An innovative leadership development initiative to support building everyday resilience in health systems

Examining liminality in professional practice, relational identities, and career prospects in resource-constrained health systems: Findings from an empirical study of medical and nurse interns in Kenya

We examine new doctors' and nurses' experiences of transitioning from training to practising as health professionals, drawing on the concept of liminality. Liminality is a stage of 'in-betweenness', involving uncertainty and ambiguity as people leave one social context and reintegrate into a new one. Surprisingly little research has explored new health professionals' experiences of liminality during role and career transitions, particularly in precarious and resource-constrained settings. Drawing on 146 qualitative interviews and seven focus groups, involving 121 new graduate medical doctors and nurses transitioning through internship training in Kenya, we describe three aspects of liminality. First, liminal professional practice, where interns realise that best practices learned during medical and nursing schools are often impossible to implement in resource constrained health care settings; instead they learn workarounds and practical norms. Second, liminal relational identities, where interns leave behind being students and adopt the identities and responsibilities of qualified professionals within pre-existing professional hierarchies of status and expertise. We explain how these new doctors and graduate nurses negotiate their liminal status, including in relation to more experienced but less qualified professional colleagues. We also discuss how interns cope with liminality due to disappointing and inadequate supervision and role modelling from senior colleagues but then find peer support and their place within their own professions. Finally, we discuss how new doctors and nurses come to terms with the precarity of working in resource constrained health systems, abandon expectations of secure, permanent employment and careers, and accept the realities of liminal professional careers. We explain how all three forms of liminality influence professionals' developing practices, identities, and careers. We call for further studies with a specific liminality lens to explore this critical period in health workers' careers, to inform policy and practice responding to global transformations in healthcare professions and practice.

Core elements of excellent hospital leadership: lessons from the five top-performing hospitals in China

Substantial evidence indicates that leadership plays a critical role in an organization's success. Our study aims to conduct case studies on leadership attributes among China's five top-performing hospitals, examining their common practices. A semi-structured interview was conducted with 8 leaders, 39 managers, 19 doctors, and 16 nurses from the five sample hospitals in China. We collected information from these hospitals on the role of senior leadership, organizational governance, and social responsibility, aligning with the leadership assessment guidelines in the Baldrige Excellence Framework. Qualitative data underwent interpretation through content analysis, thematic analysis, and comparative analysis. This study adhered to the consolidated criteria for reporting qualitative research guidelines for reporting qualitative research. Our study revealed that the leaders of the five top-performing hospitals in China consistently established "Patient Needs First" as the core element of the hospital culture. Striving to build world-renowned hospitals with Chinese characteristics, the interviewees all believed strongly in scientific vigor, professionalism, and cooperative culture. The leaders adhered to a staff-centered approach, placing special emphasis on talent recruitment and development, creating a compensation system, and fostering a supportive environment conducive to enhancing medical knowledge, skills, and professional ethics. In terms of organizational governance, they continuously enhanced the communication between various departments and levels of staff, improved the quality and safety of medical care, and focused on innovative medical and scientific research, thereby establishing evidence-based, standardized hospital management with a feedback loop. Meanwhile, regarding social responsibility, they prioritized improvements in the quality of healthcare by providing international and domestic medical assistance, community outreach, and other programs. To a large extent, the excellent leadership of China's top-performing hospitals can be attributed to their commitment to a "Two-Pillared Hospital Culture," which prioritizes putting patient needs first and adopting a staff-centered approach. Furthermore, the leaders of these hospitals emphasize hospital performance, operations management, and social responsibility.

Practical strategies to achieve resilient health systems: results from a scoping review

BACKGROUND

This paper presents the results of a systematic review to identify practical strategies to create the institutions, skills, values, and norms that will improve health systems resilience.

METHODS

A PRISMA 2020 compliant systematic review identified peer-reviewed and gray literature on practical strategies to make health systems more resilient. Investigators screened 970 papers to identify 65 English language papers published since 2015.

