Key factors for organising integrated social care for families with multiple and complex problems: an organisational empowerment perspective Open Access

Integrated care is generally characterised as a holistic and comprehensive approach that addresses the problems associated with fragmented care across various disciplines, issues, professionals and organisations (Kodner and Spreeuwenberg, 2002; Valentijn et al., 2013). More precisely, the WHO defines it as:

Integrated social care, with a focus on social support services, is considered particularly valuable for families facing multiple complex challenges, such as poverty, mental health issues, addiction or parenting difficulties (Van Eck et al., 2024). It aims to enable professionals to provide holistic, well-coordinated and comprehensive support to these families, with the goal of promoting empowerment for families, professionals and their organisations (Cleek et al., 2012). There is a growing body of knowledge about what is needed to implement integrated social care from the perspective of families and professionals (Nooteboom et al., 2021; Van Eck et al., 2024). Less is known about how it can be effectively implemented at the organisational level. This can be considered a gap, as even well-designed programmes and interventions can fail in terms of implementation if the right organisational structures and processes are lacking (Fixsen et al., 2005; Whetsell et al., 2021). The organisational requirements for integrated social care are therefore the focus of this study.

Studying organisational empowerment provides insights into how the structure and effectiveness of integrated social care can be improved. In addition, it can contribute to strengthening inter-organisational collaboration and influencing the external environment. This can support the realisation of integrated care, allowing organisations to better serve families with multiple and complex needs (Cleek et al., 2012). To our knowledge, no prior research has identified the key factors necessary for successfully organising integrated social care. Therefore, the central research question of this study is: What are the key factors for organising integrated social care for families with complex problems?

Our aim is to provide policymakers, managers and organisational leaders with insights into the factors that can support the effective organisation of integrated social care. In doing so, we seek to contribute not only practical guidance but also to expanding the theoretical application of organisational empowerment within complex service systems.

This study is grounded in empowerment theory. According to Zimmerman (1995) and Peterson and Zimmerman (2004), organisational empowerment strengthens the functioning of the internal organisation, collaboration with other organisations and the ability to influence the external environment. Although organisational empowerment has been widely cited since Peterson and Zimmerman (2004), more recent conceptual work is limited. From a more theoretical point of view, Rothman et al. (2019) provide an updated synthesis confirming the relevance of the three-level framework in complex service settings. Organisational empowerment originates from empowerment theory, which Rappaport (1987, p. 122) defines as “a process by which individuals, organisations and communities gain control over their own affairs.”

Peterson and Zimmerman (2004) argued that individual empowerment increases personal control and self-confidence; community empowerment improves quality of life and promotes social participation; and organisational empowerment focuses on increasing member empowerment and organisational effectiveness. It involves improving internal functioning, promoting external collaboration and enhancing the ability to influence the environment.

These goals align with the principles of integrated social care, which requires organisations to work across boundaries, align shared goals and respond collectively to the complex needs of families. Organisational empowerment provides a useful framework for analysing how organisational factors influence the delivery and collaboration of integrated social care. It highlights empowerment mechanisms such as shared decision-making, care coordination and interprofessional collaboration.

Within organisational empowerment theory, three interrelated levels are distinguished: intra-, inter- and extra-organisational empowerment.

Intra-organisational empowerment refers to the internal structure and functioning of the organisation, such as the infrastructure and autonomy needed to act proactively and achieve organisational goals (Peterson and Zimmerman, 2004). For instance, Christens et al. (2014) found that strong relational ties and trust within the organisation enhanced members’ capacity for collective action and adaptive problem-solving.

Inter-organisational empowerment concerns the relationships and collaboration between organisations, which are crucial for promoting coordinated service delivery (Peterson and Zimmerman, 2004). Neal (2014), for example, demonstrated that strong inter-organisational processes, such as alliance-building and information sharing, empower organisations and enhance collaboration, thereby facilitating more coordinated service delivery.

Extra-organisational empowerment includes actions taken by one or more organisations to influence their external environment, such as shaping policy, creating new services or facilities and engaging in advocacy (Peterson and Zimmerman, 2004). Griffith et al. (2008) examined how extra-organisational empowerment is used in community mobilisation efforts to address youth violence, highlighting how organisations leverage external influence to drive social change.

Furthermore, the three levels of organisational empowerment, intra-, inter- and extra-organisational, reflect the multi-layered nature of integrated social care (Valentijn et al., 2013). In answering the research question, we distinguish between key elements at each of these levels.

