From Integrated Care to Integrating Care: A Conceptual Framework of Behavioural Processes Underlying Effective Collaboration in Care | International Journal of Integrated Care (2024)

Introduction

Over the past decades, the urgency to provide holistic and seamless care for individuals, taking their specific care needs and preferences into consideration, has become stronger [, , ]. Yet, realizing such integrated care services is often easier said than done, as many impeding factors exist [, , ]. Studies to date have focused, in particular, on barriers to structural and functional integration [, ]. The former refers to “physical, operational, financial, or legal ties among operating units within a system,” and the latter to “formal, written policies, and protocols for activities that coordinate and support accountability and decision-making among operating units” []. Scholars, in this regard, have found that distance between providers, differences in regulation, unclear roles and responsibilities, and a lack of joint funding hinder collaboration and, therewith, hamper care integration [, , , ].

Yet, even under similar systems and conditions, considerable variation in the outcomes of integrated care projects has been found. For example, ostensibly successful pilot projects were found to not always transfer to other locations, despite the same structures and protocols having been implemented in these locations []. Similarly, an initiative in the Netherlands aimed at integrating care services for patients suffering from COPD/Asthma, Diabetes, or cardiovascular disease showed mixed results: from the 113 different care groups that participated in the initiative, some were able to improve care services in such a way that it enhanced care outcomes for clients, whereas other groups were unsuccessful in realizing this [, ].

Several factors might explain such outcome variation and challenges with replicating successful care integration, such as, for example, regression to the mean and unobserved structural or contextual differences across locations. Besides these factors, scholars and practitioners focusing on care integration increasingly recognize that to realize integrated care services, it is important to focus on more than structures and systems. Instead, the “human dimension” of care integration needs to be taken into consideration as well [, , , ]. After all, regardless of the type, level, and breadth of the integration initiative, all integrated care can be regarded as “people’s work”. That is, people (henceforth: actors) from different teams and organizations, with their own educational and professional backgrounds, values, and interests, as well as those of the team or organization they represent, need to collaborate in order to coordinate care around clients’ needs [, , ]. The inherent differentiation among actors that is central to integrated care initiatives is important: it gives collaboration its value, as the unique knowledge and perspectives actors can bring to the table allow them to generate unique, personalized solutions to the care needs of clients [, ] and to attune to the local and national political and societal context. Yet, these differences between actors also make collaboration particularly challenging [, , , , ]. As the aforementioned mixed findings demonstrate, some groups of actors seem to be better able to collaborate effectively and actually utilize their differences in order to generate improved care outcomes, whereas other groups are less successful in doing so.

Over the last decade, scholars and practitioners in the field of integrated care have gradually begun to explore what is needed for actors to collaborate effectively [, , , , , ]. While scholars have argued that effective joint working is a matter of ‘teamwork’ [, ], a lack of clarity exists regarding what ‘effective teamwork’ entails in practice, as the behavioural processes underlying ‘effective teamwork’ have not been studied in the field of integrated care. Hence, how actors can collaborate in such a way that they are able to utilize the differences that exist between them in order to realize outcomes that benefit all actors involved in the collaborative effort as optimally as possible is still a pressing question in need of answers. Second and relatedly, a wide range of factors have been empirically identified that have been shown to foster or hamper collaboration and, therewith, care integration. For instance, (a lack of) joint funding, shared workspaces, and shared goals have been found to enhance (hinder) collaboration [, , , , ]. However, why these interventions have been successful, that is, which mediating processes explain the success of these interventions, remains unclear.

In the current paper, we contribute to the literature on integrated care by presenting a conceptual framework that elucidates how actors can collaborate effectively (i.e., which behaviours foster effective collaboration across different types of care integration efforts, that is, from small client-focused initiatives to larger, inter-organizational projects), when they do so (i.e., which factors/interventions foster effective collaboration), and why (i.e., why certain factors/interventions have the effects they have by uncovering what contributes to their effectiveness). To do so, we draw upon research from the fields of social and organizational psychology, in which scholars have extensively studied how effective collaboration between actors can be realized [, , ]. We leverage these insights and theorize that the extent to which collaboration, and consequently, care integration, is effective depends on the behaviours the involved actors demonstrate. That is, whether actors (1) speak up and share their interests, values, and perspectives with each other, (2) listen to the information that is shared by others, and (3) process this information so as to develop a thorough understanding of each other’s interests, values, and perspectives [, , ]. In what follows, we describe these behaviours and explain the motivations and conditions driving these.

