From Theory to Policy in Resilient Health Care: Policy Recommendations and Lessons Learnt From the Resilience in Health Care Research Program

How to provide safe, high-quality care is a preeminent question for health care systems worldwide.1,2 Historically, the answer has been by trying to improve current practice, based on standardization, checklists, and lessons learned from adverse events and assessments of what went wrong in the past.3,4 Although responses have been intermittently and favorably reported in some studies, aggregate data consistently show that the rate of harm due to health care–related adverse events has hovered at between 5% and 10% for hospitalized patients.5–7 This range of adverse events has been reported since the Harvard Medical Practice Study in 1991, but with the most recent study indicating that the numbers could be as high as 24%.8 The consistency of these numbers has called for radically new approaches to advance the field of patient safety.2,4,9–12 One such approach is to investigate and understand what contributes to resilience in health care.3,4 Resilience can be defined as the capacity to adapt to challenges and changes at different system levels, to maintain high-quality care.13 Resilience in health care is crucial for quality and safety in service provision and is about the proactive, inherent capacity of the system to enact care safely and respond to constant challenges and changes at different system levels.13 Resilience research is on the agenda as never before (e.g., Wiig and O'Hara14). It focuses on understanding variability and how successful outcomes are generated in the real world of practice rather than in artificially controlled studies. Such approaches highlight how high-quality care is the result of everyday clinical work—from the unfolding processes in action across health care systems, organizations, and care settings.10,15 However, such new approaches have been criticized for lacking clearly defined practical descriptions, methods, tools, and activities to support the concepts and theory.16–19 In short: how do people keep patients safe through their daily performance in a system as complex as health care? New light has been shed on how this needs to occur in future health care services, and underpinned by systematic literature reviews; the road to travel points to multilevel studies of resilience, where tools and methods are developed, implemented, and evaluated to support resilient practices.20–23 The Resilience in Healthcare (RiH) Research Program10 was set up to accommodate these challenges through extensive research efforts over a 5-year period. This research program provides the first large-scale, cross-country study of resilience and adaptive capacity in health care across different health care contexts in specialized and community-based services.10,13,24–26 AIM The overarching aim of this paper is to share lessons learnt from the RiH Research Program (2018–2024)10 and provide research-based recommendations emanating from this work for policymakers. We do this by expanding on our earlier brief definition of what we mean by resilient performance, then presenting the capacities needed in the health care system to enact resilient performance, and finally discussing how policymakers can support translation of resilience elements and tools into policy and practice. More specifically, as patient safety research needs new perspectives to advance the current sorry state, we aim to show how resilient performance can be supported, and enhanced. It is in effect a new way of quality and safety thinking for policymakers3,4—one that can redirect activities and refocus efforts. Based on results from our 5-year empirical study, we will share the key findings and lessons learnt that those on the frontiers of policymaking should adopt. There are many pathways for successful policymakers to support care settings. One way is to focus on how to improve conditions under which people work, for example—those that enable people to do their job in successful ways. Other key fundamentals of a successful policy approach are to support health-promoting leadership, provide a psychologically safe working environment, reduce low value care and dysfunctional work practices, and involve patients, informal caregivers, health care professionals, leaders, and regulators in system improvement.24,26–33 THE RiH RESEARCH PROGRAM The RiH Research Program (2018–2024) involved researchers from Norway, England, the Netherlands, Australia, Japan, and Switzerland.10 Its primary objective was to reform and extend the understanding of quality and safety in health care by developing, implementing, and evaluating a theoretical and practical framework of resilience in health care. RiH was designed as a comprehensive research program to consider the capacity of health care systems and stakeholders to adapt to changes, variations, and/or disruptions. The RiH program10 has addressed the following research questions: How can an integrative theoretical framework for RiH be described to understand and improve quality at different system levels? How can involvement of patients and stakeholders in RiH be described and improved? How can RiH be described and improved in different health care settings? How can the role of collaborative learning in RiH be described and improved? How can RiH be identified, analyzed, and compared in different international health care settings?10 The RiH program published results throughout its duration. Fundamental papers from the initial explorative phase of the research program sought to answer what resilience in health care is13 and identified and theorized on resilience capacities.34 The many roles of stakeholders including patients, families, health care