This study was conducted within the integrated social care setting of the Social-Neighbourhood teams in Amsterdam Nieuw-West. The Social-Neighbourhood teams provide support to citizens and families facing challenges such as financial difficulties, mental and physical health issues, housing instability and addiction. Within the Social-Neighbourhood organisation, these teams consist of various professionals, including social workers, debt counsellors and social-legal advisers (legal professionals within the Dutch social domain who assist citizens with issues such as housing, welfare benefits and employment rights) who together offer integrated social care to families. The study also involved (specialised) youth care organisations, collaborating partners embedded within the Social-Neighbourhood teams, at the inter- and extra-organisational empowerment level. The municipality of Amsterdam, as the commissioning body for Social-Neighbourhood teams, also participated (Municipality of Amsterdam, 2021).

To answer the research question, a qualitative study was conducted using four focus groups. These focus groups consisted of a diverse group of participants, including professionals, policymakers, project leaders, managers and directors. Focus groups were chosen because they facilitate interaction between participants, which can provide deeper insights into the dynamics of empowerment within and between organisations. Focus groups have proven to be particularly useful in contexts where collaboration between organisations and professional roles is essential (Onwuegbuzie et al., 2009). The interactive nature of focus groups allows participants to challenge and enrich each other’s perspectives, which results in richer insights for answering the research question than methods without this dynamic element (Krueger and Casey, 2014).

Prior to the focus groups, a preliminary list of empowerment components was drawn up based on the theoretical framework of organisational empowerment (Peterson and Zimmerman, 2004; Maton and Salem, 1995; Rothman et al., 2019). These components were derived from the three levels of organisational empowerment. Two preparatory interviews were conducted with a project leader from the Social-Neighbourhood team and a professional from a youth care organisation. They provided feedback on the relevance and clarity of the proposed questions. Based on their input, minor adjustments were made to better align the questions. The final list of questions formed the basis for the four focus groups.

Participants were selected based on their relevant experience and expertise within the three levels of organisational empowerment. In collaboration with a project leader from the Social-Neighbourhood team, and the research team (MvE, MC, RE and TvR), a diverse group of potential participants was identified.

Participants were selected based on their roles related to these three levels of empowerment, ensuring a broad representation, from social workers and debt counsellors to senior managers and directors. Focus groups 1 and 2 included Social-Neighbourhood team professionals (social workers, debt counsellors, social-legal advisers, experts by experience and team managers), group 3 included external partners such as Youth-care workers and project leaders from the Social-Neighbourhood team and Specialised Youth Care. Group 4 included directors, general managers, project leaders, from the Social-Neighbourhood team, Youth Care organisations and a municipal policy adviser (see Table 2 for details). Only individuals with relevant experience in integrated social care who were available and willing to participate were included.

Recruitment took place via email and telephone. The purpose of the study and the importance of each participant’s contribution were clearly explained. Table 1 provides an overview of the components and organisational empowerment level per focus group. This purposive sampling method was designed to ensure a balanced range of perspectives from key actors involved in organising and delivering integrated social care. The aim was to develop a comprehensive understanding of the key elements required for effective organisational empowerment in this context.

This study was approved by the Ethics Review Board of Tilburg University [SB_RP245]. All participants were informed about the study, what was expected of them, their rights and provided signed informed consent prior to the focus groups. As part of the ethical assessment, attention was given to data management and security, verification of data integrity, data coding and anonymisation.

The data analysis was based on the three levels of organisational empowerment: intra-, inter- and extra-organisational. All focus group discussions were recorded and transcribed verbatim. The transcripts were uploaded to Atlas.ti (version 25) for analysis.

An open, inductive coding approach and thematic analysis were used, following principles outlined by Braun and Clarke (2006). Two researchers (MvE and CA) read the transcripts to become familiar with the data. Initial codes were generated and based on the work of Rothman et al. (2019) similar codes were then clustered into broader categories. For example, several initial codes about the importance of direction and alignment (“lack of shared goals”, “unclear role of organisations”) were clustered into the broader category “vision and positioning”. From this category, the key factor “shared vision” was derived. Similarly, initial codes reflecting the quality of leadership interactions (“limited guidance from managers in integrated social care”) were grouped under the category “leadership”, from which the key factor “supportive leadership” was extracted. MvE conducted the initial coding, which was then reviewed by CA. They discussed their interpretations to ensure reliability and depth. Through comparison across categories, codes and transcripts, 23 main findings were identified that reflect recurring key factors described by the 34 participants. The codes were grouped and categorised according to the three empowerment levels. To improve accuracy, the researchers (MvE and CA) held regular discussions during the analysis process.