RESULTS

Practical strategies focus efforts on system changes to improve a health system's resilience components of collective knowing, collective thinking, and collaborative doing. The most helpful studies identified potential lead organizations to serve as the stewards of resilience improvement, and these were commonly in national and local departments of public health. Papers on practical strategies suggested possible measurement tools to benchmark resilience components in efforts to focus on performance improvement and ways to sustain their use. Essential Public Health Function (EPHF) measurement and improvement tools are well-aligned to the resilience agenda. The field of health systems resilience lacks empirical trials linking resilience improvement interventions to outcomes.

CONCLUSIONS

The rigorous assessment of practical strategies to improve resilience based on cycles of measurement should be a high priority.

Mentorship as an overlooked dimension of research capacity strengthening: how to embed value-driven practices in global health

Mentorship in global health remains an overlooked dimension of research partnerships. Commitment to effective mentorship models requires value-driven approaches. This includes having an understanding of (1) what mentorship means across different cultural and hierarchical boundaries in the health research environment, and (2) addressing entrenched power asymmetries across different aspects including funding, leadership, data and outputs, and capacity strengthening. Existing guidance towards equity and sustainability fails to inform how to navigate complex relationships which hinder effective mentorship models. We focus this perspective piece on human capacity strengthening in research partnerships through mentorship. Using a case study of a research partnership, we describe the lessons learnt and the challenges faced in the mentor mentee relationship while maintaining an effective and sustainable partnership. Human capacity strengthening must research projects and collaborations, and recognise local leadership and ownership. To be transformative and effective, practices need to be driven by common values across research teams.

Not just surveys and indicators: narratives capture what really matters for health system strengthening

Health system strengthening remains elusive and challenging. Health systems in many countries in sub-Saharan Africa are frequently characterised as weak, with inadequate management and accountability mechanisms, and poor human and financial resources. Putting patients and staff at the heart of health systems is an essential step towards strengthening them. As one of the three pillars of quality in health care, understanding patient experiences is key to moving towards people-centred care. Yet patient experiences are not a singular concept. Patient narratives can convey individual experiences of illness and health care, which complement and augment epidemiological and public health evidence. These narratives, gathered with rigorous, interview-based research and shared with digital tools (audio and video), can generate persuasive evidence. This evidence has important potential for influencing policy and practice, and for supporting people-centred care, but has not been tested systematically in low-income countries. In the Kenyan context of newborn health, work under way is generating evidence to show the transformative potential of patient narratives.

A management perspective on resilience in healthcare: a framework and avenues for future research

Recent major health shocks, such as the 2014-16 Ebola, the Zika outbreak, and, last but not least, the COVID-19 pandemic, have strongly contributed to drawing attention to the issue of resilience in the healthcare domain. Nevertheless, the scientific literature appears fragmented, creating difficulties in developing incremental research in this relevant managerial field.To fill this gap, this systematic literature review aims to provide a clear state of the art of the literature dealing with resilience in healthcare. Specifically, from the analysis of the theoretical articles and reviews, the key dimensions of resilience are identified, and a novel classification framework is proposed. The classification framework is then used to systematize extant empirical contributions. Two main dimensions of resilience are identified: the approach to resilience (reactive vs. proactive) and the type of crisis to deal with (acute shocks vs. chronic stressors). Four main streams of research are thus identified: (i) proactive approaches to acute shocks; (ii) proactive approaches to chronic stressors; (iii) reactive approaches to acute shocks; and (iv) reactive approaches to chronic stressors. These are scrutinised considering three additional dimensions: the level of analysis, the resources to nurture resilience, and the country context. The classification framework and the associated mapping contribute to systematising the fragmented literature on resilience in healthcare, providing a clear picture of the state of the art in this field and drawing a research agenda that opens interesting paths for future research.

