Why does collaboration on patient care falter?

This issue is highlighted by RESINNREG fellow Trude Senneseth. In her doctoral work, she examines the collaboration between the specialized health service Helse Bergen, the municipalities Øygarden and Askøy, and Nav regarding adult patients in mental health and substance abuse.

With over 20 years of experience as a clinical psychologist in municipal and specialized health services in Helse Bergen, 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.

Read more about the RESINNREG doctoral program here

Good Intentions, Incorrect Expectations

There is 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, says Senneseth.

Regardless of the good intentions employees have in the systems, it 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. Through several service design projects, patients have responded to how they experience the consequences of collaboration challenges, she adds.

- 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.

RESINNREG fellow Trude Senneseth examines the collaboration between the specialized health service Helse Bergen, the municipalities Øygarden and Askøy, and Nav regarding adult patients in mental health and substance abuse in her research.

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 emphasized, leading to a loss of trust that we understand their unique situation and needs. There is 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.

According to the Store norske leksikon, 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 organizations, 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 organizations to offer cooperation and interaction.

Measuring Collaboration

She collects research data through a leadership network where the four parties have a total of 17 representatives.

Established concurrently with the start of the research, the network consists of leaders at various levels, including clinic directors, municipal managers, and unit leaders. This provides them with good access to incorporate feedback from employees closer to the service users.

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 recognized that there have been many poor collaborative relationships, where we cannot expect high-quality and efficient task resolution. In the leadership network, we reflect on questions like: How does my organization trip yours unintentionally? How are you tripping me? What can we do or avoid doing to prevent tripping each other? No one wants to sabotage each other and the patient, emphasizes the researcher.

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 realize 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 organization were a bit unrealistic, she says.

Finding Room for Action

Discussion and reflection in the network around 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 observes a clear development in the years she has followed the leadership network.

It has simply become a culture change, with less blame distribution 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, 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 concludes.

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 is interesting to see how much the leaders achieve even though the solutions must be within existing frameworks. Shared co-created knowledge provides leaders with much better control data and opportunities for strategic leadership for cohesive services.

- 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.