Background
Stakeholders in resilient healthcare
Aim
Methods
Research setting
Research design
Defining the phenomenon of interest and the analytical boundaries
Data collection
No | Project statusa | System level | Empirical setting | Research study participants | Relevance to Qualityb | Relevance to Resilienceb | Data sources |
---|---|---|---|---|---|---|---|
1 | Finalised 2013 | Micro, meso, macro | Hospital maternity services | Midwives, Nurses, Doctors, Ward/Unit managers, Clinical directors, Medical directors, Clinic lead | Patient safety; risk assessment. Patient experiences; patient centeredness. | Implementation of quality improvement measures. Organisational capacity for adaptation; resources, organisation. Larger system capacity for adaptation; regulation; framework conditions. | Narrative Interview |
2 | Finalised 2019 | Micro and macro | National regulatory body County Governor’s office | Family carers, Regulatory investigators | Patient experiences; involvement (next-of-kin). Patient safety; adverse events. | Improvements to regulatory methods. Larger system capacity for adaptation; regulation. | Narrative |
3 | Ongoing | Micro and meso | Nursing homes Home healthcare services | Service directors, Nursing home managers, Home healthcare managers, Nurses, Nursing assistants, Enrolled nurses | Patient experiences; involvement. | Development and test of quality improvement intervention. Individual capacity for adaptation; knowledge, competence. Team/unit capacity for adaptation: learning. Organisational capacity for adaptation; resources, organisation. | Narrative Interview |
4 | Finalised 2016 | Micro | Transitional care – hospital admission and discharge | Ambulance workers, Nurses, Doctors, Patients, Family carers | Care coordination; care transitions, collaboration across service providers and care levels. Patient experiences; involvement. | Variation in work practice. Individual capacity for adaptation; knowledge, competence, learning, personal characteristics. Team/unit capacity for adaptation: communication. Organisational capacity for adaptation; organisation, culture, resources. | Narrative Interview |
5 | Finalised 2019 | Micro and meso | Home healthcare services | Nurses, Enrolled nurses, Care assistants, Physiotherapists, Occupational Therapists, Social workers, Home healthcare managers, Project managers, Professional development managers | Patient safety; risk awareness, risk assessment. | Changes to healthcare processes; variation in work practice. Individual capacity for adaptation; knowledge, competence, learning, personal characteristics. Team/unit capacity for adaptation: communication, learning. Organisational capacity for adaptation: resources, organisation, culture. | Narrative Interview |
6 | Finalised 2013 | Micro | Hospital surgical unit (two surgical departments) | Surgeons, Surgical nurses, Anaesthetists, Nurse anaesthetists, Clinic director, Section manager | Patient safety; adverse events. | Variation in work practice; teamwork. Individual capacity for adaptation; knowledge, competence, learning, personal characteristics. Team/unit capacity for adaptation: communication, collaboration, learning. Organisational capacity for adaptation: resources, organisation, culture. | Narrative |
7 | Finalised 2015 | Micro | Transitional care – discharge from hospital to primary care | Nurses, Doctors, Head nurses, Patients, Family carers | Care coordination; care transitions. Patient experiences; involvement. | Variation in work practice. Individual capacity for adaptation; knowledge, competence, learning. Team/unit capacity for adaptation: communication. Organisational capacity for adaptation; resources, culture, organisation. | Narrative Interview |
8 | Finalised 2020 | Micro | Psychiatric in-patient care | Patients, Nurses, Psychologists, Doctors | Patient experiences; involvement, patient centeredness. Patient safety; risk assessment. | Variation in work practice; stakeholder actions and contributions. Individual capacity for adaptation; knowledge, competence, personal characteristics. | Narrative Interview |
9 | Ongoing | Micro | Cancer department in two hospitals | Family carers, Nurses, Doctors, Ward/Unit managers | Care coordination: collaboration across service providers and care levels. Patient experiences; involvement (next-of-kin). | Stakeholder actions and contributions; knowledge-brokering; co-creation. Team/unit capacity for adaptation; collaboration, learning. | Narrative Interview |
10 | Finalised 2020 | Micro and meso | The interface between primary and secondary care – hospitals, nursing homes | Hospital doctors, General practitioners, Nursing home doctors, Nurses, Nursing home managers | Care coordination; collaboration across service providers and care levels, care transitions. | Variation in work practice. Individual capacity for adaptation; competence. Team/unit capacity for adaptation: communication, collaboration. | Narrative Interview |
11 | Finalised 2020 | Micro and macro | Hospital and general practice | General practitioners, Radiologists, Trainee radiologists, Radiographers, Doctor case managers | Care coordination; patient pathways, collaboration across service providers and care levels. | Variation in work practice. Individual capacity for adaptation: knowledge, competence, personal characteristics. Organisational capacity for adaptation; organisation, culture. Larger system capacity for adaptation; regulation, framework conditions. | Narrative Interview |
