Exploring the influence of health system factors on adaptive capacity in diverse hospital teams in Norway: a multiple case study approach.

OBJECTIVES: Understanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers in defined settings such as hospitals. There is little knowledge of how hospital teams are affected by the rules and regulations imposed by multiple governmental bodies, and how health system factors influence adaptive capacity in hospital teams. The aim of this study is to explore the extent to which health system factors enable or constrain adaptive capacity in hospital teams. DESIGN: A qualitative multiple case study using observation and semistructured interviews was conducted between November 2020 and June 2021. Data were analysed through qualitative content analysis with a combined inductive and deductive approach. SETTING: Two hospitals situated in the same health region in Norway. PARTICIPANTS: Members from 8 different hospital teams were observed during their workday (115 hours) and were subsequently interviewed about their work (n=30). The teams were categorised as structural, hybrid, coordinating and responsive teams. RESULTS: Two main health system factors were found to enable adaptive capacity in the teams: (1) organisation according to regulatory requirements to ensure adaptive capacity, and (2) negotiation of various resources provided by the governing authorities to ensure adaptive capacity. Our results show that aligning to local context of these health system factors affected the team's adaptive capacity. CONCLUSIONS: Health system factors should create conditions for careful and safe care to emerge and provide conditions that allow for teams to develop both their professional expertise and systems and guidelines that are robust yet sufficiently flexible to fit their everyday work context.

Designing a learning tool for translating resilience in healthcare into practice: A qualitative mixed methods study.

There is currently a lack of tools that focus on strengthening resilient performance of healthcare systems through learning from positive healthcare events. Such tools are needed to operationalize and translate resilience in healthcare and, thus, advance the field of patient safety by learning from both positive and negative events and outcomes. The purpose of this study is to describe the developmental process of one such tool to enable operationalization of resilient healthcare and aid future tool development. The development process featured a complex, multi-step, design through involvement of a range of different stakeholders. A combination of publicly available platforms, cross-sectional knowledge, step-by step instructions and a learning tool that engages participants in collaborative practice to facilitate discussions across stakeholders and system levels is proposed as a means to create awareness of when and what contributes to resilient performance is fundamental to understanding and improving healthcare system resilience.

Identifying, categorising, and mapping actors involved in resilience in healthcare: a qualitative stakeholder analysis.

BACKGROUND: Resilience in healthcare is the capacity to adapt to challenges and changes to maintain high-quality care across system levels. While healthcare system stakeholders such as patients, informal carers, healthcare professionals and service managers have all come to be acknowledged as important co-creators of resilient healthcare, our knowledge and understanding of who, how, and in which contexts different stakeholders come to facilitate and support resilience is still lacking. This study addresses gaps in the research by conducting a stakeholder analysis to identify and categorise the stakeholders that are key to facilitating and sustaining resilience in healthcare, and to investigate stakeholder relationships relevant for the enactment of resilient healthcare systems. METHODS: The stakeholder analysis was conducted using a sample of 19 empirical research projects. A narrative summary was written for 14 of the projects, based on publicly available material. In addition, 16 individual interviews were undertaken with researchers from the same sample of 19 projects. The 16 interview transcripts and 14 narratives made up the data material of the study. Application of stakeholder analysis methods was done in three steps: a) identification of stakeholders; b) differentiation and categorisation of stakeholders using an interest/influence grid; and c) investigation and mapping of stakeholder relationships using an actor-linkage matrix. RESULTS: Identified stakeholders were Patients, Family Carers, Healthcare Professionals, Ward/Unit Managers, Service or Case Managers, Regulatory Investigators, Policy Makers, and Other Service Providers. All identified stakeholders were categorised as either 'Subjects', 'Players', or 'Context Setters' according to their level of interest in and influence on resilient healthcare. Stakeholder relationships were mapped according to the degree and type of contact between the various groups of stakeholders involved in facilitating resilient healthcare, ranging from 'Not linked' to 'Fully linked'. CONCLUSION: Family carers and healthcare professionals were found to be the most active groups of stakeholders in the enactment of healthcare system resilience. Patients, managers, and policy makers also contribute to resilience to various degrees. Relationships between stakeholder groups are largely characterised by communication and coordination, in addition to formal collaborations where diverse actors work together to achieve common goals.

No size fits all - a qualitative study of factors that enable adaptive capacity in diverse hospital teams.

