Exploring stakeholder perspectives to facilitate the implementation of shared decision-making in coordinated individual care planning

ABSTRACT

This article explores conditions for implementing shared decision-making (SDM) in coordinated individual care planning (CIP) with individuals with complex mental health needs. SDM in CIP are described as central, although such user centred collaboration still remains to be realised. Research underlines the need for a changed way of working, where user expertise is valued and a balance of power is promoted. The aim of the present study is to investigate the conditions for implementing SDM in connection with CIP for and with people with mental illness. To better understand the context and conditions that can promote such an implementation, altogether 15 participants were interviewed in three regions in Sweden within the scope of a stakeholder analysis. Both hindering and supporting factors were identified with respect to an implementation process, such as staff turnover, differences in work culture and committed leadership. Further focus should be directed specifically towards professionals working more closely with CIP and towards in-depth analysis of the construct of culture in terms of implementation processes.

ABSTRAKT

I denna artikel undersöks förutsättningarna för att implementera delat beslutsfattande (DBF) i samordnad individuell vårdplanering (SIP) för personer med komplexa psykiska behov. DBF i SIP beskrivs som centralt, även om ett sådant personcentrerat samarbete fortfarande återstår att förverkliga. Forskning understryker behovet av ett förändrat arbetssätt, där användarnas expertis värdesätts och en balanserad maktfördelning främjas. Syftet med den här studien är att undersöka förutsättningarna för att implementera DBF i samband med SIP för och med personer med psykisk ohälsa. För att bättre förstå sammanhanget och de villkor som kan främja en sådan implementering intervjuades totalt 15 deltagare i tre regioner i Sverige inom ramen för en intressentanalys. Både hindrande och stödjande faktorer identifierades med avseende på en implementeringsprocess, såsom personalomsättning, skillnader i arbetskultur och engagerat ledarskap. Ytterligare fokus bör riktas specifikt mot yrkesverksamma som arbetar närmare med SIP och mot en djupgående analys av kulturkonstruktionen när det gäller implementeringsprocesser.

KEYWORDS:

• Shared decision-making (SDM)
• coordinated individual care planning (CIP)
• workplace culture
• stakeholder analysis

NYCKELORD:

• Delat beslutsfattande (DBF)
• Samordnad individuell plan (SIP)
• Arbetsplatskultur
• Stakeholderanalys

Introduction

This article explores conditions for implementing shared decision-making (SDM) in coordinated individual care planning (CIP) with individuals with complex mental health needs. For those with complex needs and in need of care and support from a variety of services, navigating mental health systems often poses unreasonably high demands (Baker et al., 2018).

In Sweden, the mental health system is made up of two main actors, spanning the health care and social work contexts. Psychiatric care is provided by the regional health care system, which offers inpatient treatment, medical assessment and medical treatment. Social services are based in the municipalities and provide social care and support. In addition, psychiatric care is often sub-specialised on the basis of different diagnoses or the occurrence of abuse, and social services are divided into a number of actors, such as financial support, housing support and activity support. For service users, this fragmentation increases the risk of not receiving support that matches their specific needs because of lack of inter-professional, cross-organisational collaboration (Baker et al., 2018; Erlandsson et al., 2022). To address this problem, the intention with CIP is to coordinate care and support for people with complex care needs. This model is similar to how coordinating support with care plans is organised in other countries such as Norway and the UK (Matscheck & Piuva, 2022a). In Sweden, carrying out CIP with people in need of support from both social services and health care is required by law since 2010, to ensure user participation and that individual needs are met. A key aim of CIP is that the service user should be an active participant in the planning and decision-making process. However, recent research on CIP processes highlights a lack of collaborative deliberation and implementation of SDM (Knutsson & Schön, 2020; Nykänen, 2019).

SDM has been highlighted as a method to achieve the goal of user influence, as it goes beyond the suggestion of ethical principles and consists of concrete actions (Levin et al., 2017). SDM involves an interactive process in which service users and providers work together to make decisions. Key components of SDM include provider and service user participation in all stages of the decision-making process, including information sharing, deliberation (discussing options in relation to the service user’s values and preferences) and reaching a decision about the best course of action (Duncan et al., 2010; O'Connor et al., 2009).

