Paper selection (systematic review)
A total of 2763 titles and abstracts were screened, which were filtered down to 116 full texts, resulting in 51 included papers for the overall review. These were then screened for relevancy to the barriers, and success/contextual factors of partnering, which resulted in 34 included papers. Reference scanning and citation tracking resulted in a further four papers, giving a total of 38 papers included in this final analysis (figure 1). Agreement between independent reviewers was 100%.
Document characteristics
Systematically identified studies included case studies (n=17), reviews (n=16), case control study (n=2), survey (n=2), and theoretical papers (n=1). Unfortunately, we were not able to identify any opinion pieces or commentaries that had sufficient analytical depth to inform the review. In terms of types of partnerships, covered mixed partnership types (n=16), mergers (n=9), alliances (n=3), joint working (n=2), contracting (n=1), joint commissioning (n=1), vanguard arrangement (n=1), accountable care organisations (n=1), community health partnerships (n=1), buddying (n=1), primary care partnerships (n=1), and combined trusts (n=1) (table 1).
Twelve purposively identified papers were also drawn upon, which outlined middle-range theories, and we used these to elucidate the workings of mechanisms. These included one paper for partnership synergy (30), one for trust (31), two for conflict (32,33), one for power (34), one for coordination (35), one for leadership (36), two for organisational flexibility (34,37), one for task complexity (38), and two for proximity theory (39,40).
Main findings
The results of our analysis of the included studies identified a range of mechanisms as essential processes upholding collaboration functioning, namely: conflict, trust, power, faith, interpersonal communication, leadership styles, cultural integration, and task complexity. These mechanisms uphold the ability for partnerships to perform (or have ‘task achievement’), through mechanisms of ‘partnership synergy’, and with avoidance of ‘collaborative inertia’. Although mechanisms can relate to both changes in reasoning and resources that an intervention introduces, the majority of mechanisms we identified relate to processes of reasoning by actors (41). The review also identified a range of contextual factors that affect which of these mechanisms are activated and how (additional file 1). The following sections present the interactions between these various elements.
Partnership performance mechanisms
Frequently mentioned in seven of the systematically-reviewed studies was the concept of partnership synergy (12,13,42–47), which was first coined by Lasker, Weiss, and Miller (2001) as a means for explaining how partnerships achieve advantage over independent, competitive working. Partnership synergy is put forward as an intermediate outcome that comes after the functioning of the partnership but precedes the effectiveness of it (figure 2) (30). This means that when working well together, a combination of resources and skills of the partners is what enables achievement above and beyond what would have been possible individually. Synergy can be comprised of other, lower-level mechanisms that together lead to improved ability to achieve, such as reduced duplication of effort, economies of scale, and competitive advantage (30) - these lower-level mechanisms will depend on the aims and structure of each individual partnership. Next to the concept of synergy is that of collaborative inertia, put forward by Huxham (2003), one of the systematically identified studies, in which organizations and actors get bogged down in the day to day functioning of the partnership (12). While trying to optimise the daily functioning, achievement of the actual aims of the partnership fall by the wayside as significant manpower and time is devoted to partnership functioning rather than accomplishment of outcomes. It is possible that a partnership will engage in a period of inertia in its earlier stages of formation, before synergy is later achieved. This concept of inertia was also put forward by a number of the included studies (12,14,43,44,48).
As partnership functioning relies on many other contextual factors and the mechanisms that enable collaboration, these will be explored as elements that enable synergy and thus partnership effectiveness and accomplishment of its aims, in the following section.
Partnership functioning mechanisms
Trust
Building and maintaining trust was a key mechanism identified by 16 papers in the review, and trust can be affected by a number of contexts (9,10,12,13,42,43,45,48–53). As trust was mentioned so frequently, we sought to include a robust middle-range theory for this element, and we identified Vangen and Huxham (2003) and their trust-building loop in inter-organisational collaborations as a framework. Trust has been defined in a myriad of heterogeneous ways, but we draw on the concept as a key component of social structures (organisations), with trust being formed as a result of networks and norms between actors in the social structure (54). The trust-building loop proposes that a certain degree of trust is required to set the risk tolerance of each partner with respect to how ambitious the aims they agree to are. As more is accomplished by the partnership, trust will be reinforced – but if failures occur, trust will be reduced; these successes or failures will again affect the risk tolerance in a cyclical manner (31).
