Resilience and Adaptive Capacity in Hospital Teams

Student thesis: Doctoral ThesisDoctor of Philosophy


Introduction Resilient Healthcare, a field derived from Resilience Engineering, provides a set of theoretical principles for understanding quality and safety in complex systems. So far, these principles have been used to capture individual, departmental, and organisational proactive responses to variable conditions and how this flexibility, involving anticipating, monitoring, responding, learning, and coordinating, contributes to safety. Empirical exploration of Resilient Healthcare has primarily taken place in specific healthcare settings such as emergency departments and surgery, with specific activities such as flow procedures, anaesthesia, blood transfusion, nurse handover, electronic charting, and patient discharge. Understanding healthcare work beyond these limited settings and activities is important, as most patient encounters in the hospital occur in ward settings beyond surgery and emergency care. The role of the team in flexible adaptation also needs to be explored, as effective teamwork is widely recognised as a contributor to healthcare safety.

Healthcare teams are diverse and their need for adaptive capacity, the challenges they face, and their ability to coordinate are also likely to be different. Current research on healthcare teams involves teams that are easily defined, such as resuscitation teams, surgical teams, or teams in a simulation lab. Thus, the full range of healthcare teams and their capacity to adapt has not yet been captured. To better understand how to improve teamwork and safety, we must first understand how teams are already adapting to variable conditions in complex organisations. This includes aspects such as the clinical and organisational challenges they face, the dynamics of the team, how flexible teamworking can be supported, as well as more broadly understanding and categorising the different types of teams that exist in healthcare.

Aims and objectives The aim of this PhD was to investigate how adaptive capacity is hindered or supported by organisational and contextual factors in different types of hospital teams.
The study objectives were to:
1. Review the concept of adaptive teamwork, synthesising available cross-disciplinary research, clarifying key definitions, and identifying factors that might impact team adaptive capacity
2. Develop an empirically derived typology for classifying types of hospital teams based on their structure, membership, and function
3. Identify the misalignments, adaptions, pressures, and trade-off decisions of hospital teams in practice
4. Understand differences between types of hospital teams, both in the misalignments and pressures they experience and in the adaptations and trade-off decisions they make, using mixed qualitative methods in two hospitals in England

Methods The study was conducted in three phases:
- Phase 1: A scoping review of adaptive teamwork Phase one involved a scoping literature review to systematically map existing research on adaptive teamwork and to identify gaps in knowledge. The primary research question was: What do we know about the structure and function of adaptive teams in practice?
- Phase 2: Theory development Phase two involved analysis of data previously collected by the larger research team to better understand work-as-done and team structure in hospital teams. The data included 88.5 hours of hospital ethnography on five different hospital wards. An inductive-deductive approach to data analysis was undertaken.
- Phase 3: A case study of adaptive teamwork in England Phase three consisted of data collection in two hospitals situated within one Trust (one large and one community hospital), with five teams per hospital (two total teams of each type). In total, 144 hours and 54 minutes of ethnography were completed across the two hospitals and 24 semi-structured interviews were conducted. The overarching aim of the case study was to investigate how adaptive capacity is hindered or supported by organisational and contextual factors in different types of teams. This phase was conducted in a directed rather than exploratory way, building on the data from phase two and increasing the depth of understanding of all five team types. In this phase, both interview and observational data were analysed using the typology and two frameworks produced in phase two. The England case study will eventually contribute to a comparative, cross-country analysis to synthesise and compare findings between countries and healthcare systems (Anderson, Aase, et al., 2020).

Ethics and dissemination The overall Resilience in Healthcare research programme that this study is part of has been granted ethical approval by the Norwegian Centre for Research Data (Ref.No. 8643334). Ethical approval to conduct the study in England was granted through King’s College London Research Ethics Office (LRS/DP-21/22-26055). HRA REC approval was 10
also granted (22/HRA/1621; IRAS 312079). A research passport was obtained, and letter of access received from local Trust R&D.

Results The phase one scoping review included 204 documents and mapped their geographies, fields, settings, and designs. Terminology used to describe elements of the adaptive process were compared. A new conceptualisation of the team adaptive cycle was proposed, along with a new definition for team adaptive capacity. Future opportunities for research were proposed, including the opportunity to study adaptive teams in situ and to consider differences in team adaptive capacity based on unique team features. The second phase of the study resulted in the conceptualisation of: a typology of healthcare teams (paper under review), the Concepts for Applying Resilience Engineering Model 2.0 (published paper), and the Pressures Diagram (published paper). Building on this, the third phase suggested that teams’ adaptive strategies varied based on team type, although demand-capacity misalignments occurred across all team types, suggesting that team type impacts adaptive capacity. While adaptations supported teams’ abilities to overcome misalignments, they also required resources and were more or less possible depending on team type. Likewise, while pressures occurred across all team types, trade-off decisions varied depending on the team type. These findings have implications for team training, workforce planning, and resourcing, and can inform future work that aims to strengthen adaptive capacity and teamworking.

Conclusions Overall, this thesis makes unique and important contributions to the literature on both resilient healthcare and adaptive teamwork. It has developed multiple new practical and theoretical models and typologies that have subsequently been used internationally in research. A novel approach combining teamwork and resilient healthcare theory was used successfully to understand and compare healthcare misalignments, adaptations, pressures, and trade-offs in five different team types. The finding that adaptive strategies and trade-off decisions differ based on team type challenges existing teamwork improvement practices, which take a one-size-fits-all approach to conceptualising and training teams. The results provide foundational knowledge to guide future intervention design, which may potentially bring about wider changes in training and sustaining successful teams and supporting their adaptive capacity.
Date of Award1 Mar 2024
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorJanet Anderson (Supervisor), Anne Marie Rafferty (Supervisor) & Gabriel Reedy (Supervisor)

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