Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada

Strategies to strengthen the resilience of primary health care in the COVID-19 pandemic: a scoping review

BACKGROUND

Primary Health Care (PHC) systems are pivotal in delivering essential health services during crises, as demonstrated during the COVID-19 pandemic. With varied global strategies to reinforce PHC systems, this scoping review consolidates these efforts, identifying and categorizing key resilience-building strategies.

METHODS

Adopting Arksey and O'Malley's scoping review framework, this study synthesized literature across five databases and Google Scholar, encompassing studies up to December 31st, 2022. We focused on English and Persian studies that addressed interventions to strengthen PHC amidst COVID-19. Data were analyzed through thematic framework analysis employing MAXQDA 10 software.

RESULTS

Our review encapsulated 167 studies from 48 countries, revealing 194 interventions to strengthen PHC resilience, categorized into governance and leadership, financing, workforce, infrastructures, information systems, and service delivery. Notable strategies included telemedicine, workforce training, psychological support, and enhanced health information systems. The diversity of the interventions reflects a robust global response, emphasizing the adaptability of strategies across different health systems.

CONCLUSIONS

The study underscored the need for well-resourced, managed, and adaptable PHC systems, capable of maintaining continuity in health services during emergencies. The identified interventions suggested a roadmap for integrating resilience into PHC, essential for global health security. This collective knowledge offered a strategic framework to enhance PHC systems' readiness for future health challenges, contributing to the overall sustainability and effectiveness of global health systems.

Exploring the influence of health system factors on adaptive capacity in diverse hospital teams in Norway: a multiple case study approach

OBJECTIVES

Understanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers in defined settings such as hospitals. There is little knowledge of how hospital teams are affected by the rules and regulations imposed by multiple governmental bodies, and how health system factors influence adaptive capacity in hospital teams. The aim of this study is to explore the extent to which health system factors enable or constrain adaptive capacity in hospital teams.

DESIGN

A qualitative multiple case study using observation and semistructured interviews was conducted between November 2020 and June 2021. Data were analysed through qualitative content analysis with a combined inductive and deductive approach.

SETTING

Two hospitals situated in the same health region in Norway.

PARTICIPANTS

Members from 8 different hospital teams were observed during their workday (115 hours) and were subsequently interviewed about their work (n=30). The teams were categorised as structural, hybrid, coordinating and responsive teams.

RESULTS

Two main health system factors were found to enable adaptive capacity in the teams: (1) organisation according to regulatory requirements to ensure adaptive capacity, and (2) negotiation of various resources provided by the governing authorities to ensure adaptive capacity. Our results show that aligning to local context of these health system factors affected the team's adaptive capacity.

CONCLUSIONS

Health system factors should create conditions for careful and safe care to emerge and provide conditions that allow for teams to develop both their professional expertise and systems and guidelines that are robust yet sufficiently flexible to fit their everyday work context.

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.

Resilience, sense of danger, and reporting in wartime: a cross-sectional study of healthcare personnel in a general hospital

BACKGROUND AND AIMS

Maintaining healthcare services and ensuring the presence of healthcare personnel (HCP) during periods of conflict and high-intensity warfare in Israel including the significant security event that occurred on May 2021, pose significant challenges for hospitals in the range of missile attacks. The May 2021 event, marked by intense hostilities and military actions, brought about heightened security escalations and increased risks in the region. Despite the prevailing threat of missile attacks and ongoing security concerns, hospitals in the affected areas were required to sustain their services and uphold care standards. In light of these circumstances, this study aims to identify the factors that influence the percentage of HCP reporting for work during these intense periods of security escalations and wartime in Israel. Specifically, it explores the relationships between resilience, sense of danger, and HCP absenteeism in the context of the ongoing conflict. The findings of this study can provide valuable insights for designing interventions aimed at decreasing HCP absenteeism during security escalations, wartime, and emergency situations, ultimately contributing to the resilience and effectiveness of healthcare delivery in this challenging environment.

