The substance field went through a large process of change starting in January 2004 when the substance reform altered both the legal basis and the organization of services for persons with substance use problems (Lie & Nesvåg, 2007). The Norwegian Regional Health Authority took over responsibility of the specialist health services for people with substance use addiction. Earlier, these duties were the Norwegian counties’ responsibility. The responsibility for coordinating these services on a communal level was still held by the communes themselves. Substance services became juxtaposed with psychological health services and somatic health services, falling under the name “multidisciplinary specialized treatment for substance abuse” (Lie & Nesvåg, 2007). There are a number of descriptions for the accumulation of problems associated with the living conditions among people with substance use–related challenges in Norway. For many of these individuals, their challenges started early in life. Growing up is, for many, characterized by drug problems and mental health difficulties within their family and, also many, by bad experiences in school (Lauritzen, Ravndal, & Larsson, 2016).
Problems concerning living conditions grow with increased use of substances. In addition, many substance users have poor finances and inadequate housing, or no housing at all. Many people with substance use problems also experience loneliness and conflicted family relationships. They often experience a lack of meaningful activities as well and have limited education or work experience (Lauritzen et al., 2016). Research and statistics show that persons with substance use problems are at risk of premature mortality as well as comprehensive health-related and social challenges. Many people with substance use problems also have poor somatic and psychological health (Gjersing & Bretteville-Jensen, 2014).
Many countries have sought reforms aimed at maximizing the potential for service users to regain as much control as possible over care decisions throughout the trajectory of their care (European Commission, 2005; Ness et al., 2014; Ness, Kvello, Borg, Semb, & Davidson, 2017; Norwegian Ministry of Health and Care Services, 2008–2009; World Health Organization, 2013). Both the organization of substance use services and the comprehensive needs of the service user group create and intensify the need for collaboration. Collaborating with users of substance use services can be both demanding and unpredictable (Deans & Soar, 2005). The Escalation Plan for substance use services notes that many users need services from several sectors and levels. This tendency presents greater demands for co-organization and coordination within and among the service levels. Coordinated and consecutive treatment courses are a crucial part of this plan (Norwegian Ministry of Health and Care Services, 2015). The responsibility for collaboration lies with the municipalities. According to the Escalation Plan, the role of municipalities is key to the successful creation of better follow-up and aftercare. However, a need exists to better connect the efforts of municipal services to one another and to those of other services, such as specialist health services, the Norwegian Labour and Welfare Administration (NAV), and volunteer and idealistic organizations.
Collaboration is not presented as merely a goal but also a challenge for services (Norwegian Ministry of Health and Care Services, 2015). At present, people with severe substance use and mental health problems receive consecutive and coordinated services to an inadequate extent (Norwegian Directorate of Health, 2014). The need to shape services and interventions so that the individual encounters a coordinated, holistic, and accessible system of assistance is noted, among other places, in the Escalation Plan for substance use services 2016–2020 (Norwegian Ministry of Health and Care Services, 2015). Internationally and in Norway, the requirement for collaboration has been described in public statements and legal texts for over 20 years (Willumsen, 2009a). Among others, the Law for Specialist Health Service and laws that regulate health and social services in the municipalities contain regulations regarding collaboration.
Lie and Nesvåg (2007) evaluated the effects of substance use care reform on collaboration, within the municipalities and the different specialist health services. They noted it is doubtful that substance use care reform has led to more holistic, coherent, and individualized services. Their conclusion was that the greatest challenge for cross-disciplinary specialized services is developing models of collaboration and forms of practice that meet the requirements for coherent and individualized treatment (Lie & Nesvåg, 2007). Concepts that are often used when discussing this type of collaboration are cross-disciplinary, interprofessional or multidisciplinary collaboration, and cross-sector collaboration (Willumsen, 2009b). We have chosen to use the word “interprofessional” in relation to all these terms in this article. Although the need for interprofessional collaboration is thoroughly described in the research literature, less is known about how practitioners experience collaboration.