Trust underpins the majority of decision-making that is undertaken in a partnership, and also is tied keenly into other mechanisms such as respect, conflict, and power, which all may affect trust as an outcome (31). For example, as previously mentioned, every time a conflict occurs between organisations, it is likely that trust between them will be reduced (33). Trust is put forward by Vangen and Huxham (2003) to mean “the ability to form expectations about aims and partners’ future behaviours in relation to those aims” (31). Scholars argue that trust and risk are keenly interlinked, and trust is required to ‘take a risk’ in believing that a partner will do what is against their own interest for the collective good (55). This places the ‘trustor’ in a vulnerable position relative to the trustee. When results of these risks arise, they can build more trust or have it broken down depending on the outcome. A number of contexts are important for modulating the initial level of trust with which partners enter an arrangement as well – which can act as a buffer against future conflicts and task failures.
Trust building, synergy, and task achievement
Trust building is another factor that needs to take place throughout the process of collaboration and is likely to be cyclical in nature, as acts which beget trust are usually reciprocated (31). Mutual successes such as achievement of outcomes reinforce trust in both parties (figure 1) (31,56). This loop was explicitly mentioned by included systematically identified studies (10,12,43). This means that outcomes need to be realistic and agreed upon by both parties, thus, if outcomes are too overambitious then trust will also be reduced as they are unachievable (figure 3). Relatively unambitious intermediate aims and outcomes formulated at the beginning of a collaboration may thus serve to solidify and build trust early on, enabling achievement of higher ambition stakeholder-centric targets later (57). This means that:
Unambitious aims (context) à easier task achievement (mechanism) à increased trust and risk appetite (outcome).
As such, in some cases:
Failure to achieve aims (context) à conflict (mechanism) à further reduction in trust (outcome) (figure 3).
Trust is also essential to maximising collaborative synergy. As Jagosh et al. (2015) and Lucero et al. (2020) have identified in their analyses of public sector partnerships, without trust, partners will not be able to work together in a functional manner. This means that:
High trust (context) à partnership synergy (mechanism) à task accomplishment/performance (outcome).
Historical context
It is evident that a certain minimum level of trust needs to be maintained at all times for a collaboration to avoid dissolution, and that certain factors are likely to modulate the level of trust already in place when people begin to initially work together. As mentioned by papers in our systematic review, these factors could include whether the organisations involved have had pre-existing collaborations that were successful (or not) (10,48,60,61), as well as the historical context of collaborations in the geographical area in which the organisations are located, and a partner’s reputation (13). These factors have the potential to act as enablers or barriers to potential collaboration by modulating the pre-existing level of trust and suspicion with which partners will begin collaborating. For example:
Existing successful collaborations (context) à better initial trust (mechanism) à greater ambition in objectives (outcome) (figure 3).
Formalisation
The degree to which a collaboration is formalised was mentioned in included studies as a method of instilling trust between partners by cementing tasks and accountability in contractual, legal terms based on relational contracting (43,61). Formal agreements forged at the beginning of such arrangements in the Connecting stage can also serve as a scaffolding which holds up and solidifies trust between partners (figure 3) (56,62). This is because, as rules are laid down with a legal mandate to uphold them, there is an understanding that the other side will follow them. Thus, we hypothesise that:
Legal agreements (context) à greater initial trust (mechanism) à greater risk threshold and ambition (outcome).
Conflict
Inter-organisational conflict
A further mechanism explicitly mentioned throughout the included papers was conflict; many factors lead to conflict if not properly managed, including cultural differences, the management of individualist vs. collectivist interests, power dynamics, congruence of aims and objectives, whether partnerships are dissolved as appropriate, ongoing evaluation, organisational ownership of decision-making, and the pace of partnership development (10,12,13,51,52,63). Ideally, all of these factors are overseen by conflict resolution mechanisms that rely upon mutually agreed governance and accountability arrangements between partners. However, there are also other mechanisms at play that can prevent conflicts arising before they even happen, for example, developing cultural integration plans that ensure that conflicts arising due to cultural differences in workforces are planned for and mitigated (64).
