To gain a deeper understanding of the development of a joint vision for Close Care, its obstacles and opportunities, in the region of Sörmland based on national health and social services reforms.
Seven semi-structured interviews were conducted with thirteen stakeholders. Documentation from the process was used to enhance the findings. A qualitative content analysis was performed.
Stakeholders described Close Care as entailing “person centeredness, cooperation, and resource sharing” but found it “too abstract”. Participation in developing the vision varied, with experiences of “external pressure” and low “readiness for organisational change”. Views on a regional vision’s “relevance and usability” differed. Participants highlighted several opportunities for the Close Care vision, such as: “a stepping-stone for implementation”, “harmonises with other health care visions” and “forming a cross municipal and regional network”. They also noted obstacles like “symbolic alienation”, “cognitive complexity”, “short-term economic reality” and “uncertainty around implementation”.
Opportunities and obstacles for the vision of Close Care can inform complex healthcare reforms that require stakeholder cooperation.
Understanding Close Care may enable health system stakeholders to more effectively cooperate around the citizens’ needs.
Research on common ground has mainly focused on national or international policy levels and individual hospitals, professionals or patients. This study offers insights on regional and municipal cooperation in health care driven by a common vision.
Introduction
After decades of initiatives aimed at creating “integrated care and social services” to address gaps in the healthcare system (Cheng and Catallo, 2019), the WHO published a strategy for integrated and person-centred care in 2015 (World Health Organisation). The aim was to serve as an inspiration and vision for its member countries as they venture out in challenging and reinventing their health care systems to more effectively meet their citizens’ future needs. The strategy was a response to a series of developments that called for a fundamental shift in health care. Medical–technical development has increased specialisation that, while saving lives, has also increased costs and led to an increased fragmentation of health care and social services (Borges et al., 2019; Calciolari et al., 2022). Concurrently, the disease pattern has changed; lifestyle diseases are now a main driver of health care costs (NCD Countdown, 2030 collaborators, 2018). Thus, more collaborative work among different stakeholders, professionals and health care providers is needed where proactive early health interventions are called for (Schroeder, 2007; Xyrichis et al., 2018; Calciolari et al., 2022).
Yet, several barriers exist, which need to be addressed to support the transition to integrated and person-centred care, including legal, structural and financial barriers (Bolous et al., 2022; Dahlborg and Tengelin, 2022; Shand and Turner, 2019). There are also crucial barriers that stem from the fact that integrated and person-centred care is likely to involve multi-organisation collaboration on a micro, meso and macro level (Hujala and Laihonen, 2023) Collaboration between multiple actors requires another approach to governance compared to how individual organisations are governed (Minkman, 2017; Sandberg, 2022; Shand and Turner, 2019). Multi-organisation efforts are more horizontal and non-hierarchic, holding trust at their core (Minkman, 2017; Bolous et al., 2022). Information sharing and big data used for steering complex integration is key as: “In essence, health services are methodologically “noisy” environments. Identifying what constitutes the “active ingredient” of the new service represents a challenge to researchers (Kaehne, 2019). Despite global efforts, there remains a lack of consensus on the term “integrated health and social services” (Cheng and Catallo, 2019; Xyrichis et al., 2018). This highlights the need for actors from different organizations to develop a shared understanding and common vision for new care provision (Henriksen et al., 2003; Minkman, 2017).
A government investigation in Sweden (2017–2021), Good and Close Care—A Reform for a Sustainable Health Care System (SOU, 2019, p. 19), identified challenges similar to those noted by the WHO. It found that the national health care system is more focused on illness and organization than on patients and is less cost-efficient than most European systems. Close Care is presented as the essential transition for the Swedish health care system over the next decade to effectively allocate resources and address future health needs. There is an urgent need to proactively address fragmented care and improve collaboration among healthcare actors to deliver more person-centred and integrated care (SKR, 2020; Arwidson and Fornstedt, 2023; Läkaresällskapet, 2023). The Swedish Association of Local Municipalities and Regions (SALAR) has outlined four main transition journeys within the Close Care concept (SKR, 2023).
