Health and social care professionals’ experiences of collaborative planning—Applying the person‐centred practice framework

Abstract Aim To explore how person‐centred practice framework can be applied to professionals participating in collaborative planning. Design An explorative, deductive approach. Method Eleven professionals from health care and social care participated in the study. A deductive content analysis was performed using a framework for person‐centred practice for the analysis. Results Practicing person‐centred care and collaborative planning is a complex process that needs to take into account system factors on both the macro‐ and the microlevel. Everyone working within the system needs to apply the same approach. Using a framework analysis offered new insights into how person‐centred care is expressed in practice during collaborative planning between the patient, and healthcare and social care professionals.

. Social workers have in their work for a long period focused on the individual and his or hers context. Barriers to implement PCC include an increased understanding of what it means to be with and care for a person, the relationship between social work and health care and the person that respect his or her personhood (Washburn & Grossman, 2017).
Every country tends to employ its own approach to integration of health and social services. Nevertheless, common features among these approaches are holistic care assessment, comprehensive care planning and care coordination (Wodchis, Dixon, Anderson, & Goodwin, 2015). Studies have shown collaborative person-centred care plans are associated with improvements of physical and psychological health status, capability to self-manage (Coulter et al., 2015) and a reduction in the length of hospital stay (Ulin, Olsson, Wolf, & Ekman, 2016). However, several studies have revealed that collaborative planning is a difficult challenge and the implementation and outcome are not always satisfactory (Jansen, Heijmans, & Rijken, 2015;Reeves et al., 2014). In Sweden, the region and the municipality collaborate and establish a collaborative plan for persons needing health care and social care. In this study, we wanted to explore how the person-centred practice framework developed by McCormack and McCance (2016) could apply to professionals participating in collaborative planning.

| BACKG ROU N D
The person-centred practice framework developed by McCormack and McCance (2016) assists professionals and teams in understanding the elements of person-centredness and how they can be implemented in practice. The framework has four domains: prerequisites; the care environment; person-centred processes; and personcentred outcomes (Figure 1). It also takes into consideration multidisciplinary and interprofessional settings and the complexity of person-centred practice.
The prerequisites focus on the professionals, and the attributes needed to deliver PCC (McCormack & McCance, 2016). The attributes are being professionally competent, having developed interpersonal skills, being committed to the job, being able to demonstrate clarity of beliefs and values and knowing oneself. The care environment focuses on the context in which care is delivered and is contributing towards achieving PCC. The characteristics of the care environment are appropriate skill mix, systems that facilitate shared decision-making, sharing of power, effective staff relationships, organizational systems that are supportive, potential for innovation and risk-taking and the physical environment. The person-centred processes focus on activities for delivering care and making the person-centred practice work. The activities are working with patients' F I G U R E 1 Person-centred practice framework (McCormack & McCance, 2016) beliefs and values, engaging authentically, being sympathetically present, sharing decision-making and providing holistic care. The last domain, person-centred outcomes, represents the anticipated results. The outcomes are a good care experience, involvement in care, a feeling of well-being and the existence of a healthful culture (McCormack & McCance, 2016).
An international health policy survey in 2014 found that Sweden ranked at the bottom of 10 countries when it came to involving patients in their care and decision-making (Commonwealth Fund, 2014). Different health regulations have been launched mandating that professionals practise according to a PCC approach. According to Swedish law (SFS, 2017:612), the region and the municipality shall collaborate and establish a collaborative plan for persons needing health care and social care. The law also transferred the responsibility for collaborative planning after hospital discharge to the health centres (HC), and the collaborative planning should preferably take place after the patient has arrived home (SFS, 2017:612). The new way of working changed the roles and responsibilities for the professionals involved in healthcare and social care organizations. Earlier studies in the north part of Sweden have indicated that the collaborative planning process is complex and the new way of working is challenging for the professionals (Jobe, Engström, & Lindberg, 2019;Jobe, Lindberg, Nordmark, & Engström, 2018).
We wanted to explore how the person-centred practice framework developed by McCormack and McCance (2016) can add further knowledge to an area often described as multifaceted. Accordingly, this study aims to explore how the person-centred practice framework can be applied to professionals participating in collaborative planning.

| S TUDY DE S I G N
The study was conducted using an explorative, deductive approach (Elo & Kyngäs, 2008).