12 | Ongoing | Micro and meso | Municipal home healthcare services | Nurses, Occupational therapists, Older patients / people, Professional development managers | Patient safety; risk awareness, risk assessment. | Changes to healthcare processes; variation in work practice. Individual capacity for adaptation; knowledge, competence, learning, personal characteristics. Team/unit capacity for adaptation; communication, learning. Organisational capacity for adaptation; resources, organisation, culture. | Narrative Interview |
13 | Ongoing | Macro | Employees at the ministry, the directorate, and the Norwegian board of health supervision | Actors at the macro level at governmental regulatory bodies | Patient safety; risk regulation, risk management process, adverse events. | Improvements to regulatory methods. Individual capacity for adaptation; knowledge. Larger system capacity for adaptation; regulation. | Narrative |
14 | Finalised 2020 | Micro and meso | Nursing homes | Nurses, Nursing assistants, Care assistants, Nursing home managers, Nursing home doctors | Patient safety; adverse events. Care coordination; collaboration across service providers. | Variation in work practice; trade-offs; disruption. Individual capacity for adaptation; knowledge, competence. Team/unit capacity for adaptation; communication. Organisational capacity for adaptation; resources, organisation, culture. | Narrative Interview |
15 | Ongoing | Micro | Adolescent mental health services | Patients, Family carers, Nurses, Ward/Unit managers | Patient experiences: involvement, patient centeredness. | Variation in work practice; stakeholder actions; co-creation. Individual capacity for adaptation; knowledge, competence, personal characteristics. Team/unit capacity for adaptation; communication, collaboration. Organisational capacity for adaptation; resources, organisation, culture. | Interview |
16 | Ongoing | Micro | Transitional care – discharge from hospital to primary care | Patients, Family carers, Nurses, Doctors, Clinical nutritionists, Physiotherapists, Patient organisations | Care coordination; care transitions, collaboration across service providers and care levels. Patient experiences; involvement, patient centeredness. | Variation in work practice; stakeholder actions; knowledge-brokering; co-creation. Individual capacity for adaptation; knowledge, competence, personal characteristics. Team/unit capacity for adaptation; communication, collaboration. Organisational capacity for adaptation; resources, organisation. | Interview |
17 | Ongoing | Micro and meso | Home healthcare services | Patients, Family carers, Nurses, Occupational therapists, Physiotherapists, Home healthcare managers, Service managers, Case managers | Patient experiences; involvement, patient centeredness. | Variation in work practice; stakeholder actions; co-creation. Individual capacity for adaptation; knowledge, competence, personal characteristics. Team/unit capacity for adaptation; communication. Organisational capacity for adaptation; resources, organisation, culture. | Interview |
18 | Ongoing | Micro | Staff development in home healthcare services | Nurses, Healthcare assistants, Professional development managers, Home healthcare managers | Patient safety; risk assessment. | Variation in work practice; development and test of quality improvement intervention. Individual capacity for adaptation; knowledge, competence, personal characteristics. Team/unit capacity for adaptation; communication, collaboration, learning. Organisational capacity for adaptation; resources, organisation, culture. | Interview |
19 | Finalised 2020 | Meso and macro | External assessment prior to ISO certification | External assessors, Hospital managers, Ward/Unit managers | Patient safety, risk management. Clinical effectiveness: effects | Quality improvement measures; organisational development. Organisational capacity for adaptation; resources, organisation, culture. Larger system capacity for adaptation; regulation, framework conditions. | Interview |
Data analysis
Stakeholder identification
Meaning units from narrative (Project 7) that indicate performance variability | Factors influencing performance variability | Adaptations made in response to variation | Stakeholders involved in adaptations | Stakeholder relationships |
Considerable variations were identified in the time (hour of day) the patient was determined medically fit for discharge; discharge process was found to be more rushed when the patients were declared medically fit after noon. This was because of the reduced possibility to prepare the discharge requirements for care transfer if the transfer was to take place the same day. The healthcare personnel stated that time pressure affected precision in their work. When decisions are made later in the day, this also creates time pressure for local municipality personnel who have to initiate processes related to care planning and post-care transfer on their end. This time pressure was exacerbated by financial penalties for delayed discharge; these encourage municipal staff to rush care planning to avoid paying the daily fee. The next of kin played an important role as advocates in the decision making regarding post-discharge arrangements. In some cases, the next of kin questioned whether their involvement and persistence had an impact on the level of post-discharge care offered. | Patient characteristics Degree of familiarity with patient Time of discharge Time pressure to complete task Competing task demands Availability of information Availability of resources External financial demands | Involvement of patients’ next-of-kin in decision-making (at discharge). Family members actively advocate for patients. | Patients Family members Healthcare professionals | Patients and family: fully linked Family and healthcare professionals: collaboration Healthcare professionals from different provider organisations: communication and collaboration |
