Why are models for collaboration so confusing and difficult? Perceptions by health and social care professionals on developing and implementing models for collaboration

ABSTRACT

Introduction

Many situations in health and social care require collaboration to ensure seamless and good care with the person in focus. However, collaboration can be a difficult and confusing process. Hence, organizations often support it by developing and implementing models for collaboration.

Aim

This study aimed to explore health and social care professionals’ perceptions of collaboration models, as well as what difficulties they perceived in developing and implementing them in a municipality.

Method

Data was collected in a Swedish municipality, through mainly interviews with participating professionals and analysed using inductive content analysis.

Results

The professionals’ responses illustrated variations in perceptions of what constitutes a collaboration model (i.e. core values, a framework, a process, or a function) and why collaboration models are needed (i.e. for the good of the resident, for the good of the organization, or for the good of society). Furthermore, several perceived difficulties in developing and implementing collaboration models were captured.

Conclusion

The varied perceptions of collaboration models, together with the captured difficulties, help explain why models for collaboration are seen as confusing and difficult to develop and implement. This study can increase healthcare managements’ understanding of the complexity of collaboration models and assist future development and implementation.

KEYWORDS:

• Collaboration
• collaboration models
• health and social care professionals
• municipality
• models for collaboration

Introduction

I've never been in a context where I've felt as confused as I have when I've been involved in this … I think it's been terribly difficult because, at times, I've felt that it's just me who doesn't understand. I have been in meetings where there have been a lot of people and information, and after 10 minutes, I have wondered: ‘Does everyone else understand everything that is happening now? Is it just me?’ But I have felt that I can't just sit there and I kind of have had to say, ‘I'm sorry, but I really don't understand anything … ’ So, on a direct question [about the perceptions of the collaboration model] I would really just like to say ‘pass’ … because it's so confusing to me. Eh, I've probably thought for a while that I had an idea of what it is and that now we're roughly on the same track, and then there's a meeting and then all of a sudden … you realise, ‘but what happened now?’ Now I understand that we are not talking about the same things at all.

(The head of the department answer to the question: ‘What is the Intraorganizational Collaboration Model all about?’)

Many situations in health and social care require collaboration to ensure seamless and good care with the person in focus. However, collaboration can be a difficult and confusing process. Hence, organizations often support it by developing and implementing models for collaboration.

Health and social care in Swedish municipalities requires intra-organizational collaboration, which is collaboration between different departments within municipalities and involves, for example, children, people with disabilities, those with substance abuse problems, and the elderly. Collaboration is required when people in certain personal circumstances need support and assistance from several different departments within a municipality [1]. It is, therefore, important for municipalities to enable productive collaboration across administrative boundaries [2] so that a resident in need encounters well-functioning and integrated organizations where resources are used effectively. Collaboration with the person's best interest in focus is based on a person-centred approach [3,4]. In collaborations like these, conditions for optimizing person-centred support need structure. Hence, forums which support person-centred care must be created, and existing forums might need to be optimized or changed [5] so as to offer the residents seamless care where they are at the centre of the care and service. In Sweden, there is currently a transition to the ‘Good and Close Care’ approach [6], which concerns all members of society, from children and young people to the elderly. ‘Good and Close Care’ emphasizes the need for collaboration around the person by several professionals.

Collaboration within the health and social care system occurs in a complex and adaptive system with fuzzy boundaries and consists of several individuals working within the system. Hence, the system depends on these health and social care professionals [7]. The specialization of professionals within different areas means that they are knowledgeable of their areas. However, this also results in a demarcation between different professional groups [8]. A profession includes specific codes and ethics, which are gained through education [9]. Professionals working within municipalities contributing to the health and social care system may include professions such as nurses, social workers, and teachers. Some of these professionals work on an administrative level as managers or leaders, regulating and developing the care and service provided [8] and are important for the support of the collaboration between the departments in a municipality. Collaboration between professionals in municipalities occurs across the boundaries of specializations to bridge the gap between departments [1]. Otherwise, there is a risk that people, problems, and issues will fall through organizational gaps. These gaps occur when the responsibility or competency of a professional or a department ends without another professional or department taking over [10].

