Symbolic boundaries in transition to adult care

Adolescents and young adults (AYAs) experience inadequate healthcare. The relative newness of the field of adolescent care reflects the “in-between” category societies ascribe to adolescents and young adults – in between the innocence and hope childhood represents, and fully formed and “productive” citizens that adulthood represents. AYAs have distinctive bio-social needs that represent a fluid and multi-faceted transition between childhood and adulthood. Previous research has acknowledged health challenges of and service inadequacies for AYAs, as well as perceived differences between pediatric and adult care systems. Yet, little research has explored in detail the perspectives of, and processes engaged in by various stakeholders of adolescent care that enact such differences between pediatric and adult care, and responses to those differences. Such research is needed to understand bio-medicine’s linear response to adolescent health, and what is, in reality, required to care for AYAs into the future. The aim of this research is to explore the multi-level influences and meanings that coalesce around particular communities in the care of AYAs. To do so, the research relies on sociological theory relating to social and symbolic boundaries. Such theory accounts for the way people come to share common perspectives and behaviours that distinguish them from other groups and exercise agency in crossing professional and organizational boundaries. Set within an interconnected health system in a large urban centre of Quebec, Canada, an interpretive qualitative strategy was engaged, featuring 43 semi-structured interviews with young adults, parents, and pediatric, adult, and primary care providers. A thematic approach was used to analyze narratives between and within the different groups identified. The findings show that the transition from adolescent to adult care involves two fundamentally different cultures of care that can collide with each other. Pediatric care is rooted in the family and the emulation of a safe, home-like environment, while adult care focuses on the autonomous individual and their ability to care for themselves. Intergroup differences and tensions impede patient transfer, most typically by slowing it down and disconnecting patients from the specialized care to which they had been accustomed. In response, the professionals who comprise health organizations, and patients and families, extend their boundaries to manage the challenges of transition from pediatrics to adult care. In their informal work, they reflect and create interdependence in the form of coordinated health corridors that form practice structures for colleagues to follow. Nevertheless, such processes, reliant on the goodwill of individuals rather than being institutionalized, have limited impact in terms of penetrating strong service boundaries to coordinate care for AYAs, sustainable knowledge transfer and shared experiential learning within and across professional and organizational boundaries. Through informal work and the resulting corridors of care, actors involved in transitional care adjust their identities and render boundaries more permeable, fostering organizational learning, and structuring new norms in the adult care system. The resulting adaptive regulation models sustainable structures and, hence, paves the way for reforms to more formally institutionalize optimal transitional practice structures from adolescent to adult care. The focus on boundaries, perceptions, identities, processes and meaning-production shows the adaptive strength of actors, individually and collectively, and the lack of institutionalization of practice that hinders the sustainable delivery of adolescent-friendly health

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