The aim of this study was to explore how practitioners experience collaboration in the substance use services. The theoretical perspectives used are national guidelines as well as systemic and social constructionist theory. With collaboration within substance use services as the point of departure, the research question for this study was: “How do practitioners experience interprofessional collaboration within substance use services?”
The aim of the study was to collect rich and wide-ranging descriptions of practitioners’ experience with collaboration within substance use services. Thus, a qualitative research approach with an emphasis on phenomenology and hermeneutics was considered the most appropriate choice. Interpretative phenomenological analysis (IPA) was selected as the method of analysis. IPA is described as phenomenological and hermeneutic (Smith, Flowers, & Larkin, 2009). Phenomenology refers to experiential knowledge and is concerned with attaining proximity to the personal lifeworld of the informant (Kvale & Brinkmann, 2009). The focus lies on the experience interviewees have of the world in which they live, the interplay between people, and the contexts in which their experiences occur (Langdridge, 2007). IPA acknowledges that access to interview subjects’ experiences is always dependent on what they want to tell us and on the way researchers interpret the empirical material in an effort to understand their subjects’ experiences (Langdridge, 2007). Hence, IPA is described as hermeneutic. Hermeneutics encompasses expressing, interpreting, and explaining as well as translating from one language to another (Lægreid & Skorgen, 2006). Hermeneutics promotes the importance of interpreting people’s actions through a focus on deeper content meaning than is immediately apparent (Thagaard, 2009). Through IPA, attempts are made to explain, describe, interpret, and locate the meaning of what the informants have said (Smith et al., 2009). The interviews were conducted over a four-week period. They lasted between 90 and 150 minutes and were transcribed verbatim.
- Step one involved immersing oneself in the original data by reading and re-reading the transcripts. The most powerful recollections, reflections, and initial observations later served as inspiration for elaboration of the discussion.
- Step two examined semantic content and language on an exploratory level. All statements that were connected to the research question were noted on the left side of the paper and served as initial codes.
- Step three involved working primarily with the initial codes that were considered most significant and connecting them to our own reflections and relevant theory. These connections were noted on the right side of the paper and were named focused codes (see Table 1).
- Step four involved assigning numbers to the most significant codes and marking them according to the interview, page, and line number from which they were collected to make them easy to find and to render the research process transparent.
- Step five involved looking for patterns across codes by placing each code on a large surface and then searching for connections among them. The codes that were connected were considered as a single category.
- Step six concerned naming the overarching categories. The four identified overarching categories were (1) energy and discomfort, (2) problematic organizational structures, (3) closeness and distance in relation to the service user, and (4) the experienced collaborator.
The study intended to illustrate the phenomenon of collaboration from different perspectives. The recruitment of informants was therefore based on a “strategic sample” (Thagaard, 2009). The informants did not merely have specific knowledge connected to the research question but represented different positions in relation to collaboration. This distinction is important in relation to the study’s phenomenological and hermeneutic point of departure. The choice of informants was also strategic in the sense that the sample consisted of practitioners with three-year health or social education degrees. The aim was to collect data from informants who, in terms of education level and profession, could be considered equivalent to one another.
The informants were recruited with the help of practitioners and collaboration partners in one of the larger cities in Norway. These collaboration partners represented different helping services that are often involved in collaborations within the substance use services. The collaboration partners also had knowledge of the research project so that they could help identify people who fulfilled the criteria. Five interviews were conducted. Two of the informants represented primary health services, one represented a non-profit organization, one came from NAV and one came from secondary health services. In addition, it became clear that all the informants had experience in several workplaces within the substance use services.
The semi-structured interview was the method chosen for data collection. The semi-structured interview is neither an open conversation nor a closed-questionnaire conversation (Kvale & Brinkmann, 2009). The interviews were performed in accordance with the interview guidelines, which encompassed specific themes and contained suggestions for questions (Kvale & Brinkmann, 2009). Nevertheless, two questions were posed to all five informants. The first question addressed their experiences with established collaboration tools, responsibility groups, and the individual plan. The individual plan is a tool that sets out what services are required as well as the goals, resources, responsible service providers, coordinator, and close relatives. When service users require the coordination of two or more services over time, a legal right to an individual plan is triggered (Kjellevold, 2013). The other question concerned whether informants’ thoughts regarding collaboration in the field differed from those regarding collaboration in other contexts within the health and social services.
