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.

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.

Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives.

INTRODUCTION: Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media. METHODS: Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis. RESULTS: Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills. CONCLUSIONS AND IMPLICATIONS: This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

A qualitative study of leaders' experiences of handling challenges and changes induced by the COVID-19 pandemic in rural nursing homes and homecare services.

BACKGROUND: The COVID-19 pandemic had a major impact on healthcare services globally. In care settings such as small rural nursing homes and homes care services leaders were forced to confront, and adapt to, both new and ongoing challenges to protect their employees and patients and maintain their organization's operation. The aim of this study was to assess how healthcare leaders, working in rural primary healthcare services, led nursing homes and homecare services during the COVID-19 pandemic. Moreover, the study sought to explore how adaptations to changes and challenges induced by the pandemic were handled by leaders in rural nursing homes and homecare services. METHODS: The study employed a qualitative explorative design with individual interviews. Nine leaders at different levels, working in small, rural nursing homes and homecare services in western Norway were included. RESULTS: Three main themes emerged from the thematic analysis: "Navigating the role of a leader during the pandemic," "The aftermath - management of COVID-19 in rural primary healthcare services", and "The benefits and drawbacks of being small and rural during the pandemic." CONCLUSIONS: Leaders in rural nursing homes and homecare services handled a multitude of immediate challenges and used a variety of adaptive strategies during the COVID-19 pandemic. While handling their own uncertainty and rapidly changing roles, they also coped with organizational challenges and adopted strategies to maintain good working conditions for their employees, as well as maintain sound healthcare management. The study results establish the intricate nature of resilient leadership, encompassing individual resilience, personality, governance, resource availability, and the capability to adjust to organizational and employee requirements, and how the rural context may affect these aspects.

Leading Quality and Safety on the Frontline - A Case Study of Department Leaders in Nursing Homes.

Purpose: The role of healthcare leaders is becoming increasingly complex, and carries great responsibility for patients, employees, and the quality of service delivery. This study explored the barriers and enablers that department leaders in nursing homes encounter when managing the dual responsibilities in Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS). Methodology: Case study design with data collected through semi structured interviews with 16 department leaders in five Norwegian municipalities. We analyzed the data using qualitative content analysis. Results: Data analysis resulted in four themes explaining what department leaders in nursing homes experience as barriers and enablers when handling the dual responsibility of HSE and QPS: Temporal capacity: The importance of having enough time to create a health-promoting work environment that ensures patient safety. Relational capacity: Relationships have an impact on work process and outcomes. Professional competence: Competence affects patient safety and leadership strategies. Organizational structure: Organizational frameworks influence how the dual responsibilities are handled. Conclusion: Evidence from this study showed that external contextual factors (eg, legislations and finances) and internal factors (eg, relationships and expectations) are experienced as barriers and enablers when department leaders are enacting the dual responsibility of HSE and QPS. Of these, relationships were found to be the most significant contributor.

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study.

BACKGROUND: Quality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes. METHODS: This study is based on an exploratory qualitative methodology. The empirical data was collected through the 'Improving Quality and Safety in Primary Care - Implementing a Leadership Intervention in Nursing Homes and Homecare' (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory. RESULTS: Enablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing. CONCLUSION: This study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

External inspection approaches and involvement of stakeholders' views in inspection following serious incidents - a qualitative mixed methods study from the perspectives of regulatory inspectors.

OBJECTIVE: The objective was to gain knowledge about how external inspections following serious incidents are played out in a Norwegian hospital context from the perspective of the inspectors, and whether stakeholders' views are involved in the inspection. METHODS: Based on a qualitative mixed methods design, 10 government bureaucrats and inspectors situated at the National Board of Health Supervision and three County Governors in Norway, were strategically recruited, and individual semi-structured interviews were conducted. Key official government documents were selected, collected, and thematically analyzed along with the interview data. RESULTS: Our findings overall demonstrate two overarching themes: Theme (1) Perspectives on different external inspection approaches of responding and involving stakeholders in external inspection following serious incidents, Theme (2) Inspectors' internal work practices versus external expectations. Documents and all participants reported a development towards new approaches in external inspection, with more policies and regulatory attention to sensible involvement of stakeholders. Involvement and interaction with patients and informal caregivers could potentially inform the case complexity and the inspector's decision-making process. However, stakeholder involvement was sometimes complex and challenging due to e.g., difficult communication and interaction with patients and/or informal caregivers, due to resource demands and/or the inspector's lack of experience and/or relevant competence, different perceptions of the principle of sound professional practice, quality, and safety. The inspectors considered balancing the formal objectives and expectations, with the expectations of the public and different stakeholders (i.e. hospitals, patients and/or informal caregivers) a challenging part of their job. This balance was seen as an important part of the continuous development of ensuring public trust and legitimacy in external inspection processes. CONCLUSIONS AND IMPLICATIONS: Our study suggests that the regulatory system of external inspection and its available approaches of responding to a serious incident in the Norwegian setting is currently not designed to accommodate the complexity of needs from stakeholders at the levels of hospital organizations, patients, and informal caregivers altogether. Further studies should direct attention to how the wider system of accountability structures may support the internal work practices in the regulatory system, to better algin its formal objectives with expectations of the public.

