Introduction
This study began with unanswered questions in practice, and in seeking to answer these questions it has informed understanding of collaboration and responded to calls for research which examines the relationship between structural influences and individuals (Williams and Sullivan, 2009; San Martin Rodriguez et al., 2005). The emergent theory of Interactive Navigation explains the complexity involved in collaboration and the Collaboration Compass provides a model to support planning, facilitation and analysis of collaboration in practice. This chapter will summarise key findings, explore the implications of Interactive Navigation and suggest the potential uses of the Collaboration Compass model to inform future policy, practice and research. A reflection on the personal and professional implications of the research journey will follow and the chapter conclusion will close the thesis.
Summary of Key Findings
The findings and discussion present collaboration as a social device used in
navigating complex healthcare situations and managing collaborative relationships. Structural co-ordinates of certainty, uncertainty, limits and goals orientate the situation and Interactive Mechanisms are used to direct collaboration according to navigation of co-ordinates. The process of navigating between competing
Situational Co-ordinates is influenced by power, and this navigation directs collaboration into four different areas which produce developing, maintaining, limiting or disrupting collaboration.
Developing collaboration involves intense interaction as goals are developed and new ways of working are rehearsed to establish routines. Maintaining collaboration requires co-ordination to create certainty and maintain communication and trust over longer periods. Limiting factors within the situation reduce communication and trust and this produces minimal, but functional collaboration which is effective only in the short term. The area of disrupting collaboration is orientated by limits and uncertainty in the situation. Loss of two way communication and trust in this area results in disillusion for professionals and anxiety, fear and guilt for patients.
169 Power creates differences in the capability individuals have for interacting within the healthcare situation. The implicit power in patient and professional roles is socially constructed and is embedded in the way healthcare systems operate and in the way roles are perceived. While both patients and professionals navigate the situation, it is professionals who have more power and the capability to use Interactive
Mechanisms to direct collaboration into a position which is professionally manageable, and which also reproduces and reinforces existing power
relationships. Patients have less capability to use interaction and, unless they have a condition which is of symbolic significance to professionals, they have limited capability to direct collaboration.
The theory of Interactive Navigation proposes that interaction is used to direct collaboration into four areas, with very different consequences for patient and staff experiences. The theory is conceptualised as a navigational device in the form of the Collaboration Compass. This model presents a tool to inform understanding of collaboration and to support navigation of health care situations, with appropriate direction of collaboration in practice to achieve the desired outcome.
The findings from this study have implications for current health and social care policy which places collaboration at the centre of services, but which is also vague about what collaboration means, who it involves and how it takes place.
Collaborative working has a clear place in reorganised services and new models of care (NHS England, 2014; 2016) and collaborative enterprise is promoted as core in the provision of an efficient, effective and sustainable NHS (NHS England and NHS Improvement, 2016). Such promotion of collaborative working between agencies has been called ‘a convenient fiction’ in the face of relationships that are more fragile than policy makers assume (West et al., 2015, p 114).These policies discuss collaboration in general terms and assume a simplicity in collaborating to deliver integrated working (NHS England, 2016; 2015). Collaboration is referred to in singular and undifferentiated terms; assuming that in practice it is one entity, and one act, which can be implemented in any situation. The findings from this study present collaboration as a far more complex concept, which requires more
recognition from policy makers, managers, practitioners and patients if collaborative health and social care developments are to succeed.
The theory of Interactive Navigation displays the competing influences and complex interaction involved in collaborating to deliver care. Collaboration is revealed as an intricate social device bound within the situation, and which has the potential to exist
170 in different forms. Although complex relationships have been recognised, the
mechanisms involved in implementing collaborative integrated care have previously been regarded as hidden (Novikov et al., 2016; National Audit Office, 2017).
