Factors influencing the formation of balanced care teams: the organisation, performance, and perception of nursing care teams and the link with patient outcomes: a systematic scoping review

BACKGROUND

The composition of care teams is crucial for delivering patient-centered healthcare, yet assembling a well-balanced team remains a challenge. This difficulty stems from the intricate dynamics of team capacity, culture, context, and the demands of the job. The current literature offers limited guidance for decision-makers on how to effectively navigate these dynamics to compose a balanced care team.

METHODS

We conducted a systematic scoping review of literature spanning from 2009 to 2022. The aim was to identify factors that significantly influence the work environment, team performance, nursing outcomes, and patient outcomes within healthcare settings. Our review focused on extracting and synthesizing evidence to uncover these influencing factors.

RESULTS

Our analysis identified 35 factors that play a significant role in shaping the work environment and influencing team performance, nursing outcomes, and patient outcomes. These factors were categorized into nine key domains: workload, leadership, team composition, stress and demands, professional relationships, safety, logistics and ergonomics, autonomy and responsibility, and transparency and task clearness.

CONCLUSIONS

To improve patient care and nursing job satisfaction, policymakers and decision-makers can consider these influencing factors in the design and management of care teams. The findings advocate for strategic adjustments in these domains to enhance a team's balance. Furthermore, our review underscores the need for further research to fill the identified gaps in knowledge, offering a directive for future studies into optimal care team composition. This systematic approach to team composition can significantly impact patient outcomes and nurse satisfaction, providing a roadmap for creating more effective and harmonious teams.

Strategies for adapting under pressure: an interview study in intensive care units

BACKGROUND

Healthcare systems are operating under substantial pressures. Clinicians and managers are constantly having to make adaptations, which are typically improvised, highly variable and not coordinated across teams. This study aimed to identify and describe the types of everyday pressures in intensive care and the adaptive strategies staff use to respond, with the longer-term aim of developing practical and coordinated strategies for managing under pressure.

METHODS

We conducted qualitative semi-structured interviews with 20 senior multidisciplinary healthcare professionals from intensive care units (ICUs) in 4 major hospitals in the UK. The interviews explored the everyday pressures faced by intensive care staff and the strategies they use to adapt. A thematic template analysis approach was used to analyse the data based on our previously empirically developed taxonomy of pressures and strategies.

RESULTS

The principal source of pressure described was a shortage of staff with the necessary skills and experience to care for the increased numbers and complexity of patients which, in turn, increased staff workload and reduced patient flow. Strategies were categorised into anticipatory (in advance of anticipated pressures) and on the day. The dynamic and unpredictable demands on ICUs meant that strategies were mostly deployed on the day, most commonly by flexing staff, prioritisation of patients and tasks and increasing modes of communication and support.

CONCLUSIONS

ICU staff use a wide variety of adaptive strategies at times of pressure to minimise risk and maintain a reasonable standard of care for patients. These findings provide the foundation for a portfolio of strategies, which can be flexibly employed when under pressure. There is considerable potential for training clinical leaders and teams in the effective use of adaptive strategies.

Identifying resilience: a system safety review of trauma and orthopaedic theatres

A prospective, qualitative study, of trauma and orthopaedic theatres was undertaken using the CARe QI handbook and the SEIPS framework, with the aim of preventing future Never Events. The study demonstrated a new approach, focussed on understanding 'work as done' to identify opportunities to improve system resilience, tested, using the Model for Improvement. Undertaken during the Covid-19 pandemic, it demonstrates that such conditions should not be a deterrent to observational studies, but requiring greater time and resource than a standard investigation, the approach may not align with current organisational or regulatory expectations. At the conclusion of this study, the mean time between Never Events in theatres had increased from 46 to 224 days, an achievement that had not previously been possible using the regulatory required, safety I, investigatory approach. These findings should be used to inform future PSIRF and Never Event Frameworks, to ensure effective systems-based analysis and improvement.

Entangled in complexity: An ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs

AIM

The aim of this study was to visualize vulnerabilities and explore the dynamics of inter-professional collaboration and organizational adaptability in the context of care transitions for patients with complex care needs.

DESIGN

An ethnographic design using multiple convergent data collection techniques.

METHODS

Data collection involved document review, participant observations and interviews with healthcare and social care professionals (HSCPs). Narrative analysis was employed to construct two illustrative patient scenarios, which were then examined using the Functional Resonance Analysis Method (FRAM). Thematic analysis was subsequently applied to synthesize the findings.