As mentioned by Lumineau, Eckerd, and Handley (2015), conflict between organisations is often very different from inter-personal conflicts due to the level of interaction, decision-making parties, incentives and motivations of key stakeholders, governance structures for preventing and managing conflict, repair mechanisms available for resolution of disputes, and the institutional context. Essentially, the situations become much more complex due to the myriad actors and mechanisms involved. Conflicts can also take numerous forms, such as whether they are competence-based (relating to skills or knowledge of partner) or more fundamental, integrity-based conflicts (33). These have differing implications for how resolvable they are with different management strategies.
Perhaps the most pertinent categories of management strategies include constructive (joint problem solving and persuasion) vs. destructive (domination) conflict resolution strategies which are clearly evocative of the type of relationship that is at play between partners (32). The outcomes of conflict are typically a function of the effectiveness of the conflict resolutions in place and the type of relationship which already existed (33). As already mentioned, this could manifest in a loss of trust, or in the case of re-commitment that arises from a constructive management process, could potentially lead to improved trust due to a gain in collaborative working spirit. We suggest that conflict is keenly linked to trust, and that conflict can be both a context and a mechanism depending on the element of analysis. For example:
Murray et al., (2018) suggest that:
Conflict between partners (context) à can lead to reduced trust (mechanism) à reduced ambition and faith in the partnership (outcome)
Likewise, Auschra (2018) suggests that:
Having a shared vision (context) à is likely to reduce conflict (mechanism) à leading to improved trust (outcome)
Constructive conflict resolution strategy à improved trust à greater task achievement
Destructive conflict resolution strategy à reduced trust à reduced task achievement
Accountability & commitment
As discussed previously, accountability and conflict resolution mechanisms are key and should be established as a part of the governance of the arrangement in the Planning phase of a collaboration (56). Effective conflict resolution and accountability processes are essential to modulating the impact that conflict has on the partnership itself, as mentioned by studies in the systematic review (43,47,51). As conflict causes loss of trust, loss of satisfaction with the partnership (faith), and loss of task accomplishment, if effective measures are in place, then the likelihood of conflict spiralling out of control and causing the downfall of the partnership is much lessened. Likewise, the inverse is true as well (33). As such:
A context of preparedness and accountability (context) à reduced conflict (mechanism) à a smaller reduction in trust (outcome) (figure 3).
Intra-organisational conflict
The literature reported that conflicts can also arise within organisations involved in a partnership, which have the potential to reduce the organisation’s effectiveness (9,65,66). For example, workforce churn brought about by people leaving the organisation, due to the additional workload brought about by the partnership, or due to other factors such as pay imbalances, will likely lead to conflict and reduce organisational effectiveness (43,50). Likewise, if lower-level staff are not involved in the decision-making around collaborative involvement and the shape the entity should take (context), then there may be conflict (mechanism), which could lead to a reduction in faith (outcome) (9). Rather than in the case of inter-organisational conflicts, if managed prior to getting out of control, conflicts within organisations can likely be dealt with without involving the other partner. Factors such as workforce churn could easily be noticed by another partner and could lead to conflict in that case, however, if managed properly, should not escalate to such a degree. Intra-organisational conflict reduces the ability for an organisation to accomplish the aims of a partnership by wasting organisational time on conflict resolution and by reducing faith in the partnership. In this case:
Intra-organisational conflict (context) à reduced faith (mechanism) à reduced task accomplishment (outcome).