While SDM originated in the medical field, more recently there has been a growing demand to incorporate SDM into the field of social work and social service delivery in several countries, including the USA (Stovell et al., 2016), the UK (Nykänen et al., 2021) and Israel (Levin et al., 2017). A CIP process that includes SDM requires an active collaboration between user and caregivers, where users’ and caregivers’ knowledge and experiences are deliberated. It also requires a system that includes opportunities for collaboration with other authorities, and easy access to knowledge about services and evidence. Nonetheless, most important is that the participating caregivers begin to see the users as knowledge carriers, as individuals that not only are provided with information, but partners to collaborate with (Knutsson & Schön, 2020).

SDM is rooted in principles and ethics vital for a positive recovery procedure (Dahlqvist-Jönsson et al., 2015). However, from a staff perspective, Jones et al. (2021) suggest that SDM needs to be better utilised. Dahlqvist-Jönsson et al. (2015) stress the need for more personal support, having access to knowledge, being involved in a dialogue and clarity about responsibilities. Previous research also illustrate how a CIP process characterised by SDM is hindered by collaboration problems between providers (Knutsson & Schön, 2020) and by service users’ needs being regarded as secondary to providers’ responsibilities and costs (Grim et al., 2019; Matscheck & Piuva, 2022a, 2022b). Additionally, challenges such as staff’s lack of competence in CIP, lack of resources, different organisational cultures (Matscheck & Piuva, 2022a, 2022b) and ambiguities of responsibilities between service providers have been reported (Knutsson & Schön, 2020).

Against this background, the aim of the present study is, through a stakeholder analysis, to explore the conditions for implementing SDM in CIP in the context of the Swedish mental health system. More specifically we aim to investigate structural and contextual factors described by key personnel (managers and quality directors) that hinder implementation of SDM in CIP and identify potential strategies for overcoming them. This knowledge will contribute to the understanding of how SDM in CIP processes will fit into ordinary practice and what is required for a successful implementation.

Design

Following the guidelines for stakeholder methodology (Schmeer, 1999), this study aims to capture input from managers and quality directors with an overarching knowledge of collaboration structures and service development in the participating regions. Besides mapping organisational conditions for implementing SDM in CIP, the stakeholder analysis explores complex mechanisms within and between the services, such as value conflicts and contextual and collaborative conditions. One of the principles of this form of analysis is to embrace complexity and to engage and motivate relevant stakeholders to sanction the implementation (Reed et al., 2019). Accordingly, the framework for Successful Healthcare Improvements From Translating Evidence in complex systems (SHIFT-Evidence) was applied as a conceptual tool for eliciting and clarifying stakeholders’ insights about local challenges, needs and resources, providing a guiding structure for formulating the research questions, developing the interview protocol and discussing the findings. The framework, developed to guide practice and research in change processes, presents principles, rationales and strategies needed for successful implementation. Table 1 illustrates how the research questions of the current project are operationalised from the framework.

Table 1. SHIFT-evidence framework.

Principle	Rational	Strategies to overcome	Research questions
Act scientifically and pragmatically	Knowledge of existing evidence needs to be combined with knowledge of the unique conditions in the local setting	Understanding initial problems and opportunities	What are the unique needs, goals, challenges, preferences and starting points in relation to SDM in the context of CIP?
		• Identify potential solutions
		• Share knowledge
Embrace complexity	To implement interventions, existing needs and problems must be identified and addressed	Understand processes and methods in current practices	Which structural and contextual factors and conditions exist within the services that need to interact when performing SDM in CIP and that need to be taken into account in its implementation?
		• Identify systemic issues	What are the attitudes and perspectives that need to be understood in relation to the introduction of SDM in CIP?
		• Understand the starting points, attitudes and perspectives in the varying services
Engage and empower	Change requires engagement and insights from stakeholders with experience in the local system	Engage those responsible and those affected by a change	How can stakeholders be engaged in a systematic effort to develop and achieve implementation of SDM in CIP?
	Changes need to be adapted to their perspectives, needs, motivations, concerns and preferences	• facilitate dialogue between individuals and actors
		• foster a culture of willingness to learn and freedom to act
		• Provide space, resources, training and support

Participants

Three regions in Sweden participated in the study and within these three regions four sites were selected for implementation. These sites were seen as ‘test beds’ for the implementation of SDM in CIP within the framework of a research project including initial stakeholder analysis, staff training, evaluation of the implementation and of outcomes. The services in focus are psychiatric outpatient and inpatient care and social service units that support adult service users with mental health problems. At the four sites, key stakeholders were contacted and invited to participate in individual interviews. A total of 15 participants were purposively recruited to represent stakeholders with senior and middle management roles in community social service organisations and regional health care organisations (see Table 2). Ages ranged from 37 to 64 years, with an average age of 50. Twelve of the participants were female and three were male. The participants were stakeholders with a mandate to create a supportive infrastructure so that time, administrative and human resources are available to support implementation. All participants had previously been introduced to the intervention and what SDM in the context of SIP entails.

