Designing a better place for patients: professional struggles surrounding satellite and mobile...

This article was published in an Elsevier journal. The attached copyis furnished to the author for non-commercial research and

education use, including for instruction at the author’s institution,sharing with colleagues and providing to institution administration.

Other uses, including reproduction and distribution, or selling orlicensing copies, or posting to personal, institutional or third party

websites are prohibited.

In most cases authors are permitted to post their version of thearticle (e.g. in Word or Tex form) to their personal website orinstitutional repository. Authors requiring further information

regarding Elsevier’s archiving and manuscript policies areencouraged to visit:

http://www.elsevier.com/copyright

http://www.elsevier.com/copyright

Author's personal copy

Social Science & Medicine 65 (2007) 1536–1548

Designing a better place for patients: Professional strugglessurrounding satellite and mobile dialysis units

Pascale Lehouxa,b,�, Genevieve Daudelina,b, Blake Polandc, Gavin J. Andrewsd,Dave Holmese

aGRIS Montreal, Que., CanadabUniversity of Montreal, Montreal, Que., CanadacUniversity of Toronto, Toronto, Ont., CanadadMcMaster University, Hamilton, Ont., CanadaeUniversity of Ottawa, Ottawa, Ont., Canada

Available online 27 June 2007

Abstract

The professional claims and struggles involved in the design of non-traditional health care places are rarely

problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This

paper offers insights into such professional tensions and their impact on health care delivery by examining the design of

two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed

by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by

experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects,

nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews

with managers (mostly nurses) and physicians (n ¼ 18), and from on-site observations. Nephrologists, medical internists,

and managers all supported the goal of providing ‘‘closer-to-patient’’ services. However, they held varying opinions on

how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore

the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms.

Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and

beyond professional groups, who sought to measure up to ‘‘ideal standards’’ while acknowledging the contingencies of

health care places.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Design; Professionalization; Place; Health technology; Dialysis; Closer-to-patient services; Normativity; Canada

In Canada, as in many industrialized countries,the prevalence of terminal renal failure is steadilyincreasing. Hospital-based dialysis treatments re-

move toxins from the patient’s blood. Each treat-ment takes 3–4 h and must be performed 3 times aweek for life. Although dialysis is considered anestablished, effective treatment that prolongs life, itis costly (about $CDN 80,000 per patient, per year),and nephrologists are in short supply and oftenconcentrated in urban centres. This is pushinghospital managers and clinicians to find new waysof delivering dialysis services. One recurrent concern

ARTICLE IN PRESS

www.elsevier.com/locate/socscimed

0277-9536/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.

doi:10.1016/j.socscimed.2007.05.029

�Corresponding author. Tel.: +1 514 343 7978.

E-mail addresses: [email protected] (P. Lehoux),

[email protected] (G. Daudelin),

[email protected] (B. Poland), [email protected]

(G.J. Andrews), [email protected] (D. Holmes).


in the Canadian context is the distance somepatients have to travel in order to receive theirtreatments (up to 125 km).

In this paper, we examine how two independentteams of medical specialists, nurses and managersdesigned new dialysis service delivery models aimedat reducing the distance between patients anddialysis units. They created non-traditional healthcare places—settings that are similar to, but distinctfrom, established hospital-based ambulatory clinics.We argue that the design of these ‘‘closer-to-patient’’ units opened up space for a re-negotiationof clinical tasks and responsibilities, and renderedmore explicit both the norms to which dialysisservices should ‘‘ideally’’ conform and the normsthat constitute ‘‘reality’’. This normative duality islinked to two aspects that underlie health carespatial transformations and are generally less wellunderstood: the role professional groups play in thedesign of non-traditional health care settings, andthe way clinical norms and patients’ expectationsare defined (and selectively addressed) through thatprocess. As our study illustrates, innovative provi-ders are struggling between the pursuit of profes-sional ideals and interests and the contingencies ofhealth care places.

Perhaps because the professional struggles in-volved in the design of non-traditional health careplaces tend to fade away over time, researchers havenot paid much attention to the implications of thesetensions on the organization of health care. Ouranalyses are thus geared to making more explicit thenormative assumptions and spatial implications ofrival professional claims. Throughout such strug-gles, patients’ expectations tend to be ignored orsimply assumed. This paper thus seeks to contributeto the literature by (1) clarifying the professionaltensions that underpin the reconfiguration ofdialysis services, and (2) reflecting on the ways inwhich the design of non-traditional health caresettings structures, and is structured by, profes-sional hierarchical and normative assumptions.

Professional dynamics that shape the design of non-

traditional health care places

The design of health care places encompassesnormative considerations that reveal, materializeand extend significant aspects of professionalcultures and dynamics. These places rely on aparticular health care delivery model that organizesthe work of social agents and the use of various

technologies. In such a situation, design goes farbeyond simply deciding about the arrangement ofphysical entities such as walls, machines andelectrical components—it involves envisioning andmaterializing socio-technical practices. Hence, whenprofessionals are the designers, the resultingmaterial and spatial arrangements can be seen asan extension of their ethos, which may seek toimpose upon others particular ways of workingand interacting (Hinchliffe, 1996; Kenny & Duckett,2004). Before examining more closely how norma-tive assumptions are built into design processes, wewill first explain our conception of place.

According to Kearns and Moon (2002), therehave been significant developments in human andhealth geography in the past few decades. Movingbeyond the mapping of the distributive features ofhealth services and their consequences (e.g., access,use, practice variations), qualitative critical geogra-phers have shown the extent to which the experienceof health and health care is deeply structured byspatial dimensions (Andrews, 2002; Kearns, 1993).Place is now ‘‘seen as an operational ‘living’construct which ‘matters’ as opposed to being apassive ‘container’ in which things are simplyrecorded’’ (Kearns & Moon, 2002, p. 609). Studiesinspired by this conceptual line of enquiry, oftendrawing on cultural theory, have provided in-depthanalyses of how place is socially and spatiallyembedded (Hess, 2004) in the everyday activitiesof health professionals and lay individuals (Cartier,2003; Popay et al., 2003). Smyth (2005) also suggeststhat the appeal for a ‘‘reformed medical geography’’has generated new insights into the relationshipsbetween place and different therapeutic processes.Work on therapeutic places such as clinics orhospitals has shown that ‘‘the specific geographicallocation is often of less significance in its therapeuticrole than the physical, social and symbolic organi-zation of the space itself’’ (2005, p. 488). Forinstance, Gesler and colleagues (2004) observed theway health care places result from the intertwinedinfluences of a spectrum of professionals andexperts:

