Critical issues for employees in inter-municipal health care services: a multiple case study

IMC has been described as involving contracts or joint production with other local governments. The goal is to gain economics of scale, improve service quality, and promote regional service coordination across fragmented local government regions [7, 8]. IMC in various municipal service deliveries are a widespread phenomenon, particularly in small municipalities [9‐11]. Inter-municipal cooperation can be seen as a so-called governance network. Governance networks can be defined as “more or less stable patterns of social relations between mutually dependent actors, which form around policy problems and/or clusters of means and which are formed, maintained and changed through a series of games” [12], and refers to a horizontal interaction between autonomous, yet interdependent actors [13].

In the last decades, network organising, in contrast to traditional hierarchical structures, has become more popular. Flexibility and the ability for rapid adaptation are found to be among the greatest advantages of networks [14]. It has also been expressed that it can change democratic processes found in traditional hierarchical organisations, both in a positive and a negative way. It can provide an alternative way for stakeholders to achieve democracy. Sørensen and Torfing [15] express that “…governance networks provide a supplement to representative democracy that grants an extra channel of influence to those who are intensely affected by certain decisions” [15]. In an inter-municipal health care setting, this will imply that patients and users of the services potentially will have more influence on the service. Moreover, it is expressed that contemporary problems in public sector requires flexibility, and that governance networks potentially has the advantage to be able to self-organize [16]. This implies more power, autonomy and influence for employees in IMC. Such organisational democracy can be both positive and negative for the employees. Potential advantages for employees are enhanced commitment, the feeling of more responsibility and a more participatory climate overall [17]. Potential disadvantages are the increased demands and accountability such a change of power can imply for the employees [17]. On the other hand, network governance has also been found to represent a threat to democracy, when democracy is defined from theories of liberal democracy such as Habermas [18] and Rawls [19] and described by Sørensen and Torfing [20]. Literature on IMC specifically, has identified challenges involving the potential democratic deficit of such cooperation [11]. Questions can be asked about whether local councils are informed about decision-making processes and budget control in inter-municipal service delivery [11]. However, if one sees democracy from the view of new post-liberal theory such as that of Etzioni [21] and Young [22], their emphasis is on the need for both a horizontal and vertical balance structure, and hence governance networks can play a positive role in democracy [20].

The concept of POS can shed light on employees and their influence in IMC settings. In general, employees perceived organisational support (POS) is found to positively influence affective commitment, job satisfaction, positive mood at work, desire to remain with the organisation, and turnover intentions [23]. POS consist of employees’ common global perception concerning the extent to which the organisation values their contribution and cares about their well-being [23]. For the employees, the organisation gets humanlike characteristics that lead to the perception that the organisation has a favorable or unfavorable orientation against them [24]. Based on organisational support theory [24], the organisations’ favorable treatment regarding fairness, supervisor support and organisational reward and job conditions will most likely increase POS, and hence how employees perceive how their contribution is valued and their well-being cared for in the organisation [25]. POS has also been addressed regarding change related uncertainty in organisations [26]. POS was found to be a mediator of the relationship between employee’s adaptability and perception of change-related uncertainty and employees’ satisfaction and performance [26]. POS lead to responsible behavior such as knowledge sharing behavior that benefits the organisation [27]. Knowledge sharing is important for the fulfilment of common goals amongst cooperative partners [28]. Trust in supervisor is also found to be of importance for knowledge sharing behavior [27].

In inter-organisational theory, the focus is primarily on the collaboration across organisational boundaries, however, the employees are also part of the partnership and network they inhabit [29]. Despite an extensive focus on coordination and collaboration in health care services, as well as on inter-organisational coordination and IMC, few studies have focused exclusively on IMC in health care services, and there is a lack of contextual grounding on research and theory on employees in this setting. As a result, we do not know how to manage and coordinate the work of health care personnel in this setting in order to meet their needs involved in the production of current and future health care services. The role of employees in improving service production has for long been a topic in the management literature (e.g. C Grönroos and P Voima [30]) but few studies have addressed how and under what conditions employees can contribute to improved service production in general (e.g. J Gummerus [31]) and in particular to inter-organisational health care service production. To address this gap, this study aims to explore critical issues for employees in inter-municipal health care services. This will have important implications for personnel management in inter-organisational cooperation’s in public health care services. The aim is elaborated in the following research questions:

RQ1: What critical issues are experienced by employees working in inter-municipal health care services?

RQ2: How and why do inter-municipal employees experience the identified critical issues?

RQ3: How do identified critical issues affect employees and working practices in inter-municipal health care services?

Furthermore, similarities and conflicts in inter-disciplinary theory on network governance and POS are examined, and thereby contributing to managerial and theoretical enhancement.

