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Collaboration in organizational borderlands – Achieving seamless care for patients with complex care needs
Linnaeus University, Faculty of Health and Life Sciences, Department of Health and Caring Sciences. (ReAction)ORCID iD: 0000-0002-3103-9253
2025 (English)Doctoral thesis, comprehensive summary (Other academic)
Sustainable development
SDG 3: Ensure healthy lives and promote well-being for all at all ages
Abstract [en]

Aim: The overall aim was to explore inter-organizational collaboration and adaptability in care coordination, focusing on seamless care for patients with complex care needs.

Methods: This thesis employed diverse qualitative methodologies across four studies. Studies I–III used an ethnographic approach with convergent data collection techniques, including document review, participant observations, and interviews with healthcare and social care professionals. Studies I and II applied the Functional Resonance Analysis Method to explore care transitions and identify vulnerabilities. Study III constructed a grounded theory of inter-organizational collaboration from insights across healthcare and social care domains. Study IV utilized a web-based questionnaire to collect written critical incidents reported by registered nurses in ambulance care. These incidents were analyzed using Critical Incident Technique and Interpretive Description, focusing on adaptation, decision-making, and learning in ambulance care during the COVID-19 pandemic. Lastly, findings from all studies were synthesized.

Findings: Seamless care for patients with complex needs depends on timing and precision in planning and information exchange across care provider boundaries. Gaps in these processes can increase vulnerabilities (I, II). Effective care coordination relies on bridging professional and organizational divides through established collaboration pathways while stretching across organizational boundaries, rather than dissolving them (III). Continuous learning is central, leveraging lessons learned from adaptations made under pressure to foster resilience and ensure effective care delivery (IV). Coordinating care in organizational borderlands—the spaces where professional roles and organizational boundaries intersect—requires continuous communication, negotiation, and shared decisionmaking. Adaptability enables healthcare professionals to navigate the complexities of real-world care and bridge the gap between protocols and practice by balancing standardized procedures with context-specific, flexible decision-making.

Conclusion: Well-defined boundaries, established collaboration pathways, and adaptability are necessary to overcome challenges in fragmented healthcare systems. When maintained with flexibility, boundaries facilitate coordination by defining roles and responsibilities while still allowing healthcare professionals to adapt to emerging situations. Rather than needing to be dissolved, boundaries provide a structure that reduces ambiguity and supports effective collaboration. Striking a balance between stability and adaptability is, therefore, essential for achieving seamless care for patients with complex care needs.

Place, publisher, year, edition, pages
Växjö: Linnaeus University Press, 2025. , p. 140
Series
Linnaeus University Dissertations ; 558
Keywords [en]
adaptability, care coordination, care transitions, complex care needs, integrated care, inter-organizational collaboration, resilience, Roy Adaptation Model
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
URN: urn:nbn:se:lnu:diva-134581DOI: 10.15626/LUD.558.2024ISBN: 978-91-8082-263-3 (electronic)ISBN: 978-91-8082-262-6 (print)OAI: oai:DiVA.org:lnu-134581DiVA, id: diva2:1928008
Public defence
2025-02-28, Fullriggaren,, Hus Magna, Kalmar, 10:00 (Swedish)
Opponent
Supervisors
Funder
The Kamprad Family Foundation, 20190249Available from: 2025-01-16 Created: 2025-01-16 Last updated: 2025-01-17Bibliographically approved
List of papers
1. Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method
Open this publication in new window or tab >>Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method
2023 (English)In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 851Article in journal (Refereed) Published
Abstract [en]

Background

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

Methods

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

Results

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals’ performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

Conclusions

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2023
Keywords
Complexity, care transitions, hospital discharge, patient safety, resilience, Functional Resonance Analysis Method
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-123671 (URN)10.1186/s12913-023-09832-7 (DOI)001049208400001 ()2-s2.0-85167761648 (Scopus ID)
Funder
The Kamprad Family Foundation, 20190249Linnaeus University
Available from: 2023-08-13 Created: 2023-08-13 Last updated: 2025-01-16Bibliographically approved
2. Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs
Open this publication in new window or tab >>Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs
2024 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, p. 1-18Article in journal (Refereed) Epub ahead of print
Abstract [en]

Aim: The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs.

Design: An ethnographic design using multiple convergent data collection techniques.

Methods: Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

Results: Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed ‘safe care transition pathway’ addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions.

Conclusion: To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions.

Implications: The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology  integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
Keywords
care transitions, complex care needs, Functional Resonance Analysis Method, inter-professional collaboration, organizational adaptability, patient safety, resilience
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-128968 (URN)10.1111/jan.16203 (DOI)001205266300001 ()2-s2.0-85191200287 (Scopus ID)
Available from: 2024-04-20 Created: 2024-04-20 Last updated: 2025-01-16
3. Negotiating care in organizational borderlands: a grounded theory of inter-organizational collaboration in coordination of care
Open this publication in new window or tab >>Negotiating care in organizational borderlands: a grounded theory of inter-organizational collaboration in coordination of care
Show others...
2024 (English)In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 24, no 1, article id 1438Article in journal (Refereed) Published
Abstract [en]

Background: Although coordination of care and integrated care models aim to enhance patient satisfaction and perceived care quality, evidence regarding their practical implementation remains scarce. Understanding the nuances of collaboration across care providers to achieve effective coordination of care is imperative for seamless care integration. The aim of this study was to construct a grounded theory of how inter-organizational collaboration is performed to support coordination of care for patients with complex care needs.