Introduction: Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. By examining how performance emerges in everyday work in different healthcare settings, the research seeks to receive knowledge of the enablers for adaptive capacity. Hospitals are defined as complex organizations with a large number of actors collaborating on increasingly complexity tasks. Consequently, most of today's work in hospitals is team based. The study aims to explore and describe what kind of team factors enable adaptive capacity in hospital teams. Methods: The article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation (115 h) and interviews (30), followed by a combined deductive and inductive analysis of the material. Results: The study identified four main themes of team related factors for enabling adaptive capacity; (1) technology and tools, (2) roles, procedures, and organization of work, (3) competence, experience, knowledge, and learning, (4) team culture and relations. Discussion: Investigating adaptive capacity in four different types of teams allowed for consideration of a range of team types within healthcare and how the team factors vary within and across these teams. All of the four identified team factors are of importance in enabling adaptive capacity, the various attributes of the respective team types prompt differences in the significance of the different factors and indicates that different types of teams could need diverse types of training, structural and relational emphasis in team composition, leadership, and non-technical skills in order to optimize everyday functionality and adaptive capacity.

Making tacit knowledge explicit through objects: a qualitative study of the translation of resilience into practice.

Introduction: It is common practice to use objects to bridge disciplines and develop shared understanding across knowledge boundaries. Objects for knowledge mediation provide a point of reference which allows for the translation of abstract concepts into more externalized representations. This study reports from an intervention that introduced an unfamiliar resilience perspective in healthcare, through the use of a resilience in healthcare (RiH) learning tool. The aim of this paper is to explore how a RiH learning tool may be used as an object for introduction and translation of a new perspective across different healthcare settings. Methods: This study is based on empirical observational data, collected throughout an intervention to test a RiH learning tool, developed as part of the Resilience in Healthcare (RiH) program. The intervention took place between September 2022 and January 2023. The intervention was tested in 20 different healthcare units, including hospitals, nursing homes and home care services. A total of 15 workshops were carried out, including 39-41 participants in each workshop round. Throughout the intervention, data was gathered in all 15 workshops at the different organizational sites. Observation notes from each workshop make up the data set for this study. The data was analyzed using an inductive thematic analysis approach. Results and conclusion: The RiH learning tool served as different forms of objects during the introduction of the unfamiliar resilience perspective for healthcare professionals. It provided a means to develop shared reflection, understanding, focus, and language for the different disciplines and settings involved. The resilience tool acted as a boundary object for the development of shared understanding and language, as an epistemic object for the development of shared focus and as an activity object within the shared reflection sessions. Enabling factors for the internalization of the unfamiliar resilience perspective were to provide active facilitation of the workshops, repeated explanation of unfamiliar concepts, provide relatedness to own context, and promote psychological safety in the workshops. Overall, observations from the testing of the RiH learning tool showed how these different objects were crucial in making tacit knowledge explicit, which is key to improve service quality and promote learning processes in healthcare.

Learning does not just happen: establishing learning principles for tools to translate resilience into practice, based on a participatory approach.

BACKGROUND: Theories of learning are of clear importance to resilience in healthcare since the ability to successfully adapt and improve patient care is closely linked to the ability to understand what happens and why. Learning from both positive and negative events is crucial. While several tools and approaches for learning from adverse events have been developed, tools for learning from successful events are scarce. Theoretical anchoring, understanding of learning mechanisms, and establishing foundational principles for learning in resilience are pivotal strategies when designing interventions to develop or strengthen resilient performance. The resilient healthcare literature has called for resilience interventions, and new tools to translate resilience into practice have emerged but without necessarily stipulating foundational learning principles. Unless learning principles are anchored in the literature and based on research evidence, successful innovation in the field is unlikely to occur. The aim of this paper is to explore: What are key learning principles for developing learning tools to help translate resilience into practice? METHODS: This paper reports on a two-phased mixed methods study which took place over a 3-year period. A range of data collection and development activities were conducted including a participatory approach which involved iterative workshops with multiple stakeholders in the Norwegian healthcare system. RESULTS: In total, eight learning principles were generated which can be used to help develop learning tools to translate resilience into practice. The principles are grounded in stakeholder needs and experiences and in the literature. The principles are divided into three groups: collaborative, practical, and content elements. CONCLUSIONS: The establishment of eight learning principles that aim to help develop tools to translate resilience into practice. In turn, this may support the adoption of collaborative learning approaches and the establishment of reflexive spaces which acknowledge system complexity across contexts. They demonstrate easy usability and relevance to practice.