RESULTS

Inconsistencies in timing and precision during care transitions pose risks for patients with complex care needs as they force healthcare systems to prioritize structural constraints over individualized care, especially during unforeseen events outside regular hours. Such systemic inflexibility can compromise patient safety, increase the workload for HSCPs and strain resources. Organizational adaptability is crucial to managing the inherent variability of patient needs. Our proposed 'safe care transition pathway' addresses these issues, providing proactive strategies such as sharing knowledge and increasing patient participation, and strengthening the capacity of professionals to meet dynamic care needs, promoting safer care transitions.

CONCLUSION

To promote patient safety in care transitions, strategies must go beyond inter-professional collaboration, incorporating adaptability and flexible resource planning. The implementation of standardized safe care transition pathways, coupled with the active participation of patients and families, is crucial. These measures aim to create a resilient, person-centred approach that may effectively manage the complexities in care transitions.

IMPLICATIONS

The recommendations of this study span the spectrum from policy-level changes aimed at strategic resource allocation and fostering inter-professional collaboration to practical measures like effective communication, information technology integration, patient participation and family involvement. Together, the recommendations offer a holistic approach to enhance care transitions and, ultimately, patient outcomes.

REPORTING METHOD

Findings are reported per the Consolidated Criteria for Reporting Qualitative research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review

BACKGROUND

Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management.

OBJECTIVES

To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio.

METHODS

Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored.

RESULTS

Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support.

CONCLUSION

The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

Conceptualising learning from resilient performance: A scoping literature review

Resilient performance is a crucial characteristic of complex socio-technical systems, enabling them to sustain essential functionality during changing or stressful conditions. Resilience Engineering (RE), a sub-field of safety research, focuses on this perspective of resilience. RE emphasises its "cornerstone model", presenting the RE system goals of "anticipating, monitoring, responding and learning". The cornerstone of learning remains fragmented and undertheorized in the existing literature. This paper aims to enrich RE research and its practical implications by developing a nuanced and comprehensive understanding of the role of learning from resilient performance. To achieve this aim, a scoping literature review was conducted to assess how learning is conceptualised in the RE literature and the theoretical foundations on which previous work rest. The main findings show that RE researchers view learning as the process of understanding the system, sharing knowledge, and re-designing system properties. The application of established learning theories is limited. This paper contributes to research by proposing an organisational process for the RE cornerstone of learning, paving the way for deeper discussions in future studies about learning from resilient performance within complex socio-technical systems.

Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies

OBJECTIVE

The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments.

DESIGN

In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised.

DATA SOURCES

Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature.

ELIGIBILITY CRITERIA

Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure.

RESULTS

5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies).

CONCLUSIONS

The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.

A resilience view on health system resilience: a scoping review of empirical studies and reviews

BACKGROUND

Prompted by recent shocks and stresses to health systems globally, various studies have emerged on health system resilience. Our aim is to describe how health system resilience is operationalised within empirical studies and previous reviews. We compare these to the core conceptualisations and characteristics of resilience in a broader set of domains (specifically, engineering, socio-ecological, organisational and community resilience concepts), and trace the different schools, concepts and applications of resilience across the health literature.

METHODS

We searched the Pubmed database for concepts related to 'resilience' and 'health systems'. Two separate analyses were conducted for included studies: a total of n = 87 empirical studies on health system resilience were characterised according to part of health systems covered, type of threat, resilience phase, resilience paradigm, and approaches to building resilience; and a total of n = 30 reviews received full-text review and characterised according to type of review, resilience concepts identified in the review, and theoretical framework or underlying resilience conceptualisation.

RESULTS

The intersection of health and resilience clearly has gained importance in the academic discourse with most papers published since 2018 in a variety of journals and in response to external threats, or in reference to more frequent hospital crisis management. Most studies focus on either resilience of health systems generally (and thereby responding to an external shock or stress), or on resilience within hospitals (and thereby to regular shocks and operations). Less attention has been given to community-based and primary care, whether formal or informal. While most publications do not make the research paradigm explicit, 'resilience engineering' is the most prominent one, followed by 'community resilience' and 'organisational resilience'. The social-ecological systems roots of resilience find the least application, confirming our findings of the limited application of the concept of transformation in the health resilience literature.

CONCLUSIONS

Our review shows that the field is fragmented, especially in the use of resilience paradigms and approaches from non-health resilience domains, and the health system settings in which these are used. This fragmentation and siloed approach can be problematic given the connections within and between the complex and adaptive health systems, ranging from community actors to local, regional, or national public health organisations to secondary care. Without a comprehensive definition and framework that captures these interdependencies, operationalising, measuring and improving resilience remains challenging.