Many hospital designs in the UK have beenbased mainly on expert discourses that emphasizeefficiency in terms of costs and clinical function-ality. These values reflect the priorities ofkey participants in the design process andtheir assumptions about the relationship be-tween healing and environment. Professional

ARTICLE IN PRESSP. Lehoux et al. / Social Science & Medicine 65 (2007) 1536–1548 1537


knowledges associated with Western medicalscience, environmental psychology, landscape anddesign aesthetics have been powerful contributingdisciplines. (Gesler, Bell, Curtis, Hubbard, &Francis, p. 118)

While Edginton (1997) explored the relationshipbetween morality and the design of place, andKearns and Barnett (2000) questioned the consu-merist ideology that can drive modern hospitaldesign, health geographers have somehow neg-lected professional dynamics and design processes1

(Michael, Green, & Farquhar, forthcoming). Im-portant issues have not been studied: How dovarious groups of providers participate in thecreation of new health care places? Over what issuesdo they struggle for dominance and control? Whatare the implications for clinical care and patients?These questions point to the need to exploreprofessional dynamics and their impact on designprocesses.

According to Moran and Alexander (1997), theprofessionalization of medicine is the result of thesuccessful mobilization of new expertise developedthrough clinical research and the various technolo-gical opportunities offered by industry:

The making and implementation of health carepolicy are deeply influenced by occupations thathave succeeded in using the occupational strategyof professionalism for the defense of collectiveinterests. Doctors have been the most importantof these professions. They owe much of thatimportance to an alliance forged early in thepresent century with an emergent research elite inuniversities and with business interests. (Moran& Alexander, 1997, p. 578)

In fact, when professionals help design clinicaltools such as medical imaging devices (Blume,1992), they tend to favour innovations that areclosely aligned with their quest for autonomy,control over their expertise and tasks, and marketclosure (Abbott, 1988). However, such self-inter-ested goals cannot be explicitly pursued andarticulated in a design project without a reasonableand credible integration of other, publicly legitimateclaims. In the case of medicine and nursing, themost powerful and convincing claims usuallyinvolve efficacy, safety and patient wellness. These

can be openly pursued and, more importantly, theyeclipse some of the professional interests of a groupof innovators, who can then either choose tocompete or collaborate based on what is ‘‘goodfor the patient’’ (Lehoux, 2006).

In fact, the official quest to determine what is bestfor the patient may overshadow the conflict-riddennegotiations and value judgments that pervade thedesign of health care places. Design is first andforemost an intentional endeavour, one that articu-lates means and ends (Gauthier, 1999). The designof any technology and, by extension, of health caredelivery models, starts with the assumption that thecurrent ways of doing things are neither optimal norsatisfactory. New interventions are thus, by defini-tion, normative because they bring together variousmeans to correct, improve or support better

practices and actions. However, as Bucciarelli notes,the object to be designed ‘‘is not one thing’’ to allindividuals involved in the process. ‘‘Each indivi-dual’s perspective and interests are rooted in his orher special expertise and responsibilities. Designingis a process of bringing coherence to theseperspectives and interests, fixing them in theartifact’’ (1994, p. 187). Consequently, professionalperspectives that envision and promote the ‘‘ideal’’scenario for patients may get stronger collectivesupport during the design process even though theirmaterialization may be less sustainable in practice.

Moreover, a health care delivery model maygenerate various tensions and negotiations after itsdesign has been settled. As Wai and Sui (2003)observes, a design has no real existence until it isimplemented and used. Rather, its existence de-pends upon local contingencies and the way usersreact and interact. These reactions may take multi-ple forms across social groups because innovations‘‘represent a kind of confirmation of the primacy ofcertain interests,’’ and ‘‘they establish the grandeurof different actors’’ (Gauthier, 1999, p. 42). Thedeployment and organization of technology andoccupational groups in new places exert a pivotalinfluence on power dynamics and clinical interac-tions, in part because of the knowledge and skillsthat practitioners, and sometimes patients, may(or may not) get to acquire, master and apply.

It is through this process that technological‘‘opportunities’’ can exert a significant influenceover the development of professional practices(Abbott, 1988; Blume, 1995). Technological innova-tion can provoke struggles between groups ofmedical specialists (Moran & Alexander, 1997).

ARTICLE IN PRESS

1See Knox, O’Doherty, Vurdubakis, and Westrup (2005) for an

examination of various ‘‘modes of ordering’’ and of the way

places in and around airports are enacted.

P. Lehoux et al. / Social Science & Medicine 65 (2007) 1536–15481538


New technology-driven projects that threaten aclinical practice or that are not perfectly alignedwith a specialty’s clinical ethos may be sidelined,while others are pushed forward and imposethemselves as ‘‘the future.’’ Nevertheless, the designof health care delivery models, and especially thosethat depart from established institutional standards,requires a collaborative process (or at least anexplicit willingness to collaborate) because morethan one category of provider is usually involved inboth their design and implementation. In suchsituations, without collaboration—even of a super-ficial or transitory nature—innovation may not bepossible.

To summarize, various bodies of research reveal aneed to more closely investigate the claims andnorms mobilized by professional groups whendesigning non-traditional health care settings, in-cluding the socio-technical arrangements that makesuch places imaginable and eventually feasible. Theliterature also points out the need to consider whoseexpectations are taken into consideration during thedesign process. Once materialized, technology andplace express values and structure the socialinteractions of their users—be they practitionersor patients—in a way that is compatible with, orreinforces, certain normative judgments about whatconstitute desirable health care practices. Finally,design processes involve both competitive andcollaborative dynamics between, within and beyondprofessional groups.

Multiple case study design

The analyses presented here are part of a broaderstudy that assessed the organizational and clinicaldimensions of two dialysis delivery models imple-mented in two administrative regions. Our mixed-method case study, conducted from January 2002 toMarch 2004, captured key moments in the designand implementation phases (Lehoux, Daudelin,Pineault, St-Arnaud, & Sicotte, 2004).