Interactive Navigation and the Collaboration Compass model (figure 34) offer policy makers, managers and those who are required to collaborate, a way to view the Interactive Mechanisms of collaboration and to identify the Situational Coordinates which influence the direction and outcomes of collaboration in any situation. Figure 34: The Collaboration Compass Model
Implications for National and Local Policy
Interactive Navigation theory and the identification of four different areas of collaboration suggest that some areas of national and local policy may potentially hinder rather than promote collaboration by failing to account for complexity and by making collaboration in itself the goal in delivering integrated working. As care environments become more complex, with reorganisation and fragmentation of care, there is an increased need for collaboration. This also creates more complex situations to navigate with added competing demands, new limitations and
increased uncertainty. Although uncertainty promotes the development of collaboration, and can begin the changes promoted by policy, it can also lead to
171 disruption and failure. To counteract the disruptive influences of uncertainty, policy makers must be clear about the goals which are to be achieved and avoid making collaboration a goal in itself.
Current NHS policy places collaboration at the centre of care delivery and service redesign, but remains vague about what constitutes collaboration in practice (NHS England, 2014; 2015; 2017). Such policy makes collaboration a goal through the assumption that joint working will provide a solution to other NHS problems. Broad brush depictions of collaboration present a picture of intense communication and partnership working in a range of newly established services. Expectations of collaboration are created through detailed specifications for integrated services (NHS England, 2017a) and many examples of different collaborative endeavours (NHS England, 2015b, 2017d). The substantive theory of Interactive Navigation identifies the intensive interaction portrayed in such depictions as the rehearsal of developing collaboration, but also identifies such intense use of interactive
resources as not sustainable in longer term ongoing practice. Policy needs to address the ongoing requirement of collaborative practice, and the theory of Interactive Navigation can support consideration of differing types of collaboration appropriate to different situations.
Collaboration is a device with which to achieve goals, rather than being a goal in itself. As with any other device, collaboration requires understanding, planning and resourcing for maximum effectiveness. Developing collaboration requires intense interaction with resources needed to rehearse, build trust and embed new methods of communication and coordination. Policy makers must consider the investment needed in this area of collaboration if new ways of working are going to be fixed in practice. However, not all situations require such levels of investment or such intense collaboration. The activity and resourcing needed to develop collaboration is difficult to maintain, and an expectation of this level of collaboration in all situations is problematic for the sustainability of new NHS services.
Effective and sustainable collaboration requires policy which recognises and prepares for the differing collaborative requirements of healthcare situations, and the different directions collaboration can take in practice. Interactive Navigation identifies a need for certainty if collaboration is to move beyond development, and this is something which can be lacking during the change involved in policy driven reorganisation of services. For collaboration to thrive and maintain in the long term,
172 policy must promote aspects of certainty along with the inevitable creation of
uncertainty during the change involved in reorganising the NHS.
The theory of Interactive Navigation identifies the role coordination plays in creating certainty and maintaining collaboration, but also recognises the impact of competing demands on those who take on a coordination role. This understanding is vital for policy makers who advocate collaboration in integrated services. In some areas an identified coordinator role has been shown to be effective (Gabitova and Burke, 2014; Palos and Hare, 2011; Gilburt, 2016), but expectations that professionals can take on this additional role can have detrimental effects (Williams and Sullivan, 2010; Long et al., 2013; McEvoy et al., 2011) and eventually lead to limiting or disrupted collaboration. The role coordination plays in maintaining collaboration should be promoted more explicitly in policy, and considered in the resourcing of situations where collaboration needs to be maintained over longer periods of time. Coordination is recognised as part of person centred care (Brummel-Smith et al., 2016; NHS England, 2013) and there are a range of possibilities in practice to fulfil the need for co-ordination (Gilburt, 2016), but the importance for policy is the recognition that coordination has a significant role in maintaining collaboration and patient participation, as well as in organising the delivery of person centred care. Interactive Navigation identifies where there are clear goals coordination can be used to maintain the certainty, communication and trust vital for positive
experiences. It is this navigation of care situations and the direction of collaboration, which is required to maintain person centred care over longer periods of time. The implication for policy is that coordination has an important role in directing and sustaining collaboration which is a vital part of delivering and person centred care in complex care situations. The theory of Integrative Navigation and use of the
Collaboration Compass model can be used in the development of policy which directs sustainable collaboration as part of long term patient centred care.