Living through uncertainty: a qualitative study on leadership and resilience in primary healthcare during COVID-19

BACKGROUND

Resilience is often referred to when assessing the ability of health systems to maintain their functions during unexpected events. Primary healthcare forms the basis for the health system and thus its resilient responses are vital for the outcomes of the whole system. Understanding how primary healthcare organisations are able to build resilience before, during, and after unexpected or sudden shocks, is key to public health preparedness. This study aims to identify how leaders responsible for local health systems interpreted changes in their operational environment during the first year of COVID-19, and to elucidate how these views reflect aspects of resilience in healthcare.

METHODS

The data consist of 14 semi-structured individual interviews with leaders of local health systems in Finland representing primary healthcare. The participants were recruited from four regions. An abductive thematic analysis was used to identify entities from the viewpoints of the purpose, resources, and processes of resilience in the healthcare organisation.

RESULTS

Results were summarised as six themes, which suggest that embracing uncertainty is viewed by the interviewees a basis for primary healthcare functioning. Leading towards adaptability was regarded a distinct leadership task enabling the organisation to modify its functions according to demands of the changing operational environment. Workforce, knowledge and sensemaking, as well as collaboration represented what the leaders viewed as the means for achieving adaptability. The ability to adapt functioned to comprehensively meet the population's service needs built on a holistic approach.

CONCLUSIONS

The results showed how the leaders who participated in this study adapted their work during changes brought on by the pandemic, and what they viewed as critical for maintaining organisational resilience. The leaders considered embracing uncertainty as a principal feature of their work rather than viewing uncertainty as aberrant and something to avoid. These notions, along with what the leaders considered as critical means for building resilience and adaptability should be addressed and elaborated in future research. Research on resilience and leadership should be conducted more in the complex context of primary healthcare, where cumulative stresses are encountered and processed continuously.

A network of empirical ethics teams embedded in research programmes across multiple sites: opportunities and challenges in contributing to COVID-19 research and responses

Covid-19 continues to teach the global community important lessons about preparedness for research and effective action to respond to emerging health threats. We share the COVID-19 experiences of a pre-existing cross-site ethics network-the Global Health Bioethics Network-which brings together researchers and practitioners from Africa, Europe, and Southeast Asia. We describe the network and its members and activities, and the work-related opportunities and challenges we faced over a one-year period during the pandemic. We highlight the value of having strong and long-term empirical ethics networks embedded across diverse research institutions to be able to: 1) identify and share relevant ethics challenges and research questions and ways of 'doing research'; 2) work with key stakeholders to identify appropriate ways to contribute to the emerging health issue response - e.g., through ethics oversight, community engagement, and advisory roles at different levels; and 3) learn from each other and from diverse contexts to advocate for positive change at multiple levels. It is our view that being embedded and long term offers opportunities in terms of deep institutional and contextual knowledge, existing relationships and access to a wide range of stakeholders. Being networked offers opportunities to draw upon a wide range of expertise and perspectives, and to bring together internal and external insights (i.e.drawing on different positionalities). Long term funding means that the people and resources are in place and ready to respond in a timely way. However, many tensions and challenges remain, including difficulties in negotiating power and politics in the roles that researchers and research institutions can and should play in an emergency, and the position of empirical ethics within research programmes. We discuss some of these tensions and challenges and consider the implications for our own and similar networks in future.

A network of empirical ethics teams embedded in research programmes across multiple sites: opportunities and challenges in contributing to COVID-19 research and responses