Table 2. Participants (N = 15).

Region	Occupational setting
	Regional psychiatry	Municipal social services
A (n = 6)	Overarching directors heading the quality development programme (n = 2)	Quality development programme directors (n = 3)
	Quality development programme director (n = 1)
B (n = 5)	Coordination manager (n = 1)Quality development programme director (n = 1)	Quality development programme director (n = 1)
		Department managers (n = 2)
C (n = 4)	Unit manager (n = 1)	Quality development programme director (n = 1)
	Specialist nurse (CIP coordinator) (n = 1)	Unit manager (n = 1)

CIP = coordinated individual care planning.

Data collection

The interviews were conducted online by the last author and lasted between 45 and 60 min.¹ Informed consent was obtained orally and recorded, and all participants were informed that they could withdraw their consent to participate at any time. A semi-structured interview guide, based on the SHIFT-Evidence framework (Reed et al., 2019), was used with open and specific questions designed to elicit rich and detailed information. Questions were formulated on the basis of the research questions, which in turn were themed around the three key principles of the SHIFT-Evidence framework (see Table 1), with the aim of eliciting current problems in unique settings and how they might be addressed by the intervention – SDM in CIP, conditions (systemic and cultural) that may hinder or facilitate implementation, and strategies for aligning implementation with the motivations and concerns of people affected. The recorded interviews were transcribed verbatim.

Data analysis

In the present study, where there is great complexity both in terms of the intervention and the context in which it is to be implemented, we seek to explore multiple perspectives, tensions and value conflicts in relation to what drivers and values motivate different stakeholders. To capture this complexity, the analysis used an inductive approach to gain a broad and inclusive understanding of participants’ perceptions and views (Graneheim et al., 2017). Accordingly, the procedure involved coding the concrete descriptions and as a second step sorting these codes into themes (Graneheim et al., 2017). The analysis yielded five themes (Graneheim et al., 2017) that were understood as vital to the implementation of SDM. In the discussion section, these derived findings were then related to the constructs of the SHIFT-Evidence framework to clarify hinders for implementation and priorities and activities required to achieve implementation.

Results

In general, the stakeholders had a positive view regarding the implementation of SDM in CIP. Still, they identified several hindering factors. There was a high degree of consistency between the different participants’ perceptions of challenging factors and the necessary priorities to address them, indicating that the findings highlight phenomena that are fairly common across the three regions involved.

The five themes identified in the analysis were (1) the importance of acquiring and making use of knowledge; (2) the importance of continuity and time with the service user and co-workers; (3) the impact of follow-up and evaluation of the intervention; (4) the need to involve service users in the intervention and (5) the importance of collaboration. The excerpts come from stakeholders’ narratives of the service user’s needs, cooperation, workplace culture and whether they were ready for the implementation of SDM in light of hindering as well as supporting factors. The themes are discussed below along with citations from participants that are specified with numbers 1–15.

Theme 1: the importance of acquiring and making use of knowledge

Knowledge of what CIP is and how a CIP meeting is set up was expressed as fundamental. The stakeholder interviews indicated that staff’s knowledge base was influenced by the overarching (and often subtle) workplace culture. For instance, it is a question of workplace culture whether you feel comfortable with disclosing (as participant no. 4 said, ‘to dare to say’) that you do not understand the CIP process or that it went wrong or that you do not have enough knowledge. As highlighted in the quote below, basic understanding of the purpose of CIP among staff is perceived as a prerequisite for driving an implementation process.