An important consideration was how the research process would affect participants’ identities and interests (Denscombe, 2002). A careful ethical consideration process was therefore necessary. The research project was approved by the Norwegian Centre for Research Data (NSD). All participants obtained an informed consent process and signed a consent form. They also received copies of the ethical approvals for the research project. Participants were also informed of the possibility of withdrawing from the research project at any stage without a need for explanation. Their names were anonymized in the transcripts.
Energy and discomfort
The informants had many descriptions and thoughts concerning collaborations that had functioned well. As one informant said, “There’s energy in the system. Collaboration gives you the energy to keep hope alive and gives energy to the user.” The informants said that for collaboration to be a good experience, good communication, a functional assignment of roles, respect for other professionals’ efforts, shared interests, and engagement in the case were necessary. It was also noted that participants’ (both collaboration partners and service users) ability to relate to one another in a proper and respectful way was important. Respect also included understanding one another’s structural conditions and not creating unrealistic expectations in the user. As one informant said, “It’s not as if the collaboration partners can do everything the way they want to. We need to understand this.” The informants also expressed a desire for the collaboration partners to understand the role practitioners had in the user’s life. As one informant said:
I never attend collaboration meetings if I haven’t been invited by the user. My role is to be there so that the user feels heard and dares to present their experience. This doesn’t mean that I swallow the experience the user has as a whole.
The informants experienced many practical collaboration problems in an inflexible system where both small and large failures could make the work difficult for everyone involved. They spoke about disappointments when their work became more difficult because of the decisions and behaviors of others. For example, an outstanding payment could stop a process many collaboration partners had worked hard to achieve. Many of the informants said they sometimes felt badly treated as collaboration partners or had witnessed conflicts in the collaboration. According to one informant, conflicts and poor treatment could involve exaggerated negative focuses or undertones that were perceived as uncomfortable. Other times, power relations in the collaboration were a factor. In the words of one informant:
It happens now and then that people run their own courses too much, they’re enough on their own, they listen too little to others. No one is more important than anyone else when the client has invited them to participate.
Another informant described the situation as follows:
There are those who think that it’s us who should say what the need is and then communicate it to the others, and then the others are to do it. That’s not necessarily wrong but it creates resistance.
The informants expressed negative thoughts about the collaboration partners as being particularly damaging if they were communicated to the service users. This perception also applied to how the workplaces of others were discussed. According to the informants, distrust was not restricted to the relationships among the people involved in the collaboration. Rather, it also affected relationships among institutions or service units.
Problematic organizational structures
All the informants described mixed experiences with the concrete collaborations in which they participated. However, they felt that collaboration was necessary for achieving good-quality services for users. In this connection, the informants expressed that the structural conditions and organization of the substance use services were of great significance, both for individual practitioners and for collaboration purposes. One informant described the situation as follows:
The goal of collaboration is to sew together a plan with different institutions and that these institutions do the things they have the authority and competence to do. This must be done in a certain order or within a certain period and they (the steps) must glide as well as possible. Then it might well be that the client isn’t followed up [with] and that everything falls apart because of that [lack of follow-up]. That happens a lot, of course, but [it ought to be] to the least extent possible that things should fall apart because of poor collaboration.
The informants described substance use services as a fragmented field with many official helpers connected to many different systems. As one informant said:
It’s an interdisciplinary field, and there’s competition about which view should be the leading one. There are several perspectives; people come from different traditions. This doesn’t have to be a problem, but it can become one if one view is placed ahead of the others without this [decision] being accepted by the others.
The informants described substance use services as a fragmented field with many official helpers connected to many different systems. As one informant said:
I heard in a meeting that it doesn’t cost you (the specialist health service) anything to want something.