- (1)
From organisational focus to person centred and relationship focused
- (2)
From stand-alone health care services to integrated and person-centred care
- (3)
From reactive care to proactive and health preventive measures
- (4)
From citizens and patients as passive receivers of care to proactive co-creators
Despite political and strategic support, recent evaluations of Close Care in Sweden report minimal changes from the perspectives of patients, the healthcare system, and professionals (Myndigheten för vård och omsorgsanalys, 2021, 2023). One reason for this may be the complexity of the decentralized Swedish healthcare system, which relies on a “soft” steering model from the national level. This complex structure allows the 21 regions and 290 municipalities, along with private actors, to determine how to implement established laws and operationalize health and social services (Sandberg, 2022; Poksinska and Wiger, 2024). A complex organization is characterized by diverse perspectives and high interdependence among stakeholders, making it challenging to achieve a clear overview (Palmberg Broryd, 2021, pp. 20–21).
Thus, the Swedish health care system governance is comprised of several complex adaptive macro- and meso systems where legislation, different organisations such as regions and municipalities and private and public actors, as well as financial incentives must be explored to reach common goals through the coordination of resources. However, the actual care is usually performed in microsystems that are not always aware of the whereabouts and motives of the larger organisations (Hujala and Laihonen, 2023; Plsek and Wilson, 2001; Sandberg, 2022). To govern such complex systems, a joint vision becomes essential.
Consequently, SALAR called for all 21 regions in Sweden to develop a vision for Close Care. The mission of developing a joint vision of Close Care for the small region of Sörmland, with its 300,000 inhabitants divided up into nine municipalities, was initiated in 2019. A series of principles were developed by the Regional Steering Group, which is the structure for cooperation between the regional functions and its nine municipalities, namely, cooperation, trust, proactiveness, competence, and digitalisation (Sörmland, 2020). The overall aim of the project was to support the transition to Close Care on a regional and municipal level according to the project directive adopted in November 2021 by the Regional Steering Group (FoU i Sörmland, 2023).
Prior to this study, participants identified the need for joint direction, engagement, and ownership of the transition to Close Care, emphasizing collaboration among key stakeholders to develop a shared vision encompassing perspectives from citizens, employees, and organizations. The resulting vision document, detailing three target areas, is shown in Figure 1. The Regional Steering Group accepted the vision in March 2022, followed by approval from the regional board and its nine municipalities over the next six to eight months (FoU i Sörmland, 2023).
The concept “Close Care”, which has been introduced by the Swedish government, is to our knowledge sparsely investigated in research. In addition, there is little knowledge of the transformation of this national concept into a regional actionable vision with its obstacles and opportunities identified by the stakeholders involved in the transition.
This study’s purpose was to gain a deeper understanding of the development of a joint vision, for Close Care in the region of Sörmland and its obstacles and opportunities. The research questions were as follows:
- (1)
How do the involved parties understand the concept of Close Care?
- (2)
What are the stakeholders’ experiences in the process of developing the vision of Close Care in Sörmland?
- (3)
What are the possible opportunities and obstacles that the stakeholders foresee with the developed vision of Close Care?
Methods and materials
Research design
This interview study is part of a larger four-year collaborative research project between the region and its nine municipalities and the University of Mälardalen inspired by Participatory Action Research (PAR) (Herr and Anderson, 2005; McIntyre, 2008; Watson Bongiorno, 2015), initiated in September of 2022, with the aim of following and supporting the transition to Close Care in Sörmland. The findings from these interviews will be used with stakeholders to further discussions and understanding of the concept of Close Care.
Data collection
Three individual interviews and four focus group interviews (n = 2–5 per group) were conducted, with one focus group for each area of the region (South, West, North) representing all nine municipalities. An additional focus group was held for the joint steering group for health care in the region and municipalities. In total, 13 participants (10 women, three men) were interviewed, identified through purposeful sampling by project leaders to ensure relevant stakeholder involvement in the vision development process (Kelly, 2010, p. 317). Interviews took place from May to July 2023 using a semi-structured interview guide (Kvale and Brinkman, 2009) based on the research questions.
