Developing a culture of pride, confidence and trust: enhanced collaboration in an interdisciplinary team

Background: Collaborative work is an inherently complex phenomenon. This article explores elements that enhance collaboration and argues that collaboration – understood as evolving processes whereby social entities actively and reciprocally engage in joint activities aimed at achieving a common goal – has not been given sufficient attention in the relevant Norwegian reforms. The Norwegian government implemented the Coordination Reform in January 2012, the aim of which was to provide a sustainable and high-quality health service (Ministry of Health and Care Services, 2012 ). This article uses the term ‘collaboration reform’ as this is the literal meaning of the Norwegian title Samhandlingsreform, and because collaboration seems to describe the aim of the reform better than coordination. Aim: To explore how facilitated processes enhance collaboration in an interdisciplinary team, and discuss how the findings inform issues of collaboration between hospitals and municipal health services. Methods: The design was a cooperative inquiry, that is, a participatory and shared approach to research that aims to facilitate understanding of a shared experience by virtue of cycles of action and reflection. Findings/results: Taking part in facilitated processes gave the team members added awareness about their work, made them more able to handle complex situations and gave them confidence in their own competence and that of their and colleagues. The processes also gave team members opportunities for enhanced sharing and a broader agenda, to notice and detect, and to create a story about who we are and what we do. Conclusions: Trusting and knowing each other is a foundation for collaborative work. The facilitated processes provided structure and direction, addressed power imbalances and kept the focus goalcentred. Cross-boundary collaboration between hospitals and municipal health services could improve with an awareness of collaboration as an evolving process involving reciprocity between social entities and participation in joint activities aiming at achieving a shared goal. Formal guidelines and agreements on a local basis could help promote joint responsibility for patients’ best interest. Implications for practice: • Provision of integrated and coordinated services for patients can be improved by social entities engaging in joint activities • There is a need for facilitated networks across boundaries in the health services • Collaboration may improve with greater focus on the processes of sharing tasks and responsibilities • Knowledge about cooperating partners is crucial to optimise provision of integrated and coordinated services for patients Keywords: Collaboration, cross-boundary work, practice development, multistage focus groups, Norwegian collaboration reform, facilitation of processes in team working together to develop practice Online journal of FoNS in association with the IPDC (ISSN 2046-9292) © The Authors 2017 International Practice Development Journal 7 (Suppl) [4] fons.org/library/journal 2 Introduction The ‘Family Ambulatory’ is a recently established interdisciplinary team that works with pregnant women and parents at risk of substance abuse and/or mental illness. This is a low-threshold service that aims to ensure easy access to services, motivates parents to seek help and helps to facilitate their navigation of the health and welfare system (Lee and Zerai, 2010). The team is part of the welfare state’s front-line services for the prevention of harm to children caused by parents’ poor mental health or substance abuse. The belief is that children are helped when parents are supported (FOUSAM, 2016). This article explores how facilitated processes enhanced the team’s ability to provide high-quality services. Its findings reveal tacit knowledge of elements that contribute to enhanced collaborative work, and this may shed light on issues concerning the ‘collaboration reform’. Background The Norwegian welfare state introduced the Coordination Reform in January 2012, the aim of which was to provide a sustainable and high-quality health service (Ministry of Health and Care Services, 2012). This article uses the term ‘collaboration reform’ as this is the literal meaning of the Norwegian title Samhandlingsreform, and because collaboration seems to describe the aim of the reform better than coordination. Prerequisites for the reform are collaboration across different levels of services, cooperation between health workers of various professions in the services and the involvement of patients, service users and patients’ relatives. The reform aims to ensure that patients receive the correct treatment, at the right time and place, through integrated and coordinated health services. ‘Good quality... will be ensured by strengthening the competence of employees and increasing cooperation between the levels of services’ (Office of the Auditor General of Norway, 2015-16, p 7). The Family Ambulatory team involved in this study is organised under the child medical section in the specialist health services. They also work closely with other specialised services like adult and children’s mental health services, services for substance abuse and inpatient family treatment programmes. At the same time the service is more flexible than other specialist services, and is easier to gain access to for families and for health and social services in the civic sector (no formal referral is required and appointments are tailored to the need of each family). In addition to the clinical services (like child assessments, observations and guidance regarding parent-child-relationship, child assessments etc.), the team offers supervision and advice for civic services and organises workshops and seminars (FOUSAM, 2016). Collaborative work is an inherently complex phenomenon (Patel et al., 2012). Healthcare organisations operate in multifaceted contexts of conflicting demands and objectives, and handle highly challenging daily tasks (Ramanujam and Rousseau, 2006). Consequently, it is not enough to label a group of healthcare professionals a ‘team’; attention needs to be paid also to coordination, role allocation and shared responsibility. It is difficult for people to question the norms and values of their own profession or organisation, and this may thwart communication across boundaries (Edmondson and Harvey, 2017). There may also be boundaries of language use and terminology, as well as competing interests or agendas. Working across boundaries gives team members the opportunity to examine their own perceptions in a new light and to reflect on a project or the way they are working (Edmondson and Harvey, 2017). Ramanujam and Rousseau (2006) suggest explicit goal setting, feedback, service redesign and positive involvement of staff as measures that add to the quality of health services. To achieve a positive impact on patient outcomes, there is a need to develop authentic and effective teamwork to facilitate a culture of safety and quality in terms of the way the team is organised, its composition and how it works together (West and Lyubovnikova, 2013). Bedwell et al. (2012) suggest that teamwork is an instantiation (or form) of collaboration. These authors say both teamwork and collaboration represent ‘evolving processes whereby two or more social entities actively and reciprocally engage in joint activities aimed at achieving at least one shared © The Authors 2017 International Practice Development Journal 7 (Suppl) [4] fons.org/library/journal 3 goal’ (p 130). However, collaboration is a broader concept than teamwork, since it can ‘involve groups, units, organisations, or any cross-level combination thereof’, as well as individuals (p 135). The authors argue that successful collaboration is difficult, possibly because of a ‘lack of understanding as to what conceptually and practically constitutes collaboration’ (p 128). The 3C Collaboration Model divides collaboration into the dimensions: communication, coordination and cooperation (Fuks et al., 2008). These authors argue that each C contains all three Cs: for example, coordination will not be possible without communicating about tasks and methods and paying attention to the actual acts of cooperation. And, using coordination as substitute for collaboration may ignore the fact that collaboration involves active and reciprocal participation and a process, rather than just focusing on outcomes. The Norwegian National Strategy for Quality Improvement in Health and Social Services (Directorate of Health and Social services, 2005) underlines the need for a culture of collaboration in the health services. By focusing on what it takes to work well and establish a solid foundation, there is better chance of solving the tasks in line with the requirements for good-quality health services – that they will be safe, secure, effective, integrated and coordinated, involve users and give them influence, use resources in a good way and be accessible and fairly distributed (Directorate of Health and Social Services, 2005). In this study two parallel facilitated processes were carried out together with the interdisciplinary team to support the team’s establishment, provide data for evaluation of its services and strengthen the ability to work as a team. Multistage focus groups were used as a way of including staff perspectives in an evaluation (FOUSAM, 2016) of the total service. At the same time, practice development (Dewing, 2010; Dewing et al., 2014) was used to enhance a culture of person-centredness. In practice development external facilitators engage team members in developing their knowledge and skills, aiming thereby to change the culture and organisation of care (Dewing et al., 2014). An underlying aim of practice development is that the individual (patient, service-user, family member, health worker) should be given attention and be valued on his or her own terms. Creativity is explored and encoura