| Method
Two domains of the person-centred practice framework (McCormack & McCance, 2016), the care environment and person-centred processes (Table 1), were analysed using deductive content analysis inspired by Elo and Kyngäs (2008). The data used did not contain attributes of the informants or results of the collaborative planning. Therefore, the other two domains of the framework, prerequisites and person-centred outcomes, were omitted.

| Participants
Eleven professionals, working for either the region or municipality (Table 2), from two different municipalities in the northern part of Sweden were asked to participate in the study. Purposive sampling was used to select participants as we sought to include a variety of professionals participating in collaborative planning (Sandelowski, 1995). Managers from two municipalities and three health clinics helped find participants and informed them about the study. The first author then contacted those 11 who had agreed to participate.

| Data collection
Data were collected between November 2018-January 2019. Semistructured interviews were used to collect data. Participants were asked about their experiences of working with the collaborative planning process and working according to a person-centred approach. The participants were also presented with previous research findings related to patients and informal caregivers' experiences of the collaborative planning conference and asked for their thoughts (Jobe et al., 2018(Jobe et al., , 2019.

| Data analysis
The audiotaped interviews were transcribed and read through several times, to gain an initial impression of the content and to search for features and patterns. The framework for person-  (Elo & Kyngäs, 2008). The analysis process continued until no further abstraction was deemed appropriate.

| Ethical considerations
All participants received verbal and written information about the study, and signed informed consent was collected. They were informed of their voluntary participation and right to withdraw at any time without further explanation and that their confidentiality would be guaranteed when the results were presented. The Ethical Regional Board, Umeå, Sweden, granted permission for the study under number dnr 2016/397-31.

| RE SULTS
To present the findings, we used the attributes from two domains from the person-centred practice framework, the care environment and the person-centred processes (

| Shared decision-making systems
The actors had an overall agreement related to the collaborative planning process and worked according to a person-centred approach. They had different systems for patients' medical records.
Professionals working at the municipality could access parts of the patient's medical record after informed consent from the patient.
Professionals from health care and social care had not discussed and agreed together on a mutual definition of the person-centred approach or a way to practice the collaborative planning process. Individual professionals also had different prerequisites, (Nurse, municipality) Meetings between actors used to take place only at the management level, and the professionals wished there were regular opportunities for them too to meet, discuss, reflect and learn from each other.

| Effective staff relationships
The new way of working had improved the teamwork within the municipalities during the collaborative planning process, and they thought they had an excellent collaboration, both with fellow colleagues and also between professionals with different specialities.
Their teamwork and communication were facilitated by physically sitting together as a team at the same place.
We have to work together, and at the municipality we have a continuous dialogue. The rehab personnel and we in home health care (nurses, nurse assistants and managers) are using the same office.
(Unit manager, municipality) Relations between the actors were more complex. Participants expressed discontent with actors and professionals who did not assume responsibility, did not do their part in the process and were hard to reach. There could also be conflicts between professionals related to what care and services they thought the patients should get.

| Power sharing
Participants described a smooth relationship with colleagues on different levels of the healthcare system. For instance, the occupational therapists or the physiotherapists at the municipality could easily contact and ask their colleagues at the hospital to carry out any assessment they wanted or thought was lacking before the patient went home. On the other hand, a hierarchy among areas and professionals also became evident. For example, medical staff felt that social care was prioritized in the patient's home and they were just seen as consultants. Participants from the municipality felt there were gaps in the process between actors when the patient was discharged. Not all HCs assumed responsibility or followed the process and participants from the municipalities thought the HCs wanted to transfer the responsibility of the patient to the municipality.
The HCs want to hand over the patient and the responsibility to the municipality. You take over. It feels strange since they have the medical responsibility.
(Social worker, municipality) There were times when professionals from the municipalities wished the HC did not accept the patient to be discharged from the

| Potential for innovation and risk-taking
Guidelines had been developed for the collaborative planning process and conference. Nevertheless, not all professionals followed the guidelines or interpreted the tasks and the planning process in the same way. The many different ways of working caused frustration. At the same time, the participants did not want guiding principles that were too narrow.

| Working with patients' beliefs and values
Before the conference, each professional assessed the needs of the patient. Not all of them contacted the patient and made the assessment together with the patient. Participants expressed concern for trusting the patient's views at times. They also felt they were not given the time and resources needed to make the assessment in a good way, and many times, they had to rely on informal caregivers and other professionals to provide the information needed.

| Sharing decision-making
During the conference, the professionals should be setting goals together with the patient. Participants were frustrated with the quality of the conferences and felt that many of them did not serve their purpose. It felt more like an administration tool then an opportunity to agree on the care and services together with the patient.