It’s important, as staff, to understand the purpose of it [CIP]. Why do the CIP? If you don’t understand why it’s supposed to be of value, it’s hard to motivate yourself to do it. So, to really understand the benefit of it, both for the patient and for the staff’s sake. (4)

Even when basic knowledge levels are in place, lack of experience and confidence may cause staff to be overly cautious, especially in activities demanding proactive engagement of professionals outside their own organisation. As expressed by one stakeholder:

You don’t know what forms exist and you’re afraid that it will be a big deal, like, to send out an invitation or to fill out this form, … there is such a great respect for it, that it needs to be taken so seriously to convene [various actors] to a CIP. (5)

Another aspect of knowledge highlighted in the interviews was knowledge amongst staff on legal regulations and on areas of responsibility of all involved organisations. As noted below, lack of such clarity compromises the proper functioning of the CIP process for all parties, involving misdirected time and energy spent during meetings. The following quote reflects this uncertainty, even when it comes to how CIP meetings are currently conducted,

When there is a CIP meeting, the regions think that the municipality should do these things, and vice versa. So, you sit and point at each other. And then you think that what you should strengthen is that all parties gain knowledge of, yes, partly as you describe, this legal requirement [to implement CIP]. You gain knowledge about each other’s responsibilities. So that it becomes very clear, and also for the service user then. (13)

In all likelihood, such focus on division of responsibilities amongst professionals during CIP meetings may involve disempowering experiences for attending service users. The prospect of implementing SDM in the context of CIP was associated with an even greater degree of uncertainty, as the following quote illustrates,

We want to, but it's a little tricky with shared decision-making, that it's recommended, but it’s not easy to know how to work with it. I think we are at the beginning of a process there. (8)

In addition, it was doubted whether staff understood the difference between a CIP that included SDM and the current practices around CIP. Comments that related to knowledge processes on more general levels implied that building on the knowledge already existing in the organisations and connecting with learning processes that are already in motion strengthens the conditions for organisations and staff to embrace and absorb new knowledge and new methods, such as SDM. As observed by stakeholder no. 1: ‘It’s not difficult to integrate with what we already do, because we’re already talking’.

In order to generate commitment to SDM among staff and counteract reluctance and change fatigue, it was observed that leadership needs to be mindful not to present SDM in the context of CIP as something new,

I do not see it as something that competes with person-centered care … Rather, it is a tool to achieve more person-centered care. So I think in this situation it’s important not to communicate this as something that’s … like “now we are going to work on this instead of other approaches”. But rather that this reinforces the tracks that we are already trying to work on. (8)

Consequently, the need acquiring and making use of knowledge was illustrated on three levels: firstly, it concerned having basic knowledge of how SDM can be incorporated in the CIP procedure; secondly, it concerned knowledge of regulations and areas of responsibility and thirdly, it was concerned of the value of building on existing knowledge.

Theme 2: the importance of continuity and time with service users and co-workers

Illustrating the second theme the lack of continuity and time with service users and colleagues was highlighted as a major problem. From stakeholders’ comments on shortage of time and staff instability, it was evident how a prevailing lack of continuity negatively affects the functioning of work groups and the conditions for quality coordination of care and support for service users. Stakeholders expressed that time shortages prevented them from upholding a practice where the service user is placed at the centre to realise a SDM process, as expressed in the following quote,

Time is always … you wish you had as much time as you want, but unfortunately you don’t, and then there is a risk that these CIP meetings will be cut short because you need to move on to the next thing. (7)

In the quote below, staff shortages is identified as a key obstacle for adopting new practice,

If they are hesitant, it is not because of the idea of shared decision-making or because it is not needed. It’s because the way things are. Because I often find that it is not always so easy to work on development issues when you are struggling with personnel issues. You just have to find people who can take over and work with the activities. You have to run the ground service. If that doesn’t work, it’s very difficult to work on development issues. (3)

Furthermore, differentials in time resources were a potential concern between the different workplace contexts:

The region allows a maximum of 1 hour … while municipality staff [i.e. in social services], they can put in a couple of hours. It is more the task of social services to work with networks and processes and such. The region is a bit more … so there will be a clash. (9)

Suggestibly, such perception that one work context has more time at their disposal may implicitly negatively affect the distribution of responsibility in an implementation process where both contexts are expected to take equal responsibility. Further, regardless of work context, staff turnover was observed to inhibit enough time spent for anchoring new working methods. As one stakeholder noted:

… but then it is also always the case that staff are replaced and new ones arrive, and so on. I actually don’t know how they learn how to work. (4)

Lack of continuity can conceivably create a negative experience both in a work group and for a service user – aspects that shape workplace culture. At the same time, new ways of working were highlighted, e.g. combining virtual and physical meetings, which possibly could familiarise and train new staff more quickly: thus, potential obstacles can also open up for new solutions in a supportive way, assisting the implementation process.