Exploring Norwegian homecare healthcare professionals' perceptions of risk and the link to high-quality care: a qualitative multiple case study.

OBJECTIVES: Homecare is a critical component of the ongoing restructuring of healthcare worldwide, given the shift from institution- to home-based care. The homecare evidence base still contains significant gaps: There is a lack of knowledge regarding quality and safety work and interventions. This study explores how home healthcare professionals perceive and use the concept of risk to guide them in providing high-quality healthcare while maintaining resilience. DESIGN: The study design is a qualitative multiple case study. The phenomena explored were risk perception, sensemaking and adaptations of care delivered to patients in their homes. Inductive content analysis was conducted. SETTING: The study was conducted in three Norwegian municipalities. Each municipality was defined as a single case. PARTICIPANTS: Interviews with healthcare professionals were performed both individually and in focus groups of three to five persons. 19 interviews with 35 informants were conducted: 11 individual semistructured interviews and 8 focus groups. RESULTS: Four themes were identified: 'professionalism is constantly prioritising and aligning care based on here-and-now observations' 'teamwork feels safe and enhances quality' 'taking responsibility for system risk' and 'reluctantly accepting the extended expectations from society'. CONCLUSIONS: To make sense of risk when aspiring for high-quality care in everyday work, the healthcare professionals in this sample mainly used their clinical gaze, gut feeling and experience to detect subtle changes in the patients' condition. Assessing risk information, not only individually but also as a team, was reportedly crucial for high-quality care. Healthcare professionals emphasised the well-being, safety and soundness of the patients when acting on risk information. They felt obliged to act on their gut feeling, moral compass and clinical understanding of quality.

Exploring homecare leaders' risk perception and the link to resilience and adaptive capacity: a multiple case study.

BACKGROUND: Home-based healthcare is considered crucial for the sustainability of healthcare systems worldwide. In the homecare context, however, adverse events may occur due to error-prone medication management processes and prevalent healthcare-associated infections, falls, and pressure ulcers. When dealing with risks in any form, it is fundamental for leaders to build a shared situational awareness of what is going on and what is at stake to achieve a good outcome. The overall aim of this study was to gain empirical knowledge of leaders' risk perception and adaptive capacity in homecare services. METHODS: The study applied a multiple case study research design. We investigated risk perception, leadership, sensemaking, and decision-making in the homecare services context in three Norwegian municipalities. Twenty-three leaders were interviewed. The data material was analyzed using thematic analysis and interpreted in a resilience perspective of work-as-imagined versus work-as-done. RESULTS: There is an increased demand on homecare services and workers' struggle to meet society's high expectations regarding homecare's responsibilities. The leaders find themselves trying to maneuver in these pressing conditions in alignment with the perceived risks. The themes emerging from analyzed data were: 'Risk and quality are conceptualized as integral to professional work', 'Perceiving and assessing risk imply discussing and consulting each other- no one can do it alone' and 'Leaders keep calm and look beyond the budget and quality measures by maneuvering within and around the system'. Different perspectives on patients' well-being revealed that the leaders have a large responsibility for organizing the healthcare soundly and adequately for each home-dwelling patient. Although the leaders did not use the term risk, discussing concerns and consulting each other was a profound part of the homecare leaders' sense of professionalism. CONCLUSIONS: The leaders' construction of a risk picture is based on using multiple signals, such as measurable vital signs and patients' verbal and nonverbal expressions of their experience of health status. The findings imply a need for more research on how national guidelines and quality measures can be implemented better in a resilience perspective, where adaptive capacity to better align work-as-imagined and work-as-done is crucial for high quality homecare service provision.

Managing patient safety and staff safety in nursing homes: exploring how leaders of nursing homes negotiate their dual responsibilities-a case study.

