Structuring mechanisms of health care activity: a case study on pressure ulcers[Les mécanismes de structuration de l'activité des équipes de soins : Etude de cas sur la gestion des ulcères de pression]

The structuring theory encourages studying the mechanisms of interaction and coordination among teams. It thus focuses on the relationship between tools and practices, on learning mechanisms and finally on the interpretation of the meaning given to work.Method : Activity structuring mechanisms have been described in the context of a case study conducted between 2009 and 2010 in six French hospital services which were facing the challenge of preventing and treating pressure ulcers. The hypothesis that different structuring mechanisms are required to change the activity is illustrated by the analysis of the practices of three teams recognized for their expertise. The interviews that were conducted in the three teams were transcribed and analyzed inductively from the ground upward by making ascending comparisons and coding around three themes : the role of material artifacts, the learning mechanisms and finally the symbolic meanings.Results : The institutions that participated in the study have different histories and contexts that explain the diversity of the followed paths. However different common structuring processes can be described in the three studied services. Action and resources interact to produce together new working environments which give new roles and new capabilities, especially for nursing assistants. A deep expertise emerges which challenges the usual ways of doing. A collective commitment is eventually built around the construction of a special relationship between attention and action.Discussion : The recognition of the constructed nature of health care leads us to discuss teams' ability to develop general skills that go beyond any special care. The building of general capabilities enables thus teams to develop common collective skills.The study of pressure ulcers management gives us examples of inter-structuring, of learning development and of capabilities building. These structuring mechanisms give an important role to managers in the development of the working environment, in the selection and qualification of innovative practices and eventually in the sensemaking at work.