The satellite and mobile units

In the first project, a regional hospital located in alarge town (referred to as the Regional Hospital)created dialysis units in two local hospitals awayfrom the town. These were called satellite unitsbecause the nephrologists planned to be on-site onlyabout once a week, while doing virtual rounds viavideoconferencing for the patient’s other two days

of treatment. Nurses were recruited (mostly locally)and trained to work in the units. A co-treatmentapproach wherein nephrologists and local medicalinternists2 shared patient-related care was advo-cated (at least initially). Nephrologists aimed tostreamline their clinical tasks, delegating to medicalinternists any patient health problems not directlyrelated to nephrology (common serious co-morbid-ities include diabetes, amputation, cardiovascularand pulmonary disease, although these patients alsorequire general medical care). By the end of ourevaluation, they had recruited 53 patients fromvarious regions, including patients being followed inother dialysis clinics.

The second project was led by a universityteaching hospital located in a large urban centre(referred to as the University Teaching Hospital).A bus fitted to accommodate five dialysis stationstravelled back and forth between the city and twosmall towns situated within a 125-km radius. Thebus was called a mobile unit even though it had tobe parked in a very specific place—the localhospital’s parking lot. The bus needed to be hookedup (requiring an elaborate machinery in thehospital’s basement) to the hospital in order to usefiltered water, access lab and pharmacy services andsecurely connect the videoconferencing link to theMinistry of Health intranet. This emplacement alsoenabled the unit to evacuate patients to Emergencyin the event of problems. Since patients receiveddialysis treatments every other day, the bus couldalternate between two sites, providing treatment totwo sets of patients. The most experienced, auton-omous and motivated nurses from the UniversityTeaching Hospital were recruited, the principlebeing that they would be capable of working withonly limited involvement from the nephrologists(supervision from a distance via videoconferencing).Up to 17 patients who had previously received theirtreatments at the University Teaching Hospital wererecruited based on strict criteria.

Data collection and analysis

In this paper, we draw mainly from semi-structured interviews conducted with managers

ARTICLE IN PRESS

2In Quebec, medical internists complete a 5-year specialty

programme after medical school and are often considered

‘‘generalist’’ specialists because they work in a range of medical

sub-fields, including cardiology, respiratory medicine, neurology,

palliative care and intensive care.

P. Lehoux et al. / Social Science & Medicine 65 (2007) 1536–1548 1539


(n ¼ 11; mostly nurses) and physicians (n ¼ 7), andfrom on-site observations (n ¼ 41 h; 5 sites) (pa-tients’ perspectives were gathered and will bethoroughly explored in another paper). We targetedrespondents directly involved in the design, manage-ment and implementation of the new dialysisservices. Both interviews and observations wereconducted by one of the authors (GD). All inter-views were tape recorded with the consent of theinterviewee, then transcribed in electronic format(approval was also obtained from the EthicsCommittee of each hospital). Some interviews wereconducted by phone, and interviews lasted between30min and 2.5 h. The mean duration of anobservation period was 6 h (ranging from 1.5 to8.25 h). Due to the logistics of mobile unit opera-tions, the observer spent a full day with the busoccupants. The observations had two main objec-tives: to examine the use of videoconferencing byclinicians (at both ends), and to better understandthe daily social and clinical routines occurring in theunits. Interviews were qualitatively analysed withthe help of NUD*IST indexing software. Thecoding scheme relied on a mixed strategy usingboth predetermined and emerging categories.Observation notes served as a starting point forreflecting more broadly on these categories, e.g.,what was said/not said during interviews, and whathappened/did not happen during observations.Interview excerpts were translated from French toEnglish and slightly edited for the purpose of thispaper.

Designing the units: professional claims and

normative assumptions

We now describe the claims of nephrologists,medical internists and managers, and the designdecisions that attributed various responsibilities toeach category of provider. Our analyses are basedon a summary of the key tensions observed acrossthe whole set of interviews. A number of quoteswere selected to illustrate some of these tensions.

Satellite units: medical rivalry/collaboration and

pride in local nursing

The design of the satellite units relied on a numberof converging discourses regarding telemedicine,costs, distance, sharing of expertise and regionalism.The project leader, a nephrologist from the RegionalHospital, was openly a great fan of telemedicine,

stressing that it was instrumental in making theproject feasible. He also repeatedly stressed that itwould be better for the patients, allowing them tosave time and money through reduced travel.However, the key issue at the centre of this claimwas the required delimitation of the nephrologydomain based on its medical boundaries.

You have to distinguish between two differenttypes of care. There’s the nephrology/dialysispart, which requires monitoring by a nephrolo-gist. Then there’s the general medicine part, whatI’d call internal medicine or general medicine. Allof the patients who come here, three times aweek, take advantage of the opportunity to signala lot of small problems, sometimes even largeones, but problems that aren’t necessarily relatedto nephrology or dialysis. Given our broad

involvement with these patients, we’re automati-cally called upon to solve non-nephrology-relatedproblems. For a large set of non-nephrologyproblems, follow-up can be done by other peoplewho have the skills to do it. (Nephrologist 2, S3,our emphasis)

This quote suggests that a specific area of medicalcare is tightly linked to a very specific category ofprovider who possesses the knowledge and skills tointervene in that area. It is interesting to note thatthe interviewee equated general medicine withinternal medicine. In Canada, while the latter is aspecialty, it is also the training path followed bynephrologists before specializing in nephrology.Given the symbolic (and financial) hierarchy inmedical practice, this way of presenting what fallsoutside of nephrology appears slightly derogatoryfor medical internists (who have not gone as far asnephrologists). Another aspect evoked by theinterviewee was the nephrologists’ ‘‘broad’’ involve-ment with patients, which he equated with perform-ing tasks nephrologists prefer not to do. Whatremained unclear throughout the project was thenature and significance of these complaints. Ac-cording to a medical internist:

They’re very demanding patients because they’reused to being seen three times a week. They wantto tell you all about how constipated they werethis morning, the tiny scrape on their toe, theirrunny nose—a ton of insignificant little things.

ARTICLE IN PRESS

3Throughout the paper, ‘‘S’’ stands for the two Satellite Units

and ‘‘M’’ stands for Mobile Unit.