Covid-19 continues to teach the global community important lessons about preparedness for research and effective action to respond to emerging health threats. We share the COVID-19 experiences of a pre-existing cross-site ethics network-the Global Health Bioethics Network-which brings together researchers and practitioners from Africa, Europe, and Southeast Asia. We describe the network and its members and activities, and the work-related opportunities and challenges we faced over a one-year period during the pandemic. We highlight the value of having strong and long-term empirical ethics networks embedded across diverse research institutions to be able to: 1) identify and share relevant ethics challenges and research questions and ways of 'doing research'; 2) work with key stakeholders to identify appropriate ways to contribute to the emerging health issue response - e.g., through ethics oversight, community engagement, and advisory roles at different levels; and 3) learn from each other and from diverse contexts to advocate for positive change at multiple levels. It is our view that being embedded and long term offers opportunities in terms of deep institutional and contextual knowledge, existing relationships and access to a wide range of stakeholders. Being networked offers opportunities to draw upon a wide range of expertise and perspectives, and to bring together internal and external insights (i.e.drawing on different positionalities). Long term funding means that the people and resources are in place and ready to respond in a timely way. However, many tensions and challenges remain, including difficulties in negotiating power and politics in the roles that researchers and research institutions can and should play in an emergency, and the position of empirical ethics within research programmes. We discuss some of these tensions and challenges and consider the implications for our own and similar networks in future.

Strengthening respectful communication with patients and colleagues in neonatal units - developing and evaluating a communication and emotional competence training for nurse managers in Kenya

Introduction: Effective communication is essential to delivering compassionate, high-quality nursing care. The intensive, stressful and technical environment of a new-born unit (NBU) in a low-resource setting presents communication-related challenges for nurses, with negative implications for nurse well-being, team relationships and patient care. We adapted a pre-existing communication and emotional competence course with NBU nurse managers working in Kenya, explored its' value to participants and developed a theory of change to evaluate its' potential impact. Methods: 18 neonatal nurse managers from 14 county referral hospitals helped adapt and participated in a nine-month participatory training process. Training involved guided 'on the job' self-observation and reflection to build self-awareness, and two face-to-face skills-building workshops. The course and potential for future scale up was assessed using written responses from participant nurses (baseline questionnaires, reflective assignments, pre and post workshop questionnaires), workshop observation notes, two group discussions and nine individual in-depth interviews. Results: Participants were extremely positive about the course, with many emphasizing its direct relevance and applicability to their daily work. Increased self-awareness and ability to recognize their own, colleagues' and patients' emotional triggers, together with new knowledge and practical skills, reportedly inspired nurses to change; in turn influencing their ability to provide respectful care, improving their confidence and relationships and giving them a stronger sense of professional identity. Conclusion: Providing respectful care is a major challenge in low-resource, high-pressure clinical settings but there are few strategies to address this problem. The participatory training process examined addresses this challenge and has potential for positive impacts for families, individual workers and teams, including worker well-being. We present an initial theory of change to support future evaluations aimed at exploring if and how positive gains can be sustained and spread within the wider system.

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.

Understanding intra- and interprofessional team and teamwork processes by exploring facility-based neonatal care in kenyan hospitals

BACKGROUND

Within intensive care settings such as neonatal intensive care units, effective intra- and interprofessional teamwork has been linked to a significant reduction of errors and overall improvement in the quality of care. In Kenya, previous studies suggest that coordination of care among healthcare teams providing newborn care is poor. Initiatives aimed at improving intra- and interprofessional teamwork in healthcare settings largely draw on studies conducted in high-income countries, with those from resource-constrained low and middle countries, particularly in the context of newborn care lacking. In this study, we explored the nature of intra- and interprofessional teamwork among health care providers in newborn units (NBUs) of three hospitals in Kenya, and the professional and contextual dynamics that shaped their interactions.

METHODS

This exploratory qualitative study was conducted in three hospitals in Nairobi and Muranga Counties in Kenya. We adopted an ethnographic approach, utilizing both in-depth interviews (17) and non-participant observation of routine care provision in NBUs (250 observation hours). The study participants included: nurses, nursing students, doctors, and trainee doctors. All the data were thematically coded in NVIVO 12.

RESULTS

The nature of intra- and interprofessional teamwork among healthcare providers in the study newborn units is primarily shaped by broader contextual factors and varying institutional contexts. As a result, several team types emerged, loosely categorized as the 'core' team which involves providers physically present in the unit most times during the work shift; the emergency team and the temporary ad-hoc teams which involved the 'core' team, support staff students and mothers. The emergence of these team types influenced relationships among providers. Overall, institutionalized routines and rituals shaped team relations and overall functioning.

