Managers' role in supporting resilience in healthcare: a proposed model of how managers contribute to a healthcare system's overall resilience

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.

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.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals

BACKGROUND

Central to Safety-II is promoting resilience of healthcare practices. In the "Room for Resilience" research project we focus on the role of horizontal and vertical accountability in healthcare teams and aim to discover how the relation between the two impacts team reflections and discussions. In this article, we report on an explorative study at the start of the project which aimed to assess the structures and dynamics of horizontal and vertical accountability.

METHODS

A qualitative study in six teams in three hospitals in the Netherlands. For the project, each team selected a specific clinical process to work on (e.g. pain assessment). We interviewed healthcare professionals, managers, and quality advisors about these processes, how they are discussed in practice and how teams need to account for them. Additionally, we observed the processes and how teams discuss them in practice. In total, we conducted 35 interviews and 67.5 h of observation. Transcripts and field notes were analyzed using thematic analysis.

RESULTS

Professionals at times varied in what they considered the right approach in the clinical process, with differing views on the importance of certain actions. When processes were discussed, this mostly was done during clinical work, and it often concerned reflections about the care for a specific patient instead of reflecting on the team's general approach of the clinical process. Organized reflections on the processes were sparse. How processes were conducted in practice deviated from guidelines, mainly due to staff shortages, a perceived lack of value of a guideline, equipment issues, and collaboration issues. For most processes, accountability to hierarchical layers consisted of quality indicator scores. Professionals were tasked with registering indicator data but did not find this meaningful for their work.

CONCLUSIONS

The observed different perspectives within teams on what good quality care is show the importance of having team reflections about these processes. How vertical accountability was organized at times impacted the conditions for teams to discuss resilient performance. Following these findings, we recommend that reflection on resilient practice and the role of accountability processes is organized on all levels in (and outside) the organization.

Responsive and resilient healthcare? 'Moments of Resilience' in post-hospitalisation services for COVID-19

BACKGROUND

COVID-19 caused disruption to healthcare services globally, resulting in high numbers of hospital admissions and with those discharged often requiring ongoing support. Within the UK, post-discharge services typically developed organically and were shaped over time by local need, funding, and government guidance. Drawing on the Moments of Resilience framework, we explore the development of follow-up services for hospitalised patients by considering the links between resilience at different system levels over time. This study contributes to the resilient healthcare literature by providing empirical evidence of how diverse stakeholders developed and adapted services for patients following hospitalisation with COVID-19 and how action taken at one system level influenced another.

METHODS

Qualitative research comprising comparative case studies based on interviews. Across three purposively selected case studies (two in England, one in Wales) a total of 33 semi-structured interviews were conducted with clinical staff, managers and commissioners who had been involved in developing and/or implementing post-hospitalisation follow-up services. The interviews were audio-recorded and professionally transcribed. Analysis was conducted with the aid of NVivo 12.

RESULTS

Case studies demonstrated three distinct examples of how healthcare organisations developed and adapted their post-discharge care provision for patients, post-hospitalisation with COVID-19. Initially, the moral distress of witnessing the impact of COVID-19 on patients who were being discharged coupled with local demand gave clinical staff the impetus to take action. Clinical staff and managers worked closely to plan and deliver organisations' responses. Funding availability and other contextual factors influenced situated and immediate responses and structural adaptations to the post-hospitalisation services. As the pandemic evolved, NHS England and the Welsh government provided funding and guidance for systemic adaptations to post-COVID assessment clinics. Over time, adaptations made at the situated, structural, and systemic levels influenced the resilience and sustainability of services.

CONCLUSIONS

This paper addresses understudied, yet inherently important, aspects of resilience in healthcare by exploring when and where resilience occurs across the healthcare system and how action taken at one system level influenced another. Comparison across the case studies showed that organisations responded in similar and different ways and on varying timescales to a disruption and national level strategies.

