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Table 1 Descriptions, aims and methods used to study and factors that develop RHC

From: Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience

 Study referenceDescription of RHCAim of studyMethods used to study RHCFactors used to develop RHC
Peer-reviewed articles
1.Gittell, J 2008 (USA) [33]• Organisational resilience … incorporates insights from both coping and contingency theories. It refers to the maintenance of positive adjustment and the ability to flourish or thrive amid adverse conditions when rigidity might otherwise be expected.• Explore the role of relationships and organisational practices in enabling workers to respond in a resilient way to external pressures.• Archival data.• Relational coordination between professionals by sharing goals, knowledge and mutual respect.
• Interviews.• Frequent, timely, accurate and problem- solving communication for effective coordination.
• Observations.
• Surveys.
2.Mash B, J, et al. 2008 (South Africa) [34]• The organisation’s ability to remain true to its core values, competencies and vision rather than invest in a specific structure.• Explore how to create more successful practice teams based on doctors and nurses experience.• Interviews.• Staff meeting and discussion with an ongoing exchange of ideas and experiences.
• Observations and documentation of changes in progress markers and success of strategies.
• Communication with respect, appreciation and trust.
• Teamwork that enables health care professionals to easily interact and commit to each other.
• Structured questionnaire.
• Effective leadership by sharing the vision, and identifying values.
• Feedback for reflection and learning.
3.Brattheim B, et al. 2011 (Norway) [47]• … process variation related to flexibility is an integral part of how actors deal with uncertainty, variability and high risk, enhancing safety in unpredictable settings. The resilience engineering approach to managing variations centres on attention to essential properties of adaptive behaviours.• Identify the characteristics and sources of abdominal aortic aneurysm process variability within and between different hospitals.
• Develop suggestions for how to design IT-based process support to enhance resilience in this process.
• Observations.• Capability of awareness.
• Semi-structured interviews.• Capability to gain knowledge from experience.
• Reduce unintended process variation.
4.Nemeth C, et al. 2011 (USA) [43]• The ability of systems to mount a robust response to unforeseen, unpredicted, and unexpected demands and to resume or even continue normal operations.• Develop information and communication technology to support crisis management in healthcare settings.• Observational study.• N/A
• Cognitive task analysis.
• Interviews.
• Resilience is an emergent property of systems that is not tied to tallies of adverse events or estimates of their probability.• Artefact analysis.
• Work domain analysis.
• Studies how people at all levels of an organization try to anticipate paths that may lead to failure, to create and sustain strategies that are resistant to failure, and to adjust tasks and activities to maintain margins in the face of pressure to do more and to do it faster.• Process tracing.
• Rapid prototyping.
• Evaluation.
• A resilient system can adjust its functioning prior to, during, or following changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress.
• The notion of resilience frees safety research from hindsight bias by making it possible to understand how workers anticipate possible adverse outcomes and act in advance to avert them.
5.Ross A, et al. 2012 (UK) [44]• The capacity of a system to adapt safely to changing conditions. Resilience can be defined as the ability of a system to self-correct and adapt to disturbances so that normal operations can be maintained even when unexpected conditions are encountered.• Investigate how clinical staff deliver inpatient diabetes care.• Interviews.• Understanding the nature of the gap and how front-line practitioners bridge it and sometimes fail.
• Cognitive task analysis.
• Identify how resilience is created and/or breaks down.• Specialist team to coordinate decision making for various medical conditions that open a line for education, detecting problems and managing them early.
• Provide a basis for designing interventions to improve care.
• Good feedback, communication and monitoring.
• Updating knowledge.
6.Crowe S, et al. 2014 (UK) [35]• The capability of a health system to mitigate the impact of major external disruptions on its ability to meet the needs of the population during the disruption.• Explore the feasibility of assessing resilience across local health services and develop a computer software to assess resilience of different service reconfigurations in the NHS in England.• Computer software modelling tool to assess resilience.• N/A
• Optimisation and heuristic methods to capture response.
7.Clay-Williams R, et al. 2015 (Australia and Denmark) [48]• N/A• Investigate whether FRAM can be used to identify process elements in a draft guideline in order to develop a new guideline that aligned with WAD.• FRAM.• Realign WAI with WAD in implementing guidelines.
• Meetings.