professionals, and leaders have been explored,24,29,35 alongside investigation of how learning from everyday work occurs.36 This work formed the backdrop for the second phase of the program, which was to develop a resilience learning tool that was implemented and tested in diverse health care contexts (nursing homes, homecare, hospitals) to aid translation of resilience theory into practice.37–39 Building on this work (e.g., Wiig et al,13 Ree et al,31 Haraldseid-Driftland et al,26 Lyng et al34), we now turn to a crucial component of the larger study: tips and recommendations for policymakers. TIPS FOR SUCCESS: RECOMMENDATIONS FOR POLICYMAKERS We derived 8 policy recommendations from the RiH research program. Define resilience from a system perspective while acknowledging the role of individuals Resilience and resilient performance in complex adaptive systems is considered a system responsibility. First and foremost, we found that to tailor improvement in health care quality, policymakers should be specific about their understanding of resilient performance and what they are trying to achieve by supporting it. Our definition ("the capacity to adapt to challenges and changes at different system levels, to maintain high quality care")13 helps broadens the perspective of resilience to include multiple layers of health care and supports the integration of patients and users as contributors to resilient performance. Although our research takes a system perspective, we acknowledge the role of individuals. As such, resilience is not the responsibility of individuals, but rather reflects the performance of the system, which is of course enabled by the individuals comprising the system and their collaboratively achieved outcomes. Systems depend on individuals who can see opportunities and handle stress, adapt to changes and challenges in everyday work, and are able to continue working despite physical and mental strain. This requires individually tailored approaches from the system and its leaders. Hence, those at the leading edge of policymaking need to emphasize resilient performance within a system perspective, while at the same time seeing individuals as key players creating resilient performance on which the system ultimately depends.28,29,34,40,41 Hence, the system needs policymakers to promote and tailor-make the conditions that support individuals within the system.42 Consider patients and families as continuous, deep sources of resilient performance Patients and their families play a fundamental role in resilient performance in direct and indirect ways. Research indicates that they should be encouraged to be even more of a source of enhanced care.13,24,35,43,44 However, they all-too-often are not considered as part of the team or as partners in care. We have identified patients and stakeholders as both direct and indirect contributors to resilient performance. They hold multiple roles in the patient journey—in both long-term and acute care contexts. Many policymakers can do much more to capitalize on the willingness and capacity of patients and families to contribute to their care and the systems providing it. This is especially the case as it is predicted that future health care services will lack sufficient clinical personnel.45–47 Patients and families need support in many areas, but our studies suggest that key areas for policy attention are competence development, providing more, better, and more timely information to patients, and not least acknowledgment of and appreciation for their essential role as sources of resilience.48 Without this, clinicians face more potential burnout.49 Involvement of patients and families should not only be reflected through engagement strategies, but it is essential that they become an integral element in the organizational culture, one in which all stakeholders are viewed as vital contributors to providing high-quality care. Prompt awareness of resilience capacities through a research-based resilience framework A resilience capacity relates to an actual or potential ability to perform or withstand stress and is linked to the definition of resilience in health care that grounds the RiH Research Program. Here, the focus is on adapting to challenges and changes.34 In most health care provider organizations, there is a need for an assessment and operationalization of the kinds of capacities needed. The goal here is to enhance the inherent adaptive capacity that underpins resilient performance over time. Our research points to the need to bolster awareness and monitoring of resilience capacities within organizations and across organizational boundaries.34 The Resilience Capacities Framework34 has been validated across contextual settings and countries50; it documents 10 resilient capacities: structure, learning, alignment, coordination, leadership, risk awareness, involvement, competence, facilitators, and communication. Such a framework for conceptualizing and talking about resilience capacities can support discussion between stakeholders, making tacit knowledge explicit about resilience in organizations.39 4. Promote a culture of collaborative learning to structure feedback and establish learning arenas for resilience A culture of collaborative learning focuses on the collaborative element in learning where people in organizations adapt and learn together at work.13 Learning is fundamental to change and improvement. Resilient performance relies on collaborative learning within and across boundaries in teams and organizations.13,26,38 Our work strongly suggests that most people, including policymakers, fully appreciate that learning from success and what works well is important, but less policymaker attention is directed toward nurturing such learning processes. Our work