METHODS

During a relative calm period from December 2021 to January 2022, a cross-sectional study was conducted at a southern Israeli general hospital, situated within the range of missile attacks in the midst of a longstanding conflict. The study focused on HCP who were employed before May 21, which marked the end of the last war state at that time. The questionnaire, consisting of measures for resilience using the Conor-Davidson scale (CD-RISC 10) and the sense of danger assessed with the Solomon & Prager inventory, was administered online to all hospital employees at Assuta Ashdod Hospital, located in the southern city of Ashdod, Israel. This approach was chosen due to the challenging nature of conducting a study during an existing war, making it impractical to carry out the research during such periods of active war.

RESULTS

In total, 390 employees completed the survey (response rate of 24%). Of this sample, 77.4% reported fully to work during the last security escalations in May 2021. Most of the sample (84.1%) felt insecure on the way to work. The HCP who reported fully to work had a higher level of resilience than employees who reported partially or did not come to work at all (p = .03). A higher sense of danger in the workplace correlated with a 73% increase in absenteeism (p < .01). Absenteeism (partial or full) was higher among HCP with children who require supervision (p < .01). Hospital preparedness for emergencies as perceived by the employees increased HCP attendance at work (p = .03).

CONCLUSIONS

Hospital management should consider designing programs aimed at potentially strengthening the level of resilience and fostering a greater sense of security among hospital personnel, which might encourage greater attendance at work during wartime, crises, or emergencies.

Systems resilience in the implementation of a large-scale suicide prevention intervention: a qualitative study using a multilevel theoretical approach

BACKGROUND

Resilience, the capacity to adapt and respond to challenges and disturbances, is now considered fundamental to understanding how healthcare systems maintain required levels of performance across varying conditions. Limited research has examined healthcare resilience in the context of implementing healthcare improvement programs across multiple system levels, particularly within community-based mental health settings or systems. In this study, we explored resilient characteristics across varying system levels (individual, team, management) during the implementation of a large-scale community-based suicide prevention intervention.

METHODS

Semi-structured interviews (n=53) were conducted with coordinating teams from the four intervention regions and the central implementation management team. Data were audio-recorded, transcribed, and imported into NVivo for analysis. A thematic analysis of eight transcripts involving thirteen key personnel was conducted using a deductive approach to identify characteristics of resilience across multiple system levels and an inductive approach to uncover both impediments to, and strategies that supported, resilient performance during the implementation of the suicide prevention intervention.

RESULTS

Numerous impediments to resilient performance were identified (e.g., complexity of the intervention, and incompatible goals and priorities between system levels). Consistent with the adopted theoretical framework, indicators of resilient performance relating to anticipation, sensemaking, adaptation and tradeoffs were identified at multiple system levels. At each of the system levels, distinctive strategies were identified that promoted resilience. At the individual and team levels, several key strategies were used by the project coordinators to promote resilience, such as building relationships and networks and carefully prioritising available resources. At the management level, strategies included teambuilding, collaborative learning, building relationships with external stakeholders, monitoring progress and providing feedback. The results also suggested that resilience at one level can shape resilience at other levels in complex ways; most notably we identified that there can be a downside to resilience, with negative consequences including stress and burnout, among individuals enacting resilience.

CONCLUSIONS

The importance of considering resilience from a multilevel systems perspective, as well as implications for theory and future research, are discussed.

Power and politics in a pandemic: Insights from Finnish health system leaders during COVID-19

Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experience issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n = 53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems.

Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic

BACKGROUND

Health challenges like coronavirus disease 2019 (COVID-19) are becoming increasingly complex, transnational, and unpredictable. Studying health system responses to the COVID-19 pandemic is an opportunity to enhance our understanding of health system resilience and establish a clearer link between theoretical concepts and practical ideas on how to build resilience.