Many noted that especially in primary health services, a limited economy also limits the possibilities over which practitioners have control. The informants thought that these structural conditions created a lack of stability in the services:
It happens that people leave treatment and don’t have anywhere to live. That’s completely crazy actually; why isn’t this money used in the primary health services for everyday follow-up or housing?
The informants agreed that services often took a long time and that it was difficult to contact the appropriate professionals. Several of the informants said they experienced the system’s awkwardness in meetings with a group of service users who do not always follow up with plans. Consequently, the informants described great frustration when the next step in the intervention chain was not in place and when collaboration meetings were insufficient. Several of the informants expressed that in such situations, they felt as though their own efforts were wasted.
The informants had similar experiences and thoughts regarding the individual plan (IP). They described the IP as a potentially useful tool. According to the informants, the IP can be helpful if the user feels ownership of it and if the service providers are flexible and responsible. One of the informants described this situation as follows:
The IP is a tool that isn’t used as it was intended. It’s written because it’s mandatory to write one, [but] the content is vague; these plans become too static and demand much work.
The informants also described experiencing service users who had a distanced relationship with the Individual Plan; however, they were more positive toward the responsibility group meetings. One of the informants described these meetings as the most important arenas for collaboration. Several of the informants stated that they viewed this way of working as having great potential and therefore wanted these meetings. Some of the informants noted that the meetings were often set in motion too late or were too seldom conducted. The informants also noted that follow-up on the responsibility groups was not always conducted as they wished.
Closeness and distance in relation to the service user
The informants indicated that service users often require different services but cannot always follow through with the interventions. Consequently, they noted, it was important to have a shared understanding of the utility of taking full advantage of the times when service users were available. As one of the informants expressed:
There are many problems with meeting up for appointments, and there are difficulties getting hold of them (the service users). This requires that everyone is, in a way, on board with the fact that this is how it is. And collaboration has to be arranged on this basis.
The informants had long-term experience in substance use services and shared many of the same understandings regarding how, in different situations, it was appropriate to accommodate the users. However, their competence was challenged in meetings with professionals who had less experience with substance use. The informants also noted how some of the service users’ behavior could challenge practitioners with either less experience or a different understanding of the problem. One of the informants expressed this tendency as follows:
They are manipulative, and there’s nothing negative in that for me; it’s something people have learned when they’ve lived as they’ve lived for so long. They’ve learned to think, ‘What can I get here?’ That’s behavior we’re supposed to help them unlearn with collaboration.
When the informant’s own dialogue with service users became hard, the difficult aspects could often be addressed at the next meeting with the collaboration partner. As one of the informants described:
I think it’s very important to understand that it’s not about us as collaboration partners but that many in substance use services feel desperation and powerlessness in many situations.
The experienced collaborator
The informants felt that the structural conditions of the substance use services systems influenced the individual practitioners. As one informant described it:
Systems shape you as well. If your ideals are clashing all the time, then no one can stand the fight. To stay in working order, you have to allow yourself to be shaped.
Another informant expressed the situation as follows:
Barriers in the systems do something to people. When there are poor structural conditions and less competence, you choose narrower points of view to be able to manage in your working day. People get burnt out when there are such conditions. Many quit, and that’s also unfortunate. Give better conditions; then people will stay longer and be satisfied, and then they do a good job.
For the informants, collaboration was often a difficult balance between loyalty to the user and loyalty to the collaboration partners and systemic requirements. The informants emphasized the importance of experience in learning the art of balance and said that they had themselves had learned to be better collaboration partners over the years. Several of the informants described how listening and appearing diplomatic had significance for good collaboration and how they had themselves learned to be more respectful. As two of the informants expressed:
I’ve perhaps learned to keep quiet about things I don’t know anything about to avoid conflicts and so that others who do know can bring in the important knowledge.
(…) then I went into the trenches on behalf of a user. It turned out that I’d been manipulated, was way too naive. I ended up in a verbal argument, was a little too pushy, and then it turned out that he’d been offered the service. For the user, I was the hero, but that doesn’t help anyone if the others think I can’t collaborate.
