded video diaries on daily activities 3 video diaries from the social management support
3 video diaries from the health management support
(Total: 6)

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Further reading

Cuccurullo, C. and Lega, F. (2011), “Effective strategizing practices in pluralistic settings: the case of academic medical centers”, Journal of Management & Governance, Vol. 17 No. 3, pp. 609-629.

Schatzki, T., Knorr-Cetina, K. and von Savigny, E. (2001), The Practice Turn in Contemporary Theory, Routledge, London.

Acknowledgements

The authors warmly thank the CERISMAS (Center for Research and Studies in Healthcare Management, in Milan) for the financial support provided for the research and publication path.

The authors also express our gratitude to the organizational board and to the members of the organization who collaborated in the research, allowing data collection and accepting to be involved in the discussion of meaning and interpretation of data. At all levels, we found a solid and enduring collaboration to build partnership between the academic and the health-care organization competences, aimed at creating new and practically anchored knowledge.

Corresponding author

Mara Gorli can be contacted at: mara.gorli@unicatt.it

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