METHODS

This narrative literature review aims to address four questions using a health system resilience framework: (i) What do we understand about the dimensions of resilience? (ii) What aspects of the resilience dimensions remain uncertain? (iii) What aspects of the resilience dimensions are missing from the COVID-19 discussions? and (iv) What has COVID-19 taught us about resilience that is missing from the framework? A scientific literature database search was conducted in December 2020 and in April 2022 to identify publications that discussed health system resilience in relation to COVID-19, excluding articles on psychological and other types of resilience. A total of 63 publications were included.

RESULTS

There is good understanding around information sharing, flexibility and good leadership, learning, maintaining essential services, and the need for legitimate, interdependent systems. Decision-making, localized trust, influences on interdependence, and transformation remain uncertain. Vertical interdependence, monitoring risks beyond the health system, and consequences of changes on the system were not discussed. Teamwork, actor legitimacy, values, inclusivity, trans-sectoral resilience, and the role of the private sector are identified as lessons from COVID-19 that should be further explored for health system resilience.

CONCLUSION

Knowledge of health system resilience has continued to cohere following the pandemic. The eventual consequences of system changes and the resilience of subsystems are underexplored. Through governance, the concept of health system resilience can be linked to wider issues raised by the pandemic, like inclusivity. Our findings show the utility of resilience theory for strengthening health systems for crises and the benefit of continuing to refine existing resilience theory.

Theorising Health System Resilience and the Role of Government Policy- Challenges and Future Directions Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

Resilient healthcare (RHC) emphasises the importance of adaptive capacity to respond to unanticipated crises such as the global coronavirus disease 2019 (COVID-19) pandemic but there are few examples of RHC research focusing on the decisions taken by macro level policy makers. The Smaggus et al paper analyses the actions of two governments in Canada and Australia as described in media releases from a resilience perspective. The paper clearly articulates the need for conceptual clarity when analysing system resilience, and integrates three theoretical perspectives to understand the types of government responses and how they were related to resilience. The paper makes a valuable contribution to the developing RHC evidence base, but challenges remain in identifying conceptual frameworks, researching macro level resilience, including identifying and accessing reliable macro level data sources, analysing interactions between macro, meso and micro system levels, and understanding how resilience manifests at different temporal and spatial scales.

Adaptation, Transformation and Resilience in Healthcare Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

Adaptive capacity is a critical component of building resilience in healthcare (RiH). Adaptive capacity comprises the ability of a system to cope with and adapt to disturbances. However, "shocks," such as the current coronavirus disease 2019 (COVID-19) pandemic, can potentially exceed critical adaptation thresholds and lead to systemic collapse. To effectively manage healthcare systems during periods of crises, both adaptive and transformative changes are necessary. This commentary discusses adaptation and transformation as two complementary, integral components of resilience and applies them to healthcare. We treat resilience as an emergent property of complex systems that accounts for multiple, often disparately distinct regimes in which multiple processes (eg, adaptation, recovery) are subsumed and operate. We argue that Convergence Mental Health and other transdisciplinary paradigms such as Brain Capital and One Health can facilitate resilience planning and management in healthcare systems.

Successful Outcomes for Whom and for What? Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

The coronavirus disease 2019 (COVID-19) pandemic is the case of a complex global crisis that requires resilient performance across all levels of healthcare systems worldwide. The analysis of government actions during the COVID-19 pandemic in Australia and Canada by Smaggus et al raises the possibility for a much needed and essential debate on the notion of outcomes in the resilience in healthcare literature. Government actions have downstream effects on stakeholders' capacity for resilience throughout the healthcare system. Yet, outcomes are fluent, multi-faceted and dependant on time, space, and stakeholder perspectives. It is appropriate and timely for the resilience in healthcare field to better grasp the nuances of successful outcomes in complex adaptive systems.

