Resilience in a prehospital setting - a new focus for future research?

There is broad agreement that a well-functioning trauma and emergency system, with a seamless treatment chain from scene to completed treatment, is essential for optimal patient outcome. However, there is a lack of studies investigating which elements contribute to increased quality and patient safety and why this treatment chain usually works well. A systematic review of studies evaluating the effects, reliability, validity and feasibility of interventions improving patient safety in emergency care identified a lack of evidence on effective safety governance strategies, particularly in the field of prehospital emergency care [9]. Simulation-based training and incident reporting systems with a focus on reducing the fear of reporting, reporting burden, and structural and systematic feedback, are promising interventions to improve the governance of patient safety in emergency care [9]. Articles discussing resilient health care in Eds recognized that to operate effectively and create value, EDs must be flexible, having the ability to rapidly adapt to the highly variable needs of patient [10]. Safety II and the resilience research is interested in examining the overwhelming majority of healthcare processes with successful outcomes to determine how high quality patient care is generated in everyday clinical practice [11]. Resilience in healthcare is conceptualized as a proactive ability to adjust to potentially harmful influences and challenges rather than to resist them, resulting in higher quality of care [12]. It’s a term that can be understood in a variety of ways, both at the individual, team and system level. Our understanding of the resilience term as a multi-level phenomenon, considers adaptive capacity to changes as a foundation for high quality care [12]. In this conceptualization resilience is defined as: the capacity to adapt to challenges and changes at different system levels, to maintain high quality care, involving flexibility, adjustments, improvisation, adaptation, and variability [12]. Current research on patient safety and resilience lacks theoretical integration of the multiple levels of the healthcare systems, from individuals and teams (micro), to organisations (meso), to regulatory bodies and policy level actors (macro) [8]. Working with severely ill or injured patients in the emergency chain demands both clinical skills and leadership at a micro level, coordination, adaptability and preparedness across tactical, operational and strategic levels at a meso level [13, 14], and development and compliance to a set of functional procedures and regulation from the regulatory bodies at the macro level [15].

To better understand and promote resilience, there is a need to explore the underlying mechanisms of adaptation, trade-offs and improvisation that occur in the emergency chain by exploring how people respond to disruptions, challenges and opportunities. There are factors, recognized at a personal level (self-efficacy, coping strategies and situation awareness) [16] and unidentified factors at system levels, influencing adaptation, trade-offs and improvisation. Identifying influencing factors for adaptation at different levels is of great importance for being able to conduct research and explore resilience in a practical perspective. Often healthcare performers are unable to follow procedures, checklists and standards in all situations. In some cases, adaptations can be necessary for safe service provision. Checklists can contribute to relieve stress and improve teamwork processes and often, in stressful situations, professionals sink to the level of their training and to automized procedures [17]. The professionals working in the field know that although protocols and guidelines have their place, work is only possible by continually adjusting what you do, which sometimes means improvising and working outside the “protocols”. This variability in performance is necessary to accommodate patients’ needs and unpredictable situations.

Although satisfactory individual technical skills, in combination with standardization and implementation of evidence-based guidelines, are prerequisite for developing multitasking skills, it is often not not enough to be prepared for challenging situations and better adaptive capacity. Given that the prehospital work conditions are so unpredictable and differs in scope and frequency, learning through everyday work is fundamental but not enough [18]. In a resilience perspective, learning through systematic training and simulation focusing on what works well is an under used learning source with a potential to significantly improve performance [19, 20]. Therefore, simulation can be an important tool for identifying factors that have an impact on adaptive capacity. However, apart from a small number of studies within certain clinical areas, healthcare research conducted from a resilience perspective in a prehospital setting is still in its infancy [7].