Résumé : Le raisonnement clinique (RC) de l’ergothérapeute en milieu communautaire s’opère dans des contextes en constante évolution. Parmi ces contextes, la dimension institutionnelle (DI) comprend les aspects légaux et règlementaires, administratifs et organisationnels, dont le processus d’optimisation de la performance. Ce processus vise à accroître l’efficience des services ergothérapiques de soutien à domicile (SAD) offerts par les Centres de santé et de services sociaux (CSSS). Or, les aspects précis de la DI, incluant l’optimisation de la performance, impliqués dans le RC et leur rôle exact dans le choix des interventions ergothérapiques sont peu connus. Cette étude visait à : (1) décrire le RC des ergothérapeutes en milieu communautaire, (2) décrire les aspects de la DI impliqués dans leur RC, et (3) explorer comment la reddition de compte et l’optimisation de la performance y sont impliqués. Une ethnographie institutionnelle (EI) a été réalisée auprès de dix ergothérapeutes recrutés dans trois CSSS québécois. Des observations et des entretiens semi-dirigés ont été conduits avec ces ergothérapeutes et 12 informateurs-clés secondaires (collègues et gestionnaires). Les documents accessibles et utilisés par ces ergothérapeutes ont également été collectés. Toutes les données ont été analysées et interprétées à l’aide du processus analytique de l’EI. Les résultats montrent d’abord que le RC des ergothérapeutes prend en considération 13 aspects de la DI. Ces aspects modulent comment les ergothérapeutes formulent le problème, envisagent les solutions et prennent les décisions (obj. 1). Ensuite, le RC des ergothérapeutes considère quasi constamment trois aspects administratifs et deux organisationnels de la DI (obj. 2). Les aspects administratifs sont : les procédures institutionnelles; l’offre de services de l’établissement; et la continuité de services. Les aspects organisationnels sont : les interventions attendues de l’ergothérapeute (mandat) et les délais d’accès aux services. Enfin, le RC des ergothérapeutes inclut une préoccupation constante quant à leur performance (obj. 3) qui restreint le temps et le suivi alloués à chaque client. Leurs évaluations et leurs interventions se limitent souvent au seul motif de référence, généralement l’autonomie dans les soins personnels et la mobilité, sauf si la sécurité du client est menacée. Cette étude offre une compréhension approfondie du rôle de la DI et, spécifiquement, du processus d’optimisation de la performance, dans le RC des ergothérapeutes en milieu communautaire. La préoccupation de la performance implique une réduction de l’étendue de l’action des ergothérapeutes. Ainsi, l’exercice de leur autonomie professionnelle, le droit d’accès aux services des clients et l’atteinte des objectifs du système de santé sont compromis. / Abstract : Community occupational therapists’ clinical reasoning (CR) takes place in constantly evolving contexts. The institutional dimension (ID) of these contexts includes legal and regulatory, administrative and organizational elements, including performance optimization processes. Such processes aim at increasing the efficiency of Health and Social Services Centers (HSSC) homecare occupational therapy services. However, the particular elements of ID involved in CR, including performance optimization, and how they are involved in the choice of occupational therapy interventions, remain unknown. This study aimed to: (1) describe the CR of community occupational therapists; (2) describe the elements of the ID involved; and (3) explore how accountability processes and performance optimization are involved. An institutional ethnography (IE) inquiry was conducted with ten occupational therapists in three Health and Social Services Centres (HSSCs) in Québec. Observations and semi-structured interviews were conducted with these occupational therapists and 12 secondary key informants (colleagues and managers). Documents accessible to and used by occupational therapists were also collected and analyzed with a data extraction grid. All data were analyzed and interpreted using the IE process. The findings revealed that the CR of community occupational therapists considers 13 elements of the ID. These elements modulate how occupational therapists formulate the problem, consider the solutions and make decisions (obj. 1). Second, the CR of participants almost constantly involves three administrative and two organizational elements of the ID (obj. 2). Administrative elements include: institutional procedures, the HSSC’s services offer, and the continuity of services. Organizational elements include: the expected response of the occupational therapist (mandate) and delays in access to services. Third, the occupational therapists’ CR includes a constant preoccupation about their performance (obj. 3), which restricts the time and follow-up allocated to each client. The clinicians’ assessments and their interventions are often limited to the object of referral, which is usually about autonomy in personal care and mobility, unless the client’s safety is threatened. This study provides a comprehensive understanding of the involvement of ID and, specifically, the performance optimization process, in the CR of community occupational therapists. The performance preoccupation is associated with a reduction in occupational therapists’ range of actions. Therefore, their capacity to be truly autonomous, the clients’ access to services as well as the fulfilment of the healthcare system’s objectives are compromised.

