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.

No size fits all - a qualitative study of factors that enable adaptive capacity in diverse hospital teams

Introduction

Resilient healthcare research studies how healthcare systems and stakeholders adapt and cope with challenges and changes to enable high quality care. By examining how performance emerges in everyday work in different healthcare settings, the research seeks to receive knowledge of the enablers for adaptive capacity. Hospitals are defined as complex organizations with a large number of actors collaborating on increasingly complexity tasks. Consequently, most of today's work in hospitals is team based. The study aims to explore and describe what kind of team factors enable adaptive capacity in hospital teams.

Methods

The article reports from a multiple embedded case study in two Norwegian hospitals. A case was defined as one hospital containing four different types of teams in a hospital setting. Data collection used triangulation of observation (115 h) and interviews (30), followed by a combined deductive and inductive analysis of the material.

Results

The study identified four main themes of team related factors for enabling adaptive capacity; (1) technology and tools, (2) roles, procedures, and organization of work, (3) competence, experience, knowledge, and learning, (4) team culture and relations.

Discussion

Investigating adaptive capacity in four different types of teams allowed for consideration of a range of team types within healthcare and how the team factors vary within and across these teams. All of the four identified team factors are of importance in enabling adaptive capacity, the various attributes of the respective team types prompt differences in the significance of the different factors and indicates that different types of teams could need diverse types of training, structural and relational emphasis in team composition, leadership, and non-technical skills in order to optimize everyday functionality and adaptive capacity.

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

Introduction

It is common practice to use objects to bridge disciplines and develop shared understanding across knowledge boundaries. Objects for knowledge mediation provide a point of reference which allows for the translation of abstract concepts into more externalized representations. This study reports from an intervention that introduced an unfamiliar resilience perspective in healthcare, through the use of a resilience in healthcare (RiH) learning tool. The aim of this paper is to explore how a RiH learning tool may be used as an object for introduction and translation of a new perspective across different healthcare settings.

Methods

This study is based on empirical observational data, collected throughout an intervention to test a RiH learning tool, developed as part of the Resilience in Healthcare (RiH) program. The intervention took place between September 2022 and January 2023. The intervention was tested in 20 different healthcare units, including hospitals, nursing homes and home care services. A total of 15 workshops were carried out, including 39-41 participants in each workshop round. Throughout the intervention, data was gathered in all 15 workshops at the different organizational sites. Observation notes from each workshop make up the data set for this study. The data was analyzed using an inductive thematic analysis approach.

Results and conclusion

The RiH learning tool served as different forms of objects during the introduction of the unfamiliar resilience perspective for healthcare professionals. It provided a means to develop shared reflection, understanding, focus, and language for the different disciplines and settings involved. The resilience tool acted as a boundary object for the development of shared understanding and language, as an epistemic object for the development of shared focus and as an activity object within the shared reflection sessions. Enabling factors for the internalization of the unfamiliar resilience perspective were to provide active facilitation of the workshops, repeated explanation of unfamiliar concepts, provide relatedness to own context, and promote psychological safety in the workshops. Overall, observations from the testing of the RiH learning tool showed how these different objects were crucial in making tacit knowledge explicit, which is key to improve service quality and promote learning processes in healthcare.

Learning does not just happen: establishing learning principles for tools to translate resilience into practice, based on a participatory approach

BACKGROUND

Theories of learning are of clear importance to resilience in healthcare since the ability to successfully adapt and improve patient care is closely linked to the ability to understand what happens and why. Learning from both positive and negative events is crucial. While several tools and approaches for learning from adverse events have been developed, tools for learning from successful events are scarce. Theoretical anchoring, understanding of learning mechanisms, and establishing foundational principles for learning in resilience are pivotal strategies when designing interventions to develop or strengthen resilient performance. The resilient healthcare literature has called for resilience interventions, and new tools to translate resilience into practice have emerged but without necessarily stipulating foundational learning principles. Unless learning principles are anchored in the literature and based on research evidence, successful innovation in the field is unlikely to occur. The aim of this paper is to explore: What are key learning principles for developing learning tools to help translate resilience into practice?