Theme 3: the impact of follow-up and evaluation of the intervention

The stakeholders were unanimous in the view that adequate evaluation and follow-up reports to managers and staff at every level would be crucial for motivating long-term implementation of SDM in CIP. It was noted that the decision to participate in the SDM in CIP project was partly stimulated by the fact that researcher-led evaluation was included in the project.

A number of quality aspects were suggested as important to capture. These concerned organisational work flow issues and staff and service users’ experiences of the CIP approach.

In the last decade, government funding has been allocated to increase the number of CIP processes, and therefore the operating budget of the services is tied to the number of meetings. A risk highlighted by several stakeholders, is that the number of new CIP meetings is viewed as a quality criterion even though the number of CIPs does not necessarily have anything to do with whether it led to positive outcomes for the service users or if the process contained collaboration and SDM. As one stakeholder expressed when commenting on a previous evaluation:

But then it turns out that you try to measure the number of CIPs. It doesn’t say much. And it’s difficult to measure the quality. So that’s the only way … , we make follow-up evaluations to see, so it can help to improve CIP. But it is very difficult to measure it and, as I said, there were a lot of meetings other than CIP. (12)

When underscoring the importance of evaluating staff experience, it was noted that staff need to feel confident in their own skills when applying new approaches. Staff sense of security, directly affects the capacity for relationship building with service users, and is a much more reliable indicator of accomplishment than counting the number of CIP meetings being conducted. As one stakeholder observed:

For me, maybe it’s more about when the staff stop being unsure of what it is they are doing. And, like, feel secure in their way of working. Then I think that then we have also reached the patients and then we have succeeded. (14)

According to the stakeholders, another important aspect to follow up, is the extent to which the actions planned in CIP were actually carried out and evaluating whether it has led to improvements in the user's life situation. As one of the stakeholders expressed:

And then the follow-up is also extremely important. That you [get] feedback and see what has happened. We don’t just have a meeting for the sake of having a meeting, but [we’re meeting to discuss] what has happened and we might have to take a new approach. (5)

Moreover, some comments on the follow-up process highlighted difficulties in connection with lack of structure and lack of service user participation, issues that also complicated measuring outcomes of the intervention:

… you have a meeting seated at a table and you talk about what you see and what you don’t see and what you need help with. And you might come to the same conclusions. But then … it has to be followed up, but then the user has left. So, it will be difficult to achieve continuity with the target group. (13)

In this theme, it appears that there was uncertainty among stakeholders regarding how the new CIP process with SDM should be evaluated and followed up. What becomes important is that all steps in the process are being described and thought through. Hence, it mostly concerned aspects of the inner setting such as implementation knowledge, compatibility and access to knowledge and information.

Theme 4: the need to increase involvement of service users in the intervention

In the fourth theme, the user perspective was highlighted when participants raised concern regarding the risk that involved parties might lose sight of the aim when they had to navigate unwieldy and complex bureaucratic systems. It became clear in the interviews that the intended implementation of SDM in CIP was perceived as benefitting both staff and service users. However, at the same time, questions were raised as to whether it would ensure the service user to be placed at the centre of the CIP process:

You work with this because somewhere you have a thought that ‘I want to do good, I want to help’. But then there are so many guidelines and so many fences and so much administration that I feel you have to, you have to do so much else. (6)

There were several descriptions where the CIP process as they are currently performed was observed to be a tool for the staff, rather than for the service user;

Instead of using CIP as a tool for the patient, it becomes a tool to get an appointment and then it all goes wrong. You use it because it becomes a bit compelling that the other party must come … in order to get a meeting sometimes you use and call a CIP [meeting] without having really established that the need for CIP is actually always there, but it’s more just to get to the meeting. Force the others to come. (7)

When considering how SDM would affect the service user needing a CIP, it was noted that it would give the service users more structure, control and empowerment. As reflected in the following quote;

