Stories and metaphors in the sensemaking of multiple primary health care organizational identities

BACKGROUND The Quebec primary health care delivery system has experienced numerous reforms over the last 15 years. In this study, we sought to examine how managers and primary care providers made sense of the creation of successive new primary care organizational forms. METHODS We conducted a longitudinal qualitative case study in a primary care practice group located in Montreal, Quebec, for over 6 years (2002 to 2008). The data sources for the study include 31 semi-structured interviews with key informants, in-situ observations of group meetings, as well as documents and field notes. Textual material was submitted to narrative and metaphor analysis. RESULTS The core metaphor of the journey came from a set of stories in which the members of this primary care group depicted the processes undertaken towards developing a multidisciplinary cooperative practice, which include an uneasy departure, uncertainty about the destination, conflict among members who jump ship or stay on board, negotiations about the itinerary, and, finally, enduring challenges in leading the way and being pioneers of change in the organization of primary care in their institutional context. Identification with the initial family medicine unit identity was persistent over time, but successive reforms further enriched its meaning as it became a multidisciplinary primary care practice pioneering organizational change. CONCLUSIONS In order to support primary care reforms in complex institutional fields, this study proposes that decision-makers undertake a journey in which they recognize both the need to capitalize on existing meaningful and legitimated organizational identities, as well as the necessity for collective leadership in the management of multiple organizational identities over time.