Methods: A qualitative design with a constructivist grounded theory approach was applied. In total, 86 participants with diverse backgrounds were recruited across multiple care settings, including hospitals, ambulance services, primary care centers, municipal home healthcare and home care services. The grounded theory was developed iteratively, based on a combination of observations and interviews, and using constant comparative analysis.

Results: Coordination of care, a complex process that occurs across interconnected healthcare organizations, is manifested as “Negotiating care in organizational borderlands.” Care coordination evolves through a spectrum of inter-organizational collaboration, ranging from “Dividing care by disease-specific expertise” to “Establishing paths for collaboration” and ultimately “Co-constructing a comprehensive whole.” These categories highlight the challenges of coordinating care across both professional and organizational boundaries. In the multifaceted healthcare landscape, effective care coordination occurs when healthcare professionals actively bridge the divides, leveraging their collective expertise. Importantly, organizational boundaries may serve a purpose and should not be dissolved to facilitate effective care coordination.

Conclusions: The key to effective care coordination lies in robust inter-organizational collaboration. Even when patients receive integrated care, healthcare professionals may have fragmented roles. This research emphasizes the importance of clearly defined lines of accountability, reinforcing mutual responsibility and facilitating bridging of professional and organizational boundaries. Healthcare professionals and policymakers can use these insights to effectively utilize inter-organizational collaboration in supporting care coordination for patients with complex care needs.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2024
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-133484 (URN)10.1186/s12913-024-11947-4 (DOI)001360152200001 ()2-s2.0-85209824436 (Scopus ID)
Funder
The Kamprad Family Foundation, 20190249
Available from: 2024-11-20 Created: 2024-11-20 Last updated: 2025-02-11Bibliographically approved
4. Bracing for the next wave: A critical incident study of frontline decision‐making, adaptation and learning in ambulance care during COVID‐19
Open this publication in new window or tab >>Bracing for the next wave: A critical incident study of frontline decision‐making, adaptation and learning in ambulance care during COVID‐19
2024 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648Article in journal (Refereed) Epub ahead of print
Abstract [en]

Aim: To explore frontline decision-making, adaptation, and learning in ambulance care during the evolving COVID-19 pandemic.

Design: Descriptive and interpretative qualitative study.MethodsTwenty-eight registered nurses from the Swedish ambulance services described 56 critical incidents during the COVID-19 pandemic through free-text questionnaires. The material was analysed using the Critical Incident Technique and Interpretive Description through the lens of potential for resilient performance.

Results: The findings were synthesized into four themes: ‘Navigating uncharted waters under never-ending pressure’, ‘Balancing on the brink of an abyss’, ‘Sacrificing the few to save the many’ and ‘Bracing for the next wave’. Frontline decision-making during a pandemic contribute to ethical dilemmas while necessitating difficult prioritizations to adapt and respond to limited resources. Learning was manifested through effective information sharing and the identification of successful adaptations as compared to maladaptations.

Conclusions: During pandemics or under other extreme conditions, decisions must be made promptly, even amidst emerging chaos, potentially necessitating the use of untested methods and ad-hoc solutions due to initial lack of knowledge and guidelines. Within ambulance care, dynamic leadership becomes imperative, combining autonomous frontline decision-making with support from management. Strengthening ethical competence and fostering ethical discourse may enhance confidence in decision-making, particularly under ethically challenging circumstances.

Impact: Performance under extreme conditions can elevate the risk of suboptimal decision-making and adverse outcomes, with older adults being especially vulnerable. Thus, requiring targeted decision support and interventions. Enhancing patient safety in ambulance care during such conditions demands active participation and governance from management, along with decision support and guidelines. Vertical communication and collaboration between management and frontline professionals are essential to ensure that critical information, guidelines, and resources are effectively disseminated and implemented. Further research is needed into management and leadership in ambulance care, alongside the ethical challenges in frontline decision-making under extreme conditions.

Place, publisher, year, edition, pages
John Wiley & Sons, 2024
National Category
Nursing
Research subject
Health and Caring Sciences, Caring Science
Identifiers
urn:nbn:se:lnu:diva-131472 (URN)10.1111/jan.16340 (DOI)001269994400001 ()2-s2.0-85198739368 (Scopus ID)
Funder
The Kamprad Family Foundation, 20190249
Available from: 2024-07-19 Created: 2024-07-19 Last updated: 2025-01-16

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Hedqvist, Ann-Therese

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12343 of 4
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