In this section, the key factors that contribute to the organisation of integrated social care for families facing complex challenges, based on findings from the focus groups are presented. These factors are categorised across the three theoretical levels of empowerment: intra-, inter- and extra-organisational. The findings are illustrated with quotes from the focus groups.

Participant roles by focus group

For the focus groups, participants were invited in different roles that were relevant to the focus of the research. Table 2 shows the number of participants in each focus group, categorised by role. A total of 34 participants took part in the focus groups, of which six people participated in two sessions, resulting in 28 unique participants.

Key factors for organising integrated social care for families with complex problems identified in this study at the intra-organisational level include: accessibility and proximity, team culture, a shared vision, collective responsibility, learning as a shared process, and leadership that creates space, connecting and visible leadership, positioning of all roles and fostering a learning organisational culture.

Respondents indicate that integrated social care within organisations is strengthened by easy access to professionals from different disciplines, such as social workers, debt counsellors, social-legal advisers and experts by experience. Physical proximity, facilitated, for example, through joint intake interviews and informal conversations, promotes familiarity and trust, according to the participating professionals. In addition, it was noted that cohesion and cooperation within multidisciplinary teams led by a single manager can be enhanced:

Depending on their role within the team, such as experts by experience, social-legal advisers and debt counsellors, participants indicate that they sometimes feel less involved because they are in the minority in relation to social workers. As a result, they feel less visible, for example, during meetings, which often focus on issues relevant to social workers. Consequently, these roles are sometimes overlooked. According to the respondents, explicitly recognising and involving these professionals is important to strengthen integrated social care:

The findings emphasise that mutual appreciation, openness and genuine interest in each other’s personality and expertise, by both professionals and managers, are key elements of empowerment and integrated social care. Respondents indicate that a culture in which these aspects are present enables professionals to express doubts, receive support and engage in collective learning:

The participants indicated that a shared vision can provide organisational members with clear direction and is considered important for integrated social care. The focus groups indicated that such a vision benefits from broad internal commitment. A common language was mentioned as a helpful tool to identify problems early and to prevent misunderstandings between professionals. Participants highlighted that this fosters collaboration and a sense of collective identity:

Respondents suggested that empowerment may increase when problem-solving is shared among professionals rather than being the responsibility of a single individual. According to the focus groups, teams in which members feel jointly responsible for providing support appear to foster a sense of shared ownership and encourage routine collaboration:

The focus groups emphasised that learning in practice during collaboration was seen as an important element in strengthening integrated social care. Respondents indicated that mutual understanding and joint development can be supported through shared reflection, case discussions and team training. At the same time, they noted that high workloads and limited time often pose challenges to engaging in joint learning:

The focus groups suggested that leadership plays an important role in integrated social care within organisations. Respondents noted the importance of managers providing space for reflection, creating calm and fostering a flexible environment where professionals feel safe to grow. According to participants, these conditions promote psychological safety and autonomy:

According to the respondents, leaders who actively connect professionals play a crucial role in empowerment and integrated social care. They are seen as role models when they show appreciation for collaboration and actively facilitate it. Participants indicated that this type of leadership helps to build trust and strengthen collaboration:

Respondents stressed that leadership should recognise all roles in the team, including less visible ones like experts by experience and debt counsellors, to promote balance and empowerment:

Respondents noted that leaders should actively promote continuous learning by providing training, reflection time and opportunities for peer consultation, as professionals often find it hard to make time for these activities. Ensuring this support is key for sustainable empowerment:

Key factors for organising integrated social care for families with complex problems identified at the inter-organisational level include joint assignments and shared interests, relationship-oriented work, flexible financing and trust-based collaboration, courage to cross boundaries, shared belief and catalysts, leadership and administrative support, cross-domain learning and reflection and positive experiences. Respondents also highlighted barriers such as high workloads, organisational silos and bureaucratic processes.