CONCLUSIONS

Poor coordination and the sub-optimal nature of intra-and interprofessional teamwork in NBUs are attributed to broader contextual challenges that include low staff to patient ratios and institutionalized routines and rituals that influenced team norming, relationships, and team leadership. Therefore, mechanisms to improve coordination and collaboration among healthcare teams in these settings need to consider contextual dynamics including institutional cultures while also targeting improvement of team-level processes including leadership development and widening spaces for more interaction and better communication.

How to work with intangible software in public health systems: some experiences from India

This commentary focuses on "intangible software", defined as the range of ideas, norms, values and issues of power or trust that affect the performance of health systems. While the need to work with intangible software within health systems is increasingly being recognized, the practical hows of doing so have been given less attention. In this commentary, we, a team of researchers and implementers from India, have tried to deliberate on these hows through a practice lens. We engage with four questions of current relevance to intangible software in the field of health policy and systems research (HPSR): (1) Is it possible to rewire intangible software in health systems? (2) What approaches have been attempted in the Indian public health system to rewire intangibles? (3) Have such approaches been evaluated? (4) What practical lessons can we offer from our experience on rewiring intangibles? From our perspective, approaches to rewiring intangible software recognize that people in health systems are capable of visioning, thinking, adapting to and leading change. These approaches attempt to challenge the often-unchallenged power hierarchies in health systems by allowing people to engage deeply with widely accepted norms and routinized actions. In this commentary, we have reported on such approaches from India under six categories: approaches intended to enable visioning and leading; approaches targeted at engaging with evidence better; approaches intended to help health workers navigate contextual complexities; approaches intended to build the cultural competence; approaches that recognize and reward performance; and approaches targeted at enabling collaborative work and breaking power hierarchies. Our collective experiences suggest that intangible software interventions work best when they are codesigned with various stakeholders, are contextually adapted in an iterative manner and are implemented in conjunction with structural improvements. Also, such interventions require long-term investments. Based on our experiences, we highlight the need for the following: (1) fostering more dialogue on this category of interventions among all stakeholders for cross-learning; (2) evaluating and publishing evidence on such interventions in nonconventional ways, with a focus on participatory learning; and (3) building ecosystems that allow experiential learnings on such interventions to be shared.

Strengthening public financial management in the health sector: a qualitative case study from South Africa

INTRODUCTION

Effective public financial management (PFM) ensures public health funds are used to deliver services in the best way possible. Given the global call for universal health coverage, and concerns about the management of public funds in many low-income and middle-income countries, PFM has become an important area of research. South Africa has a robust PFM framework, that is generally adhered to, and yet financial outcomes have remained poor. In this paper, we describe how a South African provincial department of health tried to strengthen its PFM processes by deploying finance managers into service delivery units, involving service delivery managers in the monthly finance meeting, using a weekly committee to review expenditure requests and starting a weekly managers' 'touch-base' meeting. We assess whether these strategies strengthened collaboration and trust and how this impacted on PFM.

METHOD

This research used a case study design with ethnographic methods. Semi-structured interviews (n=30) were conducted with participant observations. Thematic analysis was used to identify emergent themes and collaborative public management theory was then used to frame the findings. The authors used reflexive methods, and member checking was conducted.

RESULTS

The deployment of staff and touch-base meeting illustrated the potential of multidisciplinary teams when members share power, and the importance of impartial leadership when trying to achieve consensus on how to prioritise resource use. However, the service delivery and finance managers did not manage to collaborate in the monthly finance meeting to develop realistic budgets, or to reprioritise expenditure when required. The resulting mistrust threatened to derail the other strategies, highlighting how critical trust is for collaboration.

CONCLUSION

Effective PFM requires authentic collaboration between service delivery and finance managers; formal processes alone will not achieve this. We recommend more opportunities for 'boundary crossing', embedding finance managers in service delivery units and impartial effective leadership.