The various aspects of collaboration have been researched for decades [11,12], and previous research shows that there are several difficulties around collaboration linked to, among other things, cultural differences within an organization [13]. When professionals lack knowledge about each other's areas of competencies, it results in barriers to collaboration [1]. Several studies have focused on hindering and facilitating factors for collaboration, which is well summarized in Germundsson's [14] thesis and encapsulates issues such as communication, cultures, knowledge, legislation, power and hierarchy, goals, roles, assignments, and so forth. Hence, the knowledge at large about collaboration is vast and thorough; however, knowledge about models for collaboration is lacking. These models are created throughout Sweden and throughout the world to encourage and support collaboration. In Scotland, a well-known model named ‘Getting it right for every child’ (GIRFEC) [15] has gained much attention and even inspired the development of collaboration models in Sweden [16]. Its focus has been on early and coordinated interventions concerning children [17]. Other models in Sweden are ‘The Kronoberg model’ [18] and ‘The Lots model’ [19], which focus on collaboration for efforts regarding children and young people. A more commonly known model in Sweden, used for enhancing collaboration in the assistance of the elderly, is ‘The needs of the individual at the centre’ (IBIC) [20].

Collaboration is necessary for meeting the needs of a resident and the needs of the welfare system. However, collaboration is a complex part of health and social care, which many professionals find confusing and difficult, as illustrated in the introductory quote. In order to support intra-organizational collaboration, models of collaboration are developed and implemented, or they are built upon existing collaboration models. However, the process of developing these models and agreeing on how to collaborate is itself a collaborative process that is difficult. Thus, there’s a need for increased insight and knowledge regarding how models for collaboration are defined and perceived by health and social care professionals in a municipality and what difficulties there are in developing and implementing a collaboration model in a municipality. Therefore, the aim of this study was to explore such professionals’ perceptions of collaboration models as well as the perceived difficulties in developing and implementing such kinds of models in a municipality.

Method

The study is part of a three-year (2021–2023) research project exploring aspects of intra-organizational collaboration in the pursuit of more seamless and close health and social care with the person in focus. This study’s aim was not a predefined research area but rather emerged as a critical topic during the research process and through interacting with the case, i.e. the municipality in Sweden and the empirical material. Thus, the case was used as a frame to formulate the aim, implying a research approach of inductive character.

Study context

The context for this study is one of Sweden’s 290 municipalities and an initiative to develop a model for intra-organizational collaboration in the municipality. The municipality is situated in southern Sweden and can be regarded as a fairly typical Swedish rural municipality in terms of population size and organization. The initiative to develop a model for collaboration, hereafter referred to as the Intra-organizational Collaboration Model (ICM), mainly involved three out of the six departments in the municipality: Arbete & Välfärd (Work & Welfare), Barn & Utbildning (Children & Education), and Hälsa & Omsorg (Health & Care). The model is now currently under implementation.

The research project was initiated by the municipality as they, in the process of implementing the ICM, were interested in learning more about collaboration competencies in this context. The ICM was initially perceived as a best practice of intra-organizational collaboration with the possibility to provide deep insight into how collaboration aspects influence health and social care for the residents in a municipality. A steering group made up of four researchers with a joint interest in collaboration research and four representatives from the municipality (three heads of departments and one project coordinator) was created in 2021. It quickly became apparent that the ICM was not a typical best practice, as the implementation process was fraught with difficulties. The senior-level managers in the steering group could, at that time, not reach an agreement on if the collaboration model was implemented or even if it existed. Thus, a pre-study was designed to evaluate the current state of the ICM. The study pointed to split opinions concerning the collaboration model and aroused the researchers’ interest in the difficulties and obstacles for collaborations and in developing collaboration models. Based on the pre-study, a project plan was developed with the goal of studying intra-organizational collaboration, with a special emphasis on pre-conditions and difficulties of collaboration, by exploring health and social care professionals’ perceptions of collaboration and collaboration models. The steering group has had regular meetings throughout the process, allowing professionals from the municipality to be involved in all phases of the project, from identifying a common interest and developing the aim of the study and research questions to planning and implementation.