The role of collaborative learning in resilience in healthcare-a thematic qualitative meta-synthesis of resilience narratives.

BACKGROUND: To provide high quality services in increasingly complex, constantly changing circumstances, healthcare organizations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organizations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalizing resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study is to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels. METHODS: The method used to develop understanding of collaborative learning across diverse healthcare contexts and levels was to first conduct a narrative inquiry of a comprehensive dataset of published health services research studies. This resulted in 14 narratives (70 pages), synthesised from a total of 40 published articles and 6 PhD synopses. The narratives where then analysed using a thematic meta-synthesis approach. RESULTS: The results show that, across levels and contexts, healthcare professionals collaborate to respond and adapt to change, maintain processes and functions, and improve quality and safety. This collaboration comprises activities and interactions such as exchanging information, coordinating, negotiating, and aligning needs and developing buffers. The learning activities embedded in these collaborations are both activities of daily work, such as discussions, prioritizing and delegation of tasks, and intentional educational activities such as seminars or simulation activities. CONCLUSIONS: Based on these findings, we propose that the enactment of resilience in healthcare is dependent on these collaborations and learning processes, across different levels and contexts. A systems perspective of resilience demands collaboration and learning within and across all system levels. Creating space for reflection and awareness through activities of everyday work, could support individual, team and organizational learning.

Exploring the role of leaders in enabling adaptive capacity in hospital teams - a multiple case study.

BACKGROUND: Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. Team leaders are seen as central in coordinating clinical care, but research detailing their contributions in supporting adaptive capacity has been limited. This study aims to explore and describe how leaders enable adaptive capacity in hospital teams. METHODS: This article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation and interviews with leaders, followed by a qualitative content analysis. RESULTS: Leaders contribute in several ways to enhance their teams' adaptive capacity. This study identified four key enablers; (1) building sufficient competence in the teams; (2) balancing workload, risk, and staff needs; (3) relational leadership; and (4) emphasising situational understanding and awareness through timely and relevant information. CONCLUSION: Team leaders are key actors in everyday healthcare systems and facilitate organisational resilience by supporting adaptive capacity in hospital teams. We have developed a new framework of key leadership enablers that need to be integrated into leadership activities and approaches along with a strong relational and contextual understanding.

Exploring the nature of adaptive capacity for resilience in healthcare across different healthcare contexts; a metasynthesis of narratives.

Adaptive capacity has been described as instrumental for the development of resilience in healthcare. Yet, our theoretical understanding of adaptive capacity remains relatively underdeveloped. This research therefore aims at developing a new understanding of the nature of adaptive capacity by exploring the following research questions: 1. What constitutes adaptive capacity across different healthcare contexts? and 2. What type of enabling factors support adaptive capacity across different healthcare contexts? The study used a novel combination of qualitative methods featuring a metasynthesis of narratives based on empirical research to contribute understanding of adaptive capacity across different healthcare contexts. The findings show that adaptive capacity was found to include four forms: reframing, aligning, coping, and innovating. A framework illustrating the relatedness between the identified forms, in terms of resources, change and enablers, is provided. Based on these findings, a new definition of adaptive capacity for resilience in healthcare is proposed.

Capacities for resilience in healthcare; a qualitative study across different healthcare contexts.

BACKGROUND: Despite an emerging consensus on the importance of resilience as a framework for understanding the healthcare system, the operationalization of resilience in healthcare has become an area of continuous discussion, and especially so when seeking operationalization across different healthcare contexts and healthcare levels. Different indicators for resilience in healthcare have been proposed by different researchers, where some indicators are coincident, some complementary, and some diverging. The overall aim of this article is to contribute to this discussion by synthesizing knowledge and experiences from studies in different healthcare contexts and levels to provide holistic understanding of capacities for resilience in healthcare. METHODS: This study is a part of the first exploratory phase of the Resilience in Healthcare programme. The exploratory phase has focused on screening, synthesising, and validating results from existing empirical projects covering a variety of healthcare settings. We selected the sample from several former and ongoing research projects across different contexts and levels, involving researchers from SHARE, the Centre for Resilience in Healthcare in Norway. From the included projects, 16 researchers participated in semi-structured interviews. The dataset was analysed in accordance with grounded theory. RESULTS: Ten different capacities for resilience in healthcare emerged from the dataset, presented here according to those with the most identified instances to those with the least: Structure, Learning, Alignment, Coordination, Leadership, Risk awareness, Involvement, Competence, Facilitators and Communication. All resilience capacities are interdependent, so effort should not be directed at achieving success according to improving just a single capacity but rather at being equally aware of the importance and interrelatedness of all the resilience in healthcare capacities. CONCLUSIONS: A conceptual framework where the 10 different resilience capacities are presented in terms of contextualisation and collaboration was developed. The framework provides the understanding that all resilience capacities are associated with contextualization, or collaboration, or both, and thereby contributes to theorization and guidance for tailoring, making operationalization efforts for the identified resilience capacities in knowledge translation. This study therefore contributes with key insight for intervention development which is currently lacking in the literature.