Data management and analysis
We have taken a qualitative content analysis approach “focusing on data reduction, data display and interpretation”. There are no agreed number of steps in qualitative analysis but usually they range from 4–6 steps (Mezmir E.A., 2020). In this study the interviews were transcribed verbatim by the first author. Inspired by Granheim and Lundman’s (2004), qualitative content analysis process, the interviews were then coded thematically: yielding the following method: Listening through interviews and reading texts, identifying sentences and phrases, translating meaning units into English and condensing text, coding and grouping, forming themes, sorting the themes under research questions and verifying findings with participants. The analysis was initially conducted by the first author and subsequently discussed among all authors until consensus was reached. Findings were verified with interview participants, and quotes are referenced by participant number to ensure anonymity, with specific roles omitted using ellipses. Additionally, the first author added clarifying words in parentheses in some quotes. The first author, fluent in Swedish and English, translated the quotations.
Ethical considerations
This study (Dnr, 2023–00064 – 01) was approved by the Swedish Ethical Review Board, 20 March 2023. Verbal consent was obtained and recorded from each participant prior to the interviews. An information letter outlining the study, data usage, and participants' right to not attend or withdraw at any time was sent prior to the study.
Results
The results are sorted and presented in relation to each research question. Themes and quotes are found in Tables 1–3.
Research question 1: themes and examples of meaning units/quotes
| Research question | Themes | Examples of meaning units/quotes |
|---|---|---|
| Q1. Stakeholders’ understanding of the concept of Close Care | a. Abstract concept | “My experience is that there have been so many different definitions of what Close Care means in different operations” (participant 4) |
| “This transition to Close Care is very abstract. What is happening? Where are the concrete examples? We need to communicate much better and erase the feeling that it is an abstract project somewhere out there” (participant 5) | ||
| b. Person centredness | “I think that Close Care means that care should be close to the individual in terms of easily finding it when needed” (participant) | |
| “Close Care means somebody that listens and understands my needs and then knows where the best help is to be found, and it could be individual solutions” (participant 10) | ||
| “The word ‘close’ can mean both physically close but also close in the sense of easy access in the form digital solutions and a good relationship and trust between the professional and the citizen seeking care” (participant 12) | ||
| “It (person centred care) can become action (for the individual)” (participant 11) | ||
| c. Cooperation | “We need to cooperate with civil society … (for our citizens) to become more physically active and strengthen both physical and psychological health” (participant 13) | |
| d. Information sharing | “We need much easier information sharing between different organisations … We need joint journal systems and so on …” (participant 12) | |
| “How do we manage to instil safety in our own systems, in our own organisations, so individuals dare to build bridges, so that one dares to say ‘yes’ … without the feeling of having to be on guard to not be used and ending up at the bottom of … what is it called … the food chain” (participant 2) | ||
| e. Economic reality requiring cooperation and pooling of resources | “To work with Close Care and person centeredness is also (to work) with quality and be more economically efficient” (participant 11) |
Source(s): Authors’ own work
Research question 2: themes and examples of meaning units/quotes
| Research question | Themes | Examples of meaning units/Quotes |
|---|---|---|
| Q2. Experiences in the process of developing the vision of Close Care | a. Level of participation in the process | “We have brought people together in different constellations who have started talking about this and, thus, put Close Care on the map” (participant 13) |
| “‘I felt not always listened to’ (participant 10)We have worked through this special steering group for Close Care, but maybe we should have worked through our ordinary steering group for cooperation in the region and municipalities to get more involvement” (participant 11) | ||
| b. Relevance and usability of the developed vision | “When I saw the other region … target picture I felt: Oh, I really would have liked to have that one. It is a little crazy that one must do something unique and cannot do the same because then it is not ours” (participant 13) | |
| “I do not know if I am being controversial here, but I cannot fully understand why all regions should have different visions because I like the SALAR vision the best, and when I explain Close Care, I most often end up with that one instead (of the one from the region of Sörmland) because it makes the most sense to me” (participant 9) | ||
| c. Readiness level for organisational change under external time pressure | “… the vision (for Close Care in Sörmland) is … as all visions, a bit fuzzy, and although we were all part of developing it … it has about the right amount of fuzziness, so we can all sing on the same note. Now we need to be ambassadors for this transition” (participant 2) | |