Articulating Concepts Matters! Resilient Actions in the Norwegian Governmental Response to the COVID-19 Pandemic Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

The coronavirus disease 2019 (COVID-19) pandemic has challenged our healthcare systems and required collaboration from both centralized and decentralized system levels to adapt to the changes and challenges. This commentary offers a look into the Norwegian governmental healthcare system and response within a resilience in healthcare perspective, by analyzing the situated, structural, and systemic resilience. Such a conceptualization of resilience into three scales of organizational activity may assist our efforts to understand and explain governmental actions throughout the pandemic. Research application of resilience in healthcare to explain and discuss government actions during the COVID-19 pandemic, needs to ensure sensitivity to the overall structural, cultural, and human factor aspects of the relevant healthcare system under scrutiny as well as sensitivity to specific context within the various system levels.

Government Actions and Their Relation to Resilience in Healthcare; What We See Is Not Always What We Get Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

This commentary reviews the publication by Smaggus et al published in the IJHPM in July 2021 on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada" which analysed media releases to identify how governments contributed to resilience in healthcare (RiH). We suggest media releases might not be the best data to capture the mechanisms, activities and interactions through which government actions enhance or hinder RiH. RiH recognizes healthcare as a complex sociotechnical system, so studies into fostering capacity for RiH should be designed for complex sociotechnical systems. This means data should be derived from multiple sources to allow for diverse perspectives, and preferably include direct observations to capture the intricacies of backstage interactions.

Resilience of Health Systems: Understanding Uncertainty Uses, Intersecting Crises and Cross-level Interactions Comment on "Government Actions and Their Relation to Resilience in Healthcare During the COVID-19 Pandemic in New South Wales, Australia and Ontario, Canada"

The coronavirus disease 2019 (COVID-19) pandemic has created opportunities to study resilience in multiple, interrelated societal systems while considering the institutional, community and individual level. We aim to discuss critical, yet underrepresented, issues in resilience discourses which are fundamental to advance theories, concepts and measurement of health system resilience. These relate to a better understanding of (i) how government's handle and use uncertainties to facilitate or impede change, including the role of negotiation and conflicts, (ii) the intersections of health with multiple, co-occurring crises (systemic intersections), and (iii) cross-level interactions, ie, the interrelation between individual-level resilience, the collective resilience of groups and communities, and the resilience of a system as a whole (and vice versa). Analyses of these aspects can help to "contextualize" our understanding of resilience in complex adaptive systems. However, conceptual clarity is needed whether resilience is considered an underlying feature, outcome, or intermediate determinant of a (health) system's performance.

Reimagining consumer involvement: Resilient system indicators in the COVID-19 pandemic response in New South Wales, Australia

Background

Reflections on the response to the COVID‐19 pandemic often evoke the concept of ‘resilience’ to describe the way health systems adjusted and adapted their functions to withstand the disturbance of a crisis, and in some cases, improve and transform in its wake. Drawing from this, this study focuses on the role of consumer representatives in healthcare services in initiating changes to the way they participated in the pandemic response in the state of New South Wales in Australia.

Methods

In‐depth interviews were conducted with two cohorts of consumer representatives. Cohort A included experienced and self‐identified consumer leaders, who worked together in a COVID‐19 Consumer Leaders Taskforce; Cohort B included participants outside of this group, and purposively included consumer representatives from rural and regional areas, and culturally and linguistically diverse communities.

Results

The pause in consumer engagement to support health service decision‐making in responding to the pandemic forced consumer representatives to consider alternative approaches to participate. Some initiated networking with each other, forming new collaborations to produce consumer‐led research and guidelines on pandemic‐related patient care. Others mobilized support from community and politicians to lobby for specific healthcare issues in their local areas.

Conclusion

The response to the COVID‐19 pandemic made visible the brittle nature of previous engagement processes of involving consumers in organizational design and governance. However, the momentum for proactive self‐organization in an unexpected crisis created space for consumer representatives to reset and reimagine their role as active partners in health services. Their ability to adapt and adjust ways of working are key assets for a resilient health system.

Patient or Public Contribution

This project is a collaborative study between academic researchers and health consumer (patient and public) representatives. It followed the principles of codesign and coresearch, whereby both consumer representatives and academic researchers contributed equally to all stages of the project. The study was cofunded by both academic institutions and consumer representative organizations.