suggests strongly that learning does not just happen on its own.37 Fundamental principles of learning are needed, whether the aim is to learn from success or failure. However, sound methods and tools to facilitate the learning processes are needed. Although a variety of tools and methods have been developed to learn from adverse events, there is a scarcity of tools that prompt learning from success. We have integrated resilience theory, concepts, and learning principles into an open-access Resilience learning tool (https://rih.uis.no/). This has been implemented and evaluated with positive results for different Norwegian health care settings and is now also translated into English.37,39 Policymakers can support resilient performance by disseminating this tool, but also by creating other learning structures, providing reinforcing feedback loops, and encouraging arenas for reflection to take place so stakeholders' understanding of resilient performance can grow.36 We found that people often struggle to identify positive elements in their everyday work, because it is so common that things go well. People take this for granted and quickly move on to the next task.39 Hence, policymakers should clearly articulate the need for learning structures and provide feedback about what works well and why, and then diffuse this throughout their system. A culture of collaborative learning from everyday work and bringing positive experiences to the surface can lead the way to increased learning from everyday work that goes well, contributing to better outcomes, and feeding into a positive learning loop. 5. Position contextual awareness as integral of any assessment and support for resilience in longitudinal and continuity care chains Contextual awareness means having an understanding and specific knowledge about the inner and outer contextual settings that may affect the quality of patient care. Context matters for resilient performance and lays the foundation for individuals', leaders', teams', and organizations' adaptive capacity. Based on our research, it is clear that context-specific knowledge and understanding of diverse care settings is a key plank in successful policymaking. Other factors needed to be understood include staff challenges, e.g., the care load of staff, the emergence of diverse types of risks people face, and the complexity, technologies and work processes that are crucial to the ability to adapt and provide high-quality care.30 In our work, we also highlighted that context is not fixed. Deep knowledge of context can underpin double loop learning processes in organizations.39 Contextual awareness and understanding need to be integral to assessment processes and should be valued as an asset in supporting resilient performance.29,30 There needs to be sufficient organizational room to move, also known as slack, to take advantage of context-specific knowledge.40 This is a foundational result from our RiH research program. 6. Relational leadership is crucial in resilience and leaders must support positive relations with the workforce Relational leadership focuses on the social dynamics of how leadership relationships form and evolve in the workplace.51 Relational understanding and relational leadership stand out in our research as areas where policymakers need to pay attention in the future. Taking a Safety-I approach, huge amounts of work have been expended in developing and implementing structures, checklists, and guidelines, attempting to reduce harm. But what we have demonstrated is the essentials of relational elements needed in addition to these structural elements.23,29,31 Relational leadership is, for example, provided by health care leaders who genuinely care about and know their staff, who are trying to support their staff in having a sound life-work balance, who are constantly adapting to staff's personal needs and beliefs, and who are establishing teams that are competent now and are enabled to learn and grow over time.29 This might sound idealistic, but our results are unambiguous. They say relational leadership and relational understanding are key pillars for future health care leaders to succeed in supporting resilient health care systems. 7. Position resilience as a multilevel phenomenon and use regulatory mechanisms to establish reflexive spaces to leverage resilience into practice Resilient health care advocates for a multilevel understanding of resilience as a phenomenon, in which the influence of multiple factors across the micro, meso, and macro levels of the health care system is considered.3 This is anchored in an understanding of health care as a complex adaptive system where all system levels play a part in enabling resilient performance.52 Resilient performance relates to and depends on factors from the clinical micro system, to teams, organizations, policymakers, and regulators.27,32 Policymakers should be specific in positioning resilience as a multilevel phenomenon and use the power of regulatory mechanisms to promote what we know, and have discussed above, in support of resilient performance. Policymakers should establish regulatory mechanisms that bolster resilient performance.27,32 We encourage regulators to understand and acknowledge reflexivity as a foundation for resilience in health care organizations, and that creating and supporting reflexive spaces are key for leveraging resilience into health care regulation. Reflexive spaces can be conceptualized as physical or virtual platforms in which deep dialogical practice occurs between people. Reflexive dialogical practices are key in learning processes because they bridge tacit and explicit knowledge. By regulating arenas as reflexive spaces, or by requiring that regulated organizations set these up, people will