Integrated care as a joint decision-making process

The delivery of integrated care services can, at its very basis, be regarded as a joint decision-making process in which multiple actors with different backgrounds, interests, values, perspectives, and expertise try to make joint decisions regarding the delivery of integrated care services [cf. , , ]. Such decision-making processes occur at different levels []. For example, care professionals, clients, and informal carers need to coordinate care services around individual clients and, thus, need to make decisions, but so do policymakers of local and national governments and funding agencies (e.g. healthcare insurers) and executives of care providers.

Regardless of the level of the integration initiative, arguably, more optimal joint decisions about care services can be made when actors coordinate their actions and jointly decide what is needed for certain clients and who is able to provide this, and when. Consider, for instance, a situation in which caregivers give in to the needs and wishes of a client for additional care. While this may benefit the client, it may hamper the caregivers, whose workload further increases. In contrast, when actors collaborate and collectively design a solution to a client’s care needs that considers actors’ underlying interests and perspectives, this could result in a more optimal outcome for all actors involved []. The latter has been referred to as a ‘win-win’ outcome by Goodwin [], as all actors benefit.

Yet, realizing joint outcomes that benefit all actors isn’t always easy. Differences in backgrounds, interests, values, perspectives, and expertise, for instance, can result in misunderstandings and can hamper the decision-making process between actors [, ]. Additionally, actors may face mixed motives: they may have reasons to collaborate but also have reasons to focus mainly on their own interests []. Actors usually intend to deliver high-quality care and need each other to reach this goal, which is the reason to collaborate []. Simultaneously, actors cannot neglect their own agendas. For instance, healthcare insurers aim to operate on a sound financial basis and, thus, may place limits on the funding of care. Similarly, care organizations all need enough qualified personnel and may compete with other organizations for human capital. Thus, when making decisions, the involved actors may work with others to pursue shared goals but, at the same time, are unlikely to lose sight of their own interests [, ]. What further adds to this complexity is that the benefits associated with integrated care as well as the effort required to make integration happen, are usually not evenly distributed among actors [, ]. Resultantly, actors may perceive that some ‘win’, while others lose from collaborating, or, at the very least, that some have more to gain or lose than others. Hence, it can be challenging for actors to perceive problems as jointly faced and requiring collaborative action [].

Behaviours, motivations, and perceptions in effective collaboration

Person-based and situation-based antecedents as enhancers of collaboration

In the previous section, we have discussed three types of behaviours that social and organizational psychological research has shown to be conducive to collaboration. We have also delineated that whether actors demonstrate these behaviours in practice is dependent on their perceptions and motivational states. Actors’ perceptions and motivational states, in turn, are – according to MIP-G and voice theory – influenced by two sets of antecedents: person-based and situation-based antecedents.

Person-based antecedents refer to actors’ personality traits. Some actors possess personality traits that naturally make them more willing to speak up or which increase their epistemic or prosocial motivation. For instance, actors with personality traits such as extraversion and assertiveness are less concerned with the possible negative outcomes of voice behaviour, and, therefore, naturally more inclined to speak up compared to actors without such a trait [] (see for overviews of person-based antecedents De Dreu et al., 2008 [] and Morrison, 2014 []).

Because personality traits affect the perceptions and motivation of actors and, thereby, the behaviour they are likely to demonstrate, the extent to which actors will collaborate effectively is, to a certain extent, dependent on actors’ personality traits. For instance, if all team members have a high inclination to speak up, the group has a higher chance of reaching a creative joint decision based on the input of all members involved than a team that consists of actors who are more inclined to remain silent []. Similarly, a team that consists of members who all value cooperativeness is more likely to reach joint decisions that are beneficial to all actors involved than a team that consists of actors who go for their own interests []. Thus, the first way in which care integration can be enhanced is by forming teams of actors who possess those personality traits that are conducive to collaboration (although this is often easier said than done, see below for a discussion).

Situation-based antecedents, in turn, refer to the context in which actors operate or the structure under which their collaboration takes place [, ]. Just like person-based antecedents, they influence actors’ perceptions and motivational states. For instance, research has shown that when actors must make decisions under time pressure (a situational factor), they perceive it is less effective to engage in voice behaviour, as they believe there is little room for a (possible) dissenting opinion [].