Data collection

The main empirical material consisted of interviews, validated by participant observation at a workshop, and different types of documents created by the municipality in the process of developing the ICM. In total, 10 online interviews were conducted by the first and second authors between June 2021 and September 2022. The first four interviews were scheduled by the project coordinator working in the municipality, and the respondents were selected based on their prior involvement with the development of the ICM. These participants represented different departments as well as different roles within the municipality. With the help of snowball sampling [21], further interviews were added until no new people were suggested to interview, and a feeling of saturation had been reached. The participants represented the three different departments involved in the project.

A semi-structured interview guide was used for the interviews, which covered several central issues and was divided into four main parts: background questions, views on collaboration, perceptions of the ICM, and closing questions. The questions were designed to generate a deep and nuanced description of the participants’ perceptions and experiences, while follow-up questions were used to encourage the participants to develop on the issues. The interviews lasted approximately 40–85 minutes and were recorded and transcribed.

The participant observation took place in November 2022 during a three-hour workshop designed to give new energy to the ICM and begin its implementation. During this workshop, preliminary findings from the interviews were presented. More specifically, identified difficulties with developing a collaboration model were used as a starting point for discussion. The workshop had 21 participants from the three departments involved in the project, representing different functions and roles. The participant observation was used to validate the preliminary analysis of the interviews. Furthermore, 28 documents about the ICM (e.g. notes from meetings, summary of analysis, and mappings) that were produced before the research project was initiated were read and analysed during the pre-study and used as complementary empirical material for the current study.

Data analysis

The interview transcripts were analysed using a qualitative inductive content analysis [22]. The analysis process is illustrated in Figure 1. The process was characterized by an ongoing and iterative process involving critical and comparative reflections, individual coding, and validation between researchers to ensure the rigor of the analysis. The interview transcripts were read through by two researchers (CEL & LK) to get a deeper understanding of the empirical material, and initial ideas were captured. The two researchers then jointly went through the interviews again with the aim of capturing both perceptions of collaboration models and perceived difficulties in their implementation. The marked paragraphs were then subject to continued review and coding to summarize the sentence units, which were later grouped to create more abstract categories, hereafter referred to as ‘sub-categories’. The sub-categories concerning difficulties emerged through the coding of the interview transcripts but were also validated through participant observations at the workshop, where the participants were introduced to the sub-categories and asked to react to the identified difficulties. The sub-categories created for perceptions of collaboration models and difficulties in implementation were subject to further scrutiny in order to create higher order categories, hereafter referred to as ‘main categories’. A first draft was made individually by two researchers, validated and revised in a workshop involving all four researchers.

Figure 1. The analysis process.

Ethical considerations

A national ethical permission is not required according to Swedish legislation [23] when no sensitive data is gathered and when the study does not involve any risks to the participants. Hence, the study was approved by the ethical review committee at Kristianstad university (Reference number: U2024-2.1.12-460). The study was conducted according to the Declaration of Helsinki [24] and informed consent was obtained. Emphasis was on ensuring that the participants understood the aim of the study, that participation was voluntary, and that they could end their participation at any time. Data were handled confidentially and stored so that no unauthorized person could access it.

Findings

An overview of the findings is given in Table 1. The health and social care professionals’ perceptions of collaboration models, as well as the perceived difficulties in developing and implementing these kinds of models in a municipality, were explored. Early in the research process, it became evident that there were many different opinions about what models for collaboration actually are and that this difference in perceptions contributed to a sense of confusion and uncertainty, as illustrated in the opening quote. The participants’ responses included perceptions of what models for collaboration are and why models for collaboration are needed. As illustrated in Table 1 (and in Appendix 1, Table A1), the perceptions of what constitutes a model for collaborations ranged from core values to a function in the municipality, while the views of why these kinds of models are needed included reasons related to the resident, the organization, and society. It should be noted that many of the participants saw several reasons for why models for collaboration are needed (Appendix 1, Table A2), although the perceptions varied greatly between the respondents.

Table 1. Overview of the findings.

Different views on what constitutes a model for collaboration

A set of core values

A framework

A process

A function

Different views on why models for collaboration are needed

For the good of the resident

For the good of the organization

For the good of society

Difficulties in implementing models for collaboration

At an individual level

In the interaction between professionals and/or different departments

At an organizational level

The study further revealed a plurality of perceived difficulties with developing and implementing a model for collaboration, where 18 unique difficulties could be identified (Appendix 1, Table A3). These difficulties can be mapped according to where they emerge, with several difficulties emerging at an individual level, some in the interaction between professionals and/or different departments and others at an organizational level. Categories and sub-categories with illustrative quotes can be found in the appendix.