They’re used to being waited on. Nurses areextremely patient and nice to them so there are nolimits to what they want. (Medical Internist 1, S)

Negotiating what clinical aspects should be theresponsibility of nephrologists, medical internists ornurses turned out to be rather complicated. Initially,and despite their heavy workload, several medicalinternists saw the project as an exciting opportunityto expand their own clinical domain. However, itbecame evident that this expectation clashed withthe nephrologists’ aim:

It was clear at the beginning that the nephrolo-gists wanted our intervention to be limited togeneral patient care, not to developing localexpertise in terminal renal failure treatment. Thiswas disappointing for us because we wanted todevelop an interesting new area of expertise—onethat we weren’t familiar with and weren’tinvolved in because we didn’t have the equipmentand because patients were referred elsewhere.(Medical Internist 1, S)

In fact, access to technology and patients appearsto be necessary but not sufficient for developinglocal expertise. Although there was a ‘‘knowledgetransfer training’’ period for medical internists atthe Regional Hospital, some interviewees said it wasunstructured and lacked the support of the ne-phrologists. Several mentioned they were treatedlike interns—invited to observe, then left bythemselves to figure out exactly what was goingon. Not surprisingly, medical internists refused totake care of clinical aspects that were presented as‘‘simple enough’’ for nurses,4 and some insteadfocused their attention on how to operate thedialysis machines and on what the nephrologistswere doing.5

Moreover, according to the medical internists,dialyzed patients suffer from very complex pathol-

ogies (e.g., cardiac problems, phlebitis, hyperten-sion) that are better handled by internal medicineand require prompt management. ‘‘The problemwith dialyzed patients is not so much the dialysisitself, but all the other complications that can arise’’(Medical Internist 2, S). They also tended tounderplay the role of nephrologists (seen as‘‘technicians operating dialysis machines’’) whilestressing the pivotal skills of nurses: ‘‘What makes agood or bad dialysis unit is really the nurses.Obviously you need the leadership of nephrologists,but the success of the unit really rests on theshoulders of its nurses’’ (Medical Internist 1, S).Similarly, the local Project Manager, a nurse,emphasized the need to develop ‘‘local ways’’ ofproviding dialysis services:

Interviewee: ‘‘I’m in favour of the Ministry’s re-organization of services. The nurse—what’s herreal role? That’s what we have to work on.’’Interviewer: ‘‘And what do you think that roleshould be?’’Interviewee: ‘‘It’s the patient, care protocols,education and coordination. Anyone could orderstuff and clean up the machines.’’ (Nurse, ProjectManager, S)

From the perspective of the local hospitals,reinforcing localness meant exerting more controlover the category of nurse that should be recruitedand the types of duties these nurses could andshould perform:

The problem originated with the nephrologists,who insisted on staff with experience in dialysis.But we don’t want to be a clone of the RegionalHospital. Yes, we want to offer dialysis servicesto our population, but it has to be adapted tolocal needs and at the same time respect theproper standards. This was a big issue with thestaff—having to negotiate and recruit one nurseexternally. (Nurse, Project Manager, S)

In each satellite unit, the tailoring of the deliverymodel to local conditions was achieved throughdifferent processes but ended with a rather similarinter-professional arrangement. In one unit, therewere a number of unsuccessful (and seeminglyconfrontational) attempts by medical internists tobe more clinically active with patients. Theseinitiatives were met with explicit resistance fromthe nephrologists: ‘‘As soon as we tried to adjust adrug, control anemia or modify anti-hypertensiontreatment, we would receive a phone call from the

ARTICLE IN PRESS

4The following quote contains another hierarchical allusion,

referring to clinical work that could be done by less trained staff:

‘‘There were plenty of things to learn, but we weren’t really

encouraged to learn. They were polite. [pause] But then they told

us that in other units nurses were doing what we were supposed

to be doing! Now that was gratifying to hear! It hurt our pride’’

(Medical Internist 1, S).5They obtained additional information through other means:

‘‘We did become a little more familiar with the technology, and

the nurses were very nice, showing us how it all worked on a

technical level. For questions related to complications associated

with renal failure, we looked them up in a book and watched

what they were doing’’ (Medical Internist 1, S).



nephrologist telling us that is was none of ourbusiness and to leave it alone’’ (Medical Internist 1,S). In the other unit, the medical internists, whowere concerned about a detrimental increase in theirworkload, stated they preferred not to make‘‘incursions into nephrology,’’ but would ‘‘oftencall the nephrologists and suggest, for example, re-evaluating the patient’s weight’’ (Medical Internist2, S). This represents a less threatening and morecollaborative approach. Interestingly though, inboth units, medical internists questioned the qualityand continuity of care in this new arrangement,seeing it as a form of inefficient supra-specialization.

When listening to medical internists’ claims, onenotices the (perceived) dominance and counter-dominance (resorted to) pervading their discourses.Relational positioning associated with expertise andplace is pervasive.6 Moreover, medical internists wereupset with telemedicine, ‘‘a camera that cost $70,000’’while they were ‘‘under severe budget constraints,’’‘‘trying to trim a few thousand dollars here and thereby cutting down on secretaries, who were already inshort supply’’ (Medical Internist 1, S).7

After two years in operation, medical internistswere still perplexed but hoped that the concreteemplacement of the units in their territory wouldfacilitate positive changes. Hence, medical internistswere waiting and watching, a stance that combinedboth rivalry and cooperation. Overall, the deliverymodel being deployed in the satellite units wasunsatisfactory and required perfecting. Even somenephrologists themselves shared doubts. ‘‘I believe,however, that people still prefer to have contactwith the doctor y and we still have somewhat of aclassical role, which is probably useful anyway’’(Nephrologist 5, S). However, norms were unstable:‘‘How often should we see patients? I think there areno strict rules but I think we should continue to go

there on a regular basis, perhaps once or twice amonth, to see patients’’ (Nephrologist 5, S). Thisraises the question of what is the proper place of thepatient, and the proper distance at which he/sheshould be located from a doctor.