Power
Power was mentioned throughout the included papers as a key mechanism underlying collaborative efforts (10,13,14,50,51). Power refers generally to the influence one organisation has over another, and can stem from hierarchical position, control over critical or scarce resources, and from discursive legitimacy, or ability to mobilise external support (67). Power relations are also key to trust building; some arrangements can be characterised by a dominant partner controlling the agenda to protect its own interests. In lopsided relationships in terms of organisational size, the larger one may dominate (31). This has the potential to skew the trust relationship by lowering the initial degree of trust. In cases where collaboration is enforced by a governmental organisation, such as with buddying or competition-related acquisitions in the UK’s NHS, these power dynamics may be intrinsic to the relationship and therefore it may be very difficult to build trust (4,68). Willem and Lucidarme (2014), in their review and test of the role of trust in inter-organisational networks, propose that mandatory networks are likely to be less effective and have reduced levels of trust.
Lopsided power in relationship (context) à domination by one partner (mechanism) à reduced trust (outcome)
Reduced trust (context) à reduced risk threshold and aim ambition (mechanism) à reduced achievement (outcome)
Resource use
Douglas (1998) posits that resource exchange during partnerships relies keenly on the power dynamics within the relationship. A more dominant partner may take more resources for themselves, or dependencies may develop whereby the ‘weaker’ partner is dependent upon the stronger one for resource, which could be called an ‘unhealthy’ power dynamic (51). This ‘unhealthy’ power dynamic in which one partner dominates is characterised by any scenario in which another partner has a loss of trust arising from the dynamic. In one of the cases of a healthcare alliance analysed by Murray, D’Aunno, and Lewis (2018), cost savings that were garnered by the alliance were sequestered by the management partner, fatally reducing trust and causing the end of the alliance.
Unequal resource distribution à domination in power hierarchy (mechanism) à reduced trust
Faith
Related to trust is the concept of faith, which may also be expressed as confidence or belief in the partnership arrangement itself. While trust always relates to inter-organisational relations and belief in one’s partner, faith relates more to how actors within one or more organisations continue to believe in the collaborative endeavour as something of value. While trust is likely to modulate faith to a certain degree, as low trust in a partner could affect faith in the partnership, a scenario is also foreseeable where a partner has low trust but high faith. One partner could have been let down repeatedly by another partner in the achievement of the aims of the partnership, leading to low trust, but is not yet ready to give up on the concept of collaboration itself, as the plan is strong and the logic for how collaboration can achieve the intended outcomes for stakeholders is still clear. The concept of faith was not explicitly articulated in any of the included studies, but some have highlighted the importance of confidence and belief in the collaborative arrangement (45,51,70). We posit that faith/confidence/belief is a distinct mechanism from trust that underlines two factors: ambition and authenticity of the collaboration can serve to modulate the faith which actors hold in the partnership. It is possible that there is a faith-building loop that exists within each involved organisation in a partnership, similarly to the trust-building loop. In this sense, faith is also essential to collaborative synergy as it upholds collective desire to work on collective goals. As such:
High faith (context) à partnership synergy (mechanism) à task accomplishment/performance (outcome)
Ambition and authenticity
We suggest that Ambition, put forward by Dickinson and Glasby 2010; Round, Ashworth, Crilly, Ferlie, and Wolfe 2018; Gannon-Leary, Baines, and Wilson 2006; and Hudson et al. 1999, based on their empirical findings, is to what degree the aims and outcomes set in the planning phase of the partnership are realistic (and feasible). The level of ambition needs to be kept realistic to ensure task achievement and the building of trust between partners, as well as to maintain faith in the relationship. As Round, Ashworth, Crilly, Ferlie, and Wolfe (2018, 300) mention in their case study of an integrated care programme, the initial plan was “too ambitious with a lack of realism”, and this “hampered progress to deliver the initial objectives”.
Ambition is too high (context) à reduced aim achievement (mechanism) à reduced faith and trust (outcome)
Authenticity is another consideration, and it refers to whether the partnership actually is based upon a real need to solve a problem, or whether a collaboration is simply undertaken to look ‘trendy’ and virtuous (1,50). Inauthentic collaborations are unlikely to inspire workers to put significant effort into collaborating.
Inauthentic collaboration (context) à reduced faith in collaboration (mechanism) à reduced aim achievement (outcome)
Coordination
Increased coordination is often one of the primary motivations for organisations seeking to cooperate. Coordination refers to a reduction in duplication of effort, reduction in gaps of services, and sharing of knowledge and skills (13,35,48). The degree to which organisations are coordinated is a key mechanism underlying success and failure of partnerships.