The respondents indicated that integrated social care between organisations revolves around a clear, shared assignment that is established by the municipality or the partners involved. Without this shared assignment, the risk increases that professionals and organisations work past each other, which leads to fragmentation:

The findings showed that integrated social care begins with relationships rather than structures. Professionals who proactively connect, through introductions, visits or informal contact, build trust more rapidly. According to the respondents, formal roles and meetings alone are insufficient; informal interactions and a shared language are essential. These practices enhance empowerment by establishing trust-based, informal links across organisations:

The focus groups highlighted that flexible financing and recognition of preventive measures that go beyond formal referrals are essential elements for integrated social care. When municipalities provide financial space for trust-based collaboration and early intervention, professionals are given more opportunities to put the interests of families first:

Respondents suggested that integrated social care encounters obstacles such as high workloads, organisational silos, and bureaucratic processes. Professionals may unintentionally uphold barriers by adhering to registration procedures that are not formal rules. Respondents indicated that differences in funding, structures and workflows often keep youth and social care separate, leading to fragmentation. This weakens empowerment by limiting coordinated efforts and shared capacity:

Respondents indicated that they often hesitate to act outside formal roles, even when it benefits families. Leadership that encourages flexibility and boundary-crossing behaviour stimulates innovation and autonomy, which are essential for empowerment:

The focus group showed that a shared belief among professionals in integrated social care stimulates collaboration and commitment within organisations, especially when supported by leadership. Enthusiastic catalysts who lead by example can play a crucial role in stimulating integrated social care, thereby strengthening empowerment:

According to the respondents, managers can stimulate empowerment by prioritising collaboration, aligning efforts and building relationships that help overcome inter-organisational issues. According to the respondents, policy and financial flexibility, especially from municipalities, creates space for joint action. Supportive leadership and adaptable frameworks stimulate integrated social care:

The focus group revealed that joint learning and reflection are essential for inter-organisational empowerment, but are often hampered by workloads and fragmented domains (e.g. youth and social domains). If cross-domain learning is limited, it weakens shared insight and integrated social care:

The discussions demonstrated that collaboration on positive cases creates trust and demonstrates the practical value of integrated social care. It also emerged that shared successes stimulate further collaboration and strengthen empowerment through stronger relationships:

Finally, key factors for organising integrated social care for families with complex problems identified at the extra-organisational level include: vision, direction and administrative support; policy context; administrative consistency as a foundation; collaboration between policy and practice.

The focus groups indicated that a shared vision is important for organisations to navigate the complex environment. According to the respondents, organisations struggle to prioritise and often lose direction without such a vision. Joint assignments from the municipality contribute to stability and policy coordination, which strengthens empowerment:

The conversations indicated that frequent policy changes and initiatives from the municipality create pressure and fragmentation, which undermine the stability needed for sustainable change. In addition, the municipality’s dual role as financier and director often results in fragmented policy and unclear expectations. To foster empowerment, respondents stressed the need for coherent municipal leadership with cross-domain thinking, strategic focus, long-term collaboration and alignment between organisations:

The respondents stressed that integrated social care requires structural, long-term embedding instead of short-term pilots and temporary initiatives. According to the respondents, continuous innovation requires a lot of effort and can be destabilising. Respondents indicated that stability and the space to build on existing relationships are essential and strengthen empowerment:

The focus groups revealed that empowerment across organisational boundaries depends on consistent administrative guidelines. Municipalities play a key role in this by creating frameworks that support sustainable, integrated social care and ensure policy coherence. According to the respondents, such administrative consistency reduces fragmentation and strengthens empowerment.

During the conversations, policymakers and directors indicated their appreciation for professionals’ deep knowledge of families’ living environments and neighbourhood dynamics. This knowledge is essential for effective policy. By integrating their insights into policymaking, policy decisions can be aligned with daily practice, thereby strengthening empowerment:

Analysis showed that intra-, inter- and extra-organisational factors interact in shaping integrated social care. This reciprocal dynamic underscores how factors reinforced or constrained across levels, highlighting their continuous interplay and occasional tensions.

This study aimed to identify the key elements needed to organise integrated social care for families facing multiple and complex problems. We used organisational empowerment theory to analyse how empowerment occurs at three levels, intra-, inter- and extra-organisational, and to determine the essential conditions at each level.

At the inter-organisational level, our findings highlight the importance of trust, informal networking and shared meaning. Bureaucratic boundaries and excessive focus on task division can hinder collaboration. Personal relationships, joint learning and catalysts enhance effective functioning. Our study shows that collaboration between organisations is more about the quality of mutual relationships than about the method of organisation and structure. These findings are consistent with earlier research that shows that relational trust, shared values and informal networks are essential for effective inter-organisational collaboration (Provan and Kenis, 2008; Ring and Van de Ven, 1994; Zaheer et al., 1998).