METHODS

This paper reports on a two-phased mixed methods study which took place over a 3-year period. A range of data collection and development activities were conducted including a participatory approach which involved iterative workshops with multiple stakeholders in the Norwegian healthcare system.

RESULTS

In total, eight learning principles were generated which can be used to help develop learning tools to translate resilience into practice. The principles are grounded in stakeholder needs and experiences and in the literature. The principles are divided into three groups: collaborative, practical, and content elements.

CONCLUSIONS

The establishment of eight learning principles that aim to help develop tools to translate resilience into practice. In turn, this may support the adoption of collaborative learning approaches and the establishment of reflexive spaces which acknowledge system complexity across contexts. They demonstrate easy usability and relevance to practice.

Backstage researching resilience researchers – dilemmas and principles for data collection in the resilience in healthcare research program

Purpose

Resilience in healthcare is fundamental for what constitutes quality in healthcare. To understand healthcare resilience, resilience research needs a multilevel perspective, diverse research designs, and taking advantage of different data sources. However, approaching resilience researchers as a data source is a new approach within this field and needs careful consideration to ensure that research is trustworthy and ethically sound. The aim of this short “backstage” general review paper is to give a snapshot of how the Resilience in Healthcare (RiH) research program identified and dealt with potential methodological and ethical challenges in researching researcher colleagues.

Design/methodology/approach

The authors first provide an overview of the main challenges and benefits from the literature on researching researcher colleagues. Second, the authors demonstrate how this literature was used to guide strategies and principles adopted in the RiH research process.

Findings

The paper describes established principles and a checklist for data collection and analysis to overcome potential dilemmas and challenges to ensure trustworthiness and transparency in the process.

Originality/value

Mining the knowledge and experience of resilience researchers is fundamental for taking the research field to the next step, and furthermore an approach that is relevant across different research fields. This paper provides guidance on how other research projects can approach researcher colleagues in similar ways to gain new insight, build theory and advance their research field based on insider competence.

Exploring the nature of adaptive capacity for resilience in healthcare across different healthcare contexts; a metasynthesis of narratives

Adaptive capacity has been described as instrumental for the development of resilience in healthcare. Yet, our theoretical understanding of adaptive capacity remains relatively underdeveloped. This research therefore aims at developing a new understanding of the nature of adaptive capacity by exploring the following research questions: 1. What constitutes adaptive capacity across different healthcare contexts? and 2. What type of enabling factors support adaptive capacity across different healthcare contexts? The study used a novel combination of qualitative methods featuring a metasynthesis of narratives based on empirical research to contribute understanding of adaptive capacity across different healthcare contexts. The findings show that adaptive capacity was found to include four forms: reframing, aligning, coping, and innovating. A framework illustrating the relatedness between the identified forms, in terms of resources, change and enablers, is provided. Based on these findings, a new definition of adaptive capacity for resilience in healthcare is proposed.

The role of collaborative learning in resilience in healthcare-a thematic qualitative meta-synthesis of resilience narratives

Background

To provide high quality services in increasingly complex, constantly changing circumstances, healthcare organizations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organizations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalizing resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study is to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.

Methods

The method used to develop understanding of collaborative learning across diverse healthcare contexts and levels was to first conduct a narrative inquiry of a comprehensive dataset of published health services research studies. This resulted in 14 narratives (70 pages), synthesised from a total of 40 published articles and 6 PhD synopses. The narratives where then analysed using a thematic meta-synthesis approach.

Results

The results show that, across levels and contexts, healthcare professionals collaborate to respond and adapt to change, maintain processes and functions, and improve quality and safety. This collaboration comprises activities and interactions such as exchanging information, coordinating, negotiating, and aligning needs and developing buffers. The learning activities embedded in these collaborations are both activities of daily work, such as discussions, prioritizing and delegation of tasks, and intentional educational activities such as seminars or simulation activities.

Conclusions

Based on these findings, we propose that the enactment of resilience in healthcare is dependent on these collaborations and learning processes, across different levels and contexts. A systems perspective of resilience demands collaboration and learning within and across all system levels. Creating space for reflection and awareness through activities of everyday work, could support individual, team and organizational learning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08451-y.

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.