Professionals’ perceptions of what constitutes a model for collaboration

There were several participants who found it difficult to talk about what models for collaboration are and who had a hard time defining the aim of the current collaboration model and its main features. Still, four categories of what is perceived to constitute a model for collaboration emerged from the interviews. There was no mutual view on what models for collaboration are, but it was rather interpreted in different ways within the organization (Appendix 1, Table A1). Several professionals described a model of collaboration as being a set of core values that guide the collaboration. Something that gave a higher purpose for everybody to strive for. Some explained a model for collaboration as a framework to give structure and organize the collaboration without controlling the details. Others characterize a model for collaboration as an illustration of a certain process to follow, where routines and a stepwise description of what to do and who to involve were stressed as the most important features. Some also described it as a function that clarifies different roles, assignments, and mandates through collaboration. So, the collaboration itself does not rely on a specific person; rather, ‘to collaborate’ should be a part of role descriptions in the municipality and thus, a model for collaboration could help clarify this function in the municipality.

Professionals’ perceptions of why models for collaboration are needed

Different perceptions of why a model for collaboration is needed also emerged and resulted in three main categories: for the good of the resident, for the good of the organization and for the good of society (Appendix 1, Table A2). It should also be noted that some participants expressed that they had a hard time seeing the need for a model and consequently had little to say about the benefits of the ICM.

Although some of the health and social care professionals described the need for collaboration models as ‘for the good of the resident’ in a general way, some clear sub-categories could also be identified. The professionals highlighted the models for collaboration to be for the resident to be assisted by the best competencies and solutions. By putting the person’s needs at the centre, they should meet and get help from the professionals best qualified to do so. The need for easy and smooth contact for the resident requiring help or service from different departments was likewise seen as a reason for collaboration models, which also could ensure preventive interventions. Lastly, the opportunity to reduce the risk that a resident falls through the organisational gaps was also cited as a sub-category of collaboration models needed for the residents.

For the good of the organization was described as another overarching reason for the development and implementation of a collaboration model. It could especially help the organization structure work by offering internal clarification and efficiency. Some of the professionals even viewed a model of collaboration as potentially acting as a management tool, guiding them and making sure that they ‘checked’ each box of the collaboration model. The specific model developed in the municipality was described by some as a way to legitimate collaboration that was supported by a political decision. Yet, other professionals described aspects of the institutional theory as the driving force behind the development of the model for collaboration. They highlight how collaboration and collaboration models were trending in other municipalities and that they were inspired by this. Some saw the model for collaboration in the municipality as enabling collaboration by creating understanding for each other. The feeling of being on a team with members supplementing with different competencies, learning from each other, and trusting each other was another reason the model was viewed as needed for the good of the organization. Hence, the model could also ensure that the organization made use of the employees’ potential and competencies. Furthermore, financial savings due to the maximized use of resources and time in the organization and by the professionals involved was another reason cited for the need for collaboration models. Finally, the ability to see the whole picture, observing beyond the purview of the department oneself work in, was also described as a reason collaboration models were needed for the good of the organization.

Models for collaboration were also described as being needed for the good of society, especially highlighting economic sustainability created by being able to save resources, as well as social sustainability concerning the overall structure of society, which, by focusing on collaboration in a wider perspective, could change structures in society.

Perceived difficulties in implementing models for collaboration

Developing and implementing a model for collaboration has, in this study, proved to be both a confusing and difficult process. In the current study, we have therefore explored how concerned health and social care professionals perceive the difficulties in developing and implementing these kinds of models, and we have captured and categorized a wide variety of those difficulties (Appendix 1, Table A3). The difficulties are divided into three main categories that describe where they surface. Furthermore, the main categories consist of several sub-categories which offer further nuances of these difficulties. In total, 18 unique types of perceived difficulties were captured, which can be partly linked to the diverse views of what consists of models for collaborations and why they are needed.