At the extra-organisational empowerment level, our study shows that empowerment depends on policies that are consistent, supportive and long-term-oriented. Municipalities play a key role in this regard. They must look beyond temporary pilots or isolated assignments and instead focus on fostering stability, trust and autonomy in the workplace. Existing literature also highlights that governments and local authorities are crucial in facilitating collaboration and empowering organisations. Stable and supportive policy frameworks are essential for this (Nicholson et al., 2013). Municipalities and funders must recognise their role in creating the conditions that enable organisations to jointly influence both the system and their broader environment. In addition, a shared vision at this level proved to be critical. Without a common direction, fragmentation is likely to occur. In contrast, a shared vision provides coherence, focus and guidance for collective efforts to influence the environment and promote integrated social care at the system level.

Our study demonstrates that formal structures alone are not sufficient to realise empowerment and integrated social care. What truly matters is how people interact with one another, and the extent to which they experience space, safety and a shared vision in their work. The organisational empowerment framework offers valuable insights into these underlying dynamics. Policy fragmentation can ripple through the system, affecting other levels and placing strain on collaboration. Therefore, organisational culture, trust and connecting leadership are essential for the sustainable functioning of integrated social care. Future research could explore how leadership and shared vision can be strengthened across levels to support long-term collaboration.

Consistent with findings from other studies (Struckmann et al., 2024; Goodwin, 2016), our results indicate that integrated social care cannot be achieved solely through structural changes or a top-down approach. Integrated social care flourishes when empowerment is experienced across all levels of the system. In addition, the organisational empowerment framework provides practical insights that help conceptualise and operationalise organisational empowerment. Approached from the perspective of integrated social care, organisations and professionals require space, connection, autonomy and direction. These key factors must be present simultaneously across multiple levels.

Our study shows that organisational empowerment at the intra-organisational level means being part of an organisational culture in which trust, openness, joint reflection and shared responsibility are important for realising integrated social care. In addition, leadership plays a key role in creating a sense of calm, providing space and supporting a learning climate. The internal culture forms the foundation for how professionals collaborate with other professionals, organisations and families. These findings align with previous studies that highlight the importance of psychologically safe teams and supportive leadership (Edmondson, 1999; West and Lyubovnikova, 2013).

Compared to previous research, which mainly focuses on clinical and professional integration at the individual or team level (Kodner and Spreeuwenberg, 2002; Valentijn et al., 2013), our study provides a multilevel organisational perspective. By examining intra-, inter- and extra-organisational factors, we identify how structures, leadership and policy jointly support integrated social care. This not only provides insights for practice, but also new theoretical insights on how to make the organisation of integrated social care more evidence-based and grounded in scientific knowledge, thus supporting the professionalisation of the field.

This study has several strengths that support the reliability and depth of its findings. We captured a wide range of perspectives by conducting four focus groups across different empowerment levels and involving a diverse group, from experts by experience to policymakers. The sessions encouraged open dialogue in which respondents exchanged their perspectives. Data saturation was reached, as there was considerable repetition and no new information was added. A second researcher independently reviewed the analysis, enhancing its validity.

Nevertheless, there are limitations. Municipal input came from only one policy advisor, which somewhat limits the representation of this perspective. In addition, group dynamics and personal interests could have influenced respondents’ openness.

Integrated social care requires more than formal structures. It depends on the quality of interactions between actors, a shared vision and cohesive leadership. Organisational empowerment – at intra-, inter- and extra-organisational levels – provides a valuable framework to understand and promote these conditions. Policymakers and leaders should invest in long-term trust, professional autonomy and system coherence. Integrated social care starts with a culture of collaboration, is anchored in a shared purpose and is supported by empowering leadership.

Effective leadership and structured support are crucial at all levels for integrated social care. Hard components – financial flexibility, reduced bureaucracy and clear policies – provide necessary conditions, while soft components – trust, shared vision and collaborative behaviours – require targeted training. Professionals need development in cross-disciplinary collaboration, and leaders need coaching to guide and empower teams. Focusing on both aspects can strengthen integration and improve outcomes for families with complex needs.

The authors sincerely thank all participants of the focus groups for their time, insights and contributions to this study. Their experiences and perspectives were invaluable in helping us understand the key factors for organising integrated social care.