Nurses' challenges and strategies for safeguarding care quality and safety: A qualitative study on situated resilience

Abstract

Background: Most healthcare delivery succeeds in safeguarding high-quality care and safety. This is largely due to the adaptive capacity and situated resilience work of healthcare professionals as nurses who keeps things on track. However, much of their situated resilience work in complex everyday practice remains hidden or is done behind the scenes.

Objective: To explore situated resilience in everyday nursing practice and shed light on the often invisible efforts of nurses as they manage immediate challenges and navigate complex processes to ensure care quality and safety.

Design: A qualitative design.

Settings: The surgical and an ambulatory care team of an urban, 600-bed Dutch teaching hospital.

Participants: Nurses (N = 37), nurse practitioners (N = 2), managers (N = 5).

Methods: Data were collected through 80 hours of non-participant non-participant observations, three semi-structured interviews with nurses and one monodisciplinary (i.e. nurses) focus group. Thereafter, two multidisciplinary focus groups were conducted. Data were analysed using thematic analysis. The research protocol was approved by the ethical review board of Erasmus University Rotterdam under number ETH2122-0079.

Results: Nurses are dedicated providing the high-quality care that ensures patient safety. In daily practice they face challenges that require them to make changes to system standards. We identified three key triggers for change and emerging strategies to handle these triggers: 1) when standard risk assessment does not fit nursing practice, nurses a) seem to comply with the system, b) adopt an investigative, attentive approach. 2) when protocols and guidelines do not align with daily practices, nurses a) proactively identify potential and actual changes, b) find the "golden mean" through relational negotiation and patient advocacy. 3) when nurses and other healthcare professionals hold differing values on care quality and safety, nurses a) find allies, and b) applied various indirect means.

Conclusions: Our study reveals that situated resilience in nursing is not only a television series of actions to fix misalignments or to deal with unexpected change. It unfolds as a relational process in which nurses adapt their behaviour intuitively according to a patient's unique situation, values, and interests. By balancing the individual patient's needs and values with organizational systemic demands nurses exhibit situated resilience. By recognizing and supporting situated resilience practices, organizations not only enhance the quality of daily practice but also structurally strengthen their adaptive and resilient capacities. Further research into the role of nurses in system-level resilience and the impact of experience on resilience behaviour is needed.

Social media abstract: Nurses exhibit resilience by balancing patient's needs with organizational systemic demands, and aligning differing values in a relational process @ijnsa2025.

Keywords: Healthcare delivery; Healthcare quality; Nursing; Nursing research; Patient safety; Qualitative research.

Fig. 1

Visualization of the research process.