Exploring Adaptive Capacity in Hospital Teams : A Multiple Case Study

Abstract

Introduction: There has been performed extensive research to understand the components of what constitutes high quality healthcare. Despite efforts to improve quality the rate of change is slow, with a steady rate of approximately 10% of patients harmed during hospitalisations worldwide. This has led to the conclusion that existing methods of improvement based on reactive approaches to handling adverse events need to be supplemented with alternative perspectives such as resilience healthcare. This approach views healthcare organisations as complex systems and has a more proactive focus by seeking to understand how organisations cope with challenges, changes, complexity, and performance variability, and investigating why and how things can go well in healthcare. The ability to adapt to changes and challenges has been highlighted as key for resilient performance. Adaptive capacity enables continuous provision of high-quality care. However, there is insufficient empirical knowledge on how this capacity is enacted in healthcare. Furthermore, the increasing complexity of healthcare in hospitals leads to challenges when different groups of professionals attempt to coordinate their efforts to care for patients. This makes teamwork critical for ensuring safety. Teamwork in healthcare is diverse and there are different types of teams trying to coordinate their efforts. While there is extensive research on teams and teamwork in other domains, the amount of research related to resilience is scarce. There is, therefore, a need for more knowledge on teamwork and resilience in healthcare. Aim: The overall aim for this thesis was to develop new knowledge about how resilience is enabled in healthcare systems by exploring adaptive capacity in hospital teams in Norway. More specifically, the aim was to explore how team, organisational and healthcare system factors influence adaptive capacity in hospital teams. Methods: The study was designed as a multilevel case study of two included cases with four subunits in each case. A case was defined as a hospital with four different types of teams. The case study included observational studies of everyday work in the different types of teams, looking at types of demands, capacity and adaptations experienced by the teams. Following the observation, interviews with team members and their leaders were undertaken. The data material from both the observations and interviews was given equal weight and analysed together as one data set. In addition, an analysis of relevant documents from various national and regional bodies was used to create necessary context. Findings: The study found that there are multiple factors influencing adaptive capacity in hospital teams at different system levels. Findings pertinent to the different levels have been reported in three different papers. Paper I report on the work of hospital leaders to enable adaptive capacity in hospital teams, by building sufficient competence, mitigating risk, workload and staff needs, building relational leadership, staying close to everyday work, and having situational understanding of work practice needs. The leaders combined these four enablers with both contextual and relational understanding for a holistic approach in their decisionmaking. Paper II found four overarching themes of factors that enable adaptive capacity in the different types of hospital teams. Having sufficient and relevant tools and technology available; clear role descriptions, procedures, and organisation of work; obtaining sufficient competence, experience, and knowledge; and a positive team culture and relationships were all vital for the teams. The findings showed varying importance of the different enabling factors within the four different types of teams, indicating that there are no fixed terms of supporting teams, and that both team type and organisational setting needs to be considered. Paper III investigated the role of system level factors for adaptive capacity. Two main health system factors were found to enable adaptive capacity; organising according to regulatory requirements, and negotiation of various resources provided by the governing authorities to ensure adaptive capacity. The various resources provided to the teams affected their design and function. The different teams needed to negotiate the various rules and procedures provided by system level governors to fit with their everyday work. It was the teams’ opportunity in the system to negotiate these requirements and regulations to their own context that impacted their adaptive capacity. The findings imply that healthcare systems need to facilitate conditions that allow hospital teams to develop quality management requirements to their specific context. Conclusions: The result from this thesis identified several multilevel factors influencing adaptive capacity in hospital teams. The study shows how the front-line leaders contribute in several ways and provide a significant role for their team’s adaptive capacity. Their knowledge of everyday work and handling of risk were vital for the teams. Furthermore, they strive to be good role models and build a positive supportive culture within the teams, as this is perceived to be crucial for adaptive capacity. Various team factors influenced their adaptive capacity. Competence, experience, and knowledge were vital and a key enabler for learning in the teams. In addition, various resources such as technology and tools, guidelines and procedures were important. The key findings regarding the teams nonetheless concerned how relationships between team members and a positive, supportive culture enabled adaptive capacity. This needs further scrutiny to determine how these aspects could be enhanced within teams. System level actors provided the teams with various resources to direct and enable their everyday work. These governing regulations influenced how the teams were organised and prioritized their work. However, the system level actors are responsible for the entire health service and must contribute general regulations without knowing exactly what every day work looks like in the sharp end of healthcare. Therefore, the teams’ ability to negotiate and align these system level requirements to their own diverse contexts was significant for their adaptive capacity. Allowing hospital teams more freedom to use their professional ethos in decision making thus merits further study.