The role of local context for managers' strategies when adapting to the COVID-19 pandemic in Norwegian homecare services: a multiple case study

BACKGROUND

The COVID-19 pandemic had a major impact on healthcare systems around the world, and lack of resources, lack of adequate preparedness and infection control equipment have been highlighted as common challenges. Healthcare managers' capacity to adapt to the challenges brought by the COVID-19 pandemic is crucial to ensure safe and high-quality care during a crisis. There is a lack of research on how these adaptations are made at different levels of the homecare services system and how the local context influences the managerial strategies applied in response to a healthcare crisis. This study explores the role of local context for managers' experiences and strategies in homecare services during the COVID-19 pandemic.

METHODS

A qualitative multiple case study in four municipalities with different geographic locations (centralized and decentralized) across Norway. A review of contingency plans was performed, and 21 managers were interviewed individually during the period March to September 2021. All interviews were conducted digitally using a semi-structured interview guide, and data was subjected to inductive thematic analysis.

RESULTS

The analysis revealed variations in managers' strategies related to the size and geographical location of the homecare services. The opportunities to apply different strategies varied among the municipalities. To ensure adequate staffing, managers collaborated, reorganized, and reallocated resources within their local health system. New guidelines, routines and infection control measures were developed and implemented in the absence of adequate preparedness plans and modified according to the local context. Supportive and present leadership in addition to collaboration and coordination across national, regional, and local levels were highlighted as key factors in all municipalities.

CONCLUSION

Managers who designed new and adaptive strategies to respond to the COVID-19 pandemic were central in ensuring high-quality Norwegian homecare services. To ensure transferability, national guidelines and measures must be context-dependent or -sensitive and must accommodate flexibility at all levels in a local healthcare service system.

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.

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.

Managers' strategies in handling the COVID-19 pandemic in Norwegian nursing homes and homecare services

PURPOSE

This study aims to explore nursing home and home care managers' strategies in handling the COVID-19 pandemic.

DESIGN/METHODOLOGY/APPROACH

This study has a qualitative design with semistructured individual interviews conducted digitally by videophone (Zoom). Eight managers from nursing homes and five managers from home care services located in a large urban municipality in eastern Norway participated. Systematic text condensation methodology was used for the analysis.

FINDINGS

The managers used several strategies to handle challenges related to the COVID-19 pandemic, including being proactive and thinking ahead in terms of possible scenarios that might occur, continuously training of staff in new procedures and routines and systematic information sharing at all levels, as well as providing different ways of disseminating information for staff, service users and next-of-kins. To handle staffing challenges, managers used strategies such as hiring short-term staff that were temporary laid off from other industries and bringing in students.

ORIGINALITY/VALUE

The COVID-19 pandemic heavily affected health-care systems worldwide, which has led to many health-care studies. The situation in nursing homes and home care services, which were strongly impacted by the pandemic and in charge of a vulnerable group of people, has not yet received enough attention in research. This study, therefore, seeks to contribute to this research gap by investigating how managers in nursing homes and home care services used different strategies to handle the COVID-19 pandemic.

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.

Examining Leadership Capabilities, Risk Management Practices, and Organizational Resilience: The Case of State-Owned Enterprises in Indonesia

This study aims to assess the role of leadership in Indonesia’s State-Owned Enterprises in bringing the companies to be resilient amid uncertainties and a dynamic environment based on dynamic capability theory. Risk management practices are used to mediate the relationship between leadership capabilities and enterprise resilience. The authors conducted a quantitative and cross-sectional study using a questionnaire distributed to members of the board of directors and senior managers of Indonesia SOEs and their subsidiaries. Based on the structural equation modeling analysis, the findings reveal that leadership capabilities play a role in developing enterprise resilience and risk management practice. Additionally, risk management practice partially mediates the relationship between leadership capabilities and enterprise resilience. The empirical findings enrich the knowledge on the relationship between enterprise resilience, leadership capability, and risk management practice. These results enable management SOEs and their subsidiaries and policymakers to develop strategies and a policy framework to create and develop enterprise resilience and help SOEs navigate safely and triumphantly in uncertain and disruptive business environments. This study supports empirical evidence that expands the context of applying the enterprise resilience concept and dynamic capability theory in hybrid organization types, such as SOEs, that operate in emerging countries.