Information exchange
A common concern in the literature is the ability to exchange information between partners as required, which is often key to properly coordinating delivery of care and other aspects of work (13,14,49,50,65,71).
If information is not exchanged as required (context) à a lack of coordination in task accomplishment can occur (mechanism) à leading to conflict (outcome) (13,65).
Key to the sharing of information is the interoperability of, and devotion of resources to, information technology systems (14).
If more interoperable systems are already in place (context), à a reduction in task complexity (mechanism) à will make combining these systems more straightforward, improving task accomplishment (outcome).
Interpersonal communication
Dialogue between actors is required in order to build the trust required by the collaboration, transfer information, and properly coordinate tasks (13,43,50). However, just as communication is required to build up trust, so too is trust required for actors to desire to communicate (43). However, this element can go both ways and depends upon the culture of the actors interacting.
Conflicting cultures between partners (context) à then increased interpersonal communication (mechanism) à may lead to conflict (outcome).
Likewise, vice versa is also possible.
Interpersonal communication is also essential for collaborative synergy to be achieved and, thus, for performance to be maximised. As Lasker, Weiss, and Miller (2001; p194) put forward, “Effective communication strategies and mechanisms to coordinate partners’ activities are needed to facilitate synergistic thinking and action”. Thus:
Increased interpersonal communication (context) à partnership synergy (mechanism) à increased task accomplishment/performance
Stakeholder involvement
According to the included papers, communication with and involvement of stakeholders can make the difference between a collaboration being taken seriously or not (10,42,70,72). Inclusion of these perspectives allows for definition of the correct priorities and focusing on delivering benefits where they are needed most. Although not explicitly linked in the literature, we suggest that the ‘engagement of stakeholders’ context is keenly linked into authenticity of the partnership, increasing faith, congruence of aims/objectives, and focusing on the right outcomes.
Involvement of stakeholders (context) à increased authenticity of the collaboration (mechanism) à increased faith in the collaboration (outcome)
Leadership
Eight of the included studies mentioned leadership as being key to the success of partnerships, however, few elucidated upon why (10,42,50,51,60,69,73,74). Evans and Killoran (2000) in their realistic evaluation of five different models of partnership working mention “leadership and management skills” being enhanced through “external consultancy support” and “strong project leadership” but do not outline the mechanisms underlying these aspects. Wildridge et al (2004) mention “continuing, visible, and joint commitment from individuals in positions of leadership and influence” as very important, and Leach et al. (2019) mention in their evaluation of a buddying programme that “compassionate leadership” was key. Leadership is essential to any kind of organisation regardless of whether they are partnering with another but is not in itself a mechanism that underlies partnership, rather, can perhaps also be a context that frames the partnership from the outset. Nonetheless, a certain type of leadership style may maintain a collaborative endeavour better than others. To identify the mechanisms we turned to the theoretical literature.
According to Fillingham and Weir (2014) in their study of integrated care leadership in the UK, leadership during partnership requires different skills than those displayed during their climb of the corporate ladder. Successfully collaborating requires use of individual skills rather than their position, an ability to compete in a way that enhances the competition (through collaboration), conduction of business ethically in a way that builds trust, and development of a new focus on process and the ‘how’ rather than the ‘what’ (36). Likewise, Hunter and Perkins (2012) broadly agree, emphasising a participative and open leadership style of listening, asking questions, and co-producing solutions – a less dictatorial style (75). Huxham (2003) significantly expands on this by analysing the activities which leaders should be focusing on to move a collaboration forward, namely, facilitative behaviours which serve to involve and mobilise members. Huxham (2003) also identifies a more combative leadership approach which may occur in collaborations that have unequal power dynamics (such as those which are mandated), in which the leader engages in “collaborative thuggery” to push out those who do not align with their vision of collaboration. We posit that this, too, may work in cases where trust was compromised from the outset and collaboration is mandatory in the first place, but would be likely to undermine trust and respect in voluntary collaborations. Depending on the situation, leadership may act as either a context for another mechanism, or a mechanism in itself which allows collaboration to flourish or flounder (table 3).