We have to change our way of working to a person-centred approach. We have been working above the patient's head before and done planning for me as a professional what I should do. But now it is the patients' own planning
and I need to take a step back and ask them questions in a different way and it is really difficult to make this adjustment.

(Occupational therapist, municipality)
Even if the conference took place in the patient's home, the participants felt the power balance was a difficult issue. Having so many professionals involved made it an unnatural situation and difficult for the patient to be the main partner. They would like to reduce the number of professionals to as few as possible.

| Engaging authentically
During the interviews, it became apparent that person-centred practice and the view of the patient as a person did not mean the same thing to every professional. Not all of the professionals understood their role during the conference. Professionals that listened to and saw the patient and his or her needs formulated goals together and used their professional knowledge to break the goals down into objectives became frustrated working with colleagues practicing a different approach. There were also different ways of carrying out the conference. Commonly, the professionals took turns in discussing the identified issues and needs with the patient and participants felt they lacked a method for conducting mutual planning together with the patient, as a team, around goals acknowledged by the patient.

| Being sympathetically present
The new way of working provided more opportunities for direct contact with the patient and the e-platform made it easier to engage with the patient since the professionals could easily access informa-

| Providing holistic care
The role as a coordinator involved seeing and taking responsibility for the whole patient. Professionals found it challenging to give equal weight to all dimensions of the patient and not just to their own professional expertise. When a patient was discharged from the hospital, the municipality would provide a standardized package of care and services in the beginning until the level of care and services that was needed could be decided. With a minimum of resources and with time pressures, there was a risk that patients could continue to get services they were not in need of, thereby making them dependent. Overall, participants struggled with flexibility within the system and possibilities to see and cater to the unique patient and their capabilities.
We should build on the patients' capabilities and support them instead of offering services they are not in need of.
For example, we never train or educate them. We run and provide. We never ask whether the patients have tried this themselves. No, it is much faster to say the person has a cognitive disability and needs help.