8.Drach-Zahavy A, et al. 2015 (Israel) [36]• Identify, correct and ‘bounce back’ from errors, with obvious positive consequences for patient’s safety.• Examine the relation between the strategies used during handovers and the type and number of errors in the following shift.• Observations.• Face to face communication between health care professionals and non-professional workers with patients.
• Data extraction from patient’s chart.
• Surveys.• Interactive discussion between incoming and outgoing health care professionals that enhances safety through situational awareness.
• Exposure to a diversity of opinions.
9.Sujan M, et al. 2015 (UK) [46]• The ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions.• Demonstrate how the study of handover’s everyday clinical work can contribute novel insights into a common and stubborn patient safety problem.• Observations.• Dynamic, and context-dependent trade-offs.
• Semi-structured interviews.• Staff experience.
• Process mapping.• Intuition.
• Reconcile the gap between WAI and WAD.
• Verbal communications.
• Performance variability.
10.McCray J, et al. 2016 (UK) [42]• Team Resilience is a team’s ability to “bounce back” and “maintain” performance under adverse circumstances. Performance is the team outputs and delivery, and in the case of integrated teams in the health and social care sector, is likely to be linked to service user outcomes.• Explore the making of resilient team from the perspective of managers in health and social care organisations.• Focus groups.• Effective teamwork.
• Team relationship.
• Identify factors that affect team performance.
11. Wachs P, et al. 2016 (Brazil, USA) [51]• The intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions. In turn, performance adjustment means filling in the gaps of standardized operating procedures, whatever their extent and reason.• Investigating resilience skills in emergency departments by understanding how interactions between the elements forming a socio-technical system give rise to resilience skills.• Observations.• Individuals and Team Factors:
• Critical decision method interviews.➢ Collaborative work.
• Questionnaires.➢ Matching capacity and demand.
• Documents analysis.➢ Communication.
• Meetings.➢ Recognise the impact of small actions and decisions.
➢ Prioritise actions and decisions.
➢ Identify contextual factors that can hinder performance.
➢ Anticipation of the need for actions.
➢ Managing the trade-off between times allocated to care patients and number of patients seen.
➢ Re-plan the sequence of activities.
➢ Leadership.
➢ Workarounds involving the use of equipment and materials.
• Organisational factors:
➢ Contingency plans for crisis management.
➢ Standardisation of managerial and care processes.
➢ Support for collaborative work.
➢ Computerised system.
➢ Management of human and material resources.
➢ Measures to deal with lack of beds for admitted patients.
12.Back J, et al. 2017 (UK) [40]• The intrinsic ability of a health care system to adjust its functioning prior to, during, or following events (changes, disturbances and opportunities), and thereby sustain required operations under both expected and unexpected conditions.• Examine escalation policies in theory and practice using RHC principles.• CARE model.• Team work structure.
• Analysis of escalation policies.• Awareness of the state of the hospital system based on experience and expertise.
• Observations.
• Interviews.
13.Larcos G, et al. 2017 (Australia) [39]• … refines safety by promoting flexibility rather than compliance with protocols, guides and training.• Identify the rate and nature of interruptions the nuclear medicine technologists experience.• Observations.• Responsiveness by reacting effectively when a situation changes.
• Linear regression analysis.
• Identify strategies that support safety in the workplace.• Discussions.• Attentiveness by taking appropriate action considering the situation at hand.
• Suggest quality improvement strategies in nuclear medicine that may complement those derived from incident reporting.• Anticipation.
• Experience.
14.Pickup L, et al. 2017 (UK) [53]• Refers to how well a system is designed to recognise and respond to such shifts within an organisation and the impact on how a system function. A resilient system would be capable of identifying and adapting to potential vulnerabilities or threats to safety without the need for an incident or accident to occur.• Understand why performance might vary in blood sampling in acute hospital settings and how a Safety-II approach can inform future safety management programmes.• FRAM.• N/A
• Observations.
• Semi structured interviews.
15.Raben DC, et al. 2017 (Denmark) [49]• … focuses on how healthcare systems succeed by rapidly responding and adapting performance in everyday work.• Asses the feasibility of the LIIM and the challenges or difficulties revealed in the process of blood sampling.• FRAM.• N/A
• LIIM.
• Observations.