Collaborative leadership style (listening, asking questions, co-producing solutions) (context) à improved trust (mechanism) à better aim achievement (outcome)
Mandated collaboration and very low trust (context) à combative leadership approach, pushing out those who do not agree (mechanism) à shared vision for partnership (outcome)
Voluntary collaboration (context) à combative leadership approach, dominating power hierarchy (mechanism) à reduced trust (outcome)
Additionally, others have drawn leadership keenly into the concept of developing and integrating culture, which is key to establishing greater trust and respect between workforces and leaders (76). Factors relating to leadership which affected successful creation of a new culture included establishing organisation-wide communication channels and outlining outcomes for different staff types, involving more willing partners first, and leading in a positive and constructive manner (76).
Positive leadership style (context) à easier integration of cultures (mechanism) à greater trust (outcome)
While there are no doubt further, more detailed behaviours key to leadership styles that will uphold collaborations, these will be explored in greater depth in the next phase of theory refinement.
Culture
Culture, defined here as the attitudes and beliefs held by a workforce, is often cited as a primary reason for dissolution of collaborations if conflicts arising from differences in culture are not properly mitigated (13,14,45,51,52,65,77). Included studies suggest that auditing all organisations’ cultures, performing training around values and behaviours, implementing ongoing measurement, and even hiring and firing based on values may all contribute to general ‘preparedness’ to avoid conflict (43,47,51). Thus:
Preparedness for conflict (context) à reduce conflict (mechanism) à reducing the impact on trust (outcome).
Likewise, the distance in culture (which could be measured if one desired) is also likely to modulate the ease of integration in this respect. Thus:
Cultural closeness (context) à reduce conflict (mechanism) à avoiding degradation in trust (outcome).
Of course, as trust gradually reduces it may reach a threshold at which partnership dissolution occurs.
Organisational Flexibility
According to Kopanaki and Smithson (2013, 95), organisational flexibility refers to an organisation’s capability to face environmental disturbances, or adapt when confronted with new circumstances. Of course, flexibility will be a trait inherent to the organisation before it even enters the partnership, which will modulate the ability, and speed, with which an organisation can pivot to working together collaboratively. As such, we have considered it a context rather than a mechanism per say. Flexibility and/or capacity were mentioned frequently in the included studies of the systematic review (10,47,48,60,65,71,78). According to What Works Scotland (2015, 8), “one of the most striking themes emerging from analysis of this results chain is the need for effective partnerships to develop clear structures and processes whilst allowing for flexibility, engagement and responsiveness”. Willem and Lucidarme (2014) put forward the idea that collaborations are oftentimes intended to be more flexible alternatives to the status quo, and that low flexibility can lead to an overly bureaucratic process, reducing trust. We suggest that flexibility is not a mechanism, but rather a contextual element that impacts how well collaboration can be implemented. However, flexibility may be able to be enhanced through other means, and those means may be mechanisms in themselves. Therefore, we posit that:
Greater organisational flexibility (context) à increased trust due to improved goal achievement (mechanism) à reduced conflict (outcome) (table 3).
Task complexity
Task complexity is a mechanism that underlines how difficult tasks are to complete, with more complex tasks requiring both more resources and more manpower to achieve (38). Organisational size is a key factor that the included studies proposed affects the initial complexity of the partnership arrangement (79,80), as well as the size or type of the problem that collaboration is intended to solve (61). Gaynor et al. (2012) used econometric modelling to assess the characteristics and impact of 102 acute hospital mergers that took place in the NHS between 1997 and 2002. They found that compared to matched control hospitals, mergers tended to involve smaller hospitals with weaker financial performance. The main impact of mergers over the subsequent four years was a reduction in capacity and associated activity, with comparatively little impact on a range of performance measures, and there was little evidence of an effect of size on merger success. Fulop et al. (2002) also performed a qualitative study of mergers and found that increased size provided benefits in terms of having a larger pool of professional staff, increased attention from local authorities, and better cross-fertilisation of ideas. However, increased size also led to more remote senior managers, not enough cohesion through multiple levels of the workforce hierarchy, and a loss of informality and autonomy felt by those moving from smaller to bigger organisations. They found that:
Merger of larger organisations (context) à more task complexity (mechanism) and à slowed decision-making and internal communication (outcome).