Evaluating a system-wide, safety investigation in healthcare course in Norway: a qualitative study

OBJECTIVE AND SETTING

National, system-wide safety investigation represents a new approach to safety improvement in healthcare. In 2019, a new master's level course in Safety Investigation in Healthcare was established to support the training and development of a new team of investigators from an independent investigatory body. The course was established at one Norwegian university and a total of 19 students were enrolled and completed the course. The aim of this study was to qualitatively evaluate the course, and the objectives were to explore the students' needs and expectations prior to the course conduct, and their experiences and suggestions for improvements after course completion.

DESIGN

The study design was a qualitative explorative study with individual and focus group interviews. Data collection included five individual interviews prior to course participation and two focus group interviews, after course participation, with a total sample size of 13 participants. Data were analysed according to thematic analysis.

RESULTS

The results showed a need for a common conceptual foundation for the multidisciplinary team of safety investigators who were all employed in the same investigatory body. Course participation contributed to create reflexive spaces for the participants and generated new knowledge about the need for a broad range of investigatory tools and approaches. This contrasted with the initial aspiration among the participants to have a recipe for how to conduct safety investigations.

CONCLUSIONS

Course participation contributed to a common language among a highly multidisciplinary group of safety investigators and supported building a culture of collaborative learning. The need for additional activities to further develop a safety investigation curriculum in healthcare was identified. It is recommended that such a curriculum be co-created with independent investigators, safety scientists, patients and users, and healthcare professionals to ensure a strong methods repertoire and a sound theoretical backdrop for investigatory practice.

Capacities for resilience in healthcare; a qualitative study across different healthcare contexts

Background

Despite an emerging consensus on the importance of resilience as a framework for understanding the healthcare system, the operationalization of resilience in healthcare has become an area of continuous discussion, and especially so when seeking operationalization across different healthcare contexts and healthcare levels. Different indicators for resilience in healthcare have been proposed by different researchers, where some indicators are coincident, some complementary, and some diverging. The overall aim of this article is to contribute to this discussion by synthesizing knowledge and experiences from studies in different healthcare contexts and levels to provide holistic understanding of capacities for resilience in healthcare.

Methods

This study is a part of the first exploratory phase of the Resilience in Healthcare programme. The exploratory phase has focused on screening, synthesising, and validating results from existing empirical projects covering a variety of healthcare settings. We selected the sample from several former and ongoing research projects across different contexts and levels, involving researchers from SHARE, the Centre for Resilience in Healthcare in Norway. From the included projects, 16 researchers participated in semi-structured interviews. The dataset was analysed in accordance with grounded theory.

Results

Ten different capacities for resilience in healthcare emerged from the dataset, presented here according to those with the most identified instances to those with the least: Structure, Learning, Alignment, Coordination, Leadership, Risk awareness, Involvement, Competence, Facilitators and Communication. All resilience capacities are interdependent, so effort should not be directed at achieving success according to improving just a single capacity but rather at being equally aware of the importance and interrelatedness of all the resilience in healthcare capacities.

Conclusions

A conceptual framework where the 10 different resilience capacities are presented in terms of contextualisation and collaboration was developed. The framework provides the understanding that all resilience capacities are associated with contextualization, or collaboration, or both, and thereby contributes to theorization and guidance for tailoring, making operationalization efforts for the identified resilience capacities in knowledge translation. This study therefore contributes with key insight for intervention development which is currently lacking in the literature.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07887-6.

Balancing adaptation and innovation for resilience in healthcare - a metasynthesis of narratives

BACKGROUND

Adaptation and innovation are both described as instrumental for resilience in healthcare. However, the relatedness between these dimensions of resilience in healthcare has not yet been studied. This study seeks to develop a conceptual understanding of adaptation and innovation as a basis for resilience in healthcare. The overall aim of this study is therefore to explore how adaptation and innovation can be described and understood across different healthcare settings. To this end, the overall aim will be investigated by identifying what constitutes adaptation and innovation in healthcare, the mechanisms involved, and what type of responses adaptation and innovation are associated with.

METHODS

The method used to develop understanding across a variety of healthcare contexts, was to first conduct a narrative inquiry of a comprehensive dataset from various empirical settings (e.g., maternity, transitional care, telecare), that were later analysed in accordance with grounded theory. Narrative inquiry provided a contextually informed synthesis of the phenomenon, while the use of grounded theory methodology allowed for cross-contextual comparison of adaptation and innovation in terms of resilience in healthcare.