The informants felt that being very experienced was important in navigating substance use services. Many of the informants had worked in different areas within the field and considered experience a strength. Experience meant that they had both relationships with relevant professionals and good knowledge of the system. One informant said in the interview that the most experienced and expert practitioners, who knew the field well and were secure in their work, were often the easiest to collaborate with. The informants said that because the services offered were so fragmented, many professionals had too little knowledge about one another’s work. Another informant noted the same problem. This individual said s/he would like to have regular meetings with important collaboration partners at which it was possible to discuss cases on a general basis, address questions, and discuss possible solutions. The informant called this “building relationships in peacetime.”
Within substance use services, collaboration has become a central perspective. Collaboration has also become part of a practice that involves efforts to seriously involve service users and to create better services for those who need them (Norwegian Ministry of Health and Care Services, 2016–2020). The core of collaboration is usually described as related to practitioners’ ability to work together, listen, and take service users seriously. It arises through decisions about treatment made through shared decision-making processes (Ness et al., 2014). However, in substance use services it appears that the concept of collaboration is much more subjective. The subjective concerns the structural conditions of practitioners’ understanding of the user, the goal of the collaboration, expectations of oneself and one’s collaboration partners, and how the substance use services should be understood and managed. Thus, organizational, social, and cultural contexts are the sources that shape and influence collaborative practices (Ness et al., 2014). The informants described the following challenges related to accessibility, waiting time, and small or larger misunderstandings that could create problems for coordinated services. Thus, there is a paradox that substance use services make requirements for both collaboration and structures that complicate collaboration. Even if collaboration with service users is often described as a challenge to this paradox, it is interesting that organizational structures complicate (and are even a barrier to) practitioners’ possibilities for collaboration.
The organization or structural conditions of the substance services also complicate collaboration with external collaboration partners. The system-level challenges that the informants described can be understood as circular in that practitioners both seek and pose requirements for collaboration. Most collaboration partners are governed by guidelines and requirements. Service users within the field often have complex and long-term challenges that demand an interdisciplinary approach. Practitioners working in such systems must struggle to maintain collaborative practices with service users while often simultaneously having to address forces within the service system, such as the inability to sustain continuity of service provision or the lack of system-wide support. Therefore, the informants sought to resolve the complicated situations with a pragmatic approach in which the user’s goals are considered most important and tools that do not function are simplified. In practice, what is appropriate appears to be more important than what is optimal.
To promote collaboration within problematic structures, the informants took responsibility for the collaboration processes. The informants described this collaboration as diplomatic work that contributes to appropriate role expectations. Diplomacy, in this case, means behaving properly, understanding one another’s structural conditions, listening, and being willing to put one’s own preconceptions to the side. Collaboration is a subjective concept that should be negotiated in each individual case (Anderson & Gehart, 2007), primarily through dialogical and empathetic conversations that have a starting point in the practitioners’ and service users’ context and that have the goal of negotiating new meaning, new opportunities, equal relationships, and new solutions to the users’ challenges.
At the core of these collaborative relationships is the competence and capabilities of the people involved in listening, taking each other seriously, and respecting the perspectives of others in terms of both the relationship and the partnership in which they are involved (Ness et al., 2014). The research literature also shows that the most important foundation for collaboration is the relationship between service users and practitioners (Bordin, 1979; Denhov & Topor, 2012; Norcross & Lambert, 2011; Sweeney et al., 2014). The aim of the collaboration, therefore, is for practitioners to become “advocates” for the service users. This advocacy is accomplished by working with the parties in the service system and by coordinating with other service providers at different system levels. In practice, practitioners achieve this aim by navigating among the relationships and services that are available for the service users.