| D ISCUSS I ON
The person-centred practice framework presents attributes and relations between them for professional practice (McCormack & McCance, 2016). The framework analysis offers new insights into how PCC is expressed in practice during collaborative planning between the patient and healthcare and social care professionals from the professionals' perspective.
Practice development and implementation of PCC and collaborative planning includes substantial organizational skills and attitudinal changes across health care and social care (Eaton et al., 2015) and commitment from organizations, management teams and professionals. The organization and management need to understand the culture and context in which they work and the characteristics that may prevent them from practising effectively (McCormack, . Health and social care organizations are not designed to be integrated. They have different laws, budgets, geographical boundaries, IT systems, cultures and education of personnel (Glasby, 2016).
The results of our study disclosed that the healthcare and social care professionals were focused on enabling integrated care on an organizational and professional level, such as deciding to which actor the patient belonged. During this process, they made different interpretations. Professionals from different organizations attempt to keep the budgets of their organization balanced and therefore interpret issues differently in order to avoid responsibility for the costs (Dunér & Wolmesjö, 2015). According to Greenfield et al. (2014), integrated care has a macro and structured view and requires coordination of professional and organizational processes.
PCC has a micro viewpoint and focuses on the interactional level between professionals and patients. The two concepts operate from different perspectives and the challenge for the management is to embed them together without one perspective either dominating or hindering the other.
The results revealed that professionals believed they were already practicing PCC. However, they lacked a common understanding of the concept and practice in relation to collaborative planning. PCC is more than a set of techniques, skills and procedures. It is a personal way of approaching, connecting and partnering with the patient (Edvardsson, 2015) and a specific culture that everyone in the organization needs to apply (Dewing & McCormack, 2017 Carlström and Ekman (2012) showed that a culture of human relations reduced change-resistant and routine-seeking behaviour and flat hierarchal structures. Furthermore, they found that social competences contributed to decreased tendencies to resist change to PCC. Practice development is a complex intervention and strategies facilitating it have been identified to be a shared purpose, including reflective feedback and evaluation processes (Manley, 2016). A shared purpose has also been shown to be a powerful strategy for unifying diverse organizations, enabling them to work together in the same direction and embrace agreed values (Manley, O'Keefe, Jackson, Pearce, & Smith, 2014). There are no shortcuts when implementing a new way of working. Organization and management need to take the time required to reach a shared understanding, purpose and joint way of practicing PCC and collaborative planning within their own organization and between organizations.
Lack of integration among professionals affected the PCC practice and the collaborative planning process. The participants did not plan together as a team and decisions made were profession-specific.
However, a decision made by one professional affected the decisions of the others in the team. These findings correspond with a study by Duner (2013)  and external factors (e.g. law and regulations, finance). Teams can work in different ways and function differently during various circumstances. Working in interprofessional collaboration means that each professional brings his or her own unique skills and expertise to the team and in an interpersonal process, together with the patient, attains goals that could not be achieved by one team member alone (Jones & Phillips, 2016).
The participants in the study struggled with seeing the person behind the patient, identifying the person's needs and offering services and interventions tailored for the person. Changing this way of working is difficult (Carlström & Olsson, 2014) and requires a new way of thinking, delivering services and building relationships. A completely new system approach is needed (Eaton et al., 2015). Using standard protocols (e.g. the Comprehensive Geriatric Assessment) helps to include all aspects of the person and achieve a holistic approach in the collaborative care plan (Phillips, Mcmillan, Gibb, & Reed, 2017).
The PCC centre in Gothenburg has developed a PCC health plan at discharge that includes the patient's narrative, resources, motivations and goals. The social situation at home and the activity level of the patient is also considered. The plan created covers the care and the gap between hospital and home (Ulin et al., 2016). A study by Wolf et al. (2017) pointed out that PCC made patients feel safe and secure and increased their confidence in professionals. Patients appeared to value a human connectedness above formalized aspects of documenting agreed goals and care planning. The management must not only provide antecedents, vision and commitment to PCC but also a change in attitudes and behaviours. They have to convey and value understanding of what it means to be with and care for a person, rather than focusing solely on doing something for the person (Washburn & Grossman, 2017).
Leadership is well known to have a strong influence on organization and workplace cultures (Cardiff, 2016). Professionals have a responsibility to reflect on their own practice and relationships and participate in giving and receiving feedback to assist in building effective relationships, teams and workplaces (Manley, 2016). However, if the professionals do not experience person-centeredness themselves, it will be difficult for them to work in a person-centred way (McCormack & McCance, 2016). Person-centred leadership focuses on well-being and empowerment but also takes into consideration the context. It enables the leader to be in relation with the other team members and to facilitate workplace learning (Cardiff, 2016).
As a participant in our study said, an engaged leader creates engaged professionals. WHO (2015) proposes distributed leadership between actors across professional and organizational boundaries in order to achieve people-centred and integrated health services.
Co-leadership and co-location of services create a perception of the management role as a collective activity (Klinga, Hansson, Hasson, & Sachs, 2016). The professionals in the study stationed at the same offices in the municipality expressed satisfaction with their communication and collaboration.
In Sweden, as in many other countries, education and training are usually offered separately for each profession (Hägg-Martinell, Hult, Henriksson, & Kiessling, 2019). If students and professionals learn from, with and about each other during education and training, they will be better prepared to deliver integrated and person-centred care during practice (Machin et al., 2019). There is a need to adapt the education and training of healthcare and social care professionals to correspond with integrated and person-centred practice (Nolte, 2017).

| S TUDY LIMITATI ON S
This study has limitations; for example, only 11 participants were interviewed. When determining the sample size, we judged the quality of the data collected against the specific aim. Variation was required to allow deep analysis of the data, and the participants described experiences that were rich in content, which revealed a pattern that we found served adequately as a basis for the findings (Sandelowski, 1995).

| CON CLUS ION
Using the person-centred practice framework in the analysis of the data offered new insights into the PCC aspects of the collaborative planning process and highlighted the need for a systemic approach when implementing PCC. Professionals need to understand the values required to practice PCC and the difference between being with and caring for a person compared to only doing something for a person. There is a need for more research using the person-centred practice framework within different contexts to facilitate learning from and about good (and insufficient) examples of person-centred practice to increase the body of evidence.

ACK N OWLED G EM ENTS
We would like to thank the participants for sharing their experiences.

CO N FLI C T O F I NTE R E S T
We declare there is no conflict of interest.

AUTH O R CO NTR I B UTI O N S
IJ, ÅE and BL designed the study, analysed the data and wrote the manuscript. IJ collected the data.

DATA AVA I L A B I L I T Y S TAT E M E N T
The original data are in Swedish language. Due to the promise of confidential presentation of the participants, we prefer not to share these data.