There is such a power imbalance when we have these meetings. And so many opinions … We lose the individual in these contexts. I think with a structure [SDM in CIP], the main character becomes a main character in a different way than as it actually is today … It becomes more concrete. It is not only oral information that then disappears but it remains on paper that you can go and look back. And then maybe it gives the person a little more opportunity to actually say no to certain things, etc. And also perhaps above all that you feel that this is my meeting. (3)

Theme 5: the importance of collaboration

The final theme identifies collaboration as a structural and contextual factor that needs to be considered when implementing SDM in CIP. Collaboration was highlighted relative to relational and contextual aspects. The stakeholders emphasised the importance of building strong and trusting relationships and building a common culture between organisations for a successful implementation of SDM in CIP. The importance of perceiving strengths rather than differences in each other’s contexts was observed. As one stakeholder noted:

I think we need to be humbler. [We need to recognize] that we have different strengths within both the region and the municipality. We need to make sure to coordinate them. And collaborate all around in a different, more flexible way. (6)

In relation to SDM, there were also positive examples of collaboration with parties besides the main actors (municipality and region), where the service user’s preference was explicitly put in the centre:

I also think from the perspective of the service user, who also has the right to include those they wish – those who are important. It can be someone from a user organization or a friend or other relatives. And we also have the social insurance agency and employment services and they don’t have to be involved, but they can be important. (5)

The view that collaboration is essential, both for staff and for service users, emerged strongly in the interviews. At the same time, however, there seemed to be a risk associated with collaboration in that it can become two separate projects. On the one hand, there can be collaboration between different work structures, and on the other hand, there can be collaboration between professionals and service users. The idea with SDM in CIP is to create a common space for collaboration between all parties from the beginning.

In an implementation process where staff from different work contexts must collaborate both around the service user and with each other, it becomes a concern if there is no consensus regarding the distribution of responsibilities. The quote below illustrates this, indicating the importance of integrating two different cultures:

And this thing about integrating and working together. It’s a lot about getting two structures together where there is social services processing on the one hand, and then there’s care and support on the other. It’s bringing these different cultures together by meeting, because we want the same thing even though we have different tools. (14)

Therefore, it appears to be crucial to find an intermediate area where two cultures can find a common ground. This could also be described in practical terms:

You work in different systems, regions and municipalities and then transfer between … The municipality must enter journal notes and it must be included with the region and then it must be reflected on 1177.² Just this practical problem between different data systems, it’s something that causes trouble, I know that. (4)

A seemingly simple aspect such as not having access to the same data system can significantly complicate the work. As well as these practical problems, other concerns were raised, such as who should allowed to take the initiative in a CIP process. In the interviews with stakeholders, various potential hierarchical pathways emerged:

It’s one thing that you don’t have time to talk or be with the service user. But then, between the organizations it is probably also the case that there are somewhat narrow hierarchical corridors. Who is contacting me? … so, can you as a housing supporter contact someone in the region and get in touch regarding this issue. (6)

The problem described above by participant no. 6 is more abstract than differences in data systems. Consequently, it is more complex to address in an implementation process, because it touches on the aspect of different work cultures. This aspect of cultural diversity also shows that there are different expectations regarding work efforts and mandates connected with various professions and organisations, which can be a hindrance between the contexts:

We have such different expectations of each other and you think that social services can do your thing. We believe that the region can do this and that, but we need so much knowledge about what the limit is, so what possibilities do we really have? (12)

Such expectations also highlight a variety of decision paths, which was explained by many of the stakeholders, one of whom noted:

The regions have decision-making rights and mandates, so to speak. As far as the municipalities are concerned, it’s not like you can make decisions in the context you sit in. The region can do that, they can say we want to get into this and there’s no more discussion. You don’t need to anchor it elsewhere because you have such high positions in your own organization. (3)

Different decision-making paths in the diverse workplace contexts can be a hindrance when there also has to be collaboration around a new way of working. This final theme highlights a hierarchy between different contexts as well as within the individual context. Furthermore, this presents an obstacle when two different workplace contexts should cooperate on a more practical level such as when different journal systems are used for the same service user.

