How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco
Tóm tắt
In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.
We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.
Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.
The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
Từ khóa
Tài liệu tham khảo
Cohen, 2014, The politics of social action in Morocco, Middle East - Topics & Arguments, 2, 74
Errami, 2018, The pertinence of new public management in a developing country: the healthcare system in Morocco, Can J Adm Sci, 35, 304, 10.1002/cjas.1417
Denhardt K . Enhancing ethics in the public service: setting standards and defining values. Public Service in Transition 1999.
Hope Sr KR . The new public management: a perspective from Africa. New public management. Routledge, 2005: 222–38 p..
Oduro-Mensah, 2013, Care decision making of frontline providers of maternal and newborn health services in the greater Accra region of Ghana, PLoS One, 8, 10.1371/journal.pone.0055610
Decret n°2-06-656 relatif l'organisation hospitalière 2007.
Belghiti Alaoui A . Strategies de capacitation en stewardship Au MAROC: RAPPORT de Recherche. RABAT DHSA; 2003: 169 p.
Belghiti AA , Sahel A AZ . Stratégies de capacity building en stewardship Au Maroc Institut de médecine; 2002.
Belghiti AA , Boffin N , Brouwere D . L’espace de décision de la gestion des ressources humaines sanitaires au Maroc. Rabat Royaume du Maroc, Ministère de la santé; 2004.
Blaise PJ , Dujardin B , Kegels G . Culture qualité et organisation bureaucratique, Le défi Du changement dans les systèmes publics de santé: une évaluation réaliste de projets de qualité en Afrique 2004.
Belrhiti, 2019, Does public service motivation matter in Moroccan public hospitals? a multiple embedded case study, Int J Equity Health, 18, 10.1186/s12939-019-1053-8
Cours des comptes . Rapport de la cours des comptes sur les centre Hospitalier provincial de Skhirat -Temara. Rabat Royaumes du Maroc; 2016.
Cours des comptes . Rapport de la cours des comptes sur les centres Hospitalier Régional Marakech. Rabat Royaume du Maroc; 2016.
Cours des comptes . Rapport de la cours des comptes SUR Le centres Hospitalier Mohamed V de Tanger. Royaume du Maroc Cours des Comptes; 2016.
Marchal, 2013, Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco, BMC Health Serv Res, 13, 10.1186/1472-6963-13-469
Semlali H . The Morocco Country Case Study : Positive Practice Environements Global Health Workforce Alliance 2010.
Akhnif, 2019, The place of learning in a universal health coverage health policy process: the case of the RAMED policy in Morocco, Health Res Policy Syst, 17, 21, 10.1186/s12961-019-0421-6
Mohamed, 2016, The ethical dimension in the new public management: revisiting the theory of accountability, the case of public finances in Morocco, Eur Sci J, 12, 440
Buehler, 2015, Labour demands, regime Concessions: Moroccan unions and the Arab uprising, British Journal of Middle Eastern Studies, 42, 88, 10.1080/13530194.2015.973189
ed Kwamie ABA , Lehmann U . Leadership, management and organizational cultures. In: Health policy and systems research reader on human resources for health. Geneva: WHO, 2017 G A, K S, V G,.
AHPSR . Open Mindsets : Participartory Leadership for Health flagship report 2016. Geneva World Health Organisation; 2016.
Håvold, 2019, Power, trust and motivation in hospitals, Leadersh Health Serv, 32, 195, 10.1108/LHS-03-2018-0023
Strauss AL . Negotiations: varieties, contexts, processes, and social order. Jossey-Bass Inc Pub, 1978.
Belrhiti, 2020, Unravelling the role of leadership in motivation of health workers in a Moroccan public Hospital: a realist evaluation, BMJ Open, 10, 10.1136/bmjopen-2019-031160
Belrhiti, 2020, The effect of leadership on public service motivation: a multiple embedded case study in Morocco, BMJ Open, 10, 10.1136/bmjopen-2019-033010
Belrhiti Z . Unravelling the role of leadership in motivation of health workers in four Moroccan hospitals. Morocco: Vrije Universiteit Brussel & Institute of Tropical Medicine, 2020.
Dinh, 2014, Leadership theory and research in the new millennium: current theoretical trends and changing perspectives, Leadersh Q, 25, 36, 10.1016/j.leaqua.2013.11.005
Marion R , Rumsey MG . Organizational leadership and complexity mechanisms. In: Oxford Handbook of leadership, 2012.
Uhl-Bien M . Complexity leadership :part 1. Unites States of America: Information aged publishing, 2008.
Viitala, 2014, Leadership in transformation: a longitudinal study in a nursing organization, J Health Organ Manag, 28, 602, 10.1108/JHOM-02-2014-0032
Crozier M . The bureaucratic phenomenon. Chicago: University of Chicago Press, 1964.
Crozier M , Friedberg E . L'acteur et Le Système 1977.
Strauss A , Fagerhaugh S , Suczek B . Social organization of medical work. Chicago, London: The University of Chicago Press, 1985.