The mobile unit: medical necessity and autonomy in

nursing

The proud-to-be-local culture of the satellite unitscontrasted sharply with that of the mobile unit,where a careful pilot-project management strategywas applied. Although it was a nurse-driven project,nephrologists from the University Teaching Hospi-tal approved of the initiative, albeit with somereservations. One nephrologist, for instance, recog-nized the professional tensions resulting from thereconfiguration of dialysis services: ‘‘It’s a constantstruggle. People want their specialty to be recog-nizedyso you don’t deploy, you don’t share’’(Nephrologist 2, M). From the nephrologists’ pointof view, the mobile unit had to meet establishedstandards of care while operating with a reducedmedical presence, which in turn created uncertaintyfor the nephrologist.

The challenge was to offer the same quality ofservice while seeing patients less often or from adistance. So, the first big difference was livingwith the uncertainty since we’re always morecertain of what we see and touch than of what istransmitted to us. So, we had to work withinformation that used to be real and now wasvirtual, with hearsay, a nurse’s feeling. Thepatient tells the nurse and she transmits thatinformation. There’s always some vagueness,although this can always be dealt with by sayingto the patient, ‘‘If you’re not feeling well, I meanreally not well, or if you’re not sure, go toEmergency.’’ Usually patients know when theyhave to go. (Nephrologist 2, M)

Thus, uncertainty due to the nephrologist’sreduced presence can be managed by havingpatients know when they should seek the presenceof another doctor. This strategy amounts to a safetynet (in our assessment, we did in fact observe higherrates of hospitalization and Emergency Roomvisits). Another solution is to have nurses withspecialized knowledge and skills: ‘‘The future is indecentralization. We have to offer closer-to-patientservices. You can’t scatter nephrologists all over theplace and have them work 366 days a year. That

ARTICLE IN PRESS

6Somewhat paradoxically, the lead nephrologist seemed to be

aware of the dangers of chauvinism based on location of work:

[The project] has opened my eyes about the quality of medical

practice in regions. Often when we train, we get this

impression that medicine really only happens in large centres

like Quebec City and Montreal. But then we realized that

excellent medicine is being practiced here, so we cannot buy

into this prejudice and denigrate local hospitals. I found [the

satellite units] had a real quality team there, people we could

count on. (Nephrologist 2, S)

7Besides the clinical claims, nephrologists were perceived as

being overly concerned about obtaining official reimbursement

for telemedicine consultations.



would be a mistake. We have to train nurses whocan do more’’ (Nephrologist 1, M). Most nephrol-ogists had no doubts about the relevance of thewhole mobile unit endeavour, perhaps because fewalternatives seemed plausible: ‘‘It’s clear as day thatthis is the future’’ (Nephrologist 1, M). Stressing theimportant role of nurses in dialysis units, thisinterviewee added: ‘‘You know, medicine can belearned by doctors, but it can also be learned bynurses’’ (Nephrologist 1, M). However, his collea-gue (cited above) disagreed somewhat on thispoint—he carefully distinguished medical practicefrom nursing work.

[Practicing in the mobile unit] requires judgment,but it isn’t an act. If someone isn’t doing well, sayhe’s pale, then you can send him to Emergency.We told the nurses: ‘‘All the rest is humanrelations and it doesn’t fall outside your profes-sional responsibility to consider the possibilitythat a patient is unstable.’’ (Nephrologist 2, M)

There are a number of keys to interpreting thisquote. First, an act is understood in Quebec as amedical act, and therefore falls under the legal anddeontological code of medical practice. So clinicaljudgment can be seen as a part of the nurses’practice as long as it does not involve practicingmedicine (it cannot, therefore, be an act). Second,by using a negative form (‘‘it does not fall outside’’)to suggest that a nurse should notice and thinkabout the instability of a patient, he makes it appearas though it does not require stretching their currentjob definition to include clinically more intensepatient monitoring (without direct medical atten-dance). Third, by referring to ‘‘human relations’’, hedownplays a large component of nurses’ work.Through such circumvolutions in his argument, hereinforces the notion that nursing is ‘‘commonsense’’ and that caring does not require anyparticular skills (beyond being nice to others).

For their part, nurses could simply not talk aboutthe project without stressing that its main goal wasto increase the patient’s quality of life.

Some patients come from X, which takes two anda half hours. That’s four hours of treatment plusfive hours of travel, for a total of nine hours.Now it takes them 15min to get to the localhospital. They have four hours of treatment, and15min later they’re home. In terms of improvingthe quality of life of these patients, it’s extra-ordinary. (Nurse, Project Manager, UM2)

In fact, this claim was so convincing that very fewdared challenge it; the mobile unit actually won anaward from the Quebec College of Nurses, evidenceof professional recognition for the nurses’ initiative.The Assistant Chief of Nursing Practice explainedall the efforts deployed to recruit only the best (i.e.autonomous) nurses for their dialysis unit. None ofthem had less than ten years’ experience and all ofthem had outperformed their peers in a structuredinterview. Similarly, great care was taken toformalize treatment protocols, prescription rulesand clinical procedures in case of an emergency.This formalization relied on a clear sense ofhierarchy (among nurses as well as between nursesand doctors) and was pivotal to the nurses’ project.Certainly increasing the quality of life of patientsthrough closer-to-patient services was an ambitiousgoal. Was this why the promoters wanted only thebest nurses to work on the bus?

One nephrologist had a slightly different take onthe issue of what tasks could be delegated to nursesand patients: ‘‘Patients can learn to do their dialysison their own and do without a nurse who lives 200miles away. That’s corporatism, which doesn’tmake sense. And it’s not medical corporatism, it’snursing corporatism’’ (Nephrologist 2, M). He hadalso been reluctant to formalize procedures andseemed to value the professional experience andlearning that would help nurses signal emerginghealth problems and refer potentially unstablepatients.

You know nurses, they want things to be writtendown. But this would have taken too much paperso we didn’t do it. The nurses had a lot ofexperience so when we met with them, we trainedthem on the physical exam and told them tocontinue using their professional experience andintuition to detect things that didn’t make senseand to decide when to refer. Which they’ve donevery, very well, and which they have been happy todo. There was a bit of insecurity at the beginning,and within the group there were some variation,but it has gone well. (Nephrologist 2, M)

As illustrated by interviewees’ comments, profes-sional claims seemed to be in constant flux, whereinthe professional autonomy of nurses was officiallyvalued by both nurses and doctors, although itremained something to keep well circumscribed andformalized (even according to the nurses them-selves). For instance, nurses who were assigned tothe mobile unit and the nurse leader of the project



insisted on doing regular shifts at the UniversityTeaching Hospital. Various justifications wereoffered, such as keeping in touch with state-of-the-art dialysis technology and practice, not losing theirskills in treating ‘‘normal’’ dialyzed patients, andworking normal day shifts (instead of the 12-hourshift that included a 125-km return trip). Theimplication is that working full-time in a mobileunit may compromise nursing practice, rendering itdifficult to practice at a university teaching hospital.