Unfolding alignment - How top management work to align demand and capacity: an ethnographic study of resilience in a Swedish healthcare region

BACKGROUND

Resilient healthcare organizations maintain critical functions and high-quality care under varying conditions. While previous research has focused on the activities of frontline healthcare professionals working at the "sharp end" of care, less attention has been paid to managers at the top management level. More knowledge is needed to fully understand how the managers align demand and capacity at the "blunt end" of care. Therefore, this study aimed to explore how top managers work to align demand and capacity in a healthcare region in Sweden.

METHODS

Observations of management team meetings, interviews, and conversations were conducted with top managers responsible for healthcare in one of Sweden's 21 regions. Data collection used an ethnographic approach. Data were analyzed using qualitative reflexive thematic analysis.

RESULTS

The data showed how alignment work was done through active reflection that built on past experiences and on structures built into the organization at the same time as taking future potential outcomes and consequences into account. In addition to collaborative, preventive, supportive, and contextualizing work, which was conducted in the present, a general approach permeated the organization, which enabled connecting actions, i.e., different forms of alignment work, occurring at different points in time, and connecting different types of knowledge across organizational borders and stakeholders.

CONCLUSION

This study explored how top managers work to align demand and capacity in a healthcare region in Sweden. It was shown how four categories of work; collaborative, preventive, supportive and contextualization work, together with a general approach; focusing on opportunities, building on a stable past and taking a reflective stance, constitute alignment in practice. More; the alignment work was done in the here and now, with both the past and future in mind. The ability to take action to benefit the whole is a possibility and a responsibility for top management. In the region studied, this was done by aligning demands with capacity based on past experiences and focusing on the available opportunities to connect knowledge needed within and across organizational borders.

Coming to Grips-How Nurses Deal With Restlessness, Confusion, and Physical Restraints on a Neurological/Neurosurgical Ward

Physical restraints are viewed as potentially dangerous objects for patient safety. Contemporary efforts mainly focus on preventing bad outcomes in restraint use, while little attention is paid under what circumstances physical restraints are applied harmlessly. The aim of this research was to understand how physical restraints are used by neurology/neurosurgery ward nurses in relation to the protocol. In ethnographic action research, the Functional Resonance Analysis Method (FRAM) was used to map and compare physical restraints as part of daily ward care against the protocol of physical restraints. Comparison between protocol and actual practice revealed that dealing with restlessness and confusion is a collective nursing skill vital in dealing with physical restraints, while the protocol failed to account for these aspects. Supporting and maintaining this skillset throughout this and similar nursing teams can prevent future misguided application physical restraints, offering valuable starting point in managing patient safety for these potentially dangerous objects.

A qualitative study of organisational resilience in care homes in Scotland

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life.

Understanding complex work using an extension of the resilience CARE model: an ethnographic study

Background

Resilient Healthcare research centres on understanding and improving quality and safety in healthcare. The Concepts for Applying Resilience Engineering (CARE) model highlights the relationships between demand, capacity, work-as-done, work-as-imagined, and outcomes, all of which are central aspects of Resilient Healthcare theory. However, detailed descriptions of the nature of misalignments and the mechanisms used to adapt to them are still unknown.

Objective

The objectives were to identify and classify types of misalignments between demand and capacity and types of adaptations that were made in response to misalignments.

Methods

The study involved 88.5 hours of non-participant ethnographic observations in a large, teaching hospital in central London. The wards included in the study were: two surgical wards, an older adult ward, a critical care unit, and the Acute Assessment Unit (AAU), an extension unit created to expedite patient flow out of the Emergency Department. Data were collected via observations of routine clinical work and ethnographic interviews with healthcare professionals during the observations. Field notes were transcribed and thematically analysed using a combined deductive-inductive approach based on the CARE model.

Results

A total of 365 instances of demand-capacity misalignment were identified across the five wards included in the study. Of these, 212 had at least one observed corresponding work adaptation. Misalignments identified include equipment, staffing, process, communication, workflow, and space. Adaptations identified include process, resource redistribution, and extra-role performance. For all misalignment types observed across the five in-patient settings, process adaptations were the most frequently used adaptations. The exception to this was for staffing misalignments, which were most frequently responded to with extra-role performance adaptations. Of the three process adaptations, hospital workers most often adapted by changing how the process was done.

Conclusions

This study contributes a new version of the CARE model that includes types of misalignments and corresponding adaptations, which can be used to better understand work-as-done. This affords insight into the complexity of the system and how it might be improved by reducing misalignments via work system redesign or by enhancing adaptive capacity.