Johnson TJ Association BS , ed. Professions and power Kindle edition. Oxon, UK & New York, USA: Routledge Revivals, 2016.
Friedson E . Profession of medicine: a study of the sociology of applied knowlege: Dodd. Mead & Company 1970.
Hugman R . Power in caring professions. Houndmills, Basingstoke, Hampshire, London: The MacMillan Press LTD, 1991.
Mintzberg H . The structuring of organizations. readings in strategic management. Springer, 1989: 322–52 p..
Davies, 2019, Solidarity and responsibility in health care, Public Health Ethics, 12, 133, 10.1093/phe/phz008
Mechanic, 1962, Sources of power of lower participants in complex organizations, Adm Sci Q, 7, 349, 10.2307/2390947
Friedland R , Alford RR . Bringing society back in : symbols, practices and institutional contradictions. In: Powell WW , DiMaggio PJ , eds. The new institutionalism in organizational analysis. Chicago: Chicago University Press, 1991: 232–63 p..
Scott RW . Institutions and organizations. Thousand Oaks: Sage Publications, 2001.
Decret n°2-14-562 du 7 chaoual 146 (24 juillet 2015) pris pour l’application de la loi -cadre n°>34-09 relative au système de santé et l’offre de soins, en ce qui concerne l’organisation de l’offre de soins, la carte sanitaire et les schémas régiionaux de l’offre de soins 2015.
In Maroc Rdu santé Mdela , ed. Carte Sanitaire et situation de l’offre de soins 2019. Rabat, 2021.
Yin RK . Case study research and applications: design and methods. Thousand Oaks, California, USA: Sage publications, 2018.
Mahoney J , Rueschemeyer D . Comparative historical analysis. Comparative historical analysis in the social sciences 2003:3–38.
Patton MQ . Qualitative Research & Evaluation Methods. Thousand Oaks, London, New Delhi: Sage Publications, 2001.
l’arrêté du Ministère de la Santé N° 456-11 du 2 Rajeb 1431 (6 juillet 2010) portant règlement Intérieur des Hôpitaux ; publié au Bulletin Officiel N° 5926 du 12 rabii II 1432 (17 Mars 2011) 2011.
Rubin HJ , Rubin IS . Qualitative interviewing: the art of hearing data. Sage, 2011.
Krueger RA , Casey MA . Focus groups: a practical guide for applied research. Los Angeles, London, New Delhi, Singapore, Washington DC: Sage publications, 2014.
Miles MB , Huberman AM , Saldana J . Qualitative data analysis. 3 ed. Los Angeles, London, New Delhi, Singapore, Washington DC: Sage, 2016.
Yin RK . Qualitative research from start to Finish. New York, London: The Guilford Press, 2016.
Saldaña J . The coding manual for qualitative researchers. Los Angeles, London, New Delhi, Singapore, Washington DC: Sage, 2015.
QSR International Pty Ltd . NVivo qualitative data analysis software. 11.4 ED; 2014.
Dahir du 1 juillet 1941 modifié par dahir du 7 mai 1949 instituant l’Ordre des médecins 1941.
Akhmisse M . Histoire de la médecine au Maroc des origines l’avènement du protectorat. In: Moussaoui D , Dessarps MR , eds. Histoire de la médecine Au Maroc et dans les pays Arabes et Musulmans. Casablanca: Association Marocaine d’Histoire de la Médecine, 1995.
Agyou A . Histoire de la profession infimière Au Maroc Rabat: Ministère de la santé, Maroc; 2019.
Ghoti M . Histoire de la Médecine au Maroc, le 20 siècle :1896-1994; 1995.
Moussaoui D , Dessarps MR . Histoire de la médecine au Maroc et dans les pays Arabes et Musulmans Casablanca: Association Marocaine d’Histoire de la Médecine 1995.
Fourtassi, 2020, Medical education in Morocco: current situation and future challenges, Med Teach, 42, 973, 10.1080/0142159X.2020.1779921
OECD . Recent trends in international migration of doctors, nurses and medical students; 2019.
Dahir n°1-15-26 du 29 rabii II 1436 (19 février 2015) portant promulgation de la loi n°131-13 relative l’exercice de la médecine, 131-13 2013.
WHO . Health workforce snapshot Morocco. Geneva: World health organisation, regional officer for the eastern mediterraneen; 2020. Report No.: WHO-EM/HRH/645/E.
Arrêté n° 2.06.620 Du 24 Rabii premier 1428 (13 avril 2007) relatif aux règlement interieur Du conseil des infirmièrs Du Ministère de la santé 2007.
Freidson E . Professionalism, the third logic: on the practice of knowledge. University of Chicago press, 2001.
Kitchener, 2000, Supervising Professional Work under New Public Management: Evidence from an ‘Invisible Trade’, British Journal of Management, 11, 213, 10.1111/1467-8551.00162
Begun JW , Thygeson M . Managing complex healthcare organizations. In: Handbook of healthcare management. Northampton: Edward Elgar, 2015: 1–17.
