Lost in translation? 'Evidence' and the articulation of institutional logics in integrated care pathways: from positive to negative boundary object?

Abstract

This article examines the translation of a clinical governance concept - integrated care pathways (ICPs)--into an infrastructural technology. Building on previous work, the application of boundary object theory is extended in this article to argue that stakeholder enrolment in pathway methodology may be less thoroughgoing than originally assumed. Pathways have effectively aligned management and nursing interests around a quality agenda and nurses have emerged as the leaders in this field, but doctors have rather lower levels of engagement. It is suggested that the contradictory logics inherent in pathway philosophy (primarily as these relate to 'evidence') and the social organisation of ICP development foster a transformation of the concept when this is translated into the technology, creating a negative boundary object from the perspective of doctors. Medicine is a powerful actor in health care, which is consequential for whether pathways, as designated boundary objects, become boundary objects-in-use. It also has implications for the diffusion of the concept as a mechanism of clinical governance and the credibility of nurses as emergent leaders in this field. Qualitative case studies of ICP development processes undertaken in the UK National Health Service and ethnographic research on the ICP community provide the empirical foundations for the analysis.