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

Abstract

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.

Keywords

• integration: relational coordination: inter-sectoral collaboration: vocational rehabilitation: mixed-methods