Introduction
Learning is fundamental to quality and safety improvement efforts in healthcare and has been an integral part of researchers’ and policy makers’ agendas for decades. The traditional logic, both within healthcare, workplaces, and education is that learning from adverse events helps improve structures and systems, and avoids future reoccurrences, thereby ensuring safer and better outcomes [
1‐
5]. Within healthcare, this traditional approach - focusing on adverse events and ‘find and fix’ solutions - is known as ‘Safety-I’ [
6]. However, recent studies show that despite a range of efforts over the past two decades, the rate of healthcare related adverse events holds steady at between 5 and 10% for hospitalized patients [
7‐
9] and has even been reported to be as high as 24% [
10]. This consistency of these figures over time could imply that traditional ‘Safety-I’ methods, such as root cause analysis [
11] and checklists, are inadequate for maintaining high quality and safe care [
12]. Research within the educational sector has also pointed out the difficulties of learning from error, due to the multi-facetted and complex contexts within which errors occur, which could even imply that this approach is counter-productive [
13,
14]. Research within the healthcare setting has therefore called for a radical change in the approach to understanding and improving the quality and safety of patient care. This new theoretical approach, known as Resilient Healthcare or Safety-II, takes into account the complexity of care process and tries to understand and learn from what predict positive outcomes in addition to studying errors [
12,
15].
In recent years, interest in resilient healthcare, and in particular, ‘Safety-II’, has increased. The focus here is on everyday work and performance variability. This approach asks: how are patients kept safe in complex, challenging, pressurized environments, through normal working conditions and practices? Understanding how safe care is
created, and how things go right so often, is seen as a key source of learning [
12,
16‐
21]. Resilient healthcare research explores how healthcare organizations, their staff, patients, and informal carers anticipate, monitor, respond and learn when facing disruptions and/or possibilities for innovation [
16,
18,
22,
23]. In this research field, resilience is defined as the capacity to adapt to challenges and changes at different system levels in order to maintain high quality care [
6]. Resilient healthcare offers a systems perspective on how individuals, teams, and organizations successfully adapt to their changing circumstances [
24]. This systems approach is important since it shifts the responsibility for providing high quality patient care from individuals alone and instead puts the focus on the system’s ability to enable resilient performance among the actors in the system. Learning is central to developing resilient systems– it enables us to develop understanding over time, and to deeply appreciate what happens and why [
25,
26].
Based on the premise that resilience in healthcare is a systems perspective, the learning component within resilience refers to organizational learning. This occurs when an organization adapts its enterprise by assimilating new knowledge, while simultaneously exploiting existing knowledge to change and improve their systems, routines, rules and procedures [
27]. Given the complexity of healthcare, resilient performance depends on high levels of collaboration and interconnection across different system levels (individuals, teams and organizations), and between different stakeholders (including healthcare professionals, patents, and families) [
28‐
30]. The learning element within the resilient healthcare literature therefore builds on the importance of collaborative learning - that is learning through work and learning together [
31,
32]. Learning in professional environments works best when it occurs continuously and is a collective enterprise – when healthcare professionals, patients and families, leaders, and policy makers exchange information, share knowledge, offer support to each other, and coordinate, negotiate and align efforts to deliver care safely [
30]. However, beyond these general statements, we lack detailed empirical knowledge about how learning processes for translating resilience to practice occur, how learning principles may support resilience activities, and more specifically how such theoretical positioning can be translated from theory into practice to improve quality and safety of care [
6,
12,
30,
33]. In short, we need a more detailed picture of learning processes for resilience in healthcare in situ.
Optimally, complex interventions need an underpinning program theory which describes the mechanisms and contexts that are hypothesized to produce the desired outcomes [
34]. To scale up efforts to strengthen resilient healthcare, exploration of the collaborative learning mechanisms that underpin the adaptations, trade-offs, and improvisations that occur when people respond to disruptions is needed [
6,
19,
30]. We propose that theoretical anchoring, understanding of learning mechanisms, and establishing foundational principles for learning in resilience are key requirements when designing interventions aimed at strengthening resilient performance. Experts in resilient healthcare argue that learning from both positive and negative events is important, and while many tools and approaches for learning from adverse events have been developed, tools for learning from successful events are limited [
35]. The resilient healthcare literature has called for resilience interventions [
20,
36], and new tools to translate resilience into practice have started to emerge e.g. [
37‐
40]. In this context, a learning tool can be understood as an artefact that people collectively interact with to support organizational learning i.e. a change in organizational knowledge [
41]. In terms of translating theory into practice, the learning tool must add to or transform the situated organizational knowledge [
41]. Learning principles, conceptualised as pedagogical ideas, are foundational for any learning tool, process, or activity aiming to translate research or theory into practice [
34]. However, to date there is no consensus or evidence around what these learning principles should be. Without this, success and innovation in the field is unlikely to occur.
The resilience in healthcare program
The longitudinal research program
Resilience in Healthcare (RiH) (2018–2024) [
6,
12] builds on the ideas of adaptive capacity, learning from what usually goes right, and understanding everyday work practices within complex healthcare systems. Its focus is on how people learn collaboratively, in the real world of practice, as a fundamental aspect of resilient healthcare. The project develops resilient healthcare theory and aims to translate resilience capacities into practice through development of a collaborative learning framework and tools [
12,
19,
22,
42]. In doing so, the project seeks to advance current thinking in resilient healthcare and help reduce the gap between theory and practice [
20,
21,
23,
36].
Aim and research question
The specific aim of this paper is to describe how the RiH program uses multiple methods and a participatory approach to establish learning principles for tools to help translate resilience into practice. To develop a resilience learning tool for healthcare professionals working in different contexts and across different levels in the healthcare system, the RiH project requires basic foundational principles to ensure and promote translation, relevance, and uptake of any future resilience interventions aimed at testing the tool. The research question guiding our study was: What are key learning principles for developing learning tools to help translate resilience into practice?
Strengths and limitations
The development of the learning principles in this study was a result of an iterative approach of discussions and refinement, featuring a range of activities with different stakeholders. While the range of activities included in this study ensured that multiple different views were taken into consideration, the stakeholders involved in the Type A activities were only from a Norwegian context. The specific healthcare context, including fewer private hospitals and a government funded healthcare system, could therefore have influenced the findings. On the other hand, the Type B activities included international participants who thereby contributed with important international context during the refinement of the principles. However, the study could have benefitted from a broader international collaboration where stakeholders from different context contributed in all activities.
The learning principles were developed by a group of researchers who acted concertedly and gathered information from a wide range of sources which contributes positively to the trustworthiness of the findings. However, involving such a wide range of parties could risk fragmentation and difficulty in seeing the holistic picture. This issue was prevented by having one researcher (CHD) leading the developmental process and through dividing the process up into multiple stages, where consensus was reached between each stage. The approach could have been even more directly participatory, by asking the stakeholders to help develop and form the principles or contribute as a part of the research team. It could be viewed as a limitation that this study was not grounded within a theoretical learning framework, since the study touches upon educational and learning components. However, the aim of this study was to elaborate on the learning element within resilience in healthcare theory, and to facilitate translation of resilience into practice. The study was therefore grounded within the resilience in healthcare theory so as to best suit the study’s purpose. Future studies might benefit from investigating the connections between the learning element in resilience in healthcare theory and how this relates to and builds upon different general learning theories.
Future research should test the principles in a broader international context and further describe the importance of learning within the resilient healthcare literature to improve the ability to operationalize the resilience in healthcare theory through further developing the principles.
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