A First-line management team's strategies for sustaining resilience in a specialised intensive care unit-a qualitative observational study

Abstract

Objectives: Acute care units manage high risk patients at the edge of scientifically established treatments and organisational constraints while aiming to balance reliability to standards with the needs of situational adaptation (resilience). First-line managers are central in coordinating clinical care. Any systemic brittleness will be evident only in retrospect through, for example, care quality measures and accident statistics. This challenges us to understand what successful managerial strategies for adaptation are and how they could be improved. The managerial work of balancing reliability and adaptation is only partially understood. This study aims to explore and describe how system resilience is enhanced by naturally occurring coordination performed in situ by a management team under variable circumstances.

Design: An explorative observational study of a tertiary neonatal intensive care unit (NICU) in Sweden. One year of broad preparatory work followed by focused shadowing observations of coordination analysed through inductive-deductive content analysis from a perspective of resilience engineering.

Participants: A team of managers (ie, clinical coordinators, head nurses, senior medical doctors).

Results: The results describe a functional relationship between operational stress and a progression of adjustments in the actual situation, expressed through recurring patterns of adaptation. Managers focused on maintaining coherence in escalating problematic situations by facilitating teamwork through goalsetting, problem-solving and circumventing the technical systems' limitations.

Conclusions: Coordination supports a coherent goal setting by increased team collaboration and is supported by team members' abilities to predict the behaviour of each other. Our findings suggest that in design of future research or training for coordination, the focus of assessment and reflection on adaptive managerial responses may lie on situations where the system was 'stretched' or 'needed reorganisation' and that learning should be about whether the actions were able to achieve short-term goals while preserving the long-term goals.

Keywords: health policy; health services administration & management; organisation of health services; qualitative research; risk management.

Figure 1

The studied NICU in a tertiary level hospital with surgical capacity. Managers are visually located to illustrate their vicinity to the clinical care teams. Overarching goals are presented at the base of the figure with examples of how they are expressed in daily work. A selection of peripheral wards and units are illustrated in the surrounding area. The arrows are double headed to symbolise a two-way relationship of demands and possibilities for negotiation of for example patient transfers.

Figure 2

Illustration of the work of balancing goal-settings for system wide coherence, maintaining the umbrella perspective and streamlining communication to meet rapidly changing demands with the shadowed clinical coordinator at the centre. The width of the double headed arrows visualises an estimation of the most frequently observed communication for the respective manager.