The COVID-19 pandemic and disruptions in a district quality improvement initiative: Experiences from the CLEVER Maternity Care programme

BACKGROUND

 Many health systems were poorly prepared for the coronavirus disease 2019 (COVID-19) pandemic and found it difficult to protect maternity and reproductive health services. The aim of the study was to explore the influence of the COVID-19 pandemic on the ability of maternity healthcare providers to maintain the positive practices introduced by the CLEVER Maternity Care programme and to elicit information on their support needs.

METHODS

 This multimethod study was conducted in midwife-led obstetric units (MOUs) and district hospitals in Tshwane District, South Africa and included a survey questionnaire and qualitative reports and reflections by the CLEVER implementation team. Two five-point Likert-scale items were supplemented by open-ended questions to provide suggestions on improving health systems and supporting healthcare workers.

RESULTS

 Most of the 114 respondents were advanced midwives or registered nurses (86%). Participants from MOUs rated the maintenance of quality care practices significantly higher than those from district hospitals (p = 0.0130). There was a significant difference in perceptions of support from the district management between designations (p = 0.0037), with managers having the most positive perception compared with advanced midwives (p = 0.0018) and registered nurses (p = 0.0115). The interpretation framework had three main themes: working environment and health-system readiness; quality of patient care and service provision; and healthcare workers' response to the pandemic. Health-facility readiness is described as proactive, reactive or lagging.

CONCLUSION

 Lessons learned from this pandemic should be used to build responsive health systems that will enable primary healthcare workers to maintain quality patient care, services and communication.

Resilient and responsive healthcare services and systems: challenges and opportunities in a changing world

Background

Resilient and responsive healthcare systems is on the agenda as ever before. COVID-19, specialization of services, resource demands, and technology development are all examples of aspects leading to adaptations among stakeholders at different system levels whilst also attempting to maintain high service quality and safety. This commentary sets the scene for a journal collection on Resilient and responsive health systems in a changing world. The commentary aims to outline main challenges and opportunities in resilient healthcare theory and practice globally, as a backdrop for contributions to the collection.

Main text

Some of the main challenges in this field relate to a myriad of definitions and approaches to resilience in healthcare, and a lack of studies having multilevel perspectives. Also, the role of patients, families, and the public in resilient and responsive healthcare systems is under researched. By flipping the coin, this illustrates opportunities for research and practice and raise key issues that future resilience research should pay attention to. The potential of combining theoretical lenses from different resilience traditions, involvement of multiple stakeholders in co-creating research and practice improvement, and modelling and visualizing resilient performance are all opportunities to learn more about how healthcare succeeds under stress and normal operations.

Conclusion

A wide understanding of resilience and responsiveness is needed to support planning and preparation for future disasters and for handling the routine small-scale adaptation. This collection welcomes systematic reviews, quantitative, qualitative, and mixed-methods research on the topic of resilience and responsiveness in all areas of the health system.

Relationship between management and resilience in healthcare: a study protocol for a systematic review

INTRODUCTION

Management has been identified as a critical component of organisational resilience when responding to adverse events and crises, as managers must ensure an effective operational response and provide direction and guidance to teams. While there are many management approaches, strategies and interventions that have been applied and studied in healthcare, the impact of them in relation to resilience in healthcare has not been explored, particularly at the organisational level. Understanding the impact of management approaches, strategies and interventions on resilience has the potential to inform healthcare organisations on how to better use management to prepare and respond to organisational adverse events. The objective of this mixed-methods systematic review is to understand the relationship between management and organisational resilience in healthcare, including management approaches and strategies that promote resilience in healthcare.

METHODS AND ANALYSIS

A search through MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PubMed and EMBASE will be conducted between 1 August 2021 and 31 December 21. This review will consider empirical quantitative, qualitative and mixed-methods studies published in English from 2010 to the present that meet the inclusion and exclusion criteria. Selected studies will be assessed in detail and extracted data will be reviewed by two independent reviewers. Results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram. This review will follow a convergent integrated approach to data synthesis and integration.

ETHICS AND DISSEMINATION

This systematic literature review includes no collection of primary data; hence ethical approval will not be sought. The outcomes from this review will be disseminated in a peer-reviewed journal, as conference presentation, and as condensed summary for managers in healthcare and policy-makers.

PROSPERO REGISTRATION NUMBER

CRD42020223362.