Tactical command in NHS hospitals during sudden-onset critical and major incidents: a constructivist grounded theory approach

This article constructs a theory of tactical command based on the lived experience of individuals in NHS tactical commander roles, including the concerns they had and how they sought to address them. Building on research into sudden-onset incidents in NHS hospitals, seven components of managers' response (navigating an unfamiliar landscape; lack of preparedness; absorbing accountability; effecting cultural change; seeking reassurance; constructing a single version of the ‘truth’; and challenging previous assumptions) are placed within the context of hospitals as complex adaptive systems responding to crisis. This centres around the concept of taking responsibility for the organisation, with a focus on patient, staff, hospital and public safety. This role requires tactical commanders to undertake boundary identification, interface management and consequence mitigation. Suggestions are made about how this theory and the associated insights into organisational complexity could contribute to training for tactical command and to understanding the effectiveness of hospital responses to a sudden-onset incident.