An inductive multiple qualitative case study strategy was applied. Employees with different experiences of IMC were included to develop a rich dataset. According to Yin, “A case study is an empirical inquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between phenomenon and context may not be clearly evident” [32]. The focus of present study was the critical issues for employees in newly established inter-municipal health care services. Because of its strong relation with the context, a case study approach was established. Further, a multiple case study was established to get the analytic benefit of applying replication across the cases in various contexts, and hence increase analytic generalisability. Multiple case studies are more parsimonious than single case studies, but also more robust and generalizable [33]. Qualitative data from individual and focus group interviews, observational studies, workshops and several reports were collected, and a cross-case analytical method to yield contextually grounded and generalisable findings was adopted [34].

The study took place in Norway, a country with three levels of political administration: state, county and municipal. In addition to these three formal administrative levels, Norway is divided into districts, which are organised by culture, common language or geography. The districts are larger than the municipalities but smaller than the counties and may span county borders. The districts in the present study are formal districts with a council and representatives from each participating municipality. Norway implemented the “Coordination Reform” in 2012 [35]. Because this reform entails the delivery of more health services via local governments, and because many municipalities are sparsely populated, the need for IMC has increased.

The participants in the interviews, observational studies and workshop came from two districts in Norway. The districts were chosen because both had newly established inter-municipal health services and hence were comparable in terms of the inter-municipal services. The contexts varied; one district comprised a mix of coastal and inland municipalities and the other comprised only inland municipalities. They differed in numbers of municipalities and population, enabling us to provide findings applicable across different contexts.

District 1 contained four municipalities with less than 10,000 inhabitants in total. The district council had established a health project grounded in the coordination reform [35]. The health project established several health-related inter-municipal projects, all rooted in the district council steering committee.

District 2 contained six municipalities with a total of 35,000–40,000 inhabitants. To adapt to the “Coordination Reform” [35], the district established a district health network that comprised managers of all six municipalities, the district hospital and the regional user committee, and union representatives. The main objective of establishing this network was to facilitate health care cooperation between the municipalities and between the municipalities and the hospital. One of the mandates of the network was to initiate and steer inter-municipal health care services.

Six inter-municipal health services, representing the six cases were included in the study; inter-municipal dementia team, psychologist, substance abuse therapist, occupational therapist, palliation project and substance abuse team. The six cases involved 12 employees of the inter-municipal health care services and five collaborating partners such as community nurse, general practitioner and inter-municipal ICT-personnel. The research team contacted managers in the district, who identified participants meeting the following inclusion criteria: project managers and employees in an inter-municipal public health care service. In addition, employees working in health care services, managers, ICT-personnel and collaborative health personnel in the municipalities, were included. Altogether, seventeen persons participated in the study (Table 1), including six who participated in multiple aspects of the study, such as interviews, observational studies and workshop. This approach was adopted to ensure an in-depth understanding of the phenomenon. Interview and observational data were collected over eight months. Pseudonyms are used to denote districts, municipalities, teams and the individual informants to protect participant privacy.

The inter-municipal health care services in this study were mainly organised as projects with fully or partially external public funding. The services were organised either on the basis of inter-municipal teams or as individual employees serving several municipalities (hereafter “individual service”). All the services were newly established from three months to 1.5 years prior to the start of the study.

In District 1, the dementia team was structured such that the employees and the project manager carried out their main work in their respective municipalities with part-time inter-municipal employment. The substance abuse therapist and psychologist had a 100% inter-municipal position each and served all four municipalities. One municipality served as the host municipality and fulfilled management responsibilities.

In District 2, the project “Palliation in Vik [anonymised district name]” was established as a competence-enhancing project for district health personnel financed by external public funding. Only the role of project leader had an inter-municipal component (30%) for the coordination of competence-raising measures. The occupational therapist was employed in a service that entailed her serving the involved municipalities individually. This position was administratively organised by one of the municipalities, whereas the hospital was responsible for professional supervision. The Vik substance abuse team consisted of four positions, including a project manager. One of the municipalities, the one in which the team was based, served as a host municipality.

Multiple data collection methods such as interviews, observational studies, workshop and document studies were used to strengthen the theoretical grounding by triangulating the evidence [36].

The data analysis was conducted in iterative phases, and the research questions and findings obtained during the process revealed a need for different approaches as visualized in Fig. 1.

The qualitative software program Nvivo [37] was used for the analysis. The research questions guided the analysis:

RQ1: What critical issues are experienced by employees working in inter-municipal health care services?

First, case analysis was conducted on all individual cases. Data sources relevant to each case were analysed using qualitative content analysis, as inspired by Graneheim and Lundman [38] and recommended by Kohlbacher [39]. The content was analysed through a series of readings of data relevant to each case. The data were analysed and developed inductive codes and categories based on the research questions. Examples are seen in Table 2. Second, cross-case analysis was conducted on the cases inter-municipal dementia team, psychologist and substance abuse therapist in District 1 and on the cases occupational therapist, palliation project and substance abuse team in district 2. The cross-case analysis in each district examined replications of, contrasts with, and extensions to emergent findings. Third, findings replicated across cases in both districts were analysed across the two districts to identify replications of, contrasts with and extensions to emergent findings. The initial findings of the present study are the categories replicated across cases within a district, and across districts.