An integrated primary care-based programme of PRE-Pregnancy cARE to improve pregnancy outcomes in women with type 2 Diabetes (The PREPARED study): protocol for a multi-method study of implementation, system adaptation and performance

BACKGROUND

The number of women of childbearing age with Type 2 diabetes(T2DM) is increasing, and they now account for > 50% of pregnancies in women with pre-existing diabetes. Diabetes pregnancies without adequate pre-pregnancy care have higher risk for poor outcomes (miscarriages, birth-defects, stillbirths) and are associated with increased complications (caesarean deliveries, macrosomic babies, neonatal intensive-care admissions). The risks and costs of these pregnancies can be reduced with pregnancy preparation (HbA1c, ≤ 6.5%, 5 mg folic acid and stopping potentially harmful medicines). However, 90% of women with T2DM, most of whom are based in primary care, are not adequately prepared for pregnancy. This study will evaluate a programme of primary care-based interventions (decision-support systems; pre-pregnancy care-pathways; pregnancy-awareness resources; professional training; and performance monitoring) to improve pregnancy preparation in women with T2DM.

METHODS

The study aims to optimise the programme interventions and estimate their impact on pregnancy preparation, pre-pregnancy care uptake and pregnancy outcomes. To evaluate this multimodal intervention, we will use a multi-method research design following Complex Adaptive Systems (CAS) theory, refining the interventions iteratively during the study. Thirty GP practices with ≥ 25 women with T2DM of reproductive age (18-45 years) from two South London boroughs will be exposed to the intervention. This will provide > 750 women with an estimated pregnancy incidence of 80-100 to study. The research involves: a clinical audit of processes and outcomes; a process evaluation informing intervention feasibility, implementation, and behaviour change; and a cost-consequences analysis informing future economic evaluation. Performance data will be collected via audits of GP systems, hospital antenatal clinics and pregnancy outcomes. Following CAS theory, we will use repeated measurements to monitor intervention impact on pregnancy preparation markers at 4-monthly intervals over 18-months. We will use performance and feasibility data to optimise intervention effects iteratively. The target performance for the intervention is a 30% increase in the proportion of women meeting pre-pregnancy care criteria.

DISCUSSION

The primary output will be development of an integrated programme of interventions to improve pregnancy preparation, pre-pregnancy care uptake, and reduce adverse pregnancy outcomes in women with T2DM. We will also develop an implementation plan to support the introduction of the interventions across the NHS.

TRIAL REGISTRATION

ISRCTN47576591 ; February 8, 2022.

Mapping registered nurse anaesthetists' intraoperative work: tasks, multitasking, interruptions and their causes, and interactions: a prospective observational study

INTRODUCTION

Safe anaesthesia care is a fundamental part of healthcare. In a previous study, registered nurse anaesthetists (RNAs) had the highest task frequency, with the largest amount of multitasking and interruptions among all professionals working in a surgical team. There is a lack of knowledge on how these factors are distributed during the intraoperative anaesthesia care process, and what implications they might have on safety and quality of care.

OBJECTIVE

To map the RNAs' work as done in practice, including tasks, multitasking, interruptions and their causes, and interactions, during all phases of the intraoperative anaesthesia work process.

METHODS

Structured observations of RNAs (n=8) conducted during 30 procedures lasting a total of 73 hours in an operating department at a county hospital in Sweden, using the Work Observation Method By Activity Timing tool.

RESULTS

High task intensity and multitasking were revealed during preparation for anaesthesia induction (79 tasks/hour, 61.9% of task time spent multitasking), anaesthesia induction (98 tasks/hour, 50.7%) and preparation for anaesthesia maintenance (86 tasks/hour, 80.2%). Frequent interruptions took place during preoperative preparation (4.7 /hour), anaesthesia induction (6.2 /hour) and preparation for anaesthesia maintenance (4.3 /hour). The interruptions were most often related to medication care (n=54, 19.8%), equipment issues (n=40, 14.7%) or the procedure itself (n=39, 14.3%). RNAs' work was conducted mostly independently (58.4%), but RNAs interacted with multiple professionals in and outside the operating room during anaesthesia.

CONCLUSION

The tasks, multitasking, interruptions and their causes, and interactions during different phases illustrated the RNAs' work as done, as part of a complex adaptive system. Management of safety in the most intense phases-preparing for anaesthesia induction, induction and preparing for anaesthesia maintenance-should be investigated further. The complexity and adaptivity of the nature of RNAs' work should be taken into consideration in future management, development, research and education.