The aim of this study was to explore how homecare services work to support the elderly people during the COVID-19 pandemic in Gävle, Sweden. This study has been done by using qualitative methods to get a deeper understanding and knowledge about how homecare services are supporting elderly people at their homes during the COVID-19 pandemic. Furthermore, to collect the data for this qualitative study, semi-structured interviews have been conducted with four participants who have been working with homecare services. Empowerment theory has been chosen to explain and analyse how elderly people receive the support from the homecare services to continue their daily life during the COVID-19 pandemic. In the result the data that was collected for this study was arranged in two different themes: Support Strategy and Challenges. The results showed that the homecare services continue to provide the support and services to the elderly even in the time of pandemic. The finding also shows the different strategies that Homecare services apply to cope with challenges that they face while supporting their client as well as their workers during the time of Pandemic.

In the light of an ageing society with shrinking economic resources, deinstitutionalization of elderly care is a general trend. As a result, homecare is increasing, and increasingly shared between different health and social care organizations. To provide a holistic overview about the patient care process, i.e. to be patient-centred, shared homecare needs to be integrated. This requires improved support for information sharing and cooperation between different actors, such as care professionals, patients and their relatives. The research objectives of this thesis are therefore to study information and communication needs for patient-centered shared homecare, to explore how integrated information and communication technology (ICT) can support information sharing, and to analyze how current standards for continuity of care and semantic interoperability meet requirements of patient-centered shared homecare. An action research approach, characterized by an iterative cycle, an emphasis on change and close collaboration with practitioners, patients and their relatives, was used. Studying one specific homecare setting closely, intersection points between involved actors and specific needs for information sharing were identified and described as shared information objects. An integration architecture making shared information objects available through integration of existing systems was designed and implemented. Mobile virtual health record (VHR) applications thereby enable a seamless flow of information between involved actors. These applications were tested and validated in the OLD@HOME-project. Moreover, the underlying information model for a shared care plan was mapped against current standards. Some important discrepancies were identified between these results and current standards for continuity of care, stressing the importance of evaluating standardized models against requirements of evolving healthcare contexts. In conclusion, this thesis gives important insights into the needs and requirements of shared homecare, enabling a shift towards patient-centered homecare through mobile access to aggregated information from current feeder systems and documentation at the point of need.

<p>How can we develop usable and work process-oriented ICT systems for shared homecare?</p><p>Shared homecare involves different professionals, consists of mobile work and requires immediate and ubiquitous access to patient-oriented information, supporting an integrated view on the care process.</p><p>This thesis presents a new collaborative design method for user needs analysis and requirements specification in the context of health information systems development; the Multi-disciplinary Thematic Seminar (MdTS) method. The thesis also describes the MdTS method’s application and two different usability evaluations of the developed system.</p><p>The MdTS addresses a significant problem with health information technologies; they tend to support collaborative work of healthcare professionals poorly, sometimes leading to a fragmentation of workflow and disruption of healthcare processes. Based on human-computer interaction methods, MdTS implies a multiple-user needs analysis by thorough investigation of the entire interdisciplinary cooperative work and its transformation into technical specifications in order to develop appropriate information and communication technology (ICT) for the users’ differing work situations.</p><p>Application of the MdTS resulted in a prototype, the OLD@HOME Virtual Health Record (VHR), adapted to the specific demands in shared homecare. Through mobile devices each care professional accessed patient information in profession-specific views from an integrated platform.</p><p>This thesis provides an interesting case, illustrating how mobile ICT can support shared homecare, thereby bridging health and social care activities and improving knowledge about joint work processes.</p><p>Results from the usability evaluations were overall positive. Information needed at point of care was available on mobile devices and presented in an understandable manner. However, the evaluations also indicated that it is difficult to transfer results from one homecare setting to another due to differences in operational routines.</p><p>In conclusion, application of the MdTS method, in this study, succeeded in elicitation of correct user needs and in transferring correct requirements specifications to system developers for implementation.</p>

