Exploring Adaptive Capacity in Hospital Teams : A Multiple Case Study

Introduction: There has been performed extensive research to understand the components of what constitutes high quality healthcare. Despite efforts to improve quality the rate of change is slow, with a steady rate of approximately 10% of patients harmed during hospitalisations worldwide. This has led to the conclusion that existing methods of improvement based on reactive approaches to handling adverse events need to be supplemented with alternative perspectives such as resilience healthcare. This approach views healthcare organisations as complex systems and has a more proactive focus by seeking to understand how organisations cope with challenges, changes, complexity, and performance variability, and investigating why and how things can go well in healthcare. The ability to adapt to changes and challenges has been highlighted as key for resilient performance. Adaptive capacity enables continuous provision of high-quality care. However, there is insufficient empirical knowledge on how this capacity is enacted in healthcare. Furthermore, the increasing complexity of healthcare in hospitals leads to challenges when different groups of professionals attempt to coordinate their efforts to care for patients. This makes teamwork critical for ensuring safety. Teamwork in healthcare is diverse and there are different types of teams trying to coordinate their efforts. While there is extensive research on teams and teamwork in other domains, the amount of research related to resilience is scarce. There is, therefore, a need for more knowledge on teamwork and resilience in healthcare. Aim: The overall aim for this thesis was to develop new knowledge about how resilience is enabled in healthcare systems by exploring adaptive capacity in hospital teams in Norway. More specifically, the aim was to explore how team, organisational and healthcare system factors influence adaptive capacity in hospital teams. Methods: The study was designed as a multilevel case study of two included cases with four subunits in each case. A case was defined as a hospital with four different types of teams. The case study included observational studies of everyday work in the different types of teams, looking at types of demands, capacity and adaptations experienced by the teams. Following the observation, interviews with team members and their leaders were undertaken. The data material from both the observations and interviews was given equal weight and analysed together as one data set. In addition, an analysis of relevant documents from various national and regional bodies was used to create necessary context. Findings: The study found that there are multiple factors influencing adaptive capacity in hospital teams at different system levels. Findings pertinent to the different levels have been reported in three different papers. Paper I report on the work of hospital leaders to enable adaptive capacity in hospital teams, by building sufficient competence, mitigating risk, workload and staff needs, building relational leadership, staying close to everyday work, and having situational understanding of work practice needs. The leaders combined these four enablers with both contextual and relational understanding for a holistic approach in their decisionmaking. Paper II found four overarching themes of factors that enable adaptive capacity in the different types of hospital teams. Having sufficient and relevant tools and technology available; clear role descriptions, procedures, and organisation of work; obtaining sufficient competence, experience, and knowledge; and a positive team culture and relationships were all vital for the teams. The findings showed varying importance of the different enabling factors within the four different types of teams, indicating that there are no fixed terms of supporting teams, and that both team type and organisational setting needs to be considered. Paper III investigated the role of system level factors for adaptive capacity. Two main health system factors were found to enable adaptive capacity; organising according to regulatory requirements, and negotiation of various resources provided by the governing authorities to ensure adaptive capacity. The various resources provided to the teams affected their design and function. The different teams needed to negotiate the various rules and procedures provided by system level governors to fit with their everyday work. It was the teams’ opportunity in the system to negotiate these requirements and regulations to their own context that impacted their adaptive capacity. The findings imply that healthcare systems need to facilitate conditions that allow hospital teams to develop quality management requirements to their specific context. Conclusions: The result from this thesis identified several multilevel factors influencing adaptive capacity in hospital teams. The study shows how the front-line leaders contribute in several ways and provide a significant role for their team’s adaptive capacity. Their knowledge of everyday work and handling of risk were vital for the teams. Furthermore, they strive to be good role models and build a positive supportive culture within the teams, as this is perceived to be crucial for adaptive capacity. Various team factors influenced their adaptive capacity. Competence, experience, and knowledge were vital and a key enabler for learning in the teams. In addition, various resources such as technology and tools, guidelines and procedures were important. The key findings regarding the teams nonetheless concerned how relationships between team members and a positive, supportive culture enabled adaptive capacity. This needs further scrutiny to determine how these aspects could be enhanced within teams. System level actors provided the teams with various resources to direct and enable their everyday work. These governing regulations influenced how the teams were organised and prioritized their work. However, the system level actors are responsible for the entire health service and must contribute general regulations without knowing exactly what every day work looks like in the sharp end of healthcare. Therefore, the teams’ ability to negotiate and align these system level requirements to their own diverse contexts was significant for their adaptive capacity. Allowing hospital teams more freedom to use their professional ethos in decision making thus merits further study

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.publishedVersio

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.publishedVersio

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.publishedVersio

Backstage Researching Resilience Researchers – Dilemmas and Principles for Data collection in the Resilience in Healthcare Research Program

Purpose Resilience in healthcare is fundamental for what constitutes quality in healthcare. To understand healthcare resilience, resilience research needs a multilevel perspective, diverse research designs, and taking advantage of different data sources. However, approaching resilience researchers as a data source is a new approach within this field and needs careful consideration to ensure that research is trustworthy and ethically sound. The aim of this short “backstage” general review paper is to give a snapshot of how the Resilience in Healthcare (RiH) research program identified and dealt with potential methodological and ethical challenges in researching researcher colleagues. Design/methodology/approach The authors first provide an overview of the main challenges and benefits from the literature on researching researcher colleagues. Second, the authors demonstrate how this literature was used to guide strategies and principles adopted in the RiH research process. Findings The paper describes established principles and a checklist for data collection and analysis to overcome potential dilemmas and challenges to ensure trustworthiness and transparency in the process. Originality/value Mining the knowledge and experience of resilience researchers is fundamental for taking the research field to the next step, and furthermore an approach that is relevant across different research fields. This paper provides guidance on how other research projects can approach researcher colleagues in similar ways to gain new insight, build theory and advance their research field based on insider competence.publishedVersio

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.publishedVersio

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.publishedVersio

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

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

IntroductionIt 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.MethodsThis 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 conclusionThe 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

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.publishedVersio