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Reading: Exploring the quality paradigms in Integrated Care: the need for emergence and reflection


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Exploring the quality paradigms in Integrated Care: the need for emergence and reflection


Wilma van der Vlegel

Hogeschool Utrecht, University Of Applied Sciences, NL
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Despite the abundance of projects on integrated care there is a lack of knowledge on what works in what context. This could be due to the fact that people use different lenses through which they see the world. These lenses are described in the four paradigms of quality: Empirical, Reflective, Reference, and Emergence. The empirical and reference paradigm fit best in circumstances that are certain or can be planned; the reflective paradigm and emergence paradigm fit best in circumstances which are uncertain and cannot be planned. Integrated Care could benefit applying knowledge from all four paradigms, which we call epistemic fluency. In a previous article Van Kemenade & Van der Vlegel-Brouwer (2019) shed light on the presence of the four paradigms of quality in Integrated Care and in the most used definitions of Integrated Care. They propose a new overarching definition. This study aims to explore the use of quality paradigms in integrated care research. Secondly, the presence of each paradigm is studied in different contexts, looking at the different countries of origin, the domain of impact in research, policy or practice and role of the patient.

Theory and Methods: 

This article explores research on integrated care from four paradigms of quality management. Peer reviewed articles from the International Journal of Integrated care, research & theory papers, perspective papers, policy papers, integrated care cases from January 2015 – December 2019 are included (n=258) in this study. Based on the four quality paradigms and their characteristics two reviewers assessed all abstracts and placed every article in one of the four quality paradigms. Discrepancies were resolved by reading the article in full and discussion between the reviewers.


The reference paradigm was most prevalent since 147 (57.6%) studies were placed in this paradigm. 55 (21.6%) of the studies were placed in the empirical paradigm and 45 (17.6%) of the studies were placed in the reflective paradigm. Only 8 (3.1%) of the studies were placed in the emergence paradigm.  An active patient role was found in less than 20% of all the studies.

Discussion and conclusions:

All four paradigms occur within the reviewed articles, although the reflective and most of all the emergence paradigm seem undervalued. That is noteworthy since these two paradigms fit best in a context of complexity and uncertainty, where the 21st  century is in. Although integrated care as a movement embraces the attention for complexity, context and client-centeredness, the paradigmatic commitments in the articles of the IJIC from 2015-2019, reflect this only marginally. More awareness of all paradigms, especially the emergence paradigm, and reflection on the used epistemologies, is needed. On this road to a scientific integrated care paradigm we should embrace complexity and the patient perspective.


Lessons learned /future research:

The authors will present the four quality paradigms and their findings from the literature study. After the presentation participants will be able to review their research based on the four quality paradigms. A discussion will be held on the conclusions and the barriers and facilitators for improvement.

How to Cite: van der Vlegel W. Exploring the quality paradigms in Integrated Care: the need for emergence and reflection. International Journal of Integrated Care. 2021;21(S1):45. DOI:
Published on 01 Sep 2021.


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