How can we develop usable and work process-oriented ICT systems for shared homecare? Shared homecare involves different professionals, consists of mobile work and requires immediate and ubiquitous access to patient-oriented information, supporting an integrated view on the care process. This thesis presents a new collaborative design method for user needs analysis and requirements specification in the context of health information systems development; the Multi-disciplinary Thematic Seminar (MdTS) method. The thesis also describes the MdTS method’s application and two different usability evaluations of the developed system. The MdTS addresses a significant problem with health information technologies; they tend to support collaborative work of healthcare professionals poorly, sometimes leading to a fragmentation of workflow and disruption of healthcare processes. Based on human-computer interaction methods, MdTS implies a multiple-user needs analysis by thorough investigation of the entire interdisciplinary cooperative work and its transformation into technical specifications in order to develop appropriate information and communication technology (ICT) for the users’ differing work situations. Application of the MdTS resulted in a prototype, the OLD@HOME Virtual Health Record (VHR), adapted to the specific demands in shared homecare. Through mobile devices each care professional accessed patient information in profession-specific views from an integrated platform. This thesis provides an interesting case, illustrating how mobile ICT can support shared homecare, thereby bridging health and social care activities and improving knowledge about joint work processes. Results from the usability evaluations were overall positive. Information needed at point of care was available on mobile devices and presented in an understandable manner. However, the evaluations also indicated that it is difficult to transfer results from one homecare setting to another due to differences in operational routines. In conclusion, application of the MdTS method, in this study, succeeded in elicitation of correct user needs and in transferring correct requirements specifications to system developers for implementation.

This paper deals with one of quality standards in homecare services {--} individual planning during the homecare services. It shows principal and content of individual planning during the assistance with a client on present legislative background. It pays attention to homecare services characteristic and specification of its target group, particularly to skills, knowledge and key competences of employees, who are necessary for discovering clients´ personal goals, activating their resources and settling adequate support. There are also integrated theoretical requirements with practical instructions of methods usage and techniques of individual planning during homecare services with communicative and non-communicative clients. These principals are contact, dialog and relationship between key worker and client. The aim of this material is to give proposal for methodical content of individual planning in homecare services, thus set of rules describing course of this process.

L’expansion de l’organisation de la production des biens et services sous forme de réseau, découlant de la recherche de flexibilité face à une concurrence économique accrue, soulève des enjeux importants pour les relations industrielles. Notre thèse s’intéresse au processus de précarisation des emplois dans les segments externalisés des réseaux de production. Elle se base sur trois études de cas portant sur les réseaux de services publics et privés d’aide à domicile au Québec. Les études en droit critique ont montré que le droit du travail, fondé sur le modèle de l’entreprise intégrée et de la relation d’emploi bipartite, ne parvient pas à identifier comme employeurs certaines organisations dont l’action a pourtant un effet déterminant sur les conditions de travail dans les réseaux. Notre thèse visait donc à mettre en lumière la réalité empirique des relations de pouvoir qui traversent les réseaux et leurs effets et ce à partir d’un modèle analytique transdisciplinaire intégrant les dimensions juridiques et sociologiques. Les résultats nous amènent d’abord à constater que l’employeur juridique des travailleuses employées par les prestataires privés intégrés aux réseaux – une majorité de femmes – est le plus souvent une agence de location de personnel, une entreprise d’économie sociale ou même l’usager-ère des services d’aide à domicile. Cet employeur est rarement identifié aux organismes publics, donc sous l’égide de l’État, qui exercent un pouvoir prépondérant dans ces réseaux. Le décalage entre la régulation juridique du travail et la réalité empirique du pouvoir intra-réseau entraîne une précarisation de la protection sociale et des conditions de travail de ces travailleuses. Ainsi, la faible protection de leurs droits de représentation et de négociation collectives facilite l’imposition de la « disponibilité permanente juste-à-temps », combinant les logiques du lean et du travail domestique, ainsi qu’une déqualification sexuée et racialisée de leurs emplois par rapport à la situation dans le secteur public. Notre étude montre néanmoins que certaines pratiques innovatrices d’action collective réticulaire ont pu influencer la dynamique de pouvoir, en particulier celles portées par des associations locales de personnes handicapées recourant aux services et par un syndicat de travailleuses d’agence. / The increasing trend towards organizing the production of goods and services into networks as a result of the quest for flexibility in the face of fierce economic competition raises critical issues for industrial relations. Our thesis examines the precarization of jobs in the externalized segments of production networks. It is based on three case studies focusing on the networks of public and private homecare services in Quebec. Critical law studies have shown that labour law, based on the model of the integrated firm and the binary employment relationship, fails to identify as employers some organizations whose action nevertheless has a decisive impact on working conditions in these networks. Our thesis thus aimed to shed light on the empirical reality of the power relations prevailing throughout the networks and their effects, using an interdisciplinary analytical model that integrates the legal and sociological dimensions. Results indicate that the legal employer of workers – most of them women – employed by private service providers integrated into the networks is most often an employment agency, a social economy enterprise or the individual using the homecare services. This employer is rarely identified as being among the public organizations which, under the aegis of state, exercise predominant power over these networks. The gap between the legal regulation of labour and the empirical reality of intra-network power leads to a precarization of the social protection and working conditions of these women workers. Thus, the weak protection of their rights to collective representation and collective bargaining facilitates the imposition of “just-in-time permanent availability”, combining lean management logic with domestic work logic, and leads to a gendered and racialized deskilling of their jobs compared to the situation prevailing in the public sector. Our study nevertheless shows that some innovative practices involving reticular collective action – in particular practices implemented by local associations of disabled persons using the services and by a union of female agency workers – have had an influence on these power dynamics.