• Identifying leading indicators for blood sampling among patients in a Biomedical Department.• Semi-structured interviews.
• Focus groups.
• Walk-throughs.
16.Damen NL, et al. 2018 (Australia and Denmark) [50]• N/A• Understand and compare WAI and WAD in preoperative anticoagulation management.• FRAM.• N/A
• Interviews.
• Examine the utility of FRAM to reconcile WAI and WAD.
17.Merandi J, et al. 2018 (USA) [52]• Resilience is an essential part of Safety II. Safety II requires an “adjustment to functioning,” which goes beyond “good catches” (situations in which error is avoided by performing an expected task).• Identify factors in a hospital system and individuals that support increased resilience in delivering patient care.• Focus groups.• Individuals and team factors:
➢ Situational awareness.
➢ Experience and expertise.
• Resilient systems require humans to learn from what goes right and develop adaptations and flexibility to incorporate that learning going forward.➢ Recognising the inevitability of error.
➢ Teamwork.
➢ Effective, open and clear communications.
➢ Training.
➢ Careful examination and feedback after errors.
➢ Double- check.
➢ Prioritising work.
➢ Commitment to standard procedures.
➢ Bridging experience from other microenvironments.
• Structural and environmental factors:
➢ Familiarity and proximity.
➢ Shift resource availability.
18.Raben DC, et al. 2018 (Denmark) [54]• N/A• Investigate how complex processes produce positive outcomes despite variability in the early detection of sepsis using FRAM.• Document reviews.• Experience.
• Focus groups.• Ability to multi-task.
• Observations.
• Interviews.
• FRAM.
19.Rosso C, et al. 2018 (Brazil) [41]• The ability of the health care system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required performance under both expected and unexpected conditions.• Develop and test a framework design, which combines insights from lean production and RE.• FRAM.• Creation of conditions to design and construct systems that have the capacity of resilience.
• Stream mapping.
• Notes from observations, focus groups and other documents.• Modelling designs by developing innovative artefact to solve practical problems and make scientific contribution.
• Resilience in health care … shed light on the gap between WAI and WAD, as well as on new approaches for patient safety, which rely on learning from every day work, instead of only from adverse events.
20.Wahlström M, et al. 2018 (Finland) [45]• The intrinsic ability of a system to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions.• Explore surgeons’ adaptations to situational demands within robotic surgery.• Core-task analysis.• Mindfulness characterises: anticipation, backups, holistic consideration of patient anatomy, and thoughtful damage minimisation.
• Action-perception-cycles.
• Observations.
• Video analyses.• Technical developments and medical knowledge.
• Interviews.• Situational interpretation.
• Self-confrontation video sessions.
• Workshops.
Book chapters
21.Cuvelier L, et al. (France) [55]• The intrinsic ability of a system to adjust its functioning so that it can sustain required operations under both expected and unexpected conditions.• Identify strategies used by anaesthesiologists to avoid negative consequences of variability in everyday work.• Open-observations.
• Incidents.
• Interviews.
• Care protocols.
• Experience.
• Making situations more predictable.
• Increase knowledge.
• Vocational training.
• Cognitive trade-off.
• Mobilisation of additional resources.
• It is not only the system’s ability to cope with unforeseen variability that fall outside the expected areas of adaptations, but also looks at its ability to operate in foreseen conditions.
• A resilient system is the one capable to detect that the conditions have changed, to assure transition to another state and to operate in the new state of resilience achieved.
22.Pariès J, et al. (Switzerland) [56]• The ability to make sacrificing decisions, such as accepting failures to reach an objective in the short term to ensure another long-term objective, or ‘cutting one’s losses’ by giving up initial ambitions to save what is essential.• Observe how the ICU in the University Hospital of Geneva was functioning after the merger of two hitherto separate units.• Observation grid.• Anticipation capacity.
• Skills and accuracy of team’s perception.
• Understand how and why the merger units succeeded or failed in controlling variations.• Trade-offs.
• Diversity of experiences.
• The ability to acknowledge the need to shift from one mode to the other. It measures the quality and robustness of trade-offs; their stability in the presence of disturbances.• Interactions with patients.
• Intuition.
• Sacrificing decisions.
• Functional reconfiguration.
• Collaboration between different job profiles.
• Strong team spirit.