Meaning units from interview (Project 15) that indicate performance variability | Factors influencing performance variability | Adaptations made in response to variation | Stakeholders involved in adaptations | Stakeholder relationships |
[Patient participation and shared decision-making] is easier to achieve in practice with those [patients] who are motivated and have resources behind them and within their network, then it is much easier to succeed. … For those who seek treatment and believe in it, who are motivated and want it, it is easy to make it happen. For those [patients] who have a more complex picture and who are more unwell, and perhaps have less support, et cetera, then it is far more demanding and … the healthcare personnel and therapists must use their clinical competence and make a discretionary assessment as a provider. You cannot standardise it [patient care] 100%, you have to offer different menus to different people. Some people get a simpler menu, while others get one with many options … or where multiple steps … is what is required to be able to establish collaboration or create a secure environment [for the patient]. Whereas if you were to do that with every single young person who comes into mental health care, then you would not have managed to help more than the tip of the iceberg of those who need it. So an assessment is required along the way by the staff. Family members often have an important role in … the follow-up of measures put in place [for the young person] but will depend on their capacity for cooperation and engagement in follow-up over time. | Patient characteristics Patient needs Patient capacity Degree of family support Family capacity for involvement Staff / team competency Staff / team experience Staff / team capacity Unit / ward capacity | Extra or special efforts to engage patients by healthcare professionals. Involvement and engagement of family by healthcare professionals. Family involvement in follow-up of care. | Patients Family members Healthcare professionals | Patients and family: fully linked Patients and family: not linked Family and healthcare professionals: collaboration Family and healthcare professionals: not linked |
Project No | Patients | Family Carers | Healthcare Professionals | Ward/Unit Managers | Organisation Managers | Regulatory Investigators | Policy Makers | Other Service Providers | Stakeholders according to system level | Stakeholder interest/influence | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Doctors | Nurses | Allied | Other | Service Managers | Case Managers | Micro | Meso | Macro | External / cross-level | Subjects | Players | Context-setters | |||||||
1 | ● | ● | ● | ● | ● | ● | ● | ● | P | HC, WM | OM | ||||||||
2 | ● | ● | ● | ● | F | ||||||||||||||
3 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P | HC, WM | OM, RI, PM | |||||
4 | ● | ● | ● | ● | ● | ● | P | F, HC | |||||||||||
5 | ● | ● | ● | ● | ● | ● | ● | ● | ● | HC, OM | PM | ||||||||
6 | ● | ● | ● | ● | ● | ● | ● | ● | ● | P | HC, WM, OM | PM | |||||||
7 | ● | ● | ● | ● | ● | ● | ● | P | F, HC | PM | |||||||||
8 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P, F, HC, OSP | WM, PM | ||||||
9 | ● | ● | ● | ● | ● | ● | ● | ● | P | F, HC, WM, OSP | |||||||||
10 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P | F, HC, WM | OM, PM | ||||||
11 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P, F, HC, OSP | PM | ||||||
12 | ● | ● | ● | ● | ● | ● | ● | ● | ● | P | F, HC, RI | OM, PM, OSP | |||||||
13 | ● | ● | ● | ● | ● | ● | ● | WM, OM | RI, PM | ||||||||||
14 | ● | ● | ● | ● | ● | ● | ● | ● | ● | P | HC, WM, | PM | |||||||
15 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P, F, HC, OSP | WM, OM, PM | ||||||
16 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P, F, HC, OSP | PM | |||||||
17 | ● | ● | ● | ● | ● | ● | ● | ● | ● | ● | P, F, HC | WM, OM | |||||||
18 | ● | ● | ● | ● | ● | ● | ● | ● | P | HC, WM | OM | ||||||||
19 | ● | ● | ● | ● | ● | ● | WM, OM, OSP |
Stakeholder categorisation
Stakeholder relationships
Patients | Family Carers | Healthcare Professionals | Ward/Unit Managers | Organisational Managers | Policy Makers | Regulatory Investigators | Other Service Providers | |
---|---|---|---|---|---|---|---|---|
Patients | Communication Collaboration | Not linked Communication Collaboration | Communication Collaboration | Not linked | Not linked | Not linked | Not linked | Communication |
Family Carers | Communication Collaboration | Communication | Communication Collaboration | Not linked | Not linked | Not linked | Communication | Communication |
Healthcare professionals | Communication Collaboration | Communication Collaboration | Communication Coordination Collaboration Fully linked | Fully linked | Coordination Fully linked | Coordination | Communication | Communication Coordination |
Ward/Unit managers | Not linked | Not linked | Fully linked | Coordination | Communication Coordination Fully linked | Communication Coordination | Communication | Coordination |
Organisational managers | Not linked | Not linked | Coordination Fully linked | Communication Coordination Fully linked | Communication Coordination | Communication Coordination | Communication | Coordination |
Policy Makers | Not linked | Not linked | Communication Coordination | Communication Coordination | Communication Coordination | Coordination | Coordination | Coordination |
Regulatory Investigators | Not linked | Communication | Communication | Communication | Communication | Coordination | Not linked | Not linked |
Other Service Providers | Communication | Communication | Communication Coordination | Coordination | Coordination | Coordination | Not linked | Not linked |