In the Quebec geographical context, the logicbehind delocalizing nurses (who reside near theUniversity Teaching Hospital) also raised the issueof the model’s generalizability.

A mobile unit is infinitely more flexible than afixed unit. The investment benefits two sites. Inaddition, these nurses are trained and are used todoing it, and that’s better than having part-timenurses. You know, it’s like driving a car—whenyou do it once in a while, your reflexes are not asgood as when you do it everyday. The same istrue for medicine. (Nephrologist 1, M)

However, geographical mobility remains limitedbecause patients require treatment every other day,nurses need to get back home and the bus still needsto interface with a local hospital (for secureelectronic links, filtered water supply, rapid accessto an emergency room and so on). Hence, althoughthe University Teaching Hospital culture went handin hand with the nursing autonomy discourse, lessapparent normative and material constraints calledinto question the mobile unit’s long-term survival.Furthermore, nurses were not simply defendingtheir professional status against doctors. Rather,they were mostly struggling within their ownnormative framework of what constitutes propernursing care. Throughout the design and implemen-tation processes, their professional ethos was largelygeared to formalizing work procedures suited to thisnon-traditional health care setting, which by andlarge paralleled that of the medical profession.

Comparing the assumptions and implications of the

two designs

As Table 1 summarizes, the satellite units weremainly a nephrologist-driven project that relied onstrong regional and local pride.8 Mostly local nurses

without experience in dialysis were recruited andtrained, and tolerance toward some of their (initial)shortcomings was manifest. Although nephrologistsfrom the Regional Hospital did not have formalauthority over their work, nurses collaboratedwillingly (referring to it as a ‘‘mother-child’’relationship). For various reasons, medical inter-nists proved to be stronger rivals than nurses in there-negotiation. In the long run, and once the dialysismachines had been emplaced and the videoconfer-encing link proven to be superfluous,9 nephrologistsmay have been at risk of becoming redundant. Thispartly explains why they resisted more strongly. Theapparent submissiveness of the local nurses rein-forced the ability of nephrologists to emplace theirauthority from a distance, but also emphasized thelegitimacy of their localness (e.g., given their limitedexperience, nurses were not asked to performbeyond normal standards). As a result, the video-conferencing system, although seen as imperfect,succeeded in forming robust links between localnurses and remote nephrologists.

In the mobile unit, relying on expert nurses wasclosely in tune with provincial policy initiativesseeking to authorize ‘‘advanced nursing practice’’.Nephrology is a fertile clinical ground for thisinitiative as nurses already play a significant role.Nonetheless, this expert nurse identity was notestablished unequivocally; the mobile unit wasdesigned and operated as a remote care unit thatfunctioned materially and clinically under a tightlymanaged autonomy. Nurses’ responsibilities wereincreased and the visibility of the project (plus ourevaluation) generated a high level of self-regulationthat aimed to create a new clinical practice that wasto be both cherished and submitted to the higheststandards. Nephrologists did not greatly resist theproject and partook in the University TeachingHospital culture, which supports such innovation.Thus, the project was a collaborative extension ofboth professions’ ethos.

ARTICLE IN PRESS

8As suggested by one reviewer, the professional cultures we

observe may also be shaped by the broader institutional culture

(footnote continued)

wherein these groups work. Because we are focusing in one small

area of care (dialysis within the nephrology service), we did not

gather much empirical information about the institutional

culture.9Telemedicine was seen as redundant because on-site medical

internists could take care of the patients: ‘‘I think telemedicine is

a formidable tool, but it shouldn’t be used here and for this type

of care’’ (Medical Internist 1, S).



Discussion

There is widespread recognition that the restruc-turing of health care in many Western societies hasled to an increasing diversity of places in whichhealth and social care is received (Brown & Duncan,2002). As a result, ‘‘health care sites now includevirtually every setting where human beings resideand frequent’’ (McKeever & Coyte, 1999, p. 1).Such changes have pushed geographers and socialscientists to examine the various ways in whichhealth care places affect and transform providers’and patients’ experience of clinical care (Cartier,2003). This paper has drawn on this perspective tocontribute to the current body of knowledge in fourways.

First, although our qualitative findings are con-text dependent and, therefore, potentially transfer-able only to similar organizational contexts, our

analytical framework can inspire case studies to beconducted elsewhere. As Table 1 indicates, thedesign of the two models started with a similarproblem definition but resulted in different inter-professional and spatial arrangements. Our analy-tical framework could help shed light on otherprofessional-driven initiatives that involve the (re)-design of health care delivery models aimed atreducing spatial barriers.

Second, while we agree with the idea thattherapeutic environments should be considered asphysical, social and symbolic environments (Gesler,Bell, Curtis, Hubbard, & Francis, 2004, p. 119), wealso suggest pushing the analyses of places further bybringing to the fore the professional ethos (norms,culture and interests) underlying their design. Morespecifically, Table 1 shows the particular clinicalnorms associated with patient-centred care in eachmodel. The professionals involved in the design and

ARTICLE IN PRESS

Table 1

Normative assumptions and spatial implications for the two types of ‘‘closer-to-patient’’ dialysis units