• Leadership mechanisms.
• Flexible delegation.
23.Laugaland K, et al. (Norway) [57]• The ability of health care system to succeed under varying conditions to increase the proportion of intended and acceptable outcomes.• Explore how different wards and units in hospital and primary care adjust their functions to sustain new demands imposed by system reforms.• Observations.• Multi-faceted outcomes from different perspectives.
• Interviews.• Interconnections between systems.
• Adjustments could be deemed successful from one perspective but not from the viewpoint of others.
• Different outcomes thus represent different judgement of values that need to be explored and acknowledged in order to be able to share a common ground on what constitutes acceptable, successful outcomes.
24.Stephens RJ, et al. (USA) [68]• Capacity for manoeuvre.• Analyse strategies taken by staff for regulating capacity for manoeuvre in terms of RE concepts.• Observations.• Coordinate adaptive capacities across units.
• Regulate the capacity for manoeuvre.
• Reduce the risk of decompensation in hospital units.
• Reciprocity.
25.Anderson JE, et al. (UK) [58]• The ability of the health care system to adjust its functioning prior to, during, or following events (changes, disturbances and opportunities), and thereby sustain required operations under both expected and unexpected conditions.• Investigate how care of older people was delivered, how decisions were made and how people adapted to pressure in clinical environment.• Interpretive approach.• Balance different goals during discharge process.
• Observations.• Plan and co-ordinate the different tasks for discharge across different staff groups, agencies, and families and carers.
• Interviews.
• Design and implement interventions to increase the safety and quality of care.• CARE model.
• … ability or capacity for adaptation, rather than a state of the system.
• Understands the complexities of the whole system rather than focuses on a discrete part.
26.Debono D, et al. (Australia) [59]• Adapt, flex and navigate competing demands so as to adjust under expected or unexpected conditions in order to sustain required operations.• Explore nurses’ role and explanations of workarounds when using electronic medication management systems to understand the gap between WAI and WAD.• Comparing WAI (process mapping) with WAD (observations, interviews and focus groups).• Workarounds.
• The shifting and jostling demands of delivering care that prioritise one goal over another in a continually changing way, the role of context in influencing that process, and ongoing judgements about when to use [or not use] primary and secondary workarounds.
27.Deutsch E, et al. (Unstated) [37]• Reinforcing appropriate actions and resources making the margins and constraints of the system visible, and developing team behaviours that have the potential to improve the adaptive capacity of the team.• Explore the role of simulation to understand and support the emergence of RHC.• Simulation.• N/A
• NASA-TLX score.
• Debriefing.
• Analyse the simulation performance from the perspective of four abilities for resilience.
28.Furniss D, et al. (UK) [60]• It can adjust its functioning prior to, during, or following events (changes, disturbances, and opportunities), and thereby sustain required operations under both expected and unexpected conditions.• Investigate if the RMF can be used to extract resilience strategies during interviews.• RMF.• Provide an alternative means for clinicians to access relevant medical information.
• Semi-structured interviews.
• Explore resilient strategies in anaesthetic’s environment.• Take time for mental preparation.
• Take drugs and equipment to emergency calls.
• Maximise information extraction.
29.Heggelund C, et al. (Norway) [61]• N/A• Explore the resilience mechanisms used in maternity services in two Norwegian hospitals.• Theoretical framework using the four cornerstones of resilience: anticipation, monitoring, learning, and response.• Identify the content and evaluate the variability in the four cornerstones of resilience.
• Flexible organising.
• Qualitative interviews, focus group interviews, field notes from observations (meso and micro level) and analysis of national documents (macro level).• Cultural factors (openness, support, communication, cohesion and trust).
• Mixing experienced and inexperienced people.
• Knowledge and experience.
• Buffer of staff familiar with the services.
• Procedures and the use of checklists and protocols.
• Simulation.
• Multi and inter disciplinary training.
• Teamwork.
• Statistics available for employees.
30.Horsley C, et al. (New Zealand) [62]• The ability of the health care system to adjust its functioning prior to, during or following events (changes, disturbances, opportunities) and thereby sustain required operations under both expected and unexpected conditions.• Assess aspects of team functioning in a Critical Care Complex, describe elements of a functional team and how this forms a foundation to adapt to different situations using a Team Resilience Framework.• Team Resilience Framework.• Shared understanding of current situation.