Discussion

Consistent with the SHIFT framework’s guiding principle of embracing complexity (Reed et al., 2019), the findings drew attention to a number of systemic and attitudinal factors that need to be understood and addressed when tailoring and supporting the implementation. Stakeholders described a variety of factors as hindering implementation processes such as high staff turnover, lack of time, the intricacies inherent in actively involving service users, difficulties in measuring the intervention and organisational hierarchies. As for attitudes and perceptions, the findings highlighted multiple perspectives, tensions and value conflicts. On the other hand, stakeholders expressed an overall positive attitude towards SDM. They emphasised the importance of cooperation between the two work contexts, noting that it was vital to build strong relationships, both between organisations and between staff and service users.

As regards performing CIP with high levels of SDM, clarifying the responsibilities of mental health service providers to put policy and guidelines into practice is a particularly urgent matter as this is legally required; the health care providers cannot avoid it at their discretion. However, to share decision-making power, staff need to experience that they possess knowledge and authority and manage a workplace that nurtures a culture of cooperation and user involvement. As such, the guiding principle of the SHIFT framework, which asserts the importance of engaging and empowering staff (Reed et al., 2019), was evident. Not least, the findings underscored the importance of presenting SDM-CIP to personnel not as something new, but as something that aligns with and builds on what they already know and do – so as not to overwhelm them and create resistance.

Moreover, the findings highlight two significant topics crucial for the successful implementation of SDM in CIP processes: workplace culture and organisational conflict and time. These local knowledge from the stakeholders’ perspectives are indispensable in shaping the design and execution of improvement initiatives in complex systems (Reed et al., 2019), aimed at maximising the likelihood of success during the implementation of SDM in CIP processes.

Workplace culture

Based on the findings, the shared perceptions, values and norms that make up organisational culture partly concern staff’s constructions of difference – staff create distinctions between and within their work contexts, which is crucial when it comes to implementation because these distinctions could implicitly be seen as an obstacle.

As stressed by stakeholders, staff turnover was a major concern. It also affected workplace culture: who is supposed to socialise new staff? As described by others regarding new ways of working, staff training and user involvement are vital for change (Davidson et al., 2017; Knutsson & Schön, 2020). In a similar way, workplace culture is shaped by a collegial process influenced by attitudes concerning service users. Furthermore, a socialisation process is an adjustment process that occurs when staff acquire the attitudes, behaviour, skills and knowledge required at their workplace, in a continuous learning process (Hasenfeld, 2010). Thus, staff may embrace organisational values and adapt to stances taken by co-workers when assuming their own roles within a specific culture in the implementation process. Along the same lines, Alvesson (2003) emphasises that what is common to a certain group can be expressed in a symbolic way as a guiding purpose whereby a group of individuals express themselves towards the outside world. It is, therefore, not only the characteristics of the service users that determine the culture within the workplace. To a great extent, staff generate culture, though more often implicitly. There is a kind of ‘othering’ occurring between and within the work context, which also is highlighted through an obvious lack of a person-centred culture, even though the ambition at all sites should be to support such an approach. However, it is possible to make the workplace culture visible by making the employees’ norms, values and attitudes explicit. From the findings, the value of creating cross-organisational contact were evident, such as joint staff training where staff from community-based social services and regionally based psychiatric services get the opportunities to meet, face-to-face or digitally, and share knowledge of their respective workplace cultures, policies and routines. This local knowledge about workplace culture are important for providing actionable guidance to practice, which is described in the SHIFT-Evidence as the principle of engaging and empowering (Reed et al., 2019), asserting the importance of facilitating dialogue between individuals and actors, foster a culture of willingness to learn and providing opportunities for collaborative learning across organisational borders. Suggestibly, trainings in SDM-CIP should be performed with staff groups from the different services that perform CIP, and possibly also with service user representatives.

Organisational conflict and time

On an overall level, managing time in the context of implementing SDM in CIP was fraught with difficulty and contradiction. The contradictory element involved there on the one hand being a strong belief in the potential of SDM and on the other hand a shortage of time for implementing the intervention since this would take time out of an already full workday. As Knutsson and Schön (2020) highlight, SDM is vitally important; however, apparently it is difficult to implement. There was a clear desire among the participants to promote increased participation and SDM; nevertheless, there was a lack of conditions such as time and enabling processes in the organisations to realise SDM. Previous research also points to the need for regulation and follow-up to promote a new way of working (Matscheck & Piuva, 2022b; Nykänen et al., 2021). In our findings, SDM in CIP was understood as something ‘optional’ to perform, even though it has been required by law since 2010. This lack of a clear policy can be understood as an obstacle to long-term implementation.

