A reflective process for analysing organisational resilience to improve the quality of care

Student thesis: Doctoral ThesisDoctor of Philosophy


The Resilience Analysis Grid (RAG) is an approach to analysing organisational resilience based on the idea that four abilities (responding, monitoring, learning and anticipating) underpin resilient system performance (Hollnagel, 2010). Although the RAG has undergone some rudimentary methodological development, it requires significant further elaboration and testing. 
Research Questions 
How can the RAG be further developed to provide a replicable context specific process? How can the views of healthcare staff be incorporated for analysing organisational resilience? 
A constructivist epistemology informed an exploratory sequential mixed method research design with nursing staff on an Acute Medical Unit (AMU) in a large, inner city London teaching hospital. 
Phase One 
This qualitative element of the study used focus groups to explore nurses’ everyday clinical work. Eighteen nurses took part in nine focus groups, with two to five participants in each focus group. A thematic analysis found that the nurses work was extremely complex, and that social interaction facilitated their adaptations. 
Phase Two 
This quantitative element of the study used a cross-sectional survey design, with survey items directly informed by the thematic analysis of the focus group data, to explore the views of 77 nurses on the AMU about how well the system could respond, monitor, learn and anticipate. The results showed the nurses thought the AMU was most effective at responding and least effective at monitoring. 
Phase Three 
This qualitative element of the study used semi-structured interviews with seven nurses to reflect on the survey results and explore system level interventions to improve the potential for resilient performance. The nurses provided detailed insights into the survey results and suggested high-level interventions for improving the potential for resilient system performance. 
This thesis advanced the RAG by developing a replicable process for healthcare professionals to analyse the organisational resilience of their healthcare systems. It also showed the resilience engineering theoretical perspective can be used to engage healthcare professionals to analyse the organisational resilience of their healthcare system and work towards interventions for quality improvement. The main limitations were the findings were restricted to a nursing population, the lack of evaluation, the limited findings on quality improvement and the lack of Patient and Public Involvement (PPI). The copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without proper acknowledgement.
Date of Award1 Jul 2019
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorJanet Anderson (Supervisor) & Anne Marie Rafferty (Supervisor)

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