| “When we started with this work, it felt a little bit like Oh, no! Sörmland is behind, we need to catch up as fast as possible and quickly produce a vision for Close Care” (participant 13) | ||
| “There is a national directive to make a vision (for Close Care) … I find that model of management a bit troublesome” (participant 11) | ||
| “It is a very difficult situation as everything has been delayed because of the pandemic and we are entering an economic regression. Terrible timing. We should have made this transition five years ago” (participant 2) |
Source(s): Authors’ own work
Research question 3: themes and examples of meaning units/quotes
| Q3a. Opportunities in the vision of close care | a. Common stepping stone for implementation | “A movement has started, and there is an incentive among co-workers because they now see the need (for a change) …” (participant 13) |
| “I believe it is important to have a vision, and it has been a good process … it is established, and nobody really questioned the layout or content …” (participant 7) | ||
| “Deep down, I feel that we have agreed on Close Care in Sörmland … I think the visual picture is nice … citizens in the middle and co-workers and the organisation looking out over Sörmland. I am satisfied with the picture” (participant 12) | ||
| b. Harmonisation with other visions for health care | “All regions shape their own picture/vision of what is important, but if we look at the other regions and wording at large, they are more or less the same” (participant 12) | |
| c. Cross municipal and regional network formed | “We have brought people together who have started talking about this” (participant 13) | |
| “The municipality has a strength in that they have appointed process leaders for Close Care” (participant 6) | ||
| Q3b. Obstacles in the vision of Close Care | a. Symbolic alienation | “There is a lot of talk about this ‘Care’, and I believe the major challenge in the future will be to remove the word ‘Care’ to take the target picture a step further and broaden it” (participant 8) |
| “The social services stop listening as soon as they hear ‘Close Care’; (they say) that is not for us” (participant 11) | ||
| “Personally, I believe the whole expression of this project is wrong because it is the transition of the ordinary health care system that should transform in the future until new needs are discovered” (participant 12) | ||
| b. Cognitive complexity and uncertainty how to use the vision | “The more you work, the more you see the complexities … we have ten different organisations in Sörmland with different resources and capabilities and so on … and we are all different people” (participant 12) | |
| “There are so many different projects but the whole is maybe not always there” (participant 9). | ||
| “How will the people ‘on the floor’ understand that they should act differently when everything in the organisation is the same?” (participant 3). | ||
| “The picture now given is that everything will now be done by primary care. I do not know how many times I have heard this … Instead of us all working together to solve everything” (participant 2). | ||
| “We suffer from ‘perspective overload’. There are so many different things to take in and process all at once” (participant 11) | ||
| c. Short-term economic reality and resource scarcity | “Thinking back, I would like to send a message to the politicians to not just ‘bake in’ the Close Care money into the general budget to fill general budget holes” (participant 7) | |
| “I would say that maybe the real obstacle is not the economic situation. Resources can be more than money … resources are also staff which might be our biggest challenge. It is not really money, there is money in Sweden, but not personnel” (participant 5) | ||
| “Our health informants should be able to inform about the Close Care vision, but they cannot really see their own part in this: ‘it costs money, and it is not our problem’. Who should own this responsibility?” (participant 9) |
Source(s): Authors’ own work
Stakeholders’ understanding of the concept of Close Care
In Table 2 the results from the research question two are presented with themes and quotes.
Close Care is seen as abstract, not easily defined, and the understanding depends on which organisation and context one is operating within.
Participants considered the person centredness theme as a key aspect of understanding Close Care. The meaning of Close Care is the care organised around the individual’s needs and the word “close” can mean both physically close but also close in the sense of easy access in the form digital solutions and a good relationship and trust between the professional and the citizen seeking care. The concept of person centredness is also mentioned as something that is not new.
Another theme central for how participants understand Close Care is the need for cooperation. Effective Close Care relies on cooperation among all stakeholders within and outside the health and social care system. This is seen as challenging in a highly specialized and stressed environment. Cooperation within organizations, between organizations, and with external actors, such as civil society for preventive measures, is essential.
The importance of information sharing is also emphasised as a crucial aspect for Close Care. This inevitably means that there are much higher demands in the future for different care and social service providers to share information and to cooperate to meet patients’ needs and wishes. However, information sharing, and communication do not only revolve around systems; an equally challenging task is building trust among employees to share information with each other.