There are several difficulties with developing and implementing a model for collaboration which can be linked to the individual, i.e. the health and social care professional. Prestige, lack of motivation and fatigue, a personality that is more self-centred, as well as old grudges and past experiences of previous attempts to develop models for collaboration were raised as aggravating factors.

Other difficulties surface when people or organizations meet. These include a lack of consensus concerning collaboration and collaboration models but also a lack of consensus concerning the objectives of a collaboration model and a general lack of mutual understanding. Lack of trust, as well as one's own interests, can counteract prioritizing what is best for the municipality. Furthermore, the different ‘languages’ of professionals and departments as well as differences in roles, routines, and needs, create additional difficulties.

Several difficulties can also be linked to the organizational level, including what the organization’s management does or does not do. Issues such as lack of management, unclear tasks, mandate and confidentiality are raised as hindering the development of collaboration models. Also, the management’s lack of clear communication that actually defined the collaboration model is seen as a difficulty, as are the lack of resources/time and relationships and team feeling. To summarize, health and social care professionals see many varied difficulties with developing and implementing a model for collaboration in a municipal context, which we argue are important to recognize.

Discussion

This study aimed to explore health and social care professionals’ perceptions of collaboration models, as well as perceived difficulties in developing and implementing these kinds of models in a municipality. Models for collaboration often aim to support collaboration; however, in this case, it became obvious that the aim of the model and the process of developing and implementing the model were confusing and difficult for the professionals.

The different views on what constitutes a model for collaboration and why a model of collaboration is needed can affect the usability of a model, as well as complicate the starting point for its development and implementation. In this case, the ICM was interpreted in four different ways: as a set of core values, as a framework, as a process, or as a function. This illustrates different goals regarding the model; however, it can be argued that in order to have a complete model for collaboration, all four aspects should be present. Interestingly, the results also suggest that models for collaboration can have different reasons to be needed. They can be for the good of the resident, the organization, and society. A number of arguments for the ICM's value are seen in the sub-categories of reasons for needing a collaboration model and are probably highly recognizable to professionals working with developing and implementing models for collaboration. Some confusion or difficulties related to the development and implementation of the ICM may relate to a lack of understanding of the collaboration models’ complex value and a failure to take a wider perspective into account, acknowledging all the levels. Committed managers are highlighted as essential for leading change, and furthermore, managers from different levels should be involved to enhance the sustainability of change [25].

The difficulties related to developing and implementing a model of collaboration surfaced at different levels: at an individual level, in the interaction between professionals and/or different departments, and at an organizational level. However, management ultimately has the responsibility for handling these difficulties, no matter at which level they surface. Accordingly, one should not be surprised by these difficulties; rather, they must be recognized and accepted, and an effort must be made to resolve them. Furthermore, when developing and implementing a model for collaboration that’s useful in practice, collaboration between the people who are affected by that model or otherwise involved is necessary, i.e. collaboration is needed for the development of the collaboration model.

It is also critical to consider in which context the collaboration model is being developed and implemented since those circumstances play an important part as well. Health and social care services in a municipality are a complex and adaptive system [7], which requires health and social care professionals at different levels in that system for it to work in the best possible way [26]. A system theoretical approach views problems as a part of a system encapsulating different people and levels/blocks, and it is useful to analyse and identify challenges [27,28]. Furthermore, a person-centred approach, where the interests of the person receiving care or service are the main focus [3,4], aligns with a system theoretical approach where a person is seen as affected and depending on several interconnected and reciprocal contexts and structures [29]. The difficulties in implementing a model of collaboration surfaced at an individual level, in the interactions between professionals and/or different departments, and at an organizational level; while the reasons described as why a model for collaboration is needed include: for the good of the resident (i.e. the person), the organization, and society. This implies that, in a system theoretical view, models for collaboration are needed at several levels and that people at several levels must be involved in the development and implementation of a collaboration model in order for it to be successful.

