Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study

Sanford, Natalie; Lavelle, Mary; Markiewicz, Ola; Reedy, Gabriel; Rafferty, Anne Marie; Darzi, Ara; Anderson, Janet

doi:10.1016/j.apergo.2022.103688

Cited by 22 publications

(28 citation statements)

References 30 publications

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“…First the umbrella perspective of the overall situation and future needs (long term perspective and planning), and second, to be aware of the immediate ongoing situation (short term planning and response), taking into account all facets in their decision-makings, and reorganising to support adaptive capacity in teams. However, leaders were clear about the consequences of common trade-offs, such as sacrificing scheduled competence development for staff to respond to acute patient situations or a sudden and unexpectedly high flow of incoming patients [28][29][30]. Such trade-offs reduced the overall resilience of the teams in the longterm and was a constant struggle for the team leaders to manage.…”

Section: Leading Through Contextual Understandingmentioning

confidence: 99%

Exploring the role of leaders in enabling adaptive capacity in hospital teams – a multiple case study

Fagerdal

Lyng

Guise

et al. 2022

BMC Health Serv Res

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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.

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Section: Leading Through Contextual Understandingmentioning

confidence: 99%

Exploring the role of leaders in enabling adaptive capacity in hospital teams – a multiple case study

Fagerdal

Lyng

Guise

et al. 2022

BMC Health Serv Res

Self Cite

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“…Safety is just one of many goals to be achieved in executing tasks, and so productivity and safety conflict with each other [28,29]. Employees find solutions to deal with goal conflicts, but little is known about how they achieve this through improvisations [30,31]. With this research we shed more light on the success of local ingenuity, whether in accordance with rules or not, within an operational unit of a military organisation.…”

Section: Implications For This Researchmentioning

confidence: 94%

Goal Conflicts, Classical Management and Constructivism: How Operators Get Things Done

Boskeljon-Horst

Boer²,

Sillem

et al. 2022

Safety

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In this study we identify the differences in goal realisation when applying two conflicting paradigms regarding rule perception and management. We gathered more than 30 scenarios where goal conflicts were apparent in a military operational unit. We found that operators repetitively utilized certain routines in executing their tasks in an effort to realize several conflicting goals. These routines were not originally intended nor designed into the rules and not explicitly included in documentation. They were not necessarily at odds with the literal wording and/or the intent of rules and regulations, although we did find examples of this. Our data showed that local ingenuity was created innovatively within the frame of existing rules or kept invisible to those outside the unit. The routines were introduced and passed on informally, and we found no evidence of testing for the introduction of new risks, no migration into the knowledge base of the organisation, and no dissemination as new best practices. An explanation for this phenomenon was found in the fact that the military organisation was applying a top-down, classical, rational approach to rules. In contrast, the routines were generated by adopting a constructivist view of rules as dynamic, local, situated constructions with operators as experts. The results of this study suggest that organisations are more effective in solving goal conflicts and creating transparency on local ingenuity if they adopt a constructivist paradigm instead of, or together with, a classical paradigm.

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“…The wards included in the study were: two surgical wards, an older adult ward, a critical care unit, and the Acute Assessment Unit (AAU), an extension unit created to expedite patient flow out of the Emergency Department. Preliminary results from this analysis have been reported in a conference paper [ 12 ] and a separate analysis related to hospital pressures has also been published [ 19 ].…”

Section: Methodsmentioning

confidence: 99%

“…Events were observed where they occurred naturally, and so observations were not necessarily confined to the ward area. The observations included activities such as: ward rounds, medication rounds, and general ward activities, as well as coordinating events such as handovers, board rounds, multi-disciplinary team (MDT) meetings, and bed meetings [ 12 , 19 ]. In-depth ethnographic field notes were transcribed and uploaded into NVivo 12 for storage, organisation, and analysis on a password-protected computer.…”

Section: Methodsmentioning

confidence: 99%

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Understanding complex work using an extension of the resilience CARE model: an ethnographic study

Sanford

Lavelle

Markiewicz

et al. 2022

BMC Health Serv Res

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Background Resilient Healthcare research centres on understanding and improving quality and safety in healthcare. The Concepts for Applying Resilience Engineering (CARE) model highlights the relationships between demand, capacity, work-as-done, work-as-imagined, and outcomes, all of which are central aspects of Resilient Healthcare theory. However, detailed descriptions of the nature of misalignments and the mechanisms used to adapt to them are still unknown. Objective The objectives were to identify and classify types of misalignments between demand and capacity and types of adaptations that were made in response to misalignments. Methods The study involved 88.5 hours of non-participant ethnographic observations in a large, teaching hospital in central London. The wards included in the study were: two surgical wards, an older adult ward, a critical care unit, and the Acute Assessment Unit (AAU), an extension unit created to expedite patient flow out of the Emergency Department. Data were collected via observations of routine clinical work and ethnographic interviews with healthcare professionals during the observations. Field notes were transcribed and thematically analysed using a combined deductive-inductive approach based on the CARE model. Results A total of 365 instances of demand-capacity misalignment were identified across the five wards included in the study. Of these, 212 had at least one observed corresponding work adaptation. Misalignments identified include equipment, staffing, process, communication, workflow, and space. Adaptations identified include process, resource redistribution, and extra-role performance. For all misalignment types observed across the five in-patient settings, process adaptations were the most frequently used adaptations. The exception to this was for staffing misalignments, which were most frequently responded to with extra-role performance adaptations. Of the three process adaptations, hospital workers most often adapted by changing how the process was done. Conclusions This study contributes a new version of the CARE model that includes types of misalignments and corresponding adaptations, which can be used to better understand work-as-done. This affords insight into the complexity of the system and how it might be improved by reducing misalignments via work system redesign or by enhancing adaptive capacity.

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Capturing challenges and trade-offs in healthcare work using the pressures diagram: An ethnographic study

Cited by 22 publications

References 30 publications

Exploring the role of leaders in enabling adaptive capacity in hospital teams – a multiple case study

Exploring the role of leaders in enabling adaptive capacity in hospital teams – a multiple case study

Goal Conflicts, Classical Management and Constructivism: How Operators Get Things Done

Understanding complex work using an extension of the resilience CARE model: an ethnographic study

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