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Why does collaboration on patient care falter?
It is not merely the employees, but also the systems and leaders that need to improve collaboration.
In her research, Trude Senneseth examines the collaboration between the specialist health service Bergen Hospital Trust, the municipalities Øygarden and Askøy, as well as the Norwegian Labour and Welfare Administration NAV, regarding adult patients within mental health and substance abuse.
With over 20 years of experience as a clinical psychologist in municipal and specialist health services in Bergen Hospital Trust, Senneseth has frequently encountered significant frustration and concern for her patients when collaboration breaks down.
However, Senneseth believes this isn't about employees intentionally causing difficulties, but rather a proliferation of misunderstandings about the roles and responsibilities of the other parties concerning patients.
Good intentions, incorrect expectations
"There's probably not a person working in mental health and substance abuse who does not feel the challenges in collaboration and interaction. We have many expectations of each other that do not align with reality. We simply lack sufficient knowledge about each other; we know too little about what each other does," Senneseth says.
Regardless of how good the intentionsof employees in the systems are, this is insufficient on its own. When parties are uncertain about what the others are doing, patients may fall through the cracks, and their essential needs may go unmet.
“Adults with mental health issues, and sometimes substance abuse problems, require multiple concurrent services. They depend on the units cooperating effectively," she says.
Through several service design projects, patients have responded to how they experience the consequences of collaboration challenges.
“They feel insecure because they don't know what to expect from the different units. At times, they also experience units speaking derogatorily about each other, causing them to lose trust transitioning from one system to another,” Senneseth says.
Undermining trust and patient safety
Poorly functioning collaborative relationships can also directly impact patient safety, according to Senneseth.
“Patients often feel that what is important to them is not emphasised, leading to a loss of trust that we understand their unique situation and needs. There's a risk they won't receive what they need when they need it, compromising patient safety,” she says.
Senneseth strongly desires her research to contribute to improved collaboration for the mentioned patient group. Central to her work are theoretical frameworks surrounding ‘social innovation’ and ‘action research’.
Social innovation involves finding new solutions to societal problems and does not aim to achieve commercial results.
Senneseth's research project also includes a service innovation component. The goal here is to facilitate collaboration across units and establish a comprehensive service offering for patients. This project has received support from the public Stimulab scheme.
Action research refers to research where the researcher is actively involved; they can propose change measures, participate in and control the measures, and evaluate their effects.
“The social innovation aspect of the research involves changing relationships, gaining access to new knowledge, and altering the understanding of what the problem really is. Everyone's perspectives are considered,” Senneseth explains.
“My role as an action researcher has been to work alongside organisations, see what tools we can find to make collaboration easier, understand what is important for our common users, and identify what we can use in organisations to offer cooperation and interaction.”
She collects research data through a leadership network where the four parties have a total of 17 representatives.
The network, which was established at the same time as the research began, consists of leaders at various levels, including clinic directors, municipal managers, and unit leaders. They therefore also have good access to bring feedback from employees who are closer to the users of the services.
The leadership group meets several times a year to address issues and share experiences to learn from and about each other. Since 2019, Senneseth has mapped and measured collaboration using the Joint Action Analytics tool.
Before the meetings, leaders, along with their employees, respond to surveys about their collaboration with the other parties. Senneseth presents the results from these surveys at the leadership network's meeting.
“Many have recognised that there have been many poor collaborative relationships, where we can't expect high quality and efficient task resolution," she says.
In the leadership network, they reflect on questions like: How does my organisation inadvertently hinder your organisation? How are you hindering me? What can we do or avoid doing to prevent tripping each other up?
"No one wants to sabotage each other and the patient,” she emphasises.
Senneseth's main finding is that when leaders look at the data together and discuss it, they learn a lot about each other. They are surprised they didn't know more about each other before, and they didn't realise how many actors are involved.
“When they understand that the others are working very hard to solve the same problem they are working so hard on, they stop being so accusatory that the others ‘aren't doing anything’. They might understand that the expectations of the other organisation were a bit unrealistic,” she says.
Finding room for action
Discussion and reflection in the network about the problem are crucial to finding solutions.
“It turns out that leaders have room for action when they get to know the other leaders, understand how others lead, and feel confident that we are in this together. They actually have a greater room for action than they initially think,” says Senneseth, who has seen a clear development over the years she has followed the leadership network.
It has simply become a culture change, with less blame-shifting and more desire to collaborate to find new solutions. Leaders describe that they have more empathy for each other when sharing common despair over challenging fates that are difficult to provide good help for.
“They manage to stretch further to meet each other, avoiding the trap of accusing others of common shortcomings. The result is simply better for both the common patients and those working in the services,” she says.
At the same time, Senneseth has noted that the pressure on the services has increased. Apart from competence support for innovation projects, there has been no increase in resources.
“So it's interesting to see how much the leaders achieve even though the solutions must be within existing frameworks. Jointly created knowledge provides leaders with much better control data, and opportunities for strategic leadership for cohesive services,” she says.
“They didn't have that before. Then they were subjected to challenging goals without control data and tools to create change. These leaders show that you can create room for action yourself by co-creating local data that makes sense in your own context.”
Senneseth, T. & Berg, L.N. Public Sector leaders collaborating across organisations for social innovation: The impact of relational data, Conference: Forskningens dag i Helse Bergen 2023. DOI: 10.13140/RG.2.2.33970.38085
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