There are situations which require the intense activity of developing collaboration, others which require coordination to maintain collaboration in the long term, but there are also many instances in healthcare where collaboration is required over shorter periods of time. Interactive Navigation identifies some situations which have strong elements of certainty, but also feature limiting factors which restrict the interaction available. In this type of care situation, where the life and work
commitments of patients, and the workload, funding and resources in healthcare can all inhibit interaction. In such situations limited collaboration provides a
173 functional way to support the delivery of short term care. The theory of Interactive Navigation presents this as a functional and effective form of collaboration in some healthcare situations. Although it does not meet current policy expectations of collaboration, limited collaboration is taking place in practice, and provides a pragmatic solution to collaborating within the limitations of some healthcare situations. Recognition of this type of collaboration provides policy makers with a range of collaborative possibilities and the option to support limited collaboration in situations of certainty and limitation where coordination is not possible. It may be that this area of collaboration is preferable to the disruption or loss of collaboration altogether.
The identification of four different areas of collaboration as identified in the
Collaboration Compass model provides policy makers with a more detailed picture with which to represent collaborative working. Policy which recognises and accepts that differing areas of collaboration are appropriate in differing situations, will offer acceptable alternatives to the current expectations of uniform intense collaboration. This will distinguish expectations of collaborative practice and allow collaborators freedom to identify the most appropriate area of collaboration for each situation. This has implications for the drive to implement more collaborative leadership approaches within the NHS (NHS Improvement, 2016). Collective leadership (Allen et al., 1998) has been proposed as the optimum style to create caring cultures within the NHS (The Kings Fund, 2014) with simultaneous focus on individual and collective contribution to culture and shared responsibility for leaders and followers. In this approach everyone has the potential to lead, which is in stark contrast to the command and control leadership style which has been a feature of more
hierarchical NHS organisations. Interactive Navigation identifies that shared leadership in practice takes place when there are clear goals, but also in response to an element of uncertainty. The mechanisms of rehearsal, trust, communication and shared coordination are all involved in facilitating the development of
collaborative relationships and the expectation of a more hierarchical leadership style contributes to uncertainty and the limitation of shared leadership activity. The theory of Interactive Navigation can inform policy and practice which supports practitioners in the rehearsal of new shared leadership approaches and
responsibilities, thereby producing new social structures which reproduce collective leadership and alter the limiting balance of power currently found in the hierarchy of the NHS.
174 Interactive Navigation recognises the potential negative effects of disrupted
collaboration, and potentially of disrupted collaborative leadership approaches, found in practice. Identifying limiting factors and the causes of uncertainty, which orientate and direct disrupted collaboration can assist local and national policy makers in producing policy which supports collaborative situations, rather
predisposes them to disruption and failure. Developing policy which provides the right balance of Situational Co-ordinates will support the development and
maintenance of collaboration, while less well balanced policy orientation can only produce limited or disrupted collaboration, with the associated negative impacts on patient and professional experiences and outcomes.
Interactive Navigation and the Collaboration Compass present a way of
conceptualising influences in practice situations, and the methods of interaction between individuals which result in four distinct areas of collaboration. This enables collaboration to be discussed in relation to the situations in which it takes place, but also in terms of the specific interaction which occurs when collaboration is
developed, maintained, limited or disrupted. Such differentiation within policy will assist understanding of a complex concept, but also support translation of policy into different areas of practice which require differing direction of collaboration.