Mintzberg H . Structure in fives: designing effective organizations. New Jersey, USA: Prentice-Hall, Inc, 1993.
Blaise P , Sahel A , Afilal R . Ten years of quality projects and their effect on the organisational culture of the Morrocan health care system. Quality in services: higher education, health care, local government. 7th" Toulon-Verona" Conference; 2-3 September 2004, Toulon, France, 2004.
Kirkpatrick I , Ackroyd S , Walker R . Professions and Professional Organisation in UK Public Services. In: The new managerialism and public service professions. Springer, 2005: 22–48 p..
Weber M . Economy and society: an outline of interpretive sociology. Univ of California Press, 1978.
van Mook, 2009, Professionalism: evolution of the concept, Eur J Intern Med, 20, e81, 10.1016/j.ejim.2008.10.005
Moore WE . The professions: roles and rules. Russell Sage Foundation, 1970.
Décret n° 2-96-796 Du 11 chaoual 1417 (19 février 1997) fixant Le régime des études et des examens en Vue de l'obtention Du doctorat, Du diplôme d'études supérieures approfondies et Du diplôme d'études supérieures spécialisés ainsi que les conditions et modalités d'accréditation des établissements universitaires assurer La préparation et La délivrance de CES diplômes 1997.
CNCES . CAHIER des NORMES PEDAGOGIQUES NATIONALESDUDIPLOME de DOCTEUR en MEDECINE. Rabat Commission Nationale de Coordination de l'Enseignement Supérieur, Ministère de l’éducation nationale, formation professionnelle, enseignement supérieur et recherche scientifique; 2015.
Le décret n° 2-64-422 du 26 joumada II 1384 (2 novembre 1964 intituant l’ordre des médecins. 1964.
Décret n° 2-82-356 Du 16 rebia II 1403 (31 janvier 1983) fixant Le régime des études et des examens en Vue de l'obtention Du diplôme de docteur en médecine (Arabe) 1983.
Décret n° 2-85-144 du 7 hija 1407 (03 aout 1987) fixant le régime des études et des examens en vue de l’obtention du diplôme de docteur en pharmacie 1987.
Décret n° 2-82-444 Du 16 rebia II 1403 (31 janvier 1983) fixant Le régime des études et des examens en Vue de l'obtention Du diplôme de docteur en médecine dentaire (Arabe) 1983.
Freidson E . Professional dominance: the social structure of medical care. Transaction Publishers, 1974.
Regan, 1984, Some limits to the hospital as a negotiated order, Soc Sci Med, 18, 243, 10.1016/0277-9536(84)90086-8
Décret N° 2.93.602 Du 29 Octobre 1993 creation of Instituts de formation aux Carrières de Santé (IFCS) « 1993.
Arrêté n° 2.06.620 Du 24 Rabii premier 1428 (13 avril 2007) relatfi aux règlement interieur Du conseil des infirmièrs Du Ministère de la santé 2007.
Mintzberg, 1999, Organigraphs: drawing how companies really work, Harv Bus Rev, 77, 87
Maines DR , Charlton JC . The negotiated order approach to the analysis of social organization. Studies in Symbolic Interaction 1985.
De Geyndt, 2017, Does autonomy for public hospitals in developing countries increase performance? evidence-based case studies, Soc Sci Med, 179, 74, 10.1016/j.socscimed.2017.02.038
Belrhiti, 2018, Complex leadership in healthcare: a scoping review, Int J Health Policy Manag, 7, 1073, 10.15171/ijhpm.2018.75
Uhl-Bien, 2007, Complexity leadership theory: shifting leadership from the industrial age to the knowledge era, Leadersh Q, 18, 298, 10.1016/j.leaqua.2007.04.002
Gilson, 2016, Everyday politics and the leadership of health policy implementation, Health Syst Reform, 2, 187, 10.1080/23288604.2016.1217367
Héritier, 2008, The shadow of hierarchy and new modes of governance, J Public Policy, 28, 1, 10.1017/S0143814X08000755
Barasa, 2017, Hospitals as complex adaptive systems: a case study of factors influencing priority setting practices at the hospital level in Kenya, Soc Sci Med, 174, 104, 10.1016/j.socscimed.2016.12.026
Gilson, 2018, Strengthening health system leadership for better governance: what does it take?, Health Policy Plan, 33, ii1, 10.1093/heapol/czy052
Zimmerman B , Lindberg C , Plsek P . A complexity science primer: what is complexity science and why should I learn about it. Adapted From: Edgeware: Lessons From Complexity Science for Health Care Leaders, Dallas, TX: VHA Inc, 1998.
Zimmerman B , Lindberg C , Plsek P . Edgeware: lessons from complexity science for health care leaders. 2nd ed. USA: Irving, Tex: VHA, 1998.
Zimmerman, 1994, Intensive care at two teaching hospitals: an organizational case study, Am J Crit Care, 3, 129, 10.4037/ajcc1994.3.2.129
Kernick D . Complexity and healthcare organization: a view from the street. Radcliffe Publishing, 2004.