The categories served as a framework for addressing the following research question:

RQ2: How and why do inter-municipal employees experience the identified critical issues?

The same strategy, qualitative content analysis, was used in the further analysis of the data. Each category was analysed individually within each case using an inductive approach. Cross-case analysis was conducted within each district. Several local conditions exist regarding each identified category from RQ1, and replication logic across all cases was not obtained. However, the most important and prominent categories were identified. Finally, findings from each district were analysed, and a common theme was identified and considered as evidence for accomplishing literal replication.

RQ3: How do identified critical issues affect employees and working practices in inter-municipal health care services?

Each category from RQ1 was analysed individually within each case, using an inductive approach. Cross-case analysis was conducted within each district. The cross-case analysis revealed few to zero replications across cases in the various regions regarding the identified critical issue "support", which compelled the researchers to refine and extend the analysis approach. The findings indicated differences in how both teams and individual services were affected. Hence, the cases composed as teams and those composed as single services were analysed across cases but not across districts. The cross-case analysis in each group obtained findings that were replicated across cases. The replication logic confirmed the refinement of our analysis and suggested that service composition had more impact than district characteristics on how critical issues affect employees in inter-municipal services. Regarding the identified critical issues "differences" and "geographical distance", common themes were identified and considered as evidence for accomplishing literal replication. 

To obtain robust findings, a multiple-case design that allowed replication of findings was conducted. Data analysis revealed that no further replication was feasible, contributing to data saturation. The discussion actively uses existing literature from other contexts or viewpoints to enhance internal validity and analytic generalisability.

Both participant and nonparticipant observation can influence the participants’ behaviour. To reduce this potential bias, multiple data collection methods are used in the analysis of data.

The nature of case study design enables the transfer of findings to other contexts. The findings in the present study were replicated across two districts with diverse characteristics, indicating applicability to other settings and groups.

The research team consisted of multiple investigators, with multi-disciplinary competence. The complementary insights provided by a team can improve data richness and increase the likelihood of capitalising on novel insights from the data, while convergence from multiple investigators improves confidence in the findings [36].The prior knowledge of the researchers might affect the research process. The researchers avoided thinking about specific relationships between theory and findings during the data gathering and analysis. The participants varied in terms of age and gender, thus reflecting diverse perspectives on IMC. The constant use of different perspectives from researchers, various data collection methods and cross-case analysis comprised the strategy to avoid a unilateral focus, and hence researcher bias.

The data collection evolved over time, and the initial interviews gave new insights that influenced the decision to broaden the research question and made it necessary to include more participants to ensure saturation, and, hence, replication between multiple perspectives. The research team had open discussions regarding data consistency. To reduce the threat of selective bias, external colleagues working in inter-municipal health care services were consulted to check the possibility of rival or other reasonable explanations. In case studies, the extensive use of empirical evidence can result in too much reliance on theory with excessively detailed findings, and a lack of overall perspective [36]. Rather than trying to capture everything, this study focuses on findings that were replicated across multiple cases and in different contexts and avoids explaining rival findings across cases.

The sample size in the present study was small and the geographical setting was limited. This study does not emphasize or distinguish between different organisations and formalizations of IMC which can potentially affect critical issues related to IMC. Further research is needed to address these limitations

The findings of present study have some implications, which can guide managers of IMC in a health care setting. Employees were found to be affected by several critical issues, in which potentially can have negative impact on both job satisfaction and POS. This in turn, may affect turnover intentions and the employees’ perception on how the organisation values their contribution and cares about their well-being [25, 54]. In network governance theory, networks are described to be flexible, and they can change the existing democratic system [14, 20]. Findings in present study provides a contextually grounded support for these theories. However, the flexibility was only present in the services organised in team-structures, suggesting that the positive effect work across organisational borders are also dependent on how the employees are organised at the local level. Organising the employees in a team structure were found to hinder the negative impact of employment in inter-municipal health care services, and it could in addition better utilize the positive effects of IMC. Teams were more flexible in terms of their ability to match employees with suitable patient cases, as well as coping with time-schedules and distances. Team members made use of co-worker support and did not express challenges regarding lack of supervisor support. Future health care will be characterized by rapid changes and development. Thus, the ability to quickly adapt to environmental changes could potentially meet future needs. It was also apparent that employees in the inter-municipal services were guided and made decisions, based on a bottom-up strategy, supporting post-liberal theories suggesting that networks can enhance democracy by providing an additional channel for the stakeholder voice [21, 22]. Further, managers should be aware of the challenges related to differences amongst the cooperating municipalities, and the geographical distance. This lead to increased workload for the employees and decreased efficiency and effectiveness in the services. Managers should consider to putting in place measures to minimize the possibility of negative effects for the employees regarding geographical distance and differences amongst the municipalities.

The mandate of an inter-municipal service should be precisely explained, and flexibility within a defined framework can generate effective services with user involvement based on a bottom-up strategy.