Satellite Units Mobile Unit

Problem setting Number of patients is increasing and these patients are

needy and demanding

Number of nephrologists is limited and they should

streamline their work to nephrological problems only

Normative

assumptions

Ideally, nephrologists should retain control over

nephrological issues while medical internists should take

care of non-nephrology-related problems

Ideally, expert nurses can provide most of the care

needed under the close supervision of nephrologists,

while general practitioners can provide comprehensive

follow-up of patients

In practice, the collaboration of medical internists is not

essential

In practice, patients can see another doctor if something

goes wrong and nurses can detect and/or manage most

problems

Design decisions Use of videoconferencing by nephrologists in

conjunction with on-site visits

Use of videoconferencing by nephrologists to talk to

nurses when needed

Loosely define the scope of responsibilities for medical

internists

Formally define the scope of responsibilities for nurses

and nephrologists as well as the rules of collaboration

Recruit and train local nurses

Recruit patients who accept or wish to receive treatments

in the SU

Recruit the most autonomous nurses

Recruit the most stable and autonomous patients

Inter-professional

arrangement

Nephrologists do both on-site visits and virtual rounds

and exert control over medical internists’ initiatives

Nephrologists support the nurse-driven innovative

project and only provide the ‘‘medically required’’ care

Local nurses are not expected to outperform and

collaborate easily with nephrologists from the Regional

Hospital

Nurses strive to meet high-level standards of care and

risks are actively avoided (e.g., recruiting stable patients,

formal referral when in doubt)

Spatial

implications

Non-traditional health care places that mimic a

traditional dialysis unit except for the ‘‘relative’’ absence

of nephrologists

A non-traditional place that looks and functions like a

non-traditional place

Machines, nurses and patients are emplaced in local

hospitals while medical internists are ‘‘waiting and

watching’’

Limited spatial autonomy despite the unit’s mobility

Patients travel every four months to see their

nephrologist



implementation of the units sought to measure up to‘‘ideal standards’’ while constantly having to ac-knowledge the contingencies of places ‘‘in practice.’’This normative duality (ideal/real world) is intimatelylinked to the professionals who participated in thedesign of the units and to the way they selectivelyaddressed clinical norms and patients’ expectations.As our empirical case studies illustrate, the patients’good can officially serve as an overarching goal,overshadowing some of the self-serving professionalaims and interests. In addition, when informants wereasked to clarify in what ways their model met‘‘standard’’ clinical norms, they tended to referinstead to their non-traditional and unique character-istics (see also Holmes & Gastaldo, 2002). This is anexample of how place, despite the currently strongevidence-based medicine culture, has not ‘‘become allbut irrelevant in health and social care’’ (Poland,Lehoux, Holmes, & Andrews, 2005, p. 170).

Third, instead of simply observing open conflictsbetween professions, we exposed subtle but inexor-able tensions within and beyond professional groups.One analytical thread that may explain this politicalnexus lies, we argue, in the spatial dimensions of thesocio-technical arrangements. By exploring thearguments of each professional group in bothprojects, we showed how the aim of offeringcloser-to-patient services was not in itself the only(or even, at times, the primary) organizing logic—infact, several other concerns fuelled the designprocess. What appeared to matter the most tonephrologists in both projects was streamliningtheir clinical tasks. Officially, provisions had to bemade to delegate a number of tasks to otherproviders; otherwise, the quality of care would havebeen perceived as compromised. To obtain govern-ment approval and funding, everyone involved inthe projects had to clearly define the norms to whichthey would adhere. While some of the professionalclaims appeared to be well entrenched, others werefar more supple. As stressed by Popay et al. (2003,p. 56), normative guidelines do not dictate action;‘‘rather, they provide an idealized notion of ‘theproper thing to do’ around which people negotiate.’’In both projects, the proper thing to do was to moveservices closer to patients and away from nephrol-ogists. To do so, spatial constraints were used tojustify why nurses and machines had to travelbetween sites (the mobile unit) or why they had tobe emplaced at sites (the satellite units).

A final contribution of this paper lies in itsemphasis on design as an intentional but indetermi-

nate activity (Bucciarelli, 1994). Although only onedesign materializes, designers envision several pos-sible competing futures. Consider the examplesTatum (2004, p. 70) gives.

Possibilities for the design of single artifacts aremuch more open that we ordinarily imagine.yThe design of machinery to slaughter andprepare chickens for market is likely to beradically different in the small-farm context of‘‘community supported agriculture’’ than it is inthe mass production plans more common today.And the design of a vehicle for local groceryshopping by low-income single parents may notresemble the highway-capable ‘‘car’’ that now isalmost the only option available.

Just because most of the technologies and placessurrounding us are familiar and seem to fit our dailyhabits fairly logically does not mean they must bethe way they are. For instance, the restructuring ofhealth care services is often posited as aiming tostandardize across space the way health care isdelivered and the type of services accessible topatients (Cartier, 2003). Nevertheless, significantvariation is likely to be observed in the case ofspecialized services such as dialysis, not onlybecause of practitioners’ autonomy and authoritybut also because of the spatial and socio-culturalcontexts in which services are delivered (Agnew,1993; Andrews, 2002). By showing how closer-to-patient dialysis services have been envisioned andmaterialized in two different models, this paperillustrates how various design decisions can struc-ture, and be structured by, spatiality (Thrift, 2004).

There are, of course, limitations to our study andareas requiring further research. Although weinterviewed patients, this paper chose to examinemore fully providers’ and managers’ perspectives.What remains unclear is the extent to which variouspatients’ views, beyond a few contacts establishedwith official representatives from patient associa-tions, were being sought and considered by theproject leaders. As Gesler and colleagues observe,hospital design may not be ‘‘responsive to variationsin patient experiences of hospital settings and insocial and cultural interpretations of what makesfor an efficient and therapeutic health care setting’’(2004, p. 118). Because the lives of dialyzed patientsare deeply structured by the time–space constraintsimposed by the treatments themselves (three times aweek and up to four hours per treatment), andbecause they clearly inhabit the dialysis units,

ARTICLE IN PRESSP. Lehoux et al. / Social Science & Medicine 65 (2007) 1536–15481546


further research could examine how their experienceof place compares with that of other chronic-carepatients (Russ, Shim, & Kaufman, 2005).

Conclusion

This paper rendered more explicit how profes-sional struggles, including those one may assumewere already settled, underpin the re-distribution ofclinical tasks in non-traditional dialysis units. De-sign processes structure, and are structured by,professional dynamics and normative assumptions.Our empirical analysis highlights the way technol-ogy and place become objects of contention betweenand within groups who, by virtue of their locationwithin clinical hierarchies, tacitly possess authorityover their design. Design participants openlynegotiate on the basis of their ability, as membersof a profession and/or a multidisciplinary team, toprovide the safest and most effective patient-centredcare. Instead of assuming there would be cleardominance by one professional group, we havebrought to the fore the competitive and collabora-tive ramifications shaping the design and implemen-tation of both projects. In the satellite units, bothrivalry and collaboration took place betweennephrologists and medical internists, while bothgroups conceded limited autonomy to the localnursing staff. In the mobile unit, the overarchingrule was to stick to medically required care and tofoster highly regulated nursing autonomy. Theconflicts between these rationales may never besettled once and for all, a phenomenon that maycontribute to the specificity and uniqueness of non-traditional health care places.