RESULTS

The results identified an imbalance between adaptation and innovation. If short-term adaptations are used too extensively, they may mask system deficiencies and furthermore leave the organization vulnerable, by relying too much on the efforts of a few individuals. Hence, short-term adaptations may end up a barrier for resilience in healthcare. Long-term adaptations and innovation of products, processes and practices proved to be of a lower priority, but had the potential of addressing the flaws of the system by proactively re-organizing and re-designing routines and practices.

CONCLUSIONS

This study develops a new conceptual account of adaptation and innovation as a basis for resilience in healthcare. Findings emerging from this study indicate that a balance between adaptation and innovation should be sought when seeking resilience in healthcare. Adaptations can furthermore be divided into short-term and long-term adaptations, creating the need to balance between these different types of adaptations. Short-term adaptations that adopt the pattern of firefighting can risk generating complex and unintended outcomes, but where no significant changes are made to organization of the system. Long-term adaptations, on the other hand, introduce re-organization of the system based on feedback, and therefore can provide a proactive response to system deficiencies. We propose a pattern of adaptation in resilience in healthcare: from short-term adjustments, to long-term reorganizations, to innovations.

Patient and stakeholder involvement in resilient healthcare: an interactive research study protocol

INTRODUCTION

Resilience in healthcare (RiH) is understood as the capacity of the healthcare system to adapt to challenges and changes at different system levels, to maintain high-quality care. Adaptive capacity is founded in the knowledge, skills and experiences of the people in the system, including patients, family or next of kin, healthcare providers, managers and regulators. In order to learn from and support useful adaptations, research is needed to better understand adaptive capacity and the nature and context of adaptations. This includes research on the actors involved in creating resilient healthcare, and how and in what circumstances different groups of patients and other key healthcare stakeholders enact adaptations that contribute to resilience across all levels of the healthcare system.

METHODS AND ANALYSIS

This 5-year study applies an interactive design in a two-phased approach to explore and conceptualise patient and stakeholder involvement in resilient healthcare. Study phase 1 is exploratory and will use such data collection methods as literature review, document analysis, interviews and focus groups. Study phase 2 will use a participatory design approach to develop, test and evaluate a conceptual model for patient and stakeholder involvement in RiH. The study will involve patients and other key stakeholders as active participants throughout the research process.

ETHICS AND DISSEMINATION

The RiH research programme of which this study is a part is approved by the Norwegian Centre for Research Data (No. 864334). Findings will be disseminated through scientific articles, presentations at national and international conferences, through social media and popular press, and by direct engagement with the public, including patient and stakeholder representatives.

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.

Resilience in Healthcare (RiH): a longitudinal research programme protocol

INTRODUCTION

Over the past three decades, extensive research has been undertaken to understand the elements of what constitutes high quality in healthcare. Yet, much of this research has been conducted on individual elements and their specific challenges. Hence, goals other than understanding the complex of factors and elements that comprises quality in healthcare have been privileged. This lack of progress has led to the conclusion that existing approaches to research are not able to address the inherent complexity of healthcare systems as characterised by a significant degree of performance variability within and across system levels, and what makes them resilient. A shift is, therefore, necessary in such approaches. Resilience in Healthcare (RiH) adopts an approach comprising a comprehensive research programme that models the capacity of healthcare systems and stakeholders to adapt to changes, variations and/or disruptions: that is, resilience. As such, RiH offers a fresh approach capable of capturing and illuminating the complexity of healthcare and how high-quality care can be understood and advanced.

METHODS AND ANALYSIS

Methodologically, to illuminate what constitutes quality in healthcare, it is necessary to go beyond single-site, case-based studies. Instead, there is a need to engage in multi-site, cross-national studies and engage in long-term multidisciplinary collaboration between national and international researchers interacting with multiple healthcare stakeholders. By adopting such processes, multiple partners and a multidisciplinary orientation, the 5-year RiH research programme aims to confront these challenges and accelerate current understandings about and approaches to researching healthcare quality.The RiH research programme adopts a longitudinal collaborative interactive design to capture and illuminate resilience as part of healthcare quality in different healthcare settings in Norway and in five other countries. It combines a meta-analysis of detailed empirical research in Norway with cross-country comparison from Australia, Japan, Netherlands, Switzerland and the UK. Through establishing an RiH framework, the programme will identify processes with outcomes that aim to capture how high-quality healthcare provisions are achieved. A collaborative learning framework centred on engagement aims to systematically translate research findings into practice through co-construction processes with partners and stakeholders.

