Multi-method investigation of normative integration in a novel inter-sectoral collaboration between mental health care services and public sick leave insurance organizations in Denmark

Introduction: Inter-sectoral integration is increasingly warranted between the health care sector and other welfare-sectors. However, lack of normative integration (shared mission, values. and culture) among stakeholders is considered an important barrier. An integrated vocational rehabilitation intervention was established in a novel collaboration between public mental health care and sick leave insurance organizations in Denmark. The purpose of this study is to describe how normative integration was developed between the professionals in the inter-sectoral teams delivering the intervention.Theory and Methods: Gittells’ theory of relational coordination (RC) was used to design the interventions’ integration-activities. The theoretical sub-concepts from RC shared knowledge, shared goals and respect were considered aspects of normative integration and constituted the main analytical framework for this study. A mixed methods approach was used to examine the professionals’ perceptions of and experiences with mutual respect, shared goals, and shared knowledge across sectoral borders. This was investigated abductively through 30 semi-structured interviews with professionals and supervisors, 12 participant observations of inter-sectoral meetings, document analysis of 12 inter-sectoral plans, and the validated RC questionnaire. Contextual factors influencing normative integration was investigated inductively through the same data. Data collection began one year after intervention initiation.Results: Synthesizing data showed that mutual respect was established through trust and shared experiences between individual workers from the two sectors. Development of shared goals mainly took place through a growing focus on the predefined purpose of the intervention ‘fast return to work’, though this was initially difficult to internalize for health care professionals. Inter-sectoral meetings with both professionals and the service user on sick leave were assessed to have great potential as a forum for the creation of shared knowledge about the service users. Few inter-sectoral working relationships with co-located full-time professionals supported the development of normative integration.Discussions: This study found that the shared experiences between individual professionals from two sectors were key to the creation of normative integration in the inter-sectoral team. Organization of integrated teams with very few inter-sectoral relationships might be difficult to implement and could compromise intra-professional specialization. However, we argue that team-size and full-time commitment of employees should be considered important factors in novel team-based inter-sectoral collaboration.Conclusions: Normative integration in the intervention was developed through professional’s adaption of intervention goals, increasingly better use of intersectoral meetings and respect build on shared experiences and trust. Few inter-sectoral relationships, full-time employees and co-location were valued important for integration by the professionals.Lessons learned: Few inter-sectoral relationships and shared experiences were facilitators of normative integration across sectors.Limitations: Following initial data collection, the organization of professionals was changed, and analysis showed that there was considerable potential for further development of normative integration thereafter. The long-term perspective was subsequently only investigated through follow-up interviews with supervisors 2.5 years after intervention initiation.Suggestions for future research: We suggest the development of respect, shared goals, and shared knowledge in newly established inter-sectoral integration should be investigated with a long-term longitudinal design

Developing Interpersonal Trust Between Service Users and Professionals in Integrated Services:Compensating for Latent Distrust, Vulnerabilities and Uncertainty Shaped by Organisational Context

Introduction: Studies show a need for trust between stakeholders in integrated services. However, few studies have investigated how trust develops between stakeholders on a micro-level. In a Danish intersectoral intervention for persons on sick leave due to common mental disorders, we explored why trust is needed and how trust is developed between micro-level stakeholders. Methodology: The qualitative study was based on 12 observations of  inter-organisational meetings, 16 interviews with service users, 24 interviews with health care professionals and employment consultants, and 8 interviews with supervisors. The analysis was guided by the theoretical concepts (dis-) trust, vulnerability and uncertainty. Results: Latent distrust between involved organisations, and vulnerabilities and uncertainties related to employment consultants’ statutory power over service users caused a perceived need for interpersonal trust. Time to establish knowledge-based relationships, healthcare professionals’ caring approach, and creating a feeling of sharing interests were compensating trust-building strategies that were often regarded as positive. Discussion and conclusion: Trust in personal relationships between stakeholders appeared to compensate for contextually shaped distrust, vulnerability and uncertainty. Identifying latent distrust, vulnerabilities, uncertainties, and power structures might be key to improving trust-building strategies in a specific context. The time-consuming process of trust-building between micro-level stakeholders should be supported structurally

Multi-method investigation of normative integration in a novel inter-sectoral collaboration between mental health care services and public sick leave insurance organizations in Denmark

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Developing Normative Integration among Professionals in an Intersectoral Collaboration: A Multi-Method Investigation of an Integrated Intervention for People on Sick Leave Due to Common Mental Disorders

Introduction: Intersectoral integration is recommended in vocational rehabilitation, though difficult to implement. We describe barriers to and strategies for the development of normative integration in an intersectoral, team-based vocational rehabilitation intervention. Method: Attitudes and behaviours regarding the development of shared culture, norms, and goals in the collaboration between health care professionals and employment consultants were investigated through 30 semi-structured interviews, participant observation of 12 intersectoral meetings, and document analysis of 12 joint plans. Results: Organisational factors and unsettled power balance between professionals constituted barriers to the development of a shared culture. These issues were resolved by establishing smaller work teams, and through health care professionals' gradual acceptance of employment consultants' control in their capacity as administrators of legislation. Some barriers to shared norms were resolved explicitly, whereas implicit diverging norms were continuously negotiated. The development of shared goals was supported by clarifying the fit between individual, professional, and organisational goals, though the alignment of goals required a paradigmatic change of mindset among the health care professionals. Conclusion: This study shows how normative integration among health care professionals and employment consultants is feasible in co-located intersectoral teams, with positive implications for the delivery of coherent support