L’expansion de l’organisation de la production des biens et services sous forme de réseau, découlant de la recherche de flexibilité face à une concurrence économique accrue, soulève des enjeux importants pour les relations industrielles. Notre thèse s’intéresse au processus de précarisation des emplois dans les segments externalisés des réseaux de production. Elle se base sur trois études de cas portant sur les réseaux de services publics et privés d’aide à domicile au Québec. Les études en droit critique ont montré que le droit du travail, fondé sur le modèle de l’entreprise intégrée et de la relation d’emploi bipartite, ne parvient pas à identifier comme employeurs certaines organisations dont l’action a pourtant un effet déterminant sur les conditions de travail dans les réseaux. Notre thèse visait donc à mettre en lumière la réalité empirique des relations de pouvoir qui traversent les réseaux et leurs effets et ce à partir d’un modèle analytique transdisciplinaire intégrant les dimensions juridiques et sociologiques. Les résultats nous amènent d’abord à constater que l’employeur juridique des travailleuses employées par les prestataires privés intégrés aux réseaux – une majorité de femmes – est le plus souvent une agence de location de personnel, une entreprise d’économie sociale ou même l’usager-ère des services d’aide à domicile. Cet employeur est rarement identifié aux organismes publics, donc sous l’égide de l’État, qui exercent un pouvoir prépondérant dans ces réseaux. Le décalage entre la régulation juridique du travail et la réalité empirique du pouvoir intra-réseau entraîne une précarisation de la protection sociale et des conditions de travail de ces travailleuses. Ainsi, la faible protection de leurs droits de représentation et de négociation collectives facilite l’imposition de la « disponibilité permanente juste-à-temps », combinant les logiques du lean et du travail domestique, ainsi qu’une déqualification sexuée et racialisée de leurs emplois par rapport à la situation dans le secteur public. Notre étude montre néanmoins que certaines pratiques innovatrices d’action collective réticulaire ont pu influencer la dynamique de pouvoir, en particulier celles portées par des associations locales de personnes handicapées recourant aux services et par un syndicat de travailleuses d’agence. / The increasing trend towards organizing the production of goods and services into networks as a result of the quest for flexibility in the face of fierce economic competition raises critical issues for industrial relations. Our thesis examines the precarization of jobs in the externalized segments of production networks. It is based on three case studies focusing on the networks of public and private homecare services in Quebec. Critical law studies have shown that labour law, based on the model of the integrated firm and the binary employment relationship, fails to identify as employers some organizations whose action nevertheless has a decisive impact on working conditions in these networks. Our thesis thus aimed to shed light on the empirical reality of the power relations prevailing throughout the networks and their effects, using an interdisciplinary analytical model that integrates the legal and sociological dimensions. Results indicate that the legal employer of workers – most of them women – employed by private service providers integrated into the networks is most often an employment agency, a social economy enterprise or the individual using the homecare services. This employer is rarely identified as being among the public organizations which, under the aegis of state, exercise predominant power over these networks. The gap between the legal regulation of labour and the empirical reality of intra-network power leads to a precarization of the social protection and working conditions of these women workers. Thus, the weak protection of their rights to collective representation and collective bargaining facilitates the imposition of “just-in-time permanent availability”, combining lean management logic with domestic work logic, and leads to a gendered and racialized deskilling of their jobs compared to the situation prevailing in the public sector. Our study nevertheless shows that some innovative practices involving reticular collective action – in particular practices implemented by local associations of disabled persons using the services and by a union of female agency workers – have had an influence on these power dynamics.