La mise en œuvre de services cliniques intégrés sous l’angle du sensemaking organisationnel : le cas des services intégrés en santé mentale et en dépendance

The main objective of this thesis is to further our understanding of the implementation process of integrated care in an organizational context. It is structured on the sensemaking perspective (Weick, 1995).   At first, we studied how actors construct the meaning of the integration project they had to implement, and the impact of this sensemaking on clinical and organizational issues. The context studied is a new organization created to provide ultra-specialized services to patients suffering from co-occurring mental health and addiction disorders. We used a qualitative research strategy and based our analysis on longitudinal data (8 years) collected from three sources: semi-structured interviews, observations and document analysis. This analysis has resulted in two articles. While the first article focuses on the transformation of professional practices, the second article examined the phenomenon in terms of organizational identity.  Secondly, we conducted a critical analysis of the literature,focused on current trends in the way implementation studies of integrated services are carried out. The results are presented in the third article. Four main findings emerge from this work. The first finding is that the implementation of integrated care is a dynamic phenomenon, not without strain or tensions. In other words, this is an evolutive phenomenon that is defined and redefined depending on events, but never completely renewed. The enaction and commitment of professionals appeared to be key explanatory mechanisms of this phenomenon. The second finding is that implementation is actualized through interrelated levels of integration, which means that the context of implementation and the object that is implemented co-evolve and become mutually transformed. Our results showed that the concept of "coupling practices" was useful to capture this dynamic. The third finding is that implementation remains deeply rooted in the meaning that organizational members collectively construct of the integration project, through their everyday actions and interactions. This sensemaking leads to understanding how the content and form of the integration project are shaped according to circumstances, both from clinical and organizational aspects. The fourth finding is that these dynamics remain relatively unexplored to date in the scientific literature on the implementation of integrated care for co-occurring disorders. We hypothesize that this lack of recognition may explain some of the actual difficulties in implementing these services. Overall, these findings considerably enrich general understanding of the phenomenon by revealing the dynamics that constitute it and the issues it raises. Also decision makers and researchers consideration of these dynamics has the potential to promote and improve integrated practices.

Keyphrases: Sensemaking, Double diagnostic, Étude qualitative, Integrated care, Implementation, Dual diagnosis, Change process, Professional practices, Organizational identity, Qualitative study