Participants discussed the theme of economic reality and resource pooling, agreeing that timely actions in collaboration could enhance the efficiency of healthcare and social services while improving staff satisfaction and finances.
Experiences in the process of developing the vision of Close Care
In Table 2 the results from the research question two are presented with themes and quotes Participation in the process was central to the experience, encompassing both the development of the vision and broader discussions about Close Care among stakeholders Participants expressed varying levels of satisfaction with their involvement; some municipal representatives felt underconsulted, which they believed hindered the process’s effectiveness. Over time, cooperation within the Close Care network improved, but participants recognized the need for broader organizational buy-in. Some suggested that a separate steering group might not have been the most effective strategy. Regarding the relevance and usability of the Close Care vision, opinions diverged: some questioned the necessity of individual regional visions, while others found the national vision from SALAR and those of other regions helpful independently or as complements to their own.
Also vital for the experience of developing a vision was the organization’s readiness for change and external pressure. Regions and municipalities faced SALAR-imposed deadlines to develop a vision, leading to concerns about how national directives influenced their actions. Participants noted that the stressful timing of the vision development made organizations more hesitant to engage in the process for developing a new vision for health and social care.
Opportunities and obstacles with the vision for Close Care
In Table 3 the results from the research question three are presented with themes and quotes.
All interviewees agreed that developing the Close Care vision fostered a shared understanding of the concept across organizations and municipalities. Many emphasized the need for a common stepping stone or visualization among different actors to advance this complex transition. Alongside national and regional visions, some healthcare organizations in the nine municipalities created their own. Most participants noted that the alignment of the Close Care vision in Sörmland with other visions is a significant advantage. However, opinions were mixed regarding its clarity; some viewed the vagueness as necessary for achieving consensus, while others found it too general to facilitate actionable steps.
Participants highlighted the formation of the Close Care Network as a significant opportunity. This network includes representatives from healthcare and social services across the region and all nine municipalities, coordinated by project leaders from the Research and Development department. However, concerns were raised about the regional organization’s lack of activity compared to local municipalities in nominating process leaders and representatives to the network.
In the interviews, participants purveyed how wording, the messenger, or colour scheme contribute to a sense of alienation, denoted in the theme symbolic alienation. For example, the term “Close Care,” focusing solely on healthcare, caused participants engaged in self-care, civil society, schools, and social services to distance themselves from the vision as they felt their work area was neglected. Additionally, the graphic profile and colour scheme in the illustration for the vision posed further reasons for feeling alienated.
The second obstacle identified was cognitive complexity. Many participants noted that the plethora of perspectives within the Swedish health and social service sector create challenges in understanding necessary reforms, leading to “perspective overload.” The numerous ongoing projects in the region hinder a holistic view, and while SALAR stated that the transition to Close Care does not entail a new organizational level (SOU, 2019), participants struggled to explain this new approach to front-line workers within the existing framework. They also found it difficult to convey that the transition does not require primary care to handle everything.
The short-term economic reality and resource scarcity was present in discussions The reality of how to launch the new vision for Close Care put a damper on enthusiasm. However, However, regarding resource scarcity, the concern was not only for money scarcity, but also for the ability to recruit qualified staff.
Discussion
Based on a regional case in Sweden where a vision for Close Care was developed, this study’s purpose was to gain a deeper understanding of the development of the vision in a complex setting with many actors requiring cooperation. Through interviews and documentation, the aim was to answer three main research questions: how the involved parties understand the concept of “Close Care”, their experiences of developing a joint vision, and the possible opportunities and obstacles that stakeholders see with the vision of Close Care.
Results discussion
The findings indicate a common understanding of Close Care among participants, aligning with definitions in the national vision, such as person-centredness and integrated care (SOU, 2019). However, stakeholders still have many questions about how to implement this new approach throughout the healthcare value chain. Despite shared understandings, participants found the vision for the transition to Close Care confusing and abstract. This aligns with international research and a national evaluation, which noted that cultural, organizational, and legal barriers hinder the transition. A lack of understanding of what the concept means in everyday practice also obstructs efforts to transform short-term projects into lasting system changes (Myndigheten för vård och omsorgsanalys, 2021).