• Simulation.• Allocate or self-nominate roles to team staff.
• Interviews and in-practice observations.• Efficient communication.
• Explicit about expectations.
• The ability to adapt over multiple timescales that marks the concept of resilience as different from concepts of robustness or rebound, in which temporary stressors on the system (i.e., patient admissions, acute events, disasters) must be absorbed without overt failure.• Know what to monitor.
• Flexible response to events.
• Learn why things go right.
• Open and productive team climate.
• Debriefings.
• RHC should expand its aspiration beyond safety or even ‘sustaining operations’ to seeing the potential for this approach to advance health care towards the long-held goals of safe, patient-centred care delivered by engaged staff.• Checklists.
• Team training.
• Human factors teaching.
• Shared team concept.
• Psychological safety.
31.Hounsgaard J,et al. (Denmark) [63]• N/A• Elucidate the impact of variability on everyday work in a spine centre.• FRAM.• Mnemonic systems.
• Interviews.
32.Hunte G, et al. (Canada) [64]• The ability of a system to adjust its functioning prior to, during, or following events (changes, disturbances and opportunities), and thereby sustain required operations under both expected and unexpected conditions. Central to this proactive approach is the understanding that safety is dynamic, emerges from everyday practice, and is something a system does.• Evaluate the RAG to develop a context-specific framework to be used by emergency care providers and ancillary staff and leaders to assess and monitor over time.• Dialogue workshop.• Team-environment.
• RAG.• Exploitation of resources.
• Systematic (re)prioritisation.
• Effective linkages, communication and attention to cross-scale interactions.
• In a resilient system, large increases in work processed contribute to only small increases in recovery, and the system is able to keep pace.
33.Nakajima K, et al. (Japan) [38]• To promote resilient health care, it is essential to understand how health care professionals actually work in a given environment. One way to understand everyday clinical work is based on the concepts of work-as-imagined and work-as-done.• Understand how work is actually done for handling KCL concentrate injection solutions in Japanese hospitals.• Direct and indirect approaches to represent WAD (minutes and memoranda of hospital committees, medication supply data, observations, interviews, and expert opinions).• Resource allocation.
• Systemic approach.
34.Ross A, et al. (UK) [65]• … to study responding, monitoring, anticipation and learning at all levels.• Explore how delivery of care happened in inpatient diabetes care by using the CARE model to guide their interpretation.• CARE model.• Inpatient care cycle.
• Interviews using cognitive task analysis techniques.• Workarounds and outcome trade-offs.
• Distributing expertise at the ward level.
35.Sujan M, et al. (UK) [66]• RHC is able to reconcile the gap between the way everyday clinical work unfolds WAD with the way managers and administrators think about clinical practice WAI.• Evaluate how safety cases are used in health care systems.• Process map and FMEA.• Communication and building trust between stakeholders.
• FRAM.
• Understand the gap between WAI and WAD in clinical handovers in emergency care.• Proactive and mindful.
36.Zhuravsky L, (New Zealand) [67]• The ability of the health care system to adjust its functioning prior to, during, or following events (changes, disturbances and opportunities), and thereby sustain required operations under both expected and unexpected conditions.• Demonstrate the practical application of RHC approach on sustained nursing performance after the Christchurch earthquake in New Zealand in 2011.• Autoethnographic methodology.• Leadership (individual and shared).
• Simulation and debriefings.
• Training.
• Workarounds.
• Proactive monitoring of signs of stress, fatigue and anxiety.
• Utilise technical capabilities.
• Handovers.
• Double-loop approach to learn.
• Realignment of WAI with WAD.
  1. Note: N/A is used when studies did not report methods used to study and/or factors to develop resilience
  2. CARE Concepts for Applying Resilience Engineering, FRAM Functional Resonance Analysis Method, FMEA Failure Mode Effects Analysis, ICU Intensive Care Unit, IT Information Technology, KCL Potassium Chloride, LIIM The Leading Indicators Identification Method, NASA-TLX The National Aeronautics and Space Administration- Task Load Index, RAG Resilience Analysis Grid, RE Resilience Engineering, RMF Resilience Markers Framework, UK The United Kingdom, USA The United States of America, WAD Work As Done, WAI Work As Imagined