Acknowledgements

This paper is based on empirical materialgathered under a research contract with the QuebecMinistry of Health and Social Services (principalinvestigator: P. Lehoux). The authors wish toacknowledge the support, in the form of seedfunding, of the ‘‘Health Care, Technology andPlace: An Interdisciplinary Capacity EnhancementTeam’’ (Institute of Health Services and PolicyResearch—Canadian Institutes of Health Re-search). The first author holds a Canada ResearchChair on Innovations in Health (2005–2010). Weare grateful to the patients, managers and physi-cians who participated in our study for sharing theirexperience and opinions. A preliminary version of

this paper was presented at a seminar at the Centrefor Health Economics and Policy Analysis (CHE-PA), McMaster University, on March 16, 2005 inHamilton (Canada). Several comments formulatedby participants helped clarify our observations.

References

Abbott, A. (1988). The system of professions: An essay on the

division of expert labor. Chicago: University of Chicago Press.

Agnew, J. (1993). Representing space: Space, scale and culture in

social science. In J. Duncan, & D. Ley (Eds.), Place/culture/

representation. London: Routledge.

Andrews, G. J. (2002). Towards a more place-sensitive nursing

research: An invitation to medical and health geography.

Nursing Inquiry, 9(4), 221–238.

Blume, S. S. (1992). Insight and industry: On the dynamics of

technological change in medicine. Cambridge, MA: MIT Press.

Brown, T., & Duncan, C. (2002). Placing geographies of public

health. Area, 33, 361–369.

Bucciarelli, L. L. (1994). Designing engineers. Cambridge, MA:

MIT Press.

Cartier, C. (2003). From home to hospital and back again:

Economic restructuring, end of life, and the gendered

problems of place-switching health services. Social Science &

Medicine, 56, 2289–2301.

Edginton, B. (1997). Moral architecture: The influence of the

York Retreat on asylum design. Health and Place, 3, 91–99.

Gauthier, P. (1999). Technological intervention and the malady

of happiness. Design Issues, 15(2), 40–54.

Gesler, W., Bell, M., Curtis, S., Hubbard, P., & Francis, S.

(2004). Therapy by design: Evaluating the UK hospital

building program. Health and Place, 10(2), 117–128.

Hess, M. (2004). Spatial relationships? Towards a reconceptua-

lization of embeddedness. Progress in Human Geography,

28(2), 165–186.

Hinchliffe, S. (1996). Technology, power and space—The means

and ends of geographies of technology. Environment and

Planning D: Society and Space, 14, 659–682.

Holmes, D., & Gastaldo, D. (2002). Nursing as means of

governmentality. Journal of Advanced Nursing, 38(6), 557–565.

Kearns, R. A. (1993). Place and health: Towards a reformed

medical geography. The Professional Geographer, 46, 67–72.

Kearns, R. A., & Barnett, J. R. (2000). Happy meals in the

Starship Enterprise: Interpreting a moral geography of health

care consumption. Health and Place, 6, 81–93.

Kearns, R. A., & Moon, G. (2002). From medical to health

geography: Novelty, place and theory after a decade of

change. Progress in Human Geography, 26(5), 605–625.

Kenny, A., & Duckett, S. (2004). A question of place: Medical

power in rural Australia. Social Science & Medicine, 58,

1059–1073.

Knox, H, O’Doherty, D., Vurdubakis, T., & Westrup, C. (2005).

Enacting airports: Space, movement and modes of ordering.

EBK Working Paper 2005/20.

Lehoux, P. (2006). The problem of health technology: Policy

implications for modern health care systems. New York:

Routledge.



Lehoux, P., Daudelin, G., Pineault, R., St-Arnaud, J., & Sicotte,

C. (2004). Evaluation des unites satellites et mobile d’hemodia-

lyse. R04-02, GRIS, Universite de Montreal.

McKeever, P., & Coyte, P. (1999). Place in health care: Sites,

roles, rights and responsibilities. Report prepared under

the auspices of a SSHRC/CHSRF Health Institute Design

Grant.

Michael, Y. L., Green, M. K., & Farquhar, S. A., forthcoming.

Neighborhood design and active aging. Health and Place.

Moran, M., & Alexander, E. (1997). Technology, American

democracy and health care. British Journal of Political

Sciences, 27, 573–594.

Poland, B., Lehoux, P., Holmes, D., & Andrews, G. (2005). How

place matters: Unpacking technology and power relations in

health and social care. Health and Social Care in the

Community, 13(2), 170–180.

Popay, J., Thomas, C., Williams, G., Bennett, S., Gatrell, A., &

Bostock, L. (2003). A proper place to live: Health inequalities,

agency and the normative dimensions of place. Social Science

& Medicine, 57(1), 55–69.

Russ, A. J., Shim, J. K., & Kaufman, R. (2005). Is there life on

dialysis?: Time and aging in a clinically sustained existence.

Medical Anthropology, 24, 297–324.

Smyth, F. (2005). Medical geography: Therapeutic places, spaces

and networks. Progress in Human Geography, 29(4), 488–495.

Tatum, J. S. (2004). The challenge of responsible design. Design

Issues, 20(3), 66–80.

Thrift, N. (2004). Movement-space: The changing domain of

thinking resulting from the development of new kinds of

spatial awareness. Economy and Society, 33(4), 582–604.

Wai, K., & Sui, W. (2003). Users’ creative responses and

designers’ roles. Design Issues, 19(2), 64–73.

ARTICLE IN PRESSP. Lehoux et al. / Social Science & Medicine 65 (2007) 1536–15481548

Designing a better place for patients: professional struggles surrounding satellite and mobile...

Documents

Transcript of Designing a better place for patients: professional struggles surrounding satellite and mobile...