The acceptance of a joint vision among decision-makers marks not the end, but the beginning of an implementation process in a complex organization; significant work remains to establish new ways of working. A review by Calciolari et al. (2022) identified seven interconnected dimensions in integrated care: person-centred care, clinical integration, professional integration, organizational integration, systematic integration, functional integration, and normative integration. In Sweden, the focus has been on person-centred care, clinical integration, and professional integration, with some emphasis on normative integration. However, challenges persist due to a lack of organizational, systemic, and functional integration, complicating the realization of the joint vision. This lack of maturity and suitable frameworks for integrated care and interprofessional practice is a common challenge across many countries and organizations (Xyrichis et al., 2018; Cheng and Catallo, 2019; Kaehne, 2019; Calciolari et al., 2022).
Regarding the process of developing the vision, the findings suggest that the process of bringing people together from different parts of the health care and social services system and encouraging them to cooperate (for example, in the format of the cross municipal and regional Close Care Network) was one of the most valuable contributions of the process. However, these discussions have primarily occurred at the management level. The daunting task of communicating the vision to the masses of front-line workers remains. Recent research has highlighted the challenges of involving front-line workers in healthcare change processes (Slåtsveen et al., 2023; Xyrichis et al., 2018).
Participants largely agree that a common vision for the region and its nine municipalities is essential for advancing the transition to Close Care. While project organizations can facilitate faster progress, they may also risk overshadowing main operations and preparing personnel for change. Additionally, collaboration in such environments can be challenging (Cheng and Catallo, 2019; Palmberg Broryd, 2021). Research indicates that knowledge sharing in projects can be highly specific, in addition to the expectations to participate and jointly collaborate. This could be related to this study’s results on the importance of information sharing and discussions about making Close Care a “project” at a Research and Developmental unit (Lajčin and Guzoňová, 2023). In this study, the theme of “organisational complexity” illustrates this in terms of the continuous need for information and inclusion so that the individual stakeholders do not lose their footing. Change within a healthcare organisation necessitates that individuals adopt new identities as part of the transition process (Shand and Turner, 2019; Campbell, 2020). This transformation, however, can be challenging, as not all individuals readily embrace change owing to the discomfort it entails.
In “A Theory of Organizational Readiness for Change,” Weiner defines organizational readiness as a shared psychological state in which members feel committed to and confident in their ability to implement change. This perspective is particularly relevant for examining changes that require collective behaviour to achieve desired outcomes (Weiner, 2009); such as those promised in the Close Care vision. Health care workers and managers may use various strategies to resist change and protect their identities. One strategy is to dissociate from a proposed vision or strategy, either partially or entirely. This study identified instances, where participants criticized the vision’s colour scheme or the term “Close Care” for being too narrow and not inclusive of their own operations. Such criticisms may justify a lack of engagement in the process, allowing individuals to remain passive observers. By disengaging due to symbolic elements that do not resonate with them, individuals can maintain a distance from the initiative. We define this phenomenon as “symbolic alienation,” a cognitive process where minor symbolic expressions in documents, such as vision statements or illustrations, create a sense of alienation that hinders acceptance, in this instance the Close Care vision.
A significant challenge to implementing reforms is the real or perceived scarcity of monetary and personnel resources. Participants acknowledged that a shared vision of Close Care could lead to long-term savings through cooperation and resource pooling, but securing funding in an already financially strained system is a short-term obstacle. Public healthcare expenses in Sweden have risen from 5.5% of Gross National Product (GNP) in 1970 to 11% in 2018, making Sweden one of the EU countries with the highest healthcare costs relative to GNP (Gralén et al., 2019). In 2023, many of the 21 regions reported budget deficits in the billions of Swedish kronor, increasing pressure on the health and social welfare system. While the SOU report on Close Care states that the reform is “not made to save money,” it aims to “increase quality of care while controlling costs” (2019, pp. 20).