As situation-based antecedents can affect actors’ perceptions and motivation, changing the context of the decision-making process, sometimes even in a subtle way, can alter actors’ perceptions and motivation, and, thereby, their behaviour. For instance, reducing time pressure increases actors’ willingness to engage in voice behaviour []. Thus, a second way in which the integration of care services can be enhanced is by creating a context that is favourable for collaboration.

All in all, person-based and situational antecedents affect the extent to which effective collaboration can be realized []. Prior research, however, suggests that the latter tends to be more influential than the former [, ]. This is an important insight, as it is often more feasible to change the situational conditions than it is to alter group composition. After all, changing the team composition in integrated care initiatives or in policy-making contexts is not always feasible. Therefore, the next question to be addressed is which situation-based antecedents influence actors’ perceptions and motivational states, and according to what principles the context can be altered to enhance care integration.

Integrating care: An overview of aspects that enhance the process

One of the most pressing challenges scholars and practitioners in the field of integrated care currently face is to delineate what makes actors collaborate effectively [; ]. By drawing upon insights from the fields of social and organizational psychology, we have built a conceptual framework that attends to what collaboration entails in terms of the behaviour of actors involved. The framework is illustrated in Figure 1.

Figure 1

Conceptual overview of the process of integrating care.

Specifically, we have argued that for actors to realize joint outcomes and, thus, to collaborate effectively, it is necessary that actors (1) exhibit voice behaviour and share their interests, values, and perspectives, (2) listen to what is shared by other actors, and (3) thoroughly process this information in order to develop a thorough understanding of each other’s interests, values, and perspectives.

Whether actors demonstrate these three types of behaviour, in turn, depends on actors’ motivation and the perceptions they hold. Specifically, whether actors make their voices heard depends on if they consider it safe and effective to do so. Whether actors are open to each other’s perspectives and, as such, willing to listen to one another depends on their levels of social motivation. Finally, actors’ information processing depends on their level of epistemic motivation. Whereas the three behavioural states, and the accompanying motivational states and perceptions, were discussed separately, all three are essential for integrating care. If actors, for example, are willing to share their ideas but do not thoroughly process the information that is shared, it is likely that the integration attempt will remain unsuccessful.

Actors’ perceptions and motivational states are, in turn, influenced by person-based and situation-based antecedents. Some actors possess personality traits (person-based antecedents) that naturally make them more inclined to demonstrate the three types of behaviour outlined above. Hence, these actors could be asked to participate in the integration project. Further, actors could be encouraged to demonstrate the three types of behaviour that are conducive to collaboration as well by (slightly) altering the context of the collaborative endeavour.

Discussion

In this paper, our aim was to develop a better understanding of how effective collaboration between actors involved in care integration can be realized. By leveraging insights from social and organizational psychological research, we contribute to the literature on integrated care by offering a conceptual framework on the behavioural aspects of care integration. By doing so, we increase understanding of how actors can collaborate effectively and when they do so. Additionally, our framework sheds light on why well-known facilitators and barriers to collaboration have the effects they have by untangling the underlying behavioural mechanisms that explain the effects of such interventions. In what follows, we discuss our work in light of the existing literature.

From the notion that care integration can, in essence, be regarded as “people’s work”, we have theorized that the behaviours actors demonstrate will affect the extent to which they are able to collaborate effectively. Specifically, we have shown that effective collaboration is dependent on the extent to which actors voice their perspectives and ideas, attentively listen to, and thoroughly process the unique input shared by other actors. By doing so, we offer an explanation for why ostensibly successful pilot projects were found to not always transfer to other contexts [, ]. Further, it explains why similar systems and structures do not lead to similar outcomes and why across systems and countries, similar barriers to integration exist. It is the behaviour of the actors that largely cause variations in outcomes, but, situation-based conditions also matter because they lead actors to engage in certain behaviours.