Additionally, collaboration is a relational work task, and many of the difficulties in implementing a model for collaboration were described as related to the interaction between professionals and/or different departments. Studies have highlighted the importance of creating space for building relations and getting to know each other in order to collaborate [30] and create trust and security [31]. However, creating that space emphasizes a need for more than time for meetings and deliberation. Collaborating involves integrating different perspectives, which is complicated [12]. The professionals working within the municipality who are collaborating with each other must deal with the paradox of having interpretive precedence related to their professions and the need to integrate different perspectives [32] when the aim to provide the best service in assisting the resident is the main focus. Hence, the difficulties described in the results as related to the interaction between professionals and different departments are tensions which cannot be avoided but need to be continuously dealt with by the people who are collaborating.

The question of when a model of collaboration should be implemented is not found in the empirical material of this study. Surprisingly, none of the respondents highlighted thoughts about the timing of the ICM’s implementation. A critical reflection is that the implementation of models that have not yet been fully developed may not be beneficial. At the same time, however, it is impossible to think through every detail and modifications that might be needed in advance. The ‘plan, do, study, and act’ circle is a useful method for development and improvement in healthcare [33] and emphasizes the need for a contentious process.

Methodological considerations

This study was conducted in collaboration with a Swedish municipality; the research questions were based on its need for knowledge of the process in the implementation and developed in dialogue. Also, member check [34] were conducted continuously, as well as the passing on of knowledge and information, during the process of the study in order to contribute to the practical implementation of the collaboration model.

This study illustrates one case and, thereby, one context, which limits transferability. However, one case does provide the possibility to dig deeper. Hence, the study provides useful knowledge and insights for professionals and municipalities in similar situations. Additionally, when conducting research studies in collaboration with people from outside academia, it is important for the researchers to be able to critically reflect on the process [35]. Aiming to strengthen the credibility of the study, two of the researchers, LK and CEL, collaborated closely with persons from the municipality and were thereby able to use their insight in the analysis, while MH and AW were able to perform quality check during the analysis and review the emerging findings. Illustrative quotes are provided in the appendix to strengthen confirmability. Ethical considerations were made during the process. Since participants were engaged in a collaborative project, they were informed of their rights as participants in a study before every data collection e.g. that their participation or decline to participate would not affect the overall collaboration.

Conclusion

This study aimed to explore health and social care professionals’ perceptions of collaboration models as well as the perceived difficulties in developing and implementing such kind of models in a municipality. Hence, new insights into this area are provided, including professionals’ views on what constitutes collaboration models, and why they are needed. The results show that collaboration models are needed for the good of the resident, the organization, and society, therefore they should include these levels to ensure better implementation in a municipality and increase sustainability. The different views on what constitutes a model for collaboration, together with a multitude of captured difficulties in their implementation, help explain why models for collaboration are seen as confusing and difficult to develop and implement. Municipalities should agree on the aim of the model in the development of it, as well as be aware of the complexity when implementing intra-organizational collaboration models. Hence, difficulties on the individual level, in the interaction between professionals and/or different departments and at an organizational level is of importance and should all be considered. This study can increase healthcare organizations’ and the management's understanding of the complexity of collaboration models and assist future development and implementation of such models, specifically within different departments in municipalities.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by The Research Platform for Collaboration for Health, Kristianstad University, Sweden: [Grant Number Nr 11/2022].

Notes on contributors

Christine E. Laustsen

Christine E. Laustsen, Reg. OT, Ph.D., is a lecture in health sciences. Her research interests focus on collaboration between academia and healthcare professionals, interprofessional collaboration, and research on ageing and health.

Lisa Källström

Lisa Källström, Ph.D., is an associate professor in public administration. Her primary research interests are value co–creation, stakeholder collaboration and actors' involvement in the work of government. Inclusive place branding is a special area of expertise.

Maria Haak

Maria Haak, Reg. OT, Ph.D., is a professor in health sciences. Her research interest concerns activity, participation and autonomy among teenagers and very old persons. She has extensive experience in qualitative methodology and involving knowledge users in research.

Albert Westergren

Albert Westergren, RN, Ph.D., is a professor of nursing science and healthcare strategist. He has researched various areas such as nutrition, sleep, pain, incontinence, stroke, Parkinson's disease, elderly care and service, and has a special focus on psychometrics and metrology. He has over 100 scientific publications.

Appendix 1

Table A1. Identified views on what models for collaboration are.