In sum, to facilitate implementation of SDM, it is important that staff receive support in managing the challenges they face in terms of time, structural facilitation, enhanced knowledge and so on. Knowledge can be conveyed in different ways. What becomes apparent in this study is that there is an intention to deepen the understanding regarding SDM in CIP, which can be done by working from the concept of two experts: users and practitioners (Dahlqvist-Jönsson et al., 2015). Furthermore, concerning the aspect of time it is vital that long-termism is pursued rather than short-termism. That is, what could in short term generate increased work tasks may in the long term actually generate less work. In light of the SHIFT-Evidence framework (Reed et al., 2019), these challenges underscore the importance of tailoring the implementation programme to align with stakeholders’ motivations and concerns, and of providing resources in the form of time and support to foster a climate of reflective learning and co-creation in order to engage and empower them.

Limitations

The findings showed that stakeholders often seemed to want to reflect on the current CIP processes, rather than SDM in CIP, which may indicate that while they have knowledge and experience with CIP, they cannot fully conceptualise a CIP process integrated with SDM. This possible uncertainty in respondents’ perception of the questions creates uncertainty in our interpretation of their responses and can be considered a credibility issue.

Conclusion

In conclusion, the current analysis highlights that an adequate knowledge base, continuity and time with the service user and co-workers, follow-up and evaluation, involvement of service users and a trustful relationship between professionals are important conditions for an implementation of SDM in CIP with people with mental illness. This includes a need to define a successful CIP differently, with different metrics, including staff experience and confidence, collaboration, as well as service users’ experiences of SDM.

The results from the study inform psychiatric care and social services on how to improve the implementation of SDM in CIP. A broader understanding of SDM in CIP is important in social work with individuals with complex mental health needs. In line with what Erlandsson et al. (2022) stress without a broader understanding, there is a risk that individuals with complex mental health problems will not be involved at all, or that pseudo-autonomous decision-making will be used routinely without sufficient attempts to involve them. These findings thus indicate a gap between stakeholders’ narrative and everyday practice. Therefore, staff also need guidance on how to utilise SDM on a more regular basis. However, further research with staff members performing CIP in practice would add to our understanding of strategies needed for the implementation of SDM in CIP.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Familjen Kamprads Stiftelse; Forskningsrådet om Hälsa, Arbetsliv och Välfärd.

Notes on contributors

Peter Andersson

Peter Andersson is registered psychotherapist and social worker and holds a PhD in social work, Stockholm University working at the department of social work as a senior lecture and researcher. He has authored several articles on residential treatment for children and youth in Sweden from the staff perspective. His research includes workplace violence within youth residential institutions, including preventive measures and treatment interventions for youth regarding violent behaviour.

Ulla-Karin Schön

Ulla-Karin Schön is a social worker and professor in social work. Her research lies in the field of mental health and disability and people's opportunities to participate in social life, in education and in meeting with social services and health care.

Petra Svedberg

Petra Svedberg is a professor in nursing at Halmstad University, her research is centred around user involvement, shared decision-making and quality improvements in healthcare. The research focuses on questions about how health innovations, in the form of interventions supported by digital services and health data analysis, can be developed, implemented and evaluated to provide healthcare organisations with knowledge and support to achieve high quality of care and improved health outcomes for particular groups. I have carried out most research projects in co-production with service users and stakeholders. One of a research project that I am a project leader for right now investigating how existing knowledge from implementation and improvement research can be mobilised to increase the success of Artificial Intelligence implementation initiatives in healthcare.

Katarina Grim

Katarina Grim is an assistant professor in Social work at Karlstad University, Sweden. Her PhD project aimed at exploring how service user perspectives can be included in SDM in Swedish mental health services. Predominantly, her research is performed in collaboration with service user representatives, with the aim of including the voices and knowledge of service users in developing recovery-oriented and evidence-based mental health services. In recent years, she has studied barriers and facilitators of implementing a variety of interventions and initiatives that focus on systematically integrating the knowledge of users in services at individual, organisational and systemic levels. Her research interest especially regard issues regarding the legitimacy of service users as knowledgeable agents. In all research, she draws on her own experiences of being a mental health service user.

Notes

1 The Ethical Committee in Stockholm approved the study (ref No. 2020-00584).

2 A Swedish website and telephone helpline giving information and advice about health and care.