ETHICS AND DISSEMINATION

The RiH research programme is approved by the Norwegian Centre for Research Data (No. 864334). The empirical projects selected for inclusion in this longitudinal research programme have been approved by the Norwegian Centre for Research Data or the Regional Committees for Medical and Health Research Ethics. The RiH research programme has an embedded publication and dissemination strategy focusing on the progressive sharing of scientific knowledge, information and results, and on engaging with the public, including relevant patient and stakeholder representatives. The findings will be disseminated through scientific articles, PhD dissertations, presentations at national and international conferences, and through social media, newsletters and the popular media.

Defining the boundaries and operational concepts of resilience in the resilience in healthcare research program

BACKGROUND

Understanding the resilience of healthcare is critically important. A resilient healthcare system might be expected to consistently deliver high quality care, withstand disruptive events and continually adapt, learn and improve. However, there are many different theories, models and definitions of resilience and most are contested and debated in the literature. Clear and unambiguous conceptual definitions are important for both theoretical and practical considerations of any phenomenon, and resilience is no exception. A large international research programme on Resilience in Healthcare (RiH) is seeking to address these issues in a 5-year study across Norway, England, the Netherlands, Australia, Japan, and Switzerland (2018-2023). The aims of this debate paper are: 1) to identify and select core operational concepts of resilience from the literature in order to consider their contributions, implications, and boundaries for researching resilience in healthcare; and 2) to propose a working definition of healthcare resilience that underpins the international RiH research programme.

MAIN TEXT

To fulfil these aims, first an overview of three core perspectives or metaphors that underpin theories of resilience are introduced from ecology, engineering and psychology. Second, we present a brief overview of key definitions and approaches to resilience applicable in healthcare. We position our research program with collaborative learning and user involvement as vital prerequisite pillars in our conceptualisation and operationalisation of resilience for maintaining quality of healthcare services. Third, our analysis addresses four core questions that studies of resilience in healthcare need to consider when defining and operationalising resilience. These are: resilience 'for what', 'to what', 'of what', and 'through what'? Finally, we present our operational definition of resilience.

CONCLUSION

The RiH research program is exploring resilience as a multi-level phenomenon and considers adaptive capacity to change as a foundation for high quality care. We, therefore, define healthcare resilience as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care. This working definition of resilience is intended to be comprehensible and applicable regardless of the level of analysis or type of system component under investigation.

Perceptions of telecare training needs in home healthcare services: a focus group study

Background

The implementation and use of telecare requires significant changes to healthcare service organisation and delivery, including new ways of working for staff. Competency development and training for healthcare professionals is therefore required to enable necessary adaptation of clinical practice and ensure competent provision of telecare services. It is however unclear what skills healthcare staff need when providing care at a distance and there is little empirical evidence on effective training strategies for telecare practice. Training should however emphasise the experiences and preferences of prospective trainees to ensure its relevance to their educational needs. The aim of this study was to explore healthcare professionals’ perceptions of training related to the general use of telecare, and to identify specific training needs associated with the use of virtual visits in the home healthcare services.

Methods

Six focus group interviews were held with a total of 26 participants working in the home healthcare services in Norway, including registered nurses, enrolled nurses, physiotherapists, occupational therapists, social workers, health workers, and healthcare assistants. The data material was analysed by way of systematic text condensation.

Results

The analysis resulted in five categories relevant to telecare training for healthcare professionals: Purposeful training creates confidence and changes attitudes; Training needs depend on ability to cope with telecare; The timing of training; Training must facilitate practical insight into the patients’ perspective; and Training content must focus on the telecare process. Findings are discussed in light of implications for the form and content of a training program for healthcare professionals on how to undertake virtual home healthcare visits.