Category	Illustrative quote
Core values	But for me, the ICM has actually been, … a bit two-part. I would have liked … that it communicated these core values. What is it, who are we there for, and what do we think is required for us to be able to meet their needs. It's getting a bit fuzzier … up in the clouds, but still, something that shows and signals what we stand for. (A)
A framework	So, for me, collaboration is probably more that there is an organised structure, or an organised model perhaps then … which you actually work with and where it is not just about you and I being able to call each other, but it's more about how we should work, it is a more accepted way of working, you could say. (J)
A process	For me, collaboration means that … we as professionals [working in] a public organisation should have elaborated methods to work on cases that are feasible … You must have routines regardless of who sits in that place, so it must be clear how it must be handled. (E)
A function	And there, I also think, … with the ICM, that it is dangerous to rely too much on a specific person, that there is a person over there who knows everything. It is life-threatening; we need to have it on the role instead of on the person … that there is some sort of role description. We cannot have one oracle that sits somewhere and knows everything, and then that person disappears [leaves their job] … (I)

Table A2. Identified views on why models for collaboration are needed.

Main category	Sub-category	Illustrative quote
For the good of the resident	For the resident to be assisted by the best competencies and solutions	But what I'm thinking is, in some way, that you should bring together different experiences, skills, knowledge that different professionals have. And be able to agree on a question or a client or whatever it may be. And to be able to make use of everyone's different skills and experiences … to come up with a common question, way of working or something. For me, the work is often about individual clients, for example, or different target groups or issues that we work with. And where there are many different actors. So, it's a way to gather it, find one way to work. (C)
	Easy and smooth contact for the resident	And [for the resident] to run to five different departments, different times, it kind of gets bad so easily, it is not going to be good. And therefore, it is believed that everyone must gather around the individual person instead and reduce the number of visits. (J)
	Preventive intervention	And the second part would rather be about early preventive measures. Where I would like us to clarify for our employees how we work with early preventive measures. (A)
	Reduce the risk that the resident falls through the organizational gaps	The risk was great that the resident would slip through the cracks. And what really prevented this sometimes was this collaboration between the case managers at the base level. (E)
For the good of the organization	Internal clarification and efficiency	The ICM, at least when I thought of it from the beginning, should be a way of describing how we can work together and which qualities we feel are important in people who must collaborate so that we place the right people in the right place. Or to equip the people for the task in order to be able to collaborate and do well for the organisation. (I)
	Management tools	Then, it is also a challenge to implement these flow charts so that people really follow them. We know this from SIP (current meeting forms) and everything like this, but I absolutely believe that it is a good management tool, absolutely. (D)
	Legitimacy	… it became a political mission, and we were to set the foundations, forms for, get the basis for an ICM together with health and welfare. (B)
	Institutional theory as the driving force	I think that apart from the fact that there are trends throughout Sweden and perhaps the world because such trends come at different times, now we have to do this. So, it's a trend then. It's also about the fact that we had made a study visit to Scotland and looked at this Scotland model and wanted to capitalise on it somehow. (J)
	Enabling collaboration by creating understanding for each other	That there is a lack of prestige, that we have our different tasks in the different departments, but that it is just as natural to contact another department to work horizontally and not in silos. (G)
	Use of the employees’ full potential and competencies	But it's really about taking advantage of people's skills. (F)
	Financial savings (resources and time)	And that everyone makes their work more efficient so that, in the longer term, if we work together for this individual person, we will win. So, it might cost money now, but in the long run, we will make money or make a lot of money if we work preventively. And catches families, children and young people, the elderly before it is too late and costs so much. So, it is clear that it is a financial issue with collaboration, but it is very difficult to see quick results … they may come in 20 years. (F)
	To see the whole picture	And when you perhaps also can see this slightly higher goal and not get stuck in your own bubble. But can look up and see the benefits for the whole. (D)
For the good of society	Economic sustainability	So, I think it will be necessary in the future to collaborate more because there will be more and more demands on service, treatment and welfare services. And if we don't work together, the resources won't be enough, so that we wouldn't be able to offer, what can I say, the service and support that is actually desired. And I think that, in the future, you will see much more collaboration and working in other ways, only to cope with the welfare society. (G)
	Social sustainability	How do we co-create to make this as good as possible for this person that we know, or if we're talking about the overall structure of society, how can we co-create to make it safer or prevent drug abuse or whatever it may be. (H)

Table A3. Identified difficulties with developing and implementing a model for collaboration in a municipal context.