In extension, we have provided insight into how collaboration can be enhanced. For long, scholars and practitioners in the field of integrated care have assumed that effective collaboration is a matter of ‘having the right people in the right place’ [, ]. Indeed, as we have theorized, some actors may naturally be inclined to demonstrate behaviours that are conducive to collaboration. Yet, even when actors involved in the process of integrating care do not possess the personality traits that are deemed favourable for this process, effective collaboration may still be realized by (slightly) altering the context of the collaborative endeavour. To this end, our framework can be used to understand (retrospectively) and to predict (prospectively) under what circ*mstances effectively collaboration can be realized. In recent years, scholars in the field of integrated care have reported under what circ*mstances collaboration turned out to be effective. For instance, the formulation of shared goals among actors [, ], leaders who emphasize collaboration [], joint working spaces [], and joint funding [, , ] have been identified as enablers of collaboration. Our conceptual framework increases understanding of why precisely collaboration was enhanced under these circ*mstances. That is, these circ*mstances enabled actors to demonstrate the three types of behaviour that underlie effective collaboration.

In addition, our framework sheds light on what “good leadership” in integrated care may entail. Whereas studies identified “a lack of leadership” as a barrier to integration and “good leadership” as an enabler [, , ], little is known about what a “good leader” exactly does [, ]. Zooming in on actors’ behaviour, our framework underscores the need for leaders to facilitate actors to engage in voice behaviour, listening behaviour, and information processing. While leaders may select those team members who are naturally inclined to demonstrate these types of behaviours (the person-based antecedents in our conceptual framework), a more feasible action is often to put effort into developing a context that is favourable for collaboration. The situation-based antecedents in our conceptual framework provide guidance on how to do so. Our framework does not only delineate how a fruitful context for effective collaboration can be developed, but also shows the other, more negative side, of the coin. That is, situation-based antecedents may also negatively affect actors’ motivation and perceptions [, ]. For instance, if actors are stimulated by their leader to solely consider the goals of their own organization, this decreases the chance that they will have a prosocial motivation. What this essentially means is that when starting an initiative to integrate care, leaders need to carefully consider the people, the structure, and the context in which the collaborative endeavour takes place.

Leaders also play an important role in creating a level playing ground for all actors involved in the integration initiative. While all actors involved can contribute in their own unique ways, this is not to say that all actors are necessarily “equivalent.” That is, (perceived) differences in power and status may exist, which may hinder joint working [, , ]. Dos Santos and Giovanella [], for instance, described how political stakeholders offered health administrators little room to speak up, causing them to have little influence on the decisions about new health policies in Brazil. Relatedly, research has shown that actors with relatively high status within the group tend to disregard the information shared by low-status actors [, ]. Leaders can play a role here by inviting all actors for input, thereby enhancing actors’ voice efficacy beliefs. Similarly, leaders may induce a criticality norm in the group, causing actors to become more likely to listen to and process information shared by others [].

A next step forward would be to test and further explore the proposed relationships in our conceptual framework in the context of integrated care settings. For instance, as a starting point, scholars could test (e.g., by means of survey research) whether the three behaviours outlined in our framework have a positive, significant effect on the extent to which actors involved in integrating care perceive the decision-making process and outcome as successful. Comparing results across different integrated care settings (ideally at different levels) would enable conclusions as to whether the framework is indeed generic, as proposed, or whether specific contextual moderators affect the influence of the three central behaviours on the success of care integration. Furthermore, it would be worthwhile to examine the interplay between different situation-based antecedents and to investigate if some antecedents are more influential than others.

Conclusion

To reach integrated care, actors need to collaborate. Having the right people, structures, systems and processes in place, is one thing. Engaging in the most appropriate behaviours to achieve the desired collaboration is another. By drawing on literature from the fields of social and organizational psychology, we aimed to address this matter. In line with the notion that the integration of care services is in essence “people’s work”, we have demonstrated that the outcomes of collaborative endeavours depend on how actors interact. Specifically, we have argued that three types of behaviour enhance collaboration and have delineated how person-based and situational antecedents can influence these behaviours. As such the structures under which collaboration takes place configure behaviours of actors and how they demarcate their boundaries (i.e., responsibilities and ownership).

Our conceptual framework implies that the outcomes of integrating efforts are, to quite some extent, people- and context-dependent. Integrated care simply is not a predefined outcome exactly mirroring other pilots and examples. Integrated care is not a well-defined end-state. Rather, it is an ongoing process of adjusting, learning, improving, and being resilient in a context in which people, structures, systems, and societies are continuously changing and moving forward and backward. This underlines our argument that integrated care essentially revolves around integrating care. The latter is a verb, which refers to behaviour that requires ongoing attention.

Reviewers

Two anonymous reviewers.

Competing Interests

The authors have no competing interests to declare.

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