This study emphasizes the importance of collaboration in the transition to Close Care. Various challenges can hinder collaboration, including differing goals among stakeholders, limited participation, difficulty finding common ground, and the need to balance system knowledge with existing knowledge (Xyrichis et al., 2018; Lindhult and Axelsson, 2020). We liken reforming the health and social service system to open-heart surgery: changes must occur while the system is still operational to maintain essential functions. Some actors may resist change, preferring to restore the status quo, like blood clotting during surgery. If successful, the system’s functioning and circulation will improve, but individual actors may struggle to see this outcome due to their focus on immediate issues. Currently, the vision for Close Care remains largely confined to decision-makers and initial project participants. The cross-sectional regional and municipal network recognizes the difficult transition ahead, while non-inaugurated front-line workers continue to operate within the traditional healthcare paradigm, potentially working against the reform as they attempt to stabilize the system.
Rogers' diffusion of innovation theory provides a framework for understanding readiness for systemic change. Developed in the 1960s, this model was adopted in the handbook for Swedish municipal and regional project leaders of Close Care (SKR, 2020). It categorizes actors in transitions as ranging from early adopters to laggards resistant to change. The model posits that a critical mass of 15–25% of an organization must support the transition to drive it effectively (SKR, 2020). Further research is needed to assess how many Swedish health and social services workers and stakeholders support the new vision of Close Care, as participants in this study varied from early adopters to laggards according to Roger’s theory.
However, it could be questioned if the diffusion theory (based on a more traditional and hierarchical setting) is the best model to understand change and interprofessional cooperation in a complex health care setting. Some new frameworks for interprofessional practise such as the “InterProfessional Activity Classification Tool (InterPACT) looking at the collaboration in interprofessional teams with subheadings under: Teamwork, Collaboration, Coordination and Networking (Xyrichis et al., 2018) and the INTEGRATE framework (Calciolari et al., 2022) with its seven dimensions of integration might be more effective tools for addressing and accessing the effectiveness of the vision for “Close Care” in Sweden and its subsequent transition. As pointed out in the vast literature on the topic of integrated care the effects and outcomes for the stakeholders, is to some degree evidenced with some positive outcomes for professionals but the outcome for the actual citizen or patient is still poorly evidenced (Kaehne, 2019).
Methodological limitation and strengths
Several methodological considerations are important to note. This study does not include the perspectives of front-line health workers, relying instead on interpretations from management and project leaders. Participants were recruited through purposeful sampling to identify stakeholders involved in developing the vision, a method that effectively utilizes resources when research questions are clearly defined (Palinkas et al., 2015). The study employs a mix of individual and focus group interviews to gather in-depth information; however, focus groups may lead to self-censorship compared to one-on-one interviews (Sim and Waterfield, 2019). Nonetheless, group discussions can stimulate valuable dialogue. A strength of this study is that preliminary findings were presented to participants for their reflections and validation. Additionally, the themes identified have high transferability, applicable to other organizations facing similar complex reforms (Hellström, 2008). Traditional research paradigms often adopt a hierarchical view of knowledge, where experts hold and disseminate information (Holmstrand, 2006; Herr and Anderson, 2005). In this Close Care transition research project, we aimed to foster a democratic process where participants contributed creatively. Identifying and involving all relevant stakeholders to generate useable knowledge about the vision posed a challenge in this complex transition driven by a vision.
Conclusions
This study reaffirms prior research emphasizing the necessity for a shared understanding and evaluation frameworks among stakeholders regarding person-centred and integrated care, referred to as Close Care in Sweden. However, the vision for transitioning to Close Care remains abstract and confusing. While facilitating stakeholder engagement is valuable, the findings echo previous studies indicating that the complex multi-organizational context limits the involvement of all relevant stakeholders.
The development of a unified vision can serve as a critical stepping stone for transitions and change processes. However, organizations must recognize the significant investment of time, personnel, and financial resources required to navigate cognitive complexity, symbolic alienation, and uncertainty, ensuring that the visioning process is not just resource-intensive without yielding benefits. Effective implementation of Close Care requires cross-sectional and interprofessional dialogue, concrete communication, and actionable plans to translate the vision into practical, daily applications that serve individual citizen needs.
Moreover, the insights gained in this study may extend beyond Close Care, offering valuable implications for integration transition projects within various health and social service organizations driven by a vision.
Further research is needed to explore the concept and implementation of Close Care, validating the findings of this study and assessing the long-term effects of a vision-driven approach on the transition of healthcare and social services. As “Action without a vision can become a nightmare but a vision without action is a daydream”.