Implications for Collaborative Practice
National policy drives the broad shape and direction of healthcare practice, but the translation of policy into operational services happens at organisational and
individual level in practice situations. As national policy drives collaboration and places it at the centre of health service transformation (NHS England 2014; 2016; 2017) there is a danger that collaborative working becomes seen as a resource, which can be simply implemented in challenging situations in order to bring about desired improvements. However, collaboration is not a panacea (Williams and Sullivan, 2010) and the theory developed in this study shows it to be a complex and multifaceted social device, integral to the structure of situations and the agency of individual collaborators. Interactive Navigation and the use of the Collaboration Compass have a number of implications if the benefits of collaboration are to be realised in practice.
It is not unusual for collaboration to be developed without organisational support (Kvarnstrom, 2008), but increasingly collaboration is being directed by organisations to establish new models of care (NHS England, 2017a, b, e). Pilot sites for new
175 policy are often funded to provide positive examples of change (NHS England, 2015c; 2017e), but outside of the vanguards it can be challenging for organisations to find equivalent funding, and collaboration then happens within existing resources. This places an additional requirement into the existing tensions between competing demands, and limitations can add to the uncertainty of the situation. The theory presented in this thesis suggests that such situations are more likely to be disrupted or fail.
Interactive Navigation theory explains why such situations, orientated by limitations and uncertainty, can lead to disrupted collaboration. Simply understanding what leads to disrupted collaboration is not enough if it is to be avoided in practice, and action to redirect collaboration is required. The Collaboration Compass model offers a tool to support the planning of efficient and effective use of existing resources and promotes thought about how interaction can be used to direct collaboration which is appropriate to the situation.
The theory identifies that new models of care and new ways of working require time and opportunities for rehearsal in the development of collaboration. This may be more than the daily time and effort, which has previously been identified as a requirement (Gardner, 2006). Such investment of time can be difficult to achieve, but in terms of establishing new routines and new ways of working, it is worth the effort, if clear goals for the collaboration are agreed. Time spent developing collaboration also opens opportunities to plan how such newly developed
collaboration can be maintained, and to include patients in the development of their collaborative care.
Some feel it is unrealistic to expect patients to participate in healthcare on the same footing as professionals (Drinka and Clark, 2000). The findings of this study show that traditional roles and relationships persist, despite professionals assuming that care situations at home are empowering for patients. Interactive Navigation
proposes that including patients as collaborators in developing collaboration can have a significant impact on power relationships within the situation. Being part of the rehearsal, with shared co-ordination, communication and trust between patient and professionals, has the potential to nurture the interactive capability of patients. Competencies required for collaborative practice have been identified (Freeth and Reeves, 2004; Hornby and Atkins, 2000), but these are only related to professionals rather than service users, and contain complex skills and specific knowledge of health care systems. The Collaboration Compass model can be used to support
176 discussions between patients and professionals about the influences and
interactions in the care situation. This has the potential to prepare both patients and professionals for future interaction. Increasing the capability of patients to interact with professionals will enable joint direction of collaboration into positions which are right for all in the situation. The theory of Interactive Navigation explains that by developing collaboration in this way, new social structures can be produced in the expectations of patient and professional roles, and collaborative capability can be rehearsed and reproduced through the agency of individuals interacting, with patients actively navigating their care situation and directing collaboration.
It seems from the findings of this study that some situations, such as end of life, are symbolic for professionals, and the maintenance of collaboration is viewed as having particular importance. The challenge for practice is how to achieve this in all appropriate situations, and not only those that have some symbolic importance for professionals. Patients who have the capability to interact effectively with
professionals will have more control in navigating their healthcare situation, rather than being directed by professionals. This brings the possibility that patients could take on the role of coordinator to maintain collaboration in their own care, or join in the decision to identify who should coordinate. Although professionals can take on this role they are not always the most efficient or effective at maintaining
coordination in the long term (Cross and Parker, 2004). If collaboration disrupts then patients may be left trying to direct collaboration on their own. The Collaboration Compass model may be useful in facilitating explicit conversations about who would