Understanding Complex Work Using the Resilience Mechanisms Framework: An Ethnographic Study

This ethnographic study explored the types of challenges faced by healthcare workers and the adaptations they use to overcome them in everyday work.

Resilient Healthcare (RHC) is a field that applies insights from multiple domains including safety science, ergonomics and human factors, engineering, psychology, sociology and more. A key focus within RHC is to better understand healthcare as complex adaptive systems, and thus, the types of challenges, constraints, levers and sacrificing decisions necessary to ensure safe and reliable work.

It’s noted that under RHC, complexity is framed “as a key feature of healthcare work in straightforward language has the advantage of increasing understanding and supporting adoption into practice” (p1).

One method used within RHC is the CARE framework (Concepts for Applying Resilience). CARE seeks to explore how healthcare work is accomplished through adaption to pressures and problems – shown below.

CARE draws on alignment and misalignment to highlight disparities between work-as-imagined (WAI) and work-as-done (WAD). WAI is seen as the alignment between demand and capacity, but because complex work environments cannot fully be specified in advance disparities will exist. Thus, CARE models the disparities as misalignments between demand and capacity. This includes the use of workarounds and making adjustments to ensure operations continue.

The authors of this study applied a new framework for understanding misalignments, which they called the Resilience Mechanisms Framework.

Key objectives were thus:

1. To identify and classify types of misalignments between demand and capacity experienced by healthcare ward teams

2. To identify and classify types of adaptations that are made in response to misalignments

Sample was from a large teaching hospital in London over a 6 month period from two observers, including 80 hours of observations.

Results

Key results included:

·????????351 misalignments between demand and capacity in ward work were identified across five wards.

·????????Of those, 212 had at least one related adaptation.

·????????They note that “Misalignments and adaptations were seen in each team, regardless of structure, design, function, and leadership” (p4).

·????????Six types of misalignments and three types of adaptations were identified and consequently compiled into a framework (shown below).

·????????Some of the categories were further sub-divided.

It’s noted that each misalignment and adaptation had both positive and negative implications for patient care, quality and safety.

Under “extra-role performance”, it was observed that the ward manager took on other duties like delivering patient meals when the ward was overwhelmed. This allowed patients to receive their meals more quickly and freed up other staff for more pressing tasks, but this extra-role performance also had negative effects. This included the ward manager temporarily disregarding admin tasks, skipping meals, staying late and other things that could “contribute to role blurring, staff turnover, and stress and burnout” (p6).

Some misalignments naturally paired with adaptations, like staffing misalignments were often coupled with staff redistributions. Further, when equipment malfunctioned or was inadequate people then compensated. Notably though, “process misalignments and extra-role performance were also used to overcome these misalignments” (p6).

Across all misalignments, process adaptations were the most frequently used types of adaptations – where workers most often adapted by “changing how the process was done. The exception to this was for staffing shortages, which were most frequently responded to with extra-role performance” (p6).

Also observed was that workers often spontaneously assisted with work outside their direct responsibility (extra-role performance) and this occurred more often than teams responding by reshuffling among their own tasks. Other process and environmental misalignments were countered frequently by staff taking on additional responsibilities.

Resources were found to have been rarely redistributed when demand was greater than capacity.

In many cases when staff advocated for additional resources it was not fulfilled. This “necessitated that staff adapt in other ways, most often with extra-role performance and adapting processes” (p7).

In concluding, it’s said that “Misalignments are a ubiquitous feature of healthcare work and workers are adept at devising adaptations to ensure the system keeps working” (p7).

Workers “respond to varied misalignments by adapting how processes are done in the absence of additional support and resources” (p7).

[** In my view these findings support previous research that work is successful because of people continually adapting rather than because of our systems and rules. Indeed, Wears & Hettinger (2014) argued that “People are the most adaptable element in any complex work system”.

However, the “tragedy” of workers’ ability to continually adapt is that this adaptability “makes dysfunctional work systems and practices appear to be performing better than they actually are. In the end, these invisible adaptations, filling gaps as they appear, can leave frontline workers “twisted like pretzels” around poorly designed or frankly dysfunctional systems as they contort themselves to get their work done” (Wears & Hettinger, 2014, p.338).]

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Authors: Sanford, N., Lavelle, M., Markiewicz, O., Reedy, G., Rafferty, A. M., & Anderson, J. E. (2021). Ergonomics & Human Factors 2021, Eds R Charles & D Golightly, CIEHF.