Conclusion

Appropriate preparation and training for telecare use is important for healthcare professionals and must be taken seriously by healthcare organisations. To facilitate the knowledge, skills and attitudes required for new ways of working and enable quality and safety in telecare practice, staff should be provided with training as part of telecare implementation processes. Telecare training should be hands-on and encourage an overall patient-centred approach to care to ensure good patient-professional relationships at a distance.

Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses

This paper reports the thoughts and feelings experienced by registered mental health nurses caring for distressed and/or disturbed service users in acute inpatient psychiatric settings in England. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; prevailing feelings experienced by nurses were fear, anxiety and vulnerability. To enhance care quality, nurses expressed the need for better communication with service users, and preventing the use of coercive measures and promotion of alternative methods of care and management. The nurses considered that debriefing dialogues following untoward incidents, practice development initiatives, education and training together with clinical supervision could be the way forward. The paper builds on the existing literature in offering clear explanations of nurses' thoughts and feelings when caring for distressed and/or disturbed service users in an English acute, inpatient psychiatric setting. Despite the small sample size and the limitations that it generates, the study findings will be of interest to the wider mental health nursing community. The findings will link to other national and international studies and therefore be valuable for future research studies of this kind. Collectively, they are building up a general picture of the distress, cognitive and emotional dissonance experienced by mental health nurses when using coercive interventions. The findings will help to develop mental health nurse education and enhance practice. High levels of distress and disturbance among service users experiencing acute mental illness is a major problem for mental health nurses (MHNs). The thoughts and feelings experienced by these nurses when caring for service users are of paramount importance as they influence clinical practice and caregiving. Similarly to research by other countries, this paper reports national, qualitative data regarding the thoughts and feelings of English MHNs who care for these service users within acute inpatient psychiatric settings. Data were collected from focus groups in which MHNs working in acute inpatient settings in England participated and analysed using inductive content analysis. Findings highlighted three broad themes: (1) emotional and cognitive dissonance; (2) therapeutic engagement; and (3) organizational management and support. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; the prevailing feelings experienced by nurses were fear, anxiety and vulnerability. Nurses would like better communication with service users, prevention of coercive measures and the use of alternative methods of care and/or management to ensure enhanced care. Participants considered practice development initiatives, education, training, staff and managerial support including debriefing and clinical supervision as the way forward. Despite the small sample size and its limitations, these national data add to the existing literature, and the study findings link to those of other studies both nationally and internationally. Collectively, these studies are building up a general picture of the distress, cognitive and emotional dissonance experienced by MHNs when using coercive interventions. The findings will help to develop MHN education and enhance practice.

Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature

Background

Patient safety risk in the homecare context and patient safety risk related to telecare are both emerging research areas. Patient safety issues associated with the use of telecare in homecare services are therefore not clearly understood. It is unclear what the patient safety risks are, how patient safety issues have been investigated, and what research is still needed to provide a comprehensive picture of risks, challenges and potential harm to patients due to the implementation and use of telecare services in the home. Furthermore, it is unclear how training for telecare users has addressed patient safety issues. A systematic review of the literature was conducted to identify patient safety risks associated with telecare use in homecare services and to investigate whether and how these patient safety risks have been addressed in telecare training.

Methods

Six electronic databases were searched in addition to hand searches of key items, reference tracking and citation tracking. Strict inclusion and exclusion criteria were set. All included items were assessed according to set quality criteria and subjected to a narrative synthesis to organise and synthesize the findings. A human factors systems framework of patient safety was used to frame and analyse the results.

Results

22 items were included in the review. 11 types of patient safety risks associated with telecare use in homecare services emerged. These are in the main related to the nature of homecare tasks and practices, and person-centred characteristics and capabilities, and to a lesser extent, problems with the technology and devices, organisational issues, and environmental factors. Training initiatives related to safe telecare use are not described in the literature.

Conclusions

There is a need to better identify and describe patient safety risks related to telecare services to improve understandings of how to avoid and minimize potential harm to patients. This process can be aided by reframing known telecare implementation challenges and user experiences of telecare with the help of a human factors systems approach to patient safety.