Developing a Patient Safety Culture in Primary Dental Care

Patient safety should be at the heart of any healthcare service. Systems, teams, individuals and environments must work in tandem to strive for safety and quality. Research into patient safety in dentistry is still in the early stages. The vast majority of the research in this area has originated from the secondary care and academic fields. Approximately 95% of dental care is provided in the primary care sector. In this paper, we provide an overview of the evidence base for patient safety in dentistry and discuss the following aspects of patient safety: human factors; best practice; the second victim concept; potential for over-regulation and creating a patient safety culture. Through discussion of these concepts, we hope to provide the reader with the necessary tools to develop a patient safety culture in their practice.

Understanding adaptive teamwork in health care: Progress and future directions

Health care teamwork is a vital part of clinical work and patient care but is poorly understood. Despite poor teamwork being cited as a major contributory factor to adverse events, we lack vital knowledge about how teamwork can be improved. Teams in health care are diverse in structure and purpose, and most patient care depends on the ability of different professionals to coordinate their actions. Research in this area has narrowly defined health care teams, focused mainly on a small range of settings and activities and addressed a limited range of research questions. We argue that a new approach to teamwork research is needed and make three recommendations. First, the temporal and dynamic features of teamwork should be studied to understand how teamwork unfolds sequentially. Second, contextual influences should be integrated into study designs, including the organization of work, tasks, patients, organisational structures, and health care system factors. Finally, exploratory, rather than confirmatory, research designs are needed to analyse the complex patterns of social interaction inherent in health care work, to build our theoretical understanding of health care teams and their work, and ultimately to develop effective interventions to support better teamwork for the benefit of patients.

Multilevel influences on resilient healthcare in six countries: an international comparative study protocol

INTRODUCTION

Resilient healthcare (RHC) is an emerging area of theory and applied research to understand how healthcare organisations cope with the dynamic, variable and demanding environments in which they operate, based on insights from complexity and systems theory. Understanding adaptive capacity has been a focus of RHC studies. Previous studies clearly show why adaptations are necessary and document the successful adaptive actions taken by clinicians. To our knowledge, however, no studies have thus far compared RHC across different teams and countries. There are gaps in the research knowledge related to the multilevel nature of resilience across healthcare systems and the team-based nature of adaptive capacity.This cross-country comparative study therefore aims to add knowledge of how resilience is enabled in diverse healthcare systems by examining adaptive capacity in hospital teams in six countries. The study will identify how team, organisational and national healthcare system factors support or hinder the ability of teams to adapt to variability and change. Findings from this study are anticipated to provide insights to inform the design of RHC systems by considering how macro-level and meso-level structures support adaptive capacity at the micro-level, and to develop guidance for organisations and policymakers.

METHODS AND ANALYSIS

The study will employ a multiple comparative case study design of teams nested within hospitals, in turn embedded within six countries: Australia, Japan, the Netherlands, Norway, Switzerland and the UK. The design will be based on the Adaptive Teams Framework placing adaptive teams at the centre of the healthcare system with layers of environmental, organisational and system level factors shaping adaptive capacity. In each of the six countries, a focused mapping of the macro-level features of the healthcare system will be undertaken by using documentary sources and interviews with key informants operating at the macro-level.A sampling framework will be developed to select two hospitals in each country to ensure variability based on size, location and teaching status. Four teams will be selected in each hospital-one each of a structural, hybrid, responsive and coordinating team. A total of eight teams will be studied in each country, creating a total sample of 48 teams. Data collection methods will be observations, interviews and document analysis. Within-case analysis will be conducted according to a standardised template using a combination of deductive and inductive qualitative coding, and cross-case analysis will be conducted drawing on the Qualitative Comparative Analysis framework.

ETHICS AND DISSEMINATION

The overall Resilience in Healthcare research programme of which this study is a part has been granted ethical approval by the Norwegian Centre for Research Data (Ref. No. 8643334 and Ref. No. 478838). Ethical approval will also be sought in each country involved in the study according to their respective regulatory procedures. Country-specific reports of study outcomes will be produced for dissemination online. A collection of case study summaries will be made freely available, translated into multiple languages. Brief policy communications will be produced to inform policymakers and regulators about the study results and to facilitate translation into practice. Academic dissemination will occur through publication in journals specialising in health services research. Findings will be presented at academic, policy and practitioner conferences, including the annual RHC Network meeting and other healthcare quality and safety conferences. Presentations at practitioner and academic conferences will include workshops to translate the findings into practice and influence quality and safety programmes internationally.