Objective: Within healthcare, the role of leader is becoming more complex, and healthcare leaders carry an increasing responsibility for the performance of employees, the experience and safety of patients and the quality of care provision. This study aimed to explore how leaders of nursing homes manage the dual responsibility of both Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS), focusing particularly on the approaches leaders take and the dilemmas they face. In addition, we wanted to examine how leaders experience and manage the challenges of HSE and QPS in a holistic way. Design/setting: The study was designed as a case study. Data were collected through semi structured individual interviews with leaders of nursing homes in five Norwegian municipalities. Participants: 13 leaders of nursing homes in urban and rural municipalities participated in this study. Results: Data analysis resulted in four themes explaining how leaders of nursing homes manage the dual responsibility of HSE and QPS, and the approaches they take and the dilemmas they face: 1.Establishing good systems and building a culture for a work environment that promotes health and patient safety.2.Establish channels for internal and external collaboration and communication.3.Establish room for maneuver to exercise leadership.4.Recognizing and having the mandate to handle possible tensions in the dual responsibility of HSE and QPS. Conclusions: The study showed that leaders of nursing homes who are responsible for ensuring quality and safety for both patients and staff, experience tensions in handling this dual responsibility. They acknowledged the importance of having time to be present as a leader, to have robust systems to maintain HSE and QPS, and that conflicting aspects of legislation are an everyday challenge.

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.

Patient positioning on the operating table and patient safety: A systematic review and meta-analysis.

AIM: To identify occurrence of harmful incidents related to patient positioning on operating table. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Eight databases including Ovid, Medline, Embase, CINAHL, the Cochrane Library, Epistemonikos, Scopus, Web of Science and Google Scholar were systematically searched from the inception of the databases to August 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram depicting the flow information. REVIEW METHODS: The Cochrane Risk of Bias Tools were used to assess the risk of bias. Risk of harm with 95% confidence interval (CI) was estimated for each included study, and an overall risk was calculated using meta-analysis. RESULTS: Of the 22 included reports, two were randomized controlled trials (RCTs), five had a prospective cohort design, three had a cross-sectional design, and 12 were register-based studies. Intraoperative peripheral nerve injuries, perioperative pressure ulcers, musculoskeletal injuries, vascular injuries, postoperative pain and eye injuries were related to supine, lithotomy, Trendelenburg, prone and beach chair positioning. Overall risk of any harm was estimated as 0.2%. Studies with patients placed in prone positioning (8 study samples) had the highest risks of harm varying from 0.19 to 0.81, with an overall risk of 0.33. Meta-analysis of the two RCTs showed higher risk of chemosis with head-down positioning than with head in neutral position (overall relative risk = 1.64; 95% CI: [1.25, 2.14]). CONCLUSIONS: Harmful incidents related to patient positioning occur and consequences can be severe. The operating room teams should be aware of the harms and prevent and treat them seriously. IMPACT: This review underlines that research is sparse on patient positioning on operating table and harmful incidents. There is a need for high-quality, well-designed studies that focus on harmful incidents and prevention of harm related to patient positioning. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as this is a review of previous research.

A resilience perspective on healthcare personnels' experiences of managing the COVID-19 pandemic: a qualitative study in Norwegian nursing homes and come care services.

BACKGROUND: The COVID-19 pandemic led to new and unfamiliar changes in healthcare services globally. Most COVID-19 patients were cared for in primary healthcare services, demanding major adjustments and adaptations in care delivery. Research addressing how rural primary healthcare services coped during the COVID-19 pandemic, and the possible learning potential originating from the pandemic is limited. The aim of this study was to assess how primary healthcare personnel (PHCP) working in rural areas experienced the work situation during the COVID-19 outbreak, and how adaptations to changes induced by the pandemic were handled in nursing homes and home care services. METHOD: This study was conducted as an explorative qualitative study. Four municipalities with affiliated nursing homes and homecare services were included in the study. We conducted focus group interviews with primary healthcare personnel working in rural nursing homes and homecare services in western Norway. The included PHCP were 16 nurses, 7 assistant nurses and 2 assistants. Interviews were audio recorded, transcribed and analyzed using thematic analysis. RESULTS: The analysis resulted in three main themes and 16 subthemes describing PHCP experience of the work situation during the COVID-19 pandemic, and how they adapted to the changes and challenges induced by the pandemic. The main themes were: "PHCP demonstrated high adaptive capacity while being put to the test", "Adapting to organizational measures, with varying degree of success" and "Safeguarding the patient's safety and quality of care, but at certain costs". CONCLUSION: This study demonstrated PHCPs major adaptive capacity in response to the challenges and changes induced by the covid-19 pandemic, while working under varying organizational conditions. Many adaptations where long-term solutions improving healthcare delivery, others where short-term solutions forced by inadequate management, governance, or a lack of leadership. Overall, the findings demonstrated the need for all parts of the system to engage in building resilient healthcare services. More research investigating this learning potential, particularly in primary healthcare services, is needed.

Resilience perspective on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic: a meta-synthesis.