How each participant understands the meaning of his or her own participation in the collaboration or how he or she perceives the phenomenon of collaboration can also be understood in terms of personal constructions (Gergen, 2009). Through a respectful approach in which all the participants are open to the divergent constructions of those involved, conditions are established for a collaborative relationship, one that is marked by the shared construction of understanding the presented challenges. Anderson (1997) writes that during such connections, problems are linguistic positions that often describe different issues and are interpreted in different ways. She further claims that there is seldom agreement regarding what the problem is and calls these different descriptions “competing realities.” When one informant hopes that the collaborating partners will not “diverge,” it is often in relation to collaboration experiences that have been characterized by competing “realities.” Seikkula and Arnkil (2007) describe meetings at which the client’s problems are discussed on the surface, while at another level, there is competition regarding who has the competence to define the case. Within the substance use services, this competition is connected to the power to define how the user’s substance use problems are understood and to decide what type of treatment or interventions are required. From a social constructionist understanding of collaboration, none of those involved can be said to have “the truth” regarding how the work should be done. In the meantime, the user him or herself will be given more power of definition in relation to choosing the interventions that support her or his own goals. Thus, successful collaboration in substance use services requires the free flow of information and the sharing of feedback among all parties so that they are on track with the changing intentions that often arise.
The goals of the informants were largely influenced by the wishes expressed by the user and by their closeness to or distance from the user’s daily life. The informants said that such closeness affects the practitioners and that this “effect” often influences collaboration. Practitioners can feel powerlessness, desperation, and frustration, and at times, such feelings emerge in dialogues with other professionals. The informants used expressions such as “manipulation” and “taking sides too strongly with the user.” They described that closeness to the significant challenges the user faces influences practitioners. Some of the informants said in this interview that it was hard to stand alone in cases. Others felt that an understanding of that desperation on behalf of the user could lead to the use of overly strong language and moving forward too aggressively in the collaboration. They referred to having been reprimanded strongly by worried collaboration partners, but when these professionals knew what their partners were dealing with, they were better able to understand the strongly worded statements as expressions of concern and not as criticism of themselves. Therefore, a decisive factor in good collaborative relationships appears to be that the frameworks of the collaboration partners are known to all involved so that unrealistic expectations are not created.
The informants said that working within a context in which service users often have difficulties with living conditions frequently leads to collaboration goals such as “increased quality of life,” “security,” and “better everyday life.” These terms are unclear and may be viewed as very different from those of the collaboration partners. Practitioners may therefore have competing priorities and understandings of what is necessary to achieve the goals of the collaboration. For example, “increased quality of life” can mean becoming drug-free but it can also mean access to a dwelling or better health. Vangen and Huxham (2009) challenged the idea that a shared goal is important for collaboration to be beneficial. They believe that it is necessary to strive for agreement about goals, but that the idea that such agreement can be achieved in the first place is paradoxical.
Possible limitations of the research
Five interviews could be considered as a relatively small number from a research perspective. However, qualitative research is not dependent upon numbers (Sandelowski, 2001). An increased number would not necessarily have strengthened the findings. Thus, the interviews were only with practitioners. People with substance use–related challenges were not included in this research project. This limitation restricts the findings to the sole viewpoint of the practitioners. By including people with substance use–related challenges, the analysis could have been more nuanced and variated.
The findings show that the organization of the substance use system imposes requirements for collaboration, increases the need for collaboration, and simultaneously makes collaboration challenging. The substance use field was described as an organizationally fragmented context characterized by narrow structural conditions and inflexible rules. This organization created practical challenges for the provision of the long-term, coordinated services that practitioners wanted and tried to achieve.
The necessity of free-flowing information and feedback sharing is fundamental.
Meaningful factors for collaboration included respectful interaction between and experience with all involved parties. Experience consisted of good knowledge of one another’s working contexts and roles in the context of collaboration and substance use services. Such experience-based collaboration competence can be understood as a way of dealing with the organizational challenges that both require and hinder collaboration.
We will argue that professionals in the substance abuse field need more awareness in that good collaborative processes do not come by themselves. Clarity of frames, objectives, and culture of collaboration is important, and means of collaboration need to be negotiated in each individual case. The necessity of free-flowing information and feedback sharing is fundamental, both in the collaboration between the service users and the professionals and between professionals and professionals.
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