As such, the organisational size is a context that primarily modifies the mechanism of task complexity, and as discussed above, achievement of more ambitious tasks requires greater risk threshold, meaning a requirement for greater trust (31).
Larger organisational size (context) à greater complexity of task (mechanism) à greater trust requirement between partners (outcome)
Ease of acquiring partner
On the whole, inter-organisational collaborations are entered into to solve a problem through some achievement that collaboration enables. Mandell & Steelman (2003) mentioned that partnerships founded upon solving simpler problems may make it easier to get potential partners to the table, as they may feel the stakes are low enough to ensure their individual goals can still be maintained and the expected difficulty of the task is reduced (61). Simpler problems may also link into trust, as easier achievement early on in the process can reciprocally foster more trust between partners (figure 3).
Simpler problem to solve (context) à reduced complexity of task (mechanism) à lesser trust requirement between partners (outcome)
Regulatory environment
Regulatory bodies, i.e. those above the collaborating ones in the hierarchy (i.e. governmental or health regulation authority bodies), can impose legal or resource constraints, or incentives, for partnership to occur. This was cited frequently as a barrier or enabler for partnership (13,52,61). For example, in the UK, the Competition and Markets Authority has posed a barrier to circumvent for NHS providers seeking to collaborate (4). Auschra (2018) provides evidence that these barriers can manifest by forbidding collaboration entirely, stopping it before it even begins, or causing additional time and financial cost considerations (i.e. legal problems hampering information exchange, pooling of budgets, and bureaucracy requirements). Therefore, it is possible for a:
Favourable regulatory environment (context) à reduce task complexity (mechanism) à enhancing task achievement (outcome).
This will go on to improve trust and faith. Vice versa is also possible.
Geographical proximity
Geographical proximity of partners has been lauded as a contextual element which can lead to failure if not considered highly enough in the initial phases of a partnership (13,52,65,81). Small geographical distances enhance casual face-to-face interactions (both planned and impromptu) and therefore fosters information transfer and trust through improved mutual understanding (39,40). However, some outline that it may also lead to greater informality which has potential to undermine task achievement (65). As such:
Greater proximity (context) à enhanced interpersonal communication (mechanism) à fostering trust (outcome).
Point of entry into collaborating
The point of entry into a collaboration is highly likely to shape the nature of the relationship that follows (11,82). In addition to the contextual factors in additional file 1, our review sought to identify entry points and drivers for partnering in included studies and categorised them using bottom-up thematic analysis into 6 categories (table 2). In the case of seeking to partner due to funding and resource concerns, market opportunities, or innovation, a partnership is likely to be shaped primarily by the regulatory environment, history of prior collaboration, and stereotypes from knowledge of other collaborations in the area, all of which together serve the context to determine the initial level of trust.
In the case of existing interdependence, it is likely that it will be a collaboration moving from a less integrated form to a more integrated form, i.e. they may have been members of a network but are now moving to a full merger. In this case it is unlikely to be considered unless they already have a positive relationship, thus, the initial level of trust is likely to be elevated. As mentioned previously, policy directives (i.e. mandated) partnering, are likely to drastically lower trust and power dynamics from the outset. Likewise, entering a partnership primary with the goal of avoiding marketplace threats is also likely to lower trust, as an organisation will still be entering the arrangement from a standpoint of relative negative performance and fear.
The role of entry points and drivers will be fully explored in a future paper as part of phase 2 of our realist synthesis, due to length considerations and the requirement for further systematic searching. However, in this current paper we posit that:
Mandated collaboration (context) à creates power imbalances (mechanism) à reduced initial trust (outcome).
Mandated collaboration is likely to require significant task achievement and goodwill to overcome. This will be explored further in the discussion.