Balancing adaptation and innovation for resilience in healthcare - a metasynthesis of narratives.

BACKGROUND: Adaptation and innovation are both described as instrumental for resilience in healthcare. However, the relatedness between these dimensions of resilience in healthcare has not yet been studied. This study seeks to develop a conceptual understanding of adaptation and innovation as a basis for resilience in healthcare. The overall aim of this study is therefore to explore how adaptation and innovation can be described and understood across different healthcare settings. To this end, the overall aim will be investigated by identifying what constitutes adaptation and innovation in healthcare, the mechanisms involved, and what type of responses adaptation and innovation are associated with. METHODS: The method used to develop understanding across a variety of healthcare contexts, was to first conduct a narrative inquiry of a comprehensive dataset from various empirical settings (e.g., maternity, transitional care, telecare), that were later analysed in accordance with grounded theory. Narrative inquiry provided a contextually informed synthesis of the phenomenon, while the use of grounded theory methodology allowed for cross-contextual comparison of adaptation and innovation in terms of resilience in healthcare. RESULTS: The results identified an imbalance between adaptation and innovation. If short-term adaptations are used too extensively, they may mask system deficiencies and furthermore leave the organization vulnerable, by relying too much on the efforts of a few individuals. Hence, short-term adaptations may end up a barrier for resilience in healthcare. Long-term adaptations and innovation of products, processes and practices proved to be of a lower priority, but had the potential of addressing the flaws of the system by proactively re-organizing and re-designing routines and practices. CONCLUSIONS: This study develops a new conceptual account of adaptation and innovation as a basis for resilience in healthcare. Findings emerging from this study indicate that a balance between adaptation and innovation should be sought when seeking resilience in healthcare. Adaptations can furthermore be divided into short-term and long-term adaptations, creating the need to balance between these different types of adaptations. Short-term adaptations that adopt the pattern of firefighting can risk generating complex and unintended outcomes, but where no significant changes are made to organization of the system. Long-term adaptations, on the other hand, introduce re-organization of the system based on feedback, and therefore can provide a proactive response to system deficiencies. We propose a pattern of adaptation in resilience in healthcare: from short-term adjustments, to long-term reorganizations, to innovations.

Developing a Next-of-Kin Involvement Guide in Cancer Care-Results From a Consensus Process.

BACKGROUND: In hospital cancer care, there is no set standard for next-of-kin involvement in improving the quality of care and patient safety. There is therefore a growing need for tools and methods that can guide this complex area. OBJECTIVE: The aim of this study was to present the results from a consensus-based participatory process of designing a guide for next-of-kin involvement in hospital cancer care. METHOD: A consensus process based on a modified Nominal group technique was applied with 20 stakeholder participants from 2 Norwegian university hospitals. RESULT: The participants agreed on the 5 most important priorities for hospital cancer care services when involving next-of-kin. The results showed that next-of-kin stakeholders, when proactively involved, are important resources for the patient and healthcare professionals in terms of contribution to quality and safety in hospitals. Suggested means of involving next-of-kin were closer interaction with external support bodies, integration in clinical pathways, adjusted information, and training healthcare professionals. CONCLUSION: In this study, we identified topics and elements to include in a next-of-kin involvement guide to support quality and safety in hospital cancer care. The study raises awareness of the complex area of next-of-kin involvement and contributes with theory development and knowledge translation in an involvement guide tailored for use by healthcare professionals and managers in everyday clinical practice. IMPLICATIONS FOR PRACTICE: Service providers can use the guide to formulate intentions and make decisions with suggestions and priorities or as a reflexive tool for organizational improvement.