Team resilience : exploring adaptive management of complexity in healthcare

<p dir="ltr">Background: The research on safety in health care has during the last decades moved towards understanding how safety is managed as an integral part of everyday clinical work (ECW). Resilient healthcare (RHC) defines safety as an emergent property which is constantly present in teams everyday work, where normal variation and risks caused by the continuously changing healthcare system are managed. Safety is a dynamic non-event, and it infiltrates all levels and dimensions of an organization.</p><p dir="ltr">A resilient organization has an intrinsic capacity to adjust its functioning prior to, during, or following expected and unexpected situations. Evidence of such adaptations could be identified by exploring how healthcare teams manage ECW in the complex adaptive system (CAS) of healthcare. Understanding the dynamics of team resilience and factors supporting it may provide knowledge on versatile strategies and opportunities to sustaining and enhancing patient safety in the frontline.</p><p dir="ltr">Aim: The aim of this thesis is to deepen the understanding on how risks are proactively managed by healthcare teams - what resilience and sustaining safety look like in healthcare teams, and what factors support the proactive management of complex situations in everyday work.</p><p dir="ltr">Methods: Thesis is comprised of four sub-studies. Both quantitative and qualitative methods from deductive and inductive approaches are used, in an explorative research design, conducted in intraoperative anaesthesia care, in Sweden and in Finland.</p><p dir="ltr">Study I observed the surgical team in situ, using a prospective, structured observation tool (WOMBAT). From 26 observation sessions and 169 observation hours the type and frequency of tasks, multitasking, interruptions and their causes, and interactions were described. Data was analyzed using descriptive statistics. Study was conducted in Sweden.</p><p dir="ltr">Study II analyzed further data from study I, visualizing work as done by mapping all phases of intraoperative anaesthesia care process, conducted by the registered nurse anaesthetists' (RNA). 30 observation sessions including 73 observation hours were analyzed using descriptive statistics.</p><p dir="ltr">Study III explored factors supporting anaesthesia teams in managing complex everyday situations during intraoperative anaesthesia care process. Individual interviews with anaesthesia nurses (n=9) and anaesthesiologists (n=6) were conducted using cognitive task analysis (CTA) on case scenarios constructed from studies I and II. The interviews were analyzed using the framework method. Study was conducted in Finland Study IV investigated the conceptual structure, operationalization and contextualization of team resilience in healthcare. The phased principle-based concept analysis with quality criteria was used. Data was collected through scoping review and analyzed with reflexive content analysis.</p><p dir="ltr">Findings</p><p dir="ltr">Study I elucidated the work as done (WAD) among the surgical team members in the CAS of an operating room (OR). Teams dealt with multitasking and interruptions. Task distribution reflected the interactions and constant adaptations. RNAs task intensity, multitasking, number of interruptions and contacts were the highest among the operation team.</p><p dir="ltr">Study II illustrated RNAs WAD and adaptations, comprising of phases with variation regarding the level of complexity through task intensity, task distribution, amount of multitasking, interruptions and interactions. Most intensive phases were anaesthesia induction and preparation for anaesthesia maintenance.</p><p dir="ltr">Study III elucidated further, how safety is sustained during the expected and unexpected complex situations during intraoperative anaesthesia care. Safety was sustained in the team level through strategies, supported by organizational prerequisites. Management of complex situations benefits from high-quality teamwork and non-technical skills.</p><p dir="ltr">Study IV described team resilience in healthcare being understood relatively consistently, but an unambiguous definition was lacking. Two aspects, systemic and team, composed a dualistic component of team resilience in healthcare, affecting both concept and characteristics in the definition. The presence of resilience skills and interactions between individuals completed the concept of team resilience, which previously has been broadly defined as an emergent system property. A new model and a theoretical definition were proposed.</p><p dir="ltr">Conclusions</p><p dir="ltr">Everyday complexity in intraoperative anaesthesia care consists of multiple simultaneous processes in an interprofessional team, in addition to profession specific tasks, multitasking, interruptions and interactions, in the CAS of an OR. Exploring WAD during the intraoperative anaesthesia, a picture of a complex, dynamic process, including multiple moments of adaptations is elucidated.</p><p dir="ltr">The concept team resilience in healthcare is multifaceted, embracing both systemic and team perspectives of resilience. This duality should be seen as a clarifying lens to further research, assisting in further operationalization of the concept. Team resilience is supported by active processes from both organization and team level strategies and actions.</p><p dir="ltr">Team resilience is present as an intrinsic team capacity, but when a trigger for adaptation is identified, it changes to an active status, resulting in a possible re- organization of courses of action. These moments of adaptation should be identified as a safety potential situations for learning, how safety is proactively managed during everyday care.</p><p dir="ltr">As the context of this thesis was in intraoperative anaesthesia care and previous studies explored team resilience mostly in hospital context, to further clarify the conceptual structure and position of team resilience in healthcare, the model presented in this thesis, underlying behavioural and systemic factors and adjacent concepts should be explored in various contexts, situations and types of teams.</p><h3>List of scientific papers</h3><p dir="ltr">I. Göras C*, Olin K*, Unbeck M, Pukk Härenstam K, Ehrenberg A, Tessma MK, et al. Tasks, multitasking and interruptions among the surgical team in an operating room: A prospective observational study. BMJ Open 2019;9:e026410. *Both authors contributed equally.<br><a href="https://doi.org/10.1136/bmjopen-2018-026410" rel="noreferrer" target="_blank">https://doi.org/10.1136/bmjopen-2018-026410</a><br><br></p><p dir="ltr">II. Olin K, Göras C, Nilsson U, Unbeck M, Ehrenberg A, Pukk Härenstam K, et al. Mapping registered nurse anaesthetists ' intraoperative work: tasks , multitasking , interruptions and their causes , and interactions: a prospective observational study. BMJ Open 2022;12:e052283.<br><a href="https://doi.org/10.1136/bmjopen-2021-052283">https://doi.org/10.1136/bmjopen-2021-052283</a><br><br></p><p dir="ltr">III. Olin K, Klinga C, Pukk Härenstam K. Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: An interview study. BMC Health Services Research 2023 23:651.<br><a href="https://doi.org/10.1186/s12913-023-09674-3">https://doi.org/10.1186/s12913-023-09674-3</a><br><br></p><p dir="ltr">IV. Olin K, Hybinette K, Pukk Härenstam K. Exploring the concept of team resilience in healthcare - a phased principle-based concept analysis, and potentials for development. Theoretical Issues in Ergonomic Science 2025 1-21.<br><a href="https://doi.org/10.1080/1463922X.2025.2516518">https://doi.org/10.1080/1463922X.2025.2516518</a><br></p>