Introduction
Over the past two decades, most scholars have focused on the structural and process
challenges involved in delivering integrated care. The resulting knowledge on barriers
and enablers has informed many positive system changes. However, researchers and practitioners
continue to emphasize the seemingly intractable problems inherent in fostering collaboration
and cooperation across professional and organizational boundaries. This dissertation
argues that these ongoing challenges point towards the need to supplement existing
frameworks and practices focused on structure, process and culture, with an understanding
of the social cognitions that characterize the behaviours of actors within health
care systems.
Purpose
The aim of this dissertation was to explore the theoretical, empirical and practical
utility of shared mental model (SMM) theory to the field of integrated care. SMM theory
is used extensively in the team performance literature to help explain team dynamics
and functioning [1]. When multiple individuals develop a common psychological structure
for understanding their environment, this is referred to as an SMM [2]. SMMs allow
individuals to behave in ways that are consistent and coordinated with each other
in the completion of interdependent tasks [1, 2].
Study I
The first study in this dissertation examines the evolution of integrated care strategies
over 25 years [3]. Six major, interrelated shifts were identified in strategy content:
from a focus on horizontal integration to an emphasis on vertical integration;
from acute care and institution-centered models of integration to a broader focus
on community-based health and social services;
from economic arguments for integration to an emphasis on improving quality of care
and creating value;
from evaluations of integration using an organizational perspective to an emerging
interest in patient-centered measures;
from a focus on modifying organizational and environmental structures to an emphasis
on changing ways of working and influencing underlying cultural attitudes and norms;
and
from integration for all patients within defined regions to a strategic focus on integrating
care for specific populations.
These shifts highlight the importance of attention to meanings and perceptions (i.e.,
mental models) and can be used as a descriptive framework against which to assess,
compare and track integrated care strategies over time.
Study II
The second study draws from SMM theory, and an exploratory, theory-driven literature
review, to explain the value of a SMMs perspective to integrated care efforts and
to develop a theoretical framework of antecedents, outcomes and moderators of mental
models of integrated care (MMIC) [4]. MMIC are defined as cognitive structures that
represent knowledge and beliefs about integrating services. The framework suggests
that mental model similarity contributes to improved processes (e.g., communication
and cooperation) and performance (e.g., strategy implementation and willingness to
continue working together). Two key factors are identified as precursors to mental
model similarity, namely stakeholder characteristics (e.g., position/sector similarity
and past integration experience) and environmental factors (e.g., funding mechanisms
and system commitment to integrated care).
Study III
The final paper validates and improves the framework of MMIC content using a two-round,
web-based modified Delphi process with a diverse, pan-Canadian group of integration
experts, including policymakers, planners, managers, care providers, educators, researchers
and patient advocates [5]. In the first round, 90 individuals responded (52% response
rate), representing a wide range of professional roles and organization types from
across the continuum of care. In the second round, 68 individuals responded (75.6%
response rate). The quantitative and qualitative feedback from experts was used to
revise the framework. The resulting “Integration Mindsets Framework” outlines important
knowledge and beliefs whose convergence or divergence across stakeholder groups may
influence interprofessional and interorganizational relations. The framework consists
of two overarching types of mental models, a strategy mental model, which is a conceptualization
of what is being integrated and how, why and for whom it is being integrated, and
a relationships mental model, which is a conceptualization of the organizations, groups
and individuals involved in integration and how they are connected. These two types
of mental models consist of a total of 19 knowledge-based and belief-based content
areas (please refer to Evans et al. [5] for the full framework).
Summary
Figure 1 summarizes the conceptual thinking that emerged from the three studies. The
construct of “Integration Mindsets” is at the heart of Figure 1 and is defined as
an individual's way of thinking about integration that is based on knowledge and beliefs
regarding the strategy for achieving integration (i.e., Strategy Mental Model) and
the roles and relationships of those involved in the integration process (i.e., Relationships
Mental Model) [5]. The similarity of Integration Mindsets is shaped by contextual
factors at multiple levels [4]. The similarity of Integration Mindsets, in turn, influences
strategic processes and proximal outcomes. The relationships among Integration Mindset
similarity, strategic processes, and proximal outcomes are moderated by mental model
type (strategy and/or relationships) and mental model content (knowledge and/or beliefs).
Both formal and informal feedback from integrative processes and performance continually
shape integration strategy content (i.e., what is decided) and the similarity of Integration
Mindsets. Thus, shared Integration Mindsets are not a static “state”, but rather a
dynamic process in which knowledge and beliefs are continuously modified and negotiated.
Implications for integrated care
A socio-cognitive perspective on integrated care focuses attention on the evolution
and interplay of meanings, interpretations, and knowledge about integration – and
their potential impact on practice. Together, the studies provide theory-based, expert-validated
constructs and frameworks that enable researchers and practitioners to understand,
track and manage integration mindsets over time and across professional and organizational
boundaries. The Integration Mindsets Framework can be used to direct and focus early
discussions and planning efforts among team members or partnering organizations and
to assess organizational or system readiness for integration. Awareness of the extent
to which integration mindsets are shared and where similarities and differences lie
can also help guide change management interventions. Finally, shared integration mindsets
may be used as one indicator, among many, of a successful and sustainable integration
activity.
The results presented in this review are based on the author’s thesis presented at
the University of Toronto on 5 December 2013.