be brought together to enable reflection on current challenges, adaptations, and daily needs in practice.27 If it sounds as if we are proposing for health care organizations to be thoughtfully and strategically agile, then that is a correct conclusion. Our research program indicates that providing flexible, reflexive spaces for staff is necessary for enabling adaptive capacity and resilient performance. Regulation and resilience are not an odd couple53; policymakers have the power to drive change and support resilience and resilience reflection through regulation.32,54 8. Advocate adaptive capacity as positive and needed for change and improvement Adaptive capacity in health care constitutes flexibility and is based on reframing, aligning, coping, and innovating, in response to external and internal demands stemming from different organizational levels, to ensure quality of care.33 Adaptations in health care systems are crucial, as standardization and top-down policies are unable to cover all situations in the complex arenas of clinical practice. Health care systems need sufficient adaptive capacity—to give clinicians enough space to effectively manage themselves, and risks, challenges, and changes.29,33,55 We have identified enablers for adaptive capacity that policymakers need to consider and positively promote, to support required changes and improvement processes that health care systems will be exposed to in the nearest future.33 Our 4 enablers for adaptive capacity are as follows: first, knowledge and the ability to integrate and combine different knowledge sources are a prerequisite; second, the organizing of resources and being able to coordinate and ensure buffers, continuity of staff, and stakeholders; third, communication and frequent face-to-face exchange; and fourth, trust and the ability to have conviction in one's own and other team members' competence.33 However, adaptations need to be monitored and coupled with contextual understanding to ensure that they are not just band-aid solutions masking system deficiencies, but instead represent valuable efforts for the organization. Policymakers need to place these enablers up front to strengthen resilience of future health care systems. DISCUSSION Taking resilience thinking from the research desk to policymakers' work is a journey not a destination. However, key policy agencies and national bodies such as the European Union and the World Health Organization call for resilient performance and for researchers to identify ways of supporting adaptive capacity, flexibility, agility, and well-being among the work force.56–58 Through a large-scale international RiH program,10 we have theorized about resilience in an integrated framework, we have developed and tested a resilience learning tool to translate resilience into practice and evaluated results, and we have identified the multiple roles and influences of patients and other key health care system stakeholders in resilience. Based on the lessons learnt from this 5-year research program, we have suggested 8 policy recommendations as our tips for successful translation of resilience into policy and practice to promote worldwide impact (Fig. 1).FIGURE 1: Policy recommendation for resilient performance.Overall, in response to the literature (e.g., Iflaifel et al,12 Berg et al,22 Ellis et al,21 Forsgren et al59) and our findings, our recommendations are designed to promote an integrative multilevel perspective on resilience for policymakers and for their policy formulation activities. In particular, the relational elements of resilience highlighted in our research are in line with Gittel's60 work but has largely been missing in the current resilient health care literature. In the end, the vital role of policy leaders in supporting resilience and adaptive capacity emphasizes a strong awareness of the enabling leadership skills and practices to support the workforce's performance.29,56 The resilience literature has for years called for interventions to translate resilience into practice.20,21 Our research shows ways of doing this through assessing resilience capacities, improving contextual understanding,34 and establishing an open-access, freely available Resilience learning tool to guide collaborative learning processes to learn from everyday work and successful operations.39 There is a need for policymakers to support, require, and nurture arenas and reflexive spaces to promote positive relations and mutual understanding of current problems and practices. Articulating, and in fact talking about workarounds, good practices and capacity-demands challenges are crucial for problem solving and practice improvement, but not always in line with regulatory rules and demands.27,61 This needs to change, and regulators need to a larger degree acknowledge the complexity of the systems they regulate in a wider perspective where they reduce attention to individuals. We argue that these recommendations, if adopted, will go a long way toward addressing current needs for better governance structures, improved middle-level leadership skills, and the strengthening of human resource capacities, communication, and collaboration in support of resilient performance.59 CONCLUSIONS It is time to move the field of resilience in health care from theory to policy, with the aim of supporting improved practice. To do this, we encourage policymakers to consider the 8 research-based recommendations presented in this paper. Each health system must examine how the recommendations will fit with their own context. There are few higher goals than to put continuous effort into supporting resilient performance as a positively oriented way to improve patient safety and quality of care for the benefit of future patients everywhere.