Safer@home-Simulation and training: the study protocol of a qualitative action research design

INTRODUCTION

While it is predicted that telecare and other information and communication technology (ICT)-assisted services will have an increasingly important role in future healthcare services, their implementation in practice is complex. For implementation of telecare to be successful and ensure quality of care, sufficient training for staff (healthcare professionals) and service users (patients) is fundamental. Telecare training has been found to have positive effects on attitudes to, sustained use of, and outcomes associated with telecare. However, the potential contribution of training in the adoption, quality and safety of telecare services is an under-investigated research field. The overall aim of this study is to develop and evaluate simulation-based telecare training programmes to aid the use of videophone technology in elderly home care. Research-based training programmes will be designed for healthcare professionals, service users and next of kin, and the study will explore the impact of training on adoption, quality and safety of new telecare services.

METHODS AND ANALYSIS

The study has a qualitative action research design. The research will be undertaken in close collaboration with a multidisciplinary team consisting of researchers and managers and clinical representatives from healthcare services in two Norwegian municipalities, alongside experts in clinical education and simulation, as well as service user (patient) representatives. The qualitative methods used involve focus group interviews, semistructured interviews, observation and document analysis. To ensure trustworthiness in the data analysis, we will apply member checks and analyst triangulation; in addition to providing contextual and sample description to allow for evaluation of transferability of our results to other contexts and groups.

ETHICS AND DISSEMINATION

The study is approved by the Norwegian Social Science Data Services. The study is based on voluntary participation and informed written consent. Informants can withdraw at any point in time. The results will be disseminated at research conferences, peer review journals, one PhD thesis and through public presentations to people outside the scientific community.

Development, implementation and initial evaluation of narrative virtual patients for use in vocational mental health nurse training

Simulation techniques such as virtual patients (VPs) are valuable tools for teaching and learning a range of clinical proficiencies. Compared with other forms of simulation, however, the reported use of VPs within nursing is limited. Descriptions of simple, low cost methods for the development of VP devices could help facilitate their wider implementation and use in nursing education and training. In order to encourage broader use of VP technologies within nursing, this paper aims to expand current knowledge of VP creation by reference to the development of two virtual mental health patients produced for a multilingual e-learning course for European mental health nurses. Focusing on narrative VPs, the paper provides a brief overview of various types and potential uses of VP techniques, along with central elements of good practice in VP development. The five phase development framework used in the creation of the two VPs is presented. Processes detailed include the design and construction of case scenarios and multimedia components, in addition to initial usability and validity testing. VPs like those described here are a relatively inexpensive way of integrating virtual simulation technology into nursing education, particularly within online, blended and/or cross-cultural learning environments.

What can virtual patient simulation offer mental health nursing education?

This paper discusses the use of simulation in nursing education and training, including potential benefits and barriers associated with its use. In particular, it addresses the hitherto scant application of diverse simulation devices and dedicated simulation scenarios in psychiatric and mental health nursing. It goes on to describe a low-cost, narrative-based virtual patient simulation technique which has the potential for wide application within health and social care education. An example of the implementation of this technology in a web-based pilot course for acute mental health nurses is given. This particular virtual patient technique is a simulation type ideally suited to promoting essential mental health nursing skills such as critical thinking, communication and decision making. Furthermore, it is argued that it is particularly amenable to e-learning and blended learning environments, as well as being an apt tool where multilingual simulations are required. The continued development, implementation and evaluation of narrative virtual patient simulations across a variety of health and social care programmes would help ascertain their success as an educational tool.

Vidarabine-loaded nanoparticles: a physicochemical study

The chemical reaction of vidarabine (VIDA) with isohexyl cyanoacrylate nanoparticles in a pH-dependent fashion occurs only in the presence of dioctylsulfosuccinate (DOSS). The formation of an ion pair with DOSS allows a better contact of VIDA with the monomer during the polymerization process taking place in micelles. On the basis of molecular weight profiles of the polymer, determined by gel permeation chromatography (GPC), it is proposed that VIDA induces the polymerization of cyanoacrylic monomers through a zwitterionic pathway. This mechanism allows the covalent linkage of the drug with the polymer, which is consistent with NMR experiments. The present study illustrates the need for physicochemical studies in the design of new colloidal drug delivery formulations.