Main category	Sub-category	Illustrative quote
At an individual level	Prestige	And then it is also about a lack of prestige. That you don't stick to your territory. If it's about cooperation, then you have to open your doors … (G)
	Lack of motivation and fatigue	Now there is probably also a, a fatigue and a frustration … Because people have heard about this [the ICM]. And somewhere you don't get a delivery, and then I think that then you have somewhere … well, you have lost them a little, so you need to work up, like, a trust in it again. (A)
	Personality	I’m thinking, I’m a person who likes to work with other people, to learn from others and share so that we can do something good together. Some are more self-centred. (F)
	Old grudges and past experiences	Maybe it can be a little more difficult in the other departments, in some of the other departments anyway. Where it is difficult to explain that this time it is something new, because many people were involved in the old journey, where it ended up being nothing. So, this is something that is … Well, now we have a 2.0 version where we will become more concrete and where it actually will really become an established way of working. (H)
In the interaction between professionals and/or different departments	Lack of consensus concerning collaboration and collaboration models	Then it was difficult because it was a bit like we were talking about different things. And it is a little difficult to find a collaboration model if you have difficulties with it … That there were slightly different ideas about what it should be. (C)
	Lack of consensus concerning the objectives of a collaboration model	But what I noticed quite quickly was that you didn't have a common base to stand on, that you didn't really agree on what it should lead to. Whether it was a model, a way of working or whatever it was. (G)
	Lack of mutual understanding	And since I got involved here as a manager, it's been more about us not really understanding each other. The will was there, so to speak. (B)
	Lack of trust	And also trusting each other, it's not possible for everyone to know everyone's assignments, it's not possible to learn. It's just as if you were to learn each other's entire job. But then there must be some form of mutual trust. That what is said is what applies, and that is the way it is. (C)
	Own interests	And I also believe in letting go of one's own interest and starting to think about the whole, thinking about what will happen to the patient and what will be best for the municipality as a whole. (H)
	Different ‘languages’	Well, sometimes it works very well when you get along with a person and when we speak the same language. But then, with someone else, it doesn't work at all. And sometimes, I think we kind of have different terms and concepts. When I say ‘team’, I mean one thing. But when someone else says ‘team’, they mean something else. We rarely clarify the concepts or roles or anything like that. (I)
	Differences (in roles, routines, needs, etc.)	Health & Care has a different target group and, as I understand it, already has its own routines. So there, I think, needs look different. (B)
At an organizational level	Lack of management	I think their [management's] function is to be clear about what they expect. ‘This is what we must do. This is the goal.’ And maybe then also allocate resources and talk about who will do what. A clarity in that. (D)
	Unclear tasks	But when this later started, then everyone was so overloaded with work that there was no one internally who could do this … then we went into a reorganisation, and then the pandemic came. And since the pandemic, no one has done anything besides the pandemic. (D)
	Mandate	I think the mandate is very important here; who has the mandate … That and that the steering starts from there; that is your starting point. Then those who sit there should certainly not do everything. (F)
	Confidentiality	Yes, it always interferes with collaboration. I think it is the big problem that causes us to be governed under different laws … then there can also be other things that block collaborative work, but that's the big thing, I think. That we are almost working against each other with this, with the confidentiality and consent that you cannot create. (J)
	Lack of clear communication (actually defining the ICM)	… we need to clarify what it is because the ICM as a concept becomes too difficult. We couldn't describe what it was that we were going to do. What is the ICM? (I)
	Lack of resources/time	Just because the cost ends up in more than one place, it cannot be an obstacle to implement the, what shall we say, the efforts that are needed. And therefore, you can say that even budget issues can be, if I may say so, a non-success factor. And you get caught up in this, who pays for the party? (G)
	Relationships and sense of being on a team	… relationship building rather than the formal stuff. More informal, getting to know each other, trusting each other and then also being open to making mistakes. Sometimes things go wrong, and then you must also be able to dare to say so and ask, ‘What can we do so that it will not go wrong next time?’ Allow yourself to make a mistake and admit it. (H)