OBJECTIVE: To identify, review and synthesise qualitative literature on healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic. DESIGN: Systematic review with meta-synthesis. DATA SOURCES: Academic Search Elite, CINAHL, MEDLINE, PubMed, Science Direct and Scopus. ELIGIBILITY CRITERIA: Qualitative or mixed-methods studies published between 2019 and 2021 investigating healthcare professionals' adaptations to changes and challenges resulting from the COVID-19 pandemic. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a predesigned data extraction form that included details about publication (eg, authors, setting, participants, adaptations and outcomes). Data were analysed using thematic analysis. RESULTS: Forty-seven studies were included. A range of adaptations crucial to maintaining healthcare delivery during the COVID-19 pandemic were found, including taking on new roles, conducting self and peer education and reorganising workspaces. Triggers for adaptations included unclear workflows, lack of guidelines, increased workload and transition to digital solutions. As challenges arose, many health professionals reported increased collaboration across wards, healthcare teams, hierarchies and healthcare services. CONCLUSION: Healthcare professionals demonstrated significant adaptive capacity when faced with challenges imposed by the COVID-19 pandemic. Several adaptations were identified as beneficial for future organisational healthcare service changes, while others exposed weaknesses in healthcare system designs and capacity, leading to dysfunctional adaptations. Healthcare professionals' experiences working during the COVID-19 pandemic present a unique opportunity to learn how healthcare systems rapidly respond to changes, and how resilient healthcare services can be built globally.

Learning tools used to translate resilience in healthcare into practice: a rapid scoping review.

BACKGROUND: Historically, efforts to improved healthcare provisions have focussed on learning from and understanding what went wrong during adverse events. More recently, however, there has been a growing interest in seeking to improve healthcare quality through promoting and strengthening resilience in healthcare, in light of the range of changes and challenges to which healthcare providers are subjected. So far, several approaches for strengthening resilience performance have been suggested, such as reflection and simulation. However, there is a lack of studies that appraise the range of existing learning tools, the purposes for which they are designed, and the types of learning activities they comprise. The aim of this rapid scoping review is to identify the characteristics of currently available learning tools designed to translate organizational resilience into healthcare practice. METHODS: A rapid scoping review approach was used to identify, collect, and synthesise information describing the characteristics of currently available learning tools designed to translate organizational resilience into healthcare practice. EMBASE and Medline Ovid were searched in May 2022 for articles published between 2012 and 2022. RESULTS: The review identified six different learning tools such as serious games and checklists to guide reflection, targeting different stakeholders, in various healthcare settings. The tools, typically, promoted self-reflection either individually or collaboratively in groups. Evaluations of these tools found them to be useful and supportive of resilience; however, what constitutes resilience was often difficult to discern, particularly the organizational aspect. It became evident from these studies that careful planning and support were needed for their successful implementation. CONCLUSIONS: The tools that are available for review are based on guidelines, checklists, or serious games, all of which offer to prompt either self-reflection or group reflections related to different forms of adaptations that are being performed. In this paper, we propose that more guided reflections mirroring the complexity of resilience in healthcare, along with an interprofessional collaborative and guided approach, are needed for these tools to be enacted effectively to realise change in practice. Future studies also need to explore how tools are perceived, used, and understood in multi-site, multi-level studies with a range of different participants.

The rise of resilient healthcare research during COVID-19: scoping review of empirical research.

BACKGROUND: The COVID-19 pandemic has presented many multi-faceted challenges to the maintenance of service quality and safety, highlighting the need for resilient and responsive healthcare systems more than ever before. This review examined empirical investigations of Resilient Health Care (RHC) in response to the COVID-19 pandemic with the aim to: identify key areas of research; synthesise findings on capacities that develop RHC across system levels (micro, meso, macro); and identify reported adverse consequences of the effort of maintaining system performance on system agents (healthcare workers, patients). METHODS: Three academic databases were searched (Medline, EMBASE, Scopus) from 1st January 2020 to 30th August 2022 using keywords pertaining to: systems resilience and related concepts; healthcare and healthcare settings; and COVID-19. Capacities that developed and enhanced systems resilience were synthesised using a hybrid inductive-deductive thematic analysis. RESULTS: Fifty publications were included in this review. Consistent with previous research, studies from high-income countries and the use of qualitative methods within the context of hospitals, dominated the included studies. However, promising developments have been made, with an emergence of studies conducted at the macro-system level, including the development of quantitative tools and indicator-based modelling approaches, and the increased involvement of low- and middle-income countries in research (LMIC). Concordant with previous research, eight key resilience capacities were identified that can support, develop or enhance resilient performance, namely: structure, alignment, coordination, learning, involvement, risk awareness, leadership, and communication. The need for healthcare workers to constantly learn and make adaptations, however, had potentially adverse physical and emotional consequences for healthcare workers, in addition to adverse effects on routine patient care. CONCLUSIONS: This review identified an upsurge in new empirical studies on health system resilience associated with COVID-19. The pandemic provided a unique opportunity to examine RHC in practice, and uncovered emerging new evidence on RHC theory and system factors that contribute to resilient performance at micro, meso and macro levels. These findings will enable leaders and other stakeholders to strengthen health system resilience when responding to future challenges and unexpected events.